Modified imhauser osteotomy
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A brief discussion of proximal femoral osteotomies used in SCFE treatment with emphasis on modified Imhauser osteotomy
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Modified imhauser osteotomy
- 1. Modified Imhäuser Osteotomy Shady Mahmoud MRCS, Msc ortho Assistant Lecturer of Orthopaedic Surgery Ain Shams University 2018
- 2. Proximal femoral osteotomy • Three levels at the proximal femur were described to perform osteotomy: subcapital, basal neck, and intertrochanteric. • It aims to correct a proximal femoral deformity e.g. moderate-severe SCFE to restore the hip biomechanics near normal, improve ROM, and restore the normal contact between the acetabulum and the thick weight bearing articular cartilage.
- 3. The nearer to the physis the greater correction power but with higher risk of developing AVN and chondrolysis.
- 4. Dunn osteotomy • In 1964, Dunn developed his own osteotomy utilizing a posterior approach with trochanteric osteotomy to get access to the posterior callus. • It is composed of gentle resection of the formed callus protecting the posterior periosteum as well as slight neck shortening.
- 5. Modified Dunn Procedure • However, this procedure was not reproducible as the studies tried to imitate his technique has ended with high AVN rates with a range 10-100%. Therefore, Dunn osteotomy fell out of favor. • In 1992, Ganz et al described modified Dunn procedure where a safe surgical dislocation approach was used to avoid AVN.
- 6. • nevertheless, it is technically demanding, with lack of long- term results studies, variable AVN results in later studies (4.5% to 26% ), and mainly used for unstable cases or stable cases with open physis SCFE.
- 7. Kramer Osteotomy • Kramer et al described an extra-capsular basal neck osteotomy utilizing an anterior or anterolateral approach in an attempt to decrease the risk of AVN.
- 8. • However, AVN (4%) and chondrolysis are still reported which attributed to the fact that the hip capsule is attached posteriorly to the intertrochanteric line exposing the posterior periosteum to the risk of injury when using this type of osteotomy. • Moreover, 16% of the cases reported poor results.
- 9. Southwick Osteotomy • Southwick described a biplanar osteotomy just below the lesser trochanter to deal with stable moderate-severe SCFE patients. • He conducted his study on 55 hips with good functional outcomes and no AVN. • He utilized the anterolateral approach to get access to the femur and made biplanar anterolateral wedge osteotomy causing flexion and valgus to counter the posteromedial slippage deformity of SCFE and fixed them with external fixator.
- 11. The degree of valgus was determined by subtracting the abduction range between the diseased and healthy sides or head shaft angle differences on AP view. The degree of flexion was determined by subtracting the flexion range between the diseased and healthy sides or better head shaft angles differences on frog lateral view.
- 12. Imhäuser Osteotomy • In 1957, Imhäuser depicted a tri-planar osteotomy slightly proximal to Southwick osteotomy level, hence higher correction power, through which flexion, valgus, and internal rotation were done. • He conducted his osteotomy on 55 hips and followed them clinically and radiologically for 11-22 years. All patients were pain free except 1 (2%) and all patients had full ROM apart of 18 (26%) had limitation. • Radiologically, 73% showed excellent features and 27% showed degenerative changes.
- 14. • According to Imhäuser, the complete correction of the deformity is not the aim and the full restoration of the anatomical relationship between the femoral head and acetabulum could not be achieved in most of the cases. • It is a secondary prophylactic deformity that targets to counter the original deformity as possible with the merit of low AVN when compared to subcapital osteotomy.
- 15. combining Imhäuser osteotomy with an additional procedure could be the gold treatment option as it achieves the goals without posing the high risk of AVN and chondrolysis displayed by modified Dunn procedure
- 16. Modified Imhäuser Osteotomy • In 2014, Bali et al addressed the functional outcomes of 20 SCFE patients underwent Imhäuser osteotomy with/without osteochondroplasty and followed up for 4.8 years average. • They were 2 groups: a group underwent concomitant osteochondroplasty at the same session, modified Imhäuser osteotomy, and the other had Imhäuser osteotomy only. • There was better non-arthritic hip score (NAHS) in the modified Imhäuser group in comparison to Imhäuser group.
- 18. In situ pinning Intertrochanteric Imhauser Osteotomy Osteochondroplasty • Anesthesia: GA or spinal anesthesia. • Positioning & approach: supine – Watson-Jones • 3 components Surgical Technique
- 19. In situ pinning via the plate taken independently
- 20. Proximal holes Shaft holes Non-locked Proximal femoral plate 5
- 26. Flexion limit • The limit of flexion degree allowed in Imhäuser osteotomy varies between 30o-45o among studies. • The limit in Schai et al study is about 30o to avoid long term hip flexional deformity, transient chondrolysis, and anterior femoral neck impingement. • Bali et al identified the limit at 45o the degree after which bone to bone contact could be difficult to be achieved.
- 27. Variables • There are three studies in which Imhäuser osteotomy and osteochondroplasty were performed through safe surgical dislocation approach (Spencer et al , Rebello et al , and Erickson et al studies). • They have fair results with low WOMAC score outcomes, AVN development, or poor alpha angle correction.
- 28. Variables • Several studies used 95o AO angled blade plate for osteotomy fixation; however, improper plate positioning is a risk.
- 29. Advantages • Imhäuser osteotomy provides satisfactory surgical correction potentials for moderate-severe stable SCFE. • Their flexible behavior allows the adjustment of flexion, valgus, and internal rotation to be tailored for each patient individually.
- 30. Advantages • Compared to modified Dunn procedure, it is an effective, safe, and reproducible realignment osteotomy option. • The low correction power fact could be overcomed with an additional procedure as osteochondroplasty (modified Imhäuser osteotomy) to improve the range and avoid the impingement and its hazardous sequalae.
- 31. Disadvantages • Complications of Imhäuser osteotomy documented in the literatures are generally low. • Overall, it can be divided into: general surgical risks implant related complications specific complications
- 32. General surgical risks • Infection : superficial, deep, or osteomyelitis. • Potential nerve injury such as sciatic nerve: may be the result of improper plate positioning or faulty patients' positioning. • Potential vascular injury : perforating arteries and medial circumflex femoral artery.
- 33. General surgical risks • Delayed union and non-union (pseudo arthrosis) at the osteotomy level. • Thromboembolic complications. • Intraoperative and postoperative bleeding and anemia. • Heterotopic ossification.
- 34. Implant related complications • Fatigue failure of the implants. • pull out of the plate. • Incorrect implant positioning: especially with 95o AO angled blade plate. • Need of later implant removal.
- 35. Specific complications • Limb length discrepancy: results from postero-caudal displacement of the epiphysis, halted longitudinal growth with in-situ pinning, and large wedge resection during Imhäuser osteotomy.
- 36. Specific complications • Transient restrictions of ROM (transient chondrolysis): attributed to capsuloligamentous contractures especially in long standing cases that could be aggravated by excessive flexion correction during the osteotomy.
- 37. Indication • Moderate-severe SCFE. • Stable SCFE. • Open and closed physis.
- 38. Contraindications • Mild stable SCFE. • Unstable SCFE. • Traumatic epiphysiolysis. • Neglected SCFE cases with OA or chondrolysis.
- 40. Case 1 • a 14-year-old boy. •RT hip pain and limping for 5 months. • The hip problem was interfering with his daily routine, a figure that was evident in both HHS and WOMAC with values of 57.23 and 29%, respectively. • No history of trauma or previous surgery and his BMI was 33.2
- 42. Case 1
- 43. Case 1
- 47. Case 2 • A 16-year-old boy. •Bilateral intermittent hip pain and limping for 1.5 years. •Diagnosed with bilateral SCFE and underwent in situ pinning on Lt side one year before. •He suffered of limited outdoor activities with HHS at 36.6 and WOMAC at 42.7%
- 48. Case 2 • On examination
- 49. Case 2
- 50. Case 2
- 51. Case 2
- 54. Summary • Imhäuser osteotomy is a triplanar osteotomy performed at the level of lesser trochanter with three components: flexion, valgus, and internal rotation to counter the SCFE deformity especially stable types with Southwick angle >30O. • Modified Imhäuser osteotomy is adding osteochndroplasty to Imhäuser osteotomy to remove hump triggering arthritis and compensate for the lower correction potentials compared to the more proximal osteotomies.
- 55. Summary • Modified Imhäuser osteotomy offers comparable clinical outcomes with modified Dunn procedure without its possible irreversible complication of AVN , and maintains the safety displayed by Imhäuser osteotomy. • It can be considered to be the best option for the treatment of chronic stable moderate-severe SCFE.
- 56. Summary • It is recommended to combine the osteotomy and osteochondroplasty with in situ pinning at an early age once the diagnosis has been established as there is a negative correlation between patients' age and the functional outcomes. • It is also advocated to fix the physis (in-situ pinning) by only one screw to lessen the possible risk of pin penetration.
- 57. Thank you
Editor's Notes
- Surgical Technique
- Anaesthesia Seventeen hips were performed under general anesthesia and three were performed under spinal anesthesia. Positioning All patients were performed supine utilizing the anterolateral hip approach (Watson-Jones approach) Components The procedure is composed of 3 components: in-situ pinning, Imhäuser osteotomy, and open neck osteochondroplasty.
- In situ pinning was required in 16 hips (as 4 Cases had closed physis). It was Performed through the proximal holes of the plate in 14 cases In 2 cases ,that were severe, in-situ pinning from through the plate was inapplicable and was taken independently.
- The used plate is non-locked proximal femoral plate to allow free orientation of the proximal screws to reach the deformed head with ease. It is formed of proximal holes and shaft holes The proximal hole configuration was inverted triangle and the screw utilized In them are 6.5 mm cancellous screws. The minimum number of shaft holes were five and screws utilized in them are 4.5 mm cortical screws.
- Imhauser osteotomy The level of osteotomy is just above the lower border of the lesser trochanter. The anterolateral femoral border is identified which is considered as the common base of the planned two wedges to be resected, one on the anterior surface of the femur and its apex medial represent the degree of required flexion correction. and the other on the lateral surface and its apex posterior represent the degree of required valgus correction. The level is determined by intraoperative visualization and confirmed by fluoroscopic imaging The first screw is inserted as in situ pinning then the osteotomy is proceeded.
- The osteotomy is proceeded either by an electrical saw or by osteotomes
- But before completing the osteotomy, the second screw is delivered to stabilize the plate in the required degree of flexion. As demonstrated in this model, the angle created between the shaft of femur and the plate in the sagittal view represent the degree of flexion that will be achieved and the angle between the femoral shaft and the plate in the coronal view represent the degree of valgus that will be achieved. This is the clinical appearance of the flexion angle in side view After osteotomy completion, Complete fixation of the plate is followed. And this is the clinical appearance of the resected anterolateral 2 wedges
- For osteochondroplasty, an interval is developed between tensor fascia lata and gluteus medius muscle. Then, the anterior hip capsule is exposed and opened in T-shape fashion to identify The hump.
- The hump is peeled off using curved osteotome or high-speed burr
- The first case is 14-years-old boy complained of RT hip pain and limping for 5 months. The hip problem was interfering with his daily routine, a figure that was evident in both HHS and WOMAC with values of 57.23 and 29%, respectively. No history of trauma or previous surgery his BMI was 33.2
- On examination, waddling gait and bilateral externally rotated gait were observed positive Drehmann sign, positive impingement sign, and limited ROM with no internal rotation in the right side.
- Preoperative plain x ray revealed rt chronic severe stable SCFE with open physis and lt mild SCFE
- a two-staged procedure was proceeded to deal with the problem. The first stage was targeting the severe side with our protocol and the second one was in situ pinning for the left side 3 weeks after.
- This is the postoperative gait after 1 year follow up And this is the ROM
- This photograph demonstrates the right leg position before and after surgery And this demonstrates the symmetry of internal rotation in prone position
- These are radiological and clinical comparison before and after the surgery
- The second case is16-years-old boy suffered of Bilateral intermittent hip pain and limping for 1.5 years. He was Diagnosed with bilateral SCFE and underwent in situ pinning on Lt side one year before. The condition limited his outdoor activities with HHS at 36.6 and WOMAC at 42.7%
- On examination, waddling gait, antalgic gait and bilateral externally rotated gait were observed positive Drehmann sign and impingement were eminent on the right side and limited ROM in both sides
- Radiographic imaging showed bilateral SCFE: the right side was severe, and the left one was moderate. Southwick angle of right side was 64o and left side was 48o
- Two-staged procedure was performed to tackle the condition. The first stage was our protocol targeting the right side and the second one was Imhäuser osteotomy and osteochondroplasty for the left side 14 months later. Radiographic imaging parameters are improved substantially as seen in the x rays.
- This is the postoperative gait after 1.5 year follow up And this is the ROM, and the abductor function
- No trendenlenburg sign in the right side and left side Full abduction And full IR
- These are radiological and clinical comparison before and after the surgery