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Dietrich M, Kabelitz M, Dora C, Zingg PO. Perioperative Fractures in Cementless Total Hip Arthroplasty Using the Direct Anterior Minimally Invasive Approach: Reduced Risk With Short Stems. J Arthroplasty 2018; 33:548-554. [PMID: 28993084 DOI: 10.1016/j.arth.2017.09.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 09/05/2017] [Accepted: 09/11/2017] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND The direct minimally invasive anterior approach (DMIAA) and the use of uncemented stems demonstrated an increase in intraoperative fractures in recent literature. Whether the different design of the stems additionally influences the incidence of perioperative local complications, was the goal of this study. METHODS From January 2008 until June 2010, all patients undergoing primary cementless total hip arthroplasty, using a DMIAA, were consecutively included. The choice of the implant was defined by the day of operation. Age, gender, body mass index, type of prosthesis, and the practical experience of the performing surgeon were retrospectively analyzed. Of main interest were intraoperative fractures, postoperative hematoma, and wound healing. RESULTS Six hundred forty consecutive patients (64 years [18-94], 339 female, 53%, body mass index 26) have been included. A Quadra-H stem (Medacta) was used in 457 patients (71%). In 183 (29%) patients, a short stem designed for the DMIAA (130 Fitmore, Zimmer and 53 AMIStem, Medacta) was used. We counted 34 (5.3%) intraoperative fractures (16 at the greater trochanter, 18 proximal shaft fractures), 20 (4%) hematomas, and 8 (2%) wound healing problems. The standard length stem showed more local complications (11.8% vs 4.4%) (P = .014, odds ratio 1.63, confidence interval 1.1-2.4) and significantly more (6.8% vs 1.6%) intraoperative fractures (P = .027, odds ratio 1.98, confidence interval 1.1-3.6). CONCLUSION The standard length stem showed more perioperative complications, especially periprosthetic fractures. It seems that these implants not only put more stress to proximal osseous structures, but there might also be more traction and irritation to the soft tissue while preparing, resulting in more hematomas and wound healing problems.
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Affiliation(s)
- Michael Dietrich
- Department of Orthopaedics and Traumatology, Clinic for Surgery, Waid City Hospital, Zurich, Switzerland
| | - Method Kabelitz
- Department of Orthopaedics, University of Zurich, Zurich, Switzerland
| | - Claudio Dora
- Department of Orthopaedics, University of Zurich, Zurich, Switzerland
| | - Patrick O Zingg
- Department of Orthopaedics, University of Zurich, Zurich, Switzerland
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Nishiyama D, Matsuzaki K, Yamazaki S, Takiguchi N, Harada T, Sando S. Risk factors associated with complications following total hip arthroplasty using the two-incision technique. J Orthop Surg (Hong Kong) 2017. [DOI: 10.1177/2309499016684084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The frequency of the complications following total hip arthroplasty (THA) using the two-incision technique is well documented. However, few reports have analyzed the preoperative patient–related factors associated with the complications. The purpose of this study was to estimate the incidence of early complications following primary two-incision THA and to define the risk factors associated with perioperative complications. Materials and Methods: The subjects of this retrospective study were 1218 consecutive patients who underwent primary two-incision THA. The incidence of hip dislocation, stem subsidence, intraoperative femoral fracture, and nontraumatic postoperative femoral fracture was evaluated. The association between complications and preoperative patient–related factors, including gender, obesity, Crowe classification, age, body mass index (BMI), and morphological parameters of the proximal femoral medullary cavity, were investigated. Results: The incidences of complications were dislocation (1.1%), stem subsidence (0.9%), intraoperative femoral fracture (1.2%), and postoperative femoral fracture (0.7%). Obesity (BMI > 30) influenced the occurrences of stem subsidence and postoperative femoral fractures ( p = 0.0001, p = 0.019). Crowe classification significantly correlated with intraoperative femoral fractures (Grade II: odds ratio (OR) 4.63, 95% confidence interval (CI), 1.32–15.6; Grade III and IV: OR 8.96, 95% CI, 2.2–34.94). Additionally, the outer diameter of the femur 10 cm below the lesser trochanter tended to be small in patients who developed a femoral fracture. Conclusions: The early complication rate was comparable to other methods used in uncemented THA. It is necessary for patients with risk factors revealed in this study to pay careful attention or consider other surgical approaches to avoid complications. Further studies considering femur morphology are required.
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Affiliation(s)
- Daisuke Nishiyama
- Department of Orthopaedic Surgery, Saiseikai Wakayama Hospital, Wakayama, Japan
| | - Kosaku Matsuzaki
- Department of Orthopaedic Surgery, Saiseikai Wakayama Hospital, Wakayama, Japan
| | - Satoru Yamazaki
- Department of Orthopaedic Surgery, Saiseikai Wakayama Hospital, Wakayama, Japan
| | - Noboru Takiguchi
- Department of Orthopaedic Surgery, Saiseikai Wakayama Hospital, Wakayama, Japan
| | - Teiji Harada
- Department of Orthopaedic Surgery, Saiseikai Wakayama Hospital, Wakayama, Japan
| | - Shigeki Sando
- Department of Orthopaedic Surgery, Saiseikai Wakayama Hospital, Wakayama, Japan
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Molli RG, Lombardi AV, Berend KR, Adams JB, Sneller MA. A short tapered stem reduces intraoperative complications in primary total hip arthroplasty. Clin Orthop Relat Res 2012; 470:450-61. [PMID: 21971877 PMCID: PMC3254753 DOI: 10.1007/s11999-011-2068-7] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND While short-stem design is not a new concept, interest has surged with increasing utilization of less invasive techniques. Short stems are easier to insert through small incisions. Reliable long-term results including functional improvement, pain relief, and implant survival have been reported with standard tapered stems, but will a short taper perform as well? QUESTIONS/PURPOSES We compared short, flat-wedge, tapered, broach-only femoral stems to standard-length, double-tapered, ream and broach femoral stems in terms of intraoperative complications, short-term survivorship, and pain and function scores. PATIENTS AND METHODS We retrospectively reviewed the records of 606 patients who had 658 THAs using a less invasive direct lateral approach from January 2006 to March 2008. Three hundred sixty patients (389 hips) had standard-length stems and 246 (269 hips) had short stems. Age averaged 63 years, and body mass index averaged 30.7 kg/m(2). We recorded complications and pain and function scores and computed short-term survival. Minimum followup was 0.8 months (mean, 29.2 months; range, 0.8-62.2 months). RESULTS We observed a higher rate of intraoperative complications with the standard-length stems (3.1%; three trochanteric avulsions, nine femoral fractures) compared with the shorter stems (0.4%; one femoral fracture) and managed all complications with application of one or more cerclage cables. There were no differences in implant survival, Harris hip score, and Lower Extremity Activity Scale score between groups. CONCLUSIONS Fewer intraoperative complications occurred with the short stems, attesting to the easier insertion of these devices. While longer followup is required, our early results suggest shortened stems can be used with low complication rates and do not compromise the survival and functional outcome of cementless THA. LEVEL OF EVIDENCE Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ryan G. Molli
- Joint Implant Surgeons, Inc, 7277 Smith’s Mill Road, Suite 200, New Albany, OH 43054 USA
- Mount Carmel Health System, New Albany, OH USA
- Orthopedic Institute of Michigan, 14555 Levan Road, Suite 116, Livonia, MI 48154 USA
| | - Adolph V. Lombardi
- Joint Implant Surgeons, Inc, 7277 Smith’s Mill Road, Suite 200, New Albany, OH 43054 USA
- Department of Orthopaedics, The Ohio State University, Columbus, OH USA
- Department of Biomedical Engineering, The Ohio State University, Columbus, OH USA
- Mount Carmel Health System, New Albany, OH USA
| | - Keith R. Berend
- Joint Implant Surgeons, Inc, 7277 Smith’s Mill Road, Suite 200, New Albany, OH 43054 USA
- Department of Orthopaedics, The Ohio State University, Columbus, OH USA
- Mount Carmel Health System, New Albany, OH USA
| | - Joanne B. Adams
- Joint Implant Surgeons, Inc, 7277 Smith’s Mill Road, Suite 200, New Albany, OH 43054 USA
| | - Michael A. Sneller
- Joint Implant Surgeons, Inc, 7277 Smith’s Mill Road, Suite 200, New Albany, OH 43054 USA
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Ki SC, Kim BH, Ryu JH, Yoon DH, Chung YY. Total hip arthroplasty using two-incision technique. Clin Orthop Surg 2011; 3:268-73. [PMID: 22162788 PMCID: PMC3232353 DOI: 10.4055/cios.2011.3.4.268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 11/23/2010] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND To evaluate the effectiveness of minimally invasive surgery total hip arthroplasty (THA) using the two-incision technique as described by Mears. METHODS From January 2003 to December 2006, sixty-four patients underwent total hip arthroplasty using the one-incision (group I) and two-incision (group II) technique by one surgeon. There were 34 hips in group I and 30 hips in group II. There was no difference in age, gender, and causes of THA between the two groups. We evaluated the operation time, bleeding amount, incision length, ambulation, hospital stay, and complications between the two groups. RESULTS There was no difference in the bleeding amount between the two groups. Operation time was longer in the two-incision group than in the one-incision group. Operation time of the two-incision technique could be reduced after 15 cases. Patients started ambulation after surgery earlier in group II than group I, and the hospital stay was shorter in group II than in group I. There was no difference in clinical results between the two groups. There was no difference in component position of the acetabular cup and femoral stem between the two groups. Intraoperative periprosthetic fracture occurred in four cases (13.3%) in group II. CONCLUSIONS Two-incision THA has the advantage of rapid recovery and shorter hospital stay. However, longer operation time and a high complication rate compared to one-incision are problems that need to be solved in the two-incision technique.
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Affiliation(s)
- Sung-Chan Ki
- Department of Orthopaedic Surgery, Kwangju Christian Hospital, Gwangju, Korea
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Krych AJ, Pagnano MW, Coleman Wood K, Meneghini RM, Kaufman K. No strength or gait benefit of two-incision THA: a brief followup at 1 year. Clin Orthop Relat Res 2011; 469:1110-8. [PMID: 21076897 PMCID: PMC3048252 DOI: 10.1007/s11999-010-1660-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Accepted: 10/25/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Using comprehensive gait analysis and strength testing, we previously investigated the early (2-month) functional outcome after THA using two-incision and mini-posterior surgical approaches and found an advantage for the mini-posterior approach. Benefits included improved muscle strength, a less antalgic gait, and better hip function as reflected by changes in hip moments during level walking and stair climbing. We questioned how these differences in function would fare with longer followup. QUESTIONS/PURPOSES We determined whether the observed early functional advantages for the mini-posterior technique over the two-incision technique were still present 1 year postoperatively. PATIENTS AND METHODS We prospectively enrolled 22 patients with primary degenerative arthritis of the hip; of these, 21 completed gait and strength testing at 2 months, and 19 completed comprehensive gait and strength testing at 1 year (11 two-incision hips, eight mini-posterior hips). The 19 patients included 11 men and eight women with a mean age of 65 years (range, 40-85 years) and a mean (BMI) of 29 (range, 21-39). RESULTS At 1 year postoperatively, the patients who had the mini-posterior THA had greater improvement in hip flexion strength and internal rotation strength, greater increase in hip flexor internal moment, and greater increase in single-leg stance time on level ground over the patients who had the two-incision THA. CONCLUSIONS Compared with the two-incision approach, patients undergoing mini-posterior THA had persistently better function, including hip flexor and internal rotator muscle strength, hip flexor internal moment, and single-leg stance during level walking. LEVEL OF EVIDENCE Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Aaron J. Krych
- Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905 USA
| | - Mark W. Pagnano
- Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905 USA
| | - Krista Coleman Wood
- Orthopedic Motion Analysis Laboratory, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN USA
| | - R. Michael Meneghini
- Department of Orthopaedic Surgery, New England Musculoskeletal Institute, University of Connecticut Health Center, Farmington, CT USA
| | - Kenton Kaufman
- Orthopedic Motion Analysis Laboratory, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN USA
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A prospective randomized trial of mini-incision posterior and two-incision total hip arthroplasty. Clin Orthop Relat Res 2010; 468:3348-54. [PMID: 20668969 PMCID: PMC2974893 DOI: 10.1007/s11999-010-1491-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2009] [Accepted: 07/16/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND The two-incision approach to THA has been controversial, with some authors reporting its use is associated with a rapid recovery whereas others report no differences in outcomes and a higher risk of perioperative complications secondary to increased surgical complexity. QUESTIONS/PURPOSES We therefore compared early postoperative variables including pain, length of stay, functional recovery, complications, and complexity of the mini-posterior and two-incision approaches to THA. PATIENTS AND METHODS We prospectively enrolled 72 patients scheduled for THA and randomized them into two groups: mini-incision posterior approach and the two-incision approach. Preoperative teaching, anesthetic protocols, implants used, and rehabilitation pathways were identical for both groups. All variables were assessed at a maximum of 1 year postoperatively. RESULTS All key outcomes were similar in the two groups: mean visual analog scale (VAS) scores for pain during the first 3 postoperative days and the first 6 weeks, total narcotic requirements in the hospital and during the first 6 weeks, mean length of stay (51 hours versus 48 hours), and mean Harris hip scores and SF-12 scores. Achievement of functional milestones was similar between the two groups. There was one reoperation in each group. Mean operative time was longer for patients in the two-incision group (98 minutes versus 77 minutes), however the accuracy of component positioning was similar. CONCLUSIONS We found no differences in perioperative outcomes between these two approaches for THA. Variables other than the surgical approach including perioperative protocols, patient expectations, and the patient's general health may have a greater effect on outcomes such as pain during the early postoperative period, functional recovery, and length of hospital stay. The use of small incisions for THA was safe as was a shortened hospital stay in selected patients.
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