A standardized soft tissue release technique to lower the risk of greater trochanteric fractures for the anterior approach in total hip arthroplasty

INTRODUCTION: The direct anterior approach (DAA) is suggested to accelerate postoperative recovery and decrease the dislocation risk after primary total hip arthroplasty (THA). However, exposure of the femur can be challenging. Insufficient exposure increases the risk for intraoperative femoral fracture. MATERIALS AND METHODS: Of 435 consecutive anterior THA, the first 102 consecutive THA in 94 patients were treated with an external rotator tendon "release-on-demand" (RoD). The following 311 consecutive patients (333 THA) underwent routine release of the conjoint tendon (CTR) of its bony insertion on the greater trochanter only. Retrospective analysis recorded trochanteric fractures, intraoperative calcar fractures, postoperative periprosthetic fractures, stem subsidence, ossifications, and dislocations. RESULTS: Three (2.9%) fractures of the greater trochanter were recorded in the RoD group, but no (0.0%) fractures occurred in the CTR group (p = 0.002). There was no significant difference in the occurrence of intraoperative calcar fractures (0% (RoD) vs. 1.2% (CTR), p = 0.267), postoperative periprosthetic fractures (0% (RoD) vs. 0.3% (CTR), p = 0.560), stem subsidence (2.0% (RoD) vs. 1.2% (CTR), p = 0.565) or ossifications (2.9% (RoD) vs. 1.6% (CTR), p = 0.344) between these groups. There were no dislocations within a minimum 12 months follow-up period. CONCLUSION: The routine release of the conjoined tendon (CTR group) decreases the shear forces on the tip of the greater trochanter during DAA THA and eliminates the risk of greater trochanter fractures. The routine release of the conjoined tendon did not increase the risk of postoperative dislocations.