Article

Distal Extension of the Direct Anterior Approach to the Hip Poses Risk to Neurovascular Structures: An Anatomical Study

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Abstract

The anterior approach to the hip gained popularity for total hip arthroplasty in recent years. Distal extension of the anterior approach, sometimes needed intraoperatively, potentially endangers neurovascular structures to the quadriceps. The aim of this study was to determine the anatomical structures placed at risk by distal extension of the anterior approach to the hip. Seventeen cadaveric hemipelves from twelve human specimens were dissected. The femoral nerve and its branches and the vessels arising from the lateral femoral circumflex artery were assessed in relation to the distal extension of the anterior approach. The damage caused by the introduction of a cerclage cable passer was also investigated. The area immediately distal to the intertrochanteric line is a common entry point for several nerve branches and is a useful distal landmark for surgeons to use to protect important neurovascular structures. The distal extension of the anterior approach compromises the nerve supply to the anterolateral portions of the quadriceps. Introduction of a cerclage cable passer through the anterior access also jeopardizes nerve branches to the vastus lateralis, lateral parts of the vastus intermedius, and branches of the lateral femoral circumflex artery. Distal extension of the direct anterior approach to the hip is challenging to accomplish without neurovascular injury to anterolateral parts of the quadriceps muscle group. In addition, important neurovascular structures are endangered with the introduction of a cable passer through the anterior approach. Distal extension of the direct anterior approach to the hip beyond the intertrochanteric line may compromise neurovascular structures supplying the quadriceps muscle. Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.

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... The direct anterior approach for THA was developed as a true internervous and intermuscular surgical approach 8 with proposed benefits of faster recovery, quicker return to function, and less pain. Despite superiority claims and widespread marketing 9 , conflicting or equivocal findings have been published regarding implant alignment and placement [10][11][12][13][14][15][16] ; nerve damage [17][18][19][20] ; muscle damage 21,22 ; intraoperative and early postoperative complications including time under anesthesia, blood loss, fracture, dislocation, and wound problems 14,15,20,[23][24][25][26][27][28][29][30][31] ; pain 23,32,33 ; hospital length of stay 20,23,24,28,32,33 ; and functional outcomes 14-16,20,24,28,32-39 . Limitations of this approach have been identified and include increased surgical time 15 , greater blood loss 15 , lateral femoral cutaneous nerve injury 17,40 , complex femoral exposure and preparation 40 , radiation exposure with intraoperative imaging, wound complications 25 , and a technical learning curve [40][41][42] associated with proximal femoral fractures and loosening. ...
... The mechanisms of early THA failure are provided in Table II by primary surgical approach. Twelve femoral periprosthetic fractures (4 following the direct anterior approach, 6 following the direct lateral 18,2017 approach, and 2 following the posterior approach) that occurred later than 90 days after surgery (mean = 27.3 months, SD = 20.6 months) were excluded from the table. ...
... It has been documented that marketing has biased claims of superiority without reference to peer-reviewed literature 9 . Equivocal findings have been published regarding implant alignment and placement [10][11][12][13][14][15][16] ; nerve damage [17][18][19][20] ; muscle damage 21,22 ; intraoperative and early postoperative complications including time under anesthesia, blood loss, fracture, dislocation, and wound problems 14,15,20,[23][24][25][26][27][28][29][30][31] ; pain 23,32,33 ; hospital length of stay 20,23,24,28,32,33 ; and functional outcomes [14][15][16]20,24,28,[32][33][34][35][36][37][38][39] . ...
Article
Background: The direct anterior approach for total hip arthroplasty (THA) is marketed with claims of superiority over other approaches. Femoral exposure can be technically challenging and potentially lead to early failure. We examined whether surgical approach is associated with early THA failure. Methods: A retrospective review of 478 consecutive early revision THAs performed within 5 years after the primary THAs at 3 academic centers from 2011 through 2014 was carried out. Exclusion criteria resulted in a final analysis sample of 342 early-failure THAs. The surgical approach of the primary operation that was revised, the time to the revision, and the etiology of the failure leading to the revision were documented. Results: Analysis of the revisions due to early femoral failure showed them to be more common in patients who had undergone the direct anterior approach (57/112; 50.9%) than in those treated with the direct lateral (39/112; 34.8%) or the posterior (16/112; 14.3%) approach (p = 0.001). In multivariate regression analysis controlling for age, sex, laterality, Dorr bone type, body mass index (BMI) at revision, bilateral procedure (yes/no), and femoral stem type, the direct anterior approach remained a significant predictor of early femoral failure (p = 0.007). The majority of early revisions due to instability were associated with the posterior (19/40; 47.5%) or direct anterior (15/40; 37.5%) approach (p = 0.001 for the comparison with the direct lateral approach [6/40; 15.0%]). Conclusions: Despite claims of earlier recovery and improved outcomes with the direct anterior approach for THA, our findings indicate that that approach may confer a greater risk of early femoral failure and, along with the posterior approach, confer a greater risk of early instability compared with the direct lateral approach. Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
... 1 3 posterior and lateral approaches; whereas, the DAA is often considered for primary THA only. This concern is, among others, based on the assumption that the distal extension of the DAA is limited due to associated damage of neurovascular structures [16]. Thus, exposure might be insufficient for revision surgery [16,17]. ...
... This concern is, among others, based on the assumption that the distal extension of the DAA is limited due to associated damage of neurovascular structures [16]. Thus, exposure might be insufficient for revision surgery [16,17]. Additionally, the limited visualization of the acetabular cup and the femoral stem as well as the technical difficulty to remove the femoral stem through this approach further discourages surgeons from using the DAA in the revision setting. ...
... At the authors institution, the femoral diaphysis is accessed at the posterior border of the vastus lateralis muscle, since splitting the vastus lateralis muscle or using the interval between the rectus femoris muscle and the vastus lateralis muscle endangers innervating branches of the femoral nerve to the structures lateral to the incision, thereby affecting the vastus lateralis and the lateral portions of the vastus intermedius [16,17,24]. If revision of the femoral component is performed, it is often necessary to have a direct approach down the femoral medullary canal to safely exchange the femoral stem. ...
Article
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Background To date, only limited literature exists regarding revision of total hip arthroplasty (THA) through the direct anterior approach (DAA). However, as the popularity of the DAA for primary surgery is increasing, surgeons will be confronted with the challenge of performing revision surgery through the DAA. The aim of this study was to review the potential of the DAA in the revision setting and to report the clinical results, radiologic outcomes and complication rates of 63 patients undergoing revision THA through the DAA.Methods From 01/2009 to 08/2017, 63 patients underwent revision THA through the DAA. Depending on the performed procedure, patients were separated into 4 groups: liner and head exchange (21 patients), revision of the acetabular cup (26 patients), revision of the femoral stem (13 patients) or revision of both components (3 patients). Postoperative complications as well as the clinical and radiological outcome were assessed retrospectively.ResultsAt a mean follow-up of 18 months, the overall complication and re-operation rates were 14.3% and 12.7%, respectively. Specifically, the complication and re-operation rates were 14.2% and 9.5% after liner and head exchange, 15.4% after revision of the acetabular cup, 15.3% after revision of the femoral stem and 0% after revision of both components. The mean postoperative HHS at 1 year postoperatively was 91 (range 74–100).Conclusion The DAA offers appropriate exposure for exchange of mobile liners and acetabular cup revision. In selected cases with appropriate stem design, femoral stem revision through the DAA is feasible. However, surgeons should be aware of the technical difficulties related to femoral revision and be prepared to extend the approach distally or perform a trochanteric osteotomy.
... There is, however, limited evidence suggesting a marked difference in outcomes between the DAA and other surgical approaches [3][4][5][6][7][8]. In fact, some studies suggest that the DAA requires a long learning curve which may lead to increased rates of complication [2,[9][10][11][12][13]. ...
... Many of our patients agreed that the DAA had superior outcomes to other approaches. Yet, a large amount of peer-reviewed literature contradicts this claim [1][2][3][4][5][6][7][8][9][10][11][12][13][28][29][30][31]. A meta-analysis of 12 randomly controlled trials compared the DAA with other techniques of THA, showing that the DAA has similar rates of complications, transfusions, and post-operative radiographic results [8]. ...
... The QF is reported to show little morphological variation, only duplication of the VM or vastus lateralis (VL) in some cases [2,3]. However, its morphological variability has been increasingly studied in recent years [4][5][6][7]. A fifth head of the QF, the tensor vastus intermedius (TVI), has been observed [4][5][6][8][9][10][11]. Also, recent studies suggest that the QF is not exactly a quadriceps; since cases of six, seven, or eight bellies have been observed, it should be termed a multiceps femoris [7,12]. ...
... However, its morphological variability has been increasingly studied in recent years [4][5][6][7]. A fifth head of the QF, the tensor vastus intermedius (TVI), has been observed [4][5][6][8][9][10][11]. Also, recent studies suggest that the QF is not exactly a quadriceps; since cases of six, seven, or eight bellies have been observed, it should be termed a multiceps femoris [7,12]. ...
Article
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Introduction: The quadriceps femoris consists of four muscles: the rectus femoris, vastus medialis, vastus intermedius, and vastus lateralis. However, the effect of additional quadriceps femoris heads on the vasti muscles and patellar ligaments is unknown. The aims of the present study are to determine the relationship between additional quadriceps femoris heads and the vasti muscles and patellar ligaments and to review the morphology of the vastus lateralis, vastus medialis, and vastus intermedius. Materials and methods: One hundred and six lower limbs (34 male and 19 female cadavers) fixed in 10% formalin were examined. Results: On all lower extremities, the vastus lateralis consisted of superficial, intermediate, and deep layers. The vastus medialis, on the other hand, consisted of only the longus and obliquus layers. The quadriceps head had one or more supplementary heads in 106 dissected limbs from 68 cadavers (64.1%). The distal portion of the patella was wider in lower limbs without supplementary heads than in type IA but narrower than in type IIIA. In general, the distal portion of the patella was narrower in specimens with a supplementary head than in those without (19.03 SD 3.18 mm vs. 20.58 SD 2.95 mm, p = 0.03817). Other patellar ligament dimensions did not differ significantly. Conclusion: The quadriceps femoris muscle is characterized by high morphological variability. Occurrence of extra heads is at the level of 64.1%. The vastus lateralis consists of three parts (superficial, intermediate, and deep), and vastus medialis consists of two (longus and oblique).
... However, previous anatomical dissections revealed that the interaction between the components of the quadriceps muscle group is more complex and intricate than was initially described. Furthermore, dissections revealed different morphological findings between the VI and VM compared to classic descriptions in the literature [10,12,13]. Loss of knee extension occurs most rapidly due to inactivity of the VM (28). ...
... This interpretation is supported by the innervation pattern of both muscles (Fig. 5). With regard to its innervation, the VI can also be divided into a medial and lateral section [10][11][12][13]. ...
Article
Purpose: Although the vastus medialis (VM) is closely associated with the vastus intermedius (VI), there is a lack of data regarding their functional relationship. The purpose of this study was to investigate the anatomical interaction between the VM and VI with regard to their origins, insertions, innervation and function within the extensor apparatus of the knee joint. Methods: Eighteen human cadaveric lower limbs were investigated using macro-dissection techniques. Six limbs were cut transversely in the middle third of the thigh. The mode of origin, insertion and nerve supply of the extensor apparatus of the knee joint were studied. The architecture of the VM and VI was examined in detail, as was their anatomical interaction and connective tissue linkage to the adjacent anatomical structures. Results: The VM originated medially from a broad hammock-like structure. The attachment site of the VM always spanned over a long distance between: (1) patella, (2) rectus femoris tendon and (3) aponeurosis of the VI, with the insertion into the VI being the largest. VM units were inserted twice-once on the anterior and once on the posterior side of the VI. The VI consists of a complex multi-layered structure. The layers of the medial VI aponeurosis fused with the aponeuroses of the tensor vastus intermedius and vastus lateralis. Together, they form the two-layered intermediate layer of the quadriceps tendon. The VM and medial parts of the VI were innervated by the same medial division of the femoral nerve. Conclusion: The VM consists of multiple muscle units inserting into the entire VI. Together, they build a potential functional muscular complex. Therefore, the VM acts as an indirect extensor of the knee joint regulating and adjusting the length of the extensor apparatus throughout the entire range of motion. It is of clinical importance that, besides the VM, substantial parts of the VI directly contribute to the medial pull on the patella and help to maintain medial tracking of the patella during knee extension. The interaction between the VM and VI, with responsibility for the extension of the knee joint and influence on the patellofemoral function, leads readily to an understanding of common clinical problems found at the knee joint as it attempts to meet contradictory demands for both mobility and stability. Surgery or trauma in the anteromedial aspect of the quadriceps muscle group might alter a delicate interplay between the VM and VI. This would affect the extensor apparatus as a whole.
... However, both techniques split the VL and can cause damage to one or both of the neurovascular bundles. The terminal branches of the MNVL course from anteroproximal to posterodistal in the substance of the muscle and a VL split leads to denervation of the muscle posterior to the split [21]. In addition, the majority of the proximal insertion of the VL and VI is peeled off the femur. ...
... In addition, the majority of the proximal insertion of the VL and VI is peeled off the femur. In a recent anatomic study, Grob et al described a neurovascular web of branches of the LFCA and motor branches of the femoral nerve coursing toward the VL and VI [21]. The authors concluded that a distal extension of the DAA poses a risk to neurovascular structures. ...
Article
Background: The direct anterior approach (DAA) is becoming more popular as the standard surgical approach for primary total hip arthroplasty. However, it has been associated with an increased incidence of intraoperative femoral fractures in particular during the learning curve. Distal extension of the approach may be needed in case of intraoperative complications. The aim of the present study is to describe the distal extension of the DAA using the femoral interbundle technique. Methods: A stepwise approach based on a cadaveric study to extend the DAA distally is presented. The interval between the neurovascular bundles running to the vastus lateralis is used to gain access to the femur. Clinical and electromyography results of 5 patients undergoing a revision of the femoral component through an extended anterior approach are reported. Results: In 2 cases, the proximal bundle was exposed whereas in 3 cases the interval between the proximal and distal bundle was developed and cerclage wires were applied around the isthmus of the femur. All fractures had healed at 6 months of follow-up. Four cases had a normal electromyography, and 1 case demonstrated a neuropraxia of a branch to the vastus lateralis. All cases had a 5/5 extension power of the quadriceps muscle clinically. Conclusion: The interbundle technique is an alternative way to gain additional exposure of the femur during the DAA and is based on precise knowledge of the periarticular neurovascular structures. This approach can be helpful to safely deal with intraoperative complications such as fractures requiring proximal femoral cerclage wiring during the anterior approach.
... In direct anterior approach for total hip arthroplasty, there are various potential sources of blood loss which may contribute to the substantial post-operative bleeding. Of particular concern in this surgical approach is the ascending branch of the lateral femoral circumflex artery, which has been commonly identified as a source which requires haemostasis [8]. To achieve haemostasis intra-operatively, suture ligation or electrical cautery are commonly used. ...
... In addition, investigators have also noted that skin incision healing is quite slow, because of which, they argued, application of electrocautery should be limited to reduce the postoperative complications [13]. In comparison to conventional bipolar cautery, a new blood loss device known as a bipolar sealant is able to provide haemostasis at lower temperatures (<100°C) [6][7][8][9][10]. The bipolar sealant delivers radiofrequency energy in a saline medium for haemostatic sealing and coagulation of tissue. ...
... Similar to Manrique et al. [12], the authors emphasized superior acetabular exposure in the revision setting with the anterior approach and simplified ability to address defects in any acetabular region. The DAA is also extensile distally, although there is concern for neurovascular compromise to the vastus lateralis and lateral portions of the vastus intermedius [49]. A study by Kennon et al. [50] found no clinical neurologic deficits with the DAA, and techniques have been described [14] to avoid potential neurologic compromise by leaving a bridge of tissue with the nerve supply undisturbed, which is our preference. ...
Article
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A 74-year-old female patient presented to our clinic with pelvic discontinuity after multiple revision total hip surgeries requiring custom triflange acetabular reconstruction, which we accomplished through a direct anterior approach to the hip. The direct anterior approach to the hip has grown in popularity but still has the reputation of being a minimally invasive approach without the capacity for extensile exposure in the revision setting. We describe the extensile technique and demonstrate through our case the ability to perform the most challenging cases through this approach and discuss the potential benefits of its utilization. Keywords: Direct anterior approach, Triflange, Revision hip arthroplasty, Extensile hip approach, Pelvic discontinuity, Acetabular defect
... Currently, it is uncertain whether the QF can be regarded as a quadriceps muscle. Although the previous literature has only reported the possibility of the duplication of the VL or VM (Le Double, 1897;MacAlister, 1875), recent studies have indicated the possibility that there may be a fifth head of the QF: the tensor of the vastus intermedius (TVI) (Bonnechère, Louryan, & Feipel, 2020;Golland & Mahon, 1986;Grob et al., 2015;Veeramani & Gnanasekaran, 2017;Willan, Mahon, & Golland, 1990). ...
Article
Purpose The quadriceps femoris (QF) consists of four muscles: the rectus femoris; vastus medialis; vastus lateralis, and vastus intermediate. The tendons of all of these parts join together into a single tendon that attaches to the patella. The QF is a powerful extensor of the knee joint that is needed for walking. A growing number of publications have examined the fifth head of the QF muscle. There is no information about the possibility of other heads, and there is no correct classification of their proximal attachments. Further, the frequency of occurrence of additional heads/components of the QF remains unclear. Methods One hundred and six lower limbs (34 male and 18 female) fixed in 10% formalin solution were examined. Results Additional heads of the QF were present in 64.1% of the limbs. Three main types were identified and included subtypes. The most common was Type I (44.1%), which had an independent fifth head. This type was divided into two subtypes (A‐B) depending on its location relative to the vastus intermediate. The second most common type was Type II (30.8%), which originated from other muscles: IIA from the vastus lateralis; IIB from the vastus intermediate, and IIC from the gluteus minimus. In addition, Type III (25%) was characterized by multiple heads : IIIA–two heads with a single common tendon; IIIB–two heads with two separate tendons; IIIC–three heads (lateral, intermediate, medial), and IIID–four heads (bifurcated lateral and bifurcated medial). Conclusion The introduction of a new classification based on a proximal attachment is necessary. The presence of the fifth, sixth, seventh, or eighth head varies. This article is protected by copyright. All rights reserved.
... Only in recent years, interest and enthusiasm have emerged for the anterior approach whether complex revision is indicated or not, and several authors have focused on extension of this approach proximally 9,19 or distally 20,21 and on the anatomy of the surrounding structures involved in the direct anterior approach. 20,21 However, to our knowledge, there is no report on surgical outcomes of revision THA through the direct anterior approach using reinforcement devices for hips with large acetabular bone defects. The direct anterior approach is a reasonable approach for acetabular reconstruction. ...
Article
Full-text available
Background: The direct anterior approach has gained popularity in total hip arthroplasty (THA) over the past decade. However, there are few reports that describe the use of this approach for cases of complex revision. The purpose of this study was to report the surgical procedure and early clinical results of acetabular revision in the presence of bone defects using a Kerboull-type reinforcement device through the direct anterior approach. Methods: Eleven patients who had undergone acetabular reconstruction using a Kerboull-type reinforcement device for aseptic or septic loosening bone defects were enrolled. All procedures were performed using the direct anterior approach on a standard operating table. The mean age was 71.8 years, the mean period from initial surgery to revision THA was 14.5 years, and the mean follow-up period was 19.8 months. Results: The Kerboull-type acetabular reinforcement device with cemented cup combined with allogenic femoral head bone grafts was used in all hips. The mean operative time and intraoperative blood loss were 148 min and 743 g, respectively. None of the patients required allogeneic blood transfusion. One patient required revision surgery 11 months postoperatively because of device displacement. No other major or minor orthopedic complications were observed. Conclusion: The direct anterior approach allows for less invasive acetabular reconstruction using a Kerboull-type reinforcement device.
... Beim vorderen Zugang zum Hüftgelenk können Nerven auf drei Ebenen direkt geschädigt werden [1][2][3]6]. ...
... Spontaneous rupture of the femoral artery through atherosclerotic plaques has also been described (4). Distal extension of the direct anterior approach, may increase the risk of vascular injuries (5). The aim of this study, describing a case of late bleeding in a female patient undergoing surgery for total hip arthroplasty via anterior approach, is to highlight the effectiveness of endovascular techniques for the treatment of early and late bleeding after surgery. ...
Article
Vascular injuries represent an uncommon complication of total hip arthroplasty, with an incidence of 0.1-0.3% as reported in the literature. The aim of the study is the description of a case of late bleeding in a female patient undergoing surgery for total hip arthroplasty in right osteoarthritis through direct anterior approach. The treatment carried out was a selective embolization of the main ascending branch of the lateral circumflex artery. This was performed by placing two spirals following an angiography, which was revealing an active spreading of contrast at the right femoral circumflex ascending artery. The effectiveness of endovascular techniques for the treatment of early and late bleeding after surgery is pointed out.
... To avoid this risk, we have reduced to the minimum the number of retractors used, two for most of the time, three only for acetabular preparation, and all of them are provided with blunt edges. We also take care not to damage the nervous and vascular branches for the thigh muscles (Fig. 4B) [31]. Moreover, in the supine position, the force required to elevate the femur, with the elevator that crushes the underlying TFL, gluteus medius and maximus, is much more of the force required in the lateral decubitus to translate anteriorly the femur. ...
Article
The direct anterior approach to the hip is judged to be difficult and even after many solutions, such as special operating tables, have been proposed to perform it, in some reports the complication rate remains high. The complications reported are nerve lesions, dislocation, muscles damages, intraoperative fractures. We describe a modification of the anterior approach, undertaken keeping the patient in lateral decubitus, in order to gain a better range of leg movement and a significant reduction of the force applied to the retractors, the technique was named ALDI (anterior lateral decubitus intermuscular) approach. The surgeon starts behind the patient as in all the other traditional approaches, to maintain unchanged the acetabular view and the dexterity in cup implantation. For the femoral preparation, he moves in front of the patient to have a better visualization. In a series of 150 patients, with a mean operative time of 51.38minutes (range, 40-112), we had no intraoperative fractures, one (0.6%) lateral femoral cutaneous nerve temporary neurapraxia, one (0.8%) posttraumatic dislocation four years after the operation and, no revisions for aseptic loosening or infection. At the 5 years follow-up, the mean Oxford Hip score was 45.2 (range, 38-48; SD 2.6), the mean Harris Hip Score was 96,7 (range, 76-100; SD 2.8), and the mean UCLA score was 7 (range, 5-10; SD 1.4). The possibility to always obtain the optimal position of the surgical window with reduced tension on the muscles, and the unchanged initial surgeon position, could make the ALDI approach the ideal technique for the surgeons that decide to perform an anterior approach.
... The tendons of all four muscles unite to form a single tendon, which inserts into the patella [12]. All heads of the quadriceps femoris are innervated by branches originating from the femoral nerve and supplied by branches of the deep femoral artery [13]. ...
Article
Full-text available
PurposeWe present a case of a seven-headed quadriceps femoris (QF) muscle and a systematic review of the literature concerning this anatomical variation.Methods During a routine dissection of the lower limbs of a 72-year old cadaver, a QF with supernumerary heads was identified. Each head of the muscle was photographed and subjected to further measurement.ResultsIn addition to the four traditional heads of the QF muscle, we found a tensor of the vastus intermedius (TVI) muscle and two additional muscle bellies composed of tendons. Attachments of the TVI tendon and additional tendons were localized on the superior medial border of the patella.Conclusion It is important to be aware of morphological variability of the quadriceps femoris muscle. The described case assists clinicist with avoiding misdiagnoses around the knee.
... One risk of the DAA is damage to the area of the lateral femoral cutaneous nerve (LFCN) with or without formation of scar tissue (Fig. 1, yellow arrows) [22,23]. The standard strategy to avoid this is to split the TFL fascia laterally and to continue preparation strictly subfascially. ...
Article
Full-text available
IntroductionSurgical approaches through smaller incisions reveal less of the underlying anatomy, and therefore, detailed knowledge of the local anatomy and its variations is important in minimally invasive surgery. The aim of this study was to determine the location, extension, and histomorphology of the deep layer of the iliotibial band during minimally invasive hip surgery using the direct anterior approach (DAA). Materials and methodsThe morphology of the iliotibial tract was determined in this cadaver study on 40 hips with reference to the anterior superior iliac spine and the tibia. The deep layer of the tractus iliotibialis was exposed up to the hip-joint capsule and length and width measurements taken. Sections of the profound iliotibial tract were removed from the hips and the thickness of the sections was determined microscopically after staining. ResultsThe superficial tractus iliotibialis had a length of 50.1 (SD 3.8) cm, while tensor fasciae latae total length was 18 (SD 2) cm [unattached 15 (SD 2.5) cm]. Length and width of the deep layer of the tractus iliotibialis were 10.4 (SD 1.3) × 3.3 (SD 0.6) cm. The deep iliotibial band always extended from the distal part of the tensor fascia latae (TFL) muscle to the lateral part of the hip capsule (mean maximum thickness 584 μm). Tractus iliotibialis deep layer morphology did not correlate to other measurements taken (body length, thigh length, and TFL length). Conclusions The length of the deep layer is dependent on the TFL, since the profound part of the iliotibial band reaches from the TFL to the hip-joint capsule. The deep layer covers the hip-joint capsule, rectus, and lateral vastus muscles in the DAA interval. To access the precapsular fat pad and the hip-joint capsule, the deep layer has to be split in all approaches that use the direct anterior interval.
... Abb. 2 dargelegten Parametern. Selbstverständlich ist im Rahmen der präoperativen Abklärungen das allgemeine Operationsrisiko abzuschät- [31]. Ist die quadrilaterale Fläche oder der vordere Pfeiler betroffen, kann die Stabilisierung über einen anterioren Zugang erfolgen. ...
Article
In most cases periprosthetic fractures of the acetabulum are complex injuries and are extremely challenging for the treating medical team. Over the years the frequency of this overall rare entity has increased due to demographic changes. In recent years several treatment algorithms were published and provided the possibility of developing standardized treatment concepts. The classification of the fractures and a dedicated preoperative strategy are highly important for the quality of patient-centered care. In the literature the frequency of intraoperative fractures was initially given as 0.4%; however, several studies have been published in which a far higher rate of intraoperative fractures was detected by computed tomography (CT), often referred to as so-called occult fractures. The causes are multifactorial and there is significant association with whether cement-free press-fit acetabular cups were used or cemented forms. In approximately 75% of the cases a low energy impact was the cause of the fracture. In these patients systemic processes, such as osteoporotic alterations of the bony substance or the possible presence of low-grade infections should be considered. This article gives an overview of the diagnostics, planning, challenges and osteosynthetic treatment options for periprosthetic fractures of the acetabulum.
... In particular, abduction and extreme external rotation could cause rupture of atherosclerotic plaque and subsequent formation of blood clots. The risk of vascular complications has been reported to be greater for an anterior than for a posterior approach [8,29,30]. The location of the Hohmann retractor during the surgery is also very important. ...
Article
Full-text available
There are an increasing number of vascular complications after hip replacement, some of which can be life-threatening. However, there are few reports of lower limb ischemic symptoms after undergoing an otherwise uncomplicated classic total hip replacement. We report a patient with small weight who developed postoperative limb ischemia resulting from blood clots caused by insertion of a Hohmann retractor close to small anterior acetabular osteophytes. Ultrasonography and angiography revealed her symptoms to be the result of femoral artery intimal injury with lower extremity arterial thrombosis, which led to pain, numbness, and decreased skin temperature. The patient underwent timely percutaneous intervention with a femoral artery stent, which relieved her symptoms. The discussion reviews femoral artery injury during total hip arthroplasty.
... A further example of surgical importance is seen when considering the direct anterior approach to the hip, which is commonly used in performing total hip replacement surgery. Authors have demonstrated that if a distal extension of the procedure is needed, in the case of operative complications such as femoral fracture, there is an increased risk of damaging the neurovascular bundles associated with the quadriceps femoris [8]. This potentially damages the tensor vastus intermedius, and so having a complete anatomical understanding of the muscle and its neurovasculature can allow surgeons to make operative decisions. ...
Article
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Background: This review aims to summarise the relevant literature surrounding the tensor vastus intermedius, a newly discovered muscle, and to discuss its morphology and potential clinical importance. No such review currently exists in the literature. Materials and methods: A comprehensive literature search regarding the tensor vastus intermedius was performed using PubMed and Google Scholar in July 2020. Principles of Evidence-Based Anatomy and the Anatomical Quality Assessment Tool were employed to ensure a high-level review. All relevant papers were included and citation tracking was performed to uncover further publications. Results: The tensor vastus intermedius is found in the anterior compartment of the thigh and has a similar morphology to the other vasti muscles. It has four main variations and a consistent neurovascular supply. The muscle has been implicated in a number of case reports and surgical procedures, which are described in detail in this paper. Conclusions: In the four years since the tensor vastus intermedius was formally described, a significant amount of work has been done to help us understand its structure and function. Further efforts are needed to gain a full picture as to its clinical importance. As such, it is recommended that this muscle should be acknowledged in anatomical education.
... The use of DAA, however, has been limited to use in primary hip arthroplasty. Enthusiasm for the DAA has arisen in recent years, whether in nuanced revisions or complex primary procedures; thus only recently have authors concentrated on the extension of this approach, either proximally or distally, as well as on the morphology of the surrounding anatomical structures in the DAA 14,29,30) . ...
Article
The direct anterior approach (DAA) is an established approach for total hip arthroplasty (THA) but has been sparingly tried for revisions. The purpose of this study was to examine the available literature in order to consolidate information available on revision THA using the DAA. A PubMed, Embase, and Scopus search was performed using relevant keywords. Studies reporting on patients undergoing revision THA using DAA were included for analysis. In a review of the literature, nine studies matched the pre-decided inclusion criteria with 319 hip joints undergoing revision THA. Mean follow-up of all included studies was 34 months. The indications of revision after primary THA in decreasing order were aseptic loosening (53%), prosthetic joint infection (20.7%), peri-prosthetic fracture (16.9%), dislocation (7.2%), psoas impingement (1.9%), polyethylene wear (1.2%), pain (0.6%), and instability (0.3%). Of the 319 revisions evaluated, 107 underwent a stem revision, 142 underwent cup revision, 49 underwent a combined revision, and 21 underwent isolated liner/head change. A statistically significant improvement in functional score (P<0.05) was observed for all studies reporting on functional outcomes. A low complication rate (51/319, 16.0%), which includes dislocation (12), infection (12), loosening of the acetabular shell (5), peri-prosthetic fractures (6), haematoma (4), and transient nerve palsy (6), was reported. Based on available level III-IV evidence, DAA appears to be a reliable alternative for revision of the failed hip arthroplasty with acceptable complication rates. Evidence of a higher quality is needed to further characterize its role in revision scenarios.
... A femoral shortening osteotomy performed through a lateral subvastus approach would have to be done through a new incision. A distal extension of the direct anterior approach to perform a femoral shortening osteotomy poses a great risk for neurovascular structures supplying the quadriceps muscle [44]. We acknowledge that other authors perform THA for higher grade dysplasia as well with satisfactory results; however, we limit the indication to DDH grade A and B according to Hartofilakidis for the above-mentioned reasons. ...
Article
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Background Developmental dysplasia is challenging to treat with total hip arthroplasty via the direct anterior approach (DAA). Reconstructing the former anatomy while restoring the acetabular bone stock for future revisions in this young patient collective combined with the known advantages of the DAA would be desirable. The purpose of this study was to analyze the feasibility, radiographic outcome and clinical outcome of primary uncemented total hip arthroplasty with bulk femoral head autograft for acetabular augmentation through a DAA with a minimal follow-up of 12 months. Methods A retrospective, consecutive series from March 2006 to March 2018 of 29 primary total hip arthroplasty with acetabular augmentation with bulk femoral head autograft through a direct anterior approach was identified. All complications, reoperations and failures were analyzed. Radiographic and clinical outcome was measured. Results 24 patients (29 hips) with a mean age of 43 (18–75) years and a mean follow-up of 35 months (12–137) were included. Surgical indication was secondary osteoarthritis for developmental dysplasia of the hip (Hartofilakidis Grade A ( n = 19), B ( n = 10)) in all cases. We noted no conversion of the approach, no dislocation and no acetabular loosening. The center of rotation was significantly distalized by a mean of 9 mm (0–23) and significantly medialized by a mean of 18 mm (6–29). The bone graft was fully integrated after 12 months in all cases. Conclusion Acetabular reconstruction with femoral head autograft in primary THA through a direct anterior approach seems to be a reliable option for the treatment of secondary osteoarthritis in patients with DDH Hartofilakidis grade A and B. Prospective cohort studies with a large sample population and a long-term follow-up are necessary to confirm our findings.
... It is interesting to ask whether the variant described here could be useful in this procedure. In the literature, we found another example of an additional structure in the QF region: a tensor of the vastus intermedius (TVI), a fifth head of the QF [6,[11][12][13]24]. This muscle usually grows out from the VL and VI. ...
Article
Full-text available
Purpose The aim of the present case is to describe an interesting variation of the additional head of the rectus femoris. Methods A male body donor, 81 years old at death, was subjected to routine anatomical dissection for research and teaching purposes at the Department of Anatomical Dissection and Donation, Medical University of Lodz, Poland. Results We have found an example of an accessory head of the quadriceps femoris, a double-headed rectus femoris in which the proximal attachment is connected to the rectus femoris muscle originating from the anterior inferior iliac spine. The muscle belly of this additional structure is separate but fused distally with the vastus lateralis muscle. It then passes into the patellar ligament inserted into the tibial tuberosity. Conclusions Knowledge of the possible occurrence of an additional head is nevertheless important for clinicians, especially for orthopedists performing reconstructive surgeries. It could also be significant for physiotherapists arranging rehabilitation plans after such surgeries because it could potentially help to achieve faster recovery.
... Ein ehemals anteriorer Zugang zur Hüfte sollte aufgrund des erhöhten Risikos der Schädigung neurovaskulärer Strukturen nicht gewählt bzw. erweitert werden [54]. Der (antero-)laterale Zugang zur Hüfte kann meist auch verwendet werden. ...
Article
In contrast to periprosthetic fractures of the femur, periprosthetic fractures of the acetabulum are rare complications - both primary fractures and fractures in revision surgery. This topic is largely under-reported in the literature; there are a few case reports and no long term results. Due to an increase in life expectancy, the level of patients' activity and the number of primary joint replacements, one has to expect a rise in periprosthetic complications in general and periprosthetic acetabular fractures in particular. This kind of fracture can be intra-, peri- or postoperative. Intraoperative fractures are especially associated with insertion of cementless press-fit acetabular components or revision surgery. Postoperative periprosthetic fractures of the acetabulum are usually related to osteolysis, for example, due to polyethylene wear. There are also traumatic fractures and fractures missed intraoperatively that lead to some kind of insufficiency fracture. Periprosthetic fractures of the acetabulum are treated conservatively if the implant is stable and the fracture is not dislocated. If surgery is needed, there are many possible different surgical techniques and challenging approaches. That is why periprosthetic fractures of the acetabulum should be treated by experts in pelvic surgery as well as revision arthroplasty and the features specific to the patient, fracture and prosthetic must always be considered. Georg Thieme Verlag KG Stuttgart · New York.
Article
Background: Femoral component revision is the treatment of choice for Vancouver type B2/B3 periprosthetic femur fractures (PFFs). The purpose of this study was to report the clinical outcome of revision total hip arthroplasty with the use of a modified extended trochanteric osteotomy (ETO) in PFF treatment. Methods: A total of 43 cases between 2000 and 2014 were analyzed. Clinical and radiographic evaluation was performed with a mean follow-up of 40 months. Patient survival after revision surgery, complications, radiographic outcomes, and quality of life and hip function were assessed. Results: Merle d'Aubignè and Postel score averaged 15, and mean postoperative Harris hip score was 70. Radiographic evaluation revealed that the ETO and fractures healed in all but 1 patient within 9 months. Component stability and apparent osseointegration were not coincident with healing of the osteotomy and fracture sites proximal to the inserted stem. Six patients (15%) developed postoperative complications, which included the following: 1 nonunion with progressive subsidence, 2 hip dislocations, 2 deep infections, and 1 breakage of the modular junction of the revision stem. Conclusion: The modified ETO with a lateral approach to the hip for the treatment of PFF is compatible with fracture healing, a low dislocation rate, and good clinical results. However, component stability and apparent osseointegration are coincident with fracture healing only in the distal aspect of the inserted stem. Absence of proximal osseointegration might lead to poor osseous support resulting in inadequate fatigue strength at the junction of the dual modular revision stem.
Article
In recent years the direct anterior approach to total hip arthroplasty has become increasingly popular. This popularization took place at a time when posterior approach surgeons were struggling with dislocation risks and slowed recovery due to now outdated techniques. However, at the same time that the anterior approach gained popularity, the standard posterior approach was also adapted and modernized. We present a modern minimally invasive posterior approach that we believe achieves the same degree of soft tissue preservation, with similar early recovery benefits as compared to the direct anterior approach, but with a lower risk profile and the potential for step wise adoption and a surgeon controlled learning curve.
Article
Objective: To retrospectively compare the mid-term effectiveness between by direct anterior approach (DAA) and by posterolateral approach in total hip arthroplasty (THA). Methods: Between January 2009 and December 2010, 110 patients (110 hips) treated with THA and followed up more than 5 years were chosen in the study. THA was performed on 55 patients by DAA (DAA group), and on 55 patients by posterolateral approach (PL group). There was no significant difference in gender, age, body mass index, types of hip joint disease, and preoperative Harris score between 2 groups ( P>0.05). The operation time, amount of bleeding, length of hospital stay, postoperative complications, and the Harris scores were recorded and compared. Results: There was no significant difference in operation time and length of hospital stay between 2 groups ( t=0.145, P=0.876; t=1.305, P=0.093). The amount of bleeding was significantly less in DAA group than in PL group ( t=2.314, P=0.032). All patients were followed up 5-7 years (mean, 5.97 years). Complications happened in 5 cases (9.1%) of DAA group and in 3 cases (5.5%) of PL group, and there was no significant difference in the incidence of complications between 2 groups ( χ2=0.539, P=0.463). There was significant difference in Harris scores at 6 months after operation between 2 groups ( t=2.296, P=0.014), but no significant difference was found in Harris score at 1 year and 5 years between 2 groups ( t=1.375, P=0.130; t=0.905, P=0.087). Further analysis, at 6 months after operation, the joint function score in DAA group was significantly higher than that in PL group ( t=1.087, P=0.034), while there was no significant difference in the pain score and range of motion score between 2 groups ( t=1.872, P=0.760; t=1.059, P=0.091). Conclusion: THA by DAA has the advantages of less bleeding and faster recovery. The short-term effectiveness is superior to the THA by traditional posterolateral approach, but there is no obvious advantage in the mid-term effectiveness.
Article
Background: The direct anterior approach (DAA) to the hip has been criticized as an approach that is limited to primary arthroplasty only. Our study objective was to demonstrate, in a cadaveric setting, that an alternate extension of the DAA can be used to reach the femur at the posterior border of the lateral vastus muscle without endangering the nerve supply. Methods: The iliotibial tract is split anteriorly and pulled laterally, thereby opening the interval to the lateral-posterior aspect of the vastus muscle. The muscle fascia is incised at the posterior border to access the femoral diaphysis. The vastus mobilization is started distally and laterally to the greater trochanter, leaving a muscular bridge between the vastus and the medial gluteal muscle intact. If it is necessary to open the femoral cavity for implant retrieval, we perform an anterior wall osteotomy instead of an extended trochanteric osteotomy. Results: It was possible to split the iliotibial band and pull it laterally, thereby exposing the entire vastus lateralis muscle. The junction of the vastus lateralis and vastus intermedius was not encountered in all cases, nor was the nerve supply with all nerve fibers in that interval. Conclusion: The alternate technique described here for accessing the femoral diaphysis allows for easy access to the lateral aspect of the vastus lateralis and the femoral diaphysis. Using this technique, it should also be possible to access the femur and perform all necessary reconstructive procedures on it without damaging the surrounding nerve structures.
Article
The direct anterior (DA) approach for total hip arthroplasty (THA) has become increasingly popular. However, femoral access can be more technically challenging in difficult cases as compared with other approaches. Conjoint tendon release can improve proximal femoral exposure, but its effect on patient function and pain has not been studied. This study evaluated the effect of conjoint tendon release on length of stay (LOS), inpatient pain medication requirements, and functional outcomes of patients undergoing DA THA. The authors retrospectively reviewed charts of all primary DA THAs conducted by a single surgeon between August 2012 and July 2015. Patient demographics, bilateral THA cases, intraoperative conjoint tendon or other soft tissue releases, intraoperative complications, LOS, and inpatient pain medication data were evaluated. One-year functional outcome scores, including the Western Ontario and McMaster Universities Osteoarthritis Index and the Harris Hip Scores, were also reviewed. The authors identified 312 primary DA THAs, with 29 concurrent bilateral THAs. The conjoint tendon was released in 180 cases, whereas a tensor fascia lata (TFL) was released for 29 cases. Mean LOS was 1.3±1.1 days, with patient age (P=.002), bilateral THA (P<.001), TFL release (P=.005), and intraoperative complications (P=.002) predictive of LOS. Mean daily morphine equivalent dose narcotic use was 43.2±48.2 mg, with age being a negative predictor of narcotic use (P=.019). Conjoint tendon release was not predictive of LOS, inpatient pain medication requirements, or outcome scores. Given that conjoint release improves femoral exposure but does not affect LOS or 1-year patient-reported outcomes, intraoperative thresholds for conjoint release should be low. [Orthopedics. 201x; xx(x):xx-xx.].
Thesis
Die Implantation einer Hüfttotalendoprothese ist eine der erfolgreichsten operativen Eingriffe der letzten Jahrzehnte. Aufgrund der demografischen Entwicklung und exzellenter postoperativer Ergebnisse wird die Anzahl dieser Eingriffe in den nächsten Jahren weiter zunehmen. So kommen Fast-Track-Programme mehr und mehr zur Anwendung, um die postoperative Mobilität der Patient/-innen zu verbessern und eine frühzeitige Entlassungsbereitschaft zu ermöglichen. Neben einer adäquaten Schmerztherapie nimmt dabei die frühe Mobilisierung eine zentrale Rolle ein, wobei ältere, adipöse und schwer erkrankte Patient/-innen häufig von einer Frühmobilisierung ausgeschlossen werden. So konnten die Ergebnisse dieser Studie die Effektivität einer Frühmobilisierung bestätigen und nachweisen, dass nach Implantation einer primären Hüfttotalendoprothese die bereits am Operationstag beginnende Mobilisierung mit einer signifikant kürzeren RFD verbunden war. Zudem waren die frühmobilisierten Patient/-innen in Bezug auf ihre Mobilität während der ersten fünf Tage nach der Operation im Vorteil. Eine vermehrte Schmerzsymptomatik, ein vermehrter Schmerzmittelkonsum oder eine höhere Komplikationsrate konnte während des stationären Aufenthaltes nicht dargestellt werden. Auch bei älteren, adipösen und schwer erkrankten Patient/-innen ließ sich nach sofortiger postoperativer Mobilisierung ein positiver Effekt nachweisen. Während die Komplikationsrate durch die bereits am Operationstag beginnende Mobilisierung verringert werden konnte, waren die RFD-Unterschiede in allen Untergruppen größer, so dass im Rahmen von Fast-Track-Programmen diese Patient/-innen aus o. g. Gründen nicht von einer frühen Mobilisierung ausgeschlossen werden sollten.
Article
Full-text available
Total hip arthroplasty through an anterior approach has been increasing in popularity amongst surgeons and patients. Anterior approach hip arthroplasty seems to offer improved early outcomes in terms of pain, rehabilitation and length of stay. No difference in long-term outcomes has been shown between anterior and posterior or lateral approaches. Proper formal training, utilization of fluoroscopy and adequate experience can mitigate risks of complications and improve early and medium-term outcomes. Cite this article: EFORT Open Rev 2018;3:574-583. DOI: 10.1302/2058-5241.3.180023.
Article
Resumen La vía de acceso anterior realizada según el método de Hueter-vaina es una vía intersticial que ofrece el camino más directo para el acceso de la cadera. Cuando se realiza en una mesa convencional, requiere seguir unos tiempos de liberación articular precisos ayudados por un entorno ancilar específico. Esta técnica proporciona al cirujano una gran libertad de evaluación en tiempo real de la estabilidad articular y de las longitudes de los miembros. En el postoperatorio, la ganancia funcional es rápida y las luxaciones son raras, lo que facilita la integración de los pacientes en circuitos de recuperación rápidos. En cambio, su aprendizaje es largo y las dificultades técnicas son numerosas. En particular, hay que insistir en la importancia de la exposición femoral, de la que depende la realización correcta de la artroplastia. Una vez superada la fase de aprendizaje, la vía de acceso anterior directa en mesa convencional permite ampliar las indicaciones hacia las reintervenciones acetabulares, incluso complejas.
Chapter
The ideal hip replacement relieves pain and restores joint function. Anatomic reconstruction with attention to mechanical force balance is essential for longevity. This can be achieved through careful attention to the summative parameters of global offset and leg length. With these parameters in mind, surgeons can reliably reconstruct optimal functional joint mechanics in most cases. The anterior approach to the hip offers distinct advantages toward achieving this goal compared to lateral and posterolateral approaches.
Chapter
Introducing the direct anterior approach (DDA) to the hip joint in a university hospital is a multilevel challenge. A good preparation of the whole team includes multiple changes: changed patient information, adapted rehabilitation for the physiotherapist, shorter hospitalization and organization time for the social workers, knowledge and use of the instruments and HANA-table for operating room staff, changed but simplified after-care on the wards, and acquisition of surgeons’ knowledge and skills. The whole department has to be familiar with the new methods. Surgical preparation includes training of the technique to understand new anatomical references, material, pitfalls, and choice of the right patient and anticipating intraoperative challenges with the new technique. Fellowships and cadaveric dissections are good options to learn, reduce complications, and shorten the learning curve. Choosing simple first cases is challenging and needs a well-founded selection to prevent complications. With each case, the team finally gains more experience for the further performance of more complex total hip arthroplasty through the DAA with the main objective of superior clinical results for the patient.
Article
Background No prior studies have examined outcomes based on approach concordance between primary and revision total hip arthroplasty (THA). There is theoretical concern that performing surgery through multiple planes could potentiate dislocation risk. This study aimed to assess impact of utilizing concordant versus discordant surgical approaches between primary and revision THA on incidence of dislocation, re-revision, reoperation, and non-operative complications. Methods Between 2000–2018, 705 revision THAs were retrospectively identified in patients who underwent primary THA at the same academic center. Surgical approach was determined for primary and revision THA from operative notes with dislocations, re-revisions, reoperations, and complications determined from our total joint registry. Complication rates were compared between those with concordant and discordant surgical approaches. Mean age was 65 years, 50% were female, mean BMI was 31 kg/m², and mean follow-up was 4 years. Results Surgical approach discordance occurred in 97 cases (14%), which was more frequent when the direct anterior approach was used for primary THA (72%, p<0.001) compared to lateral (12%) or posterior (10%) approaches. There were no statistically significant differences in the incidence of dislocations, re-revisions, reoperations, and non-operative complications among those with concordant and discordant approaches for the overall cohort and when analyzed by primary approach (p>0.05 for all). Conclusion Comparable dislocation and complication rates were observed among revision THAs with concordant and discordant approaches between primary and revision THA. These data provide reassurance that changing versus maintaining the surgical approach from primary to revision THA does not significantly increase dislocation or re-revision risk.
Article
Lateral trochanteric pain (LTP) is a common complication after total hip arthroplasty (THA). The goals of this study were to report the incidence of LTP after direct anterior approach (DAA) THA, describe the treatment course and outcomes, and examine patient-specific and implant-related potential risk factors. A retrospective review identified patients who underwent primary DAA THA with at least 1-year follow-up. Postoperative functional outcome scores and LTP occurrence were recorded. Patient demographics, surgical indications, implant characteristics, medical comorbidities, and radiographic parameters were obtained. Logistic regression analysis was used to identify risk factors. A total of 610 THA procedures were performed for 563 patients (mean follow-up, 30.9±15.2 months). The overall incidence of LTP was 11.6%. All cases of LTP were successfully treated conservatively, although these patients, compared with patients who did not have postoperative LTP, experienced significantly lower functional outcome scores (Harris Hip Score, 96.6±4.7 [range, 55-100] vs 89.9±8.5 [range, 42-100], respectively; P<.001). Logistic regression analysis identified female sex (odds ratio, 2.30; 95% CI, 1.32-4.02), diabetes mellitus (odds ratio, 2.32; 95% CI, 1.11-4.88), hypertension (odds ratio, 1.94; 95% CI, 1.15-3.28), and the use of an offset acetabular liner (odds ratio, 2.50; 95% CI, 1.06-5.91) as independent risk factors for LTP. There was no correlation between LTP and radiographic parameters. The incidence of LTP after DAA THA is similar to reported rates for other THA surgical approaches. Female sex, medical comorbidities, and the use of offset acetabular liners are likely associated, and patients should be counseled appropriately. Postoperative LTP results in worse functional outcomes, although all cases can be treated conservatively. [Orthopedics. 202x;4x(x):xx-xx.].
Chapter
The incidence of nerve injury ranges from 0.17% to 3.7% during primary hip arthroplasty and is reported to be as high as 7.5% in revision surgery. It is an often serious complication arising from this frequently performed surgical procedure. There is a wide range of severity of nerve injury, with more severe injuries having a notable impact on the patient’s overall functional outcome. In describing the pathophysiology and risk factors for nerve injury during total hip arthroplasty, the authors will delineate preventative measures and appropriate steps for referral and subsequent management.
Article
Riassunto La via d’accesso anteriore eseguita utilizzando il metodo di Hueter (mini open) è un approccio interstiziale che permette la via più diretta per avvicinarsi all’anca. Eseguito su tavolo operatorio standard, richiede tempi di rilascio articolari precisi coadiuvati da uno strumentario ausiliario specifico. Questa tecnica offre all’operatore grande libertà nella valutazione della stabilità articolare e della lunghezza degli arti in tempo reale. Dopo l’intervento, il guadagno funzionale è veloce e le lussazioni sono rare e ciò facilita l’integrazione dei pazienti nei circuiti di recupero rapido. Di contro, l’addestramento richiede tempo e si possono presentare molte insidie tecniche. In particolare, va sottolineata l’importanza dell’esposizione femorale, che condiziona il buon esito del completamento dell’artroplastica. Terminata la fase di apprendimento, la via d’accesso anteriore diretta su tavolo operatorio standard consente di estendere le indicazioni a revisioni acetabolari anche complesse.
Preprint
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Introduction: The quadriceps femoris consists of four muscles: the rectus femoris, vastus medialis, vastus intermedius and vastus lateralis. However, the effect of additional quadriceps femoris heads on the vasti muscles and patellar ligaments is unknown. Materials and Methods: One hundred and six lower limbs (34 male and 19 female cadavers) fixed in 10% formalin were examined. Results: On all lower extremities, the vastus lateralis consisted of superficial, intermediate and deep layers. The vastus medialis, on the other hand, consisted of only the longus and obliquus layers. Additional quadriceps femoris heads affected both the vasti muscles and the patellar ligaments. Conclusion: There is a strong correlation between the presence of accessory quadriceps femoris heads and effects on vasti muscles and patellar ligament.
Chapter
Over the last decade, MIS, or soft tissue sparing, THA has emerged as a viable alternative to “conventional” THA. Much has been published both in the scientific literature as well as lay literature with regard to the advantages of various minimally invasive techniques. Most of the attention has been focused on the anterior approach. However, as more data has become available regarding complication rates, it has become clear there is a price to the adoption of these techniques. We propose an alternative minimally invasive approach, referred to as the “direct posterior approach,” that offers a similar level of preserved anatomic structures with the added benefit of a readily extensile approach that is familiar to most surgeons. As such, it is a viable approach for both primary and revision total hip arthroplasty.
Article
Riassunto Gli interventi all'anca sono tra le operazioni più frequenti nella chirurgia ortopedica e traumatologica. L'anca è un'articolazione portante profonda e quindi di difficile accesso poiché è circondata da importanti masse muscolari necessarie per la locomozione. Questa articolazione subisce grandi sforzi ed è pertanto particolarmente esposta all'artrosi, ma in caso di traumi ad alta energia anche a fratture e a lussazioni. Dal suo sviluppo, negli anni Sessanta, grazie a John Charnley, l'artroplastica dell'anca ha rivoluzionato la vita di milioni di pazienti in tutto il mondo. Usando le parole di Learmonth in Lacet è “l'intervento del secolo”. Per permettere il trattamento delle patologie dell'anca sono state descritte numerose vie d'accesso. Queste vie d'accesso all'anca vengono definite in base alla localizzazione dell'approccio chirurgico: anteriore, anterolaterale, laterale, posteriore e mediale rispetto all'articolazione coxofemorale. La via posteriore è la più polivalente, la più sicura e facile da realizzare e quindi la più utilizzata sia in chirurgia primaria sia negli interventi di revisione. Oggigiorno, le vie laterali sono meno utilizzate, mentre la via anteriore è in auge. La via mediale è utilizzata più raramente a causa dei rischi infettivi inerenti la prossimità con il perineo. In questo capitolo non trattiamo le osteotomie femorali utilizzate nella chirurgia di revisione protesica.
Article
Resumen Entre las operaciones más frecuentes en cirugía ortopédica y traumatología se encuentran las intervenciones quirúrgicas sobre la cadera. La cadera es una articulación profunda que soporta peso y por lo tanto es de difícil acceso, ya que está rodeada de importantes masas musculares necesarias para la locomoción. Esta articulación soporta cargas importantes y por ello está particularmente expuesta a la artrosis, así como a fracturas y luxaciones en caso de traumatismos de alta energía. Desde su desarrollo en la década de 1960, gracias a John Charnley, la artroplastia de cadera revolucionó la vida de millones de pacientes en todo el mundo. Es la «cirugía del siglo» según las palabras de Learmonth en Lancet. Se han descrito numerosas vías de acceso para permitir el tratamiento de las patologías de la cadera. Estas vías de acceso de la cadera se definen por la localización de la vía de acceso quirúrgico: anterior, anterolateral, lateral, posterior y medial en relación a la articulación coxofemoral. La vía posterior es la más polivalente, la más segura y la de más fácil realización y, por lo tanto, la más utilizada tanto en cirugía primaria como en las de revisión. En la actualidad, las vías laterales se utilizan menos, mientras que la vía anterior está en boga. La vía medial se utiliza con menos frecuencia debido a los riesgos infecciosos inherentes a la proximidad al perineo. En este artículo no se tratarán las osteotomías femorales utilizadas durante la cirugía de revisión protésica.
Article
Objective Direct anterior approach (DAA) is becoming a popular option for both primary and revision total hip arthroplasty (THA). Adequate exposure is crucial in the setting of revision THA. The purpose of this article is to describe two different techniques for expanded femoral exposure through the DAA, the anterior extended trochanteric osteotomy and anterior cortical window. Methods Extensile exposure were carried out in cadavers, using the contralateral hip as a control. The exposure and technical viability were assessed. Results It was demonstrated that both extensile techniques can be carried out safely. Conclusions Extensile exposures including femoral osteotomies can be safely carried out for revision THA via DAA.
Article
Objective: Acetabular revision arthroplasty and osseous defect management through the direct anterior approach (DAA) with or without proximal extension. Indications: Aseptic or septic component loosening, periacetabular osseous defects, pelvic discontinuity, intrapelvic cup protrusion, anterior pseudotumors, iliopsoas tendonitis, polyethylene wear or iliopsoas abscess. Contraindications: Clinically relevant gluteal tendon lesions, active infection, morbid obesity, large abdominal pannus, ASA (American Society of Anesthesiologists) score > III, inguinal skin infection. Surgical technique: Electrocautery dissection is recommended to dissect the Hueter interval and to debulk pericapsular scar tissue. At all times during capsular debulking, it should be made sure not to damage the iliopsoas tendon or the neurovascular bundle. A stepwise releasing sequence can facilitate dislocation of the prosthesis. Most cases can be revised via the standard DAA but certain circumstances require an intra- or extrapelvic extension. Access to the anterior gluteal surface of the ilium can be provided using a "tensor snip". More posterior access is provided by the extensile extrapelvic approach described by Smith-Petersen. The intrapelvic Levine extension offers access to the entire visceral surface of the ilium and large parts of the anterior column. Postoperative management: Patient revised via the intra- or extrapelvic extension and patients suffering from extensive soft tissue or osseous defects should undergo postoperative weight-bearing restrictions with 20 kg for 6 weeks. Results: Based on our studies, there is no limitation on the type of acetabular implant that can be used in DAA revision arthroplasty. Moreover, virtually all types of periacetabular osseous defects can be managed through the approach and its extensions. Acetabular revision arthroplasty via the DAA and its extensions is safe and can result in good midterm results.
Article
Conversion to total hip arthroplasty (THA) is frequently more resource intensive and morbidity prone than primary THA. However, reimbursement for both hospitals and surgeons performing these procedures do not appear to provide appropriately matching resource utilization. Ultimately, patient access to these necessary surgeries becomes a question of concern if appropriate incentives are not aligned. Conversion THA is a broad topic and this paper seeks to highlight the technical difficulties and preoperative and postoperative pitfalls associated with this procedure to help address all issues and parties helping to support this procedure.
Article
Background: Blood supply of the proximal metaphysis of the femur comes mainly from the lateral circumflex femoral artery (LCFA). Essentially, the anterior approach has gained popularity in hip surgery but routinely requires the ligation of the ascending branch of the LCFA. Until now, there is no study analysing the effect of previous hip surgery on the vascularization of the proximal femur. Notably, it might, however, have consequences on osteointegration of uncemented prosthesis as well as in the management of early complications. Therefore we conducted a retrospective study to address the following questions: (1) Is the blood supply of the trochanteric region impaired by previous hip surgery, (2) does the anterior approach alter it more than other ones? Hypothesis: We hypothesised that the surgical approach to the hip influences blood supply of the proximal femur, as visualised by retrospective analysis of femoral digital subtraction arteriograms (FDSA). Patients and methods: A retrospective review of 1280 FDSA, performed for vascular indications with a standard frame rate, between 07/2014 and 06/2016 in a single institution. Qualitatively sufficient FDSA were divided into 4 groups according to the history of previous hip surgery: hip replacement through an anterior approach (n=10) or through a lateral approach (n=31), cephalomedullary nailing for fractures of the proximal femur (n=5), and a control group of 50 continuous patients without previous hip surgery. The number of frames was counted between contrast injection into the femoral bifurcation and filling of the ipsilateral vessels of the greater trochanter to measure a potential delay/impairment of its arterial perfusion. Anatomic variations of the LCFA were also recorded. Results: The number of frames between contrast injection and visualisation of the blood supply of the greater trochanter was 3.6±0.9 (mean±SD) in the control group (p<0.001 vs. all other groups). In patients with a hip replacement, the delay was 7.0±1.9 frames for the anterior approach and 5.2±1.1 frames for the lateral approach, respectively. In patients after cephalomedullary nailing, a delay of 4.8±1.5 frames was measured. The delay in the anterior approach group was significantly longer (p<0.001) compared to all other investigated groups. The ascending branch of the LCFA could not be detected after the anterior approach. As after lateral approach or as in the control group, the transverse branch was detectable in approximately 2/3 of the patients. Discussion: Arterial perfusion of the greater trochanter is impaired after hip surgery, particularly after an anterior approach. The clinical relevance of these findings still needs to be investigated. It might, however, explain some early aseptic failures of uncemented stems. Moreover, it should be considered in early revision surgery, because combining different approaches might critically impair femoral blood supply. Level of evidence: III, retrospective case control study.
Article
The femoral nerve (FN) is described as originating from the lumbar plexus (L2, L3 and L4) and in its course it emits branches destined to each one of the quadriceps femoral muscle (QFm), which are originated in an isolated way or, from common trunks. The detail of the distribution of the FN in the QFm, allows to diminish risks associated with different surgical interventions carried out in the anterior thigh area. With the purpose of describing the distribution of FN in the QFm components. Fifteen formalized lower limbs were used, 10 on the left side and 5 on the right side of adult individuals, Brazilians, located in the Anatomy Laboratories of the State University of Ciências da Saúde de Alagoas (UNCISAL) , Maceió, Brazil. The FN was classified into four types according to its branch and distribution. Type II was subdivided into 3 subtypes and presented in 60 % of the samples and type III in 20 %. The FN was divided from medial to lateral in 5 branches (B1, B2, B3, B4, B5), where B1 was the most medial. The B1 gave rise to an average of 2.47 secondary branches (sB) and to 2.58 tertiary branches (tB), in 13.3 % the B1 did not emit sB. In 73.3 %, only one component of the QFm was invested; B2 gave rise to an average of 3.93 sB and 3.58 tB. In 26.7 %, it invested only one component of the QFm; B3 gave rise to an average of 3.33 sB and 2.0 tB. In 80 %, it invested only one component of the QFm. The distribution of B4 and B5 are shown in the text. Biometric results of origin, diameter and length of the mentioned branches are shown in tables. The data obtained in this research complements the knowledge of the regional anatomy, being able to be used by the surgical clinic and to carry out treatments that improve neurological disorders that affect the region.
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Over the last decade, MIS, or soft tissue sparing, THA has emerged as a viable alternative to “conventional” THA. Much has been published both in the scientific literature as well as lay literature with regard to the advantages of various minimally invasive techniques. Most of the attention has been focused on the anterior approach. However, as more data has become available regarding complication rates, it has become clear there is a price to the adoption of these techniques. We propose an alternative minimally invasive approach, referred to as the “direct posterior approach,” that offers a similar level of preserved anatomic structures with the added benefit of a readily extensile approach that is familiar to most surgeons. As such, it is a viable approach for both primary and revision total hip arthroplasty.
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Sir–There are several advantages with the direct anterior approach for total hip arthroplasty. However, it is technically demanding with its own unique set of complications which implies a substantial learning period (Masonis et al. 2008, Barton and Kim 2009, Bhandari et al. 2009, Goytia et al. 2012). A recent report in the Acta Orthopaedica, titled “High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach” (Spaans et al. 2012) presents the early results of the direct anterior approach, which showed no improvement in functional outcome and a higher early complication rate compared with the posterolateral approach. The authors found no learning effect regarding operating time, blood loss and hospital stay after 46 cases. Several studies have shown that the learning curve of the anterior approach requires more than 46 patients. During this learning curve, the complication rate is higher because of the technical difficulties. The complication rate, operating time and blood loss diminish after the surgeon has gained more experience (Masonis et al. 2008, Berend et al. 2009, Bhandari et al. 2009, Seng et al. 2009, Goytia et al. 2012). Spaans et al. report the use of a minimal invasive technique. In fact the anterior approach itself is not a minimal invasive technique and the incision sometimes needs to be enlarged to obtain a good view of the operative field. When a surgeon starts with the direct anterior approach, we would always advice to not to use the minimal invasive technique. Readers may interpret the Spaans et al. article as showing the direct anterior approach for total hip arthroplasty gives a higher complication rate than the posterolateral approach. However the high complication rate in their study seems to be due to the effect of the learning curve and the use of a minimal invasive approach, instead of the use of the direct anterior approach. The learning curve is not unique for the direct anterior approach (Salai et al. 1997). Also the posterior approach is a technical demanding procedure with its own set of complications and indeed its own learning curve. Moreover, the learning curve is longer when using a minimal invasive technique (Swanson 2007).
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There is growing interest in minimally invasive surgery techniques in total hip arthroplasty (THA). In this study, we investigated the learning curve and the early complications of the direct anterior approach in hip replacement. In the period January through December 2010, THA was performed in 46 patients for primary osteoarthritis, using the direct anterior approach. These cases were compared to a matched cohort of 46 patients who were operated on with a conventional posterolateral approach. All patients were followed for at least 1 year. Operating time was almost twice as long and mean blood loss was almost twice as much in the group with anterior approach. No learning effect was observed in this group regarding operating time or blood loss. Radiographic evaluation showed adequate placement of the implants in both groups. The early complication rate was higher in the anterior approach group. Mean time of hospital stay and functional outcome (with Harris hip score and Oxford hip score) were similar in both groups at the 1-year follow-up. The direct anterior approach is a difficult technique, but adequate hip placement was achieved radiographically. Early results showed no improvement in functional outcome compared to the posterolateral approach, but there was a higher early complication rate. We did not observe any learning effect after 46 patients.
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Less invasive approaches for hip arthroplasty have been developed in order to decrease traumatisation of soft tissue and shorten hospital stay. However, the benefits with a new technique can be at the expense of a new panorama of problems. This manuscript describes, with emphasis on postoperative complications, our experience from the first 200 cases of unilateral hip replacement using the direct anterior minimally invasive (MIS) approach. A straight incision in front of the greater trochanter was used and the tensor muscle was approached subfascially and retracted laterally. The joint was opened and the femoral head was removed. Usually excellent acetabular exposure was obtained. In order to get access to the proximal femur, the hip capsule was released posterolaterally so that the femur could be lifted using a special retractor behind the tip of the trochanter. After insertion of the prostheses, the wound was closed using running sutures in the fascia overlying the tensor, sub- and intracutaneously. There was a small influence of BMI on the duration of surgery, and obese patients tended to have the cup positioned at a higher degree of deviation. There were in total 17 complications of which 5 necessitated revision surgery; 3 peroperative femoral fractures and 2 dislocations. Another 4 dislocations were treated with closed reduction and did not recur. 3 cases of nerve injury were noted, all resolved within 12 months. Three cases of DVT were diagnosed as well as 2 cases of postoperative infection; none of these led to chronic disability. The technique is perhaps more technically demanding than the lateral approaches used today due to the somewhat limited surgical exposure. Morbidly obese or very muscular patients as well as patients with a short femoral neck or acetabular protrusion can represent particular problems. Our results indicate that there are certain risks when adopting this procedure but the complications noted are avoidable.
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Minimal incision total hip arthroplasty (MI THA) techniques were developed to decrease postoperative pain and recovery time. Although these techniques have increased in popularity, the long-term survivorship of these procedures is unknown. We therefore investigated whether the time to revision in our referral practice was shorter for patients who underwent primary MI THA compared to primary traditional THA. We retrospectively reviewed 46 revision THAs performed during a 3-year period. We excluded revisions performed for infection and rerevisions. Patients with incisions less than or equal to 10 cm were defined as having had MI THA. Fifteen of the 46 patients (33%) had undergone primary MI THA. At the time of primary index THA, the mean ages of the MI and non-MI patients were 65 years and 55 years, respectively. The mean time to revision was 1.4 years for the MI patients compared with 14.7 years for the non-MI patients. Twelve of the 15 patients having MI THA required revision within 2 years of primary THA compared to 4 of the 31 patients without MI surgery (OR = 26.5, 95% CI 4.4-160.0). There were no differences between the groups with regard to age, gender, or body mass index. The most common reasons for revision in the MI THA group were intraoperative fracture and failure of femoral component osseointegration. Our data suggest MI THA may be a risk factor for early revision surgery and the long-term survival therefore may be lower than that for non-MI surgery. Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Article
Total hip arthroplasty has become one of the most frequently performed and successful reconstructive procedures in orthopaedic surgery since its introduction more than forty years ago1. While there have been many changes in implant designs and biomaterials, surgical approaches have remained relatively unchanged over the years. Recently, in response to the evolution of minimally invasive procedures such as angioplasty, laparoscopic abdominal surgery, and arthroscopy, orthopaedic surgeons have expressed an increased interest in minimally invasive surgical approaches to total hip arthroplasty. A variety of surgical approaches have been utilized for the performance of total hip arthroplasty; these include anterior, anterolateral, direct lateral, transtrochanteric, and posterior techniques2-11. The modified anterior approach developed by one of us (K.J.K.) provides effective access to the hip through a small incision and the use of secondary incisions for acetabular and/or femoral instrumentation (Fig. 1)12,13. This surgical approach has been utilized by the three senior authors (K.J.K., J.M.K., and R.S.W.) in more than 6000 total hip arthroplasties over the past thirty years. The purpose of this report is to present the perioperative clinical parameters and short-term clinical outcomes documented in our extensive patient database established twenty years ago. Fig. 1 Performance of an anterior approach for total hip arthroplasty with a one, two, or three-mini-incision technique depends on the surgical profile of the patient. ### Patient Positioning The operating table is oriented at right angles to the walls to provide the surgeon with accurate references for anatomical orientation. The patient is positioned supine with the axis of the pelvis at a right angle to the long axis of the table (Fig. 2). The uninvolved lower limb is abducted and is placed on an arm board extending beyond the edge of the operating table in order to allow for adduction of the …
Article
A modified anterior approach to the hip developed by the senior author has been utilized in performing over 7000 hip replacement operations at this joint replacement center in the past three decades. It can be readily applied to both primary and revision surgery, and involves muscle splitting and sparing of the major hip muscles, innervation, and function. Since the late 1970s, Yale orthopaedic residents have been taught this minimally invasive anterior approach using one, two, or three mini-incisions without fluoroscopy, special operating room tables, or special retractors. The authors’ overall experience has documented a very low incidence of dislocation and minimal perioperative complications. While a smaller skin incision is desirable by patients for cosmetic reasons and decreased healing time, what goes on beneath the skin is far more important. A well-placed total hip replacement should never be compromised. While many of these patients can ambulate the same or first postoperative day quite well, the authors do not advocate outpatient total hip arthroplasty as some proponents have. Bone is still cut, tissues bleed, clots can form, and the traditional complications of arthroplasty, while reduced, can still occur.
Article
An especially low-odor embalming technique was developed over a 30-years-period using a totoal of 977 complete cadavers, numerous cadavers after autopsy, and in vitro series of fresh beef. The color, consistency, and transparency of the tissue were very well preserved. The technique met high standards of preservation without releasing harmful substances into the environment. Concentrations of formaldehyde in room air remained under the limit of detection by Dräger capillaries. The efficacy for disinfection of the method was confirmed by bacteriologic tests. None of the cadavers or samples developed molds.
Article
The direct anterior approach (DAA) is generally accepted method for minimal invasive arthroplasty of the hip. As good results for total hip arthroplasty are already published, there is a lack of evidence for the implantation of bipolar hip hemiarthroplasty (BHH) in elderly patients with osteoporosis after femoral neck fracture. For hip arthroplasty using a direct anterior approach (DAA) in elderly patients with femoral neck fractures, a number of modifications of the original technique are being described. The modified DAA considers in particular the co-morbidity and the bone quality of the geriatric patient population. A consecutive series of 16 hemiarthroplasties using this technique is presented. In all 16 cases, the BHH was implanted in modified DAA technique. Mobility measured by 4-item Barthel Index, pain via visual analogue scale (VAS), duration of surgery, external length of incision and blood loss were evaluated. There was no major operative complication during the procedures. The pain level decreased from 7 (preoperatively) to 0 at postoperative day 40. The Barthel Index increased from 5 at first postoperative day to 40 at day 40. Early postoperative mobilisation is efficiently accelerated. Mean operating time was 71 min; the medium skin incision length was 8 cm. The mean haemoglobin level decreased from 118 g/dl preoperatively to 101 g/dl at first postoperative day. The described modifications of the DAA help to implant a BHH gently in elderly patients with increasing risk of complications like iatrogenic fractures, wound or prosthesis infections and haematoma. This will hopefully lead to a faster rehabilitation and lower mortality rate for patients with femoral neck fractures in the future.
Article
The direct anterior approach for total hip arthroplasty has gained popularity throughout the last decade. Early reports showed successful results with rapid functional recovery and low dislocation rates. However there is some concern about the high number of complications induced by the technique. The aim of this study was to examine the early radiological outcome and perioperative complications in a consecutive series of 300 total hip arthroplasties performed through a minimal invasive anterior approach with the aid of a positioning table. We observed 9(3%) intra-operative complications : two femoral perforations, 4 calcar fractures and 3 greater trochanter fractures. There were 42 (14%) postoperative complications and 20 (6.7%) patients required a surgical re-intervention. Our major finding was early peri-prosthetic femoral fracture in 5 patients, not noticed during surgery. The dislocation ratio (2 cases, 0.66%) was low. The complication ratio decreased throughout our series, but statistical significance could not be shown (p = 0.26). Surgeons should be aware of the high risk of occult intra-operative fractures when starting with this technique.
Article
Primary total hip arthroplasty has been one of the most successful orthopaedic procedures of the last century. Several classical surgical approaches to the hip have been described. Each approach has advantages and disadvantages. Recently, minimally invasive techniques have been developed with incisions less than 10cm. The goals of minimally invasive surgery are minimal soft tissue damage and a shorter hospital stay, faster recovery and return to work, less pain, and improved cosmetic results. The disadvantages are less visibility, longer operation time, nerve injuries, higher incidence of femoral fractures, malposition of the components and a long learning curve. The originator results with these techniques were promising. Subsequently, more controversial results have been published. Further follow-up and development is necessary to compare the results with the classical proven approaches.
Article
Recent attention in THA has focused on minimally invasive techniques and their short-term outcomes. Despite much debate over the outcomes and complications of the two-incision and the mini-lateral and mini-posterior approaches, complications arising from use of the anterior THA on a fracture table are not well documented. We determined the intraoperative and postoperative complications with the anterior approach to THA through an extended single-surgeon patient series. We reviewed 800 primary THAs performed anteriorly with the aid of a fracture table over 5 years and recorded all intraoperative and postoperative complications up to latest followup (average, 1.8 years; range, 0-5 years). Patients with severe acetabular deformity or severe flexion contractures were excluded and those surgeries were performed with a lateral approach during the time period of this study. Intraoperative complications included 19 trochanteric fractures, three femoral perforations, one femoral fracture, one acetabular fracture, one bleeding complication, and one case of cardiovascular collapse. There were no ankle fractures. Postoperative complications included seven patients with dislocations; seven with deep infections; one with delayed femur fracture; 37 with wound complications, among which 13 had reoperation for local débridement; 14 with deep venous thrombosis; and two with pulmonary embolism; and 31 other nonfatal medical complications. The main intraoperative complications of trochanteric fractures and perforations occurred mostly early in the series, while the main postoperative complications related to wound healing were prevalent throughout the entire series. Despite potential advantages of use of a fracture table, surgeons should be aware of the potential complications of trochanteric fractures, perforations, and wound-healing problems associated with this technique. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Article
There is still conflicting evidence about the true benefit of minimally invasive (MI) techniques in total hip replacement (THR). The aim of this prospective study was to evaluate the safeness of a MI approach during the learning curve of a single surgeon. Second, clinical and radiographic results among the MI THR group were compared with the results using a standard transgluteal (Bauer) approach. 86 primary unilateral total hip arthroplasties (THAs) through a MI, anterior (Micro-hip(®)) approach were performed by a single senior surgeon (ES), representing a consecutive series of patients after beginning with the MI technique. Cases were compared to a matched cohort of patients who were treated with a standard transgluteal (Bauer) approach. Operation time, incision length, perioperative blood loss, haemoglobin level and blood transfusions were monitored. Complications were documented and followed up 1 year postoperatively. The Harris Hip Score (HHS), range of motion, use of analgetics, the Trendelenburg sign, sensibility of the lateral femoral cutaneous nerve and the acetabular/femoral component placement as well as potential heterotopic ossifications were analysed in both the groups after 12 months postoperatively. 74 MI THR patients and 60 standard THR patients were available for the one year follow-up. Operative time was significantly longer in the MI group, reduction in the haemoglobin level during the first 24 h was significant and the length of skin incision was significantly shorter. No significant differences were found for HHS, range of motion, use of analgetics, the Trendelenburg sign, and the acetabular/femoral component placement, heterotopic ossifications and intra- and postoperative complications. Sensibility of the lateral femoral cutaneous nerve was affected in three patients in the MI group. Radiographic evaluation revealed no component migration, implant subsidence or radiolucency signs in both the groups. Consistent with recent meta-analysis we found reduced blood loss, similar clinical/radiographic outcome and similar complication rates compared to standard THA. Our study shows, that MI THR is a safe procedure during the learning curve of an experienced surgeon.
Article
There are no data regarding the efficacy and safety of minimally invasive hip arthroplasty technique performed by community practice orthopedists. The early clinical and radiographic results of primary total hip arthroplasty using a minimally invasive anterior approach to the hip performed on a fracture table were studied. Two hundred thirty-one consecutive patients (247 hips) of 5 community practice surgeons were studied. The average surgical time (164 minutes) and estimated blood loss (858 mL) were more than double, and the major complication rate (9%) was 6 times that reported by an innovator of the procedure. However, no postoperative dislocations occurred. Adequate training is critical to reduce the risk of complications during the learning experience of minimally invasive hip arthroplasty procedures by community practice surgeons.
Article
An especially low-odor embalming technique was developed over a 30-years-period using a total of 977 complete cadavers, numerous cadavers after autopsy, and in vitro series of fresh beef. The color, consistency, and transparency of the tissue were very well preserved. The technique met high standards of preservation without releasing harmful substances into the environment. Concentrations of formaldehyde in room air remained under the limit of detection by Dräger capillaries. The efficacy for disinfection of the method was confirmed by bacteriologic tests. None of the cadavers or samples developed molds.
Article
Patients without prior hip surgery and body mass index lower than 30 undergoing primary total hip arthroplasty were eligible to participate in a randomized prospective study comparing a minimally invasive with a standard approach. The patients were randomized to receive incisions of 8 cm (group A, n = 28) or 15 cm (group B, n = 32). The groups were similar demographically. Patients in group A had significantly less intraoperative blood loss (P < .003) and less total blood loss (P < .009). Fewer patients in group A limped at 6 weeks (P < .04). Operative time, transfusion requirements, narcotic usage, length of hospital stay, achievement of rehabilitation milestones, cane usage, and complications were similar in both groups. There was no difference between the groups at 1- and 2-year follow-up. Compared with a standard incision, patients who underwent a minimally invasive total hip arthroplasty demonstrated decreased blood loss and limped less at 6-week follow-up.
Article
A modified anterior approach to the hip developed by the senior author has been utilized in performing over 7000 hip replacement operations at this joint replacement center in the past three decades. It can be readily applied to both primary and revision surgery, and involves muscle splitting and sparing of the major hip muscles, innervation, and function. Since the late 1970s, Yale orthopaedic residents have been taught this minimally invasive anterior approach using one, two, or three mini-incisions without fluoroscopy, special operating room tables, or special retractors. The authors' overall experience has documented a very low incidence of dislocation and minimal perioperative complications. While a smaller skin incision is desirable by patients for cosmetic reasons and decreased healing time, what goes on beneath the skin is far more important. A well-placed total hip replacement should never be compromised. While many of these patients can ambulate the same or first postoperative day quite well, the authors do not advocate outpatient total hip arthroplasty as some proponents have. Bone is still cut, tissues bleed, clots can form, and the traditional complications of arthroplasty, while reduced, can still occur.
Article
The lateral surgical approach to the proximal femur potentially damages the nerve supply to the vastus lateralis (VL) muscle. This study describes the detailed anatomy of the nerve supply to the VL muscle based on dissection of ten cadaveric lower limbs. In all specimens, a single nerve trunk arose from the femoral nerve, which is most subsequently divided into two main divisions. These divisions gave two branches each. These branches coursed from anteriorly and proximally to posteriorly and distally within the muscle. When the muscle was reflected anteriorly from its attachment to the linea aspera, there was no damage to its innervation. Splitting of the VL in the midlateral line of the femur, however, resulted in denervation of the posterior half of the muscle. Precise knowledge of the nerve supply to the VL will help avoid iatrogenic denervation of the muscle in surgical procedures at the proximal femur through the lateral approach.
Primary total hip arthroplasty using an anterior approach and a fracture table: short-term results from a community hospital Minimal incision surgery as a risk factor for early failure of total hip arthroplasty
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Woolson ST, Pouliot MA, Huddleston JI. Primary total hip arthroplasty using an anterior approach and a fracture table: short-term results from a community hospital. J Arthroplasty. 2009 Oct;24(7):999-1005. Epub 2009 Jun 2. 10. Graw BP, Woolson ST, Huddleston HG, Goodman SB, Huddleston JI. Minimal incision surgery as a risk factor for early failure of total hip arthroplasty. Clin Orthop Relat Res. 2010 Sep;468(9):2372-6.