The outcome of trochanteric reattachment in revision total hip arthroplasty with a Cable Grip System: mean 6-year follow-up.

We have reviewed 251 hips that were revised by the senior authors with subsequent reattachment using the Dall-Miles Cable Grip System. Of these patients, 223 were available for follow-up. A trochanteric slide osteotomy was used for most cases (n = 170), and the remainder had conventional trochanteric osteotomy to facilitate surgical exposure. Follow-up period was 1 to 8 years. Forty-eight percent (n = 108) of the hips had a previous trochanteric osteotomy. Thirteen percent (n = 30) had a prior trochanteric nonunion. Of the 223 hips, 91% (n = 204) of the trochanters remained attached to the trochanteric bed when reapproximated by the cable grip system. The 2 multifilament cables were passed medially through drill holes in the lesser trochanter in 67% (n = 149) of cases. Of the hips, 16% (n = 35) had 2 cables passed through bone lateral to the prosthesis, and 17% (n = 39) had cables passed 1 medial and 1 lateral to the prosthesis. Cable breakage was noted in 10% (n = 23) of cases. Of those 23, 70% (n = 16) were stainless steel. Unraveling of the cable occurred in 18% (n = 41) of cases. There were 19 nonunions (9%). Of the 19 nonunions, 74% (n = 14) were stainless steel. The trochanter was reattached to bone in 9 hips, to cement in 4 hips, and to a proximal femoral allograft in 6 hips (P = .0001). Eight of the 19 hips (42%) had the cables placed lateral to the prosthesis (P = .0002). When bone-to-bone apposition was achieved at surgery, the nonunion rate was 4%. In this difficult group of revision procedures, the Dall-Miles Cable Grip has provided reliable trochanteric fixation. Factors associated with successful trochanteric healing include use of vitallium cables, use of a trochanteric slide osteotomy, cables passed medially through the lesser trochanter, cerclage rather than intramedullary placement, and bone-to-bone apposition.     

Extended trochanteric osteotomy via the direct lateral approach in revision hip arthroplasty

A review of the results of the extended trochanteric osteotomy through a modified direct lateral approach in revision total hip arthroplasty was done. We reviewed 44 patients (45 procedures) at a minimum of 2 years followup (mean, 3.8 years; range, 2.1-7.2 years). There were 26 men and 18 women with a mean age at the time of surgery of 70.8 years (range, 36.9-90.4 years). Indications for use of the trochanteric osteotomy included facilitation of cement removal (25 procedures), proximal femoral varus deformity (14 procedures), trochanteric malposition (five procedures), and previous trochanteric osteotomies with significant bony overgrowth (three procedures). The mean length of the osteotomy was 133.9 mm. The mean migration of the osteotomized fragment was 2.1 mm (range, 0-20 mm) with significantly more proximal migration seen with the use of cerclage wires when compared with cables. There were two cases of trochanteric escape, for which the patients required repeat open reduction internal fixation. There were two late fractures of the greater trochanter. One femoral component had early subsidence for which the patient required re-revision with a further extended trochanteric osteotomy. The mean time to union of the remaining 40 hips was 10.3 months (range, 6-24 months). There only was one dislocation postoperatively. The extended trochanteric osteotomy through the modified direct lateral approach in revision total hip arthroplasty is a reproducible and reliable technique with a lower dislocation rate but a higher incidence of trochanteric fracture and escape than previously described with its use in the posterior approach.     

Revision total hip replacement without trochanteric osteotomy

Revision total hip replacement has traditionally required a trochanteric osteotomy for successful cement removal and component reinsertion. In this study the authors have concluded that in most instances the revision total hip replacement procedure can be successfully performed without trochanteric osteotomy. The advantages are underscored by the high percentage of trochanteric complications with trochanteric osteotomy for revision total hip replacement and the ease of rehabilitation without trochanteric osteotomy. Also, improved functional results without trochanteric osteotomy were noted. The specific indications for the procedure included revision total hip replacement with ununited prior trochanteric osteotomy, revision total hip replacement with femoral shaft fractures, and revision total hip replacement with stem fractures requiring only acetabular revision. The contraindications to the procedure are fibrous union or ununited trochanteric osteotomy from prior total hip replacement, severe acetabular protrusion of the acetabular component, advanced myositis ossificans, ankylosis of the hip, and advanced proximal femoral osteoporosis. The operating room records, x-rays, and outpatient records of 63 total hip revisions in 52 patients were reviewed. There was a minimum 2-year follow up with a range from two years to seven years. The patients were divided into two groups, comparing 21 trochanteric osteotomized revisions to 44 with trochanteric sparing techniques. Both groups were analyzed for age, type of implant, intraoperative perforation of femur, intraoperative femoral shaft fractures, intraoperative cortical window, component malpositioning extraneous cement, intraoperative blood loss, operating time, postoperative leg length inequality, persistent abductor weakness, average first day of ambulation, wound infection, dislocation, nonunion of the trochanter, and postoperative pain. In the nonosteotomized group, there was a 21% decreased blood loss, a 14% decrease in persistent abductor weakness, a 14% decrease in subluxation and dislocation, a 30% decrease operating time and a 50% reduction in intraoperative femoral perforation. In the osteotomized group there were six cases of fibrous union of the greater trochanter, two cases requiring removal of broken wires for trochanteric bursitis. A detailed surgical technique and representative cases are presented. In carefully selected cases, revision total hip replacement is optimally performed without trochanteric osteotomy. Postoperative trochanteric problems of nonunion, broken wires, bursitis, and abductor weakness can effectively be eliminated by avoiding trochanteric osteotomy.(ABSTRACT TRUNCATED AT 400 WORDS)     

Trochanteric union following revision total hip arthroplasty

Ninety-nine patients (106 hips) with a trochanteric osteotomy during revision total hip arthroplasty were evaluated at a minimum of 5 years after surgery. Trochanteric reattachment was done with monofilament cobalt-chromium wires. The influence of the following variables on trochanteric union was examined: a prior trochanteric osteotomy, an existing trochanteric nonunion, trochanteric advancement to the lateral femur, use of vertical (in addition to horizontal) wires through the trochanter, and use of a trochanteric mesh. Overall, union occurred in 92 of the 106 trochanters (87%). Fifty-three of 61 trochanters (86.9%) healed after an initial osteotomy, whereas 34 of 38 (89.5%) healed after a repeat osteotomy. Five of the 7 trochanters with an existing nonunion healed, and 5 of 5 trochanters reattached to a bulk allograft healed. Twenty-nine of 36 trochanters (80.5%) reattached to cancellous bone healed, compared with 58 of 65 (89.2%) that were reattached to the lateral femoral cortex. Ninety percent (83/92) of the trochanters reattached in conjunction with use of a chrome-cobalt mesh healed, compared with 64.3% (9/14) of those without (P < .05). Of the variables studied, only the use of mesh was statistically significant. Osteotomy through a previously healed trochanter, advancement of the trochanter to cortical bone, existing trochanteric nonunion, trochanteric reattachment to a bulk allograft, and lack of vertical wires for fixation did not adversely affect the likelihood of obtaining trochanteric union.     

股骨大转子延长截骨在假体稳定股骨柄翻修中的应用

目的 评估大转子延长截骨在股骨假体固定稳定型全髋关节翻修术中应用的中期临床效果.方法 1998年1月至2005年6月对27例患者(27髋)采用大转子延长截骨对股骨柄和(或)骨水泥壳固定稳定的全髋关节翻修.临床随访评估包括Harris评分和WOMAC评分,术前Harris评分平均42.7分,WOMAC评分平均55.6分;影像学评估包括术后拍摄X线片,对比观察截骨块愈合时间、是否存在截骨延迟愈合或不愈合,截骨块是否发生移位以及假体是否下沉等.结果 共19例患者(19髋)获得随访,平均随访时间5.3年.无一例发生术中或术后骨折.术后Harris评分平均87.3分,WOMAC评分平均46.3分.所有患者大转子截骨块均于术后6个月内愈合.无股骨大转子截骨块向近端移位,3例发生股骨柄下沉,平均下沉3.4 mm,无钢丝断裂.结论 对于假体固定稳定型股骨柄翻修,采用股骨大转子延长截骨有利于手术操作和翻修假体的植入和固定,有利于截骨块的愈合,降低术中、术后并发症发生率,中期疗效显著.     

大转子延长截骨在股骨柄翻修术中的应用

目的 报道大转子延长截骨在股骨柄翻修术中的应用及其疗效。方法 从 1998年 1月～ 2000年 1月,采用大转子延长截骨术取出股骨柄、骨水泥,行翻修术 11例。男 7例,女 4例。年龄 53～ 69岁,平均 65.4岁。翻修原因 :股骨柄断裂 2例,人工股骨头置换术后髋臼骨关节炎 8例,假体位置异常 1例。结果 11例患者术后第 2 d均在助行器辅助下下床行走,术后 3个月大转子延长截骨处临床愈合后,改扶单拐行走, 6个月后弃拐行走。术后随访 6～ 30个月,大转子延长截骨处骨性愈合, Harris评分平均为 89.6分。结论 大转子延长截骨术多用于翻修术中取出固定牢固的骨水泥或非骨水泥假体柄。其适应证包括 :(1)股骨柄近端断裂,远端仍牢固固定者; (2)人工股骨头置换术后发生髋臼骨关节炎伴髋关节强直,股骨柄固定牢固,需行全髋翻修者; (3)股骨柄安放位置错误,但骨水泥固定良好者; (4)不伴有假体松动的早期严重感染需行翻修者。该方法显露充分,术后恢复快,是一种较好的股骨柄固定牢固的翻修方法。主要并发症有截骨处不愈合、移位及截骨片骨折。     

Trochanteric osteotomy and fixation during total hip arthroplasty

Once used routinely, trochanteric osteotomy in total hip arthroplasty now is usually limited to difficult primary and revision cases. There are three types: the standard trochanteric osteotomy and its variations, the trochanteric slide, and the extended trochanteric osteotomy. Each has unique indications, fixation techniques, and complications. Primary total hip arthroplasty procedures requiring the enhanced exposure provided by trochanteric osteotomy may be needed in patients with hip ankylosis or fusion, protrusio acetabuli, proximal femoral deformities, developmental dysplasia, or abductor muscle laxity. Trochanteric osteotomies in revision arthroplasties, primarily the extended trochanteric osteotomy, facilitate the removal of well-fixed femoral components, provide direct access to the diaphysis for distal fixation, and enhance acetabular exposure.     

Implant stability in revision total hip arthroplasty: Allograft bone packing following extended proximal femoral osteotomy

One method of revising the femoral component in revision total hip arthroplasty in the presence of compromised femoral bone stock is to pack the upper femur with particulate allograft and then to cement the femoral component into the allograft bed. This technique is being used clinically with encouraging results. Additionally, surgical exposure of the femoral canal during revision total hip arthroplasty can be greatly improved with an extended trochanteric osteotomy, which is subsequently repaired with wires or cables. To assess the feasibility of performing the allograft bone packing technique following an extended trochanteric osteotomy, the stability of this construct in a cadaver model was measured, using micromotion sensing instruments and loads applied on a materials testing machine. The stability of the cemented allograft impaction construct following extended trochanteric osteotomy was comparable to the stability of the control construct, which consisted of a similar impacted allograft construct without osteotomy. The stability of the osteotomized side was comparable to that of the control side. It is concluded that the initial in vitro stability of the allograft impaction technique following extended proximal femoral osteotomy is adequate to justify experimental in vivo use.     

Trochanteric non-union—Does it influence the rate of revision following primary total hip replacement? A minimum of 15 years follow-up

OBJECTIVE: Trochanteric non-union may alter the biomechanics and the forces going through the hip joint leading to increased polyethylene wear and hence a higher revision rate. The aim of our study was to determine if trochanteric non-union was associated with a higher incidence of acetabular and/ or femoral revision for mechanical failure, i.e. aseptic loosening. MATERIALS AND METHODS: Three hundred and twenty-six total hip replacements performed in 318 patients between 1979 and 1989 were reviewed. The status of the trochanter was determined using the senior author's (JPH) classification of trochanteric union/non-union. The mean follow-up was 16.7 years (15-25 years). RESULTS: 20.5% (61/297) of hips with united trochanter and 20.6% (6/29) with un-united trochanter had been revised at the latest follow-up. The difference was not significant (p-value > 0.1, odds ratio 1.01). CONCLUSION: We could not find any influence of trochanteric non-union on acetabular or femoral revision rate over a mean follow-up period of 17 years (range 15-25 years).     

Use of Cortical Strut Allograft After Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty

Background

Cortical strut allografts restore bone stock and improve postoperative clinical scores after revision total hip arthroplasty (THA). However, use of a cortical strut allograft is implicated in delayed healing of an extended trochanteric osteotomy (ETO). To date, there are no reports directly comparing ETO with or without cortical strut allografts.

Combined vertical and horizontal cable fixation of an extended trochanteric osteotomy site

BACKGROUND: The use of an extended trochanteric osteotomy facilitates exposure and aids in the removal of a well-fixed femoral implant and cement during revision total hip arthroplasty. Occasionally, nonunion, fracture, and trochanteric migration have been reported following osteotomy. We evaluated the rate of healing of the osteotomy site and of implant stability when fixation was accomplished with use of vertical trochanteric and horizontal metaphyseal cable fixation (combined cable fixation). METHODS: The clinical and radiographic results of revision total hip arthroplasty with use of an extended trochanteric osteotomy followed by implantation of a distally porous-coated component and combined cable fixation of the osteotomy site in forty-two consecutive patients (forty-three hips) were reviewed. Intraoperative fracture at the osteotomy site occurred in five hips (12%). RESULTS: All osteotomy sites healed by six months, with an average time to union of fifteen weeks. One implant subsided 5 mm in a patient in whom a fracture had occurred at the time of the osteotomy. No trochanteric migration occurred. Two patients required a reoperation: one because of instability, and another because of recurrent infection. CONCLUSIONS: The extended trochanteric osteotomy facilitates revision of a well-fixed femoral component. Despite occasional intraoperative fracture at the osteotomy site, combined vertical trochanteric and horizontal metaphyseal cable fixation resulted in an excellent rate of healing and implant stability.     

大转子延长截骨在全髋关节翻修术中应用的临床评价

目的 回顾性研究采用大转子延长截骨(extended troehanteric osteotomy,ETO)行全髋关节翻修术后股骨柄的位置变化,评价ETO在股骨假体稳定件髋关节翻修术中的作用.方法 1998年1月至2007年6月,采用ETO对股骨柄或骨水泥壳固定稳定性全髋关节33例33髋进行翻修.翻修术后采用Harris评分和MOMAC评分评估髋关节功能,摄动态X线片观察截骨块愈合、假体位置改变及股骨柄与股骨髓腔匹配等情况.结果 25例随访12～103个月,平均63个月.Harris评分由术前平均38.4分,提高到末次随访时88.7分;WOMAC评分由术前平均56.2分,降至末次随访时42.8分.大转子截骨块均在术后4～10个月骨性愈合.3例发生股骨柄下沉.平均3.4mm.股骨柄假体出现外翻、内翻各1例.无术中或术后骨折、钢丝断裂、感染、假体周围骨溶解以及异位骨化发生.术后关节脱位1例.结论 对假体固定稳定性股骨柄进行翻修,采用ETO有利于假体的安全取出,术后截骨块愈合率高,延长截骨不影响假体稳定性.股骨柄下沉、位置改变、截骨块骨折等并发症发生率低.     

Proximal femoral allograft treatment of Vancouver type-B3 periprosthetic femoral fractures after total hip arthroplasty

BACKGROUND: Periprosthetic femoral fractures following total hip arthroplasty are becoming more prevalent. When a fracture occurs in a femur with substantial proximal bone deficiency, the surgical options for revision are limited. One option includes the use of a proximal femoral allograft. METHODS: We retrospectively assessed the results and complications of the use of a proximal femoral allograft to treat twenty-five Vancouver type-B3 periprosthetic fractures in twenty-four patients. The mean duration of follow-up was 5.1 years. Clinical results were graded with use of the Harris hip score. Radiographs were assessed for evidence of trochanteric union, host-allograft union, allograft resorption, and component loosening or fracture. Failure of the procedure was defined as the need for revision surgery requiring graft removal. RESULTS: The mean postoperative Harris hip score was 70.8. At the time of the final follow-up, twenty-one of the twenty-four patients reported no or mild pain and twenty-three patients were able to walk; fifteen required a walking aid. The greater trochanter united in seventeen of the twenty-five hips, and osseous union of the allograft to the host femur occurred in twenty hips. There was mild graft resorption in four hips and moderate graft resorption in two. Four (16%) of the twenty-five hips required repeat revision. CONCLUSIONS: The use of a proximal femoral allograft for the treatment of a Vancouver type-B3 periprosthetic femoral fracture can provide a satisfactory result in terms of pain relief and function at five years.     

Trochanteric Slide Osteotomy on Previously Osteotomized Greater Trochanters

The sliding trochanteric osteotomy is a useful and safe technique facilitating exposure of the hip in a complex arthroplasty. The modified sliding trochanteric osteotomy preserves the posterior capsule and short external rotators, allows anterior dislocation of the hip, and is associated with a lower dislocation rate. With the increased incidence of failed THAs and need for revision, there is an increased need for better exposure of challenging hips. Therefore, trochanteric osteotomies in hips that previously had osteotomies are not uncommon and likely will become frequent in the future. We evaluated use of the modified trochanteric slide osteotomy on greater trochanters that previously had osteotomies and were healed. We reviewed 38 patients with repeated osteotomies and 38 matched control patients with osteotomies on greater trochanters that did not have previous osteotomies. The minimum followup was 13 months (mean, 37 months; range, 13–73 months). Thirty-three osteotomies (87%) healed with bony union, four (11%) had fibrous union, and one (3%) had nonunion. Two (5%) patients had a new onset abductor lurch develop. Two (5%) patients had persistent trochanteric pain and two (5%) had dislocations. The bony union, fibrous union, and nonunion rates, and the abductor lurch, persistent trochanteric pain, and dislocation rates, were similar to those of the control patients. Repeated osteotomy on a previously healed greater trochanter osteotomy is a reliable procedure with similar clinical outcome and complication rates as a primary osteotomy.     

Cortical strut allografts for the treatment of femoral fractures and deficiencies in revision total hip arthroplasty

Thirty-three hips had revision total hip arthroplasty, using an average of three cortical strut allografts fixed to the femur with cables and followed-up for a mean of 4 years. The indications for strut allografts were ectatic femurs or segmental defects of the femoral diaphysis (22 hips), femoral fractures (10 hips), and severe proximal femoral osteolysis (1 hip). Twenty-one hips had an excellent or good clinical result, 6 had a fair clinical result, and 6 had a poor clinical result. Reoperation was done in six hips, but in only two hips was reoperation related to failure of the allograft. Nine of the 10 femoral fractures repaired with allograft struts healed by 3 to 6 months. Radiographs showed partial or complete bridging of the allograft to host bone with peripheral remodeling and minimal resorption in 30 of 33 hips. Strut allografts, fixed with multiple cables, are an important adjunct to femoral component revision for the restoration of deficient femoral bone stock and in the treatment of periprosthetic femur fractures.     

全髋关节翻修术中大转子粉碎性骨折或截骨不愈合的治疗

目的 探讨在全髋关节翻修术中采用张力带方法治疗大转子粉碎性骨折或截骨不愈便的临床效果。方法 1992年1月～1998年10月，对295例行全髋关节翻修术中大转子粉碎性骨折或截骨不愈合的19例(20髋)患者进行治疗，男7例．女12例；年龄63～76岁，平均69岁。20髋中，16髋为假体松动伴骨溶解在翻修术中发生股骨大转子骨折，4髋为全髋关节置换时采用股骨转子截骨入路。因转子截骨不愈合致髋外展肌力不足而行翻修术。采用多枚克氏针加张力带钢丝固定的方法进行治疗。结果 术后随访12～118个月,平均30个月。Harris髋关节评分从术前的平均45分恢复至随访时的平均89分。19髋达一期愈合，1髋固定失败后再次行大转于张力带固定后愈合。19髋平均愈合时间为166周。所有病例术后均无髋关节脱位。结论 在全髋关节翻修术中使用多枚克氏针加张力带钢丝固定的方法治疗股骨大转子骨折或截骨不愈合，可以提高愈合率，维持正常的髋关节外展肌功能。该方法也适用于大转子粉碎性骨折或骨质疏松的患者。     

Fractures of distally-fixed femoral stems after revision arthroplasty

We identified five (2.3%) fractures of the stem in a series of 219 revision procedures using a cementless, cylindrical, extensively porous-coated, distally-fixed femoral stem. Factors relating to the patients, the implant and the operations were compared with those with intact stems. Finite-element analysis was performed on two of the fractured implants. Factors associated with fracture of the stem were poor proximal bone support (type III-type IV; p = 0.001), a body mass index > 30; (p = 0.014), a smaller diameter of stem (< 13.5 mm; p = 0.007) and the use of an extended trochanteric osteotomy (ETO 4/5: p = 0.028). Finite-element analysis showed that the highest stresses on the stem occurred adjacent to the site of the fracture. The use of a strut graft wired over an extended trochanteric osteotomy in patients lacking proximal femoral cortical support decreased the stresses on the stem by 48%.We recommend the use of a strut allograft in conjunction with an extended trochanteric osteotomy in patients with poor proximal femoral bone stock.     

Anterior trochanteric slide osteotomy for primary total hip arthroplasty. Review of nonunion and complications

The radiographic results of 73 anterior trochanteric slide osteotomies were retrospectively reviewed at an average of 36 months after primary hip arthroplasty to determine the incidence of nonunion of the trochanter and complications related to trochanteric hardware. In each case, the trochanter was retracted anteriorly, with the gluteus medius and vastus lateralis muscle insertions left intact. Reattachment was performed with 2 monofilament wires or cables passed through the lesser trochanter in each case. Ninety-two percent of the trochanters healed; nonunion was associated with anterior displacement of the trochanteric fragment with external rotation of the femur. The incidence of repeat surgery for hardware-related problems was 28%. Although the slide osteotomy prevented proximal migration of the trochanteric fragment, the incidence of hardware complications was too high to justify the routine use of this approach in primary hip arthroplasty.     

Trochanteric slide osteotomy in revision total hip arthroplasty for loosening

We used a trochanteric slide osteotomy (TSO) in 94 consecutive revision total hip arthroplasties (90 with replacement of both the cup and stem). This technique proved to be adequate for removing the components, with few complications (two minor fractures), and for implanting acetabular allografts (18%) and reinforcement devices (23%). Trochanteric union was obtained in most patients (96%), even in those with septic loosening (18/19), major femoral osteolysis (32/32), or previous trochanteric osteotomy (17/18). TSO is versatile, since it can be extended by a femoral flap (four cases) or a distal femoral window (eight cases). Despite significant bone loss, in 24% of the femora and 57% of the acetabula, favourable midterm results were achieved and only six reoperations were required, Including two for trochanteric nonunion and two for loosening. It leaves the lateral femoral cortex intact so that a stem longer than 200 mm was needed in only 25% of patients. This is a considerable advantage compared with the extended trochanteric osteotomy in which the long lateral flap (12 to 14 cm) requires an average length of stem of 220 mm beyond the calcar. TSO provides an approach similar in size to the standard trochanteric osteotomy but with a rate of nonunion of 4% versus 15%. It reduces the risk of difficulties with removal of the stem, and removes the need for routine distal anchoring of long revision stems. The limited distal femoral compromise is very important in patients with a long life expectancy.     

Reattachment of the greater trochanter using the Dall-Miles cable grip system in revision hip arthroplasty

Clinical and radiographic results of trochanteric osteotomy after revision hip arthroplasty in 62 hips were reviewed. The osteotomized fragment had been reattached using the Dall-Miles cable grip system in each hip. The patients' average age at operation was 64.4 years (range, 40–86 years). The average duration of follow-up was 30.0 months (range, 12–60 months). Trochanteric nonunion was found in 19 hips (30.6%). Trochanteric nonunion developed in 14 (38.9%) of 36 hips with each cable attached around the medial cortex bone, in 2 (16.7%) of 12 hips with each cable passed in a drill hole, and in 3 (21.4%) of 14 hips with one cable passed through a hole and the other attached around the medial cortex. Fragmentation developed in 18 hips (29.0%). In 3 of these 18, the fragments had migrated close to the acetabular component. Cable breakage was seen in 4 hips (6.5%), and bone absorption around the cable in the medial cortex was seen in 17 hips (27.4%). There were 16 hips (25.8%) that presented symptoms at the greater trochanter, including spontaneous pain and tenderness. When the Dall Miles cable grip device is used for reattachment of the greater trochanter, attention should be paid to the condition of the trochanteric bed, the tension of the abductor muscles, and to the placement of the cables and the H-shaped grip. Received: February 28, 2000 / Accepted: September 24, 2000