Valgus Osteotomy Procedure for Intracapsular Neck of Femur Fracture
Valgus intertrochanteric osteotomy is an effective procedure for treating neglected or ununited intracapsular femoral neck fractures in young patients (under 60 years), with reported union rates of 91-94% when properly performed. 1, 2
Patient Selection and Preoperative Planning
Ideal candidates:
- Young patients (typically under 60 years)
- Neglected or ununited intracapsular femoral neck fractures
- Time since injury ≥3 weeks
- Adequate bone stock (neck resorption ratio >0.5) 2
Preoperative assessment:
- Evaluate neck resorption ratio (critical predictor of union)
- Plan osteotomy angle (avoid excessive valgus >15° compared to contralateral side) 2
- Assess bone quality and viability of femoral head
Surgical Procedure Step-by-Step
1. Anesthesia and Positioning
- Either spinal or general anesthesia is appropriate 3
- Position patient supine on fracture table
- Prepare and drape the affected limb using standard sterile technique
2. Approach and Exposure
- Make a lateral incision starting 5cm proximal to the greater trochanter, extending distally along the femoral shaft
- Incise and reflect the fascia lata
- Identify and protect the vastus lateralis
- Expose the lateral aspect of the proximal femur
3. Osteotomy Execution
- Identify the level for intertrochanteric osteotomy (typically 1-2cm below the lesser trochanter)
- Insert a guide wire to mark the planned osteotomy line
- Create a laterally-based wedge with the apex medially
- The wedge angle typically ranges from 30-40° depending on preoperative planning
- Remove less bone laterally to achieve valgus correction
- Complete the osteotomy with an oscillating saw
- Remove the bone wedge
4. Fracture Reduction and Fixation
- Reduce the osteotomy site to create valgus alignment
- Verify alignment under fluoroscopy
- Aim for a final neck-shaft angle of approximately 140-145° 4
- Avoid excessive valgus (>15° compared to contralateral side) as it leads to poor functional outcomes 2
5. Internal Fixation Options
Dynamic Hip Screw (DHS) with 120° double-angle barrel plate 1
- Insert guide pin into femoral head through the fracture site
- Confirm position with fluoroscopy (central or slightly posterior in AP view, central in lateral view)
- Measure and drill for DHS screw
- Insert appropriate length DHS screw
- Attach 120° double-angle barrel plate and secure to femoral shaft
Alternative: Double-angle blade plate 5
- Insert blade at appropriate angle into femoral head
- Secure plate to femoral shaft
6. Closure
- Insert drain if needed
- Close wound in layers
- Apply sterile dressing
Postoperative Management
- Multimodal analgesia incorporating preoperative nerve block is recommended 3, 6
- Administer tranexamic acid to reduce blood loss and transfusion requirements 3, 6
- Begin early mobilization with protected weight-bearing
- Follow-up radiographs at 2,6, and 12 weeks to assess healing 6
- Expect union in approximately 10-18 weeks 1, 4
Common Pitfalls and Complications
- Inadequate preoperative assessment of neck resorption (ratio <0.5 increases nonunion risk) 2
- Excessive valgus alignment (>15°) leading to poor functional outcomes 2
- Implant cut-through or penetration into joint (4% incidence) 4
- Avascular necrosis (may occur but doesn't necessarily affect union) 2
- Limb length discrepancy (6% incidence) 4
- External rotation deformity (68% incidence) 4
Important Considerations
- For unstable (displaced) femoral neck fractures in older adults, arthroplasty is generally recommended over fixation 3
- Valgus osteotomy is primarily indicated for young patients where head preservation is the goal 1, 7
- Expected functional outcomes: Harris Hip Score improvement from pre-op 66.6 to post-op 88 points 1
- Most patients with united fractures can achieve functional activities like cross-legged sitting and squatting 1
This procedure offers a cost-effective solution for challenging femoral neck fractures in young patients, with high union rates when properly executed and appropriate patient selection.