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.

JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 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 - 10 cm) The postoperative radiographic outcomes showed an average acetabular abduction was 44.9 ± 7.50 (range 30 - 650), cup 0 anteversion was 14.8 ± 5.2 (range - 28 ) The mean Harris hip score 90.8 ± 3.6 (range 83 - 96) 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 188 JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 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 postoperative recovery and dislocation rates 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 cm distal and lateral to the anterior superior iliac spine (ASIS) and ending cm anterior to the greater trochanter it is possible to perform the procedure consistently with an - 12 cm incision length 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 Figure 1: Hip joint evaluation preoperation on AP view radiograph Figure 2: Leg position on the orthopaedic table 189 JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 * 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 Figure 3: Acetabular reaming 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 Figure 4: Femur rasp head is removed and measured * Acetabulum preparing: The lateral cobra retractor is repositioned inside the With slight external rotation and gentle traction on the femur, acetabular exposure is typically excellent; circumferential hip capsule to keep the tensor muscle visualization can help in removing retracted A Hohmann retractor is placed osteophytes, reaming, and cup placement on the anterior-inferior acetabular wall A A manual assessment is done to ensure similar Hohmann is placed on the anterior the anteromedial edge of the cup is acetabulum with the spike of the retractor covered by the anterior medial acetabular resting directly on bone to avoid femoral rim to lessen the likelihood of iliopsoas nerve injury (figure 3) irritation post-operatively 190 JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 * 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 191 JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 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 - 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 Injury Level Osteoarthritis Avascular Femoral neck Complication (OA) necrosis (AVN) fracture Total Easy (no posterior hip capsule release) 15 23 48 Difficult (partial posterior hip capsule release) 22 0 27 Very difficult (short external roble 1T1tation muscle and posterior hip capsule release) 0 Total 20 46 76 As described by Judet, we 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 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] 192 JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 Table 2: Function outcome with HHS improvement Follow-up Postoperative Osteoarthritis: 80.2 ± 3.4 (72 - 86) AVN: 79.63 ± 4.9 (71 - 89) Femoral neck fracture: 83.1 ± 3.8 (76 - 88) Complcations: 79.0 ± 0.0 (79) Mean HHS: 80.2 ± 4.4 (71 - 89) months year years years 86.7 ± 4.3 89.3 ± 3.8 89.9 ± 3.9 90.1 ± 4.0 (77 - 93) (81 - 93) (83 - 93) (85 - 96) 87.9 ± 4.1 89.7 ± 5.9 91.9 ± 3.2 (80 - 93) (59 - 93) 89.5 ± 3.9 (80 - 93) 87.7 ± 3.1 89.8 ± 3.1 (86 - 93) 92.8 ± 0.5 (92 - 93) 87.3 ± 2.9 89.0 ± 0.0 (89) 89.0 ± 0.0 (89) - - 87.6 ± 4.1 89.6 ± 5.2 89.9 ± 3.8 90.8 ± 3.6 (77 - 93) (59 - 93) (80 - 93) (83 - 96) (85 - 91) (86 - 96) (83 - 90) 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 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 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 cases were Brooker grade ossification Especially, no complications on orthopaedic table had been reported CONCLUSION of component positioning, facilitates to The mini-invasive anterior approach for permit adequate exposure of the proximal total hip replacement has gained popularity femur As with all techniques, the skill and recently The results also showed that is an experience of the surgeon are critical to effective and safe technique which provides the success of the procedure The surgeon small incision, less muscle damage, early had also undergone cadaver training and postoperative function… and reduces the fellowship with an experienced mentor risk of complications The use of a modified before attempting the first mini-invasive orthopaedic table performed by experienced surgery of total hip arthroplasty using an surgeons allows for real time assessment orthopedic table 193 JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 REFERENCES Sculco TP Minimally invasive total hip arthroplasty: In the affirmative J Arthroplasty 2004, 19, pp.78-80 Judet J, Judet R The use of an artificial femoral head for arthroplasty of the hip joint J Bone Joint Surg 1950, 32B, pp.166-173 Jill Wehling Anterior approach to total hip arthroplasty The Surgical Technologist 2013, pp.303-307 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 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 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 194 ... 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,... of the direct anterior approach for total hip arthroplasty Orthop Clin North Am 2009, 40 (3), pp.371-375 Phillip H Horne, Steven A Olson Direct anterior approach for total hip arthroplasty using. .. 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