Indications for Simple Varus Intertrochanteric Osteotomy for the Treatment of Osteonecrosis of the Femoral Head Hiroshi Ito1, Teruhisa Hirayama1, Hiromasa Tanino1, Takeo Matsuno1, and
Trang 1Indications for Simple Varus
Intertrochanteric Osteotomy for
the Treatment of Osteonecrosis
of the Femoral Head
Hiroshi Ito1, Teruhisa Hirayama1, Hiromasa Tanino1,
Takeo Matsuno1, and Akio Minami2
Summary. The purpose of this study was to evaluate the long-term results of simple varus intertrochanteric osteotomy for osteonecrosis of the femoral head Forty hips
in 31 patients were included, with an average age at the time of surgery of 34 years(range, 21–51 years) The mean duration of follow-up was 12.1 years (range, 5–23years) Osteonecrosis was high-dose-steroid-induced in 20 patients, alcohol-induced
in 7 patients, and idiopathic in 4 patients The amount of varus correction ranged from 15° to 40° (mean, 23°) The JOA hip score increased from a preoperative average
of 71 points to 85 points at the most recent follow-up Thirty (75%) of the 40 hipsshowed good or excellent results, 10 (25%) hips had fair or poor results, and 4 hipsneeded prosthetic arthroplasty In 28 hips with equal to or greater than 25% postop-erative lateral head index, 24 (86%) hips showed good or excellent results Average shortening of leg length was 1.8 cm Our findings indicate that if necrotic lesions are limited medially and the lateral part of the femoral head remains intact, good long-term results can be obtained by simple varus osteotomy
Key words. Osteonecrosis of the femoral head, Varus intertrochanteric osteotomy, Long-term clinical results, Lateral head index, Joint-preserving operation
Introduction
The treatment of osteonecrosis of the femoral head is clinically challenging The extent and location of the necrotic lesion affect the prognosis of osteonecrosis [1–4].Many studies have shown that the prognosis of this disease without treatment is poor [1–5] It is important to preserve the hip joint, especially for young and active patients Total hip arthroplasty in young patients is undesirable because of its limited endur-ance [6,7] Joint-preserving procedures include core decompression [8,9], femoral osteotomies [1,8,10–27], and vascularized or nonvascularized bone grafting
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[8,20,22,28] The purpose of osteotomy for osteonecrosis of the femoral head is to move the necrotic lesions away from the weight-bearing portions of the hip joint The lesions of the weight-bearing portions should then be replaced by normal articular cartilage and subchondral bone by osteotomy [1,8,10–27] Many studies have exam-ined the usefulness of various types of osteotomies for the treatment of osteonecrosis
of the femoral head Results of varus intertrochanteric osteotomies have been reported with various failure rates
The purpose of this study was to evaluate the long-term results of simple varus intertrochanteric osteotomy for osteonecrosis of the femoral head
Materials and Methods
From January 1979 we performed simple varus intertrochanteric osteotomies for the treatment of osteonecrosis of the femoral head; 40 hips in 31 patients (20 men and
11women) were included in this study Average age at the time of surgery was 34years (range, 21–51 years), and the mean duration of follow-up was 12.1 years (range,
5–23 years) The diagnosis of osteonecrosis was made based on the clinical history, physical examination, and radiologic evaluation Osteonecrosis was high-dose-steroid-induced in 20 patients, alcohol-induced in 7 patients, and idiopathic in 4patients All 31 patients complained of hip pain while walking at the time of operation
No previous operative treatment was performed in any hips To be considered for osteotomy, the patients had to show a hip movement range of at least 90° for the flexion-extension arc and 25° for abduction Ten hips were stage II, 27 hips were stage III, and 3 hips were stage IV according to the Steinberg classification [29] From 1985
on, we used magnetic resonance (MR) imaging to confirm the diagnosis
Surgical Technique
The patient was positioned in the lateral decubitus position with the extremity draped free on the table Using a longitudinal lateral approach, a 15-cm incision was made from the greater trochanter distally along the femur shaft, exposing the lesser tro-chanter and lateral surface of the femur shaft Capsulotomy was not performed in any patients Two Kirschner wires were inserted as osteotomy guides (Fig 1A); one was placed perpendicular to the femur shaft, the other was placed in the direction for the seating chisel, and intraoperative fluoroscopy was used to confirm the chisel position and the amount of varus correction From the lateral cortex of the medial lesser tro-chanter, osteotomy was performed using a power saw (Fig 1B) A wedge-shaped bony fragment was resected from the proximal fragment (Fig 1C) For fixation of proximal and distal fragments, an AO 90° double-angle blade-plate was used (Fig 1D) The amount of varus correction ranged from 15° to 40° (mean, 23°) Flexion and extension correction was not generally taken into account, and only simple varus correction was performed Osteotomy was designed to gain 25% or more on the postoperative lateral head index (LHI) by radiography (Fig 2) [18]
Postoperative Treatment
All patients began straight leg-lifting excises from the day after surgery and used wheelchairs for 4 weeks Partial weight-bearing was started 4 to 6 weeks after the
Trang 3Varus Intertrochanteric Osteotomy 21
A
B
C
D
Fig 1 Technique of simple varus osteotomy using intraoperative radiography or fluoroscopy.
A Kirschner wires were inserted as osteotomy guides Angleα was the preoperatively planned
varus correction angle B After insertion of the chisel, perpendicular osteotomy was performed
using a power saw from the lateral cortex of the medial lesser trochanter C Proximal osteotomy was performed, by which the half-wedged fragment was resected D An AO 90° double-angle
blade-plate was used for fixation of the proximal and distal fragment
Trang 422 H Ito et al.
operation with two crutches Full weight-bearing was usually allowed 8 to 12 weeksafter the operation The average hospitalization was 3 months The patients were encouraged to use two crutches to prevent injury 3 to 4 months postoperatively
Evaluation
Clinical evaluation was performed according to the Japanese Orthopaedic Association (JOA) hip scoring system Hips with a score of 90 to 100 points were defined as showing excellent results, 80 to 89 points as good results, 70 to 79 points as fair results, and less than 70 points as poor results Statistical analysis of the data was performed
by the Mann–Whitney U test and the Fisher’s exact probability test Probability values
less than 0.05 were considered significant
Results
The result was excellent in 10 hips, good in 20, fair in 6 hips, and poor in 4 Overall,
30 (75%) of the 40 hips showed good or excellent results (Figs 3, 4) Three hips needed total hip arthroplasty and 1 hip needed hemiprosthetic arthroplasty The JOA hip score increased from a preoperative average of 71 points (range, 28–78 points) to 85points (range, 50–100 points) at the most recent follow-up Progression of collapse was found in 9 (23%) hips The average postoperative LHI was 48% in the excellent
or good groups and 23% in the fair or poor groups (Mann–Whitney U test, P= 0.001)
In 28 hips with equal to or greater than 25% of postoperative LHI, 24 (86%) hips showed good or excellent results
A-P view
Fig 2 Lateral head index (LHI) value A-P, anteroposterior
Trang 5Varus Intertrochanteric Osteotomy 23
with placement of a bone graft that later showed radiographic union One patient needed total hip arthroplasty An average shortening of the leg length was 1.8 cm(range, 1.0–3.5 cm) In the group of 6 hips with varus correction greater than 25°, the rate of limping at the final outcome (4 of 6) was significantly higher than that of the remaining 34 hips with varus correction less than 25° (6 of 34) (Fisher’s exact test,
P< 0.03) There were no other significant complications such as deep infection or pulmonary embolism
Fig 3 Radiographic findings of a 47-year-old man with steroid-induced osteonecrosis of the
right hip a An anteroposterior view showing stage II osteonecrosis (arrows) The LHI was 23%.
b Radiography after a 23° simple varus osteotomy fixed with an AO double-angle blade-plate
The postoperative LHI was 70% c Radiography 16 years after osteotomy Reduction in the size
of necrotic lesions was found (arrows), and the clinical result was excellent
Fig 4 Radiographic findings of a 27-year-old man with steroid-induced osteonecrosis of the
left hip a The LHI was 20% and the superolateral portion of the femoral head remained normal
(arrows) b Radiography after 35° simple varus osteotomy fixed with a Wainwright–Hammond
plate Postoperative LHI was 37% c Radiography 15 years after the osteotomy The patient
reported no hip pain; however, a limp due to limb shortening was observed
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Discussion
Several studies have advocated varus intertrochanteric osteotomy in hips in which a lateral intact area of the femoral head can be placed into the acetabular weight-bearing portion by osteotomy [1,14,15,19–21] Kerboul et al [15] emphasized that the purpose of osteotomy was to remove the necrotic part of the femoral head from the zone of maximum pressure and to replace it with the normal posterolateral part They reported that when the superolateral and posterior surfaces of the femoral head remained normal, good results were obtained Our findings indicate that if necrotic lesions are limited medially and the lateral part of the femoral head remains intact, good long-term results can be obtained by simple varus osteotomy, which supports the results of Kerboul et al [15]
Excessive varus correction is related to a high incidence of postoperative limp because of abductor muscle weakness and limb shortening Jacobs et al [14] reported that the results of intertrochanteric osteotomies were closely related to the size of the necrotic lesions and a relatively high incidence of limp in the varus osteotomy patients Sakano et al [21] reported good clinical results using Nishio’s curved intertrochan-teric varus osteotomy Our results indicated that excessive varus correction should
be avoided and that the correction angle should be planned up to 25° In hips with correction angles within 25°, postoperative limp was sometimes found several months after the osteotomy, but this usually improved within 1 or 2 years
Sugioka reported a technique of transtrochanteric anterior rotational osteotomy for osteonecrosis in 1978 Successful results by this technique were described by several other Japanese surgeons [10,18,23] In the United States, however, successful results were not obtained with this technique [11,12,13] Sugioka’s osteotomy has sometimes been described as a technically demanding procedure [11–13,19] Atsumi
et al [10] emphasized the importance of the postoperative varus position rather than the valgus position and described their technique of posterior rotational osteotomy and excellent results
In the surgical technique of intertrochanteric osteotomy, it is often difficult to obtain precise correction angles as preoperatively planned Kerboul et al [15] reported that the angulation after osteotomy was exactly as planned in 45% of the operations, but only approximately so in the remaining cases Varus-valgus angulation correction
is relatively easy by measuring the angle of the guided Kirschner wires in relation to the femur shaft Flexion-extension correction is sometimes difficult because the intra-operative lateral views of intertrochanteric regions are sometimes slightly oblique when the patient is in the operative lateral decubitus position, and corrective guides such as Kirschner wires on the true lateral view sometimes do not depict true flexion-extension correction angles We therefore prefer simple varus osteotomy in which flexion-extension correction does not have to be considered
In the radiographic follow-up, a demarcation line and sclerotic change in the necrotic area were found during the follow-up period in successfully treated hips Demarcation lines and sclerotic changes in the necrotic lesions that gradually reduce
in size represent the repair process of osteonecrosis Sugioka et al [24] reported that necrosis can heal when mechanical stress is withdrawn from the necrotic lesion Varus intertrochanteric osteotomy may be indicated if the intact area occupies a
Trang 7Varus Intertrochanteric Osteotomy 25
larger area in the superolateral portion, an assertion that coincides with the findings
of the present study
In conclusion, hips with a small-to-medium necrotic lesion, a medial necrotic location, postoperative LHI greater than 25%, and a thick demarcation line seen on radiography with sclerotic change in the necrotic lesion are the best indications for osteotomy
13 Tooke SMT, Amstutz HC, Hedley AK (1987) Results of transtrochanteric rotational osteotomy for femoral head osteonecrosis Clin Orthop 224:150–157
14 Jacobs MA, Hungerford DS, Krackow KA (1989) Intertrochanteric osteotomy for avascular necrosis of the femoral head J Bone Joint Surg 71B:200–204
15 Kerboul M, Thomine J, Postel M, et al (1974) The conservative surgical treatment of idiopathic aseptic necrosis of the femoral head J Bone Joint Surg 56B:291–296
16 Maistrelli G, Fusco U, Avai A, et al (1988) Osteonecrosis of the hip treated by trochanteric osteotomy: a four- to 15-year follow-up J Bone Joint Surg 70B:761–766
inter-17 Marti RK, Schüller HM, Raaymakers ELFB (1989) Intertrochanteric osteotomy for non-union of the femoral neck J Bone Joint Surg 71B:782–787
18 Masuda T, Matsuno T, Hasegawa I, et al (1988) Results of transtrochanteric rotational osteotomy for nontraumatic osteonecrosis of the femoral head Clin Orthop 228:–74
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19 Mont MA, Fairbank AC, Krackow KA, et al (1996) Corrective osteotomy for crosis of the femoral head: the results of a long-term follow-up study J Bone Joint Surg 78A:1032–1038
osteone-20 Saito S, Ohzono K, Ono K (1988) Joint-preserving operations for idiopathic avascular necrosis of the femoral head: results of core decompression, grafting, and osteotomy
J Bone Joint Surg 70B:78–84
21 Sakano S, Hasegawa Y, Torii Y, et al (2004) Curved intertrochanteric varus osteotomy for osteonecrosis of the femoral head J Bone Joint Surg 86B:359–365
22 Scher MA, Jakim I (1993) Intertrochanteric osteotomy and autogenous bone-grafting for avascular necrosis of the femoral head J Bone Joint Surg 75A:1119–1133
23 Sugano N, Takaoka K, Ohzono K, et al (1992) Rotational osteotomy for non-traumatic avascular necrosis of the femoral head J Bone Joint Surg 74B:734–739
24 Sugioka Y, Hotokebuchi T, Tsutsui H (1992) Transtrochanteric anterior rotational osteotomy for idiopathic and steroid-induced necrosis of the femoral head: indica-tions and long-term results Clin Orthop 277:111–120
25 Sugioka Y, Katsuki I, Hotokebuchi T (1982) Transtrochanteric rotational osteotomy
of the femoral head for the treatment of osteonecrosis: follow-up statistics Clin Orthop
29 Steinberg ME, Hayken GD, Steinberg DR (1995) A quantitative system for staging avascular necrosis J Bone Joint Surg 77B:34–41
Trang 9Transtrochanteric Rotational
Osteotomy for Severe Slipped Capital Femoral Epiphysis
Satoshi Nagoya, Mitsunori Kaya, Mikito Sasaki,
Hiroki Kuwabara, Tomonori Iwasaki, and Toshihiko Yamashita
Summary. We performed transtrochanteric rotational osteotomy to treat severe slipped capital femoral epiphysis in four young patients All four male patients, with
an age range of 12–22 years, were followed for an average of 2 years and 10 months.The JOA score of 37 points preoperatively improved to an average of 90 points post-operatively The posterior tilt angle (PTA) of 82° preoperatively improved to an average of 24° postoperatively The flexion angle of the affected hip joint in neutral improved from 10°–25° to 70°–90° Although one patient with acute on chronic type
of SCFE developed osteonecrosis of the femoral head after the operation, the function
of the hip joint was restored Our results suggest that transtrochanteric rotational osteotomy is a valuable option for the treatment of severe slipped capital femoral epiphysis in young patients
Key words. Transtrochanteric rotational osteotomy (TRO), Slipped capital femoral epiphysis, Posterior tilt angle
Introduction
The rationale of treatment for slipped capital femoral epiphysis (SCFE) is prevention
of deterioration of slip angle and restoration of the range of motion in young patients However, it is difficult to treat severe slipping greater than 70° We have employed transtrochanteric rotational osteotomy (TRO) with varus angulation for such severe cases The aim of this study is to report the clinical results and to clarify the usefulness
of this procedure for severe SCFE
Materials and Methods
Since 1996, 19 consecutive patients with SCFE were treated in our department TRO with varus angulation was applied for patients with severe slipping greater than 70°.All patients were male; age at operation ranged from 12 to 22 years A 22-year-old
Department of Orthopedic Surgery, Sapporo Medical University, South 1 West 16 Chuo-ku, Sapporo 060-8543, Japan
Trang 1028 S Nagoya et al.
man developed SCFE secondary to hypopituitarism Three patients were categorized
to chronic type, and 1 patient was acute on chronic type To evaluate the severity of posterior shifting of the femoral head, we used posterior tilt angle (PTA), which is an angle between the epiphyseal line and a line perpendicular to the femoral shaft axis (Fig 1) PTA in the lateral view was 70°–89° preoperatively Hip flexion angle was
10°–25°, and Drehmann sign was positive in all cases before surgery All patients needed a relatively long time interval to obtain an adequate diagnosis from initial onset of the symptoms because of late consultation with an orthopedic surgeon.The operative procedure is determined according to PTA For a PTA less than 40°,
we used in situ pinning with screws Three-dimensional corrective femoral omy, such as the Southwick osteotomy [1], is employed when the PTA is between 40°and 70° When the PTA exceeds 70°, we need to lift up the slipped epiphysis to the weight-bearing rim by anterior rotation of the femoral head in TRO Because anterior rotation results in valgus position of the femoral head, we need to apply varus angula-tion simultaneously
osteot-The operation was performed according to Sugioka’s femoral osteotomy [2] with anterior rotation of 60°–70° and varus angulation of 40° (Fig 2A,B) After 2 days bed rest, wheelchair transfer was prescribed, and partial weight-bearing was allowed 8weeks after operation; full-weight bearing was then permitted after 4 months Bone scintigraphy was planned 1 week after the operation to confirm that the blood supply was preserved in the rotated femoral head
The Japanese Orthopedic Association (JOA) score was used to evaluate the clinical results Complications such as infection, deep venous thrombosis, pulmonary embo-lism, massive bleeding, and nerve palsy were investigated
L
l v w
Fig 1 Radiograph shows the posterior tilt angle (PTA), an angle between a line perpen- dicular to the epiphyseal line and the femoral shaft axis
Trang 11Transtrochanteric Rotational Osteotomy for Severe SCFE 29
Fig 2 A Anteroposterior (AP) view of left hip joint Solid line indicates osteotomy line, which
declined 20° varus to the line perpendicular to the femoral neck axis B Lateral view of left hip
joint Solid line indicates osteotomy line, which declined 20° to the baseline perpendicular to the femoral neck axis Dashed line indicates base line perpendicular to the femoral neck axis
A , anterior aspect; P, posterior aspect
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Results
The JOA score of 37 points preoperatively improved to an average of 90 points operatively The PTA of 82° preoperatively improved to an average of 24° postopera-tively (Table 1) The fl exion angle improved from 10°–25° to 70°–90° (Table 2) There was an average of leg discrepancy of 2–4 cm postoperatively One patient had decreased blood supply of the femoral head detected in bone blood scintigraphy 1 week after operation, which resulted in partial osteonecrosis of the femoral head with segmental collapse (Fig 3) There was no infection, deep venous thrombosis, pulmonary embo-lism, massive bleeding, or nerve palsy after the operations Case 3 is a representative case (Fig 4)
post-Table 1 Comparision of preoperative and postoperative
posterior tiltangle (PTA)
Case Preoperative (°) Postoperative (°)
Table 2 Restoration of range of motion (ROM) of the hip joint
by the transtrachanteric rotational osteotomy (TRO)
Case number Preoperative (°) Postoperative (°)
Trang 13Transtrochanteric Rotational Osteotomy for Severe SCFE 31
Pre op Post op
Case 3 a
b
Fig 4 A AP view of left hip joint before and after operation B Radiograph shows severe slipped
capital femoral epiphysis (SCFE) in case 3 with 80° of PTA (a) The configuration of the hip joint was successfully restored with 15° of PTA after the operation (b)
A
B