Aims

The most effective surgical approach for total hip arthroplasty (THA) remains controversial. The direct anterior approach may be associated with a reduced risk of dislocation, faster recovery, reduced pain and fewer surgical complications. This systematic review aims to evaluate the current evidence for the use of this approach in THA.

Introduction. Total hip arthroplasty (THA) is undertaken to relieve pain and to restore mobility. The orthopaedic community remains divided on the influence of surgical approach in achieving functional recovery most quickly and effectively. We report a study comparing THA performed through a posterior (Posterior) against anterior approach (Heuter). Methods. Fifty patients were prospectively enrolled and randomized for Posterior or Heuter procedures. Informed patient consent and local ethics approval was obtained. All patients received an uncemented, ceramic-on-ceramic prosthesis performed by a single surgeon. Functional outcome was assessed by time to achieve milestones of walking, stair climbing, hip movement and balance. Kinematic data on level-ground walking and the effect of fatigue was assessed using a portable gait analysis system at 6-, 12-, and 24-weeks post-operatively. Results. The Heuter group showed significantly quicker balance control, on average 10 days earlier, than the posterior group (p< 0.05). The achievement of the other milestones of independent and distance walking, stair climbing and hip movement also showed quicker recovery overall in the Heuter group; this was, however, not statistically significant (p>0.05). Kinematic data suggested that there were no statistical differences in stance phase stability (p=0.73) or pulling acceleration (p=0.77) between the 2 groups at each time point. Fatigue, effected via timed, gentle mobilisation on a treadmill, also did not significantly result in a difference. Discussion. The Heuter approach is rarely used in the UK, although its recent resurgence can be attributed to its perceived theoretical benefit of sparing muscle; this contrasts with the detachment of muscle required for the Posterior approach. Our experience show that the Heuter approach does not compromise the quality of gait, and it offers advantages in the rate of functional recovery, especially that of balance control

Introduction: There have been several recent studies outlining the role of femoroacetabular impingement (FAI) as a cause of early osteoarthritis in the non-dysplastic hip. The lesions can either be on the femoral side “cam” or acetabular “pincer”. The aim of surgical treatment of FAI is to improve the femoral head neck offset thereby improving joint clearance and preventing abutment of the femoral neck against the acetabulum. The classic treatment for FAI pioneered by Ganz involves dislocation of the femoral head through a trochanteric flip osteotomy. The procedure is extensive, technically difficult and not without complications. Hip arthroscopic debridement of FAI lesions offers similar results to open procedures allowing for full inspection of the joint and the treatment of any chondral lesion but with a quicker recovery time. It nonetheless has a very long learning curve and even in the most experienced hands the treatment of impingement lesions is complicated and technically challenging. The purpose of this cadaveric study was to assess the degree of exposure obtained using two different limited anterior approaches to the hip which would allow effective surgical treatment of cam and pincer FAI. Methods: We investigated two mini anterior approaches to the hip joint based on the Heuter and direct anterior approach to compare the parts of the acetabulum and femoral head exposed for the treatment of FAI in a total of 20 hips in 10 (5 male, 5 female) cadaveric specimens. Neurovascular structures were recorded in relation to the two approaches. The area of femoral head and acetabular rim exposed via each approach was documented and quantified. Results: We found that the two approaches were easy and reproducible. Both allowed exposure to the anterolateral aspect of the femoral head. The mean length of acetabular rim accessible via the Heuter approach was 1.9cm (1.1–2.4) and 2.2cm (1.2–3) using the direct anterior approach The area of acetabular rim accessible varied according to the approach (p< 0.001). We also found that the position of the anterior inferior iliac spine in relation to the acetabular rim also affected the area of acetabular rim exposed (p< 0.001). The most proximal nerve branch to sartorious was found 7.3cm (6.5–8.7cm) distal to the anterior inferior iliac spine. The most proximal nerve branch to rectus femoris was located 8.6cm (7–10) distal to the anterior inferior iliac spine and was consistently found to be distal to the nerve to sartorious. Discussion: Treating impingement of the hip through a direct open approach is not a novel idea. A recent report of failed arthroscopic labral debridement, describes treatment of the underlying bony impingement in some cases by a combination of hip arthroscopy followed by anterior arthrotomy. In summary cam and pincer impingement of the hip can be treated by either the direct anterior or Heuter approach. The choice of approach would be dictated after careful consideration as to which portion of the anterior acetabular rim required surgery, with more lateral acetabular lesions being favoured by the Heuter approach and more medial impingement sites by the anterior approach we have described

Purpose: The surgical approach is an essential element for precise reduction and rigid fixation of fractures of the acetabulum. In cases where the anterior column is mainly involved and total hip arthroplasty (THA) is indicated, classical approaches do not allow double assess to the anterior column necessary for reduction and fixation and to the femoral canal for insertion of the prosthesis. Combining Heuter’s anterior approach and Letournel’s ilio-femoral approach provides access to the anterior column and to the often associated posterior hemi-transverse fracture, while allowing insertion of the total hip prosthesis. Material and method: This combined approach was used for ten among 60 THA performed for fracture of the acetabulum. Seven were primary procedures and three were differed reconstruction procedures. Mean patient age was 60.6 years (range 50 – 85 years). Fracture types were: acetabular wall and anterior column (n=8), anterior column and posterior hemi-transverse (n=2). All fresh fractures exhibited major acetabular damage associated with fracture of the femoral neck. A hybrid THA was used for all cases after fixation of the fracture. The femoral heads were used as graft material for deficient anterior columns in two patients and as “piecemeal” grafts for the others. Results: Mean follow-up was 36 months (range 24–35 months). At last follow-up all fractures had healed and all acetabular components exhibited solid fixation with no sign of migration. The mean outer diameter of the ace-tabular components inserted was 56 mm (52–64) using a 2 mm press-fit and one screw. The only complication was one postoperative anterior dislocation. Pain relief and function were satisfactory in all patients at last follow-up with a Postel Merle d’Aubigné score of 16 (13–18). Discussion: This anterior surgical approach enables good access to the acetabular walls and anterior columns, allowing solid fixation and relatively easy THA. The Kocher-Langenbech approach is still better in case of posterior deficiency or when posterior fixation requires space for inserting an acetabular component. We reserve it for THA used to treat fresh fractures of the acetabulum with major damage to the acetabulum and/or the femoral head, with or without neck fracture in patients aged 55 years or more. For differed reconstruction, we also use this approach if the acetabular damage involves the anterior column

Aims

It has been suggested that the direct anterior approach (DAA) should be used for total hip arthroplasty (THA) instead of the posterior approach (PA) for better early functional outcomes. We conducted a value-based analysis of the functional outcome and associated perioperative costs, to determine which surgical approach gives the better short-term outcomes and lower costs.

Aims

We assessed the difference in hospital based and early clinical outcomes between the direct anterior approach and the posterior approach in patients who undergo total hip arthroplasty (THA).

Guiding growth by harnessing the ability of growing bone to undergo plastic deformation is one of the oldest orthopaedic principles. Correction of deformity remains a major part of the workload for paediatric orthopaedic surgeons and recently, along with developments in limb reconstruction and computer-directed frame correction, there has been renewed interest in surgical methods of physeal manipulation or ‘guided growth’. Manipulating natural bone growth to correct a deformity is appealing, as it allows gradual correction by non- or minimally invasive methods.

This paper reviews the techniques employed for guided growth in current orthopaedic practice, including the basic science and recent advances underlying mechanical physeal manipulation of both healthy and pathological physes.