Recommendation None
Question 4: Does MIS THR have similar complication rates to standard approaches?
Findings
Finally, when assessing the overall clinical value of MIS THR it is critical to look at the overall incidence of compli- cations as well as their severity. Mow et al. have shown evidence of more subcutaneous tissue necrosis and/or poor wound healing after the mini-incision procedures34. All two-incision cohort studies report relatively long surgi- cal times compared with those of open techniques, thus confirming the high degree of difficulty of this procedure.
Although Berger33 reported a low risk of femoral fracture (1%), others reported fracture rates of 7–9%.35,36 One author reported a 4% early revision rate for treatment of postop- erative fractures that were assumed to have occurred intra- operatively but were not detected by fluoroscopy or by mini-incision THRs, Vail and Callaghan6 concluded that
although these could be done safely in patients who are not obese there were no real differences in clinical outcome (Table 18.3). Having said that, Howell et al.31 gave signifi- cant importance to the psychological impact of improved cosmesis on patient attitude, satisfaction, and motivation for recovery. They cautioned that this appeal should not be underestimated when evaluating less invasive THR surgeries, with most studies reporting improved cosmesis and patient satisfaction with these smaller-incision approaches.32,33
Recommendation
• No significant difference was found with regards to patient function, but the evidence is moderate as current tools to evaluate patient function may not be sufficiently sensitive. The positive impact on patient cosmesis is strong
Table 18.3 Summary of clinical studies on mini-incision THR
Study Study
type
Surgical approach
No.
mini-incision/
standard
Mini-incision benefits / disadvantages
Mini-incision group BMI loss
Transfusion LOS Incidence of complications
Incidence of malposition
Ogonda et al. 2005
RP Posterior 100
100
None NS NS NS NS
Wright et al. 2005
RP Posterior 50
50
None NS NS NS NS
Chimento et al. 2005
RP Posterior 28
32
EBL 43 mL TBL 126 mL Limp at 6 weeks
NS NS NS NS
de Beer et al. 2005
M CC Lateral 30
30
EBL 67 mL NS NS NS NS
DiGioia et al. 2005
M CC Posterior 35
35
HHS at 3 and 6 months
0.7 units 1.1 units
NS NS NS
Woolson et al. 2004
CS CC Posterior 50 57
None Yes NS NS Mini-incision with
more wound complications
Mini-incision with more AC and FC Wright
at al. 2004
CC Posterior 42
42
ST -7 minutes HHS -3 points
Yes NS NS NS NS
Howell et al. 2004
CS CC Anterior-inter muscular
50 57
EBL 82 mL ST +13 min
Yes NS 4 days
5 days
NS NS
O’Brien and Rorabeck
CS CC Lateral 34
53
ST -6 min Yes NS 5.4 days
6.2 days
IO fracture 6%
2% NS
NS
A, change; AC, acetabular component; BMI, body mass index; CC : case controlled; CS, consecutive series; EBL, estimated blood loss; FC, femoral component; HHS, Harris hip score; IO, intraoperative; LOS, length of hospital stay; M :matched; NS, not statistically significant; RP, randomized prospective; ST, surgical time; TBL, total blood loss.
Reproduced from Vail and Callaghan.6
C H A P T E R 1 8 Minimally Invasive Techniques in Total Hip Arthroplasty
2. Berry DJ, Berger RA, Callaghan JJ, Dorr LD, Duwelius PJ, Hartzband MA, et al. Symposium: minimally invasive total hip arthroplasty. development, early results, and a critical analysis.
J Bone Joint Surg 2003;85:2235–46.
3. Pour AE, Parvizi J, Sharkey PF, Hozack WJ, Rothman RH.
Minimally invasive hip arthroplasty: what role does patient pre- conditioning play? J Bone Joint Surg Am 2007;89:1920–7.
4. Fehring TK, Mason JB. Catastrophic complications of minimally invasive hip surgery. A series of three cases. J Bone Joint Surg Am 2005;87:711–14.
5. Sculco TP, Jordan LC. The mini-incision approach to total hip arthroplasty. Instr Course Lect 2004;53:141–7.
6. Vail TP, Callaghan JJ. Minimal incision total hip arthroplasty. J Am Acad Orthop Surg 2007;15:707–15.
7. Penenberg B, Bolling WS, Riley M. Percutaneously assisted total hip arthroplasty (PATH): a preliminary report. J Bone Joint Surg 2008;90:209–20.
8. Bertin KC, Rottinger D. Anterolateral mini-incision hip replace- ment surgery: a modified Watson-Jones approach. Clin Orthop Relat Res 2004;429:248–55.
9. Watson-Jones R. Fracture of the neck of the femur. Br J Surg 1935;23:787.
10. Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg Br 1982;64:17–19.
11. Rachbauer F, Kain MSH, Leunig M. The history of the anterior approach to the hip. Orthop Clin North Am 2009;40(3):
311–20.
12. Smith-Petersen MN. A new supra-articular subperiosteal approach to the hip joint. Am J Orthop Surg 1917;15:592–95.
13. Light TR, Keggi KJ. Anterior approach to hip arthroplasty. Clin Orthop Rel Res 1980;152:255–60.
14. Judet J, Judet R. The use of an artificial femoral head for arthro- plasty of the hip joint. J Bone Joint Surg 1950;32B:166–73.
15. Anterior Total Hip Arthroplasty Collaborative Investigators.
Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observational study. Orthop Clin North Am 2009;40:329–42.
16. Pagnano MW, Leone J, Lewallen DG, Hanssen AD. Two-incision THA had modest outcomes and some substantial complications.
Clin Orthop Relat Res 2005;441:86–90.
17. Mardones RM, Pagnano MW, Nemanich JP, Trousdale RT. The Frank Stinchfield Award: muscle damage after total hip arthro- plasty done with the two-incision and mini-posterior techniques.
Clin Orthop Relat Res 2005;441:63–7.
18. Tang R, Evans H, Chaput A, Kim C. Multimodal analgesia for hip arthroplasty. Orthop Clin North Am 2009;40:377–87.
19. Chimento GF, Pavone V, Sharrock N, Kahn B, Cahill J, Sculco TP.
Minimally invasive total hip arthroplasty: a prospective rand- omized study. J Arthroplasty 2005;20:139–44.
20. Ogonda L, Wilson R, Archbold P, Lawlor M, Humphreys P, O’Brien S, Beverland D. A minimal-incision technique in total hip arthroplasty does not improve early postoperative out- comes. A prospective, randomized, controlled trial. J Bone Joint Surg Am 2005;87:701–10.
21. Krych AJ, Pagnano MW, Wood KC, Meneghini RM, Kaufmann K. No benefit of the two-incision THA over mini-posterior THA:
a pilot study of strength and gait. Clin Orthop Relat Res 2010;468:565–70.
immediate postoperative radiographs.37 Another report showed a high 10% early revision rate for fracture, disloca- tion, and infection in patients who had THR with the two- incision procedure.38 Two other studies also showed a relatively high incidence of nerve injury at 2.5–3.2%36,39 with the two-incision technique. Other less invasive approaches such as the mini-posterior as well as the ante- rior Hueter approach have not reported higher rates of complications. In a multicenter study of 9 surgeons and 1277 THRs examining the introduction of the anterior Hueter approach,15 the overall rate of revision was 2.7%
with an incidence of proximal fracture of 1.8% including calcar splits. Obviously, the higher rate of complications associated with the two-incision technique reflects the dif- ficulty in surgical exposure as well as the lack of familiarity for the surgeon in terms of patient positioning and instrumentation.
Recommendation
• The integration of new surgical techniques and approaches such as MIS may have a higher initial compli- cation rate [overall quality: strong.]
• In regards to reproducibility, if the surgical technique is sound then it can be safely reproducible [overall quality:
moderate]
Summary of recommendations
• With similar anesthetic protocols the length of the incision had little impact on patient recovery and length of stay. More importantly, the two-incision technique was actually inferior to the mini-posterior approach. Similarly, the use of narcotics postoperatively was not affected by the length of the incision but dependent on multimodal analgesia
• MIS hip surgery showed no difference in blood loss
• No significant difference was found with regard to patient function, whereas the positive impact on cosmesis is strong
• The integration of new surgical techniques and approaches such as MIS may have a higher initial compli- cation rate
• With regard to reproducibility, if the surgical technique is sound then it can be safely reproducible
References
1. Rorabeck CH, Bourne RB, Laupacis A, Feeny D, Wong C, Tugwell P, et al. A double-blind study of 250 cases comparing cemented with cementless total hip arthroplasty. Cost- effectiveness and its impact on health-related quality of life. Clin Orthop 1994;298:156–64.
31. Howell JR, Masri BA, Duncan CP. Minimally invasive versus standard incision anterolateral hip replacement: a comparative study. Orthop Clin North Am 2004;35:153–62.
32. Wright JM, Crockett HC, Delgado S, Lyman S, Madsen M, Sculco TP. Mini-incision for total hip arthroplasty: a prospective, con- trolled investigation with 5-year follow-up evaluation. J Arthroplasty 2004;19:538–45.
33. Berger RA, Jacobs JJ, Meneghini RN, Della Valle CJ, Paprosky W, Rosenberg AG. Rapid rehabilitation and recovery with mini- mally invasive total hip arthroplasty. Clin Orthop Relat Res 2004;429:239–47.
34. Mow CS, Woolson ST, Ngarmukos SG, Park EH, Lorenz HP.
Comparison of scars from total hip replacements done with a standard or a mini-incision. Clin Orthop Relat Res 2005;441:
80–5.
35. Pagnano MW, Leone J, Lewallen DG, Hanssen AD. Two-incision THA had modest outcomes and some substantial complications.
Clin Orthop Relat Res 2005;441:86–90.
36. Archibeck MJ, White REJ. Learning curve for the two-incision total hip replacement. Clin Orthop Relat Res 2004;429:232–38.
37. Pagnano MW, Leone J, Lewallen DG, Hanssen AD. Two-incision THA had modest outcomes and some substantial complications.
Clin Orthop Relat Res 2005;441:86–90.
38. Bal SB, Haltom D, Aleto T, Barrett M. Early complications of primary total hip replacement performed with a two-incision minimally invasive technique. J Bone Joint Surg 2005;87A:
2432–38.
39. Pagnano MW, Leone J, Lewallen DG, Hanssen AD. Two-incision THA had modest outcomes and some substantial complications.
Clin Orthop Relat Res 2005;441:86–90.
40. Cheng T, Feng JG, Liu T, Zhang XL. Minimally invasive total hip arthroplasty: a systematic review. Int Orthop 2009;33:1473–81.
22. de Beer J, Petruccelli D, Gandhi R, Winemaker M. Single-incision, minimally invasive total hip arthroplasty: length doesn’t matter.
J Arthroplasty 2004;19:945–50.
23. Ogonda L, Wilson R, Archbold P, Lawlor M, Humphreys P, O’Brien S, Beverland D. A minimal-incision technique in total hip arthroplasty does not improve early postoperative out- comes. A prospective, randomized, controlled trial. J Bone Joint Surg Am 2005;87:701–10.
24. Chimento GF, Pavone V, Sharrock N, Kahn B, Cahill J, Sculco TP.
Minimally invasive total hip arthroplasty: a prospective rand- omized study. J Arthroplasty 2005;20:139–44.
25. DiGioia AM, Plakseychuk AY, Levison TJ, Jaramaz B. Mini- incision technique for total hip arthroplasty with navigation. J Arthroplasty 2003;18:123–28.
26. Ogonda L, Wilson R, Archbold P, Lawlor M, Humphreys P, O’Brien S, Beverland D. A minimal-incision technique in total hip arthroplasty does not improve early postoperative out- comes. A prospective, randomized, controlled trial. J Bone Joint Surg Am 2005;87:701–10.
27. Cheng T, Feng JG, Liu T, Zhang XL. Minimally invasive total hip arthroplasty: a systematic review. Int Orthop 2009;33:1473–81.
28. Chimento GF, Pavone V, Sharrock N, Kahn B, Cahill J, Sculco TP.
Minimally invasive total hip arthroplasty: a prospective rand- omized study. J Arthroplasty 2005;20:139–44.
29. Bennett D, Ogonda L, Elliott D, Humphreys L, Beverland DE.
Comparison of gait kinematics in patients receiving minimally invasive and traditional hip replacement surgery: a prospective blinded study. Gait Posture 2006;23:374–82.
30. Dorr LD, Maheshwari AV, Long WT, Wan Z, Sirianni LE. Early pain relief and function after posterior minimally invasive and conventional total hip arthroplasty. A prospective, randomized, blinded study. J Bone Joint Surg Am 2007;89:1153–60.
Management of Femoral Periprosthetic Fractures After Hip Replacement
Tamim Umran, Donald S. Garbuz, Bassam A. Masri, and Clive P. Duncan
University of British Columbia, Vancouver, BC, Canada
Case scenario
An 81 year old woman presents with severe thigh pain and inability to weight bear after a simple slip and fall. She had a previous total hip arthroplasty (THA). Examination reveals external rotation deformity of the leg, bony crepi- tus, and tenderness around the proximal and mid thigh.
Neurovascular exam is normal. Radiographs demonstrate a displaced periprosthetic femur fracture.
Relevant anatomy and pathomechanics
It is useful, when considering treatment, to divide the femur into three regions with reference to the stem: tro- chanteric (A); around or just below the stem (B); and distal to that (C). Furthermore, to integrate this with treatment, it is useful to subdivide the B type into those with a well- fixed stem (B1), a loose stem (B2), and a loose stem with poor bone stock (B3).
Importance of the problem
The prevalence of periprosthetic fractures ranges between 0.4 and 3.9% for all arthroplasties depending on whether it occurs in the primary or the revision setting.1–3 These numbers have been steadily increasing over time as a func- tion of the advancing age of the population and the increas- ing use of total hip arthroplasty (THR). This chapter discusses risk factors, diagnosis, management options, and outcomes of postoperative periprosthetic femur fractures, as supported by current available literature.
Top five questions
Etiology
1. Are there patient factors that may be predictive of a periprosthetic femur fracture?
Diagnosis
2. What classification system is effective in guiding treatment?
Therapy
3. What is the optimal management and outcome of Vancouver type A fractures?
4. What is the optimal management and outcome of Vancouver type B fractures?
5. What is the optimal management of Vancouver type C fractures (intraoperative and postoperative)?
Evidence-Based Orthopedics, First Edition. Edited by Mohit Bhandari.
© 2012 Blackwell Publishing Ltd. Published 2012 by Blackwell Publishing Ltd.
19
Difficulty arises when comparing the results in these studies due to variability in length of follow-up, patient demograph- ics, number of revision arthroplasties, types of implants used, technical methods employed to treat the fractures, and vari- able outcome measures used to assess patients.
Question 1: Are there patient factors that may