Extended slide trochanteric osteotomy for revision total hip arthroplasty

BACKGROUND: The purpose of this study was to assess the rate of union, time to union, and complications associated with the extended slide trochanteric osteotomy. We also evaluated how outcomes were influenced by the preoperative cortical-bone thickness, the preoperative cancellous-bone quality of the greater trochanter, the number of cables used to reattach the trochanteric osteotomy fragment, and the use of cortical strut augmentation. METHODS: We reviewed the results for forty-six hips in forty-five patients who underwent a revision total hip arthroplasty with an extended slide trochanteric osteotomy between December 1991 and December 1996. Twenty-three patients were men, and twenty-two were women; the mean age at the time of the operation was 66.3 years. Two hips had an isolated acetabular revision, fifteen had an isolated femoral revision, and twenty-nine had acetabular and femoral revisions. One patient (one hip) was lost to follow-up. RESULTS: At a mean of forty-four months after the operation, the rate of union of the distal osteotomy site was 98 percent (forty-four of forty-five hips), with no change in the femoral component position. The time to union was not significantly correlated with the number of cables, the preoperative cortical-bone thickness, or the preoperative cancellous-bone quality of the greater trochanter. Interestingly, the time to bridging-callus union was significantly longer in the hips with a strut allograft than in the hips without a strut allograft (p = 0.04, t test for independent samples). Two fractures of the osteotomy fragment occurred, but neither necessitated another revision. CONCLUSIONS: The extended slide trochanteric osteotomy allows extensive acetabular and femoral exposure, facilitates removal of distal cement or a well fixed porous-coated stem, and allows reliable reattachment and healing of the trochanteric fragment.     

Extended trochanteric osteotomy for 2-stage revision of infected total hip arthroplasty

We evaluate the rate of osteotomy healing, implant stability, and eradication of infection when an extended trochanteric osteotomy, with interval placement of an antibiotic-impregnated cement spacer and delayed osteotomy fixation, is used to treat the chronically infected total hip arthroplasty. Thirteen cases were followed for a minimum of 2 years. All patients had complete healing of the extended trochanteric osteotomy within 6 months. At an average follow-up of 39 months, recurrent infection occurred in 3 (23%) patients. Femoral component subsidence of 5 mm occurred in 2 patients, both of which had recurrent infection. Extended trochanteric osteotomy with interval placement of an articulating antibiotic-impregnated cement spacer and delayed osteotomy fixation permits reliable healing of the osteotomy.     

Modified sliding trochanteric osteotomy in revision total hip arthroplasty

Traditional trochanteric sliding osteotomy preserves the lateral aspect of the greater trochanter, the abductors, and vastus lateralis in continuity. Our modification uses a lateral approach to the hip and osteotomy immediately anterior to the insertion of the posterior capsule and external rotators onto the greater trochanter. The osteotomy and attached abductors and vastus lateralis are translated anteriorly, leaving the posterior capsule and external rotators attached to the proximal femur. This surgical approach preserves the posterior soft-tissue stabilizing structures that resist posterior dislocation of the hip. In a retrospective review of 2 consecutive 2-year series of acetabular component revisions only between 1997 and 2001, 4 of 27 acetabular revisions using a traditional trochanteric slide subsequently dislocated; only 1 of 30 subsequent cases using a modified sliding trochanteric osteotomy dislocated. Modified sliding trochanteric osteotomy facilitated surgical exposure and produced a trend toward a lower dislocation rate that did not reach statistical significance with the small numbers of patients available.     

Anterior trochanteric slide osteotomy for primary total hip arthroplasty. Review of nonunion and complications

The radiographic results of 73 anterior trochanteric slide osteotomies were retrospectively reviewed at an average of 36 months after primary hip arthroplasty to determine the incidence of nonunion of the trochanter and complications related to trochanteric hardware. In each case, the trochanter was retracted anteriorly, with the gluteus medius and vastus lateralis muscle insertions left intact. Reattachment was performed with 2 monofilament wires or cables passed through the lesser trochanter in each case. Ninety-two percent of the trochanters healed; nonunion was associated with anterior displacement of the trochanteric fragment with external rotation of the femur. The incidence of repeat surgery for hardware-related problems was 28%. Although the slide osteotomy prevented proximal migration of the trochanteric fragment, the incidence of hardware complications was too high to justify the routine use of this approach in primary hip arthroplasty.     

Extended trochanteric osteotomy via the direct lateral approach in revision hip arthroplasty

A review of the results of the extended trochanteric osteotomy through a modified direct lateral approach in revision total hip arthroplasty was done. We reviewed 44 patients (45 procedures) at a minimum of 2 years followup (mean, 3.8 years; range, 2.1-7.2 years). There were 26 men and 18 women with a mean age at the time of surgery of 70.8 years (range, 36.9-90.4 years). Indications for use of the trochanteric osteotomy included facilitation of cement removal (25 procedures), proximal femoral varus deformity (14 procedures), trochanteric malposition (five procedures), and previous trochanteric osteotomies with significant bony overgrowth (three procedures). The mean length of the osteotomy was 133.9 mm. The mean migration of the osteotomized fragment was 2.1 mm (range, 0-20 mm) with significantly more proximal migration seen with the use of cerclage wires when compared with cables. There were two cases of trochanteric escape, for which the patients required repeat open reduction internal fixation. There were two late fractures of the greater trochanter. One femoral component had early subsidence for which the patient required re-revision with a further extended trochanteric osteotomy. The mean time to union of the remaining 40 hips was 10.3 months (range, 6-24 months). There only was one dislocation postoperatively. The extended trochanteric osteotomy through the modified direct lateral approach in revision total hip arthroplasty is a reproducible and reliable technique with a lower dislocation rate but a higher incidence of trochanteric fracture and escape than previously described with its use in the posterior approach.     

Lateral trochanteric pain following primary total hip arthroplasty

The purpose of this study was to evaluate the incidence of lateral trochanteric pain (LTP) following primary total hip arthroplasty (THA) and identify risk factors. From 1993 to 1998, 543 primary THAs were performed for osteoarthritis. Lateral trochanteric pain was identified in 24 (4.4%) of 543 patients. The incidence of LTP with the posterior approach was 1.2% (1/82), and the incidence with the direct lateral approach was 4.9% (23/461). Leg length discrepancy, femoral offset, and heterotopic ossification were not correlated with LTP. No patient required operative treatment. Lateral trochanteric pain after primary THA was significantly more common in females (P < .04) and in patients who had a direct lateral approach (P < .01). Lateral trochanteric pain in this series was effectively treated with nonoperative modalities.     

全髋关节翻修术中大转子粉碎性骨折或截骨不愈合的治疗

目的 探讨在全髋关节翻修术中采用张力带方法治疗大转子粉碎性骨折或截骨不愈便的临床效果。方法 1992年1月～1998年10月，对295例行全髋关节翻修术中大转子粉碎性骨折或截骨不愈合的19例(20髋)患者进行治疗，男7例．女12例；年龄63～76岁，平均69岁。20髋中，16髋为假体松动伴骨溶解在翻修术中发生股骨大转子骨折，4髋为全髋关节置换时采用股骨转子截骨入路。因转子截骨不愈合致髋外展肌力不足而行翻修术。采用多枚克氏针加张力带钢丝固定的方法进行治疗。结果 术后随访12～118个月,平均30个月。Harris髋关节评分从术前的平均45分恢复至随访时的平均89分。19髋达一期愈合，1髋固定失败后再次行大转于张力带固定后愈合。19髋平均愈合时间为166周。所有病例术后均无髋关节脱位。结论 在全髋关节翻修术中使用多枚克氏针加张力带钢丝固定的方法治疗股骨大转子骨折或截骨不愈合，可以提高愈合率，维持正常的髋关节外展肌功能。该方法也适用于大转子粉碎性骨折或骨质疏松的患者。     

大转子滑移截骨在人工全髋关节置换术治疗强直髋时的应用

目的:探讨大转子滑移截骨技术在人工全髋关节置换术治疗强直髋时的作用,以及其可能出现的并发症。方法:回顾性总结2010年4月至2014年12月治疗的强直髋12例,男9例,女3例;平均年龄49.9岁(37~62岁)。临床效果评估采用Harris评分,影像学评估包括大转子截骨愈合情况、假体松动情况和异位骨化情况。结果 :随访时间15~22个月,平均17.3个月。Harris评分术前43.96±8.46,术后88.00±6.11,术后评分明显改善(t=-18.34,P=0.00)。所有大转子截骨均骨性愈合,未见假体松动、异位骨化、假体脱位发生。术后感染1例,大转子区域疼痛1例。结论:大转子滑移截骨技术在人工全髋关节置换术治疗强直髋时是一种有效的增加手术暴露的方式,未发现严重的截骨相关性并发症,截骨愈合率可靠。     

Extended proximal femoral osteotomy for severe acetabular protrusion following total hip arthroplasty: A technical note

Exposing and removing the femoral and acetabular components after severe intrapelvic protrusion has occurred can be difficult and dangerous. An extended proximal femoral osteotomy carried distally to the level of the stem lip allows for atraumatic removal of the femoral stem without the need for preliminary dislocation. The exposure afforded by the osteotomy also facilitates acetabular component removal.     

Treatment of comminuted trochanteric fractures and non-union of trochanteric osteotomy in revision total hip arthroplasty

To explore the clinical efficacy of thetreatment of comminuted trochanteric fractures andtrochanteric osteotomy non-union in revision total hiparthroplasty with tension-band f‘Lxation.     

Sliding trochanteric osteotomy preserves favorable abductor biomechanics in revision total hip arthroplasty

The outcome of sliding trochanteric osteotomy in revision total hip arthroplasty was assessed by comparing preoperative and postoperative static radiographic biomechanics and clinical hip abductor function of 22 consecutive operations (20 patients). Preoperative and postoperative pelvic radiographs were reviewed to quantify the biomechanical reconstruction of the hip abductor mechanism. Abductor muscle length and abductor moment arm were increased significantly (P <.05) by the operation. There was a significant (P <.05) increase in maximum degrees of active hip abduction from the preoperative to the postoperative state, an average of 32 months (range, 6-65 months) after surgery. The dysfunction index (a radiographic representation of hip torque) correlated positively (r =.63; P <.05) with active hip abduction. Sliding trochanteric osteotomy improves abductor biomechanics and may protect against trochanteric migration in revision total hip arthroplasty.     

Extended osteotomy for periprosthetic femoral fractures in total hip arthroplasty

Total hip arthroplasty periprosthetic fractures that involve a loose prosthesis and are located at or beyond the tip of the prosthesis are difficult to manage and have higher complication and nonunion rates. In this case report, I describe a fracture-site exposure that allows simple insertion of a long, distally fixed revision prosthesis. In an extended femoral osteotomy, the entire proximal fragment opens the upper segment in "clamshell" fashion. The proximal segment is repaired with or without femoral strut allografts and multiple cerclage wires. With this method, 7 periprosthetic fractures united successfully, and none has required further reconstruction.     

股骨大转子延长截骨在假体稳定股骨柄翻修中的应用

目的 评估大转子延长截骨在股骨假体固定稳定型全髋关节翻修术中应用的中期临床效果.方法 1998年1月至2005年6月对27例患者(27髋)采用大转子延长截骨对股骨柄和(或)骨水泥壳固定稳定的全髋关节翻修.临床随访评估包括Harris评分和WOMAC评分,术前Harris评分平均42.7分,WOMAC评分平均55.6分;影像学评估包括术后拍摄X线片,对比观察截骨块愈合时间、是否存在截骨延迟愈合或不愈合,截骨块是否发生移位以及假体是否下沉等.结果 共19例患者(19髋)获得随访,平均随访时间5.3年.无一例发生术中或术后骨折.术后Harris评分平均87.3分,WOMAC评分平均46.3分.所有患者大转子截骨块均于术后6个月内愈合.无股骨大转子截骨块向近端移位,3例发生股骨柄下沉,平均下沉3.4 mm,无钢丝断裂.结论 对于假体固定稳定型股骨柄翻修,采用股骨大转子延长截骨有利于手术操作和翻修假体的植入和固定,有利于截骨块的愈合,降低术中、术后并发症发生率,中期疗效显著.     

Surgical challenges in complex primary total hip arthroplasty.

Complex primary total hip arthroplasty (THA) is defined as primary THA in patients with compromised bony or soft-tissue states, including but not limited to dysplastic hip, ankylosed hip, prior hip fracture, protrusio acetabuli, certain neuromuscular conditions, skeletal dysplasia, and previous bony procedures about the hip. Intraoperatively, provisions must be made for the possible use of modular implants and/or bone grafts. In this article, we review the principles of preoperative, intraoperative, and postoperative management of patients requiring a complex primary THA.     

Revision total hip replacement without trochanteric osteotomy

Revision total hip replacement has traditionally required a trochanteric osteotomy for successful cement removal and component reinsertion. In this study the authors have concluded that in most instances the revision total hip replacement procedure can be successfully performed without trochanteric osteotomy. The advantages are underscored by the high percentage of trochanteric complications with trochanteric osteotomy for revision total hip replacement and the ease of rehabilitation without trochanteric osteotomy. Also, improved functional results without trochanteric osteotomy were noted. The specific indications for the procedure included revision total hip replacement with ununited prior trochanteric osteotomy, revision total hip replacement with femoral shaft fractures, and revision total hip replacement with stem fractures requiring only acetabular revision. The contraindications to the procedure are fibrous union or ununited trochanteric osteotomy from prior total hip replacement, severe acetabular protrusion of the acetabular component, advanced myositis ossificans, ankylosis of the hip, and advanced proximal femoral osteoporosis. The operating room records, x-rays, and outpatient records of 63 total hip revisions in 52 patients were reviewed. There was a minimum 2-year follow up with a range from two years to seven years. The patients were divided into two groups, comparing 21 trochanteric osteotomized revisions to 44 with trochanteric sparing techniques. Both groups were analyzed for age, type of implant, intraoperative perforation of femur, intraoperative femoral shaft fractures, intraoperative cortical window, component malpositioning extraneous cement, intraoperative blood loss, operating time, postoperative leg length inequality, persistent abductor weakness, average first day of ambulation, wound infection, dislocation, nonunion of the trochanter, and postoperative pain. In the nonosteotomized group, there was a 21% decreased blood loss, a 14% decrease in persistent abductor weakness, a 14% decrease in subluxation and dislocation, a 30% decrease operating time and a 50% reduction in intraoperative femoral perforation. In the osteotomized group there were six cases of fibrous union of the greater trochanter, two cases requiring removal of broken wires for trochanteric bursitis. A detailed surgical technique and representative cases are presented. In carefully selected cases, revision total hip replacement is optimally performed without trochanteric osteotomy. Postoperative trochanteric problems of nonunion, broken wires, bursitis, and abductor weakness can effectively be eliminated by avoiding trochanteric osteotomy.(ABSTRACT TRUNCATED AT 400 WORDS)     

Lesser trochanteric osteotomy in total hip arthroplasty for treating CROWE type IV developmental dysplasia of hip

Purpose

The study was designed to evaluate the efficacy and safety of lesser trochanteric osteotomy for femoral shortening in total hip arthroplasty in treatment of 28 cases of CROWE IV developmental dysplasia of the hip (DDH).

Methods

Patients underwent progressive femoral shortening at the level of lesser trochanteric to make reduction possible into the anatomical acetabulum in all hips. The results were collected and evaluated clinically and radiographically.

Results

The mean follow-up period was 55.3 months. The average postoperative leg length discrepancy was eight millimetres for unilateral THA patients. A modified Merle d’Aubigné scale was improved from 9.3 preoperatively to 15.9 postoperatively. Sciatic nerve palsy was confirmed in two hips which resolved completely in six months. The Trendelenburg sign was positive in two hips at the final follow-up. No revision surgery was required by the final follow-up.

Conclusion

Lesser trochanteric osteotomy proved to be safe and effective in femoral shortening for treatment of CROWE IV DDH without the problem of nonunion at the site of osteotomy.     

Surgical challenges in complex primary total hip arthroplasty

Complex primary total hip arthroplasty (THA) is defined as primary THA in patients with compromised bony or soft-tissue states, including but not limited to dysplastic hip, ankylosed hip, prior hip fracture, protrusio acetabuli, certain neuromuscular conditions, skeletal dysplasia, and previous bony procedures about the hip. Intraoperatively, provisions must be made for the possible use of modular implants and/or bone grafts. In this article, we review the principles of preoperative, intraoperative, and postoperative management of patients requiring a complex primary THA.     

Primary hip arthroplasty through a limited posterior trochanteric osteotomy

This study evaluates primary hip replacement performed using a modified posterior approach through a limited posterior trochanteric osteotomy bone block that includes the insertions of the posterior capsule and short external rotators--as this may enhance secure reattachment of the posterior soft-tissue envelope and protect against postoperative instability. Sixty-eight consecutive primary hip replacements performed through a posterior trochanteric osteotomy were prospectively followed. Two were lost to follow-up before a minimum of 2 years after the arthroplasty; the remaining 66 hips were followed for a mean of 10 years (range: 2 to 15). The median Harris hip score improved from 43 to 84 points (p < 0.0001). Radiographic union of the osteotomy was confirmed in 64 hips (94%). Two episodes of early dislocation occurred 5 days and 8 months postoperatively; both were successfully managed nonoperatively without continuing instability. There were no cases of late instability. Posterior approach to the hip joint through a posterior trochanteric osteotomy is associated with high union rates and a low rate of late instability after hip replacement.     

Abductor muscle performance in total hip arthroplasty with and without trochanteric osteotomy. Radiographic and mechanical analyses

Total hip arthroplasty was performed for unilateral hip disease in 26 patients with trochanteric osteotomy (TS) and 27 patients without osteotomy (NS). Early postoperative recovery of function, pain, mobility, radiographic changes, and abduction torques were recorded and evaluated. Theoretic analysis of hip mechanics based on radiographic measurements was compared with measured abduction torques for each patient. Function, pain, and mobility ratings were similar for both groups pre- and postoperation. Radiographic measurements demonstrated better mechanical reconstruction of hips in both groups. There was a trend, but no statistically significant correlation, of mechanical parameters and measured isokinetic or isometric abduction torques at the hip joint in the TS group. In the NS group, no correlation was found between mechanical parameters and measured torques. A significant improvement in recovery of torque was found in the NS group when compared to the TS patients.     

A system for trochanteric osteotomy and reattachment for total hip arthroplasty with a ninety-nine percent union rate

In certain circumstances osteotomy of the greater trochanter in total hip arthroplasty is of benefit. To attack the problem of nonunion following trochanteric osteotomy, the authors apply several different wiring techniques. To quantify the efficacy of these approaches, they have reviewed 804 consecutive total hip arthroplasties in which the greater trochanter was osteotomized, including 725 primary total hip arthroplasties. Ninety-nine percent of the trochanters united. Among the 79 revision cases, the trochanter united in every case. The use of two independent vertical wires with one transverse wire was the preferred technique.