Minimally invasive total hip arthroplasty with the anterior approach

Abstract

Background: Total hip athroplasty with the anterior surgical approach is advised because the dissection is entirely within intermuscular planes. In this report we describe a minimally invasive technique of anterior total hip arthroplasty, with the early outcomes.

Materials and methods: The technique of minimally invasive total hip arthroplasty with anterior approach (Smith-Petersen) is described. We reviewed data on 100 consecutive patients who underwent anterior total hip arthroplasty with uncemented components. Mean patient age was 61 years (range 33-91). Mean patience BMI 29.8 (range 18.1-51.8).

Results: Minimum follow up duration is 10 months. The mean duration of surgery was 53 min (range 34-87) with mean blood loss 185 cc (range 65-630), and the mean incision length was 10.4 cm. Clinical and radiographic outcomes were similar to historical outcomes of standard total hip arthroplasty.

Conclusions: With proper surgeon training, minimally invasive total hip replacement with the anterior surgical interval is safe and efficacious.

Keywords: Anterior approach of hip; Total hip arthroplasty; minimally invasive surgery.

Conflict of interest statement

Conflict of Interest: None.

Figures

Figure 1

(a) Leg positioning on the HANA orthopedic table is shown, with a fracture drape covering the operative left leg. (b) A right hip is shown draped, with the abdominal drape over the plastic fracture drape, and the hook spar exiting the drapes through a hole. (c) A right hip incision is shown, with teh fascia over the tensor split

Figure 2

In the left hip shown (a), the tensor is retracted laterally, and the rectus femoris muscle is retracted medially. A cobra retracts the tensor laterally (b), and a Hohman retractor retracts the psoas/rectus femoris medially, exposing the hip capsule. The second sharp Hohman is on the anterior acetabular wall

Figure 3

Femoral head exposure (a) after anterior capsulotomy. A corkscrew (b) is placed in the head after maximum external rotation, to facilitate anterior dislocation of the femoral head

Figure 4

The femoral head is dislocated anteriorly (a) by using a skid in the hip joint, anterior traction on the corkscrew handle, and gentle external rotation of the leg. Removing a few millimeters of the anterior acetabular wall will facilitate this step. With the head anteriorly dislocated, the lesser trochanter and calcar are exposed by subperiosteal elevation of the medial hip capsule (b). The proposed calcar cut has been marked with a pen, in relationship to the lesser trochanter. The corkscrew has been removed to make the calcar cut. The femoral head is removed (c) by cutting the calcar first and then making the lateral cut, thereby avoiding inadvertent injury to the greater trochanter. Another option is to remove a segment of the femoral neck in situ, followed by extraction of the head

Figure 5

Excellent acetabular exposure (a) is possible with the anterior surgical approach to the left hip joint shown. Reaming (b) is done under direct vision, and X-ray control is not mandatory. Care should be taken to avoid levering the reamer handle on the tissues in the distal part of the incision

Figure 6

The acetabular shell placement is shown (a). Bearing insertion is easy, since adequate exposure is possible with the anterior approach. The surgeon's hand lifts up the femur as the leg is externally rotated to ensure that the proximal femur is not caught behind the acetabulum (b). One sharp Hohman is placed around the calcar, and the other is between the thick capsule at the top of the trochanter and the abductor muscles

Figure 7

The curved awl is used to open the proximal femur under direct vision (a). A Hohman retractor protects the proximal incision. Rasping of the canal (b) is done under direct vision, with specially angled inserter handles

Figure 8

A ML taper stem (Zimmer) has been impacted in place (a) using an angled inserter handle. Since the calcar is visible, the danger of unrecognized proximal femur fracture is decreased. A trial head is assembled on the stem (b). Alternatively, the broach could have been left in place, thereby allowing trial reductions using various neck lengths and offset options

Figure 9

After final reduction, hip stability is assessed in maximal external rotation (a), and leg lengths can be confirmed. The approach is anatomically correct in that the overlying muscles fall in place and close the wound spontaneously as shown in this left hip (b). The fascia over the tensor is then reapproximated

Figure 10

A typical incision on the left hip is shown following staple closure. An incision length of 8-15 cm is sufficient for all primary total hip replacements using the approach described