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    Trochanteric Osteotomies in Revision THA: Indications and Surgical Techniques

    The authors present an overview of the indications, contraindications, and technical pearls for the most common types of trochanteric osteotomies, with a focus on extended trochanteric osteotomy.

    Authors

    Ryan S. Charette, MD; Wayne G. Paprosky, MD; and Neil P. Sheth, MD

    Disclosures

    Dr. Charette has no disclosures relevant to this article. Dr. Paprosky has disclosed that he is a consultant for and receives royalties from Zimmer Biomet and DePuy Synthes. Dr. Sheth has disclosed that he is a consultant for Zimmer Biomet, Smith & Nephew, and Medacta.

    Introduction

    Total hip arthroplasty (THA) is a well-tolerated surgical procedure that reduces pain and improves functional status, offering patients with end-stage degenerative joint disease a better health-related quality of life. [1] Medium- and long-term data have shown a high percentage of patients retain a well-functioning prosthesis. [2-4] This success has led to an expansion of indications to younger and more active patients and with it, projections that the rate of both primary and revision THA will continue to increase exponentially over the next 2 decades. [5] 

    Although trochanteric osteotomy is rarely done with a primary THA, revision procedures may require advanced techniques to enhance exposure. Historically, the Wagner osteotomy was described as an anterior proximal femoral osteotomy. [6] Other more-common osteotomies about the greater trochanter include the standard (trochanteric flip), slide, and extended trochanteric osteotomy (ETO).

    This review presents an overview of the indications, contraindications, and technical pearls for these most common osteotomies, with a focus on ETO.

    Standard Osteotomy

    Indications

    Indications for the standard trochanteric osteotomy are now rare, but it can be used:

    • In patients with laxity of the abductor musculature and global instability during primary THA
    • With distal advancement to properly tension the abductors if stability cannot be acquired despite reestablishing anatomic hip center, leg length, and offset. (The trochanteric slide osteotomy can also be used in this scenario.)
    • When extensile acetabular exposure is required, such as cases of complex acetabular revision

    A relative contraindication to the standard osteotomy is when using the direct lateral approach, as a portion of the abductor mechanism is released before the osteotomy, making subsequent repair difficult. 

    Technique and Fixation

    The standard osteotomy is begun by releasing the proximal portion of the vastus lateralis origin to release the vastus tubercle. A blunt instrument is then inserted between the gluteus minimus and the hip capsule. An oscillating saw or osteotome is used to make the osteotomy from just distal the vastus tubercle toward the inserted instrument, at an angle less than 45° to the femoral diaphysis. The osteotomy is then freed of tethering soft tissue attachments and reflected proximally.

    A successful fixation technique must provide compression at the osteotomy site and resist both proximal displacement and antero-posterior (AP) rotation due to the pull of the abductors.   Fixation constructs using 2, 3, or 4 monofilament wires have been described. [7-12] Jensen et al [8] described a 3-wire technique with a 99% union rate, which has since been modified to a 4-wire technique. [12]

    The 4-wire technique involves 2 vertical wires (1 anterior, 1 posterior) placed through separate drill holes in the trochanteric fragment and fed through vertical tunnels traversing from the proximal surface of the neck cut and out the lateral femoral cortex distal to the osteotomized fragment. Two transverse wires are then placed, with each being fed through a separate anterior and posterior drill tunnel in the trochanteric fragment and a drill tunnel in the lesser trochanter.

    Several modifications to the standard osteotomy have been described: [13]

    • The chevron osteotomy is a biplane osteotomy that inherently provides resistance to AP and rotational displacement.
    • The partial osteotomy is an oblique osteotomy that is taken as a thin wafer of bone, which is retracted anterior with the gluteus medius and vastus lateralis insertions attached.
    • The horizontal osteotomy is similar to the standard, however, the direction of the osteotomy is 70° to 90° to the femoral diaphysis. In addition, the entire insertion of the gluteus minimus and medius are kept intact on the fragment.
    • The vertical osteotomy is indicated in cases in which the trochanter has previously been advanced to the lateral femoral cortex. The osteotomy is parallel to the lateral cortex of the proximal femur, leaving 3 to 5 mm of cancellous bone for re-attachment. The insertions of the gluteus medius and minimus remain intact on the osteotomized fragment.

    Complications

    Non-union rates with all types of fixation of the standard osteotomy have been reported from 0.5% to 38%. [13] Non-union can result in hip pain, abductor insufficiency, and instability.  Symptomatic non-union is often treated with revision fixation; however the cause of symptoms can be multifactorial, and other sources of pain should be ruled out before proceeding with revision.

    Trochanteric bursitis is thought to result from prominent hardware, but hardware removal has unpredictable outcomes in resolving lateral hip pain. [14] The relationship between trochanteric osteotomy and development of heterotopic ossification (HO) is poorly understood. Morrey et al [15] showed no difference in HO rate between different approaches to the hip.

    Trochanteric Slide Osteotomy

    Indications

    The trochanteric slide osteotomy (TSO) was first described by English [16] and was later championed in its modern form by Glassman et al. [17]

    Indications in the primary setting are similar to those for the standard osteotomy. The TSO is helpful in revision surgery to maintain the integrity of the diaphysis, such as when using a cemented femoral component or when impaction grafting. [13] Contraindications include lack of adequate trochanter thickness or medial cortical bone, which would not allow for adequate fixation.

    The major advantage of the TSO over the standard osteotomy is an intact vastus lateralis and gluteus medius attachment, which compress the fragment with a medially directed force and prevent proximal migration.

    Technique and Fixation

    After the trochanter is encountered, usually through a strait lateral incision, the interval between the gluteus minimus and the hip capsule is developed bluntly and an instrument is inserted in this plane. The vastus lateralis is incised along its posterior edge, approximately 10 cm distal to the vastus ridge, and a retractor is placed from posterior to anterior underneath the muscle to expose the femur.

    The osteotomy is initiated posteriorly with an oscillating saw and is taken in the direction of the previously mentioned interval. The caudal extent of the osteotomy is just distal to the vastus ridge. The hip can then be dislocated anterior or posterior.

    The osteotomy fragment is usually repaired using 2 monofilament wires or cables passed medially around the proximal femur and around the trochanteric fragment. In cases of difficult fixation, such as with a thin fragment, a cable grip system can be used, such as that described by Dall and Miles. [18] This cable grip system has been shown to provide greater resistance to displacement than an isolated wire or cable system. [11]

    Complications

    Early non-union rates have been reported from 1.5% to 38%. [16,17,19,20] English [16] reported a lower non-union rate with a bolt and bone graft construct versus wire fixation (2.5% versus 4.3%).  More-recent data suggest similar non-union rates around 4%, compared with reported 15% to 20% non-union rate for the standard osteotomy. [21] 

    Cable breakage or fraying is a noted complication of the cable grip system, reported to be as high as 47%. [19,20] Cable fragmentation can be a source of metallic debris leading to third-body wear. [20] Abductor lurch or Trendelenburg sign has been reported in 23 of 82 patients with radiographic union of the osteotomy fragment. [17]

    Extended Trochanteric Osteotomy

    Indications

    Extended trochanteric osteotomy in its current form was described by Younger and Paprosky [22] as a modification of an anterior trochanteric osteotomy described by Wagner. [23] The most common indication for using an ETO is to facilitate removal of a well-fixed, extensively porous coated or diaphyseal fitting femoral implant.

    Other indications in revision THA include: [24-26]

    • Removal of cement following extraction of a cemented stem
    • Treatment of periprosthetic femur fractures
    • Avoidance of greater trochanter compromise or placement of the stem in varus in the setting of proximal femur varus remodeling

    In primary THA, an ETO can be used in patients with significant proximal femoral deformity or when enhanced acetabular exposure in required. [13]

    Relative contraindications for using an ETO include severe osteolysis of the proximal femur and implantation of a cemented stem.

    Technique and Fixation

    Diligent preoperative planning is essential when performing an ETO. Factors affecting timing of the osteotomy (ie, relative to hip dislocation and stem removal) include the presence of a periprosthetic fracture, significant heterotopic ossification, and a well-fixed femoral component.

    The length of the osteotomy from the tip of the greater trochanter should also be planned. The osteotomy should be extensile enough to: [27]

    • Complete the task at hand
    • Allow for at least 2 cerclage cables to be passed for fixation
    • Render 4 cm to 6 cm of isthmic diaphyseal fit for the revision femoral component

    Most femoral revision osteotomies measure 12 cm to 15 cm in length. [28]

    An ETO is most commonly performed through a posterior approach to the hip. After dissection through skin, fat, and the fascia of the tensor fascia lata, a posterior capsular approach is undertaken along the posterior border of the vastus lateralis, extending along the capsular and short external rotator attachment to the posterior greater trochanter/piriformis fossa. The insertion of the gluteus maximus can be recessed to aid in exposure. The femur is then exposed distally by elevating the posterior border of the vastus lateralis from the lateral intermuscular septum, taking care to maintain the tendinous attachment at the vastus ridge.

    After the length of the osteotomy is measured, a pencil tip burr is used to make the transverse limb, which should extend one third the diameter of the femoral shaft and have rounded corners (Figure 1). The posterior limb is then made with the leg in internal rotation, using an oscillating or microsagittal saw (Figure 2). The leg is placed in external rotation and the distal anterior limb is created using the pencil tip burr (Figure 3).

    Figure 1. A pencil tip burr is used to create the transverse limb of the osteotomy with rounded corners.

    Figure 2. An oscillating saw is used to create posterior limb of the osteotomy.

    Figure 3. A pencil tip burr is used to create the distal aspect of the osteotomy’s anterior limb.

    With the leg in external rotation, the pseudocapsule at the anterior corner of the greater trochanter is released using electrocautery (Figure 4). A series of broad, flat osteotomes are then placed from posterior to anterior along the length of the posterior limb to complete the osteotomy (Figure 5). A prophylactic cable can be placed 1 cm distal to the osteotomy to prevent propagation into an uncontrolled femoral shaft fracture (Figure 6).

    Figure 4. The anterior pseudocapsule is released with electrocautery.

    Figure 5. A series of broad, flat osteotomes are placed from posterior to anterior in the posterior limb to complete the osteotomy.

    Figure 6. A prophylactic cable is placed distal to the osteotomy.

    Reduction and fixation of the fragment begins by placing the leg in slight internal rotation and neutral abduction. The authors prefer to place the proper revision stem before fixing the osteotomy. This ensures proper distal fixation of the implant, as there is no proximal interference from the osteotomy. In addition, placement of the implant before osteotomy fixation provides direct visualization of the implant fit distally to ensure proper sizing.

    A pointed fracture reduction clamp is then used to anatomically reduce the fragment, followed by passage of 2 or 3 cables circumferentially. Proximal bone stock may need to be removed with a burr to accommodate the proximal shape of the prosthesis.

    Postoperatively, the patient should be restricted to toe touch weight-bearing with no active abduction, and then advanced at 6 to 8 weeks after radiographs show no migration of the fragment. A hip abduction brace can be used postoperatively, although its use has not been shown to reduce dislocation rate. [29]

    Complications

    When compared with more-limited approaches, ETO has a lower rate of femoral shaft fracture, inadvertent femoral perforation, and cement retention. [30] Union rates have been reported at more than 98% in revision THA and complex primary THA, [22,31-33] as well as in patients with periprosthetic fracture [26] or periprosthetic infection. [34]

    Fracture can occur intraoperatively or postoperatively, and can often be found at the base of the greater trochanter, just proximal to the vastus ridge. These fractures typically require fixation with a trochanteric claw plate or wires. Patients with broken cables may require operative intervention, even in the case of a healed osteotomy, to prevent third body wear.

    Although proximal migration of the ETO fragment is less common than with the standard osteotomy or TSO, it has been reported and can lead to abductor weakness, construct failure, and gait abnormalities. [11,35] If there is no evidence of instability or significant abductor weakness, a trial of non-operative therapy with restrictions on active abduction can be tried. In symptomatic patients or patients with apparent instability, revision fixation with a stronger cable grip system can restore alignment. In the case of a loose femoral component, it may be necessary to revise the stem.

    Conclusion

    Trochanteric osteotomy is a powerful tool that can be used in primary and revision THA. It can be broadly categorized into 3 types: standard osteotomy, TSO, and ETO. The TSO has largely replaced the standard osteotomy in North America, given its higher propensity for union. [13] The ETO is particularly useful in revision THA with a well-fixed component and has shown low rates of non-union and complications.

    Author Information

    Ryan S. Charette, MD, is a resident in the Department of Orthopaedic Surgery at the University of Pennsylvania in Philadelphia. Wayne G. Paprosky, MD, is Professor, Department of Orthopaedic Surgery, at Rush University, Chicago, Illinois. Neil P. Sheth, MD, is Assistant Professor, Department of Orthopaedic Surgery, at the University of Pennsylvania in Philadelphia.

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