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FEATURE ARTICLE

Trochanteric Osteotomy for Incarcerated Dislocation Due to Interposed Posterior Wall Fragments Jeffrey O. Anglen, MD Michael Hughes

Abstract

A series of 12 patients was retrospectively reviewed to ly longer operations with more blood loss. Patients with evaluate the use of sliding trochanteric osteotomy for osteotomy tended toward a higher incidence of post- reduction of hip dislocations that were irreducible due to traumatic arthritis, but Harris hip scores at 2 years were interposed posterior wall fragments. Compared to simi- identical to matched comparisons. No adverse effects of lar patients who did not have irreducible dislocation or trochanteric osteotomy were identified. trochanteric osteotomy, the 12 patients had significant-

Incarcerated hip dislocation is a severe ular fracture were identified through a gent operation (Figure 1). When they injury with poor prognosis. When the search of the Orthopaedic Trauma Service could not be taken directly to the operat- reduction is blocked by fragments of a database at the University of Missouri ing room, skeletal traction was applied. comminuted posterior wall, forceful Health Sciences Center, a level 1 trauma Trochanteric osteotomy was an intraoper- repeated attempts at reduction, pre- or center. All patients were operated on by a ative decision. intraoperatively, may further damage the single, fellowship-trained orthopedic With the early patients in this series, a articular surface. Trochanteric osteotomy traumatologist. Charts and radiographs variety of maneuvers were attempted during the surgical exposure of such cases were reviewed by a research assistant prior to osteotomy, including forceful has been found to facilitate reduction and who was uninvolved in the care of the manipulations of the leg, hip rotation with lessen trauma to the joint. patients, using a simple data collection distraction, and femoral distractor use. Due to reported complications and instrument designed to collect demo- However, substantial posterior wall frag- potentially detrimental effects of tro- graphic variables, operative findings and ments with attached capsule wedged chanteric osteotomy, a retrospective occurrences, follow-up complications, between the head and socket in the review of our experience with this tech- and outcomes. Charts were reviewed for made the hip tight and pre- nique was performed to evaluate the injury severity score, operative time, time vented adequate access for fragment risks and benefits. from injury to surgery, estimated blood removal. Longitudinal distraction often loss, and outcome determinants such as increased the tension in abductor muscles MATERIALS AND METHODS degenerative joint disease, avascular and actually made the femoral head hard- Patients undergoing trochanteric necrosis, heterotopic bone, osteotomy er to extract from the acetabulum. It was osteotomy during exposure for an acetab- nonunion or other complication, average found by experience that trochanteric range of abduction, subsequent surgeries, osteotomy relaxed the muscular tension From the Department of Orthopedic Surgery, and Harris hip score, calculated from data enough to allow bone fragments to be University of Missouri Hospital and Clinics, in the chart. extracted. Later in this series, osteotomy Columbia, Mo. Attempted closed reduction was per- was performed early and routinely. Reprint requests: Jeffrey O. Anglen, MD, Boone Orthopaedic Associates, LLC, Broadway formed in the emergency department; The trochanteric osteotomy technique Medical Plaza, 1601 E Broadway, Ste 300, however, when the hip could not be used in this series is similar to that Columbia, MO 65201-8022. reduced, patients were posted for emer- described by Bray et al1 using a gigli saw

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A B C Figure 1: AP pelvic radiograph of a posterior hip dislocation with associated posterior wall fracture (A). AP pelvic radiograph after failed attempt at closed reduction of the hip (B). CT revealing the cause of reduction failure—an interposed fragment of the posterior acetabular wall (C).

matches were found for each index than for those who did not (mean: 3.2 patient. hours, range: 2-4.8 hours) (P=.024). Statistical analysis was performed Estimated blood loss was greater for using Systat for Windows (Systat Inc, patients with an osteotomy, 1280 cc ver- Evanston, Ill). A one-tailed t test was sus 720 cc (P=.037). Approximately 40% used to analyze continuous variables, of both groups had visible injury to the such as injury to surgery time, operative femoral head at surgery, and similar per- time, and blood loss. centages suffered marginal impaction of Figure 2: AP pelvic radiograph of the same acetabular cartilage (40% for the osteoto- patient after open reduction and internal RESULTS my group and 27% for the comparison fixation with trochanteric osteotomy. Twelve patients (2 women and 10 group, P=.42). men) with acetabular fractures who Heterotopic ossification was absent in underwent trochanteric osteotomy were 60% of patients in both groups. No in the interval between the abductors and identified. All osteotomies were per- patient developed Brooker grade 4 (anky- hip capsule. The vastus lateralis origin on formed for reduction of an incarcerated losis) heterotopic ossification, but 4 the lateralis ridge of the was kept dislocation during open reduction inter- patients (1 osteotomy, 3 comparison) intact in connection to the trochanteric nal fixation procedures. Average patient developed grade 3 heterotopic ossifica- fragment, in a “trochanteric flip,” as age was 46 years, and average weight tion, which did not require excision. This described by Siebenrock et al.2 It was was 95.5 kg. Average patient age of the difference was not statistically signifi- believed that this technique would allow comparison group was 43 years and aver- cant. more secure fixation of the trochanter age weight was 90.2 kg, which were not Of the osteotomy patients, 50% devel- and preserve trochanteric blood supply. statistically significantly different (P=.32 oped significant degenerative joint dis- The osteotomy was fixed with two large and P=.26, respectively). ease based on radiographic signs (sclero- fragment cancellous screws (Figure 2). Average injury severity score of sis, joint narrowing, osteophytes) and All patients received prophylactic treat- osteotomized patients was 19.1, and 16.8 clinical criteria (pain, stiffness, limitation ment against heterotopic ossification, for comparison patients (P=.35). The of range) compared to only 23% of the either single-dose postoperative radiation osteotomy group consisted of 5 posterior comparison patients; however, this differ- or 6 weeks of indomethacin (75 mg oral- wall fractures, 4 transverse and posterior ence was not statistically significant ly twice daily), according to a random- wall fractures, and 3 posterior column (P=.217). Two patients in each group ization protocol. and posterior wall fractures. The compar- developed radiographic signs of avascu- To evaluate patient outcomes, a com- ison group consisted of 12 posterior wall lar necrosis with pain and restricted range parison group of patients (without incar- fractures, 7 transverse and posterior wall of motion. cerated hip dislocation or trochanteric fractures, and 3 posterior column and The average Harris hip score was osteotomy) matched for gender, age posterior wall fractures. essentially identical between the two (within 5 years), weight (within 20 kg), Average time from injury to surgery groups (82 and 83) at final follow-up, and fracture type (including dislocation) was shorter for patients who required an which averaged 27 months (range: 12-62 were selected and reviewed. These osteotomy, 47 hours (range: 5-113 hours) months) for the osteotomy group and 22 patients were not intended to be a “con- versus 83 hours (range: 4-240 hours) months (range: 12-66 months) for the trol” group, but rather to provide a con- (P=.038). Operative time was longer for comparison group. Data for both groups text in which to place the outcome of patients who required an osteotomy is shown in the Table. these patients. From one to four adequate (mean: 4.5 hours, range: 2.3-8.3 hours) All trochanteric osteotomies united

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without migration or hardware complica- tions. Seven (58%) of 12 patients had a TABLE positive Trendelenburg sign. In the com- Study Population Demographics parison group, 7 (32%) of 22 patients had a positive Trendelenburg sign, a differ- Osteotomy Comparison Demographic Patients Group ence that was not statistically significant (P=.244, Fisher exact test). One patient Age (y)* 46 (19-70) 43 (17-71) Weight (kg)* 95.5 (61-129) 90.2 (52-140) had elective screw removal for mild Injury severity score* 19 (10-34) 17 (9-41) symptoms of bursal irritation. Fracture type Posterior wall 5 12 Transverse and posterior wall 4 7 DISCUSSION Posterior column and posterior wall 3 3 As noted by McKee et al3 in 1998, Injury to surgery time (hr)* 47 (5-113) 83 (4-240) irreducible fracture dislocation of the Operative time (hr)* 3.9 (2.3-8.3) 2.2 (2-4.8) Estimated blood loss (mL)* 1167 (350-3000) 690 (350-1200) hip is a severe injury with a poor prog- Marginal impaction (%) 42 (5/12) 27 (6/22) nosis. Only 6 of 23 patients in their Injury to femoral head (%) 42 (5/12) 36 (8/22) study had a satisfactory outcome due to Heterotopic ossification (%) 42 (5/12) 32 (7/22) Degenerative joint disease (%) 50 (6/12) 23 (5/22) a variety of problems including avascu- Avascular necrosis (%) 17 (2/12) 9 (2/22) lar necrosis, rapid chondrolysis, sciatic Trendelenburg sign positive (%) 60 (7/12) 32 (7/22) nerve palsy, heterotopic ossification, Harris hip score* 81 (40-97) 83 (60-95) Follow-up (mos)* 27 (12-62) 22 (6-66) and severe ipsilateral lower extremity injuries. Approximately one third (7/23) *Represented as mean (range). р had undergone or were awaiting total Note. Shaded comparisons have a P .05. hip arthroplasty (THA). They noted that the most common structures blocking hip reduction were posterior acetabular achieved union with pain-free active in obese patients; high transverse frac- wall fragments (13/23 cases). McKee et abduction. Heterotopic ossification ture with posterior wall or entrapped al3 stated that “although it may appear developed in 4 patients and was of no fragments; unreduced fracture Ͼ2.5 that removal of the offending fragment clinical significance in 2. The authors weeks old; and certain complete frac- of bone from the acetabulum should be believed this was consistent with the tures of both columns. Three patients straightforward, it was often extremely reported rate in the literature for patients experienced abductor attachment prob- difficult.” Maneuvers to facilitate this who did not undergo trochanteric lems or failure, 11 required additional process included complete paralysis, a osteotomy. surgery (screw removal) as a result of traction pin in the femoral neck, and the Siebenrock et al2 reported the use of trochanteric osteotomy, and a 44% use of large “thoracic” clamps to grasp trochanteric flip osteotomy in 10 con- incidence of heterotopic ossification and remove the fragments. They did not secutive “selected” acetabular fracture including 5 patients with ankylosis was mention trochanteric osteotomy, which cases. They stated the osteotomy was reported. They believed trochanteric we found to be useful. performed for “better visualization of osteotomy increased the complications Trochanteric osteotomy is a stan- large posterior wall fragments with cra- of fracture management. dard procedure in THA4,5 but has been nial extension.” No cases of avascular A variety of osteotomy techniques rarely used or discussed in acetabular necrosis, functionally significant hetero- have been reported in the fracture and fracture fixation. Mears and Rubash6 topic ossification, trochanteric non- arthroplasty literature.1,2,5,7,9,10 In this and Senegas et al7 advocated trochan- union, or migration were reported. Five series, we used a technique similar to teric osteotomy as a routine part of patients had excellent outcomes, 4 good, that described by Bray et al,1 with the their respective lateral approaches to and 1 fair due to degenerative joint dis- exception that the fibers of the vastus acetabular fracture surgery. ease. None of these authors mentioned lateralis were left attached to the Bray et al1 reported the use of trochanteric osteotomy to facilitate hip trochanteric fragment, as described by trochanteric osteotomy in 10 of 51 cases reduction in irreducible dislocation. Siebenrock et al.2 We believe this treated surgically over 2 years. Heck et al8 reported a larger series improves the healing and stability of the Indications for trochanteric osteotomy of 55 patients who underwent trochan- trochanter after repair. It limits the included obesity, Ͼ3 week delay to teric osteotomy as part of a posterior or trochanter displacement and may there- surgery, revision fixation, and “certain triradiate approach to the acetabulum fore limit the visualization of the superi- complex” fractures. Their osteotomy was for fracture fixation. Their indications or dome area. However, in this series, made with a gigli saw and repaired with for trochanteric osteotomy were inabil- the osteotomy was being performed for two cancellous screws; 9 of 10 patients ity to visualize the dome, particularly tension release to allow disimpaction of

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incarcerated fragments rather than for numbers of both groups were small. R. Trochanteric flip osteotomy for cranial exten- sion and muscle protection in acetabular fracture exposure. The prevalence of heterotopic ossifica- fixation using a Kocher-Langenbeck approach. J The reported complications of tion and avascular necrosis was similar Orthop Trauma. 1998; 66:387-391. osteotomy include nonunion in up to between the two groups, and the Harris 3. McKee MD, Garay ME, Schemitsch EH, 1,4,8,11-13 Kreder HJ, Stephen DJ. Irreducible fracture-dis- 30%, migration in up to hip score was the same. Irreducible hip location of the hip: a severe injury with poor 19%,11,14 and bursitis or hardware dislocation patients had over twice the prognosis. J Orthop Trauma. 1998; 12:223-239. complications in up to 20%.8 These prevalence of significant degenerative 4. Mallory TH. Total hip replacement with and without trochanteric osteotomy. Clin Orthop. problems are expected to be more hip disease, and the Trendelenburg sign 1974; 103:133-135. common in the arthroplasty popula- was more frequently positive, but these 5. Schutzer SF, Harris WH. Trochanteric tion, in which bone quality is poorer differences were not statistically signifi- osteotomy for revision total hip arthroplasty. 97% union rate using a comprehensive approach. and fixation is with wire techniques. In cant. They also had shorter intervals Clin Orthop. 1988; 227:172-182. acetabular fractures, with younger between injury and surgery, reflecting 6. Mears DC, Rubash HE. Extensile exposure patients, uncompromised proximal the more urgent nature of this condition. of the . Contemporary Orthopaedics. 1983; 6:21-31. femur bone and lag screw fixation, Although the mean time from injury to 7. Senegas J, Liorzou G, Yates M. Complex nonunion, or trochanteric migration is surgery of approximately 50 hours may acetabular fractures: a transtrochanteric lateral sur- less likely. seem excessive for a condition consid- gical approach. Clin Orthop. 1980; 151:107-114. 8. Heck BE, Ebraheim NA, Foetisch C. Direct The relationship of trochanteric ered an orthopedic emergency, it should complications of trochanteric osteotomy in open osteotomy to heterotopic bone formation be remembered that this hospital is a ter- reduction and internal fixation of acetabular frac- is unclear. Some authors believe tiary referral center in a rural area. Often, tures. Am J Orthop. 1997; 26:124-128. 9. Naito M, Ogata K. Self-compressive osteo- trochanteric osteotomy increases the risk patients were referred from hospitals tomy of the greater trochanter. Int Orthop. 1997; of heterotopic ossification,6 whereas oth- many hours away, and often our institu- 21:119-121. ers have seen no relationship.1,8,15 Heck et tion was the third hospital to which they 10. Reinert C, Bosse M, Schacherer T, Brum- 8 Ͼ back RJ, Burgess AR. A modified extensile expo- al believed young, male patients with had been sent. Seven patients had a 24- sure for the treatment of complex or malunited head injury and delay to surgery were hour delay from injury to surgery. When acetabular fractures. J Bone Joint Surg Am. 1988; particularly at risk, and that the role of delay due to patient condition occurred 70:329-337. 11. Clarke RP Jr, Shea WD, Bierbaum BE. Tro- trochanteric osteotomy was less signifi- after arrival to our hospital, patients were chanteric osteotomy: analysis of patterns of wire cant. Siebenrock et al2 believed trochan- placed in skeletal traction using 20 lb fixation failure and complications. Clin Orthop. teric osteotomy would reduce the inci- through a femoral pin. 1979; 141:102-110. 12. Churchill MA, Brookes M, Spencer JD. dence of heterotopic ossification by pro- The procedures involving osteotomy The blood supply of the greater trochanter. J tecting the abductor muscles from dam- were longer and had higher blood loss, Bone Joint Surg Br. 1992; 74:272-274. age. In our study, no difference in het- reflecting higher severity of injury and 13. Amstutz HC, Maki S. Complications of trochanteric osteotomy in total hip replacement. erotopic ossification was found between more difficult surgery. During the time J Bone Joint Surg Am. 1978; 60:214-216. trochanteric osteotomy patients and period covered by this study, the authors 14. Sorensen S, Kromann-Andersen C, comparison cases; however, all of our changed their practice and began to per- Hougaard K, Friggard E, Zdravkovic D. Complications following osteotomy of the patients received prophylaxis. Most form trochanteric osteotomy routinely greater trochanter in total hip replacement arthro- authors recommend some type of pro- when hip dislocation was complicated plasty using the lateral approach. Acta Orthop phylaxis against heterotopic ossifica- by incarcerated posterior wall frag- Scand. 1981; 52:223-226. 15. DeLee J, Ferrari A, Charnley J. Ectopic tion in any patient with acetabular ments. It was our subjective impression bone formation following low friction arthroplas- fracture surgery through a posterior that multiple forceful attempts to ty of the hip. Clin Orthop. 1976; 121:53-59. approach.1,8,10,16 Indomethacin and remove wall pieces and reduce the hip 16. Routt ML Jr, Swiontkowski M. Operative treatment of complex acetabular fractures. single-dose radiation appear to be was damaging to the joint surface as Combined anterior and posterior exposures dur- equally efficacious.17,18 well as the entrapped fragments, and ing the same procedure. J Bone Joint Surg Am. Irreducible hip dislocation due to reduction could be accomplished gently 1990; 72:897-904. 17. Moore KD, Goss K, Anglen JO. Indo- incarcerated posterior wall fragments is and quickly with trochanteric osteoto- methacin versus radiation therapy for prophylaxis a serious injury with a high rate of post- my. No detrimental effects of osteotomy against heterotopic ossification in acetabular frac- traumatic degenerative joint disease. were identified. tures: a randomized, prospective study. J Bone Joint Surg Br. 1998; 80:259-263. No statistically significant differences 18. Burd TA, Lowry KJ, Anglen JO. Indo- were reported in outcomes at approxi- REFERENCES methacin compared with localized irradiation for mate 2-year follow-up when compared 1. Bray T, Esser M, Fulkerson L. Osteotomy the prevention of heterotopic ossification follow- of the trochanter in open reduction and internal ing surgical treatment of acetabulum fractures. 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