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World J Orthop. May 18, 2016; 7(5): 301-307
Published online May 18, 2016. doi: 10.5312/wjo.v7.i5.301
Valgus osteotomy for nonunion and neglected neck of femur fractures
Viju Daniel Varghese, Abel Livingston, P R Boopalan, Thilak S Jepegnanam
Viju Daniel Varghese, Abel Livingston, P R Boopalan, Thilak S Jepegnanam, Department of Orthopaedics-Unit 3, Christian Medical College, Vellore 632004, Tamil Nadu, India
Author contributions: Jepegnanam TS conceived of and designed the study, performed all the analysis, and wrote the manuscript; all authors contributed to this manuscript.
Conflict-of-interest statement: The author has no interests, commercial or otherwise, which represent a conflict of interest in relation to this study.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Thilak S Jepegnanam, Professor, Department of Orthopaedics-Unit 3, Christian Medical College, Ida Scudder Road, Vellore 632004, Tamil Nadu, India. thilakjepegnanam@yahoo.com
Telephone: +91-416-2282091 Fax: +91-416-2232035
Received: October 24, 2015
Peer-review started: December 9, 2015
First decision: January 4, 2016
Revised: February 2, 2016
Accepted: February 23, 2016
Article in press: February 24, 2016
Published online: May 18, 2016
Abstract

Nonunion neck of femur can be a difficult problem to treat, particularly in the young, and is associated with high complication rates of avascular necrosis due to the precarious blood supply and poor biomechanics. The various treatment options that have been described can be broadly divided according to the aim of improving either biology or biomechanics. Surgeries aimed at improving the biology, such as vascularized fibula grafting, have good success rates but require high levels of expertise and substantial resources. A popular surgical treatment aimed at improving the biomechanics-valgus intertrochanteric osteotomy-optimizes conditions for fracture healing by converting shear forces across the fracture site into compressive forces. Numerous variations of this surgical procedure have been developed and successfully applied in clinical practice. As a result, the proximal femoral orientation for obtaining a good functional outcome has evolved over the years, and the present concept of altering the proximal femoral anatomy as little as possible has arisen. This technical objective supports attaining union as well as a good functional outcome, since excessive valgus can lead to increased joint reaction forces. This review summarizes the historical and current literature on valgus intertrochanteric osteotomy treatment of nonunion neck of femur, with a focus on factors predictive of good functional outcome and potential pitfalls to be avoided as well as controversies surrounding this procedure.

Keywords: Neck of femur, Valgus intertrochanteric osteotomy, Head shaft angle, Neck resorption ratio, Nonunion

Core tip: Valgus intertrochanteric osteotomy is a viable treatment option for nonunion neck of femur. Size of the proximal fragment appears to be a significant predictive factor of fracture union. While valgus orientation of the proximal femur is important for fracture union, excessive valgus can lead to a poor functional outcome. The neck resorption ratio may be useful for measuring the proximal fragment and the head shaft angle may be useful for studying proximal femoral alignment in the presence of neck resorption.