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Sarmiento Osteotomy for Intertrochanteric Frx

- Discussion:
    - involves creating an oblique osteotomy of the distal fragment (valgus osteotomy) to obtain stability in unstable intertroch frx;
    - this osteotomy changes frx plane from verticle to near horizontal & creates contact between the medial and posterior cortex of proximal and distal fragments;
          - goal is too obtain medial stability;
    - advantage of this valgus osteotomy is that valgus realignment of proximal fragment makes up for less of length at ostetomy site so that limb lengths remain equal;

- Technique:
    - a 45 deg oblique osteotomy of distal frag begins just below flare of greater trochanter and crosses distally and medially to exit about 1 cm distal to apex of fracture;
          - if osteotmy is made too transverse it places head in exaggerated valgus position;
          - this results in leg's being too long or hip's being unstable;
          - excess valgus may incr joint reactive forces and incr DJD;
          - to avoid this, the medial end of the osteotomy should exit 1 cm below frx surface medially to compensate for incr length caused by valgus osteotomy;
    - guide wire & then implant are inserted at 90 deg to plane of frx of the proximal fragment;
          - w/ more vertical alignment of frx, insert guide pin so that it ends up more inferiorly in the femoral head (otherwise, the osteotomy will be placed in varus;
                - note, however, the guide pin must still enter center of femoral head;
    - insert 135 sliding screw in usual manner;
    - frx is reduced and impacted;
    - medial cortical opposition and, hence, stability are restored;

    - Pitfalls:
    - avoid creating an external rotation deformity which would place the shaft in slight internal rotation;
    - w/ severe medial comminution, even a valgus osteotomy may not create enough bony contact to ensure stability

The unstable intertrochanteric fracture: treatment with a valgus osteotomy and I-beam nail plate.  A preliminary report of one hundred cases.

Treatment of unstable intertrochanteric fractures of the femur: a prospective trial comparing anatomical reduction and valgus osteotomy.

The unstable intertrochanteric fracture in the eldlery.  A technical note on valgus resection osteotomy and fixation with 150 deg dynamic hip screw.