Effect of Postoperative Neck-Shaft and Anteversion Angles on Biomechanical Outcomes in Proximal Femoral Osteotomy: An In Silico Study.

Effective surgical planning is crucial for maximizing patient outcomes following complex orthopedic procedures such as proximal femoral osteotomy. In silico simulations can be used to assess how surgical variations in proximal femur geometry, such as femur neck-shaft and anteversion angles, affect postoperative system mechanics. This study investigated the sensitivity of femur mechanics to postoperative neck-shaft angles, anteversion angles, and osteotomy contact areas using patient-specific finite element analysis informed by neuromusculoskeletal models. A sequential neuromusculoskeletal modeling and finite element analysis pipeline was used to simulate postoperative mechanics in three pediatric patients with varying demographic and anatomic features. Nine surgical configurations derived from permutations of the clinical envelope of neck-shaft angles and anteversion angles were simulated for the stance phase of gait. The outcome mechanics assessed were peak von Mises stresses on the bone-implant contact surfaces as well as interfragmentary movement and strain on the osteotomy location. Peak von Mises stress and interfragmentary movement and strain were on average 38% more sensitive to surgical variation in neck-shaft angle compared to anteversion angle. A significant negative correlation was detected between contact area and interfragmentary movement (r = -0.90, p < 0.0001) and strain (r = -0.45, p = 0.017). Overall findings suggest neck-shaft angle significantly influences postoperative femur mechanics and highlight the importance of maximizing contact area to limit interfragmentary motion and foster an optimal mechanical environment for bone healing and callus formation following proximal femoral osteotomy. Between-patient variation in sensitivity to proximal femoral geometry reinforced the importance of patient-specific surgical planning.