Segmental osteotomy for femoral neck stress fracture in patient with osteogenesis imperfecta

A 39-year-old female employed in a demanding and active job interacting with the public complained of right hip pain. Previously diagnosed with osteogenesis imperfecta, she exhibited a leg-length discrepancy of 5 centimeters (cm), with the right leg being longer than the left, and a severe varus deformity of the femoral shaft. Mayo Clinic's comprehensive medical and orthopedic examinations revealed a right femoral neck stress fracture.

Complexity

The case is complex due to the preoperative 5-cm leg-length discrepancy, with the right longer than the left. A standard osteotomy to correct right femur alignment would exacerbate this discrepancy in length. In addition, the patient's femoral head protrusion and overhanging ilium complicated intramedullary instrumentation.

Solution

When conservative measures such as weight-bearing restriction failed, in consultation with her orthopedic team, the patient chose multiple osteotomies of the right femur. In this two-osteotomy approach, the team performed a segmental osteotomy near the apex of the deformity. The intercalated segment of bone was split in a coronal plane, allowing the femoral shortening to occur. The varus angulation was corrected to improve femoral neck stresses by realigning the neck in a more vertical position. After inserting a rod across the osteotomy, an interlocking screw was advanced across the femoral neck into the femoral head. The team equalized leg length and improved the femoral neck alignment to promote healing and prevent the development of future femoral neck stress fractures.

Outcome

The patient began immediate postoperative full weight-bearing on her femur. She returned to work within weeks of treatment with no complications. Stephen A. Sems, M.D., lead orthopedic trauma surgeon at Mayo Clinic in Minnesota, comments: "She's doing great! She has a healed osteotomy and femoral neck stress fracture, with leg-length correction and improved femoral neck alignment. I just received a Christmas card from her, and she's back at work enjoying interacting with the public — and pain-free."