title: Trans trochanteric approach with coronal osteotomy of the great trochanter: A new technique for extra-capsular trochanteric fracture patients treated by total hip arthroplasty (THA) in elderly.
abstract: Several surgical approaches could be used in hip arthroplasty or trauma surgery: anterior, anterolateral, lateral, posterior (with or without trochanterotomy), using or not an orthopedic reduction table. Subtrochanteric and extra-capsular trochanteric fractures (ECTF) are usually treated by internal fixation with mandatory restrictions on weight bearing. Specific complications have been widely described. Mechanical failures are particularly high in unstable fractures. Hip fractures are a major public health issue with a mortality rate of 12%-23% at 1 year. An alternative option is to treat ECTF by total hip arthroplasty (THA) to prevent decubitus complications, to help rapid recovery, and to permit immediate weight bearing as well as quick rehabilitation. However, specific risks of THA have to be considered such as dislocation or cardiovascular failure. The classical approach (anterior or posterior) requires the opening of the joint and capsule, weakening hip stability and the repair of the great trochanter is sometimes hazardous. For 15 years, we have been treating unstable ECTF by THA with cementless stem, dual mobility cup (DMC), greater trochanter (GT) reattachment, and a new surgical approach preserving capsule, going through the fracture and avoiding joint dislocation. Bombaci first described a similar approach in 2008; our trans fractural digastric approach (medial gluteus and lateral vastus) is different. A coronal GT osteotomy is performed when there is no coronal fracture line. It allows easy access to the femoral neck and acetabulum. The THA is implanted without femoral internal rotation to avoid extra bone fragment displacement. With pre-operative planning, cup implantation is easy and stem positioning is adjusted referring to the top of the GT after trial reduction and preoperative planning. The longitudinal osteotomy and trochanteric fracture are repaired with wires and the digastric incision is closed. This variant of Bombaci approach could be use routinely for hemiarthroplasty or THA in the cases of unstable ECTF. It reduces complications usually linked to this procedure. Blood loss, operating time, and pain are limited, allowing fast recovery in order to decrease morbidity and mortality.
authors.affiliation: Clinique des Cèdres 21 rue Albert Londres 38432 Echirolles France.
authors.forename: Francois
authors.initials: F
authors.lastname: Steffann
authors.affiliation: Clinique des Cèdres 21 rue Albert Londres 38432 Echirolles France.
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Prudhon
authors.affiliation: Clinique Saint-George 2 Avenue de Cimiez 06100 Nice France.
authors.forename: Jean-Marc
authors.initials: JM
authors.lastname: Puch
authors.affiliation: Clinique du Parc 155 Ter Boulevard de Stalingrad 69006 Lyon France.
authors.forename: André
authors.initials: A
authors.lastname: Ferreira
authors.affiliation: Clinique Saint-George 2 Avenue de Cimiez 06100 Nice France.
authors.forename: Loys
authors.initials: L
authors.lastname: Descamps
authors.affiliation: Groupe Lépine 175 rue Jacquard CS 50307 69727 Genay Cedex France.
authors.forename: Régis
authors.initials: R
authors.lastname: Verdier
authors.affiliation: Clinique Emilie de Vialar 116 rue Antoine Charial 69003 Lyon France.
authors.forename: Jacques
authors.initials: J
authors.lastname: Caton
keywords: Dual mobility cup; Extra capsular trochanteric fracture; Femoral neck fracture; Hip surgical approach; Total hip arthroplasty