Total Hip Arthroplasty in Proximal Femoral Deformity
Introduction
Total Hip Arthroplasty (THA) in the setting of deformity in the proximal femur can be a challenging proposition. For practical purposes during THA, the femur may be considered deformed when the shape and size of the femur is sufficiently altered to necessitate compensation for the anatomy using special techniques or implants.1 The cause for proximal femoral deformity can vary from developmental abnormalities to previous surgeries. Preoperative planning helps in predicting implant requirements, technical issues and assists in achieving optimal biomechanical reconstruction of the hip and femur. Treatment has to be individualized depending upon the anatomy of the deformity and patient needs. Options include femoral osteotomy (fitting bone to the implant), use of modular implants, custom implants, and use of short-stemmed prosthesis or hip resurfacing. Difficult exposure, risk of femoral fracture or perforation, implant malposition, suboptimal implant fixation, failure to restore normal hip biomechanics can all compromise the results. Access to a wide range of implants has, however, helped surgeons to deal with such deformities.
Total Hip Arthroplasty in Proximal Femoral Deformity
Etiology
Common causes for proximal femoral deformity complicating THA include developmental dysplasia of the hip, previous surgery (osteotomy), secondary osteoarthritis due to Perthes disease, postseptic arthritis, slipped capital femoral epiphysis, post-traumatic deformity, coxa vara and coxa valga deformities.
Other conditions include metabolic conditions like Paget’s disease, those associated with large femoral canals like ankylosing spondylitis, rheumatoid arthritis, alcoholic bone disease and with narrow femoral canals like achondroplastic dwarfism, spondyloepiphyseal dysplasia, etc.
In case of revision surgery, loosening of the femoral component can create a varus deformity.
Typical anatomical deformities are associated with specific diagnosis like developmental dysplasia. Also, the diagnosis may affect acetabular structure, bone metabolism and other systemic issues relevant to hip arthroplasty which may affect operative treatment.
Types of Deformity
Berry has proposed a classification of femoral deformities on the basis of location of the deformity and geometry of the deformity.1 Both the site and geometry of deformity can
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Table 34.1: Classification of proximal femoral deformity
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Site of deformity |
1. |
Greater trochanter |
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2. |
Femoral neck |
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3. |
Metaphysis |
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4. |
Diaphysis |
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Geometry of deformity |
1. |
Angular (varus, valgus, flexion, extension) |
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2. |
Translational (medial, lateral, anterior, posterior) |
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3. |
Torsional (increased or decreased femoral anteversion) |
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4. |
Abnormality of size (markedly smaller or larger femoral canal) |
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influence the type of implant used, size and position of the implant and the need for a corrective femoral osteotomy (Table 34.1)
Other important considerations in these deformities, as described by D’Antonio et al, include (1) presence of segmental or cavitatory defects (2) quality of bone, and
(3) biomechanical significance of the deformity.2
Harris et al have attempted to classify deformities in the proximal femur following previous osteotomy (intertrochanteric and subtrochanteric) based on the severity of angulation and displacement as (1) severe—more than 30 degrees angulation in either plane or more than 20% displacement (2) mild/moderate—less than 30 degree angulation and less than 20% displacement.3
Stuchin has classified extra-articular femoral deformities as intramedullary, extramedullary and combined. Intramedullary categories include expanded, constricted, and obstructed. Constriction or obstruction may be caused by bone or an implant. Extramedullary deformities include the variety of femoral shaft problems: angular, rotatory, translational, and longitudinal,
i.e. leg-length discrepancy. Complex deformities, such as developmental dysplasia of the hip, may draw on both intramedullary and extramedullary elements or may be combined.4
Preoperative Planning
Important considerations during preoperative planning include choice of exposure, difficulties in canal preparation, implant geometry, choice of implant fixation, need for femoral osteotomy, radiological planning of osteotomy, restoration of hip biomechanics including offset, leg length and center of rotation of the hip. Radiologic assessment to evaluate the full extent of the femoral deformity and its effect on the overall mechanical axis of the lower limb is beneficial especially in severe deformities.
GREATER TROCHANTER
Deformities at the level of the greater trochanter with bearing on total hip arthroplasty include: an overhanging trochanter and a high riding trochanter.1 The overhanging greater trochanter is an impediment to gain clear access to the metaphyseal opening of the femoral canal, thus predisposing it to fracture during canal preparation. Also, it may result into varus placement of the femoral component. The high riding greater trochanter has potential to cause extra-articular impingement with the pelvis and compromise hip stability (posterior hip instability in flexion and internal rotation of the hip). It also places the hip at a mechanical disadvantage due to the decreased length of the abductors.
Trochanteric osteotomy can be used in such a scenario to safely enter the femoral canal. Use of the slide technique will allow protection of the abductor insertion. Trochanteric advancement is required to reposition the trochanter if it is high riding to optimize the soft tissue tension and thus restore the abductor moment arm.
Sometimes a greater trochanter that is positioned anteriorly due to rotational component of the deformity can prevent exposure of the femoral canal via the anterolateral approach. In
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such a case, a posterior approach will be advisable to prevent inadvertent damage to the greater trochanter during femoral broaching.5
FEMORAL NECK LEVEL DEFORMITY
Total Hip Arthroplasty in Proximal Femoral Deformity
The common types of femoral neck deformities classified are increased varus (coxa vara), increased valgus (coxa valga) and torsional deformities.1
THA in coxa vara deformity involves dealing with reduced abductor lever arm and limb-length discrepancy. Use of lateral offset stems for these deformities allow to recreate the normal offset, restore abductor tension, and prevent excessive overlengthening.
Coxa valga deformities preclude use of standard femoral components placed in standard neutral alignment. In simple valgus deformities, one has to care for leg length and expects to position the femoral stem proud in the metaphysis to obtain proper length. For a severely valgus neck, modified implants with a reduced medial metaphyseal flare are useful, which ensure neutral femoral component alignment despite the deformity.1
Torsional femoral deformities can lead to inadequate hip motion (excessive anteversion causing decreased external rotation) and hip instability (excessive anterior anteversion— anterior instability, and, decreased anteversion or retroversion—posterior instability) if the femoral component is implanted matching the native version. Minor variations of version can be compensated during femoral canal preparation, but larger variations require modifications in surgical technique. Metaphyseal filling uncemented implants may not achieve optimal fit and fill in such situations. Options include use of cemented implant, modular implants with proximal sleeves for version adjustment without compromising proximal fixation, modular tapered fluted distally fixing implants if proximal bone stock is poor, custom implants matching the proximal femoral geometry and finally, derotational femoral osteotomy for severe torsional deformity usually at the subtrochanteric level.
METAPHYSEAL LEVEL DEFORMITY (FIG. 34.1)
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Intertrochanteric region deformities can render proximal fit and fill for uncemented monoblock proximally porous coated implants difficult. Modular implants with the proximal sleeve positioned to accommodate the deformity and the stem placed in a position to maximize joint stability and optimal diaphyseal contact are useful. Another option is to use extensively porous coated implants or distal fixing stems to bypass the proximal deformity and to achieve fixation predominantly in the distal diaphyseal region. Some cases may benefit from the use of customized femoral implants.
Figure 34.1: Metaphyseal level deformity in a patient with previous intertrochanteric osteotomy with planned corrective osteotomy
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Figure 34.2: Cementless THA with modular implant with proximal porous coated sleeve with concurrent osteotomy (healed) in same patient as in Figure 34.1
Osteotomy for deformity correction in the metaphyseal region can be difficult to fix due to the small proximal fragment, which is at risk of fracture or devascularization. Some severe deformities may require resection of part of the involved segment of the medial metaphyseal bone and implantation of a calcar replacement prosthesis or preferably long stem tapered modular fluted stems with diaphyseal fixation.
DIAPHYSEAL LEVEL DEFORMITY (FIGS 34.2 AND 34.3)
A corrective osteotomy is usually needed for significant deformities at this level. Some deformities can be ignored if they are sufficiently distal so as to allow the use of a short stemmed implant. Cemented components can be used to compensate for the deformity, if required, by the use of smaller sized implants in order to achieve an adequate cement mantle. The shape of the osteotomy usually preferred are transverse, oblique, wedge or a step cut.6 The osteotomy can be used to achieve uniplanar or biplanar correction of angular, rotational or combined components of the deformity. A shortening subtrochanteric osteotomy
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Figures 34.3A and B: Varus and excessive anterior bowing of the femur in a patient with DHS implant
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Total Hip Arthroplasty in Proximal Femoral Deformity
Figures 34.4A and B: Cementless THA with a distally fixing tapered modular fluted stem with concurrent osteotomy for deformity correction in same patient as in Figure 34.2
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Figure 34.5: Varus bowing of femoral diaphysis in association with a loose cemented femoral component
may be required in cases of developmental dysplasia of the hip to prevent neurologic traction injury due to acute lengthening of the limb.
Extended trochanteric osteotomy is a technique which has proved useful in difficult revision total hip arthroplasty.7 The technique involves an osteotomy of the greater trochanter that includes a variable length of femoral diaphyseal bone which is levered open on an anterolateral hinge of muscle and periosteum. The advantages of this approach for revision surgery include a wide exposure that facilitates the removal of existing implants and retained cement, correction of femoral deformity, and direct access to the femoral diaphysis for the implantation of revision components. It has also been described in relation to complex primary total hip arthroplasty in relation to proximal femoral deformities.8
Both cemented and cementless components have been described in association with a femoral osteotomy. Cement leakage from the osteotomy site makes its use technically challenging in association with an osteotomy. Uncemented long-stemmed implants are needed for osteotomies below the subtrochanteric level or when extended trochanteric osteotomies are used. Use of implants with distal flutes, both proximally coated and distal fixing stems (Figs 34.4 to 34.6) help in achieving rotational stability with a transverse osteotomy, which is technically easiest to perform. Stable fixation of the osteotomy is achieved with the femoral
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Figure 34.6: Femoral osteotomy with preservation of soft tissue attachments
implant alone, but if required, adjunctive fixation in the form of plates, cables and strut grafts can be used.
Surgical Technique
Technical pearls of THA in angular femoral diaphyseal deformity with concurrent osteotomy using two types of modular, cementless implants are discussed below in reference to an unpublished series including the senior author. Both implants have distal flutes for adequate rotational control. One type has a proximal porous coated sleeve (SROM, DePuy, Warsaw, Indiana) and the other is a grit-blasted tapered conical stem which achieves predominantly distal diaphyseal fixation (LinkMP stem, Waldemar Link, Hamburg, Germany).
Meticulous preoperative planning is required to ascertain the osteotomy site, and the implant size for both the proximal and distal osteotomy fragments. A transverse or an oblique osteotomy is planned at the apex of the deformity, assuring sufficient proximal bone for engagement of the proximal fragment within the modular proximal body of the SROM implant (Fig. 34.1). If this is not possible, a Link MP implant is preferred. The length of the implant is chosen to achieve 2 cortical diameters of intimate bony contact beyond the osteotomy. The proximal body is chosen to recreate appropriate offset and length.
A standard posterolateral approach with minimal stripping of muscle fibers from the femur is preferred and every attempt is made to maintain maximal viability of the bone adjacent to the osteotomy (Fig. 34.7). In cases utilizing an SROM femoral component (Fig. 34.8), the fragment distal to osteotomy is prepared with cylindrical reamers upto 0.5 mm less than the major diameter of the distal flutes to allow a firm press-fit, followed by proximal fragment preparation with the bone millers. The proximal section is then reduced independently to assure adequate soft tissue tension. The actual implant then impacts the proximal segment against the distal segment, which allows axial, but not rotational displacement until the osteotomized bones are well apposed.
In cases where proximal bone is deficient, Link MP stem is preferred (Figs 34.6 and 34.9). After the osteotomy, the distal fragment is prepared with conical reamers to the planned depth to reconstitute leg length. The length of the implant is chosen to obtain intimate bony contact of the entire distal cone of the implant within the distal fragment, assuring that any areas of bony attenuation are bypassed. After impacting the distal body of the implant, the proximal fragment is reduced over it, considering the appropriate rotation and subsequently prepared for proximal body insertion. Cerclage cables are used to secure the proximal
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Figure 34.7: Patient with girdlestone procedure for infected THA with valgus malunion of subtrochanteric fracture
Figure 34.8: THA in same patient with femoral osteotomy and fixation with modular, tapered distally fixing stem. Additional fixation with trochanteric claw plate and cables to secure the proximal fragment
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Total Hip Arthroplasty in Proximal Femoral Deformity
Figure 34.9: Treatment of patient as in Figure 34.5 with a modular tapered conical stem with distal diaphyseal fixation and concurrent osteotomy. Use of cerclage cables in the distal fragment to shield hoop stresses during implant insertion
osteotomy fragment to the prosthetic head-neck segment. A single cerclage cable can also be placed around the distal fragment to shield it from hoop stresses during implant insertion (Fig. 34.6). Intraoperatively, the C-arm is used liberally to appropriate distal reaming angulation and bony contact (Fig. 34.10).
Postoperatively, thromboembolic prophylaxis with warfarin is given for 6 weeks. Patients are instructed to keep 20 lbs partial weightbearing with crutches for six weeks. No bracing or casting is used routinely. If callus formation is evident at that time, full weightbearing with crutches is allowed.
Complications
The incidence of reported complications in THA with proximal femoral deformity is higher in most reported series. The most common complication found is femoral perforation and fracture which may be due to the deformity and poor quality of bone related to previous
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Figure 34.10: Use of C-ARM during implantation of the distal component to gauge the distal fit
surgery (osteotomy). The use of intraoperative fluoroscopy has been helpful to avoid intraoperative fractures during stem insertion in this group of patients. It has been found to occur with the use of both cemented and uncemented femoral implants.
Patients with proximal femoral deformity also may be theoretically at an increased risk of dislocation due to bony impingement of the femur against the pelvis. However, many other factors like patient age, soft tissue weakness, acetabular deformities, etc. may play a role in early dislocations.
Complications like infection in these cases are usually related to previous surgeries and implants.
Cases which require trochanteric osteotomies can potentially develop problems related to the procedure like trochanteric nonunion and trochanteric bursitis.
Outcomes and Literature Review
Total Hip arthroplasty in association with proximal femoral deformity has been described in literature in relation to specific diagnoses, specific type of implants used and with respect to femoral osteotomies. Very few articles have discussed this issue in a generic fashion. Furthermore, there is no scoring system to evaluate the severity of the deformity, so comparison of results of different studies becomes difficult.
Type of Fixation
Review of literature on the outcome of cemented femoral implants in proximal femoral deformity shows differing conclusions.
Ferguson et al reported on the results of cemented THA in 215 hips after failed intertrochanteric osteotomy with a minimum follow-up of five years.9 They reported improvement in clinical scores for conversion after failed intertrochanteric osteotomy similar to primary THA in a comparable group of patients. But the total revision rate was 18.1%, with an aseptic revision rate of 14.9%, and the total cumulative probability of failure was 20.6% at 10 years which was higher than the comparable group with primary THA.
However, Boos et al in a case control study of 74 patients who underwent cemented THA in patients with previous proximal femoral osteotomy and a diagnosis matched control group of 74 primary procedures found no significant difference in the rate of perioperative complications (11% each) or in the septic (8% v 3%) and aseptic (4% each) revision rates.10 They concluded that cemented THA in patients with previous femoral osteotomy, though technically demanding, was not associated with a significant complication rate. Furthermore,
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Total Hip Arthroplasty in Proximal Femoral Deformity
the clinical and radiographic outcome in this group of patients was similar to primary THA. Iwase et al in a study of 30 patients with conversion THA after valgus intertrochanteric osteotomy with an average follow-up of 7 years, reported that the survivorship of 12 cemented stems was significantly higher than those of 18 uncemented conventional stems.11 They concluded that the design of the cementless stem they used may be responsible for the failures. In both of the previous studies, the extent of deformity was not clearly defined.
Shinar and Harris reported on the outcome of 22 cemented THA following failed proximal femoral osteotomy using second generation cementing techniques at an average follow-up period of 15.8 years.3 Two of 19 femoral components (10.5%) were revised for aseptic loosening and 2 additional femoral components were loose. All 4 loose or revised femoral components occurred in patients who had severe deformity (greater than 20 degree angulation in any plane and more than 20% displacement). Only 6 of the 10 femoral components in the severe group remain solidly fixed. None of the femoral components in the mild/moderate deformity group were revised or were loose. They concluded that outcome of cemented THA with second generation technique is not affected by previous proximal femoral osteotomy except in cases with severe deformities.
In general, cemented implant fixation can be compromised if deformity leads to poor implant alignment, poor cement mantle, poor cement technique or a poor cement bone interface. Patients with proximal femoral deformity also may have sclerotic bone in conditions like previous osteotomy, fracture, and, Paget’s disease, leading to decreased cement-bone interdigitation.
Uncemented implants may also be at risk of loosening in patients with proximal femoral deformity if initial fit and fixation of the prosthesis to the bone is compromised. However, use of modular implants which help in achieving independent distal and proximal fixation hold promise in these type of patients.
Breusch et al reported on 48 hips who had undergone conversion THA with a grit blasted tapered cementless prosthesis for a failed intertrochanteric osteotomy of the hip and with a mean follow-up of 11 years (5-15 years).12 3 hips underwent femoral revision—one for infection and two for aseptic loosening of the stem. Survival of the stem was 94% at 10 years, and survival with femoral revision for aseptic loosening as an end point was 96%. There was no radiographic evidence of femoral osteolysis, stress-shielding or loosening. They concluded that the use of these stems is technically easier than cemented stems in patients with previous osteotomy and their midterm results were comparable to THA using similar stems in patients without deformity.
Suzuki et al published data on 30 uncemented THAs in 27 patients with previous valgus intertrochanteric osteotomy with a mean follow-up of 7 years.13 They used both uncemented monoblock and modular femoral components. They reported a 100% survival rate of the femoral components. All femoral components showed good bony integration. They concluded that cementless hips achieved excellent results at midterm follow-up. They also advised use of modular femoral components in THA after previous valgus intertrochanteric osteotomy.
Biant et al prospectively evaluated 55 patients with anatomically difficult femurs treated with a modular cementless stem with proximal porous sleeve for an average follow-up of 10 years.14 They reported a survival rate of 100% for the femoral components at 10 years with no femurs showing any radiological signs of loosening. Five patients had osteolysis in Gruen zone 1, three had osteolysis in zone 7, and two showed osteolysis in both zones 1 and 7. No osteolysis was observed around or distal to the prosthetic sleeve. Union occurred in 11 femurs which required femoral shortening by subtrochanteric osteotomy with the femoral component acting as an intramedullary fixation device.
Mortazavi et al evaluated 58 hips in 51 patients with THA after proximal deformity at mean follow-up of 4 years.15 Nonprimary cementless components were used in 22 (25%) femurs. In 21 (23%) hips, osteotomy was required to properly fit the cementless stem in the femur. Radiographically, all femoral components showed stable bone ingrowth except 2 hips (3.5%) with stable fibrous ingrowth and 1 hip (2%) with loosening. There were 2 (3.5%)
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revisions in 2 patients for periprosthetic fracture and femoral loosening. The mechanical failure rate was 9% (5 hips). They concluded that despite technical difficulties, cementless femoral reconstruction provides a reliable and durable result in patients with proximal femoral deformity.
Femoral Osteotomy and THA
Several studies have described outcomes of total hip arthroplasty with concurrent osteotomy. The extent of deformity in most of the studies is variable. Midterm results are available for the use of cementless modular components used along with osteotomy for proximal femoral deformity and shortening osteotomies.
Papegelopoulos reviewed 31 THAs in 28 patients (20 primary and 11 revisions) with concurrent femoral osteotomy.6 22 cementless and 9 cemented stems were used. In 29 hips (93%) of cases, bone grafting at the osteotomy site was performed. A uniplanar wedge osteotomy was performed in 19 hips, biplanar osteotomy in 4 hips, and a step-cut procedure in 8 hips. 3 hips (15%) in primary group and 1 hip in the revision group had osteotomy nonunion with mean time to osteotomy union being 30 weeks (primary) and 40 weeks (revision). 1 cemented stem was revised in the primary group for loosening and 2 stems (1 cemented and 1 uncemented) were revised for loosening in the revision group.
Huo et al reported on 26 oblique femoral ostotomies in conjunction with primary or revision hip arthroplasty using a variety of stems.16 Their technique utilized an oblique osteotomy, while maintaining the muscle attachments to the bone with a resulting average time to union of 16 weeks. Fourteen hips had nonmodular stems with limited distal rotational control. Three of these 14 hips were revised for loosening, 1 hip was revised for nonunion, and 1 hip had radiographic evidence of loosening. Twelve hips in the series had a modular SROM implant used, with no revisions in this series, and one hip with radiographic evidence of loosening. The average time to union of the osteotomy was 16 weeks. The authors concluded that the failures in this series were due to implant geometry with limited porous surface for fixation, and no distal fragment rotational control.
Takao et al reported on 33 hips in patients with Crowe type 4 dysplasia treated with THA and subtrochanteric shortening osteotomy using cementless, modular components with proximal sleeve and distal flutes.17 At a mean follow-up period of 8 years, they reported an improvement in clinical scores in all patients. 4 patients had intraoperative femoral fractures in proximal part and 4 in the distal part which were stabilized by wiring. 1 stem developed progressive radiolucent lines near the proximal sleeve which progressively subsided and was revised after 4.8 years with a cemented implant. The patient with stem loosening had Dorr Type C bone and required femoral neck resection at the base of the femoral neck. They surmised that stem loosening occurred because of insufficient proximal rotational stability due to hypoplasia of the femoral neck and insufficient distal rotational stability due to poor bone quality.
An unpublished series comprising of 24 patients (2 with Bilateral involvement) with 26 hips with a transverse or oblique femoral osteotomy for femoral deformity—a multicentric study, (unpublished work including the senior author) underwent transverse or oblique femoral osteotomy along with insertion of a modular stem for correction of angular or rotational femoral deformity at 3 centers. 3 types of implants were used—modular stem with proximal fixation (S-ROM) in 10 hips, distally fixing stem (Link MP) in 15 hips, and, 1 with a stem with tapered conical distal fixation (Mallory-Head STS); all had distal flutes for rotational control. Average follow-up period was 6 years. 25 out of 26 osteotomies showed signs of healing at an average of 3.5 months. One case developed fracture of proximal fragment, 1 case with a healed osteotomy developed symptomatic loosening at 5 years. Both were S-ROM stems which were revised to a distally fixing stem. There was 1 case of perforation of femur by the posterior distal tip of the implant treated with strut allografting. 1 patient had a stress fracture treated with protected weight bearing. 24 out of 26 hips demonstrated evidence of bony ingrowth. No additional
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fixation or strut graft at the osteotomy site was used, as the authors believe that it leads to additional muscle stripping, devascularization and diminished remodeling potential. Independent fixation of the proximal and distal osteotomy fragments with a modular stem, in conjunction with a muscle sparing technique, likely allows greater construct rigidity and improved vascularity, with the potential for improved osteotomy healing and osseointegration.
Role of Hip Resurfacing
Hip resurfacing in patients with proximal femoral deformity has been proposed as an alternative in selected cases which preclude the use of standard implants. Fifteen patients (seventeen hips) who underwent metal-on-metal resurfacing hip replacements associated with femoral deformities were studied by Mont et al.18 At an average of 3 yrs follow-up, all patients showed improvement in clinical scores. But they noted that all patients in their study had a femoral deformity of less than 20 degrees and they also recommended that for patients with femoral deformity more than 20 degrees a corrective osteotomy would be required to provide satisfactory biomechanics.
A longer follow-up would be required to see if resurfacing can significantly extend the duration of time to first revision in these patients without compromising the outcomes of subsequent THA.
Summary
Proximal femoral deformity thus requires modifications in surgical technique, use of special implants and corrective osteotomy depending upon the severity of the deformity. Appropriate preoperative planning regarding exposure, templating of components, planning the osteotomy at the level of the deformity and ensuring correction of all components of the deformity, and, optimal biomechanical reconstruction of the hip is crucial.
Clinical outcome is generally less successful as compared to primary THA in patients without any femoral deformity with an overall higher rate of complications. Proper counseling of patients regarding expected outcome is important. Use of new types of modular implants can offer solutions for cases with significant deformities, though their long term results still need to be evaluated.
Illustrative Case (Figs 34.11A to I)
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A 68 year old female status post resection of infected THA with antibiotic loaded cement spacer in-situ underwent reimplantation to THA with concomitant femoral osteotomy due to the femoral deformity using a distally fixing, tapered, modular, fluted stem.
Figures 34.11A and B: Preoperative radiographs with cement spacer in-situ, bowed femur, defects in the proximal and midshaft femoral regions
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Figure 34.11C: Transverse femoral osteotomy with a prophylactic cable in the distal fragment
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Figure 34.11D: Distal stem inserted after reaming the distal fragment
Figure 34.11E: C-arm for assessment of distal stem fit
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Total Hip Arthroplasty in Proximal Femoral Deformity
Figure 34.11F: Trial reduction with trial proximal segment
Figures 34.11G and H: Postoperative radiographs (6 weeks) with healing osteotomy
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Figure 34.11I: 1 year postoperative radiograph with healed osteotomy
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Berry DJ. Total hip arthroplasty in patients with proximal femoral deformity. Clin Orthop Relat Res 1999;369:262-72.
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D’Antonio J, McCarthy JC, Bargar WL, Borden LS, Cappelo WN, Collis DK, et al. Classification of femoral abnormalities in total hip arthroplasty. Clin Orthop Relat Res 1993;296:133-9.
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Shinar AA, Harris WH. Cemented total hip arthroplasty following previous femoral osteotomy: an average 16-year follow-up study. J Arthroplasty 1998;13(3):243-53.
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Stuchin SA. Extra-articular deformities and the role of hip resurfacing - a proposed classification system. Bull NYU Hosp Jt Dis 2009;67(2):135-7.
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Belzile EL, Laflammes G. Total hip arthroplasty in proximal femoral deformities and retained hardware. Semin Arthroplasty 2008;19(4):314-22.
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Papagelopoulos PJ, Trousdale RT, Lewallen DG. Total hip arthroplasty with femoral osteotomy for proximal femoral deformity. Clin Orthop Relat Res 1996;332:151-62.
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Younger TI, Bradford MS, Magnus RE, Paprosky WG. Extended proximal femoral osteotomy. A new technique for femoral revision arthroplasty. J Arthroplasty 1995;10:329-38.
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Della Valle CJ, Berger RA, Rosenberg AG, Jacobs JJ, Sheinkop MB, Paprosky WG. Extended trochanteric osteotomy in complex primary total hip arthroplasty. A brief note. J Bone Joint Surg Am 2003;85-A(12):2385-90.
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Iwase T, Hasegawa Y, Iwasada S, Kitamura S, Iwata H. Total hip arthroplasty after failed intertrochanteric valgus osteotomy for advanced osteoarthrosis. Clin Orthop Relat Res 1999;364:175-81.
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Breusch SJ, Lukoschek M, Thomsen M, Mau H, Ewerbeck V, Aldinger PR. Ten-year results of uncemented hip stems for failed intertrochanteric osteotomy. Arch Orthop Trauma Surg 2005;125(5):304-9.
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Suzuki K, Kawachi S, Matsubara M, Morita S, Jinno T, Shinomiya K. Cementless total hip replacement after previous intertrochanteric valgus osteotomy for advanced osteoarthritis. J Bone Joint Surg Br 2007;89(9):1155-7.
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Biant LC, Bruce WJ, Assini JB, Walker PM, Walsh WR. The anatomically difficult primary total hip replacement: medium- to long-term results using a cementless modular stem. J Bone Joint Surg Br 2008;90(4):430-5.
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Mortazavi SM, Restrepo C, Kim PJ, Parvizi J, Hozack WJ. Cementless femoral reconstruction in patients with proximal femoral deformity. J Arthroplasty. 2011 Apr;26(3):354-9.
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Huo MH, Zatorski LE, Keggi KJ. Oblique femoral osteotomy in cementless total hip arthroplasty. Prospective consecutive series with a 3-year minimum follow-up period. J Arthroplasty 1995;10(3):319-27.
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Takao M, Ohzono K, Nishii T, Miki H, Nakamura N, Sugano N. Cementless modular total hip arthroplasty with subtrochanteric shortening osteotomy for hips with developmental dysplasia. J Bone Joint Surg Am 2011;93(6):548-55.
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Mont MA, McGrath MS, Ulrich SD, Seyler TM, Marker DR, Delanois RE. Metal-on-metal total hip resurfacing arthroplasty in the presence of extra-articular deformities or implants. J Bone Joint Surg Am 2008;90(Suppl 3):45-51.