Trochanteric Transfer Research Articles

Significant Clinical Improvement after Trochanteric Transfer

Significant Clinical Improvement after Trochanteric Transfer

A long-term follow-up study of the clinical and radiographic outcome of distal trochanteric transfer in Legg-Calvé-Perthes' disease following varus derotational osteotomy.

To assess the long-term effect of distal trochanteric transfer (DTT) on the clinical and radiographic outcomes of patients with Legg-Calvé-Perthes' disease (LCPD) following a varus derotational osteotomy (VDRO). For this single centre cross-sectional retrospective study we analysed the data of 22 patients (24 hips) with LCPD who had greater trochanteric overgrowth (GTO), following a VDRO performed in our institution between 1959 and 1983. GTO was defined as an articular trochanteric distance (ATD) of < 5 mm. We compared the radiographic and clinical outcomes of patients who underwent DTT for GTO (ten patients, ten hips) with those who did not (12 patients, 14 hips). Age at presentation was 6.9 years (4 to 10) and 8.0 years (3.2 to 12) respectively. Symptoms associated with the hip and general quality of life were assessed using the Harris hip score (HHS) and the Short Form (SF)-36 questionnaires. At long-term follow-up of the DTT group, the ATD was 21.7 mm (standard deviation (sd) 9.8) and the centro-trochanteric distance (CTD) was 13.8 mm (sd 8.3). In the control group the ATD was -0.6 mm (sd 7.8) and the CTD was 32.5 mm (sd 10.2). These differences were statistically significant (p < 0.001). The mean HHS and SF-36 scores were 68.4 (sd 25.0) and 62.0 (sd 27.7) for the DTT group and 73.2 (sd 24.2) and 73.3 (sd 21.5) for the control group, respectively. There was no statistically significant difference in the HHS (p = 0.63) or SF-36 score (p = 0.25). There were four patients who had undergone hip arthroplasty in the DTT group (40%) and one patient (7.1%) in the control group (p = 0.07). The mean age at the time of arthroplasty was 45.3 years (42.1 to 56.5) and 43.6 years respectively. Six patients in the DTT group suffered from moderate to severe osteoarthritis (Tönnis grade 2 or 3) compared with eight patients in the control group (60% versus 57.1%, p = 0.61). Although DTT improved the radiographic results in the long-term follow-up of patients with GTO following VDRO, there was no clinical benefit seen in the HHS, SF-36 or incidence of osteoarthritis compared with patients who had not undergone DTT. Cite this article: Bone Joint J 2017;99-B:987-92.

Guided growth of the trochanteric apophysis combined with soft tissue release for Legg–Calve–Perthes disease

During the initial fragmentation stage of Perthes disease, the principle focus is to achieve containment of the femoral head within the acetabulum. Whether by bracing, abduction casts, femoral and/or pelvic osteotomy, the goals are to maximize the range of hip motion and to avoid incongruity, hoping to avert subsequent femoro-acetabular impingement or hinge abduction. A more subtle and insidious manifestation of the disease relates to growth disturbance involving the femoral neck. We have chosen to tether the greater trochanteric physis, combined with a medial soft tissue release, as part of our non-osteotomy management strategy for select children with progressive symptomatology and related radiographic changes. In addition to providing containment, we feel that this strategy addresses potential long-range issues pertaining to limb length and abductor mechanics, while avoiding iatrogenic varus deformity caused by osteotomy. This is a retrospective review of 12 patients (nine boys, three girls), average age 7.3 years old (range 5.3–9.7), who underwent non-osteotomy surgery for Perthes disease. An eight-plate was applied to the greater trochanteric apophysis at the time of arthrogram, open adductor and iliopsoas tenotomy, and Petrie cast application. We compared clinical and radiographic findings at the outset to those at an average follow-up of 49 months (range 14–78 months). Six plates were subsequently removed; the others remain in situ. Eleven of twelve patients experienced improvement in pain, and alleviation of limp and Trendelenburg sign at latest follow-up. The majority had improved or maintained range of motion and prevention of trochanteric impingement demonstrated by near normalization of abduction. Neck-shaft angles, Shenton’s line, extrusion index, center edge angles and trochanteric height did not change significantly. One patient underwent subsequent trochanteric distalization and no other patients have undergone subsequent femoral or periacetabular osteotomies. Leg length discrepancy worsened in four patients and was treated with contralateral eight-plate distal femoral epiphysiodesis. As a group the mean leg length discrepancy did not change significantly. There were no perioperative complications. six trochanteric plates were subsequently removed after an average of 43.7 months (range 28–69) due to irritation of hardware; the others remain in situ, pending further growth. We employed open adductor and iliopsoas tenotomy and Petrie cast application and guided growth of the greater trochanter as a means of redirecting the growth of the common proximal femoral chondroepiphysis. The accrued benefits of preventing relative trochanteric overgrowth with a flexible tether are the avoidance of iatrogenic varus and weakening of the hip abductors. The goals are to preserve abductor strength and avoid trochanteric transfer or intertrochanteric osteotomy.

Greater trochanteric transfer for the treatment of coxa brevis in children and adolescents

Objective To evaluate the effect of greater trochanteric transfer for the treatment of coxa brevis in children and adolescents.Methods From August 2005 to January 2011,twenty patients (22 hips)with coxa brevis underwent greater trochanteric transfer.Among them 18 patients (20 hips) were available for evaluation,including 4 boys and 14 girls,with an average age of 11.4 years (range,7.5-15.0 years) at operation.Five cases (6 hips) were caused by Perthes disease,and 13 cases (14 hips) were caused by developmental dysplasia of hip.Four patients (4 hips) had undergone greater trochanteric epiphyseodesis ever before.All patients were fixed with tension screw after the deformity was corrected during the operation.After operation,the human plaster spica was used for 6 weeks in all patients.Results All patients were followed up for 14 to 79 months (average,31 months).At the last follow-up,fatigue or pain in the hips disappeared or improved in 13 patients.Sixteen patients had limping and positive Trendelenburg sign preoperatively,at the last follow-up 9 patients got improvement.Twelve patients (13 hips) had limitation of abduction of the hip,the average range of abduction was 25.38°±1.20°,which was improved to 45.38°±1.05° at the last follow-up.The average articulotrochanteric distance and ratio of the distance from the greater trochanter tip to femoral head center and the radius of the femoral head at the last follow-up was (17.47+3.14)mm and 2.10±0.21,respectively,there were statistical differences compared with those before operation [(-2.89±4.62) mm and 1.59±0.22,respectiovely].The average leg-length discrepancy at the last follow-up was (0.78t±0.26) cm,which had on statistical differences compared with that [(0.83 ±0.33) cm]before operation.Conclusion Greater trochanteric transfer for the treatment of coxa brevis in children and adolescents could improve the clinical symptom,recover the normal anatomy of the proximal femoral,restore the hip biomechanics environment,but could uot improve the leg-length discrepancy. Key words: Hip dislocation, congenital; Osteotomy; Child

Does Trochanteric Transfer Eliminate the Trendelenburg Sign in Adults?

Premature closure of the proximal femoral growth plate results in coxa brevis, which usually is associated with insufficiency of the hip abductors. Distal and lateral transfer of the greater trochanter sometimes is recommended to correct this problem. Most of what is known arises from studies of children and adolescents. We asked whether this procedure in adults with coxa brevis would eliminate hip abductor insufficiency and would improve their hip function based on the Harris hip score (HHS). We prospectively followed 11 patients, aged 19 to 55 years (mean, 40 years) who had distal and lateral trochanteric transfer. All patients had pain and a positive Trendelenburg test before surgery. This test was performed at the latest followup by three observers and the interobserver reliability was determined by the kappa coefficient. The HHS was obtained before surgery and at the latest followup. The minimum followup was 25 months (mean, 52 months; range, 25-77 months). Insufficiency of the hip abductors was eliminated in seven (according to two observers) and eight (according to one observer) of the 11 patients after surgery; the kappa coefficient ranged from 0.79 to 1.0. The mean HHS improved from 64 points preoperatively to 76 points at the final followup. The two patients with preexisting severe osteoarthritis of the hip had the worst final scores and persisted with a positive Trendelenburg test at the final followup. Distal and lateral transfer of the greater trochanter can eliminate insufficiency of the hip abductors and improve joint function in adult patients with coxa brevis and we believe should be considered for patients without severe osteoarthritis of the hip. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Greater Trochanteric Transfer for the Treatment of Coxa Brevis

We reviewed the outcomes of 28 patients for whom we did greater trochanteric transfer. Twenty-two (79%) patients treated for coxa brevis by greater trochanteric transfer had good relief of pain and limp. Four (1%) outcomes were fair and two (0.7%) were poor. Our outcomes compared favorably with those already reported in the literature. Patients who had avascular necrosis caused by Perthes disease tended to have a better outcome than those caused as a complication of treatment for hip dysplasia. A computer model based on radiographic measurements was useful in planning the placement of the transfer for biomechanical efficiency. The surgical technique and osteotomy planning is described. Our goal is to review (1) the effectiveness of our surgical procedure, (2) whether deformity etiology influences outcome, (3) the best way to achieve optimal biomechanical efficiency, and (4) how software assisted planning can assist in surgical planning.

The value of distal greater trochanteric transfer in the treatment of deformity of the proximal femur owing to avascular necrosis.

A series of 49 patients (55 hips) who had distal greater trochanteric transfer at the mean age of 13.9 years because of the deformity of the proximal femur after treatment for developmental dislocation of the hip was reviewed to verify the value of the procedure. Mean follow-up was 8.8 years. Clinical and radiologic assessment was supplemented with strain-gauging evaluation of the muscles involved. Good results were achieved in patients who had good range of movement or isolated restriction of abduction before the operation. After surgery, a 22% increase of abductors torque was found, the Trendelenburg sign disappeared in 30 individuals, and 15 patients regained normal gait. No complications were observed. Our study confirmed the value of distal transfer of the greater trochanter in treatment for proximal femur deformity owing to avascular necrosis after management of developmental dislocation of the hip and clarified indications for this procedure.

The Value of Distal Greater Trochanteric Transfer in the Treatment of Deformity of the Proximal Femur Owing to Avascular Necrosis

The Value of Distal Greater Trochanteric Transfer in the Treatment of Deformity of the Proximal Femur Owing to Avascular Necrosis

Uncemented total hip arthroplasty with subtrochanteric derotational osteotomy for severe femoral anteversion

Total hip joint arthroplasty (THA) in the presence of severe femoral anteversion (>50°) is technically demanding. This problem is often encountered in patients with osteoarthritis secondary to hip joint dysplasia or congenital dislocation. We describe a method of THA in which an uncemented femoral prosthesis is used in conjunction with subtrochanteric derotational osteotomy. This technique allows the restoration of the normal proximal femoral anatomy, including the abductor muscle lever arm without resorting to greater trochanteric transfer. Correction of the excessive femoral anteversion avoids the tendency for postoperative anterior instability. The osteotomy site may also serve as the site for femoral shortening or angular correction when required, which preserves the normal femoral flare. The prostheses used were custom CAD/CAM (computer-assisted design/computer-assisted manufacturer) in design and had the following features: a close intramedullary proximal fit, with collar, lateral flare, and hydroxyapatite coating to achieve early proximal fixation, and longitudinally cutting fluted stem to provide immediate rotational stability across the osteotomy site. Although we used CAD/CAM custom prostheses, off-the-shelf uncemented hip prostheses with similar design features have become available. We report on 7 patients who underwent THA using this technique. The average patient age was 49 years (range, 34–61 years) with a mean follow-up period of 31 months (range, 16–60 months). To date, all cases have had a satisfactory outcome with evidence of union at the osteotomy site. Harris hip scores improved from an average of 44 preoperatively to 91 by the end of follow-up period. One case was complicated by delayed union at the osteotomy site, which was successfully corrected with bone grafting and temporary plate stabilization.

The Periacetabular Osteotomy

The results of 123 periacetabular osteotomies in 115 patients were reviewed at an average clinical followup of 4.3 years. The average age of the patients at the time of the operation was 32.9 years. The preoperative diagnosis was congenital dysplasia in 101 hips, Legg-Calve-Perthes disease in 10 hips, Charcot Marie Tooth disease in four hips, epiphyseal dysplasia in three hips, congenital coxa vara in two hips, slipped capital femoral epiphysis in one hip, and posttraumatic and postinfectious dysplasia in one hip each. The ilioinguinal approach was used in 67 hips and the modified Smith-Petersen approach was used in 56 hips. A periacetabular osteotomy was combined with an intertrochanteric osteotomy and/or trochanteric transfer in 32 hips. Ten hips underwent open reduction and internal fixation of an acetabular rim fracture and 18 arthrotomies were performed at the time of periacetabular osteotomy. The average Harris hip score increased from 65 points preoperatively to 89 points at latest followup. The average Merle d'Aubigne score increased from 13.6 points preoperatively to 16.3 points at latest followup. Overall, 83% of the hips were rated clinically as good to excellent. Seven hips have undergone total hip arthroplasty and six subsequent intertrochanteric osteotomies were performed. The majority of the major complications occurred when the osteotomy was performed through the ilioinguinal approach. The latest followup radiographic severity of osteoarthrosis, according to the criteria of Tönnis, improved or was unchanged in 117 hips (95%), and progressed in only six hips (5%). The majority of the hips with preoperative changes in the periarticular bone showed some evidence of regeneration, which was shown by a decrease in the subchondral sclerosis, disappearance of cysts, or healing of an acetabular rim fracture. The short term results of the periacetabular osteotomy are encouraging from the standpoint of improvements in clinical scores and in the appearance of the joint.

Trochanteric transfer in total hip replacement: effects on the moment arms and force-generating capacities of the hip abductors.

A three-dimensional computer model of the pelvis, femur, gluteus medius, and gluteus minimus was used to evaluate the changes in muscle moment arms and force-generating capacities caused by alterations in the location of the greater trochanter. In the first part of this study, the hip center and all other aspects of joint geometry remained unaltered, while we examined changes in abduction moment arms that resulted from transfer of the trochanteric fragment to a wide variety of positions on the femur. The largest increase in average abduction moment arm was 11% (0.5 cm), which occurred with an anterolateral transfer. Most transfers resulted in moment arm changes of less than 5%. In the second part of this study, the hip center was displaced 2 cm superiorly, and the effects of a distal trochanteric transfer on the moment arms and force-generating capacities of the abductors were analyzed. The superior displacement caused a 13% decrease in the moment arm of the abductors and a 43% decrease in their force-generating capacity. The moment arm was not restored by distal transfer of the greater trochanter; however, distal transfer had the major advantage of restoring muscle lengths and force-generating capacities. These results suggest that trochanteric transfer should be considered primarily as a means to restore muscle length because it has limited potential to increase the moment arms of the two primary hip abductors.

Cure of the limp in children with congenital dislocation of the hip and ischaemic necrosis. Fifteen cases treated by trochanteric transfer and contralateral epiphysiodesis

Fifteen patients who limped and had early fatigue on walking caused by ischaemic necrosis after treatment for congenital dislocation of the hip had distal and lateral transfer of the greater trochanter. Nine of them in whom the predicted leg-length discrepancy was more than 3 cm also had epiphysiodesis of the contralateral leg. At skeletal maturity the limp was eliminated and walking distance was significantly improved in them all. In those who had epiphysiodesis the average leg-length discrepancy was 0.7 cm at maturity. Two of those not treated by epiphysiodesis used a heel raise of 1.5 cm. In seven cases the two operations were performed simultaneously without serious complications. This procedure is recommended at about the age of 12 years.

Greater Trochanteric Transfer in Children

Fifteen patients who were treated at the Alfred I. DuPont Institute with greater trochanter overgrowth were reviewed to investigate the results of a surgical procedure for greater trochanteric transfer. The aim of the paper is to present the clinical findings, X-Ray evaluation, pre and post-operative measurements based on pain, limp, Trendelemburg sign, hip abduction power and hip joint motion. The surgical procedure itself is relatively easy to perform and does not often result in complications. The greater trochanteric transfer is indicated for older children (about ten years of age) and can offer good results in patients who require elongation of the lever arm in hip abductor muscles.

The Chiari Osteotomy

Fifty-eight Chiari osteotomies performed in 51 patients were reviewed retrospectively. The indications for surgery were painful subluxation, instability, or poor acetabular coverage. The average age at surgery was 16 years (range, 7-45), and the average follow-up period was 40 months. The majority of the patients had congenital hip dislocation, but also included were patients with cerebral palsy, Legg-Calvé-Perthes disease, polio, infection, coxa vara, and epiphyseal dysplasia. Supplemental bone grafts were applied as needed. The functional results were unrelated to age, with 26 excellent, 28 good, and four poorly functional hips. After operation, 39 out of 41 had total pain relief, 41 out of 58 had a normal acetabular index, and 54 out of 58 had a normal center-edge angle. Trendelenburg gaits were unchanged by the Chiari osteotomy, but trochanteric transfer improved the gait in few cases.

Coxa Breva

Forty-four patients (50 hips) with symptomatic coxa breva underwent surgical treatment consisting of arrest and/or transfer of the "overgrown" greater trochanter. In a retrospective review, the authors compared the patients who underwent apophyseodesis to those treated by trochanteric transfer. The purpose was to clarify the indications for and results of each procedure. Patients less than or equal to 8 years of age benefited from apophyseodesis as a means of averting a Trendelenburg gait. Those patients presenting with an established Trendelenburg limp and those greater than or equal to 9 years of age are best treated by distal and lateral transfer of the greater trochanter.