Nonunion of the bone fragments during total hip replacement with T. Paavilainen osteotomy — causes of failure

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Abstract


Background. Conservative treatment options for hip dysplasia and hip dislocation in early childhood allow for good results in cases of a timely diagnosis. The preferred treatment option for patients with hip dislocation in adulthood is total hip joint replacement. The shortening osteotomy, proposed by T. Paavilainen, allows the surgeon to restore the difference in the lengths of the lower extremities during arthroplasty of the hip joint. However, according to the results of the Paavilainen technique, as presented by Russian orthopedic surgeons, the problem of nonunion of the greater trochanter fragment with the diaphysis of the femur remains unresolved, as evidenced by a massive group of clinical cases.

Aim. The aim of this study was to identify factors affecting the consolidation of bone fragments after osteotomy of the greater trochanter, according to T. Paavilainen, during total hip arthroplasty and evaluate their significance after fixation with cerclage screws in comparison with a special trochanteric fork-plate.

Materials and methods. The present study includes 208 cases that were treated at the Russian Scientific Research Institute of Traumatology and Orthopedics named after R.R. Vreden from 2003 to 2019 using various fixation techniques of the greater trochanter fragment. Patients were divided into two groups depending on their type of fixation. The quality of consolidation of a greater trochanter fragment with the femur was assessed during a follow-up period of six months or longer. The fragment of the greater trochanter was divided into the part that was not in contact with the diaphysis, or A, and the part that was in contact with the diaphysis, or B. We assessed the effect of the absolute value of the contact between fragments, the B/A ratio, the distance between the points of insertion of the screws into the diaphyseal part of the femur, the quality of the bone by the modified Barnet-Nordin index, and the history of previous surgical interventions on this joint on the consolidation.

Results. When the part of the greater trochanter was in contact with the diaphysis of the femur (B) was less than 3.5 cm, the risk ratio of nonunion of the greater trochanter fragment with the diaphysis of the femur increased. Also, a significant factor is the index of the contact of the greater trochanter fragment (B/A less than 1) with the diaphysis of the femur using the T. Paavilainen technique. In addition, the presence of surgical intervention in the hip joint history significantly increases the relative risk (RR) of nonunion of the greater trochanter fragment with the diaphysis of the femur with this method of shortening osteotomy of the femur.

Conclusion. In the absence of timely diagnosis and conservative treatment of children with hip dislocation, reconstructive-plastic techniques on the hip joint do not allow the achievement of proper results and increase the complexity of total hip arthroplasty. According to the results of this study, the absolute value of the contact between fragments (B), the index of the greater trochanter contact with the diaphysis of the femur, and the history of previous surgical intervention on this joint are objective tools for the prognostic assessment of the probability of fragment unions during total hip arthroplasty with the T. Paavilainen technique.


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About the authors

Alexandr I. Avdeev

Vreden Russian Research Institute of Traumatology and Orthopedics

Author for correspondence.
Email: spaceship1961@gmail.com
ORCID iD: 0000-0002-1557-1899

Russian Federation, 8, Akademika Baykova street, St.-Petersburg, 195427

MD, PhD Student

Igor A. Voronkevich

Vreden Russian Research Institute of Traumatology and Orthopedics

Email: dr_voronkevich@inbox.ru
ORCID iD: 0000-0001-8471-8797

Russian Federation, 8, Akademika Baykova street, St.-Petersburg, 195427

MD, PhD, Head of the Research Department of injuries and their consequences treatment

Dmitrii G. Parfeev

Vreden Russian Research Institute of Traumatology and Orthopedics

Email: parfeevd@yandex.ru
ORCID iD: 0000-0001-8199-7161

Russian Federation, 8, Akademika Baykova street, St.-Petersburg, 195427

MD, PhD, Head of Department

Anton N. Kovalenko

Vreden Russian Research Institute of Traumatology and Orthopedics

Email: tonnchik@yandex.ru
ORCID iD: 0000-0003-4536-6834

Russian Federation, 8, Akademika Baykova street, St.-Petersburg, 195427

MD, PhD, researcher of the Department of Diagnosis of Diseases and Injuries of the Musculoskeletal System

David G. Pliev

Vreden Russian Research Institute of Traumatology and Orthopedics

Email: plievd@gmail.com
ORCID iD: 0000-0002-1130-040X

Russian Federation, 8, Akademika Baykova street, St.-Petersburg, 195427

MD, PhD, Head of Hip Pathology Department

Ekaterina V. Sannikova

Vreden Russian Research Institute of Traumatology and Orthopedics

Email: sannikovaekaterina@rambler.ru
ORCID iD: 0000-0002-9171-1697

Russian Federation, 8, Akademika Baykova street, St.-Petersburg, 195427

MD, PhD, Associate Professor, The Chair of Traumatology and Orthopedics

Igor I. Shubnyakov

Vreden Russian Research Institute of Traumatology and Orthopedics

Email: shubnyakov@mail.ru
ORCID iD: 0000-0003-0218-3106

Russian Federation, 8, Akademika Baykova street, St.-Petersburg, 195427

MD, PhD, D.Sc., Chief Researcher

Rashid M. Tikhilov

Vreden Russian Research Institute of Traumatology and Orthopedics; North-Western State Medical University named after I.I. Mechnikov

Email: info@rniito.org
ORCID iD: 0000-0003-0733-2414

Russian Federation, 8, Akademika Baykova street, St.-Petersburg, 195427; 41, Kirochnaya street, Saint-Petersburg, 191015

MD, PhD, D.Sc., Professor; Professor of Traumatology and Orthopedics Department

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Supplementary files

Supplementary Files Action
1.
Fig. 1. Index of contact of the greater trochanter fragment: a — the option of fixing the greater trochanter with two screws and cerclage (group 1); b — the option of fixing the greater trochanter with an original fork plate (group 2); A — part of the greater trochanter not in contact with the femoral diaphysis; B — part of the greater trochanter in contact with the femoral diaphysis

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2.
Fig. 2. Forces acting on the hip joint in a single support phase of the step with two different types of osteotomy: K is the weight (gravity) of the body, with the exception of the mass of the limb, that acts vertically through the arm of lever b; М is the abductor muscles strength vector that supports the balance of the pelvis through the lever arm a; M1 and a1 are for subtrochanteric osteotomy; and M2 and a2 are for osteotomy according to T. Paavilainen. Pelvic equilibrium formula: K ∙ b = M ∙ a

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Copyright (c) 2020 Avdeev A.I., Voronkevich I.A., Parfeev D.G., Kovalenko A.N., Pliev D.G., Sannikova E.V., Shubnyakov I.I., Tikhilov R.M.

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