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hip•opsurg-629

Proximal Femoral Osteotomy

intermediate Level

Primary Indication

Coxa vara, coxa valga, hip dysplasia (femoral component), Perthes sequelae

Danger Structures

  • Sciatic nerve - 15-30mm posterior to hip joint depending on approach and position, injury causes foot drop and sensory loss - EXAM KEY: identify and protect, keep hip flexed to relax nerve
  • Femoral neurovascular bundle - 30-50mm medial to anterior hip joint, injury catastrophic - EXAM KEY: stay on bone with anterior retractors
  • Superior gluteal neurovascular bundle - 30-50mm proximal to greater trochanter, injury causes abductor weakness - EXAM KEY: avoid proximal dissection, stay in safe zone
  • Lateral femoral cutaneous nerve - variable position 20-50mm from anterior incisions, injury causes meralgia paresthetica - EXAM KEY: protect when visible
  • Medial femoral circumflex artery - main blood supply to femoral head, at risk during capsulotomy - EXAM KEY: careful dissection around posterior femoral neck

Visual Atlas

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Step-by-Step Technique

1

Lateral incision over proximal femur

Surgeon's Tip
EXAM KEY: Critical step in Proximal Femoral Osteotomy - ensure proper technique and visualization.
Danger Zone
  • Skin necrosis from excessive tension
  • Damage to underlying structures
2

Split vastus lateralis or elevate from intermuscular septum

Surgeon's Tip
EXAM KEY: Critical step in Proximal Femoral Osteotomy - ensure proper technique and visualization.
Danger Zone
  • Iatrogenic injury to adjacent structures
3

Apply blade plate or angle plate guide

Surgeon's Tip
EXAM KEY: Critical step in Proximal Femoral Osteotomy - ensure proper technique and visualization.
Danger Zone
  • Malposition of hardware
  • Damage to adjacent structures
4

Insert guide wire for plate at calculated angle

Surgeon's Tip
EXAM KEY: Critical step in Proximal Femoral Osteotomy - ensure proper technique and visualization.
Danger Zone
  • Malposition of hardware
  • Damage to adjacent structures
5

Pre-operative templating essential for correction angle

Surgeon's Tip
EXAM KEY: Critical step in Proximal Femoral Osteotomy - ensure proper technique and visualization.
Danger Zone
  • Iatrogenic injury to adjacent structures
6

Insert blade plate chisel along guide wire

Surgeon's Tip
EXAM KEY: Critical step in Proximal Femoral Osteotomy - ensure proper technique and visualization.
Danger Zone
  • Malposition of hardware
  • Damage to adjacent structures
7

Mark osteotomy level distal to plate entry

Surgeon's Tip
EXAM KEY: Critical step in Proximal Femoral Osteotomy - ensure proper technique and visualization.
Danger Zone
  • Malposition of hardware
  • Damage to adjacent structures
8

Transverse osteotomy (or intertrochanteric, subtrochanteric)

Surgeon's Tip
EXAM KEY: Critical step in Proximal Femoral Osteotomy - ensure proper technique and visualization.
Danger Zone
  • Iatrogenic injury to adjacent structures
9

Remove bone wedge for valgus correction

Surgeon's Tip
EXAM KEY: Critical step in Proximal Femoral Osteotomy - ensure proper technique and visualization.
Danger Zone
  • Iatrogenic injury to adjacent structures
10

Correct rotation, length as needed

Surgeon's Tip
EXAM KEY: Critical step in Proximal Femoral Osteotomy - ensure proper technique and visualization.
Danger Zone
  • Iatrogenic injury to adjacent structures
11

Close osteotomy and apply plate

Surgeon's Tip
EXAM KEY: Critical step in Proximal Femoral Osteotomy - ensure proper technique and visualization.
Danger Zone
  • Malposition of hardware
  • Damage to adjacent structures
12

Verify correction fluoroscopically

Surgeon's Tip
EXAM KEY: Critical step in Proximal Femoral Osteotomy - ensure proper technique and visualization.
Danger Zone
  • Iatrogenic injury to adjacent structures
13

Bone graft if significant gap

Surgeon's Tip
EXAM KEY: Critical step in Proximal Femoral Osteotomy - ensure proper technique and visualization.
Danger Zone
  • Iatrogenic injury to adjacent structures
14

Perform intraoperative imaging/fluoroscopy to confirm adequate position and alignment

Surgeon's Tip
EXAM KEY: Documentation of intraoperative findings is crucial for Proximal Femoral Osteotomy.
Danger Zone
  • Radiation exposure
  • Inadequate imaging
15

Irrigate wound thoroughly and achieve meticulous hemostasis

Surgeon's Tip
EXAM KEY: Copious irrigation reduces infection risk. Bipolar for hemostasis near neurovascular structures.
Danger Zone
  • Hematoma formation
  • Wound complications