JBJS | Reattachment of the Migrated Ununited Greater Trochanter After Revision Hip Arthroplasty: The Abductor Slide Technique. A Review of Four Cases*

The Journal of Bone & Joint Surgery, Volume 82, Issue 3

Articles | March 01, 2000

Reattachment of the Migrated Ununited Greater Trochanter After Revision Hip Arthroplasty: The Abductor Slide Technique. A Review of Four Cases*

KINGSLEY R. CHIN, M.D.†; GREGORY W. BRICK, M.D., F.R.A.C.S.‡, BOSTON, MASSACHUSETTS

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Investigation performed at Brigham and Women's Hospital and Harvard Medical School, Boston

The Journal of Bone & Joint Surgery. 2000; 82:401-8

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Abstract

Background: Proximal migration of the ununited greater trochanter following total hip arthroplasty may produce pain and substantial functional disability. Successful reattachment of the migrated fragment is difficult following multiple hip procedures. The purpose of this report is to describe four patients in whom a severely migrated trochanteric fragment was reattached successfully with a modified Charnley-Harris wiring technique after subperiosteal advancement of the abductor muscles from their origin on the iliac wing.

Methods: This series consisted of one man and three women with an average age of sixty years (range, fifty-one to sixty-eight years) at the time of the index procedure. The patients were followed for an average of eighty-one months (range, fifty-five to ninety-six months). All patients had undergone mobilization of the abductor muscles based on the superior gluteal neurovascular pedicle to aid with trochanteric reattachment, and all had undergone prior hip operations (average, two). Advancement of the abductor muscles was achieved through a separate transverse curvilinear incision over the iliac crest, and subperiosteal releases of the entire origins of the gluteus minimus, medius, and maximus muscles from the ilium were performed.

Results: Roentgenographic union of the trochanteric fragment occurred in all four patients. There were three excellent functional outcomes (Harris hip scores of 90, 94, and 96 points) and one fair functional outcome (76 points). The average improvement in the Harris hip score was 47.5 points (range, 35 to 58 points). Two patients continued to have a mild or moderate Trendelenburg gait postoperatively. Two patients had heterotopic bone formation of no clinical importance.

Conclusions: Use of this technique resulted in union of the greater trochanter, pain relief, and decreased functional disability without major complications in these four patients. More widespread use of this technique may be indicated for the treatment of symptomatic nonunion of the greater trochanter when the fragment cannot be reattached to its anatomical location with the hip in less than approximately 20 degrees of abduction.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Trochanteric osteotomy is sometimes used to improve exposure of both the acetabulum and the femur during difficult primary hip arthroplasty (for severe protrusio acetabuli and high-riding congenital dysplasia of the hip) or revision total hip arthroplasty. Advancement of the greater trochanter is also used to improve the effective abductor muscle strength and to so-called tension the abductor muscles to prevent dislocations. Trochanteric osteotomy is associated with a risk of nonunion and subsequent proximal migration of the trochanteric fragment. In one report², the rate of trochanteric nonunion after trochanteric osteotomy in primary total hip arthroplasty with cement was 4.9 percent (eighteen of 366) and the rate increased to 7.1 percent (fifteen of 211) after revision operations. Factors associated with nonunion include osteoporotic bone, cement within the trochanteric bed, increased tension on the attachment site, technical errors during reattachment, hardware failure, an inadequate bone bed, early postoperative mobility, patient noncompliance, postoperative irradiation, and multiple revision hip operations^1,2,4,6-13.

Amstutz and Maki¹ reported an increased risk of pain, abductor muscle weakness, and gait abnormalities, caused by contracted and weakened abductor muscles, when proximal migration of the ununited greater trochanter was more than two centimeters. In these instances, it is much more difficult to reattach the displaced fragment with conventional techniques such as scar excision, mobilization of the gluteus minimus and medius muscles from their distal attachments on the ilium above the acetabular rim, and abduction of the hip. Furthermore, reattachment of the greater trochanter with any of these techniques is liable to place the abductor muscles under substantial tension. Consequently, a variety of techniques involving use of wires^6,7,10,11 and bolts¹³ have been described for trochanteric reattachment.

Mobilization of the abductor muscles from their origin on the ilium to aid with reattachment of the migrated greater trochanter was described for use in patients with severe contraction of the abductor muscles in two reports^6,12. To our knowledge, the efficacy of this procedure for treating a severely migrated ununited trochanteric fragment has not been demonstrated. The present report describes four patients in whom a severely migrated trochanteric fragment was reattached successfully with minimal abductor tension after subperiosteal advancement of the abductor muscles from their origin on the iliac wing.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts 02114. E-mail address: kchin@partners.org.

‡Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, Massachusetts 02115. E-mail address: gbrick@partners.org.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts 02114. E-mail address: kchin@partners.org.

‡Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, Massachusetts 02115. E-mail address: gbrick@partners.org.

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FIG1-A:: Figs. 1-A through 1-D: Illustrations depicting the operative technique of distal advancement of the abductor muscles off the ilium for reattachment of a migrated ununited greater trochanteric fragment. Fig. 1-A: The hip is approached through the original incision (B). A curvilinear incision (A) can be used to subperiosteally elevate the abductor muscles off the ilium for trochanteric advancement.

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FIG1-B:: Fig. 1-B All fibrous tissue and capsule around the joint and above the acetabular rim are removed. A Cobb elevator is used to elevate the abductor muscles off the ilium; the elevation remains subperiosteal to avoid the superior gluteal neurovascular structures that are commonly found within three to five centimeters from the top of the greater trochanter.

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FIG1-C:: Fig. 1-C The abductor muscles are elevated subperiosteally from the ilium until the trochanteric fragment can be advanced freely.

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FIG1-D:: Fig. 1-D The trochanteric bed is debrided, cancellous bone graft from the exposed ilium is applied, and the trochanteric fragment is reattached with wires (A, B, C, and D) under compression with the hip in neutral abduction.

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FIG2-A:: Figs. 2-A through 2-D: Case 2. Figs. 2-A and 2-B: Preoperative roentgenograms of the migrated ununited greater trochanter in a fifty-six-year-old woman who had a second revision total hip arthroplasty because of prosthetic loosening and trochanteric migration that had occurred less than twelve months previously.

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FIG2-B:: Figs. 2-A and 2-B: Preoperative roentgenograms of the migrated ununited greater trochanter in a fifty-six-year-old woman who had a second revision total hip arthroplasty because of prosthetic loosening and trochanteric migration that had occurred less than twelve months previously.

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FIG2-C:: Fig. 2-C: Postoperative roentgenogram made four weeks after an abductor slide, showing the trochanter to be well fixed to its bed under compression with cerclage wires.

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FIG2-D:: Fig. 2-D: Anteroposterior roentgenogram made 2.5 years after the operation, showing a well healed trochanteric fragment.

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TABLE I: CLINICAL DATA

Case	Gender, Age at Index Op. (yrs.)	Hip	Indication for Op.	Trochanteric Migration (mm)	Type of Op.	Date of Op.	Estimated Blood Loss (ml)	Durat. of Hospital- ization (days)	Durat. of Follow-up (mos.)	Harris Hip Score⁵ (Preop./ Postop.) (points)	Follow-up Remarks
1	F, 65	R	Fracture		Hemiarthro- plasty, tro- chanteric osteotomy	1987
			Pain, loosening, broken wires		Revision, trochanteric osteotomy	1988					Postop. irradiat., 1988
			Trochanteric migration, broken wires	31	Revision, trochanteric advancement, iliac-crest bone graft	1990	1900	7	92	32/90	Grade-III³ heterotopic ossif., mild Trendelenburg gait, mild hip pain with activity
2	F, 56	L	Posttraumat. osteoarth., motor-veh. accident		Total hip arthroplasty, trochanteric osteotomy	1982
			Loosening, trochanteric migration, broken wires		Revision, trochanteric reattachment	1990
			Trochanteric migration, broken wires	35	Revision, trochanteric advancement, iliac-crest bone graft	1991	800	9			Mod. Tren- delenburg gait, mild hip pain with activity
			Loose fem. & acetab. components		Revision	1993
			Trochanteric bursitis		Wires removed	1995			82	41/76
3	F, 51	R	Osteoarth., slipped cap. fem. epiph.		Total hip arthroplasty, trochanteric osteotomy	1977
			Loose fem. & acetab. components		Revision, trochanteric osteotomy	1986
			Loose acetab. component, trochanteric migration, broken wires		Revision, trochanteric reattachment	1992
			Recur. disloc., trochanteric migration, wire cutout	25	Revision, trochanteric advancement, iliac-crest bone graft	1993	600	5			Intermit. mild hip pain with activity
			Trochanteric bursitis		Wires removed	1997			55	51/94
4	M, 68	L	Rheumatoid arthritis		Total hip arthroplasty, trochanteric osteotomy	1972
			Protrusio		Revision, trochanteric osteotomy, acetab. allograft	1989
			Trochanteric migration, broken wires	18	Revision, trochanteric advancement, iliac-crest bone graft	1990	1000	11			Grade-II³ heterotopic ossif.
			Loose acetab. component		Acetab. revision	1994			96	42/96	Died in 1998 from pneumonia

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TABLE I: CLINICAL DATA

Case	Gender, Age at Index Op. (yrs.)	Hip	Indication for Op.	Trochanteric Migration (mm)	Type of Op.	Date of Op.	Estimated Blood Loss (ml)	Durat. of Hospital- ization (days)	Durat. of Follow-up (mos.)	Harris Hip Score⁵ (Preop./ Postop.) (points)	Follow-up Remarks
1	F, 65	R	Fracture		Hemiarthro- plasty, tro- chanteric osteotomy	1987
			Pain, loosening, broken wires		Revision, trochanteric osteotomy	1988					Postop. irradiat., 1988
			Trochanteric migration, broken wires	31	Revision, trochanteric advancement, iliac-crest bone graft	1990	1900	7	92	32/90	Grade-III³ heterotopic ossif., mild Trendelenburg gait, mild hip pain with activity
2	F, 56	L	Posttraumat. osteoarth., motor-veh. accident		Total hip arthroplasty, trochanteric osteotomy	1982
			Loosening, trochanteric migration, broken wires		Revision, trochanteric reattachment	1990
			Trochanteric migration, broken wires	35	Revision, trochanteric advancement, iliac-crest bone graft	1991	800	9			Mod. Tren- delenburg gait, mild hip pain with activity
			Loose fem. & acetab. components		Revision	1993
			Trochanteric bursitis		Wires removed	1995			82	41/76
3	F, 51	R	Osteoarth., slipped cap. fem. epiph.		Total hip arthroplasty, trochanteric osteotomy	1977
			Loose fem. & acetab. components		Revision, trochanteric osteotomy	1986
			Loose acetab. component, trochanteric migration, broken wires		Revision, trochanteric reattachment	1992
			Recur. disloc., trochanteric migration, wire cutout	25	Revision, trochanteric advancement, iliac-crest bone graft	1993	600	5			Intermit. mild hip pain with activity
			Trochanteric bursitis		Wires removed	1997			55	51/94
4	M, 68	L	Rheumatoid arthritis		Total hip arthroplasty, trochanteric osteotomy	1972
			Protrusio		Revision, trochanteric osteotomy, acetab. allograft	1989
			Trochanteric migration, broken wires	18	Revision, trochanteric advancement, iliac-crest bone graft	1990	1000	11			Grade-II³ heterotopic ossif.
			Loose acetab. component		Acetab. revision	1994			96	42/96	Died in 1998 from pneumonia

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

We reviewed the charts and roentgenograms of one man and three women who had been operated on by a single surgeon (G. W. B.) because of a symptomatic migrated ununited greater trochanter. The average age of the patients at the time of the index procedure was sixty years (range, fifty-one to sixty-eight years). Migration of the greater trochanter was measured as the perpendicular distance between the trochanteric fragment and the host bone on preoperative roentgenograms. Each patient underwent mobilization of the abductor muscles based on the superior gluteal neurovascular pedicle to aid with trochanteric reattachment. Three patients had undergone two operations and one patient had had three operations prior to the index procedure. The estimated blood loss and the duration of hospitalization were determined from the operative records. The patients were followed for an average of eighty-one months (range, fifty-five to ninety-six months). Postoperative roentgenograms were reviewed at each visit. Osseous union was considered to be present if the trochanter had remained in place, there was osseous continuity between the trochanter and its bed, and the patient experienced some degree of symptomatic relief. Nonunion was documented if the trochanter was separated from its bed as demonstrated on roentgenograms or the fixation wires had broken without evidence of osseous union. Functional ability and pain were evaluated and documented by an independent evaluator from our joint registry at each follow-up visit. The Harris hip score⁵ was used to rate pain, function, hip motion, and deformity. The results were categorized as excellent (90 to 100 points), good (80 to 89 points), fair (70 to 79 points), or poor (less than 70 points). Migration was determined by comparison with the contralateral greater trochanter or with the appearance of the involved greater trochanter on the immediate postoperative roentgenograms made prior to migration.

Operative Technique

After adequate general anesthesia is achieved, the patient is placed in lateral decubitus and the greater trochanter is widely exposed through the original incision (Fig. 1-A). The pseudocapsule is completely excised circumferentially, extending above the acetabular rim. The trochanteric fragment is identified and pulled distally with a towel clip to assess its mobility and to estimate the amount of mobilization required for reattachment. If the greater trochanter cannot be brought to the desired position without undue tension, with the hip in less than approximately 20 degrees of abduction, the abductor muscles are mobilized subperiosteally from above the acetabular rim and off the ilium with use of a Cobb elevator. It is necessary to carefully avoid the superior gluteal neurovascular structures, which run approximately three centimeters proximal to the rim (Fig. 1-B). If there is still undue tension after this maneuver has been completed, the abductor muscles are mobilized from their origins on the ilium by making a separate curvilinear incision over the iliac crest (Fig. 1-C). The skin and subcutaneous tissues are incised, and the fascia is exposed. The fascia is dissected subperiosteally off the outer wing of the ilium anteriorly. Subperiosteal dissection is continued inferiorly to the acetabular rim and posteriorly to the sciatic notch and the posterior superior iliac spine. The entire abductor origin is then mobilized from the pelvis. To achieve adequate mobilization, it is essential to release the interval between the tensor fasciae latae and the gluteus medius after identifying and protecting the superior gluteal neurovascular structures. This completely relieves any tension on the trochanteric fragment and, if desired, the fragment can be readily transferred an additional two to four centimeters. The trochanteric fragment and its bed are cleaned of all fibrous or granulation tissue to expose bleeding cancellous bone. Cancellous bone graft from the iliac crest is harvested through the same exposure and is interposed between the osteotomized fragment and the femur.

Wire Technique (Fig. 1-D)

This technique is a modification of the methods described by Charnley and Ferreira⁴ and by Harris and Crothers⁶. Two holes are drilled through the lateral cortex, approximately one centimeter distal to the trochanteric bed, and directed divergently and proximally until they pierce the medial cortex near the calcar. A long 16-gauge wire (A, Fig. 1-D) is looped in half, and each end is threaded through a separate drill-hole to emerge distal to the neck of the femoral component. The loop should remain outside the bone. If the femoral component has been removed, the wires should be inserted before the femoral component is cemented. However, a trial prosthesis should be inserted before cementing to ensure that the wires do not obstruct the femoral stem. The ends of the wire (A) are brought on either side of the femoral neck from anterior to posterior. If the trochanteric fragment is fairly large and not too osteopenic, two holes may be drilled through the proximal half and the two longitudinal wires can be passed through these holes. Otherwise, the wires (A) should be passed through the abductor muscles and over the trochanteric fragment. If the trochanteric fragment is notably osteopenic, mandibular mesh can be placed over the fragment and the ends of the wire (A) are passed through the mesh. This maneuver decreases the risk of the wires cutting through the bone. Two transverse holes are then drilled anterior to posterior through the lesser trochanter or the femoral neck. Two 16-gauge wires (B and C, Fig. 1-D) are passed through these holes. A third 16-gauge wire (D, Fig. 1-D) is passed anterior to posterior just distal to the previous two transverse wires but proximal to the loop. The most distal of the three transverse wires (D) is knotted firmly against the cortex just proximal to the loop from the longitudinal wires in the lateral cortex. This wire (D) will prevent proximal migration of the loop after the longitudinal wires have been tightened. Next, one arm of the longitudinal wires (A) is passed through the loop and knotted to the other arm to compress the trochanteric fragment to its bed. Finally, the remaining transverse wires (B and C) are knotted over the longitudinal wires to further compress the trochanteric fragment to its bed.

Postoperative Management

Postoperatively, all patients are instructed to walk with two crutches and to refrain from active hip abduction for eight to twelve weeks or until roentgenograms show evidence of healing. A rehabilitation program that focuses on muscle-strengthening and endurance should be initiated after eight to twelve weeks.

Results

Introduction | Materials and Methods | Results | Discussion | References

The interval between the previous revision arthroplasty and the index procedure averaged fifteen months (range, twelve to twenty-one months). Preoperatively, all patients had complained of hip pain with walking and had demonstrated substantial abductor lurches. One patient had had recurrent hip dislocations. Preoperative roentgenograms revealed an average trochanteric gap of 27.3 millimeters (range, eighteen to thirty-five millimeters) (Figs. 2-A and 2-B). Complete nonunion was confirmed at the time of the operation, and all four migrated fragments were associated with a broken wire. The average estimated intraoperative blood loss was 1075 milliliters (range, 600 to 1900 milliliters). The average duration of hospitalization was eight days (range, five to eleven days).

Roentgenograms made at the time of follow-up after the index procedure confirmed that the trochanteric fragment remained attached to its bed in all patients (Figs. 2-C and 2-D). Heterotopic bone formation was seen on the plain roentgenograms of two of the patients. The heterotopic bone was grade III, according to the system of Brooker et al.³, in a patient (Case 1) with a history of postoperative heterotopic bone formation (grade II) after a prior revision total hip arthroplasty and prophylactic irradiation. The majority of the heterotopic bone was resected at the time of the index procedure, but the patient had a complete recurrence. The second case (grade II) occurred in a patient (Case 4) with rheumatoid arthritis who was taking twenty milligrams of Feldene (piroxicam, a nonsteroidal anti-inflammatory medication) per day for pain preoperatively and postoperatively.

All four patients had marked relief of pain and improvement in function. Two patients had a Trendelenburg gait, which was mild in one (Case 1) and moderate in the other (Case 2). At the time of the most recent follow-up, all patients reported that they could walk outside their home. One patient (Case 2) occasionally used a cane for assistance with walking. According to the postoperative Harris hip scores⁵, there were three excellent outcomes and one fair outcome. The average improvement in the Harris hip score was 47.5 points (range, 35 to 58 points) (Table I).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The frequency and degree of pain and the functional disability experienced by patients with trochanteric nonunion has been reported to depend upon the amount of separation between the trochanteric fragment and its bed^1,10,11. Nutton and Checketts¹⁰ concluded that displacement of the greater trochanter was of greater importance than osseous union in determining function of the replaced hip. They observed that abductor muscle strength was substantially reduced if the trochanteric fragment had displaced proximally more than three centimeters. In another report¹, hip abduction strength and the status with regard to a Trendelenburg gait were not affected if the trochanteric gap was less than ten millimeters (grade-I separation). However, these functional parameters were adversely affected by a gap of one to two centimeters (grade II) and one of greater than two centimeters (grade III). On the other hand, Amstutz and Yao² reported symptoms in patients with a gap of 0.5 centimeter. In the current series of four patients, the trochanteric gaps averaged 2.7 centimeters and all patients were symptomatic. However, we were unable to determine the minimum gap that was associated with symptoms because the symptoms had worsened over a long period of time. Also, this series comprised patients who had undergone multiple hip operations, which increased their risk of symptomatic nonunion^1,11.

Despite the differences in the sizes of the gaps that were associated with symptoms, it is evident that substantial trochanteric migration makes it more difficult to reattach the greater trochanter without tension. Furthermore, several reports have mentioned technical errors or hardware failure as the most common etiologies of trochanteric nonunions^1,2,9,11. We agree with Hodgkinson et al.⁷ that many trochanteric nonunions result from excessive resting tension on the trochanteric fragment and that wires must not be used to pull the trochanter down but only to hold it in place. Thus, we consider using an abductor slide whenever the separation of the greater trochanteric fragment is so wide that the fragment cannot be reattached to its anatomical location with the hip in less than approximately 20 degrees of abduction.

However, the extensile nature of this approach risks injury to the superior gluteal neurovascular structures and predisposes the patient to abductor muscle weakness and heterotopic bone formation. Neurovascular injury can be avoided if the muscles are elevated subperiosteally off the ilium and the branches of the superior gluteal nerve are identified as it exits the pelvis through the greater sciatic notch and courses along the middle one-third of the deep surface of the gluteus medius muscle. Abductor muscle weakness can be minimized if there is no injury to the neural branches and if patients are enrolled in a strengthening and endurance rehabilitation program postoperatively. No prophylaxis was used to prevent heterotopic bone formation, but only two of the four patients in this series had such formation postoperatively. One case was a recurrence, and neither case appeared to be of clinical importance. However, the small size of this series precludes us from concluding that prophylaxis against heterotopic bone formation is not required with the use of this technique.

The technique of mobilization of the hip abductor muscles from the ilium through a separate curvilinear incision allowed reattachment of the trochanteric fragment without undue tension in our four patients. No spica cast or other form of prolonged immobilization was used to protect the abductor muscles. Should the patient contract the abductor muscles inadvertently during the early postoperative period (for example, by weight-bearing or attempting to stand from a sitting position), it is likely that the abductor muscles will slide on the ilium rather than apply undue tension on the trochanteric fixation. This may increase the likelihood of a trochanteric fragment healing or at least may allow a fibrous nonunion without migration of the fragment. This technique was associated with minimal heterotopic bone formation, and it substantially improved the function of these patients. If the longitudinal and transverse wire techniques described by Charnley and Ferreira⁴ and by Harris and Crothers⁶ are used to reattach the migrated trochanteric fragment, we suggest the use of a third transverse wire (D, Fig. 1-D) to prevent the longitudinal wires from pulling out and migrating proximally.

References

Introduction | Materials and Methods | Results | Discussion | References

Amstutz, H. C., and Maki, S.: Complications of trochanteric osteotomy in total hip replacement. J. Bone and Joint Surg.,60-A: 214-216, March 1978.60-A214 1978

Amstutz, H. C., and Yao, J.: Transtrochanteric approach. In Master Techniques in Orthopaedic Surgery: The Hip, pp. 33-49. Edited by C. B. Sledge. Philadelphia, Lippincott-Raven, 1998.

Brooker, A. F.; Bowerman, J. W.; Robinson, R. A.; and Riley, L. H., Jr.: Ectopic ossification following total hip arthroplasty. Incidence and a method of classification. J. Bone and Joint Surg.,55-A: 1629-1632, Dec. 1973.55-A1629 1973

Charnley, J., and Ferreira, A. de S. D.: Transplantation of the greater trochanter in arthroplasty of the hip. J. Bone and Joint Surg.,46-B(2): 191-197, 1964.46-B(2)191 1964

Harris, W. H.: Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J. Bone and Joint Surg.,51-A: 737-755, June 1969.51-A737 1969

Harris, W. H., and Crothers, O. D.: Reattachment of the greater trochanter in total hip-replacement arthroplasty. A new technique. J. Bone and Joint Surg.,60-A: 211-213, March 1978.60-A211 1978

Hodgkinson, J. P.; Shelley, P.; and Wroblewski, B. M.: Re-attachment of the un-united trochanter in Charnley low friction arthroplasty. J. Bone and Joint Surg.,71-B(3): 523-525, 1989.71-B(3)523 1989

Jorissen, W.; Van Audekercke, R.; and Mulier, J. C.: Non union of the greater trochanter after total hip arthroplasty. Acta Orthop. Belgica,51: 270-277, 1985.51270 1985

Nolan, D. R.; Fitzgerald, R. H., Jr.; Beckenbaugh, R. D.; and Coventry, M. B.: Complications of total hip arthroplasty treated by reoperation. J. Bone and Joint Surg.,57-A: 977-981, Oct. 1975.57-A977 1975

Nutton, R. W., and Checketts, R. G.: The effects of trochanteric osteotomy on abductor power. J. Bone and Joint Surg.,66-B(2): 180-183, 1984.66-B(2)180 1984

Ritter, M. A.; Gioe, T. J.; and Stringer, E. A.: Functional significance of nonunion of the greater trochanter. Clin. Orthop.,159: 177-182, 1981.159177 1981 [PubMed]

Volz, R. G., and Turner, R. H.: Reattachment of the greater trochanter in total hip arthroplasty by use of a bolt. J. Bone and Joint Surg.,57-A: 129-131, Jan. 1975.57-A129 1975

Volz, R. G., and Brown, F. W.: The painful migrated ununited greater trochanter in total hip replacement. J. Bone and Joint Surg.,59-A: 1091-1093, Dec. 1977.59-A1091 1977

Topics

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FIG1-C:: Fig. 1-C The abductor muscles are elevated subperiosteally from the ilium until the trochanteric fragment can be advanced freely.

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FIG2-C:: Fig. 2-C: Postoperative roentgenogram made four weeks after an abductor slide, showing the trochanter to be well fixed to its bed under compression with cerclage wires.

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FIG2-D:: Fig. 2-D: Anteroposterior roentgenogram made 2.5 years after the operation, showing a well healed trochanteric fragment.

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TABLE I: CLINICAL DATA

Case	Gender, Age at Index Op. (yrs.)	Hip	Indication for Op.	Trochanteric Migration (mm)	Type of Op.	Date of Op.	Estimated Blood Loss (ml)	Durat. of Hospital- ization (days)	Durat. of Follow-up (mos.)	Harris Hip Score⁵ (Preop./ Postop.) (points)	Follow-up Remarks
1	F, 65	R	Fracture		Hemiarthro- plasty, tro- chanteric osteotomy	1987
			Pain, loosening, broken wires		Revision, trochanteric osteotomy	1988					Postop. irradiat., 1988
			Trochanteric migration, broken wires	31	Revision, trochanteric advancement, iliac-crest bone graft	1990	1900	7	92	32/90	Grade-III³ heterotopic ossif., mild Trendelenburg gait, mild hip pain with activity
2	F, 56	L	Posttraumat. osteoarth., motor-veh. accident		Total hip arthroplasty, trochanteric osteotomy	1982
			Loosening, trochanteric migration, broken wires		Revision, trochanteric reattachment	1990
			Trochanteric migration, broken wires	35	Revision, trochanteric advancement, iliac-crest bone graft	1991	800	9			Mod. Tren- delenburg gait, mild hip pain with activity
			Loose fem. & acetab. components		Revision	1993
			Trochanteric bursitis		Wires removed	1995			82	41/76
3	F, 51	R	Osteoarth., slipped cap. fem. epiph.		Total hip arthroplasty, trochanteric osteotomy	1977
			Loose fem. & acetab. components		Revision, trochanteric osteotomy	1986
			Loose acetab. component, trochanteric migration, broken wires		Revision, trochanteric reattachment	1992
			Recur. disloc., trochanteric migration, wire cutout	25	Revision, trochanteric advancement, iliac-crest bone graft	1993	600	5			Intermit. mild hip pain with activity
			Trochanteric bursitis		Wires removed	1997			55	51/94
4	M, 68	L	Rheumatoid arthritis		Total hip arthroplasty, trochanteric osteotomy	1972
			Protrusio		Revision, trochanteric osteotomy, acetab. allograft	1989
			Trochanteric migration, broken wires	18	Revision, trochanteric advancement, iliac-crest bone graft	1990	1000	11			Grade-II³ heterotopic ossif.
			Loose acetab. component		Acetab. revision	1994			96	42/96	Died in 1998 from pneumonia

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TABLE I: CLINICAL DATA

Case	Gender, Age at Index Op. (yrs.)	Hip	Indication for Op.	Trochanteric Migration (mm)	Type of Op.	Date of Op.	Estimated Blood Loss (ml)	Durat. of Hospital- ization (days)	Durat. of Follow-up (mos.)	Harris Hip Score⁵ (Preop./ Postop.) (points)	Follow-up Remarks
1	F, 65	R	Fracture		Hemiarthro- plasty, tro- chanteric osteotomy	1987
			Pain, loosening, broken wires		Revision, trochanteric osteotomy	1988					Postop. irradiat., 1988
			Trochanteric migration, broken wires	31	Revision, trochanteric advancement, iliac-crest bone graft	1990	1900	7	92	32/90	Grade-III³ heterotopic ossif., mild Trendelenburg gait, mild hip pain with activity
2	F, 56	L	Posttraumat. osteoarth., motor-veh. accident		Total hip arthroplasty, trochanteric osteotomy	1982
			Loosening, trochanteric migration, broken wires		Revision, trochanteric reattachment	1990
			Trochanteric migration, broken wires	35	Revision, trochanteric advancement, iliac-crest bone graft	1991	800	9			Mod. Tren- delenburg gait, mild hip pain with activity
			Loose fem. & acetab. components		Revision	1993
			Trochanteric bursitis		Wires removed	1995			82	41/76
3	F, 51	R	Osteoarth., slipped cap. fem. epiph.		Total hip arthroplasty, trochanteric osteotomy	1977
			Loose fem. & acetab. components		Revision, trochanteric osteotomy	1986
			Loose acetab. component, trochanteric migration, broken wires		Revision, trochanteric reattachment	1992
			Recur. disloc., trochanteric migration, wire cutout	25	Revision, trochanteric advancement, iliac-crest bone graft	1993	600	5			Intermit. mild hip pain with activity
			Trochanteric bursitis		Wires removed	1997			55	51/94
4	M, 68	L	Rheumatoid arthritis		Total hip arthroplasty, trochanteric osteotomy	1972
			Protrusio		Revision, trochanteric osteotomy, acetab. allograft	1989
			Trochanteric migration, broken wires	18	Revision, trochanteric advancement, iliac-crest bone graft	1990	1000	11			Grade-II³ heterotopic ossif.
			Loose acetab. component		Acetab. revision	1994			96	42/96	Died in 1998 from pneumonia