EL-MINIA MED., BULL., VOL. 19 NO. 2, JUNE, 2008
Mohamed
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DIRECT ANTERIOR MINI INCISION HIP REPLACEMENT
By
Mohamed Ali Ahmed Mohamed
Department of Orthopedic surgery and Trauma,
El-Minia Faculty of Medicine
ABSTRACT:
Introduction: Minimally invasive surgery (MIS) for hip replacement has become widely
discussed. MIS approach has to be less invasive to the skin, muscles, and bone, thus may
reduce complications and improve recovery. Most anterior and anterolateral mini-incision
approaches used the interval between the abductors and tensor fascia lata with risk of
muscle damage from excessive retraction. Purpose: This prospective study described the
technique and early results of the direct approach for anterior mini incision (DAMI) hip
replacement through splitting of the tensor fascia lata. Material & Methods: twenty nine
consecutive hip arthroplasties (20 hemi- and 9 total) were done through a DAMI
approach, with no muscle damage by excessive retraction or cutting. Neither special
instruments nor specially designed prostheses were needed. The average follow-up period
was 14.3 (range 10-24) months. Results: The average operative time for hemiarthroplasty was 45 minutes while that for THA was 70 minutes. The average Harris hip
score at the end of follow up was 90 (range 79-97). In cases with THA, the average cup
abduction angle was 40.5° (range, 36-44°). The average anteversion was 18.4° (range, 422°). No femoral stem mal-alignment was recorded. All the patients were allowed to
weight bear in the second post-operative day and involved in an early rehabilitation
program. No intra-operative or major post-operative complications were encountered.
Conclusions: DAMI hip approach is safe and gives excellent orientation for positioning
of prosthesis components. It also allows early and smooth post-operative rehabilitation
with fast recovery, and short hospitalization. The cosmetic appearance was very
satisfactory.
KEYWORDS:
Hip arthroplasty
Mini-incision.
Minimally invasive hip arthroplasty
INTRODUCTION:
Recently,
surgeons
and
patients become more interested in mini
invasive surgery (MIS) especially for
hip replacement. The goals were less
soft tissue disruption, less operative
time, decreased blood loss, improved
cosmoses, shorter hospital stay, faster
rehabilitation, and less complications1.
Most anterior and anterolateral mini
incision approaches use the interval
between the tensor fascia lata and the
glutei muscles, initially described by
Sayre in 18943 and later modified by
Watson-Jones4.
The reported disadvantages of
MIS include complexity, need to special
instruments, muscle damage, improper
implant positioning, and increased
complication rate5-10. Cadaver studies
showed damage to gluteus minimus in
8%, tensor fascia lata in 31%, and direct
head of the rectus in 12% and the
piriformis had to be released to mobilize
the femur in 50%11,12. Mow et al.,6
reported poor cosmetic results. Woolson
et al.,9 reported increased risk for
periprosthetic fractures, however, the
incidence of fractures with long
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Mohamed
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incisions reported to be 2-6%13. Other
authors reported better results with MIS
than the traditional approaches14-17 with
faster recovery and high patient
satisfaction.
2004 to July 2006. Hemi-arthro-plasty
was done in 20 patients with fractured
femoral neck and non-degenerative
acetabulum. These included 10 bipolar
and 10 unipolar prostheses. THR was
done in 9 patients; 6 with hip
osteoarthritis, and 3 with fractured
femoral neck and degenerative acetabulum. There were 17 males and 12
females. The age of the patients ranged
between 60 and 90 years with an
average of 71.4 years. The average BMI
of the patients was 24.4 (range 17.330.4), (Tables I, II).
This
prospective
study
describes the technique and early results
of the direct anterior mini incision
(DAMI) hip replacement approach
through splitting of tensor fascia lata.
MATERIAL & METHODS:
DAMI approach was used to treat
29 patients in the period from February
Table 1: Classification of patients according to their age:
Age
60-70
70-80
80-90
Total
No. of patients
17
7
5
29
Table 2: Classification of patients according to the used prosthesis:
Prosthesis
Total
Unipolar
Bipolar
Total
No. of patients
9
10
10
29
acetabular rim directly over the upper
border of the neck (Fig. 1, 2). Subcutaneous tissue and fascia were divided
in line with the skin incision. The
intermuscular plane between the
abductors the tensor fascia lata is
palpated. The bone of the neck of
femur is palpated under the fibers of
the tensor and can be verified by the carm. Blunt splitting of the tensor over
the neck by fingers or blunt instrument
till the capsule appears, 2 rounded
Hohmann’s retractors are placed and
splitting was completed with periosteal
elevator (Fig. 3). No severe retraction
is needed as the incision and
dissections are directly over the neck
Preoperative planning:
This is important especially
with MIS as visualization of the extraarticular landmarks
is
limited.
Technique details including level of
femoral neck cut, prosthetic neck
length, component offset, accurate
acetabular
positioning
were
determined.
Surgical Technique
In supine position, the hip is
prepped and draped with the affected
leg able to move freely. Skin incision,
5-7 cm, is made on a line extending
from the anterior tubercle of the
greater
trochanter
towards
the
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Mohamed
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and not through the intermuscular
interval which is not in line with the
neck. The glutei are saved completely
from cutting and retraction. A sharp
broad retractor is placed over the
anterior rim of the acetabulum. The
capsule is incised in H shaped manner
with the first vertical limb over the
acetabular rim, the transverse limb
directly over the neck of femur, and
the second vertical limb is at the
capsular attachment to the intertrochanteric line. The Hohmann retractors
are moved from an extracapsular to an
intracapsular position. Stay sutures are
taken at the capsular edges for later
repair in hemiarthroplasty cases.
osteotomies in non-traumatic cases.
The osteotomies are made with the hip
externally rotated (Fig. 4). The acetabulum is prepared in THR cases (Fig.
5), and the femur is prepared in all
cases, (Fig. 6). Fluoroscopy may be
used to determine proper positioning
of the trial implants. This was done in
6 cases; 2 early in the study, the 2
obese females, and the 2 muscular
males. After final reduction, the
capsule is closed or approximated as
much as possible with the leg in mild
internal rotation in hemiarthroplasty
cases. A drain is used in some cases if
there is question about hemostasis. The
splitted fibers of the tensor are then
approximated. Subcutaneous tissue
and skin then are closed. Xylocain is
injected into the joint, soft tissues and
skin to decrease the post-operative
pain.
After determination of the
required length of the neck, the
femoral head and neck are removed in
two segments using one osteotomy
plus the fracture line and two
Follow up:
Follow up was carried out every 2
weeks for 3 months after surgery,
then monthly for 1 year, and annually
thereafter till they become satisfied
with the level of activity they reached
or end of the study. We used the
Harris hip score40 (Table 3) for
evaluation at the end of the follow up
period. X-rays were done at
immediate post-operative, 3 months
post-operative, and at final follow up.
The average follow-up period was
14.3 months (range 10-24) months.
Post-operative management:
From the second post-operative
day, sitting & standing positions were
permitted. All the patients could bear
weight on the affected side with or
without walking aids and physio-therapy
started. The patients were taught by the
physiotherapist during
hospital to
continue active physiotherapy at home
after discharge.
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Table III: Harris Hip Score
Pain:
� None or ignores it (44)
� Slight, occasional, no compromise in activities (40)
� Mild pain, no effect on average activities
� Moderate Pain, tolerable but makes concession to pai, rarely moderate pain with
unusual activity; Some limitation of ordinary activity or work. May require may take aspirin
(30)
�Occasional pain medication stronger than aspirin (20)
� Marked pain, serious limitation of activities (10)
� Totally disabled, crippled, pain in bed, bedridden (0)
Limp:
� None (11)
� Slight (8)
� Moderate (5)
� Severe (0)
Support:
� None (11)
� Cane for long walks (7) � Cane most of time (5) � One crutch (3)
� Two canes (2)
� Two crutches or not able to walk (0)
Distance Walked:
� Unlimited (11) � Six blocks (8) � Two or three blocks (5) � Indoors only (2)
� Bed and chair only (0)
Sitting:
� Comfortably in ordinary chair for one hour (5)
� Unable to sit comfortably in any chair (0)
� On a high chair for 30 minutes (3)
Enter public transportation:
� Yes (1)
� No (0)
Stairs:
� Normally without using a railing (4)
� In any manner (1)
� Normally using a railing (2)
� Unable to do stairs (0)
Put on Shoes and Socks:
� With ease (4)
Absence of Deformity
� With difficulty (2)
� Unable (0)
(All yes = 4; Less than 4 =0)
Less than 30° fixed flexion contracture
Less than 10° fixed abduction
Less than 10° fixed internal rotation in extension
Limb length discrepancy less than 3.2 cm
� Yes
� Yes
� Yes
� Yes
� No
� No
� No
� No
Range of Motion (*indicates normal)
Flexion (*140°) ________
Abduction (*40°) ________ Adduction (*40°) _______
External Rotation (*40°) _____
Internal Rotation (*40°) _______
Range of Motion Scale:
211° - 300° (5)
161° - 210° (4)
31° - 60° (1)
0° - 30° (0)
Range of Motion Score: ____________
101° - 160° (3)
61° - 100 (2)
Total Harris Hip Score ____________
RESULTS:
The average operative time for
hemi-arthroplasty was 45 minutes
(range 35-65) and for THA was 70
minutes (range 55-90). The average
blood loss was 200 ml (range 100250) and no blood transfusion was
required. No major intra-operative
complications were encountered.
Difficulty in femoral exposure was
encountered in 2 obese females with
(BMI >30) that necessitates more 2
cm extension of the incision. Also,
piriformis release was required in 2
muscular males.
All patients were allowed for
weight bearing on the affected side
by the second postoperative day.
Walking aids were allowed for
patients who need it. No cases of
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EL-MINIA MED., BULL., VOL. 19 NO. 2, JUNE, 2008
Mohamed
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limp were encountered secondary to
abductor insufficiency as the abductor mechanism was not interfered
with by this approach. The average
hospital stay was 2.6 days ranging
between 2 and 6 days.
DISCUSSION:
The literatures become replete
with reports about the advantages,
safety, and patient satisfaction with
mini
incision
hip
replace7,10,11,15,17
ment
. A small incision
gives the patients more hope for less
injury, faster recovery, better
cosmoses and regaining their
activities without disability. Matta
et al.,18 reported that the main
advantage of MIS for hip
arthroplasty is avoidance of
violating the abductor tendons. Huo
and Gilbert19 reported that controversies remain about the term,
clinical efficacy, social and
financial issues of mini incision hip
arthroplasty. Many authors consider
muscle sparing to be more important than smaller incision for
achieving faster rehabilitation. Soft
tissues trauma with MIS may occur
with muscle cutting or by stress
from retractors or reamer handle19.
Our (DAMI) approach offered both
the small (5-7 cm) incision and the
muscle sparing by avoiding cutting
or excessive retraction. This
allowed
safety
and
rapid
rehabilitation.
The standard approaches have
their own disadvantages. The lateral
approach frequently complicated by
postoperative limp due to injury of
the abductors or the superior gluteal
nerve20. Traditional posterior approach is associated with a high rate of
dislocation due to division of the
posterior capsule21. Capsular repair
may decrease the rate of dislocation22, or may not23. The anterior
approach provides good exposure
for prosthesis implantation24 with a
lower risk of dislocation25. But, it is
usually associated with partial
division of gluteus medius and
minimus that lead to limp and high
risk of superior gluteal nerve
injury26. Obrant et al27 reported 23%
This approach allowed easy
and consistent acetabular component insertion in the 9 THA cases.
Analysis of the post-operative x-ray
revealed that the mean cup
abduction angle was 40.5° (range,
36-44°). The mean anteversion was
18.4° (range, 4-22°). No femoral
stem mal-alignment was recorded.
Adjustment of the limb length was
good with an average leg-length
discrepancy of 0.4 mm (range 0-7
mm).
No
major
post-operative
complications were detected as
dislocation, deep infection, or DVT.
Three cases had early superficial
wound infection within 2 weeks
postoperatively. All have been
cured within one week with daily
dressing and antibiotic therapy. One
case had a sinus discharging nonoffensive serosangeonous material
started 3 months postoperatively.
Repeated culture and sensitivity
revealed no growth. This was
managed by daily dressing till the
sinus closed.
At the end of the follow up
period (14-24 months), the mean
Harris hip score for the patients was
90 (range 79-97). All the patients
were satisfied except one who was
always complaining of pain in the
affected hip without any obvious
cause as infection, loosening, or
malalignment. He was managed
with analgesics and psychological
analysis.
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decrease in abduction strength after
anterolateral
exposure.
Being
anterior approach, DAMI provides
good exposure for easy and
consistent component positioning
and less dislocation risk. Being
direct, it avoids muscle harm by
excessive retraction with no
postoperative limp.
sion of the incision to avoid wound
edge trauma.
Acetabular orientation has
been implicated in dislocation32.
Woolson et al.,9 reported accurate
acetabular component positioning in
96% of patients with abduction
angles (35°-50°), and anteversion
angles (10°-25°). In this study, the
mean cup abduction angle was
40.5° (range, 36-44°) and the mean
anteversion angle was 18.4° (range,
8-22°).
In comparing anterior-lateral
MIS and conventional approach,
Asayama et al.,28 reported that the
only significant difference was
blood loss. With anterolateral MIS
approach, Bertin29 reported that the
mean operative time was 61 minutes,
the mean blood loss was 350 ml.
Also, he reported infrequent injury
to the lateral femoral cutaneous
nerve, abductor weakness without
abductor release, 7 fractures, 4
dislocations, and one cup migration.
In our study, the average operative
time was 45 minutes for hemiarthroplasty and 70 minutes for THA. No
major complications were detected
such as dislocation, limp, deep
infection, fractures, or nerve palsy.
Matta 200430 advocated the use of
fluoroscopy to facilitate reaming,
rasping, and component positioning.
In our study, Fluoroscopy was used
to determine proper positioning of
the trial implants in 6 cases; 2 early
in the study, in the 2 obese females,
and in the 2 muscular males.
Femoral
preparation
is
challenging in anterior approaches.
Many authors reported fractures and
recommended the use of modified
rasps, special tables, and navigation33. Our procedure led to easy
preparation with consistent component alignment, with no need for
special instruments, special table, or
navigation. Woolson et al.,9 reported 78% leg length discrepancy of 5
mm or fewer. In our study, the
average leg-length discrepancy was
0.2 mm (range 0-4 mm).
Most authors agree that
patients should be mobilized as
quickly as possible. Some advocated same-day discharges to
home34, others recommend hospital
stay for at least 3-4 days35. With our
mini-incision, weight-bearing was
allowed from the 2nd post-operative
day and fast recovery was possible.
The average hospital stay was 2.6
(range 2-6) days.
A BMI > 30 is viewed by
some authors as a contraindication
for an MIS approach to hip
replacement, while others do not see
it as an impediment31. In our study,
we had only 2 female patients with
a BMI > 30. We extended their
incision for more 2 cm and all the
procedure was completed smoothly
after that. We did not consider
obesity as a contraindication for this
procedure, but, we advocate exten-
Kelley et al.,36 reported 2-10%
dislocation rate after THR with bad
prognosis37. The accused factors
were approach type, capsular
opening, implant positioning, and
instability38,39. Matta et al.,18 reported 0.6% dislocation rate despite of
muscle sparing. In our study, the
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dislocation rate was zero. We
thought that this was attributed to
the intactness of the posterior
capsule, proper implant positioning,
repair of most of the anterior
capsule, repair of the soft tissues in
mild internal rotation, thus the
affected limb will not take an
external rotation position postoperatively.
done with a standard or a miniincision. Clin Orthop Relat Res.
2005;441:80-5.
7- Szendroi M, Sztrinkai G,
Vass R, et al., The impact of
minimally invasive total hip arthroplasty on the standard procedure. Int
Orthop. 2006; 30: 167-71.
8- Teet JS, Skinner HB,
Khoury L. The effect of the mini
incision in total hip arthroplasty on
component position. J Arthroplasty.
2006; 21: 503-7.
9- Woolson ST, Mow CS,
Syquia JF, et al., Comparison of
primary total hip replacements
performed with a standard incision
or a mini-incision. J Bone Joint
Surg Am. 2004; 86: 1353-8.
10-Howell JR, Garbuz DS,
Duncan CP. Minimally invasive hip
replacement: rationale, applied anatomy, and instrumentation. Orthop
Clin North Am. 2004; 35: 107-18.
11- Berger RA, Jacobs JJ,
Meneghini RM, et al., Rapid
rehabilitation and recovery with
minimally invasive total hip
arthroplasty. Clin Orthop Relat Res.
2004; 429: 239-47.
12- Meneghini RM, Pagnano
MW, Trousdale RT, et al., Muscle
damage during MIS total hip
arthroplasty: Smith-Peterson versus
posterior approach. Clin Orthop
Relat Res. 2006; 453: 293-8.
13-Berend ME, Smith A,
Meding JB, et al., Long-term
outcome and risk factors of proximal femoral fracture in uncemented and cemented total hip arthroplasty in 2551 hips. J Arthroplasty.
2006; 21 (suppl 2): 53-9.
14- Chimento GF, Pavone V,
Sharrock N, et al., Minimally
invasive total hip arthroplasty: a
prospective randomized study. J
Arthroplasty. 2005; 20: 139-44.
15- Kim YH. Comparison of
primary total hip arthroplasties
CONCLUSIONS:
DAMI hip approach is safe
and gives excellent orientation for
positioning of prosthesis components. It also allows early and
smooth post-operative rehabilitation
with fast recovery and short
hospitalization time that have
significant social and financial
benefits without a detrimental effect
on outcome. The cosmetic appearance was very satisfactory.
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‫الملخص العربى‬
‫ واهم ما يميز هزذا الجراحزات‬.‫أصبحت الجراحات ذات التدخل البسيط حديث جميع األوساط الطبية‬
‫قلة التداخل مع األنسجة الرخوة والجلد والعظام ممزا يتوقزع أي يز دل الزى نتزاضل أمضزل ومضزا ات‬
.‫أقل‬
‫وتشرح هذا الدراسة طريقة الجراء هذا الجراحة مى استبدال م صل ال خذ ي طريز شز العضزلة‬
.‫الشادة للص اق بمنطقة ال خذ وتبر النتاضل األولية لها‬
‫وشملت الدراسة تسعا و شريي مريضا أجرل لتسع منهم م اصل صزنا ية ااملزة ولعشزريي اخزريي‬
‫ شزهرا وأظهزرت النتزاضل أي متوسزط طريقزة‬١٤‚٣ ‫ وااي متوسط مترة المتابعة‬.‫م اصل نصف ااملة‬
‫ هزذا وقزد‬.‫ ولزم ترصزد أل مضزا ات ذات قيمزة لهزذا الطريقزة‬٩٠ ‫هاريس لتقيزيم م صزل ال خزذ ازاي‬
.‫استطاع معظم المرضى المشى مي اليوم الثانى الجراء العملية‬
‫وخلصنا مي هذا الدراسة الى أي هزذا الطريقزة امنزة وتسزهل مليزة ترايزص الم صزل وتسزم بت هيزل‬
.‫سريع للمرضى ومترة اقامة أقل بالمستش ى‬
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