[The minimally invasive anterior approach to hip arthroplasty]. / Der minimal-invasive vordere Zugang in der Hüftendoprothetik.

A modified anterior approach to the hip developed by the senior author has been utilized in performing over 7000 hip replacement operations at this joint replacement center in the past three decades. It can be readily applied to both primary and revision surgery, and involves muscle splitting and sparing of the major hip muscles, innervation, and function. Since the late 1970s, Yale orthopaedic residents have been taught this minimally invasive anterior approach using one, two, or three mini-incisions without fluoroscopy, special operating room tables, or special retractors. The authors' overall experience has documented a very low incidence of dislocation and minimal perioperative complications. While a smaller skin incision is desirable by patients for cosmetic reasons and decreased healing time, what goes on beneath the skin is far more important. A well-placed total hip replacement should never be compromised. While many of these patients can ambulate the same or first postoperative day quite well, the authors do not advocate outpatient total hip arthroplasty as some proponents have. Bone is still cut, tissues bleed, clots can form, and the traditional complications of arthroplasty, while reduced, can still occur.

Superior mesenteric vein tear with total hip arthroplasty.

Total hip arthroplasty imparts significant physical forces on the patient at the time of surgery. We report a case of an injury to the superior mesenteric vein that is thought to have occurred at the time of impaction of the acetabular component of a total hip arthroplasty. This complication has been reported previously only from high-energy nonpenetrating trauma, such as motor vehicle accidents.

Total hip replacements done without cement after acetabular fractures: a 4- to 8-year follow-up study.

Twenty-one patients (21 hips) underwent cementless total hip replacement surgeries for previous acetabular fractures. The mean age at the time of hip replacement was 52 years (range, 23-78 years). The mean follow-up was 65 months (range, 48-104 months). One hip required revision of the stem secondary to a periprosthetic femur fracture from a fall at 3 months after surgery. Good to excellent clinical rating was achieved and maintained in 19 hips. Radiographic evaluation demonstrated stable cup and stem fixation in 17 and 15 hips. Only 1 patient with radiographic loosening of the components was sufficiently symptomatic. The results in this series appeared slightly better than those reported previously in hip replacements done with cement at comparable medium-term follow-up. The mechanical failure rates remained high in this patient population: 19% for the cups and 29% for the stems.

A comparison of the cost effectiveness of one-stage versus two-stage bilateral total hip replacement.

Forty patients underwent 80 bilateral primary total hip replacements (THRs) under the same anesthesia (one-stage). Forty other patients who underwent unilateral primary THRs during the same time interval were selected to match the first 40 patients with regard to age, sex, diagnosis, weight, medical comorbidity, type of prosthesis used, and perioperative management protocol. An assumption was made in that each unilateral case represented the first side of bilateral THRs performed during two separate hospitalizations (two-stage). Analysis of the total hospital charges submitted to the insurance companies was made between the groups. On average, there was a 24% reduction (P<.05) for each case if bilateral THRs were done in one stage. This was primarily due to a significant decrease (P<.05) in the length of hospital stay in the one-stage group. There was no difference between the two groups in the operative time, estimated blood loss, or perioperative complications.

Cementless total hip replacement in patients with developmental dysplasia of the hip.

This study was conducted to evaluate the clinical and radiographic results of 22 total hip replacements done in 17 consecutive patients for coxarthrosis due to developmental dysplasia or dislocation of the hip. All operations were done using an anterior approach without trochanteric osteotomy. Standard cementless prostheses were used in all cases. There was no custom-designed prosthesis used. The acetabular cup was placed in an anatomic position in the true acetabulum in every case. Bulk autograft was necessary to reconstruct the deficient acetabular roof in only 2 hips. The average follow-up was 63 months (range, 40 months to 95 months). The average Harris Hip Score was improved from a preoperative value of 35 (range, 24 to 46), to 96 (range, 79 to 100) at final follow-up. To date, no revision has been done. Three hips showed radiographic evidence suggestive of aseptic loosening (2 stems and 1 cup), but the clinical results remain satisfactory. There is no incidence of dislocation, sciatic nerve palsy, or infection.

Total hip arthroplasty performed without cement in patients with femoral head osteonecrosis who are less than 50 years old.

Seventy-two cementless total hip arthroplasties were performed by a single surgeon in 58 patients with the diagnosis of femoral head osteonecrosis. All patients were less than 50 years old (mean, 37 years). The mean follow-up was 84 months with a minimum of 48 months. Good-to-excellent results were maintained at final follow-up in 94% of the hips. Revision rate was 1.5% each for the cups and the stems. Mechanical failure rate was 7.6% for the cups, and 6% for the stems. If the results were analyzed excluding the data from the group of patients who received the Mittelmeier prostheses, the mechanical failure rates for the cups was 0% and for the stems was 4.2%. The probability of survival for the entire series using revision as the endpoint was 96.9% at 11 years. Survival probability decreased to 88.5% if radiographic failures were included. Excluding the Mittelmeier prostheses, survival probability was estimated to be 100% for the cups using both revision and radiographic failures as endpoints; for the stems, the survival probability was 98.0% using revision as the endpoint and 95.8% including radiographic failures. Femoral osteolysis was observed in 1.5% of the hips. No hip had acetabular osteolysis. No measurements of polyethylene wear were attempted in this study. These results appeared superior to total hip arthroplasties done with early cementing techniques in this population of young patients with femoral head osteonecrosis.

Unsatisfactory results of a first-generation modular femoral stem implanted without cement. A 4- to 9-year follow-up study.

Eighty primary total hip arthroplasties were performed using a first-generation modular femoral stem inserted without cement. Modular distal sleeves made of methacrylate were used in 33% of the hips. Dorr type B or C femoral geometry was present in 80% of the cases. The mean follow-up period was 81 months with a minimum of 48 months. Satisfactory clinical results were observed in 74% of the hips at the final follow-up visit. Revision of the stem had been performed in 14% of the hips, all for aseptic loosening. The overall mechanical failure rate was 48%. Canal fill by the stem was not any better with the sleeves than without. The incidence of failure, however, was less in those hips in which sleeves were used. Femoral osteolysis was present in 19% of the hips. The experience with this particular stem design has been disappointing.

Total hip replacements using the ceramic Mittelmeier prosthesis.

One hundred twelve consecutive primary total hip replacements were performed for osteoarthritis or osteonecrosis by a single surgeon using the Mittelmeier ceramic prosthesis without cement between January 1983 and July 1984. Ninety-three of these hips were followed prospectively to a minimum of 60 months and a median of 108 months. Five (5.4%) hips have been revised for loosening. Of the remaining hips, 77 (87.5%) were rated clinically satisfactory. Cumulative survival probability using revision as endpoint was estimated to be 92.7% at 5 years and 87.9% at 10 years. However, overall mechanical failure rates were 21.5% for the cup and 22.6% for the stem. There was no case of either femoral or acetabular osteolysis observed.

Cementless total hip arthroplasties using ceramic-on-ceramic articulation in young patients. A minimum 5-year follow-up study.

Cementless total hip arthroplasties were performed in 25 consecutive young patients (27 hips), with a mean age of 36.5 years, using prostheses that offered ceramic-on-ceramic articulation. The median follow-up period was 75 months, with all hips being followed a minimum of 5 years. Revision surgery was necessary in one hip at 60 months for fracture of the cup. Ninety-six percent of the remaining hips were rated good or excellent clinically using the Harris hip scale. Radiographic loosening of one or both components was evident in 3 hips. There was no incidence of femoral or acetabular osteolysis observed at follow-up periods of 5 to 8 years.

Total hip arthroplasty using the Zweymuller stem implanted without cement. A prospective study of consecutive patients with minimum 3-year follow-up period.

A prospective study was undertaken over a 2-year period to evaluate the clinical efficacy of using the Zweymuller femoral component (Allopro, Berne, Switzerland) in cementless total hip arthroplasty. Forty consecutive patients (46 hips) were included for final evaluation. Ninety-four percent of the femurs were classified as Dorr class B or C before surgery. The mean follow-up period was 50 months (median, 48 months). Ninety-eight percent of the hips were rated good or excellent clinically. No stem was classified as definitely loose. No hip has required any reoperation. There was no incidence of femoral or acetabular osteolysis up to 6 years.

Unwashed wound drainage blood. What are we giving our patients?

Wound drainage blood was collected after total joint arthroplasty was completed in 13 consecutive patients. Peripheral blood samples were collected in the recovery room and at 6 hours postoperatively for all 13 patients. A standard enzyme-linked immunosorbency assay was done to quantify tumor necrosis factor-alpha, interleukin-1 alpha, interleukin-6, and interleukin-8 levels in the samples. At 6 hours postoperatively, the levels of cytokines were elevated significantly in the peripheral and drainage blood serum. In particular, the drainage blood serum had the most dramatic increase for all cytokines, which was significant. Reinfusion of unwashed filtered postoperative wound drainage blood has been shown not to be entirely benign; pyrogenic transfusion reaction is the most commonly reported adverse effect, but hemodynamic instability with hypotension and even myocardial infarction have been reported. The cause of these adverse events has not been defined clearly, but may be secondary to the infusion of cytokines. The present study showed the presence and significant elevation of the cytokine levels in the wound drainage blood. A comprehensive review of the literature revealed that unwashed drainage blood is a relatively dilute blood product lacking normal clotting factors and having numerous other undesirable components that may mitigate against its routine use in lieu of predeposited autologous or homologous blood. This is of interest because there is evidence indicating that wound drainage blood reinfusion may be unnecessary in total joint arthroplasty when autologous blood is available. Use of drains in this surgery also may be unnecessary and has been shown to increase the amount of blood loss and the need for transfusion.

Oblique femoral osteotomy in cementless total hip arthroplasty. Prospective consecutive series with a 3-year minimum follow-up period.

Success of total hip arthroplasty using cementless implants is dependent on intimate contact of the prostheses with viable host-bone and achievement of optimal fit and rigid implant fixation. A technique of oblique femoral osteotomy has been used to correct proximal femoral deformity and to facilitate difficult revision surgery in selected cases. This prospective study included 26 osteotomies performed in 25 consecutive patients with a minimum follow-up period of 3 years. The median follow-up period was 50 months. Eighty-four percent of the reconstructions remained in situ at the final follow-up examination, with 81% of them rated clinically excellent or good. Three stems were revised for aseptic loosening at a mean interval of 46 months. One additional femoral revision was necessary for nonunion of the osteotomy. Two of the remaining stems were classified as radiographically loose. Although oblique femoral osteotomy serves as a useful adjunct surgical technique in difficult femoral reconstructions, nearly 25% of the hips in this study either failed or were loose at the medium-term follow-up examination. Long-term success of this technique with cementless prostheses remains to be defined.

Effect of preoperative autologous blood donation and intraoperative and postoperative blood recovery on homologous blood transfusion requirement in cementless total hip replacement operation.

BACKGROUND: Blood transfusion is often necessary in operations for total hip replacement (THR). This study was done to investigate the efficacy of three different methods of autologous blood conservation and transfusion in patients undergoing primary THR without cement. STUDY DESIGN: One hundred fifty-five patients with osteoarthritis underwent unilateral cementless THR using normotensive general anesthesia performed by a single surgeon. The patients were divided into four groups depending on which conservation method was used. Ten different demographic and hematologic parameters were recorded and analyzed by using analysis of the variance and multiple regression methods. RESULTS: All three methods were effective in reducing the need for homologous blood transfusions. The greatest benefit was realized when both preoperative autologous blood donation and intraoperative salvage using the Cell Saver were combined. The addition of postoperative salvage and retransfusion of wound drainage blood using the Solcotrans System did not significantly reduce further the chance of homologous blood transfusions. CONCLUSIONS: The data from this study were similar to previously published reports. Regression analysis confirmed the correlation among the different variables studied. We currently offer preoperative donation and intraoperative salvage with the Cell Saver to patients undergoing cementless total hip replacement.

Anterior approach to total hip replacement: surgical technique and clinical results of our first one thousand cases using non-cemented prostheses.

Total hip replacement has evolved into one of the most frequently performed reconstructive procedures in orthopaedic surgery today. A modified anterior approach developed by the senior surgeon has been utilized in performing over 3,000 operations in the past two decades. It is a unique and facile exposure. It can be easily applied to primary and revision surgery. Noncemented prostheses have been used in over 1,000 of these operations. This article details the surgical exposure, acetabular and femoral preparation for both non-cemented and cemented prostheses, special considerations for revision surgery, and the clinical results of the experience with noncemented prostheses to date.

Primary ceramic hip replacement: a prospective study of 119 hips.

A prospective study of 119 consecutive primary ceramic total hip arthroplasties (Autophor, Smith & Nephew) was performed. Follow up was 100% at a minimum of 3 years. Six hips were revised during the course of the study (5%). Harris hip scores were 29.0 preoperatively, 78.7 at 6 weeks, and 92.6 at 3.4 years (range: 62 to 100). Ninety-one percent of the 107 surviving hips at follow up had a good or excellent hip score. The clinical results matched those of Mittelmeier. Thigh pain was a frequent finding, but rarely presented a clinical problem. Our incidence of thigh pain may be higher than that of others because no patients were lost to follow up. The ceramic portion of the Autophor Ceramic Hip was well tolerated clinically and radiographically. The femoral component was responsible for 2% to 4% of the revisions, and we have now replaced it with a stem designed for bony stabilization.

Biomechanical study of cervical spine stabilization with methylmethacrylate.

Polymethylmethacrylate (PMMA) has been used to provide immediate fixation in the spine, especially in the cervical region. With its use spreading to nontumor cases and a younger patient population, its biomechanical contribution to the stability and strength of the injured spine becomes increasingly important. The present study is unique, as it provides, for the first time, results of a three-dimensional stability and flexion strength testing of a surgical specimen removed at autopsy after 7 years. Also tested, in the identical manner, is a normal specimen to provide control data. The PMMA specimen, as compared with the control, was generally found to have less motion. Its flexion strength was at par with that of the control, although it did not exhibit the initial low-stiffness region of the normal spine specimen.

Methylmethacrylate stabilization of the cervical spine.

Several conditions that lead to instability of the cervical spine require surgical fixation, and on occasion that procedure may include the use of methylmethacrylate. In the series that we are reporting, there were eighteen patients with malignant disease, seventeen with fractures, twelve with rheumatoid arthritis, and five with osteoarthritis. In the survivors, a four-year follow-up showed excellent relief of instability and no complications attributable to the methacrylate except for one fracture of the methacrylate that did not produce symptoms.

Anterior approach to hip arthroplasty.

Direct anterior approach to the hip joint utilizing a curved transverse skin incision and splitting the tensor fascia muscle longitudinally provides an effective exposure for carrying out primary total hip arthroplasty. Excellent visualization of the acetabulum is afforded by this direct approach. Modified femoral rasps of varying lengths are employed to rasp the femur with the leg in external rotation. Trochanteric osteotomy was carried out on only three occasions in a series of 104 procedures performed on 85 patients during a three-year period. The duration of operation averaged 65 minutes. Average blood replacement was 1.9 units in unilateral hips and 3.5 units in patients operated upon sequentially. Mean postoperative stay was 12.8 days following unilateral and 22.3 days following bilateral surgery. Four patients experienced perioperative complications. The anterior approach provides a safe and effective approach to total hip arthroplasty with limited morbidity.