Chin K R, Brick G W
Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
J Bone Joint Surg Am. 2000 Mar;82(3):401-8. doi: 10.2106/00004623-200003000-00011.
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.
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.
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.
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 non-union 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.
全髋关节置换术后大转子不愈合近端移位可能导致疼痛和严重功能障碍。在多次髋关节手术后，移位骨块成功重新附着很困难。本报告的目的是描述4例患者，在将外展肌从髂骨翼起点进行骨膜下推进后，采用改良的Charnley-Harris钢丝固定技术成功重新附着严重移位的转子骨块。
本系列包括1名男性和3名女性，初次手术时平均年龄60岁（范围51至68岁）。患者平均随访81个月（范围55至96个月）。所有患者均基于臀上神经血管蒂进行了外展肌松解以辅助转子重新附着，且均曾接受过髋关节手术（平均2次）。通过在髂嵴上单独的横向曲线切口实现外展肌推进，并对臀小肌、臀中肌和臀大肌从髂骨的整个起点进行骨膜下松解。
4例患者转子骨块均实现了影像学愈合。功能结果3例为优（Harris髋关节评分为90、94和96分），1例为良（76分）。Harris髋关节评分平均提高47.5分（范围35至58分）。2例患者术后仍有轻度或中度Trendelenburg步态。2例患者有不具有临床重要性的异位骨形成。
在这4例患者中，使用该技术实现了大转子愈合、缓解疼痛并减少功能障碍，且无重大并发症。当骨块无法在髋关节外展小于约20度的情况下重新附着到其解剖位置时，对于有症状的大转子不愈合的治疗，可能需要更广泛地使用该技术。
