National Journal of Clinical Orthopaedics 2019; 3(2): 06-09

ISSN (P): 2521-3466

ISSN (E): 2521-3474
© Clinical Orthopaedics
Neglected intertrochanteric fractures treated with
www.orthoresearchjournal.com
2019; 3(2): 06-09
valgus osteotomy
Received: 03-02-2019
Accepted: 05-03-2019
Manas Chandra, Mayur Anand and BP Sharma
Manas Chandra
Safdarjung Hospital, New Delhi, DOI: https://doi.org/10.33545/orthor.2019.v3.i2a.02
India
Abstract
Mayur Anand Introduction: Malunited intertrochanteric fractures may occur due to mechanical and biological factors.
Safdarjung Hospital, New Delhi,
Malunion of intertrochanteric fractures is common in developing countries as many people rely on
India
indigenous treatment and splint age for fractures. Varus malunion is more commonly seen as compared
BP Sharma to valgus malunion. A popular surgical treatment aimed at improving the biomechanics-valgus
Safdarjung Hospital, New Delhi, intertrochanteric osteotomy-optimizes conditions for fracture healing by converting shear forces across
India the fracture site into compressive forces. The double-angled 120° plate is usually used for internal
fixation of the osteotomy.
Material and methods: A total of 14 cases operated from May 2016 to December 2019. Outcomes
analysed include radiological outcome in terms of improvement in neck-shaft angle and evidence of
radiological union at the osteotomy site. Other outcomes analysed include, measurement of limb length
discrepancy and functional outcome assessment with Oxford hip score. Results: There were significant
improvements in the postoperative neck shaft angle and Oxford hip score. Limb length discrepancy
improved to about 0.5 cms.
Conclusion: Subtrochanteric lateral closing wedge valgus osteotomy and internal fixation with dynamic
hip for maluniting intertrochanteric fracture showed good results.

Keywords: Intertrochantric femur, valgus intertrochanteric osteotomy, malunion

Introduction
In India, neglected intertrochantric fracture is a common presentation as they rely on
indigenous treatment and splintage for fractures. In these cases, malunion is common
occurring in comparison to nonunion. Varus malunion is more common than valgus malunion
in intertrochanter femur fractures [1]. Nonunion of intertrochanteric fractures is uncommon
because there is excellent blood supply and good cancellous bone in the intertrochanteric
region of the femur [5]. Due to this non-union is seen in patients with displaced comminuted
fractures of intertrochanteric region in addition to the presence of comorbidities like
uncontrolled diabetes mellitus, hemiparesis, malignancies, poor nutrition etc. Literature is
sparse regarding primary intertrochanteric nonunions and malunion and its treatment [7]. In a
malunited intertrochantric fracture, it is technically challenging to recreate the fracture and
associated with more morbidity and blood loss. It is a wise decision to accept the malunion and
correct the Coxa vara with a valgus subtrochanteric osteotomy. Intertrochanteric osteotomy
was first introduced by Pauwels [2] in 1927. The osteotomy reorientates the fracture, converting
shear forces at the fracture site into compressive forces, which enhances fracture healing [2-4].
This study aims to evaluate the results of internal fixation, valgization with 120° double angle
dynamic hip screw (DHS) in 14 patients with primary malunion of intertrochanteric fractures.

Materials and Methods

We carried out a retrospective analysis of 14 patients with primary intertrochanteric malunion
treated in our institution during 2017-2019. Most of the fractures occurred after a slip and fall
during house hold activities. A few fractures occured following road traffic accidents. The
average age was 54.5 {33-67 years} and 11 were males. The average duration between the
Correspondence
Manas Chandra index injury and surgery was 6 months {5 – 9 months}. 9 patients underwent native treatment
Safdarjung Hospital, New Delhi, with serial casts and 5 patients underwent no treatment. The right hip was affected in 10
India
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National Journal of Clinical Orthopaedics

patients and the left in 4. Clinical examination revealed a mean higher stresses acting at the site [12]. Valgus osteotomy has a high
shortening of 1.8 cm {1.5 – 2.4 cm}. All patients filled up the success rate and good reproducibility. In Indian scenario, valgus
oxford hip score questionnaire {adapted for the local language} osteotomy is an effective alternative to hip replacement surgery
to ascertain their level of function before surgery. The usual due to the high cost of the procedure. Muller [13] has insisted on
clinical findings were supratrochanteric shortening with reducing the fracture angle to less than 25 degrees to achieve
broadening of trochanteric prominence and external rotation consistent results though other authors have reported otherwise.
attitude of limb and ipsilateral abductor insufficiency. All had Valgus osteotomies using blade plates have been described by
restricted abduction and internal rotation due to coxa-vara. several authors [8-11]. Blade plates have excellent rotational
Preoperative antero-posterior and lateral x-rays of the hip joint control but are technically difficult to use. The dynamic hip
were taken. Preoperative neck shaft angle of bilateral proximal screw is an excellent implant in this situation. It allows
femur was calculated. The amount of correction needed was application of static compression during surgery with the
calculated and the angle of wedge to be resected was decided. coupling screw and also allows controlled dynamic collapse at
All patients were treated by wedge-removing valgus the fracture site maintaining the neck shaft angle. The only
intertrochanteric osteotomy. The fixation device was 120° drawback is the suboptimal rotational stability and rotational
double angle DHS in all patients. stress which may occur during reaming. Both these problems
were addressed in our series to an extent by using an anti
Results rotation screw along with the DHS in intracapsular fractures.
All patients were untreated cases of intertrochanteric fracture Recent articles on valgus osteotomies at the intertrochanteric
either due to negligent behaviour of patients belong to low level with DHS fixation has been described by Hartford et al.,
socio-economic status or due to lack of nearby medical facility 2005 [14] and Schoenfeld et al., 2006 [15]. Both techniques in the
and subsequent treatment by quack. The average blood loss was own words of the authors required extensive pre-operative
310{200 – 400 ml}. All fractures radiologically united at a mean sketching and templating to achieve the desired result. While
time of 12 weeks {10 – 14 weeks}. The average pre-operative Schoenfeld et al. removed a partial thickness wedge to minimise
neck-shaft angle was 102.4 degrees {90 - 110 degrees} which limb length discrepancy Hartford et al. used a full thickness
was corrected to134.3 degrees (128-138 degree). The mean laterally based wedge.
oxford hip score was 39.4 (38-42) at 6 month follow up. This Schoenfeld et al. also noted that the partial thickness wedge
was a significant improvement compared to pre op oxford score osteotomy may decrease the surface area of contact and may
of 16.1(11-22). There were no screw cut outs or loss of increase the chances of implant failure. Though the post-
correction. There were no incidences of deep infection. Mean operative Pauwel’s angle was much lesser in their series, the
pre-operative shortening was 1.8 centimetres which improved to final clinical, radiological and functional results were much
a mean shortening of 0.65 centimetres post-operatively. All similar to the current series. While Shoenfeld achieved a good
patient experienced improved gait except for 2 patients limb length restoration with his technique, the mean post-
demonstrated mild trendelenberg lurch at 6 month follow up operative mean limb length discrepancy in the series by Hartford
which required assistance of walking stick. All patients resumed et al. was 1 cm probably because of the full thickness wedge
their normal activities at an average of 12 weeks. technique they had used. Surgical time and blood loss were
significantly lesser in our series compared to techniques
Discussion described by these two authors. An osteotomy not only helps by
In Indian subcontinent, a large number of patient are treated by improving the biomechanics but it also improves the
local bone setters since ages. This is because of lack of hemodynamics at the nonunion site. A more horizontal fracture
knowledge and medical facilities in rural India. These patients angle was achieved in all patients and they progressed to
presents late with malunion and non-union. Nonunion of successful union. The limb shortening was brought to less than 1
intertrochanteric fractures is uncommon as these fractures tend cm in all patients.
to occur through well vascularized cancellous bone. Malunited All the patients were able to perform routine household activities
Intertrochantric fracture is a more common presentation in such when questioned at the end of 6 months which included sitting
neglected cases 6. While union in intracapsular fractures is cross legged and squatting requiring support while getting up.
complicated by biological and mechanical factors, the problem Outdoor activities like walking on roadside and uneven surfaces
with extra capsular fractures is mainly mechanical. was carried out with little difficulty and use of walking aid – a
There are many technique of treatment of malunited tripod walking stick. The results were comparable to studies by
intertrochantric fracture. Our technique was valgus angulation Jan Bartonicel et al., [16] who had published good results of
osteotomy for the treatment of these factures. Lateral closed valgus osteotomy in Intertrochanteric non-union and malunion.
wedge osteotomy is the most commonly performed procedure. Most of the published data of valgus osteotomy are for femoral
The applicability of valgus osteotomy in both intra and extra neck non-union. Our surgical technique for osteotomy was
capsular fractures is based on similar principles. similar to that of James M Hartford et al., who used full
It requires simple preoperative planning regarding amount of thickness lateral based wedge resection for achieving valgus.
wedge to be respected. Removing wedges may hinder limb To conclude, valgus osteotomy with DHS fixation is a useful
length restoration and requires careful planning and templating technique for varus proximal femur malunion in younger
to avoid the same. Subtrochanteric osteotomy was chosen to patients. Improving the biomechanics at the malunion site
avoid compromising the lateral wall fragment with a proximal coupled with a stable fixation yields good consistent results
osteotomy especially in extra capsular fractures. A very low regarding union. The sliding osteotomy technique is simple,
subtrochanteric osteotomy should be avoided as it will be saves surgical time, minimises blood loss and helps in limb
through the cortical bone where union rates are less predictable length restoration. No elaborate planning and wedge removal are
and nonunion at the osteotomy site have been reported due to required to achieve the desired results.

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National Journal of Clinical Orthopaedics

Table 1:
Pre – Op Neck Post Op Neck Pre – Op Limb Post Op Limb Pre – Op Oxford Post Op Oxford
Patient Age/Sex
Shaft Angle Shaft Angle Length Length Hip Score Hip Score
1 44/M 102 138 1.5 CM 0.5 14 38
2 56/M 105 136 1.5 0.5 11 39
3 55/F 110 132 1.8 0.6 16 40
4 48/M 105 130 2 0.8 20 42
5 52/F 108 138 2.2 1 22 38
6 33/M 95 134 2.4 0.8 16 38
7 65/M 100 130 1.8 0.5 14 40
8 58/M 105 132 1.7 0.6 12 42
9 58/M 108 138 1.5 0.5 16 38
10 67/M 95 132 1.8 0.5 20 39
11 61/F 102 136 2 0.8 22 39
12 50/M 105 138 1.7 0.5 14 38
13 67/M 90 128 1.6 0.5 16 40
14 49/M 104 138 2.2 1 12 41

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