Purpose. The posterolateral or posterior approach for total hip arthroplasty has the advantages of preserving the hip abductor musculature and providing good visualization during femoral preparation and component insertion. Although posterolateral approach is one of the popular approaches in hip arthroplasty, it has been reported high dislocation rate as a drawback. To compensate the drawback the repair of short external rotator of hip is thought to be important. Therefore, we investigated incidence of failed repaired short external rotator muscles, dislocation rate and time of failure between tendon to tendon and tendon to bone repair technique through prospective study more than 1 year follow up. Materials and methods. We performed 213 hip arthroplasties in 202 patients from May 2012 to January 2015. After exclusion of 15 hips due to follow-up loss(9 hips), death(2 hips), greater trochanteric fragment displacement(3 hips) and severe contracted short external rotator(1 hip), we investigated 198 hips in 187 patients. 57 patients were male and 130 patients were female. The mean age of patient was 70.4 (32–98) years. Reattachment short external rotator with posterior capsule to postero-superior aspect of greater trochanter(tendon to bone group, 111 hips) or to the tendon(tendon to tendon group, 87 hips) was performed. Two No.26 metal wire markers were fixed at the greater trochanter tip and short external rotator tendon respectively with a distance less than 1.2cm, and the distance between two wire markers was observed at postoperative 1 day, 2 weeks, 3 months, and annually radiographs in neutral position. When the distance was more than 2.5cm or one of the wire markers was invisible, we defined them the failure of short external rotator repair. The mean follow up period was 28.8 (12–45) months. Results. Failure rate of tendon to bone repair technique(17.1%) was significantly less as compared to that of tendon to tendon repair technique(70.1%)(p<0.001). The failure of short external rotator repair happened mostly within postoperative 2 weeks, which was 89.5% in tendon to bone(p=0.025) and 93.4% in tendon to tendon repair (p<0.001). Dislocation was observed in 2 (1.8%) hips in tendon to bone repair group and in 7 (8.0%) hips in tendon to tendon repair group respectively, which was significantly higher dislocation rate in tendon to tendon repair group. A significant correlation was also observed between failure of short external rotator repair and dislocation (p=0.032). Conclusions. Tendon to bone repair technique is superior to tendon to tendon technique in terms of failure rate of short external rotator repair in hip arthroplasty. Tendon to bone repair of short external rotator with posterior capsule was beneficial to reduce dislocation rate as compared with tendon to tendon repair technique. As majority of failure of short external rotator happened within postoperative 2 weeks, restriction of internal rotation should be recommended through the period

Purpose: The objective of this study was to observe the change in dislocation rate by introducing a capsular enhanced short external rotator repair during primary total hip arthroplasty. Dislocation after primary total hip arthroplasty is a relatively common complication. The incidence is usually between 1% and 4%, although 0% to 10% has been reported in the literature. The posterior approach is by far the most popular by surgeons, but it reportedly has an increase risk of post-operative dislocation. The posterior approach causes disruption of the posterior capsule and the short external rotators. Studies have shown that repair of the posterior capsule and the short external rotators greatly reduce the dislocation rate. Method: Review of the dislocation rate of THR’s by a single surgeon before and after the introduction of a capsular enhanced short external rotator repair (August 2002). It was a sequential cohort of 2213 Total Hip Replacements (THR), inserted over a period from January 1999 to June 2004. All cases were done by the senior author through a posterior approach using a Belfast custom stem, a 28mm head, and a cementless socket. We collected data on all dislocations which occurred on the hips inserted during this time period. We were therefore able to compare dislocation rates for THR’s done before and after the introduction of the soft tissue repair. The posterior capsule and short external rotators were reattached to the greater trochanter through drill holes using a number 5 Ethibond. Results: This dislocation rate before the introduction of the new posterior soft tissue repair was 3.9% (58 out of 1501 THR’s). After the introduction of the repair the dislocation rate was 0.9% (6 out of 712 THR’s). 81% (47 of58) of dislocations before the change of practice were classed as early dislocations (with 3 months of surgery). 83% (5 of 6) were clearly dislocators after the new soft tissue repair. Considering only the early dislocations, the dislocation rate reduced from 3.1 to 0.7%. Conclusion: Considering our reduction from 3.9% to0.9%, and results of previous studies, it is clear that the capsular enhanced and short external rotator repair is associated closely with a decreased dislocation rate. We feel other factors such as restoration of joint centre ensuring correct orientation of components are important in conjunction with the posterior soft tissue repair to keep dislocations to a minimum

INTRODUCTION. Interest in tissue-preserving or minimally invasive total hip arthroplasty (THA) is increasing with focus toward decreased hospital stay, enhanced rehabilitation, and quicker recovery for patients. Two tissue-preserving techniques, the anterior and superior approaches to THA, have excellent clinical results, but little is known about their relative impact on soft tissue. The purpose of this study was to evaluate the type and extent of tissue damage after THA with each approach, focusing on abductors, short external rotators, and the hip capsule. METHODS. Total hip arthroplasty was performed on bilateral hips of eleven fresh-frozen cadavers (22 hips). They were randomized to anterior THA performed on one side and superior THA performed on the other, in the senior authors' standard technique. Two independent examiners graded the location and extent of tissue injury by performing postsurgical dissections. Muscle bellies, tendons, and capsular attachments were graded as intact, split, damaged (insignificant, minimal, moderate, or extensive damage), or detached based on direct visual inspection of each structure. Tissue injury was analyzed with either a chi-squared (≥5 qualifying structures) or Fisher's exact test (<5 qualifying structures). P values <0.05 were significant. RESULTS. The abductor muscles or tendons were intact or insignificantly damaged in 63.6% of anterior approach specimens compared with 84.1% of the superior specimens (p= 0.03). Specifically, the gluteus minimus tendon had moderate or extensive damage in 63.6% of anterior specimens compared with none of the superior specimens (p <0.01). Short external rotators (SERs) group, defined as both the muscle and tendon of the piriformis, conjoint, obturator externus, and quadratus, were intact or insignificantly damaged in 63.6% of anterior approach specimens compared with 80.5% of the SER group of superior specimens (p = 0.02). The femoral attachments of the anterior, posterior, and superior capsules were extensively damaged or detached in 90.9%, 81.8%, and 100% of anterior approach specimens respectively compared with 0%, 9.1% and 9.1% of superior approach specimens respectively (all p <0.01). CONCLUSION. In a cadaveric study examining superior and anterior approaches to THA, the superior approach demonstrated significantly less soft-tissue destruction than the anterior approach, specifically to the gluteus minimus tendon, short external rotators, and the hip capsule

Background:. In anterior approaches for total hip arthroplasty (THA), the femoral part of the procedure requires the release of the capsule from the greater trochanter. However, it is unknown whether any other tendons of the short external rotator muscles are also damaged during capsular release procedures. The aim of this cadaveric study was to identify the bony landmarks on the greater trochanter, which indicate the individual short external rotator muscle insertions. Methods:. Forty-four hip regions from 28 embalmed cadavers were dissected. At first, micro-computed tomography (micro-CT) images were obtained to identify bony impressions on the greater trochanter. Then, the soft tissues around the greater trochanter were removed and their insertions were identified to assess correlation with micro-CT images. Results:. Using micro-CT, three clear impressions were identified on the greater trochanter of cadavers: 1) a shallow groove on the tip of the greater trochanter; 2) a deep, wide depression and groove in the anterior part of the trochanteric fossa; and 3) a deep fovea in the posterior part of the trochanteric fossa (figure B). After removal of the soft tissues around the greater trochanter, the first impression was identified as the insertion of the piriformis and the groove running along its tendon, the second impression as the insertion of the obturator internus, the gemelli and the groove running along their tendons, and the third as the impression of the insertion of the obturator externus (figure C). Figure legends A: Photographs of the anteromedial aspect of a right proximal femur showing the muscular and tendinous structures around the greater trochanter. B: Micro CT image of the same specimen after the femoral head was removed, showing the three-dimensional conformation of the greater trochanter. The shallow groove on the tip of the greater trochanter (yellow area) was identified as the insertion of the piriformis and the course of its tendon (asterisk). The deep, wide groove on the medial aspect of the greater trochanter (pink area) was identified as the insertion of the obturator internus and the course of its tendon (star). The deep depression on the medial aspect of the greater trochanter, just posterior to the insertion of the obturator internus (blue area) was identified as the insertion of the obturator externus. C: Photograph of the same specimen, after chemical removal of the soft tissue, showing tendon insertions and the course of the short external rotator muscles. The groove adjacent to the insertion of the piriformis (asterisk) indicates the course of its tendon. The groove adjacent to the insertion of the obturator internus (dagger) indicates the course of its tendon. Fh = femoral head, Pi = piriformis, Oi = obturator internus, Oe = obturator externus, Ant = anterior, and Sup = superior. Conclusions:. Bony landmarks indicating the attachment site and the course of the short external rotator muscles were identified on the greater trochanter

Background. In total hip arthroplasty (THA), preservation of the short external rotator muscles are considered to be important because they contribute to joint stability and prevent postoperative dislocation. Recently, we reported that there are bony impressions on the greater trochanter that indicate the insertions of the short external rotator tendons. In this study, we reported a method to visualize the bony impressions using preoperative CT images, and evaluate the reliability and accuracy of this method. Methods. Thirty-three hips from 24 consecutive patients undergoing THA were enrolled. The mean age was 65.3 years. Preoperative diagnoses included hip osteoarthritis in 27 hips, rheumatoid arthritis in 4 hips, idiopathic osteonecrosis in 1 hip, femoral neck fracture in 1 hip. Preoperative CT of the hip region was obtained and three-dimensional (3D) reconstruction of the greater trochanter was performed to visualize the bony impressions, that we called the obturator tendon attachment (OTA), indicating the attachment area of the obturator internus and externus muscles. Results. 3D reconstructed images of the greater trochanter were observed from medial side at 50 degrees of external hip rotation and 20 degrees of abduction (OTA view). Using OTA view, the bony impressions indicating the attachment area of the obturator internus and externus muscles can be identified in all hips. Conclusions. The bony impressions indicating the attachment area of the obturator internus and externus muscles can be visualized using preoperative 3D-CT. We considered that the findings in the present study could be helpful for surgery because the alignment of the short external rotator muscles can be estimated preoperatively and the extent of the damage to the OA during the rasping or reaming can be estimated

The direct superior approach (DSA) is a modification of the posterior approach (PA) that preserves the iliotibial band and short external rotators except for the piriformis or conjoined tendon during total hip arthroplasty (THA). The objective of this study was to compare postoperative pain, early functional rehabilitation, functional outcomes, implant positioning, implant migration, and complications in patients undergoing the DSA versus PA for THA. This study included 80 patients with symptomatic hip arthritis undergoing primary THA. Patients were prospectively randomised to receive either the DSA or PA for THA, surgery was undertaken using identical implant designs in both groups, and all patients received a standardized postoperative rehabilitation programme. Predefined study outcomes were recorded by blinded observers at regular intervals for two-years after THA. Radiosteriometric analysis (RSA) was used to assess implant migration. There were no statistical differences between the DSA and PA in postoperative pain scores (p=0.312), opiate analgesia consumption (p=0.067), and time to hospital discharge (p=0.416). At two years follow-up, both groups had comparable Oxford hip scores (p=0.476); Harris hip scores (p=0.293); Hip disability and osteoarthritis outcome scores (p=0.543); University of California at Los Angeles scores (p=0.609); Western Ontario and McMaster Universities Arthritis Index (p=0.833); and European Quality of Life questionnaire with 5 dimensions scores (p=0.418). Radiographic analysis revealed no difference between the two treatment groups for overall accuracy of acetabular cup positioning (p=0.687) and femoral stem alignment (p=0.564). RSA revealed no difference in femoral component migration (p=0.145) between the groups at two years follow-up. There were no differences between patients undergoing the DSA versus PA for THA with respect to postoperative pain scores, functional rehabilitation, patient-reported outcome measurements, accuracy of implant positioning, and implant migration at two years follow-up. Both treatment groups had excellent outcomes that remained comparable at all follow-up intervals

Economic data, clinical outcome studies, and anatomical studies continue to support the Superior Hip Approach as a preferred approach for improved safety, maximal tissue preservation, rapid recovery, and minimised cost. Clinical studies show exceedingly low rates of all major complications including femur fracture, dislocation, and nerve injury. Economic data from Q1 2013 to Q2 2016 demonstrate that CMS-insured patients treated by the Superior Hip Approach have the lowest cost of all patients treated in Massachusetts by an average of more than $7,000 over 90 days. The data show that the patients treated by the Superior Hip Approach have lower cost than any other surgical technique. Matched-pair bioskills dissections demonstrate far better preservation of the hip joint capsule and short external rotators than the anterior approach. Design principles include: Preservation of the abductors; Preservation of the posterior capsule and short external rotators; Preparation of the femur in situ prior to femoral neck osteotomy; Excision of the femoral head, thereby avoiding surgical dislocation of the hip; In-line access to the femoral shaft axis; Ability to perform a trial reduction; Independence from intra-operative imaging; Independence from a traction table; Applicable to at least 99% of THA procedures. Conclusion. In contrast to the results of the Superior Approach, the anterior approach continues to show difficulties with wound problems, infection, intra- and post-operative fracture, and failure of femoral component osseointegration and even dislocation. Evidence continues to demonstrate that the Superior Hip Approach has advantages over all other surgical approaches to the hip

Background. In total hip arthroplasty (THA), the importance of preserving muscle is widely recognized. It is important to preserve the short external rotator muscles because they contribute to joint stability and prevent postoperative dislocation. However, despite careful capsular release and femoral rasping, damage to the short external rotator muscles may occur. The Optymis Shot Stem preserves more bone and surrounding tissue than does a traditional primary stem. We investigated the usefulness of the stem in terms of the extent of preservation of the tendon attachment on the greater trochanter. Method. In this study, we enrolled 31 consecutive patients (39 hips; 6 males, 25 females) who underwent THA. Simultaneous bilateral THA was performed in 8 patients. The patients’ mean age was 56.1 years. Diagnoses included developmental dysplasia in 35 hips (Crowe group 1: 31 hips, group 2: 4 hips), and sequel of Perthes disease in 4 hips. All THAs were performed via the direct anterior approach without traction tables. The femoral procedure was performed with the hip hyperextended, and posterior capsular release was performed if the femoral procedure became technically difficult. We compared the following among patients: the operative time, intraoperative blood loss, length of hospital stay, rate of posterior capsular release, postoperative radiographic findings, WOMAC score before and after surgery, and any complications. Results. The mean operative time was 42.0 ± 8.9 min, the mean intraoperative blood loss was 308 ± 196 g, and the mean hospital stay was 6.7 ± 1.3 days. Posterior capsular release was performed in 17 hips [44%; 10 hips (32%) in Crowe group 1, 8 hips (88%) for other diagnoses]. The total WOMAC score improved significantly from 42.4 points preoperatively to 11.2 points at 3 months preoperatively. A postoperative stem subsidence ≥3 mm was observed in 1 hip (2.6%), whereas postoperative dislocation, intra- and postoperative periprosthetic fracture, and thigh pain were not observed. Conclusions. The Optymis Short Stem could be placed without performing posterior capsular release in 68% of patients with Crowe group 1 developmental dysplasia. We therefore consider the stem as useful for preserving the tendon attachment on the greater trochanter

Background. In total hip arthroplasty (THA), the importance of preserving muscles is widely recognized; therefore, muscle-sparing approaches are widely used. Recently, we reported that there are bony impressions, that we called the obturator attachment (OA), on the greater trochanter that indicate the insertions of the short external rotator tendons. In this study, we used a three-dimensional (3-D) template to evaluate damage to the insertions of the short external rotator muscles during a femoral procedure. Methods. We investigated 12 hips in 10 patients who underwent THA. Preoperative CT imaging of the hip was performed, and 3-D reconstruction of the greater trochanter was used to visualize the bony impressions that indicate the insertions of the obturator internus and externus muscles (Fig 1A). We performed preoperative 3-D templating of two different femoral prosthesis (flat tapered-wedge stem: J-Taper, cylindrical straight stem: PerFix910) and then evaluated the extent of damage to the OA during the stem placement (Fig 1B, 1C). The extent of damage to the OA was classified using the following scale: grade 0, no damage of the insertion area; grade 1, less than 1/3; grade 2, equal to or more than 1/3–2/3; grade 3, equal to or more than 2/3; grade 4, complete. Results. The attachment area of the obturator internus tendon was damaged in 9 hips (7 hips: grade 1, 2 hips: grade 2) using J-Taper and all hips (8 hips: grade 2, 4 hip: grade 3) using PerFix910. The attachment area of the obturator externus tendon was not damaged in any hip using J-Taper but was damaged in 5 hips (5 hips: grade 1) using PerFix910. Conclusions. The tendon insertion site for the obturator internus was more likely to be damaged by rasping or reaming. The tapered-wedge type stem was considered to be superior to the straight, cylindrical stem for preserving the tendon insertions on the greater trochanter. Fig.1 Three-dimensional reconstructed images of the left greater trochanter, after removal of the femoral head. A: The deep depression in the anterior part of the trochanteric fossa (blue area) indicates the insertion of the obturator internus, and the posterior depression in the trochanteric fossa (red area) indicates the insertion of the obturator externus. B: Preoperative 3-D templating of the J-taper (Kyocera, Kyoto, Japan) was performed. The insertion area of the obturator internus was damaged (Grade 1), while the insertion area of the obturator externus was not damaged. C: Preoperative 3-D templating of the PerFix910 (Kyocera, Kyoto, Japan) was performed. The most of the insertion area of the obturator internus was damaged (Grade 3), while the insertion area of the obturator externus was not damaged. Oi = obturator internus, Oe = obturator externus, Lt = lessor trochanter, Sup = superior, and Ant = anterior

We developed a modified posterior approach that preserved the short external rotator muscles to prevent dislocation after THA or BHA. The present study aimed to evaluate the effectiveness of short external rotator preserving posterior(ERP) approach for bipolar hemiarthroplasty in treatment of femoral neck fractures in patients with neurologic disorders. Between March 2004 and February 2006, we performed 187 cementless bipolar hemiarthroplasties for displaced femoral neck fractures on 36 patients with neurologic disorders, who were operated on by ERP approach (Group 1) and 151 patients without neurologic deficits, who were operated on by conventional posterolateral approach (Group 2). We compared operation time, the amount of postoperative blood loss, the early postoperative complication rates, the dislocation rate within 1 year, and duration of hospital stay between two groups. The amount of postoperative blood loss was significantly decreased in group 1(p < 0.01). There were no significant differences in mean operation time and early postoperative complication rate including wound problem, deep vein thrombosis or infection and duration of hospital stay. There was no dislocation after operation in group 1, but seven patient (4.6%) had dislocation in group 2. Nine patients (25.0%) died within postoperative 1 year in group 1 and twenty six patients (17.2%) died in group 2. Cementless bipolar hemiarthroplasty through ERP approach provides a favorable outcome for treatment of displaced femoral neck fracture in patients with neurologic disorders who is considered as high risk of dislocation. Also, it decreases the postoperative blood loss and the needs of postoperative abduction brace

The Superior Hip Approach allows for safe reconstruction of the hip while maximizing preservation of the surrounding soft tissues. The procedure involves an incision in the hip joint capsule posterior to the gluteus medius and minimus and anterior to the short external rotators. The technique involves preparation of the femur in-situ through the superior femoral neck and then excision of the femoral head, which avoids the attendant soft tissue dissection or injury associated with dislocation of the native hip. After component implantation, the capsule is closed anatomically. Two separate studies have demonstrated that over a 90-day period, patients whose hips were replaced using this technique consumed the least amount of cost of any patients treated by hip arthroplasty in the Commonwealth of Massachusetts. One study assessed all hips replaced in patients insured by Medicare over a four-year period. In this study, patients treated by the Superior Hip Approach were less costly by an average of more than $7,000 over 90 days. A second study assessed all hips replaced in patients insured by a large private insurer. This study showed again that patients treated by the Superior Hip Approach were the lowest cost patients. Notable, the cost on average was $23,500 less per procedure compared to the most well-known medical care organization in the state or roughly half the cost. Lower cost was due to both lower inpatient cost and reduced utilization of post-acute care resources. Since reduced resource utilization is a direct measure of accelerated recovery, these economic data combine with clinical outcomes and anatomical studies that document that the Superior Hip Approach is a reliable technique for achieving optimal results following THA

Purpose. Minimally invasive anterolateral approach (ALA) for total hip arthroplasty (THA) has gained popularity in recent years as better postoperative functional recovery and lower risk of postoperative dislocation are claimed. However, difficulties for femur exposure and intraoperative complications during femoral canal preparation and component placement have been reported. This study analyzes the anatomical factors likely to be related with intraoperative complications and the difficulties of access noted by the surgeons through a modified minimally invasive ALA. The aim is to define the profile for patient at risk of intraoperative complications during minimally invasive ALA. Methods. We retrospectively included 310 consecutive patients (100 males, 210 females) who had primary unilateral THA using the same technique in all cases. The approach was performed between the tensor fascia lata and the gluteus medius and minimus, without incising or detaching muscles and tendons. Posterior translation was combined to external rotation for proximal femur exposure (Fig. 1). All patients were reviewed clinically and radiologically. For the radiological evaluation, all patients underwent pre- and postoperative standing and sitting full-body EOS acquisitions. Pelvic [Sacral slope, Pelvic incidence (PI), Anterior pelvic plane angle] and femoral parameters were measured preoperatively. We assessed all intraoperative and postoperative complications for femoral preparation and implantation. Intraoperative complications included the femoral fractures and difficulties for femoral exposure (limitations for exposure and lateralization of the proximal femur). The patients were divided into two groups: patients with or without intraoperative complications. Results. Ten patients (3.2%) had intraoperative femoral fractures (greater trochanter: 2 cases, calcar: 8 cases). Five fractures required additional wiring. Difficult access to proximal femur was reported in the operative records for 10 other patients (3.2%). There was no difference in diagnosis, age, sex, BMI between the patients with or without intraoperative complications. No significant group differences were found for surgical time, and blood loss. Patients with intraoperative complication, presented a significantly lower pelvic incidence than patients without intraoperative complications (mean PI: 39.4° vs 56.9°, p<0.001). The relative risk of intraoperative complications in patients with low PI (PI<45°) was more than thirteen times (relative risk; 13.3, 95% CI= 8.2 to 21.5. p<0.001) the risk for patients with normal and high PI (PI>45°). Conclusions. Anterolateral approach for THA implantation in lateral decubitus is reported to have anatomical and functional advantages. Nevertheless, the exposure of the femur remains a limitation. This study highlights a significant increased risk in case of low PI less than 45°. This specific anatomical pattern reduces the local working space as the possibility for posterior translation and elevation of the proximal femur is less on a narrow pelvis. This limitation is due to the length and the orientation of the hip abductor and short external rotator muscles related to the relative positions of iliac wing and greater trochanter (Fig. 2). This study points out the importance of pelvic incidence for the detection of anatomically less favourable patients for THA implantation using ALA. For any figures or tables, please contact the authors directly

Introduction. In our institution, we started to perform THA with SuperPATH approach, including preservation of soft tissue around the hip (James Chow et al. Musculoskelet Med 2011) since July 2014, aiming for fast recovery and prevention of hip dislocation. For minimally-invasive approaches, however, there have been a few reports on malalignment of the implants related to shortage of operative field. The purpose of this study is to examine the short-term results of THA using SuperPATH, especially implant alignment. Materials and methods. We performed a study of 45 patients (45 hips) with osteoarthritis of the hip joint who had a THA with SuperPATH approach. There were 8 men and 37 women with an average age of 73 years, which were minimally 24 months followed. Dynasty Bioform cup and Profemur Z stem (Microport Orthopaedics) were used for all cases. Patients were clinically assessed with Merle d'Aubigne score and complications. Implant alignment and stability were radiologically evaluated by annual X-ray and CT acquired two months after surgery. Results. Merle d'Aubigne score was 10.2 (pain:2.8, mobility:4.4 walking ability:3.0) preoperatively and 16.6(pain:5.8, mobility:5.8, walking ability:5.0) at the latest follow-up. There were no dislocation and infection, but intraoperative proximal femoral fracture was found for two cases, which was managed to treat with additional circulating wire intraoperatively. Latest follow-up X-ray image showed 95% of the stem A-P alignment to be within 2 degrees and 5% to be more than 2 degrees and less than 5 degrees, while 44% of the stem lateral alignment to be within 2 degrees, 47% to be more than 2 degrees and less than 5 degrees, and 8% to be more than 5 degrees. From CT images averaged cup position found to be 40±5 degrees for inclination, and 19±5 degrees for anatomic anteversion, averaged stem anteversion to be 33±9 degrees. Annual X-ray evaluation showed no radiolucent line and less than Grade 2 stress-shielding (Engh classification) around the implants for all cases. One case had more than 5mm subsidence of the stem in early postoperative period, but not progressively subsided. No loosening of components was evident. Discussion and Conclusion. Many minimally-invasive approaches have developed, there have been many reports on fast recovery and low incidence of postoperative hip dislocation, however, the risk of complications or malalignment related to shortage of operative field has been pointed out. In this study, intraoperative proximal femoral fracture occurred for two cases. Also, though there were no loosening and the components position seemed excellent but lateral view of the X-ray showed 8% to be more than 5 degrees tilting alignment, resulting from femoral broaching required before femoral neck resection. SuperPATH approach, including pass way from between the Gluteus Medius and the piriformis tendon, can preserve the whole short external rotators and capsule of the hip joint, leading to fast recovery and low incidence of postoperative dislocation. Moreover, this approach may be friendly to the surgeons familiar with the posterior approach because of easily conversion to the conventional posterior approach

Introduction. Many minimally-invasive approaches have been described in an effort to improve short-term results of total hip arthroplasty (THA), aiming for fast recovery and prevention of dislocation. In our institution, we started to perform THA with SuperPATH approach, including preservation of soft tissue around the hip (James Chow et al. Musculoskelet Med 2011) since July 2014. The purpose of this study is to examine the short-term results of THA using SuperPATH, especially treatment progress of rehabilitation. Materials and methods. We performed a study of 30 patients (30 hips) with osteoarthritis of the hip joint who had a THA with SuperPATH approach. There were 4 men and 26 women with an average age of 71 years, which were followed up for 24 months. Patients were clinically assessed with Merle d'Aubigne score, postoperative hip pain during walking by Numerical Rating Scale (NRS:0–10), complications and treatment progress of rehabilitation in regard to moving and activities of daily living. Implant alignment and stability were radiologically evaluated by annual X-ray and CT acquired two months after surgery. Results. Merle d'Aubigne score was 10.4 (pain:2.9, mobility:4.5 walking ability:3.0) preoperatively and 16.8(pain:5.9, mobility:5.9, walking ability:5.0) at the latest follow-up. NRS showed less than 3 points for more than 50% of the THA patients next day postoperatively. For more than 80%, NRS showed less than 1 point at 7 days after surgery, and most patients acquired the ability of level ground walking for 100 meters independently by 4 days postoperatively, climbing up and down stairs independently by 5 days and wearing/taking off their socks independently by 7 days. There were no dislocation and infection, but intraoperative proximal femoral fracture was found for two cases, which was managed to treat with additional circulating wire intraoperatively. From CT images averaged cup position found to be 39±5 degrees for inclination, and 21±6 degrees for anatomic anteversion, averaged stem anteversion to be 33±9 degrees. No loosening of components was evident. Discussion and Conclusion. Many minimally-invasive approaches have developed, there have been many reports on fast recovery and low incidence of postoperative hip dislocation, however, the risk of complications related to shortage of operative field has been pointed out. In this study, intraoperative proximal femoral fracture occurred for two cases, but the components position seemed excellent and NRS showed less pain postoperatively and most of the patients acquired walking ability in a few days. SuperPATH approach, including pass way from between the Gluteus Medius and the piriformis tendon, can preserve the whole short external rotators and capsule of the hip joint, leading to fast rehabilitation progress. Moreover, this approach may be friendly to the surgeons familiar with the posterior approach because of easily conversion to the conventional posterior approach

Femoral neck fractures continue to be one of the most common orthopaedic injuries treated today. Owing to the increased longevity of patients, enduring activity of older patients, and widespread osteoporosis in the population, there are more femoral neck fractures treated nowadays than ever before. Over 1 million femoral neck fractures were treated in the >65-year-old population, in the United States, between the years 1991–2008. The treatment of femoral neck fractures is unique because some fractures are amenable to internal fixation, while others require endoprosthetic replacement, either with a hemiarthroplasty or total hip replacement. Traditionally, less displaced fractures are treated with internal fixation; however, in younger patients, an attempt to fix the displaced fractures may be performed, in order to avoid a joint replacement in this population. The age at which an attempt at internal fixation is performed is still controversial, and treatment must be individualised to each patient. In general, patients younger than 60 would likely have internal fixation of the femoral neck fracture, rather than joint replacement. The paradigm for the treatment of femoral neck fractures has been changing in the last 10 years, due to advances in implant technology, surgical technique, and scientific papers that have compared the results of all three treatment options. Larger diameter femoral heads in combination with highly crosslinked polyethylene, or dual mobility head options, provide greater joint stability today than was possible in the past, thus making THA a more appealing option. Furthermore, greater use of the direct anterior approach to THA may also reduce the postoperative dislocation rate, due to preservation of the posterior capsule and short external rotators. Therefore, the author will propose the use of arthroplasty for displaced femoral neck fractures in patients younger than 60 years of age, owing to the reliability and reproducibility of THA over ORIF. Furthermore, the advances in arthroplasty materials and surgical techniques can restore function in this group of younger patients, with greater longevity of the implant than in the past

Posterior soft tissue repair is often performed in Total Hip Arthroplasty (THA). Many reports have shown the advantage of posterior soft tissue repair in reducing their prosthetic hip dislocation rates. We describe an easy and inexpensive way of passing sutures through small drill holes in the Greater Trocanter to re-attach muscle, tendon and capsule in a posterior soft tissue repair. By using a reversed monofilament suture on a straight needle held in artery forceps and passing this in a retrograde direction through a drill hole, a suture capturing device is produced. By capturing the long ends of sutures tied in the short external rotators and the posterior capsule of the hip through 2 drill holes in the Greater Trochanter, a posterior soft tissue repair can be performed. We have used this technique successfully in over 100 consecutive THAs. We conclude that the use of a monofilament suture used in the manner describe is an excellent and inexpensive way to aid in a posterior soft tissue repair in THAs. This is done without the cost of an additional dedicated suture passing device. The suture could also be used in the skin closure if desired

Femoral neck fractures continue to be one of the most common orthopaedic injuries treated today. Owing to the increased longevity of patients, enduring activity of older patients, and widespread osteoporosis in the population, there are more femoral neck fractures treated nowadays than ever before. Over 1 million femoral neck fractures were treated in the >65 year old population, in the United States, between the years 1991–2008. The treatment of femoral neck fractures is unique because some fractures are amenable to internal fixation, while others require endoprosthetic replacement, either with a hemiarthroplasty or total hip replacement. Traditionally, less displaced fractures are treated with internal fixation; however, in younger patients, an attempt to fix the displaced fractures may be performed, in order to avoid a joint replacement in this population. The age at which an attempt at internal fixation is performed is still controversial, and treatment must be individualised to each patient. In general, patients younger than 60 would likely have internal fixation of the femoral neck fracture, rather than joint replacement. The paradigm for the treatment of femoral neck fractures has been changing in the last 10 years, due to advances in implant technology, surgical technique, and scientific papers that have compared the results of all three treatment options. Larger diameter femoral heads in combination with highly crosslinked polyethylene, or dual mobility head options, provide greater joint stability today than was possible in the past, thus making THA a more appealing option. Furthermore, greater use of the direct anterior approach to THA may also reduce the post-operative dislocation rate, due to preservation of the posterior capsule and short external rotators. Therefore, the author will propose the use of arthroplasty for displaced femoral neck fractures in patients younger than 60 years of age, owing to the reliability and reproducibility of THA over ORIF. Furthermore, the advances in arthroplasty materials and surgical techniques can restore function in this group of younger patients, with greater longevity of the implant than in the past

Several design principles were considered paramount when the surgical technique of performing total hip arthroplasty through an incision in the superior capsule without dislocation of the hip joint was developed. These design principles include: Preservation of the abductors; Preservation of the posterior capsule and short external rotators; Preparation of the femur in situ without dislocation of the hip; In-line access to the femoral shaft axis; Ability to perform a trial reduction; Independence from intraoperative imaging; Independence from a traction table; Applicable to at least 99% of THA procedures. Personal experience with more than 1950 THA using the superior capsulotomy technique over a 12-year period has demonstrated several observations: Dislocation rate of 0.15% (3 in 1950); Acute deep infection rate of 0% (0 in 1950); Universal applicability: used in 99.7% of primary THA; Lateral femoral cutaneous nerve palsy incidence: 0/1950; Femoral nerve palsy incidence: 0/1950; Transient peroneal palsy incidence: 2/1950; Length of stay (since 2010): 1.55 days; Discharge to home: 98%; 90-day cost (2/13 to 2/14) compared to other exposures in CMS patients in the same institution: $24,200 vs $30,100; Readmission costs (CMS 2/13 to 2/14) at 90 days: $0. Conclusion: Performing total hip arthroplasty without dislocation and with preservation of the abductors, posterior capsule and short external rotations has proven to have a low dislocation rate, a low infection rate, and wide applicability. CMS 12-month expenditure data documenting ZERO dollars spent on readmission for any reason within 90 days of surgery demonstrates the potential for simultaneously improving incomes and reducing cost, with particular benefit within the CMS BPCI and private bundled payment programs

Background:. Modified posterior approach and its effect on stability and functional outcome in total hip arthroplasty. Material & Methods:. A retrospective comparative evaluation was done to assess the functional outcome and rate of dislocation in 233 hips (Group A) operated before 2007 by convention posterior approach and 567 hips (Group B) were operated by modified posterior approach.(2007–2011) In this modified posterior approach technique, 2–3 stay sutures (non-absorbale Nylon) are applied in the piriformis tendon, short external rotator and proximal part of Quadratous muscle. Then a conjoint- myocapsular sleeve is raised by starting cutting (with cautery) linearly over the capsule with adherent fibers of gluteus minimus to piriformis tendon, short rotators and part of quadratus to expose and dislocate the head. After inserting the definite prosthesis, upper part of sleeve (capsule, piriformis tendon) is sutured with same nonabsorbable Nylon at the lower part of tip of greater trochanter by passing through the bone with needle or by drilling the bone; lower part of the sleeve is tied with lateral trochanteric bone. Additional stability to repair was given by closing the tendinous part of the gluteus maximus by horizontal cross mattress sutures up its attachment to the proximal femoral shaft. Results:. All patients underwent cementless total hip arthroplasty; average Harris hip score at minimum 3.1 yr follow was 88.7 in Group B & 85.2 in Group B. Group B had only one dislocation while Group A had 12 dislocations (5%). Conclusion:. This technique provide enhanced stability and improve functional outcome

The direct anterior (DA) approach for total hip arthroplasty (THA) has become increasingly popular in North America. With experience, exposure of both the acetabulum and femur can be achieved similar to those in other approaches. In cases of difficult femoral exposure, the conjoint tendon of the short external rotators can be released to improve visualisation. The effect of conjoint tendon release has not been previously explored in regards to overall outcomes, or postoperative pain. The goal of this study was to evaluate 1) the length of stay and inpatient pain medication requirements of patients undergoing DA THA on the basis of conjoint tendon release, and 2) whether conjoint tendon release influenced functional outcomes. We conducted a retrospective chart review of all cases of primary DA THAs conducted by single surgeon at LHSC University between August 2012 and July 2015. Patient demographics, bilateral THA cases, intraoperative conjoint tendon or other soft tissue releases, intra-operative complications, and length of stay (LOS) were evaluated for all cases. Inpatient pain medication data was available for all cases from Apr 2014 onwards. One year functional outcome scores, including WOMAC and Harris Hip Scores (HHS), were evaluated for all cases before August 2014. Six-week and three-month functional outcome scores were available and evaluated for a subset of cases. All data was analysed with multiple linear regression. Three hundred and twelve cases of primary DA THAs were identified, of which 29 were concurrent bilateral THAs. One hundred and eighty cases included a conjoint tendon release, while 29 cases had other soft tissue releases (tensor fascia lata). Mean age and BMI were 64.9±11.5 years and 29.0±5.3 respectively. Mean LOS was 1.3±1.1 days, with age, bilateral THA, non-conjoint tendon soft tissue release, and intra-operative complications being predictive of LOS (p<0.05). Pain medication data was available for 107 cases, of which 11 were concurrent bilateral THAs. Sixty four cases included a conjoint tendon release, while one case had other soft tissue releases. Mean daily morphine equivalent dose (MED) narcotic use was 43.2±48.2mg, with age being a negative predictor of narcotic use (p<0.05). BMI was a negative predictor of one year HHS pain, HHS total, and all WOMAC subcategory scores, while age was a negative predictor of one year HHS function and HHS total scores (p<0.05). None of the variables were predictive of six-week and three-month functional outcome scores. Conjoint tendon release was not predictive of LOS, inpatient pain medication requirements, or outcome scores. Conjoint tendon release did not affect postoperative pain, LOS, or functional outcomes. Given that conjoint release improves femoral exposure, intraoperative thresholds for conjoint release should be low. The effect of intraoperative release of other soft tissues is uncertain, as this increased LOS but not postoperative pain