Greater Trochanteric Research Articles

Cement Filling Technique to Prevent Greater Trochanter Displacement in Hip Arthroplasty for Femoral Intertrochanteric Fracture: A Technical Note.

With the increasing use of primary hip arthroplasty for management of intertrochanteric fractures, firm fixation and union of the greater trochanteric (GT) fragment are required during hip arthroplasty for management of intertrochanteric fractures. Various methods have been suggested to address this issue. However, displacement of the GT is a frequent occurrence. We have introduced a cement-filling technique for performance of hip arthroplasty of the proximal femur for achievement of immediate firm fixation of the GT. Cement filling during performance of hip arthroplasty for management of femoral intertrochanteric fractures is a valuable technique for preventing displacement of the GT and to encourage early mobilization.

Influence of greater trochanteric starting point on distal anterior cortical perforation during antegrade femoral nailing

Background: Distal anterior cortical perforation is 1 complication of antegrade femoral nailing. The effect of greater trochanteric (GT) starting points on cortical perforation risk has not been described in human femoral models. This study assessed the influence of sagittal plane starting point on rate of anterior cortical perforation using 3D CT-reconstructions of human femora. Secondarily, patient age and nail radius of curvature (ROC) were assessed as risk factors. Methods: CT scans of 53 patients (18 non-geriatric (<65 yr), 35 geriatric (>65 yr)) with non-fractured femora were converted into dynamic 3D-reconstructed renderings. Medullary nails from two manufacturers that differed in ROC were digitally templated in each femur from an anterior, central, and posterior ⅓ GT starting point. The rate of anterior cortical perforation and distance from the inner anterior cortex to the nail tip were recorded. Results: Perforation rate increased significantly as starting point moved from anterior (6%), to central (43%), to posterior (79%) regardless of patient age or implant manufacturer (P<0.001). On average, an anterior starting point positioned the nail tip furthest from the inner anterior cortex (5. mm), safely within the canal (P<0.001). Perforation rate was significantly increased in the geriatric versus non-geriatric population (47% vs. 34%) (P=0.028), and when using the nail with the larger versus smaller ROC (50% vs. 36%) (P=0.03). Conclusion: Distal nail sagittal alignment is sensitive to both patient and treatment factors. A posterior starting point, increased age (>65 yr), and increased implant ROC significantly increase risk for anterior cortical perforation of the distal femur. Level of Evidence: III

Intraoperative Greater Trochanteric Fractures During Revision Total Hip Arthroplasty May Not Always Need Surgical Fixation.

Many fixation techniques have been described to manage intraoperative greater trochanteric (GT) fractures during revision total hip arthroplasty (rTHA), but complications such as broken hardware and bursitis are common. The purpose of this study was to determine whether surgical fixation of an intraoperative GT fracture resulted in improved outcomes in rTHA. We reviewed a consecutive series of 1442 rTHA patients at our institution from 2008 to 2019. We identified all patients with an intraoperative GT fracture and noted whether the fracture was fixed surgically or left without fixation. Demographics, comorbidities, complications, radiographic union, and dislocations were compared between the groups. Of the 44 (3%) intra-operative GT fractures identified, 23 (52%) underwent fixation, most commonly with claw plates (8 patients) and cables (10 patients). There were no differences in the rates of radiographic union (86% vs 100%, P=.100), dislocations (4% vs 10%, P=.599), or re-revision (10% vs 13%, P=1.000) between the groups. Patients undergoing fixation had a higher rate of bursitis postoperatively, but it was not significant with the numbers available (35% vs 10%, P=.072). Our cohort of GT fractures at a large revision referral institution represents the largest reported series of GT fractures during rTHA. Surgical fixation in rTHA did not show improved outcomes in terms of dislocation, re-revision, and radiographic union compared with those fractures that were not fixed. There was a trend toward increased postoperative bursitis in the group undergoing surgical fixation. Further research is needed on this topic, as the number of rTHAs continues to increase. [Orthopedics. 2023;46(5):297-302.].

Greater trochanteric fractures with lntertrochanteric extension identified on MRI: What is the rate of displacement when treated nonoperatively?

Introduction. Despite the ability of MRI to identify intertrochanteric (IT) fracture extension for greater trochanteric (GT) fractures, there is no consensus about which fractures require operative intervention. Previous studies have suggested GT fractures with >50% extension into the IT region might benefit from fixation. We sought to evaluate the rate at which GT fractures with IT extension displaced, requiring operative fixation. Patients and methods. This is a Retrospective Chart Review performed at a Level 1 Trauma Center. Patients included all nonoperatively treated GT fractures (OTA/AO 31A1.1) with IT extension identified on MRI between 2010 and 2017 at our institution. Patients lost to follow up prior to radiographic evidence of healing or fracture displacement were excluded. Patient charts and imaging were reviewed for demographic data, treatment plan, percent extension into the IT region (as determined from coronal MRI images), and clinical and radiographic evidence of fracture healing. Percent extension into the IT region was measured using coronal T1-weighted MRI images. The primary outcome measures were fracture displacement requiring operation and nonunion. Results. Seventeen patients met initial inclusion criteria, with two subsequently excluded due to no radiographic follow-up. Of the 15 patients, zero had displacement of their IT fracture. None required operative intervention. All 15 patients healed their fractures. Fourteen of 15 (93%) had IT extension of 50% or less across the IT region. One patient had initial IT extension of 60%, this patient also healed without displacement. Discussion. Incomplete intertrochanteric femur fractures are a relatively newer diagnosis that have become more prevalent with the increased usage and availability of MRI. Currently, there is no consensus on the ideal treatment of these injuries. To our knowledge, this is the largest series of its kind to help guide treatment of these GT fractures with IT extension. Conclusions. Fractures with less than 50% extension into the IT region have a low likelihood of future displacement and high union rates when treated nonoperatively. Level of evidence. IV

Anthropometric And Kinematic Predictors Of Base Of Gait During Running

A narrow base of gait (BOG) during running, such that the foot crosses contralateral to the body’s line of gravity, has been implicated as a cause of iliotibial band syndrome and patellofemoral pain. BOG has been shown to vary by sex and running speed, but it is unknown if body anthropometric and running kinematic measures predict BOG. Determining predictors of BOG will clarify if BOG is a result of non-modifiable anthropometric factors or biomechanical factors, which could be modified using targeted interventions. PURPOSE: To determine if BOG at midstance during running can be predicted by anthropometric or kinematic measures. METHODS: Whole body kinematics were obtained for 71 Division I cross country runners (30 males) during treadmill running at preferred speed. Athletes were healthy with no history of stress fracture 3 months before testing or any history of lower extremity surgery. Anthropometric measures from each athlete were obtained from whole body dual-energy X-ray absorptiometry scans: greater trochanteric (GTR) and hip joint center width; leg and femur length. Kinematic measures during stance phase included: peak lateral pelvic drop, hip adduction (HADD), knee flexion (KFLEX); vertical excursion of center of mass (vCOM); anterior-posterior distance from heel to COM at initial contact. Correlations between predictors and BOG were calculated, with variables moderately correlated or better (|r| ≥ 0.3) included in subsequent analyses. Data from both limbs were included in a forward, stepwise regression to determine predictors of BOG, controlling for sex and speed. RESULTS: Stride length, vCOM, peak KFLEX and HADD, GTR width, and leg and femur length (|r| = 0.32 - 0.51) were entered into the model. The model with the best overall fit included all predictors except leg length (R2 = 0.383, BIC: -32.1). The strongest predictors were GTR width (β = -0.27), vCOM, (β = -0.18), and peak HADD (β = -0.17). CONCLUSIONS: Biomechanical and anthropometric measures explain less than 40% of the variance in BOG. Given that GTR width is the strongest predictor of BOG and is non-modifiable, BOG appears to be largely influenced by an individual’s anthropometrics. Conversely, vCOM and peak HADD are modifiable through gait retraining strategies such as step rate modification and may be targeted in those where narrow BOG is a concern.

Study to Assess the Safety and Efficacy of FX006 Administered to Patients With Greater Trochanteric Bursitis

Study to Assess the Safety and Efficacy of FX006 Administered to Patients With Greater Trochanteric Bursitis

Greater trochanteric versus piriformis fossa entry nails for femur shaft fractures: Resolving the controversy

BackgroundIntramedullary nailing is the treatment of choice for shaft of femur fractures in adults. Antegrade nails involve entry through either piriformis fossa (PE) or greater trochanteric (GT) tip. The superiority of one entry point over the other is a matter of debate, and the present review was done to determine the same. Research questionIs GT entry for antegrade femur nailing superior to the PE for shaft femur fractures in adults? ObjectiveThe present systematic review was conducted to determine the superiority of one entry point over the other by comparing the outcome parameters like operative time, exposure to fluoroscopy, mal-unions, non unions, abductor weakness, varus malalignment and Harris Hip scores (HHS). MethodologyThree databases of PubMed, EMBASE and SCOPUS were searched for relevant articles that directly compared GT with PE for nailing in shaft femur fractures in adults. ResultsWe analysed a total of 9 studies published between the years 2011–2017. There were 5 retrospective and 4 prospective studies, out of which 3 were randomised. The total number of patients was 256 in GT group and 460 in PE group. OutcomesThere was significant superiority of GT entry over PE on meta analysis; lesser operation time: standard mean difference (SMD): -21.01; lesser exposure to fluoroscopy : SMD: 36.36; lesser incidence of abductor weakness: Odd’s ratio (OR): 14.35; better functional outcome (HHS): SMD -2.48. ConclusionGT entry nails are superior to PE nails for treating shaft of femur fractures in adults. They have a shorter learning curve and better functional outcomes, however the rates of union are comparable in both.

The Frequency of Occult Intertrochanteric Fractures among Individuals with Isolated Greater Trochanteric Fractures.

PurposeIsolated greater trochanteric (GT) fractures are often identified using plain radiography of patients with post-traumatic hip pain. In many cases, the fracture extends to form an occult intertrochanteric fracture. We conducted a study to determine the frequency of occult intertrochanteric fractures in patients diagnosed with isolated GT fractures using plain radiographs.Materials and MethodsAmong 3,017 individuals who visited our emergency department with a trauma-induced pertrochanteric femur fracture between July 2004 and March 2018, 100 patients diagnosed with isolated GT fractures using plain radiographs were retrospectively analyzed. Patients were divided into two groups, those with: i) isolated GT fractures (group A) and ii) occult intertrochanteric fractures (group B). In addition, plain radiographs, magnetic resonance imaging results, and treatment methods were further analyzed in each group. If surgery treatment was needed, it was performed by one surgeon, and in all cases, a 2-hole dynamic hip screw was used.ResultsAmong the 100 cases of isolated GT fractures diagnosed using plain radiograph, additional examinations revealed that 10 (10.0%) were suffering from isolated GT fractures alone, while the remaining 90 (90.0%) were further diagnosed with occult intertrochanteric fracture. Gender, age, mechanism of injury, and bone mineral density did not correlate with fracture type.ConclusionIn our analysis, 90% of injuries initially diagnosed as isolated GT fractures were found to extend into occult intertrochanteric fractures upon further examination with additional imaging modalities. Therefore, additional evaluation should be performed to test for the potential presence of occult intertrochanteric fractures and to establish appropriate treatment plans.

What Is the Best Treatment Approach for Greater Trochanteric Pain Syndrome

Lateral hip pain sometimes is called “greater trochanteric bursitis,” but the preferred term now is greater trochanteric pain syndrome (because this

A Comparative Study between Hyaluronic Acid and Corticosteroids for the Treatment of the Greater Trochanteric Pain Syndrome

Objective: To date, there are no studies addressing the efficacy of hyaluronic acid (HA) injections at the trochanteric bursa in patients with greater trochanteric pain syndrome (GTPS). The objective of the study was to compare the efficacy and safety of HA to corticosteroid injections for the treatment of the GTPS. Methods: This prospective, randomized, two-arm trial involved 47 patients with unilateral or bilateral GTPS. Patients received an intra-bursal injection of 40 mg triamcinolone acetonide plus 1mL lidocaine, or of 60 mg HA. Patients completed visual analog scales (VAS) and Likert scales to evaluate interference of pain with daily activity, recovery from pain, and treatment satisfaction. A non-inferiority analysis was also performed. Results: Mean VAS score for pain significantly decreased comparing baseline with 1, 3 and 6 months in both treatment groups. VAS score for pain on palpation was also significantly lower than baseline in both arms. No significant differences were found between groups. Analysis of Likert scales at the sixth month didn’t detect statistically significant differences between treatment groups. The non-inferiority analysis showed that the treatment with HA was non-inferior to corticosteroids. No secondary adverse effects were found among the patients of both groups during the follow-up. Conclusions: The treatment with HA has demonstrated to be non-inferior to corticosteroids after 6 months of follow-up in patients with GTPS. Therefore, the treatment with HA may be considered an effective alternative therapeutic strategy to reduce pain in patients in whom the treatment with corticosteroids, or other therapies, have been unsuccessful or contraindicated.

Fixation of Greater Trochanteric Fracture Using Double Strands and Double Loops with Figure of 8 Wiring in Non-cement Total Hip Arthroplasty for Unstable Intertrochanteric Fracture

목적: 고령의 환자들에서 불안정한 대퇴골 전자간 골절의 치료로써 무시멘트 고관절 인공관절 전치 환술은 대퇴골 전자간 골절 치료로써 금속판이나 금속정 등의 내고정술 이외의 또 하나의 수술법으로 생각되고 있으며 대전자부 골편의 유합이 중요한 관심사 중의 하나이다. 이에 저자들은 이중 강선, 이중 고리, 8자 고정술을 이용한 대전자부 골편의 고정에 있어서 고정 방법에 따른 임상 및 방사선학적 결과를 발표하고자 한다. 대상 및 방법: 2010년 4월부터 2012년 2월까지 고관절의 불안정한 전자간 골절로 무시멘트 인공관절 전치환술 및 직경 1.0 mm의 이중 강선, 이중 고리, 8자 고정술을 시행 받은 20명 20예를 대상으로 하였다. 평균 연령은 71.1세(57-86세)였고 남자가 9명, 여자가 11명이었으며, 평균 추적관찰 기간은 6개월이었다. 술 후 환자들의 상태를 Harris hip score를 이용하여 평가하였다. 결과: 본 연구에서 수술 시간은 평균 95분, 수술 시 실혈량은 평균 800 cc였다. 최종 추시에서 Harris hip score는 평균 92.7점이었으며, 15예에서 보행거리의 감소없이 일상생활이 가능하였다. 술 후 고관절 탈구가 발생한 것은 1예였고, 고정 강선의 파손은 1예였다. 욕창과 심부정맥 혈전증 및 폐색전증이 발생한 사례는 없었다. 또한, 방사선학적으로 모든 사례에서 대퇴 주대는 해리 없이 잘 유지되었고, 13예에서 골절주위의 골생성을 확인할 수 있었으며, 골용해 소견을 보인 예는 없었다. 결론: 불안정성 대전자 골절 치료시 무시멘트형 인공고관절 치환술을 시행할 때 대전자부 골편을 고정하는데 이중강선, 이중고리, 8자 고정술을 이용한 강선 결박술이 유용한 방법으로 사료된다. 그러나 정복 방법의 개발과 함께 장기간의 추시결과에 대한 연구가 더욱 필요 할 것으로 사료된다.

Functional Outcome Following Intramedullary Nailing of the Femur: A Prospective Randomized Comparison of Piriformis Fossa and Greater Trochanteric Entry Portals

Functional Outcome Following Intramedullary Nailing of the Femur: A Prospective Randomized Comparison of Piriformis Fossa and Greater Trochanteric Entry Portals

Comparison between the Methods for Fixation of Greater Trochanteric Fragment in Cemented Bipolar Hemiarthroplasty for Unstable Intertrochanteric Fracture

Comparison between the Methods for Fixation of Greater Trochanteric Fragment in Cemented Bipolar Hemiarthroplasty for Unstable Intertrochanteric Fracture

Trochanteric Bursitis

Greater trochanteric (GT) bursitis is a common cause of hip pain. Previously, the etiology of the trochanteric pain syndrome was thought to be caused by inflammation of the subgluteus maximus bursa (i.e., bursitis). Recently, MRI and ultrasound studies have brought into serious doubt the idea that bursitis is the etiology for trochanteric pain. To our knowledge, no histologic study of GT bursitis has been reported to date. The purpose of this study is to evaluate the histopathology of patients with and without the clinical syndrome of GT bursitis to assess for the presence of bursal inflammation. This is a prospective, case-controlled, blinded study of the histopathologic features of controls and patients with GT bursitis. We recruited patients who required total hip arthroplasty (THA) for rheumatoid or osteoarthritis. Inclusion criteria for the study consisted of the following: needing THA as standard of care; THA secondary to OA or RA; age greater than 18; and minimal risk for surgery by the American Heart Association Criteria. We excluded anyone who received a GT bursa injection 9 months before surgery. Eligible participants were then stratified as cases or controls using the 1985 clinical criteria for GT bursitis. The harvesting of the bursa required no modification of the surgical procedure. The specimens were then examined by 2 independent pathologists who were blinded as to the patients' clinical status. Six bursal specimens were evaluated by 2 blinded surgical pathologists revealing primarily fibroadipose tissue with no signs of acute or chronic inflammation. There were 3 bursas in the control group and 2 specimens with clinical GT bursitis. No significant differences were found between the specimens of the 2 groups. The results of this small prospective observational histologic study, along with recent MRI and ultrasound studies on the topic, strongly suggest that there is no etiologic role of bursal inflammation in the trochanteric pain syndrome.

Comparison of intermediate-term status in Legg-Calve-Perthes Disease patients treated with Varus Derotational Osteotomy with or without subsequent epiphysiodesis of the greater trochanter

Abstract Introduction: The intermediate-term follow-up results of 15 unilateral Legg-Calve-Perthes Disease patients who received Varus Derotational Osteotomy procedures followed by epiphysiodesis of the affected hip were compared with 23 patients who received Varus Derotational Osteotomy without a subsequent epiphysiodesis. Methods: In this case-control study, parameters that were examined clinically were the presence of pain, presence of limp, leg-length discrepancy, and range of motion. Radiographic studies measured Greater Trochanteric height ratio and Mose Index. Seven patients with bilateral L-C-P disease were not included in statistical analysis, but were placed in a subgroup for comparison of clinical outcomes. Patients were classified into three groups: Good/Excellent, Fair, and Poor based on the parameters recorded. Results: Based on clinical data, 35.7% of patients who received an epiphysiodesis were found to have a good/excellent intermediate-term outcome compared to 61.9% of patients who did not receive the same procedure. Radiographic analysis showed 46.7% of patients with an epiphysiodesis to have good/excellent radiographic results compared to 43.8% of those who did not receive the procedure. Conclusions: It was concluded from this study that an epiphysiodesis may be beneficial in decreasing the height of the greater trochanter subsequent to Varus Derotational Osteotomy. Functional benefit for patients, however, was negligible and warrants further investigation.

Soft Tissue Metastases Presenting as Greater Trochanteric Pain Syndrome

Greater trochanteric pain syndrome includes a complex differential diagnosis. We report the case of a 71-year-old woman who consulted us because of pain in the lateral aspect of the hip. A diagnosis of greater trochanter bursitis was suggested, and she was treated with local injections of a mixture of corticosteroids plus anesthetic, but the condition did not improve. A pelvic MRI showed a high intensity signal in the gluteus medius and minimus and a subsequent biopsy revealed a metastasis of an adenocarcinoma of unknown origin. Although pain on the lateral aspect of the hip is often attributed to trochanteric bursitis, other diagnoses, including this rare finding of malignant disease, should be considered in the differential diagnosis of the greater trochanteric pain syndrome.

Colonna Greater Trochanteric Arthroplasty for Septic Hip Sequelae: Long-term Follow-up of Two Cases

Hip dislocation and associated instability in septic hip arthritis, caused by destruction of the femoral head and neck and damage of the proximal femoral epiphysis, is difficult to treat. Colonna greater trochanteric arthroplasty, which places the greater trochanter into the acetabulum, can provide stability and increased function in the hip joint. The greater trochanter can be remodelled to act as a femoral head. We report 2 cases of Colonna greater trochanteric arthroplasty, which were observed twelve and twenty years after surgery. Although the patient had limited motion of the hip joint, which was accompanied by pain and limping, the overall results were satisfactory. In summary, we believe that Colonna greater trochanteric arthroplasty is an effective way of achieving a stable hip joint in a difficult septic hip sequelae. Limb length discrepancy can be corrected by a limb lengthening procedure at a later stage. In addition, conversion to a total hip arthroplasty is much easier than in unreduced high dislocation.

Greater trochanter fractures: MR assessment and its influence on patient management

Eight patients with nondisplaced greater trochanteric (GT) fractures diagnosed by conventional radiographs were evaluated with magnetic resonance (MR) imaging. MR imaging demonstrated unsuspected intertrochanteric (IT) extension in each of the eight patients. This resulted in unanticipated surgical intervention in six of eight patients. Nondisplaced GT fractures are often more extensive and complex than they appear on conventional radiographs. MR imaging is useful in determining the extent and morphology of these fractures, information valuable for orthopedic management, and should be considered for definitive assessment in these patients.