Autogeneic cancellous bone grafting following transtrochanteric hip arthroplasty. An attempt to facilitate union of the greater trochanter

A technique involving the use of autogeneic cancellous bone to facilitate union of the greater trochanter following hip arthroplasty via a transtrochanteric approach is presented. This technique has not been previously reported for a large series of patients. Two hundred thirty-five patients were treated with 286 hip arthroplasty procedures via a transtrochanteric approach. All trochanters were advanced 1-2 cm distally and reattached using a three-wire technique. In 111 procedures, cancellous bone taken from the excised femoral head or neck was placed at the inferior aspect of the osteotomy site. In the remaining 175 procedures, no bone grafting was performed. Retrospectively, the incidences of trochanteric nonunion at two-year follow-up evaluation for the nongrafted versus the grafted groups were as follows: 5.7% (10 of 175) versus 2.7% (3 of 111) overall incidence, 4.3% (6 of 139) versus 1.2% (1 of 85) in patients with no previous hip surgery, 8.7% (2 of 23) versus 0% (0 of 10) in patients with previous hip surgery (excluding previous hip arthroplasty), and 15.4% (2 of 13) versus 12.5% (2 of 16) in patients following revision arthroplasty. There was no significant difference in incidence of nonunion between the grafted versus nongrafted groups in any of these categories (chi-square analysis). However, a lower incidence of trochanteric nonunion was found for the patients with autografts in each category, which may indicate a beneficial effect of cancellous bone grafting following trochanteric osteotomy.     

Trabecular bone changes in the greater trochanter after fracture of the femoral neck

Bone samples were taken from the trabecular part of the greater trochanter in 32 patients who had had a fracture of the ipsilateral femoral neck, and from 24 patients who had coxarthrosis. 42 cadavers served as controls. The samples were sectioned, stained and examined histologically.

The coxarthrosis cases differed only slightly from normal, whereas the fracture cases had increased osteoid volume and surface. Osteoclasts were also increased in number, as were active osteoblasts.     

Fracture of the greater trochanter after hip replacement

Fracture of the femur is one of the common complications of hip replacement surgery. Five percent of femur fractures involve just the greater trochanter. This series consisted of 21 women and nine men with fractures of just the greater trochanter after total or partial hip replacement. The fracture was displaced 2.5 cm or less in 90% of patients. Only three (10%) patients had an increase in the amount of displacement more than 2 months after the fracture was recognized. The direction of displacement was always medially and superiorly toward the femoral head, rather than directly superiorly as in an ununited trochanteric osteotomy. For 18 (60%) patients, the fracture was asymptomatic. For 12 patients, the fracture was painful or there was a significant limp. In six of the 12 patients, the pain and limp improved over several months. There were no dislocations or subluxations in this series. Three patients continued to have pain or limp but thought it was not severe and declined surgical repair and experienced progressive improvement. In three patients, the pain, a limp, or both persisted at 1 year and the displacement was 2 cm or more. These three patients underwent operative repair of the trochanter. Two patients experienced improvement after repair of the trochanter. The conclusion was that fractures of the greater trochanter generally are stable and usually do not require additional treatment.     

Reattachment of the greater trochanter after hip replacement

A method of performing a biplanar intracapsular trochanteric osteotomy with a Gigli saw was designed and tested prospectively in 431 cases of Charnley low friction arthroplasty. Three methods of trochanteric reattachment were tested, and a double cross-over wire with a compression spring was best; this method was successful in 222 out of 226 patients (98.2%), of which half were revision operations. Adduction seemed to be the main movement leading to trochanteric detachment.     

DHS结合大转子部松质骨螺钉治疗老年股骨转子间骨折

2006年7月～2010年8月,我院应用DHS结合大转子部松质螺钉治疗36例老年股骨转子间骨折患者,取得良好疗效。1材料与方法1.1病例资料本组36例,男12例,女24例,年龄60～85岁。均为新鲜骨折,按Evans分型:Ⅰ型7例,Ⅱ型15例,Ⅲ型14例。术前X线检查均显示有不同程度的骨质疏松,其中严重骨质     

Use of a craniotome for obtaining cancellous bone and marrow from the ilium.

The ilium is a rich source of cancellous bone and marrow for grafting. Grafts can be harvested very rapidly with a standard craniotome. The clutch mechanism prevents inadvertent soft tissue injury if both cortical plates are perforated. The surgical approach is similar to that used in other techniques. No complications have been encountered.     

Self-compressive osteotomy of the greater trochanter

Summary. We have designed a dihedral osteotomy of the greater trochanter which is V-shaped with the apex infero-medially. A single screw is used for fixation. The osteotomy was used in 24 hips (23 patients), as part of a transtrochanteric approach for acetabular reconstruction, carried out for dysplasia or in complicated acetabular fractures. There were no cases of nonunion or painful bursitis at an average follow up of 20 months. The method provides a stable reduction and bony union because of the self-compressive effect of the abductor muscles.

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Résumé. Nous présentons une nouvelle ostéotomie à angle dièdre du grand trochanter, qui est une ostéotomie en V avec l’apex en situation médiale. La fixation trochantérienne fut effectuée avec une vis unique. Une approche transtrochantérienne utilisant cette méthode fut employée pour une reconstruction acétabulaire sur 24 hanches consécutives de 23 patients qui souffraient d’une dysplasie résiduelle des hanches ou d’une fracture acétabulaire compliquée. Durant la surveillance d’une moyenne de 20 mois (12 à 33), il n’y eu pas de désunion ou de bursite douloureuse. Cette méthode facilite à la fois une réduction solide et la coaptation osseuse grace à l’effet auto-compressif des muscles abducteurs.

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Accepted: 12 July 1996     

Distal transfer of the greater trochanter

After congenital dislocation of the hip, Perthes' disease and some other conditions, the femoral neck may be short and the greater trochanter in a relatively proximal position. Distal transfer of the greater trochanter is an effective and relatively simple operation to correct this deformity. We have reviewed 26 patients (27 hips) at a mean follow-up of eight years. Pain relief and improvement in gait were maintained in 74%, and the poor results were largely due to progression of osteoarthritis. We describe a 'gear-stick' sign of trochanteric impingement, which is useful in the pre-operative assessment of patients.     

Tuberculous bursitis of the greater trochanter

A patient with tuberculous bursitis of the greater trochanter is reported. A 37-year-old woman had experienced persistent dull hip pain and noticed diffuse swelling over the greater trochanteric region. Plain radiograph revealed unremarkable osteopenic changes in the greater trochanter and faint mineralization in the vicinity of the trochanter. Computed tomogram showed erosion of the trochanter and a large soft tissue mass. Magnetic resonance imaging demonstrated a large multicystic mass. Histology of the cyst wall, showing chronic granulomatous tissue, and a positive culture of Mycobacterium tuberculosis confirmed the diagnosis of musculoskeletal tuberculosis. Complete excision of the lesion, followed by 6 months of antituberculous chemotherapy with rifampicin and isoniazid, cured the disease. There has been no sign of recurrent disease in 30 months of follow-up. Correct diagnosis was difficult because of its rarity, but modern imaging technology, magnetic resonance imaging, in particular, was extremely useful for showing the extent of the disease. Tuberculous infection should be considered as a differential diagnosis in patients with persistent hip pain. Received for publication on July 11, 1997; accepted on Nov. 6, 1997     

Trabecular bone deterioration at the greater trochanter of mice with unilateral obstructive nephropathy

Our previous study showed the early molecular responses of bone in response to obstructive nephropathy in a unilateral ureteral obstruction (UUO) mouse model. Here, we addressed the changes in trabecular bone properties at greater trochanter, the proximal and the distal metaphysis of femur in UUO mice. The male mice were subjected to UUO (n=10) or sham operation (n=10). All mice were killed on day 7 after the surgical operation. The micro-computed tomography (micro-CT) analysis for different femoral trabecular bone sites demonstrated pathological alterations of trabecular bone mass and micro-networks at greater trochanter as shown by decreases in bone mineral density/bone volume (P<0.05) and trabecular number (P<0.05) and increases in trabecular separation (P<0.01) and bone surface/bone volume (P<0.05) in UUO mice. The present study demonstrates that UUO-induced unilateral obstructive nephropathy has markedly detrimental effects on the trabecular trochanter of the femur.     

Re-attachment of the greater trochanter. The use of the trochanter cable-grip system

In comparison with monofilament wire, multifilament cable was found to be a more suitable material for fixation of the greater trochanter. It is versatile, easy to work with and has superior mechanical properties. The "trochanter cable-grip system" was developed to exploit the use of multifilament cable as a means of reattaching the greater trochanter and experimental studies have yielded excellent results. This system was subjected to clinical trials for over four years in 321 hips and, at its present state of development, the incidence of detachment has been reduced to 1.5 per cent and that of cable breakage to 3.1 per cent.     

Osteolytic lesion in the greater trochanter mimicking tumor

Two patients with an osteolytic lesion of the greater trochanter suggesting a malignant bone tumor are presented. Biopsy, microbiological and histological examination suggested a diagnosis of trochanteric tuberculosis. Treatment consisted of multiple surgical debridements and antituberculous chemotherapy. The incidence of similar cases is expected to increase with the rising incidence of tuberculosis.