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1.  The minimal invasive direct anterior approach in combination with large heads in total hip arthroplasty - is dislocation still a major issue? a case control study 
Background
There have been increasing numbers of publications in recent years on minimally invasive surgery (MIS) for total hip arthroplasty (THA), reporting results with the use of different head sizes, tribologic and functional outcomes. This study presents the results and early complication rates after THA using the direct anterior approach (DAA) in combination with head sizes ≥ 36 mm.
Methods
A total of 113 patients with THA were included in the study. The Harris Hip Score (HHS) was determined, a radiographic evaluation was carried out, and complications were recorded. The minimum follow-up period was 2 years (means 35 ± 7 months).
Results
The HHS improved from 43.6 (± 12) to 88.2 (± 14; P < 0.01). One early infection occurred, one periprosthetic fracture, and three cases of aseptic stem loosening. No incorrect positioning of the implants was observed, and there were no dislocations.
Conclusion
THA with the minimally invasive DAA in combination with large heads is associated with good to very good functional results in the majority of cases. The complication rates are not increased. The rate of dislocation mainly as an complication of the first two years can be markedly reduced in particular.
doi:10.1186/1471-2474-15-80
PMCID: PMC3975181  PMID: 24621189
Direct anterior approach; Large heads; Minimal invasive surgery; Total hip arthroplasty; Dislocation rate
2.  Total hip arthroplasty using a combined anterior and posterior approach via a lateral incision in patients with ankylosed hips 
Canadian Journal of Surgery  2013;56(5):332-340.
Background
For most patients with severely ankylosed hips, traditional surgical approaches do not provide sufficient exposure during THAs. We report our experience with a combined anterior and posterior approach using a lateral incision for total hip arthroplasty (THA) in patients with severe, spontaneous bony hip ankylosis.
Methods
Between January 2004 and December 2008, patients with severe, spontaneous bony hip ankylosis underwent THA via a combined anterior and posterior approach using a lateral incision.
Results
We included 47 patients (76 hips) with a mean age of 53 (range 22–72) years in our study. All surgeries were successful, and no significant postoperative complications occurred. The mean operative duration was 1.5 (range 1.3–1.7) hours, and mean blood loss was 490 (range 450–580) mL. The mean duration of follow-up was 5.5 (range 2–11) years. Harris hip score improved from 53 to 88 points postoperatively, and the outcome was good to excellent in 88.37% of cases. Heterotopic ossification occurred in 6 hips, and infection, which resolved with antibiotics, occurred in 1 patient.
Conclusion
This combined anterior and posterior approach to THA using a lateral incision in patients with severe, spontaneous ankylosis provides very good exposure, protects the abduction unit and results in good to excellent postoperative recovery.
doi:10.1503/cjs.000812
PMCID: PMC3788012  PMID: 24067518
3.  Comparison of a minimally invasive posterior approach and the standard posterior approach for total hip arthroplasty A prospective and comparative study 
Background
It is not clear whether total hip arthroplasty performed via a minimally invasive approach leads to less muscle trauma compared to the standard approach.
Materials and methods
To investigate whether a minimally invasive posterior approach for total hip arthroplasty results in lower levels of muscle-derived enzymes and better post-operative clinical results than those obtained with the standard posterolateral approach fifty patients in both groups were compared in a prospective and comparative study. The following parameters were examined: muscle-derived enzymes CPK, CK-MM and myoglobin pre-operatively, 24 and 48 hours post-operatively, CRP and hemoglobin on the third postoperative day, loss of blood, daily pain levels, the rate of recovery (time taken to attain predefined functional parameters), the Oxford Hip Score, the SF-36 score and the WOMAC score pre-operatively and six weeks post-surgery, the position of the implant and the cement coating by post-operative X-ray examination.
Results and Conclusions
The minimally invasive operated patients exhibited a significantly lower loss of blood, significantly less pain at rest and a faster rate of recovery but the clinical chemistry values and the other clinical parameters were comparable.
doi:10.1186/1749-799X-5-46
PMCID: PMC2918552  PMID: 20663200
4.  Anterior muscle sparing approach for total hip arthroplasty 
World Journal of Orthopedics  2013;4(1):12-18.
The purpose of this review is to examine the validity of positive claims regarding the direct anterior approach (DAA) with a fracture table for total hip arthroplasty. Recent literature regarding the DAA was searched and specific claims investigated including improved early outcomes, speed of recovery, component placement, dislocation rates, and complication rates. Recent literature is positive regarding the effects of total hip arthroplasty with the anterior approach. While the data is not definitive at present, patients receiving the anterior approach for total hip arthroplasty tend to recover more quickly and have improved early outcomes. Component placement with the anterior approach is more often in the “safe zone” than with other approaches. Dislocation rates tend to be less than 1% with the anterior approach. Complication rates vary widely in the published literature. A possible explanation is that the variance is due to surgeon and institutional experience with the anterior approach procedure. Concerns remain regarding the “learning curve” for both surgeons and institutions. In conclusion, it is not a matter of should this approach be used, but how should it be implemented.
doi:10.5312/wjo.v4.i1.12
PMCID: PMC3557317  PMID: 23362470
Total hip arthroplasty; Anterior approach; Hip; Arthritis; Joint replacement
5.  Minimally invasive total hip arthroplasty with the anterior approach 
Indian Journal of Orthopaedics  2008;42(3):301-308.
Background:
Total hip athroplasty with the anterior surgical approach is advised because the dissection is entirely within intermuscular planes. In this report we describe a minimally invasive technique of anterior total hip arthroplasty, with the early outcomes.
Materials and Methods:
The technique of minimally invasive total hip arthroplasty with anterior approach (Smith-Petersen) is described. We reviewed data on 100 consecutive patients who underwent anterior total hip arthroplasty with uncemented components. Mean patient age was 61 years (range 33-91). Mean patience BMI 29.8 (range 18.1-51.8).
Results:
Minumum follow up duration is 10 months. The mean duration of surgery was 53 min (range 34-87) with mean blood loss 185 cc (range 65-630), and the mean incision length was 10.4 cm. Clinical and radiographic outcomes were similar to historical outcomes of standard total hip arthroplasty.
Conclusions:
With proper surgeon training, minimally invasive total hip replacement with the anterior surgical interval is safe and efficacious.
doi:10.4103/0019-5413.41853
PMCID: PMC2739476  PMID: 19753156
Total hip arthroplasty; minimally invasive surgery; Anterior approach of hip
6.  The impact of minimally invasive total hip arthroplasty on the standard procedure 
International Orthopaedics  2006;30(3):167-171.
Minimally invasive total hip arthroplasty using a short skin incision is a subject of much debate in the literature. The present study estimates the possible minimal length of the exposure in an unselected patient cohort and compares the lateral mini-incision technique and traditional total hip arthroplasty (THA). One hundred and two patients were divided into three groups according to the type of surgery and length of incision: mini-incision (less than 10 cm) was performed in 38 patients; midi-incision (10–14 cm) in 43; and standard-incision (longer than 14 cm) in 21 patients. No statistical difference was found with regard to intraoperative and total blood loss, the rate of complications, and postoperative recovery. Significantly decreased body mass index (BMI), shorter operative time, and higher number of hips with malpositioning of the acetabular cup were found in the mini-incision group. These patients, however, experienced less pain in the early postoperative period and were highly satisfied with the cosmetic results. The length of incision was shortened and optimized (less than 14 cm) in 82% of patients, and mini-incision was performed in 38 patients of this unselected cohort. Because of the understandable demand of the patients for less invasive intervention, the surgeon should use a smaller but not necessarily mini-incision with minimal soft tissue trauma that still allows him to perform the procedure well, without compromising the type of implants and the otherwise excellent long-term results. Randomized prospective studies are needed to explore the real value of the minimally invasive total hip arthroplasty.
doi:10.1007/s00264-005-0049-8
PMCID: PMC2532092  PMID: 16552579
7.  Primary total hip arthroplasty: a comparison of the lateral Hardinge approach to an anterior mini-invasive approach 
Orthopedic Reviews  2009;1(2):e27.
The anterior mini-invasive (MI) approach to performing total hip arthroplasty (THA) is associated with less soft tissue damage and shorter postoperative recovery than other methods. Our hospital recently abandoned the traditional lateral Hardinge (LH) approach in favour of this new method. We compared the first 100 patients operated after the changeover to the new method (MI group) to the last 100 patients operated using the traditional method (LH group). Clinical and radiological parameters and complications were recorded pre- and postoperatively and the collected data of the two groups were statistically compared. There were no statistically significant differences between either group with regard to patient demographics or procedural data, placement of the femur component, postoperative leg discrepancy, prosthesis dislocation, blood transfusion, or postoperative dislocation of the components. The MI group had a significantly longer operating time, more bleeding, higher rate of nerve damage, and a higher percentage of acetabular component malposition whilst having a significantly shorter hospital stay and significantly fewer infections of the operative site in comparison to the LH group. Additionally, and perhaps most worrying was the clinically significant increase in intraoperative femur fractures in the MI group. The changeover to the anterior mini-invasive approach, which was the surgeons' initial experience with the MI technique, resulted in a drastic increase in the number of overall complications accompanied by less soft tissue damage and a shorter period of rehabilitation. Our results suggest that further analysis of this surgical MI technique will be needed before it can be recommended for widespread adoption.
doi:10.4081/or.2009.e27
PMCID: PMC3143982  PMID: 21808689
orthopedics; joint surgery; hip surgery; mini-invasive surgery; anterior approach; Hardinge; total hip arthroplasty.
8.  A modified two-incision technique for primary total hip arthroplasty 
Indian Journal of Orthopaedics  2008;42(3):267-274.
Background:
Minimally invasive surgery can be technically demanding but minimizes surgical trauma, pain and recovery. Two-incision minimally invasive surgery allows only intermittent visualization and may require fluoroscopy for implant positioning. We describe a modified technique for primary total hip arthroplasty, using two small incisions with a stepwise approach and adequate visualization to reliably and reproducibly perform the surgery without fluoroscopy.
Materials and Methods:
One hundred and two patients with an average age of 60 years underwent modified two-incision minimally invasive technique for primary THA without fluoroscopy. The M/L taper femoral stem (Zimmer, Warsaw, IN) and Trilogy (Zimmer) hemispherical titanium shell, with a highly cross-linked polyethylene liner, was used. Operative time, blood loss, postoperative hospital stay, radiographic outcomes and complications were recorded.
Results:
The mean operating time was 77 min. The mean blood loss was 335 cc. The mean hospital stay was 2.4 days. Mean cup abduction angle was 43.8°. Mean leg length discrepancy was 1.7 mm. Thirteen patients had lateral thigh numbness and two patients had wound complications that resolved without any treatment.
Conclusion:
A modified two-incision technique without fluoroscopy for primary total hip arthroplasty has the advantage of preserving muscles and tendons, shorter recovery and return to function with minimal complications. Provided that the surgeon has received appropriate training, primary total hip arthroplasty can be performed safely with the modified two-incision technique.
doi:10.4103/0019-5413.41850
PMCID: PMC2739461  PMID: 19753151
Minimally invasive surgery; total hip arthroplasty; two-incision surgery for THA
9.  Comparison between Bipolar Hemiarthroplasty and Total Hip Arthroplasty for Unstable Intertrochanteric Fractures in Elderly Osteoporotic Patients 
PLoS ONE  2012;7(6):e39531.
The present study was conducted to compare bipolar hemiarthroplasty (BA) with total hip arthroplasty (THA) in treatment of unstable intertrochanteric fractures in elderly osteoporotic patients. The THA group included 14 males and 26 females with a mean age of 73.4 years, and the BA group included 27 males and 45 females with a mean age of 76.5 years. Significant difference existed between the two groups in operation time, blood loss, transfusion volume and cost of hospitalization, while no remarkable difference was identified in hospitalization period, general complications, joint function, pain, rate of revision and mortality. No dislocation was observed in BA group while 3 occurred in THA group. The results indicated that for unstable intertrochanteric fractures in elderly osteoporotic patients, BA seems to be a better or more reasonable choice compared with THA for the reason of less blood loss, shorter operation time, lower cost and no dislocation.
doi:10.1371/journal.pone.0039531
PMCID: PMC3382155  PMID: 22745778
10.  Process optimized minimally invasive total hip replacement 
Orthopedic Reviews  2012;4(1):e3.
The purpose of this study was to analyse a new concept of using the the minimally invasive direct anterior approach (DAA) in total hip replacement (THR) in combination with the leg positioner (Rotex- Table) and a modified retractor system (Condor). We evaluated retrospectively the first 100 primary THR operated with the new concept between 2009 and 2010, regarding operation data, radiological and clinical outcome (HOOS). All surgeries were perfomed in a standardized operation technique including navigation. The average age of the patients was 68 years (37 to 92 years), with a mean BMI of 26.5 (17 to 43). The mean time of surgery was 80 min. (55 to 130 min). The blood loss showed an average of 511.5 mL (200 to 1000 mL). No intra-operative complications occurred. The postoperative complication rate was 6%. The HOOS increased from 43 points pre-operatively to 90 (max 100 points) 3 months after surgery. The radiological analysis showed an average cup inclination of 43° and a leg length discrepancy in a range of +/− 5 mm in 99%. The presented technique led to excellent clinic results, showed low complication rates and allowed correct implant positions although manpower was saved.
doi:10.4081/or.2012.e3
PMCID: PMC3348691  PMID: 22577504
total hip replacement; minimally invasive anterior approach; Rotex-Table; navigation system; economic reasons; ergonomic working process.
11.  Total Hip Arthroplasty Using Two-Incision Technique 
Clinics in Orthopedic Surgery  2011;3(4):268-273.
Background
To evaluate the effectiveness of minimally invasive surgery total hip arthroplasty (THA) using the two-incision technique as described by Mears.
Methods
From January 2003 to December 2006, sixty-four patients underwent total hip arthroplasty using the one-incision (group I) and two-incision (group II) technique by one surgeon. There were 34 hips in group I and 30 hips in group II. There was no difference in age, gender, and causes of THA between the two groups. We evaluated the operation time, bleeding amount, incision length, ambulation, hospital stay, and complications between the two groups.
Results
There was no difference in the bleeding amount between the two groups. Operation time was longer in the two-incision group than in the one-incision group. Operation time of the two-incision technique could be reduced after 15 cases. Patients started ambulation after surgery earlier in group II than group I, and the hospital stay was shorter in group II than in group I. There was no difference in clinical results between the two groups. There was no difference in component position of the acetabular cup and femoral stem between the two groups. Intraoperative periprosthetic fracture occurred in four cases (13.3%) in group II.
Conclusions
Two-incision THA has the advantage of rapid recovery and shorter hospital stay. However, longer operation time and a high complication rate compared to one-incision are problems that need to be solved in the two-incision technique.
doi:10.4055/cios.2011.3.4.268
PMCID: PMC3232353  PMID: 22162788
Total hip arthroplasty; Minimal invasive surgery; Two-incision technique
12.  Learning curve in tissue sparing total hip replacement: comparison between different approaches 
Background
The tissue sparing surgery (TSS) concept means not only smaller incisions but also less tissue disruption, allowing decreased blood loss and improved function. However, TSS techniques can result in more complications related to the learning curve. The aim of this study was to compare the learning curve of an experienced surgeon with different TSS approaches for total hip replacement (THR) from a clinical and surgical point of view, focussing especially on complications related to the use of different geometric stems.
Materials and methods
Sixty patients scheduled to be operated for a primary THR were enrolled in the study and were randomly assigned to surgery by one of three different TSS approaches: lateral with mini incision (group A), minimally invasive anterior (group B) and minimally invasive antero-lateral (group C). Results from the three TSS groups were compared with a control group of 149 patients (group D).
Results
Our results reveal significantly reduced blood loss in the TSS groups compared with the control group, with no differences between the TSS groups. We found better early functional scores in the two minimally invasive groups (anterior and anterolateral), and a lower rate of complications with the antero-lateral TSS approach.
Conclusion
The antero-lateral TSS approach seems to be safer and less demanding than standard THR surgery, and is suitable for use with different stems.
doi:10.1007/s10195-008-0043-1
PMCID: PMC2657353  PMID: 19384637
Antero-lateral approach; Hip replacement; Learning curve; Tissue sparing surgery
13.  Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: perioperative findings 
Background
Given the increasing demand for tissue-sparing surgery, the surgical approach is the subject of lively debate in total hip replacement. The aim of this paper is to compare the efficacy of the minimally invasive direct anterior approach and the standard lateral approach to total hip replacement surgery by observing intra- and perioperative outcomes.
Materials and methods
The authors conducted a retrospective study on a group of 419 consecutive patients undergoing total hip replacement for coxarthrosis. The patients were divided into a first group (A) of 198 patients who had surgery with the standard lateral approach, and a second control group (B) of 221 patients who had the same procedure via the minimally invasive direct anterior approach. Assessment of the two groups considered the following perioperative parameters: length of the surgical procedure, intraoperative complications, intra- and postoperative blood loss, postoperative pain, postoperative nausea and vomiting, length of stay, and type of discharge.
Results
The two groups were homogeneous when compared in relation to mean age, sex and body weight. The minimally invasive direct anterior approach was performed within an acceptable time (89 ± 19 min vs. 81 ± 15 min) and with modest blood loss (3.1 ± 0.9 g/dL vs. 3,5 ± 1 g/dL). Patients experienced less pain (1.4 ± 1.5 NRS score vs. 2.5 ± 2 NRS score), and PONV affected only 5% versus 10% of cases. Times to discharge were shorter (7 ± 2 days vs. 10 ± 3.5 days), and 58.4% versus 11.6% of patients were discharged to home.
Conclusions
In our study, patients treated with a minimally invasive direct anterior approach had a better perioperative outcome than patients treated with the lateral approach. The longer time of surgery for the minimally invasive direct anterior approach may be attributed to the learning curve. Further studies are necessary to investigate the advantages of a minimally invasive direct anterior approach in terms of clinical results in the short and long run.
doi:10.1007/s10195-011-0144-0
PMCID: PMC3163771  PMID: 21748384
Hip arthroplasty; Surgical technique; Direct anterior approach; Minimally invasive surgery
14.  Minimally invasive total hip arthroplasty: a systematic review 
International Orthopaedics  2009;33(6):1473-1481.
The purpose of this study was to compare the operative outcome between mini and standard incisions in total hip arthroplasty (THA). We identified 12 randomised or quasi-randomised control trials (RCT or qRCT) published between 1996 and 2008. Subgroup and sensitivity analyses were performed to evaluate the differences in results for surgical approach, trial quality, and follow-up duration. Operative time and blood loss were significantly reduced in the mini-incision group for studies with the posterior or posterolateral approach. Concerning postoperative complications, there were no significant differences between the two groups with no significant heterogeneity. No differences were observed between the two groups for Harris hip score and radiographic results except for cup anterversion. Although mini-incision appeared to have similar outcomes compared to standard incision, the follow-up is short-term according to current standards in THA. High-quality studies are required to compare the outcomes of these two procedures.
doi:10.1007/s00264-009-0743-z
PMCID: PMC2899157  PMID: 19277652
15.  Incidence of Lateral Femoral Cutaneous Nerve Neuropraxia After Anterior Approach Hip Arthroplasty 
Background
Although injury to the lateral femoral cutaneous nerve (LFCN) is a known complication of anterior approaches to the hip and pelvis, no study has quantified its’ incidence in anterior arthroplasty procedures.
Questions/purposes
We therefore defined the incidence, functional impact, and natural history of LFCN neuropraxia after an anterior approach for both hip resurfacing (HR) and primary total hip arthroplasty (THA).
Methods
We followed 132 patients who underwent an anterior hip approach (55 THA; 77 HR). We administered self-reported questionnaires for sensory deficits of LFCN, neuropathic pain score (DN4), visual analog scale, as well as SF-12, UCLA, and WOMAC scores at one year postoperatively. A subset of 60 patients (30 THA; 30 HR) was evaluated at two time intervals.
Results
One hundred seven patients (81%) reported LFCN neuropraxia with a mean severity score of 2.32/10 and a mean DN4 score of 2.42/10. Hip resurfacing had a higher incidence of neuropraxia as compared with THA: 91% versus 67%, respectively. No functional limitations were reported on SF-12, WOMAC, or UCLA scores. Of the subset of 60 patients followed over an average of 12 months, 53 (88%) reported neuropraxia at the first followup interval with only three (6%) having complete resolution at second followup. Improvement in DN4 scores was observed over time: 3.6 versus 2.5, respectively.
Conclusions
Although LFCN neuropraxia was a frequent complication after anterior approach THA, it did not lead to functional limitations in our patients. A decrease in symptoms occurred over time but only a small number of patients reported complete resolution.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1406-5
PMCID: PMC2919880  PMID: 20532717
16.  Posterior single-incision approach to minimally invasive total hip arthroplasty 
International Orthopaedics  2007;31(Suppl 1):1-5.
Enhanced surgical techniques and instrumentation enable surgeons to perform total hip arthroplasties through minimally invasive approaches. Using incisions typically less than 10 cm in length, surgeons can achieve adequate visualization of the surgical site while minimizing trauma to deep soft tissues. Associated reductions in morbidity should allow for improved rehabilitation and recovery. Although these techniques have been met with some controversy, a number of recent studies appear to attest to their safety and efficacy. Many of these studies have concentrated on a posterior single-incision technique for total hip arthroplasty. Favorable results for such outcomes as operative times, complication rates, pain, functional recovery, and blood loss have been reported, and patient satisfaction has been high. If surgeons and their patients are to achieve maximum benefit from minimally invasive total hip arthroplasties, it will be necessary to design effective educational tools that address the learning curve associated with these approaches.
doi:10.1007/s00264-007-0436-4
PMCID: PMC2267518  PMID: 17653544
17.  Comparison of Minimally Invasive Total Hip Arthroplasty versus Conventional Hemiarthroplasty for Displaced Femoral Neck Fractures in Active Elderly Patients 
Chonnam Medical Journal  2013;49(2):81-86.
Fractures of the femoral neck in elderly patients can be treated by internal fixation, hemiarthroplasty, or total hip arthroplasty (THA), and the treatment modality used should be determined on the basis of considerations of the degree of fracture displacement, age, functional demands, and the risk factors for surgery and anesthesia. We studied 85 active elderly patients who underwent minimally invasive two-incision THA or conventional bipolar hemiarthroplasty (BHA) within 2 weeks of injury for the treatment of acute displaced femoral neck fractures. Patients were followed up for a minimum of 24 months. The average operation times were 70 minutes in the THA group and 46 minutes in the BHA group (p=0.002), and average blood losses during the perioperative period were 921 cc and 892 cc, respectively (p=0.562). In the THA group, the average postoperative Harris hip score was 88.3 and the average Western Ontario and McMaster University score was 28.8, whereas in the BHA group the corresponding scores were 80.4 (p=0.006) and 32.5 (p=0.012), respectively. There were 2 cases of hip dislocation in the THA group, and 2 cases in the BHA group underwent conversion to THA. Our short-term follow-up results were better for minimally invasive two-incision THA than for conventional BHA for the treatment of acute displaced femoral neck fractures in active elderly patients.
doi:10.4068/cmj.2013.49.2.81
PMCID: PMC3759687  PMID: 24010071
Femoral neck fractures; Arthroplasty; Hemiarthroplasty
18.  Minimally Invasive versus Classic Procedures in Total Hip Arthroplasty: A Double-blind Randomized Controlled Trial 
Background
For total hip arthroplasty (THA), minimally invasive surgery (MIS) uses a smaller incision and less muscle dissection than the classic approach (CLASS), and may lead to faster rehabilitation.
Questions/purposes
Does minimally invasive hip arthroplasty result in superior clinical outcomes?
Patients and Methods
In this double-blind randomized controlled trial, 120 consecutive primary noncemented THAs in 120 patients were assigned to one of two groups (MIS or CLASS). The randomization sequence was stratified for two groups of surgeons, ie, those using a posterolateral approach (PL-CLASS or PL-MIS) and those using an anterolateral approach (AL-CLASS or AL-MIS). Length of the incisions was 18 cm for the CLASS procedures. MIS incisions were extended at the skin level to 18 cm at the end of the procedure. The primary end point was the Harris hip score (HHS) at 6 weeks postoperatively. Patient-centered questionnaires were obtained preoperatively and after 6 weeks and 1 year.
Results
For the patients in the MIS group (average 7.8 cm incision length), statistically significant increased mean HHSs were seen compared with the CLASS group at 6 weeks and 1 year. This difference was small and mainly caused by the favorable results of the PL-MIS. In the MIS group, surgical time was longer. A learning curve was observed based on operation time and complication rate. Although not statistically significant, the perioperative complication rate was rather high in the (anterolateral) MIS group.
Conclusions
The minimal invasive approach in THA did not show a clinically relevant superior outcome in the first postoperative year.
Level of Evidence
Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1331-7
PMCID: PMC3008875  PMID: 20352383
19.  Minimally Invasive versus Classic Procedures in Total Hip Arthroplasty: A Double-blind Randomized Controlled Trial 
Background
For total hip arthroplasty (THA), minimally invasive surgery (MIS) uses a smaller incision and less muscle dissection than the classic approach (CLASS), and may lead to faster rehabilitation.
Questions/purposes
Does minimally invasive hip arthroplasty result in superior clinical outcomes?
Patients and Methods
In this double-blind randomized controlled trial, 120 consecutive primary noncemented THAs in 120 patients were assigned to one of two groups (MIS or CLASS). The randomization sequence was stratified for two groups of surgeons, ie, those using a posterolateral approach (PL-CLASS or PL-MIS) and those using an anterolateral approach (AL-CLASS or AL-MIS). Length of the incisions was 18 cm for the CLASS procedures. MIS incisions were extended at the skin level to 18 cm at the end of the procedure. The primary end point was the Harris hip score (HHS) at 6 weeks postoperatively. Patient-centered questionnaires were obtained preoperatively and after 6 weeks and 1 year.
Results
For the patients in the MIS group (average 7.8 cm incision length), statistically significant increased mean HHSs were seen compared with the CLASS group at 6 weeks and 1 year. This difference was small and mainly caused by the favorable results of the PL-MIS. In the MIS group, surgical time was longer. A learning curve was observed based on operation time and complication rate. Although not statistically significant, the perioperative complication rate was rather high in the (anterolateral) MIS group.
Conclusions
The minimal invasive approach in THA did not show a clinically relevant superior outcome in the first postoperative year.
Level of Evidence
Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1331-7
PMCID: PMC3008875  PMID: 20352383
20.  Direct Anterior Approach for Hip Resurfacing: Surgical Technique and Complications 
Background
The direct anterior approach (DAA) for hip resurfacing arthroplasty is a technically difficult approach but theoretically reduces the soft tissue trauma to the hip because it does not require muscle detachments from the bone. Furthermore, the patient is in the supine position facilitating fluoroscopy to control component placement. However, the complications associated with the learning curve and functional outcome scores are not well defined in the literature.
Questions/purposes
We therefore asked how our first 57 operations using the anterior approach and special table extension compared with that in the literature with regard to (1) complication rate; (2) functional outcome scores; (3) component placement; and (4) length of stay.
Methods
We retrospectively reviewed 51 patients who underwent 57 hip resurfacing procedures using a DAA. There were 45 men and six women with an average age of 51 years (range, 31–63 years) and a body mass index of 28.7 kg/m2 (range, 19.7–42.0 kg/m2). The minimum followup was 0.3 months (mean, 8.7 months; range, 0.3–24.9 months).
Results
There were three atraumatic (5%) and one posttraumatic (1.8%) femoral neck fractures. Average HOOS scores were equal to or better than averages reported for total hip arthroplasty. Average cup inclination was 36.5° (range, 25°–48°). The average length of stay was 2.11 days (range, 1–4 days).
Conclusions
The surgical approach for anterior hip resurfacing is technically difficult but may have some clinical benefits. Surgeons interested in using the DAA for hip resurfacing should be very familiar with the DAA for total hip arthroplasty and with hip resurfacing.
Level of Evidence
Level IV, retrospective study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1698-5
PMCID: PMC3094629  PMID: 21161743
21.  Early Clinical and Radiographic Results of Minimally Invasive Anterior Approach Hip Arthroplasty 
Advances in Orthopedics  2014;2014:954208.
We present a retrospective review of the early results and complications in a series of 35 consecutive patients with 43 total hip arthroplasties performed through an anterior muscle sparing minimally invasive approach. We found the early complication rates and radiographic outcomes comparable to those reported from arthroplasties performed via traditional approaches. Complications included dislocation (2%), femur fracture (2%), greater trochanteric fracture (12%), postoperative periprosthetic intertrochanteric fracture (2%), femoral nerve palsy (5%), hematoma (2%), and postoperative iliopsoas avulsion (2%). Radiographic analysis revealed average cup anteversion of 19.6° ± 6.6, average cup abduction angle of 48.4° ± 7, stem varus of 0.9° ± 2, and a mean leg length discrepancy of 0.7 mm. The anterior approach to the hip is an attractive alternative to the more traditional approaches. Acceptable component placement with comparable complication rates is possible using a muscle sparing technique which may lead to faster overall recovery.
doi:10.1155/2014/954208
PMCID: PMC3955657  PMID: 24715984
22.  The effect of epsilon aminocaproic acid on blood loss in patients who undergo primary total hip replacement: a pilot study 
Canadian Journal of Surgery  2002;45(3):185-190.
Objective
To determine if the use of an antifibrinolytic agent (epsilon aminocaproic acid [EACA]) decreased perioperative and postoperative blood loss in patients who underwent total hip arthroplasty (THA).
Design
A prospective, double-blind, randomized, controlled clinical trial.
Setting
A university-affiliated tertiary care hospital with a large joint arthroplasty population.
Participants
Fifty-five patients who were scheduled for a primary THA.
Method
Patients were randomly assigned to 2 groups to receive either EACA or saline placebo perioperatively. Preoperatively, the groups were similar with respect to gender, mean age, mean hemoglobin level, operative time and prosthesis type.
Outcome measures
Blood loss from the start of surgery until the Hemovac drain was removed, and the transfusion rate and hemoglobin levels.
Results
Mean (and standard error) total blood loss for patients receiving EACA was 867 (207) mL and for patients receiving placebo was 1198 (544) mL (p < 0.025). Four patients in the EACA group received 7 units of packed red blood cells and 7 patients in the saline group required 12 units.
Conclusions
Patients receiving the placebo sustained greater total blood loss than EACA patients and were more likely to require blood transfusion. In the current climate of concern over blood transfusions during surgery, EACA administration can reduce blood loss and consequently transfusion and transfusion-related risk.
PMCID: PMC3686948  PMID: 12067170
23.  Size of cup affects the anterior capsular distance in total hip arthroplasty, as measured with ultrasound 
Background
Previously was found that sonography is a reliable method to measure a capsular distance in total hip arthroplasty hips. The aim of our current study was to investigate the relation between the implanted size of the cup and the anterior capsular distance, as measured with ultrasound one year after THA.
Methods
50 osteoarthritis (OA) patients operated on with total hip arthroplasty one year before were included in the study and the anterior capsular distance was measured sonographically. Patients were grouped with respect to cup size. The correlation between the implanted cup size and capsular distance was determined.
Results
The mean capsular distance in the whole group was 1.37 (SD 0.19) cm. The mean capsular distance in the group with small cups was 1.27 (SD 0.13) cm, in large cups it was 1.45 (SD 0.20) cm, p = 0.02. Spearman correlation analysis showed a statistically significant correlation between a greater capsular distance and the larger size of the cup (r = 0.5, p < 0.0001).
Conclusion
The greater capsular distance in successful THA hips is affected by cup size. We propose that this should be considered when evaluating sonography of the anterior capsular distance after THA.
doi:10.1186/1471-2474-15-23
PMCID: PMC3898024  PMID: 24438074
Sonography; Cup size; Capsular distance; THA
24.  The effect of posterior capsule repair upon post-operative hip dislocation following primary total hip arthroplasty 
Background
Herein, we evaluated, retrospectively, the effect of posterior capsular repair upon postoperative hip dislocation subsequent to total hip arthroplasty (THA) incorporating a posterolateral approach.
Methods
A total of 181 patients undergoing 204 primary non-complicated THA surgical procedures in the period from January 2000 to October 2005 inclusively were included in this study. The patients were separated into two groups by whether the posterior capsular repair had been incorporated in the surgical procedure. For the surgeon did not commence repairing the posterior capsule until July, 2003, all members in the group that did not undergo posterior capsular repair (142 hips from 131 patients) were collected since January, 2000 to July, 2003, while the members in the group that underwent posterior capsular repair (62 hips from 52 patients) were followed since July, 2003, to October, 2005. With a minimum follow-up period of 12 months, we evaluated the early post-operative dislocation rate.
Results
The early postoperative hip-dislocation rate for the group who did not undergo posterior capsular repair appeared to be substantially greater (6.38% versus 0%) than the corresponding figure for the group the members of which underwent posterior capsular repair. In addition, patient demographics and the orientation of acetabular components for the replaced hip joints, as presented in postoperative radiographs, did not differ between the two groups.
Conclusion
Thus, surgeons should include posterior capsular repair as an important step in the surgical procedures of posterolateral approach for all THA in order to reduce the likelihood of early hip dislocation subsequent to THA.
doi:10.1186/1471-2474-9-29
PMCID: PMC2292160  PMID: 18307820
25.  Is There Faster Recovery With an Anterior or Anterolateral THA? A Pilot Study 
Surgical technique is an important factor affecting recovery of hip function after total hip arthroplasty (THA). We therefore asked whether short-term recovery of hip strength and motion would differ between the anterior and anterolateral THA approaches. We presumed that although both approaches would improve hip function by 16 weeks postsurgery when compared with presurgery, a slower recovery would be demonstrated by the anterolateral group at 6 weeks when compared with the anterior group as a result of division and reattachment of the abductor muscles. We observed hip kinematics and kinetics during walking and isometric hip abductor strength for the involved limb. Hip abductor strength of all patients was lower than controls at all three testing times. Compared with presurgery, all patients demonstrated improved abductor strength at 16 weeks postsurgery. At 6 weeks, the patients with an anterior approach had improved late stance peak abductor moment postsurgery and reached the level of controls, but those with an anterolateral approach did not. Although the anterior approach was associated with improved gait velocity and peak flexor moments at 6 weeks compared to before surgery, we observed no differences between the two approaches for most of the isometric strength and dynamic gait measures at 6 or 16 weeks. Neither approach provided faster recovery.
doi:10.1007/s11999-009-1075-4
PMCID: PMC2806982  PMID: 19763725

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