24: Greater Trochanteric Transfer/Relative Femoral Neck Lengthening

Greater Trochanteric Transfer/Relative Femoral Neck Lengthening

Benjamin J. Shore and Michael B. Millis

Indications

Extra-articular hip impingement associated with short femoral neck/high greater trochanter

• Often done in conjunction with intra-articular surgery to address concomitant impingement via the surgical dislocation approach

• Abductor insufficiency associated with short femoral neck/high greater trochanter

Pitfalls

• If intra-articular malalignment or incongruity is present, this should be corrected simultaneously.

Controversies

• If the intra-articular malalignment is an indication for valgus intertrochanteric osteotomy, the valgus realignment may make unnecessary an otherwise-indicated trochanteric transfer.

Examination/Imaging

Supine and standing anteroposterior (AP) radiographs of both hips are obtained (Fig. 1).

FIGURE 1

Frog-leg lateral (Fig. 2) and false profile (Fig. 3) views are also obtained.

FIGURE 2

FIGURE 3

Treatment Options

• “Simple” distal/lateral transfer of the greater trochanter

• Valgus intertrochanteric osteotomy (occasionally)

Surgical Anatomy

Fascial interval between tensor and gluteus maximus

Greater trochanter and abductor insertion on trochanter

Piriformis tendon and short external rotator tendons

Medial femoral circumflex artery (MFCA) along its course posterior to greater trochanter, from the level of quadratus femoris until its terminal branches into the posterolateral/lateral aspect of the femoral head (Fig. 4)

FIGURE 4

Positioning

The patient is placed in the lateral decubitus position, operative side up.

A beanbag, pegboard, or similar stabilizing device is favored (Fig. 5).

FIGURE 5

Pearls

• Good stabilization is achieved in the lateral decubitus position.

• Excellent padding of the ipsilateral upper extremity, upper body, and trunk, as well as the downside contralateral upper and lower extremities, is needed.

Pitfalls

• Tension or pressure on the brachial plexus in either of the upper extremities

• Inadequte padding around the contralateral fibular neck and peroneal nerve

Equipment

• Pegboard or beanbag

Controversies

• The supine or “sloppy lateral” position is a poor alternative.

Portals/Exposures

A direct lateral skin incision is made; fasciotomy by the Gibson approach is preferred. The incision is continued in the proximal interval between the posterior edge of the tensor fasciae latae (TFL) and the anterior edge of the gluteus maximus (Fig. 6).

FIGURE 6

Proximal to the tip of the greater trochanter, elevation of the abductors in an anterior direction occurs in the interval between the anterior edge of the piriformis tendon and the posterior edge of the gluteus medius muscle.

The plane for the posteroanterior osteotomy of the greater trochanter is at a level just superficial to the piriformis tendon insertion onto the posterosuperior portion of the base of the trochanter (Fig. 7).

FIGURE 7

The proximal plane lies between the posterolateral capsule and the tip of the greater trochanter (this dissection is most safely done subperiosteally, hugging the bone of the posterosuperior edge of the greater trochanter) (Fig. 8).

FIGURE 8

Pearls

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Tags: Operative Techniques Pediatric Orthopaedic Surgery

Jun 7, 2016 | Posted by admin in ORTHOPEDIC | Comments Off

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