Boris Michael Holzapfel1, Kristoff Corten2, Tyler Goldberg3, Maximilian Rudert4, Michael Nogler5, Joseph Moskal6, Martin Thaler7,8. 1. Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany. boris.holzapfel@med.uni-muenchen.de. 2. Hip Unit, Orthopedic Department, Ziekenhuis Ooost-Limburg Genk, Schiepse Bos 6, 3600, Genk, Belgium. 3. 4700 Seton Center Parkway, Texas Orthopedics, LLC, 78759, Austin, TX, USA. 4. Department of Orthopedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany. 5. Department of Experimental Orthopedics, Department of Orthopedics and Traumatology, Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria. 6. Department of Orthopedic Surgery, Virginia Tech Carilion School of Medicine, Institute for Orthopedics and Neuroscience, 2331 Franklin Rd, 24014, SW, Roanoke, VA, USA. 7. Arthroplasty Center, Helios Klinikum Munich West, Steinerweg 5, 81241, Munich, Germany. 8. Center of Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University of Greifswald, Greifswald, Germany.
Abstract
OBJECTIVE: Acetabular revision arthroplasty and osseous defect management through the direct anterior approach (DAA) with or without proximal extension. INDICATIONS: Aseptic or septic component loosening, periacetabular osseous defects, pelvic discontinuity, intrapelvic cup protrusion, anterior pseudotumors, iliopsoas tendonitis, polyethylene wear or iliopsoas abscess. CONTRAINDICATIONS: Clinically relevant gluteal tendon lesions, active infection, morbid obesity, large abdominal pannus, ASA (American Society of Anesthesiologists) score > III, inguinal skin infection. SURGICAL TECHNIQUE: Electrocautery dissection is recommended to dissect the Hueter interval and to debulk pericapsular scar tissue. At all times during capsular debulking, it should be made sure not to damage the iliopsoas tendon or the neurovascular bundle. A stepwise releasing sequence can facilitate dislocation of the prosthesis. Most cases can be revised via the standard DAA but certain circumstances require an intra- or extrapelvic extension. Access to the anterior gluteal surface of the ilium can be provided using a "tensor snip". More posterior access is provided by the extensile extrapelvic approach described by Smith-Petersen. The intrapelvic Levine extension offers access to the entire visceral surface of the ilium and large parts of the anterior column. POSTOPERATIVE MANAGEMENT: Patient revised via the intra- or extrapelvic extension and patients suffering from extensive soft tissue or osseous defects should undergo postoperative weight-bearing restrictions with 20 kg for 6 weeks. RESULTS: Based on our studies, there is no limitation on the type of acetabular implant that can be used in DAA revision arthroplasty. Moreover, virtually all types of periacetabular osseous defects can be managed through the approach and its extensions. Acetabular revision arthroplasty via the DAA and its extensions is safe and can result in good midterm results.
OBJECTIVE: Acetabular revision arthroplasty and osseous defect management through the direct anterior approach (DAA) with or without proximal extension. INDICATIONS: Aseptic or septic component loosening, periacetabular osseous defects, pelvic discontinuity, intrapelvic cup protrusion, anterior pseudotumors, iliopsoas tendonitis, polyethylene wear or iliopsoas abscess. CONTRAINDICATIONS: Clinically relevant gluteal tendon lesions, active infection, morbid obesity, large abdominal pannus, ASA (American Society of Anesthesiologists) score > III, inguinal skin infection. SURGICAL TECHNIQUE: Electrocautery dissection is recommended to dissect the Hueter interval and to debulk pericapsular scar tissue. At all times during capsular debulking, it should be made sure not to damage the iliopsoas tendon or the neurovascular bundle. A stepwise releasing sequence can facilitate dislocation of the prosthesis. Most cases can be revised via the standard DAA but certain circumstances require an intra- or extrapelvic extension. Access to the anterior gluteal surface of the ilium can be provided using a "tensor snip". More posterior access is provided by the extensile extrapelvic approach described by Smith-Petersen. The intrapelvic Levine extension offers access to the entire visceral surface of the ilium and large parts of the anterior column. POSTOPERATIVE MANAGEMENT: Patient revised via the intra- or extrapelvic extension and patients suffering from extensive soft tissue or osseous defects should undergo postoperative weight-bearing restrictions with 20 kg for 6 weeks. RESULTS: Based on our studies, there is no limitation on the type of acetabular implant that can be used in DAA revision arthroplasty. Moreover, virtually all types of periacetabular osseous defects can be managed through the approach and its extensions. Acetabular revision arthroplasty via the DAA and its extensions is safe and can result in good midterm results.
Authors: Karl Grob; Rebecca Monahan; Helen Gilbey; Francis Yap; Luis Filgueira; Markus Kuster Journal: J Bone Joint Surg Am Date: 2015-01-21 Impact factor: 5.284