The Röttinger approach for total hip arthroplasty: technique, comparison to the direct lateral approach and review of literature.

BACKGROUND: Multiple approaches to the hip joint have been developed utilizing various intervals and/or intermuscular planes when performing a total hip arthroplasty (THA), each proposing certain advantages. Of these, the Röttinger approach (modified anterolateral or Watson-Jones) is potentially muscle-sparing. Multiple studies have demonstrated favorable outcomes with this approach. However, others showed more complications with a slow learning curve. Due to the paucity of evidence we conducted this study to: (I) present our operative experience and technique of the Röttinger approach; (II) compare short-term complications and operative room (OR) times of this approach to the direct lateral; and (III) review the available literature.
METHODS: This was a review of a longitudinally maintained single-surgeon database of patients who underwent primary THA using either the Röttinger or direct lateral approach. A total of 100 consecutive patients (100 hips) who underwent primary unilateral THA using the Röttinger approach between April 1st, 2012 and April 30th, 2015 were identified. These patients were compared to another cohort of 147 consecutive patients (147 hips) who underwent the procedure using the direct lateral approach (of Hardinge). The operative technique for the Röttinger approach involves accessing the hip joint through muscle-sparing technique between the tensor fascia lata and gluteus medius muscles. We evaluated and compared the short-term complications and the mean operative times for each cohort. In addition, we performed a literature search on the clinical studies that reported on the Röttinger approach using the following databases; PubMed, EMBASE, EBSCO Host, and SCOPUS. Studies published between January 1st of 2000 and September 1st of 2017 were reviewed. We included only studies that compared this approach to other standard approaches and excluded single-cohort case series, case reports, cadaveric studies, and studies not in English language.
RESULTS: At mean follow-up time of 12 weeks (range, 6 to 24 weeks), there were two patients in the Röttinger cohort who experienced lateral femoral cutaneous nerve palsies (2%), which were self-limited and resolved at 6 and 12 weeks. In the direct lateral cohort, there was one hip dislocation (2%) at 6 weeks post-operatively, which was successfully managed by a closed reduction. In patients who received the Röttinger approach, mean OR time was 130 minutes (range, 74 to 202 minutes), compared to the direct lateral cohort mean of 111 minutes (range, 71 to 222 minutes). Our literature analysis covered 2,252 patients who received the Röttinger approach vs. 19,941 patients who underwent variety of other standard approaches including anterior, direct lateral, and posterior. At final follow up (range, 6 to 52 months), patients who underwent the Röttinger approach demonstrated comparable clinical outcomes and complications to patients who underwent primary THA using other approaches.
CONCLUSIONS: In this analysis of a single-surgeon experience of the Röttinger approach compared to the direct lateral, we presented our experience with the technique and demonstrated the safety and feasibility of this relatively novel approach. Our study results demonstrated that patients who underwent this approach had similar short-term complications and OR times to those who underwent the direct lateral approach. Additionally, our findings agree with previous comparative studies that demonstrated similar outcomes of this approach. Therefore, it can be used as an alternative for primary THA.