Dislocation After Total Hip Arthroplasty Using Hueter Anterior Approach

The Journal of Arthroplasty Vol. 23 No. 2 2008 Dislocation After Total Hip Arthroplasty Using Hueter Anterior Approach Elhadi Sariali, MD, Philippe Leonard, MD, and Patrick Mamoudy, MD Abstract: A prospective study including 1764 hips has been carried out to evaluate the frequency of dislocation while using the Hueter anterior approach and the correlated factors. The dislocation group was compared with the patients without dislocation. We observed 27 dislocations (1.5%). The dislocation rate when using 28 mm head diameter was 0.5%. Two patients underwent a revision for recurrent dislocations. Correlated factors for dislocation were male sex, high body mass index, etiology of osteonecrosis, low head diameter, high bleeding, and low postoperative ROM. Dislocation risk while using Hueter approach is one of the lowest in the literature. The main disadvantages are the necessity for a specific orthopedic table and a more difficult exposure of the femur. Key words: total hip arthroplasty, dislocation, Hueter anterior approach. © 2008 Elsevier Inc. All rights reserved. Dislocation after total hip arthroplasty is a frequent complication with a prevalence ranging from 1% to 9% in the literature (Figs. 1-3). According to the Swedish National Hip Arthroplasty Register [1], dislocation is the third cause for revisions (5%), after aseptic loosening (75.7%) and sepsis (7.5%). Bozic et al [2] reviewed the results of 243 revisions performed at a tertiary medical center. Recurrent dislocation was the third most common mode of failure leading to revision, after osteolysis and loosening. The surgical approach has been clearly identified as a risk factor (Figs. 1-3). The prevalence of dislocation for posterolateral approaches is twice as important than for anterolateral approaches (Fig. 3). We found only one study [3] in the literature regarding the dislocation rate after total hip arthroplasty using a mini-incision anterior approach. The present study tries to evaluate the dislocation rate for anterior approaches. Materials and Methods A prospective noncomparative, nonrandomized study was carried out at our hospital between January 1997 and December 2003. Two senior surgeons performed 1764 consecutive primary total hip arthroplasties in 1374 patients, using a modified Hueter anterior approach. No trainees were involved in these procedures. This technique, as described by Siguier et al [3], allows an anatomical approach without muscle or tendon sections. All patients underwent general anesthesia. The patients were positioned supine on an orthopedic table (Tasserit, Sens, France) (Fig. 4) allowing traction, rotation, adduction, and lowering of the lower limb to the ground. The skin incision was centered on the apex of the great trochanter, parallel to a line joining the anterosuperior iliac crest to the fibula head (Fig. 5). First, the superficial aponeurosis of the fascia lata tensor was incised, and the muscle was detached from it. We used 2 retractors to charge the tensor laterally and retract the sartorius muscle medially. The lateral femoral cutaneous nerve runs between these 2 muscles and is protected by the anterior part of the superficial aponeurosis (Fig. 6). We then cut the innominate aponeurosis and tied off the anterior circumflex From the Department of Orthopaedic Surgery and Traumatology, Hôpital de la Croix Saint-Simon, Paris, France. No benefits or funds were received in support of this study. Reprint requests: Elhadi Sariali, MD, 154 rue de picpus 75012 Paris. © 2008 Elsevier Inc. All rights reserved. 0883-5403/08/2302-0018$34.00/0 doi:10.1016/j.arth.2007.04.003 266 Dislocation After Total Hip Arthroplasty Using Hueter Anterior Approach  Sariali et al 267 Fig. 1. Dislocation rate for posterior or posterolateral approach [23-25]. Fig. 2. Dislocation rate for transtrochanteric approach. vessels (Fig. 7). The iliacus and the rectus femoris were retracted medially to expose the anterior capsula (Fig. 8). It is useful to section the reflected tendon of the rectus femoris in very muscular patients before performing the anterior capsulectomy. Dislocation on the table was obtained through progressive traction and external rotation by manually rotating the knee at 90°. This required a trained surgical aide to manipulate the orthopedic table. As a matter of fact, a fracture may occur in the femur, knee, tibia, or ankle if the perioperative dislocation is done improperly. The femur neck was cut using an oscillating saw, thus exposing the acetabulum. The femur was conveniently exposed using external rotation, adduction, and lowering of the lower limb to the floor (Fig. 9). The exposure may be improved by cutting the posterolateral capsula. Our study included 891 women and 483 men, with an age range from 22 to 94 years (mean, 69.2 years; SD, 10.8 years). We operated on 996 right and 768 left hips. Indications were osteoarthritis (91.2%), avascular necrosis of the femoral head (7.3%), and tumors (1.5%) (Fig. 10). The prosthesis has a cemented stainless steel stem and nonretentive polyethylene cup (Tornier, Grenoble, France). The size of the femoral head was 22 mm in 1123 cases (63%) and 28 mm in 641 cases (37%). All the patients had 2-dimensional perioperative radiographic planning using templates to determine appropriate stem and cup sizes and osteotomy level of the femoral neck to avoid length discrepancy. We did not use any specific implementation device or fluoroscopy. Full weight-bearing rehabilitation and limb mobilization started the first day after surgery. The only postoperative precaution was limb crossing in a sitting position causing excessive external rotation, which may result in dislocation. All patients were reviewed clinically and radiographically at 45 days, 3 months, and 1 year postoperatively. The rate of those lost to follow up was 0% at 3 months and 27% at 1 year. The dislocation group was compared with the patients without dislocation. Various clinical and radiographic factors were analyzed in each group: age, sex, body mass index, diagnosis, range of motion (ROM), intraoperative blood loss, femoral head size, and cup position. The ROM was determined before surgery and at 3 months postoperatively; we used the values of flexion, extension, abduction, Fig. 3. Dislocation rate for anterolateral approach. 268 The Journal of Arthroplasty Vol. 23 No. 2 February 2008 Fig. 6. The lateral femoral cutaneous nerve runs between these 2 muscles (dashed line) and is protected by the anterior part of the superficial aponeurosis. Fig. 4. Patient is positioned supine on an orthopedic table allowing traction, rotation, adduction, and lowering of the lower limb. adduction, external rotation, internal rotation, and the global ROM calculated as the sum of these values. The evaluation of acetabular cup anteversion used the Pradhan [4] method. Every patient had plain pelvic x-rays as well as frontal and lateral hip x-rays before and after surgery. Distribution of variables for each group was tested for normality using the Ryan-Joiner and ShapiroWilk tests. For normally distributed variables, when the 2 groups had the same variances, differences between them were analyzed using Student t test. For abnormally distributed variables or normally distributed variables with different variances, we used the Mann-Whitney test. For qualitative parameters, we used χ2 test. A P value of less than .05 was considered to be significant. Results We found 27 (1.5%), patients with at least one dislocation, 13 (0.7%) of which occurred during the hospital stay and 14 (0.8%) after returning home. Fig. 5. The skin incision is centered on the apex of the great trochanter (vertical line), parallel to a line joining the anterosuperior iliac crest to the fibula head. All dislocations were anterior. All dislocations were early, between the 1st and the 56th postoperative days (mean, 13.8 days; SD, 15.2 days). We had 19 single dislocations, 6 double dislocations, and only 2 patients with more than 2 (mean, 1.37; SD, 0.62). The risk of a second dislocation was estimated at 26%. The dislocating mechanism in 15 cases occurred with the patient sitting in a chair and trying to stand up with a fully extended hip. One patient underwent surgery to reduce the hip without changing the implants. Two patients underwent a revision for recurrent dislocations. In one case, cup anteversion was 30° and thus modified, so we implanted an identical but less anteverted cup. In the other case, a patient with Down Syndrome did not observe the functional recommendations and had a double mobility cup implanted. We observed 21 femoral neck fractures, 7 femoral false reaming routes, and 1 great trochanter fracture during surgery. Femoral neck fractures did not cause mechanical failure, and osteosynthesis was not necessary. These patients had full weight bearing immediately after surgery. The great trochanter fracture was not displaced and did not need complementary osteosynthesis, but the patient had no weight bearing at 45 days. At 3 months' followup, his fracture had fused, and he was walking without limping. The false reaming routes had been Fig. 7. The innominate aponeurosis is incised, then the anterior circumflex vessels are tied off. Dislocation After Total Hip Arthroplasty Using Hueter Anterior Approach  Sariali et al Fig. 8. The iliacus and the rectus femoris are retracted medially to expose the anterior capsule. Sometimes, the reflected tendon of the rectus femoris is cut. Capsule is exposed. 269 P < .001). The perioperative ROM was higher in the dislocation group because there was a higher value for the global ROM (181 vs 164, P = .03), abduction (27 vs 22, P = .04), and external rotation (28 vs 22, P = .01). The postoperative ROM was lower in the dislocation group because we noted a lower value for the global ROM (206 vs 221, P = .006). We found no significant difference between the 2 groups for cup anteversion and operating time (72 vs 68 minutes). Discussion detected and corrected during the initial procedure and were without consequences. Nevertheless, we did not observe considerable heterotopic ossifications during follow-up. All these femoral complications occurred during the 250 first procedures. The dislocation group was composed of 65% men and only 35% women, giving a significant sex ratio (P < .001). The age range was 41 to 79 years (mean, 62.3 years; SD, 10.8 years) with an average of 6.95 years less than patients without dislocation (P < .001) (Fig. 11). Body mass index of patients with dislocation was 11.5% higher (P < .001) compared with the patients without dislocation (Fig. 12). In the meantime, osteonecrosis prevalence was significantly increased in the group of patients with dislocation (P < .001) (Fig. 13). Perioperative bleeding was also higher in the group of patients with dislocation, with an average increase of 186 mL. The dislocation rate with the 28-mm femoral head was 4.5 times lower in comparison to the 22-mm head (0.5% vs 2%, Only one study in the literature mentions dislocation rate after total hip arthroplasty using an anterior approach [3]. Our rate is only slightly higher, but their revision rate for recurrent dislocation is higher. Anterolateral approaches appear to have the lowest dislocation rate, ranging between 0% [5] to 3.3% [6], with an average of about 2% (Fig. 3), which is twice lower than for posterior approaches (Fig. 1). The dislocation rate for trochanterotomy is about 1.6% (Fig. 2). However, anterolateral and transtrochanteric approaches have several disadvantages. Indeed, complications associated with the transtrochanteric approach involve wire rupture, granuloma, and trochanteric nonunion, which are reported at rates of 8% [7-12]. Anterolateral approaches present a higher risk of heterotopic periprosthetic calcifications [5,13-15]. The lowest dislocation rate is obtained with the transmuscular approach as described by Hardinge [14] and modified by Frndak [13], but, on the other hand, it results in a longer postoperative painful limp Fig. 9. The femoral canal is exposed using external rotation, adduction, and lowering of the lower limb to the floor. 270 The Journal of Arthroplasty Vol. 23 No. 2 February 2008 Fig. 10. Dislocation rate by perioperative diagnoses. combined with an increased rehabilitation period and, more importantly, electromyographic abnormalities [16]. Recently, the meta-analysis by Kwon and colleagues [17] has shown that soft tissue repair after a posterior approach highly reduces the dislocation risk to a rate of about 0.49%. According to Pellicci et al [18], with this repair, the dislocation rate ranges from 0% to 0.8%. Suh and colleagues [19] found a 1% rate of dislocations. These studies include only a small number of hips (395 and 160 for Pellicci et al [18], 96 for Suh and colleagues [19]). The results are thus very interesting but have to be confirmed with larger cohorts. In comparison to the other approaches, our patients with dislocation were both younger and more active. Early return to an active lifestyle is a common dislocation risk factor. Indeed, most of our patients did not experience very much pain, which may be explained by the fact that we did not cut any muscle during surgery. The major disadvantage of this technique lies in the necessity of a specific surgical table requiring a trained aide. In fact, a femur fracture may occur when dislocating the hip or reaming the femur. The femoral fractures were located at the femoral neck and occurred during the reaming procedure, but they did not cause a mechanical failure, and immediate weight bearing was possible. These complications are probably due to the more difficult exposure of the femur. Great trochanter fractures are more difficult to manage. In fact, we think that osteosynthesis is not needed if they are not displaced because there is a continuity of the abductor muscles. In the case of important displacement, we think that osteosynthesis should be achieved, perhaps using another approach. These femoral complications occurred during the 200 first procedures and are probably due to the learning curve of the surgical approach because at present, we have no more femoral complications. Furthermore, at the moment, we choose the surgical approach in function of the probable procedure complexity. So, we do not use this minimal invasive anterior approach in case of severe femoral abnormalities such as those in developmental dysplastic hips or hip stiffness. In our study, there is a higher prevalence of osteonecrosis in the dislocation group (P < .001). Ortiguera et al [20] also reported this hypothesis, but they did not find any significant differences in their study. The perioperative ROM was higher in the dislocation group, especially for external rotation that produces dislocation, but postoperatively, the ROM was lower in this group. This result is coherent because a restricted ROM due to unfavorable implant design or positioning may cause impingement or dislocation [21]. In comparison with the study by Byström et al [22], we found that the dislocation rate was significantly higher when using 22-mm femoral Fig. 11. Patients with dislocation are 6.95 years younger (P < .001). Fig. 12. High body mass index is a correlated factor for dislocation (P < .001). Dislocation After Total Hip Arthroplasty Using Hueter Anterior Approach  Sariali et al Fig. 13. Aseptic femoral head necrosis is a correlated factor (P < .001). heads (2%) rather than 28-mm heads (0.5%). However, this Norwegian study was not homogenous, with 7 different prosthesis brands as well as different approaches. Conclusion The anterior approach minimizes the rate of dislocation after primary total hip arthroplasty. Dislocation rate after leaving the hospital is 0.8%, equivalent to that of the translateral approach [13], and the revision rate for instability is 0.11%. In the case of 28 mm head diameter, the rate of dislocation is one of the lowest in the literature, about 0.5%. 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