1 / 25

Exposure Options for Hip Revision: Trochanteric Osteotomies

Exposure Options for Hip Revision: Trochanteric Osteotomies. Andrew Tice Arthroplasty Rounds April 12, 2012 Credit: Dr. Darwish and Dr. Hamdi. 4 Osteotomy Options. Transverse Trochanteric Osteotomy Trochanteric Slide Osteotomy Modified Trochanteric Slide Osteotomy

lucie
Télécharger la présentation

Exposure Options for Hip Revision: Trochanteric Osteotomies

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Exposure Options for Hip Revision:TrochantericOsteotomies Andrew Tice Arthroplasty Rounds April 12, 2012 Credit: Dr. Darwish and Dr. Hamdi

  2. 4 Osteotomy Options • Transverse TrochantericOsteotomy • Trochanteric Slide Osteotomy • Modified Trochanteric Slide Osteotomy • Extended TrochantericOsteotomy

  3. Common Reasons for Hip Revision • Painful, aseptic loosening of one or both components • Infected total hip arthroplasty • Periprosthetic fracture • Recurrent or irreducible dislocations • Fracture or mechanical failure of implant • Progressive bone loss

  4. Preoperative Planning • Review of operative reports • X-ray analysis for type of prosthesis, amount of bone loss, templating • Equipment checklist may include: • Image intensifier and radiolucent OR table • Stem extraction instruments • Trephine reamers • Flexible osteotomes, curved osteotomes • Gigli saw • Metal-cutting instruments • Trochanteric fixation devices • Pelvic reconstruction screws/plates • Allograft bone (femoral head, struts, or segmental allograft)

  5. Surgical Approaches • Consider previous incisions and possibility of skin necrosis • Less of a problem than in the knee • Anterolateral or direct lateral gluteal-splitting approaches used more commonly for straightforward acetabular revisions • Difficult exposure to posterior column of acetabulum as well as extensile exposure of the femur • Posterolateral approach • Excellent exposure of posterior column and femoral shaft • Anterior acetabular exposure is difficult • Greater risk of dislocation

  6. TrochantericOsteotomies • Transverse Osteotomy • +++ Pelvic Exposure • + Femur Exposure • Trochanteric Slide • ++ Pelvic Exposure • ++Femur Exposure • Extended TrochantericOsteotomy • ++ Pelvic Exposure • +++ Femur Exposure

  7. Transverse Osteotomy • Indications • Complex acetabular revisions • Antiprotrusio cage • Large structural acetabular bone graft • Recurrent dislocation with soft tissue laxity • Intrapelvic migration of acetabular component • Contraindications • Severe osteolysis with inadequate bone bed for reattachment • Advancement of trochanter more than 1 cm distally • Increases risk of non-union

  8. Transverse Osteotomy • Technique • Vastuslateralis divided transversely and retracted distally • Gluteus minimum and medius bluntly elevated off capsule • Osteotomy performed with either oscillating saw, osteotome, or Gigli saw • Single plane osteotomy or Chevron biplane osteotomy • Fragment reflected proximally • Care not to stretch superior gluteal nerve • Fixation options: smooth wire, braided cables, plates plus wires

  9. Transverse Osteotomy • Complications • Non union of the fragment and proximal migration • Rates quoted from 1 to 25% with average around 2-5% • Malunion • Painful Hardware • Persistent limp

  10. Trochanteric Slide • Indications • Isolated acetabular revisions • AcetabuliProtrusio • Femoral revisions when maintaining the integrity of the diaphysis is a necessity • Contraindications • Absence of medial bone for reattachment • Insufficient trochanter thickness, with inadequate bed for repair

  11. Trochanteric Slide • Technique • Similar to Transverse osteotomy, though vastuslateralis is not divided, just lifted distal to origin • Osteotomy from posterior to anterior starting between posterior borders of gluteus medius and minimus, and piriformis and short external rotators • AP width of osteotomy approximately 2 cm • Fragment retracted anteriorly • Reattachment with 2 or 3 double-loop cerclage wires

  12. Trochanteric Slide • Complications • Non-Union • Similar rates as transverse osteotomy, though showed less superior migration more than 1 cm (11% of all nonunions) decreasing rate of abductor insufficiency and limp • Dislocation • Painful Hardware • Limp / Abduction Lurch (7%) • Malunion

  13. Modified Trochanteric Slide • Uses Lateral approach to hip • Osteotomy only extended to 1 cm anterior to insertion of posterior capsule and external rotators • Goal is to reduce risk of dislocation by preserving the posterior structures (4% dislocation rate vs. 14% with standard trochanteric slide)

  14. Extended TrochantericOsteotomy • Indications • Extraction of a well fixed femoral component • Difficult femoral cement removal • Varus remodeling of proximal femur • Avoid lateral cortex perforation • GT bony bed insufficient for healing other osteotomies • Aid in dislocation with extensive soft tissue scarring or HO • Contraindications • No intent of revising the femoral component • Revision with a cemented stem

  15. Extended TrochantericOsteotomy • Technique • Most commonly posterolateral approach • Subperiosteal elevation of VastusLateralis and release of Gluteus Maximus • Osteotomy planned pre-op to at least the level of porous surface of implant, or further for cement mantle • Need to maintain at least 5 cm of isthmicdiaphyseal bone for fixation of new implant. Usually about 12-15 cm from GT

  16. Extended TrochantericOsteotomy • Technique Continued • Osteotomy performed at may different times • Immediately to aid in dislocation, after dislocation, after stem extraction • Posterior to anterior cut • Then transverse cut is made at predetermined level • 1/3 diaphyseal circumference • Rounded corners reduce risk of iatrogenic fractures

  17. Extended TrochantericOsteotomy • Technique Continued • Medial surface of the osteotomy frequently requires burring to accomodate the revision femoral component

  18. Extended TrochantericOsteotomy • Retrospective review of 166 consecutive revision THA involving trochantericosteotomies • Nonunion rate of 1.2% • Mean time to union 12.3 weeks • 153 (92.1%) stems osseointegrated12 (7.2%) stems fibrous stable 1 (0.6%) stem unstable • Overall Complications rate (24%) and Revision Rate (10.2%)

  19. Extended TrochantericOsteotomy • Nonunion: 1-3% • Fractures: 4-20% • Upward Migration of fragment: 0-1.2% • Infection: 1-3% • Subsidence of stem

  20. References • Campbell’s Operative Orthopaedics. 11th ed. • Lakstein , D et al. Trochanteric Slide for Revision Total Hip Arthroplasty: Opening the Barn Door. SeminArthro 2011, 22:107-109. • Gross, A et al. Surgical Exposures for Primary and Revision Total Hip Arthroplasty: Modified Trochanteric Slide. SeminArthro 2004, 15:122-125. • Barrett, WP. Standard TrocantericOsteotomy. SeminArthro 2004, 15: 108-112. • Miner, TM et al. The Extended TrochantericOsteotomy in Revision Hip Arthroplasty. Journal of Arthroplasty 2001, 16:188-194. • Romero, AC et al. Sliding TrochantericOsteotomy Preserves Favorable Abductor Biomechanics in Revision Total Hip Arthroplasty. Journal of Arthroplasty 2001, 16: 55-64. • Mardones, R et al. Extended Femoral Osteotomy for Revision of Hip Arthroplasty. Journal of Arthroplasty 2005, 20: 79-83. • Goodman, S et al. Modified Sliding TrochantericOsteotomy in Revision Total Hip Arthroplasty. Journal of Arthroplasty 2004, 19: 1039-1041.

More Related