International Orthopaedics (SICOT) DOI 10.1007/s00264-015-2865-9
ORIGINAL PAPER
Oblique femoral shortening osteotomy in total hip arthroplasty for high dislocation in patients with hip dysplasia Luigi Zagra 1 & Luca Bianchi 1 & Andrea Mondini 1 & Roberto Giacometti Ceroni 1
Received: 1 April 2015 / Accepted: 23 April 2015 # SICOT aisbl 2015
Abstract Purpose The aim of this study was to evaluate outcomes after implantation of total hip arthroplasty for developmental dysplasia with high dislocation of the hip using conical stems combined with oblique subtrochanteric shortening osteotomy. Methods We retrospectively reviewed the functional scores, radiographic results, and complications in a consecutive series of 16 hips (12 patients) with Crowe IV developmental dysplasia of the hip. The average age at surgery was 53.2 years and the patients were operated on between 1999 and 2008. Results The average Harris Hip Score improved from 37.2 to 83.7 at a mean follow-up of 8.7 years. All acetabular cups were inserted into the true acetabulum and all prosthetic components were stable at the last follow-up visit. No neurovascular damage was recorded. Complications arose in six hips (37.5 %): intra-operative fracture of proximal femur requiring fixation (n=2); dislocation (n=3); and asymptomatic non-union of the osteotomy (n=1). The osteotomy healed within less than six months in all the remaining cases. Conclusions With the numbers given the oblique femur shortening osteotomy led to an increased rotational stability and proved to be a simple and effective method. Compared with transverse osteotomy and as related to our experience, this technique may be a method of choice in selected cases.
Keywords Congenital dislocation . Hip . Crowe type IV . Total hip arthroplasty . Shortening osteotomy . Oblique osteotomy
* Luca Bianchi [email protected] 1
Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
Introduction Total hip arthroplasty (THA) is the procedure of choice for many patients with symptomatic hip arthritis secondary to hip dysplasia [1]. The anatomical abnormalities associated with hip dysplasia, particularly in high dislocation, increase the complexity of THA. In severely dysplastic hips (Crowe type IV), repositioning of the hip into the anatomical centre of rotation is essential to ensure durable results and correct function of the abductor muscles [2, 3]; however, it is associated with an elevated risk of complications due to limb lengthening [4–6]. Lengthening of more than 4 cm can endanger the integrity of neurovascular structures [5, 6]. Moreover, stretching of peri-articular structures (muscles, tendons, ligaments) can lead to joint stiffness and early loosening of the implant [7]. Femoral shortening osteotomy can reduce these tension forces by facilitating reduction of the hip joint, reducing the risk of neurological traction injury and leg length discrepancy [8]. Shortening osteotomy has been described at different anatomical levels—subtrochanteric [8–13], the middle shaft (more rarely) [14] and distally [15]—and by different surgical techniques: Z-shaped [16–18], transverse [11, 19, 20] and chevron-shaped [21–23]; each of these techniques has advantages and disadvantages. Though quite a simple technique, rotational stability of a transverse osteotomy may be of concern [24, 25]. Other surgical techniques ensure greater stability and increased bone contact area, but are technically more demanding. Straight conical stems appear to be highly suitable for implantation in dysplastic narrow femoral canals [7, 9, 16, 20, 21, 26] as they allow for distal fixation and provide good stability of the osteotomy in most cases. Since 1999, we have performed oblique subtrochanteric osteotomy combined with conical stem implantation. This type of bone cutting improves rotational stability, compared
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with transverse cutting, and can favour bone healing by increasing the contact surface of the fragments. This relatively simple technique is performed with two parallel cuts. The first study using a similar technique was published by Reikeras et al. [27] in 2010. The aim of this study was to evaluate the validity of this technique by reviewing the clinical and radiological outcomes, and identifying the complications and problems that occurred in this series.
Patients and methods We retrospectively reviewed the outcomes in 16 hips with Crowe type IV developmental dysplasia of the hip (DDH) after THA combined with oblique femoral shortening osteotomy at our Institute between 1999 and 2008. Clinical data The patient series comprised 12 patients (11 women and 1 man; 4 cases of bilateral DDH); the average duration of follow-up was 8.7 years (range, 4–13); the mean age at the time of the operation was 53.2 years (range, 34–70). Before the surgery and at the last follow-up visit, clinical and radiographic assessment and detailed surgical history data were collected: prior operations (previous femoral osteotomy in 5 hips in 4 patients), operative data (surgical approach, implant type and size, type of coupling, use of screws on the acetabular side, amount of femoral resection, and use of internal fixation at the site of the osteotomy) and complications. Clinical evaluation included calculation of Harris Hip Score and assessment of ambulation to determine the presence of a limp. X-ray studies of the pelvis in the supine position and a true lateral view of the hip were obtained to evaluate the position of the acetabular component, healing of the osteotomy and the presence of a radiolucent line around the implant. No patients were lost to follow-up. Surgical technique Pre-operative planning with the help of templates is performed to approximately define the implant size, lengthening due to distal movement of the rotation centre and, therefore, the amount of femoral resection needed (Fig. 1). The posterolateral approach was used in all procedures. After neck resection and removal of the hypertrophic capsule, the first step is to prepare the acetabulum, in which the obturatum foramen and the residual pulvinar serve as landmarks. A cementless hemispherical press-fit cup (range, 42–46 mm) is inserted into the true paleo-acetabulum in all hips. Due to the life-long lack of joint function, the true acetabulum is small and shows trophic
Fig. 1 Bilateral Crowe type IV dysplasia of a 45-year–old woman. a Digital templating on antero-posterior radiograph with reference ball. The expected lengthening was 65 mm and the amount of planned femoral shortening was 25 mm. b X-rays at ten months’ follow-up shows the repositioning of the hip into the anatomic centre of rotation and the complete healing at the osteotomy site
changes. Additional screws are placed to achieve primary implant stability in two cases. After implantation of the acetabular component, the femur is placed at 90° of internal rotation and the medullary canal is prepared with sequential reaming so as to best fit it to the shape and size of the femoral component. Muscular tension and lengthening are evaluated with the aid of a trial component. After removal of the trial component, the subtrochanteric area is exposed and the oblique osteotomy is marked. The first cut of the osteotomy is made approximately 1 cm distal to the lesser trochanter in an upward lateral direction, at an angle approximately 45° relative to the longitudinal axis of the femur. The second cut is distal and parallel to the first cut according to pre-operative planning. The shortening resection is usually between 2 and 6 cm. Care should be taken to perform the resection less than the one planned, obtaining the final resection with a second parallel osteotomy if necessary. This expedient avoids the risk of excessive resection and joint instability. The diaphyseal fragment is then prepared by reaming. The joint is reduced with the trial component to check the tension of periprosthetic tissues, the stability of the joint, and the range of motion. The joint is then reduced, and
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hip abduction and external rotation are checked for possible impingement between the greater trochanter and the iliac or ischiatic bone. The posterior margin of the greater trochanter is resected in case of impingement. In this patient series, two types of conical shaped stems were used: a modular femoral component (Modulus; Lima Corporate, S. Daniele del Friuli, Italy) in 13 hips and a conical monoblock stem (Conus; Zimmer, Warsaw, IN, USA) in three. The monoblock stem comes in smaller sizes, thus affording a better fit within a very narrow medullary canal, which is sometimes present in this type of patient. In addition, modularity allows easier control of anteversion and off-set. A ceramic-on-ceramic coupling was implanted in one hip (34-year-old woman), ceramic-on-crosslinked-polyethylene in six hips and ceramic-on-standard-polyethylene implants in the remaining nine hips. The implant head diameter was 28 mm. One important advantage of oblique osteotomy is the increased rotational stability compared with the transverse technique. The osteotomy showed sufficient stability in 11 hips, so that no internal fixation was necessary. Additional fixation with cables was necessary to stabilise the proximal to the distal part of the femur in four hips. Fracture of the trochanteric area during the operation in two cases required more complex fixation (Fig. 2). If the congruency of the osteotomy site was not complete, it was filled with autologous bone graft chips taken from the resected head. In five cases requiring correction of the axis of the femur owing to previous surgeries, the resected bone was not cut in a parallel way, so as to restore the anatomical shaft axis, without compromising the congruency of the osteotomy. During the first three postoperative months, partial weightbearing (15–20 kg) with crutches was allowed. Gradual progression to full weight-bearing was permitted over the following weeks on the basis of radiographic evidence of healing at the osteotomy site.
Fig. 2 a Female patient of 49 years old with Crowe type IV dysplasia at the left side. b Postoperative X-ray shows intraoperative fracture of trochanteric area synthesised with cables. Congruency of the osteotomy site was complete. c X-rays at 13 months follow-up shows the healing of both osteotomy site and great-trochanter region
Radiographic analysis At the last follow-up visit we examined the hips for the presence of wear and osteolysis. Component loosening was evaluated according to the method described by DeLee and Charnley [28] for the acetabulum and by Gruen et al. [29] for the femur. Healing of the osteotomy was assessed according to the following radiological criteria: callus formation at the osteotomy site, restoration of continuity of the cortical bone and gradual disappearance of radiolucent lines between the fragments. Each author certifies that all investigations were conducted in conformity with ethical principles of research, and in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national).
Results Clinical outcomes At a mean follow-up of 8.7 years (range, 4–13) the Harris Hip Score improved from 37.2 (range, 24–58) before-surgery to 83.7 (65–97) after surgery. This increase was statistically significant (p=0.004, Wilcoxon’s test). Before the operation, severe limp was present in ten hips and moderate in six. No patients had slight or absent limp. After the operation, limp (evaluated according Harris Hip Score) was moderate in four hips, slight in eight and absent in four. The improvement in overall limp was statistically significant (p=0.003, Wilcoxon’s Test). X-rays Post-operative X-rays confirmed the correct position of the cup in the true acetabulum in all hips and no signs of
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component loosening were observed at the last follow-up visit in any of the hips. The osteotomy healed within less than six months in all patients but one. Complications No neurological or vascular complications were recorded. At the beginning of the series, a fracture of the proximal fragment in two hips required internal fixation with cerclages. Subsequent to these events, the osteotomy was performed more distally, about 1 cm below the lesser trochanter, and no other fracture events occurred. One case of non-union of the osteotomy occurred; the patient is now fully asymptomatic and no further surgery has been proposed. Other complications involved three dislocations within the first three postoperative months, two of which were treated with closed reduction and abduction bracing for two months. One, because it could not be resolved with closed reduction, required open reduction. During the procedure, the femoral head was replaced with a longer neck, and no recurrence of dislocation occurred. No other re-operations or revisions were necessary.
Discussion In THA for high DDH, satisfactory results have been achieved with placement of the cup into the true acetabulum [2, 3] and femoral shortening osteotomy [8, 20, 27]; however, this type of surgery is technically more demanding and the complications rate is higher than with a standard primary procedure [19, 24, 27]. The most frequent complications are intraoperative fracture, non-union at the osteotomy site, dislocations, limp, neurovascular injury and early implant failure. Here we reviewed the functional scores, complications rate and implant survivorship in a series of patients with high DDH reconstructed using straight conical stems combined with oblique subtrochanteric osteotomy. This retrospective study evaluated the short- and mid-term results in a small group of patients operated on at a single institution. These limitations notwithstanding, the study strengths are that we used the same surgical technique and two different stems, but with the same conical design suitable for press-fit insertion (Modulus in 13 hips and Conus in 3 hips). The majority of studies have reported on the use of different surgical techniques with different implant designs in the evaluation of mixed groups of cemented and cementless implants. In their well-conducted retrospective study, Krych et al. [8] evaluated cementless reconstruction combined with subtrochanteric osteotomy in 28 hips. Their preferred procedure was transverse osteotomy (step-cut osteotomy in only one case) combined with a variety of femoral implants; nonunion at the osteotomy site occurred in two cases (7 %) and fractures in five cases (18 %); the average Harris Hip Score
was 89. They attributed the cause of fractures to the attempt to achieve greater rotational stability of the implant and to the level of the osteotomy site with a tight press-fit of the prosthesis. Also, Reikerås et al. [27] considered the non-healing of the osteotomy to be a consequence of an implant that does not ensure adequate rotational stability. They prospectively evaluated 46 patients at an average follow-up of 13 years. In all hips, they used a straight press-fit stem combined with two different types of osteotomies: oblique in 41 hips and step cut in 24 hips. They found two cases of non-union, but only one of which required further surgery, and no cases of fracture. The mean Harris Hip Score was 87. Since 1999, we have combined simple oblique subtrochanteric osteotomy with straight conical stem implantation. Compared with transverse osteotomy, this type of bone cutting can improve rotational stability and can favour bone healing by increasing the contact surface of the fragments. The technique is quite easy to execute with two parallel cuts. Another advantage is that the amount of resection can be easily and gradually increased by removing more bone with a parallel cut. The main goal of this shortening osteotomy is to minimise the risk of the neurological or vascular damage and soft tissue tension, which inevitably lead to joint stiffness, whereas the effect of reduced leg length discrepancy is only secondary. The factors influencing the amount of resection are the need to avoid joint stiffness and to achieve good joint stability without excessive soft tissue release around the hip. Straight conical stems appear to be very suitable in cases with a dysplastic narrow femoral canal [30–32] as they allow for stem fixation at the diaphyseal level under the osteotomy site. The compression of the fragments exerted by the stem binds the osteotomy so that stabilisation is generally not required. Modularity is an additional advantage in such complex cases as it allows to conceptually separate system stability from anatomic restoration (length, anteversion of the neck, off-set). THA in high dislocated hips is a demanding procedure for surgeons as it poses technical challenges and more risks. The incidence of complications is higher than in standard cases, with intra-operative fracture rates from 5 to 22 % [2, 9, 33, 34] and non-union rates from 8 to 29 % [2, 35, 36]. In our series, one case of non-union was recorded that was asymptomatic and required no further surgery. At the beginning of the sequence, when we performed proximal osteotomy immediately below the lesser trochanter, two cases of proximal fragment fracture occurred. To obtain a stronger fragment and prevent the recurrence of fracture, we subsequently performed osteotomy more distally, approximately 1 cm under the lesser trochanter. Following this change in technique, no other cases of fracture occurred. Another complication was dislocation in three hips. No episodes of neurovascular injury were noted in this sequence. In summary, this type of oblique femoral shortening osteotomy proved quite simple and effective in avoiding
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major lengthening-related complications. The conical stems provided stable and durable fixation to the bone at mid-term follow-up.
16.
17. Conflicts of interest None. 18.
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Decking J, Decking R, Schoellner C et al (2003) Cementless total hip replacement with subtrochanteric femoral shortening for severe developmental dysplasia of the hip. Arch Orthop Trauma Surg 123: 356–362 Takao M, Ohzono K, Nishii T, Miki H, Nakamura N, Sugano N (2011) Cementless modular total hip arthroplasty with subtrochanteric shortening osteotomy for hips with developmental hip dysplasia. J Bone Joint Surg Am 93(6):548–555 Neumann DR, Dorn U (2007) Total hip replacement in high total hip dislocation by performing a Z-shaped shortening osteotomy. Z Orthop Ihre Grenzgeb 145(1):68–73 Howie CR, Ohly NE, Miller B (2010) Cemented total hip arthroplasty with subtrochanteric osteotomy in dysplastic hips. Clin Orthop Relat Res 468:3240–3247 Yasgur DJ, Stuchin SA, Adler EM, DiCesare PE (1997) Subtrochanteric shortening osteotomy in total hip arthroplasty for high-riding developmental dislocation of the hip. J Arthroplasty 12: 880–888 Becker DA, Gustilo RB (1995) Double-chevron subtrochanteric shortening derotational femoral osteotomy combined with total hip arthroplasty for the treatment of complete congenital dislocation of the hip in the adult. Preliminary report and description of a new surgical technique. J Arthroplasty 10:313–318 Hotokebuchi T, Sonohata M, Shigematsu M et al (2006) A new device for a v-shaped subtrochanteric osteotomy combined with total hip arthroplasty. J Arthroplasty 21:135 Sonohata M, Tajima T, Kitajima M, Ogawa K, Kawano S, Mawatari M, Hotokebuchi T (2012) Total hip arthroplasty combined with double-chevron subtrochanteric osteotomy. J Orthop Sci 17:382–389 Kiliçoģlu O, Türker M, Akgül T, Yazicioģlu O (2013) Cementless total hip arthroplasty with modified oblique femoral shortening osteotomy in Crowe type IV congenital hip dislocation. J Arthroplasty 28:117–125 Paavilainen T, Hoikka V, Solonen KA (1990) Cementless total replacement for severly dysplastic or dislocated hips. J Bone Joint Surg (Br) 72:205 Nagoya S, Kaya M, Sasaki M et al (2009) Cementless total hip replacement with subtrochanteric femoral shortening for severe developmental dysplasia of the hip. J Bone Joint Surg (Br) 91-B: 1142–1147 Reikerås O, Haaland JE, Lereim P (2010) Femoral shortening in total hip arthroplasty for high developmental dysplasia of the hip. Clin Orthop Relat Res 468:1949–1955 DeLee J, Charnley J (1976) Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop Relat Res 121:20–32 Gruen TA, McNeice GM, Amstutz HC (1979) BModes of failure^ of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop 141:17 Wagner H, Wagner M (2000) Cone prosthesis for the hip joint. Arch Orthop Trauma Surg 120:88–95 Faldini C, Nanni M, Leonetti D, Miscione MT, Acri F, Giannini S (2011) Total hip arthroplasty in developmental hip dysplasia using cementless tapered stem. Results after a minimum 10-years followup. Hip Int 21:415–420 Benazzo F, Cuzzocrea F, Stroppa S, Ravasi F, Dalla Pria P (2007) Modular stems in DDH. Hip Int 17(Suppl 5):S138– S141 Bruce WJ, Rizkallah SM, Kwon YM, Golberg JA, Walsh WR (2000) A new technique of sub-trochanteric shortening in total hip arthroplasty: surgical technique and results of 9 cases. J Arthroplasty 15:617–626 Kim YH, Seo HS, Kim JS (2009) Outcomes after THA in patients with high hip dislocations after childhood sepsis. Clin Orthop Relat Res 467:2371–2378
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ORIGINAL PAPER
Oblique femoral shortening osteotomy in total hip arthroplasty for high dislocation in patients with hip dysplasia Luigi Zagra 1 & Luca Bianchi 1 & Andrea Mondini 1 & Roberto Giacometti Ceroni 1
Received: 1 April 2015 / Accepted: 23 April 2015 # SICOT aisbl 2015
Abstract Purpose The aim of this study was to evaluate outcomes after implantation of total hip arthroplasty for developmental dysplasia with high dislocation of the hip using conical stems combined with oblique subtrochanteric shortening osteotomy. Methods We retrospectively reviewed the functional scores, radiographic results, and complications in a consecutive series of 16 hips (12 patients) with Crowe IV developmental dysplasia of the hip. The average age at surgery was 53.2 years and the patients were operated on between 1999 and 2008. Results The average Harris Hip Score improved from 37.2 to 83.7 at a mean follow-up of 8.7 years. All acetabular cups were inserted into the true acetabulum and all prosthetic components were stable at the last follow-up visit. No neurovascular damage was recorded. Complications arose in six hips (37.5 %): intra-operative fracture of proximal femur requiring fixation (n=2); dislocation (n=3); and asymptomatic non-union of the osteotomy (n=1). The osteotomy healed within less than six months in all the remaining cases. Conclusions With the numbers given the oblique femur shortening osteotomy led to an increased rotational stability and proved to be a simple and effective method. Compared with transverse osteotomy and as related to our experience, this technique may be a method of choice in selected cases.
Keywords Congenital dislocation . Hip . Crowe type IV . Total hip arthroplasty . Shortening osteotomy . Oblique osteotomy
* Luca Bianchi [email protected] 1
Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
Introduction Total hip arthroplasty (THA) is the procedure of choice for many patients with symptomatic hip arthritis secondary to hip dysplasia [1]. The anatomical abnormalities associated with hip dysplasia, particularly in high dislocation, increase the complexity of THA. In severely dysplastic hips (Crowe type IV), repositioning of the hip into the anatomical centre of rotation is essential to ensure durable results and correct function of the abductor muscles [2, 3]; however, it is associated with an elevated risk of complications due to limb lengthening [4–6]. Lengthening of more than 4 cm can endanger the integrity of neurovascular structures [5, 6]. Moreover, stretching of peri-articular structures (muscles, tendons, ligaments) can lead to joint stiffness and early loosening of the implant [7]. Femoral shortening osteotomy can reduce these tension forces by facilitating reduction of the hip joint, reducing the risk of neurological traction injury and leg length discrepancy [8]. Shortening osteotomy has been described at different anatomical levels—subtrochanteric [8–13], the middle shaft (more rarely) [14] and distally [15]—and by different surgical techniques: Z-shaped [16–18], transverse [11, 19, 20] and chevron-shaped [21–23]; each of these techniques has advantages and disadvantages. Though quite a simple technique, rotational stability of a transverse osteotomy may be of concern [24, 25]. Other surgical techniques ensure greater stability and increased bone contact area, but are technically more demanding. Straight conical stems appear to be highly suitable for implantation in dysplastic narrow femoral canals [7, 9, 16, 20, 21, 26] as they allow for distal fixation and provide good stability of the osteotomy in most cases. Since 1999, we have performed oblique subtrochanteric osteotomy combined with conical stem implantation. This type of bone cutting improves rotational stability, compared
International Orthopaedics (SICOT)
with transverse cutting, and can favour bone healing by increasing the contact surface of the fragments. This relatively simple technique is performed with two parallel cuts. The first study using a similar technique was published by Reikeras et al. [27] in 2010. The aim of this study was to evaluate the validity of this technique by reviewing the clinical and radiological outcomes, and identifying the complications and problems that occurred in this series.
Patients and methods We retrospectively reviewed the outcomes in 16 hips with Crowe type IV developmental dysplasia of the hip (DDH) after THA combined with oblique femoral shortening osteotomy at our Institute between 1999 and 2008. Clinical data The patient series comprised 12 patients (11 women and 1 man; 4 cases of bilateral DDH); the average duration of follow-up was 8.7 years (range, 4–13); the mean age at the time of the operation was 53.2 years (range, 34–70). Before the surgery and at the last follow-up visit, clinical and radiographic assessment and detailed surgical history data were collected: prior operations (previous femoral osteotomy in 5 hips in 4 patients), operative data (surgical approach, implant type and size, type of coupling, use of screws on the acetabular side, amount of femoral resection, and use of internal fixation at the site of the osteotomy) and complications. Clinical evaluation included calculation of Harris Hip Score and assessment of ambulation to determine the presence of a limp. X-ray studies of the pelvis in the supine position and a true lateral view of the hip were obtained to evaluate the position of the acetabular component, healing of the osteotomy and the presence of a radiolucent line around the implant. No patients were lost to follow-up. Surgical technique Pre-operative planning with the help of templates is performed to approximately define the implant size, lengthening due to distal movement of the rotation centre and, therefore, the amount of femoral resection needed (Fig. 1). The posterolateral approach was used in all procedures. After neck resection and removal of the hypertrophic capsule, the first step is to prepare the acetabulum, in which the obturatum foramen and the residual pulvinar serve as landmarks. A cementless hemispherical press-fit cup (range, 42–46 mm) is inserted into the true paleo-acetabulum in all hips. Due to the life-long lack of joint function, the true acetabulum is small and shows trophic
Fig. 1 Bilateral Crowe type IV dysplasia of a 45-year–old woman. a Digital templating on antero-posterior radiograph with reference ball. The expected lengthening was 65 mm and the amount of planned femoral shortening was 25 mm. b X-rays at ten months’ follow-up shows the repositioning of the hip into the anatomic centre of rotation and the complete healing at the osteotomy site
changes. Additional screws are placed to achieve primary implant stability in two cases. After implantation of the acetabular component, the femur is placed at 90° of internal rotation and the medullary canal is prepared with sequential reaming so as to best fit it to the shape and size of the femoral component. Muscular tension and lengthening are evaluated with the aid of a trial component. After removal of the trial component, the subtrochanteric area is exposed and the oblique osteotomy is marked. The first cut of the osteotomy is made approximately 1 cm distal to the lesser trochanter in an upward lateral direction, at an angle approximately 45° relative to the longitudinal axis of the femur. The second cut is distal and parallel to the first cut according to pre-operative planning. The shortening resection is usually between 2 and 6 cm. Care should be taken to perform the resection less than the one planned, obtaining the final resection with a second parallel osteotomy if necessary. This expedient avoids the risk of excessive resection and joint instability. The diaphyseal fragment is then prepared by reaming. The joint is reduced with the trial component to check the tension of periprosthetic tissues, the stability of the joint, and the range of motion. The joint is then reduced, and
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hip abduction and external rotation are checked for possible impingement between the greater trochanter and the iliac or ischiatic bone. The posterior margin of the greater trochanter is resected in case of impingement. In this patient series, two types of conical shaped stems were used: a modular femoral component (Modulus; Lima Corporate, S. Daniele del Friuli, Italy) in 13 hips and a conical monoblock stem (Conus; Zimmer, Warsaw, IN, USA) in three. The monoblock stem comes in smaller sizes, thus affording a better fit within a very narrow medullary canal, which is sometimes present in this type of patient. In addition, modularity allows easier control of anteversion and off-set. A ceramic-on-ceramic coupling was implanted in one hip (34-year-old woman), ceramic-on-crosslinked-polyethylene in six hips and ceramic-on-standard-polyethylene implants in the remaining nine hips. The implant head diameter was 28 mm. One important advantage of oblique osteotomy is the increased rotational stability compared with the transverse technique. The osteotomy showed sufficient stability in 11 hips, so that no internal fixation was necessary. Additional fixation with cables was necessary to stabilise the proximal to the distal part of the femur in four hips. Fracture of the trochanteric area during the operation in two cases required more complex fixation (Fig. 2). If the congruency of the osteotomy site was not complete, it was filled with autologous bone graft chips taken from the resected head. In five cases requiring correction of the axis of the femur owing to previous surgeries, the resected bone was not cut in a parallel way, so as to restore the anatomical shaft axis, without compromising the congruency of the osteotomy. During the first three postoperative months, partial weightbearing (15–20 kg) with crutches was allowed. Gradual progression to full weight-bearing was permitted over the following weeks on the basis of radiographic evidence of healing at the osteotomy site.
Fig. 2 a Female patient of 49 years old with Crowe type IV dysplasia at the left side. b Postoperative X-ray shows intraoperative fracture of trochanteric area synthesised with cables. Congruency of the osteotomy site was complete. c X-rays at 13 months follow-up shows the healing of both osteotomy site and great-trochanter region
Radiographic analysis At the last follow-up visit we examined the hips for the presence of wear and osteolysis. Component loosening was evaluated according to the method described by DeLee and Charnley [28] for the acetabulum and by Gruen et al. [29] for the femur. Healing of the osteotomy was assessed according to the following radiological criteria: callus formation at the osteotomy site, restoration of continuity of the cortical bone and gradual disappearance of radiolucent lines between the fragments. Each author certifies that all investigations were conducted in conformity with ethical principles of research, and in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national).
Results Clinical outcomes At a mean follow-up of 8.7 years (range, 4–13) the Harris Hip Score improved from 37.2 (range, 24–58) before-surgery to 83.7 (65–97) after surgery. This increase was statistically significant (p=0.004, Wilcoxon’s test). Before the operation, severe limp was present in ten hips and moderate in six. No patients had slight or absent limp. After the operation, limp (evaluated according Harris Hip Score) was moderate in four hips, slight in eight and absent in four. The improvement in overall limp was statistically significant (p=0.003, Wilcoxon’s Test). X-rays Post-operative X-rays confirmed the correct position of the cup in the true acetabulum in all hips and no signs of
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component loosening were observed at the last follow-up visit in any of the hips. The osteotomy healed within less than six months in all patients but one. Complications No neurological or vascular complications were recorded. At the beginning of the series, a fracture of the proximal fragment in two hips required internal fixation with cerclages. Subsequent to these events, the osteotomy was performed more distally, about 1 cm below the lesser trochanter, and no other fracture events occurred. One case of non-union of the osteotomy occurred; the patient is now fully asymptomatic and no further surgery has been proposed. Other complications involved three dislocations within the first three postoperative months, two of which were treated with closed reduction and abduction bracing for two months. One, because it could not be resolved with closed reduction, required open reduction. During the procedure, the femoral head was replaced with a longer neck, and no recurrence of dislocation occurred. No other re-operations or revisions were necessary.
Discussion In THA for high DDH, satisfactory results have been achieved with placement of the cup into the true acetabulum [2, 3] and femoral shortening osteotomy [8, 20, 27]; however, this type of surgery is technically more demanding and the complications rate is higher than with a standard primary procedure [19, 24, 27]. The most frequent complications are intraoperative fracture, non-union at the osteotomy site, dislocations, limp, neurovascular injury and early implant failure. Here we reviewed the functional scores, complications rate and implant survivorship in a series of patients with high DDH reconstructed using straight conical stems combined with oblique subtrochanteric osteotomy. This retrospective study evaluated the short- and mid-term results in a small group of patients operated on at a single institution. These limitations notwithstanding, the study strengths are that we used the same surgical technique and two different stems, but with the same conical design suitable for press-fit insertion (Modulus in 13 hips and Conus in 3 hips). The majority of studies have reported on the use of different surgical techniques with different implant designs in the evaluation of mixed groups of cemented and cementless implants. In their well-conducted retrospective study, Krych et al. [8] evaluated cementless reconstruction combined with subtrochanteric osteotomy in 28 hips. Their preferred procedure was transverse osteotomy (step-cut osteotomy in only one case) combined with a variety of femoral implants; nonunion at the osteotomy site occurred in two cases (7 %) and fractures in five cases (18 %); the average Harris Hip Score
was 89. They attributed the cause of fractures to the attempt to achieve greater rotational stability of the implant and to the level of the osteotomy site with a tight press-fit of the prosthesis. Also, Reikerås et al. [27] considered the non-healing of the osteotomy to be a consequence of an implant that does not ensure adequate rotational stability. They prospectively evaluated 46 patients at an average follow-up of 13 years. In all hips, they used a straight press-fit stem combined with two different types of osteotomies: oblique in 41 hips and step cut in 24 hips. They found two cases of non-union, but only one of which required further surgery, and no cases of fracture. The mean Harris Hip Score was 87. Since 1999, we have combined simple oblique subtrochanteric osteotomy with straight conical stem implantation. Compared with transverse osteotomy, this type of bone cutting can improve rotational stability and can favour bone healing by increasing the contact surface of the fragments. The technique is quite easy to execute with two parallel cuts. Another advantage is that the amount of resection can be easily and gradually increased by removing more bone with a parallel cut. The main goal of this shortening osteotomy is to minimise the risk of the neurological or vascular damage and soft tissue tension, which inevitably lead to joint stiffness, whereas the effect of reduced leg length discrepancy is only secondary. The factors influencing the amount of resection are the need to avoid joint stiffness and to achieve good joint stability without excessive soft tissue release around the hip. Straight conical stems appear to be very suitable in cases with a dysplastic narrow femoral canal [30–32] as they allow for stem fixation at the diaphyseal level under the osteotomy site. The compression of the fragments exerted by the stem binds the osteotomy so that stabilisation is generally not required. Modularity is an additional advantage in such complex cases as it allows to conceptually separate system stability from anatomic restoration (length, anteversion of the neck, off-set). THA in high dislocated hips is a demanding procedure for surgeons as it poses technical challenges and more risks. The incidence of complications is higher than in standard cases, with intra-operative fracture rates from 5 to 22 % [2, 9, 33, 34] and non-union rates from 8 to 29 % [2, 35, 36]. In our series, one case of non-union was recorded that was asymptomatic and required no further surgery. At the beginning of the sequence, when we performed proximal osteotomy immediately below the lesser trochanter, two cases of proximal fragment fracture occurred. To obtain a stronger fragment and prevent the recurrence of fracture, we subsequently performed osteotomy more distally, approximately 1 cm under the lesser trochanter. Following this change in technique, no other cases of fracture occurred. Another complication was dislocation in three hips. No episodes of neurovascular injury were noted in this sequence. In summary, this type of oblique femoral shortening osteotomy proved quite simple and effective in avoiding
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major lengthening-related complications. The conical stems provided stable and durable fixation to the bone at mid-term follow-up.
16.
17. Conflicts of interest None. 18.
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