TRANSTROCHANTERIC ROTATIONAL OSTEOTOMY
Nippon Steel Ywata memorial Hospital
Ichiro KATSUKI
SLIDE 2
The transtrochanteric rotational osteotomy was designed by Prof. Sugioka for the treatment of
the osteonecrosis of the femoral head in 1972. This osteotomy is made rotation around the
axis of the femoral neck. We select the anterior or the posterior rotation where the intact bone
is.
SLIDE 3
We select the anterior rotational osteotomy in the case with posterior intact area and the
posterior rotational osteotomy in the case with anterior intact area. In the case with same
extent posterior intact area and anterior, we should select the posterior rotational osteotomy.
Posterior rotation is at ease for nutritional artery of the femoral head, because of 120 or more
flexion in normal range of motion.
SLIDE 4
In typical idiopathic osteonecrosis of femoral head, the necrotic bone is accounted at the
anteriosuperior part of femoral head and the intact bone, posterioinferior part. For this reason,
the anterior rotational osteotomy is selected chiefly. As it is possible to transfer the intact area
to weight-bearing area, it is possible to protect the necrotic focus from the shear stress and
prevent the following collapse. Once the collapse is occured, the hip joint become a touch of
subluxation, bad congruity and degeneration. This procedure is able to put the joint condition
right from the subluxation and reconstruct the joint function. An escape from shear stress
makes the necrotic bone to promote natural recovery.
SLIDE 5
This is a case followed for 27 years. He had bilateral steroid-induced ostonecrosis at 24 year
old.
SLIDE 6
This is the postoperative X-P. The intact area was transferred to weight-bearing portion
bilaterally.
SLIDE 7
This film was taken at 27 years after operation. He had normal hip function. The necrotic
bone area got smaller. He has no complaint of both hip.
SLIDE 8
In this procedure, the important things to think preoperatively and during operation are as
follows. First, how to evaluate necrotic or intact area extent preoperatively is? We estimate
the hip condition after 90 degrees anterior or posterior rotation, preoperatively and make
cutout drawing with standard line for using to decide osteotomy line during operation.
Second, how to perform rotation including protection of nutritional artery is? Third, how to
rigid fixation for postoperative management is.
SLIDE 9
The important issue for this procedure is showed on this slide. The precise osteotomy makes
the hip joint to good condition. The protection of the nutritional artery for the femoral head is
also important to get good results.
SLIDE 10
For preoperative evaluation of extent necrotic or intact bone, we usually use plain X-ray,
tomography and MRI. In plain X-ray and tomography, the lateral view taken in the hip
position with 90 degrees flexion and 45 degrees abduction is important. This position shows
the condition of anterior and posterior aspect of the femoral head without overlap head and
greater trochanter. In standard 90 degree anterior rotational osteotomy, upside down of the
femoral head in lateral view shows postoperative condition, otherwise, in posterior rotation,
lateral view shows postoperative condition. The recognition of the demarcation line is also
important for judge the bone is alive or not. The demarcation line, the crescent sign and the
collapse is showed more clearly in tomography.
SLIDE 11
This schema (b) shows true lateral view of head without greater trochanter overlapping.
SLIDE 12
There is how to take the X-ray film of lateral projection.
SLIDE 13
This is the plain X-P, A-P and lateral. For the rotational osteotomy, the demarcation line is
most important in lateral view.
SLIDE 14
The tomography shows the demarcation line more clearly.
SLIDE 15
MRI is effective method for detecting of necrotic bone, but there is the possibility to estimate
the intact area smaller because the portion of band pattern shows low signal on T-1 weighted.
For the rotational osteotomy, the image with the parallel direction to neck axis is important.
CT is substituted for tomography.
SLIDE 16
In preoperative planning, we prepare the cutout drawings of hip X-ray films, A-P view and
lateral view with demarcation line and neck axis. Then, the weight-bearing area is drawn on
the A-P cutout drawing. For prospect of postoperative hip condition in anterior rotational
osteotomy, the upside-down of lateral view is piled up to A-P view. We measure the ratio of
intact area to weight-bearing area. When this ratio is over 34%, we decide to perform the
standard 90 degrees anterior rotational osteotomy. In case shown under 34%, check 90
degrees rotation adding varus. Finally, we make the cutout drawing with standard lines-neck
axis, perpendicular to neck axis at intertrochanteric area (c) and inclined 5 and 10 degrees.
SLIDE 17
This slide showscut out drawing with demarcation line and neck axis.
SLIDE 18
This slide shows the acetabular weight-bearing area. In the Japanese Specific Investigation
Committee for the osteonecrosis of femoral head, the acetabular weight-bearing area is
decided as follows. Number 1 is the lateral edge of acetabulum, number 2 the tear drop and
number 3 the point of crossing the perpendicular bisector from 1 to 2 with acetabulum. The
Japanese Committee decided that acetabular weight-bearing area was acetabular curve from 1
to 3 for the sake of convenience.
SLIDE 19
We measure the ratio intact area to acetabular weight-bearing area. This ratio is important for
decision of osteotomy. In case who get the ratio is over 34%, we decide the anterior rotational
osteotomy.
SLIDE 20
This is the measuring device for the ratio of intact area to acetabular weight-bearing area.
SLIDE 21
We estimate post rotated hip condition preoperatively. In adding varus, the intact area goes
into the acetabulum and the ratio get bigger.
SLIDE 22
The cutout drawing of A-P with 3 standard lines, 0 degree, 5 degrees, 10 degrees inclined
from perpendicular line to neck axis. During operation, we check the accuracy of osteotomy
line with comparison controlled X-ray film with this cutout drawing.
SLIDE 23
I show the anterior rotational osteotomy. Divide 10 parts and show the explanation and movie
by turns. The part of movie is taken from over the operators’ right shoulder by my colleague.
SLIDE 24
Modified Ollier’s approach is used at lateral side position. Skin incision begins from 2 cm
distal of anteriosuperior iliac spine through 2 cm distal from the base of greater trochanter to
the height of lesser trochanter. Fascia is incised as a same manner as skin incision. At anterior
side, separate the anterior margin of gluteus medius from tensor fascia lata. At posterior side,
divide the gluteus maximus fiber, then, palpate and make 2 to 3 cm incision just over the
lesser trochanter and expose the lesser trochanter. Expose the neck just proximal to the lesser
trochanter carefully for the third part of osteotomy with protection of the nutritional artery.
SLIDE 25
(Movie)
SLIDE 26
The osteotomy of the greater trochanter first part of osteotomy is the fundamental osteotomy
of this procedure. It is important to avoid the osteotme to go into head or intertrochanteric
crest and to make that osteotomy surface is perpendicular to intertrochanteric posterior wall. It
is better that the shape of intertrochanteric osteotomy-second part of osteotomy become a
square for getting wide contact area for rigid fixation after rotation.
SLIDE 27
For these reason, the direction of osteome is parallel to lower leg axis in holding at 90 degrees
knee flexion and keep cutting along gluteus medius insertion as a anterior mark. Then, we
reflect the greater trochanter proximally, separate gluteus minimus from the capsule, cut
piriforms tendon and make a ligature of the branch of lateral circumflex artery. Exposure of
the superoanterior to superoposterior capsule is finished.
SLIDE 28
(Movie)
SLIDE 29
Put up only muscle fibers with small elevator and cut them on elevator little by little. Gemelli
and obturator internus are cut from proximal side. In cutting quadratus femoris, we find the
adipose tissue in lift up quadratus femoris at the lesser trochanter, insert small elevator
between adipose tissue and muscle fiber and cut only muscle fiber. Obturator externus is
beneath gemelli and obturator internus and is cut in protecting the artery with small retractor.
In this step, important things are that do not expose only the nutritional artery and stop cutting
in finding adipose tissue. Do not care small amount muscle fiber left. In this point, posterior
capsule is exposed.
SLIDE 30
(Movie)
SLIDE 31
Already exposure of superior to posterior capsule is finished. For exposure of anterior
capsule, we insert the elevator, shown on slide, along the anterior neck and separate soft part
from the anterior capsule. Then, keeping this elevator, operator insert his index finger along
the posterior capsule and touch the tip of elevator and make open at inferior of the neck. The
circumferential exposure of the capsule is finished.
SLIDE 32
(Movie)
SLIDE 33
For the decision of osteotomy line, we prepare for X-ray control. Two Kirschner wires are
inserted from the cut surface of the greater trochanter. First one is inserted at posterior side, 1
cm apart from intertrochanteric crest and towards to middle of the lesser trochanter. Second
one is inserted at anterior side, parallel to first one and perpendicular the surface made with 2
K-wires to femoral shaft axis. In X-ray control, the same magnification A-P view is necessary
for checking with cutout drawing with standard line prepared preoperatively. For this reason,
keep hip in neutral position and knee in 90 degrees flexion, film at anterior side and parallel to
femoral shaft and X-ray beam perpendicular to femoral shaft or parallel to lower leg. Pile up
the cutout drawing to the controlled X-P and check the relationship between 2 K-wires and
standard line. We use the third wire mad an isosceles triangle for easier judgment for these
relationship. In this point, we decide the second part of osteotomy line.
SLIDE 34
(Movie)
SLIDE 35
The circumferential capsulotomy begins from superior part at just distal labrum. It extend
anterior and posterior. Then, a long curved forceps is inserted along the posterior capsule and
grasp the inferiomedial part of the capsule. Posterior to inferiomedial capsulotomy is extended
along the forceps and anterior to inferiomedial capsulotomy is kept going to the tip of forceps.
During inferomedial capsulotomy, it is necessary to retract iliopsoas complex distally.
SLIDE 36
(Movie)
SLIDE 37
This slide is already showed. Third issue is included next movie.
SLIDE 38
The standard rotational osteotomy is 90 degrees anterior or posterior. This procedure includes
3 parts of ostéotomy, first ; greater trochanteric, second ; intertrochanteric and third ; above
lesser trochanter. The angle between intertrochanteric and above lesser trochanteric osteotomy
should be obtuse because of keeping away from valgus hip postoperatively. After osteotomy,
insert a Steinmann pin at proximal fragment and a K-wire at distal fragment. These are used
for measure the postoperative rotational angle and as a handle for rotation.
SLIDE 39
(Movie)
SLIDE 40
In the anterior rotational osteotomy, a Steinmann pin is inserted to the proximal fragment and
a Kirschner wire to the distal fragment from posterior to anterior wall just beneath the surface
of greater trochanter osteotomy. In this point, the Kirschner wire is parallel to the Steinmann
pin. The Steinmann pin is used as a handle for rotation. We measure the angle made with
these two materials as a rotated angle.
SLIDE 41
Before rotation, the tenotomy of iliopsoas at the lesser trochanter and subperiosteal muscle
separation at anterior and inferior of the proximal fragment are done. Then, we make rotation
with handling Steinmann pin and flexion of the distal femur, and get good contact. When we
cannot get sufficient rotation, we check the rest of obturator externus is or not and
capsulotomy is sufficient or not at superior portion. 2 another Steinmann pins are used for
temporary fixation.
SLIDE 42
(Movie)
SLIDE 43
The rigid fixation is also important for postoperative management. Now we use the plating
system with lag screw and subscrew. The characteristic of this system is that the lag screw
and the subscrew have two way handed-right or left handed. For example, in the anterior
rotational osteotomy of right hip, we use right handed screw and in posterior rotational
osteotomy of right hip, we use left handed screw.
SLIDE 44
(Movie)
SLIDE 45
In the reattachment of the greater trochanter, now we use A-I pin method –Advance
Innovation pin, designed by Prof. Itoman.
SLIDE 46
(Movie)
SLIDE 47
30 cases 35 hips with osteonecrosis of femoral head were treated by the transtrochanteric
rotational osteotomy in my hospital. Age at operation is 24 to 27 years old, average 39 years
old. Average follow-up period is 5 years and 10 months.
SLIDE 48
29 cases 34 hips were treated with the anterior rotational osteotomy, and another 1 posttraumatic hip was treated with the 120 degrees posterior rotational osteotomy.
SLIDE 49
Results are on this slide. The judgment was done which recollapse or degenerative changes
occurred or not. Success rate is 86%. Recollapse occurred in 4 hips.
SLIDE 50
3 of 4 hips with recollapse postoperatively are concerned about steroid administration. In
steroid-induced case, recollapse occurred 3 to 9 hips. 3 hips with recollapse were the cases
with continuous over 10 mg steroid administration. Show a case treated with anterior
rotational osteotomy.
SLIDE 51
Case report ; 40 yrs. Old male, he had taken steroid for the treatment of nephrotic syndrome.
On his first visit-February, 1998, his chief complaint was left hip pain. Right hip was silent. I
did the endprosthesis because of total necrosis of his left hip. The plain X-P showed nothing,
but necrosis was detected with MRI. He visited our outpatient office again with suffering
from right hip pain in January 1999. His plain X-P and tomography showed collapse and
demarcation line.
SLIDE 52
MRI-T1 weighted in his first visit showed typical findings of osteonecrosis of right femoral
head.
SLIDE 53
I performed the 90 degrees anterior osteotomy in 1999. In December 2005, 6 years after
operation, he had no pain and good range of motion.
SLIDE 54
Japanese Specific Investigation Committee established criteria for classification of idiopathic
osteonecrosis of the femoral head in 2001. This criteria Type A to C was made by the
relationship between the part of necrotic bone and the acetabular weight-bearing area is made
use for the treatment and the management of this disease. This criteria is judged with central
coronal section of the femoral head on T1 –weighted images or A-P view of the plan X-P.
SLIDE 55
Type A ; necrotic lesions occupy the medial one-third or less of the weight-bearing portion.
Type B ; necrotic lesions occupy the medial two-thirds or less of the weight-bearing portion.
In Type A, no operation and observation is needed. In Type B, sometimes operation is needed
example for varus osteotomy or rotational osteotomy.
SLIDE 56
Type C ; necrotic lesions occupy more than the medial two-thirds of the weigh-bearing
portion. In Type C, operation should be needed. We search the intact available bone.
SLIDE 57
Now our indication of this procedure is under 60 years old, especially under 40’s, with clear
demarcation line in plain X-P and that the ratio on intact area to weigh-bearing area is more
than 34% in preoperative estimation of postoperative condition. Socially, patients have a
proper understanding of this procedure.
SLIDE 58
Thank you for attention. Merci beaucoup.