SUGIOKA OSTEOTOMY

MASAFUMI HOMMA, M.D.,D.M.Sc, Research Fellow of Orthopaedic Surgery

RICHARD BOWEN, M.D., Pediatric Orthopaedic Surgeon, Chairman

October. 26,1995

CLINICAL CASE PRESENTATION

ORTHOPAEDIC DEPARTMENT

THE ALFRED I. DUPONT INSTITUTE

WILMINGTON, DELAWARE

CASE HISTORY:

PATIENT 1.

K.B.. 12-year-old boy. B.W. 63 kg(139 Ib.) . Perthes disease. He had right hip pain and limping for seven weeks. When he was first seen at University Hospital of Niigata, the right femoral head was deformed already and collapsed slightly on X-ray. The lateral part of the femoral head showed an impingement lesion. Because good sphericity of the posterior part of the femoral head was still preserved, Sugioka's rotational osteotomy was advised. Pre-operative range of motion was flex.90, abd.35, e.r. 40, and i.r. 15. The femoral head was anteriorly rotated by 75 degrees and varus angulation by 15 degrees was made. Continuous-passive-motion and pulley exercise on a bed was started from the 1st post-operative day. Skin traction was performed for 2 weeks. After post-operative non-weight-bearing for 4 weeks, and partial-weight-bearing for 6 weeks, he has had neither limping nor pain for more than 3 years.

PATIENT 2.

W.H.. 12-year-old-girl. Post-traumatic avascular necrosis of rt. femoral head. She sustained the right femoral neck fracture by falling from a balcony. After bed-rest for 2 weeks, she started walking with crutches. She completely returned to normal activities 6 months after the trauma. She was beginning to complain of the right hip pain 2 years after the trauma. A large area of avascular necrosis was in weight bearing surface of the femoral head. The large posterior surface of the femoral head remained intact. A Sugioka osteotomy was performed with 90 degrees of anterior rotation and 15 degrees of varus angulation. After post-operative non-weight-bearing for 4 weeks, and partial-weight-bearing for 6 weeks, she has had neither limping nor pain so far.

PREOPERATIVE PLANNING:

• Anteroposterior and true lateral radiographs should be performed. For the true lateral radiograph, the patient should be positioned supine, with the hip in precisely 90 degrees of flexion and 45 degrees of abduction and with neutral rotation.
• The preoperative lateral view radiograph shows the A-P view of the femoral head as it will appear after 90 degrees of posterior rotation.
• In contrast, a preoperative lateral view in a reversed position shows the A-P view after 90 degrees of anterior rotation.

OPERATIVE PROCEDURE:

1. Skin incision: a modified Ollier's incision, or a lateral oblique incision.
2. Osteotomized the greater trochanter and reflect it proximally with the gluteus medius muscle.
3. Transect the short external rotator muscles and quadratus femoris muscle. Care must be taken to avoid injury to the posterior branch of the medial circumflex artery, which lies just above the lesser trochanter and can easily be seen at the time of transection of the short rotators and the quadratus femoris muscle.
4. A circumferential incision is made in the hip joint capsule near the acetabular rim.
5. The first osteotomy is made, 10mm distal to the intertrochanteric crest, toward the lesser trochanter, and in a plane perpendicular to the neck in every direction.
6. To determine the osteotomy plane, two K-wires are placed through the denuded surface of the greater trochanter both anterioly and posterioly in a plane perpendicular to the another K-wire which is placed along the femoral neck.
7. A second osteotomy is performed from the upper margin of the lesser trochanter to the first osteotomy line.
8. When an anterior rotation of 70 degrees or more is required, the iliopsoas tendon should be transected near the lesser trochanter before rotation.
9. Two large pins are inserted parallel into proximal and distal fragments, and femoral head is rotated anteriorly by handling proximal pin.
10. After adequate rotation, a large screw is inserted in valgus position. An A-P X-ray should be taken to ensure the weight-bearing portion is well apposed and the neck-shaft angle. Then a Steinman pin is removed and another large pin is inserted. The A-O compression screw is ineffective because of its thin shank.
11. The intentional varus position may be made in addition to anterior rotation for an extensive lesion.

POSTOPERATIVE MANAGEMENT

• Two kg of skin traction all day for 1 week and at night for additional 2 weeks.
• Quadriceps setting and active ROM exercise should be started within 10 days.
• Walking exercise in a pool is usually allowed 5 to 6 weeks after surgery.
• Partial weight bearing is started at 8 weeks and continued for 6 months after surgery.

COMPLICATIONS:

• Early: Fracture of lessor trochanter, Subtrochanteric fracture
• Late: Deep infection, Neck fracture, Delayed union, Nonunion of greater trochanter,

CLINICAL RESULTS:

• Sugioka classifed the preoperative hips into four grades: grade 1, necrosis just visible, the femoral head is still round; grade 2, the head is flattened; grade 3, the head is markedly collapsed without narrowing of the joint space; and grade 4, the head shows advanced changes with narrowing of the joint space.
• The success rate in the 23 hips of grade1 was 91%, in the 16 hips of grade 2 was 88%, in the 64 hips of grade3 was 73%, and in the 25 hips of grade 4 was 68%.
• Seventy-six of the 80 hips in which the intact area on the preoperative lateral view was more than one third of total joint surface showed no collapse of the newly created weight-bearing area (success rate: 95%). On the other hand, twenty-one of 48 hips in which the intact area was less than one third showed progressive collapse (success rate: 56%).
• Only three of 85 hips in which the intact area on the post-operative A-P view was greater than 36% showed further collapse (success rate: 96%). But five of the 22 hips in which the intact area was ranged from 21-31%, and 17 of the 21 hips in which the intact area was less than 20% showed further collapse (success rate: 77%, and19% respectively).

INDICATIONS:

• Idiopathic, steroid-induced, post-traumatic and other symptomatic osteonecrosis of the femoral head, Perthes' disease, slipped capital femoral epiphysis, primary osteoarthritis with localized erosion in the weight-bearing area, are indications for application of this procedure.
• Contraindications: 1, total necrosis; 2, complication with poor prognosis (obesity etc.)
• Indications: 1, Sugioka's grade I or II lesion; 2, grade III or IV lesion in which extent of lesion is under two thirds in lateral x-ray view; 3, unilateral grade III or IV lesion in which extent of lesion is over two thirds.
• Relative indications: 1, Bilateral grade III or IV lesion in which extent of lesion is over two thirds in younger patient.

REFERENCES:

1. Sugioka Y.: Transtrchanteric rotational osteotomy of the femoral head. In Riley, L.H.Jr.(ed.): The Hip. Proceedings of the Eighth Open Scinentific Meetingof the Hip Society. St. Louis, C.V. Mosby, 1980.pp.3-23.
2. Sugioka Y.: Transtrochanteric anterior rotational osteotomy of the femoral head in the treatment of osteonecrosis affecting the hip: A new osteotomy operation. Clin. Orthop. 130: 191-201,1978.
3. Sugioka Y., Katsuki I., and Hotokebuchi T.: Transtrochanteric rotational osteotomy of the femoral head for the treatment of osteonecrosis: Follow-up statistics. Clin. Orthop. 169: 115-126,1982.
4. Sugioka Y.: Transtrochanteric rotational osteotomy in the treatment of idiopathic and steroid-induced femoral head necrosis, Perthes' disease, slipped capital femoral epiphysis, and osteoarthritis of the hip: indications and results, Clin. Orthop. 184: 12-23,1983.