Introduction: Total hip arthroplasty preformed with the use of minimal incision surgery has received tremendous attention recently. Various surgical approaches have been introduced to minimize surgical trauma to the soft tissues. The mini invasive Modified Watson-Jones approach have been selected to decrease the perioperative complications associated with other mini invasive approaches that has been described.

The anterolateral mini incision is a new innovative approach using the intramuscular plan between the gluteus medius and the tensor fascia lata. This intermuscular interval through a small incision provides good exposure and preserves muscle integrity. Moreover, preserving the muscle integrity provides a very stable joint after implantation such that no restrictions is giving to the patient during the rehabilitation period.

Materials and Methods: Between July 2004 to September 2005, we used this approach on 60 sequential patients. Fifty patients were enrolled in this prospective study. Patients were evaluated preoperatively, immediately postoperatively, and at 3-month and 6 month follow-up according to operating time, intraoperative blood loss, subcutaneous drains blood loss, post op pain control drugs requirements, short form 36 patient questionnaire (SF-36) scores and the Harris Hip Score (HHS). 4 patients had previous THA on the contralteral side.

Results: The average operation time was 137min (range 90–200min), there were no dislocations, the mean post operation blood transfusion requirements was 1.64, the mean subcutaneous drains blood loss was 241.9ml (range 20–620ml), there was significant improvement in function, pain, SF-36 and Harris Hip Score (HHS) at the 3-month and 6-month follow-up examination. The average length of the incision was under 12cm. We had one reoperation due to deep infection. All four patients with bilateral THA preferred their last operation due to lack of post operative restrictions and due to shorter recovery of muscle strength.

Conclusion: We think that using mini invasive Modified Watson-Jones approach in total hip replacement surgeries is a preferable option. There are several advantages of using this approach compared with the more traditional techniques. Such a technique should help reduce morbidity and complication rates for those patients undergoing a total hip replacement.

Injection or aspiration of the ankle may be performed through either an anteromedial or an anterolateral approach for diagnostic or therapeutic reasons. We evaluated the success of an intra-articular puncture in relation to its site in 76 ankles from 38 cadavers. Two orthopaedic surgical trainees each injected methylene blue dye into 18 of 38 ankles through an anterolateral approach and into 20 of 38 through an anteromedial. An arthrotomy was then performed to confirm the placement of the dye within the joint. Of the anteromedial injections 31 of 40 (77.5%, 95% confidence interval (CI) 64.6 to 90.4) were successful as were 31 of 36 (86.1%, 95% CI 74.8 to 97.4) anterolateral injections. In total 62 of 76 (81.6%, 95% CI 72.9 to 90.3) of the injections were intra-articular with a trend towards greater accuracy with the anterolateral approach, but this difference was not statistically significant (p = 0.25). In the case of trainee A, 16 of 20 anteromedial injections and 14 of 18 anterolateral punctures were intra-articular. Trainee B made successful intra-articular punctures in 15 of 20 anteromedial and 17 of 18 anterolateral approaches. There was no significant difference between them (p = 0.5 and p = 0.16 for the anteromedial and anterolateral approaches, respectively). These results were similar to those of other reported studies. Unintended peri-articular injection can cause complications and an unsuccessful aspiration can delay diagnosis. Placement of the needle may be aided by the use of ultrasonographic scanning or fluoroscopy which may be required in certain instances

Introduction: The anterior and anterolateral approach to the hip traditionally are well described exposures in primary hip arthroplasty with fewer dislocations than the posterior approach. A very debilitating complication associated with the anterolateral approach however is the persistent limp and positive Trendelenburg sign. We discuss our results with respect to abductor function and morphological integrity seen on MRI when using an approach in which we preserve the majority of gluteus medius. Methods: We carried out a prospective study of thirty-nine consecutive total hip replacements performed through a gluteus medius sparing anterolateral approach. The same hip surgeon performed all these between April and October 2004. Gait analysis and Trendelenburg tests were evaluated during clinical follow-up at six weeks and three months. Coronal STIR and T1 weighted MRI sequences of the abductors were performed between four and six weeks and the findings were agreed by the consensus of two radiologists. Results: At three-month follow-up all thirty-nine patients tested Trendelenburg negative. Post-operative radiographs showed satisfactory femoral and acetabular component position. MRI findings showed the gluteus medius tendon to be intact with no shortening on T1. Artefacts were found to be less marked in the higher field strength magnet but more apparent in the STIR weighted sequences. Discussion: We have tried to incorporate the advantages of reduced dislocation rate of the anterolateral approach, whilst avoiding violation of the abductors. The clinical result and radiographic findings we have presented suggest that the described exposure is an effective and safe method of approaching the hip, with minimal disruption of the abductor mechanism. In addition to maintaining the reduced dislocation rate associated with the standard anterolateral approach. Intact abductor function allows for rapid rehabilitation

In 12 patients, we measured the oxygen concentration in the femoral head-neck junction during hip resurfacing through the anterolateral approach. This was compared with previous measurements made for the posterior approach. For the anterolateral approach, the oxygen concentration was found to be highly dependent upon the position of the leg, which was adjusted during surgery to provide exposure to the acetabulum and femoral head. Gross external rotation of the hip gave a significant decrease in oxygenation of the femoral head. Straightening the limb led to recovery in oxygen concentration, indicating that the blood supply was maintained. The oxygen concentration at the end of the procedure was not significantly different from that at the start. The anterolateral approach appears to produce less disruption to the blood flow in the femoral head-neck junction than the posterior approach for patients undergoing hip resurfacing. This may be reflected subsequently in a lower incidence of fracture of the femoral neck and avascular necrosis

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

The anterolateral surgical exposure to the distal tibia for pilon fractures has become more popular. One of the potential benefits over the commonly used anteromedial approach is a reduction in wound complications due to the improved soft tissue coverage of the anterolateral tibia. Minimal data exists regarding the rate of complications with the anterolateral approach. The purpose of this study was to evaluate wound complications in the early postoperative period associated with the use of the anterolateral approach for pilon fractures. Methods: A retrospective review was conducted to identify all operatively treated pilon fractures at our university level 1 trauma center from September 2005 through July 2007. Sixty-eight pilon fractures were identified. All patients were treated with a staged protocol utilizing immediate external fixation followed by delayed open reduction and internal fixation based upon the condition of the soft tissue envelope. Patients who had an anterolateral surgical approach were identified and their medical records were reviewed for the first six weeks postoperatively to determine the rate of wound complications. The endpoint of six weeks was chosen to identify complications related to the surgical exposure alone. Results: Thirty-six of the sixty-eight patients with pilon fractures had an anterolateral surgical exposure. One additional patient had an anterolateral incision performed for revision of a previously treated pilon fracture. 97% of these fractures were AO/OTA 43-C (three C1, nine C2, and twenty-three C3). The median time delay to definitive fixation was 19 days (10–38 days). Sixteen (44.4%) of the fractures were open, ten of which were Gustilo type III (five IIIA, four IIIB, and one IIIC). Eight of the thirty-seven patients had wound complications related to the anterolateral incision within the first six weeks of definitive fixation. Six patients (16%) had minor complications which were successfully treated with dressing changes and oral antibiotics, and two (5%) had major complications, with evidence of deep wound infection that required formal irrigation and debridement. Conclusion: In a case series with a high rate of complex open pilon fractures, open reduction and internal fixation utilizing an anterolateral approach provided good exposure of the distal tibia with a low incidence of early wound complications. Significance: Pilon fractures, especially high energy complex open ones, have a high risk of wound complications. Avoiding complications is the key in managing high energy pilon fractures. This case series provides evidence that the anterolateral approach has a low rate of wound complications in the most complex pilon fractures

Purpose: The purpose of this study was to evaluate the clinical effectiveness and outcomes of the ‘abductor sparing’ MIS Anterolateral approach (MIS Watson Jones/G3) in comparison to the MIS Direct Lateral and MIS Posterolateral approaches in primary total hip arthroplasty. Method: A multicentre, prospective, randomized controlled trial was designed to evaluate for the superiority of the new MIS Anterolateral approach (MIS Watson Jones/ G3). The sample size calculation was performed for alpha .05, power .90, to evaluate for effect size 0.5 in WOMAC using repeated measures analyses with baseline WOMAC as covariate. A total of 156 patients consented to participate in the trial and patients were assigned to MIS Antero-lateral approach or alternate MIS approach (MIS Direct Lateral or MIS Posterolateral). Patients were subjected to standardized anaesthetic and perioperative management protocols and were evaluated at standardized intervals to evaluate endpoints of early recovery (3 months) as well as endpoints of 12 and 24 months respectively. The primary outcome of interest was WOMAC, however secondary outcomes included SF-36, as well as parameters of health resource utilization and complications. Univariate and multivariate analyses were perfomed. Results: Patient groups were found to be similar at baseline with regards to demographics and baseline quality of life outcomes (p> .05). Multivariate and repeated measures analyses demonstrated no superiority of the MIS Anterolateral approach on outcomes of WOMAC and other quality of life measures in comparison to MIS Direct Lateral and MIS Posterolateral approaches (p> .05). Health care resource utlization was also similar with length of stay, blood transfusion requirements and complications (p> .05). Conclusion: Our multicentre, prospective, randomized clinical trial demonstrates that the MIS Anterolateral approach is not superior to alternate MIS surgical approaches when evaluating outcomes of quality of life, complications, and health resource utilization. Surgeons should consider these outcomes, complications, and other relevant advantages and disadvantages of select surgical approaches when deciding on a technique for use in their orthopaedic practice

Aims. The aim of this randomized trial was to compare the functional outcome of two different surgical approaches to the hip in patients with a femoral neck fracture treated with a hemiarthroplasty. Patients and Methods. A total of 150 patients who were treated between February 2014 and July 2017 were included. Patients were allocated to undergo hemiarthroplasty using either an anterolateral or a direct lateral approach, and were followed for 12 months. The mean age of the patients was 81 years (69 to 90), and 109 were women (73%). Functional outcome measures, assessed by a physiotherapist blinded to allocation, and patient-reported outcome measures (PROMs) were collected postoperatively at three and 12 months. Results. A total of 11 patients in the direct lateral group had a positive Trendelenburg test at one year compared with one patient in the anterolateral group (11/55 (20%) vs 1/55 (1.8%), relative risk (RR) 11.1; p = 0.004). Patients with a positive Trendelenburg test reported significantly worse Hip Disability Osteoarthritis Outcome Scores (HOOS) compared with patients with a negative Trendelenburg test. Further outcome measures showed few statistically significant differences between the groups. Conclusion. The direct lateral approach in patients with a femoral neck fracture appears to be associated with more positive Trendelenburg tests than the anterolateral approach, indicating a poor clinical outcome. Cite this article: Bone Joint J 2019;101-B:793–799

The purpose of this experimental study was to elucidate the accuracy of neck-cut PSG setting, and femoral component implantation using neck-cut PSG in the THA through the anterolateral-approach relative to the preoperative planning goals, and to determine the usefulness of PSG compared with the procedure without PSG. A total of 32 hips from 16 fresh Caucasian cadaveric samples were used and classified into 4 groups: cementless anatomical stem implantation with wide-base-contact PSG (AWP: 8 hips, Fig.2); (2) cementless anatomical stem implantation with narrow-base-contact PSG (ANP: 8 hips, Fig.2); (3) cementless anatomical stem implantation without PSG (Control: 8 hips); and (4) cementless taper-wedge stem implantation with wide-base-contact PSG (TWP: 8 hips). The absolute error of PSG setting in the sagittal plane of the AWP group was significantly less than that of the ANP (p=0.003).THA with wide-base- contact PSG resulted in better alignment of the femoral component than THA without PSG or with narrow- base-contact PSG. Although the neck-cut PSG did not control the sagittal alignment of taper-wedge stem, the neck-cut PSG was effective to realise the preoperative coronal alignment and medial height for THA via the anterolateral approach regardless of the femoral component type. For figures and tables, please contact authors directly

The Dall approach is a modified anterolateral approach with osteotomy of the anterior part of the greater trochanter. This approach relatively preserves the soft tissue tension during total hip arthroplasty (THA). We insert the stem and select a ball neck size so as to have a stable hip which will not dislocate easily during the trial reduction. The aim of this study is to evaluate the adequacy of this method, to measure leg length discrepancy and offset discrepancy at postoperative radiographs. We selected patients for inclusion in this study from those who have more than a 120 degree of affected hip flection angle, the opposite hip is almost normal with a low leg length discrepancy (primary OA, osteonecrosis, Crowe 1 secondary OA, femoral neck fracture). All THA were performed with cement fixation using an alignment guide to ensure accurate acetabular positioning. The ball head's diameter used were all 26mm. From September 2011 to October 2013, 22 patients met inclusion criteria among 103 THA. The mean age for 22 subjects was 66.6±12 years. The mean flexion angle of preoperative hip joints was 127.2±6.1 degrees. The cup inclination was 43.8° ± 3.5°. Anteversion was 11.8°±6°. The mean preoperative leg length discrepancy was 5.8mm±6.3mm. The mean postoperative leg length discrepancy was 0.7±3.5mm. The mean postoperative offset discrepancy was 0.7±6.6mm. There were no dislocations in this series of 103 cases. Discussion. Dislocation and leg length discrepancies are major complications following a total hip arthroplasty. A good range of motion of the preoperative hip joint is considered a high risk dislocation factor. The Dall approach with minimal release of soft tissue related to a tension of hip joint offers maximal stability and the ability to accurately restore leg length

Recent National Institute for Health and Care Excellence (NICE) guidance has advised against the continued use of the Thompson implant when performing hip hemiarthroplasty and recommended surgeons consider using the anterolateral surgical approach over a posterior approach. Our objective was to review outcomes from a consecutive series of Thompson hip hemiarthroplasty procedures performed in our unit and to identify any factors predicting the risk of complications. 807 Thompson hip hemiarthroplasty cases performed between April 2008 and November 2013 were reviewed. 721 (89.3%) were cemented and 86 (10.7%) uncemented. 575 (71.3%) were performed in female patients. The anterolateral approach was performed in 753 (93.3%) and the posterior approach with enhanced soft tissue repair in 54 (6.7%). Overall, there were 23 dislocations (2.9%). Dislocation following the posterior approach occurred in 13.0% (7 of 54) in comparison to 2.1% (16 of 753) with the anterolateral approach (odds ratio (OR) 8.5 (95% CI 2.8 to 26.3) p < 0.001). Surgeon grade and patient history of cognitive impairment did not have a significant impact on dislocation rate. Patients were discharged home in 459 cases (56.9%), to a care home or other hospital in 273 cases (33.8%). 51.8% (338 of 653) returned home within 30 days. 75 died during their admission (9.3%). 30-day mortality was 7.1% and 1-year mortality was 16.6%. Intraoperative fracture occurred in 15 cases (1.9%) of which 14 were cemented. Superficial or deep infection occurred in 33 cases (4.1%). We recommend against the continued use of the posterior approach in hip hemiarthroplasty, as enhanced soft tissue repair did not reduce dislocation rates to an acceptable level. Our findings, however, demonstrate satisfactory results for patients treated with the Thompson hip hemiarthroplasty performed through an anterolateral approach. We suggest that the continued use of the Thompson implant in a carefully selected patient cohort is justifiable

Introduction. Migration of the trial femoral head is a rarely occurring complication of total hip arthroplasty (THA) performed using the anterolateral approach (ALA). This migration of the trial femoral head under the rectus femoris is extremely risky because of the anatomical situation. Analyzing the morphological character of a case of migration may help us to avoid this risk. Objective. We analyzed the three-dimensional bone morphology using computed tomography (CT) scan images to investigate the physiological characteristics of five migration cases. Methods. We examined 108 patients (21 men, 87 women, 113 hips) who underwent THA via the ALA. The average patient age was 62.9 (range: 30–87) years and average body mass index was 24.4 (range: 18.0–36.0) kg/m2. The exclusion criteria were dysplastic coxarthroses greater than Crowe type II, previous fractures, previous hip operations, and muscle disease. Three-dimensional models of the pelvis and femur were made using ZedHip software® (Lexi, Tokyo, Japan). The anterior superior iliac spine on the affected side (A) and contralateral side (A’), anterior inferior iliac spine (I), and greater trochanter tip (G) were noted in these models. The distances A–I, I–G, and A–G and the angle formed by AA’ and AI were measured (Figure 1, 2). Each hip was classified by the presence (group M) or absence (group N) of migration during surgery. A Fisher's exact probability test, Student's t-test, and Welch's t-test were used to compare the two groups, and p-values less than 0.05 were considered significant. Results. In 5 of the 113 hips, the trial femoral heads migrated under the rectus femoris and were removed safely. No significant differences were found between the gender, height, weight, or BMI of the groups. The average A–I distance was 32.3±3.0 mm (mean±SD) in group M and 39.4±10.4 mm in group N; I–G was 52.2±8.2 mm in group M and 59.7±10.6 mm in group N; and A–G was 64.3±10.3 mm in group M and 76.3±12.3 mm in group N. The average angle formed by AA’ and AI was 50.5±5.8°. Significant differences between the two groups were found for the distances A–I and A–G. Conclusions. In 4.4% of cases, the trial femoral heads migrated under the rectus femoris, which creates a risk for serious complications because major nerve and blood vessels are located nearby. The tendency for migration was expected to be related to the balance between soft tissues. In this study, we found that migration tends to occur in patients with shorter distances between A and I, and A and G. The trial head should be dislocated more carefully in those patients

Purpose of the study: Survival of a total hip arthroplasty (THA) mainly depends on the choice of the implant and the quality of the implantation. Use of minimally invasive approaches remains a subject of controversy due to the uncertain implant position and questions concerning increased perioperative complications. The purpose of this work was to assess these two elements in a consecutive series of patients who underwent THA implanted via the minimally invasive anterolateral approach described by Rottinger. Materials and Methods: This was a consecutive series of 130 patients (84 female, 46 male, mean age 69 years, age range 46–91) operated by the same surgeon. Mean follow-up was twelve months (range 6 – 24 months). The clinical parameters studied were: the pre–and post-operative Postel-Merle-d’Aubigné (PMA) score, mean operative time, presence of perioperative surgical complications. Radiographic parameters studied were lucent lines (De Lee and Gruen), homogeneous cementing of the femoral piece, axial position of the femoral implant, angle of acetabular inclination, acetabular anteversion (Hassan), and any leg length discrepancy. Results: Intraoperative complications were: one intraoperative mobilisation of a press-fit cup, one trochanter fracture. Postoperatively, the rate of dislocation was 2.3%. In 3.8% of the patients developed skin lesions or a local haematoma but none with infection. Mean operative time was 107 minutes (range 80–210). Mean postoperative PMA score was 17.4 versus 12.4 preoperatively. Patients were able to walk without limping 3.3 months postoperatively (range 0.5–12 months). Mean cup inclination and anteversion were 46.1° (28–60°) and 12.3° (0–35°) respectively. Leg length discrepancy was +4.8mm on average (operated side). Femoral alignment was ±3° relative to the femoral axis in 83% of hips. Homogeneous cementing of the femoral stem was noted in 84%. There was a learning curve with an 11% complication rate for the first twenty hips versus 4% for the remainder of the hips in this series. Discussion: In our hands, the minimally invasive anterolateral approach described by Rottinger enables proper reproducible THA implantation. The rate of intraoperative complications is low. There is a learning curve which was an estimated twenty cases in our series. This method has become our first-intention option for implantation of THA

Aim. The objective of this study was to evaluate the intermediate term clinical and radiological results of a new short stem hip implant. Methods. In 20 consecutive patients suffering from osteoarthritis with 25 affected hip joints (five cases were bilateral), the clinical and radiological results of 25 hip arthroplasties performed in one hospital between October 2009 and May 2014 through a minimally invasive anterolateral approach using a cementless short stem prosthesis type Aida and a cementless cup type Ecofit with a ceramic on ceramic pairing were evaluated prospectively. The median age of patients at time of surgery was 60 years (range, 42–71 years), 15 male (4 were bilateral) and 5 female patients (one was bilateral) were included in the study. The median clinical follow up was 30 months (range, 2–88 months), and the median radiological follow up was 30 months (range, 2–88 months). Results. Harris Hip Score improved from a median preoperative value of 53 to a median postoperative value of 96 (range, 73–100) at follow up. 22 hips (88%) showed an excellent postoperative Harris Hip Score, 2 hips (8%) a good postoperative Harris Hip Score, and one hip (4%) a fair postoperative Harris Hip Score. Only two patients complained of postoperative thigh pain. Regarding patient satisfaction, 15 patients (60%) were very satisfied, 10 patients (40%) were satisfied. None was unsatisfied. Radiological analysis showed that 19 stems (76%) were with stable bony ingrowth, two cases (8%) showed stable fibrous ingrowth. Four cases need further follow up for proper evaluation of stem fixation.(See Figures 1,2,3). Conclusion. The intermediate term survival of this new short stem is very promising, and achieving the goals of a standard hip arthroplasty. For any figures or tables, please contact the authors directly

Aims: The purpose of this study was to compare the hip abductor strength in patients undergoing total hip replacement via anterolateral (Müller) or posterolateral (Gibson) approach. Methods: Biomechanical studies were performed prospectively on a group of 80 patients who underwent hip arthroplasty via the anterolateral (48 cases) or posterolateral approach (32 cases). There were 61 females and 19 males with an average age of 57 years (range 37 – 78 years). The isometric abductor strength was measured with the kinetic communicator device preoperatively and 6, 12 and 24 weeks postoperatively. Results: Hip abductor strength improved postoperatively in both groups. The posterolateral surgical approach was associated with statistically significant higher abductor strength values. Conclusions: Posterolateral approach significantly increases the isometric abductor strength in relation to the anterolateral approach

In fall 2004 we started with minimal invasive hip surgery at our clinic. Our requirements: Use of our standard implant system (Bicon threaded cup and Zweymüller stem), fast realization of the minimal invasive procedure through the continuation of the used, anterolateral Watson-Jones approach, modified for this technique, retaining the supine position with unchanged orientation concerning the positioning of the implant parts. Our expectations: Reduction in operative trauma through lower blood loss with less post-operative pain, less limping especially during the first weeks, less trochanter pain through the preservation of the gluteal muscle tendons, fewer posterior dislocations by preservation of the dorsal capsule, and a better cosmetic result. The patient is placed in supine position on the standard OR table with the option of tilting the legs down. The contralateral leg lies on a leg holder in extended position, flexed by approx. 20 degrees. This allows to bring the leg in hyperextension (without hyperlordosis of the lumbar spine), adduction and external rotation during broaching the femur. The main criterion of the minimal invasivness is the preservation of the gluteal tendons and not primarily the reduction of the length of the skin incision. An extensive capsular release with partial dissection of the rectus tendon for exposure of the acetabulum is necessary. For the stem implantation a notching of the piriformis can be necessary in addition to this. During the stem preparation the soft tissues should not influence the axial entrance of the rasps into the femoral canal otherwise there is a danger of a dorsolateral perforation. Right-left-lateral-double-offset rasps and the use of manipulation rasps as trial prostheses have worked satisfactorily. Retrospective analyses of numerous peri- and post-operative data were accomplished, as well as radiological evaluations regarding the optimal position of the implanted joints, and compared with a conventional control group. After a learning curve the OP duration was the same in both groups. The development of the haemoglobin and hematocrit levels were identical, 1/3 of the patients needed blood subsitution (autologous or stored blood). 90% of the analysed postoperative x-rays in standing position showed equal bilateral leg length corresponding to the preoperative planning, the planned offset was achieved in 93%. Deviations of the remaining were without clinical relevance. The complication rate was 2,5%. Conclusions: The anterolaterale approach in supine position is standardised for the minimal invasive THR. The compliance with the developed implantation technique is a requirement for the optimal positioning of the prosthesis and to avoid complications. The subjective patient assessments, especially of those who experienced both methods, are impressive

Exposure of the hip by osteotomy of the anterior part of the greater trochanter is described. This maintains the continuity of the tendinous junction between the anterior half of gluteus medius and the vastus lateralis and preserves intact the insertion of gluteus minimus into the anterior surface of the trochanter. The nerve supply to these muscles is not compromised and good abductor function is retained. The approach can be extracapsular or intracapsular. Reattachment of the osteotomised fragment is simple, and upward displacement after operation, as sometimes seen after complete osteotomy of the greater trochanter, cannot occur.

Purpose: The interest in minimally invasive surgery (MIS) for total hip arthroplasty has not waned in anyway (THA). Different surgical approaches have been used to do MIS-THA. The purpose of this study was to compare the outcome of the THA using the minimally invasive postero-lateral approach (MIS-PL) and minimally invasive antero-lateral approach (MIS-AL).

Patients and Methods: Fifty randomly assigned patients with MIS-PL and 32 patients with MIS-AL were included in the study. There were no significant differences in age, sex, diagnosis, JOA score or body mass index in each group. The operation time, length of incision, blood loss, implant position, muscle recovery and complication were observed.

Results: Total blood loss and pain was significantly less in patients undergoing THA via MIS postero-lateral approach. In addition, the MIS-PL had improved recovery of muscle strength (hip flexion and abduction) which was statistically significant. Median cup inclination was 42.3 degrees (MIS-AL) and 41.7 degrees (MIS-PL). Median cup anteversion was 18.3 degrees (MIS-AL) and 15.9 degrees (MIS-PL), respectively. Roentgenographic evaluation of femoral component positioning showed no significant difference. Other postoperative data (length of hospital stay, operation time, complication) were comparable.

Conclusion: The MIS antero-lateral approach have often been selected to decrease the risk of dislocation, but this approach needs to release the one third of the gluteus medius from the greater trochanter. MIS postero-lateral approach caused less pain and improve recovery time, postero-lateral approach is more suitable for minimally invasive total hip arthroplasty.

Injury to the spinal cord and kyphosis are the two most feared complications of tuberculosis of the spine. Since tuberculosis affects principally the vertebral bodies, anterior decompression is usually recommended. Concomitant posterior instrumentation is indicated to neutralise gross instability from panvertebral disease, to protect the anterior bone graft, to prevent graft-related complications after anterior decompression in long-segment disease and to correct a kyphosis. Two-stage surgery is usually performed in these cases. We present 38 consecutive patients with tuberculosis of the spine for whom anterior decompression, posterior instrumentation, with or without correction of the kyphus, and anterior and posterior fusion was performed in a single stage through an anterolateral extrapleural approach. Their mean age was 20.4 years (2.0 to 57.0). The indications for surgery were panvertebral disease, neurological deficit and severe kyphosis. The patients were operated on in the left lateral position using a ‘T’-shaped incision sited at the apex of kyphosis or lesion. Three ribs were removed in 34 patients and two in four and anterior decompression of the spinal cord was carried out. The posterior vertebral column was shortened to correct the kyphus, if necessary, and was stabilised by a Hartshill rectangle and sublaminar wires. Anterior and posterior bone grafting was performed. The mean number of vertebral bodies affected was 3.24 (2.0 to 9.0). The mean pre-operative kyphosis in patients operated on for correction of the kyphus was 49.08° (30° to 72°) and there was a mean correction of 25° (6° to 42°). All except one patient with a neural deficit recovered complete motor and sensory function. The mean intra-operative blood loss was 1175 ml (800 to 2600), and the mean duration of surgery 3.5 hours (2.7 to 5.0). Wound healing was uneventful in 33 of 38 patients. The mean follow-up was 33 months (11 to 74). None of the patients required intensive care. The extrapleural anterolateral approach provides simultaneous exposure of the anterior and posterior aspects of the spine, thereby allowing decompression of the spinal cord, posterior stabilisation and anterior and posterior bone grafting. This approach has much less morbidity than the two-stage approaches which have been previously described

This single incision, anterolateral intermuscular approach (AL-IM) utilises the interval between gluteus medius and tensor fascia lata. The aims of the study were to compare the quality of life, satisfaction and complications of this approach with two of the most commonly used limited incision transmuscular (TM) approaches, namely the mini-posterior (P-TM) and the mini-direct lateral (L-TM). One hundred and ninety-nine patients receiving MIS THA surgical procedures were evaluated prospectively (63 AL-IM, 68 P-TM and 68 L-TM). The outcome variables were WOMAC function, pain, stiffness, SF-12 (physical & mental), Oxford-12, satisfaction and radiological outcome. Parametric and non-parametric analyses were performed. There were no significant differences between groups in baseline characteristics including age, sex, BMI, co-morbidity, or pre-op WOMAC, SF-12, Oxford-12 (p> 0.05). However, the AL-IM group was associated with superior outcomes (p< 0.05) in WOMAC function, WOMAC pain, global WOMAC, Oxford-12 and SF-12 physical component. In the short term the AL-IM approach provides significant improvements in quality of life scores over other limited incision approaches. It provides minimal soft tissue disruption and maintains the abductor musculature and posterior soft tissue envelope, with similar complications and radiological outcomes

Introduction: This single incision, anterolateral intermuscular approach (AL-IM) utilizes the interval between gluteus medius and tensor fascia lata. The aims of the study were to compare the quality of life, satisfaction and complications of this approach with two of the most commonly used limited incision transmuscular (TM) approaches, namely the mini-posterior (P-TM) and the mini-direct lateral (L-TM). Methods: 199 patients receiving MIS THA surgical procedures were evaluated prospectively (63 AL-IM, 68 P-TM and 68 L-TM). The outcome variables were WOMAC function, pain, stiffness, SF-12 (physical & mental), Oxford-12, satisfaction and radiological outcome. Parametric and non-parametric analyses were performed. Results: There were no significant differences between groups in baseline characteristics including age, sex, BMI, co-morbidity, or pre-op WOMAC, SF-12, Oxford-12 (p> .05). However, the AL-IM group was associated with superior outcomes (p< .05) in WOMAC function, WOMAC pain, global WOMAC, Oxford-12 and SF-12 physical component. Conclusion: In the short term the AL-IM approach provides significant improvements in quality of life scores over other limited incision approaches. It provides minimal soft tissue disruption and maintains the abductor musculature and posterior soft tissue envelope, with similar complications and radiological outcomes

Introduction: The minimally invasive posterior approach has become a standard for total hip replacement (THR) but the interest for the other minimally invasive approaches has not waned in any way. We carried out a prospective and comparative study in order to analyse the interest of the anterolateral minimal invasive (ALMI) approach in comparaison to a minimally invasive posterior (MIP) approach for THR.

Material and method: We carried out a prospective and comparative study. A group of 35 primaries THR with large head using the ALMI approach, as described by Bertin and Röttinger, was compared to a group of 43 primaries THR performed through the MIP approach. The groups were not significantly different with respect to age, sex, bony mass index, ASA score, Charnley class, diagnoses and preoperative Womac index and PMA score. The preoperative Harris hip score was significantly lower in ALMI group. Early functional results have been evaluated thanks to Womac index and modified Harris hip score at 6 weeks, 3 and 6 months. A p value < 0.05 has been considered as significant.

Results: The duration of surgical procedure was longer and the calculated blood loss more important in ALMI group (respectively p=0.045 and p=0.07). The preoperative complications were significantly more frequent in this group with 4 greater trochanter fractures, 3 false routes, 1 calcar fracture, and 2 metal back bascules versus one femoral fracture in MIP group. Other postoperative data (implant positioning, morphine consumption, length of hospital stay, type of discharge) were comparable. The early functional results at 6 weeks, 3 and 6 months were also comparable. No other complication has been noted during the first 6 months in the two groups.

Discussion and Conclusion: The ALMI approach uses the intermuscular interval between the tensor fascia lata and the gluteus medius. It leaves intact the abductors muscles and the posterior capsule and short external rotators. The early clinical results are excellent despite of the initial complications related to the initial learning curve for this approach and the use of the large head with metal-on-metal bearing. The stability of the arthroplasty and the absence of muscular damage should permit to accelerate the postoperative rehabilitation in parallel with less preoperative complications after the initial learning curve.

Aims. The aim of our study was to investigate the effect of asymmetric crosslinked polyethylene liner use on the risk of revision of cementless and hybrid total hip arthroplasties (THAs). Methods. We undertook a registry study combining the National Joint Registry dataset with polyethylene manufacturing characteristics as supplied by the manufacturers. The primary endpoint was revision for any reason. We performed further analyses on other reasons including instability, aseptic loosening, wear, and liner dissociation. The primary analytic approach was Cox proportional hazard regression. Results. A total of 213,146 THAs were included in the analysis. Overall, 2,997 revisions were recorded, 1,569 in THAs with a flat liner and 1,428 in THAs using an asymmetric liner. Flat liner THAs had a higher risk of revision for any reason than asymmetric liner THAs when implanted through a Hardinge/anterolateral approach (hazard ratio (HR) 1.169, 95% confidence interval (CI) 1.022 to 1.337) and through a posterior approach (HR 1.122, 95% CI 1.108 to 1.346). There was no increased risk of revision for aseptic loosening when asymmetric liners were used for any surgical approach. A separate analysis of the three most frequently used crosslinked polyethylene liners was in agreement with this finding. When analyzing THAs with flat liners only, THAs implanted through a Hardinge/anterolateral approach were associated with a reduced risk of revision for instability compared to posterior approach THAs (HR 0.561 (95% CI 0.446 to 0.706)). When analyzing THAs with an asymmetric liner, there was no significant difference in the risk of revision for instability between the two approaches (HR 0.838 (95% CI 0.633 to 1.110)). Conclusion. For THAs implanted through the posterior approach, the use of asymmetric liners reduces the risk of revision for instability and revision for any reason. In THAs implanted through a Hardinge/anterolateral approach, the use of an asymmetric liner was associated with a reduced risk of revision. The effect on revision for instability was less pronounced than in the posterior approach. Cite this article: Bone Joint J 2021;103-B(9):1479–1487

Our unit historically performed total hip replacement (THR) through either posterior or anterolateral approaches. In November 2020 a group of 5 consultants transitioned to utilising the Direct Anterior Approach (DAA). Appropriate training was undertaken and cases were performed as dual consultant procedures with intraoperative radiography or robotic assistance. Outcomes were collated prospectively. These included basic demographics, intraoperative details, complication rates and Oxford Hip Scores. A total of 48 patients underwent DAA THR over 1 year. Mean age was 67 and ASA 2. Over this time period 140 posterior approach and 137 anterolateral approach THR's were performed with available data. Propensity score matching was performed on a 1:1 basis using BMI, Age, Sex and ASA as covariates to generate a matched cohort group of conventional approach THR (n=37). Length of stay was significantly reduced at 1.95 days (p<0.001) with DAA compared to Anterolateral and Posterior approach. There was no significant difference with length of surgery, blood loss, Infection, dislocation and periprosthetic fracture rate. There was no significant difference in Oxford Hip Score between any approach at 3 months or 1 year. The transition to this approach has not made a negative impact despite its associated steep learning curve, and has improved efficiency in elective surgery. From our experience we would suggest those changing to this approach receive appropriate training in a high-volume centre, and perform cases as dual consultant procedures

We aimed to examine outcomes between displaced femoral neck fracture (FNF) patients managed with total hip arthroplasty (THA) or hemi-arthroplasty (HA) via the anterolateral vs. posterior approach. We used data from the HEALTH trial (1,441 patients aged ≥50 with displaced FNFs randomized to THA vs. HA). We calculated each patient's propensity to undergo arthroplasty via the posterior approach, and matched them to 1 control (anterolateral approach) based on age (±5 years), and propensity score. We used Chi-Square/Fisher-Exact tests to compare dichotomous outcomes, and repeated measures ANOVA to examine differences in patient-reported outcomes (via the WOMAC subscores) from baseline to one-year postoperative. We used logistic regression to identify independent predictors of reoperation for instability in the posterior group. We identified 1,306 patients for this sub-analysis, 876 (67.1%) who received arthroplasty via an anterolateral approach, and 430 (32.9%) a posterior approach. The unadjusted rate of reoperation was significantly higher in the posterior group (10.7% vs. 7.1%). Following propensity score matching, we retained 790 patients (395 per group), with no between-group differences in patient, fracture, or implant characteristics. The matched cohort had a higher rate of comorbidities, and were less likely to be employed vs. the unmatched cohort. The rate of treatment for dislocation remained higher in the posterior group (6.1% vs. 2.0%) following matching. Repeated measures ANOVA revealed significantly better WOMAC pain, stiffness, function, and total scores in the posterior group. Between-group differences at 12-months were: pain - 0.59 (0.03–1.15); stiffness - 0.62 (0.35–0.87); function - 2.99 (0.12–5.86); total - 3.90 (0.24–7.56). We identified THA (vs. HA, odds ratio 2.05 [1.05–4.01]) as the only independent predictor of treatment for dislocation in the posterior group. Our analyses revealed that compromised patients with displaced FNFs who undergo arthroplasty via the posterior approach may report better symptoms at one-year vs. the anterolateral approach, despite a higher odds of reoperation for instability

The October 2023 Trauma Roundup. 360. looks at: Intramedullary nailing versus sliding hip screw in trochanteric fracture management: the INSITE randomized clinical trial; Five-year outcomes for patients with a displaced fracture of the distal tibia; Direct anterior versus anterolateral approach in hip joint hemiarthroplasty; Proximal humerus fractures: treat them all nonoperatively?; Tranexamic acid administration by prehospital personnel; Locked plating versus nailing for proximal tibia fractures: a multicentre randomized controlled trial; A retrospective review of the rate of septic knee arthritis after retrograde femoral nailing for traumatic femoral fractures at a single academic institution

Introduction. Total hip arthroplasty (THA) is indicated in independently mobile patients sustaining displaced intracapsular hip fractures. Studies presently suggest that the anterolateral approach is preferable to the posterior approach due to a perceived reduced risk of reoperations and dislocations. However, these observations come from small studies with short follow-up. We assessed whether surgical approach in THA performed for hip fractures effects outcomes. Patients and Methods. A retrospective observational study was performed using data collected prospectively by the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. All primary stemmed THAs implanted for hip fractures between 2003–2015 were eligible for inclusion (n=19,432). The two surgical approach groups (posterior versus anterolateral) were propensity-score matched for multiple potential patient and surgical confounding factors (n=14,536, with 7,268/group). Outcomes (implant survival, patient survival, intraoperative complications) were compared between the approach groups using regression analysis. Results. Five-year implant survival rates were similar between posterior and anterolateral approaches (97.3% vs. 97.4%; sub-hazard ratio (SHR)=1.15 (95% CI 0.93–1.42)). Five-year implant survival rates free from revision for dislocation (SHR=1.28 (CI=0.89–1.84)) and free from revision for periprosthetic fracture (SHR=1.03 (CI=0.68–1.56)) were also comparable. Thirty-day patient survival was significantly higher with a posterior approach (99.5% vs. 98.8%; hazard ratio (HR)=0.44 (CI=0.30–0.64)), which persisted at 1-year (HR=0.73 (CI=0.64–0.84)) and 5-years (HR=0.87 (CI=0.81–0.94)). The posterior approach had a lower risk of intraoperative complications (odds ratio=0.59 (CI=0.45–0.78)). Discussion. This is the largest study assessing the influence of surgical approach on outcomes following THA performed for hip fractures. In THA for hip fractures, the posterior approach had a similar risk of revision, and a lower risk of mortality and intraoperative complications compared with the anterolateral approach. Conclusion. We propose that the posterior approach is safer than the anterolateral approach when performing THA for hip fractures and should be preferred where possible

Adequate perpendicular access to the posterolateral talar dome for osteochondral defect repair is difficult to achieve and a number of different surgical approaches have been described. This cadaveric study examined the exposure available from various approaches to help guide pre-operative surgical planning. Four surgical approaches were performed in a step-wise manner on 9 Thiel-embalmed cadavers; anterolateral approach with arthrotomy, anterolateral approach with anterior talo-fibular ligament (ATFL) release, anterolateral approach with antero-lateral tibial osteotomy, and anterolateral approach with lateral malleolus osteotomy. The furthest distance posteriorly which allowed perpendicular access with a 2mm k-wire to the lateral surface of the talar dome was measured from the anterior aspect of the talar dome. The mean antero-posterior diameter of the lateral talar domes included in this study was 45.1mm. An anterolateral approach to the ankle with arthrotomy provided a mean exposure of the anterior 1/3rd of the lateral talar dome. ATFL release increased this to 43.2%. A lateral malleolus osteotomy provided superior exposure (81.5% vs 58.8%) compared to an anterolateral tibial osteotomy. Only the anterior half of the lateral border of the talar dome could be accessed with an anterolateral approach without osteotomy. A fibular osteotomy provided best exposure to the posterolateral aspect of the talar dome and is recommended for lesions affecting the posterior half of the lateral talar dome

Our previous work presented at BHS revealed a reduced risk of revision for all reasons in THAs using lipped (asymmetric) liners. Some audience members felt that this finding may be due to unaccounted confounders and the hip surgery community remains sceptical. A fully adjusted Cox model was built after exploratory Kaplan-Meier analyses. The following surgical approaches were included in the analysis: Posterior, Hardinge/anterolateral, Other. The variables included in the final Cox model included: Gender, liner asymmetry, age, head composition, stem fixation method, head diameter, indication for implantation and surgical approach. An additional analysis of the 3 most commonly used polyethylene liners with both a flat and asymmetric version was performed. In the fully adjusted Cox model, the use of a flat liner was associated with increased risk of revision for instability (HR: 1.79, 95%CI: 1.52–2.10) and increased risk of revision for all reasons (HR 1.195, 95%CI: 1.104 – 1.293) when compared to THAs utilising flat liners. This finding was upheld in the product specific analysis. When utilising flat liners, the Hardinge/anterolateral approach was associated with a reduced risk of revision for instability compared to the posterior approach (HR 0.56, 95%CI: 0.446 to 0.706). When an asymmetric liner was used, there was no significant difference in the risk of revision for instability between the Hardinge/anterolateral approach and the posterior approach (HR 0.838, 95%CI: 0.633 – 1.110). The use of polyethylene-based bearings gives the surgeon the option to use asymmetric liners. The reduced risk of revision in THAs with asymmetric liners was seen in the analysis of the complete dataset and in the product specific analysis. Our results demonstrate that the posterior approach, when used with asymmetric XLPE liners, is not associated with a higher risk of revision for instability as historical data suggested

The aim of the study is to investigate the biomechanical effects on the pelvis of the anterolateral and posterolateral approaches at the time of hip arthroplasty. In particular the study investigates the change in stress distribution, and the change in muscle recruitment pattern following surgery. The study uses an advanced finite element model of the pelvis, in which the role of muscles and ligaments in determining the stress distribution in the pelvis is included. The model is altered for the posterolateral approach by excision of the external rotators. Different levels of gluteal damage for the anterolateral approach are modelled by excising in turn the anterior third, half, and two-thirds of the gluteus medius and minimus. Although attempt is generally made to repair gluteal damage at the time of surgery, it is clear the muscle volume will be compromised immediately after surgery. In support of previous clinical studies indicating an increased risk of limp, and pelvic tilt following the anterolateral approach, significant differences were found in the muscle recruitment pattern following the anterolateral, compared to the posterolateral approach. During single leg stance and walking force transfer to the iliacus and pectineus was observed. Required levels of muscle force, to maintain coronal balance, following the anterolateral approach were found to be close to maximum sustainable levels. In addition significant alteration to the pelvic stress distribution was found following the anterolateral approach. The effects of increasing gluteal damage for the anterolateral approach were progressive, and became more pronounced when more than fifty percent of the gluteus medius and minimus were damaged. Increases in stresses around the acetabulum were observed for the posterolateral, compared to the anterolateral approach. Thus, based on a biomechanical evaluation, the anterolateral approach presents increased risk of limp, and pelvic tilt, in comparison to the posterolateral approach

Hip abductor tears(AT) have long been under-recognized, under-reported and under-treated. There is a paucity of data on the prevalence, morphology and associated factors. Patients with “rotator cuff tears of the hip” that are recognized and repaired during total hip arthroplasty(THA) report comparable outcomes to patients with intact abductor tendons at THA. The study was a retrospective review of 997 primary THA done by a single surgeon from 2012–2022. Incidental findings of AT identified during the anterolateral approach to the hip were documented with patient name, gender, age and diagnosis. The extent and size of the tears of the Gluteus medius and Minimus were recorded. Xrays and MRI's were collected for the 140 patients who had AT and matched 1:1 with respect to age and gender against 140 patients that had documented good muscle quality and integrity. Radiographic measurements (Neck shaft angle, inter-teardrop distance, Pelvis width, trochanteric width and irregularities, bodyweight moment arm and abductor moment arm) were compared between the 2 groups in an effort to determine if any radiographic feature would predict AT. The prevalence of AT were 14%. Females had statistically more tears than males(18vs10%), while patients over the age of 70y had statistically more tears overall(19,7vs10,4%), but also more Gluteus Medius tears specifically(13,9vs5,3%). Radiographic measurements did not statistically differ between the tear and control group, except for the presence of trochanteric irregularities. MRI's showed that 50% of AT were missed and subsequently identified during surgery. Abductor tears are still underrecognized and undertreated during THA which can results in inferior outcomes. The surgeon should have an high index of suspicion in elderly females with trochanteric irregularities and although an MRI for every patient won't be feasible, one should always be prepared and equipped to repair the abductor tendons during THA

The medial approach for the treatment of children with developmental dysplasia of the hip (DDH) in whom closed reduction has failed requires minimal access with negligible blood loss. In the United Kingdom, there is a preference for these children to be treated using an anterolateral approach after the appearance of the ossific nucleus. In this study we compared these two protocols, primarily for the risk of osteonecrosis. Data were gathered prospectively for protocols involving the medial approach (26 hips in 22 children) and the anterolateral approach (22 hips in 21 children) in children aged <  24 months at the time of surgery. Osteonecrosis of the femoral head was assessed with validated scores. The acetabular index (AI) and centre–edge angle (CEA) were also measured. . The mean age of the children at the time of surgery was 11 months (3 to 24) for the medial approach group and 18 months (12 to 24) for the anterolateral group, and the combined mean follow-up was 70 months (26 to 228). Osteonecrosis of the femoral head was evident or asphericity predicted in three of 26 hips (12%) in the medial approach group and four of 22 (18%) in the anterolateral group (p = 0.52). The mean improvement in AI was 8.8° (4° to 12°) and 7.9° (6° to 10°), respectively, at two years post-operatively (p = 0.18). There was no significant difference in CEA values of affected hips between the two groups. Children treated using an early medial approach did not have a higher risk of developing osteonecrosis at early to mid-term follow-up than those treated using a delayed anterolateral approach. The rates of acetabular remodelling were similar for both protocols. Cite this article: Bone Joint J 2014;96-B:406–13

The direct lateral (or anterolateral) approaches to the hip for revision THA involve detachment of the anterior aspect of the gluteus medius from the trochanter along with a contiguous sleeve of the vastus lateralis. Anterior retraction of this flap of gluteus medius and vastus lateralis and simultaneous posterior retraction of the femur creates an interval for division of gluteus minimus and deeper capsular tissues and exposure of the joint. To enhance reattachment of this flap of the anterior portion of the gluteus medius and vastus lateralis back to the trochanter, an oblique wafer of bone can be elevated along with the muscle off of the anterolateral portion of the trochanter. This bony wafer prevents suture pull out when large nonabsorbable sutures are used around or through the fragment and passed into the bone of the trochanteric bed for reattachment during closure. To prevent excessive splitting proximally into the gluteus medius muscle (and resulting damage to the superior gluteal nerve), it is often helpful to extend the muscle split further distally down into the vastus lateralis. This combined with careful elevation of the gluteal muscles off of the ilium (instead of splitting them) helps provide excellent and safe exposure of the entire rim of the acetabulum and access to the supracetabular region for bone grafting, acetabular augment placement and even fixation of the flanges of a cage. A simple method for posterior column plating via the anterolateral approach involves contouring of the distal end of the plate around the base of the ischium at the inferior edge of the socket. When an extended osteotomy of the femur is needed to correct deformity, remove a well-fixed implant or cement, the “extensile” variation of this same surgical approach involves a Wagner style (lateral to medial) osteotomy of the greater trochanter and proximal femur. The anterior portion of the femur after it is osteotomised is elevated as a separate segment while maintaining the soft tissue attachments to the bone as much as possible to aid osteotomy healing. After implant or cement removal, this approach gives excellent direct access to the distal femur for placement of a long stem revision femoral component without bone-implant conflict proximally because of the bow of the femur. The anterolateral approach (and extensile variants detailed above) can be used routinely and safely in the full range of revision THA procedures, or it can be employed selectively, if desired, in cases at increased risk for dislocation

Introduction: Avascular necrosis of the femoral head after resurfacing hip replacement is an important complication which may lead to fracture or failure. We compared the changes in femoral head oxygenation resulting from the posterior approach to those resulting from the anterolateral approach and the trochanteric flip approach. Methods: In 37 patients undergoing hip resurfacing surgery, a calibrated gas-sensitive electrode was inserted superolaterally in the femoral head via the femoral neck following division of the fascia lata. Inter-operative X-ray confirmed correct electrode placement. Baseline oxygen concentration levels were recorded immediately after electrode insertion. All results were expressed relative to this baseline, which was considered as 100% relative oxygen concentration. Oxygen levels were monitored continuously throughout the operation. 10 patients underwent surgery through the posterior approach, 12 patients through the anterolateral approach and 15 through the trochanteric flip approach. Results: A similar pattern of intra-operative reduction in femoral oxygen concentration was observed for all reviewed approaches. The average change in oxygen concentration during surgery through the trochanteric flip approach was found to be significantly less than through posterior (p< 0.02) and anterolateral (p< 0.02) approaches. Oxygen concentration following joint relocation and soft tissue reconstruction recovered significantly in the anterolateral and trochanteric flip group only. The posterior approach resulted in significantly lower oxygen concentration at the end of the procedure (22%, SD 31) than the anterolateral approach (123%, SD 99; p< 0.05) and the trochanteric flip approach (89%, SD 62, p< 0.02). Discussion and Conclusion: The anterolateral and trochanteric flip approaches disrupt the femoral head blood supply significantly less than the posterior approach in patients undergoing resurfacing. The most consistent intra-operative oxygen levels were observed during surgery through the trochanteric flip approach. Oxygen concentration during the anterolateral approach was found to be highly dependent upon leg position. The incidence of complications related to avascular necrosis might be decreased by adopting blood supply conserving surgical approaches

In 12 patients, we measured the oxygen concentration in the femoral head-neck junction during hip resurfacing through the anterolateral approach. This was compared with previous measurements made for the posterior approach. For the anterolateral approach, the oxygen concentration was found to be highly dependent upon the position of the leg, which was adjusted during surgery to provide exposure to the acetabulum and femoral head. Gross external rotation of the hip gave a significant decrease in oxygenation of the femoral head. Straightening the limb led to recovery in oxygen concentration, indicating that the blood supply was maintained. The oxygen concentration at the end of the procedure was not significantly different from that at the start. The anterolateral approach appears to produce less disruption to the blood flow in the femoral head-neck junction than the posterior approach for patients undergoing hip resurfacing. This may be reflected subsequently in a lower incidence of fracture of the femoral neck and avascular necrosis

Introduction: Aseptic loosening remains the commonest causes of failure of total hip arthroplasty. Cement mantle defects are associated with aseptic loosening. This study aimed to determine a correlation between surgical approach and cement mantle defects in the Stanmore Hip. The Stanmore total hip replacement was chosen because it has greater than an eighty-five percent survivorship over 25 years and unlike other prostheses with comparable results such as the Charnley total hip, it remains essentially unchanged to date. Method: This was a retrospective review of all Stanmore hips. AP and lateral radiographs were available for 62 patients operated via the posterior approach and 100 patients operated via the anterolateral approach. The mean cement thickness in all fourteen Gruen zones was estimated for each patient. Gruen zones IV and XI, representing the stem tip, were removed from data relating to mantle thickness. Mantles were graded as less than 2mm, 2–5mm, 5–10mm and more than 10mm. Alignment was also measured. Results: Fifty-nine percent (32/54) of cement mantle defects are seen in Gruen zones VIII to XIV. The mean cement mantle thickness in A-L approach was 3.11mm compared to 4.23mm with the posterior approach. This corresponds with the frequency of cement mantle defects occurrence. No cement defects were seen in Gruen zones IV or XI. Using the anterolateral approach, defects were observed in 49 out of 1200 zones (4.08%) and using the posterior approach in 6 out of 744 zones (0.81%). With the anterolateral approach, 19 out of 100 cement mantles (19%) had defects, compared to only 3 out of 62 (4.84%) with the posterior approach. Defects were most commonly seen in zones I, V, VIII and XII, which corresponds to valgus and posterior orientation of the stem. Discussion: The posterior approach does generate a more uniform cement mantle. Several studies suggest that a cement mantle smaller than 2mm or greater than 10mm can be detrimental to the survivorship of the arthroplasty. This study suggests that a deficient cement mantle is more likely using an anterolateral approach

Introduction: Standard approaches to the craniocervical junction (CCJ) includes the midline posterior approach and the transoral approach. Both of them are limited laterally because of the Vertebral Artery (VA). Lateral approaches in which the VA is controlled and sometimes mobilized or transposed have been developed to reach the lateral corner of the CCJ. The surgical technique and personal experience are presented. Methods: From our experience in the VA surgical exposure, we developed since 1980 two lateral approaches directed towards the CCJ: the posterolateral and the anterolateral approach. The posterolateral approach is a lateral extension of the midline posterior approach with control of the VA above the arch of atlas and opening of the CCJ up to the VA. Minimal drilling of the arch of atlas and occipital condyle is realized. It is mostly applied on intradural tumors but also in some extradural posterolateral lesions. The anterolateral approach is a superior extension of the lateral approach used to control the VA from the C6 to C2 levels. The field is opened between the sternomastoïd muscle and the internal jugular vein. Then the VA is exposed between C1 and C2 transverse processes and above C1. It is essentially applied on extradural and bony lesions around the CCJ. Experience: Posterolateral approach was applied on 109 tumors, mostly meningiomas (N=78) and neurinomas (N=22) and 4 bony malformations compressing the VA or the neuraxis. Excellent results were obtained with complete tumoral resection (Simpson grade I or II for meningioma) with only one case of worsening of the neurological condition and two cases with stabilization. Anterolateral approach was used on 139 patients with different types of tumors including neuromeningeal tumors N=36, primary bone tumors N=51, sarcoma N=16 and others types N=21, and on 3 cases of VA compression by bone malformations. Satisfying tumoral resection could be achieved in almost all cases. Sacrifice of the VA was deliberately realized in 5 patients to ensure as radical a resection as possible in case of malignant tumors or chordomas. There was no mortality in this series. Morbidity is very limited; injury of the VA was observed in two cases in which repair of the vessel could be done successfully. Stretching of the XI nerve was the cause of pain along the trapezius muscle in 5 patients. Conclusion: Lateral approach to the CCJ can be realized through two different axis of work: the posterolateral and the anterolateral approach. These approaches gives very nice and safe access to the lateral aspect of the CCJ. They complete the other approaches to the CCJ and may be used in association with them

INTRODUCTION: Standard approaches to the cra-niocervical junction (CCJ) include the midline posterior approach and the transoral approach. Both of them are limited laterally because of the Vertebral Artery (VA). Lateral approaches in which the VA is controlled and sometimes mobilised or transposed have been developed to reach the lateral corner of the CCJ. The surgical technique and personal experience are presented. METHODS: From our experience in the VA surgical exposure, we developed since 1980 two lateral approaches directed towards the CCJ: the posterolateral and the anterolateral approach. The posterolateral approach is a lateral extension of the midline posterior approach with control of the VA above the arch of atlas and opening of the CCJ up to the VA. Minimal drilling of the arch of atlas and occipital condyle is realised. It is mostly applied on intradural tumours but also in some extradural posterolateral lesions. The anterolateral approach is a superior extension of the lateral approach used to control the VA from the C6 to C2 levels. The field is opened between the sterno-mastoïd muscle and the internal jugular vein. Then the VA is exposed between C1 and C2 transverse processes and above C1. It is essentially applied on extradural and bony lesions around the CCJ. EXPERIENCE: Posterolateral approach was applied on 109 tumours, mostly meningiomas (N=78) and neurinomas (N=22) and four bony malformations compressing the VA or the neuraxis. Excellent results were obtained with complete tumoural resection (Simpson grade I or II for meningioma) with only one case of worsening of the neurological condition and two cases with stabilisation. Anterolateral approach was used on 139 patients with different types of tumours including neuromeningeal tumours N=36, primary bone tumours N=51, sarcoma N=16 and others types N=21, and on three cases of VA compression by bone malformations. Satisfying tumoural resection could be achieved in almost all cases. Sacrifice of the VA was deliberately realised in five patients to ensure as radical a resection as possible in case of malignant tumours or chordomas. There was no mortality in this series. Morbidity is very limited; injury of the VA was observed in two cases in which repair of the vessel could be done successfully. Stretching of the XI nerve was the cause of pain along the trapezius muscle in five patients. CONCLUSION: Lateral approach to the CCJ can be realised through two different axis of work; the posterolateral and the anterolateral approach. These approaches give very nice and safe access to the lateral aspect of the CCJ. They complete the other approaches to the CCJ and may be used in association with them

Introduction: Avascular necrosis of the femoral head may play a role in failure of the femoral component in metal on metal hip resurfacing arthroplasty. The purpose of our study was to determine, prospectively, femoral head perfusion during hip resurfacing arthroplasty in the posterior and anterolateral approaches. Methods: 20 hip resurfacing arthroplasties were performed in 19 patients between September 2005 and March 2006 by two different surgeons; one using the extended posterior approach and the other an anterolateral approach. There were an equal number of procedures for each approach. 1.5 gms of intravenous cefuroxime was administered following caspsulectomy and relocation of the femoral head. After 5 minutes the femoral head was dislocated and prepared as routine for the operation. Bone from the top of the femoral head and reamings were sent for assay to determine the concentration of cefuroxime. The average time taken to prepare the femur and take samples was 8.5 minutes. Results: The concentration of cefuroxime in bone was significantly greater when using the anterolateral approach (mean 15.7mg/kg; CI 12.3 – 19.1) compared to the posterior approach (mean 5.6mg/kg; CI 3.5 – 7.8; p< 0.001). In one patient, who had the operation through a posterior approach, cefuroxime was undetectable. Discussion: The posterior approach is associated with a significant reduction in the blood supply to the femoral head during hip resurfacing arthroplasty. This may be a cause for avascular necrosis and potential failure of the femoral component in this procedure

Purpose. The purpose of this study was to compare and evaluate the cost-effectiveness of the MIS Anterolateral Approach to that of the MIS Posterolateral and MIS Direct Lateral Approach. Method. A prospective randomized control trial was designed and conducted to compare the MIS Anterolateral Approach to that of the MIS Posterolateral and MIS Direct Lateral Approach. Contemporary methods for economic evaluation were used to ascertain direct and indirect costs (in Canadian dollars) along with clinical effectiveness outcomes (SF6D and Pat5D utility measures). University and hospital ethics was obtained and patients were recruited and consented to participate in the RCT resulting in the assignment of 130 patients MIS hip arthroplasty procedures. Baseline patient demographics, comorbidity, quality of life, and utility were obtained for all patients. In-hospital costing data was obtained including operating room and patient room costs as well as medication, rehab and complications. Post-discharge costs were calculated from direct and indirect costs of medication, rehab, medical costs and complications until one year post-operatively. Clinical effectiveness measures were administered at intervals until one year post-operatively. Results. Patient groupings were similar pre-operatively with regards to demographic variables and quality of life measures (WOMAC, SF36, Pat5D). Post-operatively comparison of costs and complications were not different across the different surgical approaches (p>.05). Cost-effectiveness analyses (cost/QALY) were not statistically different (p>.05) when comparing the three MIS hip arthroplasty procedures. Conclusion. Primary total hip arthroplasty is a cost-effective surgical procedure and compares favorably with other health interventions. Our study is among the first to compare the cost-effectiveness of different MIS surgical approaches using contemporary methods of cost-effectiveness analyses. Our data suggests that the MIS Anterolateral approach is not superior to the MIS Posterolateral or MIS Direct Lateral approach with regards to cost-effectiveness of the intervention. Our economic evaluation was sensitive to early post-op complications including dislocation and re-operation. Surgeons should select an MIS approach based on criteria including technical preference, reliable implant placement, patient safety and complication minimization

Aim: Avascular necrosis of the femoral head is believed to play a role in failure of the femoral component in metal on metal hip resurfacing arthroplasty. The purpose of our study was to determine, prospectively, femoral head perfusion during hip resurfacing arthroplasty in the posterior and anterolateral approaches. Methods: 20 hip resurfacing arthroplasties were performed in 19 patients between September 2005 and April 2006. Patients were divided into two groups according to approach. An equal number of operations were performed by two different surgeons; one using the extended posterior approach and the other an anterolateral approach. Intravenous cefuroxime was administered in every case following capsulectomy and relocation of the femoral head. After 5 minutes the femoral head was dislocated and prepared as routine for the operation. Bone from the top of the femoral head and reamings were sent for assay to determine the concentration of cefuroxime. Results: The concentration of cefuroxime in bone was significantly greater when using the anterolateral approach (mean 15.7mg/kg; CI 12.3 to 19.1) compared to the posterior approach (mean 5.6mg/kg, CI 3.5 to 7.8; p< 0.001). In one patient, who had the operation through a posterior approach, cefuroxime was undetectable. Conclusion: The posterior approach is associated with a significant reduction in the blood supply to the femoral head during hip resurfacing arthroplasty. This may be a cause for avascular necrosis and potential failure of the femoral component in this procedure

Subcapital fractures about the hip continue to be a common clinical scenario with which we all face. There are estimated to be over 350,000 hip fractures annually in the U.S. with 40% being displaced femoral neck fractures. The mean cost is over $30,000. Optimizing surgical care is essential with the overall goal being to perform the most effective treatment with the lowest risk of reoperation that provides the best postoperative function and pain relief. In the “young” (which is often defined as whatever age is younger than you!) reduction and internal fixation is often the most effective retaining the native femoral head. The risk of non-union and AVN is often less than potential complications that can follow an arthroplasty with 40% of displaced fractures treated with ORIF eventually requiring reoperation. Essentially for every 100 patients that undergo ORIF for displaced femoral neck fracture, choosing arthroplasty instead results in 17 conversions avoided. In the “elderly” in general we treat all displaced fractures with a total hip replacement which reduced re-admissions and is more cost effective for displaced femoral neck fractures. Aside from the medical morbidity following an arthroplasty dislocation is the primary concern. We have found the anterolateral approach reduces this significantly. Non-displaced fractures that are valgus impacted and biomechanically stable are treated with cannulated screws. Perhaps it can be argued that a hemiarthroplasty (bipolar or monopolar) has a lower risk of dislocation compared to a total hip replacement if performed by a surgical team with less frequent total hip replacement experience. However, total hip replacement results in less pain and better function when the patients are independent with intact mental status (patient not the surgeon…!). My algorithm is non-displaced valgus impacted or “stable” fractures undergo cannulated screws and the displaced fractures receive a total hip arthroplasty via an anterolateral approach

Introduction and Objective. Heterotopic ossification is the formation of extraskeletal mineralized tissue commonly associated with either trauma or surgery. While several mouse models have been developed to better characterize the pathologic progression of HO, no model currently exists to study HO of the hip, the most common location of acquired HO in patients. Owing to the unique biological mechanisms underpinning the formation of HO in different tissues, we sought to develop a model to study the post-surgical HO of the hip. Materials and Methods. Wild-type mice C57BL/6J mice were used to study the procedure outcomes, while Pdgfra-CreERT2;mT/mG and Scx-GFP reporter animals were used for the lineage tracing experiments (total n=16 animals, male, 12 weeks old). An anterolateral approach to the hip was performed. Briefly, a 2 cm incision was made centered on the great trochanter and directed proximal to the iliac crest and distally over the lateral shaft of the femur. The joint was then reached following the intermuscular plane between the rectus femoris and gluteus medius muscles. After the joint was exposed, the articular cartilage was removed using a micropower drill with a 1.2 mm reamer. The medius gluteus and superficial fascia were then re-approximated with Vicryl 5-0 suture (Ethicon Inc, Somerville, NJ) and skin was then closed with Ethilon 5-0 suture (Ethicon Inc). Live high resolution XR imaging was performed every 2 wks to assess the skeletal tissues (Faxitron Bioptics, Tucson, AZ). The images were then scored using the Brooker classification. Ex-vivo microCT was conducted using a Skyscan 1275 scanner (Bruker-MicroCT, Kontich, Belgium). 3D reconstruction and analysis was performed using Dragonfly (ORS Inc., Montreal, Canada). For the histological analysis of specimens, Hematoxylin and Eosin (H&E), modified Goldner's Trichrome (GMT) stainings were performed. Reporter activity was assessed using fluorescent imaging. Results. Substantial periarticular heterotopic bone was seen in all cases. A periosteal reaction and an initial formation of calcified tissue within the soft tissue was apparent starting from 4 wks after surgery. By XR, progressive bone formation was observed within the periosteum and intermuscular planes during the subsequent 8 weeks. Stage 1 HO was observed in 12.5% of cases, stage 2 in 62.5% of cases, and stage 3 HO in 25% of cases. 3D microCT reconstructions of the treated hip joints demonstrated significant de novo heterotopic bone in several location which phenocopy human disease. Heterotopic bone was observed in an intracapsular location, periosteal location involving the iliac bone and proximal femur, and intermuscular locations. Histological analyses further confirmed these findings. To assess the cells which gave rise to HO in this model, an inducible PDGFRα and constitutive Scx-GFP reporter mice were used. A dramatic increase in mGFP reporter activity was noted PDGFRα within the HO injury site, including in areas of new cartilage and bone formation. Scx-associated reporter activity increased in the soft tissue and periosteal periacetabular areas of injured hips. Conclusions. HO has a diverse set of pathologies, of which joint associated HO after elective surgery is the most common. Here, we present the first mouse model of hip dislocation and acetabular reaming that mimics elements of human periarticular HO. The diverse locations of HO after acetabular reaming (intracapsular, intermuscular and periosteal) suggests the activation of different and specific HO program after surgery. Such a field effect would be consistent with local trauma and inflammation, which is a well-studied contributor to HO genesis. Not surprisingly, joint-associated HO significantly derives from PDGFRα-expressing cells, which has been shown to similarly give rise to intramuscular and intratendinous HO

Background: In order to achieve a minimized need for tissue dissection resulting in a faster rehabilitation, minimally invasive surgery (MIS) in Total Hip Arthroplasty (THA) was developed. In this small incision technique the skin and musle dissection has been reduced with respect to the classical approach. Literature shows ambiguous results comparing the posterolateral minimally incisive with the classical approach. As the anterolateral approach is also a routine procedure, and to test how minimally invasive MIS is, we hypothesized that patients treated with a THA using a posterolateral or anterolateral MIS would experience improved clinical results compared with a standard incision after six weeks and no clinical differences after one year. This was tested in a double-blind randomized controlled trial with the Harris Hip Score (HHS) as a primary endpoint. Methods: One hundred and twenty consecutive primary uncemented THAs were randomized into one of four groups of 30 patients each. Either standard posterolateral or anterolateral approaches (PL- or AL-CLASS), or minimal invasive posterolateral or anterolateral approaches (PL- or AL-MIS) were performed. CLASS incisions were 18 cm. To avoid postoperative bias, MIS incisions were extended at skin level to 18 cm at the end of the procedure. The HHS as well as patient-centered questionnaires (SF-36, WOMAC and OHS) was obtained preoperatively, at six weeks and one year after the index operation. Preoperative data, blood loss, hemoglobin, muscle damage parameters and radiological parameters were analyzed. In order to detect a minimal clinically important difference of five points or more between the MIS or CLASS groups with respect to the Harris Hip Score at the 0.05 alpha level with 80% power, 120 patients were enrolled in the study. Results: Mean incision length of the THAs performed by MIS was 7.8 (SD = 1.6). In the patients of the MIS group a significant increased mean HHS was observed compared with the CLASS (p = 0.03) after six weeks and one year. This difference was caused by the favorable results of the PL-MIS (p = 0.009). Of the three patient-centered questionnaires, the SF-36 results were also favourable in the PL-MIS group after six weeks (p = 0.04). In the MIS group operation time was longer (p < 0.001) and a learning curve was observed based on operation time and complication rate. Peri-operative complications rates were not significantly different between the groups. Blood loss, hemoglobin, muscle damage parameters and radiological parameters also showed no difference. Conclusions: This double-blind, randomized study reveals an improved clinical outcome of the PL-MIS compared with the AL-MIS, PL-CLASS and AL-CLASS after six weeks and one year follow-up with the Harris Hip Score as primary endpoint

There are numerous examples in medicine where “eminence trumps evidence.” The direct anterior approach (DA) is no exception. Its meteoric rise has largely been driven by industry and surgeon promotion. This surgical approach continues to garner interest, but this interest is largely for marketing purposes, as emerging data would suggest a high risk, low reward operation. In addition, factors such as selection bias and impact bias, have substantially swayed peoples interest into making an inferior operation look better. There are several factors related to the direct anterior approach that should give us pause. Those include the surgeon learning curve, limited functional benefit and increased complications. There is no question the DA approach for total hip arthroplasty (THA) has a long and steep learning curve. The majority of studies would suggest at minimum, 50–100 cases before a surgeon is comfortable with this approach and some studies would suggest the technical difficulties of this approach remain an issue even with increasing experience. This proves difficult with an attempted rapid adoption of this technique by a surgeon who may perform less than 50 THAs per year but feel the need to offer this approach to their patients for marketing purposes. One of the many touted benefits of the DA approach is the perception of improved functional outcomes. Many of the early studies showed early improvement in gait, pain and mobility. However, these studies compared the DA approach to an anterolateral approach. Even when compared to the anterolateral approach, considered the most invasive and least muscle sparing, the benefits of the DA approach were only short term (6 weeks). The majority of retrospective studies, prospective randomised studies and meta-analyses comparing DA to a posterior approach show little, if any, benefit of one approach over another with regards to functional benefit. Another touted benefit includes a low or no dislocation risk associated with the posterior approach. On the contrary many studies have failed to demonstrate lower dislocation rates with the DA approach compared to a contemporary posterior approach. A recent registry study from the Michigan Arthroplasty Registry Quality Initiative (MARQI) showed equal dislocation rates between the DA and posterior approach. Concerns have also been raised regarding unique and more frequent complications with the DA approach compared to other surgical approaches for total hip arthroplasty. Unique complications such as ankle fractures and a high incidence of nerve injury, especially damage to the lateral femoral cutaneous nerve, have been reported. In addition, the data now clearly show a higher incidence of complications on the femoral side, including early loosening and periprosthetic fracture. As responsible surgeons, if we want to say the DA approach is different, then fine, we can say it's different. Claims of superiority of one approach over another have not been born our in the literature and in fact much of the data would suggest a high risk no reward operation for the DA approach compared to other surgical approaches for total hip arthroplasty

The posterior approach to the hip avoids violating abductors and has presumed functional advantages. The anterolateral approach risks abductor damage, but has reportedly lower dislocation rate. To determine effects of surgical approach on function and dislocation after primary and revision THR 3274 primary THRs and 66 first time revision THRs were investigated from the arthroplasty database (2000–2008). 2682 (82%) primary THRs were via anterolateral approach, 592 (18%) by posterior. Post primary dislocation rate was 50/2682 (1.9%) for anterolateral and 26/592 (4.4%) for posterior. Posterior approach had significantly better Harris Hip Scores: 91 vs 88 (P = 0.000) and function: 40 vs 37 (P = 0.000). Of the 66 revisions THRs, 30 were anterolateral and 36 posterior. Dislocation rates were 2/30 (6.7%) and 4/36 (11.1%) respectively. There was no significant difference in Harris Hip Score or Harris Hip Function 1 year after revision based on revision surgery approach. However there was a significant difference in Harris Hip Function 1 year after revision based on the approach for primary surgery (Anterolateral 30 vs Posterior 37, P=0.008) and a similar trend in Harris Hip Score (Anterolateral 79 vs Posterior 85, P = 0.198) and patients who had posterior approach for both primary and revision had the best scores overall. The clinical relevance of the modest, but statistically significant difference in Harris hip score after primary THR is unclear. That primary approach has an impact on function after revision suggests the posterior approach should be considered in younger patients likely to require revision in the future

Acetabular component malposition during total hip Arthroplasty (THA) increases the risk of dislocation, reduces the range of motion, and can be the cause of early wear and loosening. Variability in implant alignment also affects the result of THA. The purpose of this study was to compare acetabular cup positioning of three different approaches in THA. Three different approaches for cementless THA were studied in 108 operations. The direct anterior approach was used in 56, the anterolateral approach in 32 and the posterolateral approach in 50. The same cementless cup was used in all cases. The same surgeon performed all procedures with mini-incision surgery, using different approaches. To determine the accuracy of the cups, the inclination and anteversion angles were measured with a CT-investigation of the pelvis. There were no statistical differences between the three groups regarding means of the inclination and anteversion angles. But a significant range of variance, the lowest variations being in the group of the direct anterior approach, the highest in the group of the anterolateral approach

Anterior surgical approaches for total hip arthroplasty (THA) have increased popularity due to expected faster recovery and less pain. However, the direct anterior approach (Heuter approach which has been popularised by Matta) has been associated with a higher rate of early revisions than other approaches due to femoral component loosening and fractures. It is also noted to have a long learning curve and other unique complications like anterior femoral cutaneous and femoral nerve injuries. Most surgeons performing this approach will require the use of an expensive special operating table. An alternative to the direct anterior approach is the anterior-based muscle-sparing approach. It is also known as the modified Watson-Jones approach, anterolateral muscle-sparing approach, minimally invasive anterolateral approach and the Röttinger approach. With this technique, the hip joint is approached through the muscle interval between the tensor fascia lata and the gluteal muscles, as opposed to the direct anterior approach which is between the sartorius and rectus femoris and the tensor fascia lata. This approach places the femoral nerve at less risk for injury. I perform this technique in the lateral decubitus position, but it can also be performed in the supine position. An inexpensive home-made laminated L-shaped board is clamped on end of table allowing the ipsilateral leg to extend, adduct, and externally rotate during the femoral preparation. This approach for THA has been reported to produce excellent results. One study reports a complication rate of 0.6% femoral fracture rate and 0.4% revision rate for femoral stem loosening. In a prospective randomised trial looking at the learning curve with new approach, the anterior-based muscle-sparing anterior approach had lower complications than a direct anterior approach. The complications and mean operative time with this approach are reported to be no different than a direct lateral approach. Since this surgical approach is not through an internervous interval, a concern is that this may result in a permanent functional defect as result of injury to the superior gluteal nerve. At a median follow-up of 9.3 months, a MRI study showed 42% of patients with this approach had fat replacement of the tensor fascia lata, which is thought to be irreversible. The clinical significance remains unclear, and inconsequential in my experience. A comparison MRI study showed that there was more damage and atrophy to the gluteus medius muscle with a direct lateral approach at 3 and 12 months. My anecdotal experience is that there is faster recovery and less early pain with this approach. A study of the first 57 patients I performed showed significantly less pain and faster recovery in the first six weeks in patients performed with the anterior-based muscle-sparing approach when compared to a matched cohort of THA patients performed with a direct lateral approach. From 2004 to 2017, I have performed 1308 total hip replacements with the anterior-based muscle sparing approach. Alternatively, I will use the direct lateral approach for patients with stiff hips with significant flexion and/or external rotation contractures where I anticipate difficulty with femoral exposure, osteoporotic femurs due to increased risk of intraoperative trochanteric fractures, previously operated hips with scarring or retained hardware, and Crowe III-IV dysplastic hips when there may be a need for a femoral shortening or derotational osteotomy. Complications have been very infrequent. This approach is a viable alternative to the direct anterior approach for patients desiring a fast recovery. The anterior-based muscle-sparing approach is the approach that I currently use for all outpatient total hip surgeries

The anterolateral MIS-THA approach can be divided into the Modified Watson-Jones approach (MWJ) performed in the lateral position and the Anterolateral Supine method (ALS) performed in the supine position. Femoral preparation is flexible in stem selection in the MWJ method. On the other hand, the ALS method is more stable for placement on the acetabular implant. Now we introduce novel anterolateral MIS approach named AL60, it makes use of the merits of both MWJ and ALS methods. Technique. The patient is fixed at 30 degrees on the dorsal side from lateral position. That is 60 degrees on the half side from the horizontal plane, and the platform of the operating table is removed just as in the MWJ method. During surgery, the pelvis is fixed by the posterior support, and the stability of the pelvis is very good. Also, if the inclination is accurate at 30 degrees, by holding the holder parallel to the operating table when inserting the cup, the cup is theoretically inserted at Anatomical anteversion 30 degrees. The intraoperative field of view is also visible to the assistant due to the semi-lateral position. Femoral preparation is easier than the MWJ method because the affected limbs have fallen to the dorsal side already. Discussion. Since March 2017 to the end of August 2018, the AL60 method was used for 207 primary THA. There were no dislocations or fractures and any other complications. Full weight bearing was possible from the next day. The AL60 method has stability of the ALS method for acetabular preparation and the operability of the MWJ method for femoral preparation. Therefore, it can be said that new AL60 approach method makes use of the merits of both MWJ and ALS methods

Purpose of the study: The purpose of this study was to assess traumatic damage to muscles using biological markers. Two approaches were evaluated: a modified Hardinge approach (anterior hemimyotomy) and a reduced anterolateral approach (Rottinger). Material and method: This was a multicentric prospective study conducted in three centres in 2008. The first 50 patients in each centre were included. Total creatinine phosphokinase (CPK) and serum myoglobulin levels were used to evaluate muscle damage. Blood samples were taken ten hours after surgery for myoglobulaeia and at one and two postoperative days for CPK. Student’s t test was used for the statistical analysis. Results: There was no statistically significant difference in serum myoglobulin levels 10 hours postoperatively (p=0.25) or for CPK level at day 1 (p=0.098) and day 2 (p=0.105). Objective clinical recovery (Postel-Merle-d’Aubigné, Harris) and function (WOMAC and SF-12) were better at six weeks with the reduced anterolateral approach. Discussion: These findings show that muscle aggression after mini-incision is to the same order as with the standard approach. The damage is however different: section for the Hardinge type approaches, stretching and contusion for the mini-incisions. Conclusion: Use of biological markers specific for muscle tissue appears to be a simple way of quantifying muscle damage. However, adjunction of an imaging technique (MRI) might provide a more precise assessment of muscle injury

Aims. To assess the accuracy of posterior and anterolateral methods of injection into the subacromial space (SAS) of the shoulder. Patients and methods. Ethical approval was obtained and 50 patients (23 women and 27 men) with mean age of 64.5 years (42-87 years) and clinical diagnosis of subacromial impingement were recruited. Patients with old or recent shoulder fracture, bleeding disorders, and allergy to iodine were excluded. All injections were given by the consultant or an experienced registrar after obtaining informed consent. Patients were randomised into posterior and anterolateral groups and the method of injection was revealed by opening sealed envelopes just before the injection. A combination of 3mls 0.5% bupivacaine and 2mls of radiographic dye (Niopam) was injected in the subacromial space (SAS) using either anterolateral (n-22) and posterior approaches (28). AP and lateral radiographs of shoulder were taken after injection and were reported by a Consultant Radiologist blinded to the method of injection. Visual analogue scale (VAS) and Constant-Murley shoulder score was used to assess pain and function respectively. Both scores were determined before and 30 minutes after the injection. Results. 22 injections (78.5%) were accurately placed in SAS with the posterior approach and in 14 patients (63.6%) with anterolateral approach. This difference was statistically significant (P< 0.05). Only patients who received injection accurately in SAS with either method had a reduction in pain of an average of 4 points on VAS, and improvement in the Constant score of average 14 points. Conclusions. The posterior approach of SAS injection is more accurate than anterolateral approach. Injections that are correctly placed in the SAS lead to better reduction of pain and improvement in the Constant score

Purpose: The purpose of this study was to determine if correlation exists between acetabular cup positioning and factors relating to the surgeon and patient. Method: Data for 2063 patients who underwent primary or revision THA from 2004 – 2008 were compiled. The post-op anteroposterior (AP) and cross-table lateral digital radiographs for each patient were obtained. The AP radiograph was measured using Hip Analysis Suite to calculate the cup abduction and version angles (version direction determined separately). Acceptable ranges were 35–45° for abduction, and 5–20° for version. Correlations were then determined with SPSS™ software. Results: There were 1980(96%) qualifying patients. There were 1025(52%) acetabular cups that fell within the 35–45° abduction range, and 1287(70%) cups in the 5–20° version range. Regression analysis showed that the only independent predictor of acceptable abduction angle was the surgical approach (p< 0.001). Posterolateral approach was the most accurate (57% acceptability). In contrast to the posterolateral, the MIS (2 incision) approach was 3 times (95%C.I. 1.5–5, p=0.001), and the mini anterolateral approach 2.5 times (95%C.I. 1–6.5, p=0.035) more likely to have unacceptable abduction angles. The only independent predictor of acceptable version was the performing surgeon (p< 0.001), with higher volume surgeons showing greater accuracy. Conclusion: The posterolateral approach was superior to MIS (2 incision) and mini anterolateral approaches for acceptable abduction angle, and surgeon volume influenced version angle acceptability. Further analysis on variables and their influence on cup position at a lower volume medical center would provide a valuable comparison

Femoro-acetabular impingement (FAI) is an increasingly diagnosed cause of hip pain in young patients. It may progress to cause labral injury and chondral damage within the hip. Surgery can be undertaken arthroscopically but is not universally available. Open approach to the hip with surgical dislocation, labral surgery and impingement lesion reduction is an acceptable alternative. Described by Ganz in 2001 the approach must conserve the postero-lateral blood supply to the femoral head and neck, to minimize the risk of Avascular Necrosis (AVN). Ganz recommended a sliding trochanteric osteotomy to widen access, and an anterior capsulotomy avoiding dissection postero-lateral to the femoral neck. To date there has been no published support for the Hardinge-type antero-lateral approach. We describe a series of 26 consecutive patients with FAI, all managed by open osteochondroplasty during 2008 via a modified anterolateral approach and capsule preserving exposure. Trochanteric osteotomy was not undertaken. The series contained 14 males and 12 females with mean ages of 33 and 29 respectively. Patients were assessed both clinically and using the Non Arthritic Hip Score (NAHS). Assessments were undertaken pre-operatively and at 8 and 16 weeks post-operatively. The mean NAHS pre-op was 54. This improved to 87 at 16 weeks. 77% of our patients achieved a NAHS of 75 or greater indicating a good or excellent result. Three patients had poor outcome and progression of osteoarthritic symptoms. There were no complications from the osteochondroplasty and all patients were Trendelenberg negative by 16 weeks. We believe hip osteochondroplasty can be safely and effectively undertaken via an anterolateral approach, without a trochanteric osteotomy

Introduction: Avascular necrosis of the femoral head after resurfacing hip replacement is an important complication which may lead to fracture or failure. We compared the changes in femoral head oxygenation resulting from the anterolateral approach to those resulting from the posterior approach. Methods: In 22 patients undergoing hip resurfacing surgery, a calibrated gas-sensitive electrode was inserted supero-laterally in the femoral head via the femoral neck following division of the fascia lata. Inter-operative X-ray confirmed correct electrode placement. Baseline oxygen concentration levels were recorded immediately after electrode insertion. All results were expressed relative to this baseline, which was considered as 100% relative oxygen concentration. Oxygen levels were monitored continuously throughout the operation. 10 patients underwent surgery through the posterior approach, 12 patients through the antero-lateral approach. Results: During the operation patterns were similar for both groups, except following joint relocation and soft tissue reconstruction; oxygen concentration recovered significantly in the anterolateral group only. The posterior approach resulted in significantly lower (p< 0.01) oxygen concentration at the end of the procedure (22%, SD 31) than the antero-lateral approach (123%, SD 99). Discussion and Conclusion: The anterolateral approach disrupts the femoral head blood supply significantly less than the posterior approach in patients undergoing resurfacing. The incidence of complications related to avascular necrosis might be decreased by adopting blood supply conserving surgical approaches

Arthrogryposis multiplex congenita (AMC) is a rare disease with multiple joint contractures. It is widely believed that bilaterally dislocated hips should not be reduced since movement is satisfactory and open reduction has had poor results. Since 1977 we have performed a new method of open reduction using an extensive anterolateral approach on ten hips in five children with AMC. The mean age at surgery was 31.5 months (17 to 64) and the mean follow-up was 11.8 years (3.8 to 19.5). At the final follow-up all children walked without crutches or canes. Two managed independently, one required a long leg brace and two had short leg braces because of knee and/or foot problems. The clinical results were good in eight hips and fair in two and on the Severin classification seven hips were rated as good (group I or group II). We recommend the extensive anterolateral approach for unilateral or bilateral dislocation of the hip in children with arthrogryposis or developmental dislocation of the hip

The optimal surgical approach for total hip replacement (THR) remains controversial. We report the clinical outcomes of over 1000 patients in the Exeter primary outcomes study (epos) who underwent primary THR with a cemented Exeter stem (Stryker) but with various acetabular components. This was a prospective non randomised multi centre study. Patient reported hip scores (oxford hip score (OHS)) were measured before operation and at 3 months (n= 1312), 1 (n=1276), 2 (n= 1225), 3 (n=1205) and 4 (n=975) years post operatively. Physician reported scores (Merle d’Aubigne / Postel, MDAP) were measured before operation and at 12 months. All of the operations were carried out using either the anterolateral (Hardinge or modification) or posterior approach. The posterior approach gave better absolute OHS scores at 3 months and 1 year compared with the anterolateral approach. The improvement in OHS between the pre-op and relevant post-op score was better for the posterior than the Hardinge approach, and this extended to 4 years (all p< 0.05). Early dislocation rates were low in both groups. There was significantly more likely to be heterotopic ossification in the Hardinge group, while stem alignment into varus was more common in the posterior approach group. There was no significant difference between the two approaches as measured using the MDAP score at pre-op or at 12 months after surgery. These results demonstrate that initial patient perceived clinical benefit of surgery is greater using a posterior than with an anterolateral approach. This should be considered when assessing the best approach for a particular patient. The current results emphasise the value of using patient based outcome measures, as the MDAP score did not detect a difference in outcomes between the two groups

Narrowing of the femoral neck after resurfacing arthroplasty of the hip has been described previously in both cemented and uncemented hip resurfacing. Traditionally hip resurfacing has been performed via a posterior approach though other surgical approaches including the Ganz and the anterolateral approach have been well described. In addition it is known that the blood supply of the femoral neck arises largely from posterior structures and it has been postulated that neck narrowing is a consequence of poor post-operative femoral neck vascularity. Our null hypothesis in this study was that the choice of surgical approach does not influence postoperative femoral neck narrowing. We retrospectively measured the diameter of the femoral neck in a series of 135 consecutive patients who underwent uncemented cormet hip resurfacing, with follow up from one to 3 years. Our sample included 50 females and 85 men with an average age of 56.4 years (standard deviation of 9.47). Seventy six patients had a Ganz approach, 5 had an anterolateral approach and 55 had a posterior approach. There were no failures due to femoral neck fracture and no revisions to total hip arthroplasty. Eleven patients required subsequent surgery all of which were due to complications following trochanteric osteotomy. Seven patients needed removal of metalwork and 4 patients had non-union of their osteotomy requiring revision. At one year the posterior approach group had an average of 5.2% neck narrowing versus 2.7% neck narrowing in the Ganz approach group (p value 0.06). At three years the average neck narrowing amongst all patients was 6.8% (standard deviation 3.1%) but the number of patients who had had a Ganz approach was too small to meaningfully apply inference statistics. Our study shows early results which show a statistically significant reduction in the rate of femoral neck narrowing in patients who have had a Ganz approach as compared to a posterior approach for unce-mented hip resurfacing arthroplasty. It also shows a high rate of complications inherent with the Ganz approach which in our patient group are entirely related to the trochanteric osteotomy

Background: Displaced proximal humeral fractures (PHF) remain a challenge to the orthopedic surgeon. Conservative treatment yield poor results in the majority of these fractures. Surgical treatment, although preferable, lacks the proper exposure and fixation technique. The locking compression plate (LCP), which is inserted in a minimal invasive technique, utilizing an anterolateral approach to the proximal humerus, allows adequate reduction and fixation, while minimizing the risk for complications derived from extensive exposure and poor fixation. Methods: All patients admitted to our department with a complicated PHF between Jan 2004 and May 2005 were included. After obtaining informed consent, open reduction and internal fixation was performed through an anterolateral minimal invasive approach. After exposure and reduction with or without acromioplasty and rotator cuff repair, the fracture was fixated with a LCP 3.5mm. Patients were encouraged to perform pendular movements on the first post-operative day. The patients were followed closely beginning 2 weeks post-operatively and afterwards on a bi-monthly basis. Immediate complications, radiographic and functional outcome were noted. Results: 22 patients have been treated according to the treatment protocol during the study period. Minimal follow up of three months is available. A single complication was noted (deep wound infection which necessitated hardware removal). No nerve injury or hardware failures were noted. Functional outcome was good, patients regained 120°±25 of flexion, 112°±27 of abduction and 17°±8 of external rotation. Conclusions: The anterolateral approach to the shoulder and fixation with a LCP plate is a safe technique in our hospital. Rigid stabilization allows for early shoulder activation which results in a good range of motion and functional outcome on short-term follow up. Further study and long-term follow up are needed to validate this technique in treating complex proximal humerus fractures

Background: Total hip arthroplasty (THR) is a commonly performed procedure to treat displaced fractures of the femoral neck, either as a primary procedure, or as a secondary procedure after failed healing of internal fixation. Dislocation of the prosthesis remains as a problem, and controversies still exist regarding the optimal surgical approach and its influence on stability of the THR. The main issue is whether to use an anterolateral or a posterolateral surgical approach. Repair of the posterior soft tissue structures when performing a posterolateral approach has been proposed to increase the stability. Other factors such as age, gender, indication for surgery (primary, secondary), caput size and the experience of the surgeon may also influence the stability, but are not well documented. Material and Methods: Between January 1 1999, and December 31 2005, 532 consecutive THR’s in 523 patients were performed at our institution as a primary, or a secondary, procedure after fracture of the femoral neck. The patients have been followed with a prospective 6 week questionnaire, and after that via the clinics journal database. Finally, thanks to the Swedish personal identification number, a search has been done in a national registry by the Swedish National Board of Health and Welfare. For all patients, all dislocations and related reoperations until December 31 2006, or death, were registered and analyzed. Logistic regression analyse was performed in order to evaluate factors associated with prosthetic dislocation. Age, gender, indication for surgery, the surgeon’s experience, caput size and surgical approach were tested as independent variables in the model. Results: Dislocation of the THR occurred in 27 patients. In the multivariate regression analyze the posterolateral surgical approach performed without posterior repair was associated with a significant higher risk of dislocation compared with the anterolateral approach (OR 4.7, 95% CI 1.1–19.6). The 28 mm caput size was associated with a significant lower risk of dislocation compared with the 22 mm (OR 0.3, 95% CI 0.1–0.99). There was a strong, but not significant, trend of higher risk for dislocation with a posterolateral approach performed with posterior repair compared with the anterolateral approach (OR 3.3, 95% CI 0.9–11.4). Age, gender, indication for surgery or the experience of the surgeon did not affect the risk for dislocation. Interpretations: We recommend the anterolateral surgical approach and 28 mm caput size for THR after femoral neck fracture

Background: A 9- year-old child with osteogenesis imperfecta and severe cervical kyphosis associated with wedged vertebrae and progressive neurological deterioration is presented. There is no report of upper cervical kyphosis associated with wedged vertebrae in osteogenesis imperfecta in the literature. We discuss the methods and difficulties in the surgical management of this condition and to highlight the appropriate surgical approach. Methods: Methods:A 9-year-old girl presented with progressive cervical kyphosis and quadriparesis. At the age of 3 years she underwent posterior cervical fusion (C1–C6) for instability and deformity. Radiological and laboratory investigations confirmed the diagnosis of osteogenesis imperfecta. Radiographs of the cervical spine revealed a kyphotic deformity of 120° Magnetic Resonance Imaging (MRI) and Computerised Tomography (CT) scans showed anterior cord compression due to wedged vertebrae at C3 and C4. MRI-Angiography was performed pre-operatively to identify the anatomical position of the vertebral arteries. A modified anterolateral approach to the upper cervical spine was performed. Anterior C3 and C4 corpectomies with interbody fusion with cage and plate fixation was carried out. Results: Postoperatively the patient made a full neurological recovery and significant correction of the deformity was achieved and correction was maintained at final follow-up. Conclusion: Cervical kyphotic deformity in Osteogenesis Imperfecta is uncommon. Association of this condition with wedged vertebrae is rare. Surgical decompression of the upper cervical spine with severe kyphosis is a challenging problem. Which surgical approach should be used is controversial? There are difficulties exposing wedged vertebrae by a standard anterior or chin split approach to perform vertebrectomy. Costo-transversectomy has been used successfully in patients with Gibbous deformity in the thoracic spine but due the presence of vertebral artery in the cervical spine posterolateral approach is impossible. We have used a modified anterolateral approach to overcome this problem. Spinal stabilisation in children with Osteogenesis Imperfecta and poor bone quality is another challenge. We have used a small diameter MOSS cage with maxillofacial plate and screws to achieve stabilisation and fusion. The purpose of this report is to highlight the importance of diagnosis of progressive cervical kyphotic deformity in children with osteogenesis imperfecta and also to describe the difficulties encountered with surgical management of this condition

Introduction and aim: In order to harness existing surgical skill and expertise of the operator trained in conventional total hip arthroplasty (THA) it would be advantageous to adopt a mini-incision surgery (MIS) THA technique that is similar. It would also make economic sense for MIS THA to be performed using existing conventional instrumentation available in every elective orthopaedic unit. The aim of this retrospective comparative study was to verify safety, efficacy and durability of this MIS THA technique via a modified anterolateral approach developed in our hospital by the senior author. This technique utilises standard instrumentation and does not require the use of an image intensifier. Materials and Methods: The implants used in the study were the SL-Plus (Plus Endoprothetik AG, CH-Rotkreuz) and the EPF cup (Plus Endoprothetik AG, CH-Rotkreuz). We report on our experience of a consecutive series of 111 patients operated for osteoarthritis of the hip joint. Results: Fifty-nine patients (53.2%) were implanted using MIS technique; the remainder (52 cases, 46.8%) were operated using conventional THA via traditional anterolateral approach. In patients undergoing MIS technique a skin incision averaging 8 cm (range 7.5 to 9 cm) was made over the greater trochanter with two thirds lying superior to its tip. The surgical procedure lasted forty minutes on average, and no excessive retraction was needed. The small incision can be extended with ease if access proves difficult, but this proved unnecessary in any of our cases. The mean follow-up for the MIS THA group was 22.9 months compared to 33.1 months for the conventional THA group. All our MIS patients had less postoperative blood loss, needed less post operative painkillers, and mobilised earlier. There was however no significant difference in the duration of postoperative hospital stay between the two patient groups. We have had no incidence of dislocation and continue to use this technique during routine THA. Discussion and conclusion: A review of the MIS THA literature is provided to compare this technique with those described by other authors. The authors believe this to be a safe, cost effective alternative to MIS THA techniques that require special instrumentation and the use of the image intensifier

Protrusio acetabuli can be either primary or secondary. Primary or idiopathic protrusio is a rare condition of unknown etiology. Secondary protrusio may be associated with rheumatoid arthritis, ankylosing spondylitis, osteoarthritis, osteomalacia, trauma and Paget's disease. Challenges in surgery include: lack of bone stock, deficient medial support to the cup, difficulty in dislocating the femoral head, and medialization of the hip joint center. Several surgical techniques have been described: use of cement alone without bone graft; morselised impacted autograft or allograft with a cemented cup; metal cages, reinforcement rings, and solid grafts. We describe our technique of impaction grafting using autologous bone and a cementless porous-coated hemispherical cup without the use of acetabular rings or cages in patients with an average age of 46 years. Protrusion was graded depending on distance of medial wall from Kohler's line as mild (1–5 mm medial), moderate (6–15 mm medial) and severe if it was more than 15 mm medial to the Kohler's line. All patients were operated in the lateral position using a modified Hardinge's anterolateral approach. Adductor tenotomy may be required in cases of severely stiff hips. After careful dislocation of the femoral head, it was sectioned in situ into slivers to facilitate obtaining the graft. The periphery was reamed and care was taken to preserve the membrane lining the floor of the defect. Morselised graft was impacted with hemispherical impactors and the trial cup 1–2 mm larger than the last reamer placed in the desired position. The final socket was then inserted. Femoral preparation was performed in routine fashion. The mean pre-operative Harris Hip Score of 52 improved to 85 points at a mean follow up of 4 years. The average acetabular inclination angle was 42 degrees. Our results have shown incorporation of the graft in all cases. There was no evidence of progression of the protrusio or cup loosening in any of the cases. Thus far, our hips have not shown osteolytic lesions. The technique described is a satisfactory biological solution of restoring bone stock particularly in young and middle-aged patients

Introduction & aims. Correct prosthetic alignment is important to the longevity and function of a total hip replacement (THR). With the growth of 3-dimensional imaging for planning and assessment of THR, the importance of restoring, not just leg length and medial offset, but anterior offset has been raised. The change in anterior offset will be influenced by femoral anteversion, but there are also other factors that will affect the overall change after THR. Consequently, the aim of this study was to investigate the relationship between anterior offset and stem anteversion to determine the extent to which changing anteversion influences anterior offset. Method. Sixty patients received a preoperative CT scan as part of their routine planning for THR (Optimized Ortho, Sydney). All patients received a Trinity cementless shell and a cemented TaperFit stem (Corin, UK) by the senior author through an anterolateral approach. Stem anteversion was positioned intraoperatively to align with cup anteversion via a modified Ranawat test. Postoperatively, patients received a CT scan which was superimposed onto the pre-op CT scan. The difference between native and achieved stem anteversion was measured, along with the 3-dimensional change in head centre from pre-to post-op. Finally, the relationship between change in stem anteversion and change in anterior offset was investigated. Results. Mean change in anterior offset was −2.3mm (−14.0 to 7.0mm). Mean change in anteversion from native was −3.0° (−18.8° to 10.5°). There was a strong correlation between change in anterior offset and change in anteversion, with a Pearson correlation coefficient of 0.89. A 1° increase in anteversion equated to a 0.7mm increase in anterior offset. Conclusions. A change in the anteroposterior position of the femoral head is primarily affected by a change in stem anteversion, with a 1° increase in anteversion equating to a 0.7mm increase in anterior offset. The AP position of the stem in the canal, along with the flexion of the stem will also contribute. Given the well-recognised influence of leg length, medial offset and combined anteversion on restoring hip function, it seems reasonable to assume that anterior offset will also have a significant effect on the biomechanics of the replaced hip

Larger diameter femoral heads and improved operative approaches and soft tissue repair/closure have somewhat reduced the incidence of recurrent instability after total hip arthroplasty (THA). Nevertheless, hip instability remains one of the most common reasons for reoperation after THA, and accounts for roughly a quarter of hip revisions in the United States in Medicare patients. The prevalence of instability after THA varies widely, from 0.3% to 15%. Surgeons have come to understand that hip instability can be caused by implant malposition, impingement, and inadequate soft tissue tension or integrity. While the cumulative risk of instability is acceptable at approximately 2.8% with transtrochanteric approaches, this is based upon the trochanter actually healing (and often being advanced). On the other hand, trochanteric nonunion and proximal migration have been noted by many, and this frequently results in catastrophic instability. Moreover, and importantly, abductor insufficiency is one the most difficult causes of hip instability to solve. Woo and Morrey reported a 17.6% instability rate when trochanteric nonunion occurred with 1 cm proximal trochanteric migration. Alternatively, the contemporary incidence of instability with the posterolateral or anterolateral approaches, and an adequate soft tissue repair, is approximately 1–2%

A prospective randomised trial of surgical treatment for the displaced subcapital femoral fracture in patients of 70 years or more is presented. Two hundred and eighteen patients were randomly allocated into one of three treatment groups: manipulative reduction and internal fixation using Garden screws; Thompson hemiarthroplasty through a posterior (Moore) approach; and Thompson hemiarthroplasty through an anterolateral (McKee) approach. There is no significant difference in the mortality of the internal fixation and posterior arthroplasty groups. Both groups showed a significantly higher mortality than patients operated on through the anterior approach. The technical results of operation were worse in the internally fixed group, with only 40 per cent being satisfactory. Mobilisation was best achieved after the posterior approach. It is concluded that Thompson hemiarthroplasty, using an anterolateral approach, is the safest operation in this group of patients

Hip abductor deficiency (HAD) associated with hip arthroplasty can be a chronic, painful condition that can lead to abnormalities in gait and instability of the hip. HAD is often confused with trochanteric bursitis and patients are often delayed in diagnosis after protracted courses of therapy and steroid injection. A high index of suspicion is subsequently warranted. Risk factors for HAD include female gender, older age, and surgical approach. The Hardinge approach is most commonly associated with HAD because of failure of repair at the time of index surgery or subsequent late degenerative or traumatic rupture. Injury to the superior gluteal nerve at exposure can also result in HAD and is more commonly associated with anterolateral approaches. Multiple surgeries, chronic infection, and chronic inflammation from osteolysis or metal debris are also risk factors especially as they can result in bone stock deficiency and direct injury to muscle. Increased offset and/or leg length can also contribute to HAD, especially when both are present. Physical exam demonstrates abductor weakness with walking and single leg stance. There is often a palpable defect over the greater trochanter and palpation in that area usually elicits significant focal pain. Note may be made of multiple incisions. Increased leg length may be seen. Radiographs may demonstrate avulsion of the greater trochanter or significant osteolysis. Significant polyethylene wear or a metal-on-metal implant should be considered as risk factors, as well as the presence of increased offset and/or leg length. Ultrasound or MRI are helpful in confirming the diagnosis but false negatives and positive results are possible. Treatment is difficult, especially since most patients have failed conservative management before diagnosis of HAD is made. Surgical options include allograft and mesh reconstruction as well as autologous muscle transfers. Modest to good results have been reported, but reproducibility is challenging. In the case of increased offset and leg length, revision of the components to reduce offset and leg length may be considered. In the case of significant instability, abductor repair may require constrained or multi-polar liners to augment the surgical repair. HAD is a chronic problem that is difficult to diagnose and treat. Detailed informed consent appropriately setting patient expectations with a comprehensive surgical plan is required if surgery is to be considered. Be judicious when offering this surgery

Introduction. Optimal implant position is critical to hip stability after total hip arthroplasty (THA). Recent literature points out the importance of the evaluation of pelvic position to optimize cup implantation. The concept of Functional Combined Anteversion (FCA), the sum of acetabular/cup anteversion and femoral/stem neck anteversion in the horizontal plane, can be used to plan and control the setting of a THA in standing position. The main purpose of this preliminary study is to evaluate the difference between the combined anteversion before and after THA in weight-bearing standing position using EOS 3D reconstructions. A simultaneous analysis of the preoperative lumbo pelvic parameters has been performed to investigate their potential influence on the post-operative reciprocal femoro-acetabular adaptation. Material and Methods. 66 patients were enrolled (unilateral primary THAs). The same mini-invasive anterolateral approach was performed in a lateral decubitus for all cases. None of the patients had any postoperative complications. For each case, EOS full-body radiographs were performed in a standing position before and after unilateral THA. A software prototype was used to assess pelvic parameters (sacral slope, pelvic version, pelvic incidence), acetabular / cup anteversion, femoral /stem neck anteversion and combined anteversion in the patient horizontal functional plane (the frontal reference was defined as the vertical plane passing through centers of the acetabula or cups). Sub-analysis was made, grouping the sample by pelvic incidence (<55°, 55°–65°, >65°) and by pre-operative sacral slope in standing position (<35°, 35°–45°, >45°). Paired t-test was used to compare differences between preoperative and postoperative parameters within each subgroup. Statistical significance was set at p < 0.05. Results. In the full sample, mean FCA increased postoperatively by 9,3° (39,5° vs 30,2°; p<0.05). In groups with sacral slope < 35° and sacral slope > 45°, postoperative combined anteversion increased significantly by 11,7° and 12,9°, respectively. In the group with pelvic incidence > 65°, postoperative combined anteversion increased significantly by 14,4°. There was no significant change of combined anteversion in the remaining subgroups. Discussion. In this series the FCA increased after THA, particularly in patients with a low or high sacral slope on the pre-operative evaluation in standing position. This may be related to a greater difficulty for the surgeon in anticipating the postoperative standing orientation of the pelvis in these patients, as they were standardly oriented during surgery (lateral decubitus). Interestingly the combined anteversion was also increased in patients with a high pelvic incidence that is commonly associated with a high sacral slope. Conclusion. Post-operative increase of anatomical cumulative anteversion has been previously reported using anterior approach. The FCA concept based on EOS 3D reconstructions brings new informations about the reciprocal femoro-acetabular adaptation in standing position. Differences found in combined anteversion before and after the surgery show that a special interest should be given to patients with high pelvic incidence and low or high sacral slope, to optimize THA orientation in standing position

We describe the results at five years of a prospective study of a new tri-tapered polished, cannulated, cemented femoral stem implanted in 51 patients (54 hips) with osteoarthritis. The mean age and body mass index of the patients was 74 years and 27.9, respectively. Using the anterolateral approach, half of the stems were implanted by a consultant orthopaedic surgeon and half by six different registrars. There were three withdrawals from the study because of psychiatric illness, a deep infection and a recurrent dislocation. Five deaths occurred prior to five-year follow-up and one patient withdrew from clinical review. In the remaining 51 hips the mean pre-operative Oxford hip score was 47 points which decreased to 19 points at five years (45 hips). Of the stems 49 (98%) were implanted within 1° of neutral in the femoral canal. The mean migration of the stem at five years was 1.9 mm and the survivorship for aseptic loosening was 100%. There was no significant difference in outcome between the consultant and registrar groups. At five years, the results were comparable with those of other polished, tapered, cemented stems. Long-term surveillance continues

BACKGROUND. Ideal treatment of displaced femoral neck fragility fractures in the previously ambulatory patient remains controversial. Treating these patients with total hip arthroplasty has improved patient reported outcomes and reduced rates of revision surgery compared to those treated with hemiarthroplasty. However, possible increased risk of dislocation remains a concern with total hip arthroplasty. The anterolateral and direct anterior approaches to total hip replacement have been applied in the femoral neck fracture population to minimize dislocation rates. However, the anterolateral approach has been associated with abductor injury and increased rates of heterotopic ossification while the anterior approach has been associated with peri-prosthetic femur fracture, lateral femoral cutaneous nerve injury, and wound complications. The Supercapsular Percutaneously Assisted (SuperPATH) approach was developed to minimize disruption of the capsule and short-external rotators in an effort to reduce the risk of dislocation and assist in quicker recovery in the elective hip arthroplasty setting. To achieve this, the SuperPATH technique allows the femur to be prepared in situ and the acetabulum to be reamed percutaneously once the femoral head is removed. This study investigates the post-operative time to ambulation, length of stay, discharge destination, and early dislocation rate of previously ambulatory patients with a displaced femoral neck fragility fracture that were treated with a total hip arthroplasty via the SuperPATH technique. METHODS. A retrospective chart review was performed of previously ambulatory patients consecutively treated for a displaced femoral neck fragility fracture with a total hip replacement using the SuperPATH technique. Thirty-five patients were included in the study and examined for demographic data, time to ambulation, length of stay, major and minor complications during their hospital stay. Phone interviews were conducted to check for dislocation events. RESULTS. Thirty-five patients were included in the study with an average age of 75.7 years old (range 51–95). Patients spent an average of 5.35 ± 1.61 days in the hospital and were discharged on post-operative day 3.6 ±1.38. 89% of patients were able to stand and ambulate by post-operative day 1, and 97% of patients were able to stand and ambulate before discharge from the hospital. 26% of patients were able to be discharged home, 46% were discharged to in-patient rehabilitation, 23% were discharged to a skilled nursing facility, and one patient was discharged to hospice. There were no iatrogenic femoral fractures caused, no incidents of symptomatic heterotopic bone formation, and no superficial or deep wound infections. 88.5% of patients had adequate follow up averaging 370.6 ±235.18 days, with no dislocation events observed. CONCLUSION. These early results indicate that minimally invasive total hip arthroplasty utilizing the SuperPATH technique is a safe and effective treatment for displaced femoral neck fragility fractures in the previously ambulatory patient. Additionally, this technique allows for early ambulation without an increased risk of dislocation

Hip resurfacing, like other orthopaedic procedures, depends for its success upon the confluence of three factors: a well-designed device, implanted using good technique, in a properly selected patient. Cleveland Clinic has had good mid-term results in more than 2,200 patients using the Birmingham device since its FDA approval in 2006. These results are quite similar to other reported series from many centers around the world. All surgery was performed using an anterolateral approach. Males accounted for 72% of the patients, and the average age was 53 years (12‐84). More than 90% of the patients had a diagnosis of osteoarthritis, and femoroacetabular impingement was the predominant pathology. The average component head size in males was 51mm, and in females 45mm. Complications were few, with no dislocations, no femoral loosening, one socket loosening, one head collapse, 2 femoral neck fractures, and 2 deep infections. There were two patients with metallosis, one due to component malposition, and one in a small, dysplastic female. There were no destructive pseudotumors. Overall survivorship at up to 8 years was more than 99%. Survivorship in young males, under age 50 with OA was 100%. New mushroom templates for head size are described. Additional imaging recommendations including a standing lateral of the pelvis, and a CT scan for femoral anteversion may be helpful in patient selection

Identification of gait deviations and compensations in patients with total hip arthroplasty (THA) is important for the management of their fall risks. To prevent collapse of the lower limbs while balancing and supporting the body, proper combinations of joint moments are necessary. However, hip muscles affected by THA may compromise the sharing of load and thus the whole body balance. The current study aimed to quantify the control of body support in patients with THA in terms of the total support moment (Ms) and contributions of individual joint moments to Ms during walking. Six patients who underwent unilateral THA via an anterolateral approach for at least six months at the time of the gait experiment, and six age- and gender-matched healthy controls were recruited. Twenty-eight infrared retro-reflected markers were placed on specific landmarks of the pelvis-leg apparatus to track the motion of the segments during walking. Kinematic and kinetic data were measured using an 8-camera motion analysis system (Vicon, Oxford Metrics, U.K.) and two force plates (AMTI, U.S.A.). The Ms of a limb was calculated as the sum of the net extensor moments at the hip, knee and ankle during stance phase. The contributions of the hip, knee and ankle to the first and second peaks of Ms (Ms1 and Ms2) were calculated by dividing the joint moment value by the corresponding peak values of Ms. Independent t-tests were performed to compare between groups at a significance level set at α=0.05 using SAS version 9.2 (SAS Institute Inc., NC, USA). No significant differences in Ms1 and Ms2 were found between the THA group and normal controls (P >0.05). However, compared to the healthy controls, significantly increased hip and ankle contributions but decreased knee contributions to Ms1, and significantly increased hip contributions but decreased ankle contributions to Ms2 were found in the THA group. Similar Ms1 and Ms2 between groups indicates that the lower limbs in the THA group were able to provide normal body supports. However, this was achieved via an altered contributions of the hip, knee and ankle. Hip and knee extensors play important roles in supporting the body when the Ms1 occurs during early stance of walking. In the THA group, greater hip and ankle contributions but lesser knee contributions for the Ms1 indicates that the function of hip extensors were not affected but compensatory mechanisms of the knee and ankle were found. For the Ms2, hip flexor and ankle plantarflexors are important for supporting the body during late stance. Decreased hip flexor (i.e., greater hip extensor contributions) and ankle plantarflexor moments in the THA patients suggests that the hip flexors and ankle plantarflexor muscles were affected by THA surgery. Hip muscles affected by the THA may compromise the sharing of load at the hip and thus the whole body balance. Further postoperative rehabilitation is suggested for the patients following THA. Further studies on the effects of different surgical approaches on the support moments is needed for improving treatment plans

Introduction. Navigation in total hip arthroplasty (THA) has the goal to improve accuracy of cup orientation. Measurement of cup orientation on conventional pelvic radiographs is susceptible to error due to pelvic malpositioning during acquisition. A recently developed and validated software using a postoperative radiograph in combination with statistical shape modelling allows calculation of exact 3-dimensional cup orientation independent of pelvic malpositioning. Objectives. We asked (1) what is the accuracy of computer-navigated cup orientation (inclination and anteversion) and (2) what is the percentage of outliers (>10° difference to aimed inclination and anteversion) using postoperative measurement of 3-dimensional cup orientation. Methods. We performed a retrospective comparative study including a single surgeon series with 114 THAs (109 patients). Surgery was performed through the anterolateral approach with the patient in supine position. An image-free navigation system (PiGalileo, Smith & Nephew) with a passive digital reference base for the pelvic wing and one for the distal femur was used. The anterior pelvic plane (APP) was registered manually using a pointer and used as anatomical reference. After implantation of the press-fit cup (EP-Fit plus, Smith & Nephew) the final cup orientation (inclination and anteversion) was registered with the navigation system. Postoperative orientation was calculated using validated software to calculate 3-dimensional cup orientation. The postoperative anteroposterior pelvic radiograph in combination with a statistical model of the pelvis allowed calculation of inclination and anteversion referenced to the APP. The software was previously validated using CT measurements and revealed a mean accuracy of 0.4° for inclination 0.6° for anteversion with a maximum error of 3.3° and 3.6°, respectively. The mean postoperative inclination in the current series was 46° ± 4° (range, 35° – 60°) and the mean anteversion was 23° ± 6° (range, 11° – 37°). Accuracy was calculated as the absolute difference of the intraoperative registered cup orientation and the postoperative calculated orientation. An outlier was defined if cup orientation was outside a range of ±10° of inclination and/or anteversion. Results. (1) The mean accuracy for inclination was 3 ± 3° (0 – 17°) and 6 ± 5° (0 – 22°) for anteversion. (2) Three out of 114 cups (3%) were outliers for inclination. An increased percentage of outliers was found for anteversion with 23 out of 114 cups (20%; p<0.001). In total, 25 cups (22%) were outliers (See Figure 1). Conclusions. Previous studies evaluating accuracy of cup orientation were limited in numbers of hips due to the use of CT or used measurements on conventional postoperative radiographs which are prone to error due to pelvic malpositioning. Novel and validated software allows accurate and anatomically referenced measurement of postoperative cup orientation. This study is the single largest case series with 3-dimensional measurement of cup orientation for validation of navigated THA. Computer-assisted image-free navigation of cup orientation showed a high accuracy of cup orientation with 78% within a narrow range of ±10° of inclination and anteversion. Accuracy of cup inclination was increased compared to cup anteversion. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Perioperative fracture during routine THA represents one of the “not so fresh” feelings that occur for both patients and surgeons. With the increase in the use of uncemented implants and MIS techniques this truly is a problem on the rise. We have examined and quantified the risk factors associated with proximal femoral fracture during THA. Risk factors (risk ratios) identified were: uncemented stems (8.9), anterolateral approach (7.4) and female gender (2.2). Fortunately, treatment with cerclage wiring for uncemented stems has facilitated excellent stem stability and acceptable survivorship with many different femoral component designs. Reduced proximal geometry stems that better match the endosteal osseous anatomy have reduced fracture rates at our institution and maintained excellent stem survivorship. New data examining this design will be presented. In our series, cemented stems, however, had decreased survivorship in the presence of a proximal femoral fracture. MIS techniques may accelerate rehabilitation but they certainly permit limited visibility of the proximal femoral and acetabular anatomy and may result in less accurate component position. Relatively high fracture rates in series of MIS-THA have been reported. A bigger concern, however, is the unrecognised fracture that displaces postoperatively and requires a return to surgery for treatment with or without revision and mandates that we “see it before it sees us!” Cerclage wiring with looped Luque wires has been our treatment of choice for many years. Wires are significantly less expensive than cables and have proven to be durable in our series. This technique allows intraoperative repositioning and variable tightening in multiple locations. Cable fretting and breakage have been common in our experience with braided cable devices. Acetabular fracture during uncemented THA is most likely an under-reported occurrence and has been associated with elliptical component designs and under-reaming. In the presence of a stable cup, long-term performance has been acceptable

The approach to total hip arthroplasty (THA) should allow adequate visualization and access so as to implant in optimal position whilst minimizing muscle injury, maintaining or restoring normal soft tissue anatomy and biomechanics and encouraging a rapid recovery with minimal complications. Every surgeon who performs primary hip arthroplasties will expound the particular virtues of his or her particular routine surgical approach. Usually this approach will be the one to which the surgeon was most widely exposed to during residency training. There is a strong drive from patients, industry, surgeon marketing campaigns, and the media to perform THA through smaller incisions with quicker recoveries. The perceived advantage of the anterior approach is the lack of disturbance of the soft tissues surrounding the hip joint, less pain, faster recovery with the potential for earlier return to work, shorter hospital stay and improved cosmetic results. The potential disadvantages include less visibility, longer operation time, nerve injuries, femoral fractures, malposition and a long learning curve for the surgeon (and his / her patients). The anterior approach was first performed in Paris, by Robert Judet in 1947. The advantages of the anterior approach for THA are several. First, the hip is an anterior joint, closer to the skin anterior than posterior. Second, the approach follows the anatomic interval between the zones of innervation of the superior and inferior gluteal nerves lateral and the femoral nerve medial. Third, the approach exposes the hip without detachment of muscle from the bone. The mini-incision variation of this exposure was developed by Joel Matta in 1996. He rethought his approach to THA and his goals were: lower risk of dislocation, enhanced recovery, and increased accuracy of hip prosthesis placement and leg length equality. This approach preserves posterior structures that are important for preventing dislocation while preserving important muscle attachments to the greater trochanter. The lack of disturbance of the gluteus minimus and gluteus medius insertions facilitates gait recovery and rehabilitation, while the posterior rotators and capsule provide active and passive stability and account for immediate stability of the hip and a low risk of dislocation. A disadvantage of the approach is the fact that a special operating table with traction is required. Potential complications include intraoperative femoral and ankle fractures. These can be avoided through careful manipulation of the limb. If a femoral fracture occurs, the incision can be extended distally by lengthening the skin incision downward along the anterolateral aspect of the thigh, and splitting the interval between the rectus femoris and the vastus lateralis. The choice of approach used to perform a primary THA remains controversial. The primary goals are pain relief, functional recovery and implant longevity performed with a safe and reproducible approach without complications. The anterior approach is promising in terms of hospital stay and functional recovery. Although recent studies suggest that component placement in minimally invasive surgery is safe and reliable, no long-term results have been published. Further follow-up and development is necessary to compare the results with the posterior approach as most of the positive data is based on comparisons with the anterolateral approach. The proposed benefits of the anterior approach are not supported by the current available literature. The issues regarding the difficult learning curve, rate of complications, operative time, requirement for trauma tables and image intensifier should be taken into account by surgeons starting with the anterior approach in THA

Hip resurfacing has been proposed as an alternative to traditional total hip replacement in young, active patients. Metal-on-metal resurfacing devices were introduced in the 1990's, and a number of them reached the international market. The promise of bone preservation, more normal loading, greater activity, and easier revision led many surgeons to begin implanting these devices. Over time, lessons have been learned regarding patient selection, implant selection, and surgical technique. Several devices have been withdrawn from the market, and many surgeons have abandoned the procedure. We continue to perform this procedure in substantial numbers, approximately 350 per year. The triad of a well-designed device, implanted accurately, in the correct patient has never been more critical than with these implants. Following FDA approval in 2006, we studied the safety and effectiveness of one hip resurfacing device at our US institution in a large, single-surgeon series. We report our early to mid–term results in 476 patients who were under the age of 50 years at the time of hip resurfacing. Their average age was 42.8 (12–49) with an average follow-up of 4.8 years (2–8.8). Males represented 76% of the patients, and 91% had osteoarthritis. The average component size was 50.8mm (44–58) in men and 45.3mm (40–50) in women. All surgery was performed in the lateral position using an anterolateral approach. Patients were allowed 75% weight-bearing for 6 weeks, followed by avoidance of strenuous exertion (running, jumping, heavy lifting) for 12 months. Follow-up intervals were 6 weeks, 1 year, 2 years, and 5 years. Follow-up percentage was 81%. We measured a number of outcomes scores using a validated prospective observational registry at each follow-up interval. Improvement in HOOS Function was from pre-op of 41.4 + 22.7 to 93.5 + 15.2, Physical Activity Limitation improved from 2.4 + 2.5 to 8.2 + 2.6, and SF-12 Physical Composite Score improved from 31.7 +10.3 to 49.4 + 10.2. There were no device-related failures in this series. There were no femoral neck fractures, no femoral component loosening, no failure of acetabular ingrowth, and no metal-related complications or pseudotumors. Two male patients, one a known heroin user, and the other with septic discitis, had remote hematogenous sepsis requiring component removal, each at 38 months after resurfacing. One female fell down an escalator 32 months after resurfacing sustaining a fractured acetabulum requiring component revision. Overall survivorship was 99.4%. Aseptic survivorship in males under age 50 was 100%. We believe that hip resurfacing continues to offer a viable alternative for younger patients who would otherwise be candidates for total hip arthroplasty

Object. CT-based navigation system in total hip arthroplasty(THA) is widely used to achieve accurate implant placement. However, its internal structure was a trade secret. Therefore, it was hard to analyze optimal reference points. Now, we developed our own CT-based navigation system originally, and since then we have been conducting various analyses in order to use the system more effectively. The purpose of this study was to analyze the optimal area and the number of registration points, which enables to move initial errors into the acceptable range. Methods. We set the anterior pelvic plane(APP) as the reference plane, and defined the coordinates as follows: X-axis for external direction, Y-axis for anterior direction, and Z-axis for proximal direction. We made pelvic bone models after THA, a normal shape and acetabular dysplasia model, and performed registration using an originally developed CT based navigation system. At first, we registered point paired matching at 4 points, and surface matching was performed at 53 points, which were placed around the acetabulum. 20 points were on anterosuperior, 10 points were on posterosuperior, 20 points were on posterior around the acetabulum, and 3 points were on the pubis. We selected surface matching points based on the actual operation approach, calculated the accuracy of the error correction, and searched the optimal area and the number of surface matching points. Results. Initial error could correct under 2mm gradually more than 20 surface matching points on anterosuperior area of the acetabular, assumed anterolateral approach. Initial error correction was improved by adding the reference points on the pubis. In comparison with the initial error on the X-axis, corrections of the Y-axis and Z-axis were more difficult. Initial error could correct under 2mm with around 20 surface matching points on posterior area of the acetabulum, assumed posterior approach, initial error on the Y-axis direction had difficulty in correction similarly. The difference of the shape of the pelvic effected initial error correction, it was more difficult to correct initial error on Y, Z-axis on dysplasia hip. Discussion. To correct initial error needs more than 20 surface matching points at least on the both anterolateral and posterior approaches. However, it is hard to correct initial error depending on surface matching points on the Y-axis, so it is desirable to return to point paired matching. On the registration of anterosuperior area of the acetabulum, correction of the initial error improved effectively by adding reference points on the pubis in this study, so to get reference points on the pubis is recommended if possible. Moreover, it was hard to correct initial error on the Z-axis because reference points on the anterosuperior of the acetabulum were flat, therefore it is necessary to reduce the initial error on Z-axis, we should consider choosing other reference points such as on the iliac crests which can define Z-axis direction. When using the navigation system on pelvic, some tendencies and characteristics exist, and understanding them can make the operation smooth and precisely

As much as there is interest in mini-invasive surgery (MIS) total hip arthroplasty (THA), there is controversy ranging from a more advantageous to a potentially dangerous alternative to classic THA. The purpose of this study is to compare the results of 130 cementless, standard stem navigated primary THA with data collected retrospectively from 2005 to 2010 (64 classic Hardinge approach (HAL) and 66 MIS intermuscular anterolateral approach by the senior surgeon). Data include: operative time, perioperative bleeding, length of surgery, hospital stay, patient's satisfaction and pain perception. The alignment values at six months to a maximum of 60 months provided necessary statistical information for clinical and radiological comparison of the two groups. Significant differences were found between the two groups with MIS being superior with respect to less surgical time (p = 0.029) and achieving quicker rehab goals with shorter hospital stay (p <0.001). Pain perception was less in MIS group with a higher satisfaction score (p <0.001). Although both groups have the potential of nerve injury to tensor fascia muscle, it's only the classic HAL that jeopardises the glutei nerve supply. MIS approach to navigated THA seems to be an acceptable alternative with some advantages to Classic HAL

Peri-operative fracture during routine THA represents one of the “not so fresh” feelings that occur for both patients and surgeons. With the increase in uncemented implants and MIS techniques this truly is a problem on the rise. We have recently examined and quantified the risk factors associated with proximal femoral fracture during THA. Risk factors (risk ratios) identified were: uncemented stems (8.9), anterolateral approach (7.4) and female gender (2.2). Fortunately, treatment with cerclage wiring for uncemented stems has facilitated excellent stem stability and acceptable survivorship with many different femoral component designs. Reduced proximal geometry stems that match the endosteal osseous anatomy have reduced fracture rates at our institution. In our series, cemented stems, however, had decreased survivorship in the presence of a proximal femoral fracture. MIS techniques may accelerate rehabilitation but they certainly permit limited visibility of the proximal femoral and acetabular anatomy and may result in less accurate component position. Relatively high fracture rates in series of MIS-THA have been reported. A bigger concern, however, is the unrecognised fracture that displaces postoperatively and requires a return to surgery for treatment with or without revision and mandates that we “see it before it sees us!” Cerclage wiring with looped Luque wires has been our treatment of choice for many years. Wires are significantly less expensive than cables and have proven to be durable in our series. They allow intraoperative repositioning and variable tightening in multiple locations. Cable fretting and breakage has been common in our experience with braided cable devices. Acetabular fracture during uncemented THA is most likely an under-reported occurrence and has been associated with elliptical component designs and under-reaming. In the presence of a stable cup, long-term performance has been acceptable

We report an intertrochanteric fracture in a patient who had undergone hip arthrodesis 30 years previously. A 53-year-old man was injured in a head-on car crash and was referred to our hospital for treatment. Plain radiographs showed an intertrochanteric fracture of the right proximal femur and deformity of the right hip joint. He had undergone hip arthrodesis surgery 30 years previously at another hospital. Computed tomography scan showed marked atrophy of the gluteus and iliopsoas muscles. He preferred undergoing total hip arthroplasty (THA) to internal fixation. THA was performed using the anterolateral approach with the patient in the supine position as he had undergone hip arthrodesis through the Smith–Petersen approach, and we were concerned about damaging the gluteus muscle and dislocation if we took the posterolateral approach. The femoral head was removed using curved chisels under fluoroscopy. A cementless THA (J Taper stem, Aquala polyethylene liner; Kyocera Medical Corporation, Osaka, Japan) was inserted and fixed appropriately. Full weight-bearing using a walking frame was allowed 2 weeks after the surgery. Six months after the operation, he was able to walk independently and had good range of movement of the hip joint but continued to have weakness in the abductor muscles. Very few cases of proximal femur fracture in a previously arthrodesed hip have been reported. Manzotti et al. reported a similar case but they performed open reduction and internal fixation. No previous reports in the literature describe THA for intertrochanteric fracture in an arthrodesed hip. The conversion of an arthrodesed hip to THA is technically challenging. It has a high risk of complications such as nerve injuries and hip instability. We were able to treat the patient successfully, but surgeons should carefully decide the treatment method depending on the case

“Like other craftsmen, we have often two ways at least of doing the same job, the success of which is dependent upon the character and the integrity of the man. “Approaches” are for us both physical and psychological: in the case of the hip joint it seems clear that there is more than one good method and that, for the sake of those we train, we should keep an open mind.”. Norman A. Capener, 1950. Orientation relative to the abductor musculature and ease of access to the pathology in question should provide the compelling basis for selection of operative approaches to the hip, rather than being based solely on surgeon habit. Approaches to primary total hip arthroplasty remain the surgeon's choice; posterior approaches provide challenges to cup orientation and anterior approaches offer more difficult access to the proximal femur. Imperatives for a decubitus position posterior approach include pelvic dissociation with need for posterior column plating, removal of retained posterior hardware, and sciatic neurolysis after prior injury. Conversely, indications for a supine anterolateral approach include an isolated acetabular revision with a well-fixed femoral stem and the need for retroperitoneal removal of an intrapelvic acetabular component. Transgluteal approaches inflict potentially the greatest damage to the abductor musculature and are best reserved for primary operative settings; stability of a femoral endoprosthesis is optimised through this approach by preserving the posterior capsular structures. The transtrochanteric approach provides unrivaled exposure to both pelvis and acetabulum from either a supine or decubitus position, and is most helpful for removal of long well-fixed femoral stems whether cemented or cementless

Introduction. Failed operated intertrochanteric fractures (with screw cutout, joint penetration, varus collapse, nonunion, or femoral head avascular necrosis) pose treatment dilemmas. The ideal approach is re-osteosynthesis with autologous bone grafting. When the femoral head is unsalvageable, conversion to a prosthetic hip replacement is necessary. Materials/Methods. Thirty-seven patients with failed dynamic hip screw fixation (and unsalvageable femoral heads) were treated with cementless hip arthroplasty (13 underwent Bipolar Arthroplasty, 24 had Total Hip Arthroplasty) over a 5-year period (Dec 2005 to Nov 2010). Seven needed a modified trochanteric split, and the rest were managed by standard anterolateral approach. Abductor mechanism was reconstructed using strong nonabsorbable sutures (ethibond 5) or stainless steel wires. The calcar was partially reconstructed using remnant femoral head and cerclage wiring in a few cases. Results. Clinico-radiological assessment was done at three, six, 12 months and yearly thereafter over an average 36 months (range, three to 60 months). Stem loosening, lysis, subsidence and trochanteric union were studied. At last follow-up, one patient had died, and there were two instances each of stem subsidence and trochanteric nonunion. Clinical results using Harris hip scores were good or excellent. Conclusion. Management of nonsalvageable femoral heads after failed intertrochanteric fracture fixation is possible with cementless hip arthroplasty. Successful outcomes depend on functional abductor reconstruction, fracture and femoral shaft penetration prevention. Autograft, allograft or head/neck replacement components are necessary sometimes

Aims

To examine the long-term outcome of arthrodesis of the hip undertaken in a paediatric population in treating painful arthritis of the hip. In our patient population, most of whom live rurally in hilly terrain and have limited healthcare access and resources, hip arthrodesis has been an important surgical option for the monoarticular painful hip in a child.

Aims

Proper preoperative planning benefits fracture reduction, fixation, and stability in tibial plateau fracture surgery. We developed and clinically implemented a novel workflow for 3D surgical planning including patient-specific drilling guides in tibial plateau fracture surgery.

Protrusio acetabuli can be either primary or secondary. Primary or idiopathic protrusio is a rare condition of unknown etiology. Secondary protrusio may be associated with rheumatoid arthritis, ankylosing spondylitis, osteoarthritis, osteomalacia, trauma and Paget's disease. Challenges in surgery include lack of bone stock, deficient medial support to the cup, difficulty in dislocating the femoral head, and medialisation of the hip joint center. Several surgical techniques have been described: use of cement alone without bone graft; morsellised impacted autograft or allograft with a cemented cup; metal cages, reinforcement rings, and solid grafts. We describe our technique of impaction grafting using autologous bone and a cementless porous-coated hemispherical cup without the use of acetabular rings or cages in patients with an average age of 46 years. Protrusion was graded depending on distance of medial wall from Kohler's line as mild (1–5mm medial), moderate (6–15mm medial) and severe if it was more than 15mm medial to the Kohler's line. All patients were operated in the lateral position using a modified Hardinge's anterolateral approach. Adductor tenotomy may be required in cases of severely stiff hips. After careful dislocation of the femoral head, it was sectioned in situ into slivers to facilitate obtaining the graft. The periphery was reamed and care was taken to preserve the membrane lining the floor of the defect. Morsellised graft was impacted with hemispherical impactors and the trial cup 1–2mm larger than the last reamer placed in the desired position. The final socket was then inserted. Femoral preparation was performed in routine fashion. The mean preoperative Harris hip score of 52 improved to 85 points at a mean follow up of 4 years. The average acetabular inclination angle was 42 degrees. Our results have shown incorporation of the graft in all cases. There was no evidence of progression of the protrusio or cup loosening in any of the cases. Thus far, our hips have not shown osteolytic lesions. The technique described is a satisfactory biological solution of restoring bone stock particularly in young and middle-aged patients

Aims

Surgical approaches that claim to be minimally invasive, such as the direct anterior approach (DAA), are reported to have a clinical advantage, but are technically challenging and may create more injury to the soft-tissues during joint exposure. Our aim was to quantify the effect of soft-tissue releases on the joint torque and femoral mobility during joint exposure for hip resurfacing performed via the DAA.

Bilateral posterior interosseous nerve palsy in a rheumatoid patient is described. Six previous case reports and our experience indicate that steroid injection into the elbow may not produce lasting recovery and may lead to unacceptable delay before surgical decompression. An anterolateral approach for division of the arcade of Frohse is effective in cases with diffuse synovitis; where there is a local cystic swelling a posterolateral approach provides better access. Good recovery of nerve function can be expected after early operation

The two commonest types of hemiarthroplasty used for the treatment of a displaced intracapsular fracture are the uncemented Austin Moore Prosthesis and cemented Thompson hemiarthroplasty. To determine if any difference in outcome exists between these implants we undertook a prospective randomised controlled trial of 300 patients with a displaced intracapsular hip fractures. All operations were performed or supervised by one orthopaedic surgeon and all by a standard anterolateral approach. Patients were followed by a nurse blinded in the type of prosthesis to assess residual pain and mobility. The average age of the patients was 83 years and 23% were male. 73% came from their own home with the remainder from institutional care. There was no statistically significant difference in mortality between groups, with 34/151 having died at one year in the cemented group and 45/149 in the uncemented group. Pain scores (grade 1-6) were less for those treated by a cemented prosthesis (mean score 1.8 versus 2.4, p value <0.00001). Mobility change was also less for those treated with a cemented implant (p=0002). No difference was found in hospital stay. Operative complications are as listed. One case of non-fatal intraoperative cardiac arrest occurred in the cemented group. In summary a cemented Thompson Hemiarthroplasty causes less pain and less deterioration in mobility compared to uncemented Austin Moore hemiarthroplasty, without any increase in complications. The continued use of an uncemented Austin Moore cannot be recommended

Trans-articular coronal shear fractures of the distal humerus pose a significant challenge to the surgeon in obtaining an anatomical reduction and rigid fixation and thereby return of good function. A variety of approaches have been described which include the extended lateral and anterolateral approaches and arthroscopically-assisted fixation for non-comminuted fractures. Fixation methods include open or percutaneous cannulated screws and headless compression screws directed either anterior to posterior or posterior to anterior. We describe an illustrated, novel approach to this fracture which is minimally invasive but enables an anatomical reduction to be achieved. A 15 year old male presented with a Bryan and Morrey type 4 fracture as described by McKee involving the left distal humerus. He was placed in a lateral position with the elbow over a support. A posterior longitudinal incision and a 6cm triceps split from the tip of the olecranon was made. The olecranon fossa was exposed and a fenestration made with a 2.5mm drill and nibblers as in the OK (Outerbridge-Kashiwagi) procedure. A bone lever was then passed though the fenestration and used to reduce the capitellar and trochlear fracture fragments into an anatomical position with use of an image intensifier to confirm reduction. The fracture was then fixed with two headless compression screws from posterior to anterior into the capitellar and trochlear fragments (see images). Early mobilisation and rehabilitation were commenced. Follow-up clinical examination and radiographs at six weeks revealed excellent range-of-motion and function with anatomical bony union. We believe that this novel approach to this fracture reduces the amount of soft tissue dissection associated with conventional approaches and their associated risks and also enables earlier return to function with restoration of anatomy

A review of the first two hundred and ten patients undergoing Birmingham hip re-surfacing between January 2003 and June 2005 was performed. All surgeries were performed by a single consultant orthopaedic surgeon. All resurfacings were carried out utilising the antero-lateral approach to the hip. Mean review post-operatively was at six weeks. The following clinical parameters were evaluated: length of in-hospital patient stay, intra-operative blood loss and post-operative range of joint movement. In addition, the following radiological measurements were made: the acetabular inclination angle, the head-shaft angle and evidence of leg-length discrepancy. One patient experienced fracture of the femoral neck and two other patients underwent revision surgery. Our results demonstrate that the anterolateral approach represents an alternative approach, with short-term results comaprible to the posterior approach for hip resurfacing

The authors modified the original minimally invasive (MI) two-incision total hip arthroplasty (THA) technique and used large-diameter (32mm, 36mm) ceramic-on-ceramic articulation. One hundred and seventy patients that underwent unilateral MI two-incision THA retrospectively reviewed, and surgical morbidities, functional recoveries, radiological implantation properties, and complications were assessed. The mean follow-up was 30.2 months (range, 24-42 months) and mean patient age was 50.4 years (range, 22-83 years). In the lateral position, an anterolateral approach between the gluteus medius and tensor fascia lata and a posterior approach between the piriformis and gluteus medius was used. Mean operation time was 71.2 minutes (range, 48-91 minutes). Mean Harris hip score improved from 41.8 (range, 10-59) to 96.1 (range, 73-100) at last follow-up, and mean WOMAC score from 66.2 (range, 49-96) to 26.9 (range, 24-39). The mean lateral opening angle of the acetabular component was 38.2° (range, 32.1°-47.7°) and the mean stem position was valgus 1.9° (range, varus 2.3° to valgus 4.8°). One patient suffered an intraoperative femur fracture and another underwent revision surgery due to stem subsidence. No patient experienced dislocation. Our data suggest the this modified technique is safe and reproducible in terms of achieving proper implant positioning and early functional recovery. In particular, the complication rates encountered, especially the dislocation rate, were low

Purpose. Hip arthroplasty is a good treatment option for displaced femoral neck fracture in elderly patients. However, neuromuscular disease such as cerebral infarction or hemorrhage can be a concerning problem for THA since dislocation after operation can frequently occur. The purpose of this prospective study was to evaluate the functional results of modified minimally invasive (MI) two-incision total hip arthroplasty (THA) with the use of large-diameter (>38mm) metal-on-metal articulation in patients with muscle weakness. Patients and Methods. 19 consecutive patients (19 hips) with displaced femoral neck fracture with muscle weakness were enrolled. There were 11 patients with cerebral infarction, 4 patients with cerebral hemorrhage and 4 patients with Parkinson's disease. In the lateral position, an anterolateral approach between the gluteus medius and tensor fascia lata and a posterior approach between the piriformis and gluteus medius were used. Surgical morbidity, functional recovery, radiological implantation properties, range of motion (ROM) and complications were assessed. Results. The mean operation time was 73.5 minutes and the average perioperative blood loss was 725.9cc. The mean head diameter used was 44 mm (38–50). The mean lateral opening angle of the acetabular component was 38.4°, the mean anteversion of the acetabular component was 16.4°, and the mean stem position was 0.3° valgus. The average postoperative ambulation time was 2.4 days. The mean Harris hip score was 81.0 at final follow-up, and the mean WOMAC score was 42.9. At final follow-up, there was no case of dislocation. There was no hypersensitivity, no osteolysis, and no revision. Conclusions. Our study suggests that the functional results of modified MI two-incision THA with the use of large-diameter metal on metal articulation in patients with muscle weakness can produce satisfactory early functional recovery and can reduce the dislocation rate

Introduction. Varus positioning of cemented ‘composite beam’ stems is associated with increased risks of aseptic loosening and stem fracture. We investigated whether the incidence of varus malalignment of the Exeter polished, double taper design in a multicentre prospective study adversely affected outcome after total hip replacement (THR). Materials & Methods. A multicentre prospective study of 1189 THR was undertaken to investigate whether there is an association between surgical outcome and femoral stem malalignment. The primary outcome measure was the change in the Oxford hip score (OHS) at five years. Secondary outcomes included the rate of dislocation and revision, stem subsidence, quality of cementing. 938 (79.89%) were followed-up at five years. Results. 44 from a total of 1189 femoral stems (3.7%) were implanted in varus (=5° to the femoral axis). Pre-operative demographics and OHS were similar in both groups (p>0.05). Varus implantation was commoner after posterior than anterolateral approach (p< 0.001). Differences in the presence of femoral radiolucency, stem subsidence and quality of cement mantle were not significantly different (p>0.05). There was no difference in absolute OHS or OHS gain between the groups (neutral, mean = 40; varus, mean 40, p = 0.45, OHS gain neutral: 24, varus: 23, p=0.46). Differences in dislocation (p=0.54) or revision rates (p=0.35) were not significant. Conclusion. This study provides evidence that the Exeter stem may be tolerant of varus malalignment, both in terms of patient reported outcome and complication rate up to five years following surgery. Establishing whether aseptic loosening will be more common in the varus group will require longer follow-up

Protrusio acetabuli can be either primary or secondary. Primary or idiopathic protrusio is a rare condition of unknown etiology. Secondary protrusio may be associated with Rheumatoid Arthritis, Ankylosing spondylitis, osteoarthritis, osteomalacia, trauma and Paget's disease. Challenges in surgery include lack of bone stock, deficient medial support to the cup, difficulty in dislocating the femoral head, and medialisation of the hip joint centre. Several surgical techniques have been described: use of cement alone without bone graft; morsellised impacted autograft or allograft with a cemented cup; metal cages, reinforcement rings, and solid grafts. We describe our technique of impaction grafting using autologous bone and a cementless porous-coated hemispherical cup without the use of acetabular rings or cages in patients with an average age of 46 years. Protrusion was graded depending on distance of medial wall from Kohler's line as mild (1–5 mm medial), moderate (6–15 mm medial) and severe if it was more than 15 mm medial to the Kohler's line. All patients were operated in the lateral position using a modified Hardinge's anterolateral approach. Adductor tenotomy may be required in cases of severely stiff hips. After careful dislocation of the femoral head, it was sectioned in situ into slivers to facilitate obtaining the graft. The periphery was reamed and care was taken to preserve the membrane lining the floor of the defect. Morsellised graft was impacted with hemispherical impactors and the trial cup 1–2 mm larger than the last reamer placed in the desired position. The final socket was then inserted. Femoral preparation was performed in routine fashion. The mean pre-operative Harris hip score of 52 improved to 85 points at a mean follow up of 4 years. The average acetabular inclination angle was 42 degrees. Our results have shown incorporation of the graft in all cases. There was no evidence of progression of the protrusio or cup loosening in any of the cases. Thus far, our hips have not shown osteolytic lesions. The technique described is a satisfactory biological solution of restoring bone stock particularly in young and middle-aged patients

Background Context. Different minimally invasive approaches to the lumbar spine have been proposed but they can be associated with increased risk of complications, steep learning curve and longer operative time. Purpose. To report the complications associated with a minimally invasive technique of retroperitoneal anterolateral approach to the lumbar spine. Study design. Retrospective study of 179 patients who underwent anterior oblique lumbar interbody fusion (OLIF). Methods. A total of 179 patients with previous posterior instrumented fusion undergoing OLIF were included. This muscle-splitting approach consists in anterolateral exposure through a 4 cm incision followed by placement of a PEEK cage filled with bone graft and/or substitute. Results. Patients were aged 54.110.6 years with BMI of 24.84.1 kg/m2. Length of follow-up was (0.90.7 years), including 17 patients with a minimum follow-up of 2 years. A left-sided approach was done in 174 patients. The procedure was performed at L1–2 in 4, L2–3 in 54, L3–4 in 120, L4–5 in 134 and L5-S1 in 6 patients. It was done at 1 level in 56, 2 levels in 107, and 3 levels in 16 patients. Operative time and blood loss were respectively 32.513.2 min and 57131 cc per level fused. There were 19 patients with single complication and one with two complications, including two patients with postoperative radiculopathy after L3–5 OLIF. There was no abdominal weakness or herniation. Conclusion. Minimally invasive OLIF can be performed easily and safely from L2 to L5, and at L1–2 and L5-S1 for selected cases. Up to 3 levels can be addressed through a “sliding window”. It is associated with minimal blood loss and short operative time. The risk of complications is similar to that reported for traditional anterior approaches, with the advantage of decreasing the risk of abdominal wall weakness or herniation

Background:. The Rejuvenate modular neck stem (Stryker, Mahwah, NJ) was recently recalled due to corrosion at the neck-stem junction. The purpose of this study was to investigate the rate of corrosion related failures and survivorship of this implant, and analyze the correlation between the implant and patient factors with serum metal ion levels. Material and Methods:. Between June 2009 and July 2012, 123 Rejuvenate stems (97 modular and 26 non-modular) THAs were implanted in 104 patients by a single surgeon via a modified anterolateral approach. Serum Cobalt (Co) and Chromium (Cr) levels (microgram per liter [μg/L]) were obtained in all patients. In cases of elevated serum metal ion levels or symptomatic hip, patients underwent magnetic resonance imaging (MRI) for assessment of osteolysis or adverse local tissue reactions (ALTR). Correlation between implant factors (implant size, head size, head length, offset), patient factors (age, gender, BMI) with serum metal ion levels and revisions were analyzed using logistic regression models. Results:. The mean follow-up was 2.7 ± 0.6 years. The mean Co and Cr levels were 5.4 ± 5.7 μg/L (0.2–31) and 2.1 ± 1.5 μg/L (0.1–4.3), respectively. The differences between the Co and Cr levels in the two groups were statistically significant. 49% of THAs in the modular group had elevated metal ion levels (> 4.0 μg/L). There was a significant correlation between higher metal ion levels, younger age, and higher offset (p < 0.05). Presence of pain and high cobalt levels were significant predictors for revision surgery. The rate of revision at the time of this study was 26%, the majority were in the 2. nd. year after surgery. The Kaplan-Meier survivorship was 75% at the time of this study. Discussion and Conclusions:. The short-term high rate of corrosion related revision with Rejuvenate modular neck stems is extremely alarming. We anticipate more revisions in the near future. Level of Evidence: Level III, Therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence

Background: Abductor failure after total hip arthroplasty is a rare but debilitating problem. The diagnosis is difficult, and when recognized, there are few successful treatment options. The purpose of this study is to review our experience with a new surgical technique using fresh-frozen Achilles tendon allograft with an attached calcaneal bone graft to reconstruct a deficient abductor mechanism after total hip arthroplasty. Methods: From 2003 to 2006, we performed seven abductor reconstructions with Achilles tendon allograft for patients with abductor deficiency after total hip arthroplasty. Four patients had a prior posterior approach and three had a prior anterolateral approach. At a mean of 29 months from index procedure, all seven patients suffered from symptoms of lateral hip pain and abductor weakness as documented by positive Trendelenburg sign, limp, and limited motor strength with side-lying abduction. Hip arthrograms were obtained in five of seven patients. Results: The average pre-reconstruction Harris Hip Score was 34.7 and average pain score was 11.4. All five hip arthrograms showed extravasation of dye over the greater trochanter, confirming the diagnosis of a bald greater trochanter and massive abductor loss found at time of surgery. At a minimum 24 month follow-up and an average follow-up of 31 months, the post-reconstruction Harris Hip Score was 85.9 and the average pain score was 38.9. Conclusions: Abductor reconstruction with Achilles tendon allograft using calcaneal bone block fastened to the greater trochanter has offered significant relief of pain and improvement in function at early follow-up in this series of patients

Hip resurfacing is a relatively new concept in hip arthroplasty, but is being performed more frequently in the United Kingdom. We compared anteroposterior radiographs of 30 patients who had undergone cemented hip resurfacing (Cormet) with those of 30 patients who had undergone uncemented hip resurfacing (Cormet). All operations were performed using the anterolateral approach. We measured the acetabular offset, femoral offset, stem shaft angle, medialisation of the cup, head/neck ratio, cup height, leg length, and the implant seating pre-operatively, immediately postoperatively and one year postoperatively. The data were analysed by paired t-tests. There were no significant differences between any of the measurements at all three time periods. This demonstrates no loss of offset, no femoral neck thinning and no leg length reduction. We note a smaller femoral offset and a reduction on average of 2mm in seating of the femoral implant in the uncemented group as compared to the cemented group. This we attribute to movement of the femoral implant in the first year post-operatively, and as such restoration of the femoral offset to the pre-operative level. We conclude that uncemented hip resurfacing does not show any statistical benefit over cemented hip resurfacing, although we did observe a more accurate reproducible femoral offset with better seating of the implant in the uncemented group. We also note that there was no neck thinning in any of these patients at one year post-operatively

Two of commonest types of hemiarthroplasty used for the treatment of a displaced intracapsular fracture are the uncemented Austin Moore Prosthesis and cemented Thompson hemiarthroplasty. We performed this trial to determine if any difference in outcome exist between these implants. We undertook a prospective randomised controlled trial of four hundred patients with a displaced intra-capsular hip fracture. All operations were performed or supervised by one orthopaedic surgeon and all by a standard anterolateral approach. Patients were followed by a nurse blinded in the type of prosthesis to assess residual pain and mobility. The average age of the patients was eighty-three years and 23% were male. 73% came from their own home with the remainder from institutional care. There was no statistically significant difference in mortality between groups. Pain scores were less for those treated by a cemented prosthesis (p value < 0.00001). Mobility change was also less for those treated with a cemented implant (p=0002). No difference was found in hospital stay, implant related complications, re-operations or post-operative medical complications between the two groups. One case of non-fatal intraoperative cardiac arrest occurred in the cemented group. In summary a cemented Thompson Hemiarthroplasty causes less pain and less deterioration in mobility compared to the uncemented Austin Moore hemiarthroplasty, without any increase in complications. The continued use of an uncemented Austin Moore cannot be recommended

Introduction: We perform MIS since 2004 and have done 1257 THR (SL-Plus stem and since 2005 SL MIA stem with a modification in the proximal part). The operation is performed with the anterolateral approach in supine position under direct view with visible landmarks. Material and Methods: Till know we implanted 357 THR with the new designed stem and the BICON threaded cup. A precise preoperative planning for implant size, neck length and offset is obligatory and is performed with manuel templanting or digital planning on AP X-ray in standing position. We evaluated used sizes of standard and offset stems and cups, neck length, material of bearing surfaces and on the AP X-ray postoperative in standing position the inclination and anteversion angle of the cup as well as the stem position, postoperative leg length and Trendelenburg sign. Results: According to the preoperative templating we used offset stems in 30%. of our patients. The neck length small in 14%, medium in 46%, large in 40%. The range of cup inclination angle was in safe zone with an average of 45,8°, neutral stem position in 92,2%. Leg length equal in 73% and lengthening or shortening +/−in average 8,4mm and 6,5 mm. The Trendelenburg sign was negativ in 93% at the time of removal of skin sutures. Conculsion: The requirement for precise positioning of implant, leg length and muscular function are full-filled with our minimal invasive technique. Also more demanding bearing couples as CC are not at risk