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Stofferin H, Pfitscher K, Hörmann R, Gmeiner R, Thaler M. The anatomical course of the sciatic nerve in relation to different approaches in total hip arthroplasty. INTERNATIONAL ORTHOPAEDICS 2024; 48:2561-2566. [PMID: 39183228 DOI: 10.1007/s00264-024-06281-7] [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: 05/26/2024] [Accepted: 08/14/2024] [Indexed: 08/27/2024]
Abstract
PURPOSE Although sciatic nerve (SN) injury is relatively rare, it is a devastating complication after primary and revision total hip arthroplasty (THA). Therefore, precise localization of the SN is essential for arthroplasty surgeons. METHODS We dissected 50 hemipelves from formalin-fixed cadavers. The course and location of the sciatic nerve were investigated in relation to different approaches for THA with the help of anatomical landmarks like the greater trochanter (GT), the iliac tubercle, the ischial tuberosity (IschT), the infrapiriform foramen, and the suprapiriform foramen. RESULTS We found and exposed the sciatic nerve in all 50 specimens with no sex-specific differences. No SN was encountered up to 22 mm posterior from the GT. The zone affording the highest probability of finding the nerve was posterior to the GT between 32 and 55 mm in 39 (78%) cases, thus defining a danger zone for different approaches for the THA. CONCLUSION Special care should be taken with posterior and deep instrument placement between the GT and IschT during THA. Moreover, manipulations in the proximal third of the posterior approach reaching deep and posteriorly should be performed with the utmost care.
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Affiliation(s)
- Hannes Stofferin
- Institute of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Muellerstr. 59, Innsbruck, 6020, Austria
| | - Katharina Pfitscher
- Department of Obstetrics and Gynecology, Schwaz County Hospital, Swarovskistr. 1-3, Schwaz, 6130, Austria.
| | - Romed Hörmann
- Institute of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Muellerstr. 59, Innsbruck, 6020, Austria
| | - Raphael Gmeiner
- Institute of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Muellerstr. 59, Innsbruck, 6020, Austria
- Department of Neurosurgery, Medical University of Innsbruck, Anichstr. 35, Innsbruck, 6020, Austria
| | - Martin Thaler
- Arthroplasty Center, Helios Klinikum Munich West, Steinerweg 5, 81241, Munich, Germany
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University of Greifswald, Domstr. 11, 17489, Greifswald, Germany
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Fujita J, Doi N, Kinoshita K, Seo H, Doi K, Yamamoto T. Incidence and clinical outcome of lateral femoral cutaneous nerve injury after periacetabular osteotomy. Bone Joint J 2024; 106-B:11-16. [PMID: 38688486 DOI: 10.1302/0301-620x.106b5.bjj-2023-0621.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: 05/02/2024]
Abstract
Aims Lateral femoral cutaneous nerve (LFCN) injury is a complication after periacetabular osteo-tomy (PAO) using an anterior approach, which might adversely affect the outcome. However, no prospective study has assessed the incidence and severity of this injury and its effect on the clinical outcomes over a period of time for longer than one year after PAO. The aim of this study was to assess the incidence and severity of the symptoms of LFCN injury for ≥ three years after PAO and report its effect on clinical outcomes. Methods A total of 40 hips in 40 consecutive patients who underwent PAO between May 2016 and July 2018 were included in the study, as further follow-up of the same patients from a previous study. We prospectively evaluated the incidence, severity, and area of symptoms following LFCN injury. We also recorded the clinical scores at one year and ≥ three years postoperatively using the 36-Item Short Form Health Survey (SF-36) and Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) scores. Results A total of 20 patients (50%) had symptoms of a LFCN injury at one year after PAO. At ≥ three years postoperatively, the symptoms had completely resolved in seven of these patients and 13 (33%) had persistent symptoms. The severity and area of symptoms did not significantly differ between one and ≥ three years postoperatively. The JHEQ showed significant differences in the patient satisfaction and mental scores between those with and those without sypmtoms of LFCN injury at ≥ three years postoperatively, while there was no significant difference in the mean SF-36 scores. Conclusion The incidence of LFCN injury after PAO using an anterior approach is high. The outcome of PAO, ≥ three years postoperatively, is poorer in patients with persistent symptoms from a perioperative LFCN injury, in that patient satisfaction and mental health scores are adversely affected.
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Affiliation(s)
- Jun Fujita
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Nobunao Doi
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Koichi Kinoshita
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Hajime Seo
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Kenichiro Doi
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Takuaki Yamamoto
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
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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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Wang H, Zhang Z, Wang W, Sun X. Scooping Technique to Acquire Cancellous Bone for Grafting in the Masquelet Procedure: A Retrospective Study. Indian J Orthop 2023; 57:1267-1275. [PMID: 37525726 PMCID: PMC10386989 DOI: 10.1007/s43465-023-00909-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/08/2023] [Indexed: 08/02/2023]
Abstract
Background The Masquelet procedure is effective in overcoming large bone defects; however, the limited number of cancellous bone and donor site complications remains a challenge. We developed a scooping technique to harvest sufficient cancellous bone from iliac crests for grafting during the Masquelet procedure. We hypothesized that this method would be efficient and safe. Methods This retrospective study included 13 patients who underwent the Masquelet procedure with cancellous bone grafting using the scooping technique. The following parameters were observed: (1) duration and total volume of cancellous bone extraction; (2) amount of bleeding and drainage fluid, and Visual Analog Scale (VAS) score of pain at the donor site during different periods; and (3) complications and bone regeneration at the ilium at the final follow-up. Results The median follow-up duration was 17 months. There were 3 unilateral and 10 bilateral extraction sites. The mean total amount extracted, extraction duration, bleeding, and drainage were 39 mL, 23 min, 49 mL, and 44 mL, respectively. Only three patients felt pain (VAS score: 1 point) at the final follow-up. Postoperatively, one case each of hematoma and lateral femoral cutaneous nerve injury supervened, and no infections or other complications occurred. The last computed tomography examination showed varying degrees of bone regeneration in the ilium. Conclusion The scooping technique for the iliac crest produced a substantial amount of autogenous cancellous bone using a small incision. It retained the appearance and morphology of the ilium with few complications. We believe it is a successful and safe option for treating bone defects.
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Affiliation(s)
- Hui Wang
- Department of Orthopedics Surgery, The 900th Hospital of Joint Logistics Support Force, PLA 156 West Second Ring North Road, Gulou District, Fuzhou, 350025 Fujian China
- Fuzong Clinical Medical College of Fujian Medical University, 88 Jiaotong Road, Taijiang District, Fuzhou, 350025 Fujian China
| | - Zhihong Zhang
- Department of Orthopedics Surgery, The 900th Hospital of Joint Logistics Support Force, PLA 156 West Second Ring North Road, Gulou District, Fuzhou, 350025 Fujian China
| | - Wanming Wang
- Department of Orthopedics Surgery, The 900th Hospital of Joint Logistics Support Force, PLA 156 West Second Ring North Road, Gulou District, Fuzhou, 350025 Fujian China
| | - Xiaotang Sun
- Department of Orthopedics Surgery, The 900th Hospital of Joint Logistics Support Force, PLA 156 West Second Ring North Road, Gulou District, Fuzhou, 350025 Fujian China
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Dahm F, Aichmair A, Hofstaetter JG. Reply to the letter by Tomonori Shigemura. Orthop Traumatol Surg Res 2022; 108:103279. [PMID: 35472456 DOI: 10.1016/j.otsr.2022.103279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 03/14/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Falko Dahm
- II. Orthopedic Department, Orthopedic Hospital Speising, Speisinger street 109, 1130 Vienna, Austria.
| | - Alexander Aichmair
- II. Orthopedic Department, Orthopedic Hospital Speising, Speisinger street 109, 1130 Vienna, Austria; Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Speising, Speisinger street 109, 1130 Vienna, Austria
| | - Jochen G Hofstaetter
- II. Orthopedic Department, Orthopedic Hospital Speising, Speisinger street 109, 1130 Vienna, Austria; Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Speising, Speisinger street 109, 1130 Vienna, Austria
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Thaler M, Manson TT, Holzapfel BM, Moskal J. Proximal femoral replacement using the direct anterior approach to the hip. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2022; 34:218-230. [PMID: 35641789 PMCID: PMC9197819 DOI: 10.1007/s00064-022-00770-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/01/2021] [Accepted: 01/17/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Proximal femoral replacement (PFR) is a salvage procedure originally developed for reconstruction after resection of sarcomas and metastatic cancer. These techniques can also be adapted for the treatment of non-oncologic reconstruction for cases involving massive proximal bone loss. The direct anterior approach (DAA) is readily utilized for revision total hip arthroplasty (THA), but there have been few reports of its use for proximal femoral replacement. INDICATIONS Aseptic, septic femoral implant loosening, periprosthetic femoral fracture, oncologic lesions of the proximal femur. The most common indication for non-oncologic proximal femoral placement is a severe femoral defect Paprosky IIIB or IV. CONTRAINDICATIONS Infection. SURGICAL TECHNIQUE In contrast to conventional DAA approaches and extensions, we recommend starting the approach 3 cm lateral to the anterior superior iliac spine and performing a straight incision directed towards the fibular head. After identification and incision of the tensor fasciae lata proximally and the lateral mobilization of the iliotibial tract distally, the vastus lateralis muscle can be retracted medially as far as needed. Special care should be taken to avoid injuries to the branches of the femoral nerve innervating the vastus lateralis muscle. If required, the distal extension of the DAA can continue all the way to the knee to allow implantation of a total femoral replacement. The level of the femoral resection is detected with an x‑ray. In accordance with preoperative planning, the proximal femur is resected. Ream and broach the distal femoral fragment to the femoral canal. With trial implants in place, leg length, anteversion of the implant and hip stability are evaluated. It is crucial to provide robust reattachment of the abductor muscles to the PFR prosthesis. Mesh reinforcement can be used to reinforce the muscular attachment if necessary. POSTOPERATIVE MANAGEMENT We typically use no hip precautions other than to limit combined external rotation and extension for 6 weeks. In most cases, full weight bearing is possible after surgery. RESULTS A PFR was performed in 16 patients (mean age: 55.1 years; range 17-84 years) using an extension of the DAA. The indication was primary bone sarcoma in 7 patients, metastatic lesion in 6 patients and massive periprosthetic femoral bone loss in 3 patients. Complications related to the surgery occurred in 2 patients (both were dislocation). Overall, 1 patient required reoperation and 1 patient died because of his disease. Mean follow-up was 34.5 months.
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Affiliation(s)
- Martin Thaler
- Arthroplasty Center, Helios Klinikum Munich West, Steinerweg 5, 81241, Munich, Germany.
- Universitätsklinik für Orthopädie, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
- Center of Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University of Greifswald, Greifswald, Germany.
| | - Theodore T Manson
- Department of Orthopaedic Surgery, University of Maryland, 21204, Baltimore, MD, USA
| | - Boris Michael Holzapfel
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Joseph Moskal
- Department of Orthopedic Surgery, Virginia Tech Carilion School of Medicine, Institute for Orthopedics and Neurosciences, 24014, Roanoke, VA, USA
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Holzapfel BM, Corten K, Goldberg T, Rudert M, Nogler M, Moskal J, Thaler M. Acetabular defect management and revision arthroplasty via the direct anterior approach. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2022; 34:203-217. [PMID: 35680676 DOI: 10.1007/s00064-022-00767-6] [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: 12/01/2020] [Revised: 03/06/2021] [Accepted: 03/13/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Acetabular revision arthroplasty and osseous defect management through the direct anterior approach (DAA) with or without proximal extension. INDICATIONS Aseptic or septic component loosening, periacetabular osseous defects, pelvic discontinuity, intrapelvic cup protrusion, anterior pseudotumors, iliopsoas tendonitis, polyethylene wear or iliopsoas abscess. CONTRAINDICATIONS Clinically relevant gluteal tendon lesions, active infection, morbid obesity, large abdominal pannus, ASA (American Society of Anesthesiologists) score > III, inguinal skin infection. SURGICAL TECHNIQUE Electrocautery dissection is recommended to dissect the Hueter interval and to debulk pericapsular scar tissue. At all times during capsular debulking, it should be made sure not to damage the iliopsoas tendon or the neurovascular bundle. A stepwise releasing sequence can facilitate dislocation of the prosthesis. Most cases can be revised via the standard DAA but certain circumstances require an intra- or extrapelvic extension. Access to the anterior gluteal surface of the ilium can be provided using a "tensor snip". More posterior access is provided by the extensile extrapelvic approach described by Smith-Petersen. The intrapelvic Levine extension offers access to the entire visceral surface of the ilium and large parts of the anterior column. POSTOPERATIVE MANAGEMENT Patient revised via the intra- or extrapelvic extension and patients suffering from extensive soft tissue or osseous defects should undergo postoperative weight-bearing restrictions with 20 kg for 6 weeks. RESULTS Based on our studies, there is no limitation on the type of acetabular implant that can be used in DAA revision arthroplasty. Moreover, virtually all types of periacetabular osseous defects can be managed through the approach and its extensions. Acetabular revision arthroplasty via the DAA and its extensions is safe and can result in good midterm results.
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Affiliation(s)
- Boris Michael Holzapfel
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Kristoff Corten
- Hip Unit, Orthopedic Department, Ziekenhuis Ooost-Limburg Genk, Schiepse Bos 6, 3600, Genk, Belgium
| | - Tyler Goldberg
- 4700 Seton Center Parkway, Texas Orthopedics, LLC, 78759, Austin, TX, USA
| | - Maximilian Rudert
- Department of Orthopedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Michael Nogler
- Department of Experimental Orthopedics, Department of Orthopedics and Traumatology, Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Joseph Moskal
- Department of Orthopedic Surgery, Virginia Tech Carilion School of Medicine, Institute for Orthopedics and Neuroscience, 2331 Franklin Rd, 24014, SW, Roanoke, VA, USA
| | - Martin Thaler
- Arthroplasty Center, Helios Klinikum Munich West, Steinerweg 5, 81241, Munich, Germany
- Center of Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University of Greifswald, Greifswald, Germany
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Thaler M, Corten K, Nogler M, Holzapfel BM, Moskal J. Femoral revision with the direct anterior approach. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2022; 34:189-202. [PMID: 35641790 PMCID: PMC9197934 DOI: 10.1007/s00064-022-00768-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/04/2021] [Accepted: 01/17/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The advantages of the direct anterior approach (DAA) in primary total hip arthroplasty as a minimally invasive, muscle-sparing, internervous approach are reported by many authors. Therefore, the DAA has become increasingly popular for primary total hip arthroplasty (THA) in recent years, and the number of surgeons using the DAA is steadily increasing. Thus, the question arises whether femoral revisions are possible through the same interval. INDICATIONS Aseptic, septic femoral implant loosening, malalignment, periprosthetic joint infection or periprosthetic femoral fracture. CONTRAINDICATIONS A draining sinus from another approach. SURGICAL TECHNIQUE The incision for the primary DAA can be extended distally and proximally. If necessary, two releases can be performed to allow better exposure of the proximal femur. The DAA interval can be extended to the level of the anterior superior iliac spine (ASIS) in order to perform a tensor release. If needed, a release of the external rotators can be performed in addition. If a component cannot be explanted endofemorally, and a Wagner transfemoral osteotomy or an extended trochanteric osteotomy has to be performed, the skin incision needs to be extended distally to maintain access to the femoral diaphysis. POSTOPERATIVE MANAGEMENT Depending on the indication for the femoral revision, ranging from partial weight bearing in cases of periprosthetic fractures to full weight bearing in cases of aseptic loosening. RESULTS In all, 50 femoral revisions with a mean age of 65.7 years and a mean follow-up of 2.1 years were investigated. The femoral revision was endofemoral in 41 cases, while a transfemoral approach with a lazy‑S extension was performed in 9 patients. The overall complication rate was 12% (6 complications); 3 patients or 6% of the included patients required reoperations. None of the implanted stems showed a varus or valgus position. There were no cases of mechanical loosening, stem fracture or subsidence. Median WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score before surgery improved significantly from preoperative (52.5) to postoperative (27.2).
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Affiliation(s)
- Martin Thaler
- Arthroplasty Center, Helios Klinikum Munich West, Steinerweg 5, 81241, Munich, Germany.
- Department of Orthopedics and Traumatology -Experimental Orthopedics, Medical University Innsbruck, Innsbruck, Austria.
- Center of Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University of Greifswald, Greifswald, Germany.
| | - Kristoff Corten
- Hip Unit, Orthopedic Department, Heuppraktijk, Ziekenhuis Oost-Limburg Genk, Herselt, Belgium
| | - Michael Nogler
- Department of Orthopedics and Traumatology -Experimental Orthopedics, Medical University Innsbruck, Innsbruck, Austria
| | - Boris Michael Holzapfel
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Joseph Moskal
- Department of Orthopedic Surgery, Virginia Tech Carilion School of Medicine, Institute for Orthopedics and Neurosciences, 24014, Roanoke, VA, 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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Liu H, Yin L, Li J, Liu S, Tao Q, Xu J. Minimally invasive anterolateral approach versus direct anterior approach total hip arthroplasty in the supine position: a prospective study based on early postoperative outcomes. J Orthop Surg Res 2022; 17:230. [PMID: 35413925 PMCID: PMC9003954 DOI: 10.1186/s13018-022-03126-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/06/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Minimally anterolateral approach (MAA) and direct anterior approach (DAA) have been reported as beneficial for total hip arthroplasty (THA) due to their ability to reduce postoperative pain and lead to quicker rehabilitation by preserving muscle insertions. As there is an ongoing debate on the effect of these two approaches on early postoperative outcomes, this prospective study aimed to assess the difference in early clinical, radiological, and patient-reported outcomes between the two minimally invasive approaches. METHODS A total of 98 patients, 50 in the MAA group and 48 in the DAA group, were included in the study. Patients with complete data were evaluated preoperatively and postoperatively at 2, 6, and 12 weeks. Clinical measurements, including the ability to climb stairs and walk, 6-min walk test (6MWT), the Forgotten Joint Scale (FJS-12), Japanese Orthopedic Association (JOA) Hip scores, radiological evaluation, and complications were analyzed. RESULTS There were no significant differences in clinical outcomes and implant alignments between MAA and DAA groups. In regards to patient-reported outcomes, the FJS-12 was significantly higher in the MAA group compared to group DAA at 2 and 6 weeks postoperatively. However, there was no significant difference in the FJS-12 between the two groups 12 weeks after surgery. The differences also included shorter operative times (62.4 ± 9.05 min vs. 71 ± 8.01 min), less blood loss (132.6 ± 43.31 ml vs. 159.23 ± 37.25 ml), lower Hb drop (29.56 ± 8.02 g/L vs. 36.4 ± 7.12 g/L), and fewer blood transfusions in the MAA group (4.0% vs. 18.8%). The incidence of the lateral femoral cutaneous nerve (LFCN) neuropraxia after surgery was 7 (14.6%) in the DAA group and 0 in the MAA group. One fracture was found in each group and managed conservatively. CONCLUSION MAA and DAA approach yielded excellent and similar early clinical outcomes. However, better patient-reported outcomes could be achieved by MAA THA. The MAA resulted in a safer approach associated with shorter operative times, less blood loss, lower Hb drop, fewer blood transfusions, and LFCN neuropraxia than DAA. A longer follow-up is needed to further examine differences between these procedures.
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Affiliation(s)
- Hongwen Liu
- Department of Orthopaedics, Panzhihua Central Hospital, #34 Yikang Road, Panzhihua, 617067, Sichuan Province, China
- Department of Orthopedics, Fujian Provincial Hospital, Fujian Medical University, #134 East Road, Fuzhou, 350001, Fujian Province, China
| | - Li Yin
- Department of Discipline Construction Office, Panzhihua Central Hospital, #34 Yikang Road, Panzhihua, 617067, Sichuan Province, China
| | - Jiao Li
- Department of Discipline Construction Office, Panzhihua Central Hospital, #34 Yikang Road, Panzhihua, 617067, Sichuan Province, China
| | - Shaojiang Liu
- Department of Orthopaedics, Panzhihua Central Hospital, #34 Yikang Road, Panzhihua, 617067, Sichuan Province, China
| | - Qifeng Tao
- Department of Orthopaedics, Panzhihua Central Hospital, #34 Yikang Road, Panzhihua, 617067, Sichuan Province, China
| | - Jie Xu
- Department of Orthopedics, Fujian Provincial Hospital, Fujian Medical University, #134 East Road, Fuzhou, 350001, Fujian Province, 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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Holzapfel BM, Rak D, Kreuzer S, Arnholdt J, Thaler M, Rudert M. Short stem hip arthroplasty via the minimally invasive direct anterior approach. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2021; 33:288-303. [PMID: 34251469 DOI: 10.1007/s00064-021-00723-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/12/2021] [Accepted: 02/25/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Tissue-sparing, minimally invasive hip arthroplasty via the direct anterior approach (DAA) using a partially neck-preserving, calcar-guided short stem. INDICATIONS Primary and secondary osteoarthritis of the hip due to developmental dysplasia, femoroacetabular impingement, femoral head necrosis or trauma sequelae. CONTRAINDICATIONS Severe osteoporosis, active infection, American Society of Anesthesiologists (ASA) > III, large metaphyseal bone defects, severe metaphyseal deformities, Dorr type C femur. SURGICAL TECHNIQUE Supine position on a standard operating table without extension device. Classic DAA skin incision or bikini incision distal to the inguinal fold. Blunt dissection entering the Hueter interval. Capsulotomy with capsule preservation or partial capsulectomy. Intraoperatively, it is crucial to adhere to the preoperatively planned angle and height of the femoral neck osteotomy. During femoral head removal and acetabular preparation, care must be taken to avoid iatrogenic damage to the remaining neck. After cup positioning, femoral access is achieved by release of superior capsular structures. During opening of the medullary canal and broaching, femoral torsion and axis have to be taken into account for correct rotational and axial alignment. Femoral broaches are inserted in an ascending series of sizes until the last broach is firmly lodged and is in direct contact with the antero-medial femoral neck cortex. Fluoroscopic control in two planes to check for femoral anatomic and overall offset and assess whether the implant is adequately seated with cortical support at the calcar, the distal lateral and the dorsal cortex. Implantation of the definitive implants, local infiltration analgesia and wound closure. RESULTS Between 1/2011 and 12/2016 60 patients (24 female, 36 male; mean age 44 years) were treated with a partially neck-preserving short stem via the described approach. Seven patients underwent a bi-lateral procedure. Thus, 67 procedures were analysed in this retrospective cohort study. Mean follow-up was 70 months (range 28-93). The median Harris Hip Score was 48 (range 11-88) preoperatively and 98 (range 80-100) postoperatively. CONCLUSION The minimally invasive implantation of a partially neck-preserving stem via DAA provides a safe technique with good to excellent clinical results in the mid-term.
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Affiliation(s)
- Boris Michael Holzapfel
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Dominik Rak
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Stefan Kreuzer
- Memorial Bone & Joint Clinic, The University of Texas Health Science Center at Houston Medical School, 1140 Business Center Drive, Suite 101, 77043, Houston, TX, USA
| | - Joerg Arnholdt
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Martin Thaler
- Department of Orthopaedic and Trauma Surgery, Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
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Corten K, Holzapfel BM. Direct anterior approach for total hip arthroplasty using the "bikini incision". OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2021; 33:318-330. [PMID: 34338830 DOI: 10.1007/s00064-021-00721-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 03/05/2021] [Accepted: 03/19/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The classic skin incision for direct anterior approach (DAA) total hip arthroplasty (THA) is usually placed over the belly of the tensor fasciae latae (TFL) muscle parallel to the axis of the lower extremity. In the "bikini incision" technique however, a more horizontal skin incision is used and placed parallel to the skin creases, which largely corresponds to the skin's tension lines to prevent hypertrophic scarring and optimize cosmetic outcomes. INDICATIONS Primary or secondary osteoarthritis, femoral neck fracture, aseptic acetabular component loosening with sufficient bone stock and without the need for proximal extension of the approach, head and/or liner exchange. CONTRAINDICATIONS Complex primary or revision THA requiring extensile distal and/or acetabular exposure, revision with pre-existing longitudinal DAA incision, inguinal skin infection. SURGICAL TECHNIQUE The skin incision, located three fingerbreadths distal to the anterior superior iliac spine (ASIS), is orientated parallel to the groin crease. One third of the incision is medial and two thirds lateral to the ASIS. Subcutaneous dissection should only be performed in the lateral two thirds of the incision to protect the main branches of the lateral femoral cutaneous nerve (LFCN). The fascia lata is opened as far lateral over the muscle belly as possible to leave the LFCN untouched within its fascial sheet. The stepwise procedure consists of three key steps: capsular exposure, capsular release, and component insertion. The approach allows for an excellent 360° exposure of the acetabulum. The femur is aligned along the incision during femoral elevation and adduction. With this technique, DAA hip arthroplasty can be performed in a less-invasive way providing best possible functional and cosmetic outcomes. POSTOPERATIVE MANAGEMENT No restrictions in ambulation or range of motion. Deep vein thrombosis prophylaxis. RESULTS In a prospective series of 532 consecutive patients undergoing 613 primary THA with a bikini-incision in 2017, a good clinical outcome with a 2.3% incidence of wound-related problems was observed. In particular, obese patients can also benefit from the technique.
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Affiliation(s)
- Kristoff Corten
- Hip Unit, Orthopedic Department, Ziekenhuis Oost-Limburg Genk, Limburg, Belgium.
- Heuppraktijk, Herselt, Belgium.
- Reconstructive Surgery of the Hip, Hip Unit, Ziekenhuis Oost-Limburg, Genk, Ziekenhuis Maas en Kemp, Maaseik , Belgium.
| | - Boris Michael Holzapfel
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
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A New Rectus and Sartorius Sparing Approach for Periacetabular Osteotomy in Patients with Developmental Dysplasia of the Hip. J Clin Med 2021; 10:jcm10040601. [PMID: 33562732 PMCID: PMC7915261 DOI: 10.3390/jcm10040601] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 12/12/2022] Open
Abstract
Background: periacetabular osteotomy (PAO) is known as the gold standard surgical treatment in young adults with symptomatic hip dysplasia. With the aim of reducing soft tissue trauma, we developed a new rectus and sartorius sparing (RASS) approach. We hypothesized that this new PAO technique was equal regarding acetabular reorientation, complication rate, and short-term clinical outcome parameters, compared to our conventional, rectus sparing (RS) approach. Patients and Methods: we retrospectively assessed all PAO procedures performed by a single surgeon between 2016 and 2019 (n = 239 hips in 217 patients). The cases in which the new RASS technique were used (n = 48) were compared to the RS cases for acetabular orientation parameters, surgical time, perioperative reduction of hemoglobin level, and length of hospital stay (LOHS). Inclusion criteria were a lateral center-edge angle (LCEA) <25° and osteoarthritis Tönnis grade ≤1. Patients with acetabular retroversion or additional femoral osteotomy were excluded. Results: the mean patient age at the time of surgery was 29 years (14 to 50, SD ± 8.5). Females accounted for 79.5% in this series. The mean preoperative LCEA were 16° (7 to 24°, SD ± 4.4) and 15° (0 to 23°, SD ± 6) in the RASS and the RS group, respectively (p = 0.96). The mean preoperative acetabular index (AI) angles were 14° (2 to 25°, SD ± 4) and 14° (7 to 29°, SD ± 4.3), respectively (p = 0.67). The mean postoperative LCEA were significantly improved to 31° (25 to 37°, SD ± 3.5, p < 0.001) and 30.2° (20 to 38°, SD ± 4, p < 0.001), respectively. The mean postoperative AI angles improved to 2.8° (−3 to 13°, SD ± 3.3, p < 0.001) and 3° (−2 to 15°, SD ± 3.3, p < 0.001), respectively. There were no significant differences between the RASS and the RS group for surgical time, perioperative reduction in hemoglobin level, and LOHS. No blood transfusions were necessary perioperatively in either group. No major perioperative complication occurred in either group. We observed one surgical site infection (SSI) requiring superficial debridement in the RS group. Conclusion: the RASS approach for PAO showed to be a safe procedure with equivalent acetabular reorientation and equivalent clinical outcome parameters compared to the RS approach. Additionally, patients have fewer postoperative restrictions in mobilization with the RASS approach.
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