Clin Orthop Relat Res (2019) 477:1176-1187 DOI 10.1097/CORR.0000000000000659 2018 Bernese Hip Symposium What Is the Impact of a Previous Femoral Osteotomy on THA? A Systematic Review Enrico Gallazzi MD, Ilaria Morelli MD, Giuseppe Peretti MD, Luigi Zagra MD 02/11/2020 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD30p/TQ0kcqx8yGZO9yTf1dd5lN9ZPVa7AUCC2fdK0Vq4= by https://journals.lww.com/clinorthop from Downloaded Downloaded from Received: 10 August 2018 / Accepted: 8 January 2019 / Published online: 17 April 2019 https://journals.lww.com/clinorthop Copyright © 2019 by the Association of Bone and Joint Surgeons Abstract by Background Femoral osteotomies have been widely used Questions/purposes In this systematic review, we asked: BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD30p/TQ0kcqx8yGZO9yTf1dd5lN9ZPVa7AUCC2fdK0Vq4= to treat a wide range of developmental and degenerative hip (1) What are the most common complications after THA in diseases. For this purpose, different types of proximal fe- patients who have undergone femoral osteotomy, and how mur osteotomies were developed: at the neck as well as at frequently do those complications occur? (2) What is the the trochanteric, intertrochanteric, or subtrochanteric lev- survival of THA after previous femoral osteotomy? (3) Is els. Few studies have evaluated the impact of a previous the timing of hardware removal associated with THA femoral osteotomy on a THA; thus, whether and how a complications and survivorship? previous femoral osteotomy affects the outcome of THA Methods A systematic review was carried out on PubMed, remains controversial. the Cochrane Systematic Reviews Database, Scopus, and Embase databases with the following keywords: “THA”, “total hip arthroplasty”,and“total hip replacement” com- bined with at least one of “femoral osteotomy” or “inter- Each author certifies that neither he or she, nor any member of his trochanteric osteotomy” to achieve the maximum sensitivity or her immediate family, has funding or commercial associations fi (consultancies, stock ownership, equity interest, patent/licensing of the search strategy. Identi ed studies were included if arrangements, etc) that might pose a conflict of interest in con- they met the following criteria: (1) reported data on THAs nection with the submitted article. performed after femoral osteotomy; (2) recorded THA fol- Clinical Orthopaedics and Related Research® neither advocates nor lowup; (3) patients who underwent THA after femoral endorses the use of any treatment, drug, or device. Readers are osteotomy constituted either the experimental group or a encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use. control group; (4) described the surgical and clinical com- Each author certifies that his or her institution approved the plications and survivorship of the THA. The database search reporting of this investigation and that all investigations were retrieved 383 studies, on which we performed a primary conducted in conformity with ethical principles of research. on evaluation. After removing duplicates and completing a full- 02/11/2020 This work was performed at the IRCCS Istituto Ortopedico Galeazzi, Milano, Italy. text evaluation for the inclusion criteria, 15 studies (seven historically controlled, eight case series) were included in E. Gallazzi, L. Zagra, IRCCS Istituto Ortopedico Galeazzi, Hip the final review. Specific information was retrieved from Department, vi R. Galeazzi, Milan, Italy each study included in the final analysis. The quality of each study was evaluated with the Methodological Index for I. Morelli, G. Peretti, Department of Biomedical Sciences for Health, Non-randomized Studies (MINORS) questionnaire. The University of Milan, Milan, Italy IRCCS Istituto Ortopedico Galeazzi, via R. Galeazzi Milan, Italy mean MINORS score for the historically controlled studies was14of24(range,10–17), whereas for the case series, it L. Zagra (✉), IRCCS Istituto Ortopedico Galeazzi, Via R. Galeazzi 4, was 8.1 of 16 (range, 5–10). 20161 Milan, Italy, Email: [email protected] Results The proportion of patients who experienced All ICMJE Conflict of Interest Forms for authors and Clinical Or- intraoperative complications during THA ranged from 0% thopaedics and Related Research® editors and board members are to 17%. The most common intraoperative complication on file with the publication and can be viewed on request. was femoral fracture; other intraoperative complications Copyright © 2019 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited. Volume 477, Number 5 THA After Femoral Osteotomy 1177 were difficulties in hardware removal and nerve palsy; 15 femoral osteotomies [2, 7, 9, 10, 20], many patients ex- studies reported on complications. The survivorship of perience OA progression after the osteotomy. This may THA after femoral osteotomy in the 13 studies that an- result in a large number of patients who received these swered this question ranged from 43.7% to 100% in studies osteotomies presenting for THA in the years to come, that had a range of followup from 2 to 20 years. The timing particularly in referral centers where more complex THAs of hardware removal was described in five studies, three of are performed. Few studies have evaluated the impact of a which detailed more complications with hardware removal previous femoral osteotomy on a THA [1, 3, 4, 5, 8, 11, at the time of THA. 18, 19, 21-23, 25, 27–29], and most of these studies are Conclusions This systematic review demonstrated that retrospective case series or historically controlled studies. THA after femoral osteotomy is technically more de- In this context, clinical decision-making is often based on manding and may carry a higher risk of complications than anecdotal information rather than scientific evidence. one might expect after straightforward THA. Staged Therefore, a systematic review that synthesizes the hardware removal may reduce the higher risk of intra- available information could be helpful to surgeons who operative fracture and infection, but there is no clear evi- treat these patients and to provide references for dence in support of this contention. Although survivorship evidence-based decision-making. of THA after femoral osteotomy was generally high, the Specifically, in this systematic review, we asked: (1) studies that evaluated it were generally retrospective case What are the most common complications after THA in series, with substantial biases, including selection bias and patients who have undergone femoral osteotomy, and how transfer bias (loss to followup), and so it is possible that frequently do those complications occur? (2) What is the survivorship of THA in the setting of prior femoral survival of THA after previous femoral osteotomy? (3) Is osteotomy may be lower than reported. the timing of hardware removal associated with THA Level of Evidence Level III, therapeutic study. complications and survivorship? Introduction Materials and Methods Both femoral and acetabular osteotomies have been ex- Search Strategy and Criteria tensively used for the treatment of a wide range of de- velopmental and degenerative hip diseases, such as We carried out a systematic review according to the Preferred developmental dysplasia of the hip, slipped capital femoral Reported Items for Systematic Reviews and Meta-Analyses epiphysis, Legg-Calve-Perthes´ disease and even primary Statement for Individual Patient Data (PRISMA-IPD) [16]. and secondary osteoarthritis (OA) [15, 17, 30]. In general, In May 2018, two of the authors (EG, IM) searched PubMed, femoral osteotomies seek to restore, or at least improve, hip the Cochrane Systematic Reviews Database as well as biomechanics and to increase femoral head coverage and the Scopus and Embase databases using the following congruency [6]. To achieve the different purposes required, keywords: “THA”, “total hip arthroplasty”,and“total hip numerous types of osteotomies of the proximal femur have replacement” combined with at least one of the following: been developed, including osteotomies at the level of the “femoral osteotomy” or “intertrochanteric osteotomy” femoral neck as well as at the trochanteric, intertrochan- to achieve maximum sensitivity of the search strategy. teric, or subtrochanteric levels. Unpublished data and conference proceedings were ex- Despite the fact that femoral osteotomies are not per- cluded from this systematic review. The reference lists of formed as frequently as they once were, THA in the set- all retrieved articles were reviewed for further identifica- ting of a previous femoral osteotomy remains a clinical tion of potentially relevant studies. We hand-screened challenge, and so the topic is worthy of study for several reference lists of identified studies to find other studies. reasons. First, the fact that the number of femoral Each identified study was assessed using the inclusion and osteotomies has decreased, we believe this may soon exclusion criteria to determine the final list of studies that change (especially in adults) in light of newer hip- we analyzed in detail. preserving techniques that have become available as knowledge of the vascularization and pathophysiology of the proximal femur has improved; this may expand what Inclusion and Exclusion Criteria had been the indications for femoral osteotomies [12, 13, 24]. Second, although femoral osteotomies are less For this review, we defined femoral