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Version vs. Torsion: Clarifying the Anatomy While frequently used interchangeably, they represent distinct anatomical entities. Version refers to the transverse plane rotation localized proximal to the lesser trochanter, whereas torsion describes rotation distal to the lesser trochanter. Keep in mind that normal adult femoral version typically averages between 10° and 20°.
Choosing the Right Osteotomy Level Match the osteotomy site to the primary location and plane of the deformity:
Intertrochanteric Osteotomy: This is your workhorse for complex, multiplanar deformities (coronal, sagittal, and axial). It is the preferred technique for coxa vara/valga, unloading necrotic segments in AVN, and correcting residual SCFE. A major advantage is that the osteotomy sits in metaphyseal cancellous bone, which generally yields faster healing times.
Subtrochanteric Osteotomy: Ideal for isolated rotational deformities in the axial plane. Ortho Pearl: Because the cut is in cortical bone, it heals slower. Limit torsional corrections to ±20° to avoid exceeding the adaptive capacity of the surrounding hip musculature and altering abductor lever arms.
Femoral Neck & Head Osteotomy: Indicated for severe deformity precisely at the head-neck junction, residual SCFE, or symptomatic coxa magna. This requires a surgical hip dislocation (SHD) with an extended retinacular flap to safely mobilize the bone while preserving the terminal branches of the medial femoral circumflex artery (MFCA).
Version vs. Torsion
Version = rotation proximal to the lesser trochanter
Torsion = rotation distal to the lesser trochanter
Normal adult femoral version: 10°–20°
Primary Indications
Careful patient selection is the cornerstone of success.
The ideal candidate is typically under 60 years old, has a spherical femoral head, good joint congruency on functional radiographs, and mild to no osteoarthritis (Tönnis grade 0–2).
Torsional Malalignment & FAI: Indicated for symptomatic excessive femoral version (e.g., anteversion >25°–30° or true retroversion <0°) leading to femoroacetabular impingement (FAI), patellofemoral instability, anterior knee pain, or gait disturbances.
Hip Dysplasia: Utilized to correct coxa valga or coxa vara, improving femoral head coverage and normalizing joint biomechanics.
Avascular Necrosis (AVN): Effective in early to mid-stage (pre-collapse) AVN to mechanically unload the necrotic segment from the primary weight-bearing zone.
Pediatric Deformity Sequelae: Highly effective for addressing residual deformities from Slipped Capital Femoral Epiphysis (SCFE), Legg-Calvé-Perthes disease (such as symptomatic coxa magna or a high-riding trochanter with abductor insufficiency), and post-traumatic malunions.
Choosing the Right Level
Intertrochanteric Workhorse for multiplanar deformity. Use for coxa vara/valga, AVN unloading, residual SCFE. Heals faster — metaphyseal cancellous bone.
Subtrochanteric Isolated axial (rotational) deformity only. Correct up to ±20° max — cortical bone heals slower, and hip musculature has limited adaptive capacity.
Femoral Neck Reserved for deformity at the head-neck junction. Requires surgical hip dislocation (SHD) + extended retinacular flap to protect the MFCA terminal branches.
Distal (Supracondylar) First choice when excessive anteversion (>25°–30°) drives patellofemoral maltracking or instability. Locking plate → rigid fixation → early mobilization.
Pearls & Pitfalls
Frontal plane shift is real. Proximal external derotation → inadvertent varus. Distal external derotation → inadvertent valgus. Plan accordingly.
AVN preservation works. In >2,600 osteotomies, only 20.3% converted to THR at 7 years. Harris Hip Score jumped from 58 → 84 on average.
Hardware removal is not a complication — it's expected. Up to 40% of patients need reoperation; 77% of those are hardware removal only. Counsel patients preoperatively.
Piriformis = your safety landmark. During SHD, avoid dissection distal to piriformis near short external rotators — deep branch of MFCA is at risk.
Ideal Candidate Profile
Age <60 · Spherical femoral head · Tönnis grade 0–2 · Deformity amenable to correction
Bottom Line
Rigid preoperative planning with CT/MRI-based torsion mapping is non-negotiable. Match the level to the deformity. Protect the blood supply. Set realistic expectations.
References:
Nelitz M. Femoral Derotational Osteotomies. Curr Rev Musculoskelet Med 2018;11:272-9.
Rodham PL, Jido JT, Bethell H, et al. The Role of Proximal Femoral Osteotomy for the Treatment of Avascular Necrosis: A Systematic Review of Clinical and Patient-Reported Outcomes. J Clin Med 2025;14:5592.
Nelson CT, Reiter CR, Harris M, et al. Femoral rotational osteotomy for femoroacetabular impingement: A systematic review. J Orthop 2024;50:139-48.
Schaible SF, Rego P, Steppacher SD, et al. Indications and techniques of proximal femoral osteotomies in 2026. EFORT Open Rev 2026;11:415-25.