Femoral Derotation Osteotomy Technique for Excessive Femoral Anteversion

Abstract

Excessive femoral anteversion may lead to increasing stress placed on the anterior acetabulum and soft tissues, which can predispose to intra-articular hip pathology. By addressing the excessive femoral anteversion in combination with intra-articular hip pathology, the results will be durable over time. This technique details how to perform a femoral derotation osteotomy for excessive femoral anteversion after addressing intra-articular pathology with hip arthroscopy in one surgical intervention. This allows the surgeon to address both the underlying pathoanatomy and the resultant intra-articular sequelae.

Fig 1

Degree of femoral anteversion as measured on axial images from a preoperative computed tomography (CT) scan. This is a CT scan of the left hip with the patient laying supine on the CT scanning table with the patient's feet internally rotated 15°. On the left, axial images through the hip note the femoral neck with a blue line drawn down its longitudinal axis (yellow arrow) noting the angle the femoral neck produces. On the right, an axial image at the knee notes the posterior condylar axis by the red line (green arrow) from the medial to lateral posterior femoral condyle. These 2 lines form the anteversion angle of the hip (angle noted by the purple arrow). (R, right).

Fig 2

The patient is lying supine on the operating room table with the right leg being examined. The examiner's left hand is holding the patient's knee stable, whereas the right hand is manipulating rotation with the hip flexion angle held at 90° throughout. A blue line is drawn denoting the axis of the femoral shaft. When the patient's leg is in 0° of rotation, the tibia would be following the red line. The figure shows the patient in maximal internal rotation that is the angle (noted by the blue arrows) the red line (0° of rotation) makes with the black line (maximal internal rotation of the hip that in this patient is noted to be 85°).

Fig 3

Note the setup for both the arthroscopic and open portion of the case for a right hip. Head and anesthesia is to the left and the foot is to the right; the patient is supine on the traction table. Fluoroscopy enters the field from the contralateral side (green arrow) with monitors for fluoroscopy at the foot of the bed (red arrow). The arthroscopy monitor is placed at the head of the bed (yellow arrow) (A). A picture looking at the setup from the foot of the bed with the patient's right side being to the left of the screen and the left side on the right side of the screen. Fluoroscopy is coming in from the contralateral left side (green arrow) (B).

Fig 4

The patient is supine on the traction table and the picture is taken from the foot of the right leg. Before performing any osteotomy or correction, an anterior and a posterior pin are placed proximal on the femur (blue), and then an anterior and a posterior pin are placed in the distal femur (green) perfectly parallel to the proximal pins. This photograph shows the initial parallel position of the proximal (blue) and distal (green) pins before osteotomy. It is critical to be parallel because this angle is used as the zero point for after the osteotomy is performed the angle will then be changed to the correct amount of version change desired.

Fig 5

The patient is supine on the operating room table with picture being taken from the patient's right foot. The pins that were placed parallel in previous steps are now no longer parallel. This allows the surgeon to assess the amount of version that has been corrected. Excessive anteversion has been corrected by externally rotating the distal segment by approximately 20° (angle made between the anterior blue/green pins and/or posterior blue/green pins). The angle between the anterior proximal (blue) and anterior distal (green) pins is noted with the yellow single and double arrow (approximately 20°). The change in angle from the proximal posterior (blue) and distal posterior (green) pins is noted with white arrows (approximately 20°). Two sets of pins are used in case one set becomes loose.