Trochanteric Osteotomy Research Articles

Extended Trochanteric Osteotomy as a Tool in the Revision of Hip Arthroplasty Due to Aseptic Loosening

Extended Trochanteric Osteotomy as a Tool in the Revision of Hip Arthroplasty Due to Aseptic Loosening

Extended Trochanteric Osteotomy Does Not Compromise Functional and Radiographic Outcomes of Femoral Stem Revisions with the Use of an Uncemented Modular Conical Stem.

Background: Stem revisions in revision total hip arthroplasty (THA) with proximal bone stock loss may be dealt with utilizing modular, uncemented conical stems. During stem extraction, surgeons may resort to extended trochanteric osteotomy (ETO). However, ETO is associated with extensive blood loss and infections. This study compared the clinical outcomes, radiographic results and complications in THA revisions utilizing conical modular stem with and without ETO. Methods: Patients who underwent revision THA with or without ETO were assessed retrospectively. The minimal follow-up was 3 years. The functional evaluation included Harris Hip Score (HHS) and Short Form 36 (SF-36) as well as Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Numerical Rating Scale for pain assessment. The radiographic evaluation comprised bone defect assessment, osteotomy healing, stem migration and position, presence of radiolucent lines and stress shielding. Results: In total, 73 patients (80 hips) were included in the final analysis. The ETO group comprised 48 hips, and the no-ETO group comprised 32 hips. In the ETO group, pre-operative WOMAC scores were lower than in the no-ETO group (p = 0.012). No significant differences were found in terms of post-operative HHS, WOMAC, and NRS scores between groups, except worse results were found in the case of claw plate implantation. Patients in the no-ETO group exhibited better results in SF-36 than in the ETO-group. Osteotomy non-union was observed in four hips (9.5%). Stam varus/valgus position was within ±1.5 degrees (85.9%). Conclusions: ETO does not adversely impact outcomes in patients undergoing femoral stem revisions with modular conical stems. The invasive nature of these procedures prompts careful consideration in each case individually.

Is suture-based cerclage biomechanically superior to traditional metallic cerclage for fixation of periprosthetic femoral fractures: A matched pair cadaveric study

BackgroundWhile traditional metallic cerclage remains the primary method in clinical application, non-metallic cerclage systems have recently gained popularity due to low risks of soft tissue irritation and bone intrusion. The objective of this study was to assess the performance of a novel non-metallic suture-based cerclage in comparison to traditional metallic cerclage cables for fixation of periprosthetic femoral fractures. MethodsAn extended trochanteric osteotomy was performed on eight pairs of cadaveric femora, followed by reduction using either metallic cerclages (Group I) or the suture-based cerclage (Group II). A modular tapered fluted stem was then implanted in each specimen. The fragment translation during canal preparation and stem implantation was quantified using laser-scanning. Subsequently, each specimen underwent 500 cycles of multiaxial loading, with fragment translation and stem subsidence measured using a motion capture system. FindingsFollowing stem implantation, specimens in Group II exhibited a significantly greater lateral fragment translation (466 μm vs 754 μm, p = 0.017). However, there were no significant differences in anterior and distal translation between groups (p > 0.05). During multiaxial loading, the average stem subsidence in Group I was 0.36 mm (range, 0.04–1.42 mm), compared to 0.41 mm (range, 0.03–1.29) in Group II (p > 0.05). No significant difference was found in fragment translations between the two groups (p > 0.05). InterpretationThe suture-based cerclage system exhibited comparable biomechanical performance in fixation stability to conventional metallic cerclage cables. Yet, it was associated with a larger residual lateral gap between the fragments following stem implantation. Ultimately, the choice of fixation method should account for multiple factors, including patient characteristics, surgeon preference, and bone quality.

Modified trochanteric triplane osteotomy for chronic moderate to severe slipped capital femoral epiphysis - a preliminary report.

Management of chronic moderate and severe slipped capital femoral epiphysis (SCFE) remains controversial. We propose that the modified trochanteric triplane osteotomy(MTTO) with a 1300 angled blade plate, without removal of bone wedge, is effective for addressing moderate and severe chronic SCFE. A retrospective review was performed on patients who underwent MTTO for moderate to severe chronic SCFE, with at least two years follow-up. Radiological outcomes assessed were osteotomy union, alpha angle, neck shaft angle, mechanical axis deviation and limb length discrepancy(LLD). Functional outcomes were assessed using modified Harris hip score, lower extremity functional scale (LEFS) and SF-36 questionnaire. A total of 11 patients (13 hips) underwent MTTO for chronic SCFE, with a mean age of 12.9 ± 2.1 years. The pre-operative median modified Harris Hip Score was 73. 12 had severe slip and one had moderate slip. All the osteotomies went on to unite by two months. At an average of 37 months follow up, the mean neck shaft angle was 1290, mean alpha angle was 69.70, and mean LLD was 1.05cm. There was significant improvement in the post-operative modified Harris hip score (p < 0.001), the median post-operative modified Harris hip score was 96, and the median LEFS was 78. One case had bone scan evidence of AVN, but did well with bisphosphonate therapy and one case had a superficial infection. MTTO is a safe and effective option for addressing deformities in chronic moderate and severe SCFE. However, a residual proximal femoral Cam deformity persists after this procedure which may need to be treated with a simultaneous or a staged osteochondroplasty.

Posterior approaches to the acetabulum.

Posterior approaches, particularly the Kocher-Langenbeck approach, remain the workhorses in the treatment of acetabular fractures. Various modifications have been developed, each offering specific advantages depending on surgical requirements. The modified Gibson approach, for example, is suggested to provide enhanced visualization of the superior acetabulum, although recent cadaveric studies have not consistently substantiated this benefit. The Ganz approach, which involves bigastric trochanteric osteotomy with safe surgical hip dislocation, is particularly advantageous for managing complex and comminuted posterior acetabular fractures, as it enables a 360° view of the acetabulum and femoral head. Overall, posterior approaches are associated with low rates of complications, with heterotopic ossification being the most prevalent. The choice of surgical approach and patient positioning should be guided by the surgeon's preference and expertise, tailored to the specific fracture pattern and patient characteristics.

The anterior femoral cortical window as an alternative to an extended trochanteric osteotomy in revision hip arthroplasty surgery: the evolution of the surgical technique and outcomes in 22 consecutive cases.

The anterior femoral cortical window is an attractive alternative to the extended trochanteric osteotomy when removing femoral cement in revision hip arthroplasty. CT-based additive manufacturing technology has now permitted the creation of patient-specific instrumented (PSI) jigs to facilitate this. The jig simplifies creation of the window, potentiating medullary exposure through an optimally-sized window and therefore cement removal. Between 2006 and 2021 this technique was used in 22 cases at a regional hospital in New Zealand (mean age 74; range 44 to 89 years). 16 cases were for aseptic loosening and 6 for infection. We describe the technique and our case series. Bone incorporation for the cortical window was assessed in all cases using CT imaging. Oxford scores were obtained at a minimum of 6 months after revision surgery. Of the 6 septic cases 5 went onto successful stage-2 procedures, the other to a Girdlestone procedure. The mean rectangular shaped window size was 8 × 1.5 cm and in each case, this provided adequate intramedullary access. On average at minimum 5 months post-surgery, 84% bone incorporation of the cortical window occurred on CT (40-100%). The functional outcome Oxford hip score was 37 (range 22-48) for 10 cases. There were 2 cases with femoral component subsidence which then stabilised. This technique description and retrospective case series has shown the effectiveness of removing a distal femoral cement mantle in revision hip arthroplasty using an anterior femoral cortical window, recently optimised using a PSI jig. This technique is a straightforward alternative to a trochanteric osteotomy. Reliable bony integration of the cortical window occurred and functional outcomes were comparable with the mean score for revision hip procedures reported in the New Zealand Joint Registry.

SHORTENING OSTEOTOMIES OF THE FEMUR DURING TOTAL HIP ARTHROPLASTY FOR DEVELOPMENTAL HIP DYSPLASIA

Total hip arthroplasty (THA) for congenital hip dysplasia (CDH) presents a challenge. In high-grade CDH, key surgical targets include cup placement in the anatomical position and leg length equality. Lengthening of more than 4 cm is associated with sciatic nerve injury, therefore shortening osteotomies are necessary. We present our experience of different shortening osteotomies including advantages and disadvantages of each technique.89 hips, in 61 pts (28 bilateral cases), for high CDH were performed by a single surgeon from 1997 to 2022. 67 patients were female and 22 were male. Age ranged from 38 to 68 yrs. In all patients 5–8cm of leg length discrepancy (LLD) was present, requiring shortening femoral osteotomy. 12 patients underwent sequential proximal femoral resection with trochanteric osteotomy, 46 subtrochanteric, 6 midshaft, and 25 distal femoral osteotomies with simultaneous valgus correction were performed. All acetabular prostheses were placed in the true anatomical position. We used uncemented high porosity cups. Patients were followed up for a minimum of 12 months.All osteotomies healed uneventfully except 3 non-unions of the greater trochanter in the proximal femur resection group. No femoral shaft fractures in proximally based osteotomies. No significant LLD compared to the unaffected or reconstructed side. 2 patients suffered 3 and 5 degrees malrotation of the femur in the oblique sub-trochanteric group. 3 patients suffered transient sciatic nerve palsies.Shortening femoral osteotomies in the treatment of DDH are necessary to avoid injury to the sciatic nerve. In our series, we found transverse subtrochanteric osteotomies to be the most technically efficient, versatile and predictable in their clinical outcome, due to the ability to correct rotation and preserve the metaphyseal bone integrity, allowing for better initial stem stability. Distal femoral osteotomies allowed for controllable correction of valgus knee deformity.

TROCHANTERIC OSTEOTOMY AND TRANSFER DURING TOTAL HIP ARTHROPLASTY IN PATIENTS WITH DISLOCATED DYSPLASTIC HIPS: UNION RATE USING MONOFILAMENT TRANSVERSE WIRE CERCLAGE

Securing the osteotomized greater trochanter (GT) during total hip arthroplasty (THA) for dislocated dysplastic hips (DDH) poses a significant challenge. This study evaluates the union rate and effectiveness of a 2-strand transverse wiring technique utilizing the lesser trochanter for wire anchorage and tensioning.A digastric anterior slide trochanteric osteotomy was performed in 106 patients (118 hips) undergoing THA for DDH. Following uncemented stem insertion, the GT was transferred and fixed to the lateral cortex of the proximal femur using monofilament stainless steel wires. In 72 out of 106 patients (80 hips), the GT was fixed with 2 transverse wire cerclages threaded through 2 drill holes in the base of the lesser trochanter, spaced vertically 5–10 millimeters apart. The wires were wrapped transversely over the GT and tightened, avoiding contact with its tendinous attachments. Patients were regularly monitored, and GT union was assessed clinically and radiographically.Patient ages ranged from 20 to 57 years (mean 35.5), with a follow-up period ranging from 1.5 to 12 years (mean 6.2). The mean union time was 3.3 months (range 2–7). Among all hips, two developed stable nonunion and single wire breakage, but no fragment displacement (2.5%). Two hips exhibited delayed union, eventually healing at 6 and 7 months after surgery.Reattachment of the greater trochanter utilizing a 2-strand transverse wire cerclage anchored at the base of the lesser trochanter demonstrated a high rate of union (97.5%) following THA in dislocated DDH cases.

Analysis of the therapeutic effect of trochanteric flip osteotomy combined with Kocher-Langenbeck approach for high acetabular posterior wall fracture

Evaluation of the clinical efficacy of f trochanteric flip osteotomy combined with Kocher-Langenbeck approach for high acetabular posterior wall fracture. Between January 2020 and December 2022, 20 patients with high acetabular posterior wall fractures were retrospectively analyzed, including 12 males and 8 females, aged 18 to 75 years old. They were divided into two groups according to the different surgical methods. Ten patients were treated with greater trochanteric osteotomy combined with Kocher-Langenbeck approach as the observation group, including 5 males and 5 females, aged from 18 to 75 years old. Ten patients were treated with Kocher-Langenbeck approach alone as the control group, including 7 males and 3 females, aged from 18 to 71 years old. Matta reduction criteria were used to evaluate the reduction quality of the two groups, and Harris score was used to compare the hip function of the two groups at the latest follow-up. The operation time, blood loss and postoperative complications of the two groups were analyzed. All patients were followed up for 10 to 24 months. According to the Matta fracture reduction quality evaluation criteria, the observation group achieved anatomical reduction in 6 cases, satisfactory reduction in 3 cases, and unsatisfactory reduction in 1 case, while the control group only achieved anatomical reduction in 3 cases, satisfactory reduction in 3 cases, and unsatisfactory reduction in 4 cases. At the final follow-up, the Harris hip score ranged from 71.4 to 96.6 in the observation group and 65.3 to 94.5 in the control group. According to the results of Harris score. The hip joint function of the observation group was excellent in 6 cases, good in 3 cases, and fair in 1 case. The hip joint function of the control group was excellent in 2 cases, good in 3 cases, fair in 3 cases, and poor in 2 cases. In the observation group, the intraoperative blood loss ranged from 300 to 700 ml, and the operation duration ranged from 120 to 180 min;in the control group, the intraoperative blood loss ranged from 300 to 650 ml, and the operation duration ranged from 100 to 180 min. Complications in the observation group included 1 case of traumatic arthritis and 1 case of heterotopic ossification, while complications in the control group included 3 cases of traumatic arthritis, 3 cases of heterotopic ossification and 1 case of hip abduction weakness. Trochanteric flip osteotomy combined with the Kocher-Langenbeck approach significantly improved anatomical fracture reduction rates, enhanced excellent and good hip joint function outcomes, and reduced surgical complication incidence compared to the Kocher-Langenbeck approach alone. Clinical application of this combined approach is promising, although larger studies are needed for further validation.

Modified Dunn Procedure for Open Reduction of Chronic Slipped Capital Femoral Epiphysis.

Abnormal femoral head anatomy following moderate-to-severe slipped capital femoral epiphysis (SCFE) can lead to femoroacetabular impingement and premature osteoarthritis4-10. Surgical correction at the deformity site through capital reorientation has the potential to fully ameliorate this but has traditionally been associated with high rates of osteonecrosis11-15. The modified Dunn procedure has the potential to restore anatomy in hips with SCFE while protecting the blood supply to the femoral head. A surgical dislocation of the hip is performed according to the technique described by Ganz et al.16. The remaining posterosuperior portion of the greater trochanter is trimmed to the level of the femoral neck by subperiosteal bone removal performed in an inside-out manner. The periosteum of the femoral neck is gradually elevated. The resulting soft-tissue flap, consisting of the retinaculum and external rotators, holds the blood vessels supplying the epiphysis. The femoral epiphysis is pinned in situ (in unstable cases) with threaded Kirschner wires, the ligamentum teres is transected, and the femoral head is dislocated. With the femoral neck exposed, the epiphysis is gradually mobilized from the metaphysis, allowing exposure of the residual femoral neck and inspection of any posteroinferior callus. To avoid tension on the retinacular vessels during reduction of the epiphysis, the posterior neck callus is completely excised. The remaining physis is removed with use of a burr while holding the epiphysis stable. The epiphysis is gently reduced onto the femoral neck, avoiding tension on the retinacular vessels. If tension is noted, the femoral neck is rechecked for residual callus, which is excised. If no callus is found, the neck may be carefully shortened in order to minimize tension. Epiphyseal fixation is achieved with use of a 3-mm fully threaded wire inserted antegrade through the fovea to the lateral cortex below the greater trochanter. A second wire is inserted retrograde under fluoroscopy. After reducing the hip, the capsule is closed and the greater trochanter is reattached with use of 3.5-mm cortical screws. Alternatives include nonoperative treatment, in situ fixation (e.g., pinning or screw fixation), gentle closed reduction with pinning, and triplanar trochanteric osteotomy (e.g., Imhauser or Southwick osteotomies). In situ pinning of mild-to-moderate, stable SCFE yields good long-term results with low rates of osteonecrosis9. Treatment of higher-grade SCFE without reduction aims to avoid osteonecrosis and assumes that the proximal femoral deformity will remodel; however, the head-neck offset will remain abnormal, risking impingement and early-onset osteoarthritis5,8. The procedure described in the present article allows anatomic reduction of the epiphysis with a low risk of osteonecrosis. Surgical dislocation of the hip16 with development of an extended retinacular soft-tissue flap17 provides extensive subperiosteal exposure of the circumferential femoral neck and preserves the vulnerable blood supply to the epiphysis18. The Dunn subcapital realignment procedure15 with callus removal and slip angle correction allows anatomic restoration of the proximal femur. Reported results of various centers performing the procedure vary greatly with regard to the number of hips treated and the follow-up time. Most studies have been retrospective and have lacked a control group. The reported risk of osteonecrosis ranges from 0% to 25.9%19, with the wide range most likely because of the challenging nature of the technique, the low number of cases per surgeon, and the long learning curve associated with the procedure. In centers with extensive experience in pediatric hip-preserving surgery, the reported rate of osteonecrosis is low3. Studies with mid to long-term follow-up have shown no conversion to total hip arthroplasty3,20,21, but residual deformities can persist, and subsequent surgery is possible. Extensive experience in surgical hip dislocation and retinacular flap development is a prerequisite for successful outcomes and low rates of osteonecrosis.Sufficient callus and physeal remnant resections are needed to avoid tension on the retinacular vessels during epiphyseal reduction.The skin incision should be centered over the greater trochanterThe Gibson interval must be carefully prepared for adequate release and to avoid injury.Tension on the periosteal flap should be avoided to prevent stress on the retinacular vessels. AP = anteroposteriorAVN = avascular necrosis (i.e., osteonecrosis)CI = confidence intervalCT = computed tomographyK-wire = Kirschner wireMRI = magnetic resonance imagingOA = osteoarthritisSHD = surgical hip dislocationTHA = total hip arthroplastyVTE = venous thromboembolism.

Removal of uncemented components: hope for the best, prepare for the worst-technical tips and tricks.

Removing well-fixed uncemented components can be challenging. With thoughtful surgical planning, appropriate surgical instruments, and proper surgical techniques, most implants can be removed expeditiously with little bone loss and minimal impact on the subsequent reconstruction. Preoperative planning is one of the most essential steps to remove uncemented implants. Obtaining previous surgical records, although tedious, should always be attempted preoperatively to determine if specific instruments will be required and to help anticipate which steps may need special attention. These include the presence of ceramic or metal bearings and the presence of acetabular screws or stem collars. Without proper preparation and available tools, the removal of implants can negatively impact the subsequent reconstruction and patient outcomes. We will describe techniques and practical tips for removing uncemented stems from the top (intramedullary) or transfemoral using an extended trochanteric osteotomy. We will also describe techniques and tools to remove uncemented acetabular shells efficiently. Case examples will highlight these clinical situations where careful planning is necessary and potential problems that may be encountered with the recurring theme of preparing for the worst but hoping for the best. We have also included cases such as removing well-fixed cementless collared stems, broken stems, and fully coated stems.

An Extended Trochanteric Osteotomy Is Necessary for the Removal of Broken Modular Metaphyseal Engaging Femoral Stems

BackgroundModular metaphyseal engaging (MME) femoral components in total hip arthroplasty (THA) allow optimized femoral length, offset, and anteversion and are useful in patients with unusual proximal femoral anatomy. Fretting, corrosion, and stem fractures above the modular sleeve are complications associated with these implants. The purpose of this study was to identify failure mechanisms of retrieved MME femoral components at our institution, identify all broken stem cases, and evaluate how often an extended trochanteric osteotomy (ETO) was required for removal. MethodsAll consecutively retrieved MME femoral components from September 2002 to May 2023 were reviewed. Patient demographics, procedure information, component specifications, indications for removal, and requirements for further revision surgery were reviewed. Descriptive statistics were calculated for variables of interest. ResultsThere were 131 retrieved MME components. The mean age at surgery was 59 years (range, 28 to 75), 49% were women, mean body mass index was 29.4 (range, 20.7 to 33.3), and mean American Society of Anesthesiologists score was 2.4 ± 0.5. There were 102 (78%) stems of 1 design (stem A), and 29 (22%) stems of a different design (stem B). Of 131 components, 10 (7.6%) failed secondary to stem fracture proximal to the modular sleeve. Four of 102 (4%) of stem A and 6 of 29 (21% of stem B) fractured. All broken stems required additional intervention for removal during revision THA, using an ETO (N = 9) or cortical window (N = 1) in which an intraoperative proximal femoral fracture occurred. ConclusionsBroken MME stems present a challenge for orthopaedic surgeons during revision THA. When a stem fracture occurs above the ingrown sleeve, the distal splines may have osseous interdigitation into the clothespin. Thus, when revising a broken MME stem, an ETO should be performed, and the segment should be long enough to allow distal access.

The modified Hardinge approach is not inferior to trochanteric flip osteotomy for Pipkin type IV femoral head fractures: a comparative study in 40 patients

PurposeTo compare the modified Hardinge approach and trochanteric flip osteotomy for the treatment of Pipkin type IV femoral head fractures.Methods This retrospective study included 40 patients who underwent surgical treatment for Pipkin type IV femoral head fractures between 2011 and 2020 and completed at least 1 year of follow-up. The clinical outcome of the Merle d’Aubigné-Postel score and radiological outcomes, including the quality of the fracture reduction, osteonecrosis of the femoral head, posttraumatic osteoarthritis, and heterotopic ossification, were compared between the two groups. Conversion to total hip replacement was recorded as the main outcome measure, analyzed by Kaplan–Meier curve and log-rank test.ResultsNineteen and 21 patients were treated using the modified Hardinge approach (Group A) and trochanteric flip osteotomy (Group B), respectively. The estimated surgical blood loss was significantly higher in Group B (500.00 ± 315.44 mL vs. 246.32 ± 141.35 mL; P = 0.002). Two patients in Group B complained of discomfort caused by the trochanteric screws and requested implant removal. Radiographic outcomes did not differ significantly between the two groups. Clinical outcomes assessed using the Merle d’Aubigné-Postel score 1 year after injury were nearly identical (P = 0.836). Four (21.1%) patients in Group A and three (14.3%) patients in Group B underwent conversion to total hip replacement during the follow-up period; the log-rank test showed no significant difference (P = 0.796).ConclusionsThe modified Hardinge approach resulted in reduced blood loss, with clinical and radiological outcomes similar to those of trochanteric osteotomy; thus, it is an acceptable alternative to trochanteric flip osteotomy.

Modified Dunn Osteotomy for Moderate and Severe Slipped Capital Femoral Epiphysis

Background: Moderate to severe slipped capital femoral epiphysis is a condition that benefits from treatment with modified Dunn realignment osteotomy and fixation 1,2 . The results are acceptable when the procedure is performed by experienced surgeons 3,4 . Description: The patient is placed in the lateral decubitus position. Surgical hip dislocation is performed after a digastric trochanteric osteotomy. An extended retinacular flap is carefully prepared, and the epiphysis separated from the metaphysis, exposing the entirety of the femoral neck. Following this, an open reduction is performed by excising the posteromedial callus and trimming the femoral neck in order to allow capital realignment while avoiding tension on the retinacular vessels. Finally, the reduced slip is fixed with 6.5 or 7-mm cancellous screws and Kirschner wires. The femoral head is then repositioned in the acetabulum, and the trochanter is fixed distal to its original position with use of 3.5-mm self-tapping cortical screws. Closure is performed in layers after achieving adequate hemostasis. Alternatives: Operative alternatives to this technique include cuneiform osteotomy, compensatory osteotomy of the base of the neck or intertrochanteric osteotomy and controlled repositioning, and osteoplasty 5–7 . Osteotomies performed distally and away from the deformity can still lead to cam impingement, thereby failing to reduce the risk of future joint degeneration. In situ pinning has also been described for use in moderate to severe cases of slipped capital epiphysis, but the residual deformity leads to substantial femoroacetabular impingement and thus affects the prognosis of such a hip 8 . Rationale: This technique accounts for the complex anatomy of the hip joint, especially in terms of its precarious blood supply. Long-term studies have shown that corrective osteotomy performed near the physis can correct the alignment at the head-neck junction, thereby avoiding future femoroacetabular impingement. In the hands of experienced surgeons, results have been shown to be favorable 3,4 . Expected Outcomes: In a series of 30 consecutive hips, including 20 moderate and 10 severe slips, the slip angle improved significantly following the modified Dunn procedure (by 43.63° ± 8.42°; p &lt; 0.001). Osteonecrosis was observed in 2 hips (6.7%), and 1 hip had postoperative subluxation that required intervention 9 . In their series of 23 patients, Slongo et al. encountered 2 cases (9%) of osteoarthritis and osteonecrosis 10 . In their series of 40 patients from 2 different institutions, Ziebarth et al. reported no cases of chondrolysis or osteonecrosis 11 . Important Tips: The steps described need to be followed sequentially and meticulously in order to safely dislocate the hip while preserving the blood supply.The availability of an anterior pouch in draping, to deliver the leg during dislocation, will reduce the dependence on an assistant and maintain sterilityThe trochanteric osteotomy should be started with the help of a saw, completed with an osteotomy and must be about 1 to 1.5 cm thick in order to achieve good, stable fixation following relocation of the femoral head and to achieve good abductor function post-relocation.The use of curved, stout, thick scissors (“episiotomy scissors”) can help to ease the step of cutting the ligamentum teres during dislocation.The retinacular flap should be widely exposed along with removal of the posterior callus so that no tension remains on the blood supply. Acronyms and Abbreviations: SCFE = slipped capital femoral epiphysisFAI = femoroacetabular impingementMDP = modified Dunn procedureAVN = avascular necrosisTHR = total hip replacementFAER = flexion, abduction and internal rotationCT = computed tomographyMRI = magnetic resonance imagingAP = anteroposterior

Techniques for abductor reattachment in proximal femoral replacement for non-oncological reconstructions: a narrative review.

Proximal femoral replacement due to revision hip arthroplasty or catastrophic proximal femur fracture fixation failures with considerable proximal femur bone loss can lead to a substantial loss of function of the soft tissue around the hip and the abductor muscles in particular. Surgical techniques of gluteus medius repair and/or abductor mechanism reattachment/reconstruction are widely debated in the literature, but it is quite rarely dealt with in the context of megaprosthesis and femoral reconstruction, particularly in non-oncologic patients. The aim of this study is to present a narrative review of the literature on techniques for abductor reattachment in proximal femoral replacement for non-oncological reconstructions. MEDLINE, Embase, and Cochrane databases were searched by two researchers independently from inception until February 1st, 2023 (923 for MEDLINE and 963 for Embase; Cochrane is a composite of multiple databases and thus does not report a standard inception date). Articles examining proximal femoral reconstruction with megaprosthesis or allograft prosthesis were included. Studies concerning cadaver and oncologic patients were excluded. If the researchers failed to find an agreement on whether to include a study, the senior researcher would make a final decision in such cases. Data were extracted and stored, and qualitative synthesis was performed. A total of 1,157 articles from MEDLINE, 11,187 articles from Embase, and 0 articles from Cochrane were identified. Of 12,344 articles, the structured screening process revealed 10 eligible trials. Four different types of abductor musculature reconstruction/reinsertion were identified. Multiple and complex revision hip arthroplasties as well as multiple surgical procedures for proximal femur fracture fixations failures may have a great impact on proximal femur bone stock condition and soft tissue preservation requiring the use of a proximal femur megaprosthesis. In such cases, the abductor mechanism reconstruction and/or reattachment is achievable with different techniques that can be resumed in four different groups: direct suture to the prosthesis, trochanteric sleeve osteotomy, muscle-to-muscle suture, and synthetic tube augmentation suture.

Stability of Proximal Femoral Osteotomies in Pediatric Bone Models Fixed with Flexible Intramedullary Nails and Evaluated by the Finite Element Method.

Objective To evaluate the stability of osteotomies created in the subtrochanteric and trochanteric regions in a pediatric femur model fixed by flexible intramedullary rods. Method Tomographic sections were obtained from a pediatric femur model with two elastic titanium rods and converted to a three-dimensional model. This model created a mesh with tetrahedral elements according to the finite element method. Three virtual models were obtained, and osteotomies were performed in different regions: mediodiaphyseal, subtrochanteric, and trochanteric. A vertical load of 85N was applied to the top of the femoral head, obtaining the displacements, the maximum and minimum main stress, and the equivalent Von Mises stress on the implant. Results With the applied load, displacements were observed at the osteotomy site of 0.04 mm in the diaphyseal group, 0.5 mm in the subtrochanteric group, and 0.06 mm in the trochanteric group. The maximum stress in the diaphyseal, subtrochanteric, and trochanteric groups was 10.4 Pa, 7.52 Pa, and 26.4 Pa, respectively. That is around 40% higher in the trochanteric group in regards to the diaphyseal (control). The minimum stress of the bone was located in the inner cortical of the femur. The equivalent Von Mises stress on the implants occurred at osteotomy, with a maximum value of 27.6 Pa in the trochanteric group. Conclusion In both trochanteric and subtrochanteric osteotomies, fixation stability was often lower than in the diaphyseal model, suggesting that flexible intramedullary nails are not suitable implants for proximal femoral fixations.

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.

Fused hip conversion to total hip arthroplasty with the direct anterior approach: surgical technique on a regular surgical table under fluoroscopic guidance.

Conversion of a fused hip to a total hip arthroplasty (THA) is technically challenging due to the loss of anatomical references. Here, a reproducible technique using the direct anterior approach (DAA) with a regular surgical table under fluoroscopic guidance is described, which has several advantages over traditional such as lateral or posterior approaches. There were reported 11 cases of ankylosis hip that were converted to THA using the same surgical technique protocol. Clinical and radiographic outcomes were recorded at 3.2years of follow-up. A detailed preoperative evaluation was performed, including a pelvis radiological evaluation and magnetic resonance image (MRI) to assess the integrity of the periarticular soft tissue and flexor muscles. The DAA has considerable advantages, such as allowing more precise targeting during surgery, avoiding the risk of pseudoarthrosis due to the absence of a trochanteric osteotomy, preserving the abductors, and allowing an easier-to-use of intraoperative fluoroscopy due to the supine position. Besides, the use of a standard table reduces surgical time and allows assessment of limb length, hip stability, and impingement in all planes in an intraoperative dynamic range, which decreases postoperative complications. Conversion from hip fusion to THA is a rare and complex procedure. The use of DAA with a standard table and fluoroscopy helps to avoid high complications since it allows a dynamic intra-operative examination of the range of motion to rule out impingements, reduces the risk of dislocation, and allows leg lengthening verification.

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.

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.