Femoral Osteotomies

What Is Femoral Osteotomy?

Femoral osteotomy is the surgical cutting of the thigh bone (femur) at a specific level (usually the upper portion near the hip or the lower portion near the knee), repositioning the bone fragments into the planned new position, and fixing them in that position with metal implants (plate-screws or a nail).

The main purpose of this surgery is to change the shape or orientation of the femur in order to:

• Improve the distribution of loads placed on the hip or knee joint.
• Increase joint congruence.
• Correct abnormal rotation (torsion) or angulation.
• Increase joint stability.

This article will focus mainly on osteotomies performed on the upper (proximal) part of the femur, which concern the hip joint. Distal Femoral Osteotomy (DFO), performed for the knee, has been discussed in our earlier article on “Knee Osteotomy.”

Goals of Proximal Femoral Osteotomy:

• Reduce hip pain.
• Correct abnormal gait patterns (in-toeing, out-toeing, limping).
• Increase the range of motion of the hip joint.
• Ensure stability of the hip joint.
• Prevent or delay the early development of hip osteoarthritis (coxarthrosis).
• Preserve the patient’s own natural hip joint.

Why and in Whom Is Femoral Osteotomy Performed?

Proximal femoral osteotomy is performed to correct hip mechanics in various conditions. The main indications are as follows:

1. Rotational Alignment Disorders (Femoral Torsion Anomalies):
   
   • Excessive Femoral Anteversion: This is when the thigh bone is excessively rotated inward around its own axis. This condition can cause the feet and knees to point inward while walking (“in-toeing”), hip pain, and sometimes kneecap problems. 
   • Femoral Retroversion: This is when the thigh bone is rotated outward. It can cause the feet to point outward (“out-toeing”), hip impingement (FAI), and pain.  
   • These conditions are usually developmental, and if severe or symptomatic, a derotational femoral osteotomy is performed to correct them by cutting the bone and rotating it to the correct position.
2. Angular Deformities:
   
   • Coxa Vara: This is when the angle between the femoral neck and shaft is lower than normal. It can cause limping, leg shortening, and hip pain. It is corrected with a valgization (angle-increasing) osteotomy.
   • Coxa Valga: This is when the angle between the femoral neck and shaft is higher than normal. It can reduce hip stability. It can be corrected with a varization (angle-decreasing) osteotomy.
3. Sequelae of Childhood Hip Diseases:
   
   • After Perthes Disease: It can be performed to correct shape deformities (flattening, widening) resulting from impaired blood supply to the femoral head in childhood, thereby improving joint congruence and reducing pain (e.g., valgization, flexion/extension osteotomies).
   • After Slipped Capital Femoral Epiphysis (SCFE): Intertrochanteric or subtrochanteric osteotomies can be performed to correct the deformity resulting from slippage of the femoral head over the neck and to prevent impingement (FAI).
4. Femoroacetabular Impingement (FAI) (Selected Cases): Although standard FAI treatment involves arthroscopic bone shaving, in some severe femoral neck deformities or conditions such as retroversion, proximal femoral osteotomy may be an option to relieve the impingement.
5. Post-Traumatic Deformities: It can be performed to correct shape deformities and functional losses resulting from malunion of upper femoral fractures.
6. Hip Instability: Rarely, it can be applied to increase hip stability by changing femoral version.

Femoral osteotomy is a joint-preserving surgery generally preferred in young and middle-aged (generally < 50-55 years), active patients who have not yet developed advanced osteoarthritis in the hip.

Symptoms Targeted by Femoral Osteotomy

Depending on the underlying cause being treated, femoral osteotomy aims to relieve the following symptoms:

• Hip, groin, or thigh pain.
• Pain radiating to the knee (may be related to femoral torsion).
• Abnormal gait (in-toeing or out-toeing, limping).
• Rapid fatigue during activity.
• A feeling of catching, locking, or instability in the hip.
• Restricted hip movements (especially rotational movements).

Diagnosis and Preoperative Planning

A detailed evaluation is essential for deciding on and planning femoral osteotomy:

• Detailed History: The patient’s complaints, their onset, developmental history (childhood hip problems), trauma history, functional limitations, and expectations are gathered.
• Physical Examination:
  
  • Gait Analysis: Abnormalities such as in-toeing, out-toeing, and limping are carefully observed.
  • Rotational Profile Assessment: The degrees of internal and external hip rotation are measured. Special tests aimed at estimating femoral anteversion or retroversion (Ryder test, trochanteric prominence angle) are performed.  
  • The range of motion of the hip joint (flexion, extension, abduction, adduction) is measured.
  • Muscle strength and joint stability are assessed.
  • The presence of any leg length discrepancy is checked.
• Special Imaging Methods:
  
  • X-ray: AP pelvis, frog-leg lateral, true lateral hip radiographs, and full-length femur films are taken. The femoral neck-shaft angle, epiphyseal angles, findings of hip dysplasia, degree of osteoarthritis, and sequelae of previous trauma/disease are assessed.
  • Computed Tomography (CT) – Rotational Sections: This is the gold-standard method for accurately measuring the degree of femoral torsion (anteversion/retroversion). The angle between the axis of the femoral neck and the axis of the femoral condyles at the knee is calculated using special software. This measurement is critical for planning a rotational osteotomy.
  • Magnetic Resonance (MR) Imaging: May be requested to assess intra-articular structures (cartilage, labrum), blood supply to the femoral head (AVN?), and the condition of the muscles.
• Surgical Planning: By combining the clinical examination and imaging findings, the level (intertrochanteric, subtrochanteric), type (varus, valgus, derotation, flexion, extension, or combined), and exact degree of correction to be performed are precisely planned. The fixation material to be used (plate, nail) is selected.

Femoral Osteotomy Surgical Techniques (Proximal)

The surgery is performed under general or spinal anesthesia. Osteotomies performed on the upper part of the femur (near the hip joint) are generally carried out at two main levels:

1. Intertrochanteric Osteotomy: The cut is made between the greater and lesser bone prominences (greater and lesser trochanter) just below the femoral head. It is generally preferred when angular (varus/valgus) and rotational corrections are combined. Special angled plates (blade plates) or locking plates are frequently used for fixation. 
2. Subtrochanteric Osteotomy: The cut is made just below the lesser trochanter, in the upper shaft portion of the femur. It may be preferred especially for rotational corrections or larger angular corrections. Long locking plates or intramedullary nails (placed inside the bone marrow canal) can be used for fixation. 

By Type of Correction:

• Varus/Valgus Osteotomy: The neck-shaft angle is changed by making a wedge-shaped cut in the bone (open wedge – graft placed in between, or closed wedge – bone removed) or by simply cutting the bone and rejoining it at the desired angle.
• Derotation Osteotomy: The bone is cut transversely, rotated inward or outward by the planned degree, and fixed in its new position. 
• Combined Osteotomies: Both angular and rotational correction are often performed at the same time.

Fixation Methods: The bone fragments that have been cut and realigned must be fixed very securely so that they can heal. The main implants used for this are:

• Angled Plates (Blade Plate): A classic method providing strong, long-lasting fixation.
• Locking Plates and Screws: Modern anatomical plates that provide more stable fixation, especially in patients with poor bone quality.
• Intramedullary Nail: A metal rod placed inside the bone, used in some subtrochanteric osteotomies.

Prof. Dr. Murat Bozkurt performs these complex surgeries in Ankara, selecting the osteotomy technique and fixation method best suited to each patient’s deformity and bone structure.

Risks, Benefits, and the Very Long Recovery Process of Femoral Osteotomy

Femoral osteotomy is a surgery that offers significant benefits but, because it is major surgery, also carries serious risks.  

• Benefits:
  
  • Correction of the underlying bony deformity.
  • Significant reduction in hip pain and improvement in function.
  • Correction of gait disturbance (in-toeing/out-toeing, limping).
  • Improvement of hip joint mechanics and reduction of abnormal loads on the joint.
  • Preservation of the patient’s own natural hip joint.
  • Prevention or significant delay of the development of hip osteoarthritis.
  • Potential to provide relief for many years (10-20 years).
• Risks:
  
  • General surgical and anesthesia risks (infection, bleeding, clotting – DVT/PE).
  • Nonunion or Delayed Union: One of the most important risks. Failure of the cut bone to heal, or very slow healing. May require repeat surgery. Smoking increases the risk. 
  • Malunion: Healing of the bone at an undesired angle or rotation, resulting in persistence of the deformity or formation of a new deformity.
  • Nerve Injury: There is a risk of injury, particularly to the sciatic or femoral nerve (usually temporary).
  • Vascular Injury (rare).
  • Fixation Material (Plate/Screw/Nail) Problems: Loosening, breakage, or discomfort under the skin (can be removed later if necessary).
  • Leg Length Discrepancy: Even with careful attention during surgery, unwanted shortening or lengthening can sometimes occur.
  • Joint Stiffness.
  • Persistent Pain.
  • Future Need for Hip Replacement: Despite osteotomy, osteoarthritis can develop years later and a prosthesis may be needed.
• Recovery Process: Similar to periacetabular osteotomy, recovery after femoral osteotomy is also a very long (generally 1 year or more), demanding process that requires the patient’s full cooperation.
  
  • Hospital Stay: A few days.
  • Weight-Bearing Restriction: Complete healing of the bone is essential. For this reason, it is generally necessary to use crutches and place NO weight on the operated leg (non-weight bearing), or only touch-down weight bearing, for 8 to 12 weeks or longer after surgery. Adhering to this rule is vital for reducing the risk of nonunion.
  • Physical Therapy: This is the cornerstone of rehabilitation and takes months. It begins immediately after leaving the hospital. It starts with passive hip and knee movements. As bone healing progresses, the patient very gradually and in a controlled manner transitions to active movements, balance exercises, gait training, and muscle strengthening (hip, knee, core).
  • Timeline: Return to normal daily activities takes months. Return to more strenuous activities and sports generally requires at least 12 months.

Femoral Osteotomies in Ankara and Prof. Dr. Murat Bozkurt’s Approach

Femoral osteotomies are complex surgical procedures aimed at preserving the hip joint that require special expertise and experience. In Ankara, Prof. Dr. Murat Bozkurt takes the following approach in this field:

• Detailed Diagnosis and Planning: He precisely determines the underlying cause of the patient’s complaints (torsional, angular, or combined?) through clinical examination and special imaging methods, particularly rotational CT. He carefully plans the amount of correction needed before surgery.
• Correct Patient Selection: He is aware that correct patient selection (young, active, minimal osteoarthritis, suitable deformity) is critical to the success of femoral osteotomy.
• Appropriate Surgical Technique and Fixation: He selects the osteotomy technique best suited to the patient’s deformity (intertrochanteric/subtrochanteric, derotational/angular) and uses modern, stable fixation methods (locking plates, nails) to achieve successful bone union.
• Rehabilitation Management: He guides the patient through the very important long and demanding postoperative rehabilitation process, staying in close communication with physiotherapists and managing the process.

Femoral osteotomies are a valuable surgical option in selected patients for relieving pain and improving function while preserving the hip joint. However, because it is major surgery and requires a very long rehabilitation process demanding discipline, it is essential to have a detailed consultation with an orthopedic surgeon specialized in this field before making this decision. In Ankara, you can consult Prof. Dr. Murat Bozkurt’s expertise on this subject. 

For detailed information and appointments, you can contact Prof. Dr. Murat Bozkurt at 0312 502 70 74.