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A modified direct lateral approach for neck-preserving total hip arthroplasty: tips and technical notes
F. Pipino,M. Cimmino,A. Palermo
Journal of Orthopaedics and Traumatology , 2013, DOI: 10.1007/s10195-013-0224-4
Abstract: Tissue-sparing surgery for hip replacement aims to minimize muscle damage and conserve the femoral neck through the use of mini-prostheses. We propose a modification of the classical direct lateral access procedure that preserves the gluteus medius. Further advantages during the surgical phase include limited blood loss, visualization of the entire acetabulum, and sparing of the transverse ligament. Precise implantation is facilitated and normal biomechanics are preserved. The gluteus medius is divided longitudinally between the anterior third and posterior two-thirds to provide access to the gluteus minimus, which is detached from the femoral insertion together with a small portion of the vastus lateralis, forming a flap that exposes the underlying articular capsule. When the femoral head is revealed, a decision is made to either continue with its dislocation directly or to resect it and remove it separately to avoid damaging the gluteus medius during dislocation. Upon removal of the femoral head, with the limb flexed and slightly over-rotated, the acetabulum is completely visible. Limb length is maintained through the use of reference stitches on the gluteus minimus tendon and the proximal insertion of the vastus lateralis. In keeping with the minimally invasive philosophy, only pathological tissue is removed (marginal osteophytes, geodes, joint capsule, cartilage to the point of bleeding and pulvinar). We have performed more than 2,000 implants with this procedure since 1990. Advantages and potential critical points are discussed.
Development of a Retractor Holding Device to Reduce the Manpower in Total Hip Arthroplasty through Direct Anterior Approach  [PDF]
Hirotake Yo, Hirotsugu Ohashi, Ryo Sugama, Tessyu Ikawa
Open Journal of Orthopedics (OJO) , 2016, DOI: 10.4236/ojo.2016.62004
Abstract: Direct anterior approach (DAA) for total hip arthroplasty (THA) is a minimally invasive technique. In this approach, two assistants are necessary. We developed a retractor holding device called “Spider arm” to replace an assistant in the contra-lateral side. In this study, we investigated the usefulness of Spider arm in THA through direct anterior approach. 20 hips were operated without Spider arm and 21 hips were operated with Spider arm. The surgery time and the blood loss were compared. The cup position and leg length discrepancy were measured on radiography. There was no statistical significance between two groups in all parameters. No clinical complications were reported. With Spider arm, DAA-THA could be performed by two surgeons without deterioration of the surgery time and blood loss. The accuracy of cup position and leg length discrepancy was not affected. Spider arm can contribute to reducing the manpower in DAA-THA.
Primary total hip arthroplasty: a comparison of the lateral Hardinge approach to an anterior mini-invasive approach
Nathan Wayne,Reinhard Stoewe
Orthopedic Reviews , 2009, DOI: 10.4081/or.2009.e27
Abstract: The anterior mini-invasive (MI) approach to performing total hip arthroplasty (THA) is associated with less soft tissue damage and shorter postoperative recovery than other methods. Our hospital recently abandoned the traditional lateral Hardinge (LH) approach in favour of this new method. We compared the first 100 patients operated after the changeover to the new method (MI group) to the last 100 patients operated using the traditional method (LH group). Clinical and radiological parameters and complications were recorded pre- and postoperatively and the collected data of the two groups were statistically compared. There were no statistically significant differences between either group with regard to patient demographics or procedural data, placement of the femur component, postoperative leg discrepancy, prosthesis dislocation, blood transfusion, or postoperative dislocation of the components. The MI group had a significantly longer operating time, more bleeding, higher rate of nerve damage, and a higher percentage of acetabular component malposition whilst having a significantly shorter hospital stay and significantly fewer infections of the operative site in comparison to the LH group. Additionally, and perhaps most worrying was the clinically significant increase in intraoperative femur fractures in the MI group. The changeover to the anterior mini-invasive approach, which was the surgeons' initial experience with the MI technique, resulted in a drastic increase in the number of overall complications accompanied by less soft tissue damage and a shorter period of rehabilitation. Our results suggest that further analysis of this surgical MI technique will be needed before it can be recommended for widespread adoption.
Is the internal rotation lag sign a sensitive test for detecting hip abductor tendon ruptures after total hip arthroplasty?
Christian Ossendorf, Laurent Bohnert, Nadja Mamisch-Saupe, Daniel Rittirsch, Guido A Wanner, Hans-Peter Simmen, Claudio Dora, Clément ML Werner
Patient Safety in Surgery , 2011, DOI: 10.1186/1754-9493-5-7
Abstract: The patient is placed in lateral position on a stretcher with hips and knees in neutral position. The knee is flexed to 45° and the hip passively abducted and elevated by the investigator. With the foot passively abducted, the patient is then asked to bring his knee in direction to the examination table. This motion is also tested passively. The test is regarded positive, if no internal rotation is possible and/or if this is painful. If groin pain is elicited during either of the exercises, the test is also rated positive.We evaluated this test in 20 patients clinically and by magnetic resonance imaging (MRI). All patients demonstrated a positive internal rotation lag sign. Twelve of them lag of internal rotation and evidence of anterior abductor tendon rupture on MRI, 8 with lag of internal rotation and no evidence of abductor tendon rupture.The new clinical diagnostic sign presented here may improve the diagnosis of abductor tendon rupture in the future.Level of Evidence: Diagnostic study, level I.Total hip arthroplasty (THA) is one of the most frequently performed procedures in orthopaedic surgery done more than 300'000 times annually in the United States alone with an increase of 158% between 1990 and 2004 [1]. In addition, the number of total joint replacements is expected to rise to 600'000 by 2030 [2].Among the regularly performed approaches to the hip joint are the anterior (Smith-Peterson) [3,4], anterolateral (Watson-Jones) [5,6], lateral transgluteal (Hardinge) [7], and posterior (Moore), [8] approach, virtually each of which has been modified for minimally invasive hip replacement surgery [9-14] and comprises its distinct features, problems and pitfalls [15-17]. In patients with THA implanted by a direct lateral transgluteal approach, weakness of external hip rotation due to iatrogenic damage to the external rotators is possible [18,19]. Heterotopic ossifications are a possible complication [20]. Among potential consequences are mechanical malfunction, m
Short-term outcome after posterior versus lateral surgical approach for total hip arthroplasty - a randomized clinical trial*
W-C Witzleb, L Stephan, F Krummenauer, A Neuke, K-P Günther
European Journal of Medical Research , 2009, DOI: 10.1186/2047-783x-14-6-256
Abstract: We compared the short-term outcome of cementless THR using the both approaches in a prospective, randomized controlled trial. 60 patients with unilateral osteoarthritis were included. Outcome assessment was performed one day before surgery and one week, four weeks, six weeks and 12 weeks after surgery, respectively, using the Harris Hip score as primary objective.We found no significant difference in the intraindividual Harris Hip Score improvement at the pre-and three months post-operative assessments between both treatment groups (p = 0.115). However, Harris Hip scores and most functional and psychometric secondary endpoints showed a consistent tendency of a slightly better three months result in patients implanted via the posterior approach. In contrast a significant shorter operating time of the direct lateral approach was recorded (67 minutes versus 76 minutes, p < 0.001).In our opinion this slightly better short-term functional outcome after posterior approach is not clinical relevant. However, to make definitive conclusions all clinical relevant factors (i.e. mid- to long-term function, satisfaction, complication rates and long-term survival) have to be taken into account. Level of evidence: I - therapeuticMany different surgical approaches to the hip joint have been described. Currently, total hip replacement (THR) is most commonly performed via a posterior or a direct lateral approach [5].The posterior approach is considered to be associated with less problems regarding gait, since the abductor muscles are not dissected and damage to the superior gluteal nerve is very unlikely [1,7]. However, cup positioning is often more difficult and increased rates of dislocation have been reported [16,20].Critics of the direct lateral approach suggest that the violation of the hip abductors may lead to delay in recovery of abductor strength and late Trendelenburg gait [9,18]. The advantage proposed is the good exposure of the acetabulum, facilitating cup positioning whi
The direct anterior approach: initial experience of a minimally invasive technique for total hip arthroplasty
Ola Hallert, Yan Li, Harald Brismar, Urban Lindgren
Journal of Orthopaedic Surgery and Research , 2012, DOI: 10.1186/1749-799x-7-17
Abstract: A straight incision in front of the greater trochanter was used and the tensor muscle was approached subfascially and retracted laterally. The joint was opened and the femoral head was removed. Usually excellent acetabular exposure was obtained. In order to get access to the proximal femur, the hip capsule was released posterolaterally so that the femur could be lifted using a special retractor behind the tip of the trochanter. After insertion of the prostheses, the wound was closed using running sutures in the fascia overlying the tensor, sub- and intracutaneously.There was a small influence of BMI on the duration of surgery, and obese patients tended to have the cup positioned at a higher degree of deviation. There were in total 17 complications of which 5 necessitated revision surgery; 3 peroperative femoral fractures and 2 dislocations. Another 4 dislocations were treated with closed reduction and did not recur. 3 cases of nerve injury were noted, all resolved within 12?months. Three cases of DVT were diagnosed as well as 2 cases of postoperative infection; none of these led to chronic disability.The technique is perhaps more technically demanding than the lateral approaches used today due to the somewhat limited surgical exposure. Morbidly obese or very muscular patients as well as patients with a short femoral neck or acetabular protrusion can represent particular problems. Our results indicate that there are certain risks when adopting this procedure but the complications noted are avoidable.
Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: perioperative findings
Vincenzo Alecci,Maurizio Valente,Marina Crucil,Matteo Minerva,Chiara-Martina Pellegrino,Dario Davide Sabbadini
Journal of Orthopaedics and Traumatology , 2011, DOI: 10.1007/s10195-011-0144-0
Abstract: In our study, patients treated with a minimally invasive direct anterior approach had a better perioperative outcome than patients treated with the lateral approach. The longer time of surgery for the minimally invasive direct anterior approach may be attributed to the learning curve. Further studies are necessary to investigate the advantages of a minimally invasive direct anterior approach in terms of clinical results in the short and long run.
Total hip arthroplasty
Slavkovi? Nemanja,Vuka?inovi? Zoran,Ba??arevi? Zoran,Vukomanovi? Boris
Srpski Arhiv za Celokupno Lekarstvo , 2012, DOI: 10.2298/sarh1206379s
Abstract: Total hip arthroplasty is most common reconstructive hip procedure in adults. In this surgery we replace some parts of the upper femur and acetabulum with biocompatible materials. The main goal of this surgery is to eliminate pain and regain full extent of joint motion, maintaining hip stability. Surgical technique, biomaterials, design of the prosthesis and fixation techniques have evolved with time adjusting to each other. After total hip arthroplasty patients’ quality of life should be improved. There are many various postoperative complications. Some of them are fatal, and some are minor, which may become manifested years after surgery. Each next surgical procedure following previous hip surgery is associated with considerably lower chances to be successful. Therefore, in primary total hip arthroplasty, preoperative evaluation and preparation of patients are essential. Every orthopaedic surgeon needs to improve already adopted surgical skills applying them with precision and without compromise, with the main goal to achieve long-term durability of the selected implant. The number of total hip arthroplasties will also increase in future, and newer and higher quality materials will be used.
Application of bilateral direct anterior approach total hip arthroplasty: a report of 22 cases

- , 2017, DOI: 10.3969/j.issn.1671-167X.2017.02.007
Abstract: 目的:通过分析直接前入路双髋关节同时置换的临床特点,探讨直接前入路双髋同时置换的手术技巧和避免围手术期并发症的方法。方法: 回顾性分析2014年6月至2016年8月北京积水潭医院矫形骨科采用直接前入路双髋关节置换手术22例(44髋)患者的临床资料、手术效果及术后并发症等,其中男性17例,女性5例,年龄中位数为48岁(34~67岁)。股骨头缺血性坏死17例,髋关节发育不良继发性骨关节炎4例,类风湿性关节炎1例。所有患者采用平卧位直接前入路双髋关节同时置换手术治疗。结果: 本组患者全部使用生物固定型假体。手术时间平均(167±23) min,术中出血量平均(775±300) mL,术中及术后输异体血平均(327±341) mL,术后伤口引流平均(111±73) mL。术后第1天多数患者可以不需要帮助自行上下病床,5例患者术后第1天可以不用拐杖短距离行走,术后3 d有13例患者可以在保护下做下蹲动作。术后平均4 d出院,平均随访时间16个月(8~24个月)。术中出现2例大粗隆骨折,3例阔筋膜张肌损伤。术后随访3例伤口延迟愈合, 4例出现股外侧皮神经麻痹症状,2例患者大腿痛,无松动感染失败病例。Harris评分从术前平均(29±8)分,提高到术后平均(91±3)分,同术前相比差异有统计学意义(P<0.01)。结论: 直接前入路双髋关节置换术后早期患者恢复快,髋关节活动度好,但手术难度较高,在良好选择病例的情况下,术者在使用这种入路的早期仍然容易出现并发症。
Objective: To analyze the operation technique and the methods to avoid early complications on the learning curve for bilateral direct anterior approach (DAA) total hip arthroplasty (THA). Methods: We retrospectively studied a series of continued cases with bilateral avascular necrosis of the femoral head (AVN) or degenerative dysplastic hip and rheumatoid arthritis that were treated by DAA THA in Beijing Jishuitan Hospital. A total of 22 patients with 44 hips were analyzed from June 2014 to August 2016 in this study. There were 17 males and 5 females, and the median age was 48 years(range: 34-67 years). All the surgery was done by DAA method by two senior surgeons. The clinic characters, early surgery treatment results and complications were analyzed. Results: We used the cementless stems in all the cases. The average operating time was (167±23) min; the average blood loss was (775±300) mL;the blood transfusion was in average (327±341) mL;the wound drainage in average was (111±73) mL Most of the patients could move out of the bed by themselves on the first day after operation, 5 patients could walk without crutches on the first operating day, and 13 patients could squat on the third days after operation. The patients were discharged averagely 4 days after operation. We followed up all the patients for averagely 16 months (range: 8-24 months). There was no loosening or failure case in the latest follow up. In the study, 2 patients had great trochanter fracture, 2 patients had thigh pain, 4 patients had lateral femoral cutaneous nerve palsy, and 3 patients had muscle damage. The Harris scores were improved from 29±8 preoperatively to 90±3 postoperatively (P<0.01). Conclusion: The DAA THA can achieve faster recovery and flexible hip joint after operation. However it is a kind of surgery with high technique demanding. Carefully selected patients, and skilled technique, can help the surgeon avoid the early complications.
The Professional Medical Journal , 2011,
Abstract: Dislocation after total hip arthroplasty is part of spectrum ranging from neck impingement to subluxation before frank dislocationoccurs. Objectives: To assess various parameters as potential risk factors for postoperative hip dislocation. Setting: Department ofOrthopaedics in Merlin Park Regional Hospital, Galway Period: 5 years Study Design: Observational Material and Methods: In our studywe reviewed 1096 patients who underwent primary total hip arthroplasty in a consecutive period of five years. We assessed various parametersas potential risk factors for dislocation. Results: During this period 16 (1.45 %) patients dislocated their hips. According to our study theImportant factors that led to these dislocations were Retroverted cup (5 cases), trochanteric malunion/ avulsion (5 cases), Epilepsy (1 cases),Confusion/ Dementia (2 cases) Parkinsonism (2 cases). Abduction angle was found to be greater than 50 degrees in 8 cases. Conclusion:Familiarity with the risk factors assists in prevention and dictates aspects requiring further assessment, when dislocation occurs. Protection ofthe hip by bracing should be considered following revision surgery but is of questionable use in primary cases.
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