Transtrochanteric Rotational Osteotomy For Osteonecrosis Research Articles

Total hip arthroplasty after failed transtrochanteric rotational osteotomy for osteonecrosis of the femoral head: analysis of three-dimensional morphological features

BackgroundIn total hip arthroplasty (THA) after failed transtrochanteric rotational osteotomy (TRO) for osteonecrosis of the femoral head (ONFH), deformity of the proximal femur has been reported to affect stem placement. The aims of this study were to evaluate the morphological changes in the proximal femur, muscle atrophy, and soft tissue thickening in THA after TRO and the clinical outcomes.MethodsThe TRO group included 17 patients (18 hips) who underwent THA after failed TRO. The control group included 21 patients (28 hips) who underwent primary THA for ONFH. To evaluate the deformity of the proximal femur before THA, we measured the anteroposterior and mediolateral diameters of the femur on computed tomographic slices 5 mm proximal to the lesser trochanter. To evaluate muscle atrophy and soft tissue thickening, we measured the thicknesses of the psoas major, iliac, and gluteus medius muscles and the anterior capsule of the hip joint.ResultsThe ratio of the anteroposterior to mediolateral diameters of the proximal femur was significantly greater in the TRO group (p < 0.01). The thicknesses of the muscles did not differ between the two groups, whereas the anterior capsule was significantly thicker in the TRO group (p < 0.05). Varus or valgus stem alignment (> 3°) was frequent in the TRO group (p < 0.01).ConclusionsThe round shape of the proximal femur was deformed after TRO compared with primary THA for ONFH, which may have caused malposition of the stem. In addition, we should pay attention to anterior protrusion of the proximal femur and thickening of the anterior capsule.

Total hip arthroplasty using anterolateral-supine approach after transtrochanteric rotational osteotomy for osteonecrosis of the femoral head: A case report

Total hip arthroplasty using anterolateral-supine approach after transtrochanteric rotational osteotomy for osteonecrosis of the femoral head: A case report

The effect of rotational degree and routine activity on the risk of collapse in transtrochanteric rotational osteotomy for osteonecrosis of the femoral head\u2014a finite element analysis

To explore the mechanical mechanism and provide preoperative planning basis for transtrochanteric rotational osteotomy (TRO) procedure, a joint-preserving procedure for osteonecrosis of the femoral head. Eleven TRO finite element femurs with the most common types of necrosis were analyzed under multi-loading conditions. Thereafter, we made a comprehensive evaluation by considering the anatomy characters, daily activities, and risk indicators contain necrosis expansion trend, necrotic blood supply pressure, and the risk of fracture. The risk of fracture (ROF) is the lowest when standing on feet and increases gradually during normal walking and walking upstairs and downstairs. Compared with posterior rotation, rotating forward keeps more elements at low risk. Additionally, the correlation analysis shows it has a strong negative correlation (R2 = 0.834) with the average modulus of the roof. TRO finally decreased the stress and energy effectively. However, the stress and strain energy arise when rotated posteriorly less than 120°. The comprehensive evaluation observed that rotating forward 90°could reduce the total risks to 64%. TRO is an effective technique to prevent collapse. For the anterior and superior large necrosis, we recommend to rotate forward 60° to 90° (more efficient) or backward 180°. The methodology followed in this study could provide accurate and personalize preoperative planning.Graphical A proximal femur was reconstructed and modified using Mimics from a series of computed tomography. The models were meshed after solidified and performed different osteotomy, and then assigned material based on the Hounsfield Unit from CT images. Finally, 44 different TRO finite element femurs were analyzed under multi-loading conditions and evaluated comprehensively.

Effect of transtrochanteric rotational osteotomy on impingement and contact state of a femoral implant in conversion total hip arthroplasty — Retrospective simulation study

BackgroundThe transtrochanteric rotational osteotomy is a common osteotomy for osteonecrosis of the femoral head, although the results of conversion total hip arthroplasty after the osteotomy are controversial. We evaluated how deformities in the proximal femur after the osteotomy affect hip impingement and the contact state of the stem in total hip arthroplasty. MethodsWe retrospectively reviewed 35 hips (24 men) that had undergone the transtrochanteric rotational osteotomy for osteonecrosis of the femoral head (TRO-group) and compared them with 31 contralateral, unoperated hips (Primary group). The distance between the anterior and posterior greater trochanter at the cutting point of the femur, defined as the greater trochanter width and the contact area of the femoral implant surface with cortical bone were measured by CT-based three-dimensional templating software. We also calculated the hip range of motion in conversion total hip arthroplasty and analyzed the correlations between the greater trochanter width and the range of motion. FindingsThe number of bony-impingement cases was significantly greater, and the range of motion in flexion, internal rotation and external rotation was significantly less in TRO-group. There was a significant negative correlation between the greater trochanter width and range of motion of internal rotation. There were no significant differences between two groups in percentages of femoral-implant contact area. InterpretationsThe femoral implant fixation appears to be satisfactorily fixed in all zones in conversion total hip arthroplasty. However, the greater attention should be paid to minimizing bony impingement, especially on the anterior side, in conversion total hip arthroplasty.

Risk factor analysis for postoperative complications requiring revision surgery after transtrochanteric rotational osteotomy for osteonecrosis of the femoral head

BackgroundThis study investigated the risk factors for postoperative complications requiring revision surgery within 3 years after transtrochanteric rotational osteotomy (TRO) for osteonecrosis of the femoral head (ONFH).MethodsWe reviewed 127 patients (147 hips) who underwent TRO (anterior or posterior rotational osteotomy) for ONFH between January 2002 and December 2014. Two patients were lost to follow-up, and five patients with progression of femoral head collapse requiring a salvage procedure such as total hip arthroplasty within 3 years after TRO were excluded. The better hip in patients treated bilaterally was also excluded (n = 20) to avoid duplication of patient demographics, leaving 120 hips (120 patients) for the analysis. We reviewed the medical records of each patient to screen for postoperative complications that required revision surgery within 3 years after surgery, recording the patient’s age, sex, body mass index, surgical side, condition of the contralateral hip, previous alcohol intake, previous alcohol abuse, previous corticosteroid use, perioperative corticosteroid use, smoking status, preoperative stage and type of ONFH, preoperative activity level, and preoperative and final follow-up Japanese Orthopaedic Association scores. Differences between cases with and without complications were analyzed.ResultsEleven (9.2%) cases showed postoperative complications that required revision surgery. The most common complication was deep infection (n = 5), followed by nonunion of the greater trochanter (n = 3), nonunion of the intertrochanteric osteotomy site (n = 2), and femoral head fracture (n = 1). The multivariate analysis showed an independent association between previous alcohol abuse and postoperative complications (odds ratio, 13.5).ConclusionA correlation might exist between alcohol abuse and complications following a TRO procedure.

Total Hip Arthroplasty After Transtrochanteric Rotational Osteotomy for Osteonecrosis of the Femoral Head: A Mean 10-Year Follow-Up

BackgroundThe objective of the present study was to investigate clinical, quality of life, and radiographic outcomes of patients who underwent total hip arthroplasty (THA) after transtrochanteric rotational osteotomy (TRO) for osteonecrosis of the femoral head (ONFH). MethodsWe performed a case-control study. The participants were 29 patients (34 hips) who underwent THA after TRO (TRO group). These patients had a mean age at surgery of 51.6 years (range, 30-72 years) and underwent postoperative follow-up for a mean period of 10.5 years (range, 3-19 years). For the control group (primary group), we included 58 patients (68 hips) who underwent primary THA for ONFH, matching for age and gender. ResultsThe Harris Hip Scores at the last follow-up were significantly poorer in the TRO group than in the primary group. Similarly, preoperative and postoperative hip range of motion was significantly poorer in the TRO group than in the primary group. Quality of life (Short Form-36, Oxford Hip Score, and Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire) and complication rates were not significantly different between the groups. The survival rates at 10 years, with revision for any reason as the endpoint, were 81% in the TRO group and 91% in the primary group, showing no significant difference between the groups. The TRO group had a larger average postoperative leg length discrepancy and a higher rate of stem malalignment than the primary group. ConclusionThe clinical outcomes of THA after TRO for ONFH were poorer than those of primary THA.

Results of the Sugioka transtrochanteric rotational osteotomy for osteonecrosis: Frequency and role of a defect of the quadratus femoris muscle in osteonecrosis progression

BackgroundDuring transtrochanteric rotational osteotomy (RO), it is important to preserve the posterior column artery (PCA), which is generally located in the adipose tissue underneath the quadratus femoris muscle (QF). If there is a defect in the QF, the risk of injuring the PCA, subsequently resulting in total necrosis of the femoral head, may increase. Therefore, we investigated: (1) the frequency of defects of the QF at the time of RO, and (2) clinical outcome of RO based upon a defect of the QF. HypothesisThe presence of defects of the QF at the time of RO could be detected pre-operatively by magnetic resonance imaging. MethodsRO was performed in 124 hips between 2001 and 2010. In all, 95 of the hips were in male patients and 29 in female patients. The mean age was 45.4 years (range: 11–61 years) at the time of surgery and MRI was performed before RO in all cases. We retrospectively evaluated the progression of a collapse through 3 years after RO. ResultsMRI showed a defect in the QF in four hips (3.2%) (2 males, 2 females), all of which were confirmed intra-operatively. Among the four patients, one (25%) underwent total hip arthroplasty because of varus deformity of the osteotomy site due to total necrosis of the femoral head 1 year after RO. The 120 hips with a normal QF showed no evidence of total necrosis or progression of necrosis of the femoral head, indicating that the presence of defects of the QF may increase the risk of poor survivorship of this procedure. ConclusionsDefects of the QF have been reported to occur in 1–2% of all patients, whereas in our study the incidence in ON was approximately 3%. In ON patients with QF defects, pre-operative MRI evaluation of the QF appears to be important when planning RO, followed by a carefully performed surgical procedure. Level of evidenceIV; retrospective case series without control group.

The Rationale and Results of Transtrochanteric Rotational Osteotomy for Osteonecrosis of the Femoral Head

The Rationale and Results of Transtrochanteric Rotational Osteotomy for Osteonecrosis of the Femoral Head

Conversion Total Hip Arthroplasty After Previous Transtrochanteric Rotational Osteotomy for Osteonecrosis of the Femoral Head

The results of conversion total hip arthroplasty (THA) after failed transtrochanteric rotational osteotomy (TRO) are still controversial. We retrospectively reviewed 18 patients with ONFHs who had been treated previously by TRO and were later converted to THAs (conversion group). We made a matched control group of 18 primary THAs for ONFH done by same hip surgeon (PTHA group). There was an improvement in the Harris hip score and WOMAC score at the final follow-up but the improvement was not statistically significant between the two groups. Only internal rotation was significantly better in the PTHA group than in the conversion group. THA after TRO provides satisfactory clinical and radiological outcomes with no significant increase in perioperative morbidity in comparison with that in the primary THA.

Femoral Head Stress Fracture: An Unknown Complication Following Sugioka’s Transtrochanteric Rotational Osteotomy

Sugioka's transtrochanteric rotational osteotomy, as a treatment of osteonecrosis of the femoral head, has variable success rates. Its known complications include: progressive varus deformity, femoral neck fracture, and femoral head collapse. However, femoral head stress fracture has not been described as a complication of Sugioka's transtrochanteric rotational osteotomy. This article presents cases of 2 of 64 patients who underwent Sugioka's transtrochanteric rotational osteotomy between 1994 and 2006 and experienced femoral head stress fractures. Both patients were young and active. They presented with acute inability to bear weight and pain on the operated hip after mountain climbing 1 and a half to 3 years following the index surgery. Diagnosis of femoral head stress fracture was established by the presence of an inferolaterally-directed vertical fracture line from the superolateral aspect of the femoral head on computed tomography scans for both patients. One patient was successfully managed with conservative measures, whereas the other underwent total hip replacement after failed conservative treatment. We hypothesize that the direction alteration of the trabecular system due to proximal femoral segment rotation, varus positioning of the proximal femur, and inadequate placement of the screw into the necrotic femoral head may have caused the femoral head stress fractures after transtrochanteric rotational osteotomies. Stress fracture of the femoral head is a potential complication following Sugioka's transtrochanteric rotational osteotomy for osteonecrosis of the femoral head, which may be prevented by avoiding heavy exercises such as mountain climbing, until adequate remodeling of the trabecular system is gained and screws can be inserted into the femoral head subchondral bone as deeply as possible with avoidance of the necrotic area.

Transtrochanteric rotational osteotomy for osteonecrosis of the femoral head

Transtrochanteric rotational osteotomy for osteonecrosis of the femoral head

Use of a screw and plate system for a transtrochanteric anterior rotational osteotomy for osteonecrosis of the femoral head

BackgroundWe originally used two or three large cancellous screws for a transtrochanteric rotational osteotomy for osteonecrosis. Since January 2002, a screw and plate system (K-MAX Adjustable Angle Hip Screw) has been used to obtain more rigid fixation at the site of osteotomies. We investigated the clinical and radiological results of a transtrochanteric anterior rotational osteotomy. MethodsBetween January 2000 and December 2001, a transtrochanteric anterior rotational osteotomy with large cancellous screws was performed in 25 hips of 22 patients, and between January 2002 and March 2005, the K-MAX Adjustable Angle Hip Screw was used in 44 hips of 40 patients for treatment of osteonecrosis of the femoral head. Japanese Orthopaedic Association (JOA) score, postoperative management, and radiographic appearances were investigated. ResultsThe mean preoperative JOA score was 60.8 ± 12.1 points in the large cancellous screw group and 61.5 ± 14.4 points in the K-MAX Adjustable Angle Hip Screw group. This improved to 86.1 ± 13.3 points in the large cancellous screw group and 88.7 ± 6.6 points in the K-MAX Adjustable Angle Hip Screw group at the final follow-up. Intentional varus angulations were obtained in 15 of 25 hips in the large cancellous screw group and in 36 of 44 hips in the K-MAX Adjustable Angle Hip Screw group. Altogether, 23 of 25 (92.0%) cases with large cancellous screws started partial weight-bearing 7 weeks after the operation, and 43 of 44 (97.7%) cases with the K-MAX Adjustable Angle Hip Screw started 5 weeks after the operation. ConclusionsThe K-MAX Adjustable Angle Hip Screw produced clinical results similar to those with the large cancellous screws. In addition, partial weight-bearing could be started 2 weeks earlier after a transtrochanteric anterior rotational osteotomy with the K-MAX Adjustable Angle Hip Screw.

Bone remodeling of a femoral head after transtrochanteric rotational osteotomy for osteonecrosis associated with slipped capital femoral epiphysis: a case report

A rare case of a 12-year-old boy on whom a joint-preserving operation for osteonecrosis after slipped capital femoral epiphysis (SCFE) was performed, is described. Firstly, in situ pinning was performed for acute-on-chronic SCFE. However, osteonecrosis and collapse of the femoral head occurred at 7 months after surgery. Secondly, transtrochanteric rotational osteotomy (TRO) was performed against progression of the collapse of the femoral head. Eight years of X-ray observation revealed bone remodeling at the osteonecrotic region. No documentation has been reported about the potential of bone remodeling of a femoral head with osteonecrosis after SCFE. This case indicates that a joint-preserving operation such as TRO is capable of promoting bone remodeling in such circumstances.

Transtrochanteric rotational osteotomy for osteonecrosis of the femoral head: relation between radiographic features and secondary collapse

BackgroundSecondary collapse of the femoral head after transtrochanteric rotational osteotomy (TRO) for osteonecrosis of the femoral head is a major complication leading to failure. We investigated the relation between the extent and shape of a newly established healthy weight-bearing area and the incidence of secondary collapse. MethodsAltogether, 38 hips in 32 patients with a mean age of 33 years at the time of surgery were followed for a mean of 4 years. ResultsThe outcome was satisfactory in 22 hips (58%) and unsatisfactory in 16 hips (42%), with 9 requiring total hip arthroplasty. The extent of the newly established healthy weight-bearing area as depicted on the immediate postoperative radiograph was significantly greater in the satisfactory group than in the unsatisfactory group. The rate of secondary collapse was significantly higher when the newly established weight-bearing area was thin, like a beak (“beak-shaped” healthy area). The incidence of a beak-shaped healthy area was significantly higher in the steroid group than in nonsteroid group. ConclusionsWe concluded that we should be cautious when the newly established healthy weight-bearing area exhibits this beak shape, even if its extent in the weight-bearing area is large, because of the higher risk of postoperative secondary collapse. In such cases, alteration of the after-treatment program (e.g., prolonging the non-weight-bearing period) should be considered.

Comparison of the Results of Core Decompression and Sugioka's Transtrochanteric Rotational Osteotomy for Osteonecrosis of the Femoral Head

Purpose: This study conducted a comparative analysis on 49 hips treated with a core decompression procedure and 19 hips treated with a Sugioka’s transtrochanteric rotational osteotomy for a osteonecrosis of the femoral head (ONFH). Materials and Methods: This study evaluated the relationship between the Ficat and Arlet Stage and the extent of the necrotic lesion (using Shimizu’s Grade Classification), and the clinical outcome of each procedure. The patient’s outcomes were assessed after a mean follow-up of 46 months (range=36-82 months) after the core decompression and 53 months (range=37-108 months) after the Sugioka’s transtrochanteric rotational osteotomy. The results were considered successful if the patients were asymptomatic with no disease progression, and unsuccessful if there was radiographic (progression of the stage or collapse) or clinical failure (the need for an arthroplasty or subsequent salvage operation). Results: Twenty one out of 49 cases (43%) in the core decompression group and 14 out of 19 (74%) in the rotational osteotomy group showed successful outcomes. In the core decompression group, among the 22 F-A Stage I hips, 15 (68%) hips had survived according to radiological criteria. All four (100%) Shimizu’s Grade A hips of the F-A Stage I had successful results, which is in contrast to the 11 hips out of 18 hips (61%) of the Shimizu’s Grade B and C hips (p Conclusion: A core decompression is effective only in the earliest stages of osteonecrosis (F-A Stage I), which means that its success strongly depends on the location and extent of the femoral head necrosis. Sugioka’s transtrochanteric rotational osteotomy is a more dependable procedure than a core decompression for treating large lesions of nonsteroidal ONFH, particularly for patients under the age of 50.

Progressive collapse of transposed necrotic area after transtrochanteric rotational osteotomy for osteonecrosis of the femoral head induces osteoarthritic change. Mid-term results of transtrochanteric rotational osteotomy for osteonecrosis of the femoral head.

Osteonecrosis of the femoral head is usually progressive, and once collapse of the femoral head develops, joint destruction almost invariably follows. Therefore, for partial osteonecrosis of the femoral head, various types of osteotomies have been developed in an attempt to save the femoral head and maintain the natural function of the hip joint. We reviewed 25 hips in 21 patients for a mean follow-up period of 6.4 years after Sugioka's transtrochanteric anterior rotational osteotomy for osteonecrosis of the femoral head. The clinical results were excellent or good in 20 hips (80%), and radiological success was observed in 15 hips (60%) with an absence of both collapse of the newly established weight-bearing area of the femoral head and narrowing of the joint space. Progressive collapse of the transposed necrotic area was noted in 10 hips (40%), and of these 10 hips, narrowing of the joint space was observed in 7 (70%) at follow-up. A significant correlation was demonstrated between progressive collapse of the transposed necrotic area and narrowing of the joint space. Growth of an osteophyte of the femoral head was observed postoperatively in 16 hips (64%), particularly at anterior and lateral sites of the femoral head. Though collapse of a new weight-bearing area can be prevented, progressive collapse of the transposed necrotic area induces anterior joint instability, giving rise to osteoarthritic change. It is therefore concluded that prevention of the collapse of the transposed necrotic area is important for satisfactory long-term results.

Fatigue subcapital fracture of the femur after the removal of the hip plate in transtrochanteric rotational osteotomy

We report two cases of fatigue subcapital fracture of the femur after the removal of the hip plate used for fixation in transtrochanteric rotational osteotomy for osteonecrosis. Two patients, a 42-year-old man and a 43-year-old man, underwent transtrochanteric rotational osteotomy, and bony union was achieved in both patients. However, fatigue subcapital fracture of the femur occurred in both patients 15 months after the removal of the hip plate. Transtrochanteric rotational osteotomy greatly changes the trabecular bone structure in the proximal femur, thus affecting the strength of the femoral neck. Therefore, for the trabecular bone to be remodeled and for the proximal femur to achieve sufficient strength, a sufficient period is necessary after complete bony union has occurred in the transtrochanteric lesion, before removal of the plate.

Trochanteric rotational osteotomy for osteonecrosis of the femoral head.

The rate of success of transtrochanteric rotational osteotomy for osteonecrosis of the femoral head may be improved if patients are preselected using MRI. We have used three criteria for selection for osteotomy (i) minor collapse of the infarcted area, loss of congruity or the crescent sign, without narrowing of the joint space or acetabular involvement (ii) patients younger than 55 years and with a painful hip (iii) patients with an intact area constituting an arc of more than 120 degrees between the central vertical line of the femoral head and the posterior or anterior margin of the necrotic portion as seen on a midsagittal MRI. Seventeen patients were selected, with a follow-up of more than 42 months. A bone scan four weeks after operation showed adequate perfusion of the proximal segment in all hips. The hip score of Merle d'Aubigné et al improved from 13.5 points before operation to 17.2 points at the latest follow-up. Further collapse of the femoral head did not occur. The use of MRI instead of plain radiographs for the selection of patients has improved the success rate of transtrochanteric rotational osteotomy.

Trochanteric rotational osteotomy for osteonecrosis of the femoral head

The rate of success of transtrochanteric rotational osteotomy for osteonecrosis of the femoral head may be improved if patients are preselected using MRI. We have used three criteria for selection for osteotomy (i) minor collapse of the infarcted area, loss of congruity or the crescent sign, without narrowing of the joint space or acetabular involvement (ii) patients younger than 55 years and with a painful hip (iii) patients with an intact area constituting an arc of more than 120° between the central vertical line of the femoral head and the posterior or anterior margin of the necrotic portion as seen on a midsagittal MRI. Seventeen patients were selected, with a follow-up of more than 42 months. A bone scan four weeks after operation showed adequate perfusion of the proximal segment in all hips. The hip score of Merle d’Aubigné et al improved from 13.5 points before operation to 17.2 points at the latest follow-up. Further collapse of the femoral head did not occur. The use of MRI instead of plain radiographs for the selection of patients has improved the success rate of transtrochanteric rotational osteotomy.

Scintigraphic assessment of the rotated femoral head after transtrochanteric rotational osteotomy for osteonecrosis.

The purpose of this study was to assess the usefulness of bone scintigraphy in predicting progressive collapse of the femoral head after transtrochanteric rotational osteotomy for the treatment of osteonecrosis of the femoral head. We studied thirty-three hips in thirty patients with osteonecrosis of the femoral head who had undergone transtrochanteric rotational osteotomy. There were twenty male and ten female patients, with a mean age of 34.4 years at the time of the operation. The mean duration of follow-up was 10.0 years. According to the staging system of Ficat and Arlet, there were nineteen stage-2 hips and fourteen stage-3 hips at the time of the operation. Conventional anteroposterior and lateral radiographs were assessed. In addition, bone scans were performed at three weeks after the operation to predict the outcome with regard to the rotated femoral head. On the basis of the location of low scan activity within the femoral head, the scintigraphic findings were classified into one of two categories: type A if there was no low scan activity in the weight-bearing area of the femoral head or type B if low scan activity occupied the entire weight-bearing area. Six hips with collapse were studied histologically. Postoperative scintiscans revealed sixteen type-A hips and seventeen type-B hips. Of the type-A hips, only three exhibited progressive collapse of the femoral head after the osteotomy, whereas fourteen of the type-B hips exhibited progressive collapse. A significant association was found between the postoperative scintigraphic findings and the final radiographic result (p < 0.01). Bone scintiscans made three weeks after transtrochanteric rotational osteotomy were useful for predicting the final clinical result.