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Albano D, Cintioli R, Messina C, Serpi F, Gitto S, Mascitti L, Vignati G, Glielmo P, Vitali P, Zagra L, Snoj Ž, Sconfienza LM. US-Guided Interventional Procedures for Total Hip Arthroplasty. J Clin Med 2024; 13:3976. [PMID: 38999539 PMCID: PMC11242179 DOI: 10.3390/jcm13133976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/23/2024] [Accepted: 07/04/2024] [Indexed: 07/14/2024] Open
Abstract
In patients with total hip arthroplasty (THA) with recurrent pain, symptoms may be caused by several conditions involving not just the joint, but also the surrounding soft tissues including tendons, muscles, bursae, and peripheral nerves. US and US-guided interventional procedures are important tools in the diagnostic work-up of patients with painful THA given that it is possible to reach a prompt diagnosis both directly identifying the pathological changes of periprosthetic structures and indirectly evaluating the response and pain relief to local injection of anesthetics under US monitoring. Then, US guidance can be used for the aspiration of fluid from the joint or periarticular collections, or alternatively to follow the biopsy needle to collect samples for culture analysis in the suspicion of prosthetic joint infection. Furthermore, US-guided percutaneous interventions may be used to treat several conditions with well-established minimally invasive procedures that involve injections of corticosteroid, local anesthetics, and platelet-rich plasma or other autologous products. In this review, we will discuss the clinical and technical applications of US-guided percutaneous interventional procedures in painful THA that can be used in routine daily practice for diagnostic and therapeutic purposes.
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Affiliation(s)
- Domenico Albano
- IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
- Dipartimento di Scienze Biomediche, Chirurgiche ed Odontoiatriche, Università degli Studi di Milano, 20122 Milan, Italy
| | - Roberto Cintioli
- Postgraduate School of Diagnostic and Interventional Radiology, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milan, Italy
| | - Carmelo Messina
- IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20122 Milan, Italy
| | - Francesca Serpi
- IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20122 Milan, Italy
| | - Salvatore Gitto
- IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20122 Milan, Italy
| | - Laura Mascitti
- Postgraduate School of Diagnostic and Interventional Radiology, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milan, Italy
| | - Giacomo Vignati
- Postgraduate School of Diagnostic and Interventional Radiology, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milan, Italy
| | - Pierluigi Glielmo
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20122 Milan, Italy
| | - Paolo Vitali
- IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20122 Milan, Italy
| | - Luigi Zagra
- IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
| | - Žiga Snoj
- Clinical Radiology Institute, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
- Department of Radiology, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Luca Maria Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20122 Milan, Italy
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Faldini C, Rossomando V, Brunello M, D’Agostino C, Ruta F, Pilla F, Traina F, Di Martino A. Anterior Minimally Invasive Approach (AMIS) for Total Hip Arthroplasty: Analysis of the First 1000 Consecutive Patients Operated at a High Volume Center. J Clin Med 2024; 13:2617. [PMID: 38731146 PMCID: PMC11084447 DOI: 10.3390/jcm13092617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/16/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
(1) Background: Direct anterior approach (DAA) has recently acquired popularity through improvements such as the anterior minimally invasive surgical technique (AMIS). This retrospective study examines the first 1000 consecutive THAs performed utilizing the AMIS approach in a high-volume center between 2012 and 2017. (2) Methods: 1000 consecutive THAs performed at a single institution utilizing the AMIS approach were retrospectively analyzed with a minimum five-year follow-up. Full evaluation of demographic information, clinical parameters, intraoperative complications, and radiological examinations are reported. (3) Results: Overall complication rate was 9.4% (94/1000), including 8 dislocations, 57 femoral-cutaneous nerve injuries, 12 intraoperative femoral fractures, 9 infections and 8 leg length discrepancy. Implant survival rates were 98.5% at 1 year, 97.5% at 3 years, 97% at 5 years, and 95.3% at 7 years. Causes of failure included periprosthetic fractures (0.8%), implant dislocations (0.6%), septic loosening (0.5%), aseptic mobilizations (0.2%), and symptomatic limb length discrepancies (0.2%). (4) Conclusions: Controversies persist around the direct anterior approach (DAA) for THA, primarily regarding the increased complications rate during the learning curve. However, this study advocates for widespread adoption of the DAA approach. The results demonstrate acceptable complication rates and remarkable functional outcomes, affirming its viability in the broader orthopedic patient population.
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Affiliation(s)
- Cesare Faldini
- 1st Orthopaedic Department, IRCCS—Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136 Bologna, Italy; (C.F.); (V.R.); (M.B.); (C.D.); (F.R.); (F.P.)
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40126 Bologna, Italy;
| | - Valentino Rossomando
- 1st Orthopaedic Department, IRCCS—Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136 Bologna, Italy; (C.F.); (V.R.); (M.B.); (C.D.); (F.R.); (F.P.)
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40126 Bologna, Italy;
| | - Matteo Brunello
- 1st Orthopaedic Department, IRCCS—Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136 Bologna, Italy; (C.F.); (V.R.); (M.B.); (C.D.); (F.R.); (F.P.)
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40126 Bologna, Italy;
| | - Claudio D’Agostino
- 1st Orthopaedic Department, IRCCS—Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136 Bologna, Italy; (C.F.); (V.R.); (M.B.); (C.D.); (F.R.); (F.P.)
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40126 Bologna, Italy;
| | - Federico Ruta
- 1st Orthopaedic Department, IRCCS—Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136 Bologna, Italy; (C.F.); (V.R.); (M.B.); (C.D.); (F.R.); (F.P.)
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40126 Bologna, Italy;
| | - Federico Pilla
- 1st Orthopaedic Department, IRCCS—Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136 Bologna, Italy; (C.F.); (V.R.); (M.B.); (C.D.); (F.R.); (F.P.)
| | - Francesco Traina
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40126 Bologna, Italy;
- Ortopedia, Traumatologia e Chirurgia Protesica e dei Reimpianti di Anca e Ginocchio, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Alberto Di Martino
- 1st Orthopaedic Department, IRCCS—Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136 Bologna, Italy; (C.F.); (V.R.); (M.B.); (C.D.); (F.R.); (F.P.)
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40126 Bologna, Italy;
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Dai H, Deng Z, Yang L, Song C, Yu G, Luo J, Xu J. Endoscopic Arthroplasty via Mini-open Direct Anterior Approach Improves Postoperative Complications and Acetabular Components of Total Hip Arthroplasty in Obese Patients. Orthop Surg 2024; 16:998-1009. [PMID: 38384138 PMCID: PMC10984812 DOI: 10.1111/os.14015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 01/20/2024] [Accepted: 01/22/2024] [Indexed: 02/23/2024] Open
Abstract
To overcome the high-risk complications and poor alignment of acetabular components in obese patients associated with direct anterior approach (DAA) for total hip arthroplasty (THA), we innovated an endoscopic arthroplasty via mini-open direct anterior approach technique (Endo-DAA). The purpose of this study was to compare the clinical and radiographic outcomes in obese patients subjected to THA between Endo-DAA, Bikini DAA, and conventional DAA. In this retrospective controlled study, a total of 360 consecutive primary THA on obese patients (body mass index greater than 28 kg/m2) via Endo-DAA, Bikini DAA, and conventional DAA performed from October 2017 to October 2022 by different surgeons and in a single center were included. Assessments including perioperative parameters, clinical outcomes, complications, and radiologic measurements were retrieved from patients before the surgery, perioperative period and the latest follow-up. A total of 360 consecutive THA (Endo-DAA = 108, Bikini DAA = 116, Conventional DAA = 136) with complete follow-up data were analyzed. Compared to Bikini DAA or conventional DAA, Endo-DAA significantly shortened the length of incision (5.46 ± 0.53), the duration of operation (64.47 ± 12.38), and postoperative hospital stay (2.15 ± 0.89). Endo-DAA significantly reduces wound related complications compared with conventional DAA. Besides, Endo-DAA achieved a significantly better alignment of acetabular components compared to Bikini DAA or conventional DAA. Furthermore, Endo-DAA improved postoperative pain at the activity at 24 h postoperatively and early functional scores. The Endo-DAA THA technique provides better short-term clinical and radiographic results in obese patients with a low rate of postoperative complications compared to Bikini DAA or conventional DAA.
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Affiliation(s)
- Hanhao Dai
- Department of OrthopedicsShengli Clinical Medical College of Fujian Medical UniversityFuzhouChina
- Department of OrthopedicsFujian Provincial HospitalFuzhouChina
| | - Zhibo Deng
- Department of OrthopedicsShengli Clinical Medical College of Fujian Medical UniversityFuzhouChina
- Department of OrthopedicsFujian Provincial HospitalFuzhouChina
| | - Linhai Yang
- Department of OrthopedicsShengli Clinical Medical College of Fujian Medical UniversityFuzhouChina
- Department of OrthopedicsFujian Provincial HospitalFuzhouChina
| | - Chao Song
- Department of OrthopedicsShengli Clinical Medical College of Fujian Medical UniversityFuzhouChina
- Department of OrthopedicsFujian Provincial HospitalFuzhouChina
| | - Guoyu Yu
- Department of OrthopedicsShengli Clinical Medical College of Fujian Medical UniversityFuzhouChina
- Department of OrthopedicsFujian Provincial HospitalFuzhouChina
| | - Jun Luo
- Department of OrthopedicsShengli Clinical Medical College of Fujian Medical UniversityFuzhouChina
- Department of OrthopedicsFujian Provincial HospitalFuzhouChina
| | - Jie Xu
- Department of OrthopedicsShengli Clinical Medical College of Fujian Medical UniversityFuzhouChina
- Department of OrthopedicsFujian Provincial HospitalFuzhouChina
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Melman WPR, Ettema HB, Edens MA, Verheyen CCPM. Mid-term results of cemented hip arthroplasties through the direct anterior approach in the lateral decubitus position: a retrospective cohort study. J Orthop Surg Res 2024; 19:206. [PMID: 38561763 PMCID: PMC10983692 DOI: 10.1186/s13018-024-04696-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/22/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Reports show a high complication rate when starting with the Direct Anterior Approach (DAA) in a supine position for hip arthroplasty. The DAA with the patient in lateral decubitus position may avoid this problem because it supposedly provides better visibility, especially on the femoral side. However, this approach did show a rather high complication rate during the adoption of the approach at 1 year follow up in our previous report. We were interested what the overall 7 year survival estimate would be and whether improvement could be seen with growing experience. METHODS A cohort of patients undergoing total hip arthroplasty right from the start of applying the DAA in lateral decubitus position was analysed. RESULTS In total 175 hip prostheses (162 patients) were evaluated. The 7-year survival estimate was 95.1%, 95 CI: 91.8-98.4%. In 6 of 8 revisions there was aseptic loosening of the stem. By dividing the cohort into 3 consecutive groups in time we did not see a significantly improving revision rate. CONCLUSIONS In our experience, the adoption of the direct anterior approach in lateral decubitus position caused a relatively low 7-year survival estimate without an apparent decrease with growing experience, however given the low number of cases further research is needed to investigate the long-term risk of adopting a new approach.
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Affiliation(s)
- Wietse P R Melman
- Department of Orthopedic Surgery and Traumatology, Isala Hospital, Zwolle, The Netherlands.
- Department of Orthopedic Surgery and Traumatology, Saxenburgh Medisch Centrum, Jan Weitkamplaan 4a, Hardenberg, 7772 SE, The Netherlands.
| | - Harmen B Ettema
- Department of Orthopedic Surgery and Traumatology, Isala Hospital, Zwolle, The Netherlands
| | - Mireille A Edens
- Epidemiology Unit, Department Innovation and Science, Isala Hospital, Zwolle, The Netherlands
| | - Cees C P M Verheyen
- Department of Orthopedic Surgery and Traumatology, Isala Hospital, Zwolle, The Netherlands
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Smith SR, Terhune EB, Williams JC, Mayo KA. Step-cut osteotomy of the anterior superior iliac spine for increased visualisation in the Levine approach for Bernese periacetabular osteotomy surgery. Hip Int 2024; 34:248-251. [PMID: 37909542 DOI: 10.1177/11207000231209665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
BACKGROUND Hip dysplasia can lead to pain and dysfunction in the young adult. Acetabular undercoverage leads to abnormal joint loading and results in joint degeneration, accelerating need for arthroplasty in this patient population. Conceptually, treatment focuses on increasing acetabular coverage in the form of periacetabular osteotomy. The procedure can be performed through the iliofemoral approach, and performing an anterior superior iliac spine (ASIS) osteotomy can enhance the visualisation in this approach. Several techniques have been described for ASIS osteotomy. AIM The purpose this study was to report on step-cut technique for ASIS osteotomy during the Bernese periacetabular osteotomy procedure to enhance visualisation when utilising the iliofemoral approach. SURGICAL TECHNIQUE This step-cut technique enhances stability at the osteotomy site, and minimises soft tissue dissection to reduce pain and assists with maintaining a stable fixation construct postoperatively. RESULTS There were no nonunions and minimal morbidity to the lateral femoral cutaneous nerve injury in cohort of 86 patients while utilising this technique. CONCLUSIONS We recommend using this step-cut ostetomy of the ASIS during Bernese periactetabular osteotomy for benefit of increasing exposure while maintaining a low complication profile.
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Affiliation(s)
- Shelby R Smith
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - E Bailey Terhune
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Joel C Williams
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Keith A Mayo
- Department of Orthopaedic Surgery, Swedish Medical Center, Seattle, WA, USA
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Hinz N, Marsoni G, Mittelstädt H, Sonnabend F, Wallroth K, Johl C, Weigert U, Anderl C, Ortmaier R, Zeleny N, Schulz AP. Short stem hip arthroplasty with the optimys prosthesis is a safe and effective option for obese patients: a mid-term follow-up multicenter study. Arch Orthop Trauma Surg 2024; 144:1401-1414. [PMID: 37924371 PMCID: PMC10896938 DOI: 10.1007/s00402-023-05105-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/09/2023] [Indexed: 11/06/2023]
Abstract
INTRODUCTION Short stems are a valuable option in young patients undergoing total hip arthroplasty (THA) because of their bone stock preserving properties facilitating revision hip arthroplasty. Although the effect of obesity on conventional THA is well studied, data about short stem THA in obese patients are lacking. Therefore, this study aimed to investigate the influence of obesity on complications, revisions, and outcome after short stem THA. MATERIALS AND METHODS This multicenter, observational cohort study included patients undergoing short stem THA with the optimys prosthesis. Follow-up examinations were performed at specific intervals up to 7 years postoperatively. Operation characteristics, general and specific complications, revisions, VAS rest pain, VAS load pain, VAS patient satisfaction, and Harris Hip Score (HHS) were recorded and statistically compared between obese (BMI ≥ 30 kg/m2) and non-obese (BMI < 30 kg/m2) patients. RESULTS Of the 224 patients included with a mean follow-up of 87.2 months (range 81.9-104.0), 69 were assigned to the OB group and 155 to the non-OB group. A minimally invasive approach was significantly less often selected in obese patients (p = 0.049), whereas operating time and length of hospital stay were not significantly different. The rate of general and specific complications did not significantly differ between both groups. Survival of the optimys prosthesis was 99.1% at 7-year follow-up and one patient per group had to undergo revision surgery. VAS rest pain, load pain, and satisfaction improved from preoperatively to postoperatively in both groups without a significant difference between both groups. While the HHS was improved from preoperatively to postoperatively, obese patients showed a significantly lower HHS at the 7-year follow-up (p = 0.01) but still exhibited an excellent scoring above the PASS threshold. CONCLUSION Short stem THA with the optimys prosthesis is a safe and effective option also in obese patients with an excellent clinical outcome and a low complication rate.
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Affiliation(s)
- Nico Hinz
- BG Hospital Hamburg, Trauma Surgery, Orthopedics and Sports Traumatology, Bergedorfer Strasse 10, 21033, Hamburg, Germany.
| | - Giulia Marsoni
- Erzgebirgsklinikum, Orthopedics and Trauma Surgery, Jahnsdorfer Strasse 7, 09366, Stollberg, Germany
| | - Hagen Mittelstädt
- University Medical Center Schleswig-Holstein, Campus Lübeck, Orthopaedic and Trauma Surgery, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Falk Sonnabend
- Helios Klinik Köthen, Orthopedics, Hallesche Strasse 29, 06366, Köthen, Germany
| | - Karsten Wallroth
- Erzgebirgsklinikum, Orthopedics and Trauma Surgery, Jahnsdorfer Strasse 7, 09366, Stollberg, Germany
| | - Carsten Johl
- Klinikum Dahme-Spreewald, Orthopedics and Trauma Surgery, Schillerstrasse 29, 15907, Lübben, Germany
| | - Ulrich Weigert
- Practice for Orthopedics and Trauma Surgery, Friedrichstrasse 1-3, 15537, Erkner, Germany
| | - Conrad Anderl
- Ordensklinikum Linz Barmherzige Schwestern, Orthopedics, Seilerstätte 4, 4010, Linz, Austria
| | - Reinhold Ortmaier
- Ordensklinikum Linz Barmherzige Schwestern, Orthopedics, Seilerstätte 4, 4010, Linz, Austria
| | | | - Arndt-Peter Schulz
- BG Hospital Hamburg, Trauma Surgery, Orthopedics and Sports Traumatology, Bergedorfer Strasse 10, 21033, Hamburg, Germany
- Medical Faculty, Universität zu Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
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Lee SC, Ko L, Gornbein C, Nwawka OK. Sonographic Evaluation of the Lateral Femoral Cutaneous Nerve: Single-Institution Experience and Pictorial Review. Ultrasound Q 2024; 40:27-31. [PMID: 37816244 DOI: 10.1097/ruq.0000000000000669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
ABSTRACT The location of the lateral femoral cutaneous nerve (LFCN) makes it susceptible to injury with trauma, external compression, and iatrogenic injury. The objectives of this study were to report the single-institution efficacy of LFCN visualization on ultrasound (US), define the clinical characteristics of patients with LFCN palsy, and describe sonographic appearances of LFCN abnormalities by pictorial review. A retrospective chart review of LFCN cases evaluated using US at a single institution was performed, documenting rate of visibility on US, mode of nerve injury, and US imaging findings. Nerve visibility rates on US were correlated with magnetic resonance imaging (MRI) when both modalities were used. Imaging findings were confirmed with clinical/surgical history and follow-up. Retrospective review found that 170 patients underwent US for LFCN evaluation in the last 10 years. Injury was associated with surgical intervention in 56% of cases, and perineural scarring was the most common pathology described using US. Lateral femoral cutaneous nerve was visible on US in 97% of cases; MRI visualized LFCN in 60%. Chart review showed US as an effective tool in evaluating LFCN pathology, with a higher visualization rate than MRI. Through pictorial review, the array of LFCN pathology sonographically detectable is demonstrated.
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Affiliation(s)
- Susan C Lee
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY
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Almasi J, Ambrus R, Steno B. Meralgia Paresthetica-An Approach Specific Neurological Complication in Patients Undergoing DAA Total Hip Replacement: Anatomical and Clinical Considerations. Life (Basel) 2024; 14:151. [PMID: 38276280 PMCID: PMC10817486 DOI: 10.3390/life14010151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/11/2024] [Accepted: 01/19/2024] [Indexed: 01/27/2024] Open
Abstract
Introduction: Mini-invasive surgical (MIS) approaches to total hip replacement (THR) are becoming more popular and increasingly adapted into practice. THR via the direct anterior approach (MIS DAA) has become a rather controversial topic in hip arthroplasty literature in the last decades. Our retrospective observational study focuses on the prevalence of one approach-specific complication-lateral femoral cutaneous nerve (LFCN) iatrogenic lesion-and tries to clarify the possible pathogenesis of this injury. Methods: This is a retrospective single-cohort observational single-center and single-surgeon study. Our patient records were searched for the period from 2015 to 2017-after a safe period of time after the learning curve for MIS DAA. All intra- and post-operative lesions of the LFCN were recorded. Lesion of the LFCN was confirmed by a neurological examination. Minimum patient follow-up was 2 years. Results: This study involved 417 patients undergoing single-side THR via MIS DAA. Patients were examined on follow-up visits at 6 weeks, 6 months, 1 year, and 2 years after surgery. There were 17 cases of LCFN injury at the 6 weeks early follow-up visit (4.1%). All cases of clinically presenting LFCN injury resolved at the 2-year follow-up ad integrum. Discussion: Possible explanations of such neurological complications are direct iatrogenic injury, vigorous traction, hyperextension, or extreme external rotation of the operated limb. Use of a traction table or concomitant spinal pathology and deformity also play a role. Prevention involves stepwise adaptation of the approach during the learning curve period by attending cadaver lab courses, rational use of traction and hyperextension, and careful surgical technique in the superficial and deep fascial layers. Dynamometers could be used to visualise the limits of manipulation of the operated limb. Conclusions: Neurological complications are not as rare but questionably significant in patients undergoing THR via the DAA. Incidental finding of LFCN injury has no effect on the functional outcome of the artificial joint. It can lead to lower subjective satisfaction of patients with the operation, which can be avoided with careful education and management of expectations of the patients.
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Affiliation(s)
- Jozef Almasi
- Department of Orthopaedics, Nemocnica Bory Penta Hospitals International, I. Kadlecika 2, Lamac, 841 03 Bratislava, Slovakia;
| | - Richard Ambrus
- Department of Orthopaedics, Nemocnica Bory Penta Hospitals International, I. Kadlecika 2, Lamac, 841 03 Bratislava, Slovakia;
| | - Boris Steno
- II. University Department of Orthopaedic and Trauma Surgery, University Hospital Bratislava, Faculty of Medicine, Comenius University Bratislava, Antolska 11, Petrzalka, 851 01 Bratislava, Slovakia;
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Tripathy SK, Varghese P, Khan S, Neradi D, Jain M, Sen RK. Joint awareness among total hip arthroplasty patients operated through anterior approach versus posterior approach: a systematic review and meta-analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:39-46. [PMID: 37566139 DOI: 10.1007/s00590-023-03674-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023]
Abstract
PURPOSE The aim of this systematic review and meta-analysis was to compare joint awareness in patients who underwent total hip arthroplasty (THA) via the anterior approach (AA) versus the posterior approach (PA). The hypothesis was that patients who underwent THA via AA would have better forgetfulness of the artificial joint. METHODS A comprehensive search of major literature databases and bibliographic details was conducted to identify studies evaluating the forgotten joint score (FJS-12) in total hip arthroplasty (THA) patients operated through the anterior approach (AA) and posterior approach (PA). Out of 234 studies identified, seven studies met the inclusion criteria for review. The Newcastle-Ottawa Scale was used to evaluate the quality of evidence and the risk of bias in the included studies. The FJS-12 was evaluated at three months, one year, and beyond 2 years. RESULTS The mean FJS-12 at > 2 years was 82.03 in the AA group and 80.32 in the PA group. The forest plot analysis (n = 819 patients) revealed no significant difference in FJS-12 score between these two approaches (MD 2.13, 95% CI [- 1.17, 5.42], p = 0.21; I2 = 60%). However, the joint awareness was significantly lesser in the AA group at 3 months (MD 12.56, 95% CI [9.58, 15.54], p < 0.00001, I2 = 0%) and 1 year (MD 9.55, 95% CI [7.85, 11.24], p < 0.0001, I2 = 0%). CONCLUSIONS After analyzing the available literature, it was found that THA patients operated through the AA approach have significantly lower joint awareness than those operated through the PA approach in the first year of surgery. However, there is no significant difference in joint awareness between these two approaches after 2 years. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Sujit Kumar Tripathy
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019, India.
| | - Paulson Varghese
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019, India
| | - Shahnawaz Khan
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019, India
| | - Deepak Neradi
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019, India
| | - Mantu Jain
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019, India
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Chalk C, Namiranian D. Meralgia paresthetica. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:195-201. [PMID: 38697741 DOI: 10.1016/b978-0-323-90108-6.00013-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Meralgia paresthetica is a common but probably underrecognized syndrome caused by dysfunction of the lateral femoral cutaneous nerve. The diagnosis is based on the patient's description of sensory disturbance, often painful, on the anterolateral aspect of the thigh, with normal strength and reflexes. Sensory nerve conduction studies and somatosensory evoked potentials may be used to support the diagnosis, but both have technical limitations, with low specificity and sensitivity. Risk factors for meralgia paresthetica include obesity, tight clothing, and diabetes mellitus. Some cases are complications of hip or lumbar spine surgery. Most cases are self-limited, but a small proportion of patients remain with refractory and disabling symptoms. Treatment options include medications for neuropathic pain, neurolysis, neurectomy, and radioablation, but controlled trials to compare efficacy are lacking.
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Affiliation(s)
- Colin Chalk
- Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada.
| | - Dina Namiranian
- Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
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Tanabe H, Baba T, Ozaki Y, Yanagisawa N, Homma Y, Nagao M, Kaneko K, Ishijima M. Conventional versus lateral fasciotomy for prevention of lateral femoral cutaneous nerve injury in the non-fan-type nerve in total hip arthroplasty with direct anterior approach. Bone Joint J 2023; 105-B:1252-1258. [PMID: 38035608 DOI: 10.1302/0301-620x.105b12.bjj-2023-0375.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Aims Lateral femoral cutaneous nerve (LFCN) injury is a potential complication after the direct anterior approach for total hip arthroplasty (DAA-THA). The aim of this study was to determine how the location of the fasciotomy in DAA-THA affects LFCN injury. Methods In this trial, 134 patients were randomized into a lateral fasciotomy (n = 67) or a conventional fasciotomy (n = 67) group. This study was a dual-centre, double-blind, prospective randomized controlled two-arm trial with parallel group design and a 1:1 allocation ratio. The primary endpoint was the presence of LFCN injury, which was determined by the presence of numbness, decreased sensation, tingling, jolt-like sensation, or pain over the lateral aspect of the thigh, excluding the surgical scar, using a patient-based questionnaire. The secondary endpoints were patient-reported outcome measures (PROMs) using the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ), and the Forgotten Joint Score-12 (FJS-12). Assessments were obtained three months after surgery. Results The incidence of LFCN injury tended to be lower in the lateral fasciotomy group (p = 0.089). In the lateral fasciotomy group, there were no significant differences in the mean PROM scores between patients with and without LFCN injury (FJS-12: 54.42 (SD 15.77) vs 65.06 (SD 26.14); p = 0.074; JHEQ: 55.21 (SD 12.10) vs 59.72 (SD 16.50); p = 0.288; WOMAC: 82.45 (SD 6.84) vs 84.40 (SD 17.91); p = 0.728). In the conventional fasciotomy group, there were significant differences in FJS-12 and JHEQ between patients with and without LFCN injury (FJS-12: 43.21 (SD 23.08) vs 67.28 (SD 20.47); p < 0.001; JHEQ: 49.52 (SD 13.97) vs 59.59 (SD 15.18); p = 0.012); however, there was no significant difference in WOMAC (76.63 (SD 16.81) vs 84.16 (SD 15.94); p = 0.107). Conclusion The incidence of LFCN injury at three months after THA was comparable between the lateral and conventional fasciotomy groups. Further studies are needed to assess the long-term effects of these approaches.
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Affiliation(s)
- Hiroki Tanabe
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan
| | - Tomonori Baba
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan
| | - Yu Ozaki
- Department of Orthopedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | | | - Yasuhiro Homma
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan
| | - Masashi Nagao
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan
- Medical Technology Innovation Center, Juntendo University, Tokyo, Japan
| | - Kazuo Kaneko
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan
| | - Muneaki Ishijima
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan
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Drăghici NC, Văcăraș V, Bolchis R, Bashimov A, Domnița DM, Iluț S, Popa LL, Lupescu TD, Mureșanu DF. Diagnostic Approach to Lower Limb Entrapment Neuropathies: A Narrative Literature Review. Diagnostics (Basel) 2023; 13:3385. [PMID: 37958280 PMCID: PMC10647627 DOI: 10.3390/diagnostics13213385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/15/2023] Open
Abstract
Entrapment neuropathies of the lower limb are a misunderstood and underdiagnosed group of disorders, characterized by pain and dysesthesia, muscular weakness, and specific provoking movements on physical examination. The most frequent of these syndromes encountered in clinical practice are fibular nerve entrapment, proximal tibial neuropathy, sural nerve neuropathy, deep gluteal syndrome or sciatic nerve entrapment, and lateral femoral cutaneous nerve entrapment, also known as meralgia paresthetica. These are commonly mistaken for lumbar plexopathies, radiculopathies, and musculotendinous diseases, which appear even more frequently and have overlapping clinical presentations. A comprehensive anamnesis, physical examination, and electrodiagnostic studies should help clarify the diagnosis. If the diagnosis is still unclear or a secondary cause of entrapment is suspected, magnetic resonance neurography, MRI, or ultrasonography should be conducted to clarify the etiology, rule out other diseases, and confirm the diagnosis. The aim of this narrative review was to help clinicians gain familiarity with this disease, with an increase in diagnostic confidence, leading to early diagnosis of nerve damage and prevention of muscle atrophy. We reviewed the epidemiology, anatomy, pathophysiology, etiology, clinical presentation, and EDX technique and interpretation of the entrapment neuropathies of the lower limb, using articles published from 1970 to 2022 included in the Pubmed, MEDLINE, Cochrane Library, Google Scholar, EMBASE, Web of Science, and Scopus databases.
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Affiliation(s)
- Nicu Cătălin Drăghici
- “IMOGEN” Institute, Centre of Advanced Research Studies, 400012 Cluj-Napoca, Romania;
- “RoNeuro” Institute for Neurological Research and Diagnostic, 400364 Cluj-Napoca, Romania; (S.I.); (L.L.P.)
- Department of Clinical Neurosciences, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Vitalie Văcăraș
- “RoNeuro” Institute for Neurological Research and Diagnostic, 400364 Cluj-Napoca, Romania; (S.I.); (L.L.P.)
- Department of Clinical Neurosciences, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Roxana Bolchis
- Faculty of Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400347 Cluj-Napoca, Romania; (R.B.)
| | - Atamyrat Bashimov
- Faculty of Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400347 Cluj-Napoca, Romania; (R.B.)
| | - Diana Maria Domnița
- Faculty of Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400347 Cluj-Napoca, Romania; (R.B.)
| | - Silvina Iluț
- “RoNeuro” Institute for Neurological Research and Diagnostic, 400364 Cluj-Napoca, Romania; (S.I.); (L.L.P.)
- Department of Clinical Neurosciences, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Livia Livinț Popa
- “RoNeuro” Institute for Neurological Research and Diagnostic, 400364 Cluj-Napoca, Romania; (S.I.); (L.L.P.)
- Department of Clinical Neurosciences, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Tudor Dimitrie Lupescu
- “RoNeuro” Institute for Neurological Research and Diagnostic, 400364 Cluj-Napoca, Romania; (S.I.); (L.L.P.)
- Department of Clinical Neurosciences, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Dafin Fior Mureșanu
- “RoNeuro” Institute for Neurological Research and Diagnostic, 400364 Cluj-Napoca, Romania; (S.I.); (L.L.P.)
- Department of Clinical Neurosciences, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
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MANGLA N, WADHWA S, MISHRA S, SURAL S, VASUDEVA N. Cadaveric Study of Variations in the Course of Lateral Femoral Cutaneous Nerve: Insight to Prevent Injury. Medeni Med J 2023; 38:172-179. [PMID: 37766598 PMCID: PMC10542983 DOI: 10.4274/mmj.galenos.2023.23356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/06/2023] [Indexed: 09/29/2023] Open
Abstract
Objective A recent spurt in incidence of meralgia paresthetica to 0.1-81% due to minimally invasive anterior approach to hip joint has resulted in reinterest in anatomy of lateral femoral cutaneous nerve (LFCN). Familiarity with variations in the course of LFCN will reduce the morbidity associated with orthopedic procedures around the anterior superior iliac spine (ASIS) and inguinal ligament (IL). Methods Twenty five adult human formalin embalmed cadavers were dissected. Course and relations of nerve to ASIS, IL and sartorius muscle was noted, distance of nerve from ASIS at IL was measured and statistically analyzed. Results Mean distance of LFCN from ASIS at IL was 1.73±1.15 cm. Differences between two sides and sexes was statistically not significant (p=0.51 and p=0.96 respectively). Inferomedial to ASIS, 94% of LFCNs crossed IL with 92% of them present within 4 cm medial to ASIS. Majority of LFCNs (90%) exited pelvis and entered thigh posterior to IL. Out of these nerves 48% were single trunks on entry into thigh, then bifurcated into anterior and posterior branches. Remaining LFCNs bifurcated proximal to IL or at level of IL. Trifurcations were seen in 6% while a rare case of pentafication was observed. In 66% main trunk/branches were present in intermuscular cleft between sartorius muscle and tensor fascia lata. Conclusions Care should be exercised by surgeons while dissecting around IL as more than half of nerves are liable to be injured during operative procedures. This would help in better anticipation of problem, acceptance and reducing litigation.
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Affiliation(s)
- Nidhi MANGLA
- Soban Singh Jeena Government Institute of Medical Sciences and Research, Department of Anatomy, Almora, Uttarakhand, India
| | - Surbhi WADHWA
- Maulana Azad Medical College, Department of Anatomy, New Delhi, India
| | - Sabita MISHRA
- Maulana Azad Medical College, Department of Anatomy, New Delhi, India
| | - Sumit SURAL
- Maulana Azad Medical College, Department of Orthopedics, New Delhi, India
| | - Neelam VASUDEVA
- Maulana Azad Medical College, Department of Anatomy, New Delhi, India
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Homma Y, Baba T, Watari T, Hayashi K, Kobayashi H, Matsumoto M, Banno S, Ozaki Y, Ochi H, Jinnai Y, Ishii S, Tanabe H, Shirogane Y, Zhuang X, Yuasa T, Kaneko K, Ishijima M. Recent advances in the direct anterior approach to total hip arthroplasty: a surgeon's perspective. Expert Rev Med Devices 2023; 20:1079-1086. [PMID: 37942898 DOI: 10.1080/17434440.2023.2280986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/05/2023] [Indexed: 11/10/2023]
Abstract
INTRODUCTION The direct anterior approach (DAA) has its origins in the first and oldest approach for hip replacement in the literature, but at the same time it would not be fanciful to suggest its increasing popularity as the latest approach for hip replacement procedures, especially among younger surgeons. However, in a geographical context, the DAA is not considered the major approach in most countries. Moreover, the term DAA encompasses numerous variations in terms of technique. AREAS COVERED In this narrative review, we describe our recent experience of advances in the DAA in terms of improved techniques and devices, along with some of its disadvantages. Also, we express our perspective on its future application. EXPERT OPINIONS The DAA is established as one of exemplary approaches to THA. The use of fluoroscopy, the traction table, and appropriate soft tissue management has become essential in the DAA for a safe and trouble-free procedure with adequate patient comfort. With the combination of recent technologies such as robotics, three-dimensional preoperative planning, and artificial intelligence (AI)-based surgeon assist systems, we can look forward to the DAA being performed more efficiently in the future.
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Affiliation(s)
- Yasuhiro Homma
- Department of Medicine for Orthopaedics and Motor Organ, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
- Department of Orthopaedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Tomonori Baba
- Department of Medicine for Orthopaedics and Motor Organ, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
- Department of Orthopaedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Taiji Watari
- Department of Medicine for Orthopaedics and Motor Organ, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
- Department of Orthopaedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Koju Hayashi
- Department of Orthopaedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Hideo Kobayashi
- Department of Orthopaedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Mikio Matsumoto
- Department of Orthopaedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Sammy Banno
- Department of Orthopaedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Yu Ozaki
- Department of Orthopaedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Hironori Ochi
- Department of Orthopaedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Yuta Jinnai
- Department of Orthopaedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Seiya Ishii
- Department of Orthopaedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Hiroki Tanabe
- Department of Orthopaedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Yuichi Shirogane
- Department of Orthopaedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Xu Zhuang
- Department of Orthopaedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Takahito Yuasa
- Department of Orthopaedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Kazuo Kaneko
- Department of Orthopaedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Muneaki Ishijima
- Department of Medicine for Orthopaedics and Motor Organ, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
- Department of Orthopaedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
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15
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de Ruiter GCW, Oosterhuis JWA, Vissers TFH, Kloet A. Unusual causes for meralgia paresthetica: systematic review of the literature and single center experience. Neurosurg Rev 2023; 46:107. [PMID: 37148363 PMCID: PMC10162905 DOI: 10.1007/s10143-023-02023-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/06/2023] [Accepted: 05/01/2023] [Indexed: 05/08/2023]
Abstract
Meralgia paresthetica is often idiopathic, but sometimes symptoms may be caused by traumatic injury to the lateral femoral cutaneous nerve (LFCN) or compression of this nerve by a mass lesion. In this article the literature is reviewed on unusual causes for meralgia paresthetica, including different types of traumatic injury and compression of the LFCN by mass lesions. In addition, the experience from our center with the surgical treatment of unusual causes of meralgia paresthetica is presented. A PubMed search was performed on unusual causes for meralgia paresthetica. Specific attention was paid to factors that may have predisposed to LFCN injury and clues that may have pointed at a mass lesion. Moreover, our own database on all surgically treated cases of meralgia paresthetica between April 2014 and September 2022 was reviewed to identify unusual causes for meralgia paresthetica. A total of 66 articles was identified that reported results on unusual causes for meralgia paresthetica: 37 on traumatic injuries of the LFCN and 29 on compression of the LFCN by mass lesions. Most frequent cause of traumatic injury in the literature was iatrogenic, including different procedures around the anterior superior iliac spine, intra-abdominal procedures and positioning for surgery. In our own surgical database of 187 cases, there were 14 cases of traumatic LFCN injury and 4 cases in which symptoms were related to a mass lesion. It is important to consider traumatic causes or compression by a mass lesion in patients that present with meralgia paresthetica.
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Affiliation(s)
- G C W de Ruiter
- Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2501, CK, The Hague, The Netherlands.
| | - J W A Oosterhuis
- Department of Surgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - Th F H Vissers
- Medical Library, Haaglanden Medical Center, The Hague, The Netherlands
| | - A Kloet
- Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2501, CK, The Hague, The Netherlands
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Slaven SE, Ho H, Sershon RA, Fricka KB, Hamilton WG. Motor Nerve Palsy After Direct Anterior vs. Posterior Total Hip Arthroplasty: Incidence, Risk Factors, and Recovery. J Arthroplasty 2023:S0883-5403(23)00337-6. [PMID: 37019317 DOI: 10.1016/j.arth.2023.03.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/22/2023] [Accepted: 03/28/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND There is limited literature on motor nerve palsy in modern total hip arthroplasty (THA). The purpose of this study was to establish the incidence of nerve palsy following THA using the direct anterior (DA) and postero-lateral (PL) approaches, identify risk factors, and describe the extent of recovery. METHODS Using our institutional database we examined 10,047 primary THAs performed between 2009 and 2021 using the DA (6,592; 65.6%) or PL (3,455; 34.4%) approach. Postoperative femoral (FNP) and sciatic/peroneal (PNP) nerve palsies were identified. Incidence and time to recovery was calculated, and association between surgical and patient risk factors and nerve palsy were evaluated using Chi-square tests. RESULTS The overall rate of nerve palsy was 0.34% (34/10,047), and was lower with the DA approach (0.24%) than the PL approach (0.52%), P=0.02. The rate of FNPs in the DA group (0.20%) was 4.3-times higher than the rate of PNPs (0.05%), while in the PL group the rate of PNPs (0.46%) was 8-times higher than FNPs (0.06%). Higher rates of nerve palsy were observed with women, shorter patients, and non-osteoarthritis pre-operative diagnoses. Full recovery of motor strength occurred in 60% of cases with FNP and 58% of cases with PNP. CONCLUSION Nerve palsy is rare after contemporary THA through the PL and DA approaches. The PL approach was associated with a higher rate of PNP, whereas the DA approach was associated with a higher rate of FNP. Femoral and sciatic/peroneal palsies had similar rates of complete recovery.
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Affiliation(s)
- Sean E Slaven
- Anderson Orthopaedic Research Institute, Alexandria, VA; Inova Mount Vernon Hospital Joint Replacement Center, Alexandria, VA
| | - Henry Ho
- Anderson Orthopaedic Research Institute, Alexandria, VA
| | - Robert A Sershon
- Anderson Orthopaedic Research Institute, Alexandria, VA; Inova Mount Vernon Hospital Joint Replacement Center, Alexandria, VA
| | - Kevin B Fricka
- Anderson Orthopaedic Research Institute, Alexandria, VA; Inova Mount Vernon Hospital Joint Replacement Center, Alexandria, VA
| | - William G Hamilton
- Anderson Orthopaedic Research Institute, Alexandria, VA; Inova Mount Vernon Hospital Joint Replacement Center, Alexandria, VA.
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Yan L, Ge L, Dong S, Saluja K, Li D, Reddy KS, Wang Q, Yao L, Li JJ, Roza da Costa B, Xing D, Wang B. Evaluation of Comparative Efficacy and Safety of Surgical Approaches for Total Hip Arthroplasty: A Systematic Review and Network Meta-analysis. JAMA Netw Open 2023; 6:e2253942. [PMID: 36719679 PMCID: PMC9890287 DOI: 10.1001/jamanetworkopen.2022.53942] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/12/2022] [Indexed: 02/01/2023] Open
Abstract
Importance Each approach for primary total hip arthroplasty (THA) has a long learning curve, so a surgeon's choice to change their preferred approach needs to be guided by clear justifications. However, current evidence does not suggest that any of the THA approaches are more beneficial than others, and the choice of approach is mainly based on the knowledge and experience of the surgeon and individual patient characteristics. Objective To assess the efficacy and safety associated with different surgical approaches for THA. Data Sources A comprehensive search of PubMed, EMBASE, and Cochrane databases from inception to March 26, 2022; reference lists of eligible trials; and related reviews. Study Selection Randomized clinical trials (RCTs) comparing different surgical approaches, including the 2-incision approach, direct anterior approach (DAA), direct lateral approach (DLA), minimally invasive direct lateral approach (MIS-DLA), minimally invasive anterolateral approach (MIS-ALA), posterior approach (PA), minimally invasive posterior approach (MIS-PA), and supercapsular percutaneously assisted total hip arthroplasty (SuperPath), for primary THA. Data Extraction and Synthesis Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, 2 reviewers independently extracted data on study participants, interventions, and outcomes as well as assessed the risk of bias using the Cochrane risk of bias tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation framework. A frequentist framework was used to inform a series of random-effects network meta-analyses. Main Outcomes and Measures The outcomes were hip score (range, 0-100, with higher scores indicating better overall hip condition), pain score (range, 0-100, with higher scores indicating more pain), hospitalization time, operation time, quality of life score, blood loss, cup abduction angle, and cup anteversion angle. Results Of 2130 retrieved studies, 63 RCTs including 4859 participants (median [IQR] age, 64.0 [60.3-66.5] years; median [IQR] percentage male, 46.74% [38.64%-54.74%]) were eligible for analysis. Eight surgical approaches were evaluated. For hip score, DAA (mean difference [MD], 4.04; 95% CI, 1.92 to 6.16; moderate certainty), MIS-ALA (MD, 3.00; 95% CI, 0.43 to 5.59; moderate certainty), MIS-DLA (MD, 3.37; 95% CI, 1.05 to 5.68; moderate certainty), MIS-PA (MD, 4.46; 95% CI, 1.60 to 7.31; moderate certainty), PA (MD, 4.37; 95% CI, 1.87 to 6.88; high certainty), and SuperPath (MD, 5.00; 95% CI, 0.58 to 9.42; high certainty) were associated with greater improvement in hip score compared with DLA. DLA was associated with lower decrease in pain score than SuperPath (MD, 1.16; 95% CI, 0.13 to 2.20; high certainty) and MIS-DLA (MD, 0.90; 95% CI, 0.04 to 1.76; moderate certainty). PA was associated with shorter operation times compared with 2-incision (MD, -23.85 minutes; 95% CI, -36.60 to -11.10 minutes; high certainty), DAA (MD, -13.94 minutes; 95% CI, -18.79 to -9.08 minutes; moderate certainty), DLA (MD, -10.50 minutes; 95% CI, -16.07 to -4.94 minutes; high certainty), MIS-ALA (MD, -6.76 minutes; 95% CI, -12.86 to -0.65 minutes; moderate certainty), and SuperPath (MD, -13.91 minutes; 95% CI, -21.87 to -5.95 minutes; moderate certainty). The incidence of 6 types of complications did not differ significantly between the approaches. Conclusions and Relevance In this study, moderate to high certainty evidence indicated that compared with PA, all surgical approaches except DLA were associated with similar improvements of hip score but longer operation time. DLA was associated with smaller improvement of hip score. The safety of the different approaches did not show significant differences. These findings will help health professionals and patients with better clinical decision-making and also provide references for policy makers.
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Affiliation(s)
- Lei Yan
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Second Clinical Medical College, Shanxi Medical University, Taiyuan, China
- Department of Orthopedics, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Long Ge
- Evidence Based Social Science Research Centre, School of Public Health, Lanzhou University, Lanzhou, China
- Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shengjie Dong
- Orthopedic Department, Yantaishan Hospital, Yantai, China
| | - Kiran Saluja
- Bruyere Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Dijun Li
- Second Clinical Medical College, Shanxi Medical University, Taiyuan, China
- Department of Orthopedics, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - K. Srikanth Reddy
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- World Health Organization, Geneva, Switzerland
| | - Qi Wang
- Health Policy PhD Program and McMaster Health Forum, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jiao Jiao Li
- School of Biomedical Engineering, Faculty of Engineering and IT, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Bruno Roza da Costa
- Institute of Health Policy, Management, and Evaluation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Dan Xing
- Arthritis Clinic & Research Center, Peking University People’s Hospital, Peking University, Beijing, China
| | - Bin Wang
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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18
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Ilfeld BM, Smith CR, Turan A, Mariano ER, Miller ME, Fisher RL, Trescot AM, Cohen SP, Eisenach JC, Sessler DI, Prologo JD, Mascha EJ, Liu L, Gabriel RA. Ultrasound-guided Percutaneous Cryoneurolysis to Treat Chronic Postamputation Phantom Limb Pain: A Multicenter Randomized Controlled Trial. Anesthesiology 2023; 138:82-97. [PMID: 36512721 PMCID: PMC10374196 DOI: 10.1097/aln.0000000000004429] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Postamputation phantom pain is notoriously persistent with few validated treatments. Cryoneurolysis involves the application of low temperatures to reversibly ablate peripheral nerves. The authors tested the hypothesis that a single cryoneurolysis treatment would decrease phantom pain 4 months later. METHODS The authors enrolled patients with a lower-limb amputation and established phantom pain. Each received a single-injection femoral and sciatic nerve block with lidocaine and was subsequently randomized to receive either ultrasound-guided percutaneous cryoneurolysis or sham treatment at these same locations. The primary outcome was the change in average phantom pain intensity between baseline and 4 months as measured with a numeric rating scale (0 to 10), after which an optional crossover treatment was offered. Investigators, participants, and clinical staff were masked to treatment group assignment with the exception of the treating physician performing the cryoneurolysis, who had no subsequent participant interaction. RESULTS Pretreatment phantom pain scores were similar in both groups, with a median [quartiles] of 5.0 [4.0, 6.0] for active treatment and 5.0 [4.0, 7.0] for sham. After 4 months, pain intensity decreased by 0.5 [-0.5, 3.0] in patients given cryoneurolysis (n = 71) versus 0 [0, 3] in patients given sham (n = 73), with an estimated difference (95% CI) of -0.1 (-1.0 to 0.7), P = 0.759. Following their statistical gatekeeping protocol, the authors did not make inferences or draw conclusions on secondary endpoints. One serious adverse event occurred after a protocol deviation in which a femoral nerve cryolesion was induced just below the inguinal ligament-instead of the sensory-only saphenous nerve-which resulted in quadriceps weakness, and possibly a fall and clavicle fracture. CONCLUSIONS Percutaneous cryoneurolysis did not decrease chronic lower extremity phantom limb pain 4 months after treatment. However, these results were based upon the authors' specific study protocol, and since the optimal cryoneurolysis treatment parameters such as freeze duration and anatomic treatment location remain unknown, further research is warranted. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Brian M. Ilfeld
- Department of Anesthesiology, University of California San Diego, San Diego, California; Outcomes Research Consortium
| | | | - Alparslan Turan
- Departments of General Anesthesia and Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Outcomes Research Consortium
| | - Edward R. Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Palo Alto Veterans Affairs, Palo Alto, California
| | - Matthew E. Miller
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Rick L. Fisher
- Department of Anesthesiology, Naval Medical Center San Diego, San Diego, California
| | - Andrea M. Trescot
- Florida Pain Relief Group, Florida Pain Relief Group, Tampa, Florida
| | - Steven P. Cohen
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland; Johns Hopkins, Baltimore, Maryland
| | - James C. Eisenach
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Daniel I. Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Outcomes Research Consortium
| | | | - Edward J. Mascha
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Outcomes Research Consortium
| | - Liu Liu
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Outcomes Research Consortium
| | - Rodney A. Gabriel
- Department of Anesthesiology, University of California San Diego, San Diego, California; Outcomes Research Consortium
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19
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Issa M, Naja A, Sultanem S, Elias C, Saghieh S. Dual medial and anterior approach for excision of extraosseous synovial hip osteochondroma: a case report. J Med Case Rep 2022; 16:489. [PMID: 36585715 PMCID: PMC9805212 DOI: 10.1186/s13256-022-03724-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 12/12/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Osteochondromas are the most common benign bone tumors occurring near the end of long bones. In this case report, we demonstrate the successful treatment of a proximal femoral osteochondroma in a pediatric patient excised through a dual medial and anterior approach with no hip dislocation. CASE PRESENTATION We present the case of a white Arab 14-year-old boy with chronic hip pain and inability to ambulate. He failed conservative treatment and was referred to us after X-rays revealed two osseous masses. He was diagnosed with an intra-articular hip osteochondroma confirmed on magnetic resonance imaging and computed tomography scan. He was treated surgically with excision using two incisions: Smith-Petersen approach and Ferguson approach. CONCLUSION This case presents the successful resection of a symptomatic pediatric proximal femoral osteochondroma, using dual medial and anterior approaches without the need for hip dislocation. This was optimal for both the safety and accessibility of this unusual condition.
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Affiliation(s)
- Mohamad Issa
- grid.411654.30000 0004 0581 3406Orthopaedic Surgery Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ahmad Naja
- grid.411654.30000 0004 0581 3406Orthopaedic Surgery Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Serge Sultanem
- grid.411654.30000 0004 0581 3406Orthopaedic Surgery Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Charbel Elias
- grid.411654.30000 0004 0581 3406Orthopaedic Surgery Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Said Saghieh
- grid.411654.30000 0004 0581 3406Orthopaedic Surgery Department, American University of Beirut Medical Center, Beirut, Lebanon
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20
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Gerry AS, Iturregui JM, Carlson BJ, Hassebrock JD, Christopher ZK, Spangehl MJ, Economopoulos KJ, Bingham JS. Increased Risk of Lateral Femoral Cutaneous Nerve Injury in Patients With Previous Hip Arthroscopy Who Underwent a Direct Anterior Approach Total Hip Arthroplasty. Arthrosc Sports Med Rehabil 2022; 5:e103-e108. [PMID: 36866285 PMCID: PMC9971870 DOI: 10.1016/j.asmr.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/10/2022] [Indexed: 12/12/2022] Open
Abstract
Purpose To evaluate the rates of lateral femoral cutaneous nerve (LFCN) injury in patients who underwent a direct anterior approach (DAA) total hip arthroplasty (THA) with and without previous hip arthroscopy. Methods We retrospectively investigated consecutive DAA THAs performed by a single surgeon. These cases were grouped into patients with and without a history of previous ipsilateral hip arthroscopy. LFCN sensation was assessed during the initial follow-up (6 weeks) and 1-year (or most recent) follow-up visits. The incidence and character of LFCN injury was compared between the 2 groups. Results In total, 166 patients underwent a DAA THA with no previous hip arthroscopy, and 13 had a history of previous arthroscopy. Of the 179 total patients who underwent THA, 77 experienced some form of LFCN injury at initial follow-up (43%). The rate of injury for the cohort with no previous arthroscopy was 39% (n = 65/166) on initial follow-up, whereas the rate of injury for the cohort with a history of previous ipsilateral arthroscopy was 92% (n =12/13) on initial follow-up (P < .001). In addition, although the difference was not significant, 28% (n = 46/166) of the group without history of previous arthroscopy and 69% (n = 9/13) of the group with a history of previous arthroscopy had continued symptoms of LFCN injury at most recent follow-up. Conclusions In this study, patients who underwent hip arthroscopy before an ipsilateral DAA THA were at increased risk of LFCN injury compared with patients who underwent a DAA THA without a previous hip arthroscopy. At final follow-up of patients with initial LFCN injury, symptoms resolved in 29% (n = 19/65) of patients with no previous hip arthroscopy and 25% (n = 3/12) of patients with previous hip arthroscopy. Level of Evidence Level III, case-control study.
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Affiliation(s)
| | | | - Brian J. Carlson
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington, USA
| | | | - Zachary K. Christopher
- Department of Orthopedics, Mayo Clinic Arizona, Phoenix, Arizona,Address correspondence to Zachary K. Christopher, M.D., Department of Orthopedic Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd., Phoenix, AZ 85054, U.S.A.
| | - Mark J. Spangehl
- Department of Orthopedics, Mayo Clinic Arizona, Phoenix, Arizona
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21
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Dockery DM, Allu S, Glasser J, Antoci V, Born CT, Garcia DR. Comparison of periprosthetic joint infection rates in the direct anterior approach and non-anterior approaches to primary total hip arthroplasty: a systematic review and meta-analysis. Hip Int 2022:11207000221129216. [PMID: 36214269 DOI: 10.1177/11207000221129216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Periprosthetic joint infection is a serious complication and devastating mode of failure of total hip arthroplasty. Various surgical approaches exist for total hip arthroplasty, including the increasingly popularised direct anterior approach. There is no clear consensus on which approach is least associated with periprosthetic joint infection. The objective of this meta-analysis was to compare the rate of periprosthetic joint infection between surgical approaches to primary total hip arthroplasty for osteoarthritis. METHODS A search of 3 electronic databases (PubMed/MEDLINE, Embase, and Cochrane Library) was conducted for relevant studies up to June 2020 with a defined list of inclusion and exclusion criteria. Randomised controlled trials and longitudinal studies reporting periprosthetic joint infection rates after primary total hip arthroplasty for osteoarthritis were included based on surgical approach. Data extraction was completed, and a meta-analysis was then performed using OpenMeta[Analyst] software. RESULTS A total of 24,407 hips were included for meta-analysis with an overall PJI incidence of 0.57%. The incidence rate for periprosthetic joint infection was 0.77% in the direct anterior approach group and 0.44% in the non-anterior approach group. The use of an anterior approach for a total hip arthroplasty was associated with an increased risk for periprosthetic joint infection (odds ratio = 1.404; 95% confidence interval, 0.711-2.771; p = 0.03). CONCLUSIONS The direct anterior approach to total hip arthroplasty may be associated with a significantly increased risk for periprosthetic joint infection compared to non-anterior approaches, even though the overall rate was still small. This should be considered by orthopedic surgeons when choosing the surgical approach.
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Affiliation(s)
| | - Sai Allu
- Warren Alpert Medical School of Brown University, Providence, RI, USA.,Brown University, Providence, RI, USA
| | - Jillian Glasser
- Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, RI, USA
| | - Valentin Antoci
- Warren Alpert Medical School of Brown University, Providence, RI, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, RI, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Christopher T Born
- Warren Alpert Medical School of Brown University, Providence, RI, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, RI, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Dioscaris R Garcia
- Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
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22
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Peters RM, Ten Have BLEF, Rykov K, Van Steenbergen L, Putter H, Rutgers M, Vos S, Van Steijnen B, Poolman RW, Vehmeijer SBW, Zijlstra WP. The learning curve of the direct anterior approach is 100 cases: an analysis based on 15,875 total hip arthroplasties in the Dutch Arthroplasty Register. Acta Orthop 2022; 93:775-782. [PMID: 36173140 PMCID: PMC9521054 DOI: 10.2340/17453674.2022.4802] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/25/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE In the last decade, the direct anterior approach (DAA) for total hip arthroplasty (THA) has become more popular in the Netherlands. Therefore, we investigated the learning curve and survival rate of the DAA in primary THA, using data from the Dutch Arthroplasty Register (LROI). PATIENTS AND METHODS We identified all patients who received a primary THA using the DAA in several high-volume centers in the Netherlands between 2007 and 2019 (n = 15,903). Procedures were ordered per surgeon, using date of operation. Using the procedure number, operations were divided into 6 groups based on the number of previous procedures per surgeon (first 25, 26-50, 51-100, 101-150, 151-200, > 200). Data from different surgeons in different hospitals was pooled together. Revision rates were calculated using a multilevel time-to-event analysis. RESULTS Patients operated on in group 1-25 (hazard ratio [HR] 1.6; 95% CI 1.1-2.4) and 26-50 (HR 1.6; CI 1.1-2.5) had a higher risk for revision compared with patients operated on in group > 200 THAs. Between 50 and 100 procedures the revision risk was increased (HR 1.3; CI 0.9-1.9), albeit not statistically significant. From 100 procedures onwards the HR for revision was respectively 1.0 (CI 0.6-1.6) and 0.8 (CI 0.5-1.4) for patients in operation groups 101-150 and 151-200. Main reasons for revision were loosening of the stem (29%), periprosthetic infection (19%), and dislocation (16%). INTERPRETATION We found a 64% increased risk of revision for patients undergoing THA using the DAA for the first 50 cases per surgeon. Between 50 and 100 cases, this risk was 30% increased, but not statistically significant. From 100 cases onwards, a steady state had been reached in revision rate. The learning curve for DAA therefore is around 100 cases.
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Affiliation(s)
- Rinne M Peters
- Department of Orthopedic Surgery, Medical Center Leeuwarden; Department of Orthopedic Surgery, University Medical Center Groningen.
| | | | - Kyrill Rykov
- Department of Orthopedic Surgery, Martini Hospital, Groningen
| | | | - Hein Putter
- Department of Medical Statistics and Bioinformatics Statistics, Leiden University Medical Center
| | - Marijn Rutgers
- Department of Orthopedic Surgery, HAGA Hospital, The Hague
| | - Stan Vos
- Department of Orthopedic Surgery, Noordwest Ziekenhuisgroep, Alkmaar
| | | | - Rudolf W Poolman
- Department of Orthopedic Surgery, OLVG, Amsterdam; Department of Orthopedic Surgery, Leiden University Medical Center
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23
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Tanabe H, Baba T, Ozaki Y, Yanagisawa N, Banno S, Watari T, Homma Y, Nagao M, Kaneko K, Ishijima M. Lateral versus conventional fasciotomy for prevention of lateral femoral cutaneous nerve injury in total hip arthroplasty with direct anterior approach: a study protocol for a dual-center, double-blind, randomized controlled trial. Trials 2022; 23:567. [PMID: 35841003 PMCID: PMC9287917 DOI: 10.1186/s13063-022-06496-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 06/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An incision for total hip arthroplasty (THA) via the direct anterior approach (DAA) is generally made outside of the space between the sartorius and tensor fasciae latae muscles to prevent lateral femoral cutaneous nerve (LFCN) injury. Anatomical studies have revealed that the LFCN courses between the sartorius and tensor fasciae latae muscles. When the LFCN branches radially while distributing in the transverse direction from the sartorius muscle to the tensor fasciae latae muscle, it is called the fan type. Studies suggest that damage to the fan type LFCN is unavoidable during conventional fasciotomy. We previously demonstrated that injury to non-fan variation LFCN occurred in 28.6% of patients who underwent THA by fasciotomy performed 2 cm away from the intermuscular space. This suggests that the conventional approach also poses a risk of LFCN injury to non-fan variation LFCN. LFCN injury is rarely reported in the anterolateral approach, which involves incision of fascia further away than the DAA. The purpose of this study is to investigate how the position of fasciotomy in DAA affects the risk of LFCN injury. METHODS We will conduct a prospective, randomized, controlled study. All patients will be divided into a fan variation and a non-fan variation group using ultrasonography before surgery. Patients with non-fan variation LFCN will receive conventional fasciotomy and lateral fasciotomy in the order specified in the allocation table created in advance by our clinical trial center. The primary endpoint will be the presence of LFCN injury during an outpatient visit using a patient-based questionnaire. The secondary endpoints will be assessed based on patient-reported outcomes at 3 months after surgery in an outpatient setting using the Western Ontario and McMaster Universities Osteoarthritis Index, the Japanese Orthopaedic Association Hip-disease Evaluation Questionnaire, and the Forgotten-Joint Score-12. DISCUSSION We hypothesize that the incidence of LFCN injury due to DAA-THA is reduced by making the incision further away from where it is typically made in conventional fasciotomy. If our hypothesis is confirmed, it will reduce the disadvantages of DAA and improve patient satisfaction. TRIAL REGISTRATION UMIN Clinical Trials Registry, UMIN000035945 . Registered on 20 February, 2019.
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Affiliation(s)
- Hiroki Tanabe
- Department of Orthopedic Surgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Tomonori Baba
- Department of Orthopedic Surgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Yu Ozaki
- Department of Orthopedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, 3-3-20 Shinsuna, Koutouku, Tokyo, Japan
| | - Naotake Yanagisawa
- Medical Technology Innovation Center, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Sammy Banno
- Department of Orthopedic Surgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Taiji Watari
- Department of Orthopedic Surgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Yasuhiro Homma
- Department of Orthopedic Surgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Masashi Nagao
- Department of Orthopedic Surgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan
- Medical Technology Innovation Center, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Kazuo Kaneko
- Department of Orthopedic Surgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Muneaki Ishijima
- Department of Orthopedic Surgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan
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24
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O’Brien MJM, Jones DM, Semciw AI, Balakumar J, Grabinski R, Roebert J, Coburn GM, Mechlenburg I, Kemp JL. Does the use of i-FACTOR bone graft affect bone healing in those undergoing periacetabular osteotomy (PAO) for developmental dysplasia of the hip (DDH)? A retrospective study. J Hip Preserv Surg 2022; 9:165-171. [PMID: 37063347 PMCID: PMC10093896 DOI: 10.1093/jhps/hnac027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 03/02/2022] [Accepted: 05/11/2022] [Indexed: 04/18/2023] Open
Abstract
ABSTRACT
The aims of this study were to compare, in patients with and without the use of i-FACTOR bone graft during periacetabular osteotomy (PAO) surgery for developmental dysplasia of the hip (DDH), (i) bone healing at six-weeks post-operatively (ii) rate of complications. This was a retrospective review of case records. Participants were people aged 15-50 years undergoing rectus-sparing minimally invasive PAO surgery for DDH. Group 1: patients with i-FACTOR, Group 2: No i-FACTOR. The primary outcome was the rate of bone healing on radiographs at 6 weeks. The likelihood of bone healing was compared using logistic regression with Generalised Estimating Equations (GEE) and expressed as odds ratios (95% confidence intervals (CIs; P < 0.05)). The occurrence of complications was extracted from surgical records. The i-FACTOR group had 3-times greater odds of partial/full union than those without [adjusted odds ratio (95% CIs, P-value)]: [3.265 (1.032 to 10.330, P = 0.044)]. The i-FACTOR group had 89% partial/full union at 6-weeks, compared to 69% of the non-i-FACTOR group. Half of the patients had leaking of bone graft in the i-FACTOR group versus 10% in the non-i-FACTOR group, 26% of the i-FACTOR group and 12% of the non-i-FACTOR group had neuropraxia of the lateral femoral cutaneous nerve (LFCN). Complication rates were low, and similar between groups. However, the rate of LFCN neuropraxia and bone graft leakage was higher in the i-FACTOR. These findings should be confirmed in a future prospective randomised clinical trial and include outcomes such as pain and quality of life.
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Affiliation(s)
| | | | - Adam Ivan Semciw
- Department of Physiotherapy, Podiatry, and
Prosthetics and Orthotics, La Trobe University, Melbourne, VIC 3086,
Australia
| | | | - Rafal Grabinski
- Victoria House Imaging, I-Med
Radiology, Melbourne, VIC 3141, Australia
| | - Justin Roebert
- Victoria House Imaging, I-Med
Radiology, Melbourne, VIC 3141, Australia
| | - Georgia M Coburn
- La Trobe Sport and Exercise Medicine Research
Centre, La Trobe University, Melbourne, VIC 3086, Australia
| | - Inger Mechlenburg
- Department of Orthopaedics, Aarhus University
Hospital, Aarhus 8200, Denmark
- Department of Clinical Medicine, Aarhus
University, Aarhus 8200, Denmark
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25
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Goyal T, Choudhury AK, Paul S, Das L, Gupta T. The direct anterior approach without traction table: How does it compare with the posterior approach? - A prospective non-randomised trial. J Clin Orthop Trauma 2022; 31:101924. [PMID: 35941870 PMCID: PMC9356358 DOI: 10.1016/j.jcot.2022.101924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/09/2022] [Accepted: 06/17/2022] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The direct anterior approach (DAA) for total hip replacement (THR) is relatively new. It has been proved superior to other techniques concerning early functional outcomes, stability, and earlier recovery. But DAA-THR has a steeper surgical learning curve and, in its original description, needs special operating room equipment. This study aims to present clinical, functional, and radiological outcomes of DAA compared to the posterior approach (PA), performed using a routine operating table and instrumentation sets. METHODS Eighty patients undergoing THR were non-randomly allocated prospectively into Group 1 DAA and Group 2 PA. Visual analog scale (VAS) for pain was recorded preoperatively and at 6, 12, 24, 48, and 72 h after the surgery and at 1st and 2nd year postoperatively. Both groups' functional outcomes were evaluated pre-and postoperatively at 1st and 2nd-year follow-up with Harris hip score (HHS) and SF-12. Perioperative parameters like blood loss, length of hospital stay, duration of surgery, postoperative complications, and radiological prosthesis positioning were also compared between the two groups. RESULTS All patients were comparable according to their baseline demographic characteristics. DAA was found to have significantly better early HHS at one year (p = 0.001) and VAS for hip pain (p < 0.05) at 12, 24, 48, and 72 hrs postoperative period only. Clinical outcomes were comparable at the final follow-up of 2 years. Perioperative variables were also similar except the incision length, length of stay in the hospital, and average time to weight bear without walking aids which were statistically better in DAA than PA group. There was no difference in radiological prosthesis positioning. Postoperative complication rates were also comparable in the two groups. CONCLUSION Though technically demanding, DAA provides better early functional outcomes with comparable radiological outcomes and complication rates than the PA.Level of evidence: Non-randomized comparative trial, Level II.
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Affiliation(s)
- Tarun Goyal
- Department of Orthopaedics, All India Institute of Medical Sciences, Bathinda, Punjab, 151001, India,Corresponding author.
| | | | - Souvik Paul
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Lakshmana Das
- Department of Orthopaedics, All India Institute of Medical Sciences, Bathinda, Punjab, 151001, India
| | - Tushar Gupta
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
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26
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Gulbrandsen TR, Muffly SA, Shamrock A, O’Reilly O, Bedard NA, Otero JE, Brown TS. Total Hip Arthroplasty: Direct Anterior Approach Versus Posterior Approach in the First Year of Practice. THE IOWA ORTHOPAEDIC JOURNAL 2022; 42:127-136. [PMID: 35821938 PMCID: PMC9210397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Background The direct anterior approach (DAA) for total hip arthroplasty (THA) has been popularized as a less invasive technique, however outcomes within the first year of practice after fellowship have not been investigated. The primary aim was to determine differences in complications and outcomes between DAA and posterior approach (PA) in the first year of practice. The secondary aim was to determine if there was a learning curve factor in DAA and PA after fellowship training. Methods THA cases performed by two surgeons during their first year of practice were reviewed. Overall, 181 THAs (91 DAA, 90 PA) in 168 patients, were performed. Intraoperative differences (blood loss, operative time), hospital stay, complications, reoperations, and revisions were compared. Results Overall surgical complications were similar between DAA and PA (11% vs. 9%, p=0.64), but complication profiles were different: dislocation (1% vs. 4%, p=0.17), intraoperative femoral fracture (2% vs. 1%, p=0.32), postoperative periprosthetic fractures (2% vs. 3%, p=0.64). neuropraxia (3% vs. 0%, p=0.08). There was no difference in rate of reoperation (1% vs. 3%, p=0.31). There was a difference in rate of revision at final follow-up (0% vs. 6%, p=0.02). DAA consisted of longer operative time (111 vs. 99 minutes; p<0.001), however was only significant in the first 50 cases (p<0.001), while the subsequent cases were similar (p=0.31). There was no difference in the first 50 cases compared to the subsequent cases for either approach regarding blood loss, complications, reoperations, or revisions. Conclusion DAA and PA for THA performed within the first year of practice exhibit similarly low complication rates, but complication profiles are different. In our series, PA did demonstrate a higher risk of revision at final follow-up. A learning curve is not unique to the DAA. Both DAA and PA THA exhibited a learning curve in the first 50 cases performed at the start of a surgeon's practice. Level of Evidence: III.
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Affiliation(s)
- Trevor R. Gulbrandsen
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Scott A. Muffly
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Alan Shamrock
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Olivia O’Reilly
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
- OrthoCarolina Hip and Knee Center, Charlotte, North Carolina, USA
- Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Nicolas A. Bedard
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Jesse E. Otero
- OrthoCarolina Hip and Knee Center, Charlotte, North Carolina, USA
- Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Timothy S. Brown
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Rivera F, Comba LC, Bardelli A. Direct anterior approach hip arthroplasty: How to reduce complications - A 10-years single center experience and literature review. World J Orthop 2022; 13:388-399. [PMID: 35582154 PMCID: PMC9048494 DOI: 10.5312/wjo.v13.i4.388] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 10/31/2021] [Accepted: 03/27/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The direct anterior approach for total hip arthroplasty (DAA-THA) is increasing in popularity due to some advantages such as less surgical trauma, minimal dissection of soft tissues, shorter rehabilitation times, faster return to daily activities, lower incidence of dislocation. On the other hand, the literature reports a high rate of intraoperative complications, with many different rates and complication types in the published papers.
AIM To analyze our complications comparing results with the literature; to report measures that we have taken to reduce complications rate.
METHODS All DAA-THA patients with one year minimum follow up who were operated at a single high-volume centre, between January 2010 and December 2019 were included in this retrospective study. All surgeries were performed using cementless short anatomical or straight stems and press fit cups. Patients’ follow-up was performed, at 6 wk, 3 mo, then annually post-surgery with clinical and radiological evaluation. Primary outcomes were stem revision for aseptic loosening and all-cause stem revision. Second outcome was intra-operative and post-operative complications identification.
RESULTS A total of 394 patients underwent DDA-THA from January 2010 and December 2019, for a total of 412 hips; twelve patients lost to follow-up and one patient who died from causes not related to surgery were excluded from the study. The average age at the time of surgery was 61 years (range from 28 to 78 years). Mean follow-up time was 64.8 mo (range 12-120 mo). Seven stems were revised. One cortical perforation, one trochanteric and lateral cortical wall intraoperative fracture, one diaphyseal fracture, three clinically symptomatic early subsidence and one late aseptic loosening. We also observed 3 periprosthetic fractures B1 according to the Vancouver Classification. Other minor complications not requiring stem revision were 5 un-displaced fractures of the calcar region treated with preventive cerclage, one early infection, one case of late posterior dislocation, 18 case of asymptomatic stem subsidence, 6 cases of lateral cutaneous femoral nerve dysesthesia.
CONCLUSION DAA is associated to good outcomes and lower incidence of dislocation. Complication rate can be reduced by mindful patient selection, thorough preoperative planning, sufficient learning curve and use of intraoperative imaging.
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Affiliation(s)
- Fabrizio Rivera
- Department of Orthopedic Trauma, SS Annunziata Hospital, Savigliano 12038, Italy
| | - Luca C Comba
- Department of Orthopedic Trauma, Università degli Studi di Torino, Torino 10124, Italy
| | - Alessandro Bardelli
- Department of Orthopedic Trauma, SS Annunziata Hospital, Savigliano 12038, Italy
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Goh GS, Parvizi J. Nerve Injuries Following Total Hip Arthroplasty: The Influence of Surgical Approach. Orthop Clin North Am 2022; 53:129-137. [PMID: 35365257 DOI: 10.1016/j.ocl.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Nerve injuries following total hip arthroplasty are rare but devastating complications. The most important modifiable risk factor remains the choice of hip approach and surgical technique applied. The risk of nerve injuries is related to technical complexity of the procedure and anatomic variability of the nerves. Surgeons should remain cognizant of inherent risk factors, variations in the course and branching patterns of different nerves, and technical considerations of the surgical approach to mitigate risks. This article reviews the literature on postsurgical nerve injuries following total hip arthroplasty and characterizes the influence of surgical approach on the risk of this complication.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA.
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Ukai T, Suyama K, Hayashi S, Omura H, Watanabe M. The anatomical features of the lateral femoral cutaneous nerve with total hip arthroplasty: a comparative study of direct anterior and anterolateral supine approaches. BMC Musculoskelet Disord 2022; 23:267. [PMID: 35303834 PMCID: PMC8933952 DOI: 10.1186/s12891-022-05224-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/15/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Lateral femoral cutaneous nerve (LFCN) injury after total hip arthroplasty causes patient dissatisfaction. This cadaveric study aimed to assess the risk for LFCN injury after the direct anterior approach (DAA) and anterolateral supine approach (ALS) with a focus on the anatomical variations of the LFCN. METHODS Thirty-seven hemipelves from 20 formalin-preserved cadavers (10 males and 10 females) were dissected to identify the LFCN, evaluate variations, and measure the distance from the LFCN to each approach. The LFCN was classified as classical, late, multi trunk, or primary femoral. RESULTS There were no significant variations in the LFCN between the sexes. The distance from the LFCN to DAA incision (10 [0-17.8] mm) was significantly less than that from the LFCN to ALS incision (27 [0-40] mm); moreover, 64.9% of DAA incisions crossed the LFCN. The classical type LFCN was closest to the DAA incision. The DAA incision most frequently crossed the LFCN at the proximal third, and the frequency of intersection of the LFCN and DAA incisions decreased by 25% by a 10-mm shortening of the DAA proximal incision. In contrast, 27% of ALS incisions crossed the LFCN. Multi trunk type LFCN was closest to the ALS incision. There were no significant differences between each approach and LFCN variations, and the frequency of intersection of the LFCN and ALS incisions decreased by 20% by a 10-mm shortening of the ALS proximal incision. CONCLUSIONS The intersection rates between the LFCN and the DAA and between the LFCN and the ALS were approximately 65 and 30%, respectively. Approximately 20-25% of these injuries may be avoidable by a 10-mm shortening of the proximal incision.
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Affiliation(s)
- Taku Ukai
- Department of Orthopedic Surgery, Surgical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.
| | - Kaori Suyama
- Department of Anatomy, Division of Basic Medical Science, Tokai University School of Medicine, Isehara, Kanagawa, 259-1193, Japan
| | - Shogo Hayashi
- Department of Anatomy, Division of Basic Medical Science, Tokai University School of Medicine, Isehara, Kanagawa, 259-1193, Japan
| | - Haruka Omura
- Department of Orthopedic Surgery, Surgical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Masahiko Watanabe
- Department of Orthopedic Surgery, Surgical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
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Pan T, Mehta A, Mason MW. Outcomes of the Supine Anterior-based Muscle-sparing Approach for Primary and Revision Hip Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202202000-00002. [PMID: 35134005 PMCID: PMC8812599 DOI: 10.5435/jaaosglobal-d-21-00050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 12/04/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Risks and outcomes of total hip arthroplasty (THA) are believed to vary relative to the surgical approach. This study compares the supine anterior-based muscle-sparing (ABMS) approach with its modern-day counterparts. METHODS A retrospective review was done on 550 patients undergoing primary or revision THA from 2016 to 2018. Surgical modalities included direct anterior (DAA), ABMS, posterolateral, and Müller modified Hardinge approaches. Surgical data were collected, and clinical outcomes were measured by the Hip Disability and Osteoarthritis Outcome Score, Modified Harris Hip Score, UCLA, and VR-12 Mental/Physical scores preoperatively and compared clinical outcomes among approaches. RESULTS A total of 550 patients were included (447 primaries, 103 revisions). The average age was 64 years (231 men, 319 women). Approaches included 79 DAA (14%), 212 ABMS (39%), 180 modified Müller-Hardinge (33%), and 79 posterolateral (14%). The incidence of lateral femoral cutaneous nerve injury was more common with the DAA (P = 0.008), but no other clinically significant differences were noted among the groups. CONCLUSION The results of this study showed no clinically notable differences between the supine ABMS and other approaches. The supine ABMS approach is an acceptable approach in modern day THA when used by an experienced surgeon well-versed in the approach.
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Affiliation(s)
- Tommy Pan
- From the Penn State College of Medicine, Hershey, PA (Mr. Pan, Mr. Mehta, and Dr. Mason), and Penn State Hershey Medical Center, Bone and Joint Institute (Dr. Mason)
| | - Anuj Mehta
- From the Penn State College of Medicine, Hershey, PA (Mr. Pan, Mr. Mehta, and Dr. Mason), and Penn State Hershey Medical Center, Bone and Joint Institute (Dr. Mason)
| | - Mark W. Mason
- From the Penn State College of Medicine, Hershey, PA (Mr. Pan, Mr. Mehta, and Dr. Mason), and Penn State Hershey Medical Center, Bone and Joint Institute (Dr. Mason)
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Defining the Learning Curve of Anterior Total Hip Arthroplasty After Fellowship-specific Training. J Am Acad Orthop Surg 2022; 30:e131-e138. [PMID: 34534151 DOI: 10.5435/jaaos-d-21-00232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 08/11/2021] [Indexed: 02/01/2023] Open
Abstract
PURPOSE To investigate the learning curve associated with performing direct anterior total hip arthroplasty (THA) immediately after fellowship training in this approach. METHODS This was a multicenter, retrospective study that collected data on all direct anterior THAs performed by four fellowship-trained arthroplasty surgeons in their first year of practice. Demographic data, surgical time, blood loss, surgical complications, and medical complications were recorded. Regression models were created to evaluate the outcomes of interest. A generalized linear mixed model was used to estimate the effect of the number of THA procedures performed, a proxy for surgical experience with this procedure, on the variables of interest. RESULTS A total of 286 patients undergoing direct anterior THA were included in this study. A decrease in surgical complications after approximately 40 cases and a decrease in medical complications at 25 to 50 cases were observed. Both surgical time and blood loss showed no learning curve. CONCLUSION Extensive training with a direct anterior approach during fellowship minimizes the learning curve for blood loss and surgical time, but it continues to exist regarding perioperative surgical and medical complications. Recent fellowship graduates should be cautious and expect a learning curve of around 40 cases before complication rates begin to normalize.
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Dahm F, Aichmair A, Dominkus M, Hofstaetter JG. Incidence of lateral femoral cutaneous nerve lesions after direct anterior approach primary total hip arthroplasty - a literature review. Orthop Traumatol Surg Res 2021; 107:102956. [PMID: 33962046 DOI: 10.1016/j.otsr.2021.102956] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Lesions of the lateral cutaneous femoral nerve are a reported complication of the direct anterior approach (DAA) for total hip arthroplasty (THA). Little is known about the incidence rates of this lesion. The goal of this study was to answer the following questions: (1) Is the true incidence rate of LFCN lesions after DAA THA known? (2) What are the reasons for the wide range of reported incidence rates in the literature? (3) Are surgeons increasingly aware of the significance of LFCN lesions? METHODS A US Medical Library of Medicine database search was performed for DAA THA. In total, 1261 search results were screened for reported LFCN lesions. RESULTS Forty-five studies were included reporting LFCN lesions rates of 0-83%. Subgroup analysis for studies with (group A, 6 studies, n=1113 cases) and without (group B, 39 studies n=16,741) primary focus on the LFCN lesions was performed. Incidence in group A ranged from 14.8-81% (mean 31%) and 0-83% (mean 3.8%) in group B. The difference between the groups was significant (p=0.005). No uniform and time sensitive definition of postoperative LFCN lesions was found in the literature. An analysis of the publication year and the discovered incidence rate showed an increase of incidence rates [rs=0.521 (p<0.001, two-tailed)] over time. CONCLUSION Despite the absence of a uniform definition: LFCN lesions after DAA THA are a frequent and, in the past, often underestimated complication. LEVEL OF EVIDENCE IV; systematic review of level II to level IV studies.
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Affiliation(s)
- Falko Dahm
- II. Orthopedic Department, Orthopedic Hospital Speising, Speisinger Str. 109, 1130 Vienna, Austria; Division of Orthopedic Surgery, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.
| | - Alexander Aichmair
- II. Orthopedic Department, Orthopedic Hospital Speising, Speisinger Str. 109, 1130 Vienna, Austria; Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Speising, Speisinger Str. 109, 1130 Vienna, Austria
| | - Martin Dominkus
- II. Orthopedic Department, Orthopedic Hospital Speising, Speisinger Str. 109, 1130 Vienna, Austria; Sigmund Freud Medical University, Freudplatz 1, 1020 Vienna, Austria
| | - Jochen G Hofstaetter
- II. Orthopedic Department, Orthopedic Hospital Speising, Speisinger Str. 109, 1130 Vienna, Austria; Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Speising, Speisinger Str. 109, 1130 Vienna, Austria
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Zhang Y, Yao Y, Wang Y, Zhuang Z, Shen Y, Jiang Q, Chen D. Preoperative ultrasound to map the three-dimensional anatomical distribution of the lateral femoral cutaneous nerve in direct anterior approach for total hip arthroplasty. J Orthop Surg Res 2021; 16:623. [PMID: 34663391 PMCID: PMC8522191 DOI: 10.1186/s13018-021-02763-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 09/30/2021] [Indexed: 12/02/2022] Open
Abstract
Background The postoperative complaints of hypoesthesia or a burning sensation due to lateral femoral cutaneous nerve (LFCN) injury in patients are not yet solved. The present study aimed to identify the three-dimensional (3D) distribution of LFCN using preoperative ultrasound and evaluate the rate of injury in direct anterior approach for total hip arthroplasty. Methods A total of 59 patients (28 males and 31 females, age 69.0 ± 4.6 years, BMI 24.7 ± 3.0 kg/m2) were randomly allocated to the ultrasound group and 58 patients (28 males and 30 females, age 68.5 ± 4.5 years, BMI 24.8 ± 2.8 kg/m2) were in the control group. Surgeons received the data of 3D distribution of LFCN only in the ultrasound group before surgery with respect to the direction, the depth on the skin, and the length to tensor fasciae latae (TFL). The anatomical characteristics of LFCN in the surgical region were summarized. At 1 and 3 months of post surgery, the rate of LFCN injury and abnormal sensitive area was evaluated in both groups. Results There was a significant consistency in gender, age and BMI of these two groups (P > 0.05). Based on the data from the ultrasound group, over 90% of patients had one or two branches of LFCN. LFCN always courses in the fascia layer, the depth ranged from 6.8 ± 2.6 (3.0–12.0) mm to 11.1 ± 3.4 (4.0–17.0) mm and depended on the thickness of the subcutaneous fat, and length was 3.3 ± 4.6 (− 5.0–10.0) mm at proximal part and − 2.7 ± 4.7 (− 10.0–8.0) at distal end to the medial edge of TFL. Both the rate of LFCN injury and abnormal sensory area in the ultrasound group was significantly lower than those in the control group (3.4% vs. 25.9%, P = 0.001, at 1 month; 3.4% vs. 22.4%, P = 0.005, at 3 months). Conclusions LFCN mostly courses along the medial border of TFL in the fascia layer. The 3D distribution of LFCN using preoperative ultrasound mapping could help the surgeons to evaluate the risk of injury preoperatively and decrease the rate of injury during the operation. However, some branch injuries, especially for the fan type LFCN, could not be avoided.
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Affiliation(s)
- Yu Zhang
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Branch of National Clinical Research Center for Orthopedics, Sports Medicine Rehabilitation, Nanjing, People's Republic of China
| | - Yao Yao
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Branch of National Clinical Research Center for Orthopedics, Sports Medicine Rehabilitation, Nanjing, People's Republic of China
| | - Yexian Wang
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Branch of National Clinical Research Center for Orthopedics, Sports Medicine Rehabilitation, Nanjing, People's Republic of China
| | - Zaikai Zhuang
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Branch of National Clinical Research Center for Orthopedics, Sports Medicine Rehabilitation, Nanjing, People's Republic of China
| | - Ying Shen
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Branch of National Clinical Research Center for Orthopedics, Sports Medicine Rehabilitation, Nanjing, People's Republic of China
| | - Qing Jiang
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China. .,Branch of National Clinical Research Center for Orthopedics, Sports Medicine Rehabilitation, Nanjing, People's Republic of China.
| | - Dongyang Chen
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China. .,Branch of National Clinical Research Center for Orthopedics, Sports Medicine Rehabilitation, Nanjing, People's Republic of China.
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Sang W, Xue S, Xu Y, Liu Y, Zhu L, Ma J. Bikini Incision Increases the Incidence of Lateral Femoral Cutaneous Nerve Injury in Direct Anterior Approach Hip Arthroplasty: A Prospective Ultrasonic, Electrophysiological, and Clinical Study. J Arthroplasty 2021; 36:3463-3470. [PMID: 34074541 DOI: 10.1016/j.arth.2021.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/06/2021] [Accepted: 05/10/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Lateral femoral cutaneous nerve (LFCN) injury has been widely reported as one of the most common complications of direct anterior approach (DAA) hip arthroplasty. Bikini incision is considered to increase the incidence of this complication. METHODS A prospective randomized study was conducted after including ninety-nine bikini and ninety-six longitudinal incision DAA cases from May to November 2020. The occurrence of LFCN was examined using ultrasound before and after surgery. The recovery of injury symptoms was evaluated by continuous clinical follow-up until six months, and the patients were treated with mecobalamin and/or celecoxib. Sensory conduction velocity and sensory action potential amplitude of the LFCN were measured after surgery in symptomatic patients. RESULTS Eighty five (43.6%), sixty seven (34.4%), and forty three (22.0%) cases of LFCN were of the anterior trunk, posterior trunk, and fan types, respectively, before surgery. All one hundred ninety five patients completed the follow-up period. Fifty-seven patients had symptoms of LFCN injury, including thirty six and twenty one patients in the bikini group and longitudinal group, respectively, with significantly different incidence rates (36.4% and 21.9%, respectively; P < .05). Of these, thirty two (56.1%), thirteen (22.8%), and twelve (21.1%) cases were of the anterior trunk, posterior trunk, and fan types, respectively. Sensory conduction velocity and sensory action potential amplitude significantly decreased after surgery in both groups (P < .05). Seventeen cases showed reduction of symptoms within three months. Forty six cases showed self-recovery within six months and eleven cases showed persistent symptoms at the final follow-up. CONCLUSION Bikini incision DAA hip arthroplasty may increase the incidence of LFCN injury, and the anterior trunk distribution type is most likely to be affected. (Clinical Trial Registration Number: CHICTR2000035107).
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Affiliation(s)
- Weilin Sang
- Department of Joint Surgery, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Song Xue
- Department of Joint Surgery, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Yiming Xu
- Department of Joint Surgery, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Yu Liu
- Department of Orthopedics, RWTH Aachen University Clinic, Aachen, Germany
| | - Libo Zhu
- Department of Joint Surgery, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Jinzhong Ma
- Department of Joint Surgery, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
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Phruetthiphat OA, Sangthumprateep V, Trakulngernthai S, Aegakkatajit N, Chotanaphuti T, Chanpoo M. Functional outcome and complication following THA through modified direct anterior approach correlated to cadaveric study: are there any differences in Asian hip? J Orthop Surg Res 2021; 16:513. [PMID: 34416884 PMCID: PMC8377820 DOI: 10.1186/s13018-021-02661-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/11/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Direct anterior approach (DAA) has several advantages including shorter length of hospital stay, faster recovery, and better functional outcome while this approach may cause damage to the lateral femoral cutaneous nerve (LFCN) as high as 81% in the works of literature. Not much data has identified the LFCN pattern in the Asian population. Therefore, the purpose of our study was to identify characteristics of the LFCN patterns representing an Asian hip, which would aid to provide the most appropriate incision of modified direct anterior approach (MDAA) for total hip arthroplasty (THA), and to identify the clinical outcome and complications following THA through MDAA correlated with cadaveric hip in the Asian population. METHODS After IRB approval, a cadaveric study was done to identify pattern and course of the LFCN in Asian population. The MDAA defined as the incision 2 fingerbreadths posteriorly to anterior superior iliac spine to avoid injury to the LFCN. The clinical phase identified 32 patients who underwent THA because of late-stage osteoarthritis of the hip. The anterolateral skin numbness was measured along tensor fascia lata between 2 weeks until 2 years. The functional outcome assessed by Harris Hip Score (HHS) and complications were evaluated in all patients. RESULTS The characteristics of the LFCN from cadaveric study (phase 1) was predominantly in sartorius type (60.0%) followed by posterior type (26.6%), fan type (6.7%), and variant type (6.7%). The clinical phase demonstrated that 23 patients (71.9%) had no numbness while 9 patients (28.1%) came with numbness after undergoing THA through the MDAA. Finally, a small area of skin numbness remained in only 3 patients (9.4%) at 2 years follow-up. Additionally, there was no significant difference in functional score at 2 years follow-up (89.0 vs 91.2, p = 0.422) between those with LFCN injury and those without LFCN injury. CONCLUSIONS The LFCNs were divided into four types. Modified direct anterior approach, which is an alternative approach for THA, allowing for a lower rate of skin numbness and faster recovery without hip dislocation, abductor weakness, and serious nerve complication. Functional outcome was comparable with and without LFCN injury. LEVEL OF EVIDENCE Level II, prospective observation study.
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Affiliation(s)
- Ong-art Phruetthiphat
- Orthopedic Department, Phramongkutklao Hospital, 315 Ratchvidhi Road, Thung Phaya Thai, Ratchathewee, Bangkok, 10400 Thailand
| | - Vasin Sangthumprateep
- Orthopedic Department, Phramongkutklao Hospital, 315 Ratchvidhi Road, Thung Phaya Thai, Ratchathewee, Bangkok, 10400 Thailand
| | - Songpol Trakulngernthai
- Orthopedic Department, Phramongkutklao Hospital, 315 Ratchvidhi Road, Thung Phaya Thai, Ratchathewee, Bangkok, 10400 Thailand
| | - Noppadol Aegakkatajit
- Orthopedic Department, Phramongkutklao Hospital, 315 Ratchvidhi Road, Thung Phaya Thai, Ratchathewee, Bangkok, 10400 Thailand
| | - Thanainit Chotanaphuti
- Orthopedic Department, Phramongkutklao Hospital, 315 Ratchvidhi Road, Thung Phaya Thai, Ratchathewee, Bangkok, 10400 Thailand
| | - Malee Chanpoo
- Department of Anatomy, Phramongkutklao College of Medicine, Bangkok, Thailand
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Kapilow JM, Gladnick BP, Anderson LA, Peters PC, Masonis JL. Acetabular Exposure Is Enhanced With Self-Retaining Retractors During Direct Anterior Total Hip Arthroplasty. Orthopedics 2021; 44:e309-e313. [PMID: 33238015 DOI: 10.3928/01477447-20201119-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Acetabular exposure for direct anterior (DA) total hip arthroplasty (THA) can be performed using hands-free, self-retaining retractors. No current study quantitatively compares this self-retaining technique with the traditional manual technique. In 65 consecutive DA THA hips, two "best-view" digital photographs were taken of the exposure-one using Charnley/self-retaining retractors and one using a traditional three-retractor manual technique. Percent exposure of the polyethylene liner was calculated. Percent acetabular exposure averaged 80.0% using the Charnley/self-retaining technique, compared with 73.1% using the manual technique (P=.0002). A hands-free technique provides superior acetabular exposure compared with the manual technique. Increasing body mass index predicts decreasing exposure with both techniques. [Orthopedics. 2021;44(2):e309-e313.].
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Spina M, Luppi V, Chiappi J, Bagnis F, Balsano M. Direct anterior approach versus direct lateral approach in total hip arthroplasty and bipolar hemiarthroplasty for femoral neck fractures: a retrospective comparative study. Aging Clin Exp Res 2021; 33:1635-1644. [PMID: 32910422 DOI: 10.1007/s40520-020-01696-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 08/17/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND In the current literature, there is no consensus on the best surgical approach in hip replacement for femoral neck fractures (FNFs). AIM The aim of this study is to compare the direct anterior approach (DAA) and the direct lateral approach (DLA) in patients treated with bipolar hemiarthroplasty (BHA) and total hip arthroplasty (THA) for FNFs. MATERIALS AND METHODS Patients with displaced FNFs (Garden type III and IV) treated operatively using BHA and THA were enrolled. The surgical approach techniques DAA and DLA are compared. The analysed variables are: mean surgery time, number of blood units transfused perioperatively, percentage of patients transfused, perioperative complications, pain and functional outcomes at 1 and 6 months and mortality at 1, 3 and 12 months. RESULTS Between 2015 and 2017, 37 patients underwent BHA by the DAA and 38 patients underwent BHA by the DLA, 69 patients underwent THA by the DAA and 60 patients underwent THA by the DLA. For THA, the DAA compared to the DLA had a higher mean surgery time (100.8 min vs. 97.7 min), a lower mean number of blood units transfused perioperatively (1.4 U vs. 1.9 U), a significantly lower percentage of patients transfused (53.6% vs. 71.7%), a higher rate of perioperative complications (10.1% vs. 1.6%), a lower pain referred and better functional outcomes in the first 6 postoperative months and a significantly lower mortality rate at 12 months (2.9% vs. 16.7%). For BHA, the advantages of the DAA over DLA are not as significant. CONCLUSIONS The direct anterior approach in THA for FNFs provides significant benefits in the early post-operative period compared to the direct lateral approach in terms of functional recovery, residual pain, blood loss and mortality rate in the elderly active population. LEVEL OF EVIDENCE Level IV, retrospective cohort study.
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Affiliation(s)
- Mauro Spina
- Department of Orthopedics and Traumatology A, Azienda Ospedaliera Universitaria Integrata of Verona, Piazzale A. Stefani n. 1, 37126, Verona, Italia.
| | - Valentina Luppi
- Department of Orthopedics and Traumatology B, Azienda Ospedaliera Universitaria Integrata of Verona, Piazzale A. Stefani n. 1, 37126, Verona, Italia
| | - Jacopo Chiappi
- Department of Orthopedics and Traumatology B, Azienda Ospedaliera Universitaria Integrata of Verona, Piazzale A. Stefani n. 1, 37126, Verona, Italia
| | - Francesco Bagnis
- Department of Orthopedics and Traumatology B, Azienda Ospedaliera Universitaria Integrata of Verona, Piazzale A. Stefani n. 1, 37126, Verona, Italia
| | - Massimo Balsano
- Department of Orthopedics and Traumatology A, Azienda Ospedaliera Universitaria Integrata of Verona, Piazzale A. Stefani n. 1, 37126, Verona, Italia
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Ostrominski JW, Huang Q, Kamenker-Orlov Y. Beneath the Surface: Massive Retroperitoneal Liposarcoma Masquerading as Meralgia Paresthetica. Fed Pract 2021; 38:S61-S67. [PMID: 34177242 DOI: 10.12788/fp.0132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In patients presenting with focal neurologic findings involving the lower extremities, a thorough abdominal examination should be considered an integral part of the full neurologic work up.
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Affiliation(s)
- John W Ostrominski
- is a Resident Primary Care Physician; is a Pathologist in the Department of Pathology and Laboratory Medicine; and is a Primary Care Physician and Director of the Resident Primary Care Clinic; all at the West Roxbury Veterans Affairs Medical Center. John Ostrominski is Resident in Internal Medicine, Qin Huang and Yelena Kamenker-Orlov are Assistant Professors, all at Brigham and Women's Hospital and Harvard Medical School in Massachusetts
| | - Qin Huang
- is a Resident Primary Care Physician; is a Pathologist in the Department of Pathology and Laboratory Medicine; and is a Primary Care Physician and Director of the Resident Primary Care Clinic; all at the West Roxbury Veterans Affairs Medical Center. John Ostrominski is Resident in Internal Medicine, Qin Huang and Yelena Kamenker-Orlov are Assistant Professors, all at Brigham and Women's Hospital and Harvard Medical School in Massachusetts
| | - Yelena Kamenker-Orlov
- is a Resident Primary Care Physician; is a Pathologist in the Department of Pathology and Laboratory Medicine; and is a Primary Care Physician and Director of the Resident Primary Care Clinic; all at the West Roxbury Veterans Affairs Medical Center. John Ostrominski is Resident in Internal Medicine, Qin Huang and Yelena Kamenker-Orlov are Assistant Professors, all at Brigham and Women's Hospital and Harvard Medical School in Massachusetts
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Kokubo R, Kim K, Umeoka K, Isu T, Morita A. Meralgia paresthetica attributable to surgery in the park-bench position. J NIPPON MED SCH 2021; 89:355-357. [PMID: 33692308 DOI: 10.1272/jnms.jnms.2022_89-112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Meralgia paresthetica (MP) is an entrapment neuropathy of the lateral femoral cutaneous nerve (LFCN). We report a rare MP complication after microvascular decompression (MVD) surgery in the park-bench position in a patient with hemi-facial spasm. CASE The patient was a 46-year-old female (height: 155 cm, weight: 42 kg). She was neither diabetic nor a regular alcohol user. After the first MVD for right hemifacial spasm, her symptom recurred and she underwent a second MVD procedure in the park-bench position that led to the disappearance of her hemifacial spasm. However, she complained of right antero-lateral thigh pain and dysesthesia without motor weakness. The symptom was limited to the LFCN area; pelvic compression test elicited a positive Tinel-like sign. Our preliminary diagnosis was MP. As conservative therapy was ineffective she underwent LFCN block 9 months after the second MVD procedure. Her symptom improved dramatically and we made a definitive diagnosis of MP. There has been no recurrence in the course of 30 months although she reported persistent mild dysesthesia in the LFCN area. CONCLUSION MP is a rare complication after MVD surgery in the park-bench position. Symptom abatement and a definitive early diagnosis can be obtained by LFCN blocks.
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Affiliation(s)
- Rinko Kokubo
- Department of Neurosurgery, Chiba Hokuso Hospital, Nippon Medical School
| | - Kyongsong Kim
- Department of Neurosurgery, Chiba Hokuso Hospital, Nippon Medical School
| | - Katsuya Umeoka
- Department of Neurosurgery, Chiba Hokuso Hospital, Nippon Medical School
| | - Toyohiko Isu
- Department of Neurosurgery, Kushiro Rosai Hospital
| | - Akio Morita
- Department of Neurosurgery, Nippon Medical School
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Starke V, Stofferin H, Mannschatz S, Hörmann R, Dammerer D, Thaler M. The Anatomical Course of the Superior Gluteal Nerve With Regard to the Direct Anterior Approach for Primary and Revision Total Hip Arthroplasty. J Arthroplasty 2021; 36:1138-1142. [PMID: 33071031 DOI: 10.1016/j.arth.2020.09.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/14/2020] [Accepted: 09/25/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND During primary and revision total hip arthroplasty (THA) lesions of the superior gluteal nerve (SGN) can substantially compromise patient outcome. For the primary direct anterior approach (DAA) and its proximal approach extensions, especially the muscular branch entering the tensor fasciae latae (TFL) muscle is at risk. SGN lesions can result in fatty atrophy and functional loss of the TFL. Therefore, the course and branching pattern of the SGN were examined and related to the DAA and its proximal approach extension. The aim of the study is to describe safe and danger zones for the SGN with regard to the DAA and its proximal extensions. METHODS Twenty-five formalin-fixed cadavers with 48 hemipelves were dissected. The course, distribution, and branching pattern of the SGN and its muscular branch inserting into the TFL muscle were investigated with regard to the DAA with the help of anatomical landmarks like the greater trochanter and the iliac tubercle. RESULTS In 72.9% of the specimens the SGN passed the greater sciatic foramen superior to the piriformis muscle with one main trunk. The muscular branch of the SGN supplying the TFL divided from the main branch in 89.6% of the specimens at the level of the greater sciatic foramen. Before entering the TFL muscle the muscular branch showed a variable branching pattern in the interval between the gluteus medius and minimus. A danger zone for the SGN with regard to the DAA was found in the proximal fourth of the skin incision. CONCLUSION Special care in proximal instrument placement should be taken during the DAA. When extending the DAA proximally manipulations in the proximal, caudal surgical window should be performed with the utmost care.
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Affiliation(s)
- Vasco Starke
- Division of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Innsbruck, Austria
| | - Hannes Stofferin
- Division of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sidney Mannschatz
- Division of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Innsbruck, Austria
| | - Romed Hörmann
- Division of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Dammerer
- Department of Orthopaedic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Thaler
- Department of Orthopaedic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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Siddiqi A, Alden KJ, Yerasimides JG, Kamath AF. Direct Anterior Approach for Revision Total Hip Arthroplasty: Anatomy and Surgical Technique. J Am Acad Orthop Surg 2021; 29:e217-e231. [PMID: 33351524 DOI: 10.5435/jaaos-d-20-00334] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 09/10/2020] [Indexed: 02/01/2023] Open
Abstract
There has been increased interest and literature on the efficacy of direct anterior approach (DAA) for total hip arthroplasty (THA). Developments in surgical technique and instrumentation, along with exposure earlier in orthopaedic residency training, may augment the adoption of this approach among practicing orthopaedic surgeons. With the increasing number of primary THA performed through the DAA, understanding the indications and techniques associated with revision THA via the DAA has proved increasingly important. Patient positioning, understanding surgical anatomy and extensile maneuvers, and applying key reconstructive methods are essential for obtaining adequate exposure and fixation. Acetabular exposure can be facilitated through capsular and soft-tissue release, along with extensile approaches to the pelvis and acetabulum. Extensile distal extension can be performed for safe access to the femur, including extended femoral osteotomies. The purpose of this review is to describe indications, surgical anatomy, intraoperative tips, clinical outcomes, and complications after DAA for revision THA.
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Affiliation(s)
- Ahmed Siddiqi
- From the Department of Orthopedics, Cleveland Clinic Foundation, Cleveland, OH (Kamath and Siddiqi), the Hinsdale Orthopaedics, Hinsdale, IL (Alden), and the Norton Orthopedic Institute, Louisville, KY (Yerasimides)
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Thaler M, Dammerer D, Hechenberger F, Hörmann R, Van Beeck A, Stofferin H. The Anatomical Course of the Lateral Femoral Cutaneous Nerve in Relation to Various Skin Incisions Used for Primary and Revision Total Hip Arthroplasty With the Direct Anterior Approach. J Arthroplasty 2021; 36:368-373. [PMID: 32826147 DOI: 10.1016/j.arth.2020.07.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Although the direct anterior approach (DAA) has become a standard for primary and revision total hip arthroplasty, it involves a high risk of injuring the lateral femoral cutaneous nerve (LFCN). The aim of this study is to examine the course of the LFCN in relation to various skin incisions and approach extensions used for the DAA. METHODS We obtained 44 limbs and hemipelves from 22 formalin-preserved cadavers, in which LFCN was identified. All nerve branches of the LFCN were carefully traced. The branching pattern and the distribution in the thigh were described in relation to the standard approach for primary total hip arthroplasty, the skin crease bikini incision, the longitudinal extension, and the lazy S extension of the DAA. RESULTS We found 31 (70.5%) Sartorius-type, 6 (13.6%) posterior-type, and 7 (15.9%) fan-type branching patterns of the LFCN. We observed 2.02 branches per hemipelvis. All fan-type LFCNs had 3 or more than 3 branches. We found that the main branch of the LFCN was medial to the primary DAA approach as well as to the lazy S extended DAA approach. The bikini incision and the incision for the longitudinal extension of the DAA crosses the main branch of the LFCN in 100% of cases. CONCLUSION The fan-type pattern of the LFCN might be harmed by all skin incisions. Chances are high that LFCN branches could be jeopardized with a bikini-type incision and the longitudinal extension of the DAA. The risk of jeopardizing the LFCN with a lazy S-type distal extension is reduced.
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Affiliation(s)
- Martin Thaler
- Department of Orthopaedic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Dammerer
- Department of Orthopaedic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Faro Hechenberger
- Department of Ion Physics and Applied Physics, University of Innsbruck, Innsbruck, Austria
| | - Romed Hörmann
- Division of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Innsbruck, Austria
| | - Annelies Van Beeck
- Department of Orthopaedic Surgery and Traumatology, University Hosptial Antwerp, Antwerp, Belgium
| | - Hannes Stofferin
- Division of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Innsbruck, Austria
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Wang Q, Yue Y, Yang Z, Chen L, Li Q, Kang P. Comparison of Postoperative Outcomes Between Traditional Longitudinal Incision and Bikini Incision in Total Hip Arthroplasty via Direct Anterior Approach: A Randomized Controlled Trial. J Arthroplasty 2021; 36:222-230. [PMID: 32800438 DOI: 10.1016/j.arth.2020.07.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/17/2020] [Accepted: 07/19/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The purpose of this study is to compare a traditional longitudinal incision to an oblique "bikini" incision during total hip arthroplasty (THA) via direct anterior approach (DAA), in terms of the aesthetic appearance of the scar, postoperative functional recovery, and complications. METHODS This study is a single-surgeon experience in the Chinese population. Patients who came to our institute needing a THA via DAA were enrolled in our randomized controlled trial and randomly allocated to undergo traditional longitudinal incision (control) or bikini incision. Primary outcomes were measured using the scar cosmesis assessment and rating scale, the visual analog scale for pain, Oxford hip score, and University of California Los Angeles activity-level rating. Secondary outcomes were postoperative serum markers of muscle damage, inflammation, hemoglobin drop, and implant stability. The occurrence of postoperative complications, such as nerve and wound healing, was also recorded. RESULTS There were no differences in demographic or clinical characteristics before surgery. A greater proportion of patients in the bikini group were satisfied with the appearance of their scar, giving significantly better scar cosmesis assessment and rating scores. There was no difference in postoperative functional recovery, levels of serum markers, or positioning of the implant components. Incision type had no effect on duration of hospitalization. The incidence of complications did not differ significantly between groups. CONCLUSION The bikini incision can improve patients' subjective satisfaction with scar aesthetics after THA via DAA and does not detract from a quick functional recovery. Studies with larger sample sizes should be conducted to further investigate associated complications. THE CLINICAL TRIAL REGISTRATION NUMBER ChiCTR1900022870.
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Affiliation(s)
- Qiuru Wang
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yong Yue
- Department of Orthopaedics surgery, Karamay Municipal People's Hospital, Karamay, People's Republic of China
| | - Zhouyuan Yang
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Liyile Chen
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Qianhao Li
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Pengde Kang
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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Kıbıcı K, Erok B, Atca AÖ. Decompression and Neurolysis of the Lateral Femoral Cutaneous Nerve in the Surgical Treatment of Meralgia Paresthetica and the Results. INDIAN JOURNAL OF NEUROSURGERY 2020. [DOI: 10.1055/s-0040-1715785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
AbstractMeralgia paresthetica (MP), also known as Bernhardt–Roth syndrome, is a peripheral neuropathy of the primary sensory lateral femoral cutaneous nerve (LFCN). Its diagnosis is challenging, because it can mimic other clinical conditions particularly associated with upper lumbar spine or pelvis. Patients present with pain and paresthesia over the anterolateral thigh. Diagnosis is usually based on clinical examination and is supported by sensory nerve conduction (SNC) studies. The initial treatment is always conservative. In limited number of patients who are refractory to conservative managements, surgical treatment via decompression/neurolysis or neurectomy is concerned. There is still no consensus on which surgical technique is the best and the first choice. We retrospectively analyzed the surgical outcomes of 12 nonobese patients who underwent decompression/neurolysis between the years 2013 and 2018. Bilateral SNC studies were performed in all cases which supported the diagnosis. We applied conservative treatments for 3 months in addition to the treatments previously applied in other centers. Surgery was recommended for the patients who were refractory to these treatments. Preoperative and postoperative pain levels during follow-up visits were evaluated with visual analogue scale (VAS). A retrospective analysis was performed on preoperative and postoperative 6th month VAS scores. The mean preoperative VAS value was 8.75 ± 0.62 and the postoperative VAS value at the sixth month was 1.17 ± 0.72. A significant reduction in the pain was shown (p < 0.05). Our surgical results showed that decompression/neurolysis of the LFCN should be concerned as the primary surgical approach to avoid negative outcomes of resection surgeries.
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Affiliation(s)
- Kenan Kıbıcı
- Department of Neurosurgery, Altınbas University School of Medicine Bahcelievler Medical Park Hospital, İstanbul, Turkey
| | - Berrin Erok
- Department of Radiology, Cihanbeyli State Hospital, Konya, Turkey
| | - Ali Önder Atca
- Department of Radiology, Altınbas University School of Medicine Bahcelievler Medical Park Hospital, İstanbul, Turkey
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Abd-Elsayed A, Gyorfi MJ, Ha SP. Lateral Femoral Cutaneous Nerve Radiofrequency Ablation for Long-term Control of Refractory Meralgia Paresthetica. PAIN MEDICINE 2020; 21:1433-1436. [PMID: 32022852 DOI: 10.1093/pm/pnz372] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Meralgia paresthetica is a term used to describe a clinical pain syndrome related to the compression or irritation of the lateral femoral cutaneous nerve (LFCN). The LFCN is a pure sensory nerve that is susceptible to compression injury. The most common compression locations are: as it courses from the lumbosacral plexus, through the abdominal cavity, under the inguinal ligament, and into the subcutaneous tissue of the thigh. METHODS This case series is a retrospective single-center review of six patients with medically intractable meralgia paresthetica who were treated with radiofrequency ablation. To be considered for radiofrequency ablation, the patient must have been unsuccessful with medical management alone for more than two months and have a clinical diagnosis of meralgia paresthetica. Temporary relief of pain of 50% or greater was considered a positive result. Average pain scores were measured pre- and postprocedure, along with one-, two-, three-, and six-month intervals postoperation. RESULTS All patients demonstrated immediate relief in self-reported pain scores, averaging a 75.5% reduction in pain. At the one-, two-, three-, and six-month follow-ups, patients averaged a reduction of 60.0%, 58.0%, 51.4%, and 40.5%, respectively. Both the postop and one-month follow-up pain scores were lower, statistically significantly so (P < 0.05), whereas the two-, three-, and six-month follow-ups were not statistically different from pretreatment scores. CONCLUSIONS Although our study was small, radiofrequency ablation showed a clear reduction in average pain scores in a subset of patients who had failed standard medical therapy with a reduction in pain at one-month follow-up with relief of symptoms sometimes lasting longer than 12 months.
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Affiliation(s)
- Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Michael J Gyorfi
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Sung P Ha
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Singh V, Zak S, Schwarzkopf R, Davidovitch R. Forgotten Joint Score in THA: Comparing the Direct Anterior Approach to Posterior Approach. J Arthroplasty 2020; 35:2513-2517. [PMID: 32423760 DOI: 10.1016/j.arth.2020.04.074] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/07/2020] [Accepted: 04/21/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The direct anterior approach (DAA) in total hip arthroplasty (THA) has gained popularity because of potential decreased postoperative pain and quicker recovery after surgery in comparison to the posterior approach (PA). With a growing focus on patient-reported outcome (PRO) measurements after surgery, we sought to determine if one approach led to better PRO scores as determined by the Forgotten Joint Score-12 (FJS-12) questionnaire. METHODS A retrospective chart review of primary THAs between September 2016 and September 2019 at a single academic hospital was conducted. Demographic and clinical data in addition to FJS-12 scores were collected. Two groups were created based on THA approach. Frequency rates, means, and standard deviations were used to describe baseline patient characteristics. Differences in demographic data were accounted for using linear regression models. RESULTS A total of 1469 cases were identified, with 830 using the DAA and 639 the PA. Significant demographic differences were observed between the 2 groups. However, when controlling for this, there were no differences in FJS-12 scores between approaches at 1 and 1.75 years (P = .232 and P = .486, respectively). At 12 weeks, DAA patients had higher satisfaction (59.21 vs 46.8; P = .006). When controlling for surgeon case volume, no differences in FJS-12 were observed at any of the time points (P = .536, P = .452, and P = .967, respectively) CONCLUSION: DAA THA patients trended toward better PRO scores than their PA counterparts. However, when controlling for surgeon case volume, no differences were observed, which suggests that surgeon case volume and experience have an important effect on patient satisfaction and FJS-12 scores.
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Affiliation(s)
- Vivek Singh
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Stephen Zak
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Roy Davidovitch
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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Weynandt CL, Kowski A, Perka C, Rakow A. [Nerve Injuries in Hip and Knee Arthroplasty - Risk Factors, Diagnostic and Therapeutic Approaches]. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2020; 158:535-555. [PMID: 32645744 DOI: 10.1055/a-0915-9272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Iatrogenic nerve injuries are rare complications of total hip and knee arthroplasty, which may cause chronic pain and loss of function, severely affecting the patient's daily activities and quality of life. Nerves "at risk" include the sciatic nerve, the femoral nerve, the lateral femoral cutaneous nerve and the superior gluteal nerve during total hip arthroplasty, and the infrapatellar branch of the saphenous nerve as well as the peroneal nerve during total knee arthroplasty. Multiple procedure-related and patient-related factors have been identified to modify the risk of nerve injury in the course of lower limb joint replacement surgery. These include the surgeon's skills, the surgical approach, the type of implant fixation, the intraoperative positioning of the patient, as well as pre-existing scars, the patient's sex, age and comorbidities. Diagnostic and therapeutic approaches should be based on the aetiology of the lesion: iatrogenic nerve lesions can result from direct (compression or transection) and/or indirect (traction, ischemia) trauma. The majority of nerve injuries encountered in hip or knee arthroplasty has been referred to as "minor" nerve lesions, which generally respond very well to non-operative treatment. "Major" nerve lesions, such as complete motor nerve transection, may result in lifelong impairment. Any perioperatively encountered neurological deficit requires a meticulous diagnostic work-up and an individually tailored treatment strategy, respecting aetiology and anatomic site of the nerve lesion as well as the individual patient's needs and comorbidities.
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Kim CY, Chung YY, Shim SW, Baek SN, Kim CH. Early Experience of Direct Anterior Approach Total Hip Arthroplasty: Analysis of the First 53 Cases. Hip Pelvis 2020; 32:78-84. [PMID: 32566538 PMCID: PMC7295612 DOI: 10.5371/hp.2020.32.2.78] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/04/2020] [Accepted: 03/05/2020] [Indexed: 01/16/2023] Open
Abstract
Purpose To determine if it is feasible and safe for a surgeon to transition from using the posterolateral approach to direct anterior approach (DAA) by evaluating the first 53 cases of total hip arthroplasty using a DAA. Materials and Methods A retrospective review of 52 patients who underwent THA using a DAA between July 2017 and December 2018. Reasons for THA were: femoral neck fracture (n=34), avascular necrosis (n=13), and arthritis (n=6). The mean age was 70 years old. An assessment of feasibility was made by analyzing mean operative time and blood loss. Cup inclination, anteversion, and leg length discrepancy (LLD) were measured using postoperative radiology. Safety of the DAA was judged using the incidence and nature of all complications. Results The mean operative time was 112 minutes. 135 minutes for the 1st 10 cases, 100 minutes for 2nd 10 cases, 113 minutes for 3rd 10 cases, 119 minutes for 4th 10 cases, and 91 minutes for the final 13 cases. The mean blood loss was 724 mL. Average cup inclination was 40.27°; 2 cases were out of safety angle. Mean anteversion was 16.18°. No intraoperative fractures or infections were observed. LLD was detected in 3 cases, one of which underwent revision due to walking difficulty. Dislocation occurred in 3 cases, all within the first 20 cases, however, there was no recurrent dislocation. Conclusion DAA for THA was deemed to be feasible and safe based on an assessment of operative time, blood loss and complications.
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Affiliation(s)
- Chung-Young Kim
- Department of Orthopaedic Surgery, Kwangju Christian Hospital, Gwangju, Korea
| | - Young-Yool Chung
- Department of Orthopaedic Surgery, Kwangju Christian Hospital, Gwangju, Korea
| | - Seung-Woo Shim
- Department of Orthopaedic Surgery, Kwangju Christian Hospital, Gwangju, Korea
| | - Sung-Nyun Baek
- Department of Orthopaedic Surgery, Kwangju Christian Hospital, Gwangju, Korea
| | - Cheol-Hwan Kim
- Department of Orthopaedic Surgery, Kwangju Christian Hospital, Gwangju, Korea
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Foissey C, Fauvernier M, Fary C, Servien E, Lustig S, Batailler C. Total hip arthroplasty performed by direct anterior approach - Does experience influence the learning curve? SICOT J 2020; 6:15. [PMID: 32500856 PMCID: PMC7273835 DOI: 10.1051/sicotj/2020015] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 04/27/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Proficiency in the direct anterior approach (DAA) as with many surgical techniques is considered to be challenging. Added to this is the controversy of the benefits of DAA compared to other total hip arthroplasty (THA) approaches. Our study aims to assess the influence of experience on learning curve and clinical results when transitioning from THA via posterior approach in a lateral position to DAA in a supine position. METHODS A consecutive retrospective series of 525 total hip arthroplasty of one senior and six junior surgeons was retrospectively analysed from May 2013 to December 2017. Clinical results were analysed and compared between the two groups and represented as a learning curve. Mean follow up was 36.2 months ± 11.8. RESULTS This study found a significant difference in complications between the senior and junior surgeons for operating time, infection rate, and lateral femoral cutaneous nerve (LFCN) neuropraxia. A trainee's learning curve was an average of 10 DAA procedures before matching the senior surgeon. Of note, the early complications correlated with intraoperative fractures increased with experience in both groups. Operating time for the senior equalised after 70 cases. Dislocation rate and limb length discrepancy were excellent and did not show a learning curve between the two groups. CONCLUSION DAA is a safe approach to implant a THA. There is a learning curve and initial supervision is recommended for both seniors and trainees. LEVEL OF EVIDENCE Retrospective, consecutive case series; level IV.
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Affiliation(s)
- Constant Foissey
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Department of Orthopaedic Surgery and Sport Medicine, Croix-Rousse Hospital, FIFA Medical Center of Excellence 69004 Lyon France
| | - Mathieu Fauvernier
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Department of Biostatistic, Lyon Sud Hospital, University of Lyon 1 69622 Lyon France
| | - Cam Fary
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Department of Orthopaedic Surgery, University of Melbourne 3010 Victoria Australia
| | - Elvire Servien
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Department of Orthopaedic Surgery and Sport Medicine, Croix-Rousse Hospital, FIFA Medical Center of Excellence 69004 Lyon France
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EA 7424, Interuniversity Laboratory of Human Movement Science, Université Lyon 1 69622 Lyon France
| | - Sébastien Lustig
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Department of Orthopaedic Surgery and Sport Medicine, Croix-Rousse Hospital, FIFA Medical Center of Excellence 69004 Lyon France
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Université de Lyon, Université Claude Bernard Lyon 1, IFSTTAR, LBMC UMR_T9406 69622 Lyon France
| | - Cécile Batailler
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Department of Orthopaedic Surgery and Sport Medicine, Croix-Rousse Hospital, FIFA Medical Center of Excellence 69004 Lyon France
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Dall'Oca C, Ceccato A, Cresceri M, Scaglia M, Guglielmini M, Pelizzari G, Valentini R, Magnan B. Facing complications of direct anterior approach in total hip arthroplasty during the learning curve. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:103-109. [PMID: 32555084 PMCID: PMC7944837 DOI: 10.23750/abm.v91i4-s.9728] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/06/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND This study aims to evaluate complications and early postoperative clinical outcomes of direct anterior approach (DAA) in total hip arthroplasty (THA). METHODS Ninety-one consecutive patients who underwent primary elective unilateral THA between January 2013 and December 2019 were identified. Collected data included age of patient, BMI, ASA score, EBL (estimated blood loss), LOS (length of stay), operating time, and intra/postoperative complications. The recorded complications included prolonged wound drainage without infection, superficial and deep infection, dislocation, periprosthetic fracture, aseptic loosening or failure of osteointegration and nervous damage. Any reoperation, with or without prosthetic component revision, was recorded. RESULTS Fourteen complications (15,4%) and 12 (13,18%) postoperative anemizations were observed in this series. No deep infection was reported. Most common complications were nerve damage (3/91;3,29%), greater trochanter fracture (3/91; 3,29%), and wound trouble (3/91; 3,29%). Two (2,19%) dislocations were reported. One (1,09%) intraoperative periprosthetic fracture was treated with cerclage wiring. One (1,09%) revision was needed for an acetabular mobilization. One patient (1,09%) had severe periprosthetic ectopic ossifications (Brooker 4), needing reintervention because of severe limitations of the range of motion (ROM). CONCLUSIONS Complications rate in this study with THA by DAA is comparable to those reported in literature. DAA is a safe, efficient procedure but it needs a steep learning curve. (www.actabiomedica.it).
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Affiliation(s)
- Carlo Dall'Oca
- Azienda Ospedaliera Universitaria Integrata Verona, Ortopedia e Traumatologia B, Verona, Italy.
| | - Alberto Ceccato
- Department of Orthopedics and Trauma Surgery University of Verona (Italy).
| | - Matteo Cresceri
- Department of Orthopedics and Trauma Surgery, University of Verona.
| | - Marco Scaglia
- Department of Orthopedics and Trauma Surgery, University of Verona.
| | | | | | | | - Bruno Magnan
- Department of Orthopedics and Trauma Surgery, University of Verona.
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