This surgical technique was applied to 24 hips (21 patients) from October 2005 to October 2014. They were 16 male and 5 female patients, with an average age of 9.8 years (range, 6.0 to 15.6 y) at the time of index operation. The procedure was performed to improve hip joint congruency in 14 ONFH, which consisted of 10 LCPD, 2 posttraumatic, a slipped capital femoral epiphyses-associated, and a postinfectious ONFH. In another 10 hips, the procedure was performed to reorient the proximal femur and correct coxa vara. They consisted of coxa vara secondary to varization osteotomy for LCPD (3 hips), associated with osteogenesis imperfecta (3 hips) (Fig. 3), spondyloepyphyseal dysplasia (2 hips), septic hip sequelae (1 hip), and the juvenile Paget disease (1 hip). Implants used for fixation consisted of 16 locking compression plates and 8 blade plates.
Mean duration of follow-up was 4.3 years, ranging from 1.5 to 10.5 years. All cases successfully achieved valgization of the proximal femur, with an average of 24.7 degrees (range, 15.3 to 38.0 degrees), measured based on intraoperative fluoroscopy images. There was an average of 4.0 mm increase in length on the operated limb, based on pelvic anteroposterior radiographs or teleradiogram films. All osteotomies united uneventfully and no perioperative complications were noted.
Valgus osteotomy of the proximal femur has been widely used to address hip joint incongruity due to primary or secondary ONFH, and acquired or congenital coxa vara. In ONFH, proximal femoral valgization aims to redirect the head to achieve optimal congruency, thus maximizing surface contact and reducing peak contact pressure between the head and acetabulum.8 Furthermore, by reducing the head-shaft offset, there is reduction on the joint reactive forces acting across the hip joint. This delays the onset of developing degenerative arthritis.9 In the skeletally immature, optimal joint congruency has been shown to induce favorable remodeling of the femoral head.10 In coxa vara, proximal femoral valgization restores the function of the hip abductors.11 This has been shown to reduce pain and improve Trendelenberg gait.12
Findings in our series were comparable with previous reports in terms of mean age at index procedure,13,14 disease heterogenicity13–15, and follow-up duration.2,3 Various implant are used for fixation in proximal valgus osteotomy including dynamic compression plates, tension bend wires, pediatric locking hip plates, angled blade plates, and compression hip screws.2,14,16,17 In our institution, both pediatric locking hip plates and angled blade plates were used based on patient factors and at the discretion of the attending surgeon. All hips achieved valgization and there was lengthening of the operated limb, comparable with previous reports.2,14,17 No complications were noted in our series as compared with the 5.7% to 9% complication rate reported previously.13,17,18 This includes nonunion, loss of fixation, infection, and peri-implant fractures.
The step-cut technique has several advantages. Intraoperatively, the desired degree of valgization can be achieved by controlling the amount of angle α at the distal fragment. Compared with our previous experiences with valgus osteotomy without the triangular cut, the step-cut technique provides temporary intraoperative stability with minimal risk of loss of correction, making internal fixation in target configuration much easier. External fixator-assisted correction was used in selected cases in obese children, severe deformity or proximal thigh scarring due to previous surgery.19 The step-cut provides stability even after definitive fixation, without the need for postoperative hip spica immobilization. It also allows lateralization of the distal fragment, which is important in valgization of the proximal femur, as to prevent the knee from secondary deformity. In addition, the amount of the bone resected in a triangular form is relatively small, as compared with the bone resected during lateral closing wedge osteotomy, thus avoiding risk of shortening of the limb.
In conclusion, the step-cut valgus osteotomy technique was efficacious, replicable, and safe in achieving femoral head reorientation and correcting multiplanar deformity of a proximal femur.
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Keywords:Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved
valgus osteotomy; osteonecrosis of the femoral head; coxa vara