Trochanteric osteotomy in revision total hip arthroplasty

Abstract

Trochanteric osteotomy is a technique that allows expanded exposure and access to the femoral canal and acetabulum for a number of indications. There has been renewed interest in variants of this technique, including the trochanteric slide osteotomy (TSO), extended trochanter osteotomy (ETO), and the transfemoral approach, for both septic and aseptic revision total hip arthroplasty (THA). Osteotomy fixation is crucial for achieving union, and wire and cable-plate systems are the most common techniques. TSO involves the creation of a greater trochanter fragment with preserved abductor attachment proximally and vastus lateralis attachment distally. This technique may be particularly useful in the setting of abductor deficiency or when augmented acetabular exposure is needed. ETO is a posterior-laterally based extensile approach that has been successfully utilized for aseptic and septic indications; most series report a greater than 90% rate of union. The transfemoral approach, as known as the Wagner osteotomy, is an extensile femoral approach and is more anterior-based than the alternate posterior-based ETO. It may be particularly useful for anterior-based approaches and anterior femoral remodelling; rates of union after this approach in most reports have been close to 100%. Cite this article: EFORT Open Rev 2020;5:477-485. DOI: 10.1302/2058-5241.5.190063

Outcomes of Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty for Periprosthetic Joint Infection: A Systematic Review

“…In the setting of chronic periprosthetic joint infection, removal of a well-fixed femoral component is necessitated and can be technically challenging due to modern fixation techniques and component designs. ETO is a powerful technique that can facilitate removal of fully porous stems, well fixed proximally coated stems, long cement mantles, or varus/valgus remodeling [5,8,11]. Importantly, ETO minimizes the risk of intraoperative fracture and promotes predictable healing of the abductor on the osteotomized fragment [8,15,26,31].…”

“…Though useful in a multitude of revision indications, one of the more common situations for ETO is component removal for chronic periprosthetic joint infection (PJI) [3,5,10,11]. Approximately 1% of primary THAs are complicated by PJI [12].…”

The Relationship Between Arthroplasty Surgeons’ Experience Level and Optimal Cable Tensioning in the Fixation of Extended Trochanteric Osteotomy

“…There are many previous studies that have examined ETO in patients who underwent complex total hip arthroplasty or total hip arthroplasty revision following periprosthetic fractures, infection, or aseptic loosening, and that have compared the results of the use of cables, and cable grip and cable plate systems used for fixation after ETO. 1 - 3 , 13 , 14 In a retrospective study by Prudhon et al, 15 ETO was performed on 157 patients due to revision total hip surgery. In the fixation of the osteotomized trochanteric fragment, wires and cables were used with tension applied manually.…”

“…Although the number of biomechanical and clinical studies about the tension applied to the cables in the literature are limited, there are some studies reporting about the disruption of the circulation to the bone due to excessive stripping of the vastus lateralis muscle or applying excessive tension to the cables as one of the most important causes of nonunion after ETO. 3 , 7 , 16 Karakoyun et al 8 investigated the effect of excessive tension applied to the cable on bone circulation. In an experimental model, a cable of 2-mm thickness was placed in the mid-femoral diaphysis of 10 New Zealand rabbits and a tension of 400 N was applied.…”

“… 2 Although a gold standard method still has not been reported for the fixation method after ETO, several techniques including the use of cerclage wires, cables, and combination of plate and cables have been described. 3 , 4 Of them, while plate and cable combinations have been recounted to allow less migration and offer better stability than the horizontal cerclage wire and cable methods; studies reporting bursitis, pain, and abductor failure due to the combined use of plates and cables also exist. 1 , 2 , 4 - 6 On the other hand, some studies reported that successful clinical and radiological results have been obtained with isolated cable fixations which require less soft tissue dissection and aim at minimizing the blood supply in the osteotomized fragment.…”