- See:
Total Hip Replacement Menu:
- Indications for Osteotomy:
- Surgical Technique:
- release the origin of the vastus lateralis from vastus tubercle;
- osteotomy is performed 1 cm below vastus tubercle, w/ oscillating saw aimed at the junction of the greater trochanter
w/ the femoral neck;
- Sliding Osteotomy Technique:
- Extended Trochanteric Osteotomy:
- indications:
- well fixed femoral components (fully coated press fit stems;
- for revision of femoral stems placed in significant varus;
- expose the lateral femur by diving the insertion of the lateralis off the vastus tubercle and then elevating the vastus
lateralis off the linea aspera;
-
cautions: if a previous antero-lateral approach to the hip has been made, elevating the lateralis off the linea
aspera may devascularize it which will lead to catastrophic muscle necrosis;
- mark out the lines of the osteotomy w/ cautery;
- posterior osteotomy cuts are made close to the saggital midline;
- avoid stripping the vastus lateralis and instead use a small osteotome to perforate the anterior femoral cortex through the vastus lateralis;
- osteotomy fragment can then be completed by inserting the osteotome underneath the trochanter and applying a prying motion;
-
fixation:
- oseotomy fragment is secured to main femoral fragment using cobalt-chrome wires or cables (rather than stanless);
- some revision components will allow a trochanteric plate to bolt into the femoral component, thus securing the trochanter;
- reattachment with cables;
- horizontal cable is passed under the vastus lateralis;
- vertical cable is placed in a figure-of-eight pattern in two planes;
- distal portion of the figure-of-eight provided cerclage fixation just distal to the lesser trochanter;
- anterior end of the cerclage cable was then placed through an oblique drill hole in the greater trochanter;
- drill hole enters the vastus ridge and exited the medial aspect of the proximal tip of the greater trochanter;
- if the trochanter is osteolytic, the drill hole is made more distally through the lateral femoral cortex to avoid
further weakening the osteolytic bone;
- cable is passed through the drill hole and then pierces through the abductor tendon;
- cable is then crossed under the anterior part of the cerclage portion of the figure-of-eight to lie alongside the posterior end of the cable;
- figure-of-eight cable is tightened simultaneously with the most distal cerclage cable;
- references:
- Extended proximal femoral osteotomy: A new technique for femoral revision arthroplasty. TI Younger et al.
J. Arthroplasty. Vol 10. 1995. p 329-338.
- Proximal femoral osteotomy as an adjunct in cementless revision total hip arthroplasty. AH Glassman et al.
J. Arthroplasty Vol 2. 1987. p 47-63.
-
Combined Vertical and Horizontal Cable Fixation of an Extended Trochanteric Osteotomy Site
-
Extended Trochanteric Osteotomy in Complex Primary Total Hip Arthroplasty.
- Considerations for Wire Re-attachment:
- wires can theoretically undergo gavanic corrosion if they are close to or touch the metal implant;
- this is usually of little significance even if the wires break;
- use chrome-cobalt wires (Vitallium) rather than stainless steel;
- all wires in the greater trochanter tend to break in time even if trochanter is solidly united;
- w/ soft bone (rheumatoid patients), then consider use of wire mesh, which prevents the wire from cutting throught the trochanteric fragment;
- Technique of Osteotomy Reattachment:
- greater trochanter is subjected to forces in mainly two directions;
- vertical pull of glutei, which tends to pull trochanter proximally
- anterior pull is more troublesome, and the trochanter is subject to this pull every time the hip is flexed;
-
vertical resistance:
- two drill holes are made through the peripheral edges of the lateral cortex, (one drill hole is made anteriorly and the other is made posteriorly);
- the 2 mm drill is directed toward the respective edges of the calcar;
- usually these drill holes are made 2 cm below the level of the ostetomy, but in soft bone or when a trochanteric advancement is to be performed,
then it is necessary to place the holes even more inferiorly;
- wires are threaded thru these holes and are then subsequently inserted thru the Sharpy's fibers of the gluteus medius insertion;
- once, all wires have been inserted, a Harris wire tightener is then used to secure the trochanteric fragments with square knots;
-
transverse resistance:
- drill hole is made thru the lesser trochanter, and the wire is then brought upwards thru two drill holes made in the trochanteric fragment;
- this wire will prevent transverse motion as well as preventing rotation;
- Considerations for Cemented Components:
- if possible, reattach the trochanteric fragment (esp w/ extended osteotomy) prior to insertion of the cemented component (otherwise the supero-lateral
portion of the component will not be covered by cement;
- before the osteotomy fragment is tightened, place dry gel foam strips along its edges, inorder to prevent cement from leaking out;
- as suggested by McGory et al., temporarily placed hose clamps will provide maximal tension while cement hardens and later when cerclage wires are placed;
- Trochanteric Non-Union:
Complications of trochanteric osteotomy. Long-term implications.
Trochanteric osteotomy for revision total hip arthroplasty. 97% union rate using a comprehensive approach.
Chevron osteotomy and single wire reattachment of the greater trochanter in primary and revision total hip arthroplasty.
Distal transfer of the greater trochanter.
Trochanteric osteotomy for revision total hip arthroplasty. 97% union rate using a comprehensive approach.
Primary and revision total hip replacement without cement and with associated femoral osteotomy.
Complications of trochanteric osteotomy. Long-term implications.
Trochanteric Osteotomy for Total Hip Arthroplasty: Six Variations and Indications for their use.
B.J. McGrory MD, B.S. Bal MD, and W.H. Harris MD.
J. of the Am. Academy of Orthopaedic Surgeons. Vol 4. No 5. Sept 1996. p 258.
An evaluation of a method of trochanteric fixation using three wires in the Charnley low friction arthroplasty.
KP Boardman et al.
CORR. Vol 132. p 31-38. 1978.
A system for trochanteric osteotomy and reattachment for total hip arthroplasty with a 99 % union rate.
Jensen NF and Harris WH.
CORR. Vol 208. p 174-181. 1986.
Coexistence of dissimilar metals after conversion of intertrochanteric osteotomy to total hip arthroplasty. 18 patients followed for 5-20 years after conversion.
