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Specialty Update   |    
What's New in Hip Arthroplasty
Michael H. Huo, MD; Barrett S. Brown, MD
View Disclosures and Other Information
Michael H. Huo, MD
Barrett S. Brown, MD
Department of Orthopedic Surgery, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160. E-mail address for M.H. Huo: mhuo@kumc.edu

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Specialty Update has been developed in collaboration with the Council of Musculoskeletal Specialty Societies (COMSS) of the American Academy of Orthopaedic Surgeons.

J Bone Joint Surg Am, 2003 Sep 01;85(9):1852-1864
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Extract

Total hip arthroplasty remains one of the most frequently performed reconstructive procedures in orthopaedic surgery. The greatest challenges facing us today are the escalating volume of revision surgery and the increasing number of complications as the duration of in situ service of the implants continues to increase.
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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Michael H. Huo
    Posted on January 08, 2004
    Drs. Huo and Brown respond:
    University of Kansas

    We appreciate the insightful letter from Drs. Grukan and Wenz. We are familiar with the article by Wenz et al.,and regret that reference was not made to the data from their article in our review. Our paper was based upon reprts published in the Journal of Bone and Joint Surgery, Clinical Orthopedics and Related Research, the Journal of Arthroplasty, and abstracts presented at the AAOS Annual Meeting, AAHKS Annual Meeting, and the Hip Society Open and Closed Meetings. These sources of information have been the standard for writing this particular review for the past 3 years.

    The terminology used to describe this surgical technique is in a state of evolution. We are unaware of any consensus in the literature as to which term is preferable. Controversies exist with regard to whether this is a modification of an existing procedure, or should be considered an entirely "new" procedure.

    We agree with Drs. Gurkan and Wenz in the documented superior efficacy with regard to perioperative parameters and short-term clinical outcome. These issues were specifically discussed on page 1858, paragraphs 2, 3, 5, and 6. DiGioia's data reflected superiority in the mini-incision patients at 6 months in several outcome assessment parameters, but no difference at one year.

    We are completely in agreement with Drs. Gurkan and Wenz in that the major challenge is to develop training methodologies for practicing orthopedic surgeons and resident physicians. We hope that newer navigation software, instrumentation, and perhaps prosthetic designs will all contribute to reproducibly good results using this new surgical technique in performing a total hip replacement.

    We look forward to reviewing Drs. Gurkan's and Wenz's longer-term follow-up data.

    James F. Wenz, MD
    Posted on December 19, 2003
    Mini-incision Total Hip Arthroplasty
    Johns Hopkins Bayview Medical Center

    To the Editor:

    In their specialty update, “What's New in Hip Arthroplasty” (J. Bone Joint Surg. 85A:1852-1864, 2003), Drs.Huo and Brown have included the development of minimally invasive surgical technique for hip arthroplasty. We believe the technique of performing total hip arthroplasty through smaller incisions should more properly be called mini-incision arthroplasty.

    Minimally invasive surgical techniques for total hip arthroplasty involve different intermuscular surgical planes(1) than do the smaller size incisions, which are modifications of conventional approaches.

    We agree with the authors that marketing has stimulated enthusiasm for using such mini-incision approaches for total hip arthroplasties, but we do not agree that the literature lacks scientific data supporting the efficacy, safety, and superiority of this approach compared with previously described conventional approaches. The mini-incision arthroplasty we described(2) has been extensively analyzed for its accuracy and reproducibility of implantation, regardless of patient habitus. To our knowledge, our report is the first study to show that a mini-incision technique facilitates recovery after total hip arthroplasty, decreases blood transfusion requirements without an increase in complication rates or operative time, and permits earlier and more vigorous postoperative physical therapy, which may shorten hospital stays and reduce costs(2). These benefits and improved early surgical outcomes are the main goals of such an approach.

    Therefore, although controversy exists, as is appropriate for a new technique, the focus of study should be the effects of a less invasive surgical approach on improving early outcomes, as described in our paper. Our study showed that the mini-incision surgical technique can be used without compromising the accuracy and reproducibility of implantation in a demographically diverse patient population and that it significantly improved early outcomes compared with one of the widely accepted conventional surgical approaches(2). Although we did not address long-term results as have other investigators(3), our results have led to the use of this technique as a standard approach for total hip arthroplasty in our institution. Data on the long-term effects will be forthcoming. With efficacy established, the issue focuses on the methodology of training the surgeons to perform the technique safely.

    References

    1. Berger RA. Mini-incisions: two for the price of one! Orthopedics. 2002;25:472, 498.

    2. Wenz JF, Gurkan I, Jibodh SR. Mini-incision total hip arthroplasty: a comparative assessment of perioperative outcomes. Orthopedics. 2002;25:1031-43.

    3. DiGioia AM, III, Plakseychuk AY, Levison TJ, Jaramaz B. Mini- incision technique for total hip arthroplasty with navigation. J Arthroplasty. 2003;18:123-8.

    Ilksen Gurkan, MD James F. Wenz, MD

    eugene sherry
    Posted on November 10, 2003
    MIS Hip Surgery is promising
    sydney private hospital, sydney,

    To the Editor:

    Huo and Brown have written an excellent review of Hip Arthroplasty with a section on MIS Surgery (What’s New in Hip Arthroplasty; 2003; 85: 1852-1864). However they seem cautious about the future of MIS surgery. We believe that MIS surgery represents a chance to do a hip replacement better and is a quantum leap in surgical technique.

    Its advantages include better handling of the soft tissues ( the theoretical cone of dissection is reduced by 96%) with hopefully less chance of infection and DVTs; better orientation of the components (with the use of a LOLLIPOP device which uses gravity as a guide) resulting hopefully in less long term wear and loosening, and the avoidance of trial reductions with use of a spacer system. 1,2

    Our first 85 cases (with the NILNAVTM System) had an average cup orientation of 47.75° with pre- and post-operative Harris scores of 28.64 and 82.65.and discharge at 2 days.

    Whilst the long-term results remain to be seen, we believe that the future of this technique is promising.

    -Eugene Sherry, MD

    Sureshan Sivananthan, MD

    Patrick H Warnke, MD DDS

    Corresponding author: Eugene Sherry MD

    Department of Orthopaedic Surgery

    Sydney Private Hospital

    Victoria Street, Sydney, NSW 2131

    esherry@bigpond.com

    References 1. Sherry E, Egan M, Warnke PH, Henderson A, Eslick GD Minimal invasive surgery for hip replacement: a new technique using the NILNAV hip system. ANZ J Surge. 2003 Mar; 73(3): 157-61.

    2.Sherry E, Egan M, Henderson A, Warnke PH. Minimally invasive techniques for total hip arthroplasty. J Bone Joint Surg Am. 2002 Aug;84-A(8):1481.

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