Extended trochanteric osteotomy: current concepts review

  • Senthil Nathan Sambandam
  • Gopinath Duraisamy
  • Jayadev Chandrasekharan
  • Varatharaj MounasamyEmail author
General Review • HIP - ARTHROPLASTY



Revision total hip arthroplasty is a technically demanding procedure which has gained importance for more than two decades. It was a nightmare for revision surgeons during its initial years of inception before the advent of extended trochanteric osteotomy (ETO). This technique gains access to the femoral medullary canal without compromising the bone stock and aids removal of primary implant and cement mantle without further damaging the parent bone. Like any other surgery, ETO does have certain limitations and complications as reported by various authors. Though it has been routinely used by revision surgeons, thorough knowledge of technical details of ETO is still lacking. So this review article is aimed at addressing the indications, surgical procedure, fixation technique, implant selection and complication of ETO which has been presented over a period of years by various authors.


We searched in the most commonly used portals like MEDLINE (PubMed) and Google scholar using appropriate terminologies for the literature regarding the various preoperative, intraoperative and postoperative clinical scenarios in which revision surgeons utilized ETO.

Results and conclusion

ETO is an important tool in the revision surgeon’s armamentarium and can be used in variety of clinical scenarios and for various intraoperative needs and goals. Awareness about biomechanics of ETO, indications, implants selection, fixation techniques and complications is paramount for good intraoperative and postoperative outcome. ETO by posterior approach continues to be a work horse approach for most revision surgeons all over the world.


Trochanteric osteotomy Revision hip arthroplasty Hip stability 


Author contributions

Sambandam S.N., Gopinath Duraisamy, Chandrasekharan J. and Mounasamy V. contributed equally to this work. Sambandam S.N. and Gopinath Duraisamy designed the research; Sambandam S.N. and Gopinath Duraisamy performed the research; Sambandam S.N., Gopinath Duraisamy, Chandrasekharan J. and Mounasamy V. analyzed the data; and Sambandam S.N. and Gopinath Duraisamy Chandrasekharan J. wrote the paper.

Compliance with ethical standards

Conflict of interest

Each author certifies that no benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this study.


  1. 1.
    Younger TI, Bradford MS, Magnus RE, Paprosky WG (1995) Extended proximal femoral osteotomy. A new technique for femoral revision arthroplasty. J Arthroplasty 10(3):329–338. doi: 10.1016/S0883-5403(05)80182-2 CrossRefPubMedGoogle Scholar
  2. 2.
    Chen WM, McAuley JP, Engh CA Jr, Hopper RH Jr, Engh CA (2000) Extended slide trochanteric osteotomy for revision total hip arthroplasty. J Bone Joint Surg Am 82(9):1215–1219PubMedGoogle Scholar
  3. 3.
    Miner TMMN, Chong D, Paprosky WL (2001) The extended trochanteric osteotomy in revision hip arthroplasty: a critical review of 166 cases at mean 3-year, 9-month follow-up. J Arthroplasty Dec:188–194. doi: 10.1054/arth.2001.29385 CrossRefGoogle Scholar
  4. 4.
    Mardones R, Gonzalez C, Cabanela ME, Trousdale RT, Berry DJ (2005) Extended femoral osteotomy for revision of hip arthroplasty: results and complications. J Arthroplasty 20(1):79–83. doi: 10.1016/j.arth.2004.10.014 CrossRefPubMedGoogle Scholar
  5. 5.
    Lakstein D, Kosashvili Y, Backstein D, Safir O, Lee P, Gross AE (2011) The long modified extended sliding trochanteric osteotomy. Int Orthop 35(1):13–17. doi: 10.1007/s00264-009-0890-2 CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Kuruvalli RR, Landsmeer R, Debnath UK, Suresh SP, Thomas TL (2008) A new technique to reattach an extended trochanteric osteotomy in revision THA using suture cord. Clin Orthop Relat Res 466(6):1444–1448. doi: 10.1007/s11999-008-0233-4 CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Ting NT, Wera GD, Levine BR, Della Valle CJ (2010) Early experience with a novel nonmetallic cable in reconstructive hip surgery. Clin Orthop Relat Res 468(9):2382–2386. doi: 10.1007/s11999-010-1284-x CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Huffman GR, Ries MD (2003) Combined vertical and horizontal cable fixation of an extended trochanteric osteotomy site. J Bone Joint Surg Am 85-A(2):273–277PubMedGoogle Scholar
  9. 9.
    Amstutz HC, Maki S (1978) Complications of trochanteric osteotomy in total hip replacement. J Bone Joint Surg Am 60(2):214–216PubMedGoogle Scholar
  10. 10.
    Ritter MA, Gioe TJ, and Stringer EA (1981) Functional significance of nonunion of the greater trochanter. Clin Orthop 177–182. PMID:641087Google Scholar
  11. 11.
    Thompson RC Jr, Culver JE (1975) The role of trochanteric osteotomy in total hip replacement. Clin Orthop Relat Res 106:102–106. doi: 10.1097/00003086-197501000-00014 CrossRefPubMedGoogle Scholar
  12. 12.
    Paprosky WG, Sporer SM (2003) Controlled femoral fracture: easy in. J Arthroplasty 18(3 Suppl 1):91–93. doi: 10.1054/arth.2003.50074 CrossRefPubMedGoogle Scholar
  13. 13.
    Drexler M, Dwyer T, Chakravertty R, Backstein D, Gross AE, Safir O (2014) The outcome of modified extended trochanteric osteotomy in revision THA for Vancouver B2/B3 periprosthetic fractures of the femur. J Arthroplasty 29(8):1598–1604. doi: 10.1016/j.arth.2014.03.020 CrossRefPubMedGoogle Scholar
  14. 14.
    Della Valle CJ, Berger RA, Rosenberg AG, Jacobs JJ, Sheinkop MB, Paprosky WG (2003) Extended trochanteric osteotomy in complex primary total hip arthroplasty A brief note. J Bone Joint Surg Am 85-A(12):2385–2390PubMedGoogle Scholar
  15. 15.
    Tsukayama DT, Estrada R, Gustilo RB (1996) Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Joint Surg Am 78(4):512–523PubMedGoogle Scholar
  16. 16.
    Cuckler JM, Star AM, Alavi A, Noto RB (1991) Diagnosis and management of the infected total joint arthroplasty. Orthop Clin North Am 22(3):523–530PubMedGoogle Scholar
  17. 17.
    McDonald DJ, Fitzgerald RH Jr, Ilstrup DM (1989) Two-stage reconstruction of a total hip arthroplasty because of infection. J Bone Joint Surg Am 71(6):828–834PubMedGoogle Scholar
  18. 18.
    Lieberman JR, Callaway GH, Salvati EA, Pellicci PM, Brause BD (1994) Treatment of the infected total hip arthroplasty with a two-stage reimplantation protocol. Clin Orthop Relat Res 301:205–212. doi: 10.1097/00003086-199404000-00032 PubMedGoogle Scholar
  19. 19.
    Garvin KL, Evans BG, Salvati EA, Brause BD (1994) Palacos gentamicin for the treatment of deep periprosthetic hip infections. Clin Orthop Relat Res 298:97–105. doi: 10.1097/00003086-199401000-00015 PubMedGoogle Scholar
  20. 20.
    Garvin KL, Hanssen AD (1995) Infection after total hip arthroplasty. Past, present, and future. J Bone Joint Surg Am 77(10):1576–1588PubMedGoogle Scholar
  21. 21.
    Hanssen AD, Rand JA (1999) Evaluation and treatment of infection at the site of a total hip or knee arthroplasty. Instr Course Lect 111. PMID:10098033Google Scholar
  22. 22.
    Levine BR, Della Valle CJ, Hamming M, Sporer SM, Berger RA, Paprosky WG (2009) Use of the extended trochanteric osteotomy in treating prosthetic hip infection. J Arthroplasty 24(1):49–55. doi: 10.1016/j.arth.2008.01.306 CrossRefPubMedGoogle Scholar
  23. 23.
    Morshed S, Huffman GR, Ries MD (2005) Extended trochanteric osteotomy for 2-stage revision of infected total hip arthroplasty. J Arthroplasty 20(3):294–301. doi: 10.1016/j.arth.2004.09.060 CrossRefPubMedGoogle Scholar
  24. 24.
    Lim SJ, Moon YW, Park YS (2011) Is extended trochanteric osteotomy safe for use in 2-stage revision of periprosthetic hip infection? J Arthroplasty 26(7):1067–1071. doi: 10.1016/j.arth.2011.03.001 CrossRefPubMedGoogle Scholar
  25. 25.
    Malchau H, Herberts P, Eisler T, Garellick G, Soderman P (2002) The Swedish Total Hip Replacement Register. J Bone Joint Surg Am 84-A(Suppl 2):2–20PubMedGoogle Scholar
  26. 26.
    Lindahl H, Malchau H, Herberts P, Garellick G (2005) Periprosthetic femoral fractures classification and demographics of 1049 periprosthetic femoral fractures from the Swedish National Hip Arthroplasty Register. J Arthroplasty 20(7):857–865. doi: 10.1016/j.arth.2005.02.001 CrossRefPubMedGoogle Scholar
  27. 27.
    Springer BD, Berry DJ, Lewallen DG (2003) Treatment of periprosthetic femoral fractures following total hip arthroplasty with femoral component revision. J Bone Joint Surg Am 85-A(11):2156–2162PubMedGoogle Scholar
  28. 28.
    Kavanagh BF (1992) Femoral fractures associated with total hip arthroplasty. Orthop Clin North Am 23(2):249–257PubMedGoogle Scholar
  29. 29.
    Masri BA, Meek RM, Duncan CP (2004) Periprosthetic fractures evaluation and treatment. Clin Orthop Relat Res 420:80–95. doi: 10.1097/00003086-200403000-00012 CrossRefPubMedGoogle Scholar
  30. 30.
    Naqvi GA, Baig SA, Awan N (2012) Interobserver and intraobserver reliability and validity of the Vancouver classification system of periprosthetic femoral fractures after hip arthroplasty. J Arthroplasty 27(6):1047–1050. doi: 10.1016/j.arth.2011.11.021 CrossRefPubMedGoogle Scholar
  31. 31.
    Fink B, Fuerst M, Singer J (2005) Periprosthetic fractures of the femur associated with hip arthroplasty. Arch Orthop Trauma Surg 125(7):433–442. doi: 10.1007/s00402-005-0828-0 CrossRefPubMedGoogle Scholar
  32. 32.
    Haidukewych GJ, Langford J, Liporace FA (2013) Revision for periprosthetic fractures of the hip and knee. J Bone Joint Surg Am 95(4):368–376PubMedGoogle Scholar
  33. 33.
    Levine BR, Della Valle CJ, Lewis P, Berger RA, Sporer SM, Paprosky W (2008) Extended trochanteric osteotomy for the treatment of vancouver B2/B3 periprosthetic fractures of the femur. J Arthroplasty 23(4):527–533. doi: 10.1016/j.arth.2007.05.046 CrossRefPubMedGoogle Scholar
  34. 34.
    Stevens SS, Irish AJ, Vachtsevanos JG, Csongradi J, Beaupre GS (1995) A biomechanical study of three wiring techniques for cerclage-plating. J Orthop Trauma 9(5):381–387. doi: 10.1097/00005131-199505000-00004 CrossRefPubMedGoogle Scholar
  35. 35.
    Zuurmond RG, van Wijhe W, van Raay JJ, Bulstra SK (2010) High incidence of complications and poor clinical outcome in the operative treatment of periprosthetic femoral fractures: an analysis of 71 cases. Injury. 41(6):629–633. doi: 10.1016/j.injury.2010.01.102 CrossRefPubMedGoogle Scholar
  36. 36.
    Parvizi J, Rapuri VR, Purtill JJ, Sharkey PF, Rothman RH, Hozack WJ (2004) Treatment protocol for proximal femoral periprosthetic fractures. J Bone Joint Surg Am 86-A(Suppl 2):8–16PubMedGoogle Scholar
  37. 37.
    Lerch M, von Lewinski G, Windhagen H, Thorey F (2008) Revision of total hip arthroplasty: clinical outcome of extended trochanteric osteotomy and intraoperative femoral fracture. Technol Health Care 16(4):293–300PubMedGoogle Scholar
  38. 38.
    Park YS, Moon YW, Lim SJ (2007) Revision total hip arthroplasty using a fluted and tapered modular distal fixation stem with and without extended trochanteric osteotomy. J Arthroplasty 22(7):993–999. doi: 10.1016/j.arth.2007.03.017 CrossRefPubMedGoogle Scholar
  39. 39.
    Masri BA, Campbell DG, Garbuz DS, Duncan CP (1998) Seven specialized exposures for revision hip and knee replacement. Orthop Clin North Am 29(2):229–240. doi: 10.1016/S0030-5898(05)70321-7 CrossRefPubMedGoogle Scholar
  40. 40.
    McGrory BJ, Bal BS, Harris WH (1996) Trochanteric osteotomy for total hip arthroplasty: six variations and indications for their use. J Am Acad Orthop Surg 4(5):258–267CrossRefPubMedGoogle Scholar
  41. 41.
    Charity J, Tsiridis E, Gusmao D, Bauze A, Timperley J, Gie G (2013) Extended trochanteric osteotomy followed by cemented impaction allografting in revision hip arthroplasty. J Arthroplasty 28(1):154–160. doi: 10.1016/j.arth.2012.07.002 CrossRefPubMedGoogle Scholar
  42. 42.
    Masri BA, Mitchell PA, Duncan CP (2005) Removal of solidly fixed implants during revision hip and knee arthroplasty. J Am Acad Orthop Surg 13(1):18–27CrossRefPubMedGoogle Scholar
  43. 43.
    Bhamra MS, Rao GS, Robson MJ (1996) Hydroxyapatite-coated hip prostheses: difficulties with revision in 4 cases. Acta Orthop Scand 67(1):49–52. doi: 10.3109/17453679608995608 CrossRefPubMedGoogle Scholar
  44. 44.
    Harris WH, White RE, Jr., Mitchell S, Barber F (1981) Removal of broken stems of total joint components by a new method: drilling, undercutting, and extracting without damage to bone. Hip 37–45. PMID:7333893Google Scholar
  45. 45.
    King S, Berend ME, Ritter MA, Keating EM, Faris PM, Meding JB (2008) Extended femoral osteotomy and proximally coated prosthesis for hip revision. Orthopedics 31(1):67. doi: 10.3928/01477447-20080101-21 CrossRefPubMedGoogle Scholar
  46. 46.
    Zhu Z, Ding H, Shao H, Zhou Y, Wang G (2013) An in vitro biomechanical study of different fixation techniques for the extended trochanteric osteotomy in revision THA. J Orthop Surg Res. 8:7. doi: 10.1186/1749-799X-8-7 CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Barrack RL, Butler RA (2005) Current status of trochanteric reattachment in complex total hip arthroplasty. Clin Orthop Relat Res 441:237–242. doi: 10.1097/01.blo.0000191274.42410.40 CrossRefPubMedGoogle Scholar
  48. 48.
    Schwab JH, Camacho J, Kaufman K, Chen Q, Berry DJ, Trousdale RT (2008) Optimal fixation for the extended trochanteric osteotomy: a pilot study comparing 3 cables vs 2 cables. J Arthroplasty 23(4):534–538. doi: 10.1016/j.arth.2007.05.028 CrossRefPubMedGoogle Scholar
  49. 49.
    Archibeck MJ, Rosenberg AG, Berger RA, Silverton CD (2003) Trochanteric osteotomy and fixation during total hip arthroplasty. J Am Acad Orthop Surg 11(3):163–173CrossRefPubMedGoogle Scholar
  50. 50.
    Jarit GJ, Sathappan SS, Panchal A, Strauss E, Di Cesare PE (2007) Fixation systems of greater trochanteric osteotomies: biomechanical and clinical outcomes. J Am Acad Orthop Surg 15(10):614–624CrossRefPubMedGoogle Scholar
  51. 51.
    Altenburg AJ, Callaghan JJ, Yehyawi TM, Pedersen DR, Liu SS, Leinen JA, Dahl KA, Goetz DD, Brown TD, Johnston RC (2009) Cemented total hip replacement cable debris and acetabular construct durability. J Bone Joint Surg Am 91(7):1664–1670. doi: 10.2106/JBJS.G.00428 CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Bauer TW, Ming J, D’Antonio JA, Morawa LG (1996) Abrasive three-body wear of polyethylene caused by broken multifilament cables of a total hip prosthesis. A report of these cases. J Bone Joint Surg Am 78(8):1244–1247PubMedGoogle Scholar
  53. 53.
    Silverton CD, Jacobs JJ, Rosenberg AG, Kull L, Conley A, Galante JO (1996) Complications of a cable grip system. J Arthroplasty.;11(4):400-404. PMID: 8792246 Doi:  10.1016/S0883-5403(96)80029-5
  54. 54.
    Ritter MA, Eizember LE, Keating EM, Faris PM (1991) Trochanteric fixation by cable grip in hip replacement. J Bone Joint Surg Br 73(4):580–581PubMedGoogle Scholar
  55. 55.
    Paprosky WG, Martin EL (2002) Removal of well-fixed femoral and acetabular components. Am J Orthop (Belle Mead NJ). 31(8):476–478PubMedGoogle Scholar
  56. 56.
    Firestone TP, Hedley AK (1997) Extended proximal femoral osteotomy for severe acetabular protrusion following total hip arthroplasty. A technical note. J Arthroplasty. 12(3):344–345. doi: 10.1016/S0883-5403(97)90034-6 CrossRefPubMedGoogle Scholar
  57. 57.
    Aribindi R, Paprosky W, Nourbash P, Kronick J, Barba M (1999) Extended proximal femoral osteotomy. Instr Course Lect 48:19–26PubMedGoogle Scholar
  58. 58.
    Paprosky WG, Weeden SH, Bowling JW Jr (2001) Component removal in revision total hip arthroplasty. Clin Orthop Relat Res 393:181–193. doi: 10.1097/00003086-200112000-00021 CrossRefPubMedGoogle Scholar
  59. 59.
    Meek RM, Garbuz DS, Masri BA, Greidanus NV, Duncan CP (2004) Intraoperative fracture of the femur in revision total hip arthroplasty with a diaphyseal fitting stem. J Bone Joint Surg Am 86(3):480–485PubMedGoogle Scholar
  60. 60.
    Adachi JD, Loannidis G, Berger C, Joseph L, Papaioannou A, Pickard L, Papadimitropoulos EA, Hopman W, Poliquin S, Prior JC, Hanley DA, Olszynski WP, Anastassiades T, Brown JP, Murray T, Jackson SA, Tenenhouse A (2001) Canadian Multicentre Osteoporosis Study Research G. The influence of osteoporotic fractures on health-related quality of life in community-dwelling men and women across Canada. Osteoporos Int 12(11):903–908. doi: 10.1007/s001980170017 CrossRefPubMedGoogle Scholar
  61. 61.
    Masterson EL, Masri BA, Duncan CP (1998) Surgical approaches in revision hip replacement. J Am Acad Orthop Surg 6(2):84–92CrossRefPubMedGoogle Scholar
  62. 62.
    Morrey BF, Kavanagh BF (1992) Complications with revision of the femoral component of total hip arthroplasty. Comparison between cemented and uncemented techniques. J Arthroplasty 7(1):71–79. doi: 10.1016/0883-5403(92)90035-O CrossRefPubMedGoogle Scholar
  63. 63.
    Wu CC, Au MK, Wu SS, Lin LC (1999) Risk factors for postoperative femoral fracture in cementless hip arthroplasty. J Formos Med Assoc 98(3):190–194PubMedGoogle Scholar
  64. 64.
    Busch CA, Charles MN, Haydon CM, Bourne RB, Rorabeck CH, Macdonald SJ, McCalden RW (2005) Fractures of distally-fixed femoral stems after revision arthroplasty. J Bone Joint Surg Br 87(10):1333–1336. doi: 10.1302/0301-620X.87B10.16528 CrossRefPubMedGoogle Scholar
  65. 65.
    Murphy SB, Rodriguez J (2004) Revision total hip arthroplasty with proximal bone loss. J Arthroplasty 19(4 Suppl 1):115–119. doi: 10.1016/j.arth.2004.04.001 CrossRefPubMedGoogle Scholar
  66. 66.
    Lakstein D, Eliaz N, Levi O, Backstein D, Kosashvili Y, Safir O, Gross AE (2011) Fracture of cementless femoral stems at the mid-stem junction in modular revision hip arthroplasty systems. J Bone Joint Surg Am 93(1):57–65. doi: 10.2106/JBJS.I.01589 CrossRefPubMedGoogle Scholar
  67. 67.
    Aleto T, Ritter MA, Berend M (2008) Case report: superficial femoral artery injury resulting from cerclage wiring during revision THA. Clin Orthop Relat Res 466(3):749–753. doi: 10.1007/s11999-007-0109-z CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Feugier P, Fessy MH, Carret JP, Fischer LP, Bejui J, Chevalier JM (1999) Total hip arthroplasty. Risk factors and prevention of iatrogenic vascular complications. Ann Chir 53(2):127–135PubMedGoogle Scholar
  69. 69.
    Nachbur B, Meyer RP, Verkkala K, Zurcher R (1979) The mechanisms of severe arterial injury in surgery of the hip joint. Clin Orthop Relat Res 141:122–133. doi: 10.1097/00003086-197906000-00014 PubMedGoogle Scholar
  70. 70.
    Mehta V, Finn HA (2005) Femoral artery and vein injury after cerclage wiring of the femur: a case report. J Arthroplasty 20(6):811–814. doi: 10.1016/j.arth.2004.12.050 CrossRefPubMedGoogle Scholar
  71. 71.
    Ritter MA, Lutgring JD, Davis KE, Berend ME, Meding JB (2006) A clinical, radiographic, and cost comparison of cerclage techniques: wires vs cables. J Arthroplasty 21(7):1064–1067. doi: 10.1016/j.arth.2006.01.002 CrossRefPubMedGoogle Scholar
  72. 72.
    Schutzer SF, Harris WH (1988) Trochanteric osteotomy for revision total hip arthroplasty. 97% union rate using a comprehensive approach. Clin Orthop Relat Res 227:172–183. doi: 10.1097/00003086-198802000-00021 PubMedGoogle Scholar

Copyright information

© Springer-Verlag France 2016

Authors and Affiliations

  • Senthil Nathan Sambandam
    • 1
  • Gopinath Duraisamy
    • 1
  • Jayadev Chandrasekharan
    • 1
  • Varatharaj Mounasamy
    • 2
    Email author
  1. 1.Department of OrthopaedicsK.G. Hospital and Postgraduate Medical InstituteCoimbatoreIndia
  2. 2.VCU Medical Center Ambulatory Care CenterRichmondUSA

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