Femoral Shortening

International Center for Limb LengtheningRubin Institute of Advanced Orthopaedics

Sinai Hospital, Baltimore, MD

John Herzenberg, MDJennifer Wood, MD

Femoral Shortening

We have no financial disclosures relevant to the topic of this lecture.

LLRS Specialty Day – 2014 New Orleans

Closed Femoral Shortening : History

Initial Description

• 1869: Francesco Rizzoli • Two cases for post-traumatic LLD• Osteoclast used for osteotomy• Shortening & overriding femoral shaft• No internal fixation

Femoral Shortening : History

ObliqueTransverse

1. Cast 2. Tenon & Mortise (+ cast) - Calvé3. Internal Fixation - 1907 : Deutschlander: plate & screws - 1917 : Shands : wire sutures - 1918 : Fassett : Lane plate - 1923 : Royle : intramedullary pegs - 1935 : White : pins & plaster

Reported Techniques Reported Techniques for Femoral Fixationfor Femoral Fixation

Tenon & Mortise

Pins & Plaster

Closed Intramedullary Osteotomy Intramedullary Saw

• 1962: Küntscher IM saw• 1973: Winquist & Hansen

Fixation: Reamed IMN

Femoral Shortening : History

Küntscher IM saw

Indications

1. Skeletal maturity2. LLD = 2 to 6 cm

Potential advantages vs leg lengthening - Shorter hospitalization- Faster mobilization- Decreased risk of joint stiffness- Faster healing

Closed Femoral Shortening: Indications

A : Ream B & C : Osteotomy with IM sawD : Split osteotomized fragment E : Manipulate & shorten femur F : Insert IMN G : Interlocking screws if shortened ≥4cm

Closed Femoral Shortening : Winquist TechniquePositionPositionLateral Lateral on tractionon tractiontabletable

Surgical Steps

Winquist et al (1978)

Most articles published > 20 years ago 1,2,3,5,6 Position:

Supine or lateralTraction table

Osteotomy location:

Mid-diaphyseal Implant: reamed IMN

Most done withoutinterlocking screws

Closed Femoral Shortening : Review of Literature

Available Literature

Blair et al(1989)


223 patients in 223 patients in 4 studies4 studies1,2,3,51,2,3,5

• Union rate 97.5 – 100Union rate 97.5 – 100%% Most Most common complications:common complications:

• Rotational malunionRotational malunion• ARDSARDS• Distraction at osteotomy siteDistraction at osteotomy site• Delayed unionDelayed union

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Chapman etal 1991 31

Blair et al 1989 20

Winquist 1985 154

Sasso et al 1993 18

Author Year N

not stated

3.4(2 - 5)

3.7(2 -7)

4.4(3 -5)

AmountShortened

(cm)

unplanned residual LLD (2)delayed union (1)

Malrotation(2 of 15 patients reexamined)

wound infection (1)nonunion (1)

delayed union (1)malrotation > 20º (3)

distracted osteotomy site (4)

ARDS (1)malrotation (2)

distracted osteotomy site (1)

Complications

“Long-term loss of muscle force shouldbe expected after a mid-shaftshortening of the femur of more than10%” Holm et al 1994

“after two years the quadriceps andhamstrings had recovered to within93% and 96% of their preoperativevalues respectively, a change that wasnot statistically significant” Barker et al2004

Return of Muscle Strength

Barker et al (2004)

Winquist Technique Modifications

Position : Lateral, traction table Surgical StepsA : Ream B & C : Osteotomy with IM saw D : Split osteotomized fragment E : Manipulate & shorten femur:manually with 2nd unscrubbedsurgeon F : Insert IMN G : Interlocking screws if shortening≥ 4cm

Position: supine, leg free Surgical Steps

A. Identify osteotomy siteB. Elevate periosteumC. Multiple drill holesD. ReamE. Ex-fixF. Osteotomy : IM saw + osteotomeG. Split osteotomized fragmentsH. Shorten & reduce femur : ex-fix pins

/ osteotomeI. Control reduction alignment /

rotation with ex-fixJ. Insert IMNK. Interlocking screws all casesL. Remove ex-fix

Technique Modification : Multiple Drill Holes

Surgical Steps

Identifyosteotomy site

Elevateperiosteum

Multiple drillholes

ReamEx-fixOsteotomy : IM saw +

osteotomeSplit osteotomized

fragmentsShorten & reduce

femur : ex-fix pins /osteotome

Control reductionalignment / rotation withex-fix

IMNInterlocking screwsRemove ex-fix

Technique Modifications : Fixator Assisted Nailing

Proximal pin

Distal pin

Surgical Steps

Identify osteotomy siteElevate periosteumMultiple drill holesReamEx-fixOsteotomy : IM saw +


fragmentsShorten & reduce

femur : ex-fix pins /osteotome

Control reductionalignment / rotation withex-fix


Technique Modifications : Ex-fix

11stst pin: lesser trochanter pin: lesser trochanter 2nd pin: distalfemur

Ex-fix pins prior to osteotomy

Technique Modifications : Percutaneous Osteotome

Surgical Steps

Identify osteotomysite

Elevate periosteumMultiple drill holesReamEx-fix

Osteotomy: IM saw +osteotome

Split osteotomizedfragments

Shorten & reducefemur : ex-fix pins /osteotome

Control reductionalignment / rotationwith ex-fix


Closed Femoral Shortening : Surgical Technique

Surgical Steps


osteotomeSplit

osteotomizedfragments

Shorten & reduce femur: ex-fix pins / osteotome

Control reductionalignment / rotation with ex-fix


Technique Modifications : Ex-fix

Surgical Steps



fragmentsShorten &

reduce femur : ex-fix pins /osteotome

Controlreductionalignment /rotation with ex-fix


Closed Femoral Shortening : Surgical Technique

Surgical Steps



fragmentsShorten & reduce femur

: ex-fix pins / osteotomeControl reduction

alignment / rotation with ex-fix

IMNInterlocking

screwsRemove ex-

fix

Surgical Modifications : Rationale

•• Control rotation•• Prevent distraction at osteotomy

•• Less manual manipulation of leg•• Less risk of DVT

Percutaneous Osteotome

Interlocking screws

Case Example 1

• 16 y/o M

• h/o neonatal sepsis

• previous L hip surgery forcoxa vara @ age 13

• 2.5 cm LLD

Case Example 1

Pre-op Post-op

• 20 y/o F

• Left CFD / fibular hemimelia

• h/o multiple lengtheningprocedures, including ISKD

• LLD 6.5cm radiographically (

4cm functionally )

Case Example 2

Case Example 2

Case Example 2Pre-op Post-op

Case Example 321 y/o M with 3 cm LLD, h/o Perthes L hip

Preop

Post-ophealed

Immediatepost-op

Position: supine, free leg Surgical Steps

A. Identify osteotomy siteB. Elevate periosteumC. Multiple drill holesD. ReamE. Ex-fixF. Osteotomy : IM saw + osteotomeG. Split osteotomized fragmentsH. Shorten & reduce femur : ex-fix pins / osteotome

Control reduction alignment / rotation with ex-fixJ. Insert IMNK. Interlocking screws all casesL. Remove ex-fix

Closed Femoral Shortening : Our Surgical Technique

Femoral Shortening : References

1.Bianco Jr, A.J., 1978,Femoral shortening,Clinical orthopaedics and relatedresearch,136,pp.49-53.2. Blair, V.P., Schoenecker, P.L., Sheridan, J.J. & Capelli, A.M., 1989a, Closedshortening of the femur, The Journal of bone and joint surgery. American volume, 71(10),pp. 1440-7.3. Chapman, M.E., Duwelius, P.J., Bray, T.J. & Gordon, J.E., 1993, Closedintramedullary femoral osteotomy. Shortening and derotation procedures, Clinicalorthopaedics and related research (287), pp. 245-51.4. Holm, I., Nordsletten, L., Steen, H., Folleras, G. & Bjerkreim, I., 1994, Musclefunction after mid-shaft femoral shortening A prospective study with a two-year follow-up, Journal of Bone & Joint Surgery, British Volume, 76(1), pp. 143-6.5. Winquist, R.A., 1986, Closed intramedullary osteotomies of the femur, Clinicalorthopaedics and related research(212), pp. 155-64.6. Winquist, R.A., Hansen, S.T. & Pearson, R.E., 1978, Closed intramedullary shorteningof the femur, Clinical orthopaedics and related research(136), pp. 54-61.7. Barker, K.L., Simpson, A.W. Recovery of function after closed femoral shortening.JBJS Br. J Bone Joint Surg [Br]2004;86-B:1182-6.8. Küntscher, G. Intramedullary Surgical Technique and Its Place in Orthopaedic Surgery.JBJS. VOL. 47-A. XO.1965.

References

Femoral Shortening

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