So the approach that we use and it’s very important to note…this is why we call it the modified slide… we leave the posterior capsule and the external rotators attached to the main body of the femur. You have the abductors; greater trochanter; vastus lateralis; one continuous sheath and that inhibits trochanteric migration. It requires just two cerclage wires for closure. We leave the external rotators and the posterior capsule intact, attached to the main body of the femur, vastus lateralis, abductors—it’s all one continuous sheath. And then the rest of your exposure is done anteriorly.
Out of 83 cases we’ve had only 4 non-unions. Remember I don’t do this for primary hip replacements. These are all difficult primaries and complex revisions. We’ve had 4 non-unions; 4 dislocations—that’s 4.8%, but in this particular population that’s very respectable; and only 6 patients developed a new abductor lurch.
What I’m trying to say is that if you need additional exposure, don’t be afraid to take off the greater trochanter. But if you do take it off, keep the vastus attached and leave the external rotators and capsule attached to the main body of the femur.
Dr. Abdel: I think this will be an interesting discussion between two groups. I’m going to be opposing transtrochanteric osteotomy in the primary setting.
There are multiple approaches available to the surgeon when considering primary total hip arthroplasty. These include posteriorly based ones such as a posterolateral; anteriorly based incisions such as anterolateral; direct lateral; direct anterior; and bony based approaches, primarily that of the trans-trochanteric osteotomy.
When I consider the approach for my primary total hip arthroplasty, I think of three goals. First: have adequate exposure of both the femur and the acetabulum; it must be an extensile approach, if I need it. Second: I want to maximize stability with my approach. Third: I want it to be safely reproducible. That is, both you and I on a daily basis need to be able to do this approach safely.
Why do I oppose a transtrochanteric approach for primary total hip arthroplasty? Well, it’s quite simple. It breaks all three rules. It compromises future exposures. Trochanteric non-union is a real issue, reported everywhere from 5% to 30% and those that do have a non-union have up to a 20% instability rate. And it lacks safe reproducibility.
Let’s look at these in depth. What about the exposure? Is there a role for the transtrochanteric approach? Well, certainly one might argue for an ankylosed hip; those with severe acetabular protrusion; or massive heterotopic ossification may benefit with the transtrochanteric approach. However, I would argue that it makes future exposures difficult especially when we have excellent solutions including laterally based or anteriorly based extended trochanteric osteotomies that have nearly 99% union rates in complex revision settings. That’s data from our institution, including our moderator.
Unique and unacceptable complications come with the routine use of this approach in primary total hip arthroplasty.
