Transtrochanteric approaches to the hip joint are not needed for most primary total hip arthroplasties (THA) but when used can provide wide exposure to the hip joint, for both the acetabulum and femur.

A number of variations of transtrochanteric approaches exist, and each has its pros and cons. Different techniques are indicated in different circumstances. All provide the benefit of enhanced exposure to the hip compared with routine anterior, posterior, or anterolateral/direct lateral exposures to the hip, but they also carry the risk of trochanteric nonunion.

The main techniques are conventional trochanteric osteotomy with reflection of the trochanter and abductors proximally (Figure 5.1); trochanteric slide in which the abductors, greater trochanter (GT), and vastus lateralis are maintained in continuity (Figure 5.2); and extended greater trochanteric osteotomy (Figure 5.3). Detailed techniques of extended trochanteric osteotomy are described in Chapter 23.

Conventional GT osteotomies allow the GT and abductors to be reflected proximally: this protects the superior gluteal nerve and can be helpful when wide exposure to the lateral ileum is needed (Figure 5.4). The trochanteric slide keeps the abductors, GT, and vastus lateralis in continuity, which may maintain better abductor function should healing of the osteotomy fail to occur.

Conventional trochanteric osteotomies or trochanteric slide is most frequently used for the following indications: severe hip stiffness that precludes safe access to the hip with a conventional exposure or with in situ femoral neck osteotomy (Figure 5.5); proximal femoral deformity in which the GT overhangs the femoral canal precluding safe access to the canal for femoral preparation without abductor damage (Figure 5.6); selected revision hip arthroplasties, particularly when the femoral component will be retained and is bulky and wide access to the acetabulum is needed.

Routine instrumentation for THA

Oscillating saw

Trochanteric fixation of choice: 18-gauge wires, double Luque wires, trochanteric claw/cables, trochanteric hook plate and instrumentation

Wire and/or cable tighteners

Wire/cable cutters

Lateral decubitus or supine depending on surgeon preference for THA.

If lateral decubitus is chosen, a leg bag on the ventral side of the patient is used when the hip is dislocated anteriorly.

The transtrochanteric approach can be used in combination with anterior or posterior dislocation of the hip. However, in general, it is preferable to avoid taking down the abductors (such as in an anterolateral or direct lateral approach to the hip) when a transtrochanteric approach subsequently will be used because this devascularizes the GT and muscle reattachment also is more difficult.

Identify the patient in whom a transtrochanteric approach may be needed (see notes concerning indications in the Key Concepts section).

Determine what style of GT osteotomy will be most effective for the specific operative challenge.

Perform routing templating and preoperative planning for the planned primary or revision THA procedure.