14 SECTION I Hip Disorders

Procedure 5 Intertrochanteric Varus Osteotomy and Internal Fixation With a Blade Plate

Skin incision

A
Greater trochanter

Tensor fasciae latae muscle

Division of fascia lata

Operative Technique
A, The operation is performed with the child supine on a
radiolucent operating table. It is imperative to have image-
intensifier radiographic control. Some surgeons prefer to
operate on an older child on a fracture table because it is
technically easier to obtain a lateral radiograph of the hip.
A straight, midlateral, longitudinal incision is made begin-
ning at the tip of the greater trochanter and extending
distally parallel to the femur for a distance of 10 to 12 cm.
The subcutaneous tissue is divided in line with the skin
incision.
B, The fascia lata is exposed by deepening the dissection.
It is first divided with a scalpel, and it is then split longitu-
dinally with scissors in the direction of its fibers. The fascia
lata should be divided posterior to the tensor fasciae latae
to avoid splitting the muscle.

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 PROCEDURE 5 Intertrochanteric Varus Osteotomy and Internal Fixation With a Blade Plate 15

Splitting of
vastus lateralis muscle

Greater
trochanteric
apophysis

Exposed femoral shaft

D

C, With retraction, the vastus lateralis muscle is visualized.
Next, the anterolateral region of the proximal femur and
the trochanteric area are exposed. It is vital to not injure
the greater trochanteric growth plate. The origin of the
vastus lateralis muscle is divided transversely from the infe-
rior border of the greater trochanter down to the
posterolateral surface of the femur. The vastus lateralis
muscle fibers are elevated from the lateral intramuscular
septum and the tendinous insertion of the gluteus maximus.
D, The lateral femoral surface is exposed by subperiosteal
dissection. The greater trochanteric apophysis should not
be disturbed.

Continued on following page

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16 SECTION I Hip Disorders

Procedure 5 Intertrochanteric Varus Osteotomy and Internal Fixation With a Blade Plate, cont’d

Head of femur concentrically

reduced in acetabulum
Head of femur (head is covered)
uncovered
Greater Pin in center of femoral
trochanteric neck and stopped short of
apophysis capital femoral epiphysis
Steinmann pin

Line of osteotomy

E F Leg abducted and

Physis of medially rotated
femoral head

Proximal osteotomy
parallel to chisel
15°
Guide pin along
axis of neck

Chisel removed
Chisel placed 15°
off axis of neck
Distal osteotomy
perpendicular to
femoral shaft
G H
Leg adducted and
medially rotated

E and F, The femoral head is centered concentrically in the
acetabulum by abducting and medially rotating the hip, and
its position is checked with an image intensifier. Immedi-
ately distal to the apophyseal growth plate of the greater
trochanter, a 3-mm Steinmann pin is inserted through the
lateral cortex of the femoral shaft parallel to the floor of
the operating room and at a right angle to the median plane
of the patient. The pin is drilled medially along the longi-
tudinal axis of the femoral neck and stops short of the
capital femoral physis. This position of the proximal femur
can be reproduced at any time during the operation by
placing the Steinmann pin horizontally parallel to the floor
and at 90 degrees to the longitudinal axis of the patient.
This is a very dependable and simple method for properly
orienting the proximal femur.
G, The chisel for the blade plate is placed at an angle that
is determined as follows: if the chisel paralleled the guide
pin, the 90-degree blade plate would produce a 90-degree
neck–shaft angle. In this case, we sought to produce a neck–
shaft angle of 105 degrees. Thus a chisel placed 15 degrees
off of the guide pin’s axis adds 15 degrees to a 90-degree
neck–shaft angle, thereby resulting in a 105-degree final
angle.
H, The osteotomy cuts are made while the chisel is in
place. The proximal osteotomy is parallel to the chisel,
and the distal osteotomy is perpendicular to the femoral
shaft.

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 PROCEDURE 5 Intertrochanteric Varus Osteotomy and Internal Fixation With a Blade Plate 17

Medial Screw fixation

displacement
of distal
fragment

I J
Blade plate inserted

K
Closure of vastus
lateralis muscle

I, After the osteotomized triangle is removed, the chisel is
removed, and the blade plate is inserted. Careful control of
the proximal fragment and clear visualization of the entry
site of the chisel facilitate the placement of the blade.
J, The blade plate is fully seated and secured with screws
that are drilled and tapped. The angulation of the plate
produces medial displacement of the femoral shaft, which
is extremely important to the biomechanics of the hip.
Failure to displace the distal fragments medially results in
the lateral prominence of the plate and the widening of the
groin.
K, The vastus lateralis and fascia lata are closed with running
sutures. Subcutaneous and skin closure with absorbable
sutures completes the procedure.
Postoperative Care
The osteotomy is stable when the bone is of normal strength.
In reliable patients, cast immobilization is not necessary. For
less reliable children, those with osteopenic bone, and
always when an open reduction has been performed, 6
weeks in a spica cast are required.

Descargado para Alejandro Dávila Chávez (alejandro.davilac@my.uvm.edu.mx) en University of the Valley of Mexico - Tlalpan Campus de ClinicalKey.es por Elsevier en
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