Introduction

Dissemination of Total hip Arthroplasty through the direct anterior approach has, depending upon one's experience and perspective, benefitted from or been plagued by aggressive marketing. Although first developed over 60 years ago it was all but unknown until the past decade. This study exams one community surgeon's experience and thus sheds light on whether the ATHA is a viable operation for all orthopaedic surgeons.

Introduction: It has been stated that less invasive total hip arthroplasty requires patient selection to lessen complications and to promote a successful outcome. However, it is unknown if certain patients risk an increase in complications, or if unselected patients benefit from these operations. This prospective study addresses these questions.

Methods: Two patient groups, from a larger series, were studied: BMI over 30 (71 patients); Age over 80 (41 patients). The average BMI was 34 (highest 46); the average age, 84 (oldest 91). A single incision direct anterior approach was used universally. At regular follow-up WOMAC, Charnley modified Merle D’Aubigne, Harris Hip Scores and x-rays were obtained.

RESULT: Hip Scores showed significant improvement (p = 0.001 for each), component positioning was reproducible; length of hospital stay and return to full function were acceptable. However, compared to non-obese, younger patients having the same operation, the very elderly were less likely to go directly home (45% compared to 80% overall), the risk of medical complications was increased for these patients (4% of the obese and 6% of the elderly); and there was a disproportionately high incidence of mechanical complications (6% for the obese; 2.5% for the elderly).

Discussion: These data indicate that lesser invasive hip arthroplasty using a single incision anterior approach can benefit obese and elderly patients. However, the incidence of complications may be elevated. Information derived from a selected MIS series should be considered sceptically before applying it to our practices.

Introduction: Less invasive hip arthroplasty has been promoted since 2002 but with few reports having follow-up data. Existing information is often from developer-surgeons, selecting patients and investigating only the immediate post-operative course. More complete and less biased information is needed.

Methods: This prospective series, 275 hips done consecutively beginning April 2003, by a single surgeon using the direct anterior approach first described by Robert Judet, is entirely unselected: 31% obese, 16% over 80, but 22% Charnley category A. Follow-up is at least 2 years. Standardized hip scores and radiographic measurements were obtained regularly.

Result: Nine re-operations (3.5%) were required: 2 infections (0.8%), 6 component failures (2%) and 2 superficial wound infections (1%). There were 3 dislocations (1.2%). Charnley Merle d’Aubigne, WOMAC and Harris Hip Scores improved significantly (p=0.001 for each) and component positioning was reproducible. Over 80% of these patients were discharged directly home after an average length of stay 2.2 days. Walking without assistance averaged 4 weeks; return to work 6 weeks. Surgical time and hospital stay decreased significantly during the time of study (p = 0.001 for each).

Discussion: Given the excellent result from conventional hip arthroplasty, a change in technique might, at best, slightly benefit most patients at the risk of greatly harming a few. This report suggests that the single incision direct anterior approach is applicable to all THA patients, early recovery is acceptable, and a reasonable learning curve exists; but early complications may be increased when compared to the best experience using traditional approaches.

Aim: Bone loss in failed total knee arthroplasty can be managed by various techniques. This paper presents the ten year experience of one surgeon using morselized impacted allograft bone to revise failed knee replacements.

Method: Impacted bone was used in all knees having significant bone loss; no defects were replaced with augments or tumor replacement implants. Forty-eight knees having a minimum one year follow-up have been reconstructed. Maximum follow-up is ten years; the average time of follow-up is four years. Standard revision components were used in all except the first knee in this series. Except for two knees, monoblock LCS (J& J/DePuy) components were used. All knees received at least ninety cubic centimeters of bone graft. Nine knees were infected; eight were reconstructed in two stages and one in three stages.

Result: Two patients died and three were “lost” before one year follow-up could be obtained. There were four failures: two by component “spin-out”, one by fracture, and one by loosening. All failures have been satisfactorily reconstructed. None of the total knees revised for infection have failed. Histology obtained on the knees failing by fracture and loosening demonstrated viable, incorporated bone graft consistent with the findings of several authors retrieving impacted bone graft from hip reconstructions.

All patients ultimately benefited from the procedure. The average improvement in knee Society combined knee and function scores was over eighty-five points. The more functional patients experienced the most improvement.

Conclusion: This experience provides additional support for the use of impacted morselized allograft bone in reconstructing even large defects in failed knee arthroplasties.

Aims: To determine the feasibility and short-term outcome after Total Hip Arthroplasty through a limited anterior approach.

Methods: Done between April 2003 and August 2004, 100 patients (102 hips) requiring primary total hip arthroplasty comprise this study. A modification of the Smith-Peterson anterior approach developed by Robert Judet was used requiring a special fracture table (Pro-Fx, OSI) but no unique surgical instruments. A single incision was used; the natural interval between the sartorius and rectus muscles medially and the tensor muscle laterally was developed. SL-Plus stems and Plus-MPF or Encore cups were used in all cases.

This series is entirely unselected: no patients were excluded because of size or body habitus. One third of the patients had a Body Mass Index greater than 30 (obese); the maximum BMI was 45.6. One third had type C bone and nearly one tenth were category 3 anesthetic risks. Average age was 72 (range 39 to 90). A naive definition of “minimally invasive” is met: the average incision length was 9.5 centimeters (range 6.5 to 13).

Result: Time for the surgical procedure reduced from three and one half hours for the first arthroplasty to 70 minutes between the 15th and 20th operation. Previously, hospital stay averaged over 5 days using a conventional posterior approach; average stay with the “minimal” approach was less than 3 days. Only 20% of these patients required an intermediate care facility prior to returning home.

There have been three complications requiring readmission: 1 dislocation, 1 unstable acetabulum, and 1 superficial wound breakdown. There has been a total of 3 dislocations-all within 4 days of surgery, none recurrent. One DVT has been detected.

Conclusions: The early experience, “learning curve” and technical complications of the modified Smith-Peterson anterior approach are emphasized. Given the consistently reported 95% to 98% success rate of conventional hip arthroplasty it is imperative to make any change with foresight and then to document the consequence of that change. Surgical technique should not absolutely dictate implant choice. This report sheds light on the very early result of a change only to the surgical approach to total hip arthroplasty.

Clinical experience of the ICLH method of resurfacing the hip now spans 10 years. The first 36 arthroplasties, performed between 1972 and 1974, have been previously reported. This review covers in detail 204 such arthroplasties performed between 1975 and 1979 using a standard operative technique and prosthesis; these hips were consecutive and entirely unselected. Follow-up averaged 3.2 years (range two to six years). Successful hips are comparable to hips successfully replaced with stemmed prostheses. The rates of perioperative complications and failure due to infection, ectopic ossification, fracture of the femoral neck, and dislocation are favourably comparable to rates reported for stemmed total hip arthroplasties. The rate of aseptic loosening (17 per cent) greatly exceeded that found for stemmed total hip arthroplasties. Errors of patient selection, operative technique and prosthetic design have been identified. It is concluded that, although resurfacing arthroplasty of the hip may be an appealing procedure with theoretical advantages in certain instances, patient selection is essential, operative technique is demanding and changes in the design of the prosthesis are required. The procedure is still in evolution and therefore it should not yet be generally employed.

The occurrence of a radiolucent line at the interface of bone and cement in total joint prostheses is a frequently observed, although little understood, phenomenon. Because of an operative technique utilised in instances of bone loss, we have, within a single implant mass used in each of a series of 18 total knee replacements, been able to observe two separate interfaces, one between bone and cement and the other between bone and cobalt chrome. The average period of observation was 32 months. All of the knees except one demonstrated a lucency at the bone-cement interface; only one of the knees had a similar lucency at the bone-CoCr interface. One of the knees was studied histologically. In the light of the universal observation of macrophages at bone-cement interfaces and the recent finding that osteoclasts are derived from macrophages, these observations are significant in relation to the aetiology of bone-cement lucencies.