Extended Trochanteric Osteotomy Research Articles

The feasibility of a novel 3D-Printed patient specific cutting guide for extended trochanteric osteotomies

BackgroundThe extended trochanteric osteotomy (ETO) is a surgical technique utilized to expose the intramedullary canal of the proximal femur, protect the soft tissues and promote reliable healing. However, imprecise execution of the osteotomy can lead to fracture, soft tissue injury, non-union, and unnecessary morbidity. We developed a technique to create patient specific, 3D-printed cutting guides to aid in accurate positioning of the ETO and improve osteotomy quality and outcomes.MethodsPatient specific cutting guides were created based on CT scans using Synopysis Simpleware ScanIP and Solidworks. Custom 3D printed cutting guides were tested on synthetic femurs with foam cortical shells and on cadaveric femurs. To confirm accuracy of the osteotomies, dimensions of the performed osteotomies were compared to the virtually planned osteotomies.ResultsUse of the patient specific ETO cutting guides resulted in successful osteotomies, exposing the femoral canal and the femoral stem both in synthetic sawbone and cadaveric testing. In cadaveric testing, the guides allowed for osteotomies without fracture and cuts made using the guide were accurate within 6 percent error from the virtually planned osteotomy.ConclusionThe 3D-printed patient specific cutting guides used to aid in ETOs proved to be accurate. Through the iterative development of cutting guides, we found that a simple design was key to a reliable and accurate guide. While future clinical trials in human subjects are needed, we believe our custom 3D printed cutting guide design to be effective at aiding in performing ETOs for revision total hip arthroplasty surgeries.

The CCJR® Charles A. Engh, Sr, MD. Excellence in Hip Research Award: The Evolution of Revision Hip Arthroplasty and Impact on the Trainee’s Experience

BackgroundAdvances in total hip arthroplasty (THA) have resulted in evolving revision indications and intraoperative techniques, which can influence the exposure of trainees to complex cases. We report 3 decades of revision experience from a tertiary referral center that trains fellows, comparing the reasons for revision and the complexity of revisions over time. MethodsWe retrospectively reviewed all revision THAs performed at our institution from 1990 to 2022. Revision diagnoses, components revised, types of revision implants used, and exposure techniques were collected. A “complex” revision was defined as a case that involved an extended trochanteric osteotomy, triflange and cup-cage construct, or acetabular augment. ResultsA total of 3,556 THA revisions were identified (108 revisions/year). Aseptic loosening was the most common indication in 1990 to 1999 (45 per year), but decreased to 28.3/year in 2010 to 2019. From 1990 to 1999 and 2010 to 2019, fracture increased from 3.1 to 7.3 per year, infection from 2.9/year to 16.9/year, and metallosis from 0.1 to 13.2 per year. Both component revision were common from 1990 to 1994 (42.6 per year), while polyethylene exchange was most common in 2010 to 2019 (43.3 per year). A decrease was observed in “complex” cases over time: 14.8 extended trochanteric osteotomies/year in 2000 to 2004 compared to 5.4 per year in 2018 to 2022, 4.5 triflange and cup-cage constructs/year in 2004 to 2007 compared to 0.8 per year in 2018 to 2022, and 4 acetabular augments per year in 2009 to 2012 compared to 1 per year in 2018 to 2022. ConclusionsIndications for revision have changed over the decades, while the number of “complex” revisions has gradually decreased, presumably due to advances in implants and materials. If this trend extends to other training institutions, the next generation of arthroplasty surgeons will have less exposure to complex revisions during their training.

Clinical and radiographic outcomes of long monoblock, hydroxyapatite-coated stem in revision hip arthroplasty with extended trochanteric osteotomy: a multicenter study

BackgroundThe distally fixed stem used in revision total hip arthroplasty (rTHA) with extended trochanteric osteotomy (ETO) is subject to periprosthetic fracture, stem subsidence, and stress shielding. The prospective multicentric study aimed to assess the clinical and radiographic outcomes, and complications of using the Corail revision stem in rTHA with ETO.MethodsSixty-four patients undergoing rTHA with ETO using the Corail revision stem between 2019 and 2020 were enrolled in the study. We performed a postoperative follow-up of the patient and obtained radiographs and Harris hip scores (HHSs). These results were used to analyze ETO union, Engh scores, bone remodeling, stem stability and hip function.ResultsThe mean follow-up duration was 34 months (range 23–41). Sixty-two patients who underwent ETOs achieved complete healing at the final follow-up. Fifty-nine hips had bony ingrowth from the osteotomy fragment to the stem without radiolucent lines. The postoperative Engh score was 21.3 ± 3.59 (range 15.5–27.0). Forty-three hips had regeneration in the proximal femur. Two patients had transient thigh pain postoperatively. The postoperative HHS improved from 40.7 ± 16.67 (range 0–67) preoperatively to 82.1 ± 6.83 (range 73–93).ConclusionCorail revision stems are a viable and reliable option in rTHA with ETO. This stem had excellent clinical and radiographic outcomes, resulting in a high rate of ETO union and stem survival. The revision stem enabled restoration of proximal bone stock in femurs with prerevision bone defects, which were prepared for the next revision operation.Level of evidence Level IIb, Prospective self-control study.

A Monocortical Screw for Preventing Trochanteric Escape in Extended Trochanteric Osteotomy: A Simple Solution to a Complicated Problem?

Extended trochanteric osteotomy (ETO) is an established method in revision total hip arthroplasty. Proximal migration of the greater trochanter fragment and the resulting non-union of the osteotomy remains a major problem, and several techniques have been developed to prevent its occurrence. This paper describes a novel modification of the original surgical technique in which a single monocortical screw is placed distally to one of the cerclages used for the fixation of the ETO. The contact between the screw and the cerclage counteracts the forces applied on the greater trochanter fragment and prevents trochanteric escape under the cerclage. The technique is simple and minimally invasive, does not require special skills or additional resources, or add to surgical trauma or operating time, and therefore represents a simple solution to a complicated problem.

Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty.

Removal of well-fixed femoral components during revision total hip arthroplasty (THA) can be difficult and time-consuming1, leading to numerous complications, such as femoral perforation, bone loss, and fracture. Extended trochanteric osteotomies (ETOs), which provide wide exposure and direct access to the femoral canal under controlled conditions, have become a popular method to circumvent these challenges. ETOs were popularized by Wagner (i.e., the anterior-based osteotomy), and later modified by Paprosky (i.e., the lateral-based osteotomy)2. The decision to utilize the laterally based Paprosky ETO versus the anteriorly based Wagner ETO is primarily based on surgeon preference, the location and type of in situ implants, and the osseous anatomy. Typically, a laterally based ETO is most facile in conjunction with a posterior approach and an anteriorly based ETO is most commonly paired with a lateral or anterolateral approach. Attention must be paid to maintaining vascularity to the osteotomy fragment, including minimizing stripping of the vastus lateralis from the osteotomy fragment and maintaining abductor attachments to the osteotomy fragment. When utilizing a laterally based ETO, the posterior border of the vastus lateralis must be carefully elevated to provide exposure for performance of the osteotomy. When an anteriorly based osteotomy is performed, the surgeon may instead extend the abductor tenotomy proximally with use of a longitudinal split of the vastus lateralis distally, which helps to keep the anterior and posterior sleeves of soft tissue in continuity. In either approach, dissection of the vastus lateralis involves managing several large vascular perforators. We prefer performing careful blunt dissection to identify the perforators and prophylactically controlling them, with ligation of large vessels and electrocautery of smaller vessels. Vascular clips are also available in case difficult-to-control bleeding is encountered. In general, an oscillating saw (with preference for a thin blade) is utilized to complete the posterior longitudinal limb of the ETO, extending approximately 12 to 16 cm distally from the tip of the greater trochanter. Although a 12 to 16-cm zone is required to maintain maximum vascularity to the osteotomized fragment, the osteotomy length must ultimately be determined by (1) the length of the femoral component to be removed; (2) the presence of distal bone ingrowth, ongrowth, or cement; and (3) the presence of distal hardware or stemmed knee components. A smaller oscillating saw is then utilized to complete the transverse limb at the previously identified distal extent. A high-speed pencil-tip burr is utilized to complete the corners of the osteotomy in a rounded configuration, and a combination of saws and pencil-tip burrs is utilized to create partial proximal and distal anterior longitudinal limbs of the osteotomy to the extent allowed by the soft-tissue attachments. The anterior longitudinal limb may be further weakened in a controlled fashion with use of serial drill holes. The anterior longitudinal limb then undergoes controlled fracture by placement of 2 to 4 broad straight osteotomes in the posterior longitudinal limb. These osteotomes are carefully levered anteriorly in unison with a gentle, steady force. After the ETO is completed, intramedullary prostheses, hardware, and cement are removed; the acetabulum is addressed as needed; and a final femoral stem is implanted, if appropriate. After completion of the osteotomy, the osteotomized fragment must be retracted gently, with care taken to avoid a fracture and maintain vascularity. To this end, debridement of the endosteum of the osteotomized fragment, including any cement removal, should be avoided until the end of the procedure, when the osteotomy is ready to be closed. Our preferred method for closure is to place 1 prophylactic cable 1 cm distal to the osteotomy, 1 to 2 cables along the diaphyseal segment of the osteotomy, and 1 Luque wire above the less trochanter. A Luque wire is our specific choice for the location above the lesser trochanter because it sits in the effective joint space; however, the use of Luque wires distal to the lesser trochanter is also acceptable. A strut allograft or locking plate can be utilized to reinforce the osteotomy in rare cases or to bridge interprosthetic stress risers. Trochanteric implants are typically avoided because of the low rate of clinically relevant trochanteric migration with this closure technique and because of the high rate of symptomatic implants with trochanteric claws or plates. An alternative osteotomy of similar exposure is the transfemoral osteotomy. Additionally, a variety of non-extended trochanteric osteotomies, such as trochanteric slide osteotomies, offer more limited exposure. Femoral surgical exposure for revision THA can be aided by performing transfemoral osteotomies, but these provide less precise control of the separate proximal femoral osteotomized segment(s), and healing and fixation can be less reliable. Less invasive osteotomies such as non-extended trochanteric osteotomies typically do not provide adequate exposure in challenging cases for which ETO is being considered. ETOs have high union rates, and notable trochanteric migration is infrequent. The most common complications are fracture of the osteotomy fragment intraoperatively or postoperatively. Radiographic and clinical union is achieved in 98% of patients. The mean proximal trochanteric osteotomy fragment migration prior to union is 3 mm. ETO fragment migration of >1 cm occurs in just 7% of hips. Postoperative greater trochanter fractures occur in 9% of hips. The 10-year survivorship free of revision for aseptic femoral loosening, free of femoral or acetabular component removal or revision for any reason, and free of reoperation for any reason is 97%, 91%, and 82%, respectively3. Attention should be paid to patient anatomy, deformity, surgical approach, and implant type when choosing to perform a laterally based Paprosky or anteriorly based Wagner ETO.Appropriate length of the posterior longitudinal limb of the ETO is approximately 12 to 16 cm distally from the tip of the greater trochanter.Attention must be paid to maintaining vascularity to the osteotomy fragment, including minimizing stripping of the vastus lateralis from the osteotomy fragment and maintaining abductor attachments to the osteotomy fragment.A high-speed pencil-tip burr should be utilized to complete the corners of the osteotomy in a rounded configuration in order to avoid stress risers.The anterior longitudinal limb is completed by controlled fracture of the remaining intervening segment in order to maintain vastus lateralis attachments and vascular supply to the osteotomy fragment.The ETO is closed with use of cerclage cables and/or double-stranded Luque wires, typically utilizing a total of 3 to 4 in order to obtain secure fixation without compromising local biology. MFT = modular fluted tapered.

The Impact of Exchanging Cerclage Fixation after Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty for Periprosthetic Joint Infection

BackgroundAn extended trochanteric osteotomy (ETO) is a powerful tool for femoral component revision. There is limited evidence that directly supports its use in the setting of a periprosthetic joint infection (PJI). Cerclage fixation raises the theoretical concern for persistent infection. MethodsOur institutional database included 76 ETOs for revision hip arthroplasty between January 1, 2008 and December 31, 2019. The cohort was divided based on indication for femoral component revision: PJI versus aseptic revision. The PJI group was subdivided based on second-stage exchange versus retention of initial cerclage fixation. Operative time, estimated blood loss, complications, and rate of repeat revision surgery were evaluated. ResultsForty-nine patients (64%) underwent revision for PJI and 27 patients (36%) underwent aseptic revision. There was no significant difference in operative times (P = .082), postoperative complications (P = .258), or rate of repeat revision surgery (P = .322) between groups. Of the 49 patients in the PJI group, 40 (82%) retained cerclage fixation while 9 (18%) had cerclage exchange. Cerclage exchange did not significantly impact operative time (P = .758), blood loss (P = .498), rate of repeat revision surgery (P = .302), or postoperative complications (P = .253) including infection (P = .639). ConclusionAn ETO remains a powerful tool for femoral component removal, even in the presence of a PJI. A multi-institutional investigation would be required to validate observed trends toward better infection control with cerclage exchange. Cerclage exchange did not appear to increase operative time, blood loss, or postoperative complication rates.

Clinical Outcomes After Stage-One Antibiotic Coated Molded Hip Spacer

Two-stage exchange remains the gold standard for managing periprosthetic joint infection (PJI). We evaluated the outcomes of patients treated with a specific molded articulating antibiotic hip spacer for PJI at a tertiary referral center. An institutional database was retrospectively queried for patients who underwent implantation of spacer between 2009-2019. Patient demographics and clinical outcomes were collected. We identified 88 patients at an average age of 60.4 years who received a spacer implant, with an average of 4.2 years follow-up (standard deviation [SD] 2.5 years). A total of 34 patients (38.6%) had a "clean" two-stage course with successful reimplantation and no evidence of infection at 1-year follow-up. The remaining patients (61.4%) required 3.67 (±0.52) additional surgeries. Overall reimplantation rate was 72%. Causative bacterial agents included MSSA (n= 22), MRSA (n= 16), coagulase-negative Staphylococcus (n= 14), and polymicrobial (n= 12). Regarding complications, there were 13 (15%) dislocations, 16 (18%) periprosthetic fractures, 8 (9%) bent/fractured stems, and 16 (18%) patients had clinically significant subsidence. Patients with previous extended trochanteric osteotomy (ETO) experienced higher rates of bent/broken spacer stems (25% vs 3.1%; P= .006) periprosthetic fractures (37.5% vs 10.9%; P= .010), and dislocations (37.5% vs 6.2%; P= .001). The rate of infection clearance was lower in the prior ETO cohort (26.6% vs 54.2%; P= .029). We report outcomes in patients who underwent implantation of a specific molded articulating hip spacer at our institution. Infection eradication was roughly in line with published series of hip PJI treatment. There was a high rate of mechanical complications, especially in those patients who required an ETO.

Aseptic Revision of Total Hip Arthroplasty With a Single Modular Femoral Stem and a Modified Extended Trochanteric Osteotomy-Treatment Assessment With the Forgotten Joint Score-12.

BackgroundAseptic loosening is among the most common reasons for revision total hip arthroplasty (RTHA). Modular revision stems implanted through an extended trochanteric osteotomy (ETO) promise good results, but patient-reported outcome measures (PROMs) are rarely conveyed. This study used the Forgotten Joint Score-12 (FJS-12) to assess patient-reported outcome in patients who had undergone RTHA for aseptic stem loosening using a modified ETO approach with a tapered, fluted modular stem.Material and methodsA single-center analysis of aseptic RTHA was performed (2007–2019). Clinical results (range of motion, walking ability, function), radiographic results (ETO healing, stem subsidence), and PROMs (FJS-12, Harris Hip Score, European Quality of Life 5D Score) were assessed. Minimum follow-up duration was 1 year. Complications including revisions were recorded.ResultsPrimary outcome parameters were assessed on 72 patients (mean age 73.3 years, mean body mass index 27.6kg/m2). Additional PROMs were collected by phone interviews from 41 patients (mean follow-up 5.7 years). In 76%, leg length was restored, and a normal gait was achieved. After 1 year, the ETO was healed in 93%; subsidence occurred in 8.3% of cases. The mean FJS-12 at the final follow-up was 85.6 ± 23.6, and the respective Harris Hip Score and European Quality of Life 5D Score averaged 87 ± 17.8 and 72.9 ± 15.9. Complication and revision rates were 33.3% and 13.9%, respectively.ConclusionAseptic RTHA as presented here resulted in excellent PROMs in the medium term. FJS-12 score averaged 85.6 with a mean follow-up of 5.7 years. Treatment using a modular implant and a modified ETO was associated with good clinical and radiographic outcomes. Complication and revision rates were 33.3% and 13.9%, respectively.

Comparison of Functional and Radiographic Outcomes Between Two Fixation Methods for Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty: A Retrospective Cohort Study

BackgroundTo compare the functional and radiographic outcomes between two fixation methods for extended trochanteric osteotomy (ETO) in revision total hip arthroplasty (rTHA). MethodsIncluded in this study were 64 patients who underwent ETO in rTHA using either claw-plate fixation (claw-plate group, n = 31) or cable-alone fixation (cable group, n = 33) in our hospital from 2008 to 2020. The functional and radiographic results and complications were compared between the groups during a mean follow-up period of 64 and 78 months. ResultsThe Harris hip score and visual analogue scale at the last follow-up improved significantly in both groups, showing no significant statistical difference between the two fixation methods. In the cable group, the mean abductor lever arm, the proximal migration, and medial migration in the affected hip were significantly decreased compared to those in the contralateral normal hip (P < .05), whereas in the claw-plate group no significant statistical differences were observed between two sides. No or slight limping occurred in 25 patients (81%) in the claw-plate group and 16 patients (48%) in the cable group (P = .007). A multiple logistic regression demonstrated that claw-plate fixation could reduce the incidence of postoperative moderate-to-severe limping. ConclusionBoth claw-plate fixation and cable-alone fixation could improve the functional performance of rTHA with ETO, whereas claw-plate fixation could offer superior biomechanical results and gait improvement as compared with cable-alone fixation.

Revision of double-tapered, titanium, fully hydroxyapatite-coated femoral stems: ease of extraction and subsequent reconstruction.

Fully hydroxyapatite coated, double-tapered, titanium stems are the most commonly used uncemented implants in the UK with survivorship reported at 96.3% at 23 years however there is no literature on the consequences of revision. We aimed to explore the reasons for failure, ease of stem extraction, extent of bone loss and complexity of the subsequent reconstruction. Between December 2012 and March 2019, 104 cases requiring removal of the Corail® stem (DePuy Synthes, Warsaw, IN, USA) were identified from the National Joint Registry (NJR) and our local revision database. Indication for revision, surgical/reconstruction technique, complications and follow-up data were reviewed. The common reasons for revision were aseptic loosening 45.2%, infection 23.5%, instability 4.8% and peri-prosthetic fracture 12.5%. Removal of the implant without extended trochanteric osteotomy (ETO) was achieved in 94.2% of cases. Of those revised for aseptic loosening 23% were proximal, 38% were proximal/mid stem and 38% all zones. Significant bone loss is not a common feature of the failure of this stem with 95% graded as a Paprosky grade 2 or less. In terms of reconstruction, 69.2% were revised to a primary cemented stem. In the majority of cases revision can be achieved without an ETO and reconstruction possible using a primary stem as significant bone loss is not a common feature of failure of this stem design. We conclude that this stem is safe to use in younger patients who may outlast any type of primary implant and would inevitably face revision in their lifetime.

Impaction Bone Grafting for Severe Femoral Bone Loss: Surgical Technique in Revision Total Hip Arthroplasty.

The specific steps to perform this procedure include (1) preoperative planning; (2) positioning of the patient and surgical approach; (3) cautious removal of the previous components; (4) preparation of the bone graft; (5) implantation of the appropriate IBG revision system, restoring bone loss from distal to proximal and utilizing metal mesh as needed; (6) implantation of the new stem, bypassing the defect; and (7) aftercare with protected weight-bearing in order to avoid subsidence of the stem and periprosthetic fracture. There are several alternatives to the IBG technique in the setting of revision total hip arthroplasty with extensive femoral bone loss. These alternatives include distal cementless fixation (either modular or nonmodular), a megaprosthesis, or an allograft-prosthesis composite. The rationale for use of the IBG technique is restoration of bone stock. Although this issue may be irrelevant in low-demand elderly patients, we believe it is of the utmost importance among young (i.e., <60 years old) and active patients. This technique is versatile enough to be utilized in different scenarios such as periprosthetic fracture, periprosthetic joint infection (2-stage protocols), and aseptic loosening. We have reported favorable clinical and radiographic outcomes for the treatment of both aseptic and septic femoral component loosening. In all cases, we utilized vancomycin-supplemented impacted cancellous allograft without evidence of secondary effects with regard to bone incorporation, nephrotoxicity, or allergic reactions. Although it was initially contraindicated, we further extended the indication for this reconstruction alternative to cases of circumferential proximal bone loss with non-neoplastic bone defects of ≤15 cm, utilizing encompassing metal mesh and a bypassing long stem. Recently, we reported on poorer outcomes following IBG compared with the use of uncemented modular stems for the treatment of type B3 periprosthetic femoral fractures, with a significantly higher rate of infection and implant breakage for the former treatment. Nowadays, we advocate the use of this technique in young, active patients (i.e., <60 years old) with a femoral bone defect Paprosky grade IIIB or IV, in which reconstitution of bone stock is crucial to avoid an eventual implant failure in the long term. This technique requires an experienced team. This procedure should be avoided in the presence of active periprosthetic joint infection.The gluteus maximus tendon should be detached to avoid tensioning the sciatic nerve and to decrease the chance of periprosthetic femoral fracture.Massive bone loss can jeopardize correct implant orientation and restoration of biomechanics. In this scenario, surgeons might consider the intercondylar axis as a guide for femoral version.Try to avoid (if possible) trochanteric or extended trochanteric osteotomy because proximal bone stock is necessary to contain the bone grafts. In some cases, such as those in which the removal of the stem is difficult, especially with certain uncemented stem designs, an extended trochanteric osteotomy must be performed. Whether or not a cemented stem is removed, it is mandatory to remove all remaining cement in the femoral canal.Preoperative templating is a necessity to reconstruct leg length. Accurately determining the length of the mesh is the most important step to avoid shortening or overlengthening of the lower extremity.Approximately 10 cm of circumferential metal mesh should be fixed with 3 to 5 double cerclage metal wires to the remaining bone. The new femoral stem should bypass extend beyond the mesh for approximately 5 cm. If the stem does not bypass the mesh, there is an increased risk of postoperative fracture.In order to decrease the risk of intraoperative femoral fracture, the distal aspect of the femur should be secured with cerclage wires, and the proximal aspect of the femur should also be protected with cerclage wires over the mesh. As in any other complex femoral revision procedure, torsional forces in the supracondylar zone should be avoided, especially during trial or stem reduction maneuvers.Always utilize a bone graft mixed with antibiotic powder.Retrograde cementation must be done with cement that is in a more liquid state than in primary total hip arthroplasty. PO = postoperativePMMA = polymethyl methacrylateIV = intravenousLMWH = low molecular weight heparinDVT/EP = deep vein thrombosis and extended prophylaxis.

Extended Trochanteric Osteotomy with Intermediate Resection Arthroplasty Is Safe for Use in Two-Stage Revision Total Hip Arthroplasty for Infection.

Background: This study sought to compare the results of two-stage revision total hip arthroplasty (THA) for periprosthetic infection (PJI) in patients with and without the use of an extended trochanteric osteotomy (ETO) for removal of a well-fixed femoral stem or cement. Methods: Thirty-two patients who had undergone an ETO as part of a two-stage revision without spacer placement were matched 1:2 with a cohort of sixty-four patients of the same sex and age who had stem removal without any osteotomy. Clinical outcomes including interim revision, reinfection and aseptic failure rates were evaluated. Modified Harris hip scores (mHHS) were calculated. Minimum follow-up was two years. Results: Patients undergoing ETO had a significantly lower rate of interim re-debridement compared to non-ETO patients (0% vs. 14.1%, p = 0.026). Reinfection following reimplantation was similar in both groups (12.5% in ETO patients vs. 9.4% in non-ETO patients, p = 0.365). Revision for aseptic reason was necessary in 12.5% in the ETO group and 14.1% in the non-ETO group (p = 0.833). Periprosthetic femoral fractures were seen in three patients (3.1%), of which all occurred in non-ETO patients. Dislocation was the most common complication, which was equally distributed in both groups (12.5%). The mean mHHS was 37.7 in the ETO group and 37.3 in the non-ETO group, and these scores improved significantly in both groups following reimplantation (p < 0.01). Conclusion: ETO without the use of spacer is a safe and effective method to manage patients with well-fixed femoral stems and for thorough cement removal in two-stage revision THA for PJI. While it might reduce the rate of repeated debridement in the interim period, the use of ETO appears to lead to similar reinfection rates following reimplantation.

Mid-term outcomes following transfemoral revision of total hip arthroplasty for Vancouver B2/B3 periprosthetic fractures

IntroductionPeriprosthetic femoral fractures (PFF) are often the reason for revising total hip arthroplasty (RTHA). Converting these fractures into modified extended trochanteric osteotomy (mETO) facilitates stem revision. Modular revision stems are a common choice with good results. We present mid-term outcomes in patients undergoing RTHA for Vancouver B2/B3 PFF using a tapered, fluted modular stem with an mETO approach. Materials and methodsA single-center analysis of patients with RTHA for Vancouver B2/B3 PFF using a single modular implant with mETO was performed (2007 – 2019). Clinical outcome (mobility, range of motion, function), radiological outcome (fracture healing, stem subsidence) and patient reported outcome measures (FJS-12, HHS, EQ-5D) were assessed. ResultsNinety-seven patients (mean age 78.1 years, BMI 25.8 kg/m2, 85.6% B2-fractures) were included; 80 patients had complete clinical and radiological follow-ups. Normal unaided gait without limping was achieved in 38/80 patients. After one year fracture / mETO healing occurred in 74/80 patients; 5.3 years after surgery, the respective FJS-12, HHS and EQ-5D (available in 34 patients) averaged 81.3 ± 30.2, 71.4 ± 18.7 and 0.8 ± 0.2. We documented 7 in-hospital deaths, 18.8% postoperative complications and 13.8% revisions with stem revisions being most commonly for subsequent PFF or subsidence. ConclusionGood clinical and radiological outcomes and rather low complication and revision rates (18.8% and 13.8%) were achieved. FJS-12 showed excellent results in patients undergoing RTHA for Vancouver B2/B3 PFF using a cementless, dual modular titanium revision stem and an mETO approach. Joint awareness was thereby similar to previously reported primary THA results at 5.3 years follow-up.

Extended Trochanteric Osteotomy Closure Performed Before or After Canal Preparation and Stem Impaction Does Not Affect Axial Stability

BackgroundAn extended trochanteric osteotomy (ETO) safely addresses femoral component removal during challenging revision total hip arthroplasty. However, no prior study has evaluated whether a difference in axial stability exists between ETO closure performed before (reconstitution) or after (scaffolding) canal preparation and stem impaction. We hypothesized that given the absence of clinical reports of outcome differences despite the wide use of both practices, no significant difference in the initial axial stability would exist between the 2 fixation techniques. MethodsETOs were performed and repaired using the reconstitution technique for the 6 right-sided femora and the scaffolding technique for the six left-sided femora. The 195-mm long, 3.5°-tapered splined titanium monobloc stems were impacted into 6 matched pairs of human fresh cadaveric femora. Three beaded cables were placed in a standardized fashion on each specimen, 1 for prophylaxis against osteotomy propagation during reaming/impaction and 2 to close the ETO. Stepwise axial loading was performed to 2600 N or until failure, which was defined as subsidence >5 mm or femoral/cable fracture. ResultsAll specimens successfully resisted axial testing, with no stem in either ETO repair group subsiding >2 mm. The mean subsidence for the reconstitution group was 0.9 ± 0.4 mm, compared to 1.2 ± 0.5 mm for the scaffolding group (P = .2). ConclusionIn this cadaveric model with satisfactory proximal bone stock, no difference existed between the reconstitution and scaffolding ETO repair techniques, and both provide sufficient immediate axial stability in a simulated revision total hip arthroplasty setting under physiologic loads.

Outcomes of Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty for Periprosthetic Joint Infection: A Systematic Review

Extended trochanteric osteotomy (ETO) is a technique to remove well-fixed femoral stems in revision total hip arthroplasty (THA). ETO is commonly utilized in the setting of chronic periprosthetic joint infection (PJI). This article presents a systematic review concerning outcomes after ETO in the setting of PJI.

Differences between proximal bone remodeling in femoral revisions for aseptic loosening and periprosthetic fractures using the Wagner SL stem

BackgroundMonoblock taper fluted stems have been reliably used to treat proximal femoral periprosthetic fractures (PFF) and femoral aseptic loosening (AL). Although proximal femoral remodeling has been observed around the Wagner Self-Locking (SL) stem, the exact characteristics of this process are yet to be established. Our aim was to compare the remodeling that takes place after femoral revisions for PFF and AL.MethodsConsecutive patients between January 2015 and December 2017 undergoing femoral revision using the Wagner SL stem for PFF or AL without an extended trochanteric osteotomy (ETO) or bone grafting were selected from our database. Radiological follow-up was performed using plain antero-posterior hip radiographs taken postoperatively and at 3, 6, 12 months and at 24 months. The Global Radiological Score (GRxS) was utilized by four blinded observers. Intra and interobserver variability was calculated. Secondary outcome measures included the Oxford Hip Score and the Visual Analog Scale for pain.ResultsWe identified 20 patients from our database, 10 PFF and 10 AL cases. The severity of AL was Paprosky 2 in 2 cases, Paprosky 3A in 2 cases and Paprosky 3B in 6. PFF were classified as Vancouver B2 in 7 cases and Vancouver B3 in 3 cases. Patients undergoing femoral revision for PFF regained 89% (GRxS: 17.7/20) of their bone stock by 6 months, whilst patients with AL, required almost 2 years to achieve similar reconstitution of proximal femoral bony architecture 86% (GRxS: 17.1/20). Inter-observer reproducibility for numerical GRxS values showed a “good” correlation with 0.68, whilst the intra-observer agreement was “very good” with 0.89. Except immediate after the revision, we found a significant difference between the GRxS results of the two groups at each timepoint with pair-wise comparisons. Functional results were similar in the two groups. We were not able to show a correlation between GRxS and functional results.ConclusionsProximal femoral bone stock reconstitutes much quicker around PFF, than in the cases of AL, where revision is performed without an ETO. The accuracy of GRxS measurements on plain radiographs showed good reproducibility, making it suitable for everyday use in a revision arthroplasty practice.

High Rates of Spacer Fracture in the Setting of Extended Trochanteric Osteotomy With a Specific Thin-Core Articulating Antibiotic Hip Spacer

BackgroundTwo-stage revision remains the standard of care for prosthetic joint infection after total hip arthroplasty. However, there are substantial complications associated with articulating antibiotic hip spacers. Handmade and molded spacers have been shown to have higher rates of spacer fracture than antibiotic-coated prostheses (ACPs). The aim of this study is to review outcomes with an implant that is often categorized as an ACP spacer, the Zimmer-Biomet StageOne Select Femoral Spacer (ZBSO). MethodsA retrospective review was performed of 63 patients who underwent placement of a ZBSO. Patients were compared based on whether or not an extended trochanteric osteotomy (ETO) was performed using Fisher’s exact and t-tests. ResultsFive patients were excluded due to lack of follow-up or death shortly after stage 1 surgery, leaving 58 patients. Spacer fracture was noted in 5 of 58 patients (8.6%). Sixteen patients underwent ETO and 25.0% suffered a spacer fracture compared to 2.3% without ETO (odds ratio 13.7, P = .0248). There was no association between patient demographics or ETO length and spacer fracture. Two patients had periprosthetic fractures (3.4%) and 4 had dislocations (6.9%). Forty-nine patients (84.4%) went on to second-stage revision; of those 26.5% failed to clear the infection and required an average of 2.2 additional surgeries. ConclusionThe ZBSO spacer has overall complication rates similar to previously reported spacer series. Although the ZBSO looks like an ACP spacer, in the setting of ETO, it behaves like a molded or handmade spacer with a high rate of spacer fracture (25%) due to the small diameter of the core. This implant should be used with caution in combination with an ETO.

Extended trochanteric osteotomy (ETO) and fluted tapered modular stems in revision hip arthroplasty. Does ETO integrity or consolidation, really matter?

IntroductionThe objective of this study was to assess if the fracture and/or non-union of extended trochanteric osteotomy (ETO) affected the behavior and survival of modular fluted and tapered distal fixation stems in revision total hip arthroplasties (rTHA). MethodsWe retrospectively analyzed 52 rTHA in 52 patients. Preoperative diagnoses were mechanical loosening (42 cases), septic loosening (8), periprosthetic fracture (1), and femoral stem fracture (1). According to the Paprosky classification, femoral bone stock deficiencies were 19 type-II, 26 type IIIA, and 7 type IIIB. We assessed the behavior of the osteotomy (union, fracture, migration) and the survival and behavior (integration and subsidence) of prosthetic femoral stems. ResultsETO union and non-union rates were 84.61% (44 patients) and 15.38% (8 cases) respectively. There were twelve (23%) intra-operative fractures of the osteotomy fragment and 11 (21.15%) migrations (4.5 mm on average). We observed bone union in 39 (75%) stems and 13 (25%) stable fibrous unions. Nine (17.3%) stems subsided 7 mm (2–15 mm) on average before becoming stable. Stem subsidence and integration was not significantly affected by ETO fracture/no fracture or union/non-union. The postoperative Harris Hip Score (HHS) improved significantly as compared to the pre-operative HHS (38.41 ± 3.54 vs 85.29 ± 3.36; p < 0.01). Patients were followed up for 55 (24–100) months. The overall implant survival at the end of follow-up was 100%. ConclusionsIn this series, neither the non-union nor the intra-operative fracture of the ETO segment affected the behavior or medium-term survival of femoral stems.

The Relationship Between Arthroplasty Surgeons' Experience Level and Optimal Cable Tensioning in the Fixation of Extended Trochanteric Osteotomy.

IntroductionIn this study, our aim was to examine the relationship between the arthroplasty surgeons’ experience level and their aptitude to adjust the cable tension to the value recommended by the manufacturer when asked to provide fixation with cables in artificial bones that underwent extended trochanteric osteotomy (ETO).Materials and MethodsA custom-made cable tensioning device with a microvoltmeter was used to measure the tension values in Newtons (N). An ETO was performed on 4 artificial femur bones. Surgeons at various levels of experience attending the IXth National Arthroplasty Congress were asked to fix the osteotomized fragment using 1.7-mm cables and the tensioning device. The participants’ demographic and experience data were investigated and recorded. The surgeons with different level of experience repeated the tensioning test 3 times and the average of these measurements were recorded.ResultsIn 19 (35.2%) of the 54 participants, the force applied to the cable was found to be greater than the 490.33 N (50 kg) value recommended by the manufacturer. No statistically significant difference was determined between the surgeon’s years of experience, the number of cases, and the number of cables used and the tension applied over the recommended maximum value (P = .475, P = .312, and P = .691, respectively).ConclusionsNo significant relationship was found between the arthroplasty surgeon’s level of experience and the adjustment of the cable with the correct tension level. For this reason, we believe that the use of tensioning devices with calibrated tension gauges by orthopedic surgeons would help in reducing the number of complications that may occur due to the cable.

Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty: Contemporary Outcomes of 612 Hips.

Extended trochanteric osteotomies (ETOs) provide wide femoral and acetabular exposure, give direct access to the femoral medullary canal, and facilitate implant removal and new implant placement during selected revision total hip arthroplasties (THAs). Previous studies are limited by modest patient numbers and limited length of follow-up. The goals of the current study were to assess the union rate, complications, and outcomes of contemporary ETOs performed during revision THAs. From 2003 to 2013, 612 ETOs were performed during revision THAs at 1 institution using 2 techniques: Paprosky (laterally based osteotomy; n = 367) and Wagner (anteriorly based osteotomy; n = 245). The indications for the revision procedures were aseptic loosening (65%), periprosthetic joint infection (18%), periprosthetic fracture (6%), femoral implant fracture (5%), and other (6%). The mean patient age was 69 years, and 57% of the patients were male. The mean number of previous THAs was 1.6. The median duration of follow-up was 5 years (range, 2 to 13 years). The mean Harris hip scores increased from 57 preoperatively to 77 at the latest follow-up (p < 0.001). Radiographic and clinical union was achieved in 98% of the patients at a mean of 6 months (range, 1 to 24 months). The mean migration of the proximal trochanteric osteotomy fragment prior to union was 3 mm (range, 0 to 29 mm). ETO fragment migration of >1 cm occurred in 7% (37) of the 501 hips that had radiographic analysis. Nine hips (2%) had nonunion of the ETO. Intraoperative fracture of the ETO diaphyseal fragment occurred in 22 hips (4%), postoperative fracture of the ETO diaphyseal fragment occurred in 3 hips (0.5%), and postoperative fracture of the greater trochanter occurred in 41 hips (7%). Survivorship at 10 years free of revision for aseptic femoral loosening, free of femoral or acetabular component removal or revision for any reason, and free of reoperation for any reason was 97%, 91%, and 82%, respectively. This large series of ETOs shows that the union rate is high and clinically important trochanteric migration is infrequent. The most common complications are fracture of the osteotomy fragment intraoperatively or postoperatively. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.