The Journal of Arthroplasty xxx (2020) 1e8

Contents lists available at ScienceDirect

The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

Total Hip Arthroplasty With Trochanteric Ostectomy for Patients

With Angular Deformity of the Proximal Femur
Jung-Taek Kim, MD a, Hong Seok Kim, MD b, Young-Kyun Lee, MD b, *,
Yong-Chan Ha, MD c, Kyung-Hoi Koo, MD b, d
a
Department of Orthopedic Surgery, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
b
Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
c
Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, South Korea
d
Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea

a r t i c l e i n f o a b s t r a c t

Article history: Background: Total hip arthroplasty (THA) of patients with a proximal femoral deformity is technically
Received 20 March 2020 demanding. This deformity poses the risk of femoral fracture or perforation; stem malposition; and failed
Received in revised form stem fixation. To insert a femoral stem in neutral position with a good fit, we removed the greater
28 April 2020
trochanter in case of a varus deformity, and the lesser trochanter in case of valgus deformity, while
Accepted 30 April 2020
performing THA. We aimed to evaluate stem position, implant stability, clinical results, and radiological
Available online xxx
changes after THAs using this technique.
Methods: Fifteen patients (17 hips; 11 varus hips and 6 valgus hips) underwent cementless THA using the
Keywords:
total hip arthroplasty
trochanteric osteotomy technique in one institution. We evaluated procedure-specific complications:
deformity intraoperative femoral fracture, stem malposition, weakness of the abductor power and limp. Modified
femur Harris Hip Score, radiological changes, and the stability of stems were assessed at a mean of 7.1 years of
trochanter follow-up (range 2.0-15.5).
excision Results: Femoral fracture occurred during the insertion of the stem in 4 hips. All stems were aligned in
neutral position. At the latest follow-up, the mean power of the abductor was 4.3 (range 3-5). Eleven
patients had slight limp and 4 patients had moderate limp. All stems had bone-ingrown stability and no
stem was revised. The mean modified Harris Hip Score improved from 50 points at the preoperative
evaluation to 81 points at the final follow-up.
Conclusion: The trochanteric excision enabled neutral insertion of cementless stem in patients with
varus/valgus deformity of the proximal femur, and THA using this technique rendered favorable results.
© 2020 Elsevier Inc. All rights reserved.

For practical classification of complex total hip arthroplasty (THA),
Berry [1] defined “deformed femur” as the femur which requires
special techniques or implants due to its abnormal shape or size
during the arthroplasty. Proximal femoral deformitiesdmainly varus
or valgus deformitiesdoccur secondary to a childhood infection,
previous fracture, or osteotomy. It might occur in patients with
metabolic disease or renal osteodystrophy, and those with develop-
mental disorders. In the presence of these deformities, THA is chal-
lenging due to a risk of intraoperative femoral fracture or perforation,
No author associated with this paper has disclosed any potential or pertinent
conflicts which may be perceived to have impending conflict with this work. For
full disclosure statements refer to https://doi.org/10.1016/j.arth.2020.04.099.
* Reprint requests: Young-Kyun Lee, MD, Department of Orthopedic Surgery,
Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil, Bundang-gu,
Seongnam, Gyeonggi-do 13620, South Korea.
stem malposition, and failed stem fixation [1e6]. In the hips with a
varus deformity, the prominent medial tip of the greater trochanter
might impinge upon the ilium after THA. This impingement might
lead to a dislocation or a fracture of the great trochanter [7].
Additional corrective osteotomy, usually at the subtrochanteric
level, has been used to properly fit a stem in the deformed femur
[8]. However, this osteotomy is another challenging procedure,
which prolongs the operative time, increases the risk of infection,
and delays the postoperative rehabilitation. It is also associated
with intraoperative femoral fracture, osteotomy nonunion, and
femoral stem loosening in 15%-40% [9].
We developed a technique to insert a stem into the deformed
femur without a subtrochanteric osteotomy. We excised the greater
trochanter in femurs with a varus deformity, and the lesser
trochanter in those with a valgus deformity.
In this study, we evaluated procedure-specific complications,
clinical outcomes, radiological changes, and stem stability in a

https://doi.org/10.1016/j.arth.2020.04.099
0883-5403/© 2020 Elsevier Inc. All rights reserved.
2 J.-T. Kim et al. / The Journal of Arthroplasty xxx (2020) 1e8

series of THA patients, who had a proximal femoral deformity and
were operated using the trochanteric excision technique.
Materials and Methods
Patient Demographics and the Proximal Femoral Deformities
The study design and protocol of this retrospective study were
approved by the Institutional Review Board in our hospital (B2002/
592-111).
From September 2003 to May 2016, 16 patients (18 hips), who
had a varus (12 hips) or valgus deformity (6 hips) >5 of the
proximal femur, underwent THA at our institution. In varus hips,
the greater trochanter was excised by two-third to whole during
the THA process. In valgus hips, the lesser trochanter was excised as
much as necessitated to insert a femoral stem in neutral position.
One varus hip necessitated additional subtrochanteric osteotomy,
because the stem could not be engaged into the femoral canal even
after the excision of the greater trochanter.
Among the 16 patients, 1 varus patient did not return for follow-
up evaluation after postoperative 9 months. The remaining 15 pa-
tients (17 hips), who were followed up for 2.0-15.5 years (mean 7.1
years) after the THA, were subjects of this study.
There were 7 men (7 hips) and 8 women (10 hips), their mean
age at the time of arthroplasty was 51.6 years (range 27-81), and
their mean body mass index was 23.3 kg/m2 (range 18.5-28.7).
Twelve patients (14 hips) underwent THA due to secondary
degenerative arthritis of the hip: 4 patients (4 hips) due to previous
septic arthritis, 3 patients (3 hips) due to femoral head osteonecrosis,
2 patients (3 hips) due to multiple epiphyseal dysplasia, 2 patients (2
hips) due to previous trauma, and 1 patient (2 hips) due to meta-
physeal chondrodysplasia and hip arthropathy associated with long-
term hemodialysis. Two patients (2 hips) underwent conversion THA
of fused hip due to previous septic arthritis. One patient (1 hip) un-
derwent THA due to nonunion of femoral neck fracture.
Causes of the proximal femoral deformities were childhood
infection in 5 patients (5 hips), malunion after previous fracture in 5
patients (5 hips), previous osteotomy in 1 patient (1 hip), multiple
epiphyseal dysplasia in 2 patients (3 hips), metaphyseal chon-
drodysplasia in 1 patient (2 hips), and fibrous dysplasia in 1 patient
(1 hip). Two patientsdone with multiple epiphyseal dysplasia and
one with metaphyseal chondrodysplasia and hip arthropathy
associated with long-term hemodialysisdunderwent bilateral THA
(Table 1).
Preoperative radiological evaluations included anteroposterior
(AP) and translateral hip radiographs, AP and lateral radiographs of
the whole femur, a scanogram including the leg and pelvis, and 3-
dimensional computed tomography scans (Mx8000 IDT; Philips,
Eindhoven, the Netherlands) of the pelvis and proximal femur.
Due to the proximal femoral deformity, the leg length discrep-
ancy (LLD) could not be measured on AP hip radiographs [10]. Thus,
the measurement was done on scanogram. We measured the

Table 1
Demographics of 15 Patients (17 Hips) With Proximal Femoral Deformities.

Patient Gender Age Side Cause of Angular Varus or Associated Cause of Hip Intraoperative Abductor Power FU
(y) Deformity Valgus Deformitya Arthroplasty Fracture Period
Preoperative Postoperative
( ) (y)

1 Male 58 Left Sequelae of septic hip arthritis Valgus Translational Childhood septic hip Occurred 2 4 3.6
(8 )
b
2 Female 49 Right Metaphyseal Varus Stenosis/ Metaphyseal e 1 3 5.4
chondrodysplasia and HAHD (11 ) translational chondrodysplasia and HAHD
Left Metaphyseal Varus None Metaphyseal e 2 4 5.4
chondrodysplasia and HAHD (21 ) chondrodysplasia and HAHD
3 Female 27 Left Multiple epiphyseal dysplasia Valgus Stenosis Multiple epiphyseal dysplasia e 2 4 5.5
(24 )
4 Male 66 Left Sequelae of septic hip arthritis Valgus Stenosis Childhood septic hip e 2 4 3.0
(10 )
5 Male 66 Right Sequelae of septic hip arthritis Varus Rotational Fused hip due to previous e 1 3 6.1
(37 ) septic arthritis
6 Female 63 Left Malunion after previous Valgus Stenosis Nonunion of femoral neck e 3 4 4.2
fracture (8 ) fracture
7 Male 28 Right Fibrodysplasia Varus None Osteonecrosis of femoral head e 3 5 4.7
(12 )
b
8 Female 35 Right Multiple epiphyseal dysplasia Varus None Multiple epiphyseal dysplasia Occurred 3 4 11.4
(13 )
Left Multiple epiphyseal dysplasia Varus None Multiple epiphyseal dysplasia e 3 5 11.5
(8 )
9 Female 50 Left Sequelae of septic hip arthritis Valgus Stenosis Childhood septic hip e 2 4 12.9
(7 )
10 Male 50 Right Sequelae of septic hip arthritis Varus Rotational Childhood septic hip Occurred 2 4 10.0
(11 )
11 Male 63 Left Malunion after previous Valgus Stenosis Osteonecrosis of femoral head e 3 4 13.4
fracture (10 )
12 Female 43 Left Malunion after previous Varus Rotational Post-traumatic arthritis e 3 4 3.4
fracture (43 )
13 Male 58 Right Malunion after previous Varus Stenosis Post-traumatic arthritis Occurred 3 5 3.2
fracture (11 )
14 Female 81 Left Malunion after previous Varus Translational Osteonecrosis of femoral head e 3 5 2.0
fracture (13 )
15 Female 54 Left Previous osteotomy Varus Rotational Fused hip due to previous e 1 3 15.5
(36 ) septic arthritis

FU, follow-up; HAHD, hip arthropathy associated with long-term hemodialysis.

a
Deformities according to the classification of Berry [1].
b
Patient 2 and patient 8 underwent bilateral total hip arthroplasty.
 J.-T. Kim et al. / The Journal of Arthroplasty xxx (2020) 1e8 3

Fig. 1. Combined Kocher-Langenbeck and Mulliken approach. For the posterior approach, the external rotators are detached at their insertion. Afterward, the posterior capsule is
incised along the base of the femoral neck. A trapezoidal posteriorly broad-based capsular flap is created. For the anterior approach, a plane between the tensor fascia lata and
gluteus medius is identified. Muscle fibers of the gluteus medius are separated at its anterior middle one-third junction, up to 3 cm cephalad to its insertion. The combined tendon
and periosteum of the gluteus medius and vastus lateralis are separated and detached. Blunt dissection is carried out in a plane between the gluteus minimus and anterior capsule.
With adequate exposure of the anterior capsule, an anterior capsulotomy is performed.
Reproduced with permission and copyright of Journal of Arthroplasty.

vertical length between the ankle mortise and upper body of the
first sacral vertebra. When the first sacral vertebra was not visual-
ized in the scanogram, we used both sciatic notches as the proximal
references. The discrepancy between the length of the affected side
and that of the opposite side was considered as the LLD. The mean
preoperative LLD was 4.3 cm (range 0.2-7.5).
The abductor power was evaluated according to the Medical
Research Council scale by each operator [11]. The evaluation was
done in lateral decubitus position with knee extension. The patient
was asked to abduct the affected leg against the evaluator’s resis-
tance over lateral thigh. If the patient could not abduct the leg against
the gravity, the patient was placed in supine position, and was asked
to abduct the leg over the table. The abductor contraction was
palpated. The abductor power was graded into 0-5 scale. The mean
abductor power was 2.3 (range 1-3) at the preoperative evaluation.
The limp was classified according to the subscore of the Harris
Hip Score (HHS) [12]. Four patients had severe limp and 11 patients
had moderate limp. Two patients required a cane for outdoor
ambulation, and the remaining 13 did not use any walking aid.
The mean modified HHS (mHHS) was 50 points (range 36-78) at
the preoperative evaluation [13].
Preoperative Planning of Total Hip Arthroplasty
We used on-screen templating with digital radiographs to
decide the size and position of the implant [14].
Surgical Techniques and Implants
Hip arthroplasties were performed by 3 high-volume (>200 hip
surgeries/y) surgeons. Because of coexisting anatomical distortions
around each hip, the surgical approaches were individualized. The
Kocher-Langenbeck approach was used as the standard method of
exposure [15]. However, an additional lateral approach, the Mul-
liken approach, was used when the posterior approach alone could
not sufficiently expose the acetabulum or when a release of ante-
rior capsule/soft tissue was necessary to mobilize the joint or to
reduce prostheses [16,17].
Isolated Kocher-Langenbeck posterior approach [15] was used in
14 hips, and the combined approach [17] was used in 3 hips. The
length of the skin incision was about 18 cm.
The trochanteric bursa and fat tissues overlying the short
external rotators were removed to expose the gluteus medius, short
external rotators, and the sciatic nerve. Conjoined tendons of short
external rotators were cut at their insertions with electrocautery,
and the posterior capsule was incised along the trochanteric crest
from the acetabulum to the lesser trochanter.
In combined approach cases, the anterior capsule was exposed
by the Mulliken approach [16]. The femur was externally rotated,
and muscle fibers of the gluteus medius were divided at its anterior
one-third up to 3 cm proximal to the greater trochanter. The
dissection was extended along the anterior margin of the greater
trochanter and then distally in line with fibers of the vastus later-
alis. A plane between the gluteus minimus and anterior capsule was
found, and an anterior capsulotomy was performed (Fig. 1).
After the capsulotomy, the femoral head was dislocated poste-
riorly. The femoral neck was cut and the femoral head was removed.
In the next procedure, the greater trochanter was removed in
the 11 varus hips and the lesser trochanter in the 6 valgus hips so
that a femoral stem could be inserted in the neutral alignment. The
trochanters were excised as much as necessitated by rongeur,
osteotome, and electrocautery. During this procedure, careful
4 J.-T. Kim et al. / The Journal of Arthroplasty xxx (2020) 1e8
Fig. 2. Trochanteric excision technique. (A) The greater trochanter is excised in femurs with a varus deformity. (B) The lesser trochanter is excised in femurs with a valgus deformity.
attention was paid to minimize damage to the abductor muscle
fibers and iliopsoas tendon (Fig. 2).
Additional subtrochanteric valgization osteotomy was under-
taken in 1 patient, who had been previously operated with var-
ization osteotomy of the femur, during the THA. The varization
osteotomy had been performed to treat fused hip in a valgus po-
sition due to childhood infection. The valgization osteotomy was
fixed with 2 cerclage bands (Fig. 3).
We tried to place the acetabular component into 40 -45
abduction and 15 anteversion until August 2009. After then, the
cup was anteverted according to the concept of combined ante-
version [18,19]. Cups and stems were inserted in a press-fit manner.
After the implantation and reduction of the prosthesis, stability
was checked. The axial stability was checked by Shuck test [20], the
anterior stability by extension/external rotation, and the posterior
stability by flexion/internal rotation [17,21].
The hip joint capsule and short external rotators were tightly
repaired using transosseous suture through 3-4 drill holes in the
trochanteric crest [22,23].
We exclusively used cementless stems even in elderly patients,
because we were concerned of cement-related cardiopulmonary
complications [24].
BiCONTACT stem (Aesculap, Tuttlingen, Germany) was used in 9
femurs, and Bencox II stem (Corentec, Cheonan, South Korea) in 4
femurs. Each of Bencox M stem (Corentec), Corail (DePuy, Warsaw,
IN), KAR stem (DePuy), and Taperloc Microplasty (Zimmer Biomet,
Warsaw, IN) was used in 1 femur, respectively.
PLASMACUP SC (Aesculap) was used in 9 hips, Coren cup (Cor-
entec) in 4 hips, Pinnacle cup (DePuy) in 2 hips, ABT cup (Zimmer
Biomet) in 1 hip, and Mirabo cup (Corentec) in 1 hip.
The bearing coupling was alumina ceramic head-on-alumina
ceramic liner (BIOLOX Forte; CeramTec AG, Plochingen, Germany)
in 8 hips, alumina ceramic head-on-ultra-high-molecular-weight
polyethylene liner in 2 hips, and delta ceramic head-on-delta
ceramic liner (BIOLOX Delta; CeramTec AG) in 6 hips, and
metallic head-on-polyethylene liner in 1 hip.
The diameter of the femoral head was 28 mm in 7 hips, 32 mm
in 5 hips, 36 mm in 3 hips, and 22 mm in 2 hips.
Postoperative Care
Patients were educated to walk with partial weight bearing
using 2 crutches for 4 weeks [25]. After then, they were allowed to
bear full weight.
No medical thromboprophylaxis was done. Instead, all patients
received mechanical prophylaxis using an intermittent pneumatic
compression device.
Evaluation of Operative Parameters
We reviewed the medical records to estimate the operation time
and intraoperative blood loss.
Follow-Up Evaluations
Follow-up evaluations were performed at 6 weeks, 3, 6, 9, and
12 months, and every year thereafter. Patients who had not
returned for follow-up visits were contacted by telephone and were
asked to return to clinic.
Clinical evaluation was performed using the mHHS system
[12,13,26]. We also evaluated abductor power and limp at each
follow-up [11].
The radiographic evaluations were done by 2 independent ob-
servers who did not participate in the index THAs. The position of
the femoral stem was evaluated on 6-week AP radiographs. Stem
position was determined by measuring the angle between the
longitudinal axis of the stem and that of the femur. The position
was classified as neutral, valgus (>5 of lateral deviation), or varus
(>5 of medial deviation) [27]. The abduction of the acetabular
component was measured by the method of Engh et al [28]. The
anteversion of the acetabular component was calculated by the
method of Woo and Morrey [29].
The equalization of LLD was measured on a 6-week scanogram.
The 6-week AP and cross-table lateral radiographs were the
baseline studies for radiographic comparison.
The fixation of the femoral stem was evaluated with the criteria
of Engh et al [30,31] and the fixation of the acetabular component
with the criteria of Latimer and Lachiewicz [32]. The wear of liner
was measured according to the method by Livermore et al [33].
Osteolytic lesions were defined according to the criteria of Engh
et al [34]. The lesions were located according to the 3 zones
described by DeLee and Charnley [35] on the acetabular side and
according to the 7 zones described by Gruen et al [36] on the
femoral side. Heterotopic ossification was classified according to
the system of Brooker et al [37].
 J.-T. Kim et al. / The Journal of Arthroplasty xxx (2020) 1e8 5

Fig. 3. (A) A 54-year-old woman had a fused hip due to childhood septic arthritis of the left hip (patient 15 in Table 1). She had been treated with varization osteotomy of the left
femur when she was 8 years old. (B) Preoperative scanogram shows leg length discrepancy of 3.2 cm. (C) Postoperative radiograph shows optimal positions of acetabular cup and
femoral stem. (D) On the postoperative scanogram the leg length discrepancy improved to 0.2 cm. (E) Radiograph at postoperative 15 years shows no evidence of loosening or
osteolysis around the prostheses.

Results Abductor Power and Limp

Intraoperative Parameters and Femoral Fractures
The mean operation time was 152.5 minutes (range 85-355). The
mean amount of estimated blood loss was 912.3 mL (range 300-
2710). The mean amount of transfusion was 705.6 mL (range 0-2240).
Femoral fracture occurred in 4 hips during the insertion of stem,
and these 4 fractures were successfully treated with cerclage bands
(CCG System; ImplanTec, Mo €dling, Austria) (1 femur) or cerclage
wires (3 femurs).
No patient had symptomatic deep vein thrombosis or pulmo-
nary embolism.
Implant Position
All stems were placed in the neutral position. The mean ante-
version and abduction of cup were 27.4 (range 9 -47 ) and 41.3
(range 19 -57 ), respectively.
The mean power of abductor muscle improved to 4.1 (range 3-
5). At the latest follow-up, 12 patients had slight limp and 3 patients
had moderate limp. Thirteen patients (87%) perceived that their
limp was improved after the THA. Preoperatively, 2 patients used a
cane. At the latest follow-up, 1 patient kept using a cane during
outdoor ambulation.
Clinical and Radiological Outcome
No hip dislocated and no hip was revised during the follow-up.
All prostheses had bone-ingrown-stability. There was no case of
periprosthetic joint infection or periprosthetic osteolysis (Figs. 3-5).
Grade 1 of heterotrophic ossification was found in 6 hips.
The mean mHHS was 81 points (range 57-100) at the final
follow-up.
Discussion

Leg Length Discrepancy Our study showed that trochanteric excision technique enabled
neutral stem insertion and rigid stem fixation in THA of patients
After the THA, the mean LLD was 1.6 cm (range 0.2-2.9). who had a proximal femoral deformity. This technique did not
Compared to the preoperative state, the discrepancy decreased by a compromise the abductor power, and the results of THA using this
mean of 2.7 cm (range 0-4.8). technique were satisfactory.
6 J.-T. Kim et al. / The Journal of Arthroplasty xxx (2020) 1e8

Fig. 4. (A, B) A 49-year-old woman with metaphyseal chondrodysplasia and renal osteodystrophy (patient 2 in Table 1). She had multiple stress fractures and varus deformities on
both femurs. The right femoral head disappeared due to neglected femoral neck fracture and the left hip was osteoarthritic. (C, D) Postoperative radiograph shows optimal positions
of the acetabular cup and femoral stem. (E) Radiograph at postoperative 15 years shows no evidence of loosening or osteolysis around the prostheses.

THA is challenging in patients with a proximal femoral defor-
mity. The deformity often accompanies distortions of anatomies
around the hip joint. In case of previous infection, trauma, or
osteotomy, adhesion of the surrounding soft tissue is associated
[27]. There is a risk of intraoperative femoral fracture or perfora-
tion, the femoral stem might be inserted in a malposition, and
additional effort should be made to equalize the leg lengths [1e3].
Subtrochanteric osteotomy has been used for THA in patients
with a proximal femoral deformity. However, this osteotomy is
another challenging process. It needs additional fixation, carries a
risk of nonunion, and increases the risk of failed stem fixation
[38e40]. In our patients, femoral straightening osteotomy was
necessary only in 1 hip.
Previously, the use of partial trochanteric excision technique has
been reported in THA for other conditions than proximal femoral
deformities [9,41]. In 2014, Liu et al [9] reported the results of a
partial greater trochanter excision technique in THAs for 21 pa-
tients (23 hips) with Crowe type IV hip dislocations. All stems were
neutrally inserted. At a mean follow-up of 29 months, no stem was
loose, and no hip was revised. In 2017, Yoo et al [41] reported 30
patients (31 hips) who had a coxa vara deformity and underwent
THA using partial trochanteric excision. In their study, all stems
were inserted in the neutral position and had bone-ingrown sta-
bility at a mean follow-up of 5 years.
Concerns of trochanter excision include intraoperative femoral
fracture, dislocation, and abductor weakness. In the study of Liu
et al, intraoperative fractures of the proximal femur occurred in 17%
(4/23). There was no dislocation, and Trendelenburg’s sign
improved in 87% (20/23) [9]. In the study of Yoo et al, proximal
femoral crack occurred in 13% (4/31). The mean postoperative po-
wer of abductor was 4.3. Four patients (13%) had moderate limp
and 26 patients (87%) had slight limp after the arthroplasty [41].
We noted 4 (24%) intraoperative proximal femoral fractures
which occurred during the insertion of the femoral stem. Three of 4
fractures were associated with BiCONTACT stems, which had a
bulky proximal geometry, especially in the medial portion. These
fractures occurred due to a mismatch between the stem geometry
and smaller dimension of the proximal femur. The medial edge of
the stem excessively engaged and loaded a hoop stress in the
femoral calcar during the press-fitting of the stem [42].
In our patients, the abductor power improved postoperatively
even with the excision of trochanters. There are 2 explanations for
the improvement. First, if the conjoined tendon of the gluteus
medius and vastus lateralis adjacent to the trochanter is preserved
during trochanteric excision, the abductor strength is maintained
following the procedure [43]. By virtue of this mechanism, many
hips with nonunion of the greater trochanter are sufficiently
functional to obviate surgical intervention [44]. We spared the
 J.-T. Kim et al. / The Journal of Arthroplasty xxx (2020) 1e8 7

Fig. 5. (A, B) A 27-year-old woman with multiple epiphyseal dysplasia. She had osteoarthritis of the left hip and valgus deformities on the left femur (patient 3 in Table 1). (C, D)
Postoperative radiograph shows optimal positions of acetabular cup and femoral stem. (E) Radiograph at postoperative 5.5 years shows no evidence of loosening or osteolysis
around the prostheses.

conjoined tendon of the gluteus medius and vastus lateralis during
THA. Thus, the abductor could insert to the subtrochanteric area via
the conjoined tendon even after the excision of the greater
trochanter. Second, the effective lever arm of the abductor muscle
was lengthened by the correction of shortening of the affected leg.
All our patients had an LLD by a mean of 4.3 cm (range 0.2-7.5)
preoperatively, and the mean discrepancy improved to 2.7 cm
(range 0-4.8) after the THA. This increment afforded a biome-
chanical benefit for the abductor power and limp. Another concern
rises in excision of the lesser trochanter, which might compromise
the insertion of the iliopsoas tendon. A previous study explored the
insertion location of the iliopsoas tendon on the lesser trochanter to
clarify the surgical implications of the lesser trochanter excision
[45]. That study included 10 cadaveric hemipelvis specimens and
found that no tendinous insertion was present on the anterior
aspect of lesser trochanter in all specimens. The results indicated
that a partial or total excision of the lesser trochanter is feasible
without detaching the iliopsoas tendon. In our study, 12 patients
(75%) had slight limp and 4 patients (24%) had moderate limp at the
latest follow-up. Fourteen patients (88%) perceived that their limp
was improved after the THA.
In THAs of hips with deformed femur, there are several options
to avoid additional subtrochanteric osteotomy. Short stems offer
adequate fixation of the stem in femurs with angular deformities
[46,47]. Modular stem is another option especially for a valgus
deformity [48e50]. However, this stem design has inherent prob-
lems associated with corrosion or failure at the modular junction
[51e53]. Custom-made stem is a fancy option for complex de-
formities of the femurs as the geometry of implant follows the
geometry of the deformed femur [54,55]. However, the custom-
made implants are costly and mandate labor-intensive and time-
consuming process [55,56].
Our study has several limitations. First, it is a retrospective re-
view involving a small number of patients. However, the proximal
femoral deformity is a rare condition, and a large cohort prospective
study is hard to perform. Second, our study is not a randomized
clinical trial, and we could not compare the trochanteric excision
technique with femoral osteotomies. Third, our study was done in
East Asia. The mean age of patients was 51.6 years and their mean
body mass index was 23.3 kg/m2. Our results might not be gener-
alized to patients with higher body mass index in Western countries.
In conclusion, our study presented a new technique of
trochanteric excision which enabled neutral insertion and rigid
fixation of the stem in THAs of patients with proximal femoral
deformities. This technique reduced the need of subtrochanteric
osteotomy and results of the THA were satisfactory. A multicenter
study including a large cohort with a longer follow-up is warranted
to validate this technique.
8 J.-T. Kim et al. / The Journal of Arthroplasty xxx (2020) 1e8

References [29] Woo RY, Morrey BF. Dislocations after total hip arthroplasty. J Bone Joint Surg
Am 1982;64:1295e306.
[30] Engh CA, Glassman AH, Suthers KE. The case for porous-coated hip implants.
[1] Berry DJ. Total hip arthroplasty in patients with proximal femoral deformity.
The femoral side. Clin Orthop Relat Res 1990;261:63e81.
Clin Orthop Relat Res 1999:262e72.
[31] Kim JT, Jeong HJ, Lee SJ, Kim HJ, Yoo JJ. Does proximally coated single-wedge
[2] Papagelopoulos PJ, Trousdale RT, Lewallen DG. Total hip arthroplasty with
cementless stem work well in Dorr type C femurs? Minimum 10-year fol-
femoral osteotomy for proximal femoral deformity. Clin Orthop Relat Res
lowup. Indian J Orthop 2019;53:94e101.
1996:151e62.
[32] Latimer HA, Lachiewicz PF. Porous-coated acetabular components with screw
[3] Mortazavi SM, Restrepo C, Kim PJ, Parvizi J, Hozack WJ. Cementless femoral
fixation. Five to ten-year results. J Bone Joint Surg Am 1996;78:975e81.
reconstruction in patients with proximal femoral deformity. J Arthroplasty
[33] Livermore J, Ilstrup D, Morrey B. Effect of femoral head size on wear of the
2011;26:354e9.
polyethylene acetabular component. J Bone Joint Surg Am 1990;72:518e28.
[4] Kim JT, Yoo JJ. Implant design in cementless hip arthroplasty. Hip Pelvis
[34] Engh CA, Hooten Jr JP, Zettl-Schaffer KF, Ghaffarpour M, McGovern TF,
2016;28:65e75.
Macalino GE, et al. Porous-coated total hip replacement. Clin Orthop Relat Res
[5] Khanuja HS, Vakil JJ, Goddard MS, Mont MA. Cementless femoral fixation in
1994;298:89e96.
total hip arthroplasty. J Bone Joint Surg Am 2011;93:500e9.
[35] DeLee JG, Charnley J. Radiological demarcation of cemented sockets in total
[6] Zhao HY, Kang PD, Shi XJ, Zhou ZK, Yang J, Shen B, et al. Effects of total hip
hip replacement. Clin Orthop Relat Res 1976;121:20e32.
arthroplasty on axial alignment of the lower limb in patients with unilateral
[36] Gruen TA, McNeice GM, Amstutz HC. "Modes of failure" of cemented stem-
developmental hip dysplasia (Crowe type IV). J Arthroplasty 2019;34:2406e14.
type femoral components: a radiographic analysis of loosening. Clin Orthop
[7] Malik A, Maheshwari A, Dorr LD. Impingement with total hip replacement.
Relat Res 1979;141:17e27.
J Bone Joint Surg Am 2007;89:1832e42.
[37] Brooker AF, Bowerman JW, Robinson RA, Riley Jr LH. Ectopic ossification
[8] Deng X, Liu J, Qu T, Li X, Zhen P, Gao Q, et al. Total hip arthroplasty with
following total hip replacement. Incidence and a method of classification.
femoral osteotomy and modular prosthesis for proximal femoral deformity.
J Bone Joint Surg Am 1973;55:1629e32.
J Orthop Surg Res 2019;14:282.
[38] McGrory BJ, Bal BS, Harris WH. Trochanteric osteotomy for total hip arthro-
[9] Liu RY, Bai CY, Song QC, Dang XQ, Wu YJ, Wang KZ. Partial greater trochanter
plasty: six variations and indications for their use. J Am Acad Orthop Surg
osteotomy for hip reduction in total hip arthroplasty for high dislocated hip: a
1996;4:258e67.
preliminary report. BMC Musculoskelet Disord 2014;15:293.
[39] Bruce WJ, Rizkallah SM, Kwon YM, Goldberg JA, Walsh WR. A new technique
[10] Woolson ST, Hartford JM, Sawyer A. Results of a method of leg-length
of subtrochanteric shortening in total hip arthroplasty: surgical technique and
equalization for patients undergoing primary total hip replacement.
results of 9 cases. J Arthroplasty 2000;15:617e26.
J Arthroplasty 1999;14:159e64.
[40] Krych AJ, Howard JL, Trousdale RT, Cabanela ME, Berry DJ. Total hip arthro-
[11] Compston A. Aids to the investigation of peripheral nerve injuries. Medical
plasty with shortening subtrochanteric osteotomy in Crowe type-IV devel-
Research Council: Nerve Injuries Research Committee. His Majesty's Statio-
opmental dysplasia. J Bone Joint Surg Am 2009;91:2213e21.
nery Office: 1942; pp. 48 (iii) and 74 figures and 7 diagrams; with aids to the
[41] Yoo JI, Parvizi J, Song JU, Ha YC, Lee YK, Koo KH. Trochantoplasty for total hip
examination of the peripheral nervous system. By Michael O’Brien for the
arthroplasty in patients with coxa vara deformity. J Arthroplasty 2017;32:
Guarantors of Brain. Saunders Elsevier: 2010; pp.[8] 64 and 94 Figures. Brain
2199e203.
2010;133:2838e44.
[42] Yoo JJ, Kim YM, Yoon KS, Koo KH, Song WS, Kim HJ. Alumina-on-alumina total
[12] Harris WH. Traumatic arthritis of the hip after dislocation and acetabular
hip arthroplasty. A five-year minimum follow-up study. J Bone Joint Surg Am
fractures: treatment by mold arthroplasty. An end-result study using a new
2005;87:530e5.
method of result evaluation. J Bone Joint Surg Am 1969;51:737e55.
[43] Capello WN, Feinberg JR. Trochanteric excision following persistent nonunion
[13] Byrd JW, Jones KS. Prospective analysis of hip arthroscopy with 2-year follow-
of the greater trochanter. Orthopedics 2008;31:711.
up. Arthroscopy 2000;16:578e87.
[44] Baker SA, Fitzgerald Jr RH, Coventry MB. Treatment of nonunion of the greater
[14] Shin JK, Son SM, Kim TW, Shin WC, Lee JS, Suh KT. Accuracy and reliability of
trochanter. Hip 1981:15e24.
preoperative on-screen templating using digital radiographs for total hip
[45] Gomez-Hoyos J, Schroder R, Palmer IJ, Reddy M, Khoury A, Martin HD.
arthroplasty. Hip Pelvis 2016;28:201e7.
Iliopsoas tendon insertion footprint with surgical implications in lesser tro-
[15] Von Langenbeck B. Ueber die Schussverletzungen des Huftgelenks. Archi Klin
chanterplasty for treating ischiofemoral impingement: an anatomic study.
Chir 1874;16:263e339.
J Hip Preserv Surg 2015;2:385e91.
[16] Mulliken BD, Rorabeck CH, Bourne RB, Nayak N. A modified direct lateral
[46] Gamboa AE, Campbell DG, Lewis P. Short-stem hip arthroplasty as a solution
approach in total hip arthroplasty: a comprehensive review. J Arthroplasty
for limited proximal femoral bone stock. Reconstr Rev 2015;5:2.
1998;13:737e47.
[47] Patel RM, Stulberg SD. The rationale for short uncemented stems in total hip
[17] Lee YK, Kim KC, Ha YC, Koo KH. Combined anterior and posterior approach in
arthroplasty. Orthop Clin North Am 2014;45:19e31.
total hip arthroplasty for Crowe IV dysplasia or ankylosed hips. J Arthroplasty
[48] Park CW, Lim SJ, Park YS. Modular stems: advantages and current role in
2015;30:797e802.
primary total hip arthroplasty. Hip Pelvis 2018;30:147e55.
[18] Widmer KH, Zurfluh B. Compliant positioning of total hip components for
[49] Yoon PW, Kim JI, Kim DO, Yu CH, Yoo JJ, Kim HJ, et al. Cementless total hip
optimal range of motion. J Orthop Res 2004;22:815e21.
arthroplasty for patients with Crowe type III or IV developmental dysplasia of
[19] Ha YC, Yoo JJ, Lee YK, Kim JY, Koo KH. Acetabular component positioning using
the hip: two-stage total hip arthroplasty following skeletal traction after soft
anatomic landmarks of the acetabulum. Clin Orthop Relat Res 2012;470:
tissue release for irreducible hips. Clin Orthop Surg 2013;5:167e73.
3515e23.
[50] Kim SM, Lim SJ, Moon YW, Kim YT, Ko KR, Park YS. Cementless modular total
[20] Jasty M, Webster W, Harris W. Management of limb length inequality during
hip arthroplasty in patients younger than fifty with femoral head osteonec-
total hip replacement. Clin Orthop Relat Res 1996:165e71.
rosis: minimum fifteen-year follow-up. J Arthroplasty 2013;28:504e9.
[21] Woolson ST, Rahimtoola ZO. Risk factors for dislocation during the first 3
[51] Krygier JJ, Dujovne AR, Bobyn JD. Fatigue behavior of titanium femoral hip
months after primary total hip replacement. J Arthroplasty 1999;14:662e8.
prosthesis with proximal sleeve-stem modularity. J Appl Biomater 1994;5:
[22] Suh KT, Park BG, Choi YJ. A posterior approach to primary total hip arthro-
195e201.
plasty with soft tissue repair. Clin Orthop Relat Res 2004:162e7.
[52] Bobyn JD, Tanzer M, Krygier JJ, Dujovne AR, Brooks CE. Concerns with
[23] Ji HM, Kim KC, Lee YK, Ha YC, Koo KH. Dislocation after total hip arthroplasty:
modularity in total hip arthroplasty. Clin Orthop Relat Res 1994:27e36.
a randomized clinical trial of a posterior approach and a modified lateral
[53] Cook SD, Manley MT, Kester MA, Dong NG. Torsional resistance and wear of a
approach. J Arthroplasty 2012;27:378e85.
modular sleeve-stem hip system. Clin Mater 1993;12:153e8.
[24] Parvizi J, Ereth MH, Lewallen DG. Thirty-day mortality following hip arthro-
[54] Flecher X, Ollivier M, Maman P, Pesenti S, Parratte S, Argenson JN. Long-term
plasty for acute fracture. J Bone Joint Surg Am 2004;86-A:1983e8.
results of custom cementless-stem total hip arthroplasty performed in hip
[25] Engh CA, Glassman AH, Bobyn JD. Surgical principles in cementless total hip
fusion. Int Orthop 2018;42:1259e64.
arthroplasty. Tech Orthopaedics 1986;1:35e53.
[55] Hitz OF, Flecher X, Parratte S, Ollivier M, Argenson JN. Minimum 10-year
[26] Erivan R, Villatte G, Ollivier M, Paprosky WG. Painful hip arthroplasty: what
outcome of one-stage total hip arthroplasty without subtrochanteric osteot-
should we find? Diagnostic approach and results. J Arthroplasty 2019;34:1802e7.
omy using a cementless custom stem for Crowe III and IV hip dislocation.
[27] Lee YK, Kim JT, Alkitaini AA, Kim KC, Ha YC, Koo KH. Conversion hip arthro-
J Arthroplasty 2018;33:2197e202.
plasty in failed fixation of intertrochanteric fracture: a propensity score
[56] Tsiampas DT, Pakos EE, Georgiadis GC, Xenakis TA. Custom-made femoral
matching study. J Arthroplasty 2017;32:1593e8.
implants in total hip arthroplasty due to congenital disease of the hip: a re-
[28] Engh CA, Griffin WL, Marx CL. Cementless acetabular components. J Bone Joint
view. Hip Int 2016;26:209e14.
Surg Br 1990;72:53e9.