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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
Document Version
Final published version
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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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Surgicall interventions for Osteoarthritis of the hip in the young adult
Thee role of intertrochanteric osteotomies.
Stellingen n
Behorendee bij het proefschrift
Surgicall interventions for osteoarthritis of the hip in
thee young adult
Thee role of intertrochanteric osteotomies
1.. De rol van de intertrochantere osteotomie is aan het afnemen in de
huidigee heupchirurgie. (dit proefschrift)
2.2. De lange termijn resultaten van een varus osteotomie in valgus heupen
kann niet objectief voorspeld worden van een abductieopname. (dit
proefschrift) proefschrift)
3.. In geselecteerde jonge patiënten met secundaire coxarthrose kunnen
goedee en langdurige resultaten behaald worden d.m.v. een
intertrochanteree osteotomie. (dit proefschrift)
4.. Een intertrochantere osteotomie gecombineerd met een
pandakplastiekk kan goede resultaten geven bij symptomatische
heupafwijkingenn waar sprake is van een secundair gedeformeerde
femurkop.. (dit proefschrift)
5.. De lange termijn resultaten van een vroege, meer profylactische
osteotomie,, zijn superieur aan de resultaten van een osteotomie
verrichtt als de klachten en arthrose meer uitgesproken zijn.
(dit(dit proefschrift)
6.. Een intertrochantere osteotomie beinvloedt niet de lange termijn
resultatenn van een daaropvolgende gecementeerde heupprothese.
(dit(dit proefschrift)
7.7. De intertrochantere osteotomie is niet alleen een interessante
proceduree uit de geschiedenis maar heeft ook een plaats in de huidige
geneeskunst,, mits een goede indicatiestelling gebruikt wordt.
(dit(dit proefschrift)
8.. Hij heeft een hart van goud, maar helaas ook een heup van staal.
9.. The best hip replacement has an unknown but certainly finite life
whereass a hip healed after osteotomy will often last a lifetime.
(Mauricee E Muller, 1976)
10.. De helm is ontworpen om het brein te beschermen, dat zo matig
functioneertt dat het beschermd dient te worden.
Surgicall interventions for
osteoarthritiss of the hip in the young
adult t
Thee role of intertrochanteric osteotomies
ACADEMISCHH PROEFSCHRIFT
terr verkrijging van de graad van doctor
aann de Universiteit van Amsterdam
opp gezag van de Rector Magnificus
prof.mr.. P.F. van der Heijden
tenn overstaan van een door het college voor promoties ingestelde
commissie,, in het openbaar te verdedigen in de Aula der Universiteit
opp woensdag 28 juni 2006, te 12:00 uur
doorr Daniël Haverkamp
Promotiecommissie e
Promotor: :
Co-promotor: :
Overigee Leden:
Prof.. dr. R.K. Marti
Dr.. H. Eijer
Prof.. dr. R.M. Castelein
Prof.. dr. C.N. van Dijk
Prof.. dr. ir. CA. Grimbergen
Prof.. dr. E. Schade
Prof.. dr. Chr. van der Werken
Dr.. M.A. Kooijman
Dr.. M. Maas
Thee research described in this thesis nas financially supported by:
M i d i !! in:/, 'A Wf ii^-lKijiiK-frjl-, O n < i i T / H i ' \ ( }>-!h<!p;U'i.lKche C h i n n ' ü i r
[[ ( \ . O i ! i ' - I - i < U l ! t . ' | - ' i u t u l s Sii i r i i i in<j l: u n a (end1-.
Thee publication of this thesis was financially supported by:
Stichtingg Wetenschappelijk Onderzoek Orthopaedisehe Chirurgie
Hett A. Quist-Rutter fonds
Stichtingg Anna fonds
Nederlandsee Orthopaedisehe Vereniging
CïlaxoSmilhKlinc.. Utrecht
Livitt Orthopedie BV. Haarlem
Trenkerr Pharma, Brussel
DePuyy Implants. Amersfoort
Zimmerr Netherlands BV. Utrecht
Bauerfeindd Benelux BV, Haarlem
Biomett Nederland BV, Dordrecht
SynthesSynthes BV, Zeist
Malhyss Orthopaedics BV. Huis ter Heide
Strykerr Nederland BV. Waardenburg
Thee research described in this thesis was performed at the Ortbotrauma Research Centre Amsterdam (ORCA),, Department of Orthopedie Surgery
ISBN-10:90-9020721-X X
ISBN-13:: 978-90-9020721-6
Coverr design: Joost Gerritsen, Amsterdam {http://www.joostgerritsen.com) Printing:: Febodruk, Enschede
20066 D. Haverkamp, Amstelveen, The Netherlands http://www.osteotomie.nl l
// Chapter 1. Chapterr 2. Chapterr 3. Chapterr 4. Chapterr 5. Chapterr 6. Chapterr 7. Chapterr 8. Chapterr 9. Chapterr 10. Chapterr 11.
\ \
Contents s
Introductionn and Aims of this Thesis
Currentt clinical practice in the treatment of adult hip disorders: the role off intertrochanteric osteotomies versus total hip arthroplasty
SubmittedSubmitted for publication
Awarenesss and use of the intertrochanteric osteotomy in the current clinicall practice. An international survey
SubmittedSubmitted for publication
Cann the long term outcome of an intertrochanteric varus osteotomy be predictedd on an abduction correction X-ray?
SubmittedSubmitted for publication
Bilaterall intertrochanteric varus osteotomies in symptomatic hip deformities,, are early interventions really superior? A long term follow up InternationalInternational Orthopaedics (in press)
Multii directional intertrochanteric osteotomy for primary or secondary osteoarthritis.. Results after 15 to 28 years
InternationalInternational Orthopaedics
Intertrochantericc osteotomies combined with shelf plasty in young patientss with secondary OA and severe femoral head deformities. AA long term follow up
JournalJournal of Bone and Joint Surgery (Br)
Combinedd intertrochanteric osteotomy for sequelae of Legg-Calvé-Perthes'' Disease in young adults
InternationalInternational Orthopaedics
Intertrochantericc osteotomies in posttraumatic deformities
ChapterChapter in: Osteotomies for Posttraumatic Deformities & Treatment of Nonunions Nonunions
Intertrochantericc Osteotomy does not impair the long term outcome of subsequentt cemented total hip arthroplasty
Ann evaluation after a minimum 10 year follow up ClinicalClinical Orthopedics and Related Research Summaryy and Discussion of the Aims
Samenvatting g Dankwoord d Curriculumm Vitae Overigee Publicaties PagePage \ 99 \ 19 9 35 5 49 9 63 3 75 5 91 1 109 9 119 9 163 3 177 7 181 1 185 5 1899 / 1911 /
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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 , 4 6 8 12"17 19"27 29 30 33"39 4 1 : 4 7 49 51"55 57 58. 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 ' 56. 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 5. 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 42. 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) 9 45. 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 10 46 48. Others, like Schneider. Blount. Schatzker, Morscher and Maquet contributed also too the general body of knowledge on intertrochanteric osteotomies 40 44 50. 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 Bombelli32.
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 11 28. 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 1ü. 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 50.
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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57.. White,S.H.: The fate of cemented total hip arthroplasty in young patients. Clin Orthop Relat Res. 29, 1988.
58.. Wroblewski.B.M and Siney.P D.: Charnley low-friction arthroplasty in the young patient. Clin.Orthop Relat Res. 45, 1992. .
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Currentt clinical practice in the
treatmentt of adult hip disorders
thee role of intertrochanteric
osteotomiess versus total hip
arthroplasty y
D.. Haverkamp
P.P.. Besselaar
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Manyy orthopaedic surgeons consider intertrochanteric osteotomy a historical operation with no role to playy in modern clinical practice. This is true for a number of hip conditions such as idiopathic osteoarthritis,, rheumatoid arthritis and severe osteoarthritis in the elderly patient. However, there exist conditionss in selected (younger) patients where an intertrochanteric osteotomy can produce excellent andd long lasting results. In these conditions, an intertrochanteric osteotomy should therefore be the preferredd treatment z .
Historically,, the first surgical treatment for osteoarthritis was a resection of the femoral head as describedd by Girdlestone. This was a pure salvage procedure and its main aim was to reduce pain. Thee techniques of tenotomies (Voss) and the earliest intertrochanteric osteotomies by McMurray may alsoo be regarded as salvage procedures. During the development of hip surgery, the goal of treatment graduallyy changed. Apart from pain relief, function and quality of life became increasingly important. Whenn total hip arthroplasty (THA) became feasible, the goal of joint saving therapy changed from a meree salvage procedure to a palliative one. We define an osteotomy as palliative when osteoarthritic changess are too advanced to save the joint but where a replacement can successfully be delayed by thiss palliative procedure. In the meantime, the osteotomy may even facilitate a future total hip replacementt by improving the bone stock'41 )61. Former salvage types of surgery have no further rolee to play in the treatment of hip disorders as these have been superseded by THA. Muller et.al. advancedd joint saving hip surgery. They described and defined the role of intertrochanteric osteotomiess in more detail. Introducing a therapeutic type of osteotomy which can be performed if osteoarthriticc changes are not too advanced and if the cause of these osteoarthritic changes is a bio-mechanicall factor which can be corrected. If a bio-mechanical factor such as impingement, dislocating forcess (eg stress on the labrum). or a small weight-bearing area is present, an early correction of this factorr can bio-mechanically normalise the hip joint which could mean a long lasting preservation of this jointt 3 1 4 6 7 3. The differentiation between palliative and therapeutic intertrochanteric osteotomies is importantt in clinical practice. It is evident that therapeutic osteotomies should have a place in modern clinicall practice. However, this is different for palliative osteotomies in younger patients with secondary osteoarthritis.. Several studies show that the survival rates for salvage osteotomies in younger patients iss approximately 70-80% after 10 years 9 2 1 1 4 2 8 3 0 4 0 5 6 ; 5 9 7 6. The disadvantage of this type of osteotomy
iss that the results are mostly unpredictable. We believe that a palliative osteotomy in younger and well motivatedd patients should be considered and that the advantages and disadvantages should be discussedd with the patient.
Inn the modern treatment regimens of osteoarthritis of the hip THA is the treatment of choice for the elderlyy patient. During the last decennia this age limit is gradually adjusted downwards. Even so, the questionn remains whether a THA is the best solution for a young patient with a mild (secondary) osteoarthritis.. In patients with idiopathic osteoarthritis or rheumatic arthritis no benefit from joint saving
surgeryy can be expected, however in the treatment of coxa valga (antetorta), dysplasia, post-SCFE. post-LCPDD and posttraumatic deformities intertrochanteric osteotomies can give good and long lasting resultss 152142-43465355.606373. Although these disorders could all be excellently treated with hip replacement,, joint saving surgery should be the treatment of choice in these young patients since multiplee revisions of the hip replacement are inevitable in patients with a life expectancy of more than 400 years. The ongoing improvements in the field of hip arthroplasties by using new materials and improvingg existing models is very promising; however the current prosthesis are not a panacea 4673. Inn this younger patient group, the possibility of hip arthrodesis should also not be overlooked completely3. .
Inn this chapter we will in turn describe the hip conditions where intertrochanteric osteotomies can producee good to excellent results. The chapter is based on the available literature including this thesis.
Itt is normal practice to wait with surgical interventions in the elderly patient until complaints of pain or limitationss are more severe and when more advanced osteoarthritic changes have occurred. In order too achieve optimal results, it is important to perform surgery as early as possible in patients suitable for intertrochantericc osteotomies, preferably after the first typical manifestation of the hip disorder46J3. Complaintss in this patient group are not completely identical to those of the older patient. In the latter case,, complaints tend to occur after the cartilage has been destroyed to a large degree. In patients suitablee for intertrochanteric osteotomies, complaints are mostly caused by a causative factor such as incongruency,, impingement, or stress on the acetabular labrum in dysplasia. In screening these patients,, the apprehension test (extension/external rotation) and the impingement test (flexion/adduction/internall rotation) could play a role in detecting labral pathology in an early stage
1;15;18;26;31;34;37 7
Functionall X -rays could play an important role in deciding which type of intervention would be the preferredd option. An abduction view gives a radiological impression of the amount of containment and congruencyy that can be obtained by a varus osteotomy. An adduction/flexion X-ray does the same for aa valgus/extension osteotomy. In patients with a coxa valga and/or mild dysplasia, it is important to makee a clinical judgment of to the amount of femoral torsion present. If an increased antetorsion is anticipated,, then this should be verified by means of a Dunn X-ray or CT scan. In modern practice the latterr is more appropriate 72. In patients with suspected labral pathology, this can be verified by means off an Arthro-MRI.
Itt is important to discus the rehabilitation process with the patient before surgery. For instance, in case off a varus osteotomy, the anticipated leg length discrepancy should be discussed as well as the expectedd temporary occurrence of a Trendelenburg gait. As in every surgical intervention, results and patientt satisfaction appear to be improved in well informed and motivated patients.
Inn this section we will discuss some important anatomical considerations regarding the intertrochantericc osteotomy. Maurice Muller described in detail the surgical technique and this proceduree has not changed much since then 50.
Thee osteotomy is performed at the intertrochanteric level, just above the lesser trochanter. Due to the shapee of the intertrochanteric region, large contact areas exist after the osteotomy allowing corrections inn all planes while leaving sufficient contact surface post correction to achieve stability and consolidation.. A second advantage is the relatively small distance from the proximal part making the correctionn invisible from the outside. A third advantage of this osteotomy level is the rapid healing of thee metaphyseal bone. Before making the osteotomy, the seating chisel is inserted into the desired correctionn angle. When inserting the seating chisel, the anticipated correction and the three-dimensionall anatomy of the proximal femur should be considered carefully in order to avoid perforationn of the femoral neck. Perforation of the intertrochanteric fossa can damage the branches of thee dorsal circumflex artery, causing an a-vascular necrosis of the femoral head (Figure I).
Thee desired correction should be anticipated when placing the seating chisel as the blade plate should bee fixated to the femur after correction. For example, a seating chisel inserted ventrally cannot be fixatedd properly to the femur after a flexion osteotomy (Figure II).
/Figuree II
Thee seating chisel is placed to far anterior, resulting inn losing the contact with the femoral shaft after a flexionn correction
Deformitiess such as coxa valga (antetorta) and acetabular dysplasia often co-exist. In hips where the mainn deformity is on the acetabular side, an acetabulum realigning procedure should be first choice and,, if necessary, be combined with a femoral osteotomy 8,s ',34. In these cases, there is a relatively shalloww and steep acetabulum resulting in a decreased contact surface between the acetabulum and thee femoral head. Correction of the femoral side alone cannot solve this problem of containment fully andd will fail to eliminate the dislocation force present. Thus, the osteotomy is doomed to fail. However, inn some hip deformities, the main deformity lies on the femoral side with only a mild acetabular dysplasia;; the acetabulum might be shallow but not too steep. A varus osteotomy may improve the contactt area between femoral head and acetabulum in these types of hips and possibly eliminate the dislocatingg force present. Good and long lasting results may occur2 1 2 8. This will not be the case if a fixedd subluxation is present, as the weightbearing surface and the dislocating forces are not altered, makingg the expected results of an intertrochanteric osteotomy poor. The improvement of containment cann be judged preoperatively from an abduction correction view (Figure III). However, currently no objectivee measurements exist to decide whether an acetabular realigning osteotomy or an intertrochantericc osteotomy is the preferred treatment for specific patients.
Thee femoral antetorsion should not be forgotten in these patients since several have an increased femorall antetorsion which also needs to be corrected 23. A second consideration is that after the varus
osteotomy,, the position of the tip of the major trochanter should not exceed the centre of the femoral headd in order to avoid a long lasting Trendelenburg gait. If necessary, this can be avoided by performingg a distalisation of the major trochanter
Thee literature concludes that in selected younger patients with mild osteoarthritic changes due to coxa valgaa and mild dysplasia, excellent results can be obtained by intertrochanteric varus osteotomies 1:6:40.49-50.54:61:72.75 5
AA 35 year old female with symptomatic OA secondaryy to coxa valga and a mild dysplasia. A varuss intertrochanteric osteotomy was performed. Afterr 21 years she was still free of complaints (last X-ray) )
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Nott all patients who suffer from a slipped capital femoral epiphysis (SCFE) develop osteoarthritis (OA) inn adulthood. However, this patient population has an increased risk of developing OA. The patho-physiologyy behind these arthritic changes consist of acetabular-femoral impingement present in an insufficientt or uncorrected SCFE or in unnoticed sub-clinical cases 8. A prominent part of the anterior
metaphyseall femoral neck contacts the anterior part of the acetabulum during flexion 19 ';57. Based
onn the aetiology of this disorder, a valgus/flexion osteotomy with or without resection of the hump is thee best solution 24. Since the disorder is only present on the femoral side, there is no role for
acetabularr realigning procedures in these pathologic changes. The literature does not describe specificallyy the role of intertrochanteric osteotomies for post-SCFE in adults. However, several studies includee this type of patients and have reported good long- term results 21;4048:75. Early intervention appearss to produce better results in this type of disorder.
Nott all patients who suffer from Legg-Calvé-Perthes disease (LCPD) in childhood develop osteoarthritiss in adulthood although in several patients a deformed hip joint is present. This deformity consistss mainly of a broad and flattened femoral head with a short femoral neck in varus position. In mostt cases, the acetabular side is also more or less abnormal probably due to an adaptation of the developingg acetabulum to the deformed femoral head.
Osteoarthriticc changes develop in adulthood in 50% of these hip deformities 45;68. It is most likely that thesee arthritic changes are caused by an acetabular-femoral incongruency. The origin of this incongruencyy lies in the fact that the deformed femoral head does not completely fit into the acetabulum.. The aim of surgical intervention should be an (early) correction of this incongruency 66. Forr post-Perthes deformities both acetabular realigning osteotomies as well as femoral osteotomies aree described 2 ''64. The main theory explaining the development of osteoarthritis in these hipss is the hinging of the femoral head on the edge of the acetabulum. The best known is the "hinge onn abduction" in which the lateral part of the femoral head hinges on the lateral part of the acetabulum. Inn these types of hips, a valgus (extension) osteotomy should be the preferred treatment eliminating bothh the causative factor and the contractures present by a realignment of the leg. In Post-Perthes hipss where containment of the femoral head is not complete after osteotomy, adding an acetabular shelff plasty can produce excellent results (Figure IV) ' '60. In some cases, valgisation alone is not
sufficientt to restore the function of the abductors due to the relatively high position of the major trochanter.. In these cases a simultaneous distalisation of the major trochanter is advised 5538.
Figuurr IV
AA 22 year old male with a symptomatic hip deformity after a LCPD on both hips. A valgus osteotomyy was performed with a acetabular roof plasty on both hips.
Thee radiographic result after 10 and 12 years is shown in the second X-ray.
a a
Posttraumaticc deformities can be subdivided into deformities after acetabular fractures, malunions afterr femoral neck fractures and nonunions after femoral neck fractures.
Thee most well known indication for intertrochanteric valgus osteotomy is the treatment of femoral neck nonunionss as described by Pauwels4 3 5'6 3. Pauwels described that instability of the fracture is caused byy the shearing forces that occur due to the angle it creates to the resultant of the hip joint force (R). Byy placing the fracture line perpendicular to R by means of a valgus osteotomy, the fracture becomes
completelyy stable 53. This stable situation contributes to the healing of proximal femoral nonunions. Thee presence of early signs of avascular necrosis, where the femoral head is still spherical, does not necessarilyy imply a contra-indication for intertrochanteric osteotomies4363.
Femorall neck malunion is a rare complication. If a malunion is present, it can cause an impingement betweenn femoral neck and acetabulum causing early osteoarthritic degeneration. An early correction is requiredd to avoid these osteoarthritic changes '1 8. In these post-traumatic deformities, a shortening of
thee affected leg is often present. Correcting the malunion with a intertrochanteric osteotomy also allowss simultaneous intertrochanteric lengthening 152144. The direction of the deformity present in
thesee malunions is mostly varus/extension. This means that the correction needed is a valgus/flexion intertrochantericc osteotomy. A resection of the hump can be performed if impingement persists partly afterr the osteotomy 15.
Incongruencyy and osteoarthritis are common problems after acetabular fractures. In these fractures, cartilagee damage occurs during the initial trauma making it susceptible to developing secondary osteoarthritiss 42. If a malunited acetabular fracture, causing functional limitations, co-exists with an
increasedd risk of developing secondary osteoarthritis, it would seem logical to correct the acetabular sidee where the deformity is located. However, these corrections are in general too complicated or even impossiblee 22. Therefore, it could be justifiable to adjust the normal femoral side to the abnormal acetabularr side by aiming the largest part of the unaffected femoral head to the largest part of the unaffectedd acetabulum thereby restoring normal joint motion and lowering the risk of osteoarthritic degeneration.. In younger patients with more advanced osteoarthritic degeneration and where contracturess are present, a palliative osteotomy could be considered. We have been able to document goodd outcomes in this patient group. This is probably due to eliminating the contractures (re-alignment)) and could be caused by the biological osteotomy effect as well
Basedd on the average age of the patient population with avascular necrosis of the femoral head (AVN) itt seems like an ideal group to consider joint saving surgery. This is also reflected in the large number off publications on this subject. The main thought behind intertrochanteric osteotomies in AVN is that thee affected part of the femoral head is rotated away from the weight-bearing part of the joint, preventingg collapse. This can be achieved by intertrochanteric osteotomies as corrections in all three
.,, u, 21:29:39.62:65:74 dimensionss are possible
Thee literature shows no evidence of good outcomes in idiopathic AVN treated by intertrochanteric osteotomiess 1013:16:25;27:58:69-70 The benefit of intertrochanteric osteotomies is doubtful in this patient group.. Most retrospective reports concern patients with an atraumatic AVN but some studies also
includee traumatic AVN which show a better outcome. However, in these young patients, the outcome off an intertrochanteric osteotomy remains unpredictable.
AA special group of younger patients consists of those with a deformed femoral head after a post-traumaticc AVN, similar to a post-Perthes deformity. These patients may benefit from a valgus intertrochantericc osteotomy combined with an acetabular shelf plasty 23.
InIn several younger patients with secondary osteoarthritis, the pros and cons of both total hip arthroplastyy (THA) and intertrochanteric osteotomies should be considered and discussed with the patient.. We believe that in younger patients the emphasis should be on long term results as well as goodd short term results. Aronson described in 1986 that three myths in hip surgery continue to survive .. The first concerns the belief that all treated childhood hip disorders result in normal hip joints, the secondd is the belief that THA is a panacea for all hip related problems and the third concerns the belief thatt there is hardly a role left for intertrochanteric osteotomies. Aronson wrote that these myths remain popularr with orthopaedic surgeons despite the fact that the literature refutes these views. Twenty yearss on, his views still hold true.
Inn the younger patient group, we believe that the decision to perform a THA is too easily made and is oftenn based only on good short term results. The intertrochanteric osteotomy, besides given good shortt term results in selected patients, may also be regarded as an investment for the future by preservingg bone stock for a future THA. should one become necessary. Patients who may benefit from ann intertrochanteric osteotomy resulting in good and long lasting results should be carefully selected 3.
Opponentss of intertrochanteric osteotomies use the argument that osteotomies impair the outcome of futuree THA. In the literature a few reports mention a poorer long -term outcome of THA after a previouss osteotomy while several other studies showed no difference 4"f '67. In, large controlled case study,, we recently demonstrated that the long term outcome of a cemented THA is not compromised byy a (well-performed) previous intertrochanteric osteotomy 20. Although a THA after a previous osteotomyy can be a more challenging procedure with more (controllable) intra-operative complications, thee long- term outcome is identical to that of a primary THA When performing an intertrochanteric osteotomy,, attention should be paid to the feasibility of performing a future THA.
Severall retrospective studies report poor overall results for intertrochanteric osteotomies. These studiess also included older patients and hips with advanced osteoarthritis. From these studies, certain hipp conditions in selected patient groups can be isolated. In these cases we can obtain good and long lastingg results. This seems especially true for younger patients with early secondary osteoarthritis causedd by a correctable biomechanical factor.
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CUfU*! CUfU*!
Awarenesss and use of the
intertrochantericc osteotomies in
thee current clinical practice.
AnAn international survey
D.. Haverkamp
H.. Eijer
P.P.. Besselaar
Abstract t
Currentt literature shows that intertrochanteric osteotomies can produce excellent resultss in selected hip disorders in specific groups of patients. However, it appears thatt this surgical option is considered an historical one which has no role to play in modernn practice.
Inn order to examine current awareness of and views on intertrochanteric osteotomies amongg international hip surgeons, an online survey was carried out. The survey consistedd of a set of questions regarding current clinical practice and awareness of osteotomies.. The second part of the survey consisted of five clinical cases, which soughtt to elicit views on preoperative radiological investigations and preferred (surgical)) treatments.
Thee results of our survey showed that most of these experts believe that intertrochantericc osteotomies should still be performed in selected cases. Only 56% performm intertrochanteric osteotomies themselves and of those, only 1 1 % perform moree than 5 per year. The responses to the cases show that about 30 to 40% advice intertrochantericc osteotomies in young symptomatic patients.
Thiss survey shows that the role of intertrochanteric osteotomies is declining in clinical practice. .
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Thee use of intertrochanteric osteotomies appears to be declining in current clinical practice. It seems thatt many orthopaedic surgeons consider it an historical operation which has lost its place in current hipp disorder treatment. There are many retrospective studies showing overall unsatisfactory results (Tablee I) ' * w w w * ' i r ! i » 4 a i 2 H W W ii However, many of these included elderly patients with advanced
stagess of (primary) osteoarthritis. The same studies showed that the outcome in younger patients with earlyy onset secondary osteoarthritis was good. However, only a few of these studies showed survival ratess identical or superior to that of a total hip replacement and then only in selected patient groups. In aa recent long term follow-up study, we demonstrated that in specific hip disorders intertrochanteric osteotomiess can achieve good to excellent long term results 7. Several recent reviews advocated the samee message, namely that intertrochanteric osteotomies should not be forgotten as a treatment optionn in these selected cases ' . Since we believed that this view was not shared universally, we initiatedd an online international survey to investigate current awareness among orthopaedic hip surgeonss about these selected groups and to map the current clinical use of intertrochanteric osteotomies. . Author --Haverkamp.. 2005 Haverkamp.Haverkamp. 2005 HaverkampHaverkamp 2005 Haverkamp.Haverkamp. 2005 Haverkamp.Haverkamp. 2005 Haverkamp.Haverkamp. 2005 Pëcasse.. 2004 D'Souza.. 1998 Perlau.. 1996 Morssher.. 1971 Schneider.. 1979 Marti.. 2000 DePalma.. 1970 Perlau.. 1996 Toyama.. 2000 Gotoh.. 1997 Iwase.. 1996 Jmgushi.. 2002 Kubo. . Iwase.. 1996 Langlais.. 1979 Maistrelli,, 1990 Miegel.. 1984 Reigstad.. 1984 Santore.. 1983 Weisl.. 1980 Castaing.. 1981 Collert.. 1979 Linde.. 1985 Teintuner,, 1982 Zaoussis.. 1984 276 6
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766 6 :' '
22 22 14 14 to to -5 5 25 5 16 6 226 6 1 1 109 9 IC C 38 8 18 8 67 7 31 1 42 2 70 0 17 7 58 8 '5J J 277 7 77 7 103 3 45 5 '57 7 141 1 94 4 BS S 63 3 7C C Indication n All l Idiopathic Idiopathic Dysplasia Dysplasia Posttrauma Posttrauma SCFE SCFE AA VN LCPD D All l Idiopathic c All l A A OAA after Acetabular r Fractures s A A Dysplasia a Dysplasia a Dysplasia a Dysplasia a Dysplasia a Dysplasia a Dysplasia a Primair r A.' ' A A A. . All l A. . A A A A A A All l A. . *lff possible articles i a o i ee i: Typee of Osteotomy y A A , , A» A» All All All All A A All l A A A.: : All l A: : A A All l Valgus-extension n Valgus-extension n Varus s Valgus s Valgus-extension n Valgus s Valgus s Valgus-extension n Medialisation n A A Valgus s A A Varus s A A A l l Flexion n Medialisation* * rotation naree split per
rceviewrceview i Age e (Avg.. Range) 455 (16-79) 57(34-79) ) 466 (16-75) 37(17-68) ) 4444 (25-55) 38(16-60) 38(16-60) 30(19-55) 30(19-55) 38(18-53) ) 488 (38-75) 20-- 80* 700 at follow up 29(16-47) ) 57(15-81) ) 333 (24-58) 444 (23-59) 433 (22-59) 25 5 44(14-59) ) 500 (34-58) 37 7 ? ? 522 (26-66) ? ? 588 (24-74) 500 (32-69) ?? (incl 70*) 511 (25-71) 600 (32-77) <60 0 555 (37-71) 477 (21-68) ndication. . >TT i n e m e r Gradee of OA mild-advanced mild-advanced mild-advanced mild-advanced m0r/-0dVancod d mild-advanced mild-advanced mild-advanced mild-advanced mild-advanced mild-advanced mild-advanced d mild-advanced d mild-advanced d moderate--advanded d moderate--advanded d mild-advanced d moderate--advanded d mild-advanced d Advanced d Advanced d mild d Advanced d Advanced d moderate--advanded d moderate--advanded d mild-advanced d moderate--advanded d moderate--advanded d moderate--advanded d moderate--advanded d moderate--advanded d Advanced d moderate--advanded d Advanced d mild-advanced d a mm re Followw up 15-299 years 15-299 years 15-299 years 15-2915-29 years 15-2915-29 years 15-2915-29 years 4-255 years 2-122 years 5-100 years 2-144 years 12-155 years 3-222 years 1-9 9 5-100 years 5-166 years 12-188 years 200 years 2-155 years 10-144 years 200 years 3-100 years 11-155 years 12-155 years >> 10 years 111 years 10-222 years 133 5 years 55 years 1-155 years 100 years 6-155 years Survivall /Conclusion
Beterr results in young patiandts with mild OA Survivall 10 year 50% and 15 year 32%
SurvivalSurvival 10 year 72% and 15 year 56% SurvivalSurvival 10 year 91% and 15 year 78% SurvivalSurvival 10 year 71% and 15 year 56%
Survivall 10 year 60% and 15 year 30% 33%% converted after an average of 15.4 year Survivall 67% after an average of 12 year 44%% converted after an average of 6.1 year Goodd indications are LCPD. SCFE and dysplasia a
35%% converted after an average of 8 year Survivall 80 % after an average of 10 year
Painn relief in 89%. no long term results 79%% Survival after an average of 6 1 year Survivall 10 year 79%
Survivall 15 year 51%
Survivall 10 year 89% and 15 year 87% Survivall 10 year 82%
18%% good at last follow up Survivall 10 year 66% and 15 year 38% 68%% good
67%% perfect to good, better results in young patientss with secundary OA Survivall 10 year 49% Survivall 10 year 58% 75%% good
25%% good at follow up better results in young patientss with secundary OA
67%% good 466 % good after 5 year 39%% good after 5 year 65%% good 70%% good
Wee developed a questionnaire consisting of two sections. The first section consisted of questions dealingg with the use of intertrochanteric osteotomies in clinical orthopaedic practice. To assess orthopaedicc surgeons' awareness, the second part of the questionnaire consisted of questions related too five clinical cases. These cases were taken from our own long term follow-up series and the long termm outcome of the performed intertrochanteric osteotomy was known in each case . The responderss were unaware of the treatment these patients received. Table 2 shows the full questionnairee (cases excluded).
Ann invitation to respond to the questionnaire online was sent to all members of the American Associationn of Hip and Knee Surgeons, all members of the British Hip Society and members of the Dutchh Orthopaedic Society.
Inn order to identify factors which influenced surgeons to opt for an intertrochanteric osteotomy, a statisticall analysis of the required data was carried out using a Pearson correlation analysis in which p<0.055 is considered as significant.
