Trochanteric osteotomy and fixation during total hip arthroplasty

Systematic Exposure in Revision Total Hip Arthroplasty: The Posterior Approach

As indications for total hip arthroplasty (THA) continue to expand, and patients continue to live longer with more active lifestyles, the incidence of revision THA is expected to rise. General orthopaedic surgeons are now beginning to consider doing revision THA surgery because of the increased revision burden being experienced nationwide. While classical approaches to the hip can be used for simple revisions, extensile exposure techniques in conjunction with selective soft-tissue releases are often required for adequate visualization for more complex revision cases. This review provides a systematic approach to surgical exposure for revision THA using the posterior approach. The surgeon should follow a stepwise progression to obtain safe, adequate, and reproducible visualization of both the acetabulum and the proximal femur.

Trochanteric Bolt Failure in a Modular Femoral Revision System

With the incidence of primary total hip arthroplasty continuing to rise in the United States, the innovation behind improving current total hip arthroplasty systems inevitably grows with it-each new design potentially ushering in new flaws. We report a case of screw failure with the Arcos Modular Femoral Revision System-Trochanteric Bolt and Claw Technique in a 74-year-old male patient. The patient presented to the investigator's clinic for their 20-month follow-up evaluation of their complex right hip revision. Radiographs revealed failure of the screw attaching the claw plate to the stem resulting in dislodgement and relocation of the screw within the intra-articular cavity. The patient elected for nonsurgical management and will continue to be monitored. Consent by the patient involved in this case report was obtained.

Greater trochanteric osteotomy and subtrochanteric osteotomy in primary/revision total hip arthroplasty

Osteotomy of the femur is necessary in some cases of primary/revision total hip arthroplasty (THA) procedure. There are two mainly used femur osteotomy methods in THA: greater trochanteric osteotomy and subtrochanteric osteotomy. Greater trochanteric osteotomy can improve hip exposure, provide greater stability against dislocation and favorably influence the abductor moment arm. Whether in the primary or revision THA, greater trochanteric osteotomy has its unique position. Subtrochanteric osteotomy adjusts the degree of femoral de-rotation and corrects the leg length. It is widely used in hip preservation and arthroplasty surgery. All osteotomy methods have specific indications, while nonunion is the commonest complication. In this paper, we analyze the greater trochanteric osteotomy and the subtrochanteric osteotomy in primary/revision THA and summarize the characteristics of different osteotomy methods.

Comparison of Functional and Radiographic Outcomes Between Two Fixation Methods for Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty: A Retrospective Cohort Study

BACKGROUND

To compare the functional and radiographic outcomes between two fixation methods for extended trochanteric osteotomy (ETO) in revision total hip arthroplasty (rTHA).

METHODS

Included in this study were 64 patients who underwent ETO in rTHA using either claw-plate fixation (claw-plate group, n = 31) or cable-alone fixation (cable group, n = 33) in our hospital from 2008 to 2020. The functional and radiographic results and complications were compared between the groups during a mean follow-up period of 64 and 78 months.

RESULTS

The Harris hip score and visual analogue scale at the last follow-up improved significantly in both groups, showing no significant statistical difference between the two fixation methods. In the cable group, the mean abductor lever arm, the proximal migration, and medial migration in the affected hip were significantly decreased compared to those in the contralateral normal hip (P < .05), whereas in the claw-plate group no significant statistical differences were observed between two sides. No or slight limping occurred in 25 patients (81%) in the claw-plate group and 16 patients (48%) in the cable group (P = .007). A multiple logistic regression demonstrated that claw-plate fixation could reduce the incidence of postoperative moderate-to-severe limping.

CONCLUSION

Both claw-plate fixation and cable-alone fixation could improve the functional performance of rTHA with ETO, whereas claw-plate fixation could offer superior biomechanical results and gait improvement as compared with cable-alone fixation.

Greater trochanter morphology and association with patient demographics, surgical factors, and post-operative stem position: a retrospective assessment of 150 cementless THRs in 135 dogs

Background

Total hip replacement (THR) in the gold standard surgical treatment for the canine hip. While it has been shown that greater trochanter morphology affects post-operative cementless stem position in humans, trochanter morphology and the effect on cementless stem position has not been extensively evaluated in dogs. The objective of this study was to classify greater trochanter morphology and identify potential associations between trochanter morphology and patient demographics, femoral canal geometry, surgical time, technique modifications, and post-operative stem position in client-owned dogs undergoing cementless THR.

Results

In this retrospective study, medical records and radiographs of 135 dogs undergoing 150 cementless total hip replacements from 2013 to 2020 were included. Trochanters were classified in the frontal plane using an ordinal grading system adapted from human THR. A Grade I trochanter denoted a trochanter positioned lateral to the periosteal surface of the lateral femoral cortex, whereas a Grade IV trochanter denoted a trochanter positioned medial to the anatomic axis of the femur. Associations between trochanter grade and other variables were examined using ANOVA, Kruskall-Wallis, or chi-squared tests. Significance was assumed at P ≤ .05.

Trochanters were classified as follows: Grade I (44/150, 29.3%), Grade II (56/150, 37.4%), Grade III (44/150, 29.3%), Grade IV (6/150, 4.0%). Grade IV trochanters had lower anatomic lateral distal femoral angle (aLDFA; 91.0 ± 6.2°), angle of inclination (117.7 ± 10.5°), and canal flare index (1.53 ± 0.27). When compared to all groups, Grade IV trochanters were associated with longer surgical times (Grade IV: 227.0 ± 34.2 min; all grades: 183.2 ± 32.9 min) and technique modifications (Grade IV: 83.3%; all grades: 18%). Grade I trochanters had stems placed in valgus (− 1.8 ± 2.33°), whereas Grade II (0.52 ± 2.36°), III (0.77 ± 2.58°), and IV (0.67 ± 2.73°) trochanters exhibited varus stems. Depth of stem insertion was greater (11.2 ± 4.2 mm) for Grade IV trochanters.

Conclusions

Trochanter grade was associated with post-operative stem alignment and translation in the frontal plane. Grade IV trochanters were associated with altered femoral geometry, increased surgical time, technique modifications, and stem insertion depth. Pre-operative greater trochanter classification may prove useful in identifying cases requiring prolonged surgical times or technique modifications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12917-022-03174-y.

Greater trochanter osteotomy as a component of cementless total hip replacement: Five cases in four dogs

OBJECTIVE

To describe the surgical technique and report the long-term outcome of greater trochanteric osteotomy (GTO) as a component of cementless total hip replacement (THR) in dogs with severe medialization of the greater trochanter or chronic craniodorsal hip luxation.

STUDY DESIGN

Short case series.

ANIMALS

Four dogs treated with five THRs.

METHODS

Data collected from medical records included signalment, indication for THR, duration of clinical signs, body weight, pre- and post-operative radiographic assessment, surgical templating, osteotomy technique, THR implant selection, surgical time, complications, and long-term clinical and radiographic follow-up. Clinical outcomes were determined based on in-hospital history, orthopedic examination, and radiographic evaluation.

RESULTS

All five surgical procedures resulted in satisfactory long-term clinical results at follow-up a median of 48.2 months (range, 34-56 months) after THR. There were no minor complications and one major complication. One dog experienced post-operative luxation unrelated to the GTO and was successfully treated with a cup revision.

CONCLUSION AND CLINICAL RELEVANCE

GTO was effective in facilitating cementless THR in dogs with either severe medialization of the greater trochanter or chronic craniodorsal luxation.

Abductor Muscle Strength Deficit in Patients After Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

The aims of this study were to assess and quantify hip abductor muscle strength deficits after total hip arthroplasty (THA) and to determine associations with external factors.

METHODS

Studies reporting on hip abductor muscle strength before and/or after THA performed for osteoarthritis or atraumatic osteonecrosis of the hip were considered for inclusion. Data sources were Embase, Medline, and the Cochrane Central Register of Controlled Trials. Muscle strength on the affected side was compared with the healthy contralateral side or with control subjects. Study quality was assessed using a modified Newcastle-Ottawa Scale.

RESULTS

Nineteen studies reporting on 875 subjects met the inclusion criteria. Patients scheduled for THA had a mean strength deficit of 18.6% (95% confidence interval (CI) [-33.9, -3.2%]) compared with control subjects. Abductor muscle strength then increased by 20.2% (CI [5.6, 34.8%]) at 4-6 months, 29.6% (CI [4.7, 54.4%]) at 9-12 months, and 49.8% (CI [-31.0, 130.6%]) at 18-24 months postoperatively compared with preoperative values. For unilateral THA, the mean torque ratio was 86.3% (CI [75.4, 97.2%]) and 93.4% (CI [75.1, 111.6%]) before and >24 months after THA, respectively. Study quality was low to moderate.

CONCLUSION

Hip abductor muscle strength deficits may gradually improve during 24 months after THA possibly without complete recovery. Cautious interpretation of these findings is warranted because high-quality evidence is largely missing.

Medium Term Radiographic and Clinical Outcomes Using a Modular Tapered Hip Revision Implant

Background

The rate of revision hip arthroplasty surgery is rising. Surgeons must use implants with proven outcomes to help overcome the technical challenges faced during revision surgery. However, outcome studies using these implants are limited. The aim of this study is to investigate the radiographic and clinical outcomes of the Stryker Restoration stem, the most commonly used hip revision stem in the United Kingdom (UK).

Methods

A retrospective review of a single surgeon case series was performed. Immediate postoperative radiographs were analyzed for offset and leg length discrepancy. Radiographic evidence of subsidence was assessed using follow-up radiographs. Kaplan-Meier survival analysis was applied using explantation and reoperation as endpoints. Patient-reported outcomes were measured using the Oxford Hip Score and EQ-5D-5L.

Results

One hundred ninety-eight cases were identified. Mean follow-up duration was 51.8 months (range: 24-121). Stem survival during this period was 98%. Reoperation for any reason was 13%. Mean subsidence was 4.18 mm. Analysis of variance testing showed no difference in mean subsidence between revision indications. Mean offset and leg length discrepancies were measured at 4.5 mm and 4.3 mm, respectively. The mean Oxford Hip Score for participants was 27.6.

Conclusions

This series demonstrates excellent implant survival, with radiographic parameters for reconstruction and subsidence levels comparable to those in the existing literature. The tapered modular hip revision stem provides surgeons with the intraoperative flexibility to overcome some of the anatomical difficulties encountered during revision surgery; this is reflected in the radiographic and clinical outcomes of the cohort in this study.

Trochanteric osteotomy in revision total hip arthroplasty

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.

[Effectiveness of proximal femur reconstruction combined with total hip arthroplasty for Crowe type Ⅳ developmental dysplasia of hip]

Objective

To investigate the early effectiveness of proximal femur reconstruction combined with total hip arthroplasty (THA) in the treatment of adult Crowe type Ⅳ developmental dysplasia of the hip (DDH).

Methods

Between May 2015 and March 2018, 29 cases (33 hips) suffering from Crowe type Ⅳ DDH were treated with proximal femur reconstruction combined with THA. Of the 29 cases, there were 6 males (7 hips) and 23 females (26 hips), aged from 24 to 74 years with an average age of 44.9 years. The preoperative Harris hip score was 44.0±12.0. Gait abnormalities were found in all of the 33 hips with positive Trendelenburg sign, and the lower limb discrepancy was (3.8±1.6) cm. Preoperative X-ray films and CT both indicated serious anatomical abnormalities, including complete dislocation of the affected hip with significant move-up of the greater trochanter, abnormal development of the femoral neck, abnormal anterversion angle and neck-shaft angle, dysplasia of proximal femur and dysplasia of medullary cavity. The operation time, intraoperative blood loss, transfusion rate, and complications were recorded. The Gruen and DeLee-Charnley zoning methods were used to evaluate the aseptic loosening of the prosthesis on X-ray films. The Harris score was used to evaluate hip function. The lower limb discrepancy was calculated and compared with the preoperative value.

Results

The operation time ranged from 80 to 240 minutes, with an average of 124.8 minutes. The intraoperative blood loss ranged from 165 to 1 300 mL, with an average of 568.4 mL. Seventeen patients (51.5%) received blood transfusion treatment. All the incisions healed by first intention without infection or deep vein thrombosis. All patients were followed up 19-53 months, with an average of 33 months. One patient had posterior hip dislocation because of falling from the bed at 4 weeks after operation, and was treated with manual reduction and fixation with abduction brace for 4 weeks, and no dislocation occurred during next 12-month follow-up. Two patients developed sciatic nerve palsy of the affected limbs after operation and were treated with mecobalamin, and recovered completely at 12 weeks later. Trendelenburg sign was positive in 3 patients and mild claudication occurred in 4 patients after operation. X-ray films showed that all the osteotomy sites healed at 3-6 months after operation, and no wire fracture was observed during the follow-up. The Harris score was 89.8±2.8 and lower limb discrepancy was (0.6±0.4) cm at last follow-up, both improved significantly ( t=-22.917, P=0.000; t=11.958, P=0.000). The prosthesis of femur and acetabulum showed no obvious loosening and displacement, and achieved good bone ingrowth except 2 patients who had local osteolysis in the area of Gruen 1 and 7 around the femoral prosthesis, but no sign of loosening and sinking was observed.

Conclusion

The treatment of Crowe Ⅳ DDH with proximal femur reconstruction and THA was satisfactory in the early postoperative period. The reconstruction technique of proximal femur can effectively restore the anatomical structure of proximal femur, which is one of the effective methods to deal with the deformity of proximal femur.

Fixation Options Following Greater Trochanteric Osteotomies and Fractures in Total Hip Arthroplasty: A Systematic Review

BACKGROUND

The optimal system for greater trochanteric fixation following osteotomy or fracture remains unknown. This systematic review aims to synthesize the available English-language literature on 5 commonly reported trochanteric fixation methods to quantify and compare rates of complications and reoperation.

METHODS

A comprehensive search of MEDLINE and Embase databases from January 1946 to June 2017 was performed for articles in English describing fixation of trochanteric osteotomies and fractures using wires, cables, cable-plate devices, claw or locking plates, and trochanteric bolts. Pooled mean rates of complications and reoperation with 95% confidence intervals (CIs) were analyzed using a random-effects model.

RESULTS

Fifty-seven studies involving 10,956 hips were eligible for inclusion. Five studies had Level-III evidence and 52 had Level-IV evidence. The pooled mean rate of nonunion was 4.17% (95% CI, 3.21% to 5.13%; I = 79%) for wires, 5.07% (95% CI, 0.37% to 9.77%; I = 74%) for cables, 16.11% (95% CI, 10.85% to 21.37%; I = 89%) for cable-plate systems, 9.60% (95% CI, 2.23% to 16.97%; I = 59%) for claw or locking plates, and 12.42% (95% CI, 3.41% to 21.43%; I = 75%) for trochanteric bolts. Substantial heterogeneity in the data precluded formal statistical comparison of outcomes and complications between implants.

CONCLUSIONS

Available literature on the various trochanteric fixation implants is heterogeneous and consists primarily of retrospective case series. Based on the current literature, it is difficult to support the use of one implant over another. Despite superior mechanical properties, rates of complication and reoperation following cable-plate fixation remains suboptimal, especially in complex revision scenarios. Additional rigorous prospective randomized and cohort studies are needed to make definitive recommendations regarding the most reliable method of trochanteric fixation.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Current Uses of the Transtrochanteric Approach to the Hip: A Systematic Review

BACKGROUND

The indications and technique for the transtrochanteric approach to the hip have evolved greatly since its initial popularization in the 1960s. The purpose of this systematic review was to assess current uses of this approach on the basis of indications, osteotomy technique, trochanteric fixation method, complications, and functional outcome.

METHODS

A comprehensive search of MEDLINE and Embase databases from January 2000 to July 2017 was performed in accordance with the PRISMA guidelines. Articles were divided into 3 major categories on the basis of the type of hip surgery performed: (1) primary arthroplasty, (2) revision arthroplasty, and (3) joint-preserving procedures. Patient data were then analyzed according to these 3 categories.

RESULTS

Seventy-six studies (5,028 hips), mainly of Level-IV evidence, were included. Four types of osteotomy were reported for a variety of indications. Rates of nonunion were 6.0% (303 of 5,028) across all studies, 4.2% (39 of 921) for primary arthroplasty, 6.7% (114 of 1,690) for revision arthroplasty, and 4.4% (56 of 1,278) for joint-preserving procedures. Rates of dislocation were 1.5% (14 of 921) for primary arthroplasty and 4.6% (77 of 1,690) for revision arthroplasty. The rate of osteonecrosis after joint-preserving procedures was 1.1% (14 of 1,278). Rates of deep infection were 1.1% (55 of 5,028) across all studies, 0.1% (1 of 921) for primary arthroplasty, 2.1% (36 of 1,690) for revision arthroplasty, and 0.6% (8 of 1,278) for joint-preserving procedures.

CONCLUSIONS

The transtrochanteric approach remains useful in cases requiring extensile exposure of the acetabulum or femoral medullary canal. However, trochanteric complications continue to pose a clinical challenge.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Greater Trochanteric Reattachment Using the Third-Generation Cable Plate System in Revision Total Hip Arthroplasty

BACKGROUND

The purpose of the study is to evaluate the radiologic and functional results of greater trochanteric reattachment using the third-generation cable plate system in revision total hip arthroplasty (THA).

METHODS

A total of 47 trochanteric fixations (27 men and 18 women; mean age of 60.2 years) using the third-generation cable plate system in revision THA were retrospectively evaluated. The mean follow-up was 80.4 months (range 27-148 months). The osteotomized greater trochanter was reattached using the Cable-Ready system (Zimmer, Warsaw, IN) and the Dall-Miles cable system (Stryker, Mahwah, NJ). The clinical results with Harris hip score, visual analog scale, and radiologic outcomes were evaluated.

RESULTS

The mean Harris hip score was improved from 55.7 (range 17-72) preoperatively to 90.8 (range 68-100; P = .001) postoperatively, and the mean pain score was improved from 6.6 (range 3-10) to 2.5 (range 0-6; P = .001), respectively. Nonunion was observed in 6 hips (12.7%). Migration of the osteotomized greater trochanteric fragment (>1 cm) was seen in 8 hips (17.0%). Cable breakage occurred in 13 cases (27.6%). Although 5 cable plate systems were removed, there was no need for reattachment of the greater trochanter in this study.

CONCLUSION

This study showed a relatively high incidence of radiologic failure after greater trochanteric reattachment using the cable plate system in revision THA, although reattachments were not required and clinical outcome was relatively satisfactory. Periodic and close observation for the early detection of failure is necessary.

Pelvic Discontinuity Associated With Total Hip Arthroplasty: Evaluation and Management

Pelvic discontinuity is a challenging complication encountered during revision total hip arthroplasty. Pelvic discontinuity is defined as a separation of the ilium superiorly from the ischiopubic segment inferiorly and is typically a chronic condition in failed total hip arthroplasties in the setting of bone loss. After a history and a physical examination have been completed and infection has been ruled out, appropriate imaging must be obtained, including plain hip radiographs, oblique Judet radiographs, and often a CT scan. The main management options are a hemispheric acetabular component with posterior column plating, a cup-cage construct, pelvic distraction, and a custom triflange construct. The techniques have unique pros and cons, but the goals are to obtain stable and durable acetabular component fixation and a healed or unitized pelvis while minimizing complications.

Cementless total hip arthroplasty with extended sliding trochanteric osteotomy for high congenital hip dislocation: A retrospective study

Total hip arthroplasty (THA) for high congenital hip dislocation (CHD) is technically demanding. The purpose of this retrospective study was to evaluate the results of cementless THA combined with extended sliding trochanteric osteotomy. We also assessed whether chronic low back pain was relieved after surgery.The study included 19 patients (23 hips) with high CHD treated with cementless THA using extended sliding trochanteric osteotomy technique. Clinical and radiographic outcomes were evaluated.Harris Hip Score, WOMAC score, visual analog scale for low back pain and Trendelenburg sign were significantly improved (P < 0.01) compared with the preoperative. Average limb-length discrepancy in the 15 unilateral hips was reduced from 38.2 ± 7.9 mm to 6.7 ± 4.1 mm (P < 0.01). No dislocation, deep vein thrombosis, or infection occurred. Two patients (8.7%) developed sciatic nerve palsy. One (4.3%) developed symptomatic greater trochanteric bursitis. Two (8.7%) sustained proximal femur shaft fracture during implantation of the femoral component. All femoral components showed successful bony ingrowth at the final follow-up. No stem subsidence was detected. There was no acetabular loosening. Bony union of the reattached greater trochanter was obtained in all hips. Wire breakage occurred in 3 hips (13%).Cementless THA with extended sliding trochanteric osteotomy may be appropriate options for patients with high CHD.

The change in position of the sciatic nerve during the posterior approach to the hip

The aim of this cadaver study was to identify the change in position of the sciatic nerve during arthroplasty using the posterior surgical approach to the hip. We investigated the position of the nerve during this procedure by dissecting 11 formalin-treated cadavers (22 hips: 12 male, ten female). The distance between the sciatic nerve and the femoral neck was measured before and after dislocation of the hip, and in positions used during the preparation of the femur. The nerve moves closer to the femoral neck when the hip is flexed to > 30° and internally rotated to 90° (90° IR). The mean distance between the nerve and femoral neck was 43.1 mm (standard deviation (sd) 8.7) with the hip at 0° of flexion and 90° IR; this significantly decreased to a mean of 36.1 mm (sd 9.5), 28.8 mm (sd 9.8) and 19.1 mm (sd 9.7) at 30°, 60° and 90° of hip flexion respectively (p < 0.001). In two hips the nerve was in contact with the femoral neck when the hip was flexed to 90°.

This study demonstrates that the sciatic nerve becomes closer to the operative field during hip arthroplasty using the posterior approach with progressive flexion of the hip.

Cite this article: Bone Joint J 2015;97-B:1056–62.

Management of severe femoral bone loss in revision total hip arthroplasty

Femoral bone loss is a complex problem in revision total hip arthroplasty. The Paprosky classification is used when determining the degree and location of bone loss. Meticulous operative planning is essential where severe bone loss is a concern. One must correctly identify the bone loss pattern, safely remove the existing components, and proceed with the proper reconstruction technique based on the pattern of bone loss. This article discusses the etiology and classification of bone loss, clinical and radiographic evaluation, components of effective preoperative planning, and clinical results of various treatment options with a focus on more severe bone loss patterns.

Modified Mostardi approach with ultra-high-molecular-weight polyethylene tape for total hip arthroplasty provides a good rate of union of osteotomized fragments

BACKGROUND

A lateral approach is common in total hip arthroplasty because of the good exposure it provides and its low complication rates. However, a drawback of the procedure is that the abductor mechanism is damaged when the tendinous insertion of the abductor muscle is split. Here, we describe a wafer technique using ultra-high-molecular-weight polyethylene tape for promising reattachment of the abductor mechanism.

METHODS

We retrospectively evaluated 120 consecutive primary total hip arthroplasties performed using a modified Mostardi approach, which involved reattaching the trochanter using either a braided polyester suture (polyester suture group, n = 60) or ultra-high-molecular-weight polyethylene tape (UHMWPE tape group, n = 60). The osteotomized fragment was reattached by inducing bone-to-bone contact using 3-mm-wide tapes that were precisely tied with a double-loop sliding knot in conjunction with a cable gun tensioner. The abductor strength and radiographic union rate were postoperatively assessed at 4 weeks and 6 months, respectively.

RESULTS

A statistically significant lower incidence of nonunion and cutout was observed in the UHMWPE group (0 and 5.0 %, respectively) compared to the polyester suture group (8.3 and 15 %, respectively). No differences in abductor strength either preoperatively or at 4 weeks postoperatively were observed between the groups. In radiographically healed patients, abductor strength at 4 weeks post-surgery exceeded preoperative strength. The recovery rate of hip abductor strength was 109.9 ± 34.3 % in union patients and 92.9 ± 23.3 % in nonunion patients, which was statistically significant. The mean Japanese Orthopedic Association hip scores improved from 48.6 to 86.8 in union patients and from 50.3 to 85.9 in nonunion patients at 1 year postoperatively; however, this difference was not significant.

CONCLUSIONS

The modified Mostardi approach using ultra-high molecular weight polyethylene tape can promote successful union of the osteotomized fragment.

What is the survivorship of fully coated femoral components in revision hip arthroplasty?

BACKGROUND

Femoral revision using fully coated femoral components offers distinct advantages in patients with notable bone loss. With the increasing concerns being raised about the problems of stem modularity, the results and complications of revision arthroplasty using devices with limited modularity are important.

QUESTIONS/PURPOSES

We therefore asked: (1) What is the frequency of infection, aseptic loosening, and reoperations after use of these components? (2) What is the frequency of intraoperative fracture of the femur when using these components and are there any identifiable factors related to these fractures? (3) What is the 10-year survivorship of these components, and are there any identifiable factors related to survival and rerevision?

METHODS

We retrospectively reviewed prospectively obtained data on 96 patients undergoing 104 revisions with fully coated components of two different manufacturers; six patients had died (6%) and six were lost to followup (6%) before 2 years. Data on intraoperative fracture, aseptic loosening, and reoperation were analyzed. Ninety-two hips, with a minimum followup of 2 years (mean, 8 years; range, 2-16 years), were evaluated for radiographic evidence of loosening. Intraoperative fracture frequency and Kaplan-Meier survivorship was calculated to 10 years for the entire cohort of 104 hips. Demographic, radiographic, and operative factors associated with implant survival and intraoperative fracture were analyzed using chi-square and Wilcoxon tests.

RESULTS

There were three infections, nine hips (10%) had femoral component loosening (six rerevised), and there were seven other reoperations. Intraoperative complications in 17 hips (17%; 11 diaphyseal fractures, four perforations, two proximal fractures) were treated with allograft strut and cable fixation in 14 hips. Intraoperative femoral complication was more likely with the use of a curved stem [17 of 76, 22% curved; 0 of 28 straight stems (p=0.005)]. With failure defined as femoral component revision for aseptic loosening or radiographic evidence of loosening, implant survival was 88% at 10 years. Those femurs with Paprosky Grades 3B and 4 defects had a higher risk of loosening (3 of 10 for Grades 3B and 4 versus 6 of 94 hips [6%] for Grades 1, 2, 3A; p=0.03).

CONCLUSIONS

As concerns about stems with more modularity become more prominent, we find the durability of the approach using fully coated femoral components reassuring, but we will continue to follow these patients in the longer term.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Femoral bone loss in revision total hip arthroplasty: evaluation and management

Primary total hip arthroplasty (THA) is one of the most effective procedures for managing end-stage hip arthritis. The burden of revision THA procedures is expected to increase along with the rise in number of primary THAs. The major indications for revision THA include instability, aseptic loosening, infection, osteolysis, wear-related complications, periprosthetic fracture, component malposition, and catastrophic implant fracture. Each of these conditions may be associated with mild or advanced bone loss. Careful patient evaluation and bone loss classification guide preoperative planning and overall patient care. Historically, uncemented fixation has provided the best results, but cemented fixation is required in some cases.

An in-vitro biomechanical study of different fixation techniques for the extended trochanteric osteotomy in revision THA

Background

The wire fixation and the cable grip fixation have been developed for the extended trochanteric osteotomy (ETO) in the revision of total hip arthroplasty (THA). Many studies reported the postoperative performance of the patients, but with little quantitative biomechanical comparison of the two fixation systems.

Methods

An in-vitro testing approach was designed to record the loosening between the femoral bed and the greater trochanter after fixations. Ten cadaveric femurs were chosen in this study. Each femur underwent the THA, revision by ETO and fixations. The tension to the greater trochanter was from 0 to 500N in vertical and lateral direction, respectively. The translation and rotation of the greater trochanter with respect to the bony bed were captured by an optical tracking system.

Results

In the vertical tension tests, the overall translation of the greater trochanter was observed 0.4 mm in the cable fixations and 7.0 mm in the wire fixations. In the lateral tension tests, the overall motion of the greater trochanter was 2.0 mm and 1.2° in the cable fixations, while it was 6.2 mm and 5.3° in the wire fixations. The result was significantly different between the two fixation systems.

Conclusions

The stability of the proximal femur after ETO using different fixations in the revision THA was investigated. The cable grip fixation was significantly more stable than the wire fixation.

Acetabular bone loss in revision total hip arthroplasty: evaluation and management

As the number of primary total hip arthroplasty (THA) procedures performed continues to rise, the burden of revision THA procedures is also expected to increase. Proper evaluation and management of acetabular bone loss at the time of revision surgery will be an increasing challenge facing orthopaedic surgeons. Proper preoperative patient assessment and detailed preoperative planning are essential in obtaining a good clinical result. Appropriate radiographs are critical in assessing acetabular bone loss, and specific classification schemes can identify bone loss patterns and guide available treatment options. Treatment options include impaction grafting and cementation of the acetabulum, noncemented hemispheric acetabular reconstruction, structural allograft reconstruction, noncemented reconstruction with modular porous metal augments, ring and cage reconstruction, oblong cup reconstruction, cup-cage reconstruction, and triflange reconstruction.

Extended trochanteric osteotomy followed by cemented impaction allografting in revision hip arthroplasty

The aim of this study is to present the medium- to long-term results of all cases of femoral impaction allografting revision at our institution that required an extended trochanteric osteotomy (ETO) at the time of surgery. Eighteen patients with a mean age of 60 years were evaluated. Indication for revision was aseptic loosening in all cases. The mean follow-up was 123 months (51-170). Charnley-D'Aubigné-Postel scores, stem length, ETO length, ETO healing, and complications were recorded. No patient was lost to follow-up. Signs of clinical healing were noted within the first 6 postoperative months. The difference between the preoperative and postoperative clinical scores was statistically significant. No nonunion of the ETO was observed in any case. These results give support to the combined use of these techniques.

Secondary Hip Osteoarthritis due to Neurofibroma Treated with Total Hip Replacement

Background. Local plexiform neurofibroma can lead to deformity of the pelvis, valgus deformity of femoral neck, and joint capsule laxity. We report a case of secondary hip osteoarthritis with subluxation and coxa vara deformity resulting from an extra-articular neurofibroma treated with total hip replacement. Case Description. A 39-year-old man had a large benign plexiform neurofibroma at buttock which induced secondary osteoarthritis of the hip. Conservative treatment of tumor was selected because the patient had low chance of malignant transformation due to absence of other neurofibromatosis features. However, due to secondary osteoarthritis he underwent total hip arthroplasty. Anterior capsulotomy was selected to avoid large posterior hip tumor mass. In order to avoid the difficulties associated with setting tension of the abductor muscle, modified trochanteric slide osteotomy with trochanteric advancement, lateralized cup placement, and extended neck offset were used. One year after the surgery, the patient had excellent clinical function, hip stability, leg length equality and was satisfied with the outcome. Clinical Relevance. We concluded that the modified trochanteric slide osteotomy with trochanteric advancement represents a valuable approach for THR in patients with extremely elongation of the hip abductor and secondary hip osteoarthritis resulting from extra-articular neurofibroma.

Trochanteric osteotomy in primary and revision total hip arthroplasty: risk factors for non-union

BACKGROUND

Trochanteric osteotomies (TO) facilitate exposure and "true hip reconstruction" in complex primary and revision total hip arthroplasty (THA). However, non-union represents a clinically relevant complication. The purpose of the present study was to identify risk factors for trochanteric non-union.

METHODS

All cases of THA approached by TO during the past 10 years were analyzed with respect to potential risk factors for non-union.

RESULTS

In 298 cases complete data were available for analysis. Trochanteric union occurred in 80.5%, fibrous union in 5.4% and non-union 14.1%. Risk factor analysis revealed a four times higher risk for non-union in anterior trochanteric slide osteotomies compared to extended trochanteric osteotomies and a three times higher risk in cemented versus non-cemented stems. Multiple logistic regression analysis revealed patient's age and use of cement to be independent risk factors for non-union.

CONCLUSIONS

Femoral cementation and increasing age negatively influence the union of trochanteric osteotomies.

Total hip arthroplasty in the ankylosed hip

Altered biomechanics secondary to hip ankylosis often result in degeneration of the lumbar spine, ipsilateral knee, and contralateral hip and knee. Symptoms in these joints may be reduced with conversion total hip arthroplasty (THA) of the ankylosed hip. THA in the ankylosed hip is a technically challenging procedure, and the overall clinical outcome is generally less satisfactory than routine THA performed for osteoarthritis and other etiologies. Functional integrity of the hip abductor muscles is the most important predictor of walking ability following conversion THA. Many patients experience persistent limp, and it can take up to 2 years to fully assess final functional outcome. Risk factors cited for increased risk of failed THA include prior surgical ankylosis and age <50 years at the time of conversion THA.

Trochanteric osteotomy in total hip replacement for congenital hip disease

We studied the effect of trochanteric osteotomy in 192 total hip replacements in 140 patients with congenital hip disease. There was bony union in 158 hips (82%), fibrous union in 29 (15%) and nonunion in five (3%). The rate of union had a statistically significant relationship with the position of reattachment of the trochanter, which depended greatly on the pre-operative diagnosis. The pre-operative Trendelenburg gait substantially improved in all three disease types (dysplasia, low and high dislocation) and all four categories of reattachment position. A persistent Trendelenburg gait post-operatively was noticed mostly in patients with defective union (fibrous or nonunion). Acetabular and femoral loosening had a statistically significant relationship with defective union and the position of reattachment of the trochanter. These results suggest that the complications of trochanteric osteotomy in total hip replacement for patients with congenital hip disease are less important than the benefits of this surgical approach.

Migration of a broken trochanteric wire to the popliteal fossa

Wires used in fracture fixation or elective procedures can migrate within the body, and some lethal complications have been reported in the literature. We report a case of knee discomfort caused by a broken cerclage wire that has migrated from the hip region to the popliteal fossa after trochanteric osteotomy used in revision hip surgery. The authors point to the potential risks of broken orthopedic hardware.

The effect of multifilaments and monofilaments on cementless femoral revision hip components: an experimental study

BACKGROUND

Cerclage wires are widely used in revision hip surgery to reattach the lid of a femoral osteotomy. The present study compared the influence of multifilaments and monofilaments on primary stability of revision hip stems with different fixation principles.

METHODS

A standardized extended proximal femoral osteotomy was performed in the anterior cortex of 6 synthetic femora. We used a high-resolution measuring device to explore spatial micromovements of a diaphyseal and a metaphyseal fixating revision stem. Both of these were implanted in 3 femora. The specimens were measured again after consecutive restabilization of osteotomies with multifilaments and monofilaments. The movement graphs generated defined relative micromovements between stems and bones and the stabilizing effect of the two wire systems compared.

FINDINGS

Both multifilaments and monofilaments effected a major reduction of relative micromovements for both fixation principles. There were no differences in relative movements between the multifilament and monofilament treatments for the diaphyseal fixating stem. Yet for the metaphyseal fixating stem a significantly better restabilization was observed with multifilaments.

INTERPRETATION

Both multifilaments and monofilaments can support the revision hip stem in bridging the extended proximal femoral osteotomy. Yet, which wiring system should be chosen depends on the fixation principle of the revision stem. Multifilaments seem to be advantageous when used with metaphyseal fixating stems. However, the use of multifilaments with diaphyseal fixating components should be reconsidered as this might constrict the periosteal vascularity.

Modified trochanteric slide for complex hip arthroplasty: clinical outcomes and complication rates

The sliding trochanteric osteotomy preserves vastus lateralis continuity with the osteotomized greater trochanter (GT) and the abductors. The modified trochanteric sliding osteotomy (MTSO) also preserves the posterior capsule and external rotators to reduce the risk of dislocations. The purpose of this study was to evaluate our clinical and radiographic results of the MTSO exposure. Eighty-three MTSOs were reviewed. Follow-up range was 12 to 126 months. Seventy osteotomies (84.4%) healed with bony union, 9 (10.8%) had fibrous union, and 4 (4.8%) had nonunion. There was no correlation between the width of the osteotomy, intraoperative fragmentation of the GT, or the type of femoral component and the rate of union. Six (7.2%) patients developed a new abductor lurch. Patients with union of the GT had 2.8% of a lurch, and patients with either fibrous union or nonunion had a 30.7% of a lurch (P < .05). There were 4 (4.8%) postoperative dislocations. The benefits of MTSO have been well described, and this study provides evidence of an acceptably low complication rate.

Tension and motion measurement for extended trochanteric osteotomy with different fixation methods

The revision of total hip arthroplasty (THA) is becoming an increasingly common procedure around the world. The extended trochanteric osteotomy (ETO) has proved to be an effective way in revision of THA. Four generations of trochanteric osteotomy fixation systems have been developed, all of which has its own clinical application. However, few studies on the biomechanical stability of the above fixation methods have been reported, though many clinical follow-up studies showed some postoperative functional differences among them. Research in this field is mainly subject to constraints of measurement devices and 3D motion analysis. We designed a synchronous testing approach to acquire the tension data loaded to the greater trochanter and minimal rotation or migration of osteotomy fragment which could not be solved by strain gauge method. Active markers were designed to precisely track proximal femoral bed and the osteotomy fragment in 3D space. Six cadaver femurs constructed as vitro biomechanical models were chosen for a preliminary study. Each femur underwent the steps of prosthesis implanting, ETO and a series of five fixation methods in a random order with 2 wires, 3 wires, 2 wires and a short claw plate,2 cables and a short claw plate, and a long claw plate. We also gave a preliminary result of the displacement of fragment and the stiffness of femur after ETO in this paper. Further clinical significance remains to be discussed.

Clinical experience of Ganz surgical dislocation approach for metal-on-metal hip resurfacing

Although the posterior approach is the most commonly used for hip resurfacing, concerns remain in terms of risk of femoral neck fracture secondary to an osteonecrotic event. The purpose of this study was to look at the short-term results of metal-on-metal hip resurfacing done by the vascular-preserving surgical approach as developed by Ganz in 116 hip resurfacing arthroplasties performed in 106 patients (86 men, 20 women; mean age, 46.5 years; range, 19-62). At a mean follow-up of 38.3 months (range, 12-84), Harris Hip Scores improved significantly from 53.1 to 90.16 (P < .001). There were 10 nonunions (8.7%) and 21 hips (18.3%) requiring screw removal for painful bursitis. Two hips underwent conversion to total hip arthroplasty: one at 18 months for femoral loosening and one at 7 years for acetabular loosening. Although the trochanteric slide approach as developed by Ganz provides excellent exposure to the hip joint and preserves femoral head vascularity, it does carry some inherent morbidity in regard to the greater trochanter.

Total hip arthroplasty with shortening subtrochanteric osteotomy in Crowe type-IV developmental dysplasia

BACKGROUND

When surgeons perform total hip arthroplasty for hips with a high dislocation related to developmental dysplasia of the hip, obtaining long-term stable implant fixation and optimizing patient function remain challenges. The purpose of this paper was to evaluate the results of cementless arthroplasty with a simultaneous subtrochanteric shortening osteotomy in a group of patients with Crowe type-IV developmental dysplasia of the hip.

METHODS

In a retrospective study, we evaluated the results and complications of twenty-eight consecutive primary cementless total hip arthroplasties in twenty-four patients (twenty women and four men), all of whom had Crowe type-IV developmental dysplasia of the hip. The arthroplasty was performed in combination with a subtrochanteric shortening osteotomy and with placement of the acetabular component at the level of the anatomic hip center. The patients were evaluated at a mean of 4.8 years postoperatively.

RESULTS

The mean Harris hip score increased from 43 points preoperatively to 89 points at the time of final follow-up (p < 0.01). Twelve (43%) of the twenty-eight hips had an early or late complication or a reoperation. Two (7%) of the twenty-eight subtrochanteric osteotomies were followed by nonunion. There was one instance of isolated loosening of the femoral stem. One acetabular component loosened, and one acetabular liner disengaged. Four hips dislocated postoperatively. All remaining components were well-fixed at the time of the last radiographic follow-up. No sciatic neurapraxic injuries were identified.

CONCLUSIONS

Cementless total hip arthroplasty combined with a subtrochanteric femoral shortening osteotomy in patients with a high hip dislocation secondary to developmental dysplasia was associated with high rates of successful fixation of the implants and healing of the osteotomy site and a mean postoperative Harris hip score of 89 points. The complication rate, however, was substantially higher than that associated with primary total hip arthroplasty in patients with degenerative arthritis.

Claw plate fixation of the greater trochanter in revision total hip arthroplasty

The purpose of this retrospective study was to evaluate a new trochanteric claw plate for trochanteric fixation. From 1998 to 2004, 31 procedures were performed by one surgeon. Mean follow-up was 2.2 years. Indications for the procedure included 16 nonunion, 7 trochanteric osteotomy, 5 periprosthetic fractures, and 3 intraoperative fractures. Median Harris hip scores improved from 47 to 92 points (P < .0001). No patient had an abductor lurch postoperatively (P < .0001). No patient had moderate or severe pain postoperatively (P < .0001). Median active abduction increased from 0 degrees to 25 degrees (P < .0001). Osseous union occurred in 28 of 31 hips. Plate-related complications occurred in 6 of 31 hips. No significant difference was identified for outcomes based on indication. In conclusion, the claw plate in this study can sufficiently treat the complex situation of trochanteric nonunion, fracture, or osteotomy.

Results of surgical repair of abductor avulsion after primary total hip arthroplasty

Abductor avulsion after primary total hip arthroplasty (THA) is an uncommon event and is associated with the lateral approach. Results of surgical repair have only been reported in one previous study. In a retrospective review of 2657 primary THAs, we identified 19 (0.7%) patients operated upon for repair of abductor avulsion on average 19 months after primary THA. The study's aim was to assess improvement in pain and limp, patient satisfaction, and functional outcome (Harris Hip Score) after surgical repair. Eighteen patients were evaluated at a mean follow-up of 38 months. Overall, only half of the patients had substantial improvement of both limp and pain. Limping and functional outcome markedly improved with early repair (<15 months), whereas obesity was associated with worse functional results.

Triplanar trochanteric osteotomy: a modified anterior trochanteric slide osteotomy

Current methods of trochanteric sliding osteotomy typically preserve the lateral aspect of the greater trochanter, the vastus lateralis, the abductors, posterior capsule, and the external rotators. Our modification to this technique includes leaving an anterior vertical ridge of bone that resists the anterior-directed forces acting on the osteotomy. Furthermore, a chevron-shaped osteotomy provides some additional stabilization to the proximally directed pull of the abductors. We believe these modifications improve the intrinsic stability of the osteotomy, theoretically decreasing the rate of nonunion.

A modified two-incision technique for primary total hip arthroplasty

BACKGROUND

Minimally invasive surgery can be technically demanding but minimizes surgical trauma, pain and recovery. Two-incision minimally invasive surgery allows only intermittent visualization and may require fluoroscopy for implant positioning. We describe a modified technique for primary total hip arthroplasty, using two small incisions with a stepwise approach and adequate visualization to reliably and reproducibly perform the surgery without fluoroscopy.

MATERIALS AND METHODS

One hundred and two patients with an average age of 60 years underwent modified two-incision minimally invasive technique for primary THA without fluoroscopy. The M/L taper femoral stem (Zimmer, Warsaw, IN) and Trilogy (Zimmer) hemispherical titanium shell, with a highly cross-linked polyethylene liner, was used. Operative time, blood loss, postoperative hospital stay, radiographic outcomes and complications were recorded.

RESULTS

The mean operating time was 77 min. The mean blood loss was 335 cc. The mean hospital stay was 2.4 days. Mean cup abduction angle was 43.8 degrees. Mean leg length discrepancy was 1.7 mm. Thirteen patients had lateral thigh numbness and two patients had wound complications that resolved without any treatment.

CONCLUSION

A modified two-incision technique without fluoroscopy for primary total hip arthroplasty has the advantage of preserving muscles and tendons, shorter recovery and return to function with minimal complications. Provided that the surgeon has received appropriate training, primary total hip arthroplasty can be performed safely with the modified two-incision technique.

Fixation systems of greater trochanteric osteotomies: biomechanical and clinical outcomes

The development of cerclage systems for fixation of greater trochanteric osteotomies has progressed from monofilament wires to multifilament cables to cable grip and cable plate systems. Cerclage wires and cables have various clinical indications, including fixation for fractures and for trochanteric osteotomy in hip arthroplasty. To achieve stable fixation and eventual union of the trochanteric osteotomy, the implant must counteract the destabilizing forces associated with pull of the peritrochanteric musculature. The material properties of cables and cable grip systems are superior to those of monofilament wires; however, potential complications with the use of cables include debris generation and third-body polyethylene wear. Nevertheless, the cable grip system provides the strongest fixation and results in lower rates of nonunion and trochanteric migration. Cable plate constructs show promise but require further clinical studies to validate their efficacy and safety.

Sliding trochanteric osteotomy in acetabular fractures: a review of 30 cases

OBJECTIVE

To assess the results of using sliding trochanteric osteotomy as an adjunct procedure for acetabular fractures.

DESIGN

Retrospective review.

SETTING

Level 1 trauma centre.

METHODS

Thirty patients (19 men, 11 women, mean age 40 years, range 23-80 years) having fracture of acetabulum underwent sliding trochanteric osteotomy for a better exposure of the fracture involving the dome of acetabulum during the period January 1999-January 2004.

MAIN OUTCOME MEASUREMENTS

Clinical evaluation was based on modified Merle d' Aubigne and Postel scoring. Motor strength of the abductors was evaluated according to the Medical Research Council (MRC) grading system. Radiographic evaluation of the joint was also documented.

RESULTS

All the osteotomies healed within 12 weeks without any proximal migration except for one patient with infection in whom nonunion occurred. Two patients underwent removal of implants from greater trochanter because of irritation. The strength of the abductors was of Grade 2/5 in one patient, Grade 3/5 in one patient, Grade 4/5 in six patients and Grade 5/5 in the rest. Clinical scoring was excellent to good in 77%. Heterotopic ossification occurred in six patients and was of modified Brooker's classes 1 and 2.

CONCLUSIONS

This technique can be relied upon to provide an adequate exposure of the dome of acetabulum without the associated complications like malunion, non-union, etc., known to occur with standard oblique osteotomy.

Our first experience with extended proximal femoral osteotomy for revision hip surgery

INTRODUCTION

The extended proximal femoral osteotomy (EPFO) is a demanding but useful technique for revision of both cemented or noncemented femoral components.

MATERIALS AND METHODS

Between 2000 and 2004 we performed extended proximal femoral osteotomy (EPFO) in 25 cases during revision hip surgery. The main indication for doing revision surgery was aseptic loosening of both total hip arthroplasty (THA) components (18 patients), whilst in the remaining 7 patients the indications were: aseptic loosening of acetabular component in three patients, septic loosening of THA in two patients, recurrent dislocation of the THA because of incorrectly positioned femoral component in one patient and aseptic loosening of cemented hip hemiarthroplasty in one patient.

RESULTS

There were 14 women and 11 men. The mean follow-up was 22 months. The average time to revision was 8.3 years. The mean age at the time of revision was 70.3 years (range 55 to 81). At the time of the last control examination all osteotomy sites had healed with signs of remodelling. The mean time to union ranged from 11 weeks to 6 months, shown by the bridging callous formation in both radiographic projections. Bone remodelling occurred in all patients by 12 months and no complications such as nonunion, excessive fragment migration or wire breakage were found.

CONCLUSION

In our experience, the extended proximal femoral osteotomy when properly indicated represents an efficient and reliable technique in revision hip surgery.

Wiring through cannulated screws for the fixation of greater trochanter in arthroplasties performed for peritrochanteric fractures

Safe and rigid fixation of a fractured greater trochanter is often very difficult because of osteoporosis of the fragments. The authors propose a new technique using cannulated screws and wires passed through the screws to fix the greater trochanter in arthroplasties performed for peritrochanteric fractures.

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.