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Femoral neck osteotomy in skeletally mature patients: surgical technique and midterm results

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Abstract

Purpose

Using an extended retinacular flap containing the blood supply for the femoral head, proximal femur osteotomies can be performed at the neck level increasing the potential of correction of complex morphologies. The aim of this study was to analyze the safety, clinical, and radiographic results of this intra-articular surgical technique performed in skeletally mature patients with a minimum follow-up of three years.

Methods

Fourteen symptomatic adult patients (16 hips) with a mean age of 26 years underwent FNO using surgical hip dislocation and an extended soft tissue flap. Radiographs and radial magnetic resonance imaging (MRI) were obtained before and after surgery to evaluate articular congruency, cartilage damage, and morphologic parameters. Clinical functional evaluation was done using the Nonarthritic Hip Score (NAHS), the Hip Outcome Score (HOS), and the modified Harris Hip Score (mHHS).

Results

After surgery, no avascular necrosis was observed, and all the osteotomies healed without complication. The initial neck/shaft angle (range 120 to 150°) improved in all cases to a mean value of 130° ± 4.6 (p < 0.001). In eight of nine valgus hips, the high-positioned fovea capitis changed to a normal position after surgery. The NAHS score improved from a mean of 36.5 ± 14.9 to 82.9 ± 13.9 points after surgery (p < 0.001). After surgery, the mean HOS was 87.1 ± 17.6 points, and the mean mHHS was 78.6 ± 17 points.

Conclusions

In this series, femoral neck osteotomy in the adult, although technically more demanding compared with other classic osteotomies, can be considered a safe procedure with considerable potential to correct hip deformities.

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References

  1. Bartoníček J, Vávra J (2011) Valgus intertrochanteric osteotomy for coxa vara of Bucholz-Ogden types II and III in patients older than 30 years. Arch Orthop Trauma Surg 131(9):1211–1217. https://doi.org/10.1007/s00402-011-1278-5

    Article  PubMed  Google Scholar 

  2. Haverkamp D, Eijer H, Patt TW, Marti RK (2006) Multi directional intertrochanteric osteotomy for primary and secondary osteoarthritis--results after 15 to 29 years. Int Orthop 30(1):15–20. https://doi.org/10.1007/s00264-005-0024-4

    Article  CAS  PubMed  Google Scholar 

  3. Schneider W, Aigner N, Pinggera O, Knahr K (2002) Intertrochanteric osteotomy for avascular necrosis of the head of the femur. Survival probability of two different methods. J Bone Joint Surg (Br) 84(6):817–824

    Article  CAS  Google Scholar 

  4. Scher MA, Jakim I (1993) Intertrochanteric osteotomy and autogenous bone-grafting for avascular necrosis of the femoral head. J Bone Joint Surg 75(8):1119–1133

    Article  CAS  PubMed  Google Scholar 

  5. Jacobs MA, Hungerford DS, Krackow KA (1989) Intertrochanteric osteotomy for avascular necrosis of the femoral head. J Bone Joint Surg (Br) 71(2):200–204

    Article  CAS  Google Scholar 

  6. Haverkamp D, Eijer H, Besselaar PP, Marti RK (2008) Awareness and use of intertrochanteric osteotomies in current clinical practice. An international survey. Int Orthop 32(1):19–25. https://doi.org/10.1007/s00264-006-0270-0

    Article  CAS  PubMed  Google Scholar 

  7. Leunig M, Puloski S, Beck M, Siebenrock K-A, Ganz R (2005) Proximal femoral osteotomy: current indications and techniques. Semin Arthroplast 16(1):53–62. https://doi.org/10.1053/j.sart.2004.12.006

    Article  Google Scholar 

  8. Ganz R, Horowitz K, Leunig M (2010) Algorithm for femoral and periacetabular osteotomies in complex hip deformities. Clin Orthop Relat Res 468(12):3168–3180. https://doi.org/10.1007/s11999-010-1489-z

    Article  PubMed  PubMed Central  Google Scholar 

  9. Siebenrock K-A, Ekkernkamp A, Ganz R (2000) The corrective intertrochanteric adduction osteotomy without removal of a wedge. Oper Orthop Traumatol 8(1):1–13. https://doi.org/10.1007/BF03181115

    Article  Google Scholar 

  10. Suominen S, Antti-Poika I, Santavirta S, Konttinen YT, Honkanen V, Lindholm TS (1991) Total hip replacement after intertrochanteric osteotomy. Orthopedics 14(3):253–257

    CAS  PubMed  Google Scholar 

  11. Ferguson GM, Cabanela ME, Ilstrup DM (1994) Total hip arthroplasty after failed intertrochanteric osteotomy. J Bone Joint Surg Br Vol 76(2):252–257

    Article  CAS  Google Scholar 

  12. Gautier E, Ganz K, Krügel N, Gill T, Ganz R (2000) Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg (Br) 82(5):679–683. https://doi.org/10.1302/0301-620x.82b5.10426

    Article  CAS  Google Scholar 

  13. Kalhor M, Beck M, Huff TW, Ganz R (2009) Capsular and pericapsular contributions to acetabular and femoral head perfusion. J Bone Joint Surg Am 91(2):409–418. https://doi.org/10.2106/JBJS.G.01679

    Article  PubMed  Google Scholar 

  14. Ganz R, Gill TJ, Gautier E, Ganz K, Krügel N, Berlemann U (2001) Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg (Br) 83(8):1119–1124

    Article  CAS  Google Scholar 

  15. Ganz R, Huff TW, Leunig M (2009) Extended retinacular soft-tissue flap for intra-articular hip surgery: surgical technique, indications, and results of application. Instructional course lectures, 58p. 241-255

  16. Leunig M, Ganz R (2011) Relative neck lengthening and intracapital osteotomy for severe Perthes and Perthes-like deformities. Bull NYU Hosp Joint Dis 69(Suppl 1):S62–S67

    Google Scholar 

  17. Leunig M, Casillas MM, Hamlet M, Hersche O, Nötzli H, Slongo T, Ganz R (2000) Slipped capital femoral epiphysis: early mechanical damage to the acetabular cartilage by a prominent femoral metaphysis. Acta Orthop Scand 71(4):370–375. https://doi.org/10.1080/000164700317393367

    Article  CAS  PubMed  Google Scholar 

  18. Ziebarth K, Zilkens C, Spencer S, Leunig M, Ganz R, Kim Y-J (2009) Capital realignment for moderate and severe SCFE using a modified Dunn procedure. Clin Orthop Relat Res 467(3):704–716. https://doi.org/10.1007/s11999-008-0687-4

    Article  PubMed  PubMed Central  Google Scholar 

  19. Ziebarth K, Leunig M, Slongo T, Kim Y-J, Ganz R (2013) Slipped capital femoral epiphysis: relevant pathophysiological findings with open surgery. Clin Orthop Relat Res 471(7):2156–2162. https://doi.org/10.1007/s11999-013-2818-9

    Article  PubMed  PubMed Central  Google Scholar 

  20. Al-Talalwah W (2015) The medial circumflex femoral artery origin variability and its radiological and surgical intervention significance. Springerplus 4(149):1–9. https://doi.org/10.1186/s40064-015-0881-2

    Article  Google Scholar 

  21. Kalhor M, Horowitz K, Gharehdaghi J, Beck M, Ganz R (2012) Anatomic variations in femoral head circulation. Hip Int 22(3):307–312. https://doi.org/10.5301/HIP.2012.9242

    Article  PubMed  Google Scholar 

  22. Rego P, Mascarenhas V, Collado D, Coelho A, Barbosa L, Ganz R (2017) Arterial topographic anatomy near the femoral head-neck perforation with surgical relevance. J Bone Joint Surg 99(14):1213–1221. https://doi.org/10.2106/jbjs.16.01386

    Article  PubMed  Google Scholar 

  23. Kerboul M, Thomine J, Postel M, Merle d’Aubigné R (1974) The conservative surgical treatment of idiopathic aseptic necrosis of the femoral head. J Bone Joint Surg (Br) 56(2):291–296

    Article  CAS  Google Scholar 

  24. Tannast M, Siebenrock KA, Anderson SE (2007) Femoroacetabular impingement: radiographic diagnosis--what the radiologist should know. AJR Am J Roentgenol 188(6):1540–1552. https://doi.org/10.2214/AJR.06.0921

    Article  PubMed  Google Scholar 

  25. Nötzli HP, Müller SM, Ganz R (2001) The relationship between fovea capitis femoris and weight bearing area in the normal and dysplastic hip in adults: a radiologic study. Z Orthop Ihre Grenzgeb 139(6):502–506. https://doi.org/10.1055/s-2001-19231

    Article  PubMed  Google Scholar 

  26. Beltran LS, Mayo JD, Rosenberg ZS, De Tuesta MD, Martin O, Neto LP, Bencardino JT (2012) Fovea alta on MR images: is it a marker of hip dysplasia in young adults? AJR Am J Roentgenol 199(4):879–883. https://doi.org/10.2214/AJR.11.8193

    Article  PubMed  Google Scholar 

  27. Rego P, Beaulé PE, Ayeni OR, Tey M, Marin-Peña O, Dantas P, Wilkin G, Grammatopoulos G, Mafra I, Smit K, Kurz AZ (2019) Femoroacetabular impingement: what the surgeon wants to know. Semin Musculoskelet Radiol 23(3):257–275. https://doi.org/10.1055/s-0039-1683967

    Article  PubMed  Google Scholar 

  28. Christensen CP, Althausen PL, Mittleman MA, Lee J-A, McCarthy JC (2003) The nonarthritic hip score: reliable and validated. Clin Orthop Relat Res 406:75–83. https://doi.org/10.1097/01.blo.0000043047.84315.4b

    Article  Google Scholar 

  29. Martin RL, Kelly BT, Philippon MJ (2006) Evidence of validity for the hip outcome score. Arthroscopy 22(12):1304–1311. https://doi.org/10.1016/j.arthro.2006.07.027

    Article  PubMed  Google Scholar 

  30. Byrd JWT, Jones KS (2000) Prospective analysis of hip arthroscopy with 2-year follow-up. Arthroscopy 16(6):578–587. https://doi.org/10.1053/jars.2000.7683

    Article  CAS  PubMed  Google Scholar 

  31. Lavigne M, Parvizi J, Beck M, Siebenrock KA, Ganz R, Leunig M (2004) Anterior femoroacetabular impingement: part I. Techniques of joint preserving surgery. Clin Orthop Relat Res 418:61–66

    Article  Google Scholar 

  32. Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Ganz R (2004) Anterior femoroacetabular impingement: part II. Midterm results of surgical treatment. Clin Orthop Relat Res 418:67–73

    Article  Google Scholar 

  33. Leunig M, Ganz R (2011) Evolution of technique and indications for the Bernese periacetabular osteotomy. Bull NYU Hosp Joint Dis 69(Suppl 1):S42–S46

    Google Scholar 

  34. Abdelazeem H, Abdelazeem A, Al-Dars A, Hegazy M, Abdellatif N (2016) Triple attack technique for non-union of femoral neck fractures. Int Orthop 40(4):807–812. https://doi.org/10.1007/s00264-015-2808-5

    Article  PubMed  Google Scholar 

  35. Hegazy M, Basha N, Elbarbary H, Ali EMA, Khalifa AH, Mohamed MT, Diab NM, Zein AB, Abdelazeem AH, Fawaz K, Ahmed AM, Barakat AS (2020) Treatment of non-united femoral neck fracture by a novel subtrochanteric angulation lateral translation valgus osteotomy (SALVA osteotomy). Int Orthop. https://doi.org/10.1007/s00264-020-04527-8

  36. Gavaskar AS, Srinivasan P, Jeyakumar B, Raj RV (2020) Valgus intertrochanteric osteotomy for femur neck pseudoarthrosis: a simple solution to a complex problem that has stood the test of time. Int Orthop 44(4):635–643. https://doi.org/10.1007/s00264-019-04353-7

    Article  PubMed  Google Scholar 

  37. Prakash J, Keshari V, Chopra RK (2020) Experience of valgus osteotomy for neglected and failed osteosynthesis in fractures neck of femur. Int Orthop 44(4):705–713. https://doi.org/10.1007/s00264-019-04422-x

    Article  PubMed  Google Scholar 

  38. Ganz R, Parvizi J, Beck M, Leunig M, Nötzli H, Siebenrock KA (2003) Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res 417:112–120. https://doi.org/10.1097/01.blo.0000096804.78689.c2

    Article  Google Scholar 

  39. Grose AW, Gardner MJ, Sussmann PS, Helfet DL, Lorich DG (2008) The surgical anatomy of the blood supply to the femoral head: description of the anastomosis between the medial femoral circumflex and inferior gluteal arteries at the hip. J Bone Joint Surg (Br) 90(10):1298–1303. https://doi.org/10.1302/0301-620X.90B10.20983

    Article  CAS  Google Scholar 

  40. Leunig M, Slongo T, Ganz R (2008) Subcapital realignment in slipped capital femoral epiphysis: surgical hip dislocation and trimming of the stable trochanter to protect the perfusion of the epiphysis. Instr Course Lect 57:499–507

    PubMed  Google Scholar 

  41. Kalhor M, Gharanizadeh K, Rego P, Leunig M, Ganz R (2018) Valgus slipped capital femoral epiphysis: pathophysiology of motion and results of intracapsular realignment. J Orthop Trauma 32(Suppl 1):S5–S11. https://doi.org/10.1097/BOT.0000000000001085

    Article  PubMed  Google Scholar 

  42. Tannast M, Jost LM, Lerch TD, Schmaranzer F, Ziebarth K, Siebenrock KA (2017) The modified Dunn procedure for slipped capital femoral epiphysis: the Bernese experience. J Child Orthop 11(2):138–146. https://doi.org/10.1302/1863-2548-11-170046

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Ganz R, Grappiolo G, Mast JW, Matta J, Turchetto L (2017) Technical particularities of joint preserving hip surgery in osteopetrosis. J Hip Preserv Surg 4(4):269–275. https://doi.org/10.1093/jhps/hnx032

    Article  PubMed  PubMed Central  Google Scholar 

  44. Leunig M, Manner HM, Turchetto L, Ganz R (2017) Femoral and acetabular re-alignment in slipped capital femoral epiphysis. J Child Orthop 11(2):131–137. https://doi.org/10.1302/1863-2548-11-170020

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. Lerch TD, Vuilleumier S, Schmaranzer F, Ziebarth K, Steppacher SD, Tannast M, Siebenrock KA (2019) Patients with severe slipped capital femoral epiphysis treated by the modified Dunn procedure have low rates of avascular necrosis, good outcomes, and little osteoarthritis at long-term follow-up. Bone Joint J 101-B(4):403–414. https://doi.org/10.1302/0301-620X.101B4.BJJ-2018-1303.R1

    Article  CAS  PubMed  Google Scholar 

  46. Elmarghany M, Abd El-Ghaffar TM, Seddik M, Akar A, Gad Y, Ragheb E, Aprato A, Massè A (2017) Surgical hip dislocation in treatment of slipped capital femoral epiphysis. SICOT J, 3p. https://doi.org/10.1051/sicotj/2016047

  47. Huber H, Dora C, Ramseier LE, Buck F, Dierauer S (2011) Adolescent slipped capital femoral epiphysis treated by a modified Dunn osteotomy with surgical hip dislocation. J Bone Joint Surg Br 93(6):833–838. https://doi.org/10.1302/0301-620X.93B6.25849

    Article  CAS  PubMed  Google Scholar 

  48. Ziebarth K, Domayer S, Slongo T, Kim Y-J, Ganz R (2012) Clinical stability of slipped capital femoral epiphysis does not correlate with intraoperative stability. Clin Orthop Relat Res 470(8):2274–2279. https://doi.org/10.1007/s11999-012-2339-y

    Article  PubMed  PubMed Central  Google Scholar 

  49. Massè A, Aprato A, Grappiolo G, Turchetto L, Campacci A, Ganz R (2012) Surgical hip dislocation for anatomic reorientation of slipped capital femoral epiphysis: preliminary results. Hip Int 22(2):137–144. https://doi.org/10.5301/HIP.2012.9208

    Article  PubMed  Google Scholar 

  50. Aprato A, Bonani A, Giachino M, Favuto M, Atzori F, Masse A (2014) Can we predict femoral head vitality during surgical hip dislocation? J Hip Preserv Surg 1(2):77–81. https://doi.org/10.1093/jhps/hnu010

    Article  PubMed  PubMed Central  Google Scholar 

  51. Marti RK, Schuller HANSM, Raaymakers EL (1989) Intertrochanteric osteotomy for non-union of the femoral neck. J Bone Joint Surg Br Vol 71(5):782–787

    Article  CAS  Google Scholar 

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Acknowledgments

We wish to thank Professor Jacinto Monteiro, recently passed away, for all his support and encouragement in the early stage of development of the surgical techniques presented in this manuscript.

We wish to thank Professor Reinhold Ganz our mentor in hip preserving surgery for all the academic and technical support regarding the surgical techniques presented in this manuscript.

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All the clinical and radiographic records are available on the EMR of our institution.

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Authors and Affiliations

  1. Orthopaedic Department, Hospital Beatriz Ângelo, Avenida Carlos Teixeira, 32674-514, Loures, Portugal

    Paulo Rego, Inês Mafra, Filipe Oliveira & Pedro Pinto

  2. Imaging Center, MSK Imaging Unit (UIME), Hospital da Luz, Avenida Lusíada n 100, 1500-650, Lisbon, Portugal

    Vasco Mascarenhas

  3. Faculty of Medicine, University of Berne, Murtenstrasse, 11, 3008, Bern, Switzerland

    Reinhold Ganz

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  1. Paulo Rego
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  2. Vasco Mascarenhas
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  4. Filipe Oliveira
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  6. Reinhold Ganz
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Correspondence to Paulo Rego.

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The authors declare that they have no conflicts of interest.

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This article does not include results of experimental investigations on humans. Informed consent from all patients was obtained on a routine basis for surgical procedures.

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All patients included in this study gave consent to participate in this study.

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We obtained formal consent from our institutional review board to publish this study.

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Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at Hospital Beatriz Ângelo, Avenida Carlos Teixeira, 32674-514 Loures, Portugal.

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Level of evidence: IV, therapeutic study

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Rego, P., Mascarenhas, V., Mafra, I. et al. Femoral neck osteotomy in skeletally mature patients: surgical technique and midterm results. International Orthopaedics (SICOT) 45, 83–94 (2021). https://doi.org/10.1007/s00264-020-04822-4

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