■ the cutting edge

Section Editor: Bennie G.P. Lindeque, MD

Percutaneous Femoral Derotational

Osteotomy for Excessive Femoral Torsion
Omer Mei-Dan, MD; Mark O. McConkey, MD; Jonathan T. Bravman, MD; David A. Young, MD; Cecilia Pascual-Garrido, MD

the knee. In most adults, ante- manner. Closed, or “inside-

Abstract: Femoral derotational osteotomy is an acceptable version averages between 10° out,” intramedullary osteoto-
treatment for excessive femoral torsion. The described proce- and 15°. Abnormal femoral tor- mies preserve the bony peri-
dure is a minimally invasive single-incision technique based sion may cause abnormal joint osteum and prioritize blood
on an intramedullary saw that enables an inside-out osteoto- stresses, leading to subsequent supply and biological activ-
my, preserving the periosteum and biological activity in the degeneration of the labrum and ity to promote faster fracture
local bone and soft tissue. After the osteotomy is complete articular cartilage, hip pain, healing, having the additional
and correction is achieved, an expandable intramedullary and secondary osteoarthritis advantage of eliminating the
nail is used to achieve immediate stability, without the need at an early age.3 Complaints need for a second incision
for locking screws. Indications, tips, and pitfalls related to can range from posterior (but- and its associated morbid-
this novel osteotomy technique are discussed. [Orthopedics. tock) pain due to ischiofemo- ity.11-18
2014; 37(4):243-249.] ral impingement (short lesser In an open osteotomy, an
trochanter to ischial tuberosity oscillating saw, gigli saw, or
distance) to anterior hip pain chisels are commonly used.

D evelopmental dysplasia
of the hip can present as
various morphological abnor-
decreased acetabular coverage
of the femoral head.1 Other pa-
tients may present with an in-
and labral tears as the forward
facing femoral head places ex-
cessive stress on the iliopsoas
Open osteotomy, in general,
carries a higher risk of infec-
tion as well as a higher risk of
malities. The acetabulum of a creased femoral anteversion.2 and labrum.4 delayed or nonunion second-
dysplastic hip typically is char- Femoral version is defined as Femoral derotational oste- ary to damage to local soft tis-
acterized by a shallow articu- the angular difference between otomy is an established treat- sue and periosteal stripping.
lating cavity, an excessively the axis of the femoral neck ment for patients with symp- To preserve the periosteum
oblique acetabular roof, and and the transcondylar axis of tomatic excessive anteversion and the biological activity of
of the femur.5 The goal of the the bone and soft tissue in the
surgery is to correct the ante- area of the osteotomy, an intra-
The authors are from the Department of Orthopedics (OM-D, JTB, CP-
G), University of Colorado School of Medicine, Aurora, Colorado; Pacific version to a normal value, re- medullary saw was developed,
Orthopedics and Sports Medicine (MOM), North Vancouver, British Colum- ducing the stress on the joint allowing an inside-out femoral
bia, Canada; and the Department of Orthopaedics (DAY), Melbourne Ortho- and therefore secondary pain osteotomy for correction of
paedic Group, Melbourne, Victoria, Australia. and degeneration.6-10 During these rotational deformities.14
The authors have no relevant financial relationships to disclose.
Correspondence should be addressed to: Omer Mei-Dan, MD, Depart- the procedure, the increased Various methods have been
ment of Orthopedics, University of Colorado School of Medicine, 12631 E anteversion is normally cor- described to stabilize the bone
17th Ave, Mailstop B202, Academic Office 1, Rm 4602, Aurora, CO 80045 rected by rotating the distal fragments once the derota-
([email protected]). fragment externally. tional osteotomy has been
Received: November 4, 2013; Accepted: February 20, 2014; Posted:
April 15, 2014. Osteotomies can be per- performed.6,15,16 The Fixion
doi: 10.3928/01477447-20140401-06 formed in an open or closed nail (Carbofix Orthopedics,

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A B
Figure 1: Computed tomography axial cuts. Preoperative computed tomog-
raphy scans allow measurement of the bilateral femoral version. Femoral an-
teversion is the angle between the transverse axis of the knee joint, which is
best indicated by a line drawn tangential to the maximum posterior convexity B
A
of both femoral condyles, and the transverse axis of the femoral neck. Femoral
anteversion of 9.3° (A). Femoral anteversion of 28.8° (B).

Herzeliya, Israel), described in PREOPERATIVE PLANNING

this technique, is an expand- A diagnosis of excessive
able, stainless steel cylindrical femoral torsion is made using
nail folded longitudinally in a detailed clinical and radio-
specially designed press.17,18 graphic examinations.
The nail is designed to be in- Clinically, patients may re-
serted with or without ream- port anterior hip pain, psoas
ing and is then expanded up tendinitis, and buttock pain
to approximately 175% of its secondary to ischiofemoral im-
original diameter, using highly pingement. Examination in the
pressurized normal saline (up prone position is used to assess C
to 70 bars). After expansion, hip joint range of motion in Figure 2: Fluoroscopy showing a femoral derotational osteotomy. Anteropos-
the nail abuts the inner sur- neutral hip position (0° flexion/ terior intraoperative views of an awl on entry point at the tip of the greater
trochanter (A) followed by introduction of a ball-tipped guidewire (B). Intraop-
face of the medullary canal extension). Patients with ante- erative photograph showing reaming of the medullary canal (C).
along its entire length, mak- verted femurs normally present
ing interlocking unnecessary. an excessive internal rotation
This allows operating times of the hip with the knee bent to ment, dysplasia, or posterior that is observed frequently, al-
to be reduced, additional skin 90° in the prone position. Not- (ischiofemoral) impingement. though not consistently, in pa-
incisions to be eliminated, and ing the position of the patella, The authors use computed tients with increased femoral
exposure to ionizing radiation an accurate determination of tomography (CT) scan with anteversion.4
to be minimized. Previous re- the femoral anteversion can 3-dimensional reconstruction The amount of correction is
ports have described the suc- also be made. In the clinical ex- including both femoral neck determined on the basis of pre-
cessful use of the Fixion Nail amination of the rotational pro- and distal femoral condylar operative radiographs and CT
for the treatment of femoral file of patients with excessive axial views to obtain femoral scans (Figure 1). Contralat-
shaft fractures17,19; however, femoral anteversion, the patella torsion measurements, as well eral anteversion of the femur
use of this device for dero- will be pointed inward with the as full-length scanogram to should also be assessed. The
tational osteotomies, with a feet parallel. assess for possible leg-length surgical team determines the
single-incision technique, has Standard radiographic discrepancy. In cases of clinical rotational correction necessary
not yet been described. The analysis, including true antero- suspicion for pathological tibial based, in part, on the patient’s
authors present this technique posterior pelvis, cross-table torsion, CT views are extended contralateral version, as well
and discuss indications, tips, lateral, and/or Dunn views, is to the proximal tibia and ankle as physiological version of ap-
and pitfalls related to its use performed to assess for con- joint, to obtain tibial torsion proximately 15° to 20°. The
in femoral derotational oste- current pathologies such as measurements. External torsion goal is to achieve 15° to 20° of
otomies. femoroacetabular impinge- of the tibia is a clinical finding anteversion. However, because

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A B C D E
Figure 3: Under fluoroscopy, the osteotomy is performed using the intramedullary saw (A). Under C-arm, the intramedullary saw is introduced into the femoral
canal and seated at the planned level of the osteotomy (B). The saw diameter is then increased incrementally and rotated within the femoral shaft in fine clockwise
movements, performing a circumferential inside-out cut in the femur (C, D). Note the complete osteotomy performed once the intramedullary saw is removed (E).

currently inadequate intra- proximally at the iliac crest and ameter. The most common the femoral shaft in fine clock-
operative measurement tools spans the entire femur, ending nail they use is 34 to 36 cm wise movements, performing a
exist for assessing rotational inferior to the knee joint (Fig- long with a diameter of 12 mm circumferential inside-out cut
correction, the authors aim to ure 2). A 4- to 5-cm incision is prior to inflation. Reaming is in the femur (Figure 3). Once
correct to under 30° because made proximal to the greater performed just 1 cm distal to several full circles are com-
it is less than 2 SDs from the trochanter, similar to antegrade the planned level of the oste- pleted, and the surgeon feels
normal range. femoral nailing for fractures. otomy, 5 to 7 cm distal to the minimal to no bony resistance
The osteotomy is normally Using an awl, an entry point lesser trochanter. If a larger on the blade, further increase
performed 4 to 6 cm below the is established at the tip of the nail diameter is to be used and in the diameter of the blade is
lesser trochanter, where the di- greater trochanter and a ball- the medullary canal is mea- performed, until a complete,
ameter of the femur becomes tipped guidewire is introduced sured to be narrower than the or a near complete, osteotomy
thinner. (Figure 1). nail, reaming should be car- is achieved. The saw blade is
Reaming is then performed ried further distally, to 0.5 mm opposed to the cortical bone
SURGICAL TECHNIQUE starting with an 8-mm reamer, greater than the original nail via a surrounding cam de-
The patient is positioned su- in 0.5-mm increments, to open diameter. vice that stabilizes the cutting
pine on a fracture table or hip the medullary canal and ac- Once reaming is complete, complex within the canal and
arthroscopy distraction table. commodate the intramedul- the intramedullary saw (Biom- maintains a precise, horizontal
In some cases, hip arthroscopy lary saw used to osteotomize et, Warsaw, Indiana) is intro- cut. Just prior to completion of
may be required immediately the femur. In general, these duced into the femoral canal the osteotomy and confirma-
prior to the derotational oste- intramedullary saws can be and seated at the planned level tion of displacement, 2 Stein-
otomy because of concurrent expanded to 180% of their of the osteotomy. No guide- man pins are drilled—1 at the
intra-articular pathology. In this original diameter. The authors wire is used at this stage. The lateral greater trochanter and
instance, the authors use a sin- usually ream proximally to 15 saw diameter is then increased 1 at the supracondylar region
gle prep and draping setup for mm using a 15-mm saw blade incrementally (typically 10% of the distal femur—with the
both procedures. Draping starts allowing a 26-mm cutting di- at a time) and rotated within guidance of fluoroscopy. Us-

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A B

B C

D
Figure 4: Intraoperative photograph (A) and fluoroscopic images (B, C) show-
ing the pin placement allowing assessment of rotation. Anteroposterior view
C D
of the hip. The proximal pin is located at the greater tuberosity (B). Antero-
posterior view of the distal femur. The distal pin is located above the lateral Figure 5: Anteroposterior fluoroscopic image showing the Fixion nail (Carbofix
epicondyle (C). Photograph showing nail insertion (D). Orthopedics, Herzeliya, Israel) passing the osteotomy prior to expansion (A).
Fluoroscopic image showing the Fixion nail at its distal point where the medulla
opens up (B). Fluoroscopic image showing the nail fully expanded at its dis-
ing fluoroscopy and the angle to the proximal femur. The tal point and having good intramedullary purchase (C). Fluoroscopic image 6
between the Steinman pins, correction planned is usually weeks postoperatively showing the expanded nail proximally and through the
osteotomy with periosteum callus formation (D).
measured with a sterile goni- 10° varus (when the neck shaft
ometer, the varus and derota- angle is larger than 140° and
tional aspects of the planned the acetabulum has dysplastic similar to any antegrade femo- the greater trochanter tip and
osteotomy are performed. or borderline-dysplastic char- ral intramedullary device, but the distal end at the exit of the
Relative retroversion correc- acteristics) and a minimum without the use of a guidewire femoral isthmus, the nail is
tion of excessive femoral an- of 30° of external rotation (to because the Fixion nail is not expanded with a saline-filled
teversion (torsion) is achieved achieve relative retroversion) cannulated. Once the nail is pump to obtain “press-fit” in-
by rotating the distal femur (at (Figure 4). An expandable seated in the femur with the tramedullary purchase (Figure
the foot) outward, in relation Fixion nail is then introduced proximal portion flush with 5).

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Postoperative radiographs techniques need refinement.

are obtained to confirm posi- Therefore, the authors do not
tion and location of the nail correct excessive anteversion
and alignment. The Steinman if the anteversion is less than
pins are removed and the single 30° because this is near nor-
skin incision is closed (Figure mal range and the accuracy
6). Postoperatively, patients of surgical correction within a
are permitted to ambulate tight range is difficult to pre-
partial weight bearing with dict.
crutches for 6 weeks. Physical Performing the osteotomy
therapy is started immediately, closed21 helps preserve the
concentrating on passive and biological activity in the bone
active-assisted motion with and soft tissue in the area of
initiation of isometric activity the osteotomy. Intramedul-
of the thigh musculature. Pa- lary sawing has been well A B
tients progress to full weight described in the literature. Figure 6: Lateral radiograph obtained 6 weeks postoperatively. Note the os-
teotomy healing with periosteum callus (A). Lateral radiograph obtained 12
bearing within 4 to 6 weeks Kuentscher14 designed and
months postoperatively. Note the osteotomy healed (B).
according to subjective recov- developed an intramedullary
ery and radiographic evidence saw that has yielded excel-
of bony healing. lent long-term results.11,21,22
Table 1
Itoman et al21 developed a
DISCUSSION different motor-driven saw to Comparison of Intramedullary Nails With
Femoral derotational oste- achieve closed intramedullary Fixion Nails
otomy for excessive femoral osteotomy of the femur and
Intramedullary Nails Fixion Nailsa
anteversion has been described tibia, followed by subsequent
in the literature. However, the interlocked nailing. These Distal locking screws No distal locking screws
literature is vague, subjective, authors reported good long- Reaming No reaming necessary
and occasionally contradic- term results in a series of 10 Increased exposure to radiation Reduced exposure to radia-
tory.20 patients. tion

Careful evaluation of each Fixation of the osteotomy Additional skin incisions for One skin incision
distal screws
patient before surgery is cru- has been performed with
Three-point fixation Homogeneously shared
cial to obtain optimal results. various implants. Most of the forces
Physical examination, along published studies have em- a
Carbofix Orthopedics, Herzeliya, Israel.
with radiographic and CT ployed intramedullary rods,
evaluation, is vital to correct AO plates, or dynamic hip
diagnosis and appropriate pre- screws.20 Plates can be ap-
operative planning. plied with indirect reduction chanically, the intramedul- pressurized normal saline. Ad-
The technique described techniques and designed as lary position of the rods of- vantages of this nail compared
here represents an efficient “biologic” implants (eg, the fers more resistance to torque with a standard intramedullary
and elegant way to obtain this low-contact dynamic com- forces and increases load nail are listed in Table 1. Also,
correction and stabilize the pression plates), but they usu- transfer to the bone.23 when using an intramedullary
resultant osteotomy, achiev- ally destroy at least some of The authors have described nail, proximal and distal lock-
ing rapid healing and return the periosteal blood supply the use of the Fixion nail. The ing screws used with these rods
to activities of daily living. and disrupt the hematoma. concept is similar to that of the may produce some discom-
The goal of the surgery is to Intramedullary rods have the intramedullary rod. However, fort. Some patients may report
achieve 15° to 20° of femur advantage of preserving the the Fixion nail is designed to greater trochanter bursitis sec-
anteversion. This is obtained periosteal blood supply and be inserted with or without ondary to the proximal screws,
by rotating the distal fragment soft tissue, increasing the reaming and is then expanded and distal locking screws
externally. However, current odds of union and decreasing to approximately 175% of its may be located intracapsu-
intraoperative measurement the odds of infection. Biome- initial diameter, using highly larly, producing knee pain and

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Table 2

Technical Pearls

For the intramedullary saw

• Patient is placed supine on a traction table
• C-arm is positioned to enable smooth motion between proximal and distal femurs
• Assess exact entry point under C-arm so intramedullary saw can be placed correctly (just lateral to piriformis fossa)
• Reaming should avoid thinning of the anterior cortex
• Reaming starts at 8 mm and advances in 0.5-mm increments until required diameter is achieved
• Use the saw with the largest diameter that can be accommodated by the medulla, making sure after reaming that it is tight but never
forced. Advance the saw in a gentle oscillating motion.
• Once in position, increase saw diameter to expose the blade, starting in small increments. The blade is advanced slowly until the indexing
device reaches number 20 (which indicates maximum cutting diameter). Remember to return the blade to a closed position and remove
the saw to introduce a larger diameter saw if needed.
• If the saw did not complete a circumferential osteotomy but most of the cortex at 1 side (usually medial) is complete, the osteotomy can
be completed manually with a gentle lateral to medial direct force to the skin at this level.
• Once the osteotomy is complete, 2 pins are drilled (vastus ridge at the greater trochanter area and epicondyle area of the knee). Accurate
placement of the guide pin is important to judge accurate correction.
• Perform the derotation correction (distal fragment should be externally rotated) via an external rotation motion of the foot, which is locked
in the fracture table boot.
• Remove the 2 guide pins
• Insert the Fixion nail (Carbofix Orthopedics, Herzeliya, Israel)
For the Fixation nail
• Initial training
• Select the correct nail length and diameter according to the medullary canal diameter based on preoperative templating. Nail diameter
should be smaller than the medullary isthmus by approximately 2 mm.
• No reaming is necessary before insertion
• Fill the pump with sterile saline. Verify there are no air bubbles within the pump.
• Insertion point of the nail at the greater trochanter should be carefully evaluated regarding required varus-valgus correction.
• Before inflating the nail, assess correct derotation and proceed to inflate the nail
• When performing inflation of the nail, assess contact of the nail to the medullary canal using fluoroscopy. The nail should never be in-
flated beyond 70 bars (propagation of the osteotome to a fracture may occur if the nail exceeds this pressure).
• Inflation should be performed “step by step.” Stop inflating if any resistance is felt.
• Protective weight bearing should be indicated for 4 to 6 weeks postoperatively to prevent bending of the nail in obese or hyperactive
patients
• This nail should never be used in patients with fragile bones (severe osteoporosis or osteogenesis imperfecta). In this population, inflation
of the nail may produce a fracture.

swelling.24 These symptoms ing nails, which use 3-point (eg, failing to expand the Before using the intramed-
not infrequently necessitate fixation. Once bony healing nail or breaking its inserter). ullary saw, both the size of
a second surgery to remove has occurred, the nail can In 1 case, the nail deflated 2 the medullary canal and the
the screws. These complica- be deflated and removed if weeks after insertion, which thickness of the femoral cortex
tions are not observed with the deemed necessary. resulted in nonunion. The should be determined with an-
Fixion nail because locking As with any novel device authors believe that the latter teroposterior and lateral views
screws are not necessary. In or technology, surgeons must complication can be avoided of the femur. If thick cortices
addition, the Fixion nail uses become familiar with this by expanding the system pro- are observed, intramedullary
its longitudinal expanded bars intramedullary saw and nail gressively. When surgeons reaming should be considered
along the endosteal wall of the and their indications for use feel resistance in the screw to allow insertion of a saw of
femur to enable immediate ro- prior to employing either in mechanism of the pump, they adequate size. If reaming is
tational stability. Weight-bear- an operative setting. Reported should avoid inflating it fur- performed, careful evaluation
ing forces are homogeneously complications using the Fix- ther and wait for the pressure of the anterior cortex with an
shared on the entire diaphysis, ion nail have been mainly to fall below 50 bars before image intensifier should be
unlike with classical interlock- related to lack of experience proceeding.24 performed to avoid exces-

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sive thinning that could lead daver laboratory setting, prior omy: shortening and derotation pandable nailing system for
procedures. Clin Orthop Relat the management of pathologi-
to comminution of the oste- to surgery. Res. 1993; (287):245-251. cal humerus fractures. Arch
otomy. Some surgeons may Orthop Trauma Surg. 2002;
10. Brunner R, Baumann JU.
122(7):400-405.
also experience difficulty with REFERENCES Long-term effects of intertro-
chanteric varus-derotation os- 18. Pascarella R, Nasta G, Nico-
initial saw insertion. This can 1. Jacobsen S, Romer L, Soballe
teotomy on femur and acetabu- lini M, Bertoldi E, Maresca A,
be prevented by gently work- K. Degeneration in dysplastic
lum in spastic cerebral palsy: Boriani S. The fixion nail in
hips: a computer tomography
ing the saw into position, turn- an 11- to 18-year follow-up the lower limb: preliminary re-
study. Skeletal Radiol. 2005;
study. J Pediatr Orthop. 1997; sults. Chir Organi Mov. 2002;
ing it back and forth with an 34(12):778-784.
17(5):585-591. 87(3):169-174.
oscillating motion as it is ad- 2. Noble PC, Kamaric E, Sugano N,
11. Stahl JP, Alt V, Kraus R, Ho- 19. Siegel HJ, Sessions W, Casillas
et al. Three-dimensional shape of
vanced. Breakage at the bush- erbelt R, Itoman M, Schnettler MA Jr. Stabilization of patho-
the dysplastic femur: implica-
ing connection of the saw has R. Derotation of post-traumatic logic long bone fractures with
tions for THR. Clin Orthop Relat
femoral deformities by closed the fixion expandable nail. Or-
also been reported. Advanc- Res. 2003; (417):27-40.
intramedullary sawing. Injury. thopedics. 2008; 31(2):143.
ing the saw down the canal 3. Murphy SB, Ganz R, Muller 2006; 37(2):145-151. 20. Schwartz MH, Rozumalski A,
ME. The prognosis in un-
should be tight, but excessive treated dysplasia of the hip:
12. Winquist RA. Closed intramed- Novacheck TF. Femoral dero-
ullary osteotomies of the femur. tational osteotomy: surgical in-
force should not be required. a study of radiographic fac-
Clin Orthop Relat Res. 1986; dications and outcomes in chil-
Broken saws and/or connec- tors that predict the outcome.
(212):155-164. dren with cerebral palsy. Gait
J Bone Joint Surg Am. 1995;
tions may require open expo- Posture. 2014; 39(2):778-783.
77(7):985-989. 13. Thompson N, Stebbins J, Se-
sure to remove the hardware.25 4. Tonnis D, Heinecke A. Acetab-
niorou M, Wainwright AM, 21. Itoman M, Sekiguchi M, Yo-
Newham DJ, Theologis TN. koyama K, Minamisawa I.
Technical pearls and tips for ular and femoral anteversion:
The use of minimally invasive Closed intramedullary oste-
relationship with osteoarthritis
successful employment of techniques in multi-level sur- otomy for rotational deformity
of the hip. J Bone Joint Surg
this technique are outlined in gery for children with cere- after long bone fractures. Int
Am. 1999; 81(12):1747-1770.
bral palsy: preliminary results. Orthop. 1996; 20(6):346-349.
Table 2. 5. Eckhoff DG, Kramer RC, J Bone Joint Surg Br. 2010; 22. Majola A, Vainionpaa S, Vih-
Alongi CA, VanGerven DP. 92(10):1442-1448. tonen K, Vasenius J, Tormala
Femoral anteversion and arthri-
CONCLUSION tis of the knee. J Pediatr Or-
14. Kuentscher G. Intramedullary P, Rokkanen P. Intramed-
surgical technique and its place ullary fixation of cortical
Femoral derotational os- thop. 1994; 14(5):608-610.
in orthopaedic surgery: my bone osteotomies with self-
teotomy with an intramedul- 6. Blockey NJ. Derotation oste- present concept. J Bone Joint reinforced polylactic rods
lary saw and fixation with an otomy in the management of Surg Am. 1965; 47:809-818. in rabbits. Int Orthop. 1992;
congenital dislocation of the 16(1):101-108.
expanding nail is an effective, 15. Saikku-Backstrom A, Tulamo
hip. J Bone Joint Surg Br. 1984;
RM, Raiha JE, et al. Intra- 23. Ricci WM, Gallagher B, Haid-
minimally invasive surgical 66(4):485-490.
medullary fixation of femoral ukewych GJ. Intramedul-
technique. This technique al- 7. Moens P, Lammens J, Molen- cortical osteotomies with in- lary nailing of femoral shaft
lows reduced surgical time aers G, Fabry G. Femoral dero- terlocked biodegradable self- fractures: current concepts. J
tation for increased hip antever- reinforced poly-96L/4D-lactide Am Acad Orthop Surg. 2009;
and fluoroscopy exposure and sion: a new surgical technique (SR-PLA96) nails. Biomateri- 17(5):296-305.
the theoretical advantage of with a modified ilizarov frame. als. 2004; 25(13):2669-2677. 24. Stevens PM, Anderson D.
J Bone Joint Surg Br. 1995;
faster bony healing with pres- 77(1):107-109.
16. Jung ST, Chung JY, Seo HY, Correction of anteversion in
Bae BH, Lim KY. Multiple os- skeletally immature patients:
ervation of the local tissues 8. Svenningsen S, Terjesen T, teotomies and intramedullary percutaneous osteotomy and
and blood supply at the oste- Apalset K, Anda S. Osteotomy nailing with neck cross-pinning transtrochanteric intramedul-
otomy site. As with any new for femoral anteversion: a pro- for shepherd’s crook deformity lary rod. J Pediatr Orthop.
spective 9-year study of 52 chil- in polyostotic fibrous dysplasia: 2008; 28(3):277-283.
technique, to achieve con- dren. Acta Orthop Scand. 1990; 7 femurs with a minimum of 2 25. Rhinelander FW. Effects of
fidence and skill with these 61(4):360-363. years follow-up. Acta Orthop. medullary nailing on the nor-
instruments, surgeons must 9. Chapman ME, Duwelius PJ, 2006; 77(3):469-473. mal blood supply of diaphyseal
be trained, preferably in a ca- Bray TJ, Gordon JE. Closed 17. Franck WM, Olivieri M, Jan- cortex. Clin Orthop Relat Res.
intramedullary femoral osteot- nasch O, Hennig FF. An ex- 1998; (350):5-17.

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