What is the step by step procedure for a hip fracture treated with trans trochanteric rotational osteotomy?

From the Guidelines

Transtrochanteric rotational osteotomy (TRO) for hip fracture treatment involves a multi-step surgical procedure aimed at preserving the femoral head by rotating the viable portion into the weight-bearing area. The procedure begins with the patient positioned laterally on the operating table under either spinal or general anesthesia, as both are appropriate for patients with a hip fracture 1. After sterile preparation, a lateral approach to the hip is made with an incision extending from the greater trochanter distally along the femoral shaft. The fascia lata is incised, and the vastus lateralis is reflected anteriorly to expose the proximal femur. Guide wires are inserted to mark the planned osteotomy lines, followed by placement of fixation screws above the planned osteotomy to prevent femoral head displacement. The surgeon then performs the main trochanteric osteotomy, typically V-shaped, extending from the greater trochanter to below the lesser trochanter. After completing the osteotomy, the femoral head fragment is rotated (usually anteriorly) to bring the viable portion into the weight-bearing position. The rotation angle typically ranges from 60-120 degrees depending on the location and extent of the necrotic area. Once optimal positioning is achieved, the osteotomy is fixed with multiple screws or a specialized hip plate system. Intraoperative fluoroscopy confirms proper alignment and fixation. The wound is then irrigated, hemostasis achieved, and the incision closed in layers.

Some key considerations during the procedure include:

• The use of sequential compression devices and Lovenox for 4 weeks postoperatively for VTE prophylaxis 1
• Maintaining non-weight bearing for 6-12 weeks postoperatively, followed by progressive weight bearing as healing progresses
• The importance of physical therapy throughout recovery to maintain joint mobility and muscle strength

This procedure is particularly valuable for younger patients with femoral head necrosis or certain fracture patterns where preserving the native femoral head is preferable to arthroplasty. The choice of anesthesia should be made based on the individual patient's needs and medical history, with both spinal and general anesthesia being viable options 1.

From the Research

Step-by-Step Procedure for Fracture Hip by Trans Trochanteric Rotational Osteotomy

• The procedure for trans trochanteric rotational osteotomy involves several steps, including:
  • Preoperative preparation: The patient is prepared for surgery, which includes administering prophylactic antibiotics, particularly against Staphylococcus aureus, and thromboembolic prophylaxis, preferably with low-molecular-weight heparin 2.
  • Surgical approach: The surgeon performs a trochanteric osteotomy, which involves cutting the trochanter, a part of the femur, to access the femoral head and neck 3.
  • Osteotomy and fixation: The surgeon performs the trans trochanteric rotational osteotomy, which involves rotating the femoral head and neck to a new position, and fixes it in place using internal fixation devices, such as nails or plates 3, 4.
  • Postoperative care: The patient is monitored and cared for postoperatively, which includes pain management, wound care, and physical therapy to improve mobility and strength 5.

Indications and Contraindications

• The indications for trans trochanteric rotational osteotomy include:
  • Femoral head necrosis 4
  • Hip fractures, particularly those that are difficult to treat with other methods 3
• The contraindications for trans trochanteric rotational osteotomy include:
  • Poor bone quality or inadequate fixation 3
  • Active infection or presence of hardware from previous surgeries 2

Outcomes and Complications

• The outcomes of trans trochanteric rotational osteotomy can vary, with some studies reporting satisfactory results in a limited number of patients 4.
• The complications of trans trochanteric rotational osteotomy can include:
  • Further collapse of the femoral head 4
  • Vascular compromise 4
  • Need for revision surgery, such as total hip replacement 4