Introduction It is critical to achieve both proper component positioning and intact muscle balance if satisfactory results are to be attained after total hip replacement (THR). There have been fewer studies on minimally invasive (MI) THR than standard approaches. The objective of this paper is to present the early clinical and radiological results of posterolateral MI THR. Materials and methods The retrospective analysis of the records of patients undergoing posterolateral MI THR surgery between 2011 and 2014 was the basis of this study. 73 hips of 68 patients were included in the study. The acetabular component and femoral stem positions were measured on plane X-rays. Data on preoperative and postoperative hemoglobin and hematocrit values, as well as transfusion amounts, were also studied. The clinical evaluations were carried out with Harris Hip Scores. Results The mean HHS at the 3rd postoperative month was 87.60 (±7.70). Of the 73 cases, 61 were within the Lewinnek safe zone. The mean PMFA was 88.12 (±7.63°), which is within the normal ranges. The mean postoperative hemoglobin value was 9.7 g/dl (±1.3) and the mean postoperative hematocrit value was 29.8% (±3.8). A nondisplaced proximal femoral fracture line was evident on the early postoperative X-ray of one patient. One patient experienced early dislocation caused by acetabular component malpositioning and an early acetabular cup revision was necessary. Conclusion MI posterior approach for THR is a method in which the prosthetic components can be properly placed. Posterolateral MI approaches are safe when THR is performed, and afford satisfactory results. © 2016 Delhi Orthopedic Associatio

Aslan, A.

Erol, Mehmet Fatih

Günaydın, Burak

Karakoyun, Özgür

Karıksız, M.

Journal of Clinical Orthopaedics and Trauma

English

PubMed

Namik Kemal University Institutional Repository

Original ArticleEarly clinical and radiological results of minimallyinvasive total hip replacementÖzgür Karakoyun MDa,*, Mehmet Fatih Erol MDa, Ahmet Aslan MDb,Mesut Karıksız MDa, Burak Günaydın MDcaDepartment of Orthopedics and Traumatology, Namık Kemal University, Tekirdağ, TurkeybDepartment of Orthopedics and Traumatology, Afyonkarahisar State Hospital, Afyonkarahisar, TurkeycDepartment of Orthopedics and Traumatology, Kütahya State Hospital, Afyonkarahisar, Turkeyj o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a u m a 7 s ( 2 0 1 6 ) 2 1 0 – 2 1 4a r t i c l e i n f oArticle history:Received 31 December 2015Accepted 26 March 2016Available online 8 April 2016Keywords:Minimally invasiveTotal hip replacementCoxarthrosisa b s t r a c tIntroduction: It is critical to achieve both proper component positioning and intact musclebalance if satisfactory results are to be attained after total hip replacement (THR). There havebeen fewer studies on minimally invasive (MI) THR than standard approaches. The objectiveof this paper is to present the early clinical and radiological results of posterolateral MI THR.Materials and methods: The retrospective analysis of the records of patients undergoingposterolateral MI THR surgery between 2011 and 2014 was the basis of this study. 73 hipsof 68 patients were included in the study. The acetabular component and femoral stempositions were measured on plane X-rays. Data on preoperative and postoperative hemo-globin and hematocrit values, as well as transfusion amounts, were also studied. The clinicalevaluations were carried out with Harris Hip Scores.Results: The mean HHS at the 3rd postoperative month was 87.60 (7.70). Of the 73 cases,61 were within the Lewinnek safe zone. The mean PMFA was 88.12 (7.638), which is withinthe normal ranges.The mean postoperative hemoglobin value was 9.7 g/dl (1.3) and the mean postoperativehematocrit value was 29.8% (3.8). A nondisplaced proximal femoral fracture line wasevident on the early postoperative X-ray of one patient. One patient experienced earlydislocation caused by acetabular component malpositioning and an early acetabular cuprevision was necessary.Conclusion: MI posterior approach for THR is a method in which the prosthetic componentscan be properly placed. Posterolateral MI approaches are safe when THR is performed, andafford satisfactory results.# 2016 Delhi Orthopedic Association. All rights reserved.* Corresponding author. Tel.: +90 505 7511978.E-mail address: ozgurkarakoyun@yahoo.com (Ö. Karakoyun).Available online at www.sciencedirect.comScienceDirectjournal homepage: www.elsevier.com/locate/jcothttp://dx.doi.org/10.1016/j.jcot.2016.03.0030976-5662/# 2016 Delhi Orthopedic Association. All rights reserved.1. IntroductionTotal hip replacement (THR) is the most common treatmentfor hip osteoarthritis. The principal purposes of THR are painrelief and provision of a mobile and stable hip, and it is criticalto achieve proper component positioning as well as an intactmuscle balance. Anterolateral, direct lateral, transtrochan-teric, and posterolateral approaches to THR surgery have beendescribed. Recently, anterolateral and posterolateral minimal-ly invasive (MI) approaches have been developed to decreasemuscle disruption and blood loss, as well as shorten recoverytime. The most important aim of MI surgery is to protectmuscular structures and their innervation and vasculariza-tion, rather than the use of a small skin incision per se.1 Todecrease the likelihood of component malpositioning, periop-erative fractures, and excessive blood loss, new tools andimplant designs have been developed.There have been fewer studies on MI THR than standardapproaches. We retrospectively analyzed our MI THR casesand report the early clinical and radiological results in terms ofFig. 1 – Measurement of acetabular inclination and MPFA onplain X-ray.j o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a u m a 7 s ( 2 0 1 6 ) 2 1 0 – 2 1 4 211Fig. 2 – The skin incision for MI THR.perioperative and early postoperative success, complicationrates, and the early postoperative positions of the femoral andacetabular components.2. Materials and methodsWe retrospectively analyzed the records of patients undergo-ing posterolateral MI THR surgery between 2011 and 2014; 73hips of 68 patients who were operated by one seniororthopedist with 10 years experience on hip arthroplastywere included in the study. The mean body mass index of thepatients was 28.6 kg/cm2 kg (3.07). The chief complaint of allpatients was hip pain, which was resistant to analgesics. Ofthese, 44 hips were treated with the Anthology® hip system(Smith and Nephew) and 29 hips were treated with Profemur®Z stems (Wright).The etiologies were hip dysplasia in 28 patients, femoral headavascular necrosis in 6 patients, and post-traumatic arthritis in 3patients. The other 31 patients had primary hip joint arthrosis.The mean age of patients was 60.86 (10.36 years). Of thedysplastic hips, 11 were of Crowe type 1 and 12 were of Crowetype 2; there were no Crowe type 3 or 4 hips in this series.Data on preoperative and postoperative hemoglobin andhematocrit values, perioperative blood loss amounts, postop-erative hemorrhagic drainage amounts, transfusion amounts,and preoperative and postoperative 3-month follow-up HarrisHip Scores (HHS) were obtained from patient records. Theanteversion and inclination angles of acetabular componentswere measured on early postoperative radiograms. Theanteversion angles of acetabular cups were calculated usingthe 'planar anteversion of the acetabular cup' methoddescribed by Pradhan.4 Medial proximal femoral angles(MPFAs) were measured to evaluate femoral stem positions(Fig. 1). In unilateral cases, the distances between theacetabular teardrops and the lesser trochanter evident onstandard plain radiograms were used to determine lengthdiscrepancies. In addition, early postoperative radiogramswere evaluated in terms of fractures or dislocations.2.1. Surgical techniqueThe patient was placed in the lateral decubitus position underanesthesia. A 7–9 cm oblique linear skin incision, running fromthe posterolateral to the anterolateral side, at an angle of 308 tothe coronal plane, was made with the midpoint of the cut lyingon the tip of the greater trochanter (Fig. 2). Before cutting thefascia, the skin and subcutaneous fat tissue were widelyseparated from the fascia to form a mobile skin window. Thespecial instruments designed for the MISTHR are necessaryduring the operations because the standard retractors are notsuitable for this technique. The short external hip rotatormuscles were retracted posteriorly, without any tenotomy, toaccess the proximal part of the posterior joint capsule, whichwas opened with a J-shaped cut before the hip was dislocatedposteriorly. Two over-curved S-shaped Hohmann retractors,which are designed for MITHR, were placed to the femoral neckthroughout the interval between short external rotator muscleswithout any tenotomy before the femoral neck was cut with anFig. 3 – Acetabular exposure during MI THR.j o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a u m a 7 s ( 2 0 1 6 ) 2 1 0 – 2 1 4212oscillating saw. After the removal of the femoral head, theproximal femur was moved anteriorly and an over-curved S-shaped Hohmann retractor was placed on the transverseacetabular ligament, with two additional Hohmann retractorsplaced posterior and anterior to the acetabulum (Fig. 3). Afterstandard reaming, the acetabular cup and insert were placed intheir proper positions with the help of the three-dimensionalguide, which takes the ipsilateral shoulder as landmark. Forpreparation of the femur, the proximal femur was placed in the908 internal rotation position. A Hohmann retractor was placedon the tip of the greater trochanter and another one was placedjust distal to the insertion site of the piriformis muscle. Thelateral remnant of the femoral neck was removed with a squarechisel. After standard reaming and broaching, the femoralcomponent was placed in the proper position. The femoralcomponent placement was checked with the transepicondylarline of the distal femur. Finally, the femoral head was adapted tothe stem and the hip was reduced before wound closure (Fig. 4).2.2. Postoperative periodMuscle strengthening exercises were started on the operatingday. There was no restriction of any hip movements. Allpatients were allowed to bear full weight on to the operatedextremity with the help of a walker on the postoperative dayone except one patient with a proximal femoral nondisplacedfracture and one patient with early instability. The patientswere trained for the home exercises before discharge.Thromboembolism prophylaxis was prescribed for all patientsfor 35 days. The patients were invited to attend 6-weeklyclinical and radiological follow-ups (Fig. 5). Depending onperformance, mobilization with either one or two crutcheswas allowed.SPSS version 17.0 (SPSS Inc., Chicago, IL) was used foranalysis of data. The paired samples t test was used tocompare preoperative and postoperative data.3. ResultsThe mean preoperative HHS was 34.09 (7.45). The mean HHSat the 3rd postoperative month was 87.60 (7.70). Significantimprovements in postoperative compared to preoperativeHHS scores were evident. Also, there was a significant decreasein the need for analgesic use. The mean acetabular inclinationangle of the cases was 45.118 (7.738) and the mean acetabularanteversion angle was 7.488 (9.588). Of the 73 cases, 61 werewithin the Lewinnek safe zone. The mean PMFA was 88.12(7.638), which is within the normal ranges. The meanpostoperative leg length discrepancy was 2.56 (5.28 mm).None of these radiological values were clinically significant.The mean operative time was 75.1 min (12.3). The meanpostoperative stay time of the patients was 2.6 days (1.02).The mean preoperative hemoglobin value was 12.3 g/dl(1.7) and the mean preoperative hematocrit value was 38.0%(5.5). The mean postoperative hemoglobin value was 9.7 g/dl(1.3) and the mean postoperative hematocrit value was 29.8%(3.8). According to our records, the mean intraoperative bloodloss was 174.5 cm3 (18.2). The mean postoperative hemor-rhagic drainage amount was 95.6 cm3 (24.7). The mean totalblood loss was 266.5 cm3, which is significantly lower than theexpected blood loss amount after hip replacement surgeries. Wesuggest that the inconsistency of the blood loss amounts andhemoglobin and hematocrit decrease were due to hemodilu-sion, which could be caused by overhydration applied afterregional anesthesia.A nondisplaced proximal femoral fracture line was evidenton the early postoperative X-ray of one patient. The case wasfollowed up without weight bearing for 6 weeks and there wasno need for a revision surgery. One patient experienced earlydislocation caused by acetabular component malpositioningand an early acetabular cup revision was necessary. None ofFig. 4 – Incision site after wound closure.Fig. 5 – Clinical and radiological outcomes on 12-month follow-up of a bilateral MI THR case. (a) Standard anteroposteriorpelvic radiogram; (b) the operative site; (c) clinical view of the patient in a neutral standing position; (d) active hyperflexion ofboth hips in the standing position and (e) active hyperflexion of both hips in the supine position.j o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a u m a 7 s ( 2 0 1 6 ) 2 1 0 – 2 1 4 213the patients experienced infection or deep venous thrombosis.Complication-free cases were mobilized early without anyrestriction.4. DiscussionVarious surgical approaches for THR surgery have beendescribed. Although the direct anterior approach seems toafford better outcomes, this was not significantly superiorupon long-term follow-up compared to the posterolateralapproach. In addition, various MI exposures have been testedin efforts to decrease complications and hasten recovery time.In a meta-analysis, Xu et al. found no differences in thefunctional outcomes of standard and MI approaches.2 Theadvantages of the MI approach include shorter surgery timeand less blood loss; the risk of component malpositioning wasnot enhanced by MI surgery.Penenberg et al. reported that the mean blood loss during MITHR was 200 mL (100–500 mL) and 10% of 250 patients requiredtransfusions.5 Landgraeber et al. compared the conventionallateral approach and posterior MI THA in terms of hemoglobinand hematocrit decreases. The mean preoperative hemoglobinand hematocrit values were 13.93 g/dl (1.34 g/dl) and 13.85%(1.16%), respectively, and the values at 24 h postoperativelywere 11.33 g/dl (1.46 g/dl) and 11.38% (1.48%), respectively;these differences were not significant.3 In our study, decreasesin hemoglobin and hematocrit values were similar to otherstudies. Nevertheless, when the perioperative records wereconsidered, the mean blood loss amount was 266.5 cm3, whichwas lower than expected. There was no requirement for atransfusion in any of our cases.Barrett et al. reported a mean inclination of 42.48 (7.68) and amean anteversion of 25.88 (8.18) for acetabular cups in a studyincluding data on THR using the standard posterolateralapproach. A total of 24 cases (57%) were within Lewinnek'ssafe zone.6 Landgraeber et al. studied anterior MI THR cases andreported mean acetabular cup inclination and anteversionangles of 42.188 (5.048) and 19.718 (6.158), respectively.3 Rogerand Hill reported mean acetabular cup inclination and ante-version angles of 418 (21.498) and 218 (15.278), respectively, in135 cases treated via the posterior MI technique.7 In our study,the mean acetabular cup inclination was 45.118 (7.738) and themean acetabular anteversion angle was 7.488 (9.588); 61 of ourcases were within the Lewinnek safe zone. Only one of theremaining 12 cases (outside of the Lewinnek safe zone) had aninstability that required revision. Postoperative hip stabilityafter THR is known to be improved when the short externalrotators are intact.8,9 Although the Lewinnek safe zone hassome objectivity on the evaluation of the component positionsin the THR, our results were suggestive that sparing of the hipexternal rotators has a positive effect on the stability after THR.A commonly used early means of postoperative femoralcomponent evaluation is the sagittal plane position of thefemoral stem. Roger and Hill studied 135 MI posterior THR casesand found five instances of femoral stem varus positioning ofmore than 28, and three cases of such femoral stem valguspositioning.7 Poehling-Monaghan et al. compared 96 cases of MIposterior THR with standard anterolateral THR, and foundfemoral stem varus positioning in one patient and femoral stemvalgus positioning in 15. In the same paper, they also reportedthat of the 126 instances of the standard anterolateral approach,34 had femoral stem varus positioning and three had femoralstem valgus positioning.10 A high-standing greater trochanter isassociated with insufficiency of hip abductors, together with apositive Trendelenburg sign and limping.11 The level of thegreater trochanter can be objectively determined by measuringthe MPFA, i.e. the angle between the trochanter head line and theanatomical axis of the femur, which is normally 848 (808–898).12Femoral stem height, or varus or valgus, changes the angle(Fig. 2). Therefore, we evaluated the femoral stem position usingthe MPFA. The mean MPFA was 88.12 (7.638), which was withinthe normal limits. Although the long-term effects of MPFAvariations remain unclear, our results suggest that a THR with aj o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a u m a 7 s ( 2 0 1 6 ) 2 1 0 – 2 1 4214normal MPFA is associated with a stable hip joint and a morephysiological gait.The HHS of patients with coxarthrosis increased significant-ly after THR. Many reports have shown that scores after MI THRare as good as those obtained using standard approaches.3,7,10Similarly, we observed significant ameliorations in 3-monthHHS scores after THR compared to preoperative scores.We observed 1 proximal femoral fracture, which wasdiagnosed postoperatively. Poor visualization of the proximalfemur can be a disadvantage for perioperative diagnosis ofnondisplaced proximal femoral fractures occurring duringposterolateral MI THR.This study has some limitations. Although our case numberswere adequate to draw robustness, it is always possible to derivemore accurate results with larger series. Our follow-up periodwas less than 2 years, and therefore the long-term results ofposterolateral MI THR remain unknown. All surgeries wereperformed by a single surgeon and it is therefore unclearwhether other surgeons would obtain similar results. Weperformed the MITHR without any tenotomy to the shortexternal rotator muscles. At the end of the componentplacement, the gross appearances of these muscles were intact.The limitation here is we could not objectively detect thedamage on the short external rotators due to retraction.MI posterior approach for THR is a method in which theprosthetic components can be properly placed. The earlypostoperative instability rate is low and the functionaloutcomes are favorable. Although this study gives the short-term results, the high rate of the proper component position-ing gives an idea on the long-term survival rates of the THR.Posterolateral MI approaches are safe when THR is performed,and afford satisfactory results.Conflicts of interestThe authors have none to declare.r e f e r e n c e s1. Oinuma K, Eingartner C, Saito Y, Shiratsuchi H. Total hiparthroplasty by a minimally invasive, direct anteriorapproach. Oper Orthop Traumatol. 2007;19:310–326.2. Xu CP, Li X, Song JQ, Cui Z, Yu B. Mini-incision versusstandard incision total hip arthroplasty regarding surgicaloutcomes: a systematic review and meta-analysis ofrandomized controlled trials. PLOS ONE. 2013;8:e80021.3. Landgraeber S, Quitmann H, Guth S, et al. A prospectiverandomized peri- and post-operative comparison of theminimally invasive anterolateral approach versus the lateralapproach. Orthop Rev. 2013;5:e19.4. Pradhan R. Planar anteversion of the acetabular cup asdetermined from plain anteroposterior radiographs. J Bone JtSurg Br. 1999;81:431–435.5. Penenberg BL, Bolling WS, Riley M. Percutaneously assistedtotal hip arthroplasty (PATH): a preliminary report. J Bone JtSurg Am. 2008;90(suppl 4):209–220.6. Barrett WP, Turner SE, Leopold JP. Prospective randomizedstudy of direct anterior vs postero-lateral approach for totalhip arthroplasty. J Arthroplasty. 2013;28:1634–1638.7. Roger DJ, Hill D. Minimally invasive total hip arthroplastyusing a transpiriformis approach: a preliminary report. ClinOrthop Relat Res. 2012;470:2227–2234.8. Hedley AK, Hendren DH, Mead LP. A posterior approach tothe hip joint with complete posterior capsular and muscularrepair. J Arthroplasty. (5 suppl):1990;(5 suppl):S57–S66.9. Kao JT, Woolson ST. Piriformis tendon repair failure aftertotal hip replacement. Orthop Rev. 1992;21:171–174.10. Poehling-Monaghan KL, Kamath AF, Taunton MJ, PagnanoMW. Direct anterior versus miniposterior THA with thesame advanced perioperative protocols: surprising earlyclinical results. Clin Orthop Relat Res. 2014.11. Hasler CC, Morscher EW. Femoral neck lengtheningosteotomy after growth disturbance of the proximal femur.J Pediatr Orthop B. 1999;8:271–275.12. Paley D. Principles of Deformity Correction. New York: Springer-Verlag Berlin Heidelberg; 2002.

Early clinical and radiological results of minimally invasive total hip replacement

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Early clinical and radiological results of minimally invasive total hip replacement

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