Direct two-incision total hip replacement without fluoroscopy

Cementless total hip arthroplasty with anatomic-shaped implants. Does the minimal invasive anterolateral technique influence the stem position or subsidence in contrast to the standard lateral approach?

INTRODUCTION

Using cementless stems in total hip arthroplasty (THA) has revealed variable results. The risk for early aseptic loosening has been associated to certain surgical approaches and implant designs. This study determines misalignment of collared/collarless stems and the rate of subsidence using the anterolateral approach (ALA) compared to implantations via the direct lateral approach (DLA).

MATERIALS AND METHODS

One hundred consecutive patients underwent primary unilateral THA using the minimal invasive ALA in the lateral decubitus position and were compared to another cohort of 100 patients, treated trough the DLA. Clinical results were noted preoperatively and after 1 year using the WOMAC score. The radiographic evaluation included the stem alignment and subsidence.

RESULTS

Overall, all patients improved in WOMAC from 48.9 points (± 11.4; 21.0-82.0) to 3.1 (± 3.2; 0.0-22.0) (p < 0.001). For DLA and ALA, the stem was placed on average 2.5° in varus to the femoral axis. The mean alignment was about 0.5° more valgus for collarless stems. The mean subsidence in the DLA group was about 0.3 mm higher compared to the ALA group. With collarless implants, the subsidence was about 1.0 mm higher compared to collared implants (p < 0.05), especially in patients with Dorr type B femurs.

CONCLUSIONS

Changing from the DLA to the minimal invasive ALA did not significantly affect the implant position. Misalignment and a potential risk for early aseptic loosening could not be seen. The use of a collared cementless stem seems safe and is likely to prevent a relevant subsidence, even more so in Dorr type B femurs.

LEVEL OF EVIDENCE

III.

Rehabilitation of gait in patients after total hip arthroplasty: Comparison of the minimal invasive Yale 2-incision technique and the conventional lateral approach

The minimal invasive anterolateral Yale 2-incision approach for total hip arthroplasty aims minimizing damage to the muscles for faster recovery of function. Therefore the hypothesis was investigated, that during the rehabilitation process the Yale approach shows a faster return to natural gait than a conventional lateral approach. Nineteen patients had the Yale, 16 the conventional Bauer approach. Instrumented gait analysis was performed 3 days, 3 and 12 month post operatively. Velocity, cadence, step length, weight bearing, thorax lean, Trendelenburg limp, hip abduction moments, and hip muscle activation times were evaluated. Three days post-surgery a significantly greater loading of the treated limb and increased hip abduction moment were observed in the Yale group. In addition, the Yale group showed its greatest improvement in walking speed and step length between at 3 days and 3 months, whereas the conventional group showed an additional significant gain between 3 and 12 month to reach a similar walking speed as the Yale group. For all hip muscles investigated, only muscle tensor fasciae latae in the conventional group showed a significant increase in activation time between 3 days and 3 months. This study showed significantly faster return to natural gait in the Yale compared to the conventional approach, which could be biomechanically related to less impairment of abductor muscles in the Yale approach.

What is the role of minimally invasive surgery in a fast track hip and knee replacement pathway?

INTRODUCTION

Minimally invasive hip and knee replacement surgery (MIS) continues to receive coverage in both the popular press and scientific literature. The cited benefits include a smaller scar, less soft tissue trauma, faster recovery, reduced hospital stay, decreased blood loss and reduced post-operative pain. These outcomes are highly desirable and consistent with the aims of fast track hip and knee pathways. This paper evaluates the literature and discusses whether performing MIS over conventional surgical techniques offers advantages in a fast track hip and knee pathway.

METHODS

An English language literature search was performed using the MEDLINE and PubMed databases. Case series, randomised controlled trials and systematic reviews were included in the review.

RESULTS

The reported improvements in recovery brought about by MIS must be considered multifactorial. In combination with improved clinical pathways, MIS can be associated with quicker recovery and shorter length of hospital stay.

CONCLUSIONS

There is insufficient evidence to indicate that surgical technique alone makes a significant difference to recovery or reduces soft tissue trauma. No consensus on whether to use MIS techniques in fast track hip and knee replacement pathways can therefore be drawn. This is especially important given that the complication rates of MIS in the low to medium volume surgeon appear unacceptably high compared with standard approaches. It is also too early to assess the long-term effects of MIS on implant survival.

Gait asymmetry following an anterior and anterolateral approach to total hip arthroplasty

BACKGROUND

Patients with osteoarthritis of the hip demonstrate a limp while ambulating, and persistent asymmetric limb loading following unilateral total hip arthroplasty might induce further complications in the affected and contralateral limbs. The purpose of this study was to investigate pre- to postsurgical changes in gait symmetry in patients receiving either an anterior or anterolateral hip replacement.

METHODS

Three-dimensional kinematic and kinetic gait analyses were performed on 12 patients undergoing anterior surgery, 11 patients undergoing anterolateral surgery and 10 age-matched controls while level walking. A two-way mixed model analysis of variance with repeated measures was utilized to determine differences in symmetry indices and pelvic obliquity between groups and across time.

FINDINGS

At presurgery, greater single limb support time and step length asymmetry was demonstrated by both patient groups when compared to controls. While the anterior hip replacement patients demonstrated greater improvement in gait symmetry by 6 weeks postsurgery, both patient groups approached control levels by 16 weeks postsurgery. No significant differences were seen between patient groups for pelvic obliquity, limb loading or temporal-distance symmetry at any time point.

INTERPRETATION

Patients undergoing either anterior or anterolateral hip replacement enhanced their gait symmetry by 16 weeks following surgery. Improvement in gait symmetry at 6 weeks postsurgery, as compared to presurgery, was detected in patients undergoing anterior hip replacement. However, no such improvement was observed in patients receiving the anterolateral approach. Findings of this study highlight the potential impact of surgical approach on short-term changes in gait asymmetry.

Is there faster recovery with an anterior or anterolateral THA? A pilot study

Surgical technique is an important factor affecting recovery of hip function after total hip arthroplasty (THA). We therefore asked whether short-term recovery of hip strength and motion would differ between the anterior and anterolateral THA approaches. We presumed that although both approaches would improve hip function by 16 weeks postsurgery when compared with presurgery, a slower recovery would be demonstrated by the anterolateral group at 6 weeks when compared with the anterior group as a result of division and reattachment of the abductor muscles. We observed hip kinematics and kinetics during walking and isometric hip abductor strength for the involved limb. Hip abductor strength of all patients was lower than controls at all three testing times. Compared with presurgery, all patients demonstrated improved abductor strength at 16 weeks postsurgery. At 6 weeks, the patients with an anterior approach had improved late stance peak abductor moment postsurgery and reached the level of controls, but those with an anterolateral approach did not. Although the anterior approach was associated with improved gait velocity and peak flexor moments at 6 weeks compared to before surgery, we observed no differences between the two approaches for most of the isometric strength and dynamic gait measures at 6 or 16 weeks. Neither approach provided faster recovery.

[The standard implantation of a total hip prosthesis via two incisions (the Yale Technique)]

OBJECTIVE

Implantation of a total hip endoprosthesis with minimal trauma to the soft tissue. The need for visual aids (e.g., navigation or X-rays) during the procedure is frequently avoided.

INDICATIONS

All kinds of coxarthrosis for every age group, for every variation of bone construction, and even in obese patients.

CONTRAINDICATIONS

Extremely dysplastic hip joints involving the development of a secondary socket and the necessity of reconstruction of the acetabular socket (e.g., in the Harris method).

SURGICAL TECHNIQUE

Using a fixed lateral position, a small entry incision is made between the tensor fasciae latae and the sartorius muscles and the prosthesis socket is put into place. Via a second dorsal incision, after stripping the exterior rotators, the prosthesis stem and ball are implanted and the two parts of the prosthesis are attached.

POSTOPERATIVE MANAGEMENT

Full weight bearing allowed immediately. A luxation prophylaxis, in the form of a self-developed hip bodice (the so-called Yale bandage), is used until the end of the 4th postoperative week. Discharge from hospital is possible after just a few days. Upon discharge, the patient is sent to a rehabilitation facility, either as a resident or as an outpatient, for approximately 3 weeks. Return to the workplace, with only light physical activity, is possible once the wound has healed completely; this could be as soon as 14 days after the operation. Checkups are made after 4 weeks, 6 months, 1 year and then every year; these checkups include a full examination, X-rays and laboratory tests. Full exposure to sport or heavy manual labor is usually approved after the 6-month checkup.

RESULTS

Between October 2004 and April 2006, a total of 221 patients underwent surgery using this new technique (of these 15 patients underwent two-stage bilateral hip joint replacements). Patients were followed up for a minimum of 12 months and a maximum of 30 months. The Harris Hip Score improved from an average of 45.25 preoperatively to 96.4 postoperatively.

Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observational study

The authors conducted a retrospective, multicenter cohort study of 1,152 patients across nine clinical sites across the United States, evaluating complications and function associated with the anterior approach to total hip arthroplasty using an orthopedic table. Eligible patients included those with primary diagnosis of hip arthritis. Outcomes included hospital stay, use of assistive devices, complications, and function. In the cohort of 1,152 patients treated with the anterior approach to total hip arthroplasty, the authors found (i) an acceptable complication profile with a very low dislocation rate, (ii) an early return to function, and (iii) a decline in complications in surgeons with greater than 100 case experiences.

Fluoroscopy cannot recognize intraoperative fracture in patients receiving 2-incision total hip arthroplasty

Intraoperative fluoroscopy is suggested as a standard procedure in 2-incision total hip arthroplasty. Between September 2003 and July 2004, 2-incision total hip arthroplasties were done in 18 hips with and another 18 hips without the use of fluoroscopy. In group 1, the anterior skin incision was initially limited to 5 cm. Fracture or instability was checked by fluoroscopy first and then the incision was enlarged to 8 cm for visualization. In group 2, incisions were made long enough to expose the surgical field. There were 2 femoral neck fractures in the fluoroscopy group. The fractures were linear in the anteromedial femoral neck and could not be detected by fluoroscopy. Such linear fractures if overlooked could result in serious complications such as fracture displacement or implant instability. Surgeons should not rely on intraoperative fluoroscopy to check implant stability, and visualization of the surgical field should not be compromised when doing minimally invasive approach for total hip arthroplasty.

Comparison of patient satisfaction with incision cosmesis after standard and minimally invasive total hip arthroplasty

This study evaluated patient assessments and attitudes regarding incision cosmesis following standard and minimally invasive total hip arthroplasty 1 to 3 years postoperatively. A cosmesis questionnaire designed to elicit a score evaluating scar satisfaction was mailed to patients. Although the difference in total cosmesis score between the standard and minimally invasive groups was not statistically significant, patients with a standard incision had better scores at <1 year. One significant finding was worse responses in the minimal incision patients regarding sinking and curling of scar edges.

A modified two-incision technique for primary total hip arthroplasty

BACKGROUND

Minimally invasive surgery can be technically demanding but minimizes surgical trauma, pain and recovery. Two-incision minimally invasive surgery allows only intermittent visualization and may require fluoroscopy for implant positioning. We describe a modified technique for primary total hip arthroplasty, using two small incisions with a stepwise approach and adequate visualization to reliably and reproducibly perform the surgery without fluoroscopy.

MATERIALS AND METHODS

One hundred and two patients with an average age of 60 years underwent modified two-incision minimally invasive technique for primary THA without fluoroscopy. The M/L taper femoral stem (Zimmer, Warsaw, IN) and Trilogy (Zimmer) hemispherical titanium shell, with a highly cross-linked polyethylene liner, was used. Operative time, blood loss, postoperative hospital stay, radiographic outcomes and complications were recorded.

RESULTS

The mean operating time was 77 min. The mean blood loss was 335 cc. The mean hospital stay was 2.4 days. Mean cup abduction angle was 43.8 degrees. Mean leg length discrepancy was 1.7 mm. Thirteen patients had lateral thigh numbness and two patients had wound complications that resolved without any treatment.

CONCLUSION

A modified two-incision technique without fluoroscopy for primary total hip arthroplasty has the advantage of preserving muscles and tendons, shorter recovery and return to function with minimal complications. Provided that the surgeon has received appropriate training, primary total hip arthroplasty can be performed safely with the modified two-incision technique.

Posterior single-incision approach to minimally invasive total hip arthroplasty

Enhanced surgical techniques and instrumentation enable surgeons to perform total hip arthroplasties through minimally invasive approaches. Using incisions typically less than 10 cm in length, surgeons can achieve adequate visualization of the surgical site while minimizing trauma to deep soft tissues. Associated reductions in morbidity should allow for improved rehabilitation and recovery. Although these techniques have been met with some controversy, a number of recent studies appear to attest to their safety and efficacy. Many of these studies have concentrated on a posterior single-incision technique for total hip arthroplasty. Favorable results for such outcomes as operative times, complication rates, pain, functional recovery, and blood loss have been reported, and patient satisfaction has been high. If surgeons and their patients are to achieve maximum benefit from minimally invasive total hip arthroplasties, it will be necessary to design effective educational tools that address the learning curve associated with these approaches.

The science of minimally invasive total hip arthroplasty

Minimally invasive hip surgery has stimulated a new process in hip arthroplasty. There is consensus among surgeons about the benefits of anesthesia, pain management, and rapid recovery protocols. The benefits of the surgical technique for small incision surgery remain controversial. Some patients influence this controversy because they prefer minimally invasive hip surgery: they associate less body violation and better cosmesis with smaller incisions. Small incision surgery is associated with a learning curve and requires specialized instruments for favorable outcomes. Despite being a more difficult operation to perform, in skilled hands it is a safe procedure that does not increase complication rates as shown by recent prospective, randomized studies. Correct component positioning has been achieved consistently with these procedures and short-term results of small incision surgery are the same as with long incisions. New anesthesia and pain management techniques have led to remarkable early functional results, making same-day surgery possible. With improved instrumentation such as computer navigation, minimally invasive total hip arthroplasty will become more prevalent.

[Morbidity and reliability of total hip implants positioning using the posterior minimally invasive approach: a consecutive series of 100 cases]

PURPOSE OF THE STUDY

We wanted to determine whether the minimally invasive posterior approach for total hip arthroplasty leads to defective implant positioning or specific complications.

MATERIAL AND METHODS

One hundred total hip arthroplasties were performed in 98 patients via the posterior minimally invasive approach using a specific instrumentation between June 2003 and January 2004. All operations were performed by the same surgeon. The series included 59 men. Mean patient age was 61 years (range 25-83) and the mean body mass index as 26.1 kg/cm2 (14.1-40.7).

RESULTS

Mean length of the incision was 65 mm (range 45-80 mm). Mean operative blood loss was 393 ml. The VAS decreased from 2.6 on day 1 to 1.0 on day 5. The Harris score rose from 54.5 preoperatively to 85.6 six weeks postop. Mean cup abduction was 43.6 degrees and mean anteversion 16.4 degrees . The center of the hip was restituted within 5 mm in 91% of hips. Stem alignment was 0.8 degrees varus. The femoral offset and the overall hip offset were restituted within 10 mm in 88% of hips. There were no leg length discrepancies greater than 15 mm. Two patients required in addition cup fixation intraoperatively due to acetabular fracture and cup instability. There was one vertical fissuration at the lower end of the stem on one postoperative x-ray. There were no infections nor vascular or neurological lesions. Early dislocation occurred in one 78-year-old patient. There were no revisions for complications.

DISCUSSION

Total hip prosthesis implanted via the minimally invasive posterior approach is a difficult operation. Despite the use of specific instruments adapted to this limited approach, the method appear to be safe and to provide reliable results. If the incision has to be widened in a given patient, use of a familiar approach would be advisable. Experience and use of specific instruments enables proposing this technique for the majority of first intention total hip arthroplasties.

Minimal access surgery for total hip arthroplasty - current beliefs and activity profile in the UK

INTRODUCTION

There is a strong drive from patients, industry and the media to perform total hip arthroplasty (THA) through a minimal access incision. Currently in the UK, the exact definition and uptake of this procedure is not known.

PATIENTS AND METHODS

A postal questionnaire was sent to all consultant orthopaedic surgeons in the UK registered with the British Orthopaedic Association.

RESULTS

Of those performing THA, 23% have performed minimal access hip surgery (MAS). Of users, 63% perform less than 20 cases per year, 62% use the mini-posterior approach, and 12% intend to perform MAS in the future. There is an association with specialisation. The mean and mode scar sizes for MAS were 9.9 cm and 10 cm, respectively.

CONCLUSIONS

MAS is increasing in popularity but is currently performed in small numbers by those with a specialist interest in hip arthroplasty. Because no long-term results have been published regarding this procedure, it will be important to ensure that standards of implantation are not jeopardised and training remains critical. Cases should be registered with the National Joint Registry using the current definition of scar size less than 10 cm.

Early results of 1000 consecutive, posterior, single-incision minimally invasive surgery total hip arthroplasties

One thousand consecutive cementless total hip arthroplasties performed in 759 patients using a posterior, single-incision, minimally invasive surgical approach were followed prospectively for a minimum of 2 years. All surgeries were performed using a tapered, titanium, cementless femoral component and a press-fit, ingrowth acetabular component. Mean patient age was 62.3 years. Mean incision length was 8.8 cm. Harris hip scores improved from 34 preoperatively to 92 postoperatively. Component position was considered acceptable in 95.3% of patients. Six acetabular components failed to osseointegrate, whereas no femoral component was loose. Radiolucencies were limited to the upper femur and were nonprogressive. Complications and component malpositioning were within accepted standards. This consecutive series of minimally invasive total hip arthroplasties shows that satisfactory results can be consistently achieved using this surgical technique.