In Hip Replacement, Less Invasive Procedure Is More

CHICAGO — Less invasive hip and knee arthroplasty techniques continue to progress and bring new advantages for patients, said Dr. Bryan J. Nestor.

Anterior two-incision total hip arthroplasty (THA), only recently touted as being “revolutionary,” is falling into disfavor and many surgeons have abandoned this approach, said Dr. Nestor at a symposium sponsored by the American College of Rheumatology. “There are indications that the two-incision THA causes significant gluteus medius and minimus muscle destruction, so muscle sparing it's probably not,” he said. Furthermore, the piriformis and conjoint tendons, which are the external rotators of the hip, are ruptured or damaged in about 70% of patients, “and you can't repair them. But most humbling has been the high complication rate associated with this procedure in the hands of very experienced total hip surgeons: femoral fracture, neuropraxia, a 25% incidence of lateral femoral cutaneous nerve palsies, and a 5%–10% reoperation rate,” said Dr. Nestor of the Hospital for Special Surgery, New York.

The approach favored by Dr. Nestor is the posterior mini-incision THA. With this procedure, surgeons can gradually decrease the lengths of their incisions. It also affords good direct visualization and works well with cemented or uncemented components. The dislocation rate with posterior mini-incision THA is unchanged from that of the standard approach, recovery may be less painful, and it produces only one relatively small scar. Patient body mass index should ideally be under 30 kg/m

“It's important to avoid the mini incision in complicated THA; patients who require hardware removal, osteotomy correction, or bone grafting at the time of the procedure are not candidates for a limited exposure to the hip,” Dr. Nestor said, going on to describe the procedure: “The incision is placed along the posterior border of the greater trochanter, about 6–10 cm in length. It's slightly angulated anteriorly at the distal point, and it's centered on a point midway between the tip of the trochanter and the vastus ridge. Proximal extension of the incision facilitates femoral exposure, and distal extension facilitates acetabular exposure,” he said.

Dr. Nestor is heading an ongoing study comparing 55 patients (62 hips) who underwent the mini posterior approach with 38 patients (46 hips) who had the standard surgical approach. Most of the stems were cemented. From 6-week to 1-year follow-up, there was no difference in clinical performance as measured by the Harris Hip Score. In addition, there were no significant differences in cup positioning, femoral component positioning, blood loss, or complications between the two groups. “Interestingly, there were more superficial wound problems in the standard approach than in the mini approach, and that probably reflects the larger body mass index of patients in the standard incision group,” he said, concluding that the mini THA incision can be done safely.

CHICAGO — Less invasive hip and knee arthroplasty techniques continue to progress and bring new advantages for patients, said Dr. Bryan J. Nestor.

Anterior two-incision total hip arthroplasty (THA), only recently touted as being “revolutionary,” is falling into disfavor and many surgeons have abandoned this approach, said Dr. Nestor at a symposium sponsored by the American College of Rheumatology. “There are indications that the two-incision THA causes significant gluteus medius and minimus muscle destruction, so muscle sparing it's probably not,” he said. Furthermore, the piriformis and conjoint tendons, which are the external rotators of the hip, are ruptured or damaged in about 70% of patients, “and you can't repair them. But most humbling has been the high complication rate associated with this procedure in the hands of very experienced total hip surgeons: femoral fracture, neuropraxia, a 25% incidence of lateral femoral cutaneous nerve palsies, and a 5%–10% reoperation rate,” said Dr. Nestor of the Hospital for Special Surgery, New York.

The approach favored by Dr. Nestor is the posterior mini-incision THA. With this procedure, surgeons can gradually decrease the lengths of their incisions. It also affords good direct visualization and works well with cemented or uncemented components. The dislocation rate with posterior mini-incision THA is unchanged from that of the standard approach, recovery may be less painful, and it produces only one relatively small scar. Patient body mass index should ideally be under 30 kg/m

“It's important to avoid the mini incision in complicated THA; patients who require hardware removal, osteotomy correction, or bone grafting at the time of the procedure are not candidates for a limited exposure to the hip,” Dr. Nestor said, going on to describe the procedure: “The incision is placed along the posterior border of the greater trochanter, about 6–10 cm in length. It's slightly angulated anteriorly at the distal point, and it's centered on a point midway between the tip of the trochanter and the vastus ridge. Proximal extension of the incision facilitates femoral exposure, and distal extension facilitates acetabular exposure,” he said.

Dr. Nestor is heading an ongoing study comparing 55 patients (62 hips) who underwent the mini posterior approach with 38 patients (46 hips) who had the standard surgical approach. Most of the stems were cemented. From 6-week to 1-year follow-up, there was no difference in clinical performance as measured by the Harris Hip Score. In addition, there were no significant differences in cup positioning, femoral component positioning, blood loss, or complications between the two groups. “Interestingly, there were more superficial wound problems in the standard approach than in the mini approach, and that probably reflects the larger body mass index of patients in the standard incision group,” he said, concluding that the mini THA incision can be done safely.

CHICAGO — Less invasive hip and knee arthroplasty techniques continue to progress and bring new advantages for patients, said Dr. Bryan J. Nestor.

Anterior two-incision total hip arthroplasty (THA), only recently touted as being “revolutionary,” is falling into disfavor and many surgeons have abandoned this approach, said Dr. Nestor at a symposium sponsored by the American College of Rheumatology. “There are indications that the two-incision THA causes significant gluteus medius and minimus muscle destruction, so muscle sparing it's probably not,” he said. Furthermore, the piriformis and conjoint tendons, which are the external rotators of the hip, are ruptured or damaged in about 70% of patients, “and you can't repair them. But most humbling has been the high complication rate associated with this procedure in the hands of very experienced total hip surgeons: femoral fracture, neuropraxia, a 25% incidence of lateral femoral cutaneous nerve palsies, and a 5%–10% reoperation rate,” said Dr. Nestor of the Hospital for Special Surgery, New York.

The approach favored by Dr. Nestor is the posterior mini-incision THA. With this procedure, surgeons can gradually decrease the lengths of their incisions. It also affords good direct visualization and works well with cemented or uncemented components. The dislocation rate with posterior mini-incision THA is unchanged from that of the standard approach, recovery may be less painful, and it produces only one relatively small scar. Patient body mass index should ideally be under 30 kg/m

“It's important to avoid the mini incision in complicated THA; patients who require hardware removal, osteotomy correction, or bone grafting at the time of the procedure are not candidates for a limited exposure to the hip,” Dr. Nestor said, going on to describe the procedure: “The incision is placed along the posterior border of the greater trochanter, about 6–10 cm in length. It's slightly angulated anteriorly at the distal point, and it's centered on a point midway between the tip of the trochanter and the vastus ridge. Proximal extension of the incision facilitates femoral exposure, and distal extension facilitates acetabular exposure,” he said.

Dr. Nestor is heading an ongoing study comparing 55 patients (62 hips) who underwent the mini posterior approach with 38 patients (46 hips) who had the standard surgical approach. Most of the stems were cemented. From 6-week to 1-year follow-up, there was no difference in clinical performance as measured by the Harris Hip Score. In addition, there were no significant differences in cup positioning, femoral component positioning, blood loss, or complications between the two groups. “Interestingly, there were more superficial wound problems in the standard approach than in the mini approach, and that probably reflects the larger body mass index of patients in the standard incision group,” he said, concluding that the mini THA incision can be done safely.