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Purpose The study evaluates long-term results in patients treated by valgus intertrochanteric osteotomy ( VITO) for partial avascular necrosis of the femoral head (ANFH) after fracture of the femoral neck in adolescent age. Although this method is mentioned in literature frequently, there are only few studies in the literature dealing with it in detail. Methods Authors evaluated five patients at the interval of 15 to 20 years following VITO. The mean age of the patients at the time of injury was 13.6 years and at the time of VITO 16.7 years. The studied parameters included resorption of necrotic segment of femoral head, development of posttraumatic osteoarthritis and leg shortening. Results Comparison of radiographs and MRI scans before and after VITO showed resorption of the necrotic segment of the femoral head and its remodeling in all five patients. However, two patients gradually developed slight osteo - arthritic changes. In one patient, remodeling of the femoral head occurred during the first 6 years postoperatively. Subsequently, the patient developed severe osteoarthritis with marked clinical symptoms. Conclusion VITO can improve the long-term function of the hip joint in adolescents with ANFH after a femoral neck fracture, but cannot restore completely the original shape and structure of the femoral head. Keywords Femoral neck fractures, Avascular necrosis, Intertrochanteric osteotomy, Long-term results describe multiple methods of its treatment, ranging Introduction from core decompression up to total hip replacement Femoral neck fractures in children and adolescents are [7, 10–14]. One of these methods is intertrochanteric rare injuries, often associated with a number of compli- osteotomy (ITO) based on the principle of reorienta- cations. The most severe of these is avascular necrosis of tion of the necrotic segment of the femoral head away the femoral head (ANFH) [1–9]. The published studies from the weight-bearing zone of the hip joint [15–17]. Although this method is mentioned quite frequently, *Correspondence: there are only a few studies in the literature dealing with Michal Tuček it in detail, mostly in the form of case reports, with the email@example.com; firstname.lastname@example.org follow-up period not exceeding seven years [14, 15, Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské Nemocnice 18–20]. Moreover, a number of important facts have 1200, 169 02 Prague 6, Czech Republic been neglected there. The aim of this article is to present Department of Orthopaedics and Traumatology, Third Faculty some long-term clinical and radiological results of valgus of Medicine, Charles University and University Hospital Královské Vinohrady, Šrobárova 1150/50, 100 34 Prague 10, Czech Republic © The Author(s) 2023. 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The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Chochola et al. BMC Musculoskeletal Disorders (2023) 24:460 Page 2 of 9 intertrochanteric osteotomy, as well as a literature review the femoral head physis was closed. In patient N1, the on this issue. greater trochanter physis and the medial part of the fem- oral head physis were open, while the lateral part of the Material and methods femoral head physis was damaged. Study group Between 1999 and 2006, we performed valgus intertro- Methods chanteric osteotomy (VITO) in six patients for partial The indication for intertrochanteric osteotomy was ANFH after fracture of the femoral neck. Inclusion cri- ANFH involving the weight-bearing zone of the femo- teria were partial ANFH after fracture of the femoral ral head, in four cases associated with shortening of the neck in adolescent age verified by MRI, varus deformity affected lower limb by 2 cm. Radiographs of the pelvis of proximal femur and the leg shortening minimally of in AP and Lauenstein projections and AP view of the 2 cm. The results were published in 2012 . In 2021, affected hip were obtained in all the patients. ANFH five of these patients with their informed consent (two could be clearly seen on the radiographs in all five cases. male and three female), with a minimal follow-up period The patients also underwent MRI examination where of 15 years, were examined (Table 1). The mean age of the coronal and sagittal scans served to assess the extent these patients at the time of injury was 13.6 years (range, and localization of the necrosis. In all cases, coronal MRI 12–19) and at the time of VITO 16.7 years (range, 14–21); scans showed 50% to 66% involvement of the femoral the mean injury-VITO interval was 36 months (range, head and sagittal scans 30% to 50% involvement of the 24–76). The average follow-up was 17 years (range; femoral head. These findings served as a basis for preop - 15–20). The primary injury was caused in one case by a erative planning, with the aim to transpose the intact part car accident, in two cases by a fall whilst skiing, in one of the femoral head to the weight-bearing zone and to case by a fall from a tree, and in one case by slipping on resolve the limb shortening. In all the mentioned cases, a wet floor. All patients sustained a transcervical fracture our treatment of choice was VITO. All operations were (Colona Type II), that was undisplaced in two cases (N1 performed by the senior author (JB). and N4). Two patients (N1 and N4) were treated non- operatively, internal fixation by lag screws was used in VITO operative technique three patients (N2, N3 and N5). All patients developed This procedure was performed in the same manner as partial ANFH, Ratliff type 2. Except for the oldest female described in detail for adults [14, 16] under control of patient (N5), physes of the injured proximal femur were image intensifier. Preoperative planning, based on radi - open in all patients at the time of injury. At the time of ographic examination, was crucial to the success of the osteotomy, physes in patients N3, N4 and N5 were closed surgery. At surgery, the patient was placed in a supine in both the affected and the contralateral intact hips. In position, and a lateral longitudinal approach was used. patients N1 and N2, physes in the contralateral proxi- After elevating the proximal portion of the vastus later- mal femur were open. In the female patient N2, only the alis muscle anteriorly, an L-shaped anterior arthrotomy, greater trochanter physis was open in the affected femur; running in the direction of the lesser trochanter was Table 1 Basic data on patients Pt Fracture type Fracture Therapy Injury VITO Interval LLD LLD Shelf arthroplasty FU Final result age age Injury—- before Final (y) (y) (y) VITO VITO (cm) (m) (cm) N1 transcervical Nonoperative treatment 12 14 24 2 1 - 16 very good M undisplaced N2 transcervical Lag screws 12 14 24 2 1 54 m after VITO 16 good F displaced N3 transcervical Lag screws 12 18 72 2 0 - 20 good F displaced N4 transcervical Nonoperative treatment 13 16 36 2 0 19 m after VITO 19 fair M undisplaced N5 transcervical Lag screws 19 21 24 1 0 - 15 bad F displaced Pt patient, N number of patient, M male, F female, VITO age age at the time of valgus intertrochanteric osteotomy, LLD leg length discrepancy before VITO, LLD Fin final leg length discrepancy, FU follow up, y year, m month Chochola et al. BMC Musculoskeletal Disorders (2023) 24:460 Page 3 of 9 done. This improved visualization for the introduction was removed within one year after osteotomy, once of the implant blade and made it possible to release the union was assured. MRI examination was performed insertion of the medial part of the capsule in the area of in all patients two to three years after the osteotomy, the lesser trochanter, including the iliopsoas tendon. The based on which resorption of the necrotic segment was osteotomy line was made parallel to the inserted chisel. assessed. The wedge angle was determined on the basis of preop - erative measurement on MRI scans and ranged between 30 and 40 degrees. After the removal of the seating Additional procedures chisel, the blade of a 120-degree angled blade-plate was In two patients (N2 and N4) with acetabular dysplasia inserted into the proximal fragment. In patients with an that was present already before the osteotomy, Bos- open physis of greater trochanter the blade-plate had to worth shelf arthroplasty was performed, following the be inserted in such a way to prevent damage to the phy- original descriptions, 54 months (N2) and 19 months sis and, consequently, potential arrest of the growth of (N4) after VITO . These patients were operated the greater trochanter. This required modification of a on in the supine position, via the Smith–Petersen 120-degree plate to a 140-degree plate. Subsequently, a approach. Close above the attachment of the superior careful valgus reduction of fragments was done with the articular capsule of the hip joint, an arch-shaped notch limb in abduction. The plate was then fixed to the femo - 3-cm wide and 5-cm long, was made with a chisel, pass- ral shaft, limb length and range of motion in the hip joint ing obliquely proximo-medially as far as the inner cor- were examined, drains inserted, and the wound closed tex of the iliac bone. A 4 × 5 × 5 × 3 cm monocortical (Fig. 1). bone graft, harvested from the iliac wing, was firmly hammered into the notch. This self-locking extra-artic - Postoperative management ular graft covered the superior aspect of the femoral AP and lateral radiographs of the operated hip were head sufficiently without limiting the range of move - obtained. Postoperative follow-ups, including radio- ment in the hip joint (Fig. 1). The postoperative proto - graphic examination, were scheduled for 6 weeks, col was the same as for intertrochanteric osteotomy. 3 months, 6 months and 1 year. During the initial 6 postoperative weeks, the patient walked with crutches, without weight-bearing of the operated limb. Partial Postoperative assessment weight-bearing was permitted 6 weeks after surgery All patients were followed up over the whole period by and full weight-bearing after three months. Hardware the senior author (JB). The mean follow-up period was Fig. 1 Principles of operative treatment. a Patient N4, 16 years old, with polar ANFH; b valgus intertrochanteric osteotomy; c healing of osteotomy after five months; d hip joint 42 months after osteotomy and 23 months after Bosworth hip shelf arthroplasty Chochola et al. BMC Musculoskeletal Disorders (2023) 24:460 Page 4 of 9 Leg shortening 17 years (range, 15–20). Subjective assessment was based Leg shortening was fully corrected by VITO in all five on the patients’ satisfaction with the surgery. Objective patients. In two patients (N1, N2) operated on at the assessment included VITO healing time, limb lengthen- age of 14 years, with an open capital physis of the con- ing, functional results and potential complications. tralateral femur, the continued growth of the unaffected contralateral femur resulted in a final shortening of the Results operated leg of 1 cm. An overview of the results is presented in Table 1. The surgical wounds healed without complications in all Resorption of necrotic segment patients. The intertrochanteric osteotomies healed in all Comparison of radiographs and MRI scans before and patients within three months, except for female patient after VITO showed resorption of the necrotic segment N3 in whom nonunion occurred, requiring treatment five of the femoral head and its remodeling in all five patients months after osteotomy. No complications were encoun- (Fig. 2). In patient N1, remodeling of both the femo- tered after Bosworth hip-shelf arthroplasty. ral head and the entire proximal femur was observed (Figs. 3, 4 and 5). Fig. 2 Final results 15 – 20 years after valgus intertrochanteric osteotomy. N – number of patient (see Table 1), y – year Fig. 3 Remodeling of proximal femur in patient N1. a hip joint two years after an undisplaced transcervical fracture of proximal femur, treated non-operatively, with polar ANFH; b 40-degree valgus intertrochanteric osteotomy with a modified 120-degree angled blade plate, physis of greater trochanter was preserved; c the result 12 month after surgery; d complete remodeling of proximal femur 32 months after surgery; e the final result 16 years after surgery Chochola et al. BMC Musculoskeletal Disorders (2023) 24:460 Page 5 of 9 Fig. 4 Remodeling of proximal femur in patient N1 on MRI. a hip joint one month before surgery; b situation 12 months after surgery, with a clearly visible change in the shape of capital physis of injured femur; c situation 84 months after surgery Development of posttraumatic osteoarthritis permanent pain of varying intensity; she was offered total Two patients (N3, N4) gradually developed slight osteo- hip replacement, but rejected it. arthritic changes, although with minimal symptoms (Figs. 1 and 6). In one female patient (N5), remodeling of the femoral head occurred during the first six years post - Objective assessment operatively. Subsequently, her condition became gradu- Patient N1 had a full, pain-free range of motion in the ally worse and the patient developed severe osteoarthritis hip joint. In female patient N2, rotation was limited with marked clinical symptoms (Fig. 7). by 10 degrees as compared to the intact limb, and in female patient N3, rotation was limited by 15 degrees, with slight pain in extreme positions. In patient N4, Subjective assessment flexion was limited by 10 degrees as compared to the All patients assessed the effect of operation highly posi - intact limb and rotation was only in the range of 10 tively. At the final follow-up patient N1 had no com - degrees. Female patient N5 had a flexion of 0–90 plaints, female patients N2 and N3, each a mother of degrees and completely limited rotation. Patients N1 two children, reported slight pain after a higher physical and N2 showed a 1 cm shortening of the limb. load (walking 10 km). Patient N4 experienced occasional pain after normal physical load. Female patient N5 had Chochola et al. BMC Musculoskeletal Disorders (2023) 24:460 Page 6 of 9 Fig. 5 Patient N1 – the final result. a pelvic radiograph before surgery, b pelvic radiograph 16 years after surgery Fig. 6 Patient N3 – the final result – in pelvis anteroposterior and Lauenstein views. a before surgery; b 20 years after surgery Complications which was treated by refixation with a condylar plate Female patient N3 developed a biologically active non- and a lag screw and healed two months after the union after VITO, due to early full weight-bearing, reoperation. Chochola et al. BMC Musculoskeletal Disorders (2023) 24:460 Page 7 of 9 Fig. 7 Patient N5 – the final result. a hip joint before surgery; b after surgery; c the result 6 years after surgery; d – progression of osteoarthritis 15 years after surgery Boitzy  used valgus intertrochanteric osteotomy Discussion in 11 patients after a proximal femoral fracture: twice in ANFH after a femoral neck fracture in children and ado- case of varus malunion, once in varus nonunion, in five lescents is associated with limb shortening and deform- cases of ANFH and in three cases of varus nonunion ity of the proximal femur, i.e., shortening of the femoral associated with ANFH. Average patient age at the time of neck, overgrowth of the greater trochanter resulting in injury was 14 years (range, 8–20) and at the time of oste- post-traumatic varus, reduced articular-trochanteric dis- otomy 20 years (range, 9–33). The follow-up was limited tance and limb shortening. VITO allows both a reorien- to one to three years. In patients with ANFH, the result tation of the necrotic segment and, at the same time, a was fair, or poor. In one case, it was necessary to perform change of the shape of the proximal femur, with length- arthrodesis of the hip after the osteotomy. ening of the shortened limb. Various techniques of valgus Forlin et al.  reported complications in a group of intertrochanteric osteotomy have been described in the 16 children after proximal femoral fractures. The aver - literature [17, 22, 23]. We prefer the classical technique age patient age at the time of injury was 12 years (range, with the use of a 120-degree angled blade-plate, which 5–16) and average follow-up seven years (range, two to allows a lateral shift of the femoral shaft and, if need be, 24). A total of 5 patients developed ANFH Ratliff type flexion/extension of proximal fragment [14, 16, 24, 25]. 2 . Only 1 patient was treated with varus osteotomy Of great importance for indication of intertrochan- for this diagnosis 2 years post-injury. After 10 years, the teric osteotomy (ITO) in partial ANFH are preoperative patient showed a marked varus deformity of the proximal MRI scans, which serve for an exact determination of the femur requiring revalgization. The result was assessed as size of the necrotic segment and its localization. These fair. details are essential for the choice of the osteotomy type Nötzli et al.  described partial ANFH in three (varus/valgus), the wedge size, or the valgus angle. Based patients aged 13, 14 and 17 years. All patients under- on localization of the necrotic segment in sagittal MRI went intertrochanteric extension osteotomy. The follow- scans, valgus (varus) osteotomy may be combined with up period was three, three and a half, and seven years, flexion/extension osteotomy in the sagittal plane. This respectively. In two cases, the condition improved; in the was the case of patient N1, where VITO was combined third case, the femoral head was distorted. Leg shorten- with a 15-degree flexion osteotomy. From this viewpoint, ing after osteotomy was 2.0, 2.5 and 2.5 cm, respectively. the Ratliff radiological classification of posttraumatic Abbas et al.  described three patients 12, 14 and ANFH is inadequate, as it recognizes neither the size nor 15 years old, after a transcervical fracture of the femo- the location of the necrotic segment of the femoral head ral neck, who underwent rotational transtrochanteric in partial ANFH . However, an MRI-based classifica - osteotomy for polar necrosis of the femoral head. The tion is still missing in the literature. follow-up period was two, two and two and a half years, Multiple studies in the literature deal with the results of respectively. Limb length was not specified. Good results intertrochanteric osteotomy for ANFH, however, only a were achieved in all three cases. few of them focus on ANFH after femoral neck fractures in children and adolescents [14, 15, 18–20]. Chochola et al. BMC Musculoskeletal Disorders (2023) 24:460 Page 8 of 9 The problem of all these studies was a small number patients N1 and N2 who, despite limb length correction, of patients and in a majority of cases a short follow- showed limb shortening as a result of subsequent growth, up period [14, 15, 18–20]. No author, except for Abbas fortunately merely by 1 cm. et al. , mentioned the injury-osteotomy interval. In our present study, the minimal follow-up is 15 years, In the Abbas´ patients, osteotomy was performed 6 to which has no parallel in the literature In all our 5 patients, 11 months post-injury, while in our series, 2 to 7 years VITO considerably improved the function of the hip joint; post-injury as the patients were initially treated in other only in one female patient (N5) did the condition deterio- medical centers. Based on our experience and data from rate over 15 years postoperatively. literature, we believe that the interval between detection A disadvantage of this study is a small number of of ANFH and osteotomy, together with the patient´s age patients, which does not allow a detailed analysis of the and status of physes, is an important factor influenc - factors influencing the VITO result; nevertheless, the best ing the final outcome. The sooner the operation and the results seem to be associated with younger patients with greater the remodeling potential of proximal femur, the a preserved growth potential. In these patients with open better results can be expected. This has been confirmed physes of the contralateral proximal femur, however, it is by very good results achieved in our patients N1 and N2 necessary to take into account a potential relative shorten- who were operated at the age of 14 years. By contrast, ing after lengthening of the affected limb. the female patient N5 operated on at the age of 21 years Our results show that a properly indicated, planned and showed the worst result. performed VITO can considerably improve the function of In this context it is interesting to compare the state of the hip joint in adolescents with ANFH after a femoral neck physes in the patients´ proximal femurs. Patients N3, N4 fracture in the long term, but cannot restore completely the and N5 had the physes closed in both proximal femurs original shape and structure of the femoral head. However, before VITO; there occurred only remodeling of the fem- additional studies with adequate numbers of patients and oral head, without any change in the limb length. Patients long-term follow-up will be necessary in order to confirm N1 and N2 had both physes (femoral head, greater tro- these conclusions. chanter) open in the intact hip. On the affected side, the female patient N2 had only the physis of the greater Abbreviations trochanter open which, however, fused 3 months after ANFH Avascular necrosis of the femoral head VITO. In patient N1, the greater trochanter physis and ITO Intertrochanteric osteotomy MRI Magnetic resonance imaging the medial part of the femoral head physis were open, VITO Valgus intertrochanteric osteotomy while the lateral part of the femoral head physis was damaged. This patient showed after VITO a marked Acknowledgements The authors wish to thank Chris Colton Prof MD FRCS and Ludmila Bébarová remodeling of the injured proximal femur (Fig. 3) includ- PhD for their assistance in the editing of the manuscript. ing the capital physis (Fig. 4). In the female patient N2 there occurred only remodeling of the femoral head. In Authors’ contributions AC - data collection, evaluation of radiological findings, manuscript prepara- both patients (N1, N2) the intact femur kept growing for tion. JB - performing operations, postoperative assessment, finalizing the another 4 years after VITO and both physis of the prox- manuscript. PD - treatment of patients, long-term follow-up, manuscript imal femur were closed at the age of 18 years, as docu- corrections. MT - final postoperative assessment, data collection, manuscript preparation. mented also by the postoperative follow-up. During this period the intact leg became longer by 1 cm, while imme- Funding diately after VITO both limbs were of the same length Supported by IP DZRVO MO1012. in both patients. According to Ogden , physes of the Availability of data and materials proximal femur close at the age of 16 to19 years, which Basic data on patients are presented in the text, tables and figures. Obtaining corresponds with our finding. more detailed data, for example complete radiological documentation, is pos- sible for reasonable reasons after agreement with the corresponding author. Of great importance is, of course, the size and location of the necrotic segment. For these reasons, children and Declarations adolescent patients with a femoral neck fracture should be followed up regularly for a long period. In case of a Ethics approval and consent to participate suspected proximal femoral growth disturbance or Not Applicable ANFH, MRI should be performed. Early detection offers Consent to publication the possibility of a timely and optimal treatment. Unfor- Not Applicable tunately, this is not often the case. For VITO it is neces- Competing interests sary to take into account also the growth potential of the All authors declare that they have no conflict of interest. contralateral proximal femur. This was the case of our Chochola et al. BMC Musculoskeletal Disorders (2023) 24:460 Page 9 of 9 Received: 4 October 2022 Accepted: 30 May 2023 25. Bartoníček J, Vávra J, Bartoška R. Operative treatment of avascular necrosis of the femoral head after slipped capital femoral epiphysis. Arch Orthop Trauma Surg. 2011;131:497–502. 26 Ratliff AH. Fractures of the neck of the femur in children. J Bone Joint Surg Br. 1962;44-B:528–42. https:// doi. org/ 10. 1302/ 0301- 620X. 44B3. 528. 27. Ogden JA. Trauma, hip development and vascularity. In: Tronzo RG, editor. References Surgery of the hip joint, vol. 1. 2nd ed. New York: Springer; 1984. 1. 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Orthop Traumatol Surg Res. 2013;99(1Suppl):S171–86. support for research data, including large and complex data types 23. Hegazy M, Basha N, Elbarbary H, Ali EMA, Khalifa AH, Mohamed MT, et al. • gold Open Access which fosters wider collaboration and increased citations Treatment of non-united femoral neck fracture by a novel subtrochan- maximum visibility for your research: over 100M website views per year teric angulation lateral translation valgus osteotomy (SALVA osteotomy). • Int Orthop. 2020;44:2421–30. 24. Bartoníček J, Vávra J. Valgus intertrochanteric osteotomy for coxa vara At BMC, research is always in progress. of Bucholz-Ogden Types II and III in patients older than 30 years. Arch Learn more biomedcentral.com/submissions Orthop Trauma Surg. 2011;131:1211–7.
BMC Musculoskeletal Disorders – Springer Journals
Published: Jun 5, 2023
Keywords: Femoral neck fractures; Avascular necrosis; Intertrochanteric osteotomy; Long-term results
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