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of the trochanter and leaving the posterior part of the gluteus
medius intact. This transgluteal approach is a modification of the technique described by Hardinge (4). Because
the Hardinge direct lateral approach utilizes soft tissue intervals only, Dall questioned the integrity and strength
of this tendinous reattachment. He felt that a bone-on-bone repair was superior, with minimal risk of nonunion.
Dall reported on this technique in 69 primary total hip arthroplasties and noted no cases of nonunion, bursitis, or
abductor lurches (23). This modification of the Hardinge has also been called the Liverpool approach.
A modification of this technique involves leaving the gluteus medius insertion intact and only taking the insertion
of the gluteus minimus and vastus lateralis. The advocates of this modification (Ganz) claim a more rapid
recovery of abductor power and gait. They also claim that by not splitting the gluteus medius tendon, the risk of
damaging the superior gluteal nerve is decreased. This technique allows for preservation of the gluteus medius
on the greater trochanter and of the trochanteric blood supply (24). Exposure may be more difficult with this
modification; however, occasionally the gluteus minimus tendon is scarred and contracted. In these cases, the
minimus is released to prevent a tethering affect on the fragment.
Technique
In Dall's technique, the insertion of the gluteus medius and vastus lateralis is divided midway between the
anterior and posterior margins of the greater trochanter, extending not more than 2 cm above the tip of the
trochanter. The anterior margin of the gluteus medius is identified, and curved forceps are passed behind the
gluteus medius and minimus and over the anterior capsule, exiting the original incision in the gluteus medius
tendon. A Gigli saw is passed deep to the vastus lateralis and gluteus medius and minimus, with both ends
exiting the original incision (Fig. 6.10). Partial trochanteric osteotomy is performed with the hip adducted, slightly
flexed, and internally rotated. The tendency to take a very small fragment of bone is avoided by starting the saw
cut in as posterior a direction as possible. A roughly triangular part of the anterior half of the greater trochanter is
obtained, which carries with it the continuity of the anterior half of the gluteus medius with the vastus lateralis as
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well as the insertion of the gluteus minimus. The hip is now dislocated anteriorly.
Figure 6.10. A: The Gigli saw is passed deep to the gluteus medius and vastus lateralis insertions (Dall). B:
The hip is adducted, flexed, and internally rotated before cutting the fragment. C: The trochanteric fragment is
retracted anteriorly prior to dislocation.
Following reduction of the hip, the fragment will lay in its bed without difficulty. This stable osteotomy can be
approximated in many different ways. It is attached with no. 5 sutures, cables, or monofilament wires. Excessive
hardware or trochanteric grip devices are not necessary. The use of two cables, wires, or sutures is sufficient.
Drill holes in the fragment and through the lateral cortex are sufficient. The hardware should not be placed
around the neck of the prosthesis. After fixation of the fragment, a repeat of the extremes of motion should be
done to ensure adequate stability of the hip and make sure no impingement of the anterior trochanter occurs.
Harris et al. reported on a similar technique that they described as an oblique trochanteric osteotomy. The short
external rotators are left attached to the femur and a posterior cut is made superficial to the intertrochanteric
ridge. A wider anterior cut is performed that contains the insertion of both the gluteus medius and gluteus
minimus (25).
Menon et al. (26) performed a study of 100 cemented primary THAs, of which 50 were performed using an
anterior osteotomy of the greater trochanter (modified Liverpool technique, similar to Dall) and 50 utilizing a
Charnley transtrochanteric approach. A positive Trendelenburg gait was found in 18% of the anterior osteotomy
group and 22% of the Charnley group. Nonunion with migration of greater than 3 cm occurred in 8% and 10% of
the groups, respectively. In addition, 85% of patients with a Charnley-type approach had trochanteric pain or
bursitis. The authors attributed this to the use of the Dall-Miles cable-grip device and placement of the surgical
scar over the reattached portion of the greater trochanter.
Several other techniques for partial trochanteric osteotomies have been described in the literature, including the
Stracathro technique (Fig. 6.11) and the horizontal and vertical osteotomies (Fig 6.12) (14,27,28,29). The
illustrations demonstrate the variations in each surgical technique. In general, however, they have been replaced
by the aforementioned techniques or the extended trochanteric osteotomy (ETO) described below.
Figure 6.11. A,B: Elevating anterior and posterior slices of the trochanter with the insertions of the gluteus
medius and vastus lateralis provides easy access to the hip joint (Stracathro).
Figure 6.12. A: A horizontal osteotomy may be necessary in cases where an adequate cancellous bed is not
available. B: A vertical osteotomy is indicated in revision cases where the trochanter has previously been
advanced to the lateral femoral cortex.
Extended Trochanteric Femoral Osteotomy
The surgeon faced with removal of well-fixed femoral implants during revision THA can find this to be an
extremely difficult, time-consuming, and occasionally disastrous undertaking. The exposure afforded by a
standard trochanteric osteotomy gives minimal access to ingrowth surfaces of cementless implants or the bone–
cement interface of a cemented stem. Cement remaining distal to the prosthesis tip usually requires removal prior
to reimplantation. Traditional attempts to remove these implants and the distal cement plug involved flexible
osteotomes, high-speed burrs, ultrasonic devices, and cement removal guides. Each of these may cause
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damage to existing bone stock, with perforations of the femoral cortex, eccentric reaming, and occasionally total
loss of continuity of the trochanteric portion of the femur with the remaining proximal femoral tube.
In 1991 Cameron described the use of a trochanteric osteotomy with distal extension to remove a square-
shouldered Moore cementless implant that had subsided and drifted laterally (30). He felt that removal of the
prosthesis in this situation would result in avulsion of the greater trochanter and the use of a classic trochanteric
osteotomy would leave an unacceptable bed for trochanteric reattachment.
Cameron begins the osteotomy with a standard posterior or anterolateral exposure, extending from the tip of the
trochanter to a variable point distal to the vastus tubercle where the horizontal osteotomy is made. The
trochanteric fragment then includes one-quarter to one-third of the circumference of the femur, while retaining the
gluteus medius and minimus attachments. After completion of the revision, the trochanteric fragment is held in
place with cerclage wires and reinforced, if necessary, with cortical allograft struts.
Emerson and Head utilized a similar technique, for revision of cemented femoral components (31). They reported
on 21 extended trochanteric osteotomies with no cases of trochanteric migration or broken wires. Four of the
osteotomies had delayed healing, but all had united by 6 months postoperatively.
Utilizing the original technique by McFarland and Osborne and modifying the technique described by Cameron,
Paprosky et al. described a technique, now commonly referred to as the ETO, in which an intact muscle-osseous
sleeve composed of a portion of the anterolateral proximal femur is removed with the greater trochanter, gluteus
medius, and vastus lateralis (32). This technique involves the creation of an osteotomy of the greater