Correction of complex three-dimensional deformities at the proximal femur using indirect reduction with angle blade plate and patient-specific instruments: a technical note

doi:10.21203/rs.3.rs-470789/v1

Download PDF

Research Article

Correction of complex three-dimensional deformities at the proximal femur using indirect reduction with angle blade plate and patient-specific instruments: a technical note

https://doi.org/10.21203/rs.3.rs-470789/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background

Corrective osteotomies in complex proximal femoral deformities can be challenging wherefore subsidies in preoperative planning and during surgical procedures are considered helpful. Three-dimensional (3D) planning and patient-specific instruments (PSI) are already established in different orthopedic procedures. This study gives an overview on this technique at the proximal femur and proposes a new indirect reduction technique using an angle blade plate.

Methods

Using computed tomography (CT) data, 3D models are generated serving for the preoperative 3D planning. Different guides are used for registration of the planning to the intraoperative situation and to perform the desired osteotomies with the following reduction task. A new valuable tool to perform the correction is the use of a combined osteotomy and implant-positioning guide, with indirect deformity reduction over an angle blade plate.

Results

An overview of the advantages of 3D planning and the use of PSI in complex corrective osteotomies at the proximal femur is provided. Furthermore a new technique with indirect deformity reduction over an angle blade plate is introduced.

Conclusion

The understanding of complex deformities at the proximal femur is enhanced by the use of preoperative 3D planning and the additional PSI allow an accurate intraoperative execution. Further advancements in this technique, such as indirect deformity reduction over an angle blade plate, allow complex corrections with fewer surgical steps and less harm to the surrounding soft tissue.

Orthopedics

Orthopedic Surgery

3D printing

corrective osteotomy

deformity correction

hip osteotomy

Proximal femoral osteotomies play an important role in pediatric orthopedic surgery to treat different congenital deformities or childhood diseases related deformities [1–5]. In adults, corrective osteotomies to the proximal femur have become less frequent due to the increasing efficacy of total hip arthroplasty (THA) [6]. However, especially in young patients such joint-preserving procedures should be considered before performing THA to maintain the native joint, in particular with regard to the high revision rates in such patients [7]. Therefore, different femoral osteotomies still hold their position in the treatment of adults suffering from proximal femoral deformities [8–10]. However, due to the potential complexity of such cases a detailed preoperative analysis of the individual deformity seems mandatory and potential technical subsidies during surgery may be useful. The application of three-dimensional (3D) planning and the use of patient-specific instruments (PSI) have already been established in different orthopedic procedures [11–16]. Zheng et al. [17] previously described the application of 3D-printed navigation templates for locking compression pediatric hip plates (LCP-PHP) in children with femoral neck fractures or hip dysplasia. A recent literature review of Baraza et al. [18] summarized improved accuracy and decreased procedure times in corrective osteotomies of the femur by the application of PSI compared to conventional methods. Overall, an increasing trend of the implementation of 3D planning and the use of PSI at the proximal femur can be observed. Therefore, it was the aim of this study to present an overview of this technique at the proximal femur and to introduce a new technique with indirect deformity reduction using PSI in combination with an angle plate to further improve the toolkit in these demanding surgical tasks.

Preoperative 3D planning

Using computed tomography (CT) data, 3D triangular surface models are generated using already proven segmentation methods [11, 15, 19]. Regularly, the CT should contain the hip and knee. Especially in cases with large rotational corrections, the ankle can be included to consider the maintenance of the mechanical leg axis in the planning, as such procedures may influence the mechanical leg axis [20]. The 3D models are then imported for the planning into a computer-aided design (CAD) software. The deformed bone can then be superimposed onto the healthy side as already described for the humerus [13, 21]. The superimposition allows an overview with a better understanding of the underlying deformity and enables an assessment of the needed correction in all planes (Fig. 1). After determining the desired correction, the surgical task can be planned and the different required PSI can be drafted.

Design of patient-specific guides

Basic guide

The basic guide is the first used PSI, serving for registration between the preoperative 3D planning and the intraoperative situation. Hence, this guide must contain individual characteristic landmarks in its profile to ensure a precise fit in one specific position. A lateral subvastus approach to the proximal femur is frequently used in corrective osteotomies of the proximal femur [22, 23]. Using such an approach, the trochanteric ridge often serves as a suitable landmark together with the specific circumference of the femoral shaft. The appropriate guide position can further be ensured by integrating stabilizing arms in the guide design [24]. However, removal of the whole soft tissue in the region of the guide-storage is still necessary to guarantee the specific guide position. Once the basic guide is located, reference pins can be placed over the integrated drill sleeves. These reference pins serve for setting of all the following guides. To prevent unnecessary bone weakening, the position of these reference pins can be planned in an orientation that these boreholes can be used for later plate fixation (Fig. 2).

Osteotomy and implant-positioning guides

In a next step the osteotomy guide, respectively in some cases a combination of an osteotomy and implant-positioning guide can be placed over the reference pins to find its defined position. Most osteotomies at the proximal femur can be performed using an oscillating saw blade. Here, the direction and cutting depth of the saw blade is prescribed by the integrated cutting slit in the guide [13, 14]. However, if a more complex osteotomy is needed, such as a curved osteotomy, this can be achieved using interlinked drill holes, which can be incorporated in the guide design likewise [13]. With regard to the later osteotomy fixation, the placement of the chosen implant can already be considered at this step of the surgery planning. A common implant for fixation of intertrochanteric osteotomies is the use of an angle blade plate [25, 26]. Using such an implant, the blade position in the femoral neck can be defined ahead of the osteotomy using a combination of an osteotomy and implant-positioning guide. Therefore, an additional chisel slit has to be integrated in the guide design (Fig. 3). Same as the cutting slit for the osteotomy, the chisel slit guides the seating chisel in its direction and depth. Additionally, a K-wire hole can be integrated in the guide just above the chisel slit. Placing a K-wire in the defined chisel direction allows C-arm control of the chisel direction ahead of chiseling, serving as a second safety check for an appropriate blade placement. The major advantage of using such a technique is that setting the blade position in the femoral neck before the osteotomy in combination with the predefined screw holes on the femoral shaft (i.e. already placed reference pins using the basic guide) allows later indirect deformity reduction over the angle blade plate. Or in other words, by defining the proximal and distal implant position before the osteotomy; the implant can simply be placed after the osteotomy into the chiseled slit proximally and over the reference pins distally, resulting in the planned deformity correction (Fig. 3). Another advantage of this technique is that the production of an additional reduction guide will become redundant.

Reduction guides

Depending on the chosen implant, an indirect reduction over the plate as described above might not be possible. This applies, for example, if the chosen implant is a straight plate like a common Locking Compression Plate (LCP), a frequently used implant for fixation of subtrochanteric rotational osteotomies [20]. In these cases, the deformity correction can be achieved using a reduction guide. This reduction technique is based on direct deformity reduction over the previously placed reference pins. Using this technique, two parallel reference pins are inserted each, proximal and distal from the osteotomy. After the osteotomy, the reduction guide can be placed over the proximal and distal reference pins, aligning them and resulting in the planned reduction of the deformity [13]. Using such a reduction technique, the guide-storage of the reduction guide should be planned outside of the desired plate position, to maintain the desired correction by keeping the reduction guide in place during implant positioning (Fig. 4).

Even though THA shows increasing efficacy, corrective osteotomies in adults retain their position in orthopedic surgery. Beside posttraumatic conditions, non-treated or insufficient treated congenital conditions, or deformities related to childhood diseases may also require corrective osteotomies in adults [8–10, 23]. However, correction of complex deformities at the proximal femur can be challenging [27–29], wherefore a detailed preoperative analysis of the deformity and intraoperative subsidies may be useful to achieve the desired deformity correction. The previous literature in the application of 3D planning and the use of PSI in corrective osteotomies at the proximal femur mainly focused on pediatric patients and is lacking the implementation in adults. Furthermore, the indirect deformity reduction over an angle plate using 3D planning and PSI in proximal femoral osteotomies is not yet described. Therefore, the here presented technique is intended to expand the toolkit in planning and correcting deformities at the proximal femur as accurate and valuable as possible. Examples of patients that have undergone corrective osteotomy of the proximal femur using this technique are illustrated in Fig. 5.

With the ongoing development in orthopedic surgery, the use of 3D planning and PSI has become increasingly popular. The beneficial use of this technique has already been described for corrective osteotomies at different locations [11, 13–15]. At the proximal femur, Zheng et al. [17] showed reduced damage to the femoral neck epiphysis, decreased surgery time as well as decreased radiation exposure in the placement of LCP-PHP in children with femoral neck fracture or developmental dysplasia of the hip using 3D planning and PSI. Reduced surgical and fluoroscopy time was also confirmed by Cherkasskiy et al. [30] in triplane proximal femoral osteotomy in children with slipped capital femoral epiphysis using preoperative patient-specific 3D models for surgical planning. Beside reduced radiation exposure and shortened surgery time, Shi et al. [31] also showed improved accuracy using 3D planning and PSI compared to conventional techniques in children with proximal femoral corrective osteotomy in developmental dysplasia of the hip. In a review, Baraza et al. [18] similarly stated improved accuracy in corrective femoral osteotomies using 3D planning and PSI compared to conventional techniques. The improved accuracy probably is a result of the assistance of the PSI, enabling the surgeon in a precise execution of the preoperative planning into the intraoperative situation. Furthermore, the preoperative 3D planning facilitates a better understanding of the underlying deformity, allowing for more accurate preoperative decision-making and probably further improving the surgical accuracy. This objective, in our opinion, seems mandatory as inappropriate preoperative planning or accidental deviations from this planning may result in unintended postoperative results. In addition to the recognized unexpected impact of femoral rotational osteotomies on the mechanical leg axis [32, 33], it is known that mal-angulation of such rotational osteotomies may result in even more considerable mechanical leg axis deviations not only in the frontal plane, but also in the sagittal plane [20, 34]. Furthermore it has to be expected that this undesirable deviations are even more decisive in correcting multiplanar deformities. Therefore, a precise preoperative planning and a surgical execution with the highest accuracy possible seem important especially in cases with complex deformities, requiring corrections in multiple planes.

However, some issues need to be mentioned using the here described technique. First of all, for the correct guide placement, an appropriate exposure of the characteristic landmarks of the bone is mandatory and minimal invasive procedures using 3D planning and PSI on the proximal femur are not yet available. However, the invasiveness of the surgery can still be kept low due to the detailed preoperative planning with a minimum number of boreholes (due to the fact, that the boreholes for the guides already serve for later implant placement) and the integrated cutting / chiseling slits on the PSI direct the surgeon in the desired orientation without further extensive exposure, as it is needed to control for orientation of the osteotomy or the implant placement in some conventional procedures. Furthermore, with the here described indirect reduction technique, further extensive soft tissue removal for placement of additional guides outside of the implant storage (e.g. reduction guide) gets redundant and therefore preserves surrounding tissue compared to previous techniques. Another issue is the financial aspect. An appropriate preoperative 3D planning and the production of the PSI result in additional costs. Therefore, for each individual case it has to be weighed out if the benefits from this technique justify these costs. Probably especially in young patients with complex deformities requiring multiplanar corrections, these additional costs should be warranted.

The use of 3D planning and PSI in complex corrective osteotomies at the proximal femur can be a useful tool in understanding the individual deformity and performing the aimed deformity reduction. The described indirect reduction over the implant is a simple tool in achieving the desired correction, preserves surrounding soft tissue, and spares additional surgical steps and the production of additional guides.

3D: Three-dimensional; PSI: Patient-specific instruments; CT: Computed tomography; THA: total hip arthroplasty; LCP-PHP: Locking compression pediatric hip plates; CAD: Computer-aided design; LCP: Locking compression plate.

Ethics approval and consent to participate: Ethics Committee approval was not necessary for this study (waiver no. 2021-00215 issued by the Ethics Committee of eastern Switzerland). All patients gave their informed consent to participate in this study.

Consent for publication: All patients gave their informed consent for publication of this study.

Availability of data and materials: Anonymized source data can be obtained from the corresponding author on reasonable request.

Competing interests: None declared.

Funding: No funding was received for conducting this study.

Authors' contributions: All authors contributed to the study concept and design. All authors performed material preparation and analysis. Lukas Jud wrote the first draft of the manuscript and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Acknowledgements: None.

Lyu X, Fu G, Feng C, et al (2020) Clinical and radiological outcomes of combined acetabuloplasty with acetabular redirectional osteotomy and femoral shortening for children older than 9 years of age with developmental dysplasia of the hip: A retrospective case series. J Pediatr Orthop Part B. https://doi.org/10.1097/BPB.0000000000000774
Dreher T, Wolf SI, Heitzmann D, et al (2012) Long-term outcome of femoral derotation osteotomy in children with spastic diplegia. Gait Posture. https://doi.org/10.1016/j.gaitpost.2012.04.017
Carroll K, Coleman S, Stevens PM (1997) Coxa vara: Surgical outcomes of valgus osteotomies. J Pediatr Orthop. https://doi.org/10.1097/00004694-199703000-00016
Davids JR, Gibson TW, Pugh LI, Hardin JW (2013) Proximal femoral geometry before and after varus rotational osteotomy in children with cerebral palsy and neuromuscular hip dysplasia. J Pediatr Orthop. https://doi.org/10.1097/BPO.0b013e318274541a
Copeliovitch L (2011) Femoral varus osteotomy in Legg-Calve-Perthes disease. In: Journal of Pediatric Orthopaedics
Aprato A, Pellegrino P, Kain MSH, Masse A (2014) Do osteotomies of the proximal femur still have a role? Curr. Rev. Musculoskelet. Med.
Mäkelä KT, Eskelinen A, Pulkkinen P, et al (2011) Results of 3,668 primary total hip replacements for primary osteoarthritis in patients under the age of 55 years. Acta Orthop. https://doi.org/10.3109/17453674.2011.618908
Hersche O, Casillas M, Ganz R (1998) Indications for introchanteric osteotomy after periacetabular osteotomy for adult hip dysplasia. Clin Orthop Relat Res. https://doi.org/10.1097/00003086-199802000-00004
Pécasse GABM, Eijer H, Haverkamp D, Marti RK (2004) Intertrochanteric osteotomy in young adults for sequelae of Legg-Calvé-Perthes’ disease - A long term follow-up. Int Orthop. https://doi.org/10.1007/s00264-003-0513-2
Buly RL, Sosa BR, Poultsides LA, et al (2018) Femoral Derotation Osteotomy in Adults for Version Abnormalities. J Am Acad Orthop Surg. https://doi.org/10.5435/JAAOS-D-17-00623
Fucentese SF, Meier P, Jud L, et al (2020) Accuracy of 3D-planned patient specific instrumentation in high tibial open wedge valgisation osteotomy. J Exp Orthop. https://doi.org/10.1186/s40634-020-00224-y
Jud L, Vlachopoulos L, Beeler S, et al (2020) Accuracy of three dimensional-planned patient-specific instrumentation in femoral and tibial rotational osteotomy for patellofemoral instability. Int Orthop. https://doi.org/10.1007/s00264-020-04496-y
Vlachopoulos L, Schweizer A, Meyer DC, et al (2016) Three-dimensional corrective osteotomies of complex malunited humeral fractures using patient-specific guides. J Shoulder Elb Surg. https://doi.org/10.1016/j.jse.2016.04.038
Jud L, Müller DA, Fürnstahl P, et al (2019) Joint-preserving tumour resection around the knee with allograft reconstruction using three-dimensional preoperative planning and patient-specific instruments. Knee. https://doi.org/10.1016/j.knee.2019.02.015
Fürnstahl P, Vlachopoulos L, Schweizer A, et al (2015) Complex osteotomies of tibial plateau malunions using computer-assisted planning and patient-specific surgical guides. J Orthop Trauma. https://doi.org/10.1097/BOT.0000000000000301
Jud L, Singh S, Tondelli T, et al (2020) Combined Correction of Tibial Torsion and Tibial Tuberosity–Trochlear Groove Distance by Supratuberositary Torsional Osteotomy of the Tibia. Am J Sports Med. https://doi.org/10.1177/0363546520929687
Zheng P, Yao Q, Xu P, Wang L (2017) Application of computer-aided design and 3D-printed navigation template in Locking Compression Pediatric Hip Plate TM placement for pediatric hip disease. Int J Comput Assist Radiol Surg. https://doi.org/10.1007/s11548-017-1535-3
Baraza N, Chapman C, Zakani S, Mulpuri K (2020) 3D - Printed Patient Specific Instrumentation in Corrective Osteotomy of the Femur and Pelvis: A Review of the Literature. 3D Print Med. https://doi.org/10.1186/s41205-020-00087-0
Lorensen WE, Cline HE (1987) Marching cubes: A high resolution 3D surface construction algorithm. In: Proceedings of the 14th Annual Conference on Computer Graphics and Interactive Techniques, SIGGRAPH 1987
Jud L, Vlachopoulos L, Häller T V., et al (2020) The impact of mal-angulated femoral rotational osteotomies on mechanical leg axis: A computer simulation model. BMC Musculoskelet Disord. https://doi.org/10.1186/s12891-020-3075-1
Vlachopoulos L, Dünner C, Gass T, et al (2016) Computer algorithms for three-dimensional measurement of humeral anatomy: Analysis of 140 paired humeri. J Shoulder Elb Surg. https://doi.org/10.1016/j.jse.2015.07.027
Van Bosse HJP, Saldana RE (2017) Reorientational proximal femoral osteotomies for arthrogrypotic hip contractures. J. Bone Jt. Surg. - Am. Vol.
Strecker W, Keppler P, Kinzl L, Hehl G (1998) Proximale femurosteotomien zur korrektur posttraumatischer veränderungen. Chirurg. https://doi.org/10.1007/s001040050552
Jud L, Fürnstahl P, Vlachopoulos L, et al (2020) Malpositioning of patient-specific instruments within the possible degrees of freedom in high-tibial osteotomy has no considerable influence on mechanical leg axis correction. Knee Surgery, Sport Traumatol Arthrosc. https://doi.org/10.1007/s00167-019-05432-3
Said GZ, Farouk O, Said HGZ (2010) Valgus intertrochanteric osteotomy with single-angled 130° plate fixation for fractures and non-unions of the femoral neck. Int Orthop. https://doi.org/10.1007/s00264-009-0885-z
Müller ME (1984) Intertrochanteric Osteotomy: Indication, Preoperative Planning, Technique. In: The Intertrochanteric Osteotomy
Banaszek D, Spence D, O’Brien P, Lefaivre K (2018) Principles of Valgus Intertrochanteric Osteotomy (VITO) after Femoral Neck Nonunion. Adv. Orthop.
Ganz R, Horowitz K, Leunig M (2010) Algorithm for femoral and periacetabular osteotomies in complex hip deformities. In: Clinical Orthopaedics and Related Research
Ippolito E, Farsetti P, Valentini MB, Potenza V (2015) Two-stage surgical treatment of complex femoral deformities with severe coxa vara in polyostotic fibrous dysplasia. J Bone Jt Surg - Am Vol. https://doi.org/10.2106/JBJS.N.00230
Cherkasskiy L, Caffrey JP, Szewczyk AF, et al (2017) Patient-specific 3D models aid planning for triplane proximal femoral osteotomy in slipped capital femoral epiphysis. J Child Orthop. https://doi.org/10.1302/1863-2548.11.170277
Shi Q, Sun D (2020) Efficacy and safety of a novel personalized navigation template in proximal femoral corrective osteotomy for the treatment of DDH. J Orthop Surg Res. https://doi.org/10.1186/s13018-020-01843-y
Nelitz M, Wehner T, Steiner M, et al (2014) The effects of femoral external derotational osteotomy on frontal plane alignment. Knee Surgery, Sport Traumatol Arthrosc. https://doi.org/10.1007/s00167-013-2618-5
Lee SY, Jeong J, Lee K, et al (2014) Unexpected angular or rotational deformity after corrective osteotomy. BMC Musculoskelet Disord. https://doi.org/10.1186/1471-2474-15-175
Jud L, Andronic O, Vlachopoulos L, et al (2020) Mal-angulation of femoral rotational osteotomies causes more postoperative sagittal mechanical leg axis deviation in supracondylar than in subtrochanteric procedures. J Exp Orthop. https://doi.org/10.1186/s40634-020-00262-6

Download PDF

Editorial decision: Major revision
22 May, 2021
Reviewer #2 agreed at journal
02 May, 2021
Reviewers invited by journal
28 Apr, 2021
Reviews received at journal
28 Apr, 2021
Reviewer #1 agreed at journal
28 Apr, 2021
Review #1 received at journal
28 Apr, 2021
Editor assigned by journal
27 Apr, 2021
Submission checks completed at journal
27 Apr, 2021
Editor invited by journal
27 Apr, 2021
First submitted to journal
27 Apr, 2021

You are reading this latest preprint version

Correction of complex three-dimensional deformities at the proximal femur using indirect reduction with angle blade plate and patient-specific instruments: a technical note

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Background

Methods

Preoperative 3D planning

Design of patient-specific guides

Basic guide

Osteotomy and implant-positioning guides

Reduction guides

Discussion

Conclusion

Abbreviations

Declarations

References

Status:

Version 1