Estudio que mide los resultados a largo plazo de la elongación del cuello femoral en niños

1. Intermediate to Long-Term Results of Femoral Neck
Lengthening (Morscher Osteotomy)
Mark Eidelman, MD,* Doron Keshet, MD,w Scott Nelson, MD,z and Noam Bor, MDy
Background: Femoral neck lengthening and transfer of the
greater trochanter were introduced by Morscher as treatment
for patients with coxa breva and overgrowth of the greater
trochanter. In this study we evaluated intermediate and long-
term results of this operation.
Methods: We reviewed clinical and radiographic results of 18
patients (20 hips) who were treated by Morscher osteotomy. Ten
patients had Perthes disease, 4 had developmental dysplasia of
the hip, and 4 had avascular necrosis of the hip. The median age
at surgery was 16 years [interquartile range (IQR): 14 to 17.5].
The median follow-up period was 7 years (IQR: 4.5 to 10). All
patients were evaluated clinically by means of Harris Hip Score
(HHS) before and after surgery.
Results: Preoperative clinical examination revealed that all pa-
tients had a limp and a positive Trendelenburg test. Median
HHS was 72.5 (IQR: 69 to 83). Postoperatively, the Trende-
lenburg test was negative in 14 hips and positive in 6 hips.
Postoperative median HHS was 94.5 (IQR: 89 to 96). Radio-
graphic examination showed progression of osteoarthritis in 3
patients. One operation failed and was converted to total ar-
throplasty (total hip replacement) after 4 years. Two hips re-
quired total hip replacement 10 years after the operation. Leg
length discrepancy was reduced in 17/20 hips. Overall patient
satisfaction level was good-excellent in 12 patients, fair in 4, and
bad in 2 patients. Postoperative complications included blade
migration (1 patient (and wire breakage (2 patients).
Conclusions: Morscher osteotomy can be effective for the
treatment of patients with short femoral neck and overgrowth of
the greater trochanter with a positive Trendelenburg test and
mild leg length discrepancy. A congruent nonarthritic hip joint
is a prerequisite for the success of the operation.
Level of Evidence: Level IV.
Key Words: femoral neck lengthening, Morscher osteotomy,
coxa breva
(J Pediatr Orthop 2016;00:000–000)
Coxa brevis (short femoral neck) and overgrowth of
the greater trochanter are deformities of the proximal
femur believed to be related to an ischemic impairment of
the upper femoral epiphysis. Several pathologies can
cause this deformity: Perthes disease, developmental
dysplasia of the hip (DDH), postinfectious state, post-
traumatic state and idiopathic avascular necrosis
(AVN).1,2 Regardless of the underlying cause, the ische-
mic necrosis of the proximal femoral epiphysis leads to
morphologic changes of the femoral head and femoral
neck. These changes include diminished longitudinal
growth of the femoral neck and a relative greater tro-
chanteric “overgrowth.” Subsequently, these morpho-
logic changes have direct influence on hip biomechanics
and clinical presentation.
The short femoral neck reduces the lever arm of the
hip abductor muscles and the high greater trochanter
reduces the tension of the abductor muscles, contributing
to abductor muscle insufficiency and subsequent
Trendelenburg sign and gait. Other common clinical
findings are mild leg length discrepancy (LLD), reduced
hip range of motion, impingement of the overgrown
greater trochanter in abduction, and anterior impinge-
ment in forward flexion.1–3
The purpose of surgical treatment for coxa brevis
and overgrowth of the greater trochanter is restoration of
the normal anatomy of the proximal femur and restora-
tion of limb length, thereby improving hip biomechanics,
gait, abductor force, and hip range of motion. In 1980,
Morscher developed the femoral neck lengthening os-
teotomy (FNLO) for correction of this complex de-
formity. The principle of the surgical technique is
lateralization of the femoral shaft along a double os-
teotomy, thereby lengthening the neck and the limb si-
multaneously due to the obliquity of the osteotomy.4 The
purpose of this study was to evaluate the intermediate to
long-term results of the operation,by assessing Harris Hip
Score (HHS), LLD and satisfaction at long-term follow-
up compared with preoperative assessment, and to de-
termine what proportion of hips have gone on to ar-
throplasty at long-term follow-up. To the best of our
knowledge this study contains the largest group of pa-
tients with the longest follow-up.
METHODS
The study is a retrospective case series. All data
were extracted in 3 medical centers by 3 orthopaedic
From the *Pediatric Orthopedics Unit; wRambam Health Care Center,
Haifa; yPediatric Orthopedics Unit, Ha-Emek Hospital, Afula,
Israel; and zOrthopaedic Surgery, Loma Linda University, Loma
Linda, CA.
No funding received for this study from any organization.
None of the authors received financial support for this study.
The authors declare no conflicts of interest.
Reprints: Doron Keshet, MD, Rakefet 14, Atlit, Israel. E-mail: doron.
keshet@gmail.com.
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ORIGINAL ARTICLE
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2. surgeons, using the same criteria. We used both electronic
and paper charts, x-rays were assessed on digital software
and on hard copy radiographs. Between the years 1990
and 2013, we operated on 18 patients (20 hips). The me-
dian age at surgery was 16 years [interquartile range
(IQR): 14 to 17.5]. The median follow-up period was 7
years (IQR: 4.5 to 10). Three patients had prior pelvic
osteotomies to address acetabular pathologies. All pa-
tients that had FNLO were included in the study.
Clinical evaluation included measurement of LLD,
Trendelenburg sign and hip range of motion. Level of
function, pain and restriction of daily activity were
documented and expressed via the HHS. This was eval-
uated at the last examination before the surgery and at
the latest follow up after surgery.5,6
Radiologic assessment included plain pelvic radio-
graphs and long limb x-rays, taken preoperatively and
during follow-up.
Surgical Technique
The patient lies in the supine position on a radio-
lucent operating table, with a 20-degree tilt toward the
contralateral side. The key point of the procedure is ac-
curate placement of the first K-wire. This wire should
create a neck-shaft angle of 130 degrees to assure the
correct final neck-shaft angle (Fig. 1A). It should also be
positioned in the correct anteversion, parallel to the ref-
erence wire (Fig. 1B).
Additional proximal wires are inserted at the level
of the greater trochanter and at the level of the proximal
FIGURE 1. Placement of the first K-wire. This wire should create a neck-shaft angle of 130 degrees to assure the correct final neck-
shaft angle (A). It should also be positioned in the correct anteversion, parallel to the reference wire (B). Additional proximal wires
are inserted, at the level of the greater trochanter and at the level of the proximal border of femoral neck in a parallel manner, the
“moving fragment” is marked in white background and black stripes (C).
FIGURE 2. Additional wires are inserted parallel to the chisel
and just above the level of the lesser trochanter.
FIGURE 3. Using multiple drills, a “tunnel” is created in the
moving fragment to accommodate for the plate and to ease its
insertion.
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3. border of the femoral neck in a parallel manner. We
coined the bone fragment between these 2 osteotomies as
the “moving fragment,” usually 15 to 25 mm wide
(Fig. 1C, marked in white background and black stripes).
The next step is insertion of the chisel exactly in the
middle of femoral head, halting 10 mm short of the fem-
oral head cartilage.
Additional wires are inserted parallel to the chisel
and just above the level of the lesser trochanter (Fig. 2).
Osteotomies are carried out as planned and the
“moving fragment” is temporarily removed. Using mul-
tiple drills, a “tunnel” is created in the moving fragment
to accommodate the plate and to ease its insertion
(Fig. 3).
A 130 degree blade-plate is driven through the
femoral neck into the femoral head. No additional valg-
ization was performed. Under traction and abduction, the
plate is fixed to the femoral shaft. Tension band wiring is
used for fixation of the greater trochanter. Recently, an
additional solid screw has been used for further stability
of the fixation (Figs. 4A, B).
Postoperative management consists of restricted
weight-bearing for 6 weeks, followed by weight-bearing as
tolerated.
RESULTS
No patients were lost for follow-up. There were
several underlying pathologies causing the coxa brevis in
our patients: 10 had Perthes disease, 4 had DDH, and 4
had AVN of the hip (posttraumatic, postseptic, and idi-
opathic).
Preoperative clinical examination revealed that all
patients had a limp and a positive Trendelenburg test.
Median HHS was 72.5 (IQR: 69 to 83). Postoperatively,
the Trendelenburg test was negative in 14 hips and
positive in 6 hips. Postoperative median HHS was 94.5
(IQR: 89.5 to 96) (Table 1). In general, all patients pre-
sented postoperatively with unlimited range of motion
except 2 patients (3 hips) with prior hip joint incon-
gruence. We found that patients with low HHS had more
pain, a worse limp and worse function hence breaking
down to subgroups does not influence the results.
Radiographic examination showed progression of
osteoarthritis in 3 patients. One operation failed and was
converted to total arthroplasty after 4 years. Two hips re-
quired total hip replacement 10 years after the operation.
LLD was reduced in 17/20 hips (mean 1.3 cm of reduction,
from mean LLD of 2.1 cm to mean LLD of 0.8cm).
Overall patient satisfaction level was good-excellent
in 12 patients, fair in 4 and bad in 2. Postoperative
complications included blade migration (1 patient (and
wire breakage (2 patients).
Figures 5A–D show an example of a girl who suf-
fered from bilateral Perthes disease who underwent bi-
lateral femoral neck lengthening at 13 and 14 years of age.
After 7 years of follow-up, she demonstrated good clinical
and radiographic outcome.
DISCUSSION
Regardless of the underlying cause of the deformity,
short femoral neck and overgrowth of the greater tro-
chanter are morphologic changes that significantly alter
the normal anatomy of the proximal femur and, hence,
alter normal hip biomechanics. Various procedures were
developed to correct this deformity and to improve hip
biomechanics.7–10
Distal transfer of the greater trochanter8,9 can im-
prove hip biomechanics by changing the abductor lever
arm. However, success of this procedure is limited due to
failure to address other morphological changes of the
FIGURE 4. A and B, The plate is fixed to the femoral shaft. Tension band wiring is used for fixation of the greater trochanter and
an additional screw is used for further stability of the fixation.
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4. TABLE 1. Patient and Hip Characteristics
Patient
No./Sex Etiology
Age at
Surgery
Follow-
up (y) Side
Trendelenburg
Preoperative
Trendelenburg
Postoperative
LLD
Preoperative
LLD
Postoperative
Harris Hip Score
Preoperative
Harris Hip Score
Postoperative Remarks
1/F Perthes 16 4 R + + 2 0 69 76 THR
2/M Perthes 17 24 R + 2 0.5 83 96
3/M Perthes 20 10 L + + 2 0 70 71 THR
4/M Perthes 20 10 R + + 0 1.5 74 70 THR
5/M Perthes 16 19 R + 2.5 1 76 93 Wire
breakage
6/M Perthes 14 14 L + + 2.5 0 70 90
7/F Perthes 13 11 L + 3 1.5 89 97
8/F DDH 20 8 L + 3 1 79 96
9/M Septic hip 17 8 R + 4 2 60 89 Wire
breakage
10/M Perthes 14 4 R + 3 1 76 93
11/F DDH 13 7 R + 3 0.5 71 96 Blade
migration
12/F DDH 13 4 L + 2 0.5 88 96
13/M Perthes 15 7 R + 2.5 1 69 99
14/M Perthes 16 5 R + 2.3 1 67 97
15/M Posttraumatic
AVN
17 10 L + 3 0 69 88
16/F Idiopathic
AVN
16 3 L + 2.5 1 83 99
17/F Perthes 13 7 R + 2 0.5 89 96
18/F Perthes 14 6 L + 0.5 1.5 89 96
19/M Septic hip 25 4 L + + 0 0 60 88
20/F DDH 18 3 L + 1.9 1.5 61 91
AVN indicates avascular necrosis; DDH, developmental dysplasia of the hip; F, female; L, left; LLD, leg length discrepancy; M, male; R, right; THR, total hip replacement.
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5. femoral head.8 Valgus intertrochanteric osteotomy11,12
can improve neck-shaft angle and can theoretically im-
prove abductor mechanism, but it does not change rela-
tions between overriding trochanter and the femoral head
nor the relation between the femoral head and the ace-
tabulum. Recently developed relative neck lengthening8,13
may address pathologies of the femoral head and improve
abductor mechanism by distal transfer of the greater
trochanter. Inspection of the acetabulum is an essential
part of this procedure that allows treatment of acetabular
pathology. However, this is a technically demanding
procedure with need of surgical hip dislocation, devel-
opment of an extended retinacular flap with the potential
risk of AVN of the femoral head.
In 1980 Morscher developed the FNLO to address
correction of neck length, LLD, and abductor tension.
Preliminary results were published in 1988, describing 15
patients who underwent the surgery, confirming good
outcome with regard to biomechanics and function.4
In 1990, Morscher published a series of 37 patients
who underwent FNLO, with a mean follow-up period of
8 years (range, 1 to 16 y), and concluded that it improves
leg length, abductor force and gait, provided that there
are no or minimal arthritic changes in the hip joint.14
All patients presented in this study, when evaluated
before surgery, had abnormal gait, positive Trendelen-
burg sign, LLD, pain and fatigue during activity. On
postoperative follow-up, LLD was reduced in all patients,
with mean 1.3 cm of reduction, from mean LLD of 2.1 cm
to mean LLD of 0.8 cm, similar to the results presented by
Morscher in his work.14 Most of the patients had negative
Trendelenburg sign, improved gait pattern and reported
better function, reduced fatigue, and less hip discomfort.
Data were validated by an objective criteria measured by
the HHS (preoperatively and at the latest follow-up) and
demonstrated improvement in all parameters with a me-
dian increase of 17 points (IQR: 8.2 to 27.2).
There were several complications in our series:
hardware failure in 3, wire breakage in 2, and blade mi-
gration requiring revision surgery in 1. There were no
cases of nonunion or infection.
During follow-up, 3 patients presented clinical and ra-
diologic signs of osteoarthritis. One patient demonstrated
rapid deterioration to end-stage osteoarthritis, requiring total
FIGURE 5. A–D, Bilateral femoral neck lengthening in a 13-year-old girl. Seven-year follow-up radiographs demonstrates good
outcome.
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6. hip replacement within 4 years. Another patient who un-
derwent bilateral femoral neck lengthening had slow pro-
gression to end-stage osteoarthritis, requiring bilateral total
arthroplasty after 10 years of follow-up. It should be noted
that all 3 hips showed radiographic signs of incongruity and
osteoarthritis before femoral neck lengthening, emphasizing
the importance of having a correct indication for this oper-
ation. The limitation of this study is that despite using the
same surgical technique, the procedure was performed in 3
different medical centers.
CONCLUSIONS
We believe that the Morsher’s operation requires
meticulous preoperative planning and execution. A pre-
requisite for a favorable outcome is congruent hip joints
with no radiographic signs of osteoarthritis.
This long-term follow-up study demonstrates that
Morsher’s operation is a safe and predictable procedure
for restoration of normal hip anatomy and biomechanics
in adolescents and young adults with coxa brevis and
trochanteric overgrowth, combined with mild LLD.
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