Complex Primary Total Hip Replacement SKS Marya
INDEX
ABCDEFGHIJKLMNOPRSTUV
Page numbers followed by f refer to figure and t refer to table
A
Abductor dysfunction 6
Abnormal neurovascular structures 6
Abnormality of trochanters and metaphysis 131f
Acetabular
and femoral component orientation 8
bone defects 88, 89, 90f
cup 50, 145
deficiency 6
erosion 62f
floor crossing ilioischial line 34f
fractures 21, 32
orientation 88
protrusio 8
reconstruction 23, 115
reinforcement ring 117
templating 72
Acetabulum
preparation 75
prosthesis 80
reconstruction 88
Active tuberculosis 33f
Activities of daily life 115
Additional anterior visualization 23
Advanced
degenerative changes 12
destruction of hip 87f
American Academy of Orthopedic Surgeons 150
Anakinra 71
Anesthesia consideration 97
Ankylosing spondylitis 32, 33f, 103f, 104, 131
Ankylosis 76
in nonfunctional position 98f
Anterior
neurovascular structures 7
superior iliac spine 142, 146
Anteversion of acetabular cup of average pelvis 147t
Antirheumatic drugs in perioperative period 71t
Appropriate geometrical placement of prosthesis 7
Arthrocentesis 156
Arthrodesis of hip 91
Arthroplasty 58
for hip ankylosis 7
Articular proximal segment 125
Aseptic loosening 155
around implant 153f
Aspiration 46
Aspirin 71
Austin Moore arthroplasty 61f
Autologous blood transfusion 73
Avascular necrosis 11, 57
AVN
left hip with core decompression 13f
right hip with failed fibular grafting 13f
Azathioprine 71
B
Bekhterev disease 95
Bilateral ankylosis of hip 98f, 101f
Bipolar hemiarthroplasty 59
Birmingham hip resurfacing 14
Bone
augments 29
cement implantation syndrome 63
grafts 29, 38
scan 156
Bypassing screw holes 28
C
Calcar replacement necks 139
Causative disease 34
Causes of postoperative pain 152t
Cement fracture 155
Cemented
acetabular component 75
implants 49
socket 41
stems 155
Cementless arthroplasty 63
Center of rotation 88
Central fracture dislocation 24
Cerebral palsy 107
Cerebrovascular accident 107, 109
Charcot’s arthritis 110
Check X-ray after Birmingham hip resurfacing 139f
Chemoradiotherapy exposure 11
Childhood septic arthritis 131
Choice of prosthesis 23
Chondrolytic type of acetabulum 75
Chondrosarcoma
of right acetabulum 124f
right hip 124f
Chronic hip abductor atrophy 7
Classification of hip fractures 56
Combined deficiencies 156
Complete hemogram 154
Complex
primary hip
arthroplasty 1
conditions 6
situations 26
Complications of endoprosthesis 129
Computer-assisted
navigation in complex primary total hip arthroplasty 142
surgery 142, 143
Conditions with
decreased muscle tone 109
increased muscle tone 107
Contraindications of hip arthroplasty in bone tumors 120
Conventional hip endoprosthesis 126f
Conversion primary hip arthroplasty for proximal femoral fracture 9
C-reactive protein 46, 154
Creatine kinase 95
Crowe’s
classification of dysplastic hips 113t
grading of dysplasia 114f
Cystic and sclerotic changes in femoral head 12
D
Decompression sickness 11
Deep vein thrombosis 78, 102
Deepening of socket 34
Deficiency of floor 24
Defining neck-pelvis junction 7
Degenerative arthritis 16f
left hip 17f
Destructive bony lesion of proximal femur 125f
Developmental dysplasia of hip 131
Difficult dislocation 8, 24
Difficulties in surgical techniques 84
Direct lateral procedures 3
Dislocated
prosthesis 153f
THR 59f
Dislocation
hip 11
of femoral head 74
Down’s syndrome 107, 110
Durel energy X-ray absorptiometry 54
Dynamic hip screw 28
E
Ectopic ossification 102
Ehlers-Danlos syndrome 32
Enneking’s grading 125
Erythrocyte sedimentation rate 154
Excessive
femoral neck-shaft anteversion 6
tumor load 123f
Exposure
for complex primary total hip arthroplasty 1
of acetabulum 90
F
Failed
internal fixation for fracture neck femur 57, 57f
total hip arthroplasty 32
Fat pad sign 99
Femoral
canal preparation 76
discontinuity 156
head
dislocation 74
subluxation or dislocation 6
neck osteotomy in ankylosed hip 99f
prosthesis 80
reconstruction 118
registration 145
stem 50, 146
stenosis 156
templating 73
Final reduction and check X-ray 137f
Flattening of femoral head 12
Fracture neck of
femur 11, 134f, 138f
displaced 54f
Fractured stem 155
Future of computer-assisted surgery 148
G
Gaucher’s disease 11
Geriatric fracture centers 65
Gigli saw 74
Girdlestone
hip 92f
procedure 51
Glucocorticoids 71
Greater trochanter 28
H
Harris hip score 51
Healed
central fracture dislocation 33f
tuberculosis 33f
Hemiarthroplasty 54, 61
Heterotopic ossification 78, 152
High hip center 117
Hip
arthroplasty in tumors around hip joint 122
dysplasia 6
History of endoprosthetic use in bone tumors 120
Horizontal and vertical coordinate method 72
Hydroxychloroquine 71
Hyperparathyroidism 32
I
Iatrogenic fractures 77
Identification of
acetabular walls and insertion of cup 89f
true acetabulum and hip center 7
Idiopathic chondrolysis 32
Indications of
hip arthroplasty in bone tumors 122
total hip arthroplasty 97
Infected prosthesis 156
Inflammatory arthritis 8, 74
Insufficiency fracture 156
Internal fixation 57
Intraoperative fracture 152
Irritation of psoas 152
Ischial tuberosities 36f
J
Juvenile rheumatoid arthritis 131
K
Knee flexion 154
Kohler’s line 8, 72, 73
L
Large doses of steroids 11
Late complications of total hip arthroplasty in rheumatoid arthritis 78
Leflomide 71
Leg length discrepancy 8
Legg-Calve-Perthes disease 6, 131
Lesser trochanter 28
Limb length
considerations 23
discrepancy 6
Linear accelerator for radiation prophylaxis of ectopic ossification 100f
Long screw causing causalgic pain 151f
Loose prosthesis 156
Loosening of prosthesis 155f
M
Management of
broken screws/drill bits 28
greater trochanter 30
rheumatoid arthritis 69
Marfan’s syndrome 32
Marie-Strumpell disease 95
Massive ABC of proximal femur 123f
Matrix calcification 124f
McMurray osteotomy 138f
Mean platelet volume 96
Measurement and grading of protrusio 36
Medial
displacement osteotomy 116f
wall
displacement osteotomy 116
perforation 116
Method of calculating anatomic position of acetabulum 89f
Methotrexate 71
Minimally invasive surgery 74
Multiple screw fixation 58f
Muscular tendonitis 152
Mushroom head 113
Myelomeningocele 107, 110
Myeloproliferative disorders 11
N
Nerve injury 152
Nonunion of trochanteric osteotomy 152
O
Oblong acetabular prostheses 117
Old ankylosed hip 91f
Osteogenesis imperfecta 32
Osteolysis 104f
and loosening of prosthesis 79t
Osteomalacia 32, 33f
Osteoporosis 8, 54, 55
Osteoporotic femoral neck fractures 54, 55
Osteotomy 134
Otto pelvis 32
P
Paget’s disease 32, 156
Paprosky’s classification 50
Parkinson’s disease 107, 108
Pelvic
obliquity 111
viscera 124f
Periprosthetic fractures 78
Perthes’ disease 11
Poliomyelitis 107, 110
Polymerase chain reaction 46
Position of jig for cup orientation 89f
Posterior fracture dislocation 25
Postoperative
heterotrophic ossification 8
infected THR 47f
THA 91
Preparation of acetabulum and implantation of component 135f
Primary
protrusio 32
soft tissue sarcoma 124
Problems
of dislocating hip 24
with existing implants 24
Progressive radiolucency 155
Prosthesis
failure 152
in situ 128f
Protecting sciatic nerve 7
Protein energy malnutrition 56
Protrusio
acetabuli 32, 33f, 75
in healed tuberculosis left hip 34f
Proximal
bone loss 28
femoral osteotomies 5, 5f
Proximally abductors and rotators 127f
Proximity of nerve 24
Psoriatic arthritis 32
Pubic rami 152
R
Radiation induced osteonecrosis 32
Radiological classification of
ankylosing spondylitis 97f
hip pathology 96
Ranawat’s method 36, 36f
Reactivation of infection 85
after THA 85
Recrudescence of infection 84
Registration of pelvis and acetabulum 144
Removal of
implant 29
and proximal fragment 135f
metalwork 9
Restoration of hip center of rotation and femoral offset 8
Restore hip center 25
Results of
cemented femoral prosthesis in RA 76
total hip arthroplasty 76
uncemented
acetabular cup in protrusio 76
femoral prosthesis 76
Rheumatoid arthritis 32, 33, 41, 69, 131
Rituximab 71
S
Sacral fractures 152
Sacroilitis 95
Schanz osteotomy 131
Secondary
osteoarthritis 34, 134f
of hip 138f
protrusio 32
Septic
loosening 155
markers 23
Sequelae of hemiarthroplasty 32
Severely deformed proximal femur 131f
Shenton’s line 73
Shepherd crook deformity 131
Sickle cell
anemia 11
disease 32
Signs of protrusio 72
Small cup with
high hip center and subtrochanteric osteotomy 117f
screw fixation 116
Soft tissue
contracture 6
swelling on plain X-ray 124f
Spinal injury 107
S-rom femoral stems 119f
Staging of
AVN femoral head 11
malignant tumors around hip 125
Staphylococcus aureus 51, 78
Stress
fracture 152, 156
sites 156
Stretching of adductors 152
Subchondral collapse producing crescent sign 12
Subtrochanteric osteotomy 118f
Sulfasalazine 71
Surgical technique of endoprosthesis 126
Systemic lupus erythematosus 11
T
Tabes dorsalis 110
Tc99 bone scan 156
Tear gluteus medius 152
Teardrop configuration 35
in protrusio 35f
THA in
active tuberculosis of hip 86
ankylosed hips 90
girdlestone hips 92
Thalassemias 11
Thigh pain 152
THR in old acetabular fractures 22
Timing of
arthroplasty 70
operation 84
revision surgery 46
TNF-alpha inhibitors 71
Total hip
arthroplasty 12, 14, 21, 37, 59, 115, 84, 101f, 107, 108, 131, 150
for old tuberculous hip arthritis 84
in acute fractures of acetabulum 22
in protrusio 37
in proximal femoral deformity 131
in rheumatoid arthritis 69, 80t
replacement 11, 54, 123, 142, 150
after girdlestone arthroplasty 44
for failed trochanteric fractures 28
in ankylosing spondylitis 95, 103
in avascular necrosis hip 11
in dysplastic hips 113
in protrusio acetabuli 32
Total leukocyte counts 154
Tracker
attachment devices for pelvic 144f
related problems 148
Treatment of AVN femoral head 12
Trendelenburg’s test 152
Trifoliate pelvis 33f
Triradiate exposure 3
Trochanteric
and proximal femoral osteotomies 4
bursitis 152
flip 23
nonunion 78
osteotomy 4, 23, 74, 119
Truncal imbalance 111
Tuberculosis 32
of hip 87f
Type of canal 80
U
Uncemented
acetabular component 75
socket 40
stems 156
V
Vascularized fibular graft 18
Vastus lateralis herniation 152
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Chapter Notes

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Exposures for the Complex Primary Total Hip Arthroplasty1

Henry Budd
Vikas Khanduja
The purpose of this chapter is to explore the obstacles that an arthroplasty surgeon may encounter when undertaking the approach to the complex, or difficult, primary hip arthroplasty and propose a strategy to deal with the same. The complex primary hip is that where the risk of intraoperative technical difficulty, perioperative complications or risk of early failure is higher than usual and these cases invite the use of multiple techniques to achieve an adequate surgical exposure necessary to perform a successful arthroplasty. Significant bony deformation of the femur or acetabulum can occur secondary to congenital, developmental and acquired conditions resulting in axial, angular or versional abnormalities in combination with surrounding soft tissue abnormalities that require consideration when planning a surgical strategy. The principal aim of exposing the complex primary hip, like that of the routine primary hip arthroplasty, is to apply anatomical knowledge and surgical experience to safely reach the hip joint, adequately exposing the femur and acetabulum and allow controlled implantation of the prosthesis. Several key factors must be considered when deciding the most appropriate approach to use for the complex primary arthroplasty where gross anatomic distortion is often encountered, precluding the use of non-extensile approaches routinely utilized for the majority of primary hip arthroplasties. The complex hip arthroplasty often demands an extensile approach with further modifications to provide a wide exposure of the anterior and the posterior aspect of the acetabulum and the femur facilitating the performance of a femoral or pelvic osteotomy, bone grafting and acetabular reconstruction in addition to leg lengthening. The main approaches and modifications to consider are the extended posterolateral approach, trochanteric and proximal femoral osteotomy and the triradiate exposure which can then be applied by the surgeon to individual surgical scenarios including acetabular protrusio, bone deficiency, ankylosis, limb lengthening and osteoporosis. The anterior and anterolateral approaches will not be discussed since, while they can be used for complex primary hip arthroplasty, they are not extensile and less suited to the demands of these procedures than the alternatives discussed below.
The key approaches and techniques of osteotomy will be described first followed by the specific clinical situations in which they can be applied and the techniques of exposure required for each.
 
APPROACHES USED FOR THE COMPLEX PRIMARY HIP ARTHROPLASTY
 
Posterior and Posterolateral Approaches and Modifications
This is the utility approach to the hip commonly applied to standard primary hip arthroplasty and also used for the complex primary and revision hip arthroplasty due to its extensile nature. Originally popularized by Gibson and Moore, having recognized the advantage of a potentially bloodless field, rapid exposure and limited potential muscle dennervation, the posterior approach has undergone numerous modifications in response to the demands of both complex primary and revision arthroplasty since its original inception by Von Langenbeck in 1874 as an approach to drain suppurative arthritis.1–32
zoom view
Figure 1: Posterior approach
For the posterior approach, the patient is placed in the lateral decubitus position and secured with anterior and posterior stabilizing posts. The skin incision described by Moore in the Southern approach is placed longitudinally over the posterior third of the greater trochanter distally with the proximal limb extending in the direction of the fibers of gluteus maximus towards the posterior superior iliac spine and distally in line with the femoral shaft for 10 to 15 cm (Figure 1). After incising the skin and fat, the fascia lata is incised over the greater trochanter and split distally while proximally aponeurosis of gluteus maximus and its fibers are split and gently separated. The trochanteric bursa is encountered next, incised anteriorly and swept posteriorly with a swab to protect the sciatic nerve posteriorly exposing the short external rotators. Care is taken to protect the sciatic nerve throughout, especially important where it may be surrounded by dense fibrous scar tissue in cases where previous hip surgery has been performed or in the presence of an underlying destructive primary pathology. Dissection of the sciatic nerve is only rarely necessary given the significant added risk of iatrogenic injury. Stay sutures are placed in the piriformis tendon proximally while a retractor keeps the overhanging gluteus medius out of the operative field. The piriformis, obturator internus and gemelli with the posterior capsule are then divided as the hip is internally rotated and the hip is dislocated in flexion, adduction and internal rotation. In certain scenarios the quadratus femoris and gluteal sling can be released from the femur to further enhance exposure through the posterior approach and to enhance achieve exposure posteriorly the gluteus maximus insertion to the femur can be incised leaving a tendinous cuff for later repair. A modification of this approach described by Shaw uses an osteotomy of the posterior third of the greater trochanter which is reflected backwards with the short external rotators, hip capsule as well as the posterior gluteus medius allowing access to the hip and reliable closure by reattaching the bony fragment.4
Hip dislocation can be complicated by protrusio acetabulae, the presence of abundant marginal acetabular osteophytes, significant heterotrophic ossification, Coxa Magna and surrounding soft tissue contracture. In these cases osteotomy must be performed in situ if dislocation cannot safely be achieved by performing an extended capsulotomy and removal of osteophytes or heterotrophic ossification. After performing the femoral osteotomy the head is removed and retractors are positioned behind the anterior and posterior wall of the acetabulum and under the transverse acetabular ligament to adequately expose the acetabulum.
Where further exposure of the anterior or posterior acetabular walls or columns is required such as with the Crowe IV high hip dislocation, the posterolateral Kocher-Langenbeck approach can be considered in preference to the routine posterior approach. This hybrid of the original approach later modified by Moore as the posterior approach and the Kocher incision is well known to pelvic and acetabular surgeons for reconstruction of acetabular fractures.3,5 This approach is placed more anteriorly over the greater trochanter and for cases of complex primary hip arthroplasty may also require the Harris modification with a posteriorly directed third limb distally that allows posterior soft tissues to be retracted.6
For further exposure of the proximal femur required when there is femoral dysplasia, a narrow femoral canal or rotational deformity, a proximal 3femoral osteotomy is planned and the incision can be continued distally. Subsequently, one of the techniques described in the osteotomy section is utilized to expose the femur adequately.
 
Triradiate Exposure
This refers to a combined anterior and posterior approach using a triradiate skin and fascia incision.23 It has been suggested for use in complex primary arthroplasty cases such as protrusio acetabuli, marked obesity, osteoporosis and ankylosis. The three equal limbs of the incision are centered over the prominence of the greater trochanter with the distal limb overlying the mid-lateral line of the femur and the two proximal limbs at 120° to this anteriorly and posteriorly (Figure 2). After completing the incision of the skin and subcutaneous fat, a 1cm wide strip of fascia lata is exposed along each limb after which it is incised. Once each fascial flap is retracted the standard anterolateral and posterior capsular exposures can be used to gain access to the hip through partial capsulotomies. Where extensive anterior and posterior capsulotomy is required for exposure meticulous repair must be performed to reduce the risk of dislocation. While devascularization of skin apices, subcutaneous tissue and fascia is a concern, in a series of 47 procedures in 46 cases, Krackow et al report satisfactory healing of the triradiate incision including a case of an auxiliary iliac crest incision for bone graft harvesting.23 This extensive approach can be used where trochanteric osteotomy is to be avoided, such as with morbidly obese patients, those with osteoporosis and major debilitation where the risk of reattachment failure is higher. The triradiate skin incision is, however, best avoided in patients with diabetes mellitus, fragility of the skin from steroid use or in some cases of previously scarred skin from surgery although on occasion these can be incorporated.
zoom view
Figure 2: Triradiate approach
 
Direct Lateral Procedures
The continuity of the gluteus medius and the vastus lateralis over the greater trochanter has been exploited by a number of classical surgical exposures including that described by Learmonth, Hardinge as well as previously by MacFarland and Osborne who noted that the gluteus medius and vastus lateralis are in “direct functional continuity” through the thick “tendinous” perisoteum covering the greater trochanter (Figure 3).24–26 Modifications of these techniques can be similarly applied in both revision and complex primary arthroplasty surgery providing adequate exposure for both proximal femoral osteotomy and arthroplasty.
zoom view
Figure 3: Direct lateral
4The key advantage of these techniques is that they expose the proximal femur without the need for trochanteric osteotomy. These approaches are suitable in some complex primary hip arthroplasty situations, particularly when the surgeon is less familiar with the posterolateral approach or when they are relatively contraindicated in situations where the abductor muscles are already significantly weakened, such as in hip ankylosis.
The anterior slide can be used to expose the entire length of the femoral shaft if indicated. The continuity of the vastus lateralis and gluteus medius is maintained and proximally the common insertion is released from the anterior margin of the greater trochanter while maintaining a tendinous cuff and continued distally by subperiosteal dissection elevating the vastus lateralis from the intermuscular septum, which is maintained while perforating blood vessels, are ligated. Where a further extensile exposure of the acetabulum is required the vastus slide can be extended proximally with incorporation of the Smith-Peterson or the Henry acetabular approach.
Another useful soft tissue vastus lateralis approach described by McMinn to visualize the whole acetabulum and proximal femur utilizes an apex distal V-shaped subperiosteal flap of proximal vastus lateralis and fascia with gluteus medius and minimus reflected off the greater trochanter and proximal femur.40 This exposes the hip capsule and following capsulotomy the entire acetabulum, without the need for a trochanteric osteotomy. An increase in leg length can also be accommodated with this approach since at closure a simple V-Y plasty of the myofascial flap is performed.
 
TROCHANTERIC AND PROXIMAL FEMORAL OSTEOTOMIES
 
Trochanteric Osteotomy
Trochanteric osteotomy has been widely used by surgeons to achieve satisfactory circumferential exposure of the hip joint without compromising soft tissue attachments and is the ultimate extensile approach to the hip joint. In the complex primary hip arthroplasty, trochanteric osteotomy is useful not only to prepare the dysplastic femur but also to allow improved exposure of the hip capsule and the acetabulum, particularly in hips that are stiff or in cases of severe acetabular protrusio or gross proximal femoral deformity. A trochanteric osteotomy may be favored over the posterolateral approach where it is perceived that hip dislocation will be problematic with a significant risk of intraoperative femoral shaft fracture due to limited hip rotation particularly prominent in ankylosing spondylitis, acetabular protrusio and severe heterotrophic ossification where trochanteric osteotomy is followed by an in situ femoral neck osteotomy. However, in situations where a significant risk of heterotrophic ossification is predicted including ankylosing spondylitis, the use of preoperative radiotherapy may increase the risk of non-union of the trochanteric osteotomy and other soft tissue strategies should be considered as an alternative.
A great many modifications of the trochanteric osteotomy are described varying the extent, orientation and fixation of the osteotomy and with variable results. The basic types of trochanteric osteotomy are the simple conventional transverse transtrochanteric, the extended conventional, the Chevron (biplane), the partial trochanteric, the anterior trochanteric slide, the Stracathro and the vertical and horizontal osteotomy.7–12 The osteotomy should provide adequate access to the proximal femur and acetabulum, allow soft tissue preservation and enable reliable stable fixation with satisfactory union rates safeguarding abductor function. The conventional trochanteric osteotomy, routinely employed by Charnley when performing hip arthroplasty allows excellent visualization of the proximal femur and acetabulum but this transtrochanteric technique presents a significant risk of trochanteric complications including non-union and migration due to unopposed abductor pull and the unstable uniplanar orientation of the osteotomy7. The Chevron 30° trochanteric osteotomy with its greater surface area and intrinsic rotational stability can be used as an alternative where the primary purpose of the trochanteric osteotomy is to improve exposure of the acetabulum and upper femur as opposed to improving access to the dysplastic or small femur. 5The study by Weber and Stumer in 1979 compared patients with a transtrochanteric osteotomy with patients with a Chevron osteotomy and reported a 11% pseudoarthrosis rate in the conventional group and 1.5% in the Chevron group illustrating why the transtrochanteric technique is now largely historical.13 However, there are still potential problems with the Chevron osteotomy including intraoperative fracture during fixation and the inability to place it anteriorly or posteriorly.14
In cases of ankylosis, a trochanteric osteotomy followed by an in situ neck cut exposes the proximal femur and acetabulum allowing further assessment of bone stock and deformity to be made and a better approximation of the anatomic location of the acetabulum.15 Modification of the technique with the extended trochanteric osteotomy has lessened the risk of complications and allowed for reliable union.9,14–20
The trochanteric slide osteotomy described by English in 1971 solves the problem of proximal migration of the trochanter by osteotomizing the origin of the vastus lateralis muscle along with the osteotomy but this does not significantly increase access to the proximal femur and cannot be used where changes in leg length are anticipated.21 An alternative to the trochanteric slide is the Stracathro approach, which maintains continuity of the gluteus medius and the vastus lateralis by performing a thin osteotomy of the anterior and posterior lateral greater trochanter which has the vastus lateralis and gluteus medius tendons attached proximal and distal and the short external rotators posteriorly.11 The osteotomised fragments can then slide backwards and forwards exposing the hip, which can then be dislocated anteriorly and repair can be achieved by suturing the bony fragments with their tendinous attachments to the greater trochanter.
 
Proximal Femoral Osteotomy
A proximal femoral osteotomy is required where a significant proximal femoral deformity is present or femoral shortening is necessary and this can be achieved in a number of ways. The common types of proximal femoral osteotomy are the transverse osteotomy, step-cut, uniplanar or biplanar wedge and Chevron (Figures 4A and B).
zoom view
Figures 4A and B: Proximal femoral osteotomies
6These may be combined with a separate trochanteric osteotomy in some cases to assist exposure of the true acetabulum and restoration of abductor tension. Younger et al describe an extended proximal femoral osteotomy for use in revision hip surgery to remove the well-fixed femoral stem but still relevant in complex hip arthroplasty scenarios where there is significant deformity of the proximal femur.9 This osteotomy takes the greater trochanter and proximal femur with attachment of the gluteus medius and minimus and opens on an anterolateral periosteal and muscle hinge exposing the femoral canal allowing preservation of blood supply and preventing proximal migration after reattachment.9 Firestone describes another form of extended trochanteric osteotomy, wherein the lateral femoral cortex is osteotomized just lateral to the linea aspera and extended distally but continuity is maintained with the proximal femur.18 In a case series of 6 patients undergoing an extended trochanteric osteotomy for complex primary hip arthroplasty Della Vale et al suggested that in selected cases, particularly where existing implants must be removed and femoral deformity must be corrected, this technique had a satisfactory rate of union and was less technically demanding than alternatives including a wedge or step-cut osteotomy.22
 
COMPLEX PRIMARY HIP CONDITIONS
 
Hip Dysplasia
The approach must address the following key obstacles in this condition:
  • Acetabular deficiency
  • Femoral head subluxation or dislocation
  • Limb length discrepancy
  • Abnormal neurovascular structures
  • Soft tissue contracture
  • Excessive femoral neck-shaft anteversion
  • Abductor dysfunction
A patient with developmental hip dysplasia invites a multitude of important challenges to the surgeon performing a total hip arthroplasty. The hip dysplasia may be secondary to developmental dysplasia of the hip, Legg-Calve-Perthes disease and slipped upper femoral epiphysis among others. Gross anatomical distortion of the acetabulum and proximal femur can be present which must be carefully considered when planning the surgical approach that will offer maximal exposure and arthroplasty to be safely performed. The femoral head lies proximal to the true acetabulum in the high dislocation and the frequently atrophic abductor muscles therefore pass almost horizontally rather than in their normal vertical orientation.27–29 The femoral nerve and profunda femoris artery are at significant risk of direct laceration or indirect traction injury as they pass across the patient’s true acetabulum having looped backwards up to the position of the displaced femoral neck before descending27,30 and the normal anatomical planes are absent and cautious dissection must be followed before placement of retractors around the acetabulum.30 Rotational deformity of the proximal femur is also manifest with substantial femoral anteversion, a shortened femoral neck and posterior placement of the greater trochanter, potentially resulting in anterior dislocation if not corrected intraoperatively.31–33 Identification of the true acetabulum is a further challenge though it is possible to identify it by opening the hip capsule and passing a finger down within the capsule through the hourglass contracture and into the true acetabulum.30
The Crowe classification described in 1979 is a useful guide to the technique required to achieve adequate exposure of the hip and restore the hip center while also allowing for femoral shortening and derotation.34 This classification groups patients according to the degree of dysplasia and dislocation; and in Crowe 3 and 4, the hip joint is completely dislocated, but in the latter, also called the high dislocation, the acetabulum is insufficiently developed and more than 100% subluxation is present. Restoration of the anatomical hip center is an important goal to reduce acetabular wear rates and restore normal hip biomechanics but in the Crowe 4 completely dislocated hip this can result in significant leg lengthening and potential sciatic and femoral nerve traction injury.35,36 The subtrochanteric and transtrochanteric approaches afford excellent exposure, allow alteration of leg length, rotational correction, restoration of the hip center and protect against nerve injury and are most suited to complex 7primary hip arthroplasty. The posterior approach can also be used for these cases given its extensile nature but other approaches, including the direct lateral modified Hardinge approach, have been successfully implemented for Crowe 4 dysplastic hips, however, these will frequently also require a proximal femoral osteotomy to be performed and therefore are more suited to the milder cases.37
The ideal subtrochanteric osteotomy will allow shortening, adjustment of the rotational alignment of the femur, access to the dysplastic proximal femur and acetabulum in addition to reliable fixation and union. Although the femur is shortened during the operation, the distalization of the femoral head to sit in the true acetabulum often results in an overall leg lengthening. The transverse subtrochanteric osteotomy described by Yasgur allows shortening and derotation to be performed and either a cemented or uncemented femoral component used.33 Alignment and length can be determined intraoperatively by reducing the proximal femur with trial femoral component and checking bony overlap. When required, osteotomies can be re-cut which compares favorably to Chevron and step-cut osteotomies which require careful preoperative templating and planning since they are less amenable to alteration. This osteotomy can then be secured with locking plate fixation and reinforced if necessary with cables. Bruce et al have also described a subtrochanteric shortening femoral osteotomy for use with a modular femoral component, which is performed with the prosthesis in situ and judged by measuring the distance between the center of the femoral head and acetabular component with the leg placed under maximal tension.38 This technique was suggested for use in patients with a relatively straight proximal femur and good bone quality where an uncemented prosthesis could be used.38
In some situations the dysplastic femoral canal may be too narrow at the isthmus for the smallest size femoral stem, although many manufacturers do produce specialist stems for such situations, and in these cases, adequate exposure can be achieved by splitting the femoral shaft anteriorly and posteriorly while also performing a trochanteric advancement.39 To expose the proximal femur the vastus lateralis can be detached proximally or the McMinn V-Y vastus lateralis procedure can be used which also enables later adjustment of abductor tension at closure.40
 
Arthroplasty for Hip Ankylosis
The approach must address the following key obstacles in this condition:
  • Identification of the true acetabulum and hip center
  • Chronic hip abductor atrophy
  • Defining the neck-pelvis junction
  • Protecting the sciatic nerve and anterior neurovascular structures
  • Leg lengthening
  • Appropriate geometrical placement of prosthesis
Surgical reconstruction of the spontaneously ankylosed or surgically arthrodesed hip with total joint arthroplasty requires adequate visualization of the anterior and posterior proximal femur and the site of the planned acetabulum. Challenges include not only those due to the primary disease process but also as a consequence of prior surgery.
The surgical incision will need to be planned considering the deformity present and where there is a fixed flexion deformity of 90°, the incision will curve sharply backwards at the greater trochanter in line with the deformity. While various approaches can be considered it is vital not to cause significant soft tissue damage, and abductor dennervation or devascularization through dissection in these cases since the abductors are already atrophic and a transtrochanteric approach would therefore be preferable to gain optimal acetabular exposure and also allow for leg lengthening. The transtrochanteric approach spares the remaining abductors while the posterior approach also preserves abductor function while the anterolateral and direct lateral approach risk direct abductor damage and dennervation through injury to the inferior branch of the superior gluteal nerve. Access to the femoral medullary canal is also facilitated by a trochanteric osteotomy since the greater trochanter often overlies this in these patients. Alternatively, the combined posterior and anterolateral approach has been successfully applied to gain exposure of the posterior and anterior neck 8respectively which can then be osteotomised from both sides in turn.41 It may also be advisable to perform a release of the tensor fasciae lata, rectus femoris, gluteus medius and minimus through a second incision placed along the iliac crest to allow mobilization of the proximal femur and exposure of the acetabulum which can then be prepared. It must also be remembered that after prolonged flexion with fixed flexion deformity the leg must be maintained in flexion throughout the procedure to prevent femoral nerve injury.
The critical step in arthroplasty for the ankylosed hip is the osteotomy of the femoral neck that requires adequate exposure so the neck-pelvis junction can be identified and ensure that the acetabular wall is not mistaken for the edge of the femoral neck and subsequently compromised. This is achieved both by visualization and feel, where it is possible to identify the line of the femoral neck by palpating down to the lesser trochanter and pubofemoral arch prior to performing osteotomy.42 The anterior and posterior neurovascular structures must also be protected while the osteotomy is performed 1cm from the pelvis. This is assisted by placing a large blunt retractor anterior to the neck and subperiosteal dissection posteriorly to protect the sciatic nerve.43 After completion of the neck osteotomy attention can be turned to removal of the femoral head and subsequent acetabular preparation, both facilitated by exposure of preserved key landmarks including the acetabular fovea and obturator foramen.
Ankylosis can occur following significant heterotrophic ossification in patients with head injury where ossified material is present within soft tissue planes and can form peri-articular bony bars. The planned surgical approach must allow exposure and excision of heterotrophic ossified material and neck osteotomy and following this removal of the bony bars.
 
Acetabular Protrusio
The approach must address the following key obstacles in this condition:
  • Restoration of the hip center of rotation and femoral offset
  • Risk of fracture during dislocation
  • Leg length discrepancy
In cases of acetabular protrusio, with medial wall deficiency and medial migration of the hip center beyond Kohler’s line, the approach must allow adequate exposure of the femoral neck and performance of in situ osteotomy, adequate acetabular exposure and leg lengthening where superior migration of the femoral head has occurred. Such cases can be performed through posterior, posterolateral, anterolateral, direct lateral and transtrochanteric approaches successfully re-establishing the center of hip rotation and restoring leg length and offset. Exposure of the acetabulum is however best achieved with the transtrochanteric approach offering an excellent view of the anterior and posterior acetabulum, access to the femoral neck to perform osteotomy and the ability to correct abductor tension as offset and leg length is restored.
 
Inflammatory Arthritis
The approach must address the following key obstacles in this condition:
  • Osteoporosis and risk of intraoperative fracture
  • Acetabular and femoral component orientation
  • Difficult dislocation
  • Postoperative heterotrophic ossification
Many conditions are responsible for inflammatory arthritis affecting, among other joints, the hip, resulting in degenerative change. These include rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, chondrocalcinosis and gout amongst many others.
In juvenile rheumatoid arthritis, care must be taken to avoid femoral fracture during hip dislocation due to coexisting osteoporosis, and an adequate capsulotomy or in some cases total capsulectomy and possibly in situ femoral neck osteotomy is necessary to dislocate the femoral head without applying a significant rotational force. Extensive soft tissue contracture release will also assist safe dislocation of the femoral head. The presence of osteoporosis can also lead to fragmentation of the greater trochanter during surgery if a transtrochanteric approach is 9utilized as is often necessary in cases where the proximal femoral canal is difficult to enter, but where possible the posterior, direct lateral or anterolateral approach are more suitable for these patients.
In patients with ankylosing spondylitis attention to accurate patient positioning in the lateral decubitus position with appreciation of the presence or absence of the normal lumbar lordosis is crucial to achieving appropriate acetabular orientation as well as a wide exposure. Hip dislocation can be difficult in some cases and may necessitate a planned in situ neck osteotomy after dislocation is attempted following iliopsoas tenotomy, partial or complete capsulectomy and release of soft tissue adhesions. A trochanteric osteotomy can be useful to achieve adequate circumferential acetabular visualization since it may not be possible to reliably expose the femoral neck using either the anterolateral or posterior approach which can subsequently lead to a difficult in situ osteotomy in severe cases and potentially removal of some acetabular wall to identify and cut the neck. This however must be balanced against the risk of postoperative non-union of the greater trochanter if postoperative irradiation is planned to reduce the risk of heterotrophic ossification in these cases. Fluoroscopy can also be used to assist identification of the femoral neck and to perform the osteotomy, although this should not be necessary with a carefully planned surgical approach such as the transtrochanteric, posterolateral or even combined posterior and anterolateral.
 
Conversion Primary Hip Arthroplasty for Proximal Femoral Fracture
The approach must address the following key obstacles in this condition:
 
Removal of Metalwork
Adequate access to the proximal femur for broaching/burring: Failure of metalwork following a proximal femoral fracture ultimately results in a complex primary total hip arthroplasty. The chosen approach must be extensile distally and allow removal of metalwork from the lateral femur achieved by subperiosteal dissection and elevation of vastus lateralis, access to the often medialized proximal femur for broaching and removal of dense sclerotic bone within the canal and reattachment of the malunited greater trochanter and attached abductors.
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