The operative procedure of total hip arthroplasty can be viewed as two separate but yet closely connected stages: the exposure of the joint and the fixation of the components.

Exposure by trochanteric osteotomy adds a further demand – the knowledge and understanding of osteotomy and osteosynthesis. Failure to achieve bony union, or any problems resulting from it, are immediately obvious. Benefits, if any, cannot be attributed to the method as they can only be assessed by the long-term results. Unfortunately, studies of long-term results, rarely, if ever, take into account the method of exposure as used at the primary operation. It is, therefore, not at all surprising that a combination of trochanteric osteotomy and 22.225 mm head diameter of the Charnley design strike fear into many orthopaedic surgeons. The net result is obvious – practice away from both the design and the method of exposure.

Evidence supporting this method of exposure will be found in the pages of this volume; arguments against should be looked up in various publications. Surgeons seriously committed to this method of treatment will have to consider the provision of revision facilities. This, now more extensive procedure, may demand more extensive exposures. It could be argued that trochanteric osteotomy could offer this, but revision procedure may not be the ideal time to undertake a new, to the surgeon, method of exposure. It is interesting that “extended trochanteric osteotomy” is gaining favour and even the length of the lateral femoral cortical fragment has become of sufficient interest to warrant a publication.

Trochanteric osteotomy is not merely the method that gives an excellent exposure of the acetabulum and the access to the medullary canal; it is an integral part of the concept. Medialisation of the cup with lateral and distal transposition of the greater trochanter, aimed to reduce the load on the hip, wear of the UHMWPE cup, protect the bone-cement interface and prolong the time during which the operation would remain successful. Charnley was well aware of the criticisms: broken wires, early dislocation, discomfort and “… trochanteric non–union damaging the surgeon’s reputation.”

Charnley withheld the publication of the details of the technique until he “… believed that the problem of the trochanter has been truly solved or at least for … surgeons who were prepared to follow with understanding of the technique described.”

Using the “cross–wire” technique in 1020 LFAs, bony union was achieved in 95 %, fibrous union in 2.6 % and complete trochanteric detachment in 2.4 %. The failure rate was more common with residents in training than the senior staff but “… relief of pain was not significantly influenced by the defective trochanteric non–union.”

It is generally perceived that trochanteric osteotomy as the method of exposure when combined with the 22.225 mm diameter head carries a high incidence of dislocation.

What are the facts?

Here we are concerned with the results spanning nearly 50 years of the clinical practice of the Charnley LFA using trochanteric osteotomy and several methods of reattachment usually using wires as the main material.

A review of 23,380 primary LFAs carried out over a 47 year period by over 350 surgeons at Wrightington Hospital is summarised in Tables 18.1, 18.2, 18.3, and 18.4.