Extract
Since the original description of intertrochanteric femoral osteotomies for
the treatment of nonunion of the femoral neck in the middle part of the last
century, the indications for the procedure have expanded. Femoral neck
nonunion remains a valid indication, as does femoral neck malunion. Other
indications include osteonecrosis of the femoral head,
Legg-Calvé-Perthes disease, limb-length inequality, and slipped capital
femoral epiphysis. Developmental dysplasia of the hip may be an indication;
however, modern advances in the techniques of rotational pelvic osteotomy,
either alone or in combination with a femoral osteotomy, have supplanted the
isolated femoral osteotomy as the procedure of choice for the majority of
patients with that disorder.
Since the original description of intertrochanteric femoral osteotomies for
the treatment of nonunion of the femoral neck in the middle part of the last
century, the indications for the procedure have expanded. Femoral neck
nonunion remains a valid indication, as does femoral neck malunion. Other
indications include osteonecrosis of the femoral head,
Legg-Calvé-Perthes disease, limb-length inequality, and slipped capital
femoral epiphysis. Developmental dysplasia of the hip may be an indication;
however, modern advances in the techniques of rotational pelvic osteotomy,
either alone or in combination with a femoral osteotomy, have supplanted the
isolated femoral osteotomy as the procedure of choice for the majority of
patients with that disorder.
Great strides have been made in the field of total hip arthroplasty.
However, the problems of wear-debris generation and osteolysis remain,
particularly for young, active patients. Even an optimal hip replacement is
not expected to survive for the lifetime of a healthy patient younger than
fifty years of
age1-11.
Therefore, total hip replacement, especially in a younger patient, should be
considered an operation of last resort. If an identifiable anatomic and/or
biomechanical abnormality can be diagnosed and corrected, it may be possible
to postpone hip arthroplasty for many years, and even forever in some
patients. Once arthritis is present, an osteotomy may serve as a bridge to
carry the patient safely into the age range appropriate for total joint
replacement, but total hip arthroplasty remains the mainstay of treatment for
advanced hip disease.
As with any surgical undertaking, a detailed preoperative history must be
recorded. Antecedent trauma and prior or current treatment are important
details to elicit. The patient may have vague anterior groin or greater
trochanteric pain that has been treated for years as a "groin
pull" or "trochanteric bursitis." They often describe
difficulties with athletics and endurance. Some may come with radiographs that
have been interpreted by a radiologist as normal despite the presence of
substantial dysplasia.
Before considering a patient for osteotomy, the surgeon must obtain a clear
understanding of the patient's goals and motivation. A complete medical and
social history is thus important, especially in terms of lifestyle and
occupation. Morscher noted that the outcome of an osteotomy in patients whose
occupation requires strenuous labor is not as good as that in patients with a
more sedentary job and
lifestyle12. In
general, it is unrealistic to anticipate that the patient will have an
unlimited capacity for running and impact sports after an osteotomy, as some
degree of irreversible damage to the articular cartilage has usually occurred
prior to the surgery.
A complete evaluation of the patient for sources of pain other than the hip
joint, especially the spine, should be performed. Assessment of the patient's
general health, including the degree of fitness and the presence of obesity,
is also important. The status of the ipsilateral knee and contralateral hip
joints must be evaluated, as should gait, abductor strength (Trendelenburg
sign), and lower-limb length (both actual and apparent). When the hip is
examined, attention must be directed to the presence of contractures and an
exact determination of the range of motion in all planes. Provocative tests
are useful for patients with suspected pathological changes in the labrum of
the hip, including any patient with
dysplasia4,13,14.
These tests include the apprehension test of hip extension and external
rotation as well as the impingement test of flexion-adduction-internal
rotation13,15-20.
The position of maximal comfort for the hip, both at rest and when the patient
is standing, should be determined and correlated with radiographic findings.
For example, a varus osteotomy is contraindicated in a patient with coxa valga
who is uncomfortable when the hip is in abduction and who has radiographic
signs of fixed subluxation.
Radiographic assessment includes both supine and standing anteroposterior
views of the pelvis as well as anteroposterior and frog-limb lateral views of
the involved hip. One of the most useful additional views is the false-profile
radiograph21. This
special oblique view provides the best plain radiographic documentation of the
anterior coverage of the femoral head and is a true lateral view of the
proximal part of the femur.
Functional anteroposterior views of the hip with the femur in abduction or
adduction permit characterization of the joint and demonstration of the
adequacy of motion in the required plane prior to any angular
intertrochanteric osteotomy. Obtaining these views with fluoroscopy with
capture of key images should be considered.
An anteroposterior radiograph with the hip in adduction and flexion
approximates the position of the joint after a valgus-extension
intertrochanteric osteotomy. Since the overall alignment of the lower
extremity will be changed by an osteotomy, a full-length standing radiograph
allows one to measure the biomechanical axis. This allows prediction of the
effect of the surgery on the weight-bearing axis, especially as it may affect
the knee.
Depending on the specific condition being treated, additional views may be
useful. For example, if the intertrochanteric osteotomy is being planned as an
adjunct to a rotational pelvic osteotomy, an anteroposterior radiograph of the
hip in abduction and internal rotation will confirm articular congruency. A
finding of fixed subluxation on this radiograph is a contraindication to
rotational pelvic osteotomy. For patients with osteonecrosis, the radiographs
described by Schneider can help with spatial localization of the necrotic
segment of the femoral
head22,23.
Anterior lesions can be visualized on an anteroposterior radiograph made with
the hip in about 30° of flexion. The posterior aspect of the femoral head
can be seen better with the hip in extension with the central x-ray beam
angled caudally about 40°. A magnetic resonance imaging scan is often
performed for patients with osteonecrosis. It helps to localize and quantify
the head involvement as well as to assess the contralateral hip. However, most
decisions regarding reconstructive surgery of the hip can be made on the basis
of high-quality plain radiographs alone.
For an isolated femoral osteotomy to be indicated, the major deformity or
problem should be on the femoral side of the hip joint and not on the
acetabular side. If there is deformity on both sides of the joint or the major
deformity is on the acetabular side, femoral osteotomy alone is either
contraindicated or a secondary
option24.
There must be a compelling reason to choose a hip osteotomy rather than an
implant arthroplasty for a patient who is older than sixty years of age.
However, a patient's physiologic age and life expectancy are more relevant
than chronologic age.
Reconstructive osteotomies have the best results when performed for clearly
correctable biomechanical abnormalities in joints with, at most, mild
arthrosis and a good range of motion. Deviation from these principles may
yield good results but will do so less frequently. One of the most difficult
decisions is determining just how much arthrosis is too much for a salvage
osteotomy. The risks of increased stiffness, pain, or other modes of clinical
failure increase with the degree of preoperative degenerative
changes24.
Moderate overweight status (a body-mass index of between 27 and 30) should
be considered a relative contraindication, and obesity (a body-mass index of
>30) should be considered a nearly absolute contraindication. Absolute
contraindications to osteotomy include severe joint stiffness (<60° of
flexion), neuropathic arthropathy, severe osteopenia, inflammatory arthritis,
and active infection. Finally, patients must be willing to commit to
abstaining from smoking for three months postoperatively.
An anteroposterior radiograph with a magnification marker in the plane of
the bone allows preoperative determination of several linear measurements.
Sound planning and successful surgery do not require computer-based
technology; however, a computer can facilitate the cross-comparison of
multiple surgical options with accuracy and
speed25-27.
Factors that can be planned preoperatively include the osteotomy level,
angulation, wedge resection (if any), limb length, displacement, effect on
mechanical axis alignment, fixation choice or choices, bone-grafting, and
compatibility with a future total hip arthroplasty. We bring all of the
relevant preoperative planning drawings or computer printouts to the operating
room and post them for easy reference during the procedure. Attention to
detail and technique during the surgery follows from meticulous planning of
the procedural details before the surgery. A carefully planned elective
operation leads to a low-stress, successful technical procedure in the
operating room.
Indications for an isolated varus intertrochanteric osteotomy include
certain cases of osteonecrosis, limb-length discrepancy (the ipsilateral limb
longer) associated with mild dysplasia and coxa valga, and some cases of early
osteoarthritis28. A
minimum of 15° of passive abduction preoperatively is a prerequisite. In
the past, medial displacement of the femoral shaft was suggested to be the
most important part of an intertrochanteric
osteotomy29-31.
However, experience over the past twenty years has shown that good results do
not depend on medial displacement and that problems with healing as well as
with future placement of a femoral stem increase with the degree of
displacement. Therefore, minimal, if any, medial displacement of the distal
fragment is recommended. It must be kept in mind that the stem of a total hip
arthroplasty will likely need to fit in the femur in the future. We use an AO
90° blade-plate to fix the osteotomy site.
Varus intertrochanteric osteotomy has several drawbacks. Substantial
shortening of the limb is guaranteed if a full wedge is resected. An
opening-wedge technique can preserve length but is associated with a longer
time to bone union. A Trendelenburg gait is common and may persist permanently
in up to 30% of
patients32,33.
Subsequent distal transfer of the greater trochanter may be required to
address abductor dysfunction. A bulge from the prominence of the greater
trochanter due to varus positioning may be undesirable, and it can predispose
the patient to bursitis. It should be expected that the period of
rehabilitation prior to restoration of a limp-free gait will be longer after a
varus intertrochanteric osteotomy than after a valgus intertrochanteric
osteotomy.
The most common indication for a valgus intertrochanteric osteotomy is a
nonunion of the femoral neck. By converting shear stresses into compressive
forces, the osteotomy increases the likelihood of union of the fracture and
hence avoids the need for a less desirable hemiarthroplasty.
Correction of proximal femoral deformity, both iatrogenic (postoperative)
or posttraumatic (as in the case of fracture malunion), may also be achieved
with valgus intertrochanteric osteotomy. By restoring the anatomy and hence
normalizing the hip biomechanics, pain and limb-length inequality (if any) may
be decreased and the range of motion may be improved.
Early osteoarthritis can be treated with a valgus intertrochanteric
osteotomy. Maistrelli et al. reported the results of 277 valgus-extension
osteotomies in patients with a mean age of fifty-two
years32. They
reported a 67% rate of good or excellent results after eleven to fifteen years
of follow-up. The results were better in patients who were less than forty
years old and had unilateral disease and hip flexion of =60°. The
rationale under these conditions is to utilize the noninnervated medial
"capital drop" osteophytes, if present, as a new fulcrum along
with the "floor" osteophytes of the
acetabulum34. This
more medial fulcrum acts as a new enter of rotation for the hip joint. Lateral
impingement is reduced, weight-bearing forces are moved away from the painful
superolateral aspect of the femoral head and toward the medial osteophytes,
and the lever arm of the body weight is reduced. The Bombelli concept of an
additional extension component to the osteotomy allows improved anterior
coverage of the femoral head and elimination of any fixed flexion contracture.
Extension, which refers to the relative position of the distal fragment at the
osteotomy site, is therefore "apex-anterior." Ideally, these
features improve joint congruity and the radiographic appearance of the joint
as well as increase the weight-bearing surface area. In patients with minimal
flexion contracture (with or without adduction), a valgus-extension
intertrochanteric osteotomy increases the restricted anatomic range of motion
so that it is closer to the functional range of motion needed for daily
activities. This reduces a major source of pain and impingement. The extension
component also relaxes the stresses of hyperlordosis on the lumbar spine and
often permits patients to rest without pain in the supine position for the
first time in years.
Reliable fixation is usually achieved with use of a high-angled
blade-plate; however, in patients with small bone dimensions (as in some types
of spondyloepiphyseal dysplasia), a 90° blade-plate may be utilized. A
summary of indications,
contraindications35-37,
and potential complications is provided in Tables
I and
II.
The basic principles of the valgus osteotomy were established by Pauwels in
193538,39
and were subsequently refined by
Müller40-42.
The primary purposes of valgus osteotomy are to shift the weight-bearing line
medially and, most importantly, to place the fracture plane more horizontally
to reduce the shear stress on the
fracture43,44.
The procedure is most successful when the fracture is undisplaced, when there
is no femoral neck resorption, and when the femoral head is viable
(Figs. 1-A and 1-B). There is a
role for intertrochanteric osteotomy in the treatment of acute femoral neck
fractures, although the procedure is rarely done for this indication.
The disadvantage of valgus osteotomy, particularly if the femoral head and
neck are placed in extreme valgus (>150°), is that the trochanteric
lever arm is shortened. A greater abductor pull is then required to
counterbalance the body weight during the single-limb stance phase. As a
consequence, pressure on the femoral head is increased, possibly leading to
early degeneration of the cartilage. There is usually enough neck resorption
and shortening accompanying nonunion of the femoral neck for the valgus
osteotomy to compensate and for the limb length to remain relatively normal.
However, many of these nonunions result in a more varus positioning of the
femoral head and hence shortening of the limb. In these circumstances, the
limb-lengthening ability of the valgus intertrochanteric osteotomy without
wedge resection may be exploited to equalize the limb lengths. Rigid internal
fixation is essential so that the patient can start partial weight-bearing
using crutches immediately after surgery.
Preoperative Planning
Passive adduction of at least 15° is a prerequisite for a valgus
intertrochanteric osteotomy. Maximum-adduction radiographs should be made to
ensure that the head of the femur moves freely within the acetabulum in the
desired direction. The goal of the osteotomy is to reduce the angle between
the femoral neck fracture and the horizontal to between 20° and 30°.
Preoperative planning includes determining the size of the bone wedge to be
removed (if any), the position of the seating chisel (which will determine the
position of the blade-plate in the proximal fragment), and the size and angle
of the blade-plate to be used. When the seating chisel is noted to cross the
nonunion on the preoperative plan, a screw should be placed proximal to the
chisel position to stabilize the femoral head during insertion of the
chisel.
In a patient with a short ipsilateral limb, a wedge of bone should not be
resected during the angular correction so the limb can be lengthened. The
change in limb length is a net consequence of (1) the magnitude of angular and
frontal plane correction, (2) the magnitude of lateral displacement, and (3)
the slope of the osteotomy cut. This consequence has to be planned and then
referenced in the operating room. Conversely, when there is no difference
between limb lengths, or if the ipsilateral limb is long, partial or
full-wedge resections should be planned.
It is difficult to attempt to gain >2.5 cm in limb length at the time of
surgery and doing so may overstretch the sciatic nerve. Thus, patients with a
limb-length discrepancy of >2.5 cm may have residual shortening.
Results
Marti et al.45
reported on fifty nonunions of the femoral neck treated by valgus
intertrochanteric osteotomy. The union rate was 94%. At 7.1 years
postoperatively, only seven limbs had required prosthetic replacement, as the
result of persistent nonunion in three, failure of the fixation in one, and
osteonecrosis in three. This report again demonstrated that the Pauwels
osteotomy provides a high percentage of good results even in the presence of
osteonecrosis of the femoral head, assuming there has been no collapse.
Anglen46
reported on thirteen patients with failed internal fixation of the femoral
neck who were treated with a valgus intertrochanteric osteotomy. The interval
from the injury to the osteotomy ranged from four to fifty-four weeks. At an
average of twenty-five months postoperatively, the femoral neck fracture had
healed in all patients. Twelve of the thirteen patients returned to full
weight-bearing without pain.
The principles of osteotomy for the treatment of posttraumatic or
postoperative deformity are similar to those for nonunion. Often, shortening
of the limb and malrotation are major sources of patient dissatisfaction and
disability. The valgus intertrochanteric osteotomy is particularly useful
under these circumstances (Figs. 2-A and
2-B). When the patient has a shortened limb following a varus
intertrochanteric osteotomy for the treatment of a dysplastic hip, reversal of
the previous varus osteotomy and concomitant rotational pelvic osteotomy can
solve both the postoperative and the underlying problems (Figs.
3-A,
3-B,
3-C,
3-D).
When present, a rotational deformity is usually external, but occasionally
there is an internal rotation deformity. The rotational correction, if needed,
must be performed after the transverse component of the osteotomy and prior to
any wedge resection.
Results
Bartonicek et
al.47 described
their use of valgus intertrochanteric osteotomy for the treatment of eleven
patients with a varus malunion and four patients with a varus nonunion. Their
indications for surgery were varus nonunion or varus malunion with limb
shortening of >2 cm associated with limp, abductor muscle insufficiency,
hip pain, and back pain. The patients were treated with a valgus
intertrochanteric osteotomy fixed with a 120° double-angled bladeplate.
The osteotomy site healed without complications in fourteen of the fifteen
patients. The average lengthening achieved by the osteotomy was 2 cm (range, 1
to 5 cm). In all patients, the resulting range of flexion of the hip joint was
>90°, and the average Harris hip score improved from 73 points before
the surgery to 92 points at the time of final follow-up. Osteoarthritis or
osteonecrosis of the femoral head did not develop in any patient.
The progression of degenerative changes of the hip after slipped capital
femoral epiphysis largely correlates with the degree of the initial slip, with
arthritis developing around twenty years after slips of >30°. The
altered biomechanical conditions of the hip joint with deformation of the
proximal part of the femur may result in an impingement of the femoral neck
metaphysis against the anterior aspect of the acetabular rim.
Imhauser48,49
introduced the triplane intertrochanteric osteotomy to restore joint congruity
with the intention of decreasing the prevalence of later hip arthritis. The
reorientation of the predominantly posteriorly slipped femoral epiphysis is
achieved by an intertrochanteric flexion osteotomy, which reduces the
potential for femoroacetabular impingement. Occasionally, a relative
overgrowth of the greater trochanter occurs in patients with this condition
because the proximal femoral physis closes
prematurely50. This
can be treated with an adjunctive or stand-alone trochanteric osteotomy with
lateral-distal advancement of the greater trochanter. Because the femoral head
slips posteriorly and into varus, the deformity includes extension, varus, and
external rotatory components. When the slip angle is 30° to 60°,
correction of all three components of the deformity is preferred. The
angulation of the intertrochanteric osteotomy is primarily flexion, with
valgus and internal rotation of the distal fragment as needed.
Results
Imhauser49,51
reported that, of sixty-eight hips in fifty-five patients followed for eleven
to twenty-two years, only 27% showed early degenerative changes and only one
had severe coxarthrosis and complained of pain. Five hips had a substantial
limitation of motion, with one patient being dissatisfied with the result
because of this limitation. In a distillation of the literature, Aronson et
al.52 concluded
that, by the fourth decade of life, severe slipped capital femoral epiphysis
increases the risk of hip osteoarthritis by a factor of 20 compared with the
risk in the normal population. It should be noted, however, that there were
inadequate controls in the reported series. Aronson et al. also reported on a
series of Bombelli's patients, in whom a total of twenty-four grade-2 slips
were corrected with primary triplane intertrochanteric osteotomy. The group
followed for more than two years, who had had a preoperative mean slip angle
of 58°, had a 39% gain in the total arc of motion. All patients were free
of pain at two to ten years postoperatively, with no cayou ses of
osteonecrosis, chondrolysis, infection, or nonunion.
The goal of osteotomy for osteonecrosis of the femoral head is to rotate
the diseased area away from the weight-bearing zone, thereby transferring
forces to a less involved or normal region. Since most lesions are
anterolateral, a flexion-valgus intertrochanteric osteotomy is usually the
osteotomy of choice. Osteotomy in this situation does not restore normalcy to
the hip, but it can decrease pain and improve function while preserving the
joint, delaying or possibly avoiding subsequent
surgery53.
Intertrochanteric osteotomy is indicated for selected patients with Ficat
stage-II or III osteonecrosis as well as some patients with a stage-IV lesion.
Preoperative radiographs should include anteroposterior views in neutral,
abduction, and adduction as well as Schneider and lateral views. The
radiographs are critical to determine the stage and the amount of femoral head
involvement. The necrotic angle, as described by Kerboul et
al.54, represents
the extent of disease as assessed by measuring the arc of the necrotic sector
involved on the anteroposterior and lateral radiographs and summing these
angles. Kerboul et al. considered a lesion to be large when the summed angle
was >200° and small when it was <130°. Wagner and
Zeiler55 considered
the definition of small to be <200° and large to be >230°.
The type of osteotomy should be chosen on the basis of the location of the
necrotic segment. Because most necrotic segments are on the anterior aspect of
the femoral head, flexion is an important part of the osteotomy. However, a
flexion osteotomy will worsen a flexion contracture and should not be
performed when one is present. As is the case with slipped capital femoral
epiphysis, flexion osteotomy should be accompanied by a release of the
tethering anterior capsule to avoid overconstraining the hip joint. There has
been some speculation that this release also contributes to pain relief as a
result of capsular
denervation56.
Valgus osteotomy is indicated when the main area of involvement is lateral,
with the goal of transferring load to the uninvolved medial aspect of the
femoral head. In addition, in the presence of early degenerative arthrosis
(Ficat stage IV) with an inferomedial (or "capital drop")
osteophyte, salvage valgus osteotomy may reduce superolateral joint pressure
and widen the superior joint space by levering about the
osteophyte57. A
varus component may be added to a flexion osteotomy when the lateral aspect of
the femoral head is spared and the lesion is medial. Potential candidates for
varus osteotomy may have less pain when the limb is in an abducted
position.
A discussion of osteotomies for osteonecrosis cannot be complete without
mentioning the Sugioka transtrochanteric rotational osteotomy, which was
initially reported in Japan in 1973 and was first described in the
English-language literature in
197858. The Sugioka
technique rotates the femoral head around the longitudinal axis of the femoral
neck and permits greater rotation than do angulation osteotomies.
Results
Jacobs et al.59
reported a good or excellent result in five of six hips with stage-II
osteonecrosis and in eleven of sixteen hips with stage-III disease. Maistrelli
et al.60 reported a
75% rate of good results at two years and a 58% rate of good or excellent
results at an average of 8.2 years after 106 intertrochanteric osteotomies
performed to treat osteonecrosis of the femoral head. Saito et
al.61 reported an
excellent result in four patients in whom varus osteotomy had been performed
for stage-III disease.
Scher and
Jakim62 performed a
prospective study of forty-five hips in forty-three patients who had Ficat
stage-III osteonecrosis of the anterosuperior part of the femoral head. Their
operation consisted of a valgus flexion intertrochanteric osteotomy, curettage
of the avascular segment, and autogenous bone-grafting. Survivorship analysis
indicated an 87% success rate at five years and at ten years.
Simank et al.63
compared the results of core decompression and intertrochanteric osteotomy for
atraumatic osteonecrosis of the femoral head. A total of 177
procedures—ninety-four core decompressions and eighty-three
osteotomies—were performed for osteonecrosis in patients with a mean age
of forty-one years at the time of the surgery. With the need for additional
surgery defined as a failure, survival rates at six years postoperatively were
similar between the groups when the disease was in the early, precollapse
stages, with a 74% survival rate after the osteotomies and a 78% rate after
the core decompressions. However, when the disease was in the advanced stages,
the rate of survival after the core decompressions was lower (56%) than that
after the osteotomies (76%).
Sugioka et al.64
reported success in 78% of 474 patients. Patients with stage-II disease had an
89% success rate; those with stage-III, a 73% rate; and those with stage-IV, a
70% rate. Ninety-three percent of the lesions involving less than one-third of
the articular surface were successfully treated compared with only 64% of
those involving more than one-third of the femoral head. Their results are
less favorable than those reported in the North American
literature56,65.
Treatment options for the sequelae of Legg-Calvé-Perthes disease
depend on the degree of congruency and the limb-length status. When the
ipsilateral limb is short, a valgus intertrochanteric osteotomy with
lengthening is the procedure of choice on the femoral side, with or without an
adjunctive rotational pelvic osteotomy. If the limb lengths are equal or
nearly equal and the main problem is muscle fatigue, a stand-alone
lateral-distal trochanteric advancement osteotomy can be done. If the patient
also has hip pain, a trochanteric advancement with a pelvic osteotomy is
indicated.
Before an intertrochanteric osteotomy is recommended, a radiograph made
with the limb in adduction should demonstrate improvement in the appearance of
the hip joint. Up to 3 cm of length can be obtained with a non-wedge
resection, open valgus or valgus/extension biplane intertrochanteric
osteotomy. In recent years, very few articles have been published on the
results of osteotomy in adults for this
indication66,67.
Trochanteric Advancement
Wagner contended that when trochanter overgrowth occurs, the functional
consequences are always the
same68. Elevation
of the trochanter decreases the tension and mechanical efficiency of the
pelvic and trochanteric muscles; shortening of the femoral neck moves the
greater trochanter closer to the center of rotation of the hip, decreasing the
lever arm and the mechanical advantage of the muscles and impairing muscular
stabilization of the hip; the line of pull of the muscles becomes more
vertical, increasing the pressure forces concentrated over a diminished area
of hip joint surface; and impingement of the trochanter on the rim of the
acetabular roof during abduction limits the range of motion. Transfer of the
greater trochanter laterally and distally restores normal tension to the
trochanteric muscles and improves mechanical efficiency, places a more
horizontal pull on the pelvic and trochanteric muscle action to more uniformly
distribute forces over the hip joint, and decreases acetabular impingement in
abduction. Lloyd-Roberts et
al.69,70
reported that the procedure improves gluteal efficiency and increases the
range of abduction, which is limited by impingement of the trochanter on the
ilium.
The most common indication for intertrochanteric osteotomy has been the
adult sequelae of developmental dysplasia of the hip
(Figs. 4-A and 4-B). Bombelli
et
al.34,71-73
reported on the morphologic features of osteoarthritis of the dysplastic hip.
The vast majority of patients (95% of those in the series treated with a
valgus-extension intertrochanteric osteotomy reported on by Bombelli et
al.72) had
superolateral rather than medial degenerative changes, and this group has the
best results from the intertrochanteric
osteotomy74,75.
In 1980,
Morscher12 reviewed
the results of 263 patients at his institution and compared them with the
results of a Swiss multicenter study of more than 2200 intertrochanteric
osteotomies performed in the 1970s. Morscher reported excellent long-term
outcomes in one-third of all patients and satisfactory results in another
third; one-third eventually needed total hip arthroplasty.
Proximal femoral osteotomy is frequently indicated as a method of delaying
total hip arthroplasty, but it should not compromise the eventual result of
the arthroplasty. As such, many experienced osteotomy surgeons advocate
planning for a possible or eventual arthroplasty during the preoperative
preparations for the osteotomy. Total hip templates can be used over the final
osteotomy plan to ensure that a femoral stem will fit appropriately. Although
there have been some reports of the results of total hip arthroplasty after
intertrochanteric osteotomy, and those results have been encouraging,
additional study with longer follow-up is required to determine if the results
of total hip arthroplasty after osteotomy are comparable with those of primary
total hip arthroplasty performed for the same
condition76-78.
Despite the numerous advances in technology and the technique of hip
arthroplasty, this operation is not always the procedure of choice for all
patients or all hip conditions. Proximal femoral osteotomy remains a versatile
and useful alternative in many situations. Intertrochanteric osteotomy has an
enduring role in the treatment of posttraumatic conditions (femoral neck
nonunions and malunions), limb-length discrepancy, osteonecrosis, slipped
capital femoral epiphysis, certain cases of dysplasia and secondary
osteoarthritis, and selected cases of deformity following Perthes disease,
among others.
The importance of careful preparation and detailed, virtually step-by-step
planning prior to any osteotomy cannot be overemphasized. Since the best
results are achieved when the surgery is done prior to the development of
irreversible radiographic signs of deterioration, complications could leave a
patient much worse off than before the surgery, and at a young age. Careful
study, cadaveric dissections, and visits to centers with extensive experience
are valuable building blocks for the surgeon. This surgery should not be
undertaken casually or infrequently.
Booth RJ. The closing circle:
limitations of total joint arthroplasty. Orthopedics.
1994;17:
757-9.17757
1994
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