Surgical interventions for osteoarthritis of the hip in the young adult : the role of intertrochanteric osteotomies - Chapter 1 Introduction and Aims of this thesis.

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Surgical interventions for osteoarthritis of the hip in the young adult : the role of

intertrochanteric osteotomies

Haverkamp, D.

Publication date

2006

Link to publication

Citation for published version (APA):

Haverkamp, D. (2006). Surgical interventions for osteoarthritis of the hip in the young adult :

the role of intertrochanteric osteotomies.

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Duringg the last 40 years major changes have occurred in the treatment of osteoarthritis of the hip joint.

Inn the older patient it has become an easy to manage problem with excellent results due to

improvementss in total hip replacement surgery. For the young and active patient osteoarthritis of the

hip,, mainly caused by childhood hip disorders, often remains a condition which is difficult to manage.

Despitee great improvements in the field of total hip replacement (THR) unfortunately problems still

remain;; wear, debris generation and osteolysis remain problematic. Even the most optimal THR is not

expectedd to survive longer than the life expectancy of a healthy patient who is under the age of 50.

Thee survival rates of THR concerning patients younger than 55 are shown in Figure I and are based

onn a literature review

"

"

"

"

. Based on these diverse survival rates

itt can be said that in these young patients THR should be reserved as a final option. Other

possibilitiess are joint-preserving therapies like intertrochanteric osteotomies and acetabular realigning

osteotomiess '

. In the last decade the knowledge on hip pathology is greatly improved, and the

rolee of impingement as causative factor for OA and labrum lesions as early signs of OA has become

clear.. Several treatment options like surgical dislocation of the hip, hip arthroscopy and acetabular

osteotomiess could be an important expansion of the joint preserving treatment strategies. Arthrodesis

off the hip joint should not be forgotten as an option

_{. In this young patient group the role of}

joint-preservingg surgery is a particular important one. Intertrochanteric osteotomies are not just procedures

whichh were performed in the past, but there are still valid indications for its use now. It is important for

uss to identify these indications and patient populations in order to improve the treatment for this patient

group. .

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Osteoarthritiss of the hip in young patients is not merely a theoretical problem.

Accordingg to the RIVM (National Institute for Public Health and the Environment) a total of 260.000

patientss under the age of 50 suffered from osteoarthritis of the hip joint in the Netherlands in 2000.

(Tablee I). This means that 1.6 % of the Dutch population under the age of 50 suffers from osteoarthritis

off the hip at a young age which suggests that this poses significant problems for our society.

Inn view of these large numbers of patients it is even more essential to identify which patients can be

successfullyy treated with joint preserving surgery like the intertrochanteric osteotomy. We would

thereforee not only be concerned with short term results but, more importantly, with long term results.

Thiss thesis will emphasise on the role of the intertrochanteric osteotomy in the treatment of

osteoarthritiss of the hip joint.

OAA overall OA Hip

Age e

0-4 4

5-9 9

10-14 4

15-19 9

20-24 4

25-29 9

30-34 4

35-39 9

40-44 4

45-49 9

50-54 4

55-59 9

60-64 4

65-69 9

70-74 4

75-79 9

80-84 4

male e

0.0 0

0.2 2

0.0 0

0.3 3

0.3 3

2.3 3

5.5 5

8.5 5

11.0 0

19.7 7

36.0 0

45.0 0

65.1 1

92.3 3

128.6 6

130.9 9

168.4 4

female e

0.0 0

0.0 0

0.1 1

0.5 5

1.6 6

1.3 3

2.3 3

3.3 3

8.5 5

18.2 2

39.1 1

67.6 6

111.0 0

167.9 9

211.9 9

271.9 9

317.7 7

male e

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.3 3

0.8 8

0.9 9

1.6 6

4.9 9

11.3 3

16.9 9

23.1 1

36.6 6

46.1 1

61.3 3

84.3 3

female e

0.0 0

0.0 0

0.0 0

0.0 0

00 1

0.2 2

0 8 8

0 6 6

1.7 7

4.4 4

9 8 8

15.6 6

34.5 5

66.4 4

81.8 8

122.1 1

124.5 5

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Beforee the era of total hip replacement, intertrochanteric osteotomies were the most important

treatmentt option for osteoarthritis of the hip. The first intertrochanteric osteotomies were described by

McMurrayy in 1935

. The surgical procedure described, consisted of an osteotomy at the

intertrochantericc level without surgical fixation after which the hip was allowed to find its optimal

position. .

Blountt developed the first reliable fixation for osteotomies in 1945 which was superseded by Muller

whoo perfected the art of internal fixation (AO/ASIF)

_{. The fixation which Blount introduced was}

essentiall as the type of osteotomy changes from this point on, the correction achieved by the

osteotomyy was now calculated preoperatively and fixation was necessary to maintain this calculated

correction. .

Pauwelss introduced the concept of adding a (calculated) angular correction (varus/valgus) to the

intertrochantericc osteotomy around 1950, since then adaptations have been made by Muller and later

byy Bombelli

. Others, like Schneider. Blount. Schatzker, Morscher and Maquet contributed also

too the general body of knowledge on intertrochanteric osteotomies

. Imhauser adjusted the

osteotomyy correction in 1962 for a specific group of patients who suffered from a slipped capital

femorall epiphysis, a correction which was subsequently popularised by Bombelli

.

Thee theoretical foundation of the intertrochanteric osteotomy lies in its biomechanical explanation. This

biomechanicall analysis was first described by Pauwels and was partially based on research carried

outt by Wolff, Braune and Fischer at the end of the 19th century. Wolff's law concerning the need for a

physicall stress to stimulate and maintain bone structures is well known. Braune and Fischer plotted

thee centres of gravity of the hip joint in the 31 phases of gait by investigating soldiers and cadavers.

Later,, Fick estimated the force factor present in the hip abductors in 1910

. This work was ignored

inn clinical practice until Pauwels integrated this into a theory concerning the biomechanical vectors of

thee hip joint in a 2-dimensional plane (coronal plane) and based his theory of varus/valgus osteotomy

onn these calculations. Later. Bombelli expanded this theory into a 3-dimensional context, which is still

thee best theoretical explanation published. By studying the hip joint during gait in a 3-dimensional

contextt he realised that correction in the sagittal plane could be just as important as corrections in the

coronall plane

. Therefore, the extension and flexion possibilities, which were already added to the

intertrochantericc osteotomy by Schneider, could be explained biomechanically. An important part of

thee work of Pauwels and Bombelli concerns how to use osteophytes in the careful preoperative

planningg phase

.

Ass mentioned earlier, the development of total hip replacement by Charnley in the early 60s was an

importantt step in the treatment of osteoarthritis of the hip. General orthopaedic surgeons seemed to

losee interest in joint preserving therapy in the early days of arthroplasty. Later it was recognized that

arthroplastyy was not a panacea for all and the need for joint-saving surgery became evident. Early on,

Charnleyy emphasised that total hip replacement should be performed sparingly in the young patient

18

.. Although he was definitely not a supporter of femoral osteotomies, he was clear about the

limitationss of THR in the young and active patient. This point of view is still valid in our modern clinical

practicee and should not be forgotten. In this thesis we will evaluate the role of intertrochanteric

osteotomiess in the current clinical practice, but more importantly the role it should play in treatment

strategiess of hip disorders.

Thee aims of this thesis are:

1)) To investigate the role of the intertrochanteric osteotomy in current clinical practice.

Too investigate whether the preoperative correction X-ray can predict the long term

outcomee of the osteotomy.

Too investigate if intertrochanteric osteotomies performed at an earlier stage have superior

longg term outcomes compared to those performed when complaints and osteoarthritis

havee become more severe.

Too identify which role the intertrochanteric osteotomy should play in modern practice by

identifyingg the valid indications.

Too investigate whether a subsequent total hip replacement is jeopardized by a previous

osteotomy. .

Beforee starting to investigate what the role of intertrochanteric osteotomies should be in orthopaedic

clinicall practice, we will begin by gathering information about the role it plays and to review the

literature.. An overview of the available literature, including this thesis, can be found in Chapter 2.

Ann online survey was held among international experts to investigate the awareness of orthopaedic

surgeonss regarding intertrochanteric osteotomies and to identify the role intertrochanteric osteotomies

playy in current clinical practice. This is described in Chapter 3.

Inn the preoperative planning of intertrochanteric osteotomies, correction X-rays are made to decide

whetherr osteotomy is indicated for a specific patient. In Chapter we describe a specific group of

patientss for whom a varus intertrochanteric osteotomy could be the treatment of choice. We will also

analysee whether the available long term results could have been predicted from these preoperative

abductionn correction views. In this chapter we introduce a new objective measurement to help decide

whetherr an intertrochanteric osteotomy could be of benefit to these patients.

Inn the literature it is often hypothesised that the optimal effect of an osteotomy can be achieved when

itt is performed at an early stage. We will test this hypothesis in Chapter by comparing patients with

bilaterall symmetrical hip deformities, in which one side was operated for complaints and the

contralaterall side for minor to no complaints.

Thee most important study is shown in C 6. From a large group of patients with a long follow up

periodd the valid indications to perform intertrochanteric osteotomies are distilled. The surgical

techniquee and long term results of the acetabular shelf plasty combined with an intertrochanteric

osteotomyy is described in Chapter 7. In Chapte the role of intertrochanteric osteotomy in a group of

youngg adult patients with Legg-Calvé-Perthes Disease in their childhood is further explored. The valid

post-traumaticc indications for an intertrochanteric osteotomy are described in Chapt< The last

chapterr of this thesis, Chapte 10, concerns the question whether long term results of an eventual total

hipp replacement after a previous osteotomy are impaired.

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