Sep 6, 1993 - femoral intertrochanteric osteotomy in 215 hips, with a minimum follow-up .... Femoral derotation gave a mean. 72 months of relief and valgus.
TOTAL
HIP
ARTHROPLASTY
AFTER
INTERTROCHANTERIC GARY
From
M.
FERGUSON,
the Mayo
OSTEOTOMY
MIGUEL
Clinic
E. CABANELA,
DUANE
Foundation,
Rochester,
and Mayo
M. ILSTRUP USA
From 1969 through 1982, 305 hips in 290 patients had total hip arthroplasty for failed femoral intertrochantericosteotomy. Ofthese, we reviewed2l5 hips (70.5%) with a minimum follow-up of five years. The results were good or excellent in 79%, but there were technical problems at operation in 23% and a total perioperative complication rate of 11.8%. Late complications occurred in 13.1 % including seven late infections (3.2%). At a mean follow-up of ten years, 39 hips had been revised (18.1%), there was probable loosening in 19.5% of stems and 12.6% of cups and possible loosening in 11.4% of stems and 7.2 % of cups.
The
cumulative
ten years was 20.6%. We recommend be advised, planned possible need for a and that screws and soon after union of
FAILED
probability
of failure
at
that intertrochanteric osteotomy and executed bearing in mind the subsequent total hip arthroplasty, plates should be routinely removed the osteotomy.
AND
PATIENTS
Thejoint
replacementregistry
records
BoneJoint
Received
Total
Surg
[Br]
1994;
10 May
1993;
Accepted
hip
from
1969
the long-term
revision
6 September
who had
had either inadequate
respects
between
not been
1993
failed
femoral
intertrochanteric
with
a minimum
follow-up
it is performed
ntis,
osteotomy
THA
after
in 215
hips,
of five years.
5.6%,
Perthes’
arthritis,
reported. of cemented
MD, Senior Resident in Orthopedics School of Medicine, Rochester, Minnesota
55905,
M. E. Cabanela, MD, Consultant, Department of Orthopedics, and Mayo Foundation, and Professor of Orthopedics Mayo Medical School, Rochester, Minnesota 55905, USA. D. M. Ilstrup, MS, Associate, Section of Biostatistics, Mayo Foundation, and Assistant Professor of Biostatistics Mayo Medical School, 200 First Street SW, Rochester, USA.
©1994 British Editorial Society 0301-620X/94/271 1 $2.00
252
and Joint
small
numbers
necrosis,
lupus
with
other
rheumatoid coxa
vara,
erythematosus,
arthold septic
and
right hips were equally were men. The mean
of
the
authors
USA.
Mayo
Mayo Minnesota
Clinic
Clinic
been
and
55905,
osteotomy postoperative,
psoriatic
represented and age at osteotomy
approach acetabuli
had had
cemented,
of
but
7.3 and
after
the
been
been
used.
years. latest
A
in all cases; All
canal
had not been years, giving
by
arthroplasty.
used
femoral
had
no
components plugging
and
used. The mean age a mean time after
The preoperative, follow-up radiographs
one-year were
evaluated for loss ofbone stock and evidence of loosening, using the Mayo hip score (Kavanagh and Fitzgerald 1985). We
Surgery
(GMF)
cement pressurisation at TI-IA was 61.4
to Dr M. E. Cabanela. of Bone
follow-up
was 54.5 years and just over half of the osteotomies been performed at the Mayo Clinic. All the records and radiographs were reviewed
had
be sent
radiographs no differences
had been osteoarin 6.5%, and slipped
developmental
systemic
metal-backed
should
we excluded
long-term
osteotomy arthritis
with
disease,
transtrochanteric
Correspondence
hips,
lost to follow-up, or reviewed, however,
with
as avascular
arthritis. Left and 58% ofthe patients
one
G. M. Ferguson, Mayo Graduate
been We
those
those lost. The diagnosis before thritis in 79%, post-traumatic such
the results
the 420
provided osteotomy
and
in
have
Clinic failed
demographic data, operation, postoperative and complications in all 305 hips, finding
diagnoses,
reviewed
From
died (n = 79), radiographs.
epiphysis
when
1982.
Mayo
a previous
ties. These exclusions left 305 hips in 290 patients; all operative records were available for these cases. Of these, 215 hips had been followed up for at least five years (mean 10.1). The other 90 hips were in patients
after
(THA),
results
have
after
through
with
84 with severe congenital deformity of the acetabulum and 15 which had undergone either a Milch subtrochanteric osteotomy (10) or an osteotomy after a previous fusion (5). We also excluded eight treated by endoprostheses and eight which had had surface replacement arthroplas-
osteotomy, is known to have a high of complications and infection, but
arthroplasty
an intertrochanteric short-term incidence We
76-B:252-7.
ofthe
of all patients
in these J
METhODS
clinical
performance
used results,
the
same giving
(excluding
scoring up
system to
range ThE
JOURNAL
80
to evaluate
points
of motion) OF BONE
for
and AND JOINT
the clinical
up to 20 SURGERY
TOTAL
HIP ARThROPLASTY
AFTER
FAILED
INTERTROCHANTERIC
253
OSTEOTOMY
Figure
Fig.
la - Ten years after right valgus and left varus osteotomies. Figure lb - Ten years after conversion. There were problems at operation with retained screws, but both THAs were functioning well.
la
Fig. lb
points gained and
for radiographic by questionnaire clinical
appearance. in 68%,
examination
This information was telephone call in 8.1%,
in 23.9%.
If a patient
Mayo Clinic, to us.
a radiograph
Statistics.
Comparisons two-sample
of continuous variables t-tests or rank-sum tests
made
with
necessary. squared estimated
Comparisons of proportions tests. The cumulative probability as a function of time since
Kaplan-Meier were
was
could
attend the and mailed
made
method. with
Comparisons
log-rank
taken
not
locally were when
were with chiof failure was surgery by the
of failure
curves
All 305
tests.
teric osteotomies. varus, and in 96 medial
VOL.
hips had had femoral
displacement
76-B. No. 2, MARCH
in
1994
23.4%,
and
placed in had been
a combination
derotation
and valgus in 6.2%. Other hips had (2.6%), medial and varus displacement (2.3%), varus derotation (2.0%), and derotation alone (0.3%). All but four osteotomies had been fixed with a plate or spline (Wainwright, Harris or AO blade plate) and
distal
cortical
screws;
four
internal fixation. The disease progressed patients; 10.8% had nonunion The
highest
nonunion
and 47.1 months mean 72 months
intertrochan-
In 96 (31.5%) the neck was in valgus (Fig. la). There
displacement
valgus
rate
had
spica
casts
after osteotomy and 1.3% became (18%)
was
in the
with
no
in all infected.
17 hips
with
post-traumatic arthritis, with a 13% rate in the osteoarthritic cases. Varus osteotomy had a 23% nonunion rate; valgus osteotomy produced 4% nonunion. Varus and valgus osteotomies gave similar periods of pain relief, 40
RESULTS
Osteotomy.
medial
of
longest
Femoral valgus
derotation derotation
gave a gave the
mean relief (93.5 months). four infected patients were treated successfully, there was no relationship between infection of the All
and
respectively. of relief and
G. M. FERGUSON,
254
osteotomy
and
Although
later
no patient
arthroplasty,
hip
was
infection
infected
taken
at this time
28 specimens
to plate
culture
obtained
is
(the
not
Staphylococcus
total
known). epidermidis,
of these
arthroplasty, with the healed.
cases
three
with
biotics,
changed
of such
of
positive
specimens
cultures
grew
Streptococcus
biotics;
a deep
infection
after
In
the
of
cultures
for
surgeon’s the
opinion
ideal also
in 34. 1 % and
24.3%. Breakage ( Fig. ib). Femoral
the
arthroplasty
was
difficulty
in removal
osteotomy incision
described in reaming of plates
the and
of these implants occurred shaft osteotomy was never
the
than
as difficult
in
and
more
rarely
A Charnley
cobalt-chrome Fig.
2),
other Charnley Charnley-M#{252}ller,
Fig.
with
prosthesis a variety
in
in 20.7% required to
was used of
other
in 90
designs,
patterns, but including the Harris Aufranc-Turner, T-28, and the
2a
osteotomy. Figure 2b - The Charnley stem is in a varus 2c - Fourteen years later the stem and the cup are loose.
thrombosis
to the
clinical
the anti-
other
antibiotics
(8.6%)
oxacillin,
and
clindamy-
and penicillin.
The
4.4 days. used for prophylaxis
(DVT),
found and
infection.
cephazolin
cephamandole,
arthroplasty
follow-up arthroplasty was done
femoral screws
3). We
mean against
except in four patients, or pulmonary embolism.
evening hospital. removed 26.9%;
outcome
after
operation
at the time of this made no
as regards
hip
score,
loosening or revision rates. The final follow-up score was not affected by the original type of osteotomy. Nonunion of the osteotomy (n = 33) did not affect
incision in less
venous
difference
to fit the prosthesis.
Figure 2a - Failed by the plate. Figure
(64.3%);
none of whom developed DVT The drug was usually started the and continued during the time in The osteotomy fixation was TI-LA in 71.8%, or earlier in
was
mainly HD-2,
(6.3%),
196
(14.1%),
anti-
patients
(29.5%;
lincomycin
in
of the
according
36.4%.
hips
cephalothin
prophylactic
positive
(Fig.
a postoperative
to the sensitivity
with course
in four
and exposure
help
used
included
had
deep
hips
a three-week
There
was
three
were
the
compromised 5% of cases, canal
prosthesis
of
The mean operating time in 305 TI-IA was 171 minutes (90 to 320). Blood loss averaged 1340 ml (50 to 4100) and the mean transfusion was 3.3 units of packed cells (0 to 10). The mean hospital stay was 16.9 days (8 to 62). in 290
of the
cm, ampicillin,
hip
organism. Total hip arthroplasty. hips
none
Methicillin
viridans,
Streptococcus, Corynebacacnes, and Neisseria species.
developed
‘osteotomy’
no relationship between the type of osteotomy choice of prosthesis. All but three patients received prophylactic
duration of prophylaxis was Warfarin was routinely
same
treated
double-curved
arthroplasty.
at the time were
D. M. ILSTRUP
one had a superficial wound infection cultured organism which subsequently
but Fifteen
number Twenty-one
and one each a-haemolytic terium, Proprionibacterium None
after
actively
M. E. CABANELA,
revision
rate,
the
loosening
hip score. Of the five revisions in the presence of osteotomy for stem loosening and four
both
components.
was
The bone stock always adequate
one
patient
the
acetabulum:
required
or the
on the femoral or acetabular to support a prosthesis, and corticocancellous
this
rate,
performed after nonunion, one for loosening of
hip
was
grafting
functioning
side only
to augment
well
at seven
years. For
Fig.
the
long-term
follow-up
2b
position with poor medial There has been considerable
Fig. cement. Cement polyethylene
THE JOURNAL
of 215
group
fills wear.
the
2c
the intertrochanteric
OF BONE
hips
AND JOINT
hole
left
SURGERY
TOTAL
HIP
ARThROPLASTY
AFTER
FAILED
INTERTROCHANTERIC
OSTEOTOMY
255
Figure 3a - Old medial valgus-displacement osteotomy. Figure 3b - A double-curved ‘osteotomy’ stem was chosen; there are cement-bone radiolucent lines at one year although the patient was asymptomatic.
mean
preoperative
Mayo
possible
80 (6 to 73),
clinical
and
improved
Clinic
radiological
to a mean
hip
score
95%
below
59.
score
at
with
(.
.
.0 CD
CD 0
Varus osteotomy
30
..
30
.0
20
0
20
0.
a >
.
10
I 0.
E
(
00
2
4
8 10 6 Years since THA
12
14
2
0
4
Fig. 5
Fig. 4 Cumulative probability of method) with 95% confidence
Fig.
total hip intervals.
arthroplasty
failure
McNeice
(Kaplan-Meier
Fig.
and
1979;
Amstutz
-
Figure 6b One year
Wroblewski
Cortical defects left after removal of screws often healed within one year, but in four patients
appeared
to start
loosening
and
Cumulative probability of total varus osteotomies (Kaplan-Meier
6a
Figure 6a - A painful hip 14 years after varus osteotomy. cement has extruded through cortical holes. Figure 6c symptomatic at two years and the stem subsided.
(Gruen,
at these
failure
sites
(Fig.
and
-
The early later there
Fig. postoperative is already
term
1982).
led to symptomatic
radiograph a complete
loosening
(1982)
or plates loosening
effect
outcome
of previous
of THA
intertrochanteric
has
been
analysed
and
Chamley
121 pain
cases of osteotomy converted and the range of motion was
No
numbers
(1972)
were
reported
given
for
osteotomy
by others.
a one-year to THA: significantly
complications,
on the
Dupont
follow-up
of
Benke, who
sions
with
a minimum
follow-up
82%
had
little
pain
Their
infection
6c
and rate
Baker
had
and
Dounis
osteotomy
conver-
of one
year
(mean
4.7):
75%
could
walk
long
was
8.6%
with
technical
in 17.1%. success osteotomy,
rate
for with
conversion after mean improvement
Mayo hip score from 34 of 80 points is similar to the success rates reported
to 85 of 100 for primary
in comparable
and
87% had no improved.
from
or for
at five
long-
revision.
or no
valgus and intervals.
a stable cement-bone interface, but some line at the interface. The hip became
105 patients
Our clinical intertrochanteric
DISCUSSION
shows radiolucent
and
reviewed
distances.
6).
failure after 95% confidence
hip arthroplasty method) with
6b
difficulties
The
10
6
Years since THA
patients.
our institution,
techniques,
found years
Beckenbaugh
and using 24%
although
loose
the same stems
relatively
THE JOURNAL
and few
OF BONE
failed of points TFIA
Ilstrup
(1978),
cement-fixation 6.5%
loose
needed
AND JOINT
cups
revision.
SURGERY
TOTAL
Stauffer
(1982)
described
and a cup-loosening only 4.3% of loose
HIP ARThROPLASTY
a stem-loosening
rate stems
of 1 1.3% and 3.1%
rate
at ten years, ofloose cups
revision. In our series, more loose components revision: 7.9% of the 11.6% with loose cups, of the 19.5% with loose stems. The reason
younger
mean
of 3.2% positive
an infection,
examined. should
age of our patients.
Our deep
also increased the revision cultures in 28 patients,
developed
although
Perhaps
all hips
routine
aspiration
have
to THA. The role of residual loosening is uncertain, but
AFTER
patients
although required
cited
infection
previous
rate
were
so
osteotomies before
conver-
sion
in four of our must decrease and
small
penetrations
of difficulty time such least
site,
The presence of cement-bone of
cement
of cortical holes interdigitation,
through
of broken
in removing
screw
cultures
plates
and
screws
metal
implants
holes
from (20.7%)
(24.3%)
at the
long-term
after intertrochanteric be similar in quality et al 1981; Stauffer
clinical
results
of
cemented
THA
osteotomy have been reported to to those after primary TI-IA (Salvati 1982; Sutherland et a! 1982), but we
experienced a complication rate of 24.9%, technical problems in 23% and an aseptic revision rate of 14.9%. They warrant careful counselling when considering
conversion
to TI-IA (Poss
1984)
and very careful
and execution of any primary femoral Indications must be strictly applied, and
VOL.
76-B, No. 2, MARCH
1994
planning
osteotomies. perhaps only
OSTEOTOMY
are close 1984)
257
to the ideal
should
candidate
osteotomy
should
of the femoral
limb canal
minimal patients
screws in any form party related
will
with and need
(Morscher,
be considered.
planned
and
No benefits commercial
preserve
the mechan-
distortion should be
of the told that
to be removed.
have been received directly or indirectly
or will be received to the subject of this
from article.
a
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Gruen
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GJ, Baker AS, Dounis E. Total hip replacement osteotomy: a clinical review. J Bone Joint Surg 570-1.
Dupont JA, Charnley failures of previous 77-87.
the and
of THA all argue in favour of the routine removal of implants soon after an osteotomy has healed, and at six months before any conversion to THA.
The
plates
Benke
may act as stress risers in the mantle. The incidence of positive tissue osteotomy
ical axis proximal
cortical defects in causing they seemed to be implicated
39 revisions. the quality
who by Poss
The
required and 12.1% may be the
all patients
for culture
INTERTROCHANTERIC
of 29.9%
rate. We obtained only one of whom
not
with
FAILED
J.
Low-friction
operations.
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EA, Wilson PD Jr, Jolley MN, et al. A ten-year follow-up study of our first one hundred consecutive Charnley total hip replacements. J BoneJoint Surg [Am] 1981; 63-A:753-67.
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a clinical
review
