Intertrochanteric osteotomies do not impair long-term outcome of subsequent cemented total hip arthroplasties

Short-term results of total hip arthroplasty using a tapered cone stem for patients with previous femoral osteotomy

PURPOSE

In total hip arthroplasty (THA) for patients with previous femoral osteotomy, we hypothesized that a tapered cone stem may be an option due to the altered morphology of the proximal femur. The purpose of this study was to assess the short-term results of THA after femoral osteotomy using a tapered cone stem, and to identify issues that require further attention.

METHODS

Twenty-two hips in 21 consecutive patients who underwent THA after femoral osteotomy using a Wagner Cone tapered cone stem were retrospectively reviewed, with a mean follow-up period of 34.4 (range, 24-50) months. Clinical information was obtained from medical records. On preoperative radiographs, the Dorr type was classified based on the anteroposterior cortical index. On postoperative radiographs, the degree of stem subsidence and the stem location with the highest canal fill ratio were assessed.

RESULTS

The mean Harris hip score significantly improved from 55.2 at baseline to 84.8 at final follow-up. Radiologically, stem subsidence (>3 mm) was observed in seven hips, and it stabilized within 1 year after THA in all cases. In five of seven hips with stem subsidence, the highest postoperative canal fill ratio was observed in the distal third of the stem. The proportions of males and Dorr type A were significantly higher among hips with stem subsidence than among those without. During the follow-up period, no hips showed implant loosening or required revision surgery.

CONCLUSIONS

The occurrence of stem subsidence should be noted when using Wagner Cone stems for Dorr type A femurs after femoral osteotomy.

Adult Idiopathic Bilateral Coxa Vara with Hip Osteoarthritis Treated with Bilateral Proximal Femur Osteotomy: A Case Report

CASE

We reported a case of a 25-year-old woman with idiopathic bilateral coxa vara who had initial presentation of hip osteoarthritis. She was later treated with bilateral subtrochanteric valgus osteotomy. A good functional outcome was recorded without nonunion or deformity recurrence. The arthritis of the hips also decelerated.

CONCLUSIONS

Coxa vara first diagnosed in adulthood was relatively uncommon, and the cause in this present case was uncertain. Subtrochanteric valgus osteotomy seemed to be a suitable treatment for this case.

What Is the Impact of a Previous Femoral Osteotomy on THA? A Systematic Review

BACKGROUND

Femoral osteotomies have been widely used to treat a wide range of developmental and degenerative hip diseases. For this purpose, different types of proximal femur osteotomies were developed: at the neck as well as at the trochanteric, intertrochanteric, or subtrochanteric levels. Few studies have evaluated the impact of a previous femoral osteotomy on a THA; thus, whether and how a previous femoral osteotomy affects the outcome of THA remains controversial.

QUESTIONS/PURPOSES

In this systematic review, we asked: (1) What are the most common complications after THA in patients who have undergone femoral osteotomy, and how frequently do those complications occur? (2) What is the survival of THA after previous femoral osteotomy? (3) Is the timing of hardware removal associated with THA complications and survivorship?

METHODS

A systematic review was carried out on PubMed, the Cochrane Systematic Reviews Database, Scopus, and Embase databases with the following keywords: "THA", "total hip arthroplasty", and "total hip replacement" combined with at least one of "femoral osteotomy" or "intertrochanteric osteotomy" to achieve the maximum sensitivity of the search strategy. Identified studies were included if they met the following criteria: (1) reported data on THAs performed after femoral osteotomy; (2) recorded THA followup; (3) patients who underwent THA after femoral osteotomy constituted either the experimental group or a control group; (4) described the surgical and clinical complications and survivorship of the THA. The database search retrieved 383 studies, on which we performed a primary evaluation. After removing duplicates and completing a full-text evaluation for the inclusion criteria, 15 studies (seven historically controlled, eight case series) were included in the final review. Specific information was retrieved from each study included in the final analysis. The quality of each study was evaluated with the Methodological Index for Non-randomized Studies (MINORS) questionnaire. The mean MINORS score for the historically controlled studies was 14 of 24 (range, 10-17), whereas for the case series, it was 8.1 of 16 (range, 5-10).

RESULTS

The proportion of patients who experienced intraoperative complications during THA ranged from 0% to 17%. The most common intraoperative complication was femoral fracture; other intraoperative complications were difficulties in hardware removal and nerve palsy; 15 studies reported on complications. The survivorship of THA after femoral osteotomy in the 13 studies that answered this question ranged from 43.7% to 100% in studies that had a range of followup from 2 to 20 years. The timing of hardware removal was described in five studies, three of which detailed more complications with hardware removal at the time of THA.

CONCLUSIONS

This systematic review demonstrated that THA after femoral osteotomy is technically more demanding and may carry a higher risk of complications than one might expect after straightforward THA. Staged hardware removal may reduce the higher risk of intraoperative fracture and infection, but there is no clear evidence in support of this contention. Although survivorship of THA after femoral osteotomy was generally high, the studies that evaluated it were generally retrospective case series, with substantial biases, including selection bias and transfer bias (loss to followup), and so it is possible that survivorship of THA in the setting of prior femoral osteotomy may be lower than reported.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Surgical treatment for young adult hip dysplasia: joint-preserving options

Developmental dysplasia of the hip (DDH) is a spectrum of disorders that results in anatomic abnormalities leading to increased contact stress in the joint and, eventually, secondary osteoarthritis. However, many patients with DDH become symptomatic before the severe degenerative changes of the hip because of abnormal hip biomechanics, mild hip instability, impingement, or associated intra-articular pathology. Early diagnosis and appropriate treatment for DDH are of the utmost importance. With the modification of techniques like pelvic osteotomy and capsular arthroplasty, and the introduction of intracapsular procedures such as arthroscopy and femoral head-neck junction osteochondroplasty, many young patients with symptomatic hip dysplasia may benefit from joint preservation procedures. We review the current development of these concepts and the associated surgical techniques.

[Hip arthroplasty in the presence of proximal femoral deformity]

INTRODUCTION

Proximal femoral deformities may result in pain in the ipsilateral hip joint and profound functional disability, ultimately requiring arthroplasty. 

PROCEDURE

Primary hip replacement procedures in the presence of markedly altered anatomy of the proximal femur present a technical challenge for the orthopedic surgeon. The deformity and its underlying condition, whether congenital or acquired, may complicate canal preparation and affect the choices of implant, exposure and postoperative physiotherapy protocol. Furthermore, a two- or multi-stage treatment may be required, e.g. for implant removal, for femoral osteotomy or to rule out infection.

DISCUSSION

Treatment strategies must be individually tailored, respecting patient needs, the etiology, the anatomic site and the geometry of the deformity encountered, bone quality, soft tissue deficits, the presence of retained implants in the proximal femur, infection status and comorbidities.

Survivorship of the cementless Spotorno femoral component in patients under 50 years of age at a mean follow-up of 18.4 years

The long-term survival of the cementless Spotorno CLS femoral component in patients aged > 50 years at the time of arthroplasty was investigated. Survivorship analysis of a consecutive series of 85 patients (100 hips; under 50 years of age at a mean follow-up of 18.4 years (16.3 to 20.8)) was performed. The clinical and radiographic outcomes were satisfactory. The overall rate of survival of the femoral component was 93.5% (95% confidence interval (CI), 90.9 to 96.1) after 19 years. Survival with revision for aseptic loosening as the end point was 95.7% (95% CI 93.6 to 97.8%) at 19 years. This study demonstrates an excellent long-term survival of the Spotorno CLS femoral component after 16 to 20 years in young patients undergoing total hip arthroplasty.

Does previous osteotomy compromise total hip arthroplasty? A systematic review

Hip osteotomy surgery has increased over the past several years, yet the impact of these procedures on subsequent total hip arthroplasty (THA) remains controversial. The purpose of this study was to perform a systematic review of the literature to determine the clinical results, procedure complications, and survivorship of THA following previous hip osteotomy. Ten studies met inclusion criteria. The operative time and estimated blood loss were higher in the post-osteotomy cohorts; while the clinical results and survivorship between groups were similar. THA following previous pelvic and femoral osteotomy provides pain relief and improved function with similar complication rates, clinical outcomes, and survivorship compared to hips undergoing routine primary THA. These procedures can be technically more demanding with increased operative times and intraoperative blood loss.

Cemented total hip arthroplasty with retention of some existing hardware

We report a case of a 63-year-old man who presented an end stage hip osteoarthritis 42 years after a proximal femoral osteotomy performed for the treatment of an intracapsular femoral neck fracture. A cemented total hip arthroplasty was implanted using a standard posterior approach. The osteotomy hardware was totally covered with a new cortical bone formation. A layer of bone tissue was removed, the screw heads were broken and the nail plate was also removed. The screw threaded portions were retained because they did not interfere with cemented femoral stem implantation. Fourteen years after total hip arthroplasty, the patient reported no pain and expressed high satisfaction with the surgery. The hip radiograph showed wear of the polyethylene cup and no periprosthetic osteolysis. Retention of hardware can be considered, especially in patients who have had hardware for several years, without any negative symptoms.

Novel technique for removal of a broken intracortical screw during THA

Most reports regarding hardware removal involve the violation of the cortex to allow a specialized to tool to extract a retained fragment. This leaves large, unfilled screw holes that act as stress risers for months postoperatively. This article describes a novel technique to remove a retained intracortical screw fragment during total hip arthroplasty. Conversion of an intertrochanteric osteotomy to a total hip arthroplasty can be made more difficult by anatomical changes to the femur and retained hardware. Direct access to the intramedullary canal during total hip arthroplasty allowed for the safe removal of a retained intracortical screw using this technique.

[Joint-preserving surgery of the adult hip. Intertrochanteric femoral osteotomy]

Due to advances in total joint replacement, intertrochanteric osteotomy (ITO) is performed more infrequently in spite of good clinical results. Nevertheless, there are several good indications for this joint-preserving procedure in adults. Detailed biomechanical knowledge and precise clinical examination are prerequisites for correct indications and planning of ITO. The main target of this surgical procedure is improvement of joint congruency and normalization of load transfer to protect damaged cartilage. Very good results can be obtained in hip dysplasia, non-union of the femoral neck and proximal femoral deformities if the therapeutic principles are followed. Higher failure rates have to be expected in femoral head necrosis and osteoarthritis, depending on the degree of pre-existing cartilage damage.

Does previous hip arthroscopy negatively influence the short term clinical result of total hip replacement?

INTRODUCTION

The risk that hip preserving surgery may negatively influence the performance and outcome of subsequent total hip replacement (THR) remains a concern. The aim of this study was to identify any negative impact of previous hip arthroscopy on THR.

METHODS

Out of 1271 consecutive patients who underwent primary THR between 2005 and 2009, 18 had previously undergone ipsilateral hip arthroscopy. This study group (STG) was compared with two control groups (CG, same approach, identical implants; MCG, paired group matched for age, BMI and Charnley categories). Operative time, blood loss, evidence of heterotopic bone and implant loosening at follow-up were compared between the STG and the MCG. Follow-up WOMAC were compared between the three groups.

RESULTS

Blood loss was not found to be significantly different between the STG and MCG. The operative time was significantly less (p < 0.001) in the STG. There was no significant difference in follow-up WOMAC between the groups. No implant related complications were noted in follow-up radiographs. Two minor complications were documented for the STG and three for the MCG.

CONCLUSION

We have found no evidence that previous hip arthroscopy negatively influences the performance or short-term clinical outcome of THR.

Osteochondral mosaicplasty of the femoral head

Young adults with osteochondral lesions of the femoral head are at risk of rapid progression to symptomatic arthritis of the hip joint. Between January 2008 and July 2009, 10 patients were treated for femoral cartilage damage by a osteochondral mosaicplasty of the femoral head through a trochanteric flap with dislocation of the hip. The consecutive series had the following exclusion criteria: acetabular chondropathy, age above 25 years, and femoral head osteonecrosis. Patients were followed up after surgery using the Oxford-12 score, Harris hip score and the Merle d'Aubigné score, and activity assessed by the UCLA and Devane scores. Radiological evaluation by computed tomographic (CT) arthrography was undertaken in all patients at 6 months and plain radiographs. Mean follow-up was 29.2 months (20-39 months). The Postel Merle d'Aubigné score improved from the pre-operative period to the latest follow-up, from 10.5 points (8-13) to 15.5 points (12-17). Global range of motion increased from 175.4° (140-215) to 210.7° (175-240). All radiological investigations at latest follow-up showed that the autograft plugs were well-incorporated at the site of osteochondroplasty in the femoral head with intact cartilage over them and smooth interfaces between articulating bony surfaces. Osteochondral autograft transplantation may be a new alternative option for osteochondral lesions of the femoral head, but this has to be confirmed with longer follow-up and in a larger number of patients. The results of similar surgery in the knee have been mixed, and in the hip the technique is demanding, requiring familiarity with surgical hip dislocation.

Long-term results of cementless femoral reconstruction following intertrochanteric osteotomy

PURPOSE

The objective of this retrospective cohort study was to assess the long-term outcome of cementless femoral reconstruction in patients with previous intertrochanteric osteotomy (ITO).

METHODS

We evaluated the clinical and radiographic results of a consecutive series of 45 patients (48 hips, mean age 50 years) who had undergone conversion hip replacement following ITO with a cementless, grit-blasted, double-tapered femoral component. Clinical outcome was determined using the Harris hip score. Stem survival for different end points was assessed using Kaplan-Meier survivorship analysis.

RESULTS

At a mean follow-up of 20 (range, 16-24) years, 11 patients (12 hips) had died, and no patient was lost to follow-up. Six patients (six hips) underwent femoral revision, two for infection, three for aseptic loosening and one for periprosthetic fracture. Mean Harris hip score at final follow-up was 78 points (range, 23-100 points). Stem survival for all revisions was 89% (95%CI, 75-95) at 20 years, and survival for aseptic loosening was 93% (95%CI, 80-98).

CONCLUSIONS

The long-term results with this type of cementless femoral component in patients with previous intertrochanteric osteotomy are encouraging and compare well to those achieved in patients with normal femoral anatomy.

Algorithm for femoral and periacetabular osteotomies in complex hip deformities

BACKGROUND

Residual acetabular dysplasia of the hip in most patients can be corrected by periacetabular osteotomy. However, some patients have intraarticular abnormalities causing insufficient coverage, containment or congruency after periacetabular osteotomy, or extraarticular abnormalities that limit either acetabular correction or hip motion. For these patients, we believe an additional proximal femoral osteotomy can improve coverage, containment, congruency and/or motion.

PURPOSES

We provide algorithms for (1) identifying patients we believe will benefit from proximal femoral osteotomy, (2) selecting the appropriate osteotomy, and (3) choosing the sequence of these osteotomies.

METHODS

Anteroposterior, false-profile and functional radiographs and MR can identify most patients we believe will benefit from periacetabular and femoral osteotomies. Recently described techniques, including relative femoral neck lengthening, femoral neck osteotomy and femoral head osteotomy have expanded indications for a combined procedure. Historically performed first, periacetabular osteotomy is now frequently performed following femoral osteotomy.

RESULTS

The rate of intertrochanteric osteotomy performed with periacetabular osteotomy has decreased from approximately 10% in the first 500 surgeries to about 2% currently. Among 151 relative neck lengthenings (23 with PAO), 53 femoral neck osteotomies (4 with PAO) and 14 femoral head osteotomies (11 with PAO), eleven complications occurred including osteonecrosis in two and delayed unions in eight. No complication occurred following a combined procedure.

CONCLUSION

Although isolated periacetabular osteotomy can provide sufficient coverage, containment and congruency for most patients with residual hip dysplasia, some may benefit from an additional proximal femoral osteotomy. Knowing the appropriate indications, selection, and sequencing of these osteotomies is critical for enhancing patient outcomes.

Total hip arthroplasty after failed treatment for osteonecrosis of the femoral head

This article presents results for total hip arthroplasty after failed transtrochanteric rotational osteotomy according to Sugioka and after failed bone impaction grafting, both initially performed for osteonecrosis of the femoral head. After a minimal follow-up of 2 years, 33 hips were studied. In total hip arthroplasty after failed osteotomy, when compared with total hip arthroplasty after failed bone impaction grafting, clinical and radiologic outcome was less favorable, more complications were observed, and there was a higher revision rate for a technically more demanding procedure.

Combined intra-articular and varus opening wedge osteotomy for lateral depression and valgus malunion of the proximal part of the tibia

BACKGROUND

Reconstructive surgical measures for treatment of posttraumatic deformities of the lateral tibial plateau are seldom reported on in the literature. We report the long-term follow-up results of a consecutive series of reconstructive osteotomies performed to treat depression and valgus malunions of the proximal part of the tibia.

METHODS

From 1977 through 1998, a combination of an intra-articular elevation and a lateral opening wedge varus osteotomy of the proximal part of the tibia was performed in twenty-three consecutive patients. The patients were assessed clinically and radiographically at a minimum of five years postoperatively.

RESULTS

A correction of the intra-articular depression and the valgus malalignment was achieved and the anatomic lower-extremity axis was restored in all patients. The clinical results were evaluated at a mean of thirteen years (range, two to twenty-six years) after the reconstructive osteotomy. Two patients had an early failure and were considered to have had a poor result. Two other patients had severe progression of osteoarthritis after the osteotomy, four had slight progression, and fifteen had no progression. There were no nonunions. There were two superficial wound infections, which were treated successfully without surgical intervention. According to the scale of Lysholm and Gillquist, the subjective result was excellent for seventeen patients (74%), good for three, fair for one, and poor for two.

CONCLUSIONS

A knee-joint-preserving osteotomy can provide satisfactory results in active patients with painful posttraumatic lateral depression and valgus malunion of the proximal part of the tibia.

Awareness and use of intertrochanteric osteotomies in current clinical practice. An international survey

Current literature shows that intertrochanteric osteotomies can produce excellent results in selected hip disorders in specific groups of patients. However, it appears that this surgical option is considered an historical one that has no role to play in modern practice. In order to examine current awareness of and views on intertrochanteric osteotomies among international hip surgeons, an online survey was carried out. The survey consisted of a set of questions regarding current clinical practice and awareness of osteotomies. The second part of the survey consisted of five clinical cases and sought to elicit views on preoperative radiological investigations and preferred (surgical) treatments. The results of our survey showed that most of these experts believe that intertrochanteric osteotomies should still be performed in selected cases. Only 56% perform intertrochanteric osteotomies themselves and of those, only 11% perform more than five per year. The responses to the cases show that about 30–40% recommend intertrochanteric osteotomies in young symptomatic patients. This survey shows that the role of intertrochanteric osteotomies is declining in clinical practice.

Varus rotational osteotomies for adults with hip dysplasia: a 20-year followup

Untreated hip dysplasia predisposes young adults to early arthritis. Varus rotational osteotomies are considered one option to delay or eliminate total hip arthroplasty. We update a report from 1991 by retrospectively reviewing 40 of 48 patients (83.3%) who had 45 varus rotational osteotomies from 1971 to 1986 with a minimum followup of 15 years (mean, 22.6 years; range, 15-34 years). Results were assessed using Hospital for Special Surgery hip scores and radiographic parameters. The average age of the patients at followup was 57.2 years (range, 38-81 years). Fourteen patients (35%) (16 hips) had no additional procedures at 21.2 years followup (range, 15-27 years). The average Hospital for Special Surgery hip score was 33.7 with a Tönnis scale of 1.7 (mild-moderate osteoarthritis). Twenty-six patients (65%) (29 hips) had total hip arthroplasties an average of 9.75 years (range, 2-27 years) after varus rotational osteotomy. As in the initial study, the degree of preoperative osteoarthritis was a predictive value for success of the varus rotational osteotomy. Additionally, younger patients with minimal hip subluxation and osteoarthritis, and a better preoperative Hospital for Special Surgery hip score were predictors of success.