Gopinathan Nirmal Raj, Pebam Sudesh, Vijay G. Goni, Mohak Kataria
(Chandigarh, Inde)
Introduction :
Proximal femoral pathological fractures and complications of proximal femoral fractures tends to result in considerable morbidity in paediatric population if not identified and managed in a proactive manner. The etiology varies from complication of trauma i.e., femoral neck fracture to pathological fractures that tends to occur in lesions like fibrous dysplasia, cystic lesions, etc. Although Ganz’s safe surgical dislocation approach has revolutionized hip preservation and management of proximal femoral intra-articular pathologies like femoro-acetabular impingement other proximal femoral pathologies mentioned above needs patient specific customization of proximal femoral realignment, mechanical and biological reconstruction. The author presents his experience of management of such pathologies with mechanobiological reconstruction by valgus osteotomy using angle plate guided and avascular fibular grafting.
Key words: Valgus osteotomy, Angle blade plate, avascular fibula, fibrous dysplasia, proximal femoral pathology, coxa vara
Procedure description: The procedure was based upon the Pauwel’s description of realigning the forces transferred across proximal femur converting shear to compression and utilizing angle blade plate described by Muller to stabilize the osteotomy. This was combined with Nagi et al’s description of avascular fibula providing good biological scaffold and together all of them provides mechanobiological reconstruction.
Materials and methods :
After obtaining departmental review board permission, the author reviewed cases of proximal femoral pathologies up to 18 years of age managed by valgus osteotomy using ABP and avascular fibula grafting over a period of 10 years with minimum follow-up of at least 24 months after surgical intervention. A total of 17 patients who were managed in the manner described for various proximal femoral pathologies were included in the study. The patients were assessed clinically, functionally and radiologically. Clinical evaluation was carried out recording complaints if any, evaluation of gait, hip range of motion, limb length discrepancy, etc. Functional evaluation was done using modified Harris hip score. Radiological evaluation included pelvis with femur to assess neck shaft angle and scannogram to assess overall limb alignment.
Results :
Out of the 17 cases included, 15 of them were available for follow-up. Two girls operated one for failed neck femur fixation and one for proximal femoral cyst was not available for follow-up and were not traceable by telephonically also. One of the patients with fibrous dysplasia required repeat surgery as the lesion outgrew blade edge and one patient with aneurysmal bone cyst required sclerosant injection for persistence of lesion after surgery. Three of the included patients had avascular necrosis at the time of intervention. 14 of them had excellent modified Harris hip scores and one with osteoporosis had fair score. The girl with osteoporosis had to undergo one more intervention for progressive subluxation of hip with got arrested but not completely located. Descriptive statistical analysis was performed on the data recorded during follow-up.
Discussion :
It has been well documented in the literature that valgus osteotomy is a viable option to salvage proximal femur in adults and also in children. Combining avascular fibula adds biological scaffold and is not easily resorbed in pathological fractures. Instead of replacing pathological area by hardware inserting fibula from the host facilitates earlier incorporation and healing and is not readily resorbed like the cancellous graft. The follow-up patients also had no complaints with respect the donor area. Two of them required repeat surgeries, one fibrous dysplasia intervened earlier and had outgrown the implant and the other kid with osteoporosis was taking antipsychotic medications which constantly hindered bone healing and led to complication. Overall, 14 of the 15 followed patients had excellent scores with no complaints of limb length discrepancy.
Conclusion :
To conclude, pathological fractures of proximal femur can be effectively managed with valgus osteotomy and avascular fibula grafting and is a good hip preservation technique which addresses both mechanics and biology.