Cementless total hip replacement after previous intertrochanteric valgus osteotomy for advanced osteoarthritis

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.

Challenges in Total Hip Replacement after McMurray's Osteotomy: A Report of 3 Cases and Review of Literature

Background

McMurray's osteotomy of the hip was a popular surgery practiced for almost 5 decades for the management of the fractured neck of the femur and hip osteoarthritis since its first description in 1936. It is an oblique, medial displacement intertrochanteric osteotomy. In the long term, McMurray's osteotomy patients develop limb length discrepancy and secondary osteoarthritis due to the altered biomechanics of the hip and may require total hip replacement (THR). THR after the previous osteotomy is more challenging than that for unoperated hip joints due to severe distortion of the hip anatomy and soft-tissue contractures. These challenges are related to distorted bony anatomy, soft-tissue contractures, and the choice of implants.

Methods

Three patients with previous McMurray's osteotomy of the hip developed secondary osteoarthritis and underwent total hip replacement. We discussed specific challenges encountered during THR and techniques to deal with such problems.

Results

All patients had pain-free hip, with minimal residual shortening (average, 1.2 cm) at an average follow-up of 3.67 years (range, 1 to 6 years). The Harris hip score improved significantly postoperatively and no complications were encountered.

Conclusions

A detailed and careful preoperative planning, correct execution of surgical techniques, and postoperative rehabilitation are the keys to the successful management of these cases.

Modular stem in total hip arthroplasty for patients with trochanter valgus deformity: surgical technique and case series

Background

Trochanter valgus deformity (TVD) is a rare condition of total hip arthroplasty (THA). Femoral osteotomy could be required in correcting the deformity to implant femoral stem in severe TVD. In this study, we described one unpublished technique of reverse sleeve of S-ROM to get through the complex situation. This study aimed to summarize and evaluate its technical challenges, safety and effectiveness.

Methods

From January 2006 to December 2014, we enrolled patients whose sleeves were implanted towards the great trochanter in THA with TVD. Their demographics, perioperative and postoperative information were recorded. To explore its indication, we measured and analyzed the ratio of greater trochanter/lesser trochanter (G/L ratio) and trochanter valgus angle (TVA).

Results

Twelve patients (1 male and 11 female, average age 42.30 ± 10.23) had mean follow-up of 6 years. Among them, only two patients had intraoperative femoral fracture. The survivorship of femoral prosthesis was 100%. The Harris hip score (HHS) increased from preoperative 34.31 ± 14.43 to postoperative 84.12 ± 11.33. All patients’ G/L ratio were larger than 1.50.

Conclusions

The reverse sleeve of S-ROM was a reliable method for the patients with severe TVD, which brought satisfying clinical outcomes in mid-term follow-up.

Total hip arthroplasty with femoral osteotomy and modular prosthesis for proximal femoral deformity

Background

Severe anatomical abnormalities exist in proximal femoral deformities (PFDs). Total hip arthroplasty (THA) is associated with drawbacks such as high surgical complexity, long operation time, requirement for high surgical skills, high incidences of postoperative complications, and poor efficacy.

Objective

This study aimed to investigate the short-term efficacy of THA with femoral osteotomy and modular prosthesis implantation for femoral fixation and reconstruction in patients with PFD.

Methods

A total of 15 patients (15 hips) with rotational PFD treated with THA with femoral osteotomy and modular prosthesis between August 2012 and September 2014 were included. There were 10 male (10 hips) and 5 female (5 hips) patients. Preoperative limb shortening, intraoperative osteotomy length, and postoperative limb length were recorded. The Harris hip score was adopted for assessing the clinical results. Postoperative radiography was performed to observe the prosthesis position, as well as the presence or absence of abnormalities such as osteolysis, loosening, and subsidence of the prosthesis.

Results

All 15 patients were followed up postoperatively, with a mean follow-up duration of 62.5 (range 20–85) months. The postoperative limb-length discrepancy (1.0 ± 0.5 cm) was significantly less than the preoperative discrepancy (3.2 ± 1.2 cm) (t = − 2.501, P = 0.002). The Harris hip score significantly improved from a mean of 47.2 ± 9.9 points preoperatively to 89.7 ± 3.9 points during the last follow-up visit (t = 21.31, P = 0.001). Immediate postoperative radiographs showed restoration of limb alignment after femoral osteotomy, excellent initial press-fit fixation of the S-ROM prosthesis, and good canal filling. According to Engh’s criteria, all 15 hips were graded as ingrown bones. No infection, prosthesis loosening, periprosthetic fracture, or other complications occurred.

Conclusion

In patients with femoral deformities treated with THA, precise osteotomy, good coaptation of the osteotomy surfaces, and correct choice of modular S-ROM prostheses for femoral reconstruction and fixation remain the key factors for surgical success.

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.

[Hip arthroplasty after pelvic and femoral osteotomies]

Pelvic and femoral osteotomies can be a challenge even for experienced orthopedic surgeons. Residual metal may complicate the insertion of the endoprosthesis in some cases. Sometimes, the anatomical modification of the previous osteotomy complicates the total hip replacement. This may require the use of an acetabular revision system for the primary implantation. Femoral deformities can require additional osteotomies of the femur during the implantation. In every case, accurate preoperative planning should be performed. A preoperative CT with 3D reconstruction is a powerful tool for further information beyond conventional imaging.

Total Hip Arthroplasty After Periacetabular and Intertrochanteric Valgus Osteotomy

BACKGROUND

We performed periacetabular osteotomy (PAO) combined with intertrochanteric valgus osteotomy (TVO) to obtain better congruity for patients with acetabular dysplasia and nonspherical femoral head. These patients with PAO-combined TVO demonstrate long-term progression of osteoarthritis, thereby, needing conversion to total hip arthroplasty (THA) and is difficult due to morphological changes. The objective of the present study was to investigate outcomes of patients who underwent THA after PAO-combined TVO.

METHODS

We performed 3 groups' case-control study. The participants were 20 patients (20 hips) who underwent THA after PAO-combined TVO (PAO-TVO group); these patients had a mean age at surgery of 56.3 years and underwent postoperative follow-up for a mean period of 6.8 years. For the control group, we included 53 patients (57 joints) who underwent THA after PAO and 76 patients (80 joints) who underwent primary THA for hip dysplasia matching age, sex, and time of surgery.

RESULTS

Harris hip score at the last follow-up was significantly poorer in PAO-TVO group compare with PAO group and primary group. Short Form-36 of Physical Component Summary was significantly poorer in PAO-TVO group compared with primary group. The socket position in the PAO-TVO group was significantly superior and lateral compared with that in the primary THA group. Considering socket placement in Lewinnek's safe zone and stem malalignment, there were no significant differences in the 3 groups.

CONCLUSION

Harris hip score and Short Form-36-Physical Component Summary for THA after PAO-combined TVO were significantly poorer compared to those of primary THA.

[Hip arthroplasty in the presence of proximal femoral deformity]

INTRODUCTION

Proximal femoral deformities may result in pain in the ipsilateral hip joint and profound functional disability, ultimately requiring arthroplasty. 

PROCEDURE

Primary hip replacement procedures in the presence of markedly altered anatomy of the proximal femur present a technical challenge for the orthopedic surgeon. The deformity and its underlying condition, whether congenital or acquired, may complicate canal preparation and affect the choices of implant, exposure and postoperative physiotherapy protocol. Furthermore, a two- or multi-stage treatment may be required, e.g. for implant removal, for femoral osteotomy or to rule out infection.

DISCUSSION

Treatment strategies must be individually tailored, respecting patient needs, the etiology, the anatomic site and the geometry of the deformity encountered, bone quality, soft tissue deficits, the presence of retained implants in the proximal femur, infection status and comorbidities.

How have alternative bearings and modularity affected revision rates in total hip arthroplasty?

BACKGROUND

Total hip arthroplasty (THA) continues to be one of the most successful surgical procedures in the medical field. However, over the last two decades, the use of modularity and alternative bearings in THA has become routine. Given the known problems associated with hard-on-hard bearing couples, including taper failures with more modular stem designs, local and systemic effects from metal-on-metal bearings, and fractures with ceramic-on-ceramic bearings, it is not known whether in aggregate the survivorship of these implants is better or worse than the metal-on-polyethylene bearings that they sought to replace.

QUESTIONS/PURPOSES

Have alternative bearings (metal-on-metal and ceramic-on-ceramic) and implant modularity decreased revision rates of primary THAs?

METHODS

In this systematic review of MEDLINE and EMBASE, we used several Boolean search strings for each topic and surveyed national registry data from English-speaking countries. Clinical research (Level IV or higher) with ≥ 5 years of followup was included; retrieval studies and case reports were excluded. We included registry data at ≥ 7 years followup. A total of 32 studies (and five registry reports) on metal-on-metal, 19 studies (and five registry reports) on ceramic-on-ceramic, and 20 studies (and one registry report) on modular stem designs met inclusion criteria and were evaluated in detail. Insufficient data were available on metal-on-ceramic and ceramic-on-metal implants, and monoblock acetabular designs were evaluated in another recent systematic review so these were not evaluated here.

RESULTS

There was no evidence in the literature that alternative bearings (either metal-on-metal or ceramic-on-ceramic) in THA have decreased revision rates. Registry data, however, showed that large head metal-on-metal implants have lower 7- to 10-year survivorship than do standard bearings. In THA, modular exchangeable femoral neck implants had a lower 10-year survival rate in both literature reviews and in registry data compared with combined registry primary THA implant survivorship.

CONCLUSIONS

Despite improvements in implant technology, there is no evidence that alternative bearings or modularity have resulted in decreased THA revision rates after 5 years. In fact, both large head metal-on-metal THA and added modularity may well lower survivorship and should only be used in select cases in which the mission cannot be achieved without it. Based on this experience, followup and/or postmarket surveillance studies should have a duration of at least 5 years before introducing new alternative bearings or modularity on a widespread scale.

Novel technique for removal of a broken intracortical screw during THA

Most reports regarding hardware removal involve the violation of the cortex to allow a specialized to tool to extract a retained fragment. This leaves large, unfilled screw holes that act as stress risers for months postoperatively. This article describes a novel technique to remove a retained intracortical screw fragment during total hip arthroplasty. Conversion of an intertrochanteric osteotomy to a total hip arthroplasty can be made more difficult by anatomical changes to the femur and retained hardware. Direct access to the intramedullary canal during total hip arthroplasty allowed for the safe removal of a retained intracortical screw using this technique.

Complex primary total hip arthroplasty

Although total hip arthroplasty is now a classic procedure that is well controlled by orthopedic surgeons, some cases remain complex. Difficulties may be due to co-morbidities: obesity, skin problems, muscular problems, a history of neurological disease or associated morphological bone deformities. Obese patients must be informed of their specific risks and a surgical approach must be used that obtains maximum exposure. Healing of incisions is not a particular problem, but adhesions must be assessed. Neurological diseases may require tenotomy and the use of implants that limit instability. Specific techniques or implants are necessary to respect hip biomechanics (offset, neck-shaft angle) in case of a large lever arm or coxa vara. In case of arthrodesis, before THA can be performed, the risk of infection must be specifically evaluated if the etiology is infection, and the strength of the gluteal muscles must be determined. Congenital hip dysplasia presents three problems: the position and coverage of the cup, placement of a specific or custom made femoral stem, with an osteotomy if necessary, and finally lowering the femoral head into the cup by freeing the soft tissues or a shortening osteotomy. Acetabular dysplasia should not be underestimated in the presence of significant bone defect (BD), and reconstruction with a bone graft can be proposed. Sequelae from acetabular fractures presents a problem of associated BD. Internal fixation hardware is rarely an obstacle but the surgical approach should take this into account. Treatment of acetabular protrusio should restore a normal center of rotation, and prevent recurrent progressive protrusion. The use of bone grafts and reinforcement rings are indispensible. Femoral deformities may be congenital or secondary to trauma or osteotomy. They must be evaluated to restore hip biomechanics that are as close to normal as possible. Fixation of implants should restore anteversion, length and the lever arm. Most problems that can make THA a difficult procedure may be anticipated with proper understanding of the case and thorough preoperative planning.

Technical considerations in total hip arthroplasty after femoral and periacetabular osteotomies

The purpose of this article is to outline key technical considerations in the performance of total hip arthroplasty after common osteotomies of both the proximal femur and acetabulum. Attention is called to anatomic variation, both innate and incurred. After a femoral osteotomy, specific focus should be placed on incision selection, residual hardware management, abductor handling, and proper version establishment. After a periacetabular osteotomy, similar concern should be granted to cup position and fixation. Results of total hip arthroplasty after common osteotomies are also reviewed and importance of these issues highlighted.

Long-term results of cementless femoral reconstruction following intertrochanteric osteotomy

PURPOSE

The objective of this retrospective cohort study was to assess the long-term outcome of cementless femoral reconstruction in patients with previous intertrochanteric osteotomy (ITO).

METHODS

We evaluated the clinical and radiographic results of a consecutive series of 45 patients (48 hips, mean age 50 years) who had undergone conversion hip replacement following ITO with a cementless, grit-blasted, double-tapered femoral component. Clinical outcome was determined using the Harris hip score. Stem survival for different end points was assessed using Kaplan-Meier survivorship analysis.

RESULTS

At a mean follow-up of 20 (range, 16-24) years, 11 patients (12 hips) had died, and no patient was lost to follow-up. Six patients (six hips) underwent femoral revision, two for infection, three for aseptic loosening and one for periprosthetic fracture. Mean Harris hip score at final follow-up was 78 points (range, 23-100 points). Stem survival for all revisions was 89% (95%CI, 75-95) at 20 years, and survival for aseptic loosening was 93% (95%CI, 80-98).

CONCLUSIONS

The long-term results with this type of cementless femoral component in patients with previous intertrochanteric osteotomy are encouraging and compare well to those achieved in patients with normal femoral anatomy.

Cementless femoral reconstruction in patients with proximal femoral deformity

Distorted proximal femoral anatomy can pose a great technical challenge during total hip arthroplasty. Fifty-eight total hip arthroplasty were performed in 51 patients with proximal femoral deformity from 1998 to 2006. All hips except 2 were treated with cementless prosthesis. Twenty-three patients had a retained hardware that had to be removed. Nonprimary cementless components were used in 22 (25%) femurs. In 21 (23%) hips, osteotomy was required to properly fit the cementless stem in the femur. At the time of latest follow-up (4 years on average), functional scores showed significant improvement. Radiographically, all femoral components showed stable bone ingrowth except 2 hips (3.5%) with stable fibrous ingrowth and 1 hip (2%) with loosening. There were 2 (3.5%) revisions in 2 patients for periprosthetic fracture and femoral loosening. The mechanical failure rate was 9% (5 hips). Despite technical difficulties, cementless femoral reconstruction provides a reliable and durable result in patients with proximal femoral deformity.

Long-term results of intertrochanteric varus osteotomy for dysplastic osteoarthritis of the hip

The beneficial role of intertrochanteric varus or valgus osteotomy in the treatment of hip osteoarthrosis has been recognised since the 1920s. Even today, it has an important role to delay the need for hip replacement in younger patients. The purpose of this study was to evaluate the long-term results of intertrochanteric varus osteotomy for dysplastic osteoarthritis of the hip. Between 1980 and 1995, 52 hips with dysplastic osteoarthritis underwent an intertrochanteric varus osteotomy. All patients could be followed up after 17.8 years. Radiographic assessment included centre-edge (CE) angle of Wiberg and collodiaphyseal (CCD) angle. Dysplastic hip dislocation was classified according to Crowe. Osteoarthritis was graded according to Tönnis. Preoperative osteoarthritis was Tonnis grade 1 in 19 hips, grade 2 in 28 and grade 3 in five. Complications were also documented. Clinical evaluation included score according to Merle d'Aubigné, Harris Hip Score and range of motion. Six of 52 patients underwent total hip replacement (THR) within five years after intertrochanteric osteotomy. In these cases, preoperative osteoarthritis was grade 3 in four cases and grade 2 in one case according to Tönnis. Twenty-five of 52 patients underwent THR after an interval of five to ten years after intertrochanteric osteotomy. In these cases, preoperative osteoarthritis was grade 3 in one case and grade 2 in 24 cases according to Tönnis. Sixteen of 52 patients underwent THR after an interval of ten to 15 years after intertrochanteric osteotomy. In these cases, preoperative osteoarthritis was grade 2 in four cases and grade 1 in 12 cases according to Tönnis. In five patients the hip was functioning well after a period longer than 15 years. In all these cases osteoarthritis was grade 1 according to Tönnis. In 40.4% of patients, THR was delayed longer than ten years. The osteotomy performed well at a mean time of 9.7 years after the procedure (range 3-21). Intertrochanteric varus osteotomy for dysplastic osteoarthritis of the hip should be considered in early or mild osteoarthritic changes of the hip. Good prognosis with delay of THR of more than ten years can be expected to exceed 40%, even when indications are less than optimum.