■ The Revision Hip: A Potpourri of Options

Trochanteric Osteotomy and Advancement: A Technique for Abductor Related Hip Instability

DOUGLAS A. DENNIS, MD; CHRISTOPHER B. LYNCH, MD

urrent indications for Figure 1: Preoperat- Ctrochanteric osteotomy ive AP (A) and roll- up (B) radiographs include improving exposure to demonstrating well- the femoral intramedullary fixed, well-aligned canal through correction of THA components. proximal femoral angular deformities, such as medial greater trochanteric overhang1; improving general exposure to the acetabulum and femoral canal in complex primary and revision hip total hip arthro- plasty (THA)2; and facilitating 1B exposure to the anterosuperior acetabular rim and femoral Figure 2: AP radiograph 1 year neck in operative management following repeat revision THA with of femoroacetabular impinge- 1A trochanteric osteotomy and advance- ment.3 An additional indica- ment demonstrating a revised acetabular component, a larger dia- tion for trochanteric osteotomy meter femoral head (32 mm) without is in the patient with recurrent etc) surrounding and support- a skirted neck, and a united greater dislocation following THA ing the hip is not adequately trochanter. with well-aligned components tensioned to maintain hip sta- and no evidence of mechanical bility. Trochanteric osteotomy impingement. and distal advancement of the that has proved reliable with In many of these patients, greater trochanter have been high union rates. the soft-tissue envelope (myo- used to tighten the surround- tendinous units, hip capsule, ing capsuloligamentous struc- SURGICAL TECHNIQUE tures and abductor mecha- Osteotomy From Colorado Joint Replace- nism, increasing the moment 2 The vastus lateralis ridge is ment, Denver, Colo. arm and the force generating initially located. The lateral Reprint requests: Douglas A. capacity of the abductor mus- This article presents a tro- aspect of the vastus lateralis Dennis, MD, Colorado Joint Replacement, 2425 S Colorado culature to improve hip stabil- chanteric osteotomy, advance- origin is incised transversely, Blvd, Ste 270, Denver, CO 80222. ity4 (Figures 1 and 2). ment, and fixation technique subperiosteally elevated, and

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GTB

3A 3B 4A 4B Figure 3: Intraoperative photograph of a greater trochanteric osteotomy (A). An osteotome is placed at the vastus lateralis ridge and directed towards the trochanteric fossa to complete the osteotomy. The greater trochanter with attached abductor musculature is elevated proximally from the trochanteric bed to expose the hip (B). Abbreviations: GMM=gluteus medius muscle, GT=greater trochanter, GTB=greater trochanteric bed, and PF=proximal femur. Figure 4: Intraoperative photograph demonstrating the position of the greater trochanter prior to advancement (A) and after advancement (B). retracted for 1-2 cm distally tioned in a neutral abduc- ation. A drill is used to create abductor tendon for 1 cm from the vastus ridge. The tion–adduction position. an appropriately sized hole in down to the tip of the greater trochanteric fossa is identified. Advancement of the the lesser trochanter. A second trochanter where each prong Beginning at the lateral cortex, greater trochanter with the leg 2.0-mm multifilament cable is of the trochanteric grip will be just distal to the vastus later- in an adducted position may passed through this drill hole inserted to ensure placement alis ridge, an oscillating saw result in insufficient abductor and around the proximal of the trochanteric grip direct- or osteotome is used to osteo- tension, whereas advance- femur. Great care is mandato- ly into the bone. tomize the greater trochanter ment with the leg abducted ry during cable passage to The lesser trochanteric along a plane directed towards risks an excessively tight avoid soft-tissue entrapment. cable is threaded through the the trochanteric fossa to create abductor mechanism when The osteotomized greater superior tunnels of the an osteotomized fragment the leg is returned to a neutral trochanteric fragment is trochanteric grip, and the free thickness of at least 1.5 cm position. advanced distally and gently ends of the inferior cable are (Figure 3A). Once the osteoto- Once the appropriate distal impacted onto the lateral threaded through the inferior my is completed, the position of the trochanteric femur and held in position tunnels of the trochanteric trochanter is elevated superi- fragment is determined, the with a bone tenaculum. An grip. The two cables are tight- orly from the lateral aspect of cancellous surface of the appropriately sized trochan- ened simultaneously until the proximal femur with the greater trochanter is minimal- teric grip (claw) fixation good cable tension is obtained gluteus medius and minimus ly sculpted to match the geom- device is selected and posi- (Figure 5). Hip range of muscles attached (Figure 3B). etry of the lateral femoral bed tioned on the advanced greater motion testing is performed onto which it will be posi- trochanter. Due to the density with both cable tensioners still Trochanteric Fixation tioned. The first of two 2.0- and thickness of the abductor in place to assure excellent After completion of mm multifilament cables is tendon insertion onto the supe- stability of the advanced required intra-articular proce- passed around the femoral dia- rior aspect of the greater greater trochanter. The two dures, the greater trochanter physis in a cerclage fashion, trochanter, a common error at cables are then locked to the is grasped with a tenaculum approximately 1-2 cm distal to this point is to place the supe- trochanteric grip and the and advanced laterally and the lesser trochanter and distal rior aspect of the fixation grip excess cable tails are cut and distally along the lateral to the previously determined too superiorly such that the removed (Figure 6). femoral shaft (Figure 4). The position of the advanced superior prongs of the device The previously elevated amount of distal advancement greater trochanteric fragment. engage only tendinous tissue vastus lateralis muscle is repo- of the trochanter is variable This cable is tightened and rather than the superior aspect sitioned over the distal cables and depends on the desired clamped onto the femur at this of the greater trochanter. To and repaired to reduce cable tension of the abductor mus- level with the tail ends left avoid this problem, it is wise irritation of the iliotibial band culature with the leg posi- intact for later trochanteric fix- to longitudinally incise the (Figure 6). Thereafter, the hip

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6A 6B Figure 5: Intraoperative photograph demonstrating the simultaneous tightening of both multifilament cables (passed through the trochanteric grip fixation device) to provide secure fixation of the advanced greater trochanter. Figure 6: Intraoperative photograph following fixation of the osteotomized and advanced 5 greater trochanter (A) and after partial coverage of the cables by the repaired vastus lateralis muscle (B). Abbreviation: VLM=vastus lateralis muscle. wound is closed in a routine The extended trochanteric proximal femoral deformity, acetabulum without the risk of avascular necrosis. J Bone Joint fashion. Weight bearing post- osteotomy, performed by and enhanced soft-tissue ten- Surg Br. 2001; 83:1119-1124. operatively is determined by extending the osteotomy dis- sion of the hip, it has been 4. Kaplan SJ, Thomas WH, Poss the fixation of any prosthetic tally into the lateral femoral associated with numerous R. Trochanteric advancement components revised during the diaphysis, has become the complications including tro- for recurrent dislocation after total hip arthroplasty. J operative procedure. Abduc- most predominant method of chanteric fracture, soft-tissue Arthroplasty. 1987; 2:119-124. tion exercises are strictly trochanteric osteotomy used in irritation secondary to fixation 5. Chen WM, McAuley JP, Engh avoided until radiographic evi- revision THA. Advantages of hardware, and nonunion rates CA Jr, Hopper RH Jr, Engh dence of trochanteric union is the extended trochanteric as high as 39%.7,8 Nonunion, CA. Extended slide trochan- teric osteotomy for revision obtained. osteotomy include wide expo- when associated with superior total hip arthroplasty. J Bone sure to the acetabulum and trochanteric migration, has also Joint Surg Am. 2000; 82:1215- 1219. DISCUSSION femoral diaphysis and creation been shown to increase the 6. MacDonald SJ, Cole C, Guerin Variations of the standard of increased surface area for incidence of hip instability and J, Rorabeck CH, Bourne RB, trochanteric osteotomy have fixation and healing of the loss of abductor power.4,9,10 McCalden RW. Extended been described such as the osteotomy. In certain revision Prolonged rigid fixation fol- trochanteric osteotomy via the direct lateral approach in revi- 3,5 trochanteric slide and THA situations, however, an lowing standard trochanteric sion hip arthroplasty. Clin extended trochanteric osteoto- extended osteotomy may be osteotomy is therefore critical Orthop. 2003; 417:210-216. my.2,6 When using a suboptimal and other tech- to facilitate union and limit 7. Koyama K, Higuchi F, Kubo trochanteric slide approach, niques should be considered. complications. M, Okawa T, Inoue A. Re- attachment of the greater tro- the tendinous attachments of An example would be a failed chanter using the Dall-Miles the gluteus muscles are left acetabular component with a REFERENCES cable grip system in revision hip arthroplasty. J Orthop Sci. intact proximally and the coexisting stable and proxi- 1. Berry DJ. Total hip arthroplasty 2001; 6:22-27. tendinous origin of the vastus mally fixed femoral compo- in patients with proximal femoral deformity. Clin Orthop. 8. Ritter MA, Eizember LE, lateralis is left intact distally. nent. An extended trochanteric 1999; 369:262-272. Keating EM, Faris PM. This provides an advantage of osteotomy may potentially Trochanteric fixation by cable 2. Miner TM, Momberger NG, grip in hip replacement. J Bone limiting trochanteric migra- destabilize the femoral com- Chong D, Paprosky WL. The Joint Surg Br. 1991; 73:580- tion should nonunion occur ponent by compromising extended trochanteric osteoto- 581. my in revision hip arthroplasty: and creates additional tro- some or all of the proximal a critical review of 166 cases at 9. Glassman AH. Complications chanteric stability to enhance osseointegration. mean 3-year, 9-month follow- of trochanteric osteotomy. up. J Arthroplasty. 2001; Orthop Clin North Am. 1992; osseous union. This technique Although the classic tech- 16:188-194. 23:321-333. limits the ability to substan- nique of greater trochanteric 3. Ganz R, Gill TJ, Gautier E, 10. Nutton RW, Checketts RG. The tially advance the greater osteotomy provides multiple Krugel N, Berlemann U. effects of trochanteric osteotomy on abductor power. J Bone Joint trochanter distally to improve advantages such as excellent Surgical dislocation of the adult hip: a technique with full Surg Br. 1984; 66:180-183. abductor tension. surgical exposure, correction of access to the femoral head and

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