results were obtained in 87% of patients (7 of 8). Eight of 9 osteotomies (89%) demonstrated radiographic evidence of healing at an average of 5 months. One.
The Journal of Arthroplasty Vol. 12 No. 8 1997
Subtrochanteric Femoral Shortening Osteotomy in Total Hip Arthroplasty for Highriding Developmental Dislocation of the Hip D a v i d J. Y a s g u r , M D , * S t e v e n A. S t u c h i n ,
MD,~- Edward
a n d P a u l E. D i C e s a r e ,
M. Adler, MD,t
MD-t-
Abstract: A surgical technique, which uses a transverse osteotomy, for subtrochanteric femoral shortening and derotation in total hip arthroplasty for highriding developmental dislocation of the hip is described. Anteversion is set by rotating the osteotomy fragments, and torsional stability is augmented with allograft struts and cables when indicated. Eight patients with 9 total hip arthroplasties were followed for an average of 43 months (range, 24-84 months). Good to excellent results were obtained in 87% of patients (7 of 8). Eight of 9 osteotomies (89%) demonstrated radiographic evidence of healing at an average of 5 months. One patient had an asymptomatic nonunion of the osteotomy site but still had a good overall clinical result. Another patient suffered fatigue failure of a distally ingrown porous device, which necessitated revision total hip arthroplasty 18 months after surgery. Subtrochanteric osteotomy in total hip arthroplasty for developmental dislocation of the hip allows for acetabular exposure and diaphyseal shortening while facilitating femoral derotation. Furthermore, proximal femoral bone stock is maintained and some of the potential complications of greater trochanteric osteotomy may be avoided. Key words: total hip arthroplasty, subtrochanteric femoral shortening osteotomy, developmental dislocation of the hip.
The high-riding d e v e l o p m e n t a l l y dislocated hip (DDH) is one of the m o s t challenging reconstructions in hip arthroplasty. There are m a n y a n a t o m i c deformities that contribute to the complexity of arthroplasty in a dysplastic hip. These include a high hip center, a small f e m o r a l canal, a n d a rotational deformity of the p r o x i m a l f e m u r that is m a n i f e s t e d b y increased f e m o r a l a n t e v e r s i o n a n d a posteriorly positioned greater t r o c h a n t e r a n d ab-
ductor m e c h a n i s m [1,2]. Each deformity creates its o w n set of obstacles. The p r o p e r position of the acetabular c o m p o n e n t in total hip a r t h r o p l a s t y (THA) for hip dysplasia r e m a i n s controversial. A l t h o u g h s o m e authors state that p r o x i m a l p l a c e m e n t of the cup is acceptable [3,41, others r e c o m m e n d positioning the cup at the true acetabular center to reduce loosening [5-13]. Most recently, P a g n a n o a n d coa u t h o r s f o u n d t h a t p l a c e m e n t of the cup at the center of the true acetabular region results in significantly smaller rates of loosening a n d revision of b o t h f e m o r a l a n d acetabular c o m p o n e n t s [11]. R e s t o r a t i o n of the hip center to the true acetabu l u m is difficult b e c a u s e of p r o b l e m s w i t h e x p o sure a n d deficient a c e t a b u l a r b o n e stock [1,2]. F u r t h e r m o r e , for C r o w e type IV c o m p l e t e l y dislocated hips [14], p l a c e m e n t of the cup at the level
From the *Insall-Scott-Kelly Institute for Orthopaedics & Sports Medicine, Beth Israel Medical Center--North Division, New York, New York, and the t-Department of Orthopaedic Surgery, Hospital for Joint Diseases Orthopaedic Institute, New York, New York. Reprint requests: Steven A. Stnchin, MD, Department of Orthopaedic Surgery, Hospital for Joint Diseases Orthopaedic Institute, 301 East 17th Street, New York, NY 10003. © I997 Churchill Livingstone Inc.
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of the true acetabulum may excessively lengthen the leg and risk neurovascular injury [1,6,I4,15]. Thus, some type of femoral shortening is necessary in the reconstruction of completely dislocated hips. The small femoral canal and increased anteversion restrict prosthesis selection [1,14,16-I9]. If the anteversion is not corrected, the arthroplasty may fail owing to recurrent anterior dislocation. If the greater trochanter and abductors are left in a posterior position, the abductor lever arm will not be restored, contributing to instability and limp. The original strategies, which used simple trochanteric osteotomy coupled with proximal shortening, solved ma ny of these problems {1,2,6, 14-16,20-25]; however, reattachment and healing of the trochanter were difficult to achieve [15, 20,25]. Davlin et al. reported a 13% incidence of trochanteric n o n u n i o n [15], and some authors conclude that this occurs following proximal shortening secondary to placement of the trochanteric fragment onto a cortical bed [201. Using these early techniques of THA in DDH, complication rates [14] approached 19%, and at a follow-up period of 15 years {16], there was a 26% revision rate, with 60% survivorship, mostly secondary to fatigue failure of primitive stem designs, recurrent instability, and acetabular loosening. Femoral dysplasia, coupled with the high-riding position of completely dislocated hips, led some authors to use microminiature femoral components [17,19]. Other authors used custom-designed cemented femoral components to minimize the amount of proximal shortening [6,17]. Complication rates were lower overall, but a 10% radiographic loosening rate of the femoral component [17,19] and a 14.5% revision rate at less than 5 years of follow-up evaluation [19] were still reported. Complex osteotomies have gained popularity in revision THA [26,27] and similar techniques have been applied to complex primary hip reconstructions with preexisting proximal femoral deformity [28] such as in DDH. Techniques have emerged to preserve the proximal femoral metaphysis and accomplish femoral shortening and derotation via subtrochanteric osteotomy [18,29-31]. Torsional stability is addressed by including stepcuts or chevron osteotomies to provide inherent stability to the construct. This additional level of complexity causes some authors [30] to advocate using an equation tO calculate, before surgery, the osteotomy geometrically. Although derotation can be predetermined, the use of step-cuts or chevron osteotomies does not readily lend itself to intraoperative adjustment.
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A transverse osteotomy will allow femoral shortening and derotation and will facilitate intraoperatire adjustment. Such a technique has been reported by Reikeraas et al [32]. In 25 cases, they used 4 cemented stems and 21 noncemented stems. The torsional stability of the construct was not reinforced by any means. At follow-up periods of 3-7 years, they reported 96% satisfactory results, with no revisions and no mechanical failures; however, they had I delayed union and 1 varus malunion (8%) in their series. We present a technique that uses a transverse subtrochanteric osteotomy in a series of 9 THAs in high-riding hips secondary to DDH. The transverse nature of the osteotomy facilitates femoral shortening and derotation, which is easily adjusted during surgery. In contrast to Reikeraas et al. {32], we enhance torsional stability with noncemented fully porous-coated stems, press-fit into the diaphysis and augmented with allograft struts and cables.
Materials and Methods Surgical Technique Templating of the preoperative anteroposterior (AP) pelvis and of the AP and frog lateral hip radiographs is of paramount importance to plan adequately for this complex reconstruction. With the cup placed at the level of the true acetabulum, the center of the hip joint is indicated on the radiograph. The center of the prosthetic femoral head, based on optimizing implant fit and offset, is also indicated. The longitudinal difference between the center of the prosthetic femoral head and true acetabular center represents the maximum amount of lengthening that would be created without shortening the femur. Dissection begins with exposure of the femoral head, neck, and pseudoacetabulum. Appropriate resection of the femoral head and neck is performed. The femur is then prepared to allow placement of a trial femoral component. Anteversion of the femoral component is controlled to match the anatomy of the proximal femoral metaphysis. Exposure of the subtrochanteric femur is accomplished by reflecting the vastus lateralis from the vastus ridge and lateral intermuscular septum, leaving a stump of tendon to repair at closure. The trial device is laid over the exposed proximal femur. The region of the prosthesis representing the transition zone between the proximal bulk and the distal cylindrical geometry is indicated on the femur. A transverse osteotomy of the subtrochanteric femur is performed at this location (Fig. 1).
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The Journal of Arthroplasty Vol. 12 No. 8 December 1997 Proximal osteotomy fragment retracted superiorly ,ulurn
Level subtro transv osteot
Lie etabulum
stus lected ;tally
Fig. 1. Diagram showing posterior approach to right hip, posterior dislocation of hip, femoral head and neck resection, and initial preparation to allow seating of trial device. Note the location of pseudoacetabulum, as well as the level of transverse subtrochanteric osteotomy.
The p r o x i m a l femoral o s t e o t o m y f r a g m e n t is t h e n retracted superiorly to facilitate e x p o s u r e of the true a c e t a b u l u m , Appropriate soft tissue a n d t e n d o n releases are p e r f o r m e d as described b y Harris et al. [2,22]. I m p l a n t a t i o n of an acetabular comp o n e n t is t h e n accomplished (Fig. 2). A trial f e m o r a l c o m p o n e n t is t h e n inserted into the p r o x i m a l f e m o r a l f r a g m e n t a n d the hip is reduced, allowing the distal f e m o r a l f r a g m e n t to override at the o s t e o t o m y site. The a m o u n t of f e m o r a l shortening is d e t e r m i n e d by applying distal traction to the leg a n d allowing the o s t e o t o m y fragments to overlap. The resection level is indicated on the femur. The second transverse o s t e o t o m y of the p r o x i m a l end of the distal fragm e n t is t h e n p e r f o r m e d w i t h an oscillating saw (Fig. 3). The m i n i m u m a m o u n t of b o n e is resected to allow for m a x i m u m correction of leg-length inequality w i t h o u t c o m p r o m i s e of the n e u r o v a s c u lar structures. The hip is dislocated a n d the trial c o m p o n e n t reinserted into b o t h o s t e o t o m y fragments. A n o t h e r trial reduction is t h e n attempted. Further diaphyseal f e m u r is resected to facilitate reduction, as needed. Parallel o s t e o t o m y surfaces are e n s u r e d to minimize a n y potential gaps at the o s t e o t o m y site, t h e r e b y e n h a n c i n g b o n y contact. A n t e v e r s i o n is set b y placing b o n e - h o l d i n g clamps onto b o t h the p r o x i m a l a n d distal fragments, w h i c h are t h e n rotated relative to one
Fig. 2. Diagram showing proximal osteotomy fragment retracted superiorly. Acetabular component has been placed with bone-graft, fixed with 2 screws and washers, as needed.
a n o t h e r until the desired a n t e v e r s i o n is achieved (Fig. 4). Hip stability is assessed while securing the o s t e o t o m y f r a g m e n t s w i t h b o n e - h o l d i n g clamps.
al reduction with noral component )roximal fragment
Distal traction on leg
Fig. 3. Diagram of initial trial reduction of hip joint with trial femoral component inserted into proximal osteotomy fragment, after appropriate soft tissue release. Level of second transverse osteotomy for diaphyseal femoral shortening is determined with distal traction on leg.
Subtrochanteric Shortening Osteotomy inTHA
Fig. 4. Diagram of second trial reduction of hip joint with trial femoral component inserted into both fragments. Anteversion is set manually by rotating fragments with bone-holding clamps.
Anteversion is adjusted to achieve the desired stability. The rotational position is indicated by marking b o t h o s t e o t o m y fragments. Final insertion of a n o n c e m e n t e d femoral comp o n e n t proceeds with standard techniques, holding the o s t e o t o m y fragments manually to ensure appropriate anteversion. Insertion of a c e m e n t e d femoral c o m p o n e n t is done with 2 batches of cement. The cleaned and dried proximal f e m u r is first h a n d p a c k e d and the c o m p o n e n t inserted. To p r e v e n t c e m e n t from leaking into the o s t e o t o m y site, the c e m e n t is u n d e r c u t 2-3 m m from the distal surface of the proximal fragment. This creates a pocket for the second batch of c e m e n t to flow into and reduces the propensity for the cement to leak into the osteotomy site. The cement is allowed to harden. Cementing into the distal fragment is t h e n done using third-generation techniques, while holding the anteversion manually. The excess cement is cleaned from the osteotomy site. Adjuvant rotational stability m a y be obtained by using single or bicortical allograft struts, reinforced with tensioned cables.
Procedure B e t w e e n 1989 and i994, 9 high-riding (Crowe type IV) DDH hips in 8 patients were treated with these techniques for primary THA using sub-
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trochanteric femoral shortening via transverse osteotomy. There were 7 left and 2 right hips in 6 w o m e n and 2 men. Their average age was 42 years (range, 22-77 years) at the time of surgery. Clinical assessment was scored according to d'Aubignd and Postel [33]. Leg lengths were m e a s u r e d clinically before and after surgery by measuring the distance from the anterior superior iliac spine to the medial malleolus. The excised diaphyseal fragment was measured with a ruler during surgery and recorded in centimeters. Zonal analysis of radiographs for evidence of loosening was done according to the methods of Gruen et al. and DeLee and Charnley [34,35]. Healing was assessed using serial radiographs, which were evaluated for consolidation of the osteotomy site and for incorporation of the cortical struts. Time to union, m e a s u r e d in the n u m b e r of m o n t h s after surgery, was n o t e d at the first followup evaluation with radiographic evidence of healing of the osteotomy site. Noncemented, diaphyseal filling femoral components were used in 7 hips in 6 patients, all of w h o m were y o u n g e r t h a n 60 years of age, and all were a u g m e n t e d with allograft struts and braided cobalt-chrome alloy cables (Dall-Miles, H o w m e d ica, Rutherford, N J). Two allograft struts were placed, 1 medially and 1 laterally, in 5 of 7 cases. In 2 cases, a single lateral allograft strut was used. The Anatomic Medullary Locking prosthesis designed for use in cases of developmental dysplasia (AML CDH, DePuy, Warsaw, IN) was used in 6 cases. This AML CDH stem is fully coated along its entire length with cobalt-chrome alloy beads. The S-ROM prosthesis (Joint Medical Products, Stamford, CT) was used in 1 case. This S-ROM stem has a porous metaphyseal collar and an uncoated, fluted distal section. Cemented femoral c o m p o n e n t s designed for use in cases of developmental dysplasia (Spectron CDH, Smith & N e p h e w Orthopaedics, Memphis, TN), were used in 2 hips in patients over the age of 60 w i t h o u t allograft struts.
Results Follow-up periods averaged 43 m o n t h s (range, 24-83 months). Eight of 9 osteotomies (89%) demonstrated radiographic evidence of healing at the time of follow-up evaluation. One patient w h o had a n o n c e m e n t e d medullary fitting stem, a u g m e n t e d with a single lateral cortical strut, had an asymptomatic n o n u n i o n at a follow-up period of 25 m o n t h s but a good overall clinical result. Good to excellent results were obtained in 87% of patients (7 of 8). Clinical scores of d'Aubignd and Postel were improved for 7 of 8 (87%) patients. The aver-
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age time to u n i o n of the o s t e o t o m y site was 5 m o n t h s (range, 3-9 months), excluding the patient with the n o n u n i o n . Leg-length inequalities were restored to an average of 1.5-cm (range, 0.5-3 cm) discrepancy after surgery, from their baseline of 5 cm (range, 3-7 cm) before surgery. Length of the resected femur, or a m o u n t of shortening, averaged 3.5 cm (range, 3-5.5 cm). At s h o r t - t e r m follow-up periods, no radiolucencies were n o t e d in the c e m e n t e d stems and all n o n c e m e n t e d implants appeared to have b o n e i n g r o w t h in at least 2 zones. There were no neurologic complications. One patient had an early dislocation at 4 weeks after surgery and was treated with an abduction orthosis for 6 weeks. There were no late dislocations. One patient suffered fatigue failure of a distally i n g r o w n porous device. In this case, an AML CDH size 10.5m m stem was implanted in an 82-kg (180-pound) man. At 18 m o n t h s after surgery, the patient u n d e r w e n t revision THA. The radiographs revealed that both the o s t e o t o m y and allograft struts had healed by the 6 - m o n t h follow-up evaluation; h o w -
ever, at the time of revision, there was minimal healing of the struts and the o s t e o t o m y was not united. In this case, there was distal i n g r o w t h of a small-diameter AML stem, w h i c h resulted in cantilever failure of the stem. This was rated as a poor outcome. A typical case is presented in Figure 5.
Discussion It has been suggested that a transverse osteotomy tends to be unstable in complex hip arthroplasty [30]. For this reason, other authors have advocated oblique [28], d o u b l e - c h e v r o n [30], or complex step-cuts [18,31] to e n h a n c e the torsional stability of the overall construct of subtrochanteric osteo t o m y in THA. We have successfully used a transverse o s t e o t o m y to effect subtrochanteric femoral shortening and derotation in 9 THAs for highriding DDH and have obtained 87% good to excellent results; however, we have e n c o u n t e r e d 2 complications, w h i c h m a y be directly attributable to bio-mechanical issues.
Fig. 5. Radiographs of both hips from a typical clinical case in which a 38-year-old woman who presented with bilateral disabling hip pain underwent bilateral staged total hiparthroplasties (THA). The technique of subtrochanteric femoral shortening was used with noncemented components, reinforced with bicortical allograft struts on the left and autograft struts on the right. These procedures were staged 6 months apart. (A) Preoperative anteroposterior (AP) pelvis radiograph depicting bilateral high-riding developmental dislocation of the hips, Crowe stage IV. (B, C) Immediate postoperative AP radiographs of (B) right and (C) left hips showing noncemented THAs with subtrochanteric femoral osteotomies reinforced with (B) autograft struts and cables on the right and with (C) allograft struts and cables on the left. A noncemented acetabular component was augmented with autogenous femoral head bone-graft and screws with washers on each side. (Figure continues.)
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Fig. 5. (Continued) (D) Three-year follow-up AP radiograph of right hip and 3.5year follow-up AP radiograph of left hip (E) showing healing of osteotomies without evidence of loosening of either component. The patient had equal leg lengths and a normal gait pattern without a limp. Radiographs revealed healing of the osteotomy site for each side at the 6-month follow-up visit. At 3.5 years after surgery, the patient was functionally much improved and was given an excellent rating overall.
In the case of the s t e m fracture, a relatively s m a l l - d i a m e t e r s t e m (10.5 m m ) was i m p l a n t e d in a n average-size m a n (82 kg). In E n g h a n d colleagues' series, 2 such i m p l a n t failures occurred, b o t h using 1 0 . 5 - m m d i a m e t e r stems {36-38]. For m e d u l l a r y fitting p r o s t h e s e s w i t h distal i n g r o w t h , the p o t e n t i a l exists for cantilever failure of the sintered stem, a n d s o m e a u t h o r s r e c o m m e n d avoiding s m a l l - d i a m e t e r m e d u l l a r y fitting stems for use in n o n c e m e n t e d THA in y o u n g , active patients {39,40]. The s u b t r o c h a n t e r i c region of the f e m u r is highly loaded [41] a n d is associated w i t h n o n u n i o n [42,43]. O s t e o t o m y in this region a d m i t t e d l y w o r s e n s the stresses b o r n e b y the stem, especially if n o n u n i o n occurs. Three factors that m a y increase the stem stress in this t e c h n i q u e are n o n u n i o n of the o s t e o t o m y site, lack of p r o x i m a l b o n y i n g r o w t h (or distal only ingrowth), and small s t e m diameter. The femoral m e d u l l a r y d i a m e t e r in DDH tends to be very narrow. Accordingly, b i o m e c h a n i c a l factors are of greater concern in s m a l l - d i a m e t e r stems. In this situation, we r e c o m m e n d r e a m i n g the diaphysis to a c c o m m o d a t e the n e x t larger, s t e m size. The prob-
lem of cantilever s t e m failure m a y be m i n i m i z e d by using fixation strategies other t h a n distal ingrowth. Conceivably, designs w i t h p r o x i m a l porous surfaces and distal fluted sections offer p r o x i m a l i n g r o w t h and rotational stability, t h e r e b y also eliminating the n e e d for cabled struts; however, i m p l a n t stresses with this type of design are not necessarily lower in the setting of a subtrochanteric osteotomy. Our experience with this type of design is not sufficient to allow us to c o m m e n t . N o n e t h e less, rotational stability of the construct m u s t be ensured, bearing in m i n d the increased implant stresses that an o s t e o t o m y causes. The issue of rotational stability is p a r a m o u n t in the technique of transverse o s t e o t o m y of the subtrochanteric f e m u r in THA. Reikeraas et al. reported 1 delayed u n i o n and 1 varus m a l u n i o n in 25 patients (8%) treated with a transverse subtrochanteric o s t e o t o m y in THA for DDH that did not use implants offering i n h e r e n t rotational stability to the construct a n d that w e r e not a u g m e n t e d with allograft struts [32]. They did not report the factors governing the o u t c o m e s of these 2 patients. In our series, an a s y m p t o m a t i c n o n u n i o n devel-
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oped in 1 patient in w h o m a noncemented medullary fitting stem was used (11%). Both of the cemented stems used in this study provided sufficient torsional stability without struts to permit healing of the femoral osteotomy. Noncemented stems were reinforced with bicortical struts in 5 of 7 cases, including the stem failure, while a single lateral strut was used in 2 cases, including the case involving the nonunion. Overall, our rate of n o n u n i o n with struts was similar to, but not statistically different from, that reported by Reikeraas et al., who did not use struts {32]. We believe it is important to obtain rotational stability in the construct. It is our preference to use a stem that offers some inherent torsional stability, by using either a cemented stem or a noncemented diaphyseal locking stem, and to supplement the construct with allograft struts. Unfortunately, our small patient numbers do not permit us to offer any statistically supported recommendations regarding the best construct for this type of complex reconstruction. Biomechanical investigations regarding the implant stresses and torsional stability of the transverse osteotomy reinforced with single or bicortical struts versus complex osteotomies would be beneficial. In addition, the longevity of these complex arthroplasties must be assessed through long-term follow-up studies. Subtrochanteric femoral shortening osteotomy in THA for high-riding DDH permits cup placement at the level of the true acetabulum, preserves proximal femoral bone stock, and reduces the need for greater trochanteric osteotomy. In addition, the sciatic nerve is protected by the presence of the femoral osteotomy, which prevents stretching of the nerve during the initial trial reductions with the isolated proximal fragment. The proximal osteotomy fragment can be retracted superiorly as easily as a greater trochanteric fragment, providing wide acetabular exposure. Furthermore, preservation of the proximal femoral metaphysis may provide better torsional stability and, perhaps, better overall fixation of the femoral prosthesis [44]. The transverse nature of the osteotomy is clearly advantageous for it allows setting anteversion by rotating the osteotomy fragments. Other authors advocate using a mathematical formula to calculate the amount of offset between the apices of the double-chevron osteotomy to plan before surgery for derotation of the proximal femur [30]. If stepcuts are used, this approach involves a similarly complex level of preoperative planning. Although the double-chevron or step-cut osteotomy may be predetermined, these techniques do not lend themselves to intraoperative adjustment as does the transverse osteotomy.
We have also used the technique in other conditions with proximal femoral deformity including posttraumatic malunion and in revision of complex osteotomies to THA for congenital coxa vara or Legg-Calv~-Perthes disease. The technique facilitates diaphyseal femoral shortening and derotation, and may avoid some of the complications of greater trochanteric osteotomy. Although the need for greater trochanteric osteotomy is diminished, there may be cases where it is unavoidable. In this circumstance, the performance of both a greater trochanteric osteotomy and subtrochanteric femoral shortening will permit the trochanter to be returned to a broad cancellous bed, as opposed to the smaller surface area of cortical bone afforded by proximal femoral shortenings.
Conclusion Subtrochanteric femoral shortening and derotation constitute a useful adjunct for THA in highriding DDH. A transverse osteotomy facilitates intraoperative adjustment of both the degree of derotation and the amount of shortening of the proximal femur. This permits acetabular fixation in the true acetabular region and allows proper femoral anteversion to be set to provide adequate hip stability. The technique corrects leg length via diaphyseal shortening, thereby minimizing the risk of sciatic neuropraxia while maximizing proximal femoral bone stock. The torsional stability of the overall construct must be achieved. When noncemented stems are used, augmentation with allograft struts and tensioned cables should be considered. Because of the increased implant stresses that an osteotomy causes, cantilever fatigue failure must be kept in mind. In this circumstance, small-diameter fully porous-coated stems should be used judiciously.
Acknowledgments We thank Dr. Victor H. Frankel and Dr. Patrick Meere for clinical contributions to this study, Mr. Hugh Nachamie for the graphic arts, and Mr. Frank Martucci for the reproduction of radiographs.
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