The primary objective of this study was to develop a validated classification system for assessing iatrogenic bone trauma and soft-tissue injury during total hip arthroplasty (THA). The secondary objective was to compare macroscopic bone trauma and soft-tissues injury in conventional THA (CO THA) versus robotic arm-assisted THA (RO THA) using this classification system. This study included 30 CO THAs versus 30 RO THAs performed by a single surgeon. Intraoperative photographs of the osseous acetabulum and periacetabular soft-tissues were obtained prior to implantation of the acetabular component, which were used to develop the proposed classification system. Interobserver and intraobserver variabilities of the proposed classification system were assessed.Aims
Methods
It is not known whether preservation of the capsule of the hip positively affects patient-reported outcome measures (PROMs) in total hip arthroplasty using the direct anterior approach (DAA-THA). A recent randomized controlled trial found no clinically significant difference at one year postoperatively. This study aimed to determine whether preservation of the anterolateral capsule and anatomical closure improve the outcome and revision rate, when compared with resection of the anterolateral capsule, at two years postoperatively. Two consecutive groups of patients whose operations were performed by the senior author were compared. The anterolateral capsule was resected in the first group of 430 patients between January 2012 and December 2014, and preserved and anatomically closed in the second group of 450 patients between July 2015 and December 2017. There were no other technical changes between the two groups. Patient characteristics, the Charlson Comorbidity Index (CCI), and surgical data were collected from our database. PROM questionnaires, consisting of the Oxford Hip Score (OHS) and Core Outcome Measures Index (COMI-Hip), were collected two years postoperatively. Data were analyzed with generalized multiple regression analysis.Aims
Methods
Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants. A total of 39 hip fusion conversions to THA were undertaken in 38 patients by a single surgeon employing a consistent surgical technique and uncemented implants. Parameters assessed included Harris Hip Score (HHS) for function, range of motion (ROM), leg length discrepancy (LLD), satisfaction, and use of walking aid. Radiographs were reviewed for loosening, subsidence, and heterotopic ossification (HO). Postoperative complications and implant survival were assessed.Aims
Methods
The purpose of this study was to compare the clinical, radiological, and patient-reported outcome measures (PROMs) in the first 100 consecutive patients undergoing total hip arthroplasty (THA) via a direct superior approach (DSA) with a matched group of patients undergoing THA by the same surgeon, using a posterolateral approach (PLA). This was a retrospective single surgeon study comparing the first 100 consecutive DSA THA patients with a matched group of patients using a standard PLA. Case notes were examined for patient demographics, length of hospital stay, operating time, intra- and postoperative complications, pain score, satisfaction score, and Oxford Hip Score (OHS). Leg length discrepancy and component positioning were measured from postoperative plain radiographs.Aims
Methods
Optimal exposure through the direct anterior approach (DAA) for total hip arthroplasty (THA) conducted on a regular operating theatre table is achieved with a standardized capsular releasing sequence in which the anterior capsule can be preserved or resected. We hypothesized that clinical outcomes and implant positioning would not be different in case a capsular sparing (CS) technique would be compared to capsular resection (CR). In this prospective trial, 219 hips in 190 patients were randomized to either the CS (n = 104) or CR (n = 115) cohort. In the CS cohort, a medial based anterior flap was created and sutured back in place at the end of the procedure. The anterior capsule was resected in the CR cohort. Primary outcome was defined as the difference in patient-reported outcome measures (PROMs) after one year. PROMs (Harris Hip Score (HHS), Hip disability and Osteoarthritis Outcome Score (HOOS), and Short Form 36 Item Health Survey (SF-36)) were collected preoperatively and one year postoperatively. Radiological parameters were analyzed to assess implant positioning and implant ingrowth. Adverse events were monitored.Aims
Methods
To establish whether there was a consensus among the members of the Hip Society (HS) on the role of direct anterior approach (DAA) contemporary primary total hip arthroplasty (THA). An online survey was sent to all 112 active and senior members of the HS, to which 71 members responded. The survey was constructed to determine whether they believed that evidence-based medicine proves, in modern clinical practice, that the DAA has significant benefits compared to risks when contrasted with other approaches. In addition, they were asked if they currently used the DAA.Aims
Methods
Whether patient-reported pain differs among surgical approaches in total hip arthroplasty (THA) remains unclear. This study’s purposes were to determine differences in pain based on surgical approach (direct anterior (DA) This was a retrospective investigation from two centres and seven surgeons (three DA, three PL, one both) of primary THAs. PL patients were categorized for incision length (6 cm to 8 cm, 8 cm to 12 cm, 12 cm to 15 cm). All patients had cementless femoral and acetabular fixation, at least one year’s follow-up, and well-fixed components. Patients completed a pain-drawing questionnaire identifying the location and intensity of pain on an anatomical diagram. Power analysis indicated 800 patients in each cohort for adequate power to detect a 4% difference in pain (alpha = 0.05, beta = 0.80).Aims
Patients and Methods
The aims of this study were to assess the exposure and preservation of the abductor mechanism during primary total hip arthroplasty (THA) using the posterior approach, and to evaluate gluteus maximus transfer to restore abductor function of chronically avulsed gluteus medius and minimus. A total of 519 patients (525 hips) underwent primary THA using the posterior approach, between 2009 and 2013. The patients were reviewed preoperatively and at two and five years postoperatively. Three patients had mild acute laceration of the gluteus medius caused by retraction. A total of 54 patients had mild chronic damage to the tendon (not caused by exposure), which was repaired with sutures through drill holes in the greater trochanter. A total of 41 patients had severe damage with major avulsion of the gluteus medius and minimus muscles, which was repaired with sutures through bone and a gluteus maximus flap transfer to the greater trochanter.Aims
Patients and Methods
Instability continues to be a troublesome complication after total hip arthroplasty (THA). Patient-related risk factors associated with a higher dislocation risk include the preoperative diagnosis, an age of 75 years or older, high body mass index (BMI), a history of alcohol abuse, and neurodegenerative diseases. The goal of this study was to assess the dislocation rate, radiographic outcomes, and complications of patients stratified as high-risk for dislocation who received a dual mobility (DM) bearing in a primary THA at a minimum follow-up of two years. We performed a retrospective review of a consecutive series of DM THA performed between 2010 and 2014 at our institution (Hospital for Special Surgery, New York, New York) by a single, high-volume orthopaedic surgeon employing a single prosthesis design (Anatomic Dual Mobility (ADM) Stryker, Mahwah, New Jersey). Patient medical records and radiographs were reviewed to confirm the type of implant used, to identify any preoperative risk factors for dislocation, and any complications. Radiographic analysis was performed to assess for signs of osteolysis or remodelling of the acetabulum.Aims
Materials and Methods
We conducted a prospective study of a delta ceramic total hip
arthroplasty (THA) to determine the rate of ceramic fracture, to
characterise post-operative noise, and to evaluate the mid-term
results and survivorship. Between March 2009 and March 2011, 274 patients (310 hips) underwent
cementless THA using a delta ceramic femoral head and liner. At
each follow-up, clinical and radiological outcomes were recorded.
A Kaplan-Meier analysis was undertaken to estimate survival.Aims
Patients and Methods
The aim of this study was to evaluate the long-term clinical
and radiographic outcomes of the Birmingham Interlocking Pelvic
Osteotomy (BIPO). In this prospective study, we report the mid- to long-term clinical
outcomes of the first 100 consecutive patients (116 hips; 88 in
women, 28 in men) undergoing BIPO, reflecting the surgeon’s learning
curve. Failure was defined as conversion to hip arthroplasty. The
mean age at operation was 31 years (7 to 57). Three patients (three
hips) were lost to follow-up.Aims
Patients and Methods
Modular or custom-made femoral components have been preferred
for total hip arthroplasty (THA) in patients with a history of Perthes’
disease because of the distortion in the anatomy of the proximal
femur. However, it has not been established whether a monobloc cementless
stem will fit the distorted proximal femur or whether the results
of the procedure are satisfactory in this group of patients. We reviewed 68 consecutive patients who had undergone THA for
childhood Perthes’ disease between June 2003 and December 2008.
There were 35 men and 33 women with a mean age of 48 years (16 to
73) at the time of index arthroplasty. Their mean body mass index
was 24.4 (18.3 to 32.9). Of the 68 hips, 32 were classified as Stulberg
class III and 36 as class IV. The mean pre-operative shortening
of the affected leg was 17.2 mm (5 to 34). The minimum follow-up
was five years (mean 8.5 years; 5.2 to 10).Aims
Patients and Methods
We wished to quantify the extent of soft-tissue damage sustained
during minimally invasive total hip arthroplasty through the direct
anterior (DA) and direct superior (DS) approaches. In eight cadavers, the DA approach was performed on one side,
and the DS approach on the other, a single brand of uncemented hip
prosthesis was implanted by two surgeons, considered expert in their
surgical approaches. Subsequent reflection of the gluteus maximus
allowed the extent of muscle and tendon damage to be measured and
the percentage damage to each anatomical structure to be calculated.Aims
Materials and Methods
We describe our technique and rationale using
hybrid fixation for primary total hip arthroplasty (THA) at the Hospital
for Special Surgery. Modern uncemented acetabular components have
few screw holes, or no holes, polished inner surfaces, improved
locking mechanisms, and maximised thickness and shell-liner conformity. Uncemented
sockets can be combined with highly cross-linked polyethylene liners,
which have demonstrated very low wear and osteolysis rates after
ten to 15 years of implantation. The results of cement fixation
with a smooth or polished surface finished stem have been excellent,
virtually eliminating complications seen with cementless fixation
like peri-operative femoral fractures and thigh pain. Although mid-term
results of modern cementless stems are encouraging, the long-term
data do not show reduced revision rates for cementless stems compared
with cemented smooth stems. In this paper we review the conduct
of a hybrid THA, with emphasis on pre-operative planning, surgical
technique, hypotensive epidural anaesthesia, and intra-operative
physiology. Cite this article:
Ideal placement of the acetabular component remains
elusive both in terms of defining and achieving a target. Our aim
is to help restore original anatomy by using the transverse acetabular
ligament (TAL) to control the height, depth and version of the component.
In the normal hip the TAL and labrum extend beyond the equator of
the femoral head and therefore, if the definitive acetabular component
is positioned such that it is cradled by and just deep to the plane
of the TAL and labrum and is no more than 4mm larger than the original
femoral head, the centre of the hip should be restored. If the face
of the component is positioned parallel to the TAL and psoas groove
the patient specific version should be restored. We still use the
TAL for controlling version in the dysplastic hip because we believe
that the TAL and labrum compensate for any underlying bony abnormality. The TAL should not be used as an aid to inclination. Worldwide,
>
75% of surgeons operate with the patient in the lateral decubitus
position and we have shown that errors in post-operative radiographic
inclination (RI) of >
50° are generally caused by errors in patient positioning.
Consequently, great care needs to be taken when positioning the
patient. We also recommend 35° of apparent operative inclination
(AOI) during surgery, as opposed to the traditional 45°. Cite this article:
This study investigates and defines the topographic
anatomy of the medial femoral circumflex artery (MFCA) terminal
branches supplying the femoral head (FH). Gross dissection of 14
fresh–frozen cadaveric hips was undertaken to determine the extra
and intracapsular course of the MFCA’s terminal branches. A constant
branch arising from the transverse MFCA (inferior retinacular artery;
IRA) penetrates the capsule at the level of the anteroinferior neck,
then courses obliquely within the fibrous prolongation of the capsule
wall (inferior retinacula of Weitbrecht), elevated from the neck,
to the posteroinferior femoral head–neck junction. This vessel has
a mean of five (three to nine) terminal branches, of which the majority
penetrate posteriorly. Branches from the ascending MFCA entered
the femoral capsular attachment posteriorly, running deep to the
synovium, through the neck, and terminating in two branches. The
deep MFCA penetrates the posterosuperior femoral capsular. Once
intracapsular, it divides into a mean of six (four to nine) terminal
branches running deep to the synovium, within the superior retinacula
of Weitbrecht of which 80% are posterior. Our study defines the
exact anatomical location of the vessels, arising from the MFCA
and supplying the FH. The IRA is in an elevated position from the
femoral neck and may be protected from injury during fracture of
the femoral neck. We present vascular ‘danger zones’ that may help
avoid iatrogenic vascular injury during surgical interventions about
the hip. Cite this article:
The aim of this cadaver study was to identify
the change in position of the sciatic nerve during arthroplasty
using the posterior surgical approach to the hip. We investigated
the position of the nerve during this procedure by dissecting 11
formalin-treated cadavers (22 hips: 12 male, ten female). The distance
between the sciatic nerve and the femoral neck was measured before
and after dislocation of the hip, and in positions used during the
preparation of the femur. The nerve moves closer to the femoral
neck when the hip is flexed to >
30° and internally rotated to 90° (90°
IR). The mean distance between the nerve and femoral neck was 43.1
mm (standard deviation ( This study demonstrates that the sciatic nerve becomes closer
to the operative field during hip arthroplasty using the posterior
approach with progressive flexion of the hip. Cite this article:
The modified Smith–Petersen and Kocher–Langenbeck
approaches were used to expose the lateral cutaneous nerve of the
thigh and the femoral, obturator and sciatic nerves in order to
study the risk of injury to these structures during the dissection,
osteotomy, and acetabular reorientation stages of a Bernese peri-acetabular
osteotomy. Injury of the lateral cutaneous nerve of thigh was less likely
to occur if an osteotomy of the anterior superior iliac spine had
been carried out before exposing the hip. The obturator nerve was likely to be injured during unprotected
osteotomy of the pubis if the far cortex was penetrated by >
5 mm.
This could be avoided by inclining the osteotome 45° medially and
performing the osteotomy at least 2 cm medial to the iliopectineal
eminence. The sciatic nerve could be injured during the first and last
stages of the osteotomy if the osteotome perforated the lateral
cortex of ischium and the ilio-ischial junction by >
10 mm. The femoral nerve could be stretched or entrapped during osteotomy
of the pubis if there was significant rotational or linear displacement
of the acetabulum. Anterior or medial displacement of <
2 cm
and lateral tilt (retroversion) of <
30° were safe margins. The
combination of retroversion and anterior displacement could increase tension
on the nerve. Strict observation of anatomical details, proper handling of
the osteotomes and careful manipulation of the acetabular fragment
reduce the neurological complications of Bernese peri-acetabular
osteotomy. Cite this article:
Large femoral heads have become popular in total
hip replacement (THR) as a method of reducing the risk of dislocation.
However, if large heads are used in ceramic-on-ceramic THR, the
liner must be thinner, which may increase the risk of fracture.
To compare the rates of ceramic fracture and dislocation between
28 mm and 32 mm ceramic heads, 120 hips in 109 patients (51 men
and 58 women, mean age 49.2 years) were randomised to THR with either
a 28 mm or a 32 mm ceramic articulation. A total of 57/60 hips assigned
to the 28 mm group and 55/60 hips assigned to the 32 mm group were
followed for at least five years. No ceramic component fractures
occured in any patient in either group. There was one dislocation
in the 32 mm group and none in the 28 mm group (p = 0.464). No hip
had detectable wear, focal osteolysis or prosthetic loosening. In
our small study the 32 mm ceramic articulation appeared to be safe
in terms of ceramic liner fracture. Cite this article:
Despite a lack of long-term follow-up, there
is an increasing trend towards using femoral heads of large diameter
in total hip replacement (THR), partly because of the perceived
advantage of lower rates of dislocation. However, increasing the
size of the femoral head is not the only way to reduce the rate
of dislocation; optimal alignment of the components and repair of
the posterior capsule could achieve a similar effect. In this prospective study of 512 cemented unilateral THRs (Male:Female
230:282) performed between 2004 and 2011, we aimed to determine
the rate of dislocation in patients who received a 22 mm head on
a 9/10 Morse taper through a posterior approach with capsular repair
and using the transverse acetabular ligament (TAL) as a guide for the
alignment of the acetabular component. The mean age of the patients
at operation was 67 years (35 to 89). The mean follow-up was 2.8
years (0.5 to 6.6). Pre- and post-operative assessment included
Oxford hip, Short Form-12 and modified University of California
Los Angeles and Merle D’Aubigne scores. The angles of inclination
and anteversion of the acetabular components were measured using
radiological software. There were four dislocations (0.78%), all
of which were anterior. In conclusion, THR with a 22 mm diameter head performed through
a posterior approach with capsular repair and using the TAL as a
guide for the alignment of the acetabular component was associated
with a low rate of dislocation. Cite this article:
