- Discussion:
- involves creating an oblique osteotomy of the distal fragment (valgus osteotomy)
to obtain stability in
unstable intertroch frx;
- this osteotomy changes frx plane from verticle to near horizontal & creates
contact between the medial and posterior cortex of proximal and distal fragments;
- goal is too obtain medial stability;
- advantage of this valgus osteotomy is that valgus realignment of proximal
fragment makes up for less of length at ostetomy site so that limb
lengths remain equal;
- Technique:
- a 45 deg oblique osteotomy of distal frag begins just below flare of greater
trochanter and crosses distally and medially to exit about 1 cm distal
to apex of fracture;
- if osteotmy is made too transverse it places head in exaggerated
valgus position;
- this results in leg's being too long or hip's being unstable;
- excess valgus may incr joint reactive forces and incr DJD;
- to avoid this, the medial end of the osteotomy should exit 1 cm below frx
surface medially to compensate for incr length caused by valgus osteotomy;
- guide wire & then implant are inserted at 90 deg to plane of frx of
the proximal fragment;
- w/ more vertical alignment of frx, insert guide pin so that it ends up
more inferiorly in the femoral head (otherwise, the osteotomy
will be placed in varus;
- note, however, the guide pin must still enter center of femoral head;
- insert 135
sliding screw in usual manner;
- frx is reduced and impacted;
- medial cortical opposition and, hence, stability are restored;
- Pitfalls:
- avoid creating an external rotation deformity which would place the shaft
in slight internal rotation;
- w/ severe medial comminution, even a valgus osteotomy may not create enough
bony contact to ensure stability;
The unstable intertrochanteric fracture: treatment with a valgus osteotomy and I-beam
nail plate.
A preliminary report of one hundred cases.
A Sarmiento and EM Williams.
JBJS-Am 1970. Oct 52(7). p 1309-1318.
Treatment of unstable intertrochanteric fractures of the femur: a prospective trial
comparing anatomical reduction and valgus osteotomy.
DW Clark and WJ Ribbans.
Injury.
Mar 21(2) 1990. p 84-88.
The unstable intertrochanteric fracture in the eldlery.
A technical note on valgus resection
osteotomy and fixation with 150 deg dynamic hip screw.
MR Zehntner and HB Burch.
Arch Orthop Trauma Surg.
Vol 108 (3) 1989. p 182-184.
