Minimally invasive total hip arthroplasty with the anterior approach using the orthopaedic table

Nội dung text: Minimally invasive total hip arthroplasty with the anterior approach using the orthopaedic table

1. JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 MINIMALLY INVASIVE TOTAL HIP ARTHROPLASTY WITH THE ANTERIOR APPROACH USING THE ORTHOPAEDIC TABLE Ho Man Truong Phu*; Nguyen Tien Binh**; Pham Dang Ninh*** SUMMARY Objectives: To describe a minimally invasive technique of anterior total hip arthroplasty with the outcomes and complications. Subjects and methods: We studied data on 69 patients (76 hips) who underwent anterior total hip arthroplasty with uncemented components using modified fracture table at Hue Central Hospital from 2010 - 2016. The operative parameters, complications, radiographic imaging (with TraumaCad software) were assessed. Functional outcomes were measured using the Harris hip score. Results: The mean age of patients was 51.67 ± 11.35 years (range 23 - 74), mean blood loss was 406.1 ± 155.5 mL (range 65 - 630) and the mean incision length was 8.1 ± 0.7 cm (range 7 - 10 cm). The postoperative radiographic outcomes showed an average acetabular abduction was 44.9 ± 7.50 (range 30 - 650), cup anteversion was 14.8 ± 5.20 (range 4 - 280). The mean Harris hip score 90.8 ± 3.6 (range 83 - 96). Especially, no complications on orthopedic surgical table using have been reported. Conclusions: The anterior approach on the orthopaedic table performed by experienced surgeons is a minimally invasive technique applicable to all primary hip patients. This technique allows accurate and reproducible component positioning and does not increase the rate of hip dislocation. Therefore we state that the minimal invasive anterior approach is safe and lead to advantages for the patients and using of the orthopaedic table improves femoral access. * Keywords: Total hip arthroplasty; Anterior approach; Minimal invasive. INTRODUCTION allowing faster patient recovery to ambulation, In the past decades, the mini-invasive normal abductor strength and decreased anterior approach to the hip for total hip dislocation rate. This approach provides a arthroplasty has become more popular and is direct view of the acetabulum with visualization of greast interest to surgeons and patients, of the anterior iliac spine landmarks to allow with the goal of improving early recovery reference for appropriate cup positioning. parameters [1]. It utilizes anterior internervous However, the femur canal preparation and intermuscular plane, and is described and component placement is considered as a modified Hueter approach, as utilized to be difficult with this approach. Attempts by Judet and Judet in 1950 [2, 3]. Due to to retract the proximal femur anteriorly the intermuscular nature, it is regarded as has been reported to contribute to proximal * Hue Central Hospital ** Vietnam Military Medical University *** 103 Military Hospital Corresponding author: Ho Man Truong Phu (bsnttrphu@yahoo.com) Date received: 30/09/2017 Date accepted: 23/11/2017 188
2. JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 femur and femoral shaft fractures. This has into hyperextension. The surgical table also necessitated dissection of muscle from requires a perineal post be used to the proximal femur as well compromising stabilize the patient and act as a counter the intermuscular nature of the approach. point for gentle traction of the operative limb (figure 2). The advantage of the modified orthopaedic table allows positioning assistance of * Surgical approach: A straight incision is made on the anterior-lateral thigh, the femur to permit adequate exposure beginning 2 cm distal and lateral to the of the femur which allows accurate femur anterior superior iliac spine (ASIS) and component positioning as well [4, 5]. The ending 2 cm anterior to the greater trochanter. results have provided a view of this procedure it is possible to perform the procedure as an effective approach by experience consistently with an 7 - 12 cm incision length. surgeons with potential benefit in post- operative recovery and dislocation rates. SUBJECTS AND METHODS We reviewed the technique as performed at Hue Central Hospital with 69 patients (76 hips) who underwent total hip arthroplasty with Zimmer implants through an anterior mini-invasive approach between 2010 and 2016 and outcome data in the using the anterior approach with a fracture table for total hip arthroplasty. The operative Figure 1: Hip joint evaluation pre- parameters, complications, X-ray pre and operation on AP view radiograph. post-operation with TraumaCad software analyze (figure 1) were assessed. The potential proximal femoral exposure on orthopaedic table is based itself on the posterior hip capsule as well as external rotation muscle releasing limitation. Functional outcomes were measured using the Harris hip score. * Patient positioning: The technique described here requires the PROfx (Union City, CA), modified orthopedic table for patient positioning in the supine position that allows for controlled positioning of each lower extremity independently, including Figure 2: Leg position on the full freedom of rotation and movement orthopaedic table. 189
3. JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 * Hip joint exposure: The subcutaneous fat is dissected bluntly until the thin fascia over the tensor fascia lata muscle is seen. Blunt dissection will minimize the risk of injury to the lateral femoral cutaneous nerve which is always at risk during anterior approaches to the hip joint. The interval between the tensor and the rectus femoris should be identified and developed distally; this step is especially necessary in heavier individuals. Figure 3: Acetabular reaming. The anterior hip capsule is opened with two flaps that are retracted by repositioning the Cobra retractors previously placed outside the hip capsule. The femoral head and anterior acetabular wall will come into view. The hip joint is then distracted using gradually applied traction from the table, and a hip skid is used to disrupt the ligamentum teres. The proximal femur head and neck is then resected at the appropriate level according to preoperative planning. The resected femoral Figure 4: Femur rasp. head is removed and measured. With slight external rotation and gentle * Acetabulum preparing: The lateral traction on the femur, acetabular exposure cobra retractor is repositioned inside the is typically excellent; circumferential hip capsule to keep the tensor muscle visualization can help in removing retracted. A Hohmann retractor is placed osteophytes, reaming, and cup placement. on the anterior-inferior acetabular wall. A A manual assessment is done to ensure similar Hohmann is placed on the anterior the anteromedial edge of the cup is acetabulum with the spike of the retractor covered by the anterior medial acetabular resting directly on bone to avoid femoral rim to lessen the likelihood of iliopsoas nerve injury (figure 3). irritation post-operatively. 190
4. JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 * Femur exposure: This is a key concept checking for impingement or subluxation to understand because it will help avoid of the femoral head the pitfalls of inadvertent injury to the * Wound closure: The wound is thoroughly trochanter, ankle, or femur. Safe retraction irrigated and closed in a layered manner. entails adequate mobilization of soft The fascia over the tensor fascia lata is tissues first, followed by placement of a closed over a deep drain. passive retractor. With the femur lifted up and laterally by the surgeon, external rotation of the femoral shaft should be at least 90° (the patella is facing 90° externally rotated) and the leg spar will be placed on the floor to hyperextend 30 - 45°, and adduct the hip 30 - 45° While keeping the proximal femur lifted, preparation of the femoral canal should not commence until the proximal femur is adequately visualized. This requires a release of the thick hip capsule off the greater trochanter from anterior to posterior while protecting the Figure 5: Incision length. abductors with a Hohmann retractor. Additional femoral mobilization can be achieved by sub-periosteal release the short external rotators and the posterior hip capsule. * Stem insertion: Once the proximal femur is adequately exposed, a Hohmann retractor is positioned behind the greater trochanter, protecting the proximal part of the skin incision from femoral broaches. The canal is opened with a curved awl. Rasps and stem inserters are mounted on instruments that are angled to clear the soft tissues proximally (figure 4). Leg lengths Figure 6: Post-operation on AP view X-ray are measured by comparing the positions with software TraumaCad. of the patellae on either leg, with the feet in neutral rotation. Preoperative templating Closure is followed by the subcutaneous and cutting the calcar at the estimated fat layer, and the skin. Length of incision level can also ensure proper leg lengths has been measured with ruler (figure 5). during anterior mini-invasive total hip The patient is allowed to weight-bear as arthoplasty. Hip stability is assessed by tolerated with anterior hip precautions maximally externally rotating the femur and instructed by the physical therapists. 191
5. JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 RESULTD AND DISCUSSION We use this procedure for the primary total hip replacements in our practice, and the results described here pertain to the first 69 patients who underwent this procedure with the mean patient age was 51.67 ± 11.35 years (range 23 - 74); the mean duration of surgery was 115.0 ± 0.2 mins (range 80 - 185 mins); the mean blood loss was 406.1 ± 155.5 mL (range 65 - 630 mL; the mean incision length was 8.1 ± 0.7 cm. The technique allowed accurate and reproducible acetabular component insertion. The mean abduction angle was 44.9 ± 7.50 (range 30 - 650), mean cup ante-version on the true lateral radiograph was 14.8 ± 5.20 (range 4 - 280) and 11/76 (14.4%) femoral stems were of varus, 12/76 (15.8%) were valgus alignment relative to the diaphyseal femoral shaft. Table 1: The potential assistance to permit adequate exposure of the proximal femur with modified orthopaedic table. Osteoarthritis Avascular Femoral neck Injury Level Complication Total (OA) necrosis (AVN) fracture Easy (no posterior hip capsule release) 15 23 9 1 48 Difficult (partial posterior hip capsule release) 5 22 0 0 27 Very difficult (short external roble 1T1tation muscle and 0 1 0 0 1 posterior hip capsule release) Total 20 46 9 1 76 As described by Judet, we do the procedure on an orthopaedic table that allows rotational control of the femur during the procedure and facilitates femoral exposure: with 58/76 (76.3%) cases that were in easy level during femoral exposure when we do changing in three dimensions the foot bar. Kennon report on using the Heuter approach for more than 3,000 THAs done using a standard flat table. They reported that secondary incisions for acetabular and/or femoral preparation are often required, and this technique also involves splitting the medial portion of the tensor fascia lata muscle. In contrast, we have not required a second incision for component placement. We think that the use of the orthopaedic table improves femoral access, decreases the necessity of secondary incisions and reduces muscle trauma that can result from forceful retraction [6]. 192
6. JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 Table 2: Function outcome with HHS improvement. Follow-up 6 months 1 year 2 years 4 years Postoperative 86.7 ± 4.3 89.3 ± 3.8 89.9 ± 3.9 90.1 ± 4.0 Osteoarthritis: 80.2 ± 3.4 (72 - 86) (77 - 93) (81 - 93) (83 - 93) (85 - 96) 87.9 ± 4.1 89.7 ± 5.9 89.5 ± 3.9 91.9 ± 3.2 AVN: 79.63 ± 4.9 (71 - 89) (80 - 93) (59 - 93) (80 - 93) (86 - 96) Femoral neck fracture: 83.1 ± 3.8 87.7 ± 3.1 89.8 ± 3.1 92.8 ± 0.5 87.3 ± 2.9 (76 - 88) (85 - 91) (86 - 93) (92 - 93) (83 - 90) 89.0 ± 0.0 89.0 ± 0.0 (89) - - Complcations: 79.0 ± 0.0 (79) (89) 87.6 ± 4.1 89.6 ± 5.2 89.9 ± 3.8 90.8 ± 3.6 Mean HHS: 80.2 ± 4.4 (71 - 89) (77 - 93) (59 - 93) (80 - 93) (83 - 96) All patients had resumed their usual activities by four weeks after the procedure, and reported satisfaction with the outcome, the mean Harris hip score (HHS) 90.8 ± 3.6, in the range 83 - 96 scores. In complications, we recognized one great trochanter fracture without concerning the manipulation on the orthopaedic table requiring cerclage wiring. One dislocation occurred within 2 months postoperatively with only 4º cup anteversion angle on radiograph. Thigh numbness was presented on objective testing in only three patients and was clinically insignificant at the six-month visit. One superficial infection after one month follow-up and 1 deep joint infection after one year visit. Leg lengths were overall restored with an average leg length discrepancy of 3.75 ± 2.84 mm in this series. No significant heterotopic ossification was recognized in this study. Only 2 cases were Brooker grade 1 ossification. Especially, no complications on orthopaedic table had been reported. CONCLUSION of component positioning, facilitates to The mini-invasive anterior approach for permit adequate exposure of the proximal total hip replacement has gained popularity femur. As with all techniques, the skill and recently. The results also showed that is an experience of the surgeon are critical to effective and safe technique which provides the success of the procedure. The surgeon small incision, less muscle damage, early had also undergone cadaver training and postoperative function and reduces the fellowship with an experienced mentor risk of complications. The use of a modified before attempting the first mini-invasive orthopaedic table performed by experienced surgery of total hip arthroplasty using an surgeons allows for real time assessment orthopedic table. 193
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