Correction of anteversion in skeletally immature patients: percutaneous osteotomy and transtrochanteric intramedullary rod

Abstract

Background: There has been reluctance by some surgeons to accept antegrade femoral nailing in children and adolescents due to concerns about producing iatrogenic osteonecrosis or growth disturbance of the femoral neck. Others believe that with the recent advent of pediatric transtrochanteric intramedullary nails, femoral fracture and osteotomy fixation may now safely be accomplished using these devices. Extrapolating from experience treating mature patients, the senior author (P.S.) has adopted the technique of percutaneous femoral osteotomy and transtrochanteric intramedullary fixation in skeletally immature patients as a standard approach for the correction of anteversion, combining this with concomitant surgery as indicated.

Methods: With the institutional review board approval, we reviewed our experience using the Phillips intramedullary rod (EBI/Biomet, Inc, Warsaw, Ind), to secure femoral osteotomies in a series of 30 patients with 40 femoral osteotomies (10 bilateral). The etiologies of anteversion included idiopathic and neuromuscular. There were 10 boys and 20 girls, ranging in age from 8 to 16 years and in weight from 32 to 60 kg. Additional surgical bony and soft tissue procedures were combined as indicated. These included supramalleolar osteotomy, hindfoot stabilization, tendon lengthening or transfers, and hemiepiphysiodesis in select patients. Two of the femoral rotational corrections were combined with shortening.

Results: Despite early mobilization without casts, each osteotomy healed primarily in an average of 3 months, and the complication rate was exceedingly low. One patient had removal of a loose distal interlocking screw at 6 weeks postinsertion. By that time, he had formed good callus and had rotational stability; thus, the outcome was not compromised. Importantly, we have not observed osteonecrosis, growth disturbance of the femoral neck, or limb length discrepancy resulting from this treatment method.

Conclusions: In the skeletally immature patient, femoral anteversion can safely be corrected using the Phillips/Biomet antegrade locked intramedullary rod, placed through a transtrochanteric approach; growth disturbance has not been encountered. This device is well tolerated, with a low complication rate. Compared with alternative techniques, recuperation is rapid and fixation problems seen with plates or crossed pins/spica are largely circumvented. The advantages include quadriceps sparing, minimal blood loss, and the use of a load-sharing, low-profile implant.

Level of evidence: IV (retrospective, clinical).