Direct Superior Approach to the Hip for Total Hip Arthroplasty.

BACKGROUND: Traditional posterior approaches to the hip, posterolateral and mini-posterior, violate the iliotibial band and the short external rotators, specifically the quadratus femoris and obturator externus muscles1-4. The direct anterior approach does not violate the iliotibial band or the quadratus femoris, resulting in earlier ambulation and lower dislocation rates1,5-9. The direct superior (DS) is a posterior approach that spares the iliotibial band, obturator externus tendon, and quadratus femoris muscle. The goal of minimally invasive surgery (MIS) is to disrupt the least amount of tissue necessary to adequately expose the hip and correctly place implants. Although MIS total hip arthroplasty (THA) has not lived up to all of its promises10-13, MIS-THA may enable early ambulation and decrease length of stay14-16. DESCRIPTION: The patient is positioned in the lateral decubitus position. An 8 to 10-cm incision is made at a 60° oblique angle starting from the posterior-proximal corner of the greater trochanter. Only the gluteus maximus fascia is incised; the Iliotibial band is completely spared. The gluteus maximus muscle is split bluntly, exposing the gluteus medius muscle, piriformis tendon, and triceps coxae (the obturator internus and superior and inferior gemellus muscles). The piriformis and conjoined tendon are released from the greater trochanter and tagged. The gluteus minimus is elevated, exposing the posterior hip capsule. An arthrotomy is performed prior to dislocating the hip with flexion, adduction, internal rotation, and axial compression. The femoral neck is resected, the acetabulum is reamed, and components or trials are impacted into position. Hip stability is assessed. Final implants are placed. The posterior capsule, piriformis, and obturator internus tendons are repaired anatomically. The fascia and skin are closed. ALTERNATIVES: Posterolateral approach.Mini-posterior approach.Direct lateral approach.Anterolateral approach.Percutaneously assisted total hip (PATH).Supercapsular PATH (SuperPath). RATIONALE: The DS approach to the hip differs from the traditional posterior and mini-posterior approaches because it preserves the iliotibial band, quadratus femoris muscle, and obturator externus tendon1, potentially suppressing dislocation. The DS approach to the hip causes less soft-tissue destruction, especially to the gluteus minimus and tensor fasciae latae muscles, compared with the direct anterior approach to the hip, suggesting DS-THA may enhance postoperative mobility1,3,14-16. DS-THA is extensile by extending the incision distally, incising the iliotibial band, and releasing the quadratus femoris muscle. This converts a DS approach to a standard posterolateral approach, providing additional visualization.

Is the Direct Superior, Iliotibial Band-Sparing Approach Associated With Decreased Pain After Total Hip Arthroplasty?

BACKGROUND: Recently, the direct superior approach (DSA) has been introduced in total hip arthroplasty (THA) with the goal of limiting soft tissue dissection. This study's purpose was to use a visual pain diagram questionnaire to determine the location and severity of pain in patients undergoing THA via a DSA vs miniposterior approach (MPA). METHODS: This was a prospective, Institutional Review Board (IRB)-approved investigation from 3 centers. Patients aged 18-70 years with a diagnosis of osteoarthritis were included. Two centers used the MPA, while 1 center the DSA. The DSA uses a 9- to 12-cm incision with its distal extent at the posterosuperior greater trochanter. Dissection into the iliotibial band is avoided, and the capsule at the inferior femoral neck is preserved. All THAs in both cohorts received a cementless, titanium, proximally coated femoral stem and a hemispherical acetabular component. RESULTS: A total of 42 DSA and 196 MPA THA patients were included. Overall, 43% of patients reported pain in at least 1 of the 8 anatomic areas assessed. There was no difference in the incidence of moderate to severe pain in any anatomic area of interest between the MPA and DSA cohorts (P = .1-.9). Specifically, the incidence of moderate to severe trochanter (17% MPA vs 17% DSA, P = .9), anterior thigh (15% MPA vs 17% DSA, P = .9), and lateral thigh pain (12% MPA vs 12% DSA, P = .9) was nearly identical in both cohorts. CONCLUSION: This study was unable to demonstrate a difference in the incidence of residual pain after use of a DSA or an MPA approach after THA.

Minimally invasive total hip arthroplasty using a transpiriformis approach: a preliminary report.

BACKGROUND: Continuing efforts have been made to develop minimally invasive surgery techniques for THA. One of the most commonly performed of these techniques is the mini-posterior approach. All reported series using this approach describe surgical detachment of the short external rotators of the hip. In 2008, Penenberg et al. described an innovative surgical technique that preserves the short external rotators. We present the results of a single-incision modification of this technique in 135 patients. DESCRIPTION OF TECHNIQUE: This technique is based on preservation of all of the short external rotators of the hip with the exception of the piriformis or conjoined tendon. This single-incision technique required the development of specialized instrumentation for exposure and reaming of the acetabulum. The specialized retractors also successfully minimized trauma to the skin and subcutaneous tissue. METHODS: For the 135 patients undergoing THA with this technique, we analyzed demographic and operative data. We recorded complications, evaluated postoperative clinical function using the Harris hip score, and assessed cup abduction angle, cup anteversion, and stem alignment on radiographs. Minimum followup was 14 months (mean, 22 months; range, 14-33 months). RESULTS: There were no dislocations, no sciatic nerve palsies, no wound complications, and low transfusion rates (8%). The postoperative Harris hip score averaged 96.5 (range, 87-100). Overall acetabular cup abduction angle averaged 41° (range, 21°-49°) and anteversion averaged 21° (range, 15°-27°). Four percent and 2% of femoral components were inserted into more than 2° varus and 2° valgus alignment, respectively. CONCLUSIONS: This technique shows promise as an alternative tissue-sparing method for minimally invasive THA. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.