By David G. Lewallen, MD
The anterolateral approach is derived from the Watson-Jones approach that was described for hip fracture in 1935 and popularized for total hip arthroplasty in the 1970s by Müller1,2.
The surgical technique involves a lateral decubitus position, with the operatively treated leg draped free. The skin incision is made directly lateral or with a slight posterior curve, and a split is made in the tensor fasciae latae to expose the trochanter. The anterior 40% of the gluteus medius attachment to the trochanter is elevated with use of a curving subperiosteal incision. A split is made proximally in the line of the gluteus medius fibers so that it extends no more than 3 cm proximal to the acetabular rim (or 5 cm proximal to the trochanteric tip) to avoid injury to the superior gluteal nerve. The gluteus minimus is detached from the trochanter, and the hip capsule is excised, or incised in a T-fashion, for later repair. Dislocation is performed anteriorward by flexing and externally rotating the adducted limb. The limb is then brought over the edge of the table and placed in a sterile pocket clipped to the side of the operating table. The femoral neck is osteotomized, and the femur is mobilized posteriorward. The acetabulum can be best visualized and prepared from the abdominal side of the patient, while femoral preparation is done from the dorsal side of the patient. At closure, capsular flaps can be repaired, and the gluteus minimus is repaired to the trochanter with direct suture to bone. The gluteus medius flap is then repaired carefully back to its trochanteric bed with use of strong nonabsorbable sutures passed directly through bone. Routine fascial, subcutaneous, and skin closure follows.
Advantages of this approach include avoidance of direct exposure of the sciatic nerve and a reduced risk of femoral head osteonecrosis following femoral head-preserving procedures. In addition, the excellent acetabular exposure facilitates accurate positioning of the acetabular component, which likely contributes in part to the reduced dislocation rate that is associated with this approach as compared with the posterior approach.
Disadvantages include the potential risk of injury to the superior gluteal nerve and a slower recovery (by a few weeks) of abductor muscle strength. In addition, the overhanging trochanter can facilitate varus positioning and flexion of the stem. Along with the decreased risk of posterior dislocation, there is a slightly increased chance of anterior instability of the hip.
Extensile versions of this approach include that popularized by Hardinge, in which the split in the gluteus medius is extended distalward, encompassing the anterior portion of the vastus lateralis3. This musculotendinous sleeve is elevated in a subperiosteal fashion off the bone and is reflected anteriorward, allowing excellent exposure of the joint. The numerous variations that have been described vary on the basis of the location of the longitudinal split in the musculotendinous sleeve overlying the trochanter. Distal extension of the vastus split reduces the risk of inadvertent proximal extension, thus reducing the risk to the superior gluteal nerve. Osteotomy of an anterior wafer of greater trochanteric bone can aid in the reattachment of the gluteus medius and vastus lateralis musculotendinous sleeve. At the superior rim of the acetabulum, added exposure of the outer aspect of the ilium can be safely achieved through elevation of the gluteal musculature off the bone (as compared with additional splitting of the gluteus medius).
Extended trochanteric osteotomies are possible as a variation of this anterolateral approach. A long transverse osteotomy of the trochanter and proximal portion of the femur can be accomplished from anterior to posterior, or a lateral-to-medial split in the proximal part of the femur with elevation of the anterior half of the proximal femoral segment can allow excellent access to the more distal femoral canal to facilitate implant or cement removal while avoiding additional soft-tissue dissection.
Summary
The anterolateral approach and its variations provide excellent access to the hip joint for routine primary and revision arthroplasty procedures. It is particularly helpful for major acetabular reconstructions because of the excellent acetabular exposure provided, and it is recommended for use in patients who are at high risk of dislocation during total hip arthroplasty, such as those with Parkinson disease, dementia, spasticity, or femoral neck fracture.
Watson-Jones R. Fractures of the neck of the femur. Br J Surg.1935;23:787.23787
1935
[CrossRef]
Müller ME. Total hip prostheses. Clin Orthop Relat Res.1970;72:46-68.7246
1970
[PubMed]
Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg Br.1982;64:17-9.6417
1982
Exposure: The Percutaneously Assisted Total Hip (PATH) Arthroplasty Approach
By Brad L. Penenberg, MD
Revision total hip arthroplasty has traditionally involved wide exposure, which requires extensive dissection (along with increased blood loss, prolonged pain, a high rate of dislocation, extended disability, and extended recovery time) as compared with the amount of dissection required for primary total hip arthroplasty1-3. In an effort to improve these parameters, we propose a soft-tissue sparing technique for use in a high percentage of patients undergoing revision total hip arthroplasty. Newly designed instrumentation, permitting the use of a portal distal to the main incision, facilitates more limited surgical dissection while providing optimal access4.
Methods
Two hundred and sixteen consecutive revision total hip arthroplasties were performed with use of a percutaneously assisted total hip arthroplasty technique (the PATH approach)4. The main skin incision is centered over the acetabulum. Rather than immediately releasing the soft tissues about the proximal part of the femur, a distal portal is created for angular access to the acetabulum and removal of the cup (Fig. 1-A). The portal permits (1) acetabular reaming with an 8-mm diameter drive shaft (Fig. 1-B), (2) cup impaction, and (3) screw placement. A portal placement guide4 identifies the portal site, posterior to the femur, through which a 10-mm diameter cannula can be placed. This location is chosen because it permits access perpendicular to the plane of the acetabulum. A modified cup holder and alignment guide (Fig. 1-C) provides unrestricted access through the main incision, and impaction of the cup proceeds through the portal. A minimum two-year follow-up review was carried out for 148 acetabular and sixty-eight combined acetabular and femoral revisions in which the proposed technique was used. A clinical and radiographic review was carried out for all patients.
Clinical Results
The mean postoperative Harris hip score was 87.5. Hospital stay ranged from one to nine days, with an average of four days. The acetabular component abduction angle ranged from 35° to 50°. Dislocation occurred in three patients (1.4%). Proximal deep venous thrombosis occurred in one patient. There were no nerve injuries, infections, or reoperations.
Conclusions
A percutaneously assisted, soft-tissue sparing approach to revision total hip arthroplasty with use of newly designed instrumentation offers the possibility of reducing risk and accelerating recovery1-3.
Mahomed NN, Barrett JA, Katz JN, Phillips CB, Losina E, Lew RA, Guadagnoli E, Harris WH, Poss R, Baron JA. Rates and outcomes of primary and revision total hip replacement in the United States Medicare population. J Bone Joint Surg Am.2003;85:27-32.8527
2003
[PubMed]
Blom AW, Astle L, Loveridge J, Learmonth ID. Revision of an acetabular liner has a high risk of dislocation. J Bone Joint Surg Br.2005;87:1636-8.871636
2005
[CrossRef]
Alberton GM, High WA, Morrey BF. Dislocation after revision total hip arthroplasty: an analysis of risk factors and treatment options. J Bone Joint Surg Am.2002;84:1788-92.841788
2002
Penenberg BL, Bolling WS, Riley M. Percutaneously assisted total hip arthroplasty (PATH): a preliminary report. J Bone Joint Surg Am.2008;90 Suppl 4:209-20.90209
2008
[CrossRef]
Extended Proximal Femoral Osteotomy for Revision Hip Replacement
By Arlen D. Hanssen, MD
Revision total hip replacement may require use of an extensile surgical approach and therefore utilization of a proximal femoral osteotomy. The use of a proximal femoral osteotomy has increased commensurate with the increased number of complex revision total hip replacements that are currently being performed1. The two primary extensile proximal femoral osteotomy techniques include (1) the classic extended trochanteric osteotomy2, and (2) the transfemoral approach3.
The classic extended trochanteric osteotomy elevates and separates the anterolateral proximal part of the femur for one-third of its circumference from the remaining femur, whereas the transfemoral approach elevates the anterior and/or the posterior one-third circumferential aspects of the proximal part of the femur from the remaining femur. The classic extended trochanteric osteotomy can be performed in conjunction with a posterolateral surgical approach but alternatively can be performed in conjunction with a direct lateral surgical approach. The indications for using these technical variations are primarily based on personal preference and experience.
Extensile osteotomy techniques are created to provide an intact muscle-osseous sleeve while providing wide acetabular exposure and to facilitate femoral component exposure and implant removal. These techniques combine the advantages of an extremely wide exposure of component-fixation surfaces and preservation of soft-tissue attachments to bone. Additionally, these approaches facilitate accurate and safe distal cement removal and diaphyseal machining under direct vision. The possibility of placing the femoral component in varus is virtually eliminated. The osteotomized fragments allow for alteration of the proximal aspect of the femur to more accurately conform to the revision prosthesis, and they also allow for adjustment of soft-tissue tension. Other advantages include protection of a weakened or osteopenic trochanter from iatrogenic injury.
The surgical indications for an extended trochanteric osteotomy include (1) removal of a well-fixed cement mantle that has a loose or well-fixed stem, (2) removal of an extensively porous-coated or tapered cementless stem, (3) removal of a well-fixed stem when the procedure is complicated by infection, to ensure complete removal of all foreign material, (4) correction of proximal femoral deformity in conjunction with a revision total hip replacement, and (5) the need for extensile acetabular exposure to remove implants with intrapelvic protrusion. These surgical approaches are particularly useful when modular femoral implants are being used, as surgical access to the mid-diaphyseal femoral region is more direct and more easily visualized with these techniques than with proximal intramedullary techniques.
The recent literature demonstrates that these extensile techniques are associated with a relatively low rate of trochanteric nonunion as compared with the rates associated with conventional trochanteric osteotomy techniques1. In comparison with traditional intramedullary femoral revision techniques, extensile trochanteric techniques are associated with fewer intraoperative femoral fractures or cortical perforations and decreased surgical time.
Jando VT, Greidanus NV, Masri BA, Garbuz DS, Duncan CP. Trochanteric osteotomies in revision total hip arthroplasty: contemporary techniques and results. Instr Course Lect.2005;54:143-55.54143
2005
[PubMed]
Paprosky WG, Sporer SM. Controlled femoral fracture: easy in. J Arthroplasty.2003;18(3 Suppl 1):91-3.1891
2003
[CrossRef]
Gross AE. Transfemoral approach to the deficient proximal femur. Instr Course Lect.1999;48:77-8.4877
1999
Insertion of a Fully Coated Femoral Stem
By Kevin L. Garvin, MD
The treatment of patients who have proximal femoral bone loss after primary total hip replacement is one of the greatest challenges facing the revision hip surgeon. This challenge has stimulated the development of several new implants and techniques that have demonstrated a high rate of success. Distal femoral fixation with use of an extensively coated cylindrical stem has been the workhorse for revision of the femur. Additionally, the development of modular implants, tapered designs, megaprostheses, and other stems have positively impacted our ability to treat this group of patients.
The purpose of this paper is to discuss the role of nonmodular stems for femoral revision, the indications for the stem, and the technical tips to help optimize patient results.
The classification system of Della Valle and Paprosky1, which describes bone loss after revision hip surgery, helps us manage patients. Several authors have reported excellent results with extensively coated stems, provided that the patients have sufficient remaining femoral bone to allow for 5 cm of so-called "scratch fit" (Paprosky types I, II, and IIIA). The results have been predictable and reproducible for a large percentage of femoral revisions.
The disadvantages and contraindications include the fact that extensively coated distally fixed stems do contribute to stress-shielding of the proximal part of the femur. The stress-shielded proximal part of the bone is prone to fracture. Additionally, nonmodular fixation is contraindicated in patients in whom the femur is extensively damaged or in whom the femoral canal has a large diameter of >20 mm.
One of the complications of an extensively coated nonmodular stem is iatrogenic fracture when the stem is inserted. To avoid this complication, the surgeon should avoid underreaming, especially in the weakened diaphyseal bone. It is important to cylindrically ream the femur to a diameter that is at least 0.5 mm greater than the diameter of the stem. The second avoidable complication is anterior cortical perforation at the stem tip. When stems longer than eight inches (20.3 cm) are used, the stem should be bowed to match the normal bow of the femur.
A second type of nonmodular stem is the taper fluted design. It has several advantages, including its resistance to axial, rotational, and bending forces. Like cylindrical stems, this design can be used in patients with deficient metaphyseal and/or diaphyseal bone and even in some patients with larger femoral defects.
The disadvantage of the tapered design is possible subsidence, and thus it is contraindicated in patients with severe diaphyseal bone loss because it is not possible to obtain osseous fixation.
The results of these two designs have been outstanding. Weeden and Paprosky2 and Engh et al.3 have both reported excellent long-term results with revision rates of less than 5% at a follow-up time of approximately ten years (follow-up ranged from 9.3 to twenty years). Similarly, Kwong et al. reported excellent results, albeit with a shorter period of follow-up (two to six years) for the taper design4.
In summary, nonmodular cylindrical and tapered-stem designs have performed in an outstanding manner for patients who have undergone femoral revision. Patients with type-IIIB and type-IV defects are not good candidates for these stems and therefore may require a modular stem, an allograft composite reconstruction, or a megaprosthesis.
Della Valle CJ, Paprosky WG. The femur in revision total hip arthroplasty evaluation and classification. Clin Orthop Relat Res.2004;420:55-62.42055
2004
[PubMed][CrossRef]
Weeden SH, Paprosky WG. Minimal 11-year follow-up of extensively porous-coated stems in femoral revision total hip arthroplasty. J Arthroplasty.2002;17(4 Suppl 1):134-7.17134
2002
[CrossRef]
Engh CA Jr, Hopper RH Jr, Engh CA Sr. Distal ingrowth components. Clin Orthop Relat Res.2004;420:135-41.420135
2004
[CrossRef]
Kwong LM, Miller AJ, Lubinus P. A modular distal fixation option for proximal bone loss in revision total hip arthroplasty: a 2- to 6-year follow-up study. J Arthroplasty.2003;18(3 Suppl 1):94-7.1894
2003
[CrossRef]
Modular Revision Femoral Stems: Eliminating Irreversible Steps in Surgical Technique
By Ormonde M. Mahoney, MD, and Tracy L. Kinsey, MSPH
Introduction
Monoblock cementless femoral components have been used extensively in total hip revision for decades and have been associated with good-to-excellent results in most cases. There have remained, however, relatively frequent problems due to instability, intraoperative fracture, and limb-length inequality1,2. This paper will review the design and implantation technique of a modular, segmentally implanted, femoral revision system. Outcomes are compared with those of a monoblock system in a similar patient cohort to identify system-specific advantages and weaknesses of the modular device.
Methods
We reviewed thirty revision total hip arthroplasty procedures in which a modular, segmentally implanted, partially hydroxyapatite-coated titanium femoral implant was used between April 2005 and July 2008. All reconstructions involved severe bone loss or malalignment and were accomplished entirely without the use of bone-graft augmentation. The patients' charts and radiographs were reviewed. Results were compared with a historical cohort of forty patients who were treated between 1995 and 2000, for the same indications, with use of a fully coated monoblock titanium device.
Clinical Results
For the modular-stem group, radiographic evidence of bone ingrowth was observed in all hips. At the time of the latest follow-up, there were no instances of subsidence and mild trochanteric pain was reported in two hips. There were no intraoperative fractures and no dislocations. Two stems have been revised, one for fracture nonunion and one for infection. Two other patients have undergone reoperation for acetabular failures. Among the monoblock-stem group, radiographic evidence of bone ingrowth was observed in all hips. There were no instances of subsidence at the time of long-term follow-up. One patient exhibited stress-shielding with thigh pain within the first postoperative year. There was one intraoperative fracture. Thirteen patients had one or more dislocations postoperatively; seven of those required reoperation. Three stems were revised due to associated infection, trauma, and loosening with fracture nonunion, all within the first three years of follow-up.
Conclusions
When compared with the use of a monoblock design, segmental implantation of the distal portion of the stem component during hip revision, with subsequent insertion of trial proximal components, gives the surgeon increased flexibility with regard to certain important intraoperative judgments. Our preliminary clinical observations suggest that both designs are capable of providing excellent short to midterm fixation in the reconstruction of a severely diseased femur without the use of allograft. The risk of dislocation appears to be substantially reduced with use of the modular device, which gives the surgeon more options in reconstituting the desired amounts of version, offset, and limb length.
Moreland JR, Bernstein ML. Femoral revision hip arthroplasty with uncemented, porous-coated stems. Clin Orthop Relat Res.1995;319:141-50.319141
1995
[PubMed]
Paprosky WG, Greidanus NV, Antoniou J. Minimum 10-year-results of extensively porous-coated stems in revision hip arthroplasty. Clin Orthop Relat Res.1999;369:230-42.369230
1999
[CrossRef]