Early results and patient satisfaction after total hip arthroplasty using a minimally invasive anterolateral approach

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1 Hip International / Vol. 19 no. 4, 2009 / pp Original article Early results and patient satisfaction after total hip arthroplasty using a minimally invasive anterolateral approach Tim Alexander WALDE 1, Dirk BLATTGERSTE 2, Stefan SEHMISCH 1, Wolfgang KUTTLER 2, Hans-Joachim WALDE 2, Georg KÖSTER 3 1 Department of Trauma Surgery, Plastic and Reconstructive Surgery, University Medicine, Göttingen - Germany 2 Department of Traumatology, Hand and Reconstructive Surgery, Nordwest-Krankenhaus Sanderbusch, Sande - Germany 3 Clinic for Orthopaedic Surgery, Waldstrasse 13, Lorsch - Germany Ab s t r a c t. Rehabilitation and patient satisfaction following a modified anterolateral approach for implantation of a total hip replacement (THR) were reviewed following 72 consecutive cases. The Harris Hip and Merle d Aubigné Scores were recorded at 6 and 12 weeks postoperatively. The patient s satisfaction with regard to the surgical result and the need for analgesia for mobilization were recorded. Rehabilitation was assessed by postoperative crutch use. Significant improvements of the Harris Hip and Merle d Aubigné scores were demonstrated. All patients thought their surgical outcome was good or better. 2 patients needed pain medicine on an irregular basis and 4 patients used crutches at 12 weeks. This study demonstrates patient satisfaction and satisfactory rehabilitation following a modified antero-lateral approach for minimally-invasive implantation of THR. (Hip International 2009; 19: ) Key Words. Clinical results, Minimally invasive, Total hip replacement Accepted: 02/07/2009 INTRODUCTION Total hip replacement (THR) has demonstrated good longterm results (1-3). Traditional surgical approaches were developed to provide a good view of the acetabulum and proximal femur. These approaches may cause damage to the periarticular tissues. Minimally-invasive THR was developed to reduce surgical trauma to the soft tissue, thereby reducing surgical morbidity and postoperative pain. Additional benefits of minimally invasive surgery may include accelerated patient rehabilitation and an increase in patient satisfaction. In recent years several studies have demonstrated the advantages of minimally invasive surgery using different techniques in relation to early clinical results (4-9). Our study describes early clinical results and patient satisfaction after implantation of a THR using a previously described minimally invasive modified antero-lateral approach in the supine position (10). Surgical and radiographic data and intraoperative and postoperative complications of 72 consecutive procedures using this minimally-invasive approach are assessed in this study. Material and Methods Neck fractures, pathological fractures and revisions were defined as a contraindication to this study. Obesity was not considered an exclusion criterion. Surgical indications included primary, secondary and dysplastic coxarthrosis. Average patient age was 65.5 years (min. Wichtig Editore, / $25.00/0

2 Clinical Results after Minimally Invasive Total Hip Arthroplasty 33, max. 83) with a majority of female patients (66.6%). Pre- and postoperative clinical evaluation At 6 and 12 weeks postoperatively, the Harris Hip Score (HSS) and the Merle d Aubigné Score were recorded (11, 12). Body weight and height were measured preoperatively to calculate body mass index (BMI). The use of pain medicine and the presence or absence of the Trendelenburg sign were recorded preoperatively and at the 6 and 12 week evaluations. Postoperative crutch use and patient satisfaction in relation to surgical outcome were recorded at both follow-up evaluations. Additional comorbidities that could have influenced the clinical outcome were noted. Modified minimally-invasive antero-lateral approach The previously described minimally-invasive approach used in this study is a modification of the conventional antero-lateral approach (Watson-Jones) in the supine position and is described as follows (10, 13). Patient positioning The patient is placed supine on a standard operating table and general anesthesia is given. To ensure proper preparation of the medullary canal and to avoid notching the abductor muscles, thus causing functional restriction, the operating table is adjusted so that the affected leg can be extended to approximately 25. Both legs are covered using a double-fenestrated surgical drape with the non-operative leg put in a sterile stockinette. The affected leg can then be adducted in external rotation and extension under the other leg during the surgical procedure. Cup and stem implantation The incision begins approximately 2 cm distal to the tip of the greater trochanter and extends approximately 8 to 10 cm cranial and anterior in a 20 curve. The fascia lata is incised in the same direction between the tensor fasciae latae and gluteus medius muscle. The edge of the fascia lata is exposed at the anterior margin of the greater trochanter and anterior edge of the gluteus medius muscle. Passing the edge of the rectus femoris muscle and the anterior margin of the gluteus medius muscle the incision is carried down to the joint capsule. Subsequently the joint capsule is partially resected to expose the antero-lateral aspect of the femoral neck and head using three modified Hohmann retractors (Zimmer Germany GmbH). Two of the retractors expose the femoral neck and the other retractor is positioned on the anterior edge of the acetabulum. To allow the resection of the femoral head through the small incision, the femoral neck is divided with a lateral opening wedge osteotomy. After extraction of the bone wedge and femoral head the neck retractors are removed and the third Hohmann acetabulum retractor is placed on the posterior edge of the acetabulum to displace the femoral neck posteriorly. The gluteus medius muscle is protected with a retractor which is positioned on the lateral edge of the acetabulum. This provides a good view of the acetabulum and enables precise reaming and implantation of the cup into the acetabulum using a cropped impactor. The femoral shaft is placed in 25 extension, adduction and external rotation, the resection surface is rotated and exposed within the operating field. Modified retractors made specifically for sufficient visualization and preparation of the femur are used (Zimmer, Germany GmbH). A straight retractor is inserted anteriorly behind the femoral neck and pushed laterally. To protect the gluteus medius muscle another retractor is placed behind the greater trochanter cranially. For improved visualization, a conventional Hohmann retractor can be placed ventrally at the femoral neck. Specialized cropped handles are used for preparation of the medullary canal and implantation of the femoral component. This enables femoral preparation and implantation of the shaft in the longitudinal femoral axis, while avoiding major damage to the soft tissue. Postoperative Mobilization Physical therapy, with the use of passive motion, was initiated on the first postoperative day. Patients with a straight stem prosthesis were allowed to bear weight as tolerated, dictated by their pain threshold until they were fully weight bearing with the assistance of two underarm crutches. Postoperative crutch use was recommended for 4 weeks. Patients with the implantation of a short stem prosthesis were asked to perform partial weight bearing (20 kg) for 4 weeks postoperatively and to increase weight bearing as tolerated afterwards with the use of crutches for 2 more weeks. Intraoperative data collection Intraoperative blood loss (in ml) was determined by calculating the difference between irrigation fluid used during surgery and the contents of the suction container. In addi- 368

3 Walde et al tion to surgery length, defined as the beginning of surgery until complete wound closure, the length of the incision (in cm) after wound closure was documented. Postoperative radiographic evaluation In order to evaluate implant position, A/P pelvis and axial radiographic views were obtained immediately after surgery. Cup position was determined by the inclination of the cup. The desired inclination as reported by Lewinnek et al. was defined as the zone between 30 and 50 (14). The angle between the medullary canal and the longitudinal axis of the femoral component was considered in the evaluation of the stem position with the ideal angle predefined to be within 3 of the neutral axis in the coronal plane. Complications For this study, all intraoperative and immediate postoperative complications were recorded. In addition to any implant malpositioning, intraoperative and immediate postoperative fractures or fissures, nerve lesions, bleeding (haematoma), dislocations, cardiac and cerebrovascular complications were recorded. Wound healing complications were considered postoperative complications. RESULTS 72 consecutive THRs were implanted using the minimally-invasive approach and evaluated prospectively. There were 47 straight and 25 short cementless stems inserted with cementless press fit cups (Zimmer, Germany GmbH). TABLE I - INTRAOPERATIVE RESULTS (n = 72) Duration of surgery (minutes) Ø 70 (min. 36, max. 120) Length of incision (cm) Ø 9.2 (min. 7.5, max. 10.5) Blood loss (ml) Ø 496 (min. 100, max. 800 ml) Inclination (angular degree) Ø /-6 Stem position Neutral 121 BMI (body mass index) Ø 28 (min. 20, max. 45) None of the cases required an intraoperative change to a conventional approach. Table I shows the intraoperative results. Other than two intraoperative fissures at the calcar that occurred within the first 10 cases in this series using the Mayo short stem (Zimmer, Germany GmbH), no other complications were observed. The two fissures were treated by partial weight bearing over 6 weeks and healed without any further complications. Clinical results showed an increase of the Harris Hip Score from 57.4 preoperatively to 77.4 and 88.4 points respectively at six and twelve weeks postoperative (Table II). The Merle d Aubigné score increased from 19.2 preoperatively to 25.3 and 27.9 points respectively at the 6 and 12 week evaluations (Tab. II). The increases were all statistically significant using Turkey`s multiple comparison test (p<0.001). Preoperatively 56 (77.8%) patients required analgesics (NSAIDs, opiates or dipyrones) on a regular basis for mobilization. At the 6 and 12 week evaluations, 19 (26.4%) and 16 (22.2%) patients respectively required analgesics. Of the 16 patients needing pain medication at 12 weeks, 12 suffered from contra-lateral arthritis of the hip, ipsi- or contra-lateral arthritis of the knee or shoulder joint and/or degenerative lumbar spine disease. One patient who needed analgesics had previously used cortisone for asthma and one patient suffered from a painful contra-lateral hip arthroplasty performed through a conventional approach. Only 2 (2.8%) of the 72 cases, used NSAIDs to decrease pain in the operative hip at 12 week follow-up. Preoperatively, 2 (2.8%) patients had a positive Trendelenburg sign. At the 12 week follow-up evaluation two different patients had a positive Trendelenburg sign. Both patients stated a subjective decrease of their Trendelenburg sign following physical therapy. At the 6 and 12 week evaluations, 59 (82%) and 15 (21%) of patients respectively used crutches for mobilization. Of the 59 cases using crutches after 6 weeks, 20 patients had a short and 39 a straight stem prosthesis implanted. 9 of the 15 patients using crutches at 12 weeks suffered from painful ipsi- or contra-lateral arthritis of the knee and/or degenerative lumbar spine disease. One patient suffered from painful vasculitis of the lower extremities and one patient had a painful arthroplasty on the contra-lateral side. At the 6 week postoperative evaluation 45 (62.5%) patients TABLE II - EARLY CLINICAL RESULTS USING HARRIS HIP SCORE AND MERLE D AUBIGNÉ SCORE (*p<0.001) Preoperative 6 week evaluation 12 week evaluation Harris Hip Score * 88.4* Merle d Aubigné score * 27.9* 369

4 Clinical Results after Minimally Invasive Total Hip Arthroplasty TABLE III - POSTOPERATIVE PATIENT S SATISFACTION 6 week evaluation 12 week evaluation Very good 45 (62.5%) 62 (86.1%) Good 27 (37.5%) 10 (13.9%) Moderate / Poor Ø Ø thought their surgical outcome was very good and 27 (37.5%) patients good (Tab. III). At the 12 week evaluation, 62 (86.1%) patients thought their result was very good and 10 (13.9%) patients good. No patient thought their surgical outcome was moderate or poor at their 6 or 12 week evaluation. All patients stated an improvement at 6 and 12 weeks postoperatively when compared to their preoperative status. DISCUSSION Postoperative hip dislocation, gluteal muscle insufficiency and nerve lesions have been reported as complications of conventional approaches used in total hip arthroplasty (15-19). Therefore various minimally-invasive approaches have been developed in recent years to reduce surgical trauma during total hip arthroplasty (10, 20-27). Most of these approaches are modifications of conventional approaches using specialized instruments and modified patient positioning, intended to reduce incision size and soft tissue trauma. Several recently published studies have demonstrated good early clinical results using several different minimally invasive approaches (4-9). Conventional approaches can cause damage to the surrounding muscles of the hip joint. While the short external rotators must be dissected in the posterior approach, the antero-lateral approach requires notching or detaching the abductors (13, 28, 29). In the case of damaged gluteus medius and minimus muscles, the patient may exhibit a positive Trendelenburg sign postoperatively (16, 17). Thus, avoiding damage to the muscles is one of the main goals of minimally invasive hip arthroplasty. The technique used in this study required modified patient positioning for femoral preparation with the affected leg extended to approximately 25, externally rotated and adducted behind the other leg. The resection surface on the neck of the femur is rotated antero-laterally and exposed in the operative field. With specialized retractors, the insertions and bellies of the gluteus medius and minimus muscles are displaced and protected. In this study only two patients had a postoperative positive Trendelenburg sign after surgery that was subjectively decreasing at the last follow-up evaluation. These results are comparable to those described by Roth and Venbrocks (5). Ideally, a minimally-invasive approach for total hip arthroplasty of the hip joint should be an easily reproducible technique that can be performed without extensive training and result in securely implanted components. The modified minimally-invasive antero-lateral approach presented in this study provides exposure of all important structures. Good component positioning was achieved in all cases. The minimally invasive technique presented in this study does not carry an increased risk for the patient, as the incision can be extended at any time to a conventional anterolateral approach. None of the cases required an intraoperative change to the conventional approach. Other than two intraoperative calcar cracks, no other complications occurred intraoperatively or immediately postoperatively. The approach presented allows for secure implantation of various types of prosthesis. Moreover, good component positioning can be achieved in obese patients (BMI >27). The biggest improvement in clinical results occurs within the first 3 months with various minimally invasive techniques (4, 7, 8). In this study, the Harris Hip and the Merle d Aubigné scores showed statistically significant increases at 6 and 12 weeks postoperatively. At 12 weeks, only 4 of 72 patients used crutches for mobilization because of their operated hip. However, 11 of the 15 patients depended on crutches at the last follow-up evaluation because of pain from other joints. 86% of the patients thought their surgical result was very good at the 12 week postoperative evaluation. All of the patients thought their result was at least as good or better at the 12 week postoperative evaluation. All patients felt their quality of life had improved at both postoperative clinical evaluations. There was a low patient requirement for postoperative analgesia. Of the 16 patients needing analgesia for mobilization, only 2 patients stated that it was for the operative hip. Dorr, et al demonstrated better early postoperative pain scores when comparing a posterior minimally invasive and conventional approach (6). The limitation of this study was the absence of a control group. The authors had already been performing this minimally-invasive technique for some time and were not comfortable changing their technique back to a conventional antero-lateral approach for the specific purpose of this study. The clinical results presented in this study have demonstrated rapid patient improvement within the early postoperative weeks. High levels of patient satisfaction and minor postoperative intake of analgesia were also demonstrated. A low complication rate was shown with secure positioning of a range of components in all patients. 370

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