Introduction

The basis of development of this chapter deals principally with the understanding of transtrochanteric approach and different types of osteotomy that are used to manage the majority of the difficult pathologies encountered in the hip.

The use of classic trochanteric osteotomy for primary total hip replacement has declined in the last three decades.1 Its use has primarily declined in North America because of increased incidence of complications and surgical time this approach added. Primary Total Hip Replacement now is generally done via a posterior, anterolateral and direct lateral approach without the use of trochanteric osteotomy. Among all the extensile approaches used for the hip surgery, trochanteric osteotomy still remains a valuable tool in difficult primary and revision hip surgery.2 Trochanteric osteotomy can be used to facilitate dislocation in patients with ankylosed hips of fusion, protrusio acetabuli and other complex primary pathologies requiring extensile exposure.3 In revision surgery it provides a good tool to well fixed femoral component extraction, acetabular exposure and varus remodeling of the proximal femur.4

The methods of trochanteric osteotomy can be broadly categorized in three types (Fig. 10.1):

1. Standard Uni/Bi planar osteotomy and its modifications

2. Trochanteric slide osteotomy

3. Extended trochanteric osteotomy.

Figure 10.1: Shows the different types of trochanteric osteotomies. (1) Standard trochanteric osteotomy, (2) Sliding trochanteric osteotomy and (3) Extended trochanteric osteotomy

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There have been several of modifications of these osteotomies that have been described in the literature such as stepped osteotomy, partial, vertical or horizontal. The first, used by Charnley,5 simply detaches the trochanter in a way to allow proximal retraction of the gluteus medius and minimus. The second is an osteotomy in continuity leaving intact the attachment of the gluteus medius proximally and of the vastus lateralis distally. The extended osteotomy is the third version and is reserved for revision procedures and includes the trochanter with the gluteus attachments but also extends distally to maintain the attachment of the vastus lateralis. The osteotomy is initiated posteriorly just anterior to the intermuscular septum and is hinged anteriorly. This exposure has been popular in recent years to facilitate removal of well-fixed femoral component. Due to wider surface area available for healing (as compared to classic osteotomy) the risk of non-union seems to be lower with extended trochanteric osteotomy. Fixation options include a variety of techniques such as wire constructs, cables, plates, bolts and plates with proximal claw.3 All these modifications were developed in order to overcome one or the other complications of the trochanteric osteotomy approach (non-union, proximal trochanteric migration, hardware irritation, bleeding) and to decrease the operative time.

Indications

The use of trochanteric osteotomy approach has decreased over the last few decades and very few centers are using this approach in primary hip arthroplasty. The use of standard trochanteric osteotomy is also useful for complex acetabular revisions requiring extensile exposure such as the use of antiprotrusio cage with ilium flange. This approach allows superior retraction of the abductor muscles and thus provides an excellent acetabular and pelvic exposure. One of the advantages of the standard trochanteric osteotomy is that it still allows use of impaction bone grafting and cemented fixation of the revision femoral stem component, which cannot be done with extended trochanteric osteotomy4 (Fig. 10.2).

The indications to trochanteric slide osteotomy are similar to standard trochanteric osteotomy.

The indications for extended trochanteric osteotomy include revision of well-fixed cemented or uncemented femoral components, femoral revisions with difficult cement revisions and the varus remodeling of the proximal femur. The osteotomy also facilitates the removal of cement through direct visualization as well as the removal of proximally fixed and extensively coated prostheses. Mobilizing the osteomized fragment anteriorly and

Figure 10.2: Shows the modification of the trochanteric osteotomy. Green line shows the horizontal osteotomy, blue line illustrates the standard osteotomy, red line shows the extended trochanteric osteotomy and black line shows the vertical osteotomy

proximal femur posteriorly can enhance acetabular exposures. The extended trochanteric osteotomy also provides a direct access to the diaphysis to allow straight reaming of the diaphysis for revision stem insertion.

Contraindications

Trochanteric Osteotomy

One of the relative contraindications to the standard trochanteric osteotomy is its use with the direct lateral (Hardinge or its modifications) approach when it is observed that the abductor mechanism has been almost completely detached from the greater trochanter thus making subsequent osteotomy and repair very difficult.4 The trochanteric slide osteotomy should also be avoided in medial calcar deficiencies or inadequate trochanteric thickness resulting in inadequate bed for repair and healing.6

Extended trochanteric osteotomy should be avoided when an implant is used with the proximal fixation method. Careful planning should be used when combined with impaction grafting of the proximal femur or in prosthesis fixed with cement as cement extrusion from the osteotomy site can result in later non-union of the osteotomy.

Technical Details for Chevron (Biplaner) Osteotomy

Using Triple Wire Technique

The steps for the procedure include:

1. Draping and preparation

2. Exposure and trochanteric osteotomy

3. Trochanteric wiring technique

4. Trochanteric wiring fixation.

   DRAPING AND PREPARATION

   • The patient is positioned in anesthetic room, making sure that the pelvis is square and patient is flat on the table. One must check true length/deformity (easy to lengthen somebody with preoperative abduction deformity)

   • The patient is draped in the standard way

   • The anatomical landmarks are identified and marked with the marker pen (Anterior superior iliac spine, tip of greater trochanter and iliac crest)

   • The surgical incision is marked with the marker pen holding both the hip/knee in flexion.

     EXPOSURE AND TROCHANTERIC OSTEOTOMY

   • Incision is made along femoral shaft, mid trochanter and about 4 fingers above the trochanter (Fig. 10.3)

   • The skin and superficial fat are incised and bleeders are identified

     Figure 10.3: Shows the skin incision for the transtrochanteric approach

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     • Bleeding is controlled. Sharp dissection is used to expose TFL (tensor fascia lata), fat is reflected to assist closure

     • TFL is incised along the fibers, making sure that it is possible to pass fingers under TFL to reach pyriformis fossa (PF), the trochanteric bursa is reflected off. Charnley retractors are used to expose the wound. Anterior edge of the abductor muscle mass is identified and cleared off fat

       Total Hip Arthroplasty

     • The origin of vastus is incised at the level of trochanteric flare, then one should continue onto straight head of rectus femoris and anterior capsule along the ant surface of the neck. With curved long clip capsule is reflected from sup/inf aspect of the neck. Curved long forceps are passed along the neck/troch junction to come out at the PF. A Steinman pin is put through greater trochanter along the neck to help in getting chevron shaped biplane osteotomy. The optimal angle between two planes should be approximately 45 degrees. Gigli saw is passed using the clip around the troch. One must make sure soft tissue/capsule is not caught especially along the posterior aspect. At this stage one should check with diathermy that sciatic nerve is not in contact with gigli saw. The greater trochanter, is osteotomized keeping hands close to the knee and protect skin edges

     • Steinmann pin is removed, the greater trochanter fragment held and the capsular attachment released along the edges. Capsulotomy is performed at posterior aspect of the hip joint (7 o' clock position for right hip and 5 o' clock position for the left hip)

     • Using diathermy and long curved clip hip capsule can be reflected off the femoral neck allowing mobilization of the proximal femur

     • Once the femoral neck is sectioned (in case of primary hip replacement) further exposure can be achieved using east west retractors/pin and chain application.

       TROCHANTERIC WIRING TECHNIQUE (FIG. 10.4)

     • The leg is positioned with hip/knee in flexion. Using the guide, lateral holes are drilled just distal to the vastus insertion for looped double wire. Wire holding forceps (preferably color coded so that the wire ends don't get mixed up) are used to hold the wire ends

     • Using trochanteric holder, the trochanteric hole is drilled in the post-inferior part of the trochanter.

     • Leg position is changed to allow anteroposterior (AP) (spring) wire insertion. Using guide, AP hole is drilled and spring wire passed, plastic protector is slid along anterior

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       Figure 10.4: Illustrates the different steps in performing trochanteric osteotomy and wiring

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       Trochanteric Osteotomy

       Figure 10.5: Illustrates the postoperative X-rays after trochanteric wiring

       cortex (to prevent cement extrusion). Again, wire holding forceps (preferably color coded so that the wire ends don't get mixed up) are used to hold the wire ends.

   • Nibbler is used to create small slot for lateral wire ends as they come over anterior/ posterior cortex of the prox femur. The loop wire end is passed anterior and posterior.

   • Pin reamer and then nibbler are used to push the wires flush to internal cortex of the femur.

   • The stem insertion and depth is checked. One must make sure wires are not causing any obstruction to stem insertion.

     Trochanteric Wiring (avoid wire kinking, fretting, twisting, use both hands to guide the wire, take out all bends)

   • Hip/knee should be positioned at 45 degrees flexion, adduction and internal rotation

   • The posterior end of the lateral wire (looped wire) is passed through the trochanteric drill hole

   • Steinmann pin is used to make tracks for the lateral 2 wires. One track at the tip or just posterior to it whole the other track is behind the first with about finger breadth distance in between wires should cross hence the bottom track is for anterior end of looped lateral wire and vice versa

   • If needed the wire loop is twisted to make sure that it is parallel to the femoral shaft

   • The tip is bent and passed through the loop

   • Wires are passed through the tensioner which is then tightened

   • Track is made for anterior end of the AP wire which is then passed through the anterior half of the Gluteus medius

   • The wires are passed through tensioner, tightened, twisted clockwise, and cut, leaving at least 3 turns on the wire

   • The distal wires (lateral looped wire ends) are retightened, tensioner pulled and wires brought to about 90 degrees and then twisted and cut

   • The wire tips are bent and buried

   • Post op X-rays showing the construct (Fig. 10.5).

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     Modification of the Standard Trochanteric Osteotomy

     Other modifications of the standard trochanteric osteotomy were developed to address the shortcomings of the standard Uniplanar osteotomy to increase the union rate and provide greater effectiveness in revision cases.3 These include partial, chevron, horizontal and vertical osteotomies.3,4,7

     Total Hip Arthroplasty

     The chevron osteotomy as described above was developed to improve intrinsic stability and decrease the non-union rate of trochanteric osteotomy which has been quoted in the literature from 1 to 25%.8

     The partial or oblique osteotomy was devised to provide a more extensile approach as well as provide bone to bone healing for anterior abductors in direct lateral approach. The advantage of this osteotomy is that the posterior trochanter and short external rotators remain intact. The horizontal trochanteric osteotomy was the modification of the standard osteotomy and the direction of the osteotomy is done at 70-90 degrees to the shaft and as far proximal as possible to allow the whole of insertion of Gluteus medius and minimus on this fragment.9 Fixation options mostly include variations of wiring techniques, e.g. double wire, triple wire techniques.

     Extended Trochanteric Osteotomy

     Extended trochanteric osteotomy is useful for revision hip surgery because it not only facilitates the removal of well fixed femoral component and cement but also increases the exposure to the acetabulum.10 There are various techniques described in the literature for performing extended trochanteric osteotomy.11,12 Wagner initially described the anterior extended trochanteric osteotomy in which the anterior half of the abductors is reflected in continuity with the anterior third of the proximal femur (Fig. 10.6).7 Younger9 modified this technique and described lateral extended trochanteric osteotomy where all the abductors are reflected with the lateral third of the proximal femur.

     TECHNIQUE OF EXTENDED TROCHANTERIC OSTEOTOMY

     The length of the osteotomy is planned pre-operatively, care is taken so that atleast 5 cm of the isthmic diaphyseal cortex is maintained for component fixation. Generally the osteotomy is about 10-15 cm long from the tip of the greater trochanter to allow secure fixation of the fragment to the medial cortex. The osteotomy is usually done through an extended postero-lateral approach (Figs 10.7A and B). This can be done at any time during the procedure before or after the stem removal.

     Figure 10.6: Illustrates different steps in extended trochanteric osteotomy

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     Trochanteric Osteotomy

     Figures 10.7A to F: Shows the different steps involved in performing extended trochanteric osteotomy (contd.)

     Steps

   • Femoral insertion of the gluteus maximus is identified and if needed incised. Stay sutures are used to assist in repairing this at the end of the procedure. Linea aspera is identified.

   • The osteotomy is marked using a diathermy (Figs 10.7C and D).

   • The drill holes are made through the single cortex which are then combined using an oscillating saw or burr (Fig. 10.7E).

   • The initial cut is made through the posterior aspect of the greater trochanter to the predetermined mark.

   • The transverse portion of the osteotomy is made so that it includes atleast one-third of the femoral diaphyseal circumference (Fig. 10.7F).

     
     Total Hip Arthroplasty

     
     

     Figures 10.7G to I: Shows the different steps involved in performing extended trochanteric osteotomy

     • The anterior arm of the osteotomy can be slightly shorter than the posterior portion or of the similar length as posterior arm (Fig. 10.7G).

     • It is important to ensure that the proximal ends of the osteotomy arms exit just anterior and posterior to the trochanter rather than through the body of the trochanter to prevent the risk of trochanteric fragmentation.

     • The osteomized fragment is carefully elevated using broad osteotomes (Figs 10.7H and I).

     • Once the femoral stem is inserted (generally an uncemented stem with atleast 4 cm of distal fixation). The osteotomy can be trimmed to accommodate the revised femoral stem though this is not always necessary.

     • Once reduced the osteotomy can be fixed with 2-4 wires or cables.

     • The cables should be passed in the submuscular plane to avoid muscle necrosis and later loosening of the wires.

     • The cables should be tightened in a fashion such as the distal cable is tightened the most and the most proximal is tightened the least to avoid the fractures and failure of fixation.

The cables are usually passed from posterior to anterior direction to avoid injury to the sciatic nerve. The first cable is inserted at the calcar just proximal to lesser trochanter. Cables are inserted at 2-3 cm distance to achieve fixation. Although there is no randomized controlled trial comparing cables and wires for fixation of trochanteric osteotomy, it has been shown that cables offer better tensile strength and resistance to failure.8,13 Once the fixation is done, the hip is moved through the range of motion to see if this osteotomy or fixation is causing any impingement.

Conclusion

Trochanteric Osteotomy

In general the indications for the use of trochanteric osteotomy in total hip arthroplasty have changed since the inception of THA from its routine use to use in difficult primaries and revision surgery. The extended trochanteric osteotomy is commonly used these days in revision surgery where uncemented distally fixed femoral stem is to be used. The trochanteric slide and the chevron osteotomy are still useful in difficult primary and revision cases.

References

1. Archibeck MJ, Rosenberg AG, Berger RA, et al. Trochanteric osteotomy and fixation during total hip arthroplasty. J Am Acad Orthop Surg 2003;11:163-73.

2. Hodgkinson JP, Shelley P, Wroblewski BM. Re-attachment of the un-united trochanter in Charnley low friction arthroplasty. J Bone Joint Surg Br 1989;71:523-5.

3. McGrory BJ, Bal BS, Harris WH. Trochanteric osteotomy for total hip arthroplasty: six variations and indications for their use. J Am Acad Orthop Surg 1996;4:258-67.

4. Wroblewski BM, Shelley P. Reattachment of the greater trochanter after hip replacement. J Bone Joint Surg Br 1985;67:736-40.

5. Charnley J. The long-term results of low-friction arthroplasty of the hip performed as a primary intervention. J Bone Joint Surg Br 1972;54:61-76.

6. Naito M, Ogata K, Emoto G. The blood supply to the greater trochanter. Clin Orthop Relat Res 1996:294-7.

7. Wagner H. [Revision prosthesis for the hip joint in severe bone loss]. Orthopade 1987;16:295-300.

8. Bal BS, Maurer BT, Harris WH. Trochanteric union following revision total hip arthroplasty. J Arthroplasty 1998;13:29-33.

9. Younger TI, Bradford MS, Magnus RE, et al. Extended proximal femoral osteotomy. A new technique for femoral revision arthroplasty. J Arthroplasty 1995;10:329-38.

10. Meek RM, Greidanus NV, Garbuz DS, et al. Extended trochanteric osteotomy: planning, surgical technique, and pitfalls. Instr Course Lect 2004;53:119-30.

11. Lakstein D, Kosashvili Y, Backstein D, et al. Modified extended trochanteric osteotomy with preservation of posterior structures. Hip Int 2010;20:102-8.

12. Lakstein D, Kosashvili Y, Backstein D, et al. The long modified extended sliding trochanteric osteotomy. Int Orthop 2011;35:13-7.

13. McCarthy JC, Bono JV, Turner RH, et al. The outcome of trochanteric reattachment in revision total hip arthroplasty with a Cable Grip System: mean 6-year follow-up. J Arthroplasty 1999;14:810-4.