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Bulletin of the NYU Hospital for Joint Diseases 2011;69(Suppl 1):S62-7
Relative Neck Lengthening and Intracapital
Osteotomy for Severe Perthes and Perthes-like
Deformities
Michael Leunig, M.D., and Reinhold Ganz, M.D.
Abstract
Intra-articular and extra-articular femoral Perthes
deformities, or either, can result in severe alterations
of the proximal femur and secondarily even involve the
acetabulum, which can lead to premature osteoarthritis
(OA) of the hip. In affected hips, joint damage due to
impingement and instability may coexist. Classically, extraarticular impingement and associated abductor insufficiency
in Perthes disease or similar pathologies are treated by
trochanteric advancement. However, this leaves intraarticular impingement and instability unaddressed. The
technique of surgical dislocation of the hip, in combination
with a retinacular flap, allows for the relative lengthening of
the femoral neck and even femoral head reduction osteotomy
in such cases. This can be combined with an acetabular
procedure to treat the secondary dysplasia. Since 2001, 14
patients with a minimum follow-up of 3 years have been
treated by this technique without complications, such as
femoral head osteonecrosis or trochanteric failures. All
patients had markedly improved pain levels, hip mobility,
and gait.
O
steotomies of the proximal femur to address biomechanical deformities are traditionally performed
at the intertrochanteric and subtrochanteric levels
and therefore are extracapsular.1 Even with transtrochanteric
rotational osteotomies2,3 at an extra-intracapsular level, the
distance to the joint can be large, leading to secondary deformities, such as leg shortening and varus or valgus of the
Michael Leunig, M.D., is Head of Orthopaedics, Schulthess Clinic,
Zürich, and University of Berne, Berne, Switzerland; Reinhold
Ganz, M.D., is Professor Emeritus, Department of Orthopaedic
Surgery, University of Berne, Berne, Switzerland.
Correspondence: Michael Leunig, M.D., Department of
Orthopaedic Surgery, Schulthess Clinic, Lengghalde 2, CH 8008
Zürich, Switzerland; [email protected].
knee, which are undesirable in most instances. The extent of
these associated deformities depends largely on the degree of
the primary correction and on the distance to the joint level.
Except for leg shortening, such adverse side corrections can
be minimized by modifications of the technique and optimal
implant selection; however, they could be more efficiently
eliminated by performing the correction directly at the level
of the deformity.
A better comprehension of the vascular supply to the
femoral head4,5 has allowed the establishment of the technique for safe surgical dislocation of the hip.6 Routine
surgical dislocation has led to a better appreciation of the
pathophysiology of hip7 and prompted intra-operative, dynamic studies on hip vascularization, which, in turn, have led
to a more detailed understanding of the perfusion process.8-10
Based on this detailed knowledge, safe approaches to the
circumference of the neck of the femur have been developed,
and new techniques, such as true femoral neck osteotomy,
and even femoral head osteotomy, have become realistic
options.
After a description of the technical considerations for
surgical dislocation of the hip,6 this report will detail how
to develop an extended retinacular flap. This retinacular flap
provides safe access to the osseous femoral neck, in order
to perform a relative lengthening of the femoral neck, and
carries the vasculature supplying the femoral head to allow
for a femoral head reduction osteotomy.
Materials and Methods
Surgical Hip Dislocation
In the past, dislocation of the femoral head out of the acetabular socket was executed rather infrequently, and publications
did not refer to it without mentioning the risk of developing
avascular necrosis of the femoral head.11-13 Following vascular injection studies that revealed the possibility of a safe
hip dislocation,6 a surgical technique was developed and has
Leunig M, Ganz R. Relative neck lengthening and intracapital osteotomy for severe Perthes and Perthes-like deformities. Bull NYU Hosp Jt Dis.
2011;69(Suppl 1):S62-7.
Bulletin of the NYU Hospital for Joint Diseases 2011;69(Suppl 1):S62-7
become a routine technique at many centers.14-21
The patient’s hip is positioned and draped in the lateral
decubitus position, with the free leg placed on a bag,
tunneled for the opposite leg. A 20 to 25 centimeter skin
incision is made longitudinally over the anterior third of
the palpated greater trochanter. The proximal fascia lata
is incised anterior to the gluteus maximus muscle, the
border of which is marked by one to several perforating
vessels. The posterosuperior border of the greater trochanter becomes visible, at least palpable, with internal
rotation of the extended hip and careful dissection of
the gliding tissue over the trochanter. This is more difficult in patients with slipped capital femoral epiphysis
or Perthes disease, where the tip of the trochanter may
even stay in contact with the posterior acetabular wall
and internal rotation may be difficult. The trochanteric
osteotomy is performed using an oscillating saw; the
osteotomy line is oriented in such a way that, proximally,
2 to 3 millimeters of the posterior portion of the gluteus
medius muscle remain attached to the stable portion of
the trochanter. With this technique, the majority of the
piriformis tendon will remain on the stable trochanter.
Further dissection of the capsule is performed proximal
to the piriformis tendon, which helps to protect the zone
of penetration of the ramus profundus into the capsule
that is distal to the piriformis tendon. Furthermore, the
constant branches of the inferior gluteal artery, running
distal to the piriformis tendon along the external rotators,
which eventually anastomose with the deep branch of
the medial circumflex artery, are protected.5,10 Distally,
the entire origin of the vastus lateralis muscle remains
on the mobile trochanter. The maximum thickness of the
trochanteric fragment should not exceed 1.5 centimeters.
The dissection of the hip capsule between the piriformis
tendon and the gluteus minimus muscle is facilitated by
slight flexion, external rotation, and abduction in the hip.
Further flexion and the use of Langenbeck retractors for
the anterior soft-tissue flap allow the exposure of the
anterior capsule. An important aspect of this step is the
mobilization of the long tendon of the gluteus minimus
muscle, which inserts into the anterior border of the mobile trochanter. As such, the trochanteric osteotomy is not
digastric, as first described by Mercati and colleagues22
but is trigastric. The next step is a Z-shaped capsulotomy
(right side). After assessing for mechanic conflicts during hip motion, the hip can be safely subluxed. Using
curved scissors, the round ligament is cut; a bone hook
pulling on the calcar widens the articular gap. This leads
to complete dislocation, while the externally rotated leg is
placed in an aseptic bag on the opposite side of the operating table. The leg position and rotation can be adjusted
to allow visualization of the entire acetabulum and the
majority of the femoral head. Morphologic abnormalities
along with labral and articular cartilage injuries are now
evaluated and registered in a drawing or photographically
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documented. When indicated, trimming of the acetabular
rim is performed. The labrum is preserved and a labral
refixation technique is utilized whenever possible. 23,17
The planned surgical steps on the intracapsular femur are
postponed for a later stage, after the elaboration of the
extended retinacular soft-tissue flap has been dissected.
As long as the femoral head cartilage is exposed to air,
it should be constantly moistened.
Extended Retinacular Soft-Tissue Flap
To develop the flap, which is extended by subperiosteal
release of the external rotators, the femoral head is initially reduced into the acetabular socket by bringing the
leg back from the bag onto the table in full extension
and mild internal rotation. The cancellous surface of
the stable trochanter is exposed using two Langenbeck
retractors. With a straight 1.5-centimeter osteotome,
the posterior portion of the stable trochanter is reduced
carefully, piece by piece. While performing this, the
osteotome should not penetrate posteriorly out of the
bone but should be used to weaken the fragment such
that it can be manually bent and broken. The mobilized
fragment is carefully turned outwards, so that a strictly
subperiosteal dissection of the fragment can be completed
under direct vision and with a knife. This process is repeated until the osteotomy surface levels the posterior
and superior surface of the neck. Repeated palpations
help to avoid cuts into the neck. At the superior circumference of the femoral neck, the periosteum anterior to
the retinaculum is incised longitudinally with a knife.
The retinacular border of the periosteum is carefully
mobilized posteriorly, facilitated by careful trimming of
the bony axilla at this level. The periosteum distal to the
quadratus femoris muscle is also incised and mobilized
posteriorly and distally. The subperiosteal flap continues
to be developed in this manner until the posterior surface
of the base of the lesser trochanter becomes visible. For
a femoral head osteotomy, the flap is further separated
from the osseous neck with the careful posteromedial dissection, using a small but sharp periosteal elevator. Care
must be taken proximally to avoid damage to the area
where the retinacular vessels enter into the epiphyseal
bone. At this point, the posterior flap contains the deep
branch of the medial femoral circumflex artery (MFCA),
the anastomoses with the inferior gluteal artery, and the
retinacular vessels. Dissection of the anterior and medial
femoral neck as advocated for subcapital reorientation24 is not necessary for intracapital osteotomy. For
most morphologies, the result of the dissection of the
retinacular flap is equivalent with relative lengthening,
described below.
At the end of the procedure, the borders of the periosteal
flap are re-approximated loosely and any tension should
be avoided. The same attitude is observed when closing
the capsule. When the tension of the piriformis tendon on
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the posterosuperior capsule is somewhat high, the tendon
can be released from the capsule, but care must be taken
to protect the deep branch of the MFCA perforating the
capsule at this level.
Relative Lengthening of the Femoral Neck
The morphological appearance of hips that have sustained
an insult during growth is frequently characterized by a
deformed epiphysis, a short femoral neck, and a greater
trochanter with a tip that is higher than the center of
the femoral head. The majority of patients with such
morphologies have had a history of Perthes disease or a
disturbance of the epiphyseal perfusion during conservative treatment of hip dysplasia, with early closure of the
head physis and undisturbed growth of the trochanteric
physis. Other etiologies, such as trauma or as sequelae
of an osteotomy, are also possible. The clinical problem in the majority of such hips may be characterized
by weakness of the gluteus medius muscle, but with a
closer look, there is also substantial pain and limitation
of motion from impingement. Impingement can be extraarticular between the greater trochanter and the pelvis.
In addition, more severe intra-articular impingement can
be associated, due to an anterior flattening of the femoral
head and a prominent anterolateral bony ridge of the short
femoral neck. In the past, extra-articular advancement
of the greater trochanter has been used frequently to
A
treat this problem25,26; it addresses the muscle weakness
and part of the extra-articular impingement. The intraarticular component of impingement is not addressed by
this procedure, and it is this component that is clinically
more important in the long-run.
The procedure described here combines two goals: 1.
the improvement of the muscular biomechanics, and 2.
the resolution of the extra- and intra-articular impingement problem to allow for joint motion gain. The operation is deemed a “relative lengthening,” because only the
superior circumference of the neck becomes longer by
the trimming away of most of the trochanteric portion in
its posterosuperior circumference, such that it becomes
continuous with the smaller contour of the neck. Leg
length remains the same, but muscle biomechanics and
clearance for hip motion is improved.27
As previously mentioned, the procedure is combined
with the treatment of the individual intra-articular impingement. At the end of the procedure, the desired distal
advancement of the trochanteric fragment is greatly
facilitated by a release of the long tendinous head of
the gluteus minimus muscle, which runs along the anterior border of the mobile trochanteric fragment. The
definitive cephalad-caudad position of the trochanteric
fragment, and therefore the amount of the trochanteric
advancement, is determined using a bone hook to adjust
the distal advancement and with palpatory assessment
B
Figure 1 A, Schematic drawing showing a femoral head reduction osteotomy. The segment to be resected is depicted as a hatched line.
The mobile fragment is pedicled on the retinaculum. The blood supply for the stable medial segment originates from the postero-medial
branch of the medial femoral circumflex artery. B, After optimal placement of the lateral fragment, a gap towards the trochanteric area
has to be filled with bone. Two or three 3.5-mm screws are necessary for fixation of the head fragment. A relative neck lengthening is
performed for trochanteric advancement.
Bulletin of the NYU Hospital for Joint Diseases 2011;69(Suppl 1):S62-7
A
B
C
D
E
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Figure 2 Perthes disease in a 12-year-old male. A, There is extrusion due to coxa magna, coax plana, and subluxation. The central
necrosis is flanked by a healthy medial and lateral epiphyseal pillar.
B, Painful hinged abduction with the acetabular edge entrenching
on the necrosis. C, Unexpected slight further subluxation 3 months
after head reduction osteotomy, although intra-operatively the head
appeared to be fully contained and stable. With regard to the clearly
improved clinical situation, the reevaluated PAO was postponed.
D, Radiographic result 2 years after the index surgery. The patient
has re-developed some pain and limping, leading to the decision
for an additional PAO. E, Nine months after PAO, the femoral head
is sufficiently covered and hip function is again normalized. The
clinically asymptomatic pseudarthrosis will be addressed by bone
grating when the hardware is to be removed.
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Bulletin of the NYU Hospital for Joint Diseases 2011;69(Suppl 1):S62-7
of the relative position of the trochanteric fragment.
Two 3.5 or 4.5 millimeter screws are usually sufficient
to stabilize the advanced trochanteric fragment.
Femoral Head Reduction Osteotomy
Based on a more advanced appreciation of hip vascularity mentioned earlier,4,5,8,10 a reduction of the size of the
femoral head by resecting a middle segment became
feasible without risking necrosis of the remaining two
fragments (Fig. 1). The first step of such a procedure
is the mobilization of the extended retinacular flap and
the relative neck lengthening described above. With
its retinacular blood supply, a lateral segment of the
head can be of unlimited size and can be separated and
mobilized. The medial segment of the head is perfused
by the posteromedial branch of the MCFA, 4,10 similar
to a Pipkin II fragment; however, it does not need to be
separated from the metaphysis. It is preferred to extend
the size of this segment not much over the level of the
fovea capitis. The resected portion of the head can be
a segment with parallel cuts, a triangular or a trapezoid
formation, according to the given deformity of the femoral head; although the osteotomies should be oriented in
a sagittal direction, there is a certain degree of spatial
variability. The goal of the resection is that the contours
of the remaining segments can be matched in congruity
without a step of the two cartilage surfaces. The final
head size should fit into the socket but should not be too
small. Peripheral irregularities can be fine-tuned with a
scalpel or osteotome. Leveling of the mobile lateral head
and neck segment may create a gap with the metaphysis;
this is filled with bone from the trochanteric trimming.
Two 3.5 millimeter screws, inserted from the mobile into
the stable head fragment, have been sufficient for fixation. The acetabular roof has more or less adapted to the
deformed head, resulting in a deformation from lateral
flattening of the edge to a severe acetabular dysplasia.
The femoral head, although smaller after the osteotomy,
may not find or keep a well-reduced and stable position
in such a socket. In such instances, it is recommended
to sufficiently increase the joint stability by adding a
peri-acetabular osteotomy (PAO). This is best performed
under the same anesthesia, after repositioning of the patient from lateral to supine decubitus. However, the first
ischial cut can be easily performed prior to repositioning
through the lateral incision, between the inferior gemellus and obturator externus muscles, with optimal visual
control of the sciatic nerve.28
Results: Case Series
Since 2001, 14 femoral head reduction osteotomies have
been performed; 13 for Perthes or Perthes-like deformities.
In one hip, a Colonna procedure could only be finished
after the head was reduced in size to fit into the maximally
excavated socket. Patients’ ages ranged between 9 and 21
years. Eight hips had a PAO, together with the reduction
osteotomy, and three had the additional surgery at a later
stage (Fig. 2). One earlier case had a femoral varus osteotomy 8 weeks later to stabilize the head in the socket.
Overall, only one hip did not need additional correction
on the acetabular side. All osteotomies healed within 6 to
8 weeks, and none developed osteonecrosis at a minimum
follow-up of 3 years. All patients reported improved motion, without substantial pain.
Discussion
Osteotomies of the proximal femur for osteoarthritis (OA) of
the hip joint have become less indicated with the increasing
popularity of total hip arthroplasty (THA), even for younger
patients. Femoral osteotomies aimed at improving coverage
and congruency as well as vertical loading of the hip29; however, the results are often unpredictable. With introduction of
the impingement concept as an initiating factor of OA,7 the
therapeutic perception changed from treating established OA
toward treating deformities of the hip leading to impingement; if possible, this should be executed before degenerative
changes of the joint cartilage are established.16-21
Relative lengthening of the femoral neck has been mentioned in earlier publications.14,25 The technique evolved over
time when intra-operative control of free motion, revealing
frequent residual impingement between the stable trochanter and the posterior acetabular wall in abduction, external
rotation, and with combinations, made removal of further
trochanteric bone necessary. The morbidity of the relative
lengthening procedure, including healing problems of the
greater trochanter, is quite small. In fact, it is not higher than
for surgical dislocation alone6; this aspect may increase the
biomechanical value of the procedure. The step from relative
lengthening of the neck to the elaboration of the extended
retinacular flap was small, but it opened the door to a new
class of intracapsular surgery.25
Femoral head reduction osteotomy has a rare but distinct
indication in older children and adolescents. It is a direct
approach to a morphology of the femoral head or the joint,
or both, which does not have a true alternative option and,
if left untreated, would deteriorate rapidly or the situation
would be unacceptable due to the caused clinical limitations.
Femoral head osteotomy is always combined with relative
lengthening of the neck. However, it may be performed
without an additional joint-stabilizing procedure if secondary deformation of the acetabulum is absent or only minimal.
We underestimated the remaining subluxation tendency in
four of our cases and had to compensate it at a later stage
with a varus intertrochanteric osteotomy and a reorientation
of the acetabulum, respectively. With the longest follow-up
at 9 years, intracapital osteotomy has promising radiolographical and clinical results and seems to be advantageous
over other salvage procedures covering the extruded portion
of the deformed femoral head, such as shelf osteoplasty or
Chiari osteotomy.
Bulletin of the NYU Hospital for Joint Diseases 2011;69(Suppl 1):S62-7
Disclosure Statement
None of the authors have a financial or proprietary interest
in the subject matter or materials discussed, including, but
not limited to, employment, consultancies, stock ownership,
honoraria, and paid expert testimony.
15.
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