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Trochanteric and Fixation During Total

Michael J. Archibeck, MD, Aaron G. Rosenberg, MD, Richard A. Berger, MD, and Craig D. Silverton, DO

Abstract

Once used routinely, trochanteric osteotomy in total hip arthroplasty now is without claws; trochanteric bolts; usually limited to difficult primary and revision cases. There are three types: and cable plates with a proximal the standard trochanteric osteotomy and its variations, the trochanteric slide, claw. Each type of trochanteric and the extended trochanteric osteotomy. Each has unique indications, fixation osteotomy has relatively unique techniques, and complications. Primary total hip arthroplasty procedures indications, contraindications, and requiring the enhanced exposure provided by trochanteric osteotomy may be complications. Individual varia- needed in patients with hip ankylosis or fusion, , proximal tions of each technique and multiple femoral deformities, developmental dysplasia, or abductor muscle laxity. fixation methods have been devel- Trochanteric in revision arthroplasties, primarily the extended oped, providing options to enhance trochanteric osteotomy, facilitate the removal of well-fixed femoral components, the effectiveness of trochanteric provide direct access to the diaphysis for distal fixation, and enhance acetabular osteotomy during THA. exposure. J Am Acad Orthop Surg 2003;11:163-173 Standard Trochanteric Osteotomy

The use of trochanteric osteotomy in ral deformities, severe developmen- Indications total hip arthroplasty (THA) has tal dysplasia, or abductor muscle Indications for the standard tro- declined since its initial advocacy by laxity resulting in global instability. chanteric osteotomy are now rare. Sir .1 Routinely done In revision procedures, trochanteric One indication may be in cases of in primary THA in the early 1970s, osteotomy can facilitate hip disloca- lax abductor musculature after THA its use essentially has been aban- tion, femoral component extraction, doned in North America because of acetabular exposure, and access to added time and complica- the proximal . The extended tions (eg, nonunion, proximal tro- trochanteric osteotomy is useful in Dr. Archibeck is in private practice, New chanteric migration, symptomatic revision cases involving the re- Mexico Center for Replacement Surgery, hardware, increased blood loss). moval of well-fixed femoral compo- New Mexico Orthopaedics, Albuquerque, NM. Dr. Rosenberg is Professor, Orthopaedic Primary THA now is generally nents, difficult acetabular exposure, Surgery, Rush–Presbyterian–St. Luke’s done via a posterior, anterolateral, and varus remodeling of the proxi- Medical Center, Chicago, IL. Dr. Berger is or direct lateral approach without mal femur. Assistant Professor, Orthopaedic Surgery, the use of a trochanteric osteotomy. The methods of trochanteric Rush–Presbyterian–St. Luke’s Medical Center. However, trochanteric osteotomy, osteotomy can be categorized into Dr. Silverton is Assistant Professor, Ortho- paedic Surgery, Henry Ford Medical Center, the most extensile of approaches, three types: the standard single- Detroit, MI. remains a valuable tool for difficult plane trochanteric osteotomy and its primary and revision THAs. A tro- modifications (eg, chevron, partial, Reprint requests: Dr. Berger, Suite 1063, 1725 chanteric osteotomy to facilitate horizontal, vertical),2 the trochan- West Harrison Street, Chicago, IL 60612. dislocation and exposure may be teric slide, and the extended tro- required during primary THA in chanteric osteotomy (Fig. 1). Fixa- Copyright 2003 by the American Academy of patients with ankylosis or fusion, tion options include a variety of Orthopaedic Surgeons. protrusio acetabuli, proximal femo- wire constructs; cables, with or

Vol 11, No 3, May/June 2003 163 Trochanteric Osteotomy and Fixation During THA

muscles, provides unparalleled ace- the inserted instrument in a proxi- Gluteus tabular and pelvic exposure, allows mal-medial direction, at an angle medius avoidance of excessive torque on ≤ 45°, to the femoral diaphysis. Al- the proximal femur, and prevents ternatively, the osteotomy can be Gluteus excessive tension on the superior done using a Gigli saw passed prox- minimus gluteal neurovascular bundle. imally to saw in a distal-lateral However, in most cases, these revi- direction, exiting 1 to 2 cm distal to A sions can be done with the standard the vastus tubercle. However, the posterior approach supplemented Gigli saw technique provides less B with the trochanteric slide or ex- control in establishing the proper tended trochanteric osteotomy. size and exit point of the trochan- C (The trochanteric slide can be con- teric fragment. Vastus verted to a conventional osteotomy Once the trochanter is osteoto- lateralis by releasing the vastus lateralis mized, any attached short external muscle origin for additional expo- rotators are released from the sure.) trochanteric fragment, allowing it to A standard trochanteric osteoto- be retracted proximally. Capsular my also can be helpful in revision resection provides excellent expo- Figure 1 The paths of the standard cases in which, because of acetabu- sure of the hip. A more extensile ex- trochanteric osteotomy (A), the trochan- lar component protrusio, hip dislo- posure can be obtained by elevating teric slide (B), and the extended trochanteric osteotomy (C). Note that the trochanteric cation is difficult. However, in such the abductor musculature proxi- slide and the extended trochanteric os- cases, a trochanteric slide also can mally from the outer table of the teotomy incorporate the origin of the vas- facilitate dislocation. iliac wing, taking care to avoid in- tus lateralis muscle, but the standard osteotomy does not. A relative contraindication to the jury to the superior gluteal nerve standard trochanteric osteotomy is and artery. its use with the direct lateral (Har- dinge) approach because the abduc- Fixation with resulting secondary global tor mechanism has, in part, been Published studies suggest a gen- instability. Generally, however, this released from the eral dissatisfaction with standard laxity can be avoided with appropri- before the osteotomy.3 This makes trochanteric osteotomy fixation tech- ate preoperative planning and intra- subsequent osteotomy and abductor niques, as evidenced by nonunion operative measures directed toward muscle repair difficult. Therefore, if a rates. A successful fixation tech- reestablishing the anatomic hip cen- trochanteric osteotomy is anticipated, nique must provide compression at ter, leg length, and offset. Despite a posterior approach is preferred. the osteotomy site. It also must these measures, a lax abductor resist both vertical displacement and mechanism occasionally can be pres- Technique ent, with resultant instability. If The standard, single-plane tro- adjustments in modular implants, chanteric osteotomy is done by re- Gluteus such as offset acetabular liners, off- leasing the proximal portion of the medius set femoral stems, and longer neck vastus lateralis muscle origin and lengths, do not provide stability exposing the vastus tubercle (Fig. 2). Gluteus without excessive lengthening (>1.5 The initiation site of the osteotomy minimus to 2.0 cm), a standard trochanteric is just distal to the vastus tubercle. osteotomy can be done with distal A blunt instrument, such as a Cush- Inserted advancement. However, a trochan- ing elevator or clamp, is inserted in instrument teric slide may be preferable. the interval between the capsule A second indication for the stan- and the muscle dard trochanteric osteotomy is the over the superior .2 need for extensile acetabular expo- Some authors have described pass- Vastus sure in complex acetabular revision, ing the instrument deep to the cap- lateralis such as implantation of an antipro- sule in this region.4 The osteotomy trusio cage with a large flange on is begun distally on the lateral Figure 2 The standard, single-plane the ilium. This approach, with su- femur with an oscillating saw or trochanteric osteotomy. perior retraction of the abductor osteotome and is extended toward

164 Journal of the American Academy of Orthopaedic Surgeons Michael J. Archibeck, MD, et al rotatory forces in the anteroposterior placed around the proximal femur nonunion generally requires revi- plane that are provided by the through drill holes in the lesser sion of and autolo- abductors with the hip in flexion.5 trochanter. Six holes are then gous grafting. In some cases, Initially, a variety of monofila- drilled in the trochanteric fragment it may be necessary to subperios- ment wire constructs were used, as from the cut surface: two are placed teally elevate the abductors from the recommended by Charnley.1 Varia- proximally (for the anterior and ilium to sufficiently mobilize the tions of wire constructs using two, posterior vertical wires) and four fragment.11 Asymptomatic trochan- three, or four wires have since been are placed just distal to the previ- teric nonunion does not require described.4,6-9 Nonunion rates with ously drilled holes (for the two intervention. wire fixation range from 1% to transverse wires). The wires are Lateral hip after trochanteric 25%.5 The different types of wire then threaded and the osteotomy osteotomy often is attributed to fixation techniques and large num- fragment is returned to its bed or prominent trochanteric hardware. ber of patient variables in each advanced distally. The two vertical However, pain relief after hardware series make it difficult to identify wires are tensioned first, followed removal is unpredictable, with the superiority of one technique by the transverse wires.2 Wire mesh fewer than half of patients achiev- over another. can be used to capture small or ing relief of symptoms.12 A trial Jensen and Harris6 reported a osteoporotic trochanteric fragments, injection of local anesthetic should 99% union rate using a three-wire making fixation more reliable. be attempted before surgical inter- technique (796/804 cases). This Although this technique pro- vention, and the patient should be method has been modified to a vides secure fixation, it is technical- thoroughly informed about the pos- four-wire technique involving two ly difficult. Additionally, the pres- sibility that the procedure will not vertical wires and one or two trans- ence of intramedullary wires can result in pain relief. verse wires (16- or 18-gauge stain- interfere with insertion of a cement- The relation between trochanteric less steel)2 (Fig. 3). Each of the two less femoral component, resulting in osteotomy and HO is unclear. The vertical wires is placed through a malpositioning or wire breakage. transtrochanteric approach has been separate drill hole in the lateral This technique also is difficult to do reported to increase the incidence femoral cortex, exiting approxi- after the femoral component has and severity of clinically significant mately 1 to 2 cm distal to the cut been implanted, as in the case of HO compared with a posterior surface. The holes can be drilled unexpected abductor muscle laxity approach without osteotomy.13 farther distally if advancement of and instability. Although there is However, Morrey et al14 found no the trochanteric fragment is desired. little published information about statistically significant difference in After the prosthetic insertion, two with trochanteric the development of HO when com- additional transverse wires are osteotomy,10 autologous bone graft- paring the anterolateral, transtro- ing is generally used in cases of chanteric, and posterior approaches. nonunion or a deficient trochanteric Because the evidence is inconclu- bed. The graft can be obtained sive, selection of approach should locally with femoral reamings or not be affected by the issue of HO. from the iliac crest. The use of prophylaxis to prevent heterotopic bone in high-risk pa- Complications tients should be considered regard- The most common complication less of approach. is nonunion; other reported compli- cations include trochanteric bursitis and heterotopic ossification (HO). Modifications of the The incidence of trochanteric non- Standard Trochanteric union with all types of fixation Osteotomy ranges from 0.5% to 38%.5 Non- Figure 3 Anterior and oblique views of union of the trochanter can result in Modifications of the standard tro- the four-wire trochanteric osteotomy fixa- tion technique. (Reprinted with permis- , abductor muscle insuffi- chanteric osteotomy were developed sion from McGrory BJ, Bal BS, Harris WH: ciency, and instability. However, to address the shortcomings of the Trochanteric osteotomy for total hip these symptoms can be multifactori- standard, single-plane osteotomy by arthroplasty: Six variations and indications for their use. J Am Acad Orthop Surg al, and the nonunion should be con- increasing stability, decreasing non- 1996;4:258-267.) firmed as the causative factor before union, and providing greater effec- initiating treatment. Symptomatic tiveness in revision cases. These

Vol 11, No 3, May/June 2003 165 Trochanteric Osteotomy and Fixation During THA

Saw or Concave Convex osteotome trochanteric trochanteric fragment bed Vastus lateralis

120¡-130¡

A B

Figure 4 The chevron, or biplane, osteotomy. A, The two limbs of the osteotomy should be directed at the center to converge at a 120° to 130° angle. B, Trochanteric fragment with a concave, chevron-shaped medial surface. (Adapted with permission from McGann WA: Surgical approaches, in Callaghan JJ, Rosenberg AG, Rubash HE [eds]: The Adult Hip. Philadelphia, PA: Lippincott-Raven, 1998, p 697.)

variations include the chevron, par- osteotomy.7 Fixation options are the gluteus medius and vastus lat- tial, horizontal, and vertical osteoto- the same as for the standard tro- eralis muscles.15 The posterior half mies (Figs. 4-7). The chevron and chanteric osteotomy. of the trochanter and the attached partial osteotomies were created for The partial, or oblique, osteoto- posterior gluteus medius and short use in primary arthroplasties, where- my was devised to provide a more external rotators remain intact. In as the horizontal and vertical extensile approach to the hip when rare cases when the aponeurosis osteotomies were designed for revi- using the direct lateral approach, as between the gluteus medius and the sion procedures.2 well as to provide bone-to-bone anterior vastus lateralis muscles The chevron, or biplane, osteoto- healing for reattachment of the over the trochanter is excessively my was developed to improve in- anterior abductors (Fig. 5). The thin, a small wafer of bone can be trinsic stability of the osteotomy advantage of this osteotomy is elevated with these attachments to and reduce the incidence of tro- preservation of the continuity of improve closure. Closure is gener- chanteric nonunion. The geometry of the cut provides inherent stabili- ty with resistance to rotation and anteroposterior displacement (Fig. 4). The chevron osteotomy can be Gluteus done using either an osteotome or Capsule medius an oscillating saw to create a frag- ment with a concave, chevron- shaped medial surface. Alter- Trochanteric natively, a Steinmann pin can be fragment placed from the anticipated exit site distal-laterally to the proximal- medial aspect of the greater tro- chanter. A Gigli saw then can be A B passed superiorly around the Figure 5 A, The partial, or oblique, osteotomy (dashed line) is a modification of the direct greater trochanter proximal to the lateral approach. B, A thin wafer of bone that contains both gluteus medius and vastus lat- Steinmann pin. The saw can be eralis attachments is elevated with an osteotome or saw, allowing anterior retraction of this myofascial sleeve. (Adapted with permission from McGann WA: Surgical approaches, in used to cut distally and laterally, Callaghan JJ, Rosenberg AG, Rubash HE [eds]: The Adult Hip. Philadelphia, PA: with the pin as the apex of the os- Lippincott-Raven, 1998, p 681.) teotomy, thereby creating a biplane

166 Journal of the American Academy of Orthopaedic Surgeons Michael J. Archibeck, MD, et al

the trochanter has previously been trochanteric migration seen with advanced to the lateral femoral cor- standard osteotomies is avoided by tex (Fig. 7). The path of the trochan- the tethering effect of the vastus lat- teric osteotomy is parallel to the lat- eralis muscle and its attachment to eral cortex of the proximal femur, the distal portion of the fragment. leaving sufficient cancellous bone (3 In addition, compression is applied to 5 mm) lateral to the cortex for re- to the fragment because the gluteus attachment to a cancellous bed. The medius and vastus lateralis muscles insertions of the gluteus medius and provide a medially directed force. It minimus remain on the osteoto- is unclear whether maintaining the mized fragment.2 vastus lateralis muscle origin im- proves blood supply to the frag- ment.19 Trochanteric Slide Osteotomy Indications Indications for use of the tro- Although English17 first described chanteric slide in primary THA are Figure 6 The horizontal trochanteric the trochanteric slide technique, similar to those for the standard osteotomy. The cut (bold dashed line) Glassman et al18 championed it in osteotomy. Revision indications starts as far proximal as possible on the lat- eral surface of the greater trochanter with- its modern form for use in revision include some isolated acetabular out dividing the fibers of the abductors hip surgery. The advantages of this revisions, protrusio acetabuli, and inserting into the trochanter. (Reproduced technique include the use of the cemented femoral revisions (eg, with permission from McGrory BJ, Bal BS, Harris WH: Trochanteric osteotomy for intact vastus lateralis muscle origin impaction grafting, cemented revi- total hip arthroplasty: Six variations and to prevent proximal trochanteric sion component) when maintaining indications for their use. J Am Acad Orthop migration. Even in cases of failed the integrity of the diaphyseal tube Surg 1996;4:258-267.) hardware and nonunion, the marked is a necessity. Contraindications include the absence of medial bone for wire or cable placement and ally done with sutures through insufficient trochanter thickness, drill holes. resulting in an inadequate bed for The horizontal trochanteric os- repair and healing. teotomy was developed to allow enhanced exposure in revision cases Technique in which a standard trochanteric Generally, a straight lateral inci- osteotomy would not preserve suffi- sion is used because it provides cient cancellous bed for reattach- optimal access to the anterior aspect ment of the trochanteric fragment of the trochanter. This can be espe- because PMMA extends into the cially important in the fused or trochanter (Fig. 6). The approach ankylosed hip when external rota- and trochanteric preparation are tion is not available to provide similar to those of the standard access to the anterior trochanter. osteotomy; however, the direction The posterior border of the gluteus of the osteotomy is done at 70° to medius muscle is identified just 90° to the femoral diaphysis as far cephalad to the piriformis . proximal as possible on the trochan- The interval between the gluteus ter so that the entire insertion of the Figure 7 The vertical osteotomy (bold minimus muscle and the capsule is gluteus minimus and medius re- dashed line) on a femur in which the developed bluntly in a posterior to mains on the fragment. The frag- greater trochanter was advanced to the lat- anterior direction, and an instru- eral femoral cortex in a previous proce- ment can be reattached to the lateral dure. (Adapted with permission from ment is inserted in this plane (Fig. femoral cortex at the time of repair.16 McGrory BJ, Bal BS, Harris WH: Tro- 8). The vastus lateralis muscle is Fixation options are the same as chanteric osteotomy for total hip arthro- incised along its posterior aspect 10 plasty: Six variations and indications for those for the standard osteotomy. their use. J Am Acad Orthop Surg 1996; cm distal to the vastus ridge, leav- The vertical trochanteric osteoto- 4:258-267.) ing a 1-cm cuff of fascia posteriorly. my is indicated in cases in which A Homan retractor is then placed

Vol 11, No 3, May/June 2003 167 Trochanteric Osteotomy and Fixation During THA

Trochanter Anterior Vastus lateralis Gluteus medius Gluteus medius

Distal Proximal

Femur Vastus lateralis Saw

Posterior A B

Figure 8 The trochanteric slide osteotomy. A, Proximally, the interval is between the capsule and the gluteus minimus. Distally, the vas- tus lateralis origin is left intact by making the exit cut distal to the vastus tubercle. B, Once the osteotomy is complete, the trochanteric fragment and its attached proximal and distal musculature are retracted anteriorly.

from posterior to anterior around component shoulder, the fragment cable placed distal to the lesser the femur under the vastus lateralis. should be contoured using a high- trochanter to avoid proximal medial The osteotomy is initiated posteri- speed burr to allow apposition. migration of the trochanter. Autol- orly with an oscillating saw, with With the provisional fixation in ogous bone graft can be used to the leg in internal rotation. The cau- place, the hip should be taken treat nonunion or when a deficient dal extent of the osteotomy is just through a range of motion to identi- trochanteric bed exists. distal to the vastus ridge, and the fy any impingement caused by mal- proximal extent is just medial to the positioning of the trochanter. The Complications piriformis fossa in the interval wires or cables are then tightened. Limited data are available on the between the gluteus minimus and When fixation is difficult, such as effectiveness of the trochanteric capsule. It is preferable to leave the with a thin trochanteric fragment, a slide osteotomy. English17 reported gluteus minimus attached to the cable grip system can be used. on 222 done for primary THAs; 120 osteotomy fragment to maintain Many fixation techniques have been were fixed with wires and 102 with abductor strength after repair. The developed using cables, claws, or a bolt and bone graft, with non- hip then can be dislocated either cable plates. Dall and Miles20 de- union rates of 4.3% and 2.5%, anteriorly or posteriorly. signed a multifilament cable system respectively. Glassman et al18 re- with a trochanteric grip for fixation. ported a 10% nonunion rate of tro- Fixation The cable grip system provided chanteric slide osteotomies in the Repair of the osteotomy is gener- greater resistance to displacement revision setting (9/90 cases) at a ally done using either two monofila- than did an isolated cable construct mean follow-up of 21 months. In ment wires (16- or 18-gauge) or two or 16-gauge wires.8 As with wire seven of the patients with non- cables with or without a claw con- techniques, however, clinical results union, the trochanteric fragment struct. Drill holes can be used in the are variable, with cable fraying or migrated proximally 2 to 26 mm trochanteric fragment, but they are breakage in up to 47% and non- (mean, 7.1 mm). Only one patient not necessary. The wires or cables union rates ranging from 1.5% to with a nonunion demonstrated clin- are passed medially around the 38%.21,22 Cable fragmentation can ically evident abductor muscle proximal femur and around the be a source of metallic debris that insufficiency. Of the remaining 82 trochanteric fragment, taking care to may cause third-body wear,22 so patients, 23 (28%) had a Tren- pass them deep to any muscle tis- some surgeons have returned to delenburg sign or abductor lurch. sue. If, as in many femoral revi- wire fixation. If a cable grip system Although many confounding fac- sions, the osteotomy fragment is is used, the cables should be sepa- tors make direct comparison diffi- prevented from seating on a bed of rated by 2 to 3 cm at the medial cult, the trochanteric slide seems to host bone by a prominent femoral aspect of the femur with the distal improve resistance to proximal

168 Journal of the American Academy of Orthopaedic Surgeons Michael J. Archibeck, MD, et al migration and has a higher reported Indications ble to place a cemented revision stem rate of union than does the standard Indications for the extended tro- after this osteotomy, cement extru- trochanteric osteotomy. For these chanteric osteotomy include femoral sion into the osteotomy site is diffi- reasons, the trochanteric slide is revision of well-fixed cemented or cult to avoid and can prevent union. generally preferred in primary and cementless components, femoral revision cases requiring a limited revision with difficult cement re- Technique osteotomy. moval, varus remodeling of the The length of the osteotomy is proximal femur, and the need for planned preoperatively as that enhanced acetabular exposure. The which will provide adequate com- Extended Trochanteric osteotomy also greatly facilitates ponent exposure and maintain at Osteotomy removal of cement through direct least 5 cm of isthmic diaphyseal cor- visualization in routine revisions. tex for revision component fixation. The extended trochanteric osteotomy Removal of well-fixed proximally Generally, the osteotomy should be is useful for revision THA because it coated femoral components is aided at least 10 cm long, measured from facilitates both femoral component by the use of flexible osteotomes or the tip of the greater trochanter, to extraction and reimplantation and a Gigli saw passed medially around allow secure fixation of the fragment enhances acetabular exposure. This the if the geometry per- to the medial femoral cortex. Fem- osteotomy also is occasionally useful mits. A well-fixed, extensively coat- oral component revision osteoto- for primary THA in a patient with ed prosthesis can be extracted by mies are typically 12 to 15 cm long. proximal femoral deformity or in- sectioning the prosthesis at the junc- The extended trochanteric osteot- traosseous hardware that extends tion of the tapered and cylindrical omy is usually done through a pos- into the diaphyseal region. How- portions and using trephines distal- terolateral approach. It may be ever, the extended trochanteric os- ly.27 Acetabular exposure also can done at any time during the proce- teotomy limits femoral component be greatly enhanced by retracting dure—before or after dislocation or options to those that rely on diaphy- the osteotomy fragment anteriorly after stem removal. The easiest time seal fixation. and the proximal femur posteriorly. is after the stem has been removed; A technique attributed to Wagner Varus remodeling (ie, apex lateral however, this is often not possible, (an extended anterior trochanteric bowing) of the proximal femur sec- so the osteotomy is usually done osteotomy in which the anterior half ondary to the presence of a failed after dislocation but before stem of the abductors was reflected in femoral component makes eccentric removal. When dislocation is dif- continuity with the anterior third of reaming and cortical perforation ficult, the extended trochanteric the proximal femur) was modified difficult to avoid in the absence of osteotomy provides excellent expo- by Younger et al23 into an extended an osteotomy because the reamers sure and can be helpful in manag- lateral trochanteric osteotomy in can pass through the lateral cortex ing dislocation in the stiff hip. which all of the abductors are re- at the apex of this deformity. With The osteotomy is initiated along flected with the lateral third of the the aid of the extended trochanteric the posterior aspect of the proximal proximal femur. In 1991, Cameron24 osteotomy, direct access to the di- femur (Fig. 9). The posterior exten- reported the use of this osteotomy aphysis is provided, which allows sion of the linea aspera is exposed in revision THA in two patients. straight reaming of the diaphysis for by partial elevation of the vastus Peters et al25 used a modified form revision stem insertion. The extend- lateralis muscle and release of the of the osteotomy in 21 patients; all ed trochanteric osteotomy requires gluteus maximus insertion sub- united by 6 months. Younger et al23 use of a femoral component designed periosteally. An oscillating saw or reported a 100% union rate by 3 to obtain fixation in the femur distal high-speed pencil-tip burr can be months, with proximal migration >2 to the osteotomy. used. Although a thin saw removes mm in 20 extended trochanteric Relative contraindications include less bone, the high-speed cutting osteotomies done for femoral revi- impaction grafting or femoral revi- instrument allows the surgeon to sion (mean follow-up, 18 months). sions in which the prosthesis will be make rounded distal corners, thus There were no fractures of the fixed with cement. Although some reducing the stress risers of sharp trochanteric fragment. Chen et al26 preliminary biomechanical data corners. The initial cut is made from reported on 46 extended trochan- imply that impaction grafting may the posterior aspect of the greater teric osteotomies with a 98% union be a sound construct after this trochanter and continues distally rate and two fractures of the tro- osteotomy, the limited clinical data along the posterior femur to the pre- chanteric fragment, neither of which indicate a higher nonunion rate in operatively determined distance (ie, required revision surgery. these patients.28 Although it is possi- 10 to 15 cm) from the tip of the

Vol 11, No 3, May/June 2003 169 Trochanteric Osteotomy and Fixation During THA

Vastus lateralis Saw Greater trochanter

Gluteus medius Linea aspera

A B

C D

Figure 9 A, The extended trochanteric osteotomy is done by cutting posteriorly from the greater trochanter along the linea aspera distally (dashed line). B, The proximal portion is cut using an oscillating saw. The transverse portion is cut to incorporate one third of the diaphyseal circumference. C, The osteotomy is scored and opened with a series of broad osteotomes. D, The osteotomy is fully opened by everting the fragment in continuity with overlying muscle. (Adapted with permission from Silverton CD, Rosenberg AG: Management of the trochanter, in Callaghan JJ, Rosenberg AG, Rubash HE [eds]: The Adult Hip. Philadelphia, PA: Lippincott-Raven, 1998, vol 2, pp 1269-1294.)

greater trochanter. The transverse fragment is carefully elevated, expos- the extended osteotomy can be done portion is then cut to include ap- ing the underlying femoral compo- after a direct lateral or anterolateral proximately one third of the femoral nent or cement mantle. approach. In addition, if the anterior diaphyseal circumference with min- It is important to release the ante- bow of the femur prohibits insertion imal elevation of the vastus lateralis rior proximal soft tissue and re- of a straight femoral component, an muscle. The distal anterior portion maining capsule from the osteoto- anterior extended trochanteric os- of the osteotomy is initiated 1 to 2 my fragment. This release prevents teotomy that includes osteotomy of cm proximal to the transverse os- anterior tethering of the proximal the anterior third of the femur in teotomy. The proximal extent of the fragment that can lead to fracture continuity with the anterior abduc- anterior limb is then cut by passing and allows the fragment to be poste- tors can be used. the saw, burr, or osteotome from riorly positioned during reattach- After addressing the , posterior to anterior between the ment. The proximal femoral shaft the new stem is inserted before the prosthetic neck and the medial can be retracted in an anterior, pos- osteotomy is reduced. Generally, a trochanter and cutting the proximal terior, or distal direction for acetab- cementless revision stem (nonmod- 1 to 2 cm. A 0.25-in straight osteo- ular exposure. To minimize the risk ular or modular) with at least 4 cm tome is used to score the anticipated of fracture with cemented femoral of distal fixation is used. Hip stabil- anterior extension of the osteotomy component extraction, the cement ity is assessed with the osteotomy from distal to proximal, deep to the adherent to the trochanteric frag- still open. After stability is ensured vastus lateralis. Alternatively, drill ment is left in place until just before and the acetabular and femoral holes can be made through the mus- repair of the osteotomy. components are in place, including cle anteriorly. With a series of broad, Although a posterior approach is the liner and , the curved osteotomes inserted in the preferred when an extended tro- extended trochanteric osteotomy is posterior limb of the osteotomy, the chanteric osteotomy is anticipated, reattached. At the time of osteot-

170 Journal of the American Academy of Orthopaedic Surgeons Michael J. Archibeck, MD, et al omy repair, the medial surface of inadvertently entrap neurovascular A single supplemental allograft the trochanteric fragment often re- structures. The cables are generally strut can be used to span the distal quires sculpting with a high-speed passed in a posterior to anterior extent of the osteotomy with an burr to accommodate the lateral direction to avoid inadvertently attenuated or fractured osteotomy profile of the revision femoral com- incarcerating the . The fragment. However, with the high ponent. proximal cable or wire is placed on osteotomy union rate reported with- the calcar just proximal to the lesser out allografts (98% to 100%),6,23,26 Fixation trochanter if bone is available to allografts typically are not used. Fixation of the extended tro- support the cable medially. This Chen et al26 found the time to bridg- chanteric osteotomy can be less cable should not rest on the prosthe- ing callus to be prolonged in cases troublesome than that of the stan- sis; therefore, if calcar bone is absent, in which strut allografts were used dard trochanteric osteotomy or the only two cables may be used, or an to supplement repair of the osteot- trochanteric slide. The osteotomy allograft can be applied medially. omy. In addition, autologous bone fragment is reapproximated back The second cable is placed just distal or allograft is not typically needed into its bed in the lateral femur. A to the lesser trochanter, and one to graft osteolytic lesions or gaps common error is to reapproximate additional cable is placed 2 to 3 cm between the proximal femur and the fragment too anteriorly, which proximal to the transverse portion of the prosthesis because these areas can result in anterior impingement the osteotomy. Additional cables remodel with time. and thus posterior . can be used depending on the length Release of the contracted anterior Relative reapproximation of the of the osteotomy. The distal cable is capsule or tissue is done if osteotomy fragment can be aided by generally secured tightly, the middle these tissues impair reattachment or abducting the leg and internally one not quite as tightly, and the if external rotation is markedly lim- rotating the femur during osteotomy proximal cable even more loosely. ited. The release is done by devel- repair. The posterior limb of the os- This sequence of graduated tighten- oping the plane between the capsule teotomy should be reapproximated, ing is done to avoid fracture of the and the more superficial gluteus leaving any longitudinal gap anteri- osteotomy at its most tenuous por- medius and minimus muscles, start- orly. Occasionally, because of varus tion, just distal to the vastus tuber- ing at the anterior border of the glu- remodeling of the proximal femur, cle. Once fixation is secured, range teus medius. A capsular scissors the medial aspect of the proximal of motion is tested again to ensure then can be passed in an anterior-to- femur will not be adjacent to the stability without impingement. posterior direction, with care taken femoral prosthesis. In such instan- ces, the transverse portion of the osteotomy can be completed cir- cumferentially, making the medial aspect a third free piece. The free medial fragment and the trochan- teric fragment then can be reduced to the prosthesis. However, this can make appropriate positioning of the trochanteric fragment more difficult because the rotational reference of the medial piece is no longer fixed. Once reduced, two to four wires or cables are passed around the di- aphysis and trochanteric fragment (Fig. 10). Both cables and wires have been used successfully. Although controversy exists about which is better, cable offers improved tensile strength and resistance to fatigue. It A B C is critically important to pass the Figure 10 A, Preoperative posteroanterior radiograph of a loose total hip arthroplasty. B, wires or cables in a submuscular Eight weeks after revision, with evidence of healing of the extended trochanteric osteoto- fashion so as not to injure the vascu- my. C, Two years after revision, with remodeling of the osteotomy site. lar supply to the osteotomy site or

Vol 11, No 3, May/June 2003 171 Trochanteric Osteotomy and Fixation During THA to avoid injury to the overlying cle is the area most susceptible to procedure. Initially implemented musculature. Alternatively, this fracture. This is also the location as a routine part of the exposure, release can be done from within the that is often attenuated by the later- trochanteric osteotomies are now hip joint, releasing the anterior teth- al profile of the previously failed selectively used for difficult prima- ering structures with electrocautery. femoral component. Intraoperative ry and revision THAs. Trochanteric Postoperatively, the patient is measures to avoid fracture include osteotomies can be classified into treated with touch-down weight release of the anterior capsular and three categories: the standard bearing and no active abduction for scar tissues from the proximal trochanteric osteotomy and its vari- 6 weeks. Abduction orthoses are trochanteric fragment to increase its ations, the trochanteric slide, and not routinely used except in patients mobility, gentle exposure of the the extended trochanteric osteoto- at high risk for dislocation. After 6 acetabulum with broad retractors, my. The standard, single-plane weeks, the patient progresses to and delayed removal of retained osteotomy and its variations are weight bearing as tolerated, and cement on the trochanteric frag- rarely done in North America but active abduction and progressive ment. If an intraoperative fracture can be used in cases that require ambulation are initiated. of the osteotomy fragment occurs, trochanteric advancement to fixation with a trochanteric claw or improve stability or in those that Complications plate is recommended. In cases of require extensile exposure of the Little has been reported about the marked attenuation of the cortex in acetabulum. The trochanteric slide, complications of the extended this region, prophylactic fixation which preserves the vastus lateralis trochanteric osteotomy. However, with a claw or plate construct may muscle origin, has largely taken the nonunion and proximal migration, be warranted. place of the standard osteotomy in the major complications of standard Another potential complication of difficult primary THAs that require and sliding osteotomies, are largely the extended trochanteric osteotomy enhanced exposure. The extended avoided with the extended osteot- is vascular injury with the use of trochanteric osteotomy is valuable omy. Four published series report proximal cerclage cables or wires. in some primary THAs and many union rates of 98% to 100%.23-26 Two Attention to detail is critical in the revision THAs because it facilitates nonunions have been reported with placement of these fixation devices. removal of well-fixed cemented or the use of this osteotomy in conjunc- cementless femoral components, tion with impaction grafting.28 provides direct access to the diaph- Intraoperative and postoperative Summary ysis for central reaming, enhances fractures of the osteotomy fragment acetabular exposure, and has a low can occur. The base of the greater The use of trochanteric osteotomies rate of nonunion and complica- trochanter distal to the vastus tuber- dates to the inception of the THA tions.

References

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172 Journal of the American Academy of Orthopaedic Surgeons Michael J. Archibeck, MD, et al

13. Errico TJ, Fetto JF, Waugh TR: Het- technique of extensile exposure for for femoral revision arthroplasty. erotopic ossification: Incidence and total hip arthroplasty. J Arthroplasty J Arthroplasty 1995;10:329-338. relation to trochanteric osteotomy in 1987;2:11-21. 24. Cameron HU: Use of a distal trochan- 100 total hip arthroplasties. Clin 19. Naito M, Ogata K, Emoto G: The teric osteotomy in hip revision. Contemp Orthop 1984;190:138-141. blood supply to the greater trochanter. Orthop 1991;23:235-238. 14. Morrey BF, Adams RA, Cabanela ME: Clin Orthop 1996;323:294-297. 25. Peters PC Jr, Head WC, Emerson RH Comparison of heterotopic bone after 20. Dall DM, Miles AW: Re-attachment of Jr: An extended trochanteric osteoto- anterolateral, transtrochanteric, and pos- the greater trochanter: The use of the my for revision total hip replacement. terior approaches for total hip arthro- trochanter cable-grip system. J Bone J Bone Joint Surg Br 1993;75:158-159. plasty. Clin Orthop 1984;188:160-167. Joint Surg Br 1983;65:55-59. 26. Chen WM, McAuley JP, Engh CA Jr, 15. Dall D: Exposure of the hip by anterior 21. McCarthy JC, Bono JV, Turner RH, Hopper RH Jr, Engh CA: Extended osteotomy of the greater trochanter: A Kremchek T, Lee J: The outcome of slide trochanteric osteotomy for revi- modified anterolateral approach. J Bone trochanteric reattachment in revision sion total hip arthroplasty. J Bone Joint Joint Surg Br 1986;68:382-386. total hip arthroplasty with a Cable Surg Am 2000;82:1215-1219. 16. Bal BS, Maurer BT, Harris WH: Tro- Grip System: Mean 6-year follow-up. 27. Younger TI, Bradford MS, Paprosky chanteric union following revision J Arthroplasty 1999;14:810-814. WG: Removal of a well-fixed cement- total hip arthroplasty. J Arthroplasty 22. Silverton CD, Jacobs JJ, Rosenberg AG, less femoral component with an ex- 1998;13:29-33. Kull L, Conley A, Galante JO: Compli- tended proximal femoral osteotomy. 17. English TA: The trochanteric ap- cations of a cable grip system. J Arth- Contemp Orthop 1995;30:375-380. proach to the hip for prosthetic re- roplasty 1996;11:400-404. 28. Hellman EJ, Capello WN, Feinberg JR: placement. J Bone Joint Surg Am 1975; 23. Younger TI, Bradford MS, Magnus RE, Nonunion of extended trochanteric os- 57:1128-1133. Paprosky WG: Extended proximal teotomies in impaction grafting femoral 18. Glassman AH, Engh CA, Bobyn JD: A femoral osteotomy: A new technique revisions. J Arthroplasty 1998;13:945-949.

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