The Results of Total Hip Arthroplasty After Sugioka Transtrochanteric Anterior Rotational Osteotomy for Osteonecrosis

Total hip arthroplasty after failed transtrochanteric rotational osteotomy for osteonecrosis of the femoral head: analysis of three-dimensional morphological features

BACKGROUND

In total hip arthroplasty (THA) after failed transtrochanteric rotational osteotomy (TRO) for osteonecrosis of the femoral head (ONFH), deformity of the proximal femur has been reported to affect stem placement. The aims of this study were to evaluate the morphological changes in the proximal femur, muscle atrophy, and soft tissue thickening in THA after TRO and the clinical outcomes.

METHODS

The TRO group included 17 patients (18 hips) who underwent THA after failed TRO. The control group included 21 patients (28 hips) who underwent primary THA for ONFH. To evaluate the deformity of the proximal femur before THA, we measured the anteroposterior and mediolateral diameters of the femur on computed tomographic slices 5 mm proximal to the lesser trochanter. To evaluate muscle atrophy and soft tissue thickening, we measured the thicknesses of the psoas major, iliac, and gluteus medius muscles and the anterior capsule of the hip joint.

RESULTS

The ratio of the anteroposterior to mediolateral diameters of the proximal femur was significantly greater in the TRO group (p < 0.01). The thicknesses of the muscles did not differ between the two groups, whereas the anterior capsule was significantly thicker in the TRO group (p < 0.05). Varus or valgus stem alignment (> 3°) was frequent in the TRO group (p < 0.01).

CONCLUSIONS

The round shape of the proximal femur was deformed after TRO compared with primary THA for ONFH, which may have caused malposition of the stem. In addition, we should pay attention to anterior protrusion of the proximal femur and thickening of the anterior capsule.

A review and meta-analysis of the survival rate of adult with osteonecrosis of the femoral head treated with transtrochanteric rotational osteotomy

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a progressive disease, and transtrochanteric rotational osteotomy (TRO) is a promising option to treat hip preservation. Compared with outcomes of non-Asian patients, those of Asian patients are different. Once ONFH has progressed to the stage of collapse, total hip arthroplasty (THA) is an unavoidable surgical procedure. However, patients treated with TRO still have a certain rate of femoral head collapse. A meta-analysis was done to comprehensively understand the outcome of TRO surgery for ONFH, in which conversion to THA was used as an endpoint event or the survival rate of patients with ONFH after TRO surgery as an indicator.

METHODS

We retrieved electronic databases from the inception of the study until June 2022, using the survival rate after TRO surgery or that after conversion to the endpoint event of THA as the effect indicator. The Risk Difference Independent unmatched samples of counting information with 95% confidence intervals (CI) were used to calculate the outcome. Also, subgroup analysis was carried out for Asian and non-Asian patients. Heterogeneity and publication bias analyses were also done for the included studies.

RESULTS

We pooled 19 studies, all of which were about applying TRO procedure for ONFH. There were 15 cohort studies, 4 case-control studies, and no randomized controlled studies. Based on the information extracted from the reported above (we extracted the relevant independent effect values separately for the case-control studies), this meta-analysis was performed based on a fixed-effect model, and META analysis was performed for an independent unpaired group of the samples. The total hip survival rate after TRO in ONFH was 0.58(95% CI = 0.45-0.72), The survival rate for Asians was: 0.68 (95% CI = 0.51-0.85) and for non-Asians was: 0.41 (95% CI = 0.17-0.64), respectively.

CONCLUSIONS

The application of TRO surgery in ONFH can effectively relieve patients' symptoms and they enjoy n a high survival rate, especially for Asian patients. This makes it a promising surgical technique.

Effect of trochanter displacement on impingement and bone contact in total hip arthroplasty performed after curved intertrochanteric varus osteotomy for osteonecrosis of the femoral head: a simulation study

Background

Curved intertrochanteric varus osteotomy (CVO) is a useful treatment option for osteonecrosis of the femoral head (ONFH). However, the effect of proximal femoral deformity in cases of CVO converted to total hip arthroplasty (THA) remains unclear. The aim of this study was to evaluate the effect of trochanter displacement on impingement and the contact state of the implant and femur in THA.

Methods

Thirty-eight hips that had undergone CVO for ONFH were reviewed and compared with a control group of 30 contralateral hips that had not undergone surgery. The range of motion (ROM) and impingement patterns and the percentage of cortical bone in the stem placement within the femur were measured by simulation using CT-based three-dimensional template software. We also measured the ROM and the number of joints that achieved the ROM required for activities of daily living when the upward displaced apex of the greater trochanter with osteotomy was resected and compared the findings with those obtained when the apex was not resected.

Results

The CVO group showed a significantly greater bony impingement in external rotation (68.4% vs. 43.3%, p = 0.033) and abduction (78.9% vs. 33.3%, p < 0.001) than in the control group. The CVO group showed a significantly smaller range of external rotation (19.0° [interquartile range; 4.0–28.8] vs. 38.0° [interquartile range; 36.0–41.8], p < 0.001) and abduction (23.0° [interquartile range; 8.5–38.8] vs. 56.0° [interquartile range; 50.3–60.0], p < 0.001) than in the control group. Significantly more joints achieved the ROM necessary for activities of daily living when the apex was resected than when it was not (10.5% vs. 63.2%, p < 0.001). The percentage of cortical bone in the stem placement position was significantly higher in the CVO group than in the control group in the proximal portion of the stem (25.5% vs. 0.0%, p < 0.001).

Conclusion

In cases requiring conversion to THA, we recommend resecting the upward displaced apex to achieve a sufficient ROM and carefully resecting the bone to avoid malignment of the stem.

Osteonecrose da cabeça femoral: Artigo de atualização

Among the pathologies that affect the hip joint, osteonecrosis of the femoral head (ONFH) is probably the most intriguing and challenging. It consists of a multifactorial disease with a highly-variable spectrum in its clinical presentation. It has a devastating effect, due to disabling painful conditions, both for usual activities and sports. Given the huge range of risk factors, such as prolonged use of corticosteroids (especially in cases of rheumatologic diseases), trauma sequelae, sickle cell anemia, HIV, alcoholism, smoking, blood dyscrasias, and several other diseases that compromise the blood supply to the femoral head, ONFH has a varied clinical presentation and prognosis, which makes it difficult to determine a specific treatment, especially in cases in which chondral involvement has not yet occurred and the hip joint is still preserved. These are the main factors found in the literature that determine the classifications of this pathology. The range of treatments includes several options for cases in which an attempt is made to save the joint: conservative treatment, traditional decompression and/or combined with some type of adjuvant treatment (homologous grafting, synthetic grafting, vascularized grafts, tantalum screws, and bone marrow aspirate injection), and, for cases in which there is already a subchondral fracture and/or collapse of the femoral head and/or a reduction in the joint space, femoral osteotomies or total hip arthroplasty are commonly performed.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Total Hip Arthroplasty After Failed Hip-Preserving Surgery with Concentrated Autologous Bone Marrow Aspirate Transplantation for Osteonecrosis of the Femoral Head: A Retrospective Study

PURPOSE

Since 2003, a hip-preserving technique-concentrated autologous bone marrow aspirate transplantation (CABMAT)-has been applied to treat osteonecrosis of the femoral head (ONFH). We investigated intraoperative and postoperative outcomes of total hip arthroplasty (THA) in patients who underwent CABMAT as hip-preserving surgery for ONFH but developed secondary hip osteoarthritis after progressive femoral head collapse.

METHODS

A total of 456 hips in 282 patients underwent CABMAT in our hospital between April 2003 and December 2018; 108 hips required THA (THA conversion rate, 23.7%). We enrolled 60 hips (26 hips in 20 men and 34 in 26 women) with a follow-up of over 2 years. We retrospectively analyzed patient background data, time to THA, surgical procedure, postoperative complications, and clinical outcomes from medical records.

RESULTS

The disease was steroid-related, alcohol-related, and idiopathic in 48, seven, and five hips, respectively. The mean age at THA was 45.7 years, and mean conversion time was 2.7 years. Cementless THA was performed in all cases; the mean operating time and blood loss were 82.7 min and 210 g, respectively. Postoperative complications were observed in four cases; intraoperative fracture, two cases; superficial infection, one case; and dislocation, one case. The mean follow-up period was 5.7 years; no loosening or deep infections occurred. No patients required revision arthroplasty.

CONCLUSION

We noted no complications related to CABMAT. After a minimum 2-year follow-up, the clinical outcomes were good. CABMAT was found to be an useful hip-preserving surgery, with little effect on conversion to THA, and THA outcomes were good.

Osteotomies for avascular necrosis of the femoral head

BACKGROUND

In osteonecrosis of the femoral head (ONFH), blood supply is insufficient for the metabolic requirements of the bone. The initial management is conservative, and, in case of failure, surgery is indicated. Osteotomies aim to change the spatial position of the necrotic portion of the femoral head. This systematic review evaluates the effectiveness and safety of osteotomies for ONFH.

SOURCE OF DATA

The systematic review, organized, conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, was performed on PubMed and Google Scholar. We analysed outcomes in term of Harris Hip Score, leg shortening, secondary collapse and blood loss. We also verified the percentage of patients who required total hip replacement (THR) after osteotomy for ONFH.

AREAS OF AGREEMENT

A total of 16 articles were selected, including 775 patients and 852 osteotomies [curved varus osteotomy in 369 (43.3%) patients; transtrochanteric rotational osteotomy in 435 (51.05%) patients; half wedge osteotomy in 48 (5.6%) patients]. There was an overall THR conversion rate of 31.5% (268 hips on 852 osteotomies).

AREAS OF CONTROVERSY

There were no prospective randomized trials, and the outcome measures employed were often heterogeneous.

GROWING POINTS

Approximately one-third of the osteotomies performed in cases of ONFH are converted to THR over a period of ~7 years. In older patients, primary THR should be considered, especially as the conversion to THR after osteotomy is technically demanding.

AREAS TIMELY FOR DEVELOPING RESEARCH

Randomized clinical studies should be conducted in order to define the parameters of the patient that can direct towards the most suitable osteotomic technique.

Outcomes of conversion THA after failed porous tantalum implant for osteonecrosis of the femoral head: a comparative matched study

BACKGROUND

As a joint-preserving surgery, porous tantalum implantation (PTI) provides an additional treatment option for osteonecrosis of the femoral head (ONFH). However, conversion to a total hip arthroplasty (THA) after failed PTI is considered a challenging procedure. The purpose of this study was to compare the clinical and radiologic outcomes and complications of THA after failed PTI with those of primary THA without any previous surgery for ONFH.

METHODS

This retrospective study included 32 patients undergoing THA after failed PTI and 25 age, sex, and body mass index matched patients who underwent primary THA without any previous surgery for ONFH between December 2009 and March 2014. All patients were followed for at least 36 months. The postoperative clinical and radiological evaluations were based on Harris Hip Score (HHS) and plain radiographs. The independent sample test and the chi-square test were used for the statistical analysis.

RESULTS

The HHS in the PTI group was similar to that in the primary group at the latest follow-up (p = 0.274), but longer operation time and greater intraoperative blood loss were observed in the PTI group (p < 0.001, respectively). No significant differences in radiological parameters and postoperative complications were found between the 2 groups (p > 0.05).

CONCLUSIONS

THA after PTI showed similar clinical and radiological outcomes to primary THA except for longer operation time and greater intraoperative blood loss.

Conventional Cementless Total Hip Arthroplasty for Hip Osteoarthritis after Distal Trochanteric Transfer: A Report of Two Cases

Distal trochanteric transfer (DTT) has been widely performed to treat developmental dysplasia of the hip or Perthes disease. Total hip arthroplasty (THA) following DTT in patients with hip osteoarthritis is one of the most challenging procedures for hip surgeons, because great care must be taken regarding anatomical abnormalities of the greater trochanter and the soft tissue attached to the greater trochanter. To the best of our knowledge, there are no reports on THA after DTT. We herein report two cases of patients who underwent THA post DTT using cementless components. After THA, both patients developed abduction temporary contraction because of leg length extension and gluteus medius hypertension. However, in both cases, the contraction was reversible within two months and the final clinical result was good. Therefore, THA can be considered an effective and safe choice for treating osteoarthritis after DTT.

Effect of transtrochanteric rotational osteotomy on impingement and contact state of a femoral implant in conversion total hip arthroplasty - Retrospective simulation study

BACKGROUND

The transtrochanteric rotational osteotomy is a common osteotomy for osteonecrosis of the femoral head, although the results of conversion total hip arthroplasty after the osteotomy are controversial. We evaluated how deformities in the proximal femur after the osteotomy affect hip impingement and the contact state of the stem in total hip arthroplasty.

METHODS

We retrospectively reviewed 35 hips (24 men) that had undergone the transtrochanteric rotational osteotomy for osteonecrosis of the femoral head (TRO-group) and compared them with 31 contralateral, unoperated hips (Primary group). The distance between the anterior and posterior greater trochanter at the cutting point of the femur, defined as the greater trochanter width and the contact area of the femoral implant surface with cortical bone were measured by CT-based three-dimensional templating software. We also calculated the hip range of motion in conversion total hip arthroplasty and analyzed the correlations between the greater trochanter width and the range of motion.

FINDINGS

The number of bony-impingement cases was significantly greater, and the range of motion in flexion, internal rotation and external rotation was significantly less in TRO-group. There was a significant negative correlation between the greater trochanter width and range of motion of internal rotation. There were no significant differences between two groups in percentages of femoral-implant contact area.

INTERPRETATIONS

The femoral implant fixation appears to be satisfactorily fixed in all zones in conversion total hip arthroplasty. However, the greater attention should be paid to minimizing bony impingement, especially on the anterior side, in conversion total hip arthroplasty.

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, therapeutic study.

Total hip arthroplasty after failed transtrochanteric rotational osteotomy for osteonecrosis of the femoral head: A systematic review and meta-analysis

BACKGROUND

Several studies have reported regarding total hip arthroplasty (THA) for osteonecrosis of the femoral head after failed transtrochanteric rotational osteotomy (TRO). However, to our knowledge, no formal systematic review and meta-analysis have been published yet summarizing the clinical results of a THA after failed TRO. Therefore, we conducted a systematic review and meta-analysis of the THA outcomes after failed TRO. We focussed on the issue whether a previous TRO affects the results of subsequent THA, including operative time, operative blood loss, radiological parameters, postoperative complications, and clinical outcomes.

METHODS

Literatures published up to January 2018 were searched in the PubMed, Web of Science, and Cochrane Library, and the pooling of data was performed using a RevMan software (version 5.3, Cochrane Collaboration, Oxford, UK). A p-value<0.05 was considered statistically significant. We calculated the mean differences (MD) for continuous data and the odds ratio (OR) for dichotomous data with 95% confidence intervals (CI) for each outcome. Statistical heterogeneity was assessed based on I² using the standard Chi². When I²>50%, significant heterogeneity was assumed, and a random-effects model was applied for the meta-analysis. A fixed-effects model was applied in the absence of significant heterogeneity.

RESULTS

Five studies were included in this meta-analysis. The results showed that operative time was significantly longer in the THA after the TRO than that for the THA without previous osteotomy (I²=92%; MD=31.62; 95% CI: 5.95 to 57.28; p=0.02). Operative blood loss was significantly greater in the THA after the TRO than that in the THA without previous osteotomy (I²=71%; MD=123.30; 95% CI: 22.21 to 224.39; p=0.02). The rate of stem malalignment was significantly higher in the THA after the TRO than that in the THA without previous osteotomy (I²=0%; OR=5.23, 95% CI: 1.95 to 14.06; p=0.001). There was no significant difference in the dislocation rate (I²=0%; OR=2.12; 95% CI: 0.64 to 6.99; p=0.22), and the postoperative Harris hip score at the final follow-up (I²=75%, MD=-0.46, 95% CI: -3.92 to 3.01, p=0.80) between the groups.

CONCLUSION

The results demonstrate that, performing the THA after the TRO is technically more demanding than the THA without previous osteotomy. TRO does not affect the clinical results of future THA, and is a sufficient therapeutic alternative in younger patients.

LEVEL OF EVIDENCE

III, systematic and meta-analysis of case control studies.