Non union Femur can be challenging especially in younger patients in whom head should be preserved whenever possible. This presentation gives an insight on tips, tricks and traps of performing Valgus or abduction osteotomy.

1. Dr Vaibhav Bagaria
Director - Dept of Orthopaedics
Sir HN Reliance Foundation Hospital
President - SICOT India
Mumbai, India
VALGUS OSTEOTOMY FOR
NON UNION NECK FEMUR
It’s Elemental! Series

2. Todays Talk
• Understanding the Principle
• Preoperative Planning
• Execution
• Case example
• Drawbacks and Alternatives

3. Why NOF are unique?
3
• Injury to Capsular arterial blood supply
• Tamponade effect
• Synovial fluid Interface
• Absence of cambium layer of the periosteum

4. Winning Combination
Biology
Bone QualityBiomechanics

7. Not all # config the same
Non union Rates can be as high as 30%

8. Pauwel’s Concept
✤ Pauwel pointed out that the
resultant force across the hip
was due to the body weight
and the muscular force of the
abductors.
✤ Force was directed
approximately 16 degrees from
the vertical plane and
approximately 25 degrees from
the anatomical axis of the
Femur

9. The Concept
✤ Typical femoral neck non
union was oriented
vertically and thus subject
to significant shear force
produced by the normal
hip joint load.

10. The Concept
✤ He proposed a valgus
osteotomy to reorient the
non union so that the
shear forces are
converted into
compressive forces.

11. Pauwels Principle
✤ Final fracture Inclination of 30 degree or
less to convert the shearing force into the
compressive forces
Proposed by Pauwel, Popularised by Muller!

12. Principle
Shear Force to Compressive Force
=

13. Pre operative planning
•Determining the level of osteotomy
•Size of the bone wedge to be removed
•Type of implant to be used
•Position of the seating Chisel/ DHS Screw

14. Calculating the size of
wedge
✤ Pauwel technique refined by Muller
✤ Goal is to have Pauwels angle of 30 degree post operatively
✤ Preoperative Pauwels angle - desired Pauwels angle =
repositioning angle
✤ The placement of chisel/ screw plate construct should be in
manner that the side plate makes and angle corresponding to
repositioning angle.

16. Blade or Screw placement
✤ Direction of the screw or blade should be in the inferior part of
the head of femur in AP and in centre in the lateral position
✤ Osteotomy site should be at least 1.5 cm distal to entry point of
Chisel or the screw.
✤ This would avoid fracture of the lateral cortex while passing the
screw.

17. Osteotomy
✤ Proximal limb of the osteotomy should be perpendicular to the
long axis of the femur
✤ Distal limb should be marked at the desired angle and wedge
removed.
✤ Location of the wedge on an AP view is indicator of how much
length would be gained post osteotomy
✤ Apex of the osteotomy should be medial to anatomical axis as
on compressing the two fragments will impact better.

18. Choice of implant
• Blade plate or DHS
• Blade plate: technically demanding but:
• Small foot print
• Remove less bone
• Better Rotational Stability
18

19. Example
✤ Suppose the original Pauwels angle is 60 degrees
✤ Desired angle = 30 degree
✤ Repositioning angle = original - desired = 60 - 30 = 30 degrees
✤ so a 30 degree wedge be removed and the blade/Screw
construct be placed in manner that allows the plate to make an
angle of 30 degree with shaft axis
✤ So for a fix angle blade plate ( 120 degrees) the chisel be
placed at 120 - 30 = 90 degree and for DHS plate ( 135 degree
plate) the screw is inserted at 135 - 30 = 105 degrees.

20. Step 1
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21. Step 2
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22. Step 3
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23. Step 4
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24. Step 5
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25. Step 6
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26. Step 7
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27. Step 8
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28. Step 9
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29. Step 10
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30. Step 11

31. Step 12

32. Step 13

33. Step 14

34. Step 15

35. Step 16

36. Follow Up

37. Pearl 1

38. Pearl 2

39. Pearl 3

40. Pearl 4
Severely Osteoporotic or neck respiration: Think Fibula

41. Results

42. Drawbacks
✤ Medializes the Shaft
✤ Excessive Valgus - > AVN ( Increase Joint Reaction Force/
kinking of posterior reticular vessels)
✤ Gait disturbances and limp
✤ Reduced femoral offset
✤ Possible Knee joint Malalignment
✤ Future THR??

43. Alternatives
Vascularised fibula?
?? Muscle Pedicle Graft
?? Girdle stone
Osteotomies : ?? 1.McMurray’s 2.Schanz 3. Dickson’s 4.
Pauwell’s Y
Replacement: ?? Bipolar ?? THR ?? Uncemented/Cemented

45. Take Home Message
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• Rewarding Surgery
• Acts by converting shear forces into compressive forces
• Careful prep planning and wedge calculation is the key
• Avoid excessive Valgisation
• Think Biology Augmentation when in doubt

46. BOS Hip Preservation Course 2017