Combined Anterior and Posterior Approach in Total Hip Arthroplasty for Crowe IV Dysplasia or Ankylosed Hips Young-Kyun Lee, Ki-Choul Kim, Yong-chan Ha, Kyung-Hoi Koo PII: DOI: Reference:
S0883-5403(15)00010-8 doi: 10.1016/j.arth.2014.12.025 YARTH 54263
To appear in:
Journal of Arthroplasty
Received date: Revised date: Accepted date:
8 September 2014 4 December 2014 28 December 2014
Please cite this article as: Lee Young-Kyun, Kim Ki-Choul, Ha Yong-chan, Koo Kyung-Hoi, Combined Anterior and Posterior Approach in Total Hip Arthroplasty for Crowe IV Dysplasia or Ankylosed Hips, Journal of Arthroplasty (2015), doi: 10.1016/j.arth.2014.12.025
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ACCEPTED MANUSCRIPT Combined Anterior and Posterior Approach in Total Hip Arthroplasty
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for Crowe IV Dysplasia or Ankylosed Hips
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short title; Combined Anterior and Posterior Approach
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Short title; Combined Approach in Complex THA
Young-Kyun Lee, Ki-Choul Kim, Yong-chan Ha, Kyung-Hoi Koo
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Young-Kyun Lee
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Department of Orthopaedic Surgery, Seoul National University Bundang Hospital
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82 Gumi-ro, 173 beon-gil, Bundang-gu, Seongnam-si, 463-707, South Korea Ki-Choul Kim (Corresponding author)
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Department of Orthopedic Surgery, Dankook University School of Medicine
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359, Manghyangro, Dongnam-gu, Cheonan 330-715, South Korea
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Tel: +82-31-787-7204
Fax: +82-31-787-4056
E-mail: [email protected] Yong-Chan Ha Department of Orthopaedic Surgery, Chung-Ang University College of Medicine 224-1 Heukseok-dong, Dongjak-gu, Seoul 156-755, South Korea Kyung-Hoi Koo Department of Orthopaedic Surgery, Seoul National University Bundang Hospital
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82 Gumi-ro, 173 beon-gil, Bundang-gu, Seongnam-si, 463-707, South Korea
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ACCEPTED MANUSCRIPT Abstract We evaluated 70 patients (71 hips) who underwent complex total hip arthroplasty (THA) through
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the combined anterior and posterior approach. Sixty-five patients (32 dislocated hips and 34
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ankylosed hips) were followed-up at a minimum of 3 years (median, 6 years; range, 3-10 years). Seven patients (10.6%), who had transient paresthesia on the anterior thigh, recovered within 3
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months. All patients had a good clinical outcome in terms of hip range of motion, pain and
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recovery of walking. At the latest follow-up, all prostheses had bone-ingrown stability without any detectable wear or osteolysis. The combined approach allows an excellent exposure of the
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acetabulum for accurate cup alignment, leg lengthening and mobilization of joint in complex THA without trochanteric osteotomy, excessive abductor release and femoral shortening
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osteotomy.
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ACCEPTED MANUSCRIPT Introduction Total hip arthroplasty (THA) in patients who have dislocation due to childhood infection or
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dysplasia is challenging, because these patients usually have hypoplastic acetabulum, limb
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shortening and ankylosis of the hip.[1-3]
Surgical concerns during THA for these conditions include; (1) release of joint capsule and
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contracted soft tissue, (2) improvement of limb length discrepancy (LLD), (3) reconstruction of
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hypoplastic acetabulum, and (4) cup implantation with an adequate position and sufficient contact.[1,2,4,5] This challenging THA usually requires extensile surgical approaches, such as
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trochanteric osteotomy, abductor release, and sometimes femoral shortening osteotomy.[2,5,6] However, these procedures can lead to complications, including nonunion of osteotomy site,
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weakness of abductor mechanism and neurovascular injuries.[7]
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The combined approach was first described in 1984 by Tronzo,[8] who recommended it for THA of fused hip and bone grafting in femoral neck fracture. He used two standard approaches:
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posterolateral (Gibson) and anterolateral (Watson-Jones) approaches, through a single lateral
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skin incision. This approach permits good exposure of front and back of the hip joint, which facilitates anterior and posterior capsulectomy, release of contracted muscles, acetabular bone graft, and decreases the necessity of trochanteric or femoral shortening osteotomy. In 1988, Lusskin reported 4 cases of complex THA using the combined approach.[9] Otherwise, no study has reported the usefulness of the combined approach. We have used an isolated posterior approach: the Kocher-Langenbeck approach, as the standard exposure method for THA. However, an additional anterior approach was made in complex THAs 1) when this posterior approach alone could not afford a sufficient exposure of the front of the hip for bone graft on the acetabulum, and 2) when anterior capsule/soft tissue release was
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ACCEPTED MANUSCRIPT necessary for mobilization of the joint, reduction of prostheses and limb lengthening, The anterior approach did not necessitate additional skin incision. We used the original combined
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approach in complex THAs since 1996. However, we experienced difficulty in exposing the
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front of the hip, a damage of abductor muscle due to excessive retraction and varus-insertion of stem. Thus, we have modified the anterior approach from the Watson-Jones approach to the
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Mulliken approach, which permitted better exposure.[10,11]
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The purpose of this study was (1) to describe a surgical technique of the modified combined anterior and posterior approach in a highly dislocated or ankylosed hip with illustrations, and (2)
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to evaluate surgical parameters, acetabular cup position, operative complications, improvement of limb length discrepancy, mobilization of hip joint, bearing surface wear, periprosthetic
Materials and Methods
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osteolysis and implant stability and Harris hip score.
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From May 2003 to December 2010, 70 patients (71 hips) with highly-dislocated or ankylosed
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hips underwent THA using a combined anterior and posterior approach at the authors’ hospital. Five patients (5 hips) were lost to follow-up before a minimum of 3 years after the arthroplasty. The remaining 65 patients (66 hips) were followed for mean 6 years (range, 3 to 10 years) after the THA. There were 24 men (25 hips) and 41 women (41 hips). The mean age of patients at the index operation was 46.3 years (range, 20 to 74 years) and the mean body mass index was 24.5 kg/m2 (range, 18.4 to 33.6 kg/m2). In 32 dislocated hips, the reason for dislocation was developmental dysplasia in 15 hips, childhood septic arthritis in 16 hips, and previous trauma in 1 hip. We measured the limb length on long length alignment films. The limb length was defined as the distance between the iliac
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ACCEPTED MANUSCRIPT crest and ankle mortis.[12] The limb length discrepancy ranged from 1 to 12 cm (mean, 5.5 cm). In 34 ankylosed hips, the reason for ankylosis was childhood septic arthritis in 20 hips, previous
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trauma in 6 hips, previous arthrodesis in 4 hips, and sequelae of Perthe’s disease in 4 hips. These
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ankylosed patients also had leg length discrepancies ranging 0 to 17 cm (mean, 3.8 cm). The mean Harris hip score was 62.1 (range, 26 to 81) at the preoperative evaluation (Table 1).
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All hips were operated with cementless prostheses; PLASMACUP SC® cup with
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BiCONTACT® stem (Aesculap, Tuttlingen, Germany) in 30 hips, Pinnacle cup with Corail stem (DePuy, Saint-Priest, France) in 26, Bencox cup with Bencox stem (Corentec, Seoul, South
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Korea) in 5, Trident cup with Omnifit stem (Stryker Orthopaedics, Mahwah, New Jersey) in 4, and SPH contact cup with C2 stem (Lima, Udine, Italy) in 1 hip.
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BIOLOX Forte alumina head and liner (CeramTec, Plochingen, Germany) were used in 40 hips,
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BIOLOX Delta alumina head and liner (CeramTec) in 24, cobalt chromium head and polyethylene liner in 2 hips. The diameter of the femoral head was 28 mm in 28 hips, 32 mm in
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31, 36 mm in 5 and 22 mm in 2 hips.
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Routine follow-up visits were scheduled for six weeks, then three, six, nine, twelve months, and six months thereafter. Patients who had not returned for regular scheduled visits were contacted by telephone. Two nurses and one private locator found and visited non-responders. Final follow-up evaluation was performed at an average of 6.0 years (range, 3 to 10 years) postoperatively. We reviewed the operation time, estimated blood loss, requirement of transfusion, perioperative complications and postoperative leg length discrepancy. Radiographic evaluations were done by two independent observers who did not participate in the operations. The equalization of leg length discrepancy was measured on three-month long length
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ACCEPTED MANUSCRIPT alignment films. Positions of the acetabular cup and femoral stem were evaluated on six-week anteroposterior radiographs. The abduction angle of the acetabular cup was measured using the
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method described by Engh et al..[13] The anteversion of the acetabular component was
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calculated using the method of Woo and Morrey.[14,15] Cups with an abduction angle of ≤30° or ≥50°,[16] or with an anteversion angle of ≤ 5° or ≥ 25°[17] were considered as outliers for the
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optimal cup position. Stem alignment was determined by measuring the angle formed between
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the longitudinal axis of the femoral stem and the longitudinal axis of the femoral canal.[18] Alignment of the stem was classified as neutral, valgus (> 5° of lateral deviation), or varus (>
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5°of medial deviation).[18]
The implant fixation, wear of bearing surface, periprosthetic osteolysis, and heterotophic
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with those at the final follow-up.
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ossification were evaluated by comparing the six-week anteroposterior radiographs at six-weeks
The fixation of the femoral component was classified with use of the method of Engh et al.[19]
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and the fixation of the acetabular component with use of the method of Latimer and
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Lachiewicz.[20] The wear of liner was calculated according to the method developed by Livermore et al..[21] Osteolytic lesions were defined according the criteria of Engh et al..[22] The lesions were recorded according to the three zones described by DeLee and Charnley[23] on the acetabular side, and the seven zones described by Gruen et al.[24] on the femoral side. Heterotopic ossification was classified according to the system of Brooker et al.,[25] whenever present. Range of hip motion and Harris hip score [26] were measured at the final follow-up. The design and protocol of this retrospective study were approved by the institutional review board, who waived informed consents.
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SURGICAL TECHNIQUE
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Patients were positioned in the lateral decubitus position. All procedures were performed by one
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senior surgeon. For the posterior approach, we used the technique described by Kocher and Langenback.[27] The hip was flexed by 30 degrees and a straight skin incision was made over
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the center of the greater trochanter, equidistant cephalad and caudad to the center of the
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trochanter. The length of the skin incision was about 18 cm.[11] The skin incision was lengthened superiorly and inferiorly to ease the exposure and to avoid a forceful and traumatic
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retraction. The fascia lata was incised and muscle fibers of the gluteus maximus were separated. The trochanteric bursa and fat tissue overlying the short external rotators were removed to
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expose the gluteus medius, short external rotators and sciatic nerve. The external rotators were
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detached with electrocautery at their insertion. Afterward, these muscles were retracted to expose the posterior capsule. The capsule was incised along the base of femoral neck using
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electrocautery. A trapezoidal posteriorly broad-based capsular flap was created. Tight tendinous
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insertion of the gluteus maximus was detached from the proximal femur and tight psoas tendon was released from the lesser trochanter to mobilize the hip joint and to restore the leg length. The posterior acetabular osteophytes, which blocked the dislocation, were removed with a curved osteotome, as required. The femoral head was dislocated posteriorly, the femoral neck was cut and the femoral head was removed. For the anterior exposure, we used the technique described by Mulliken et al..[10] The leg was abducted and externally rotated. A plane between the tensor fascia lata and gluteus medius was found. The adhesion in this plane was separated via blunt dissection, electrocautery or scissors to
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ACCEPTED MANUSCRIPT release the adhesion and flexion contracture of the hip, and to expose the anterior portion of the gluteus medius.
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Muscle fibers of the gluteus medius were separated at its anterior middle one-third junction, up
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to 3 cm cephalad to its insertion. The combined tendon and periosteum of the gluteus medius and vastus lateralis were separated and detached with electrocautery. This division was carried out
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anterior to the trochanter to leave behind a posterior tendinous cuff for suturing later. Distally,
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the dissection was curved posteriorly at the vastus ridge and taken in line with the fibers of the vastus lateralis. A plane between the gluteus minimus and anterior capsule was found proximally.
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Blunt dissection was carried out in this plane to the acetabular rim. With adequate exposure of the anterior capsule, an anterior capsulotomy was performed. Anterior osteophyte was removed.
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The leg was flexed and internally rotated to expose the back of the hip joint. Through the
were inserted (Fig. 1).
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posterior approach, the acetabulum and femur were prepared for implantation and prostheses
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Special care was taken to avoid traction injury of the sciatic nerve due to elongation of the
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operated leg during the process of insertion and reduction of the prostheses. The leg was cautiously pulled down and the tension was checked by manual palpation. Avoiding excessive tension, the amount of elongation was determined and the stem size and neck-length of the head were chosen. After implantation and reduction of the trial prosthesis, we checked the acetabular cup position and the axis of contact between the prosthetic head and acetabular liner. Then, we checked the residual flexion contracture of the hip by extending the joint. The goal of releasing the flexion contracture was an extension of 10 degrees, which is necessary for the
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ACCEPTED MANUSCRIPT normal gait pattern. When the hip was not extended to 10 degrees, we released the anterior structure of the hip joint.
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Possible tight anterior structures, including the reflected head of rectus femoris, tensor fascia lata
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and sartorius were identified by palpating and/or inspecting. When the tensor fascia lata was tight, an oblique fasciotomy was performed between the greater trochanter and anterior superior
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iliac spine. Tight rectus femoris was released at the anterior inferior iliac spine. Tight sartorius
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was released at the anterior superior iliac spine, taking care of the lateral cutaneous nerve. Finally, we rechecked the axial stability of the hip joint, using the Shuck test,[28] anterior
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stability by extension/external rotation and posterior stability by flextion/internal rotation. Careful attention was paid to the suture of the muscular layers. In the posterior side, the capsule
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and short external rotators were tightly repaired to 3 drill holes in the trochanteric crest.[11] In
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the anterior side, divided gluteus minimus was approximated and sutured. The anterior flap of
cuff.[11]
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the gluteus medius and vastus lateralis were approximated and sutured to the posterior tendinous
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After the insertion of a closed suction drainage, the fascia and skin were closed. After dressing the wound, the patient was transferred to supine position and the hip was abducted. When abduction was less than 15 degrees, tight adductor tendon was identified by palpation. Adductor tenotomy was performed using electrocautery through a short longitudinal stab wound over the tight tendon. Twenty-nine patients (29 hips) had residual defect of the capsule and muscle due to release of hip contracture and/or limb lengthening, in which soft tissue could not be tightly repaired. In these patients, abduction brace was applied for 6 weeks to prevent dislocation. After removal of the drain at 2 days postoperatively, patients were encouraged to walk with toe-
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ACCEPTED MANUSCRIPT touch weight bearing with the aid of two crutches for four weeks, and then were allowed weight-
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bearing as tolerated.
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Results
The mean operation time was 194.5 minutes (range, 92-280 minutes), the mean amount of
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estimated blood loss (EBL) was 832.7 ml (range, 200-1800 ml), and the mean amount of
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transfusion was 449.2 ml (range, 0-1600 ml).
Crack at the femoral neck occurred in 12 hypoplastic femurs during the insertion of the stem,
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which was successfully treated by a cerclage wire. Seven patients complained of a paresthesia or tingling sensation at the anterior thigh or anterolateral aspect of the lower leg, all of which
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recovered within 3 months.
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Mean postoperative leg length discrepancy was 2.9 cm (range, from 0 to 7 cm) in patients with dislocated hips (Fig. 2), and 2.1 cm (range, from 0 to 12 cm) in patients with ankylosed hips. The
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discrepancy was restored to less than 2 cm in 42 patients (64.6 %). In hips which were operated
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due to ankylosis, the mean postoperative flexion was 82.2° (range, 60° - 120°), the mean
extension was 12.2° (range, 0° - 30°) and the mean abduction was 31.1° (range, 10° - 40°) (Fig. 3). The mean cup abduction angle was 39.7 ± 6.7 (range, 19 to 51) and the mean anteversion was 21.6 ± 7.9 (range, 6 to 39). The number of outliers in cup position was 14. One stem was placed in varus and one in valgus. Two hips dislocated at postoperative 2 and 8 weeks, respectively. They were treated successfully with closed reduction and abduction bracing for two months.
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ACCEPTED MANUSCRIPT All of the acetabular cups and femoral stems had radiographic evidence of bone ingrown stability at the time of the last follow-up. There were no focal osteolysis and no measurable wear in any
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hip. Booker grade I heterotopic ossification developed in 2 hips (Table 2).
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The mean Harris hip score was 89.4 (range, 72 to 100) at the final follow-up. Four patients (4 hips) had intermittent thigh pain, but they did not need any analgesics. Although three patients
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used a shoe-lift, no patient used any kind of walking support.
Discussion
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Currently, most primary THAs are performed through either a direct anterior, lateral or posterolateral approach.[29] However, transtrochanteric approach is widely used for extensile
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exposure and soft tissue release in highly dislocated or ankylosed hips.[30,31] Some times,
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femoral shortening osteotomy should be done to reduce the prosthetic femoral head. In the transtrochanteric approach, the greater trochanter is osteomized and re-attached with wires
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or cable grip, which can induce complications including wire or cable breakage, trochanteric
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fragment migration, nonunion, bursitis, and metallosis. In a review of 68 trochanteric osteotomies, which were repaired with Dall-Miles cable grip system (Howmedica, Rutherford, NJ), trochanteric nonunion occurred in 25%, with fraying and fragmentation of the cable. Among the 51 patients with trochanteric union, 35% also had signs of fraying and fragmentation. Osteolysis around the cable was seen in 10%. Metallosis at the inferior border of the acetabulum were seen in 12%.[32] Combined approach has also been used in THAs of ankylosed hips. Li et al. operated 76 hips of 47 patients with use of a combined anterior and posterior approach and reported good to excellent results in 2 to 11 year follow-up.[33] We used a lateral approach instead of anterior
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ACCEPTED MANUSCRIPT approach in the combined approach of our patients. Our combined approach enabled a satisfactory restoration of leg length and mobilization of hip in complicated THAs of dislocated
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and ankylosed hips. This approach spares of the abductor mechanism and avoids morbidities of
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trochanteric osteotomy.[7] This approach affords an excellent exposure both front and back of the hip joint and can be extended distally to expose the femoral shaft, if needed.
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There were several limitations in our study. First, our study was a retrospective review of
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prospectively followed patients. However, a prospective study on this topic was not feasible, because the necessity of additional anterior approach was decided during the operation. Second,
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our study did not include a comparison with other approaches, such as transtrochanteric approach. Because we were already informed and concerned about osteotomy-related adverse effects, we
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did not recruit a comparison group of transtrochanteric approach. Our results were comparable
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with or better than those of the previous studies of complex THAs using transtrochanteric approach, which had approach-related complications including nonunion and bursitis (Table
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3).[6,34-38] Despite these limitations, the strength of our study is that it is the first study
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presenting the results of modified combined anterior and posterior approach for complex THA. In conclusion, our study demonstrated that a combined approach can facilitate complex THA of dislocated or ankylosed hips, which necessitate an entire exposure of the hip for capsule/muscle release and joint mobilization.
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13. Engh CA, Griffin WL, Marx CL. Cementless acetabular components. J Bone Joint Surg Br
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25. Brooker AF, Bowerman JW, Robinson RA, Riley LH, Jr. Ectopic ossification following total
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ACCEPTED MANUSCRIPT Acknowledgment No benefits in any form have been received or will be received from any commercial party
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related directly or indirectly to the subject of this article.
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ACCEPTED MANUSCRIPT Figure Legends Figure 1. For the posterior approach, the external rotators are detached at their insertion.
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Afterward, the posterior capsule is incised along the base of the femoral neck. A trapezoidal
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posteriorly broad-based capsular flap is created. For the anterior approach, a plane between the tensor fascia lata and gluteus medius is identified. Muscle fibers of the gluteus medius are
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separated at its anterior middle one-third junction, up to 3 cm cephalad to its insertion. The
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combined tendon and periosteum of the gluteus medius and vastus lateralis are separated and detached. Blunt dissection is carried out in a plane between the gluteus minimus and anterior
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capsule. With adequate exposure of the anterior capsule, an anterior capsulotomy is performed. Figure 2a. 25-year-old woman had a highly dislocated right hip with apparent leg length
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discrepancy.
and femoral components.
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Figure 2b. Radiograph obtained immediate postoperatively shows optimal positions of acetabular
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around the implants.
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Figure 2c. Radiograph at 5 year postoperatively shows no evidence of loosening or osteolysis
Figure 3a. 45-year-old man had a spontaneously fused left hip after childhood septic arthritis. Figure 3b. Radiograph obtained immediate postoperatively shows optimal positions of acetabular and femoral components. Figure 3c. Radiograph at 5 year postoperatively shows no evidence of loosening or osteolysis around the implants.
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Figure 3c
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ACCEPTED MANUSCRIPT Table 1. Demographics of patients Male : Female
24 : 41
Mean body mass index (kg/m2) Diagnosis
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Childhood septic arthritis
36
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Developmental dysplasia
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24.5 (18.4 – 33.6)
Previous trauma
7 4
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Previous arthrodesis Sequelae of Perthe’s disease
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62.1 (26 – 81)
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Mean Harris Hip Score
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46.3 (20 – 74)
Mean age (years)
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Number of hips (%) 12 (18.2) 2 (3.0)
Outlier of cup position
14 (21.2)
Infection
0 (0) 2 (3.0)
Heterotopic ossification
2 (3.0)
Paresthesia
7 (10.6)
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Dislocation
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Stem malposition
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Crack at femur
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ACCEPTED MANUSCRIPT Table 3. Clinical Results of Transtrochanteric Approach in Complex Primary Total Hip Arthroplasty
Transtrochanteric
Number of Dislocation (%) 1 (16.7)
207
Transtrochanteric
6 (2.9)
Amstutz[1]
728
Transtrochanteric
NA
Hartofilakidis et al[16]
192
Transtrochanteric
6 (3.1)
Lakstein[22]
53
Transtrochanteric
Wieser[34] Current Study
130 66
Transtrochanteric Combined
NA 2 (3.0)
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NA, not applicable
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Approach-related complication 1 nonunion (16.7%)
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7 nonunion (3.4%) 8 trochanteric displacement 35 nonunion (4.8%) 18 positive Trendelenburg sign 11 bursitis 5 nonunion (2.6%) 29 fibrous union 133 wire breakage 26 trochanteric bursitis 1 nonunion (1.9%)
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2 (3.8)
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Della Valle et al[6] English[10]
Approach
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Number of Hips 6
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16 nonunion (12.3%) -
Other Complications 1 intraoperative fracture 4 prosthesis subluxation 3 infection -
3 heterotopic ossification 5 nerve palsy
12 subsidence 1 hematoma 1 deep infection 7 transient paresthesia 2 heterotopic ossification
S0883-5403(15)00010-8 doi: 10.1016/j.arth.2014.12.025 YARTH 54263
To appear in:
Journal of Arthroplasty
Received date: Revised date: Accepted date:
8 September 2014 4 December 2014 28 December 2014
Please cite this article as: Lee Young-Kyun, Kim Ki-Choul, Ha Yong-chan, Koo Kyung-Hoi, Combined Anterior and Posterior Approach in Total Hip Arthroplasty for Crowe IV Dysplasia or Ankylosed Hips, Journal of Arthroplasty (2015), doi: 10.1016/j.arth.2014.12.025
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Combined Anterior and Posterior Approach in Total Hip Arthroplasty
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for Crowe IV Dysplasia or Ankylosed Hips
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short title; Combined Anterior and Posterior Approach
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Short title; Combined Approach in Complex THA
Young-Kyun Lee, Ki-Choul Kim, Yong-chan Ha, Kyung-Hoi Koo
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Young-Kyun Lee
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Department of Orthopaedic Surgery, Seoul National University Bundang Hospital
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82 Gumi-ro, 173 beon-gil, Bundang-gu, Seongnam-si, 463-707, South Korea Ki-Choul Kim (Corresponding author)
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Department of Orthopedic Surgery, Dankook University School of Medicine
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359, Manghyangro, Dongnam-gu, Cheonan 330-715, South Korea
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Tel: +82-31-787-7204
Fax: +82-31-787-4056
E-mail: [email protected] Yong-Chan Ha Department of Orthopaedic Surgery, Chung-Ang University College of Medicine 224-1 Heukseok-dong, Dongjak-gu, Seoul 156-755, South Korea Kyung-Hoi Koo Department of Orthopaedic Surgery, Seoul National University Bundang Hospital
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82 Gumi-ro, 173 beon-gil, Bundang-gu, Seongnam-si, 463-707, South Korea
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ACCEPTED MANUSCRIPT Abstract We evaluated 70 patients (71 hips) who underwent complex total hip arthroplasty (THA) through
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the combined anterior and posterior approach. Sixty-five patients (32 dislocated hips and 34
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ankylosed hips) were followed-up at a minimum of 3 years (median, 6 years; range, 3-10 years). Seven patients (10.6%), who had transient paresthesia on the anterior thigh, recovered within 3
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months. All patients had a good clinical outcome in terms of hip range of motion, pain and
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recovery of walking. At the latest follow-up, all prostheses had bone-ingrown stability without any detectable wear or osteolysis. The combined approach allows an excellent exposure of the
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acetabulum for accurate cup alignment, leg lengthening and mobilization of joint in complex THA without trochanteric osteotomy, excessive abductor release and femoral shortening
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osteotomy.
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ACCEPTED MANUSCRIPT Introduction Total hip arthroplasty (THA) in patients who have dislocation due to childhood infection or
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dysplasia is challenging, because these patients usually have hypoplastic acetabulum, limb
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shortening and ankylosis of the hip.[1-3]
Surgical concerns during THA for these conditions include; (1) release of joint capsule and
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contracted soft tissue, (2) improvement of limb length discrepancy (LLD), (3) reconstruction of
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hypoplastic acetabulum, and (4) cup implantation with an adequate position and sufficient contact.[1,2,4,5] This challenging THA usually requires extensile surgical approaches, such as
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trochanteric osteotomy, abductor release, and sometimes femoral shortening osteotomy.[2,5,6] However, these procedures can lead to complications, including nonunion of osteotomy site,
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weakness of abductor mechanism and neurovascular injuries.[7]
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The combined approach was first described in 1984 by Tronzo,[8] who recommended it for THA of fused hip and bone grafting in femoral neck fracture. He used two standard approaches:
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posterolateral (Gibson) and anterolateral (Watson-Jones) approaches, through a single lateral
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skin incision. This approach permits good exposure of front and back of the hip joint, which facilitates anterior and posterior capsulectomy, release of contracted muscles, acetabular bone graft, and decreases the necessity of trochanteric or femoral shortening osteotomy. In 1988, Lusskin reported 4 cases of complex THA using the combined approach.[9] Otherwise, no study has reported the usefulness of the combined approach. We have used an isolated posterior approach: the Kocher-Langenbeck approach, as the standard exposure method for THA. However, an additional anterior approach was made in complex THAs 1) when this posterior approach alone could not afford a sufficient exposure of the front of the hip for bone graft on the acetabulum, and 2) when anterior capsule/soft tissue release was
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ACCEPTED MANUSCRIPT necessary for mobilization of the joint, reduction of prostheses and limb lengthening, The anterior approach did not necessitate additional skin incision. We used the original combined
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approach in complex THAs since 1996. However, we experienced difficulty in exposing the
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front of the hip, a damage of abductor muscle due to excessive retraction and varus-insertion of stem. Thus, we have modified the anterior approach from the Watson-Jones approach to the
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Mulliken approach, which permitted better exposure.[10,11]
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The purpose of this study was (1) to describe a surgical technique of the modified combined anterior and posterior approach in a highly dislocated or ankylosed hip with illustrations, and (2)
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to evaluate surgical parameters, acetabular cup position, operative complications, improvement of limb length discrepancy, mobilization of hip joint, bearing surface wear, periprosthetic
Materials and Methods
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osteolysis and implant stability and Harris hip score.
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From May 2003 to December 2010, 70 patients (71 hips) with highly-dislocated or ankylosed
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hips underwent THA using a combined anterior and posterior approach at the authors’ hospital. Five patients (5 hips) were lost to follow-up before a minimum of 3 years after the arthroplasty. The remaining 65 patients (66 hips) were followed for mean 6 years (range, 3 to 10 years) after the THA. There were 24 men (25 hips) and 41 women (41 hips). The mean age of patients at the index operation was 46.3 years (range, 20 to 74 years) and the mean body mass index was 24.5 kg/m2 (range, 18.4 to 33.6 kg/m2). In 32 dislocated hips, the reason for dislocation was developmental dysplasia in 15 hips, childhood septic arthritis in 16 hips, and previous trauma in 1 hip. We measured the limb length on long length alignment films. The limb length was defined as the distance between the iliac
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ACCEPTED MANUSCRIPT crest and ankle mortis.[12] The limb length discrepancy ranged from 1 to 12 cm (mean, 5.5 cm). In 34 ankylosed hips, the reason for ankylosis was childhood septic arthritis in 20 hips, previous
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trauma in 6 hips, previous arthrodesis in 4 hips, and sequelae of Perthe’s disease in 4 hips. These
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ankylosed patients also had leg length discrepancies ranging 0 to 17 cm (mean, 3.8 cm). The mean Harris hip score was 62.1 (range, 26 to 81) at the preoperative evaluation (Table 1).
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All hips were operated with cementless prostheses; PLASMACUP SC® cup with
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BiCONTACT® stem (Aesculap, Tuttlingen, Germany) in 30 hips, Pinnacle cup with Corail stem (DePuy, Saint-Priest, France) in 26, Bencox cup with Bencox stem (Corentec, Seoul, South
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Korea) in 5, Trident cup with Omnifit stem (Stryker Orthopaedics, Mahwah, New Jersey) in 4, and SPH contact cup with C2 stem (Lima, Udine, Italy) in 1 hip.
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BIOLOX Forte alumina head and liner (CeramTec, Plochingen, Germany) were used in 40 hips,
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BIOLOX Delta alumina head and liner (CeramTec) in 24, cobalt chromium head and polyethylene liner in 2 hips. The diameter of the femoral head was 28 mm in 28 hips, 32 mm in
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31, 36 mm in 5 and 22 mm in 2 hips.
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Routine follow-up visits were scheduled for six weeks, then three, six, nine, twelve months, and six months thereafter. Patients who had not returned for regular scheduled visits were contacted by telephone. Two nurses and one private locator found and visited non-responders. Final follow-up evaluation was performed at an average of 6.0 years (range, 3 to 10 years) postoperatively. We reviewed the operation time, estimated blood loss, requirement of transfusion, perioperative complications and postoperative leg length discrepancy. Radiographic evaluations were done by two independent observers who did not participate in the operations. The equalization of leg length discrepancy was measured on three-month long length
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ACCEPTED MANUSCRIPT alignment films. Positions of the acetabular cup and femoral stem were evaluated on six-week anteroposterior radiographs. The abduction angle of the acetabular cup was measured using the
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method described by Engh et al..[13] The anteversion of the acetabular component was
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calculated using the method of Woo and Morrey.[14,15] Cups with an abduction angle of ≤30° or ≥50°,[16] or with an anteversion angle of ≤ 5° or ≥ 25°[17] were considered as outliers for the
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optimal cup position. Stem alignment was determined by measuring the angle formed between
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the longitudinal axis of the femoral stem and the longitudinal axis of the femoral canal.[18] Alignment of the stem was classified as neutral, valgus (> 5° of lateral deviation), or varus (>
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5°of medial deviation).[18]
The implant fixation, wear of bearing surface, periprosthetic osteolysis, and heterotophic
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with those at the final follow-up.
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ossification were evaluated by comparing the six-week anteroposterior radiographs at six-weeks
The fixation of the femoral component was classified with use of the method of Engh et al.[19]
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and the fixation of the acetabular component with use of the method of Latimer and
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Lachiewicz.[20] The wear of liner was calculated according to the method developed by Livermore et al..[21] Osteolytic lesions were defined according the criteria of Engh et al..[22] The lesions were recorded according to the three zones described by DeLee and Charnley[23] on the acetabular side, and the seven zones described by Gruen et al.[24] on the femoral side. Heterotopic ossification was classified according to the system of Brooker et al.,[25] whenever present. Range of hip motion and Harris hip score [26] were measured at the final follow-up. The design and protocol of this retrospective study were approved by the institutional review board, who waived informed consents.
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SURGICAL TECHNIQUE
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Patients were positioned in the lateral decubitus position. All procedures were performed by one
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senior surgeon. For the posterior approach, we used the technique described by Kocher and Langenback.[27] The hip was flexed by 30 degrees and a straight skin incision was made over
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the center of the greater trochanter, equidistant cephalad and caudad to the center of the
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trochanter. The length of the skin incision was about 18 cm.[11] The skin incision was lengthened superiorly and inferiorly to ease the exposure and to avoid a forceful and traumatic
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retraction. The fascia lata was incised and muscle fibers of the gluteus maximus were separated. The trochanteric bursa and fat tissue overlying the short external rotators were removed to
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expose the gluteus medius, short external rotators and sciatic nerve. The external rotators were
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detached with electrocautery at their insertion. Afterward, these muscles were retracted to expose the posterior capsule. The capsule was incised along the base of femoral neck using
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electrocautery. A trapezoidal posteriorly broad-based capsular flap was created. Tight tendinous
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insertion of the gluteus maximus was detached from the proximal femur and tight psoas tendon was released from the lesser trochanter to mobilize the hip joint and to restore the leg length. The posterior acetabular osteophytes, which blocked the dislocation, were removed with a curved osteotome, as required. The femoral head was dislocated posteriorly, the femoral neck was cut and the femoral head was removed. For the anterior exposure, we used the technique described by Mulliken et al..[10] The leg was abducted and externally rotated. A plane between the tensor fascia lata and gluteus medius was found. The adhesion in this plane was separated via blunt dissection, electrocautery or scissors to
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ACCEPTED MANUSCRIPT release the adhesion and flexion contracture of the hip, and to expose the anterior portion of the gluteus medius.
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Muscle fibers of the gluteus medius were separated at its anterior middle one-third junction, up
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to 3 cm cephalad to its insertion. The combined tendon and periosteum of the gluteus medius and vastus lateralis were separated and detached with electrocautery. This division was carried out
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anterior to the trochanter to leave behind a posterior tendinous cuff for suturing later. Distally,
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the dissection was curved posteriorly at the vastus ridge and taken in line with the fibers of the vastus lateralis. A plane between the gluteus minimus and anterior capsule was found proximally.
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Blunt dissection was carried out in this plane to the acetabular rim. With adequate exposure of the anterior capsule, an anterior capsulotomy was performed. Anterior osteophyte was removed.
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The leg was flexed and internally rotated to expose the back of the hip joint. Through the
were inserted (Fig. 1).
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posterior approach, the acetabulum and femur were prepared for implantation and prostheses
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Special care was taken to avoid traction injury of the sciatic nerve due to elongation of the
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operated leg during the process of insertion and reduction of the prostheses. The leg was cautiously pulled down and the tension was checked by manual palpation. Avoiding excessive tension, the amount of elongation was determined and the stem size and neck-length of the head were chosen. After implantation and reduction of the trial prosthesis, we checked the acetabular cup position and the axis of contact between the prosthetic head and acetabular liner. Then, we checked the residual flexion contracture of the hip by extending the joint. The goal of releasing the flexion contracture was an extension of 10 degrees, which is necessary for the
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Possible tight anterior structures, including the reflected head of rectus femoris, tensor fascia lata
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and sartorius were identified by palpating and/or inspecting. When the tensor fascia lata was tight, an oblique fasciotomy was performed between the greater trochanter and anterior superior
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iliac spine. Tight rectus femoris was released at the anterior inferior iliac spine. Tight sartorius
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was released at the anterior superior iliac spine, taking care of the lateral cutaneous nerve. Finally, we rechecked the axial stability of the hip joint, using the Shuck test,[28] anterior
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stability by extension/external rotation and posterior stability by flextion/internal rotation. Careful attention was paid to the suture of the muscular layers. In the posterior side, the capsule
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and short external rotators were tightly repaired to 3 drill holes in the trochanteric crest.[11] In
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the anterior side, divided gluteus minimus was approximated and sutured. The anterior flap of
cuff.[11]
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the gluteus medius and vastus lateralis were approximated and sutured to the posterior tendinous
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After the insertion of a closed suction drainage, the fascia and skin were closed. After dressing the wound, the patient was transferred to supine position and the hip was abducted. When abduction was less than 15 degrees, tight adductor tendon was identified by palpation. Adductor tenotomy was performed using electrocautery through a short longitudinal stab wound over the tight tendon. Twenty-nine patients (29 hips) had residual defect of the capsule and muscle due to release of hip contracture and/or limb lengthening, in which soft tissue could not be tightly repaired. In these patients, abduction brace was applied for 6 weeks to prevent dislocation. After removal of the drain at 2 days postoperatively, patients were encouraged to walk with toe-
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ACCEPTED MANUSCRIPT touch weight bearing with the aid of two crutches for four weeks, and then were allowed weight-
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bearing as tolerated.
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Results
The mean operation time was 194.5 minutes (range, 92-280 minutes), the mean amount of
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estimated blood loss (EBL) was 832.7 ml (range, 200-1800 ml), and the mean amount of
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transfusion was 449.2 ml (range, 0-1600 ml).
Crack at the femoral neck occurred in 12 hypoplastic femurs during the insertion of the stem,
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which was successfully treated by a cerclage wire. Seven patients complained of a paresthesia or tingling sensation at the anterior thigh or anterolateral aspect of the lower leg, all of which
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recovered within 3 months.
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Mean postoperative leg length discrepancy was 2.9 cm (range, from 0 to 7 cm) in patients with dislocated hips (Fig. 2), and 2.1 cm (range, from 0 to 12 cm) in patients with ankylosed hips. The
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discrepancy was restored to less than 2 cm in 42 patients (64.6 %). In hips which were operated
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due to ankylosis, the mean postoperative flexion was 82.2° (range, 60° - 120°), the mean
extension was 12.2° (range, 0° - 30°) and the mean abduction was 31.1° (range, 10° - 40°) (Fig. 3). The mean cup abduction angle was 39.7 ± 6.7 (range, 19 to 51) and the mean anteversion was 21.6 ± 7.9 (range, 6 to 39). The number of outliers in cup position was 14. One stem was placed in varus and one in valgus. Two hips dislocated at postoperative 2 and 8 weeks, respectively. They were treated successfully with closed reduction and abduction bracing for two months.
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ACCEPTED MANUSCRIPT All of the acetabular cups and femoral stems had radiographic evidence of bone ingrown stability at the time of the last follow-up. There were no focal osteolysis and no measurable wear in any
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hip. Booker grade I heterotopic ossification developed in 2 hips (Table 2).
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The mean Harris hip score was 89.4 (range, 72 to 100) at the final follow-up. Four patients (4 hips) had intermittent thigh pain, but they did not need any analgesics. Although three patients
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used a shoe-lift, no patient used any kind of walking support.
Discussion
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Currently, most primary THAs are performed through either a direct anterior, lateral or posterolateral approach.[29] However, transtrochanteric approach is widely used for extensile
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exposure and soft tissue release in highly dislocated or ankylosed hips.[30,31] Some times,
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femoral shortening osteotomy should be done to reduce the prosthetic femoral head. In the transtrochanteric approach, the greater trochanter is osteomized and re-attached with wires
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or cable grip, which can induce complications including wire or cable breakage, trochanteric
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fragment migration, nonunion, bursitis, and metallosis. In a review of 68 trochanteric osteotomies, which were repaired with Dall-Miles cable grip system (Howmedica, Rutherford, NJ), trochanteric nonunion occurred in 25%, with fraying and fragmentation of the cable. Among the 51 patients with trochanteric union, 35% also had signs of fraying and fragmentation. Osteolysis around the cable was seen in 10%. Metallosis at the inferior border of the acetabulum were seen in 12%.[32] Combined approach has also been used in THAs of ankylosed hips. Li et al. operated 76 hips of 47 patients with use of a combined anterior and posterior approach and reported good to excellent results in 2 to 11 year follow-up.[33] We used a lateral approach instead of anterior
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ACCEPTED MANUSCRIPT approach in the combined approach of our patients. Our combined approach enabled a satisfactory restoration of leg length and mobilization of hip in complicated THAs of dislocated
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and ankylosed hips. This approach spares of the abductor mechanism and avoids morbidities of
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trochanteric osteotomy.[7] This approach affords an excellent exposure both front and back of the hip joint and can be extended distally to expose the femoral shaft, if needed.
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There were several limitations in our study. First, our study was a retrospective review of
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prospectively followed patients. However, a prospective study on this topic was not feasible, because the necessity of additional anterior approach was decided during the operation. Second,
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our study did not include a comparison with other approaches, such as transtrochanteric approach. Because we were already informed and concerned about osteotomy-related adverse effects, we
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did not recruit a comparison group of transtrochanteric approach. Our results were comparable
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with or better than those of the previous studies of complex THAs using transtrochanteric approach, which had approach-related complications including nonunion and bursitis (Table
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3).[6,34-38] Despite these limitations, the strength of our study is that it is the first study
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presenting the results of modified combined anterior and posterior approach for complex THA. In conclusion, our study demonstrated that a combined approach can facilitate complex THA of dislocated or ankylosed hips, which necessitate an entire exposure of the hip for capsule/muscle release and joint mobilization.
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extended sliding trochanteric osteotomy. International orthopaedics 2011;1:13 38. Wieser K, Zingg P, Dora C. Trochanteric osteotomy in primary and revision total hip arthroplasty: risk factors for non-union. Arch Orthop Trauma Surg 2012;5:711
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ACCEPTED MANUSCRIPT Acknowledgment No benefits in any form have been received or will be received from any commercial party
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related directly or indirectly to the subject of this article.
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ACCEPTED MANUSCRIPT Figure Legends Figure 1. For the posterior approach, the external rotators are detached at their insertion.
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Afterward, the posterior capsule is incised along the base of the femoral neck. A trapezoidal
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posteriorly broad-based capsular flap is created. For the anterior approach, a plane between the tensor fascia lata and gluteus medius is identified. Muscle fibers of the gluteus medius are
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separated at its anterior middle one-third junction, up to 3 cm cephalad to its insertion. The
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combined tendon and periosteum of the gluteus medius and vastus lateralis are separated and detached. Blunt dissection is carried out in a plane between the gluteus minimus and anterior
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capsule. With adequate exposure of the anterior capsule, an anterior capsulotomy is performed. Figure 2a. 25-year-old woman had a highly dislocated right hip with apparent leg length
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discrepancy.
and femoral components.
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Figure 2b. Radiograph obtained immediate postoperatively shows optimal positions of acetabular
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around the implants.
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Figure 2c. Radiograph at 5 year postoperatively shows no evidence of loosening or osteolysis
Figure 3a. 45-year-old man had a spontaneously fused left hip after childhood septic arthritis. Figure 3b. Radiograph obtained immediate postoperatively shows optimal positions of acetabular and femoral components. Figure 3c. Radiograph at 5 year postoperatively shows no evidence of loosening or osteolysis around the implants.
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Figure 1
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Figure 2a
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Figure 2b
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Figure 2c
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Figure 3a
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Figure 3b
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Figure 3c
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ACCEPTED MANUSCRIPT Table 1. Demographics of patients Male : Female
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Mean body mass index (kg/m2) Diagnosis
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Childhood septic arthritis
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Developmental dysplasia
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24.5 (18.4 – 33.6)
Previous trauma
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Previous arthrodesis Sequelae of Perthe’s disease
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62.1 (26 – 81)
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Mean Harris Hip Score
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46.3 (20 – 74)
Mean age (years)
ACCEPTED MANUSCRIPT Table 2. Complications Complication
Number of hips (%) 12 (18.2) 2 (3.0)
Outlier of cup position
14 (21.2)
Infection
0 (0) 2 (3.0)
Heterotopic ossification
2 (3.0)
Paresthesia
7 (10.6)
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Dislocation
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Stem malposition
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Crack at femur
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ACCEPTED MANUSCRIPT Table 3. Clinical Results of Transtrochanteric Approach in Complex Primary Total Hip Arthroplasty
Transtrochanteric
Number of Dislocation (%) 1 (16.7)
207
Transtrochanteric
6 (2.9)
Amstutz[1]
728
Transtrochanteric
NA
Hartofilakidis et al[16]
192
Transtrochanteric
6 (3.1)
Lakstein[22]
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Transtrochanteric
Wieser[34] Current Study
130 66
Transtrochanteric Combined
NA 2 (3.0)
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Approach-related complication 1 nonunion (16.7%)
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7 nonunion (3.4%) 8 trochanteric displacement 35 nonunion (4.8%) 18 positive Trendelenburg sign 11 bursitis 5 nonunion (2.6%) 29 fibrous union 133 wire breakage 26 trochanteric bursitis 1 nonunion (1.9%)
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Della Valle et al[6] English[10]
Approach
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Number of Hips 6
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16 nonunion (12.3%) -
Other Complications 1 intraoperative fracture 4 prosthesis subluxation 3 infection -
3 heterotopic ossification 5 nerve palsy
12 subsidence 1 hematoma 1 deep infection 7 transient paresthesia 2 heterotopic ossification
