- ▪
Extended trochanteric osteotomy (ETO) is a valuable tool for revision arthroplasty.
- ▪
Acetabular exposure can be enhanced with this technique.
- ▪
Removal of components and cement is facilitated with an ETO.
- ▪
Implantation of a revision component is enhanced with use of an ETO.
One of the greatest challenges in revision total hip arthroplasty is achieving adequate surgical exposure. Visualization is essential to minimizing the risks of intraoperative complications in order to ensure optimal results. Altered anatomy, extensive scarring, bony overgrowth, and deficient bone stock make revision total hip arthroplasty more challenging than primary total hip arthroplasty. Preoperative planning and preparation, including anticipation of potential complications, are paramount in attaining a successful outcome. Any surgical approach used in revision hip arthroplasty should have the potential to be expanded into a more extensile exposure should the need arise. An extensile exposure helps to minimize the trauma to the soft tissues, which often are already compromised in revision hip arthroplasty.
An extended trochanteric osteotomy (ETO) of the proximal femur provides direct visualization of the femoral canal and allows for improved exposure of the acetabulum. Therefore it is ideal for removal of a well-fixed femoral component as well as the safe removal of cement. Potential advantages of ETO include decreased risk of intraoperative fracture, decreased anesthetic time, improved exposure of the acetabulum for extensive reconstructive procedures, and the ability to correct deformities of the proximal femur.
INDICATIONS AND CONTRAINDICATIONS
ETO is often recommended for difficult femoral revisions, although it can be used to correct deformity in primary arthroplasty ( Fig. 38-1 ). Ideally suited for removal of cementless or cemented femoral stems, including fractured stems, it also facilitates complete removal of distal cement, the cement plug, and bony pedestals ( Fig. 38-2 ). Other common indications include deformity of the proximal femur, revision of femoral stems placed in significant varus, previous trochanteric osteotomy with bony overgrowth or trochanteric escape, and the need to perform extensive acetabular reconstructive surgery. Relative contraindications to ETO include revisions in which a cemented stem is to be implanted, as the cement may extrude into the osteotomy site. One must be cautious in using this approach with cortical bone that is thin secondary to osteolysis and therefore renders reattachment to the femur challenging.
PREOPERATIVE PLANNING
As with all revision surgeries, preoperative planning is essential. The appropriate tools and resources need to be available. The goal of ETO is to provide adequate exposure of the femur and acetabulum while preserving the majority of the soft-tissue attachments to the osteotomy fragment in order to optimize healing. One must understand the indication(s) for the revision procedure before surgery in order to adequately plan the exposure and extraction technique, as well as the type of prosthesis to be implanted. Plain radiographs are needed to identify the type of prosthesis and for preoperative templating of the new implant. The extent of porous coating or cement fixation is important in planning the length of the femoral osteotomy. Cortical strut allograft should be available if major bony defects are expected, and cerclage wires or cables are needed for fixation of the ETO. It is crucial that aseptic loosening be differentiated from septic loosening before reimplantation.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
