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Extended Trochanteric Osteotomy

- Discussion:
     - indications:
           - well fixed femoral components (fully coated press fit stems;
           - for revision of femoral stems placed in significant varus;
           - expose the lateral femur by diving the insertion of the lateralis off the vastus tubercle and then elevating the vastus lateralis off the linea aspera; 
     - cautions: if a previous antero-lateral approach to the hip has been made, elevating the lateralis off the linea aspera may devascularize
                 it which will lead to catastrophic muscle necrosis;
     - mark out the lines of the osteotomy w/ cautery;
     - posterior osteotomy cuts are made close to the saggital midline;
     - avoid stripping the vastus lateralis and instead use a small osteotome to perforate the anterior femoral cortex through the vastus lateralis;
     - osteotomy fragment can then be completed by inserting the osteotome underneath the trochanter and applying a prying motion; 

- Fixation: 
     - oseotomy fragment is secured to main femoral fragment using cobalt-chrome wires or cables (rather than stanless);
     - some revision components will allow a trochanteric plate to bolt into the femoral component, thus securing the trochanter;
     - reattachment with cables;
     - horizontal cable is passed under the vastus lateralis;
     - vertical cable is placed in a figure-of-eight pattern in two planes; 
     - distal portion of the figure-of-eight provided cerclage fixation just distal to the lesser trochanter;
     - anterior end of the cerclage cable was then placed through an oblique drill hole in the greater trochanter;
     - drill hole enters the vastus ridge and exited the medial aspect of the proximal tip of the greater trochanter; 
     - if the trochanter is osteolytic, the drill hole is made more distally through the lateral femoral cortex to avoid further weakening osteolytic bone;
     - cable is passed through the drill hole and then pierces through the abductor tendon;
     - cable is then crossed under the anterior part of the cerclage portion of the figure-of-eight to lie alongside the posterior end of the cable;
     - figure-of-eight cable is tightened simultaneously with the most distal cerclage cable; 

- references:
- Extended proximal femoral osteotomy: A new technique for femoral revision arthroplasty.
- Proximal femoral osteotomy as an adjunct in cementless revision total hip arthroplasty.
- Combined Vertical and Horizontal Cable Fixation of an Extended Trochanteric Osteotomy Site
- Extended Trochanteric Osteotomy in Complex Primary Total Hip Arthroplasty.
- Mechanical effects of the extended trochanteric osteotomy.
- A New Technique to Reattach an Extended Trochanteric Osteotomy in Revision THA Using Suture Cord
- Extended trochanteric osteotomy: planning, surgical technique, and pitfalls.
- Extended Trochanteric Osteotomy in Complex Primary Total Hip Arthroplasty. A Brief Note.
- Trochanteric Osteotomy and Fixation During Total Hip Arthroplasty 
- Extended Femoral Osteotomy and Proximally Coated Prosthesis for Hip Revision
- When and How Do I Perform an Extended Trochanteric Osteotomy?

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