Moderator Trousdale: Let’s talk about the revision setting. Matt, when would you do some type of extended osteotomy in the revision population?
Dr. Abdel: With difficult acetabular exposures I’ll use an osteotomy. You can do an anteriorly based or laterally based one. That gives you great exposure. If there’s any issue with femoral anatomy or distal cement plugs or fixation issues, I’ll do an osteotomy. The goal here, of course, is to protect the abductor complex connected to the proximal aspect of the trochanter, so I prefer to go to an osteotomy and have a nice bony bridge with soft tissue attachment, rather than fracturing it off doing something else.
Moderator Trousdale: Good point. Allan, you taught me a few years ago that idea of leaving the posterior capsule which was a big game changer in my practice for instability issues, so I do a similar thing. You do a posterior based approach and leave those rotators intact—that’s great for post-operative instability, so thank you for that. One problem I have with the laterally or anteriorly based osteotomy is occasionally you’ll do that to increase apposition, but what do you do when you do that and the trochanter breaks off the segment of cortical lateral bone, which can happen in the revision setting? How do you handle that? Now you’ve got two pieces of laterally based trochanter instead of the one long piece?
Dr. Gross: There’s two things you can do. If worse comes to worst, you can get a short cortical strut and use it as an onlay graft so that you get continuity between the greater trochanter and that fractured piece. The other thing you can do is go to a claw if you have to. But you rarely, rarely will go to the claw.
Moderator Trousdale: Those are pretty biologically unfriendly. Matt, you mentioned you sometimes use an anterior based osteotomy versus a posterior based ETO. Tell everybody how you make the decision to do a sort of anterior Wagner-type osteotomy where the anterior half of the femur is taken off versus a laterally based osteotomy from posterior to anterior, where the whole lateral femur is taken off.
Dr. Abdel: My workhorse would, obviously, be mostly a laterally based osteotomy, but I think there is a role for the anterior based osteotomy, particularly in periprosthetic fractures. I think that kind of classic transfemoral or bony Hardinge is beneficial in those scenarios. Or if you have certain deformities you have to look at the scenarios where the trochanter is in the way, if the deformity is going to mostly be removed by taking out the anterior half of the femur, I’ll do that. But my workhorse is a laterally based osteotomy in most cases.
Moderator Trousdale: Allan, when do you do a posterior-based or laterally based fragment versus an anterior-based?
Dr. Gross: The only time we would do the anterior based is if we’ve done a transgluteal approach, we get into trouble and we need more exposure. That’s one indication. And the other is the periprosthetic fracture because sometimes that periprosthetic fracture actually communicates…it’s almost a Wagner approach having been done by the fracture.
Moderator Trousdale: Thank you gentlemen. That was a great discussion on a tough problem.
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Senior Editor: Jay D. Mabrey, M.D., whose 35 year career in orthopedics included residency at Duke University Medical Center, service in the United States Army Medical Corps, Fellowship at the Hospital for Special Surgery and a long, distinguished career at Baylor University Medical Center where, in addition to his overall leadership at that institution, developed the Joint Wellness Program that helped patients get up after surgery more quickly, developed the first virtual reality surgical simulator for knee arthroscopy and chaired the FDA Orthopaedic Device Panel, is Orthopedics This Week’s newest contributing writer and editor.
