Updated: 4/30/2021

Subtrochanteric Femoral Osteotomy with Biplanar Correction

Technique Video
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TECHNIQUE STEPS
Preoperative Patient Care
Operative Techniques
E

Preoperative Plan

1

Radiographic Review

  • Evaluate deformity of hip
  • use calibrated XR and blade plate template to determine the amount of varus/valgus correction required
  • Evaluate the femoral torsion

2

Surgical walkthrough

  • Resident can describe key steps of the operation verbally to attending prior to beginning of case
  • List potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • Blade plate set
  • blade plate insertion chisel and guide
  • Kirschner wires
  • Angle guide

2

Room setup and equipment

  • Fluoroscopy opposite from surgical side

3

Specialized fracture table

  • Assists in rotation correction

4

Patient positioning

  • Make sure patient has Foley urinary catheter in place
  • Place the operative leg in a well padded boot then affix to the table spar
  • Place the contralateral leg in a well leg holder
  • put the hip in 85° of flexion and internally rotate the foot 15°-20°
  • Prep and drape entire leg from knee up to iliac crest to make sure adequate working area
  • C-arm from contralateral side at 45° towards hip
G

Incision

1

Identify incision

  • Palpate proximal femur. Can utilize fluoroscopy for assistance to identify tip of greater trochanter and axis of femoral neck
  • Mark a straight incision directly lateral to femur. The proximal extent is at vastus ridge and distally extends as far as necessary to fit the blade plate
  • Skin incision, extend the incision proximally and distally
  • Perform a sharp dissection through the fat down to the IT band
  • Sharply split IT band and dissect through bursa tissue
H

Deep Dissection

1

Elevate the Vastus

  • Use a subvastus approach to elevate the vastus lateralis from posterior edge
  • Identify the gluteus maximus insertion, the vastus is directly anterior to it
  • Sharply cut the vastus lateralis at this junction down to bone and use a knife or sharp periosteal elevator to elevate off of bone
  • a Hohmann or similar retractor can be placed directly on anteromedial femur to elevate the muscle as it is dissected off bone
  • pay attention to perforating veins at the posterior aspect of the vastus lateralis, which may need ligation

2

Expose the femur

  • Visualize the lateral aspect of the greater trochanter by retracting the cut IT band
  • extend the incision of the posterior edge of the vastus lateralis proximally until you reach the vastus ridge
  • To expose the greater trochanter, release (from posterior anterior) the origin of vastus lateralis to the intertrochanteric line
  • leave a proximal cuff to repair however often with a plate there is too much tissue distraction and repair is difficult or impossible
I

Plate Preparation

1

Identify osteotomy site

  • Identify the approximate location of the subtrochanteric osteotomy using fluoroscopy
  • typically for a varus/valgus osteotomy the osteotomy is intertrochanteric and for a rotational osteotomy it is subtrochanteric

2

Identify blade position in femoral neck and entry point on lateral cortex

  • The target position is based on the templated position of the blade to achieve an adequate correction
  • typically the blade will be at the inferior aspect of the femoral neck on the AP hip XR

3

Prepare the greater trochanter

  • Remove some the lateral cortical bone on the greater trochanter for better seating of the plate
  • this can be done with a straight osteotome. Remove bone below where the blade enters the lateral cortex
  • Use a blade plate cutting chisel to initiate the path of the blade plate

4

Place a smooth K wire

  • Place the K wire perpendicular to the lateral cortex of the femur using a 90 degree guide

5

Confirm plate position

  • Confirm on AP and lateral to be in the correct position
  • on the AP it should be inferior to the "saddle" where the femoral neck and greater trochanter meet and directed towards the inferior aspect of femoral head
  • on the (cross table) lateral view it is to be starting on the anterior aspect of the greater trochanter and heading centrally within the femoral neck
J

Blade Placement/Osteotomy

P
P

1

Determine blade plate placement

  • Place the blade plate to see if the positioning is appropriate. The angle of the blade is determined by preoperative templating
  • Use a straight osteotome to place on the lateral cortex with fluoroscopic guidance until the correct location is identified
  • Use the osteotome to notch the lateral cortex

2

Prior to initiating the osteotomy, place a smooth wire proximal and another distal to the osteotomy location

  • Place them 20° (the number of degrees depends on the amount of correction that is indicated) apart using a triangle angle guide to mark the amount of rotation to be performed
Pearls
  • When using a specialized orthopedic table, one can also use the rotation markers at the foot of the bed to place the smooth wires. However sometimes due to soft tissue laxity they may not be a one-to-one measurement
Pitfalls
  • Greater than 20° of rotational correction can negatively affect abductor function

3

Osteotomy

  • Cut the femur using an oscillating saw perpendicular to the anatomic axis of the femoral shaft
  • take the osteotomy to the medial cortex but not beyond
  • this will keep the femur intact providing stability to aid in blade plate placement prior to final impaction
K

Implant Placement

1

Place implant

  • Place the final implant and fully seat the implant

2

Complete osteotomy

  • Once fully seated use the osteotome to complete the osteotomy
  • Place 2 "pull" screws (proximal to the osteotomy) to bring the plate as close to the lateral cortex as possible as the screws are tightened

3

Confirm placement

  • Take biplanar x-rays to confirm placement

4

  • make sure that the osteotomy is reduced in the anterior to posterior plane and medial and lateral planes
  • it is normal for the width of the adjacent proximal and distal fragments to be different due to the irregular cross-sectional shape of the femur

5

Compress the plate

  • Place a compression tool on the distal aspect of the plate using a unicortical screw distal to the plate
  • Compress to the marked line on the tool
  • Place an eccentric screw in the proximal screw hole to increase compression of osteotomy site
  • Fill the plate with the remaining screws (typically as little as 3 screws can be adequately strong)
  • Remove the compression tool
  • Inspect the plate position, osteotomy site and reduction under direct medialization and fluoroscopic confirmation
N

Wound Closure

1

Irrigation and hemostasis

  • Irrigate the wound and close

2

Deep closure

  • Repair the proximal vastus lateralis attachment
  • Close the vastus fascia with #1 Vicryl, can be sutured to gluteus maximus tendon
  • Close the IT band with a #1 Vicryl
  • Use #1 Vicryl to close some of the dead space

3

Superficial closure

  • Run a 2-0 Monocryl subcuticular and then a 3-0 Monocryl intracuticular
  • Close with Dermabond tape
Postoperative Patient Care
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