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Percutaneous Femoral Derotational Osteotomy For Excessive Femoral Torsion
Percutaneous Femoral Derotational Osteotomy For Excessive Femoral Torsion
D evelopmental dysplasia
of the hip can present as
various morphological abnor-
decreased acetabular coverage
of the femoral head.1 Other pa-
tients may present with an in-
and labral tears as the forward
facing femoral head places ex-
cessive stress on the iliopsoas
Open osteotomy, in general,
carries a higher risk of infec-
tion as well as a higher risk of
malities. The acetabulum of a creased femoral anteversion.2 and labrum.4 delayed or nonunion second-
dysplastic hip typically is char- Femoral version is defined as Femoral derotational oste- ary to damage to local soft tis-
acterized by a shallow articu- the angular difference between otomy is an established treat- sue and periosteal stripping.
lating cavity, an excessively the axis of the femoral neck ment for patients with symp- To preserve the periosteum
oblique acetabular roof, and and the transcondylar axis of tomatic excessive anteversion and the biological activity of
of the femur.5 The goal of the the bone and soft tissue in the
surgery is to correct the ante- area of the osteotomy, an intra-
The authors are from the Department of Orthopedics (OM-D, JTB, CP-
G), University of Colorado School of Medicine, Aurora, Colorado; Pacific version to a normal value, re- medullary saw was developed,
Orthopedics and Sports Medicine (MOM), North Vancouver, British Colum- ducing the stress on the joint allowing an inside-out femoral
bia, Canada; and the Department of Orthopaedics (DAY), Melbourne Ortho- and therefore secondary pain osteotomy for correction of
paedic Group, Melbourne, Victoria, Australia. and degeneration.6-10 During these rotational deformities.14
The authors have no relevant financial relationships to disclose.
Correspondence should be addressed to: Omer Mei-Dan, MD, Depart- the procedure, the increased Various methods have been
ment of Orthopedics, University of Colorado School of Medicine, 12631 E anteversion is normally cor- described to stabilize the bone
17th Ave, Mailstop B202, Academic Office 1, Rm 4602, Aurora, CO 80045 rected by rotating the distal fragments once the derota-
([email protected]). fragment externally. tional osteotomy has been
Received: November 4, 2013; Accepted: February 20, 2014; Posted:
April 15, 2014. Osteotomies can be per- performed.6,15,16 The Fixion
doi: 10.3928/01477447-20140401-06 formed in an open or closed nail (Carbofix Orthopedics,
A B
Figure 1: Computed tomography axial cuts. Preoperative computed tomog-
raphy scans allow measurement of the bilateral femoral version. Femoral an-
teversion is the angle between the transverse axis of the knee joint, which is
best indicated by a line drawn tangential to the maximum posterior convexity B
A
of both femoral condyles, and the transverse axis of the femoral neck. Femoral
anteversion of 9.3° (A). Femoral anteversion of 28.8° (B).
A B C D E
Figure 3: Under fluoroscopy, the osteotomy is performed using the intramedullary saw (A). Under C-arm, the intramedullary saw is introduced into the femoral
canal and seated at the planned level of the osteotomy (B). The saw diameter is then increased incrementally and rotated within the femoral shaft in fine clockwise
movements, performing a circumferential inside-out cut in the femur (C, D). Note the complete osteotomy performed once the intramedullary saw is removed (E).
currently inadequate intra- proximally at the iliac crest and ameter. The most common the femoral shaft in fine clock-
operative measurement tools spans the entire femur, ending nail they use is 34 to 36 cm wise movements, performing a
exist for assessing rotational inferior to the knee joint (Fig- long with a diameter of 12 mm circumferential inside-out cut
correction, the authors aim to ure 2). A 4- to 5-cm incision is prior to inflation. Reaming is in the femur (Figure 3). Once
correct to under 30° because made proximal to the greater performed just 1 cm distal to several full circles are com-
it is less than 2 SDs from the trochanter, similar to antegrade the planned level of the oste- pleted, and the surgeon feels
normal range. femoral nailing for fractures. otomy, 5 to 7 cm distal to the minimal to no bony resistance
The osteotomy is normally Using an awl, an entry point lesser trochanter. If a larger on the blade, further increase
performed 4 to 6 cm below the is established at the tip of the nail diameter is to be used and in the diameter of the blade is
lesser trochanter, where the di- greater trochanter and a ball- the medullary canal is mea- performed, until a complete,
ameter of the femur becomes tipped guidewire is introduced sured to be narrower than the or a near complete, osteotomy
thinner. (Figure 1). nail, reaming should be car- is achieved. The saw blade is
Reaming is then performed ried further distally, to 0.5 mm opposed to the cortical bone
SURGICAL TECHNIQUE starting with an 8-mm reamer, greater than the original nail via a surrounding cam de-
The patient is positioned su- in 0.5-mm increments, to open diameter. vice that stabilizes the cutting
pine on a fracture table or hip the medullary canal and ac- Once reaming is complete, complex within the canal and
arthroscopy distraction table. commodate the intramedul- the intramedullary saw (Biom- maintains a precise, horizontal
In some cases, hip arthroscopy lary saw used to osteotomize et, Warsaw, Indiana) is intro- cut. Just prior to completion of
may be required immediately the femur. In general, these duced into the femoral canal the osteotomy and confirma-
prior to the derotational oste- intramedullary saws can be and seated at the planned level tion of displacement, 2 Stein-
otomy because of concurrent expanded to 180% of their of the osteotomy. No guide- man pins are drilled—1 at the
intra-articular pathology. In this original diameter. The authors wire is used at this stage. The lateral greater trochanter and
instance, the authors use a sin- usually ream proximally to 15 saw diameter is then increased 1 at the supracondylar region
gle prep and draping setup for mm using a 15-mm saw blade incrementally (typically 10% of the distal femur—with the
both procedures. Draping starts allowing a 26-mm cutting di- at a time) and rotated within guidance of fluoroscopy. Us-
A B
B C
D
Figure 4: Intraoperative photograph (A) and fluoroscopic images (B, C) show-
ing the pin placement allowing assessment of rotation. Anteroposterior view
C D
of the hip. The proximal pin is located at the greater tuberosity (B). Antero-
posterior view of the distal femur. The distal pin is located above the lateral Figure 5: Anteroposterior fluoroscopic image showing the Fixion nail (Carbofix
epicondyle (C). Photograph showing nail insertion (D). Orthopedics, Herzeliya, Israel) passing the osteotomy prior to expansion (A).
Fluoroscopic image showing the Fixion nail at its distal point where the medulla
opens up (B). Fluoroscopic image showing the nail fully expanded at its dis-
ing fluoroscopy and the angle to the proximal femur. The tal point and having good intramedullary purchase (C). Fluoroscopic image 6
between the Steinman pins, correction planned is usually weeks postoperatively showing the expanded nail proximally and through the
osteotomy with periosteum callus formation (D).
measured with a sterile goni- 10° varus (when the neck shaft
ometer, the varus and derota- angle is larger than 140° and
tional aspects of the planned the acetabulum has dysplastic similar to any antegrade femo- the greater trochanter tip and
osteotomy are performed. or borderline-dysplastic char- ral intramedullary device, but the distal end at the exit of the
Relative retroversion correc- acteristics) and a minimum without the use of a guidewire femoral isthmus, the nail is
tion of excessive femoral an- of 30° of external rotation (to because the Fixion nail is not expanded with a saline-filled
teversion (torsion) is achieved achieve relative retroversion) cannulated. Once the nail is pump to obtain “press-fit” in-
by rotating the distal femur (at (Figure 4). An expandable seated in the femur with the tramedullary purchase (Figure
the foot) outward, in relation Fixion nail is then introduced proximal portion flush with 5).
Careful evaluation of each Fixation of the osteotomy Additional skin incisions for One skin incision
distal screws
patient before surgery is cru- has been performed with
Three-point fixation Homogeneously shared
cial to obtain optimal results. various implants. Most of the forces
Physical examination, along published studies have em- a
Carbofix Orthopedics, Herzeliya, Israel.
with radiographic and CT ployed intramedullary rods,
evaluation, is vital to correct AO plates, or dynamic hip
diagnosis and appropriate pre- screws.20 Plates can be ap-
operative planning. plied with indirect reduction chanically, the intramedul- pressurized normal saline. Ad-
The technique described techniques and designed as lary position of the rods of- vantages of this nail compared
here represents an efficient “biologic” implants (eg, the fers more resistance to torque with a standard intramedullary
and elegant way to obtain this low-contact dynamic com- forces and increases load nail are listed in Table 1. Also,
correction and stabilize the pression plates), but they usu- transfer to the bone.23 when using an intramedullary
resultant osteotomy, achiev- ally destroy at least some of The authors have described nail, proximal and distal lock-
ing rapid healing and return the periosteal blood supply the use of the Fixion nail. The ing screws used with these rods
to activities of daily living. and disrupt the hematoma. concept is similar to that of the may produce some discom-
The goal of the surgery is to Intramedullary rods have the intramedullary rod. However, fort. Some patients may report
achieve 15° to 20° of femur advantage of preserving the the Fixion nail is designed to greater trochanter bursitis sec-
anteversion. This is obtained periosteal blood supply and be inserted with or without ondary to the proximal screws,
by rotating the distal fragment soft tissue, increasing the reaming and is then expanded and distal locking screws
externally. However, current odds of union and decreasing to approximately 175% of its may be located intracapsu-
intraoperative measurement the odds of infection. Biome- initial diameter, using highly larly, producing knee pain and
Table 2
Technical Pearls
swelling.24 These symptoms ing nails, which use 3-point (eg, failing to expand the Before using the intramed-
not infrequently necessitate fixation. Once bony healing nail or breaking its inserter). ullary saw, both the size of
a second surgery to remove has occurred, the nail can In 1 case, the nail deflated 2 the medullary canal and the
the screws. These complica- be deflated and removed if weeks after insertion, which thickness of the femoral cortex
tions are not observed with the deemed necessary. resulted in nonunion. The should be determined with an-
Fixion nail because locking As with any novel device authors believe that the latter teroposterior and lateral views
screws are not necessary. In or technology, surgeons must complication can be avoided of the femur. If thick cortices
addition, the Fixion nail uses become familiar with this by expanding the system pro- are observed, intramedullary
its longitudinal expanded bars intramedullary saw and nail gressively. When surgeons reaming should be considered
along the endosteal wall of the and their indications for use feel resistance in the screw to allow insertion of a saw of
femur to enable immediate ro- prior to employing either in mechanism of the pump, they adequate size. If reaming is
tational stability. Weight-bear- an operative setting. Reported should avoid inflating it fur- performed, careful evaluation
ing forces are homogeneously complications using the Fix- ther and wait for the pressure of the anterior cortex with an
shared on the entire diaphysis, ion nail have been mainly to fall below 50 bars before image intensifier should be
unlike with classical interlock- related to lack of experience proceeding.24 performed to avoid exces-
sive thinning that could lead daver laboratory setting, prior omy: shortening and derotation pandable nailing system for
procedures. Clin Orthop Relat the management of pathologi-
to comminution of the oste- to surgery. Res. 1993; (287):245-251. cal humerus fractures. Arch
otomy. Some surgeons may Orthop Trauma Surg. 2002;
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