Minimally invasive total hip arthroplasty with the anterior approach using the orthopaedic table

Objectives: To describe a minimally invasive technique of anterior total hip arthroplasty with the outcomes and complications. Subjects and methods: We studied data on 69 patients (76 hips) who underwent anterior total hip arthroplasty with uncemented components using modified fracture table at Hue Central Hospital from 2010 - 2016.

MINIMALLY INVASIVE TOTAL HIP ARTHROPLASTY WITH THE ANTERIOR APPROACH USING THE ORTHOPAEDIC TABLE

Ho Man Truong Phu*; Nguyen Tien Binh**; Pham Dang Ninh***

SUMMARY

Objectives: To describe a minimally invasive technique of anterior total hip arthroplasty with the outcomes and complications Subjects and methods: We studied data on 69 patients

(76 hips) who underwent anterior total hip arthroplasty with uncemented components using modified fracture table at Hue Central Hospital from 2010 - 2016 The operative parameters, complications, radiographic imaging (with TraumaCad software) were assessed Functional outcomes were measured using the Harris hip score Results: The mean age of patients was 51.67 ± 11.35 years (range 23 - 74), mean blood loss was 406.1 ± 155.5 mL (range 65 - 630) and the mean incision length was 8.1 ± 0.7 cm (range 7 - 10 cm) The postoperative radiographic

outcomes showed an average acetabular abduction was 44.9 ± 7.50 (range 30 - 650), cup

Especially, no complications on orthopedic surgical table using have been reported Conclusions:

The anterior approach on the orthopaedic table performed by experienced surgeons is a minimally invasive technique applicable to all primary hip patients This technique allows accurate and reproducible component positioning and does not increase the rate of hip dislocation Therefore we state that the minimal invasive anterior approach is safe and lead to advantages for the patients and using of the orthopaedic table improves femoral access

* Keywords: Total hip arthroplasty; Anterior approach; Minimal invasive

INTRODUCTION

In the past decades, the mini-invasive

anterior approach to the hip for total hip

arthroplasty has become more popular and is

of greast interest to surgeons and patients,

with the goal of improving early recovery

parameters [1] It utilizes anterior internervous

and intermuscular plane, and is described

as a modified Hueter approach, as utilized

by Judet and Judet in 1950 [2, 3] Due to

the intermuscular nature, it is regarded as

allowing faster patient recovery to ambulation, normal abductor strength and decreased dislocation rate This approach provides a direct view of the acetabulum with visualization

of the anterior iliac spine landmarks to allow reference for appropriate cup positioning However, the femur canal preparation and component placement is considered

to be difficult with this approach Attempts

to retract the proximal femur anteriorly has been reported to contribute to proximal

* Hue Central Hospital

** Vietnam Military Medical University

*** 103 Military Hospital

Corresponding author: Ho Man Truong Phu (bsnttrphu@yahoo.com)

Date received: 30/09/2017

Date accepted: 23/11/2017

femur and femoral shaft fractures This has

also necessitated dissection of muscle from

the proximal femur as well compromising

the intermuscular nature of the approach

The advantage of the modified orthopaedic

table allows positioning assistance of

the femur to permit adequate exposure

of the femur which allows accurate femur

component positioning as well [4, 5] The

results have provided a view of this procedure

as an effective approach by experience

surgeons with potential benefit in

post-operative recovery and dislocation rates

SUBJECTS AND METHODS

We reviewed the technique as performed

at Hue Central Hospital with 69 patients

(76 hips) who underwent total hip arthroplasty

with Zimmer implants through an anterior

mini-invasive approach between 2010 and

2016 and outcome data in the using the

anterior approach with a fracture table

for total hip arthroplasty The operative

parameters, complications, X-ray pre and

post-operation with TraumaCad software

analyze (figure 1)… were assessed The

potential proximal femoral exposure on

orthopaedic table is based itself on the

posterior hip capsule as well as external

rotation muscle releasing limitation Functional

outcomes were measured using the Harris

hip score

* Patient positioning: The technique

described here requires the PROfx (Union

City, CA), modified orthopedic table for

patient positioning in the supine position

that allows for controlled positioning of

each lower extremity independently, including

full freedom of rotation and movement

into hyperextension The surgical table requires a perineal post be used to stabilize the patient and act as a counter point for gentle traction of the operative

limb (figure 2)

* Surgical approach: A straight incision

is made on the anterior-lateral thigh, beginning 2 cm distal and lateral to the anterior superior iliac spine (ASIS) and ending 2 cm anterior to the greater trochanter

it is possible to perform the procedure consistently with an 7 - 12 cm incision length

Figure 1: Hip joint evaluation

pre-operation on AP view radiograph

Figure 2: Leg position on the

orthopaedic table

* Hip joint exposure: The subcutaneous

fat is dissected bluntly until the thin fascia

over the tensor fascia lata muscle is seen

Blunt dissection will minimize the risk of

injury to the lateral femoral cutaneous

nerve which is always at risk during anterior

approaches to the hip joint The interval

between the tensor and the rectus femoris

should be identified and developed distally;

this step is especially necessary in heavier

individuals

The anterior hip capsule is opened

with two flaps that are retracted by

repositioning the Cobra retractors previously

placed outside the hip capsule The femoral

head and anterior acetabular wall will

come into view The hip joint is then

distracted using gradually applied traction

from the table, and a hip skid is used to

disrupt the ligamentum teres The proximal

femur head and neck is then resected

at the appropriate level according to

preoperative planning The resected femoral

head is removed and measured

* Acetabulum preparing: The lateral

cobra retractor is repositioned inside the

hip capsule to keep the tensor muscle

retracted A Hohmann retractor is placed

on the anterior-inferior acetabular wall A

similar Hohmann is placed on the anterior

acetabulum with the spike of the retractor

resting directly on bone to avoid femoral

nerve injury (figure 3)

Figure 3: Acetabular reaming

Figure 4: Femur rasp.

With slight external rotation and gentle traction on the femur, acetabular exposure

is typically excellent; circumferential visualization can help in removing osteophytes, reaming, and cup placement

A manual assessment is done to ensure the anteromedial edge of the cup is covered by the anterior medial acetabular rim to lessen the likelihood of iliopsoas

irritation post-operatively

* Femur exposure: This is a key concept

to understand because it will help avoid

the pitfalls of inadvertent injury to the

trochanter, ankle, or femur Safe retraction

entails adequate mobilization of soft

tissues first, followed by placement of a

passive retractor With the femur lifted up

and laterally by the surgeon, external

rotation of the femoral shaft should be at

least 90° (the patella is facing 90° externally

rotated) and the leg spar will be placed on

the floor to hyperextend 30 - 45°, and adduct

the hip 30 - 45°… While keeping the proximal

femur lifted, preparation of the femoral

canal should not commence until the

proximal femur is adequately visualized

This requires a release of the thick hip

capsule off the greater trochanter from

anterior to posterior while protecting the

abductors with a Hohmann retractor

Additional femoral mobilization can be

achieved by sub-periosteal release the

short external rotators and the posterior

hip capsule

* Stem insertion: Once the proximal

femur is adequately exposed, a Hohmann

retractor is positioned behind the greater

trochanter, protecting the proximal part of

the skin incision from femoral broaches

The canal is opened with a curved awl

Rasps and stem inserters are mounted on

instruments that are angled to clear the

soft tissues proximally (figure 4) Leg lengths

are measured by comparing the positions

of the patellae on either leg, with the feet

in neutral rotation Preoperative templating

and cutting the calcar at the estimated

level can also ensure proper leg lengths

during anterior mini-invasive total hip

arthoplasty Hip stability is assessed by

maximally externally rotating the femur and

checking for impingement or subluxation

of the femoral head

* Wound closure: The wound is thoroughly

irrigated and closed in a layered manner The fascia over the tensor fascia lata is closed over a deep drain

Figure 5: Incision length

Figure 6: Post-operation on AP view X-ray

with software TraumaCad

Closure is followed by the subcutaneous fat layer, and the skin Length of incision

has been measured with ruler (figure 5)

The patient is allowed to weight-bear as tolerated with anterior hip precautions

instructed by the physical therapists

RESULTD AND DISCUSSION

We use this procedure for the primary total hip replacements in our practice, and the results described here pertain to the first 69 patients who underwent this procedure with the mean patient age was 51.67 ± 11.35 years (range 23 - 74); the mean duration

of surgery was 115.0 ± 0.2 mins (range 80 - 185 mins); the mean blood loss was 406.1 ± 155.5 mL (range 65 - 630 mL; the mean incision length was 8.1 ± 0.7 cm The technique allowed accurate and reproducible acetabular component insertion The mean abduction angle was 44.9 ± 7.50 (range 30 - 650), mean cup ante-version

on the true lateral radiograph was 14.8 ± 5.20 (range 4 - 280) and 11/76 (14.4%) femoral stems were of varus, 12/76 (15.8%) were valgus alignment relative to the diaphyseal femoral shaft

Table 1: The potential assistance to permit adequate exposure of the proximal femur

with modified orthopaedic table

(OA)

Avascular necrosis (AVN)

Femoral neck

Easy (no posterior hip capsule

Difficult (partial posterior hip

Very difficult (short external

roble 1T1tation muscle and

posterior hip capsule release)

As described by Judet, we do the procedure on an orthopaedic table that allows rotational control of the femur during the procedure and facilitates femoral exposure: with 58/76 (76.3%) cases that were in easy level during femoral exposure when we

do changing in three dimensions the foot bar Kennon report on using the Heuter approach for more than 3,000 THAs done using a standard flat table They reported that secondary incisions for acetabular and/or femoral preparation are often required, and this technique also involves splitting the medial portion of the tensor fascia lata muscle In contrast, we have not required a second incision for component placement

We think that the use of the orthopaedic table improves femoral access, decreases the necessity of secondary incisions and reduces muscle trauma that can result from forceful retraction [6]

Table 2: Function outcome with HHS improvement

Follow-up

(77 - 93)

89.3 ± 3.8 (81 - 93)

89.9 ± 3.9 (83 - 93)

90.1 ± 4.0 (85 - 96)

(80 - 93)

89.7 ± 5.9 (59 - 93)

89.5 ± 3.9 (80 - 93)

91.9 ± 3.2 (86 - 96) Femoral neck fracture: 83.1 ± 3.8

(76 - 88)

87.7 ± 3.1 (85 - 91)

89.8 ± 3.1 (86 - 93)

92.8 ± 0.5 (92 - 93)

87.3 ± 2.9 (83 - 90)

(77 - 93)

89.6 ± 5.2 (59 - 93)

89.9 ± 3.8 (80 - 93)

90.8 ± 3.6 (83 - 96)

All patients had resumed their usual activities by four weeks after the procedure, and reported satisfaction with the outcome, the mean Harris hip score (HHS) 90.8 ± 3.6,

in the range 83 - 96 scores

In complications, we recognized one great trochanter fracture without concerning the manipulation on the orthopaedic table requiring cerclage wiring One dislocation occurred within 2 months postoperatively with only 4º cup anteversion angle on radiograph Thigh numbness was presented on objective testing in only three patients and was clinically insignificant at the six-month visit One superficial infection after one month follow-up and 1 deep joint infection after one year visit Leg lengths were overall restored with an average leg length discrepancy of 3.75 ± 2.84 mm in this series

No significant heterotopic ossification was recognized in this study Only 2 cases were Brooker grade 1 ossification Especially, no complications on orthopaedic table had been reported

CONCLUSION

The mini-invasive anterior approach for

total hip replacement has gained popularity

recently The results also showed that is an

effective and safe technique which provides

small incision, less muscle damage, early

postoperative function… and reduces the

risk of complications The use of a modified

orthopaedic table performed by experienced

surgeons allows for real time assessment

of component positioning, facilitates to permit adequate exposure of the proximal femur As with all techniques, the skill and experience of the surgeon are critical to the success of the procedure The surgeon had also undergone cadaver training and fellowship with an experienced mentor before attempting the first mini-invasive surgery of total hip arthroplasty using an orthopedic table

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3 Jill Wehling Anterior approach to total

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2013, pp.303-307

4 Barton C, Kim P.R Complications of the

direct anterior approach for total hip arthroplasty Orthop Clin North Am 2009, 40 (3), pp.371-375

5 Phillip H Horne, Steven A Olson Direct

anterior approach for total hip arthroplasty using the fracture table Curr Rev Musculoskelet Med

2011, 4, pp.139-145

6 Joel M Matta, Cambize Shahrdar, Tania Ferguson Single-incision anterior approach

for total hip arthroplasty on an orthopaedic table Clinical Orthopaedics and Related Research

2005, 441, pp.115-124

MINIMALLY INVASIVE TREATMENT FOR FRACTURES OF DISTAL TIBIA WITH LOCKING PLATE REDUCTION UNDER C-ARM