JOA - 2026-06-03 - Journal Article
Subsidence Starts Distally: Scaffolding Versus Reconstitution Closure of the Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty.
Jolissaint JE, Rodriguez S, Sanchez LA, Weiner TR, Gausden EB, Chalmers B, Rodriguez J, Sculco P
Topics
Key Takeaway
Scaffolding ETO closure achieves 50 mm of distal bicortical contact versus 28 mm with reconstitution, and >30 mm distal bicortical contact below the ETO reduces clinically significant subsidence (OR 0.12).
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Summary
This study compared scaffolding versus reconstitution ETO closure techniques in 66 revision THAs using tapered splined titanium stems, measuring radiographic subsidence as the primary outcome. Mean subsidence was significantly higher in the reconstitution group (6.0 ± 3.6 mm vs. 4.3 ± 2.9 mm, P=0.018), though rates of clinically significant subsidence (>5 mm) were equivalent (31.4% vs. 32.3%). Distal bicortical contact >30 mm below the ETO was independently protective against significant subsidence (OR 0.12), and reconstitution in healed ETOs (staged PJI revisions) performed comparably to scaffolding (4.0 vs. 4.3 mm mean subsidence).
Key Limitation
Small sample size (n=66) with no standardized follow-up duration limits the ability to detect differences in clinically significant subsidence rates between groups (31.4% vs. 32.3%), which may be underpowered.
Original Abstract
BACKGROUND
Extended trochanteric osteotomy (ETO) facilitates safe removal of well-fixed femoral stems during revision total hip arthroplasty (rTHA). The optimal ETO closure method, scaffolding (open ETO during canal preparation) or reconstitution (ETO reduced prior to preparation), remains unclear, especially regarding subsidence of tapered splined titanium stems (TSTS). We evaluated the impact of the ETO closure technique on postoperative TSTS subsidence, hypothesizing no significant difference.
METHODS
We retrospectively reviewed 66 rTHAs (2016 to 2020) performed with ETO and TSTS implantation. There were 35 cases that used reconstitution and 31 that used scaffolding. Subsidence was measured radiographically from immediate postoperative to final follow-up. Subsidence greater than five mm was deemed clinically relevant. Statistical analyses included Mann-Whitney U-tests, Chi-square tests, and multivariable logistic regressions.
RESULTS
Average subsidence was higher in the reconstitution group (6.0 ± 3.6 mm) than in the scaffolding group (4.3 ± 2.9 mm, P = 0.018). Rates of significant subsidence (greater than five mm) were similar (31.4 versus 32.3%, P = 0.958). Scaffolding achieved greater distal bicortical contact (50 ± 5.4 versus 28 ± 4.8 mm; P = 0.002), which inversely correlated with subsidence (r = -0.26, P = 0.037). Contact length within the ETO was not predictive of subsidence (P = 0.359). Logistic regression identified distal bicortical contact greater than 30 mm below the ETO as protective against significant subsidence (odds ratio (OR) 0.12, P < 0.001). Subgroup analysis revealed lower subsidence in reconstitution cases with a healed ETO (e.g., staged periprosthetic joint infection revisions) than in fresh ETOs closed with reconstitution (4.0 ± 1.1 versus 9.1 ± 2.4 mm). The ETO union rates were high (94.0%) in both groups.
CONCLUSION
Both closure techniques are viable; however, scaffolding offers superior distal fixation and reduced subsidence in fresh osteotomies. Reconstitution yields similar outcomes when the ETO is healed. Ensuring greater than 30 mm of bicortical contact below the ETO is key to minimizing stem subsidence, regardless of closure technique.