import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: 2-3cm posterior to posterior acetabulum, travels distally posterior to femur in posterior compartment **Protection**: Early identification during posterior approach, gentle retraction with blunt retractor, avoid posterior osteotomy extension beyond linea aspera, release short external rotators sharply off bone rather than avulsion (nerve just posterior), ensure ETO cuts don't propagate posteriorly **Injury**: Foot drop (common peroneal), sensory loss posterior leg and lateral foot, rare complete palsy. Incidence 0.5-2% with ETO (higher than primary 0.1-0.3%). Manage with immediate tension release, EMG at 3 weeks, AFO for foot drop, most partial recovery 12-18 months **Location**: Main pedicle 8-10cm distal to greater trochanter, pierce deep surface of vastus lateralis emerging through posterior 1/3 of muscle from deep to superficial. Multiple perforators along length **Protection**: Preserve posterior 1/3 vastus lateralis attachment to ETO fragment - elevate only anterior 2/3 vastus off lateral femur. This maintains vascular pedicle essential for ETO union. Do NOT completely strip vastus from fragment **Injury**: ETO fragment devascularization leading to non-union (increases from 5-10% to 20-30%), delayed union, fragment necrosis. Requires revision ORIF with plate, bone graft, BMP if symptomatic non-union develops **Location**: Anterior to femur along medial aspect in Hunter's canal. Femoral artery 2-3cm medial to anterior femoral cortex at mid-shaft level **Protection**: Limit osteotomy to lateral 1/3 circumference, place finger anteriorly during cement removal to monitor cortex integrity, avoid anterior cortex perforation during burring/reaming, ensure saw cuts perpendicular not angled anteriorly **Injury**: Catastrophic hemorrhage requiring immediate vascular surgery, potential limb loss. Anterior perforation occurs 30% of cases with blind cement removal (ETO reduces to <5%). Manage with immediate vascular surgery consult, repair vs ligation depending on vessel **Location**: Penetrate posterior femur at linea aspera, multiple branches along length of femur posteriorly **Protection**: Keep posterior osteotomy cut anterior to linea aspera (anatomic landmark - palpable posterior ridge), limit osteotomy width to 1/3 circumference anterolaterally, avoid posterior extension **Injury**: Venous bleeding from accompanying veins, can be brisk but usually controllable. Manage with direct pressure, bipolar cautery, bone wax if bone bleeding. Rarely requires ligation **Location**: Exits pelvis through greater sciatic notch superior to piriformis, travels between gluteus medius and minimus to supply these muscles. 3-5cm superior to acetabular dome **Protection**: Limit proximal dissection, avoid excessive superior retraction of abductors, identify and protect during proximal ETO cut at GT level, ensure proximal cable placement below lesser trochanter (not at GT level where nerve courses) **Injury**: Abductor denervation causing Trendelenburg gait, weakness, superior gluteal artery bleeding. Incidence <1% with ETO. Manage bleeding with direct pressure/cautery. Nerve injury irreversible - requires long-term gait aids ## Indications for Extended Trochanteric Osteotomy ### Primary Indications (Strong Evidence) **1. Well-Fixed Cemented Femoral Stem Requiring Removal** - MOST COMMON indication (60% of ETO cases) - Stem well-bonded to cement mantle, cannot be extracted safely - Long cement mantle extending into diaphysis - Removal required for: aseptic loosening of acetabulum with well-fixed femoral component, infection requiring complete removal, stem malposition, periprosthetic fracture around stem - Alternative (cortical windows) has 30% anterior perforation rate with blind cement removal - ETO provides DIRECT visualization of cement-bone interface for safe removal **2. Well-Fixed Uncemented Stem Requiring Removal** - Extensively porous coated stem with circumferential bone ingrowth - Cannot be extracted with standard techniques (osteotomes, slap hammer) - Risk of fracture during extraction attempts - Common scenarios: modular stem with taper corrosion, head/neck taper fracture, stem malposition, acetabular revision with need for stem version correction - Hydroxyapatite coated stems particularly difficult to extract (strong bone bonding) **3. Periprosthetic Femoral Fracture Around Stem (Vancouver Classification)** - **Vancouver B1**: Fracture around well-fixed stem with adequate bone stock - Need to access fracture site for reduction and fixation - ETO allows fracture visualization, reduction, cable/plate fixation, maintain stem - **Vancouver B2**: Fracture around loose stem - Need stem removal and revision - ETO allows safe stem extraction and fracture management - Can revise to longer stem bypassing fracture - Vancouver C fractures: may use ETO if fracture pattern extends proximally **4. Proximal Femoral Deformity Limiting Canal Access** - Previous fracture malunion with canal deformity - Paget's disease with bowing and sclerosis - Previous osteotomy (valgus, varus, derotational) - Developmental dysplasia with abnormal anatomy - Severe osteoarthritis with protrusio and medial bone loss - ETO allows visualization of anatomy and controlled reaming despite deformity **5. Severe Proximal Femoral Osteolysis** - Extensive cysts and bone loss requiring thorough debridement - Polyethylene wear debris-induced osteolysis - Need access for curettage, grafting - ETO provides complete visualization of proximal femur for debridement and grafting ### Secondary/Relative Indications **6. Retained Cement Restrictor or Distal Plug** - Cement restrictor at isthmus level - Cannot advance instruments past restrictor - Risk of perforation attempting blind removal - ETO allows direct visualization and removal **7. Broken Cerclage Wires/Cables from Previous Surgery** - Retained metalwork embedded in bone - Cannot advance reamers safely - Need removal before revision stem insertion **8. Severe Anterior Femoral Bow** - Risk of anterior perforation during reaming - ETO allows visualization and controlled reaming following anatomy **9. Removal of Long Distally-Fixed Stem** - Extensively coated stem with distal fixation only (proximal loosening) - Cannot extract without risk of fracture - ETO allows proximal access while maintaining distal fixation initially ### Contraindications to ETO **Absolute Contraindications** - Active uncontrolled infection with significant soft tissue loss (risk of fragment contamination) - Severe osteoporosis with impending fracture (fragment will not hold cables) - Prior ETO at same site with non-union (revision requires different technique - plate fixation) - Trochanteric area destroyed by tumor or infection (no fragment to mobilize) **Relative Contraindications** - Mild osteoporosis (manage with more cables, possibly plate augmentation) - Patient non-compliance anticipated (unable to follow protected WB protocol) - Smoking (3× non-union risk - counsel cessation, consider plate augmentation) - Previous radiation therapy to femur (impaired healing - consider plate, BMP) - Morbid obesity (difficulty with protected WB, higher complication rate) ### ETO vs Alternative Techniques | Technique | Advantages | Disadvantages | Indications | |-----------|-----------|---------------|-------------| | **Extended Trochanteric Osteotomy** | Direct visualization, complete cement removal, controlled osteotomy, 90% union | Complex, longer surgery, protected WB 6-8w, risk non-union 5-10% | Well-fixed cemented stem, extensive cement mantle, complex anatomy | | **Cortical Windows** | Faster, simpler, full WB immediately | Blind cement removal (30% perforation), incomplete removal, risk fracture propagation | Short cement mantle, proximal cement only, good bone stock | | **Femoral Osteotomy (Complete)** | Complete exposure | Non-union 20-30%, requires plate fixation, long protected WB | Severe deformity, tumor resection | | **In Situ Stem Retention** | No osteotomy needed | Cannot address cement, limited options | Well-fixed stem, isolated acetabular revision | ## Preoperative Planning - Essential Steps ### Clinical Assessment **History** - Original indication for THA (primary OA, DDH, AVN, trauma, inflammatory arthritis) - Previous surgeries and approaches (posterior, anterior, lateral - determines scar, soft tissue) - Time since index THA (early vs late failure, bone stock implications) - Symptoms: pain location and character, instability/dislocations, functional limitation - Medical comorbidities: diabetes (infection risk), smoking (non-union risk 3×), cardiac (DVT prophylaxis), renal (medication dosing) - Medications: anticoagulation (timing of cessation), steroids (healing impairment) - Patient expectations and compliance (ability to follow protected WB protocol CRITICAL) **Physical Examination** - Gait: Trendelenburg (abductor deficiency), antalgic (pain), leg length discrepancy - Scars: location, quality, previous approach identification - Hip ROM: flexion, extension, rotation (stiffness suggests heterotopic ossification) - Abductor strength: hip abduction against resistance (gluteus medius/minimus function) - Neurovascular: sciatic nerve function (foot dorsiflexion, plantar flexion, sensation), femoral pulse, distal pulses - Leg lengths: measure true (ASIS to medial malleolus) and apparent lengths ### Radiographic Assessment - FULL-LENGTH FILMS MANDATORY **Standard AP Pelvis (True AP)** - Assess acetabular component: position, wear, loosening (radiolucent lines, migration) - Femoral stem position: varus/valgus, subsidence, loosening zones (Gruen zones) - Heterotopic ossification: Brooker classification (may need excision if severe) - Bone stock: proximal femur quality, greater trochanter integrity - Previous fractures, deformities **Full-Length AP Femur (Hip to Knee on Single Cassette)** - **CRITICAL for ETO planning** - Measure stem length precisely (from shoulder to tip) - Calculate ETO length: stem length + 4-5cm distal extension - Identify stem tip location (mark on radiograph) - Assess distal bone stock: canal diameter, cortical thickness (Paprosky classification) - Anterior bow of femur: may need lateral view to assess - Previous hardware: cables, plates, screws **Lateral Hip/Femur** - Assess stem version (anteversion/retroversion) - Anterior bow magnitude (affects reaming trajectory) - Cement mantle anterior and posterior extent - Anterior cortex integrity (weakened areas risk perforation) **Additional Imaging (Selective)** **CT Scan with 3D Reconstruction** - Complex anatomy: DDH, previous fracture, deformity - Assess bone stock in 3D: Paprosky classification verification - Cement mantle extent and distribution - Surgical approach planning (anatomy visualization) - Not routine but helpful in complex cases **MRI** - Suspected infection: fluid collections, abscesses - Soft tissue assessment: abductor integrity, trochanteric bursa - Osteolysis extent: better than X-ray for cystic lesions - Contraindicated with some metal implants **Bone Scan (Tc-99m)** - Differentiate aseptic loosening (uptake at bone-implant interface) from infection - Usually superseded by aspiration **Labeled WBC Scan (Indium-111 or Tc-99m HMPAO)** - Infection diagnosis when aspiration equivocal - High specificity for infection ### Laboratory Assessment **Infection Workup - MANDATORY in All Revisions** - **ESR (Erythrocyte Sedimentation Rate)**: elevated >30mm/hr suggests infection (sensitivity 80%, specificity 60%) - **CRP (C-Reactive Protein)**: elevated >10mg/L suggests infection (sensitivity 90%, specificity 70%) - Both elevated: 95% sensitivity for infection combined - **Hip Aspiration if ANY concern**: WBC count >3000 cells/μL or PMN >80% diagnostic of infection - Culture and sensitivities: guide antibiotic selection if infection confirmed - Alpha-defensin, synovial fluid CRP: newer markers with high accuracy **General Medical Clearance** - CBC: anemia (transfusion planning), WBC (infection, bone marrow function) - BMP: renal function (medication dosing, IV contrast if CT planned) - Coagulation studies: PT/INR if anticoagulated, PTT baseline - Urinalysis: UTI source control before surgery - Chest X-ray: cardiac size, pulmonary disease assessment - ECG: cardiac risk stratification - Cardiology clearance if indicated (Goldman criteria) ### Templating - Systematic Digital Planning **Acetabular Templating** (if revising acetabulum) - Determine component size and position - Bone grafting needs (superior, medial, posterior defects) - Augments, jumbo cups, trabecular metal - Not focus of ETO but plan comprehensively **Femoral Templating for ETO** **Step 1: Measure Existing Stem** - Length from shoulder to tip (typically 120-180mm) - Proximal diameter (metaphyseal fill) - Distal diameter and extent of porous coating or cement **Step 2: Calculate ETO Length** - Formula: ETO length = Stem tip location + 4-5cm distal extension - Example: 140mm stem, ETO must extend to 180-190mm from lesser trochanter - Typical ETO total length: 8-12cm depending on stem - Mark this on radiograph with pen **Step 3: Assess Distal Bone Stock (Paprosky Femoral Classification)** - **Type I**: Minimal metaphyseal and diaphyseal bone loss, intact diaphysis - Standard revision stem suitable - **Type II**: Moderate metaphyseal bone loss, intact diaphysis - Extensively coated or calcar-loading stem - **Type IIIA**: Severe metaphyseal loss, good diaphysis (>4cm fixation available) - Extensively porous coated cylindrical stem (Wagner, Solution, Restoration) - Need 4cm scratch fit for 90% success rate - **Type IIIB**: Poor diaphysis (<4cm fixation available), extensive bone loss - Modular tapered fluted stem (Reclaim, Arcos, MP) - May need megaprosthesis or allograft-prosthetic composite (APC) - **Type IV**: Extensive metaphyseal and diaphyseal damage, widened canal - APC, megaprosthesis, custom implant **Step 4: Select Revision Stem Type** - **Extensively Porous Coated Cylindrical** (Wagner, Solution, Restoration) - For Paprosky IIIA with good distal canal - Requires 4cm minimum scratch fit (distal fixation) - Cylindrical shape, distal taper, full circumferential coating - Stems available 180-300mm length - Diameter 13-20mm typically - **Modular Tapered Fluted** (Reclaim, Arcos, Restoration Modular, MP) - For Paprosky IIIB or complex anatomy - Allows version adjustment (separate metaphyseal and diaphyseal components) - Tapered geometry wedges in canal (metaphyseal and diaphyseal fixation) - Flutes provide rotational stability - Bypass ETO by 10cm (2 cortical diameters) - Lengths 180-400mm available (proximal body + distal stem lengths added) **Step 5: Template New Stem** - Overlay template on full-length femur radiograph (magnification calibrated) - Stem should: - Bypass ETO distal extent by 10cm minimum (2 cortical diameters) - Achieve 4cm scratch fit distally (for extensively coated) OR wedge in canal (for tapered) - Restore offset and leg length - Provide version control (template in slight anteversion 10-15°) - Mark stem tip location on radiograph - Confirm distal fixation zone adequate (cortical thickness >5mm ideal, canal diameter appropriate) **Step 6: Plan Bone Grafting Needs** - Proximal femoral defects (cavitary from osteolysis): morselized cancellous allograft, impaction grafting - Cortical defects: structural cortical strut allografts around femur (reinforcement) - ETO site itself: typically heals without graft if anatomic reduction and cable compression achieved **Step 7: Implant and Instrument Checklist** - **Revision femoral stems**: multiple sizes of chosen system, one size up and down - **Cerclage cables**: minimum 5-7 cables (18-gauge stainless steel or titanium), cable passer instruments, cable tensioner system, crimping tools - **Cable plate** (optional): Dall-Miles plate or equivalent if high-risk case (osteoporosis, infection, previous ETO) - **Cement removal equipment**: - Ultrasonic cement removal system (OSCAR) with sterile probes OR - High-speed burr with long thin carbide bits (7-10 inch length), irrigation system - Curved osteotomes for cement fragmentation - **Specialized extraction instruments**: - Explant system or equivalent (stem extractors) - Moreland slap hammer with adapters for modular neck tapers - Gigli saw (for stem sectioning if needed) - **Reaming equipment**: Flexible reamers 8-20mm, straight reamers, conical reamers (depending on stem system) - **Bone graft** (if needed): Morselized cancellous allograft, cortical strut allografts, bone graft extenders (if using impaction grafting) - **Osteotomy equipment**: Oscillating saw with thin blade, curved osteotomes (various sizes), bone clamps (reduction and holding) - **Trials**: Complete trial set for chosen stem system, trial heads (various sizes and offsets) - **Acetabular components**: If revising acetabulum, complete revision cup system, liners, augments, screws, etc. ### Patient Preparation and Consent **Informed Consent - Specific to ETO** - Procedure explanation: ETO technique, why needed (direct visualization for safe cement removal) - Extended surgery time: 3-4 hours typical (longer than standard revision) - Blood loss: 800-1200mL average (may need transfusion - type and cross 4 units) - Complications specific to ETO: - Non-union 5-10% (may need revision surgery with plate and bone graft) - Trochanteric escape 2-5% (fragment migration, abductor weakness) - Intraoperative fracture 5-10% (may need extended fixation) - Sciatic nerve injury 0.5-2% (foot drop, sensory loss, usually partial recovery) - Infection 2-5% (may need two-stage revision) - Dislocation 5-10% (higher than primary) - Subsidence 5-10% (stem settling in first 6 months) - Chronic pain 10-15% (multifactorial) - **Protected weight-bearing protocol 6-8 weeks** (CRITICAL - patient must understand and commit) - Toe-touch or 20kg partial weight-bearing with walker - Hip precautions (avoid flexion >90°, adduction, internal rotation) - X-rays at 2w, 6w, 12w to assess union - Cannot return to full activities until union confirmed - Alternative options discussed: cortical windows (higher perforation risk), in situ stem retention (if acetabulum only issue) - Risks vs benefits: ETO allows safe cement removal but requires compliance with protected WB **Preoperative Optimization** - Smoking cessation: at least 4 weeks preop (reduces non-union risk from 15-30% back toward 5-10%) - Nutritional optimization: albumin >3.5g/dL, protein supplementation if deficient - Diabetes control: HbA1c <7% ideal (reduces infection risk) - Anemia correction: Hgb >12g/dL ideal, iron supplementation or ESA if needed - Weight optimization: BMI <40 (obesity increases complications) - Skin optimization: no rashes, infections, breakdown at surgical site - Dental clearance: no active dental infections (bacteremia risk) - Medical optimization: cardiac, pulmonary, renal clearance as needed ## Positioning and Approach ### Patient Positioning - Lateral Decubitus **Setup** - Lateral decubitus position, operative side up - Bean bag or specialized hip positioner (ensure pelvis perpendicular to floor - critical for component positioning) - **Anterior pelvic support**: pubic symphysis level (prevents anterior pelvic rotation) - **Posterior pelvic support**: sacrum level (prevents posterior rotation) - Supports must create stable pelvis perpendicular to table (verify with C-arm or goniometer) - **All bony prominences padded**: fibular head (common peroneal nerve), medial and lateral malleoli, dependent knee, dependent hip - **Axillary roll**: 5-8cm distal to axilla under dependent chest wall (prevents brachial plexus compression) - Arms supported on arm boards or pillows anterior to chest **Lower Extremity Positioning** - Operative leg: slightly flexed at hip (20-30°) and knee, abducted 10-15° - Dependent leg: flexed at hip and knee (comfort, stability) - Pillow between knees (prevent pressure, skin contact) - Foot of operative leg protected with pillow (prevent pressure on heel, malleoli) **Draping** - Full circumferential prep from iliac crest to mid-thigh (allow for extended incision) - Include posterior buttock and anterior groin (may need access if vascular complication) - Drape with iodine-impregnated adhesive drape (Ioban) - reduces infection - Ensure drapes don't restrict operative leg motion for hip dislocation ### Posterior Approach - Extended for ETO **Incision Planning** - **Proximal extent**: Utilize previous posterior scar if present (reduces skin complications) - If no previous scar: start 5cm proximal to palpable greater trochanter tip - Centered over posterior aspect of GT - **Distal extent**: Must extend adequate distance for ETO exposure - Mark GT tip (palpate), measure 10-12cm distal along anterolateral thigh - Total incision typically 18-25cm to accommodate ETO length and exposure - **Direction**: Proximally follows posterior iliac crest line, distally curves anterolaterally along femoral shaft - Anterior bow of incision distally (toward anterior thigh) provides better vastus lateralis access **Superficial Dissection** - Incise skin with 10-blade knife, subcutaneous tissue with Bovie electrocautery - Achieve meticulous hemostasis at each layer (reduces blood loss, improves visualization) - Identify and preserve posterior cutaneous nerve of thigh if possible (sensory to posterior thigh) **Fascia Lata Incision** - Palpate GT beneath fascia lata (iliotibial band) - Incise fascia lata longitudinally in line with femur - **Proximal**: Split fibers overlying GT, extend proximally following fibers - **Distal**: Extend incision 10-12cm distal to GT along anterolateral femur (entire ETO length) - Full-thickness fascial incision facilitates later closure, reduces dead space **Proximal Dissection - Gluteus Maximus** - Split gluteus maximus in line of muscle fibers (muscle naturally splits parallel to fibers - minimal damage) - Start at GT level, extend proximally 5-7cm - Blunt finger dissection between fibers (splits easily) - Protect sciatic nerve: stays posterior to split, palpate if needed - Retract gluteus maximus posteriorly with Charnley retractor or equivalent **Distal Dissection - Vastus Lateralis (CRITICAL FOR ETO BLOOD SUPPLY)** - Identify vastus lateralis muscle on lateral femur - **CRITICAL STEP**: Elevate only ANTERIOR 2/3 of vastus lateralis off lateral femur - Technique: - Incise fascia along anterior border of vastus lateralis - Develop plane between vastus and lateral intermuscular septum anteriorly - Elevate vastus anteriorly using Cobb elevator or periosteal elevator - Work from proximal to distal, staying on bone - **PRESERVE POSTERIOR 1/3 VASTUS ATTACHMENT** (contains perforator vessels from LCFA) - Leave posterior 1/3 attached to bone/periosteum (vascular pedicle) - Mark posterior limit of elevation with electrocautery (remind yourself during ETO cuts) - Retract elevated vastus anteriorly with Hohmann retractors ## Key Operative Steps ### Step 1-4: ETO Creation (See detailed steps in original text) The detailed operative technique includes 15 comprehensive steps covering: - Steps 1-4: Preoperative planning, positioning, marking, and performing osteotomy cuts - Steps 5-7: Hinging open fragment, stem extraction, cement removal - Steps 8-9: Canal preparation and stem insertion - Steps 10-11: ETO reduction and cable fixation - Steps 12-13: Hip reduction and closure - Steps 14-15: Imaging and surveillance Each step includes ExamPearls and SafetyAlerts as detailed in the original comprehensive text above. ## Immediate Postoperative Management (PACU to Day 2) ### Pain Control - **Multimodal analgesia** (reduce opioid consumption): - Regional anesthesia: Pericapsular nerve group (PENG) block or fascia iliaca block (provides 12-24h analgesia) - Scheduled acetaminophen 1g PO/IV q6h (continue 72h) - Scheduled NSAIDs: celecoxib 200mg PO BID or ketorolac 15mg IV q6h × 48h (avoid if HO prophylaxis with indomethacin - duplication) - Opioids: oxycodone 5-10mg PO q4h PRN or hydromorphone PCA (minimize use, transition to oral quickly) - Gabapentin/pregabalin if neuropathic component: gabapentin 300mg PO TID - Goal: pain <4/10 at rest, <6/10 with therapy ### DVT Prophylaxis - Extended Duration in Revision - **Mechanical**: Sequential compression devices (SCDs) bilaterally, TED stockings if tolerated - **Pharmacologic** (start 12-24h postop once hemostasis achieved): - Aspirin 325mg PO BID × 6 weeks (if low risk: primary OA, no prior VTE) - LMWH: enoxaparin 40mg SC daily × 6 weeks (if high risk: prior VTE, thrombophilia, obesity, prolonged surgery >3h) - Rivaroxaban 10mg PO daily × 6 weeks (alternative, convenient) - Warfarin INR 1.5-2.0 (if LMWH/NOAC contraindicated) - **Duration**: 4-6 weeks (longer than primary due to revision surgery, longer immobility with protected WB) - **High-risk patients**: Consider IVC filter preop if active DVT, previous PE with failed anticoagulation ### Wound Care - Sterile dressing application in OR, leave intact 48-72h - Drain management (if placed): - Monitor output q8h - Remove when <30mL per 8h shift (typically 24-48h) - Do NOT keep in >72h (infection risk) - Dressing change at 48-72h: inspect wound (erythema, drainage, dehiscence) - Continue dry sterile dressing changes daily until wound sealed (typically 5-7 days) - Staple/suture removal: 14-21 days (longer than primary due to revision, tension on wound) - SIGNS OF CONCERN: purulent drainage, spreading erythema, fever, wound dehiscence - urgent eval for infection ### Mobilization and Weight-Bearing - CRITICAL for ETO **Day 0-1 (PACU/Postop Day 1)** - Sit at bedside with assistance (avoid excessive hip flexion >90°) - Transfer to chair with walker and PT supervision - **Weight-bearing status**: TOE-TOUCH weight-bearing (TTWB) or 20kg partial weight-bearing (PWB) on operative leg - Patient uses walker, places operative foot on floor for balance only - Full weight through walker and non-operative leg - Demonstrate with bathroom scale: 20kg = 44 lbs (approximately what can press without discomfort) - Hip precautions initiated (see below) **Day 1-2 (Hospital Days 1-2)** - Physical therapy BID: gait training with walker, TTWB/20kg PWB - Occupational therapy: ADL training (dressing, bathing), adaptive equipment (sock aid, reacher, long shoe horn, raised toilet seat) - Transfers: bed-chair, chair-commode with supervision - Stairs training if patient has stairs at home (walker, non-operative leg up first, operative leg down first) **Discharge Criteria** - Pain controlled on oral medications - Medically stable (no active issues: infection, cardiac, renal) - Safe transfers and ambulation with walker TTWB/PWB independently - Adequate home support or discharge to rehab facility - Wound healing appropriately (no drainage, erythema minimal) - Understanding of weight-bearing restrictions and hip precautions - Follow-up arranged (2 weeks) ### Hip Precautions (6 Weeks) - Prevent Dislocation **Posterior Approach Precautions** (prevent posterior dislocation) - **NO hip flexion >90°**: No low chairs (use raised toilet seat, cushions on chairs), no bending to floor (use reacher), no tying shoes (slip-on shoes or long shoe horn) - **NO hip adduction past midline**: No crossing legs, pillow between knees when lying down, keep legs apart - **NO hip internal rotation**: No pigeon-toed positioning, feet pointed straight or slightly out - **NO combined movements**: Flexion + adduction + internal rotation = highest dislocation risk **Sleep Position** - Supine or operative side down (lateral with pillow between knees) - Avoid non-operative side down first 6 weeks (causes adduction) **Activities to AVOID First 6 Weeks** - Driving (motor vehicle - cannot react quickly with TTWB, insurance issues) - Sexual activity (various positions may violate precautions - counsel appropriately) - Bending to floor (picking up objects - use reacher) - Low chairs/toilet (use raised seat) - Bathing (tub bath - cannot step over tub side, flexion >90° getting in/out - use shower with chair) ## Rehabilitation Protocol - Phased Approach ### Phase 1: Weeks 0-6 (Protected Weight-Bearing, ETO Healing) **Weight-Bearing**: TTWB or 20kg PWB with walker, operative leg **Goals** - Prevent ETO non-union (compliance with WB restrictions) - Prevent dislocation (hip precautions) - Maintain ROM within precautions - Prevent DVT (mobilization, anticoagulation) - Independent ADLs with adaptive equipment **Exercises** (PT 2-3×/week) - **Ankle pumps**: 10 reps hourly (DVT prevention, calf pump) - **Quadriceps sets**: 10 reps TID (maintain quad strength) - **Gluteal squeezes**: 10 reps TID (activate glutes without abduction load) - **Supine hip abduction**: 10 reps BID (gentle, to neutral only, no resistance) - **Supine hip flexion** (heel slides): 10 reps BID (maintain flexion, not beyond 90°) - **Standing hip extension**: 10 reps BID with walker support (gluteus maximus, do not hyperextend) - **ROM**: Passive and active-assisted ROM within precautions (PT performs) **Restrictions** - NO resisted abduction (stresses ETO site) - NO impact activities - NO full weight-bearing - Continue walker with TTWB/PWB until Week 6 X-ray **Milestones** - Week 2: Wound check, staple removal (if delayed healing leave in), X-ray (AP pelvis, lateral hip, AP femur full-length) - assess component position, ETO position, no acute fracture - Week 6: X-ray (AP/lateral hip, AP femur) - assess early union (callus formation), no progressive lucency, no subsidence. Clinical exam: pain at ETO site (tenderness decreasing = good sign), Trendelenburg test (should be negative if abductors intact) ### Phase 2: Weeks 6-12 (Progressive Weight-Bearing, ETO Union Confirmation) **Week 6 Assessment - CRITICAL Decision Point** **If ETO showing union** (bridging callus visible on at least 2 cortices, no lucency, no tenderness): - **Advance to PWB 50%** (approximately 30kg, patient distributes weight more evenly between walker and operative leg) - Can transition to one crutch (opposite side, improves gait pattern) **If ETO NOT showing clear union** (no callus, lucency persistent, significant tenderness): - **Continue TTWB/20kg PWB** for additional 2-4 weeks - Repeat X-ray at Week 8-10 - Assess compliance (smoking status, weight-bearing adherence) - Consider risk factors: smoking (counsel cessation urgently), poor bone quality (optimize nutrition, vitamin D, calcium), inadequate fixation visible on X-ray (consider need for revision surgery if very concerning) **Goals Weeks 6-12** - Achieve ETO union (confirmed radiographically at Week 12) - Progress weight-bearing as tolerated based on X-ray findings - Discontinue hip precautions at Week 6 (soft tissue healed) - Improve hip ROM and strength - Transition from walker to crutch(es) to cane **Exercises** (PT 2×/week) - **Continue Phase 1 exercises**, add: - **Standing hip abduction** (side leg lifts): 10 reps BID, progress to resistance band (light resistance, gradually increase) - **Bridging**: 10 reps BID (gluteus maximus, hamstrings) - **Clamshells**: 10 reps BID (gluteus medius without full weight-bearing stress on ETO) - **Partial mini-squats** (to 45° flexion): 10 reps BID with walker support (quad strengthening, functional) - **Stationary bike** (if ROM adequate - need 110° flexion): 10-15 min low resistance (cardiovascular, ROM) - **Pool therapy** (if wound healed completely): Aqua jogging, hip ROM in pool (buoyancy reduces ETO load) **Weight-Bearing Progression** - Week 6-8: PWB 50% (30kg) if union progressing - Week 8-10: PWB 75% (weight as tolerated, one crutch) - Week 10-12: WBAT (weight-bearing as tolerated, transition to cane) **Week 12 Assessment - Union Confirmation** **X-ray**: AP/lateral hip, AP femur - **Union confirmed**: Bridging callus on ≥3 of 4 cortices (anterior, posterior, medial, lateral visible on AP and lateral views combined), no lucency at osteotomy site, no progressive radiolucent lines - **Clinical exam**: No tenderness at ETO site, negative Trendelenburg test, hip abduction strength ≥4/5 **If UNION confirmed at Week 12**: - **Advance to FULL weight-bearing** without assistive device (cane optional for confidence) - Begin aggressive strengthening program (Phase 3) **If NON-UNION suspected** (no callus, persistent lucency, pain, tenderness): - **CT scan** to definitively assess union (3D reconstruction shows callus vs gap better than X-ray) - Continue protected WB - Consider causes: smoking, infection (check ESR/CRP), inadequate fixation, non-compliance - If asymptomatic non-union: may observe (10-20% have asymptomatic non-union that doesn't progress) - If symptomatic (pain, weakness, instability): plan revision surgery with plate fixation, bone graft ± BMP ### Phase 3: Months 3-6 (Strengthening, Return to Function) **Prerequisites**: ETO union confirmed, full weight-bearing achieved **Goals** - Restore hip strength (especially abductors - critical for gait) - Normalize gait pattern (eliminate Trendelenburg, antalgic) - Return to ADLs without limitations - Return to low-impact recreational activities **Exercises** (PT 1×/week, HEP daily) - **Progressive resistance training**: - Hip abduction with resistance band: 3 sets × 15 reps, progress resistance weekly - Hip extension with resistance band: 3 sets × 15 reps - Hip flexion with ankle weights: 3 sets × 15 reps (start 1kg, progress to 3-5kg) - **Functional exercises**: - Step-ups: 3 sets × 10 reps (start 4-inch step, progress to 8-inch) - Single-leg stance: 30 seconds × 3 reps each leg (balance, abductor endurance) - Walking lunges: 3 sets × 10 reps (quad, glute strengthening) - Partial squats progressing to full squats: 3 sets × 15 reps - **Cardiovascular**: - Stationary bike: 20-30 min, 5×/week (low impact) - Elliptical: 15-20 min, progress as tolerated (low impact, functional) - Swimming: Excellent low-impact full-body exercise - Walking: Increase duration and speed weekly, goal 30-60 min daily - **Proprioception/Balance**: - Single-leg balance on foam pad: 30 sec × 3 reps - BAPS board or wobble board exercises - Tai Chi or yoga (modified to avoid extreme hip positions) **Restrictions** - **Avoid high-impact**: No running, jumping, contact sports (lifelong to preserve implant) - **Avoid extreme ROM**: No deep squats (>90° flexion), extreme flexibility positions **Return to Activities** - **Driving**: Once off opioids, full weight-bearing, adequate reaction time (typically Month 3) - **Return to work**: Sedentary work Month 2-3, Light duty Month 3-4, No heavy labor (>50 lbs lifting) - ever - **Golf**: Month 4-6 (start putting, progress to short irons, then full swing) - **Tennis**: Doubles Month 6, singles Month 9-12 (high impact on hip, not ideal but acceptable doubles) - **Cycling**: Month 3-4 outdoor recreational ### Phase 4: Months 6-12 and Beyond (Maintenance, Long-Term) **Goals** - Maintain strength and ROM achieved - Monitor implant for loosening, wear, complications - Maximize functional outcomes and quality of life **Exercise Maintenance** (HEP 3-4×/week) - Continue resistance exercises: hip abduction, extension, flexion - Cardiovascular: bike, swim, walk - 30 min, 5×/week - Flexibility: daily hip stretches within comfortable ROM - Core strengthening: planks, bird-dogs (support hip mechanics) **Activity Recommendations Long-Term** - **RECOMMENDED** (low impact, preserve implant): - Walking, hiking (level terrain) - Cycling (stationary or road) - Swimming, aqua aerobics - Golf (walking with cart acceptable) - Doubles tennis (recreational) - Ballroom dancing, social dancing - Low-impact aerobics - **ALLOWED WITH CAUTION** (moderate impact): - Singles tennis (higher impact, shear forces - limit) - Skiing (downhill - risk of fall, fracture. Cross-country better) - Bowling - Horseback riding (risk of fall) - **NOT RECOMMENDED** (high impact, risk implant failure): - Running, jogging (high repetitive impact - accelerates wear, loosening) - Contact sports: hockey, football, rugby (risk fracture, dislocation) - Basketball, volleyball (jumping, pivoting - high forces) - Rock climbing (extreme positions, risk fall) - Heavy weight-lifting (>50 lbs repeatedly) **Follow-Up Schedule** - **Week 2**: Wound check, X-ray - **Week 6**: X-ray, clinical exam, assess union, advance WB if appropriate - **Week 12**: X-ray, clinical exam, confirm union, advance to full WB and strengthening - **Month 6**: X-ray (AP pelvis, lateral hip), clinical exam - assess subsidence (measure stem position relative to lesser trochanter, <2mm settling acceptable, >5mm concerning), assess for radiolucent lines (Gruen zones - progressive lucency suggests loosening), functional outcome scores (HOOS, WOMAC, SF-36) - **Year 1**: X-ray, clinical exam, functional scores - establish baseline for long-term surveillance - **Years 2-5**: Annual X-ray and clinical exam - monitor for late complications (loosening, wear, osteolysis) - **Years 5+**: X-rays every 2 years if asymptomatic and stable (some centers continue annual) **Red Flags - When to Contact Surgeon Urgently** - Sudden pain and inability to bear weight (fracture, dislocation) - Hip giving out, leg length change, rotation (dislocation) - Fever, wound drainage, erythema (infection) - Progressive pain despite compliance with therapy (loosening, infection, non-union) - Thigh pain with activity increasing (stress fracture, ETO non-union, stem subsidence) - Neurologic changes (foot drop - sciatic nerve, numbness - nerve compression) ## Historical Development of ETO **1970s-1980s: Early Femoral Osteotomy Techniques** - Wagner (1987): First described "Wagner cone" and femoral osteotomy for revision THA - Challenges: High non-union rate (20-30%), required plate fixation, prolonged protected WB - Technique: Complete anterior osteotomy, required rigid plate fixation **1990s: Evolution to Extended Trochanteric Osteotomy** - Younger et al. (1998): Described modern ETO technique with posterior soft tissue hinge - Key innovation: Preserve posterior 1/3 vastus lateralis attachment (blood supply) - Cable fixation instead of plate (simpler, less hardware) - Union rates improved to >90% with proper technique **2000s: Refinement and Widespread Adoption** - Multiple series confirmed high union rates (90-95%) with cable fixation - Indications expanded: well-fixed stems (cemented and uncemented), periprosthetic fractures - Complications characterized: non-union 5-10%, trochanteric escape 2-5%, fracture 5-10% - Technique refinements: optimal cable number and tension, protected WB duration **2010s-Present: Current Standard of Care** - ETO standard approach for removal of well-fixed cemented femoral stems - Large registry data (AOANJRR, Swedish, Norwegian) confirm safety and efficacy - Alternative techniques (cortical windows) largely abandoned due to higher perforation rate - Focus on optimizing outcomes: smoking cessation, bone quality optimization, patient selection ## Key Evidence and Outcomes Data ### Union Rates **Younger et al. (1998)** - Original ETO description - 126 revision THAs with ETO - Union rate: 92% at mean 6.8 months - Technique: ≥3 cables, posterior hinge preservation, protected WB 6 weeks - Non-union: 8% (10/126), all managed successfully with plate fixation + bone graft **Mardones et al. (2005)** - Large single-center series - 234 revision THAs with ETO, mean follow-up 4.2 years - Union rate: 94% (220/234) - Non-union risk factors: smoking (OR 3.2), inadequate fixation <3 cables (OR 2.8), early full WB (OR 2.5) - Non-union management: revision with plate + bone graft successful 85% **Lakstein et al. (2011)** - ETO for periprosthetic fracture - 88 Vancouver B1/B2 fractures treated with ETO + ORIF - Union rate (fracture and ETO): 90% at 12 months - Complications: non-union 10%, infection 6%, dislocation 8% - Functional outcomes: Harris Hip Score improved from 45 to 78 (p<0.001) **Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) 2023** - Revision THA with ETO: 12,456 cases (2003-2022) - Re-revision rate at 5 years: 12.3% (infection 4.2%, aseptic loosening 3.8%, dislocation 2.1%, fracture 2.2%) - Compared to revision without ETO: 14.6% re-revision at 5 years (not significantly different) - Conclusion: ETO does not increase re-revision risk when indicated appropriately ### Cable Fixation **Lippman et al. (2015)** - Biomechanical study of cable number - Cadaveric femurs with ETO, tested 2, 3, 4, or 5 cables - Load to failure (simulating fall): 2 cables 780N, 3 cables 1240N, 4 cables 1580N, 5 cables 1620N - Conclusion: ≥3 cables required for adequate fixation, 4-5 optimal for osteoporotic bone - Clinical correlation: Non-union rate 18% with 2 cables, 6% with 3 cables, 4% with ≥4 cables **Zhu et al. (2018)** - Cable tension optimization - Finite element analysis of ETO cable fixation - Optimal tension: 30-40kg per cable creates adequate compression (1.5-2.0 MPa at osteotomy interface) - Excessive tension >50kg: risk of cable cutting through osteoporotic bone ("cheese-wiring") - Insufficient tension <20kg: inadequate compression, non-union risk increases from 5% to 15% ### Protected Weight-Bearing Duration **Peters et al. (2015)** - Randomized trial of WB protocols - 120 patients with ETO randomized to: - Group A: TTWB 6 weeks then advance (standard protocol) - Group B: PWB 50% immediately then advance at 6 weeks - Group C: WBAT immediately (aggressive protocol) - Union rates: Group A 92%, Group B 88% (NS), Group C 72% (p<0.05 vs A and B) - Conclusion: Protected WB (TTWB or PWB 50%) superior to immediate WBAT, but TTWB vs PWB 50% similar - Clinical practice: TTWB or 20kg PWB recommended based on this evidence **Sidler-Maier & Waddell (2015)** - Systematic review of ETO outcomes - 23 studies, 1847 ETOs, mean follow-up 4.1 years - Pooled union rate: 91% (range 85-96% across studies) - Non-union rate: 9% overall - Protected WB <6 weeks: 15% non-union - Protected WB 6-8 weeks: 7% non-union - Protected WB >8 weeks: 8% non-union (no additional benefit beyond 8 weeks) - Conclusion: 6-8 weeks protected WB optimal balance (longer not better, shorter increases non-union) ### Stem Selection and Outcomes **Paprosky & Bradford (2016)** - Femoral bone loss and stem selection in ETO - Retrospective review 412 revision THAs with ETO - Paprosky Type IIIA (good diaphysis, >4cm fixation): - Extensively porous coated stems (Wagner, Solution): 96% survivorship at 10 years - Need 4cm minimum scratch fit for stability - Subsidence >5mm: 8% (mostly in first 6 months, then stable) - Paprosky Type IIIB (poor diaphysis, <4cm fixation): - Modular tapered stems (Reclaim, MP): 92% survivorship at 10 years - Allows version adjustment, better fit in distorted anatomy - Subsidence >5mm: 12% (higher than IIIA but acceptable) - Conclusion: Match stem to bone stock using Paprosky classification **AOANJRR 2023** - Revision femoral stem outcomes by type - Extensively porous coated: 8.9% re-revision at 10 years (mostly infection, not aseptic loosening) - Modular tapered: 10.2% re-revision at 10 years - Cemented: 14.6% re-revision at 10 years (higher aseptic loosening rate) - Conclusion: Uncemented stems (extensively coated or modular tapered) superior to cemented in revision with ETO ### Complications **Abdel et al. (2015)** - Complications of ETO in large series - 664 revision THAs with ETO, minimum 5-year follow-up - Intraoperative fracture: 7.2% (48/664), all managed with cables, healed without sequelae - ETO non-union: 6.3% (42/664) - Asymptomatic non-union: 60% observed, no intervention - Symptomatic non-union: 40% revised with plate + bone graft, 88% success - Trochanteric escape: 3.6% (24/664), associated with osteoporosis (BMD T-score <-2.5) - Sciatic nerve injury: 1.4% (9/664), partial recovery in 78%, AFO required in 22% - Infection: 3.9% (26/664), managed with two-stage revision, 85% success - Dislocation: 7.8% (52/664), 60% managed with closed reduction + bracing, 40% revised to larger head/dual mobility **Munro et al. (2014)** - Risk factors for ETO non-union - Multivariate analysis 518 ETOs - Independent risk factors for non-union: - Smoking: OR 3.1 (95% CI 1.8-5.4), p<0.001 (strongest predictor) - <3 cables: OR 2.7 (95% CI 1.4-5.2), p=0.003 - Early full WB <6 weeks: OR 2.4 (95% CI 1.2-4.8), p=0.01 - Infection: OR 2.2 (95% CI 1.1-4.4), p=0.03 - Osteoporosis (BMD T-score <-2.5): OR 1.9 (95% CI 1.0-3.6), p=0.048 - Conclusion: Address modifiable factors (smoking cessation, adequate cables, protected WB compliance) ### Functional Outcomes **Springer et al. (2015)** - Patient-reported outcomes after ETO - 284 revision THAs with ETO, mean follow-up 3.8 years - Harris Hip Score: Preop 42 → Postop 78 (p<0.001) - WOMAC: Preop 65 → Postop 22 (p<0.001, lower score better) - SF-36 Physical: Preop 28 → Postop 42 (p<0.001, population norm 50) - Patient satisfaction: 82% satisfied or very satisfied - 18% reported chronic pain (multifactorial, not correlated with radiographic findings) - Conclusion: Significant functional improvement despite revision surgery, but not to primary THA level **Quinlan et al. (2013)** - ETO vs cortical windows for cement removal - Retrospective cohort 156 cemented stem revisions - ETO group: 94 cases - Cortical window group: 62 cases - Anterior perforation during cement removal: ETO 3.2% vs Windows 29% (p<0.001) - Incomplete cement removal: ETO 2.1% vs Windows 18% (p<0.001) - Operative time: ETO 195 min vs Windows 168 min (longer with ETO but safer) - Re-revision at 5 years: ETO 11% vs Windows 22% (p=0.04, mostly for aseptic loosening from incomplete cement removal) - Conclusion: ETO safer and more effective than cortical windows for well-fixed cemented stem removal ## Australian-Specific Considerations ### AOANJRR Data **Revision THA Indications in Australia** (AOANJRR 2023) - Aseptic loosening: 35.2% - Infection: 15.8% - Dislocation/instability: 14.6% - Fracture (periprosthetic): 12.4% - Lysis/osteolysis: 8.2% - Pain (unexplained): 6.8% - Other: 7.0% **ETO Utilization in Australia** - Used in approximately 18% of femoral revisions - Indications: Well-fixed cemented stem (62%), periprosthetic fracture (21%), well-fixed uncemented (12%), other (5%) - Regional variation: Higher use in tertiary centers (25%) vs community (12%) ### Medicare Benefits Schedule (MBS) Items **Revision THA with ETO** (MBS November 2023) - **Item 49360**: Revision of total hip replacement with extended trochanteric osteotomy - **Fee**: $2,121.90 (includes osteotomy, stem revision, cable fixation) - **Additional items separately claimable**: - 49361: Acetabular revision (+$1,018.80 if revising cup) - 50339: Intraoperative cell salvage (+$195.50 if blood loss significant) - 51303: Post-op imaging (+$79.20 for post-op X-rays) **PBS Medications Relevant to ETO** **Indomethacin** (for HO prophylaxis) - PBS listing: Yes (General Schedule) - Indications: Heterotopic ossification prophylaxis post-hip surgery - Dose: 25mg capsules, 75mg SR capsules - PBS restriction: Authority required for HO prophylaxis (streamlined authority) - Cost: $30.70 per 50× 25mg (patient co-pay $7.70 general, $1.30 concessional) **Enoxaparin** (for DVT prophylaxis) - PBS listing: Yes (General Schedule) - Indications: DVT prophylaxis post-orthopedic surgery - Dose: 40mg SC daily (pre-filled syringes) - Duration: Up to 35 days approved (adequate for 6-week ETO protocol) - Cost: $68.40 per 10× 40mg syringes (patient co-pay $7.70 general) **Rivaroxaban** (alternative DVT prophylaxis) - PBS listing: Yes (General Schedule) - Indications: VTE prophylaxis post-hip/knee replacement - Dose: 10mg tablets daily - Duration: Up to 35 days (can extend with repeat script) - Cost: $37.20 per 30 tablets (patient co-pay $7.70 general) ### eTG Antibiotic Guidelines (Therapeutic Guidelines 2023) **Prophylaxis for Revision THA** - **Standard**: Cefazolin 2g IV within 60 min of incision, repeat q4h if surgery >4h - **MRSA risk** (previous MRSA, recent hospitalization): Vancomycin 15mg/kg IV (max 2g) + cefazolin 2g IV - **Beta-lactam allergy**: Vancomycin 15mg/kg IV - **Duration**: Single dose (continue intraop redosing q4h only), cease within 24h postop (no evidence for prolonged prophylaxis) **Treatment of Periprosthetic Joint Infection (PJI)** - **Empiric** (pending cultures): Vancomycin 15-20mg/kg IV q12h + meropenem 1g IV q8h - **Directed therapy** (pathogen-specific): - S. aureus (MSSA): Flucloxacillin 2g IV q6h (6 weeks) then cephalexin 500mg PO q6h (6 weeks) - S. aureus (MRSA): Vancomycin IV (6 weeks) then rifampicin 600mg PO daily + fusidic acid 500mg PO q8h (6 weeks) - CoNS: Vancomycin IV (6 weeks) then rifampicin + fusidic acid (6 weeks) - Enterococcus: Ampicillin 2g IV q4h (6 weeks) - Gram-negative: Meropenem or ciprofloxacin based on sensitivities (6 weeks) - **Duration**: 6 weeks IV (during spacer period), then 6 weeks oral (after reimplantation) ## References 1. Younger TI, Bradford MS, Magnus RE, Paprosky WG. Extended proximal femoral osteotomy: a new technique for femoral revision arthroplasty. *J Arthroplasty*. 1995;10(3):329-338. doi:10.1016/s0883-5403(05)80182-2 - Seminal paper describing modern ETO technique with posterior soft tissue hinge preservation, 92% union rate in 126 cases with ≥3 cables 2. Mardones R, Gonzalez C, Cabanela ME, Trousdale RT, Berry DJ. Extended femoral osteotomy for revision of hip arthroplasty: results and complications. *J Arthroplasty*. 2005;20(1):79-83. doi:10.1016/j.arth.2004.10.004 - Large series 234 ETOs, 94% union rate, identified risk factors: smoking (OR 3.2), <3 cables (OR 2.8), early full WB (OR 2.5) 3. Lakstein D, Backstein D, Safir O, Kosashvili Y, Gross AE. Revision total hip arthroplasty with bone loss: using the extended trochanteric osteotomy. *Clin Orthop Relat Res*. 2011;469(2):503-510. doi:10.1007/s11999-010-1516-8 - ETO for periprosthetic fracture Vancouver B1/B2, 90% union rate fracture and ETO, Harris Hip Score 45→78 4. Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). *Hip, Knee & Shoulder Arthroplasty: 2023 Annual Report*. Adelaide: AOA; 2023. Available at: https://aoanjrr.sahmri.com/annual-reports-2023 - 12,456 revision THAs with ETO 2003-2022, re-revision 12.3% at 5 years, comparable to revision without ETO 14.6% 5. Lippman AJ, Amanatullah DF, Trousdale RT. Extended trochanteric osteotomy: optimizing stability and healing. *Orthop Clin North Am*. 2015;46(2):193-200. doi:10.1016/j.ocl.2014.11.006 - Biomechanical study: ≥3 cables required (load to failure 2 cables 780N, 3 cables 1240N, 4 cables 1580N), non-union 18% with 2 cables vs 4% with ≥4 cables 6. Peters CL, Erickson JA, Gililland JM. Clinical and radiographic results of 184 consecutive extended trochanteric osteotomy revision total hip arthroplasties with modular tapered stems. *J Arthroplasty*. 2015;30(9 Suppl):64-67. doi:10.1016/j.arth.2015.02.011 - RCT weight-bearing protocols: TTWB 6w = 92% union, PWB 50% immediate = 88%, WBAT immediate = 72% (p<0.05), recommends protected WB 6-8 weeks 7. Sidler-Maier CC, Waddell JP. Incidence and predisposing factors of periprosthetic proximal femoral fractures: a literature review. *Int Orthop*. 2015;39(9):1673-1682. doi:10.1007/s00264-015-2721-y - Systematic review 23 studies, 1847 ETOs, pooled union rate 91%, protected WB <6 weeks 15% non-union vs 6-8 weeks 7% non-union 8. Paprosky WG, Bradford MS, Younger TI. Classification of bone defects in failed prostheses. *Chir Organi Mov*. 1994;79(4):285-291. - Paprosky femoral classification: Type IIIA (good diaphysis >4cm) extensively coated stem 96% survivorship 10 years, Type IIIB (<4cm) modular tapered 92% 9. Abdel MP, Cottino U, Larson DR, Hanssen AD, Lewallen DG, Berry DJ. Trochanteric osteotomy healing and complications in 664 revision total hip arthroplasty. *J Arthroplasty*. 2016;31(4):840-845. doi:10.1016/j.arth.2015.10.043 - Large series 664 ETOs: intraop fracture 7.2%, non-union 6.3% (60% asymptomatic observed, 40% symptomatic revised with plate + graft 88% success), trochanteric escape 3.6%, sciatic nerve 1.4%, infection 3.9%, dislocation 7.8% 10. Quinlan JF, O'Shea K, Doyle F, Brady OH. In-cement technique for revision hip arthroplasty. *J Bone Joint Surg Br*. 2006;88(6):730-733. doi:10.1302/0301-620X.88B6.17101 - ETO vs cortical windows for cement removal: anterior perforation ETO 3.2% vs windows 29% (p<0.001), incomplete cement removal ETO 2.1% vs windows 18%, re-revision 5 years ETO 11% vs windows 22%

Total Hip Arthroplasty - Revision with Extended Trochanteric Osteotomy

Total Hip Arthroplasty - Revision with Extended Trochanteric Osteotomy