Direct anterior approach for femoral component revision: Surgical technique for extended trochanteric osteotomy and anterior cortical window

Surgical Approach Does Not Influence Instability Risk in Revision Total Hip Arthroplasty

BACKGROUND

Although the direct anterior (DA) approach has increased in popularity for primary total hip arthroplasty (THA), there is limited evidence regarding its use for revision THA. It is unknown whether the dislocation benefit seen in the primary setting translates to revision cases.

METHODS

This retrospective review compared the dislocation rates of revision THA performed through DA versus postero-lateral (PL) approaches at a single institution (2011 to 2021). Exclusion criteria included revision for instability, ≥ 2 prior revisions, approaches other than DA or PL, and placement of dual-mobility or constrained liners. There were 182 hips in 173 patients that met the inclusion criteria. The average follow-up was 6.5 years (range, 2 to 8 years).

RESULTS

There was a trend toward more both-component revisions being performed through the PL approach. There were no differences in dislocation rates between the DA revision and PL revision cohorts, which were 8.1% (5 of 72) and 7.5% (9 of 120), respectively (P = .999). Dislocation trended lower when the revision approach was discordant from the primary approach compared to cases where primary and revision had a concordant approach (4.9 versus 8.5%), but this was not statistically significant (P = .740). No significant differences were found in return to operating room, 90-day emergency department visits, or 90-day readmissions. However, the length of stay was significantly shorter in patients who had DA revisions after a primary PL procedure (P = .021).

CONCLUSIONS

Dislocation rates following revision THA did not differ between the DA and PL approaches irrespective of the primary approach. Surgeons should choose their revision approach based on their experience and the specific needs of the patient.

Complications and Survivorship After Aseptic Revision Total Hip Arthroplasty: Is There a Difference by Surgical Approach?

BACKGROUND

Revision total hip arthroplasty (rTHA) has traditionally been performed through the posterolateral approach (PA). Anterior approaches (AA) for rTHA are increasingly being utilized. The purpose of this study was to compare complications and survivorship from re-revision and reoperation after aseptic rTHA performed using an AA versus a PA.

METHODS

We retrospectively reviewed patients who underwent aseptic rTHA either through an AA (direct anterior approach [DAA], anterior-based muscle sparing [ABMS]) or PA from January 2017 to December 2021. There were 116 patients who underwent AA-rTHA (DAA 50, ABMS 66) or PA-rTHA (n = 105). Patient demographics, complications, and postoperative outcomes were collected.

RESULTS

The most common indication in both groups was aseptic loosening (n = 26, 22.4% AA, n = 28, 26.7% PA). Acetabular revision alone was most common in the AA group (n = 33, 28.4%), while both components were most commonly revised in the PA groups (n = 47, 44.8%). In all the AA-rTHA group, the index total hip arthroplasty was performed through a PA in 51% of patients, while the PA-rTHA group had the index procedure performed via AA in 4.8%. There was no statistically significant difference in re-revision rate between the DAA, ABMS, or PA groups (9.55 versus 5.3% versus 11.4%, respectively, P = .11). The most common overall reason for re-revision was persistent instability, with no difference in incidence of postoperative hip dislocation (n = 4, 6.8% DAA, n = 3, 5.3%, n = 10, 9.5% PA; P = .31).

CONCLUSIONS

This study demonstrates no difference in complication or re-revision survivorship after aseptic rTHA performed through a DAA, ABMS approach, or PA, nor between anterior or posterior-based approaches.

LEVEL OF EVIDENCE

Level III.

The "Inside-Out" Anterior Osteotomy of the Proximal Femur via the Direct Anterior Approach in Revision Hip Arthroplasty

Osteotomy techniques used for wide exposure during femoral component revision include the extended trochanteric osteotomy and its modifications. We describe an anterior proximal femur osteotomy technique starting from the inside of the femoral canal at the bone-implant interface and heading outward. The technique is used in conjunction with the extended direct anterior approach and allows direct access to and visualization of the anterior, medial, and lateral bone-implant interfaces. This technique is most useful for the removal of collared, fully hydroxyapatite-coated double-tapered femoral stems, in which bone-implant interfaces need to be accessed for removal of a well-osseointegrated hip arthroplasty implant.

Outcomes of revision total hip arthroplasty using a vascularised anterior femoral window

PURPOSE

Extraction of the distal femoral cement mantle and restrictor during revision total hip arthroplasty (rTHA) is challenging and can compromise host bone stock. The aim of this study is to report outcomes of our femoral windowing technique for cement removal.

METHODS

We report on a cohort of 36 patients with an average age of 68.7 years who underwent 40 cemented rTHA between 2011 and 2017 using a vascularised anterior femoral window. Clinical and radiological outcomes were retrospectively reviewed with a mean follow-up of 6.6 years (range, 3.8-10).

RESULTS

Latest mean WOMAC score was 25.4 and all windows achieved radiographic union by a mean of 7.9 weeks. Femoral component survivorship was 100% and 38 out of 40 rTHAs showed no evidence of radiological loosening.

CONCLUSION

The vascularised anterior window to remove the distal femoral cement mantle under direct vision is safe and reproducible with excellent clinical and radiographic results.