Greater Trochanteric Osteotomy Research Articles

Approach to the canine coxofemoral joint using an osteotomy of the deep gluteal muscle insertion for total hip replacements.

Canine total hip replacements (THR) are commonly performed using a craniolateral approach to the craniodorsal aspect of the hip which traditionally involves a partial deep gluteal tendon tenotomy (DGT). Performing an osteotomy of the insertion of the deep gluteal tendon has been utilized by some surgeons. Utilizing bone healing over tendon healing aims to improve post operative hip stability. To the authors' knowledge, this is the first published description of the novel deep gluteal osteotomy (DGO) approach. It differs from a greater trochanteric osteotomy as the latter involves an osteotomy of both the deep and middle gluteal insertions. DGT and the novel DGO approach were performed in ten medium to large breed cadavers on contralateral limbs. The surface area of acetabular exposure was measured in contralateral limbs following the approaches and the iatrogenic damage to the deep gluteal, middle gluteal and vastus lateralis muscles following femoral reaming was visually graded (none, mild, moderate or severe) based on muscle proportion damaged. There was no statistically significant difference (p = 0.8223) between the surface area of acetabular cartilage exposed by each approach with the mean surface area for the DGO approach being 2.99 cm2, whilst the mean surface area for the DGT was 2.97 cm2. In 80% of cadavers, the DGO approach achieved lower muscle damage following retraction and femoral reaming compared to the DGT approach for the middle gluteal and deep gluteal muscles (p = 0.0073). In all cadavers, overall muscle damage was lower for the DGO approach compared to the DGT approach (p = <0.001). There was no difference in vastus lateralis damage between procedures. The DGO approach may be a reasonable alternative to the DGT for approaching the hip joint and femur for Zurich THR as it provides similar exposure to the acetabulum with less muscle damage. It relies on more reliable osseous healing compared to tendon healing. Reduced muscle damage may be important for postoperative hip stability following THR. Further studies are required to biomechanically assess the strength of DGO repair compared to DGT repair as well as a case series documenting clinical outcomes.

Greater trochanteric osteotomy and subtrochanteric osteotomy in primary/revision total hip arthroplasty.

Osteotomy of the femur is necessary in some cases of primary/revision total hip arthroplasty (THA) procedure. There are two mainly used femur osteotomy methods in THA: greater trochanteric osteotomy and subtrochanteric osteotomy. Greater trochanteric osteotomy can improve hip exposure, provide greater stability against dislocation and favorably influence the abductor moment arm. Whether in the primary or revision THA, greater trochanteric osteotomy has its unique position. Subtrochanteric osteotomy adjusts the degree of femoral de-rotation and corrects the leg length. It is widely used in hip preservation and arthroplasty surgery. All osteotomy methods have specific indications, while nonunion is the commonest complication. In this paper, we analyze the greater trochanteric osteotomy and the subtrochanteric osteotomy in primary/revision THA and summarize the characteristics of different osteotomy methods.

Is osseous reattachment of the greater trochanter necessary compared to soft-tissue-only abductor repair in proximal femoral megaprosthesis reconstruction?

One of the challenges to surgical reconstruction following oncologic proximal femur resection is reliable re-establishment of the abductor mechanism. Surgical and functional outcomes following re-approximation of the abductor mechanism to a metallic endoprosthetic after tumor resection of the proximal femur have not been well established in the literature. A retrospective review was performed, inclusive of patients who received a proximal femur replacement with a metallic endoprosthesis following tumor resection. Patients were divided into two groups: (1) those that received an abductor repair involving a trochanteric osteotomy and osseous fixation of the greater trochanter/abductor mechanism to the endoprosthesis, and (2) those that did not have a trochanteric osteotomy and therefore had an abductor repair consisting of only soft tissue reattachment to the endoprosthesis. The two groups were assessed for demographic characteristics, diagnosis, surgical outcomes including rates of complication and failure, radiographic evidence of trochanteric failure, and functional outcomes. Descriptive statistics, comparative statistics, and logistic regression analyses were performed to discern differences between the two study groups. Fifty-three patients were included in the analysis, 29 had abductor reconstructions involving reattachment of the greater trochanter to the metallic endoprosthesis and 24 had soft tissue reconstruction of the abductor mechanism without bony fixation. There were no differences between the two groups for demographic data, cancer diagnosis, follow up, or survivorship. Radiographic evidence of trochanteric dissociation from the endoprosthesis was observed in 45% of osteotomy cases. Only 10% of patients in the trochanter osteotomy group and 38% of the soft tissue only group were able to resume a normal, non-Trendelenburg gait at final postoperative visit (p = .024). Need for an assistive ambulatory device was seen in 83% and 67% of the osteotomy and soft-tissue-only patients, respectively (p = .21). Re-establishing the abductor mechanism following proximal femur oncologic resection remains a challenge to orthopedic oncologists. Even when possible, salvage of the greater trochanter for reattachment to the endoprosthesis did not lead to improved function in this series, when compared to a similar cohort that received a soft-tissue-only abductor repair. Abductor mechanism reconstruction with a greater trochanteric osteotomy and subsequent fixation to the proximal femur endoprosthesis had a high rate of radiographic failure. Additionally, reattachment of the greater trochanter to the proximal femur endoprosthesis demonstrated no improvement in Trendelenburg gait or reliance on an assistive ambulatory device when compared to a soft-tissue-only abductor repair.

Sciatic notch dumbbell tumor resection: A surgical technique and report of two cases

Intrapelvic and extrapelvic sciatic notch dumbbell tumors (SNDTs) are rare soft-tissue tumors that are difficult to remove. This study aimed to report the surgical technique and evaluate the clinical findings of SNDTs. We performed a retrospective review of the clinical outcomes and primary features of two consecutive cases of SNDTs. Both patients with SNDTs had different clinical presentations and prognoses and underwent surgeries with the same technique. We performed complete surgical resection of the tumor in one patient with greater trochanteric osteotomy and pelvic osteotomy in both patients. We achieved satisfactory results in both cases by implementing the utilitarian approach and pelvic osteotomy through the greater sciatic notch to surgically resect the tumors. This technique was chosen to provide a maximum benefit to the patients.

Minimum 10-Year Outcome of One-Stage Total Hip Arthroplasty Without Subtrochanteric Osteotomy Using a Cementless Custom Stem for Crowe III and IV Hip Dislocation

BackgroundOptions for total hip arthroplasty (THA) in high dislocated hips include subtrochanteric osteotomy (STO), high hip center positioning, and 2-stage surgery with progressive lowering using an external fixator before THA. We described the long-term results of 1-stage THA performed without STO, using a cementless customized stem associated if necessary with sequential tenotomies and/or greater trochanteric osteotomy. MethodsNinety-eight consecutive THA without STO were performed using this technique. Of those 98 hips, 26 hips with high dislocation (12 class III and 14 class IV according to the Crowe classification) were evaluated at an average follow-up of 16 (10-22) years. ResultsAt the time of last follow-up, the mean Harris Hip Score was 86 points (37-100). The mean leg-length discrepancy was 7 ± 5 mm (0-17). Two transient (7.7%) nerve palsies (1 sciatic and 1 femoral) were notified. A revision was required for 6 hips (23.1%). Kaplan-Meier survivorship analysis at 15 years regarding aseptic loosening of the femoral component was 87.5% (95% confidence interval, 76.5-99.1). During the same period, acetabular implant survivorship free from revision for aseptic loosening was 96.1% (95% confidence interval, 92.7-99.9). ConclusionThe combination of intramedullary fit and extramedullary adaptation for offset and anteversion provided by the custom stem can avoid additional procedures associated to THA in high developmental dysplasia of the hip. The clinical function and long-term survival reported in this series is encouraging for THA performed in case of high hip dislocation.

Treatment of coxofemoral luxation in a mature Welsh pony by femoral head ostectomy: Long‐term outcome

SummaryA 233 kg, 4‐year‐old Welsh pony stallion presented with a unilateral coxofemoral luxation and a history of previous upward fixation of the patella. This condition was surgically managed by femoral head ostectomy using a craniodorsal approach to the luxated coxofemoral joint, without greater trochanteric osteotomy. Immediate improvement in weightbearing was observed after surgery and primary intention healing was recorded. Long‐term outcome, 4 years after surgery, was assessed by radiographic, ultrasonographic and lameness examination. The pony was in good body condition and the initial weight of this patient was restored. Despite fetlock hyperlaxity of the contralateral hindlimb, amyotrophy and mechanical lameness of the affected hindlimb, the pony showed evident comfort without apparent signs of pain and was able to trot and gallop. Bone callus was observed at imaging examination.

Ceramic on ceramic hip arthroplasty in fused hips.

Background:Most literature in the field of total hip arthroplasty (THA) for fused hips, until date has reported the results of using metal on polyethylene and ceramic on polyethylene bearings. Results of THA using ceramic on ceramic (CoC) bearings in fused hips have not been published in literature. This study reports the results of cementless THA using CoC articulation perfomed in fused hips.Materials and Methods:Twenty-three patients (25 hips) with fused hips underwent conversion to THA using CoC bearings and were followed up for a mean 5.4 years. The conventional posterolateral approach was used in 15 hips, a modified two incision technique in 7 hips and a direct lateral approach with greater trochanteric osteotomy in 3 hips. Postoperatively, range of motion exercises were encouraged after 2–3 days of bed rest and subsequent gradual weight bearing using crutches was begun.Results:Mean Harris hip score improved from 42.4 to 84.2 and mean leg lengthening of 36.6 mm was achieved. In the average 5.4 years (range 2.8-9.1 years) followup there were no cases with osteolysis around acetabular cup and femoral stem. In this study, there was no case of ceramic fracture. There was one case of squeaking.Conclusion:This study suggests that cementless THA performed for fused hips with CoC bearings can provide good early clinical results.

Treatment of femoroacetabular impingement: a systematic review.

The purpose of this review is to determine if there is a difference in outcomes after: (1) nonsurgical vs surgical treatment of FAI; (2a) surgical dislocation with greater trochanteric osteotomy, (2b) anterior mini-open, (2c) arthroscopic plus mini-open, and (2d) arthroscopic surgery for FAI; (3) difference in complication and re-operation rates; and (4a) labral refixation and (4b) labral debridement for labral injuries. A systematic review of multiple databases was performed after PROSPERO registration and using PRISMA guidelines. Level I-IV evidence clinical studies with minimum 2-year follow-up were included. Data were compared using 2-sample and 2-proportion Z-test calculators. Study methodological quality was analyzed using Modified Coleman Methodology Score (MCMS). Recommendations were made using SORT (Strength Of Recommendation Taxonomy). Twenty-nine studies were included (2369 subjects; 2507 hips). MCMS was poor. Mean subject age was 34.4+/-8.4years and mean follow-up was 3.1+/-0.9years. Statistically significant differences were observed following both nonsurgical and surgical treatment, with greater (P < 0.05) improvements following surgery (SORT B), without consistent significant differences observed between different surgical techniques (SORT C). There was a greater (P < 0.05) reoperation and complication rate following surgical dislocation vs mini-open and arthroscopic techniques (SORT A). Clinical outcomes were significantly better (P < 0.05) following labral refixation vs debridement (SORT B). Outcomes of operative treatment of femoroacetabular impingement are significantly better than nonsurgical management. Surgical treatment significantly improves outcomes, with no consistent significant differences exhibited between open and arthroscopic techniques. Open surgical dislocation has significantly greater reoperation and complication rates vs mini-open and arthroscopic techniques. Outcomes of labral refixation are significantly better than debridement in patients with labral injuries.

Iatrogenic Hip Subluxation After Surgical Dislocation Successfully Treated with Periacetabular Osteotomy: A Case Report.

The recognition of femoroacetabular impingement (FAI)1 as a cause of prearthritic hip disease has resulted in dramatic increases in the treatment of this condition2. A detailed history, physical examination, and comprehensive radiographic evaluation are important for accurate diagnosis and treatment planning, including the differentiation of mild acetabular dysplasia and FAI. We report a case of iatrogenic hip subluxation that occurred after surgical dislocation with acetabuloplasty. The patient was treated with a corrective periacetabular osteotomy (PAO) and had an excellent clinical outcome two years postoperatively. She was informed that data concerning the case would be submitted for publication, and she provided consent. A thirty-one-year-old woman was referred to our clinic with persistent left hip pain after surgical dislocation. Initially, the patient had presented to an outside institution with a three-year history of progressive left groin pain that failed to improve with conservative treatment. Preoperative imaging had included an anteroposterior pelvic radiograph, a false-profile radiograph, and a magnetic resonance arthrogram (MRA) (Figs. 1-A through 1-E). The patient had undergone a surgical dislocation of the left hip with acetabuloplasty, labral refixation, and femoral osteochondroplasty for pincer impingement at an outside hospital one year prior to presenting at our clinic. Fig. 1 The preoperative anteroposterior pelvic radiograph ( Fig. 1-A ) and the coned-down anteroposterior pelvic radiograph ( Fig. 1-B ) demonstrate borderline acetabular dysplasia (lateral center-edge angle of 20°) and apparent acetabular retroversion (relative inlet view). The preoperative false-profile radiograph ( Fig. 1-C ) demonstrates anterior undercoverage with an anterior center-edge angle of 16°. Coronal ( Fig. 1-D ) and axial ( Fig. 1-E ) MRA images demonstrate acetabular dysplasia (without subluxation) and a hypertrophic acetabular labrum. Postoperatively, the patient had noted worsening of the hip pain. Three months postoperatively, radiographs had demonstrated mild subluxation of the femoral head and delayed union of the greater trochanter osteotomy site (Fig. 2). The patient …

Reattachment of the Osteotomized Greater Trochanter in Hip Surgery Using an Ultrahigh Molecular Weight Polyethylene Fiber Cable: A Multi-Institutional Study

The purpose of this multicenter study was to evaluate the clinical performance of an ultrahigh molecular weight polyethylene (UHMWPE) fiber cable for re-attachment of the osteotomized greater trochanter in hip surgery. Included in the study were 85 hips that had undergone surgery with greater trochanter osteotomy, including 50 hip arthroplasty procedures and 35 hip osteotomies. The osteotomized greater trochanter was reattached using one or more UHMWPE fiber cables. The bone union and displacement of the greater trochanter were assessed in radiographs for up to 12 months after surgery. Non-union of the osteotomy site occurred in 4.7% of the cases. In approximately 90% of the cases, displacement was less than 2 mm at up to 12 months after surgery. The UHMWPE fiber cable was a good biomaterial for reattaching the osteotomized greater trochanter and may also be an option for osteosynthesis procedures.

Testing System for the Comparative Evaluation of Greater Trochanter Re-attachment Devices

The scope of this study was to propose and validate a specialized test bench that applies biaxial forces on an orthopedic model of Greater Trochanter (GT) re-attachment with integrated cable tension measurement. Stability of the GT fragment is evaluated using a custom triplanar video movement-analysis system with the first camera’s field of view (FOV) corresponding to the GT osteotomy plane and the second and third camera’s FOVs corresponding to the median plane of the femur in frontal and posterior views, respectively. A typical experimentation and its critical analysis conclude the paper.

A novel surgical approach for complex destructive acetabular malignancies

Current treatment of acetabular defects created by metastatic disease involve extensile approaches removing the abductors from the greater trochanter or greater trochanteric osteotomy. We have developed a technique which does not involve removal of the muscle from the greater trochanter or trochanteric osteotomy. We remove the gluteus medius muscle from its anterior origin along several inches of the anterior iliac wing and the gluteus maximus from its insertion (the conjoined tendon) along the posterior proximal femur. The entire hip joint capsule is removed from anterior and posterior to the gluteus medius and minimus taking care to leave the insertion of these muscles intact. We have performed this approach in 13 patients with known metastatic disease and our preliminary results indicate that their limp and immediate weight bearing are improvements from the current standard of care involving removal of either the insertion of the gluteus medius and minimus from the greater trochanter or greater trochanteric osteotomy.

Evolution of surgical techniques for the treatment of angular and torsional deviation in DDH: 20 years experience

The anatomical abnormalities associated with developmental dysplasia of the hip (DDH) increase the complexity of hip arthroplasty. In addition, previous femoral osteotomy can deform the proximal femur. Noncemented cups and stems are specifically designed for dysplasia to recover the true acetabular region in Crowe grade IV and sometimes Crowe grade III; additional surgical procedures are required. The purpose of the study was to analyse the surgical procedure and then the reconstructive options in DDH. From 1984 until now, total arthroplasty has been performed, on dysplastic hips, in 2,101 patients for 2,308 hips (207 patients bilateral 9% rate). All the procedures were performed by the senior authors (LS, GG) at the same hospital specialised in elective hip surgery. More than 80% of patients came from Northern Italy. The average age was 51 (range 32-83), 565 cases had involved a previous femoral osteotomy. Out of these 2,308 cases, 128 cases needed treatment for corrections of femoral side deformity; 64 cases were subjected to a greater trochanter osteotomy. In 12 cases, proximal femur shortening was involved. In 9 cases, rotational abnormality and shortening were controlled with a distal femur osteotomy. Fifty-five cases were treated by a shortening subtrochanteric osteotomy that allows corrections of any deformity. Only noncemented stems were used. Long-term results in these patients are consistently inferior (70% survival rate at 15 years) compared to those in the non-DDH population (97.7% survival at 15 years). On the femoral side, early failures are the reflection of a learning curve and are due to insufficient fixation of the osteotomy. The more promising outcomes are those involving a shortening subtrochanteric osteotomy.

Evolution of Surgical Techniques for the Treatment of Angular and Torsional Deviation in DDH: 20 Years Experience

The anatomical abnormalities associated with developmental dysplasia of the hip (DDH) increase the complexity of hip arthroplasty In addition, previous femoral osteotomy can deform the proximal femur. Noncemented cups and stems are specifically designed for dysplasia to recover the true acetabular region in Crowe grade IV and sometimes Crowe grade III; additional surgical procedures are required. The purpose of the study was to analyse the surgical procedure and then the reconstructive options in DDH. From 1984 until now, total arthroplasty has been performed, on dysplastic hips, in 2,101 patients for 2,308 hips (207 patients bilateral 9% rate). All the procedures were perfomed by the senior authors (LS, GG) at the same hospital specialised in elective hip surgery. More than 80% of patients came from Northern Italy. The average age was 51 (range 32–83), 565 cases had involved a previous femoral osteotomy. Out of these 2,308 cases, 128 cases needed treatment for corrections of femoral side deformity; 64 cases were subjected to a greater trochanter osteotomy. In 12 cases, proximal femur shortening was involved. In 9 cases, rotational abnormality and shortening were controlled with a distal femur osteotomy. Fifty-five cases were treated by a shortening subtrochanteric osteotomy that allows corrections of any deformity. Only noncemented stems were used. Long-term results in these patients are consistently inferior (70% survival rate at 15 years) compared to those in the non-DDH population (97.7% survival at 15 years). On the femoral side, early failures are the reflection of a learning curve and are due to insufficient fixation of the osteotomy. The more promising outcomes are those involving a shortening subtrochanteric osteotomy.

Surgical treatment of developmental dysplasia of the hip in adults: II. Arthroplasty options.

Total hip arthroplasty is the procedure of choice for most patients with symptomatic end-stage coxarthrosis secondary to hip dysplasia. The anatomic abnormalities associated with the dysplastic hip increase the complexity of hip arthroplasty. When pelvic bone stock allows, it is desirable to reconstruct the socket at or near the normal anatomic acetabular location. To obtain sufficient bony coverage of the acetabular component, the socket can be medialized or elevated, or a lateral bone graft can be applied. Uncemented acetabular components allow biologic fixation with potentially improved results compared with cemented cups, especially in young patients. The location of the acetabular reconstruction and the desired leg length influence the type of femoral reconstruction. Cemented and uncemented implants can be used in femoral reconstruction, depending on the clinical situation. Femoral shortening is required in some cases and can be performed by metaphyseal resection with a greater trochanteric osteotomy and advancement or by a shortening subtrochanteric osteotomy. The results of total hip arthroplasty demonstrate a high rate of pain relief and functional improvement. The long-term durability of cemented total hip arthroplasty reconstruction in these patients is inferior to that in the general population. The results of uncemented implants are promising, but only limited early and midterm data are available.

The value of trochanteric displacement in a varus producing intertrochanteric osteotomy

Surgical Principles In order to maintain or increase the abductor lever arm during a varus producing intertrochanteric osteotomy, distal displacement of the greater trochanter is often needed. Without displacing the trochanter, a significant weakness of the abductors would occur [4, 5]. With greater trochanter osteotomy, access to the hip joint is improved, permitting better visualization of the upper part of the femoral head and the roof of the acetabulum (ie, for a simultaneous shelf procedure). When a flexion component is added to the osteotomy, the trochanteric osteotomy increases the range of correction in the sagittal plane and reduces mechanical pressure on the anterosuperior surface of the femoral head [3]. The aim of an isolated greater trochanteric osteotomy is to advance distally and to lateralize the abductors. To achieve fixation, the preserved soft tissue layer, screws, or a tension wire cerclage are used [4–6, 10]. The indication of a trochanteric osteotomy combined with an intertrochanteric osteotomy has increased [1, 4, 10, 11]. The technique described in detail below is part of a varus osteotomy performed as previously described by M. E. Muller [7, 8, 10] and relies on the use of AO osteotomy plates [9].