Conventional Trochanteric Osteotomies and the Trochanteric Slide

 

 

 

INTRODUCTION

 

Sir John Charnley popularized the trochanteric osteotomy for total hip replacement. He considered it an integral component of routine primary arthroplasty for several reasons. These included improved exposure, greater stability against dislocation, and the ability to favorably influence the abductor moment arm ratio (Fig. 4-1). In his words, this permitted the surgeon to perform a true “hip reconstruction” rather than a simple replacement (1,2). Since Charnley's early writings, the indications for trochanteric osteotomy in primary total hip arthroplasty have evolved and become far more circumscribed. This is attributable to many factors. Significantly, as total hip replacement grew in popularity, the complications of trochanteric osteotomy became apparent (3,4,5,6).

 

It was soon demonstrated that, in most cases, primary total hip replacement can be successfully and usually more easily accomplished with alternative approaches that leave the trochanter intact. The implants available to Charnley provided limited choices in terms of head/neck length and offset. In addition, early polyethylene technology was limited, leading Charnley to develop and promote the “low-friction arthroplasty” concept, including the use of 22-mm heads. Given these limitations, achieving stability against dislocation and optimizing abductor function were challenging without transfer of the greater trochanter. The development of improved bearing surfaces and thus the ability to use larger heads, a wider range of femoral component choices in terms of their inherent offset and neck/shaft angles, modular heads, and acetabular liners that allow the surgeon to easily fine-tune leg length, offset, and abductor tension have all combined to diminish the biomechanical advantages of trochanteric osteotomy. These technologic advances cannot supplant the superior exposure afforded by trochanteric osteotomy (Fig. 4-2). Thus, in contemporary arthroplasty, trochanteric osteotomy

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is largely reserved for revision procedures, or difficult primary cases (Tables 4-1 and 4-2) in which wide exposure and/or interface access are desirable (7).

 

 

 

FIGURE 4-1 Classic Charnley low-friction arthroplasty performed with trochanteric osteotomy fixed in the lateralized “first position.” This, along with medialization of the acetabular component, favorably influences the abductor moment arm and increases stability against dislocation. (Radiograph courtesy of David K. Halley, MD.)

 

 

 

FIGURE 4-2 Acetabular exposure afforded by the sliding trochanteric osteotomy.

 

 

In this chapter, the standard trochanteric osteotomy and a variant, the chevron osteotomy, as well as the sliding trochanteric osteotomy (anterior trochanteric slide) are discussed. Another commonly used variant, the extended trochanteric osteotomy, is discussed in another chapter.

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TABLE 4-1 Indications for Trochanteric Osteotomy in Primary THA

 

Developmental dysplasia (Fig. 4-3) Heterotopic ossification

 

 

 

 

TABLE 4-2 Indications for Trochanteric Osteotomy in Revision THA

 

Isolated cup revision (osteolysis, malposition, loosening) (Figs. 4-7 and 4-8) Recurrent dislocation (soft tissue laxity)

Excessive leg lengthening (e.g., the need to shorten the limb) Removal of well-fixed implants (infection, trunnionosis) (Fig. 4-9) Heterotopic ossification

 

 

 

 

 

Severe protrusio

Extreme stiffness: ankylosing spondylitis (Fig. 4-4) Conversion of hip arthrodesis to total hip (Fig. 4-5) Muscular or obese patients

Prior fracture

 

• Intertrochanteric (Fig. 4-6)

• Subtrochanteric

• Acetabular

 

FIGURE 4-3 Crowe II developmental dysplasia treated with femoral head allograft. Exposure facilitated by sliding trochanteric osteotomy.

 

 

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FIGURE 4-4 A: Classic appearance of ankylosing spondylitis with bilateral hip involvement. B: Immediate postoperative film following left total hip arthroplasty using a sliding trochanteric osteotomy.

 

 

 

FIGURE 4-5 A: Intra-articular arthrodesis. B: Postconversion of arthrodesis to total hip arthroplasty using sliding trochanteric osteotomy.

 

 

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FIGURE 4-6 A: Failed internal fixation of an intertrochanteric fracture fixed with a sliding nail plate. B: After conversion to total hip replacement using a conventional trochanteric osteotomy fixed with a claw plate and cables.

 

 

 

FIGURE 4-7 A: Oversized, malpositioned (vertical, lateralized, inferiorly situated) dual mobility cup following direct anterior total hip arthroplasty. B: Immediate postoperative film following isolated cup revision using a

sliding trochanteric osteotomy.

 

 

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FIGURE 4-8 A: Catastrophic failure of the acetabular component with pelvic dissociation. The femoral component remains well fixed. B: Postoperative film following complex acetabular component revision using a sliding trochanteric osteotomy.

 

 

 

FIGURE 4-9 Access and division of the bone-implant interface of a proximally coated femoral component via a sliding trochanteric osteotomy.

 

CONVENTIONAL TROCHANTERIC OSTEOTOMY

Surgical Technique (Charnley)

The classic Charnley single-plane osteotomy (1,2,8,9) (Figs. 4-10, 4-11, 4-12, 4-13, 4-14, 4-15, 4-16 and 4-17) begins with exposure of the vastus lateralis ridge by passing a cautery transversely at the summit of the

 

trochanteric ridge. The incision is carried down to the bone, and the ascending branch of the circumflex artery is divided at the distal most extent of the anterior fibers of the gluteus medius. The anterior border of the gluteus medius is retracted cephalad to expose the anterior hip capsule. A horizontal capsulotomy is performed along the anterior aspect of the femoral neck and is extended laterally until it joins the incision made across the vastus ridge. A cholecystectomy clamp is then passed through the capsule and into the joint. The clamp is then maneuvered along the superior aspect of the femoral neck and pulled laterally into the trochanteric fossa. It is then advanced posteriorly to pierce the posterior joint capsule, making certain to pass the clamp medial to the posterior-superior tubercle of

 

 

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the greater trochanter. Once the tips of the clamp are visualized, it is used to grasp the free end of a Gigli saw that is drawn into the joint and then out of the anterior capsulotomy. Tension is applied to the handles on either end of the saw, and the handles are oriented so as to define a plane that exits through the center of the vastus ridge. The handles are then alternated back and forth to perform the osteotomy. The trochanteric fragment is retracted superiorly. Branches of the anterior and posterior circumflex arteries are ligated or cauterized as needed. The surgeon can then proceed with capsulectomy, dislocation, and arthroplasty.

 

 

 

FIGURE 4-10 Exposure of the vastus lateralis ridge by passing a cautery transversely at the summit of the trochanteric ridge. (From Charnley J. Low friction arthroplasty of the hip: theory and practice. Berlin, Germany: Springer-Verlag, 1979.)

 

 

 

FIGURE 4-11 Cephalad retraction of the gluteus medius to expose the anterior joint capsule. (From Charnley J.

Low friction arthroplasty of the hip: theory and practice. Berlin, Germany: Springer-Verlag, 1979.)

 

 

 

FIGURE 4-12 Horizontal incision into the inferior aspect of the anterior hip capsule. (From Charnley J. Low friction arthroplasty of the hip: theory and practice. Berlin, Germany: Springer-Verlag, 1979.)

 

 

 

FIGURE 4-13 Extension of the capsular incision to the vastus ridge. (From Charnley J. Low friction arthroplasty of the hip: theory and practice. Berlin, Germany: Springer-Verlag, 1979.)

 

 

 

FIGURE 4-14 A cholecystectomy is clamp passed through the capsule and into the joint, maneuvered along the superior aspect of the femoral neck, and pulled laterally into the trochanteric fossa. (From Charnley J. Low friction arthroplasty of the hip: theory and practice. Berlin: Springer-Verlag, 1979.)

 

 

 

FIGURE 4-15 The posterior capsule is pierced with the cholecystectomy clamp, which is then used to draw a Gigli saw into the joint, medical to the greater trochanter and out the anterior capsulotomy. (From Charnley J. Low friction arthroplasty of the hip: theory and practice. Berlin, Germany: Springer-Verlag, 1979.)

 

 

 

FIGURE 4-16 The limbs of the Gigli saw are drawn laterally and then alternated to create the osteotomy. (From Charnley J. Low friction arthroplasty of the hip: theory and practice. Berlin, Germany: Springer-Verlag, 1979.)

 

 

 

FIGURE 4-17 The completed osteotomy. (From Charnley J. Low friction arthroplasty of the hip: theory and practice. Berlin, Germany: Springer-Verlag, 1979.)

 

At the conclusion of the arthroplasty, the trochanter can be replaced anatomically, or advanced distally and laterally as much as 1 cm.

Charnley's fixation technique evolved with time (10). Since then, other authors have proposed a plethora of different, if not better, techniques for improving upon Charnley's technique (3,11,12,13,14,15,16,17,18).

In an early study of 225 low-friction arthroplasties performed with trochanteric osteotomy (9), four fixation techniques were compared. While the overall nonunion rate was 7%, no nonunions occurred when two crossed wires were used. Potentially confounding factors deserve mention. First, early in the study, hips were immobilized in a single hip spica for several weeks. Even after this practice was eliminated, hips were maintained in abduction for three full weeks, and weight bearing was deferred until the beginning of the fourth postoperative week. Furthermore, the ideal position for trochanteric reattachment (“the first position”) approximated the trochanter to the intact lateral femoral cortex distal to the cut surface of the trochanteric bed. Finally, in all four reattachment techniques, the wires were secured with two “half hitch” knots, a technique now known to be associated with a significant risk of wire loosening or breakage (19).

 

The crossed-wire technique then evolved into the use of three wires: a doubled vertical wire, which was tightened to itself over the lateral aspect of the trochanter, and two transverse wires, which were tightened together in cruciate fashion. Charnley later added a transverse “staple clamp” to minimize anterior-posterior motion of the trochanter with hip flexion-extension. In a subsequent article (2), he

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reported a nonunion rate of 4.2% among 379 primary total hip arthroplasties with a follow-up of 4 to 7 years.

Furthermore, he noted that fibrous union without trochanteric escape seemed to have little adverse effect on the

outcome of the arthroplasty. Jensen and Harris (13) described a four-wire technique that included one pair of vertical wires and one pair of horizontal wires. All passed through holes in the greater trochanter, capturing it and providing resistance to cyclic anterior and posterior motion, and thereby serving the same purpose of Charnley's staple clamp. The authors reported a series of 804 arthroplasties comprising 725 primaries and 79 revisions.

The overall nonunion rate was 1% (8 cases). Interestingly, all of the nonunions occurred in the primary cases.

THE DIHEDRAL (BIPLANAR) OSTEOTOMY

Wroblewski and Shelley (18) attributed the first use of a biplanar osteotomy to Debeyre and Duliveux (20). Weber and Stuhmer, in 1979, cited an historical nonunion rate of conventional trochanteric osteotomy of 10% and attributed this to the inability of tension band wiring to resist the cyclic anterior-posterior motion of a single-plane osteotomy with hip flexion and extension (21). As a solution, they described a “dihedral, self-stabilizing” trochanteric osteotomy (Fig. 4-18). The chevron configuration of the osteotomy provides inherent mechanical stability capable of resisting anterior-posterior displacement and also presents a greater surface area for initial frictional resistance and eventual bony union. Sochart et al. (22) designed a biplanar osteotome to assist in more precise osteotomy creation. Wroblewski and Shelley (18) suggested yet another technique for creation of the chevron osteotomy. A Steinmann pin is placed through the base of the greater trochanter directed at an angle of 45 degrees to the femoral shaft, exiting in the trochanteric fossa. The pin defines the apex of the dihedral osteotomy. A Gigli saw is then placed over the pin and then drawn distally and laterally to create the osteotomy.

 

 

 

FIGURE 4-18 Schematic depiction of the dihedral osteotomy. (From Weber BG, Stuhmer G. Improvements in total hip prosthesis implantation technique: a cement-proof seal for the lower medullary cavity and a dihedral self-stabilizing trochanteric osteotomy. Arch Orthop Trauma Surg 93(3): 185-189, 1979.)

 

 

 

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Results

Wroblewski and Shelley tested three different techniques for fixing the trochanter and concluded that the

highest rate of union was achieved using a double crossover wire technique, in which the one wire acted as

a vertical tension band and a transverse, spring loaded wire provided compression across the osteotomy (Fig. 4-19). They reported a union rate of 98.2% among 226 cases, half of which were revisions.

Subsequently, Weber (23) compared the results of 69 patients in whom a conventional single-plane osteotomy was used to 69 others in whom a dihedral osteotomy was employed. The nonunion rates were 11% and 1.5%, respectively. Berry and Muller (24) published the results of 127 arthroplasties performed with a chevron osteotomy and fixed with a single monofilament wire, including 53 primary cases and 74 revisions. They reported nearly identical rates of union for the two groups: 98% in primary cases and 97% in revisions.

This technique effectively neutralizes the cyclic anterior-posterior shearing forces that can destabilize a single-plane osteotomy and lead to fixation failure, nonunion, and migration. The technique is most appropriate in the presence of healthy bone and relatively normal anatomy wherein bone quality and architecture are preserved and little change in leg length is required. When significant trochanteric osteolysis is present, the trochanteric stability conferred by the biplanar configuration is lost and fixation is compromised. Likewise, the technique does not lend itself well to situations in which the leg must be lengthened beyond 1 to 2 cm. In such cases, the trochanter must be fixed at a more proximal location,

resulting in reduced bony contact and initial mechanical stability.

 

FIGURE 4-19 Two-wire technique for fixation of the dihedral osteotomy as advocated by Wroblewski, incorporating a spring wire.

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THE SLIDING TROCHANTERIC OSTEOTOMY (ANTERIOR TROCHANTERIC SLIDE)

Introduction

The principal feature of the sliding trochanteric osteotomy is the retention of the vastus lateralis attachment to the distal aspect of the osteotomized greater trochanteric segment. English described the original version of this approach in 1975 (25). Dall later described a similar osteotomy of the anterior aspect of the greater trochanter with retention of its attachment to the vastus lateralis (12). Glassman et al. (26) further described the technical details of this approach. The sliding trochanteric osteotomy is a particularly useful approach for revision surgery but is also applicable to complex primary interventions (Table 4-3).

 

The actual osteotomy removes a longer, thinner, and more vertically oriented segment of the greater trochanter than that removed during traditional osteotomy (Fig. 4-20). The advantages of this

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approach are outstanding exposure of the acetabulum and of the femoral shaft. The shaft exposure provided is especially useful in addressing problems commonly encountered during revision surgery. Examples include stem perforations, cement extrusion, acute fractures, fracture malunions or nonunions, angular deformities, and diffuse or focal bone loss requiring grafting. The deliberate creation of femoral windows to assist in the removal of

cement, fractured stems, or well-fixed cementless prostheses is also facilitated (27). The greater length of the osteotomized segment provides broad exposure to the proximal bone-cement or bone-implant interfaces anteriorly, posteriorly, and laterally. This is particularly helpful when removing well-fixed stems (28).

 

 

TABLE 4-3 Indications for the Use of the Sliding Trochanteric Osteotomy

1. Acetabular Revision

   1. When significant bone stock damage exists (noncontained rim defects) and structural allograft is required

   2. For posterior column disruptions requiring plating

   3. Severe protrusion defects

 

1. Femoral Revision

   1. Revision of well-fixed cemented stems

   2. Revision of cementless stems

   3. Revision of long stem prostheses

   4. When there is significant bone stock damage

      1. Thin femoral cortices

      2. Femoral deformities (angulation)

      3. Femoral perforations

      4. Diffuse bone stock damage, femoral ectasia

   5. Femoral Fractures

      1. Nonunion

      2. Malunion

      3. Acute fractures

 

 

 

 

 

FIGURE 4-20 Schematic representation of the sliding trochanteric osteotomy. Note that the osteotomy is longer, thinner, and more vertically oriented than the Charnley or chevron osteotomies and that it exits lateral to the gluteus minimus insertion and distal to the vastus ridge.

 

Retention of the vastus lateralis attachment to the trochanteric fragment is a safeguard to trochanteric migration if nonunion occurs. The longer osteotomy also allows the trochanter to be reattached at a more proximal location

on the trochanteric bed in those cases where the leg is significantly lengthened with distal translation of the femur relative to the abductor origins. Biomechanical studies suggest that the overall configuration of the osteotomy and the ability to lengthen the abductors contribute to improved hip mechanics (29). In a study of 22 revisions in 20 patients, the calculated abductor muscle length increased by a mean of 1.73 cm, while the abductor moment arm increased by a mean of 0.51 cm following sliding trochanteric osteotomy. Improved biomechanics was supported by the clinical observation of a significant increase in the arc of active abduction postoperatively.

 

Principles

The operative exposure respects three myofascial layers of the hip that must be clearly isolated and preserved during the dissection. The first layer is the fascia lata and the iliotibial band. The second is the gluteus medius and the vastus lateralis with the osteotomized segment of the greater trochanter between them. The third layer is composed of the gluteus minimus and the short external rotators.

 

Patient Positioning

The patient is positioned in the lateral decubitus position and stabilized with specially fabricated padded bolsters applied to the anterior superior iliac spine, the sacrum, and the interscapular area. Stability is further improved by flexing the dependent knee to 90 degrees and securing it in this position with stockinette looped around the ipsilateral ankle and tied to the table rail. The knee is thus maintained in a relatively constant position and can be used as a reference for leg length before and after completion of the arthroplasty. Points of potential nerve compromise, including the dependent axilla and peroneal nerve, are carefully padded.

 

Incision

The skin incision is similar to that used for a standard posterolateral approach, the only difference being that (ideally) it parallels the anterior border of the greater trochanter rather than passing directly over it. In revisions however, one will usually incorporate at least some portion of the prior incision(s), such as the distal portion of a previous anterolateral or lateral approach, or the entirety of a previous posterior incision, and these may deviate somewhat from the ideal. Undermining of the skin should be minimized.

 

Superficial Myofascial Layer

The iliotibial band and fascia lata are incised in line with the skin incision. Care is taken to stay posterior to the muscle fibers of the tensor fascia lata. The dissection is begun distally and continued to the inferior border of the greater trochanter. The hip is then abducted, and the interval between the gluteus maximus and underlying trochanter and abductors is developed. After sharp division of the superficial fascia overlying the gluteus maximus, its muscle fibers are bluntly split. Distally, the fascia is separated from the underlying vastus lateralis. Proximally, the tensor fascia lata must be thoroughly separated from the abductors. Placing the hip in a position of flexion, abduction, and external rotation facilitates the development of this interval. Dissection is continued until the anterior border of the gluteus medius is reached and the interval between it and the gluteus minimus is identified. The hip is then internally rotated and the gluteus maximus is separated from the external rotators. A Charnley self-retaining hip retractor is then placed.

 

Intermediate Myofascial Layer

 

The interval between the gluteus medius and minimus is developed from posteriorly to anteriorly. To complete the dissection, identify this interval anteriorly. Next, the fascia overlying the vastus lateralis is incised beginning at the vastus ridge proximally and extending distally parallel to and

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just anterior to the intermuscular septum. The fascial incision can be extended as far distally as circumstances

require. The vastus lateralis muscle is then elevated from the anterior and lateral aspects of the femoral shaft and held there with one or more Bennett retractors (Fig. 4-21). The trochanteric osteotomy is now planned.

Proximally, it begins just medial to the insertion of the gluteus medius into the greater trochanter, but lateral to the insertion of the gluteus minimus. Distally, it exits just beyond the vastus ridge. If these landmarks are used, the osteotomy will be longer (generally 5 to 6 cm), thinner (approximately 1.5 cm thick proximally and tapering distally), and more vertical than a traditional osteotomy. The osteotomy is performed with an oscillating saw (Fig. 4-22). After completing the cut, the trochanteric fragment may remain tethered to the proximal femur by the hip capsule. Extending the knee and gradually flexing and externally rotating the hip facilitate mobilization of the intermediate myofascial layer. The posterior border of the trochanteric fragment is simultaneously retracted anteriorly and laterally, and the surgeon progressively divides any anterior capsule or pseudocapsule/scar tissue from the anterior border of the osteotomized fragment. This is a critically important step. If the trochanteric fragment is anchored anteriorly, it will tend to pull away from the trochanteric bed when the hip is externally rotated (30). The intermediate myofascial layer, comprised of the vastus lateralis distally, the gluteus medius proximally, and the thin segment of osteotomized trochanter between them, can now be “slid” anteriorly and held in place with the anterior jaw of a Charnley hip retractor.

 

 

 

FIGURE 4-21 Exposure preparatory to the creation of the sliding trochanteric osteotomy. The gluteus medius muscle is isolated proximally, while the vastus lateralis is mobilized distally.

 

 

 

FIGURE 4-22 The osteotomy is created in the sagittal plane using an oscillating saw.

 

 

 

The Deep Myofascial Layer

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The gluteus minimus attachment to the remaining trochanteric bed is divided and tagged for later suturing to the undersurface of the gluteus medius prior to trochanteric reattachment. Next, the interval between the piriformis muscle and the posterior-inferior border of the gluteus minimus is scored with cautery and the minimus is elevated from the ilium sufficiently to expose the superior rim of the acetabulum. The hip is internally rotated, and the short external rotators, from the piriformis down to and including the quadratus femoris, are stripped from the proximal femur. The capsule or pseudocapsule is circumferentially excised. The hip can now be dislocated laterally by combining hip flexion, adduction, and external rotation. Occasionally, direct lateral traction applied to the femoral neck with a bone hook is required. The leg is placed in a sterile bag affixed to the operating table anteriorly. Adequate mobilization of the proximal femur may require partial or complete release of the psoas tendon. During acetabular exposure, the proximal femur is retracted posteriorly and inferiorly and may be maintained in this position with the posterior jaw of the Charnley hip retractor.

 

Closure

Closure is begun by carefully suturing the gluteus minimus tendon to the undersurface of the gluteus medius at its insertion into the osteotomized trochanteric fragment, using heavy, nonabsorbable suture. The author's preferred method of trochanteric reattachment employs two 16- or 18-gauge monofilament cobalt chromium wires as follows: two drill holes, each 2 mm in diameter, are drilled from posterior to anterior through the base of the lesser trochanter. Two cobalt chromium wires, each approximately 50 cm in length, are then passed through these holes, leaving an equal amount anteriorly and posteriorly. A total of 4-, 2-mm holes are then drilled from lateral to medial through the trochanteric bed, two anterior to the femoral prosthesis, and two posterior to it. The wires previously placed through the lesser trochanter are then passed through these holes; the ends of one wire are passed anteriorly and posteriorly and then through the inferior holes in the trochanteric bed. Likewise, the ends of the other wire are passed through the superior holes in the trochanteric bed. Corresponding holes are then placed through the osteotomized segment of the greater trochanter, and the wires are passed through them. The wires are then tightened over the lateral aspect of the trochanter with an appropriate tightener (Fig. 4-23).

The vastus lateralis fascia is repaired with a running locking suture. Drains are placed within the joint. The tendons of the piriformis and the obturator internus are sutured through drill holes in the posterior aspect of the trochanteric bed. The remaining closure is routine. Others have suggested alternative fixation methods, primarily the use of cables rather than monofilament wires (29,30,31) with no demonstrable improvement in union rates.

 

 

 

FIGURE 4-23 Technique for trochanteric reattachment after sliding trochanteric osteotomy.

 

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Results

In the author's initial series of 90 cases (26), 88 were at least the first revision of a cemented arthroplasty, one was the conversion of a noncemented endoprosthesis to a total hip arthroplasty, and one was a

primary total hip in a patient with severe developmental dysplasia. There were a total of 9 (10% nonunions), all occurring in revision cases. Only one patient with a nonunion demonstrated cephalad migration of the trochanteric fragment of greater than 1 cm (2.6 cm). Interestingly, that patient had no clinical evidence of abductor insufficiency. Furthermore, only one patient with a nonunion had a positive Trendelenburg sign.

The results supported the contention that maintenance of the distal attachment of the greater trochanter to the vastus lateralis provides a safeguard against proximal migration in the event of a nonunion.

Furthermore, the functional deficit following proximal migration was less significant than that typically observed following nonunion and proximal migration of a conventional trochanteric osteotomy. Finally, no nonunion was considered a source of pain.

In a subsequent series of 164 total hips (154 patients), a sliding trochanteric osteotomy was performed in 35 complex primary cases (2.2% of all primary cases done during the study period) and 129 revision procedures (26.8% of the revision cases performed during the study period) (4). In the primary group, at mean follow-up of 26.7 months (range: 12 to 60 months), there were four nonunions (11.4%), none of which demonstrated proximal migration greater than 2 cm. Twelve patients (35.3%) had persistent abductor lurches, ten of whom had a preoperative diagnosis of severe developmental dysplasia. Two patients (5.7%) had trochanteric bursitis. In addition, there were a total of 3 dislocations (8.6%), two of which were early and nonrecurrent and one late (after 6 months) that dislocated twice and stabilized. Mean follow-up for the revision group was 27.8 months (range: 12 to 60 months). There were 18 nonunions in this group (13.9%), 3 of which had migration of greater than 2 cm. One of these demonstrated a marked limp and developed symptoms of subluxation. The trochanter was reattached 10 months postoperatively. Successful union ensued, and the limp resolved. Ten cases (7.8%) developed trochanteric bursitis, and 27 cases (20.9%) had broken wires. There was no strong relationship between those cases with or without broken wires and nonunion or trochanteric bursitis. Other complications included a persistent abductor lurch in 24 cases (18.6%) and 6 single, nonrecurrent dislocations (4.6%).

Bal et al. (30) analyzed the results of 73 primary total hip arthroplasties performed in conjunction with an anterior trochanteric slide at a mean follow-up of 36 months (range: 24 to 54 months). In contrast to the series of primary cases presented above, all patients in this series had uncomplicated osteoarthritis.

Osteotomy was required in these otherwise routine cases because of the technical demands imposed by the use of a new ceramic hip prosthesis. Monofilament wires were utilized in the first 37 cases (35 patients) and 2-mm Dall-Miles cables in the last 36 cases (35 patients). The rate of nonunion was 8% (6/73), slightly less than the 11.4% in the above described series of complex primary interventions. However, 21/73 cases (28%) required reoperation for hardware-related problems including recalcitrant trochanteric bursitis in 17 and concerns regarding third-body wear in an additional 4 cases. The incidences of trochanteric nonunion, persistent bursitis, or the need for hardware removal did not differ significantly between the groups fixed with monofilament wires versus braided cables.

Goodman et al. (31) have described a modification of the sliding trochanteric osteotomy wherein the posterior capsule and short external rotators are left attached to the posterior aspect of the proximal femur (Fig. 4-24). The remainder of their technique is substantially similar to the conventional technique described above. The proposed benefit of this modification was the potential to decrease the incidence of postoperative dislocation observed when these posterior structures are detached. The authors compared the results of two consecutive series of isolated acetabular revisions. The first series comprised 27

 

revisions in which the traditional sliding trochanteric osteotomy was used. The dislocation rate in this group was 14.8% (4/27 cases). In the second series of 30 revisions, the modified sliding trochanteric osteotomy was employed, with a dislocation rate of 3.3% (1/30).

Lakstein et al. (32) analyzed the results of 83 cases employing this so-called modified trochanteric slide osteotomy (MTSO). Seventy-six cases (91.6%) were revisions, and seven (8.4%) were complex primary interventions, including four performed for developmental dysplasia, one for Perthes disease, one for posttraumatic osteoarthritis, and one for “difficult acetabular exposure.” The average follow-up for the entire group was 40 months (range: 12 to 126 months). In terms of healing, 70/83 (84.4%) achieved bony union and 9/83 (9%) fibrous union without significant migration, and 4/83 (4.8%) developed a nonunion with trochanteric escape. In addition, four patients (4.8%), all with bony union of their osteotomy, sustained postoperative dislocations. One required revision to a constrained liner.

 

The same group of investigators compared the results of 38 revisions using the MTSO in patients who had undergone a previous trochanteric osteotomy to a matched cohort of 38 revision cases in whom the MTSO was their first osteotomy (33). The rates of bony union (86.8%), fibrous union

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(10.5%), and nonunion (2.6%) were identical in both groups. Likewise, there were no significant differences in the incidences of abductor lurch, trochanteric pain, or dislocation between the two groups.

 

 

 

FIGURE 4-24 The modified sliding trochanteric osteotomy (MOST). Note that the posterior capsule and short external rotators remain attached to the proximal femur. (From Goodman S, Pressman A, Saastamoinen H, et al.: Modified sliding trochanteric osteotomy in revision total hip arthroplasty. J Arthroplasty 19(8): 1039-1041, 2004.)

 

 

 

 

SUMMARY

Trochanteric osteotomy remains a valuable adjunct in total hip arthroplasty and is an essential skill in the armamentarium of a dedicated hip surgeon. The principles underlying Charnley's advocacy of trochanteric osteotomy remain valid: optimization of the abductor moment arm, the reduction of joint reactive forces, the reduction of frictional torque and wear, and establishing stability against dislocation. As a result of improved implant design and materials, these goals can usually be achieved without removing the trochanter. Thus, in contemporary hip arthroplasty, the need for enhanced exposure is the most important indication for trochanteric osteotomy.

The traditional, single-plane osteotomy remains an effective approach, particularly for isolated acetabular revisions. However, there is a substantial learning curve involved in the proper execution of this approach, and the number of senior surgeons teaching this technique seems to be diminishing. While the chevron (dihedral, biplanar) osteotomy effectively resists the cyclic anterior-posterior forces that can compromise trochanteric fixation, it is less versatile than the other methods. The sliding trochanteric osteotomy combines versatility with the inherent capacity to resist cephalad migration during healing or in the event of a nonunion. In addition, should nonunion occur, trochanteric escape and functional compromise are less with this technique. Osteotomy displacement by anterior-posterior forces during hip flexion and extension is minimized if the surgeon carefully releases anterior capsule or scar tethering the osteotomized fragment anteriorly.

 

REFERENCES

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