Boris Michael Holzapfel1, Dominik Rak2, Stefan Kreuzer3, Joerg Arnholdt2, Martin Thaler4, Maximilian Rudert2. 1. Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany. boris.holzapfel@med.uni-muenchen.de. 2. Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany. 3. Memorial Bone & Joint Clinic, The University of Texas Health Science Center at Houston Medical School, 1140 Business Center Drive, Suite 101, 77043, Houston, TX, USA. 4. Department of Orthopaedic and Trauma Surgery, Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria.
Abstract
OBJECTIVE: Tissue-sparing, minimally invasive hip arthroplasty via the direct anterior approach (DAA) using a partially neck-preserving, calcar-guided short stem. INDICATIONS: Primary and secondary osteoarthritis of the hip due to developmental dysplasia, femoroacetabular impingement, femoral head necrosis or trauma sequelae. CONTRAINDICATIONS: Severe osteoporosis, active infection, American Society of Anesthesiologists (ASA) > III, large metaphyseal bone defects, severe metaphyseal deformities, Dorr type C femur. SURGICAL TECHNIQUE: Supine position on a standard operating table without extension device. Classic DAA skin incision or bikini incision distal to the inguinal fold. Blunt dissection entering the Hueter interval. Capsulotomy with capsule preservation or partial capsulectomy. Intraoperatively, it is crucial to adhere to the preoperatively planned angle and height of the femoral neck osteotomy. During femoral head removal and acetabular preparation, care must be taken to avoid iatrogenic damage to the remaining neck. After cup positioning, femoral access is achieved by release of superior capsular structures. During opening of the medullary canal and broaching, femoral torsion and axis have to be taken into account for correct rotational and axial alignment. Femoral broaches are inserted in an ascending series of sizes until the last broach is firmly lodged and is in direct contact with the antero-medial femoral neck cortex. Fluoroscopic control in two planes to check for femoral anatomic and overall offset and assess whether the implant is adequately seated with cortical support at the calcar, the distal lateral and the dorsal cortex. Implantation of the definitive implants, local infiltration analgesia and wound closure. RESULTS: Between 1/2011 and 12/2016 60 patients (24 female, 36 male; mean age 44 years) were treated with a partially neck-preserving short stem via the described approach. Seven patients underwent a bi-lateral procedure. Thus, 67 procedures were analysed in this retrospective cohort study. Mean follow-up was 70 months (range 28-93). The median Harris Hip Score was 48 (range 11-88) preoperatively and 98 (range 80-100) postoperatively. CONCLUSION: The minimally invasive implantation of a partially neck-preserving stem via DAA provides a safe technique with good to excellent clinical results in the mid-term.
OBJECTIVE: Tissue-sparing, minimally invasive hip arthroplasty via the direct anterior approach (DAA) using a partially neck-preserving, calcar-guided short stem. INDICATIONS: Primary and secondary osteoarthritis of the hip due to developmental dysplasia, femoroacetabular impingement, femoral head necrosis or trauma sequelae. CONTRAINDICATIONS: Severe osteoporosis, active infection, American Society of Anesthesiologists (ASA) > III, large metaphyseal bone defects, severe metaphyseal deformities, Dorr type C femur. SURGICAL TECHNIQUE: Supine position on a standard operating table without extension device. Classic DAA skin incision or bikini incision distal to the inguinal fold. Blunt dissection entering the Hueter interval. Capsulotomy with capsule preservation or partial capsulectomy. Intraoperatively, it is crucial to adhere to the preoperatively planned angle and height of the femoral neck osteotomy. During femoral head removal and acetabular preparation, care must be taken to avoid iatrogenic damage to the remaining neck. After cup positioning, femoral access is achieved by release of superior capsular structures. During opening of the medullary canal and broaching, femoral torsion and axis have to be taken into account for correct rotational and axial alignment. Femoral broaches are inserted in an ascending series of sizes until the last broach is firmly lodged and is in direct contact with the antero-medial femoral neck cortex. Fluoroscopic control in two planes to check for femoral anatomic and overall offset and assess whether the implant is adequately seated with cortical support at the calcar, the distal lateral and the dorsal cortex. Implantation of the definitive implants, local infiltration analgesia and wound closure. RESULTS: Between 1/2011 and 12/2016 60 patients (24 female, 36 male; mean age 44 years) were treated with a partially neck-preserving short stem via the described approach. Seven patients underwent a bi-lateral procedure. Thus, 67 procedures were analysed in this retrospective cohort study. Mean follow-up was 70 months (range 28-93). The median Harris Hip Score was 48 (range 11-88) preoperatively and 98 (range 80-100) postoperatively. CONCLUSION: The minimally invasive implantation of a partially neck-preserving stem via DAA provides a safe technique with good to excellent clinical results in the mid-term.