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Cementless total hip arthroplasty in patients with severely dysplastic hips and a previous Schanz osteotomy of the femur: techniques, pitfalls, and long-term outcome.

Eskelinen A, Remes V, Ylinen P, Helenius I, Tallroth K, Paavilainen T - Acta Orthop (2009)

Bottom Line: Trendelenburg sign was negative and there was good or slightly reduced abduction strength in 23 of 25 hips that had not been revised.There were 12 perioperative complications.Only 1 cementless press-fit porous-coated cup was revised for aseptic loosening.

View Article: PubMed Central - PubMed

Affiliation: ORTON Orthopedic Hospital, Invalid Foundation, Helsinki, Finland. antti.eskelinen@fimnet.fi

ABSTRACT

Background and purpose: Historically, a Schanz osteotomy of the femur has been used to reduce limp in patients with severely dysplastic hips. In such hips, total hip arthroplasty is a technically demanding operation. We report the long-term results of cementless total hip arthroplasty in a group of patients who had all undergone a Schanz osteotomy earlier.

Patients and methods: From 1988 through 1995, 68 total hip replacements were performed in 59 consecutive patients previously treated with a Schanz osteotomy. With the cup placed at the level of the true acetabulum, a shortening osteotomy of the proximal part of the femur and distal advancement of the greater trochanter were performed in 56 hips. At a mean of 13 (9-18) years postoperatively, we evaluated these patients clinically and radiographically.

Results: The mean Harris hip score had increased from 51 points preoperatively to 93 points. Trendelenburg sign was negative and there was good or slightly reduced abduction strength in 23 of 25 hips that had not been revised. There were 12 perioperative complications. Only 1 cementless press-fit porous-coated cup was revised for aseptic loosening. However, the 12-year survival rate of these cups was only 64%, as 18 cups underwent revision for excessive wear of the polyethylene liner and/or osteolysis. 6 CDH femoral components had to be revised due to technical errors.

Interpretation: Our results suggest that cementless total hip arthroplasty combined with a shortening osteotomy of the femur and distal advancement of the greater trochanter can be recommended for most patients with a previous Schanz osteotomy of the femur. Because of the high incidence of liner wear and osteolysis of modular cementless cups in this series, nowadays we use hard-on-hard articulations in these patients.

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Osteotomies used for various deformities of the femur. The femoral shaft is usually transected distal to the lesser trochanter, as shown by the transverse solid line in (A). A dotted line demonstrates the most distal possible level of the osteotomy. A. Proximal shortening osteotomy with distal advancement of the greater trochanter (vertical solid line) in hips with a previous proximal Schanz osteotomy. B. Segmental shortening with angular correction for hips with a previous, more distal Schanz osteotomy. Copyright for the illustrations in this figure is owned by The Journal of Bone and Joint Surgery, Inc. (published in Eskelinen et al. Cementless total hip arthroplasty in patients with high congenital hip dislocation, J Bone Joint Surg Am. 2006; 88: 80-91). Reproduced with permission.
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Figure 0002: Osteotomies used for various deformities of the femur. The femoral shaft is usually transected distal to the lesser trochanter, as shown by the transverse solid line in (A). A dotted line demonstrates the most distal possible level of the osteotomy. A. Proximal shortening osteotomy with distal advancement of the greater trochanter (vertical solid line) in hips with a previous proximal Schanz osteotomy. B. Segmental shortening with angular correction for hips with a previous, more distal Schanz osteotomy. Copyright for the illustrations in this figure is owned by The Journal of Bone and Joint Surgery, Inc. (published in Eskelinen et al. Cementless total hip arthroplasty in patients with high congenital hip dislocation, J Bone Joint Surg Am. 2006; 88: 80-91). Reproduced with permission.

Mentions: Preparation of the femur. The appropriate operative procedure was selected according to the level of the Schanz osteotomy, and was performed by one of the two methods described in detail elsewhere (Paavilainen et al. 1990, 1993, Paavilainen 1997, Eskelinen et al. 2006). Only 4 hips could be replaced without femoral shortening osteotomy. 56 hips were replaced after having performed a shortening osteotomy of the proximal part of the femur with transposition of the greater trochanter (Figures 1 and 2). In 8 hips, the Schanz osteotomy had been performed so low that the first method (shortening osteotomy performed at the level of the Schanz angle) would have resulted in inadequate limb-length correction. Thus, a metaphyseal segmental shortening osteotomy with angular correction was performed at the level of the Schanz angle, and a step method was used to stabilize the osteotomy against rotation (Paavilainen et al. 1990). The stem was used as an intramedullary nail to stabilize the osteotomy site (Figure 2). This operation was performed through the modified anterolateral approach described by Hardinge (1982), which provides better access for the corrective osteotomy.


Cementless total hip arthroplasty in patients with severely dysplastic hips and a previous Schanz osteotomy of the femur: techniques, pitfalls, and long-term outcome.

Eskelinen A, Remes V, Ylinen P, Helenius I, Tallroth K, Paavilainen T - Acta Orthop (2009)

Osteotomies used for various deformities of the femur. The femoral shaft is usually transected distal to the lesser trochanter, as shown by the transverse solid line in (A). A dotted line demonstrates the most distal possible level of the osteotomy. A. Proximal shortening osteotomy with distal advancement of the greater trochanter (vertical solid line) in hips with a previous proximal Schanz osteotomy. B. Segmental shortening with angular correction for hips with a previous, more distal Schanz osteotomy. Copyright for the illustrations in this figure is owned by The Journal of Bone and Joint Surgery, Inc. (published in Eskelinen et al. Cementless total hip arthroplasty in patients with high congenital hip dislocation, J Bone Joint Surg Am. 2006; 88: 80-91). Reproduced with permission.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2823216&req=5

Figure 0002: Osteotomies used for various deformities of the femur. The femoral shaft is usually transected distal to the lesser trochanter, as shown by the transverse solid line in (A). A dotted line demonstrates the most distal possible level of the osteotomy. A. Proximal shortening osteotomy with distal advancement of the greater trochanter (vertical solid line) in hips with a previous proximal Schanz osteotomy. B. Segmental shortening with angular correction for hips with a previous, more distal Schanz osteotomy. Copyright for the illustrations in this figure is owned by The Journal of Bone and Joint Surgery, Inc. (published in Eskelinen et al. Cementless total hip arthroplasty in patients with high congenital hip dislocation, J Bone Joint Surg Am. 2006; 88: 80-91). Reproduced with permission.
Mentions: Preparation of the femur. The appropriate operative procedure was selected according to the level of the Schanz osteotomy, and was performed by one of the two methods described in detail elsewhere (Paavilainen et al. 1990, 1993, Paavilainen 1997, Eskelinen et al. 2006). Only 4 hips could be replaced without femoral shortening osteotomy. 56 hips were replaced after having performed a shortening osteotomy of the proximal part of the femur with transposition of the greater trochanter (Figures 1 and 2). In 8 hips, the Schanz osteotomy had been performed so low that the first method (shortening osteotomy performed at the level of the Schanz angle) would have resulted in inadequate limb-length correction. Thus, a metaphyseal segmental shortening osteotomy with angular correction was performed at the level of the Schanz angle, and a step method was used to stabilize the osteotomy against rotation (Paavilainen et al. 1990). The stem was used as an intramedullary nail to stabilize the osteotomy site (Figure 2). This operation was performed through the modified anterolateral approach described by Hardinge (1982), which provides better access for the corrective osteotomy.

Bottom Line: Trendelenburg sign was negative and there was good or slightly reduced abduction strength in 23 of 25 hips that had not been revised.There were 12 perioperative complications.Only 1 cementless press-fit porous-coated cup was revised for aseptic loosening.

View Article: PubMed Central - PubMed

Affiliation: ORTON Orthopedic Hospital, Invalid Foundation, Helsinki, Finland. antti.eskelinen@fimnet.fi

ABSTRACT

Background and purpose: Historically, a Schanz osteotomy of the femur has been used to reduce limp in patients with severely dysplastic hips. In such hips, total hip arthroplasty is a technically demanding operation. We report the long-term results of cementless total hip arthroplasty in a group of patients who had all undergone a Schanz osteotomy earlier.

Patients and methods: From 1988 through 1995, 68 total hip replacements were performed in 59 consecutive patients previously treated with a Schanz osteotomy. With the cup placed at the level of the true acetabulum, a shortening osteotomy of the proximal part of the femur and distal advancement of the greater trochanter were performed in 56 hips. At a mean of 13 (9-18) years postoperatively, we evaluated these patients clinically and radiographically.

Results: The mean Harris hip score had increased from 51 points preoperatively to 93 points. Trendelenburg sign was negative and there was good or slightly reduced abduction strength in 23 of 25 hips that had not been revised. There were 12 perioperative complications. Only 1 cementless press-fit porous-coated cup was revised for aseptic loosening. However, the 12-year survival rate of these cups was only 64%, as 18 cups underwent revision for excessive wear of the polyethylene liner and/or osteolysis. 6 CDH femoral components had to be revised due to technical errors.

Interpretation: Our results suggest that cementless total hip arthroplasty combined with a shortening osteotomy of the femur and distal advancement of the greater trochanter can be recommended for most patients with a previous Schanz osteotomy of the femur. Because of the high incidence of liner wear and osteolysis of modular cementless cups in this series, nowadays we use hard-on-hard articulations in these patients.

Show MeSH
Related in: MedlinePlus