Subtrochanteric Shortening in Total Hip Arthroplasty: Biomechanical Comparison of Four Techniques

doi:10.1016/j.arth.2013.09.004

The Journal of Arthroplasty

Volume 29, Issue 4, April 2014, Pages 836-842

https://doi.org/10.1016/j.arth.2013.09.004 Get rights and content

Abstract

Safe reduction of the femoral head into the true acetabulum requires a certain amount of femoral shortening in patients with high dislocation of the hip. In subtrochanteric shortening applications, to reduce complications it is necessary to maintain a stable fixation at the osteotomy line. The purpose of this study is to investigate frequently used methods from a biomechanical point of view. Four osteotomy groups were created with composite femurs to investigate subtrochanteric osteotomies; transverse, oblique, z-subtrochanteric and double Chevron. All loading tests were carried out with two implant types both with and without strut graft and cable fixation. No single inherent feature increasing the stability of the investigated osteotomy types was found. Additionally graft application did not have a significant contribution to stability.

Section snippets

Materials and Methods

Four osteotomy types were chosen to investigate subtrochanteric osteotomies; namely transverse (Group 1), oblique (Group 2), z-subtrochanteric (Group 3) and double Chevron (Group 4). For osteotomy applications in each group, 7 fourth generation composite femurs (Sawbones, item no: 3403 medium–left) were used.

In each group a segmental resection to create 4 cm shortening was completed. All osteotomy lines were marked precisely by a white marker using a digital Vernier caliper and osteotomies were

Results

All samples in the experimental groups were tested without catastrophic failure. However a problem, which did not cause complete failure, was observed in z-subtrochanteric shortening osteotomy samples with type 1 implants. In Group 3, with z-subtrochanteric shortening osteotomy, all the non-grafted samples with type 1 implants under axial loading fissured on the anterior corner of the distal part of the osteotomy line between 2000 and 2500 N (Fig. 3). In the grafted group, two of seven samples

Discussion

Presently, in the surgical treatment of patients with high-hip dislocation, the necessity to bring the acetabulum down to the level of the true acetabulum during arthroplasty is a widely accepted procedure. This procedure helps reducing the joint reaction forces, enhances the abductor lever function and as a result corrects walking function and also lengthens the mechanical life of the acetabular component [1]. Without femoral shortening it becomes nearly impossible to bring the femoral head to

Acknowledgments

The authors thank to Mr. Coskun BAKAR (M.D. Assoc. Prof.) for his technical help in the statistical analysis.

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Cited by (57)

Is step-cut shortening osteotomy a better choice than transverse osteotomy for total hip arthroplasty for Crowe type III-IV hip dysplasia?
2024, Orthopaedics and Traumatology: Surgery and Research
Total hip arthroplasty for developmental hip dysplasia is a challenging surgery due to anatomic abnormalities. Crowe III and Crowe IV hip dysplasia generally necessitates a subtrochanteric shortening osteotomy. Transverse and step-cut osteotomy are the most common procedures for shortening of femur although there is still no consensus which one is a superior method. The objective of this study was to demonstrate whether transverse or step-cut osteotomy is superior in hips who undergo arthroplasty for high riding hip dysplasia.
Our hypothesis was that higher rates of union would be achieved in patients with Crowe III-IV hip dysplasia when the step-cut osteotomy was performed compared to transverse osteotomies.
A total of 99 hips from 90 patients (9 bilateral, 81 unilateral; 79 female, 11 male), each with a minimum follow-up duration of two years, were included in this study. The hips were classified as Crowe III (n = 16) or IV (n = 83). All hips were implanted cementless. Transverse or step-cut osteotomy was chosen for osteotomy type. The clinical and functional outcomes were assessed using the Harris Hip Score (HHS), limb length discrepancy (LLD), and limping. The complications and management of these were noted. The union rates were compared between osteotomy types.
The mean age at surgery was 48.8 (range, 21–79 years). The follow-up period was 64.3 months in average (range, 24 to 192 months). The mean Harris Hip Score before surgery was 35.6 (range, 18–50), and increased to 88.1 (range, 61–98) points at the most recent follow-up. The preoperative leg length discrepancy (LLD) measured 5.3 cm (with a range of 3 to 6.8), while the postoperative LLD reduced to 0.8 cm (with a range of 0 to 1.6). There were a total of 38 complications in 35 patients out of 99 cases, resulting in a complication rate of 38.4%. The most frequent complication observed was intraoperative femoral fractures, occurring in 13 cases. Residual limping was seen in 73.7% of all. Step-cut osteotomy was performed in 64 hips (35 CDH stem [Zimmer Biomet, Warsaw, IN, USA], 29 Wagner Cone stem [Zimmer Biomet, Warsaw, IN, USA]) and, transverse in 35 hips (22 CDH, 13 Wagner Cone). Six hips had nonunion problem and all of them were operated with a step-cut osteotomy (z-score: –7.12 and p < 0.00001, Mann-Whitney U Test).
Transverse osteotomy may be a better option while performing a shortening subtrochanteric level osteotomy for total hip arthroplasty for Crowe III-IV hips.
Level III; observational retrospective cohort study.
Transverse subtrochanteric shortening osteotomy with double tension-band fixation during THA for Crowe III–IV developmental dysplasia: 12-year outcomes
2023, Revue de Chirurgie Orthopedique et Traumatologique
Lors de la réalisation d’une prothèse totale de hanche chez un patient présentant une luxation congénitale de hanche (LCH) de haut grade, le raccourcissement fémoral permet de faciliter la réduction, de prévenir une lésion sciatique et crurale ou un excès de longueur final sur le membre opéré. Il n’existe pas de consensus concernant le type d’implant ou d’ostéosynthèse à utiliser, pourtant de ce choix dépendent directement les risques de complication per- et postopératoires les plus fréquemment retrouvés (fractures diaphysaires, luxations, pseudarthrose). Afin d’essayer de contrôler au mieux ces risques, nous avons mis au point une technique d’ostéotomie transverse de raccourcissement sous-trochantérienne associée à la mise en place d’une tige longue de coupe ovoïde sans ciment à tenue métaphysaire et d’une ostéosynthèse par double haubanage. Les objectifs de cette étude étaient d’analyser les résultats de cette technique en se concentrant sur (1) les complications et la survie de l’implant fémoral, (2) les résultats cliniques (scores fonctionnels et inégalité de longueur des membres inférieurs [ILMI]), (3) le délai de consolidation.
Cette technique permet d’obtenir un faible taux de complications peropératoire et postopératoires.
Il s’agissait d’une étude rétrospective monocentrique incluant les patients opérés de 2000 à 2015 d’une prothèse de hanche associée à une ostéotomie de raccourcissement fémorale sous-trochantérienne, fixés par un double haubanage dans le cadre d’une LCH sévère (Crowe III et IV). L’implant fémoral utilisé était une tige longue ovoïde non cimentée recouverte en totalité d’hydroxyapatite. Les complications per- et postopératoires, la survie, l’inégalité de longueur (ILMI), les scores fonctionnels (Harris [HHS]), score de hanche oubliée (Forgotten Joint Score [FJS]), la satisfaction et les résultats radiographiques ont été étudiés.
Trente et une hanches ont été incluses. Deux patients ont été perdus de vue (6,5 %, 2/31) et exclus des analyses postopératoires. Le suivi moyen était de 13,7 ans ± 4,2 [5,8–18,3]. Ont été rapportées deux fractures diaphysaires peropératoire (6,5 %, 2/31), une fracture du grand trochanter (3,2 %, 1/31), une lésion sciatique (3,4 %, 1/29) ayant complètement récupéré, soit au total 4/31 (12,9 %) complications peropératoires. En postopératoire nous avons observé 8/31 complications (25,8 %) incluant deux luxations (6,9 %, 2/29), deux enfoncements de tige (6,9 %, 2/29) et quatre pseudarthroses (13,8 %, 4/29). La survie de l’implant fémoral au dernier recul était de 87,1 % (IC95 % [76,1–99,7]). Le HHS moyen est passé de 39,6 ± 12,0 [14–61] en préopératoire à 81,7 ± 13,2 [48–100] au dernier recul (p < 0,01). Au dernier recul, 48,2 % (14/29) de hanches étaient déclarées comme oubliées et 31,0 % (9/29) étaient symptomatiques mais non gênantes. Une ILMI significative (≥ 1 cm) était présente chez 8 patients (27,6 %, 8/29) en postopératoire contre 19 (65,5 %, 19/29) en préopératoire, l’ILMI moyenne est passée de 20,8 mm ± 19,7 [0–60] à 5 mm ± 7,3 [0–30]. Le délai de consolidation moyen était de 4,3 mois ± 2,4 [2–11].
Cette technique présentait peu de complications peropératoires fracturaires ou postopératoires immédiates mais une survie du pivot fémoral inférieure aux données de la littérature et avait un taux de pseudarthrose élevé malgré des résultats postopératoires fonctionnels et cliniques satisfaisants.
IV.
Transverse subtrochanteric shortening osteotomy with double tension-band fixation during THA for Crowe III-IV developmental dysplasia: 12-year outcomes
2023, Orthopaedics and Traumatology: Surgery and Research
When performing total hip arthroplasty in patients with severe developmental dysplasia, shortening the femur facilitates reduction while also preventing sciatic or crural nerve injury and excessive length of the operated limb. No consensus exists about the optimal type of implant and best internal fixation procedure, two parameters that directly govern the risk of the most common intraoperative and postoperative complications (diaphyseal fractures, dislocation, non-union). To minimise these risks, we developed a technique combining a transverse subtrochanteric shortening osteotomy, a long ovoid-profiled, cementless stem anchored in the metaphysis, and double tension-band wiring for internal fixation. The primary objective of this study was to evaluate the outcomes of this technique with emphasis on (i) complications and femoral implant survival, (ii) clinical outcomes (functional scores and lower-limb length inequality [LLLI]), and time to healing.
Our technique is associated with low rates of intraoperative and postoperative complications.
This single-centre retrospective cohort study included patients who underwent THA with a transverse subtrochanteric shortening osteotomy and fixation using double tension-band wiring to treat severe (Crowe III or IV) developmental hip dysplasia. The femoral implant was a long, ovoid, cementless stem fully coated with hydroxyapatite. We collected the intraoperative and postoperative complications, survival, LLLI, functional scores (Harris Hip Score [HHS] and Forgotten Joint Score [FJS]), patient satisfaction, and radiographic outcomes.
The study included 31 hips in 25 patients. Two patients (2/31 hips, 6.5%) were lost to follow-up, leaving 29 hips for the analysis of postoperative outcomes. Mean follow-up was 13.7 ± 4.2 years (range, 5.8–18.3 years). The four intraoperative complications (4/31, 12.9%) consisted fracture of the diaphysis (2/31, 6.5%), fracture of the greater trochanter (1/31, 3.2%), and sciatic nerve injury followed by a full recovery (1/29, 3.4%). The 8 (8/29, 27.5%) postoperative complications consisted of dislocation (2/29, 6.9%), stem subsidence (2/29, 6.9%), and non-union (4/29, 13.8%). Femoral implant survival at last follow-up was 87.1% (95% CI, 76.1–99.7). The mean HHS increased from 39.6 ± 12.0 (range, 14–61) before surgery to 81.7 ± 13.2 (range, 48–100) at last follow-up (p < 0.01). The FJS at last follow-up indicated that the joint was forgotten in 14/29 (48.2%) cases and caused only acceptable symptoms in 9/29 (31.0%) of cases. Clinically significant (≥ 1 cm) LLLI was present in 8/29 (27.6%) patients postoperatively compared to 19/29 (65.5%) preoperatively. The mean LLLI decreased from 20.8 ± 19.7 mm (range, 0–60 mm) to 5.0 ± 7.3 mm (range, 0–30 mm). Mean time to healing was 4.3 ± 2.4 months (range, 2–11 months).
Regarding these complex procedures, this technique was associated with low rates of intraoperative fractures and early postoperative complications. However, femoral stem survival was shorter than in earlier studies and the non-union rate was high, despite satisfactory functional and clinical outcomes.
Level of evidence IV.
Minimum 10-Year Results of Cementless Ceramic-On-Ceramic Total Hip Arthroplasty Performed With Transverse Subtrochanteric Osteotomy in Crowe Type IV Hips
2021, Journal of Arthroplasty
Total hip arthroplasty (THA) performed for developmental dysplasia of the hip is a technically difficult procedure with a high complication rate, especially in the presence of completely dislocated hips. This study aimed to evaluate at least 10 years of follow-up results of cementless, ceramic-on-ceramic (CoC) THA performed with transverse subtrochanteric osteotomy in Crowe type IV hips.
We retrospectively reviewed 50 patients’ 67 hips that underwent CoC, cementless THA with transverse subtrochanteric osteotomy between 2008 and 2011. Clinical and radiological data of the hips were examined. Clinical results were evaluated using the Harris Hip Score and the Western Ontario and McMaster Universities Osteoarthritis Index.
The mean Harris Hip Score improved from 22.9 ± 9.9 preoperatively to 94.1 ± 8.1 at the final follow-up (P < 0.001). The median Western Ontario and McMaster Universities Osteoarthritis Index score improved from 72 (interquartile range: 17) preoperatively to 2 (interquartile range: 17) postoperatively (P < 0.001). The preoperative mean leg length discrepancy was improved from 4.9 ± 1 cm to 1.5 ± 1 cm in unilateral cases at the last follow-up (P < 0.001). Revision surgery was required because of nonunion in two patients, prosthetic infection in one patient, and aseptic femoral loosening in the other patient. The overall ten-year survival rate was 94% for femoral stems and 98.5% for acetabular components as per Kaplan-Meier survival analysis.
Transverse subtrochanteric shortening osteotomy combined with using cementless acetabular and femoral components with a CoC bearing surface promises successful clinical results and high prosthesis survival in the treatment of Crowe IV hips at long-term follow-up.
Satisfactory Outcomes in Patients Operated With Primary Total Hip Arthroplasty for Perthes-like Deformities: Results From a Surgical Technique Utilizing a Conical Stem, an Elevated Hip Center, and No Shortening Femoral Osteotomy
2021, Arthroplasty Today
Total hip arthroplasty (THA) performed on patients with Perthes-like deformities are technically challenging because of the patient’s abnormal hip anatomy. Patients with Perthes-like deformities are at a higher risk of revision, aseptic loosening, nerve injury, and intraoperative fracture after THA, especially if shortening osteotomies are performed. This analysis sought to examine the clinical and radiographic outcomes of a patient cohort with Perthes-like deformities receiving THA with a conical stem, an elevated hip center, and no shortening femoral osteotomy.
Twenty-six patients (27 hips) received THA with MODULUS femoral stems, ceramic or metal femoral heads, and highly cross-linked polyethylene liners between April 2011 and March 2016. All patients were treated at a single center by 4 participating surgeons. Patients completed 2 questionnaires preoperatively and at the final follow-up visit (between 1 and 5 years postoperatively): Harris Hip Score and Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire. Differences in patient-reported outcome measures (PROM) scores were measured by paired t-tests. Preoperative and postoperative anteroposterior radiographs were analyzed to monitor patient outcomes.
Significant clinical improvements were observed in all individual subcategories of the Harris Hip Score and of the Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire; the largest magnitude improvements were observed in the subcategory of pain relief for both questionnaires. No complications, including intraoperative and postoperative femoral fractures, nerve palsy, dislocations, or deep venous thrombosis, were observed.
This study found that patients treated with an elevated hip center and low stem-positioning technique using a conical, modular implant system had good clinical outcomes and did not suffer complications at the mean follow-up from surgery of 2.8 years (range: 1-5 years).
Long-Term Outcomes of Total Hip Arthroplasty With Transverse Subtrochanteric Shortening Osteotomy and Modular Stem in Crowe IV Developmental Dysplasia
2021, Journal of Arthroplasty
The reconstruction of high dislocation related to developmental dysplasia of the hip (DDH) remains challenging for joint surgeons. The aim of this study is to evaluate the rate of union, the revision rate, functional scores, and complications in patients with Crowe IV DDH treated with total hip arthroplasty, transverse subtrochanteric shortening osteotomy, and modular stem in an average 10-year follow-up.
Twenty-eight patients (33 hips) with Crowe IV DDH who were operated on between 2008 and 2013 were followed. All patients underwent uncemented total hip arthroplasty with transverse subtrochanteric shortening osteotomy and anatomical acetabular cup implantation. The mean age was 36.6 years, and the mean follow-up period was 121 months. Clinical and radiological outcomes were evaluated.
The mean Harris Hip Score significantly improved from 47.0 preoperatively to 89.6 postoperatively. The mean limb length discrepancy was significantly reduced from 3.8 to 0.8 cm. The mean osteotomy union time was 6.8 months. At the mean follow-up of 121 months, there were 3 cases of postoperative dislocation, 2 cases of intraoperative fracture, and 1 case of posterior tibial venous thrombosis. No revision occurred, and no signs of component loosening or migration were observed at the last follow-up.
Crowe IV DDH patients treated with transverse subtrochanteric shortening osteotomy, modular stem, and anatomic acetabular component insertion can have satisfactory and reliable 10-year clinical outcomes.

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: The Conflict of Interest statement associated with this article can be found at http://dx.doi.org/10.1016/j.arth.2013.09.004.

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Subtrochanteric Shortening in Total Hip Arthroplasty: Biomechanical Comparison of Four Techniques

Abstract

Section snippets

Materials and Methods

Results

Discussion

Acknowledgments

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Clin Biomech (Bristol, Avon)

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Surgical treatment of developmental dysplasia of the hip in adults: II. Arthroplasty options

J Am Acad Orthop Surg