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ORIGINAL ARTICLE Table of Contents   
Year : 2003  |  Volume : 37  |  Issue : 2  |  Page : 6
Valgus intertrochanteric osteotomy in intracapsular fracture neck of Femur


Department of Orthopaedics, PGIMS, Rohtak, India

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   Abstract 

Fifty patients of intracapsular femoral neck fractures, 40 with recent injuries [group-A]; and 10 with established nonunion [group-B]; were treated with valgus intertrochanteric osteotomy and osteosynthesis through a modified Watson Jones approach. Patients were followed for an average of 9.2 years. Radiological signs of avascular necrosis in 7.5% and union in 95% of patients [group-A] were observed in an average period of 12.4 weeks (11- 16 weeks). Union was achieved with a viable femoral head in 100% of patients [group-B], in an average of 16.1 weeks (14-40 weeks). Sound union with a viable femoral head was also achieved in a patient sustaining pathological fracture due to a simple bone cyst with no sign of recurrence till 12 years follow up.
Forty one patients (82%) were graded as good to excellent result (Harris hip score 94), five patients (10%) with a score of 75 as fair; and four (8%) with a score of 30 were graded as poor results. The potential benefit to the patient retaining a viable biologic joint justifies the use of this procedure.

Keywords: Valgus osteotomy - Fracture neck femur; Pseudarthrosis

How to cite this article:
Magu N K, Mittal R, Garg R. Valgus intertrochanteric osteotomy in intracapsular fracture neck of Femur. Indian J Orthop 2003;37:6

How to cite this URL:
Magu N K, Mittal R, Garg R. Valgus intertrochanteric osteotomy in intracapsular fracture neck of Femur. Indian J Orthop [serial online] 2003 [cited 2019 Sep 20];37:6. Available from: http://www.ijoonline.com/text.asp?2003/37/2/6/48504

   Introduction Top


Femoral neck fracture in a relatively young adult should be treated if possible with closed reduction and internal fixation, to preserve patients own hip joint. However, it may result into nonunion because of the nature of high velocity trauma, comminution and the intra-articular location of the fracture. Nonunion in these patients can be converted into union by the application of valgus intertrochanteric osteotomy. This procedure developed by Pauwel, alters the biomechanical environment [Figure 1], and changes the fracture inclination at right angle to the resultant of forces. [1] Once forgotten, the osteotomy seems to have emerged as a lifeline in preserving the hip joint and invites the attention of the Orthopaedic surgeons particularly the recently trained ones for their awareness and usefulness of the procedure. This paper presents the results of 50 patients treated between 1990 -1995 and followed for an average of 9.2 years.


   Material and Methods Top


Fifty patients, 40 with recent injuries (3 days to 3 weeks) of intracapsular fracture neck of femur [group-A]; and 10 with established nonunion of 6 months- 28 months duration [group-B]; underwent osteosynthesis and valgus intertrochanteric osteotomy through a modified Watson Jones approach between 1990-1995. Their average age was 52.3 years (9-65 years). Thirty-one patients were sedentary workers and sustained fracture after a trivial trauma; and 19 patients after roadside accidents. One patient proved to have sustained a pathological fracture due to a simple bone cyst. According to Pauwel's classification, 26 patients were of type II; and 24 type III fractures. Twenty eight patients with recent injuries [group-A] were of subcapital and 12 were of transcervical type. All the patients in [group-B] exhibited significant absorption of the femoral neck.

Quality X-rays of pelvis including both the hips in antero-posterior and frog leg views were taken. Pre-operative planning was done from the sound hip to define the steps of surgery and to select an appropriate implant for osteosynthesis. Grading of osteoporosis was done as per Singh's Index from the sound hip. [2] Surgery was performed on an ordinary operation table without the help of X-ray control. Capsule was divided in each patient to expose the fracture site. Before performing the osteotomy, fracture was reduced under direct vision in an acceptable position and stabilized with a 6.5 mm cancellous screw. No attempt was made to excise the fibrous tissue from the fracture site in patients with established nonunion. Patients having significant over-riding were put on traction to achieve limb length equality. Curettage, bone grafting or any other form of additional treatment was not undertaken in the patient sustaining pathological fracture.

As defined on preoperative planning a laterally based intertrochanteric wedge of bone was removed and distal fragment abducted. Osteosynthesis of the fracture and the osteotomy site was achieved as per standard AO techniques using a 110 /120 / or 130 double angle blade plate or their innovation. Care was taken to buttress the head of the femur with the distal limb of osteotomy in patients having a small femoral head/subcapital fracture; and in patients where femoral neck was significantly absorbed. Patients were immobilized non-weight bearing between 3-4 days postoperatively; partial weight bearing was started after 6 weeks and full weight bearing after 12-16 weeks.


   Results Top


The patients were followed for an average period of 9.2 years (7-12 years). One patient died after three years of surgery. Results were assessed clinically by Harris hip score. [3] Patients were reviewed periodically for union of the fracture and the osteotomy site; and for viability of the head of the femur at intervals of 12, 24, 52, 75, and 100 weeks and later once a year. As per Singh's index 12 patients demonstrated grade II; 25 grade III; 9 grade IV; and 4 patients grade VI osteoporosis. In 45 patients osteosynthesis was performed with 120o double angle blade plate, two patients with 110o and one with 120o osteotomy plate. In one patient (8 years old) with established nonunion, semitubular plate was contoured into a 120o double angle osteotomy plate for internal fixation.

The osteosynthesis was considered stable when;

  1. The tip of the blade was seated in the inferior quadrant of the head of the femur.
  2. There was no further comminution during osteosynthesis.
  3. The distal limb of osteotomy could buttress the femoral head.
  4. Shoulder of the blade contained minimum of 15 mm block of bone.


Stable fixation could be achieved in 41 patients. Nine patients required supplementary fixation i.e. an additional tension band wiring or skeletal traction for 3-4 weeks postoperatively. Plaster hip spica was given in one patient in whom osteosynthesis was performed with a semitubular plate [Figure 2]. In 24 patients, the blade was seated in the posterior and inferior quadrant of the head of the femur; in 21 patients it was in central and inferior quadrant; where as in 5 patients, it was in the inferior and anterior quadrant. An average of 144o neck-shaft angle was achieved in the present series (range 125o-150o). Postoperatively, significant posterior tilt of head of the femur or implant cut through was not observed in any of the patients till the last follow up.

Radiological healing was determined by the presence of bridging trabeculac across the osteotomy or nonunion/ fracture site on plain radiographs. Clinical union was defined as pain free full weight bearing without assistance. Union was achieved in 95% of the patients presenting with injuries of recent onset [Figure 3] within an average period of 12.4 weeks (range 11- 16 weeks). In one patient nonunion was observed due to inadequate valgisation of the head of the femur, and total hip arthroplasty was performed at a later date; where as in another Girdlestone arthroplasty was undertaken to get rid of infection after a revision surgery. Union was achieved in all the patients [Group B], presenting with established nonunion in an average period of 16.1 weeks (range14-40 weeks). Sound union was also observed in the patient with the pathological fracture [Figure 4].

Three patients with injuries of recent onset [group A] demonstrated signs of avascular necrosis as increased density in two; and a segmental collapse in the postero-superior area of head of the femur in one patient. In none of the patients with established nonunion [group B] radiological signs of avascular necrosis were observed till the last follow up. Trendelenberg gait was observed in 4 patients. Forty one patients were graded as good to excellent result (Harris hip score 94), five patients with a score of 75 as fair; and four with a score of 30 were graded as poor results.


   Discussion Top


Internal fixation of femoral neck fracture is followed by certain incidence of fixation failure. Nonunion may occur in one third of patients so treated, with higher rates in vertical or displaced fractures. [4] Also, a number of methods of internal fixation when used alone, have failed to achieve the desired end result. Osteoporosis directly influences the degree of displacement and the quality of internal fixation. The deficient bone stock and posterior communition plays a significant role in its biological failure to unite the fracture. [5],[6]

Surgical treatments for nonunion of femoral neck fracture include; arthroplasty, nonvascularised bone grafting, muscle-pedicle bone grafting, arthrodesis and osteotomy. Arthroplasty is an acceptable treatment in older patients. In younger patients alternative methods aimed to preserve the femoral head should be favored. Arthrodesis has a high failure rate but, when successful, it leads to a functional hip. However, it may be difficult to convince a patient for this good option. Cortical bone grafts have been associated with disimpaction or angulation of the head, leading to failure. [7] The initially reported success of Meyer's procedure has not been reproduced in a large series and the procedure has been considered unreliable. [8],[9]

The valgus intertrochanteric osteotomy plays a two-fold role. It converts the shearing forces into compression forces by placing the fracture site perpendicular to the resultant of body weight forces [Figure 1]; and it buttresses the head of the femur from below to improve the stability provided by internal fixation. The problems of genu valgum and shortening can be overcome by lateralization of the distal osteotomy fragment. Our results validate this contention that even in severe osteoporosis, a union rate of 95% is achieved in group-A patients. A significant posterior tilt of femoral head or implant cut through was not seen in any of the patients. It further validates our contention that osteosynthesis combined with valgus intertrochanteric osteotomy eliminates the risk of implant cut through by preventing posterior tilt of head of the femur. Our results compare favorably with Renaldi et al who achieved 100% union and 8% avascular necrosis in 25 patients of femoral neck fractures treated with primary osteosynthesis and valgus intertrochanteric osteotomy. [10] It seems reasonable to assume that three of the forty patients in group-A had stage- I necrosis, not visible on standard pre-operative radiographs. One of these patients showed progression to collapse of the femoral head. Marti et al while making observations on avascular necrosis mention that partial or complete collapse of head of the femur can occur up to 3 or 4 years later. [11] In many of these patients clinical result is very satisfactory for years inspite of the degenerative changes.

Avascular necrosis was not seen in any of our patients with established nonunion. Also, these patients did not show signs of necrosis preoperatively. Soto-Hall et al observed that aseptic necrosis was rare when treatment for fracture neck of the femur was neglected because patients inevitably assumed the position of greatest joint capacity (flexion, abduction. and external rotation). [12] This posture would relieve the intra-articular temponade and lessen the possibility of avascular necrosis. This probably explains why avascular necrosis was not seen in our patients with established nonunion. Ballmer et al presented 17 patients with an 88% eventual union rate after osteotomy. They combined the data from several smaller series in the European literature, resulting in 58 cases with a union rate of 96%. [13] Lifeso and Younge performed six osteotomies in a series of 57 neglected hip fractures, all of them eventually healed. [14]

In the present series, total hip arthroplasty was undertaken in one patient resulting in nonunion for failure to valgise the head of femur adequately. Arthroplasty could easily be performed with the regular prosthesis, since the osteotomy did not cause a linear displacement in horizontal plane.

The principles of treatment for pathological fractures in benign tumours are different from fractures secondary to malignant metastasis. Important treatment considerations include selection of appropriate method of biopsy, curettage of tumour, optimal filling of the tumour defect, reduction of fracture, neutralization of forces across the proximal femur to allow bone healing, and prevention of osteonecrosis. Sim and Lane reported a 20 years old man who sustained a displaced pathological fracture through a large giant cell tumour of the proximal femur. [15] This was treated with curettage, cancellous bone grafting, valgus osteotomy, and internal fixation and bone grafting was combined with it. Sound bone healing with no sign of recurrence during a follow up of 12 years justifies the usefulness of valgus inter-trochanteric osteotomy in femoral neck fractures complicated by a benign pathology.

In conclusion, valgus intertrochanteric osteotomy with osteosynthesis is a useful method in the primary treatment of nitracapsular femoral neck fractures in adults; and in established nonunions.

The potential benefit of retaining a viable biologic joint justifies the use of this procedure. A total hip replacement can safely be taken up, as a secondary procedure in case the osteotomy fails to give the desired end result.[16]

 
   References Top

1.Pauwels F. Der schenkelhalsbruch ein mechanisches problem: Grundlagen des heilungsvorganges prognose und kausale therapie. Stuttgart: Ferdinand Enke Verlag. 1935.  Back to cited text no. 1    
2.Singh M, Nagrath AR, Maini PS. Changes in the trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone Joint Surg [Am] 1970; 52-A: 457- 467.  Back to cited text no. 2    
3.Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end result study using a new method of result evaluation. J Bone Joint Surg [Am] 1969; 51-A: 737-765.  Back to cited text no. 3    
4.Lu-Yao GL, Keller RB, Littenberg B, Weniiberg JE. Outcomes after displaced fractures of the femoral neck. A meta-analysis of one hundred and six published reports. J Bone Joint Surg [Am] 1994;76-A: 15-23.  Back to cited text no. 4    
5.Garden RS. Stability and union in subcapital fractures of the femur. J Bone Joint Surg [Br] 1964; 46-B: 630-47.  Back to cited text no. 5    
6.Dalen N, Jacobsson B. Rarefied femoral neck trabecular patterns, fracture displacement and femoral head vitality in femoral neck fractures. Clin Orthop 1986; 207:97-8  Back to cited text no. 6    
7.Baksi DP. Internal fixation of ununited femoral neck fracture combined with muscle-pedicle bone grafting. J Bone Joint Surg [Br] 1986; 68-B: 239-245.  Back to cited text no. 7    
8.Kyle RF, Schmidt AH, Campbell SJ. Complications of the treatment of fractures and dislocations of the hip. In Epps Jr CH [ed]. Complications in orthopaedic surgery Ed 3. Philadelphia; JB Lippincott Co. 1994: 443- 486.  Back to cited text no. 8    
9.Zuckerman JD. Koval KJ. Hip trauma. In Frimoyer JW [ed] Orthopaedic knowledge Update 4. Rosemont, IL: American Academy of Ortliopaedic Surgeons. 1993: 525-538.  Back to cited text no. 9    
10.Rinaldi E, Marenghl P, Negri V. Osteosynthesis with valgus osteotomy in the primary treatment of subcapital fractures of the neck of the femur. Ital J Orthop Traumatol 1984; 10 [3]: 313-320.  Back to cited text no. 10    
11.Marti RK, Schuller HM, Raaymakers ELFB. Intertrochanteric osteotomy for nonunion of the femoral neck. J Bone Joint Surg [Br] 1989; 71 -B: 782-787.  Back to cited text no. 11    
12.Soto-Hall R, Johnson LH, Johnson RA. Variations in the intraarticular pressure of the hip joint in injury and disease. A probable factor in avascular necrosis. J Bone Joint Surg [Am] 1964; 46-A: 509.  Back to cited text no. 12    
13.Ballmer FT, Ballmer PM, Baumgartel F, Ganz, Mast JW. Pauwels osteotomy for nonunions of the femoral neck. Orthop Clin North Am 1990; 21: 759-767.  Back to cited text no. 13    
14.Lifeso R, Younge D. The neglected hip fractures. J Orthop Trauma 1990; 4:287-292  Back to cited text no. 14  [PUBMED]  
15.Sim F, Lang S. Joint salvaging surgery for an extensive giant cell tumour of the proximal femur complicated by a transcervical fracture. Arch Orthop Trauma Surg 1997;1 16: 431-434  Back to cited text no. 15    
16.Jaffe KA, Dunham WK. Treatment of benign lesions of the femoral head and neck. Clin Orthop 1990; 257: 134-137.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]

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Correspondence Address:
N K Magu
22/8 FM Medical enclave, PGIMS, Rohtak124001- Haryana
India
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    Abstract
    Introduction
    Material and Methods
    Results
    Discussion
    References
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