Little clinical advantage of modified Watson-Jones approach over modified mini-incision direct lateral approach in primary total hip arthroplasty

This study compared the clinical outcomes of total hip arthroplasty using a minimally invasive anterolateral approach with a muscle-sparing technique (modified Watson-Jones approach) and the modified mini-incision direct lateral approach. We randomly assigned 102 patients to the muscle-sparing group (n = 52) or the mini-incision direct lateral group (n = 50). Muscle strength recovery of hip abduction at 6 weeks after surgery was better, and creatine kinase level at 1 day after surgery was lower in the muscle-sparing group than in the mini-incision direct lateral group (P < .01). However, there was no difference in the Harris hip score, pain visual analog scale, the Western Ontario and McMaster Universities Osteoarthritis Index, and Medical Outcomes Study Short Form 36 score between the 2 groups throughout the 1-year study period.     

SuperCap入路和直接前入路全髋关节置换术的早期临床疗效比较

目的:比较SuperCap入路与直接前入路(direct anterior approach,DAA)全髋关节置换(total hip arthroplasty,THA)早期随访的临床疗效。方法:回顾分析2016年1月至2017年6月行微创SuperCap入路和DAA入路THA 70例患者的临床资料,其中SuperCap入路组30例,男15例,女15例,年龄45~71(57.96±15.46)岁;DAA组40例,男24例,女16例,年龄51~76(59.88±13.56)岁。观察比较两组患者术后3 d血红蛋白水平、术后输血率、髋臼外展角、髋臼前倾角、术后肌酸激酶水平,术后3个月和末次随访Harris评分,术后1周和末次随访疼痛视觉模拟评分(visual analogue scale,VAS),并记录末次随访并发症发生情况。结果:两组患者术后均获随访,SuperCap入路组随访时间24~30个月,DAA组随访时间24~36个月。两组患者术后3 d血红蛋白水平、术后输血率、术后1 d髋臼外展角、术后1 d髋臼前倾角比较,差异均无统计学意义(P>0.05)。两组患者术后3个月和末次随访Harris评分比较,差异无统计学意义(P>0.05)。两组患者术后6周和末次随访VAS比较,差异无统计学意义(P>0.05)。SuperCap入路组术后3 d肌酸激酶水平明显低于直接前入路组(P<0.05)。结论:SuperCap入路全髋关节置换术后临床效果可以媲美DAA入路,且软组织损伤更小,能够实现术后快速康复,同时学习曲线短,是一种安全、有效的手术入路。     

Markers of myocardial ischemia after minimally invasive and conventional coronary operation

Background. The purpose of this study was to evaluate the course of serum markers of myocardial tissue damage after two different types of minimally invasive coronary surgical procedures (MICS) as compared with conventional coronary artery bypass grafting (CABG).

Methods. We enrolled 87 patients with one- or two- vessel disease scheduled for one of the three procedures: minimally invasive direct coronary artery bypass grafting (MIDCABG) by lateral thoracotomy (n = 29), the OCTOPUS method by median sternotomy (n = 27), and CABG (n = 31). Creatine kinase activity (CK), creatine kinase MB activity (CK-MB act), creatine kinase MB mass concentration (CK-MB mass), myoglobin concentration (MG), and cardiac troponin I concentration (cTnI) were measured perioperatively until the second postoperative day.

Results. Creatine kinase-MB, CK-MB mass, and cTnI were significantly higher after CABG and were nearly maintained within the normal range in MICS. Creatine kinase and MG were significantly lower in the OCTOPUS group than in the MIDCABG or CABG groups.

Conclusions. Minimally invasive coronary surgical procedures cause less myocardial injury than CABG as indicated by specific serum markers. However, higher CK and MG reflect more substantial skeletal muscle trauma during MIDCABG operation compared with Octopus procedures.     

侧卧位直接前路全髋关节置换手术技术

直接前路是理想的髋关节微创手术入路,特征是通过神经肌肉间隙显露髋关节。与其他入路相比,直接前路髋关节置换术具有术后疼痛轻、功能恢复快和患者满意度高等优势。然而,直接前路髋关节置换存在明显的学习曲线和较高的围手术期并发症。将患者体位由经典的仰卧位转换为侧卧位,旨在秉承直接前路的优点且克服仰卧位直接前路髋关节置换术中股骨侧显露困难的难题。侧卧位时髋关节后伸、外旋和内收程度较仰卧位明显增加,可以更加安全有效地完成股骨髓腔扩髓和股骨假体的精确植入。侧卧位直接前路髋关节置换术中髋臼视角与熟知的后方入路一样,术者无需改变髋臼侧操作习惯。熟悉直接前路解剖和理解技术难点是直接前路髋关节置换手术成功的关键。     

Pain is significantly reduced by cryoablation therapy in patients with lateral minithoracotomy

BACKGROUND: In minimally invasive cardiac surgery use of a lateral minithoracotomy is associated with early postoperative rehabilitation but also relatively high pain levels during the first 3 postoperative days. Cryoablation therapy was evaluated prospectively. METHODS: From April 1999 until September 1999, 57 patients underwent lateral minithoracotomy for mitral valve operation (n = 18) or minimally invasive direct coronary artery bypass grafting (n = 39). Intraoperatively, patients were randomly assigned to cryoablation or intercostal application of local anesthetic agents. A standardized questionnaire was used for prospective pain assessment on postoperative days 1 to 7. RESULTS: From postoperative day 1 to 7 pain levels declined in all groups. Overall pain levels were significantly lower in the cryo group than in the control group (p < 0.0001, GLM). According to diagnoses, pain levels were significantly lower after MIDCABG and cryo versus control; after mitral valve operation they were lower in the cryo group and almost reached significance. CONCLUSIONS: Cryoablation is easy to perform and leads to a significant reduction in pain and lower request for additional pain medication after lateral minithoracotomy in minimally invasive cardiac operation.     

The direct lateral approach: impact on gait patterns, foot progression angle and pain in comparison with a minimally invasive anterolateral approach

Introduction  

Minimally invasive total hip arthroplasty has been successfully introduced in the past decade. Nevertheless, standard approaches such as the direct lateral approach are still commonly used in orthopaedic surgery due to easy handling, good intra-operative overview and low complication rates. However, a frequent occurrence of fatty atrophy within the anterior third of the gluteus medius muscle has been demonstrated when using the modified direct-lateral approach (mDL), which may be associated with a reduction in function, limitation of internal leg rotation, gait disorders and pain. The question addressed in this study is whether mDL-approach leads to unfavourable changes in foot progression angle (FPA), gait and to more postoperative pain compared with a minimally invasive anterolateral approach (ALMI).     

侧卧位直接前入路与后外侧入路在单侧全髋中的疗效对比

目的比较侧卧位直接前方入路(L-DAA)与后外侧入路(PLA)在单侧全髋关节置换术中的临床疗效。 方法回顾性分析2016年8月至2017年12月于重庆医科大学附属遂宁市中心医院关节外科行单侧全髋关节置换术患者共93例,纳入初次单侧置换患者,排除双侧或不能耐受手术的患者。按照手术入路不同分为L-DAA组(45例)及PLA组(48例)。所有手术均由同一组医师完成。对两组患者的身体质量指数(BMI)、围手术期各项指标(手术时间、失血量、术前血红蛋白值、术后第1天及第7天血红蛋白值、切口长度、平均住院日)、术前及术后Harris髋关节评分、术前及术后疼痛视觉模拟评分(VAS)等计数资料采用t检验分析;术后影像学评价、术中及术后并发症等计数资料采用卡方检验进行统计学分析。 结果两组患者均获得有效随访,随访时间6～16个月,平均(11.7±1.6)个月。所有患者术后均未出现深静脉血栓、感染等严重并发症。两组在BMI值、术前Harris评分、术前血红蛋白值、手术时间、切口长度、术后影像学评价、术前及术后VAS评分以及平均住院日上差异无统计学意义(P > 0.05);两组的失血量、术后第1天及第7天血红蛋白值差异具有统计学意义,后外侧入路组的失血量更多,而术后第1天和第7天的血红蛋白值更低(t ＝0.361、0.484,均为P < 0.05);同时术后3个月患侧Harris髋关节评分L-DAA组高于PLA组(t ＝0.572,P < 0.05);术后6个月Harris髋关节评分两组差异无统计学意义(P > 0.05)。L-DAA组术后均未发生人工关节脱位,PLA组术后出现2例人工关节后脱位,差异具有统计学意义(χ²＝0.465,P < 0.05)。L-DAA组术中发生2例股骨近端骨折,PLA组术中未发生股骨近端骨折,差异具有统计学意义(X² ＝0.587,P < 0.05)。 结论两种THA手术入路均能取得良好的近期临床疗效,其中L-DAA相较于PLA而言能减少手术创伤,更快恢复日常生活能力,有利于术后早期康复,符合快速康复(ERAS)理念。     

直接前方入路全髋关节置换术治疗强直性髋关节炎

目的探讨直接前方入路全髋关节置换术在治疗强直性髋关节炎中的临床效果。 方法回顾性分析2015年10月至2018年10月于福建省立医院行全髋关节置换术的强直性髋关节炎62例(66髋),纳入强直性脊柱炎合并髋关节炎行全髋关节置换的患者,排除脊柱畸形严重患者。根据手术入路分为直接前入路组和后外侧入路组,比较手术切口长度,术中出血量的差异,通过Harris髋关节功能评分、影像学评价两组患者手术效果。计量资料采用t检验,计数资料采用卡方检验。 结果直接前入路组和后外侧入路组在手术切口长度和术中出血量的差异无统计学意义(t＝1.346、1.272,均为P>0.05)。末次随访平均(25±11)个月,所有患者均解除疼痛,恢复髋关节活动功能。直接前入路组Harris评分术前平均(61±14)分,术后平均(97.8±2.9)分。后外侧入路组Harris评分术前平均(59.3±14.3)分,术后平均(97.4±3.3)分。两组组内术后Harris评分均明显高于术前(t＝14.229、14.729, P<0.001),但两组间差异无统计学意义(t ＝0.416, P>0.05)。术后X线片两组均无骨溶解及假体松动等征象,未发生术后并发症。 结论直接前方入路全髋关节置换治疗强直性髋关节炎的临床效果满意。     

Comparison of direct anterior,lateral, posterior and posterior-2 approaches in total hip arthroplasty: network meta-analysis

Total hip arthroplasty (THA) is generally considered to be one of the most successful orthopedic surgical procedures. THA patients continue to experience symptoms, most commonly pain, which prevent their return to full function and activity. Possible causes include failure of fixation, instability and damage to soft tissues, associated with the trauma of the surgical procedure. Choosing the optimal surgical approach can minimize these risks and therefore improve the outcome of THA. Surgical approaches in THA include anterior, lateral [anterolateral (Hardinge) and direct lateral (Watson–Jones)], posterior (posterolateral and posterior) and posterior-2 techniques. However, there is no current consensus regarding which approach is the most suitable. Therefore, we conducted a systematic review and network meta-analysis to compare the postoperative outcomes and complications among THA approach and identify which approach is the best for THA. We searched all RCT studies that compared intra-operative and postoperative outcomes of anterior, lateral [anterolateral (Hardinge) and direct lateral (Watson–Jones)], posterior (posterolateral and posterior) and posterior-2 approaches for THA from the PubMed and Scopus databases up to February 1, 2017. Data were independently extracted by two reviewers. A network meta-analysis was applied to assess treatment outcomes. Probability of being the best treatment was estimated using surface under the cumulative ranking curves (SUCRA). Fourteen RCTs (N = 1017 patients) met inclusion criteria. Interventions were anterior (N = 233 patients), lateral (N = 334 patients), posterior (N = 405 patients) and posterior-2 (N = 45 patients) approaches. A network meta-analysis showed that effects of anterior approach were higher to lateral, posterior and posterior-2 approaches with the pooled mean postoperative within 1 month and last follow-up of HHS of 2.56 (95% CI ? 0.79, 5.91), 4.80 (95% CI 1.33, 8.26), 10.80 (95% CI 2.10, 19.49) and 6.40 (95% CI 0.72, 12.09), 2.22 (95% CI ? 3.21, 7.66), 4.22 (95% CI ? 6.81, 15.25), respectively. For VAS, lateral approach was lower to anterior, posterior and posterior-2 approaches. In terms of complication, posterior approach was the lowest risk with RR of 0.39 (95% CI 0.19, 0.81), 0.57 (95% CI 0.21, 1.57) and 1.74 (95% CI 0.36, 8.33) when compared to anterior, followed by lateral and posterior-2 approaches. Results of SUCRA indicated anterior and lateral approaches were the first and second ranks for postoperative HHS and VAS score, while posterior and lateral approaches were the first and second ranks for postoperative complications. We recommended using lateral approach that has an acceptable postoperative pain, function and complications (second rank for all outcomes) as a surgical technique for THA.     

A double offset broach handle for preparation of the femoral cavity in minimally invasive direct anterior total hip arthroplasty

A direct anterior approach is in use for minimally invasive total hip arthroplasty. This approach uses an intermuscular and internerval plane between the sartorius, rectus femoris, and tensor fasciae latae. Although preparation of the acetabulum and implantation of the acetabular component is an easy task with the available instruments, preparation of the femoral canal through this single incision is more demanding. Instrumentation of the femur involves careful preparation of the dorsal capsule, positioning of the operated leg, and leverage of the femur. A broach handle with lateral and anterior offset for the direct anterior approach has been developed to reduce the need for leverage of the proximal femur for preparation of the cavity.     

High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach

Background and purpose There is growing interest in minimally invasive surgery techniques in total hip arthroplasty (THA). In this study, we investigated the learning curve and the early complications of the direct anterior approach in hip replacement. Methods In the period January through December 2010, THA was performed in 46 patients for primary osteoarthritis, using the direct anterior approach. These cases were compared to a matched cohort of 46 patients who were operated on with a conventional posterolateral approach. All patients were followed for at least 1 year. Results Operating time was almost twice as long and mean blood loss was almost twice as much in the group with anterior approach. No learning effect was observed in this group regarding operating time or blood loss. Radiographic evaluation showed adequate placement of the implants in both groups. The early complication rate was higher in the anterior approach group. Mean time of hospital stay and functional outcome (with Harris hip score and Oxford hip score) were similar in both groups at the 1-year follow-up. Interpretation The direct anterior approach is a difficult technique, but adequate hip placement was achieved radiographically. Early results showed no improvement in functional outcome compared to the posterolateral approach, but there was a higher early complication rate. We did not observe any learning effect after 46 patients.     

No differences between direct anterior and lateral approach for primary total hip arthroplasty related to muscle damage or functional outcome

Purpose

The aim was to compare the muscle damage and functional outcomes between patients who underwent total hip arthroplasty through a direct anterior (49 patients) or a lateral approach (50 patients).

Methods

A randomized, controlled, prospective study. The study variables were muscle damage based on post-operative levels of serum markers (citokynes and acute phase reactants) and MRI, and Harris hip score.

Results

Post-operatively, there were significantly higher mean levels in the lateral group related to interleukin 6 and 8, and tumor necrosis factor-alpha up to fourth postoperative day. By MRI at six post-operative months, the fatty atrophy in the gluteus muscles was more in the lateral group, but similar in the other muscles. The mean thickness of the tensor fasciae latae was significantly lower in the anterior group. Functional outcome was similar between groups at three and 12 post-operative months.

Conclusions

Muscle damage due to the surgical approach had no influence on functional outcome after three post-operative months. Both anterior and lateral approaches for THA are similarly safe and feasible, so the choice depends only on the preference and experience of the surgeon.

     

Minimally invasive total hip arthroplasty via direct anterior approach

BACKGROUND: Minimally invasive total hip arthroplasty (THA) aims at reduction of tissue damage to accelerate recovery. The anterior approach promises optimal soft tissue preservation. PATIENTS AND METHOD: Safety and feasibility of minimally invasive THA via an anterior approach without the use of an orthopedic table was tested in a prospective cohort study on 100 consecutive patients. There were no exclusion criteria, and cementless and cemented techniques were employed. RESULTS: No second incision was needed and neither nerve palsy nor dislocation was observed. The inclination angle of the cup was a median of 44.1 degrees and the position of the stem a median of 0 degrees varus/valgus. Short, satisfactory scars, little blood loss and postoperative pain, accelerated rehabilitation, and early discharge were noted. There were six cases of a permanent lesion of the lateral femoral cutaneous nerve. CONCLUSION: The proposed technique is safe and allows correct positioning of the cup and stem. It can be performed in a reasonable amount of time and blood loss is little.     

The direct anterior approach: First among equals-Affirms

The recent resurgence of the anterior approach to total hip arthroplasty has made it a controversial topic. While technically demanding, the direct anterior approach can be rewarding to both the patient and the surgeon when properly performed. The direct anterior approach is a true intra-nervous approach to the hip allowing for surgeon to deploy minimally invasive techniques and soft tissue handling. This article highlights the senior author’s experience with the direct anterior approach and reviews the recent literature on post operative rehabilitation, muscle strength, muscle atrophy, and complications in the direct anterior approach to total hip arthroplasty.     

体位对直接前方入路全髋关节置换术的影响

目的：探讨术中不同体位对直接前方入路（direct anterior approach,DAA）全髋关节置换术的影响。方法：回顾性分析2016年7月至2020年6月行DAA全髋关节置换术患者94例,根据术中不同体位分为2组,其中侧卧位45例,仰卧位（支架辅助下）49例。观察比较两组患者性别、患肢、身体质量指数（body mass index,BMI）等一般资料,切口长度、手术时间、术中出血量、术后24 h引流量、手术前后血红蛋白差值、术后首次下地时间、术后住院时间、术后并发症,术后1 d,1、2周,1、3、6个月的疼痛视觉模拟评分（visual analogue scale,VAS）,术后1、2周及1、3、6个月的Harris评分。结果：两组患者术后均获得随访,时间6~12（8.31±2.22）个月。两组患者的性别、手术部位、年龄、BMI、术前VAS、术前Harris评分比较差异无统计学意义（P>0.05）。仰卧位（支架辅助下）组患者切口长度、手术时间、术中出血量、术后24 h引流量、手术前后血红蛋白差值、术后首次下地时间和术后住院时间均优于侧卧位组（P<0.05）;术中、术后输血例数比较,差异无统计学意义（P=0.550）。仰卧位（支架辅助下）组术中和术后前倾角、外展角比较,差异无统计学意义（P=0.825,P=0.066）;侧卧位组术中和术后前倾角、外展角比较,差异有统计学意义（P<0.05）。仰卧位（支架辅助下）组患者术后1 d,1、2周,1个月VAS低于侧卧位组（P<0.05）,两组术后3、6个月VAS差异无统计学意义（P>0.05）。仰卧位（支架辅助下）组患者术后1周及1、3个月的Harris评分高于侧卧位组（P<0.05）,两组术后6个月的Harris评分比较,差异无统计学意义（P>0.05）。结论：仰卧位（支架辅助下） DAA全髋关节置换术与侧卧位术式相比,手术切口小、手术时间短、出血少、下地时间早、住院时间短,且术中髋臼杯位置判断误差小,具有术后恢复快的优势,但在6个月后患者的髋关节功能恢复是相同的。     

Posterolateral vs Direct Anterior Approach in Total Hip Arthroplasty (POLADA Trial): A Randomized Controlled Trial to Assess Differences in Serum Markers

Background

The direct anterior approach (DAA) for total hip arthroplasty has claimed to be a true tissue-sparing minimally invasive approach that has less tissue damage and a faster recovery when compared to the posterolateral approach (PLA). The aim of this randomized controlled trial is to measure the differences in serum markers and functional outcomes between the DAA and PLA for total hip arthroplasty.

仰卧位常规器械OCM入路与后外侧入路全髋关节置换术的疗效对照

目的:比较仰卧位常规器械OCM入路与后外侧入路全髋关节置换术的临床疗效。方法 :2017年2月至2019年1月因髋关节疾病行髋关节置换患者67例,其中微创组21例采用OCM入路,男12例,女9例;股骨颈骨折10例,股骨头无菌性坏死5例,髋关节骨性关节炎6例。传统组46例采用传统后外侧入路,男28例,女18例;股骨颈骨折24例,股骨头无菌性坏死12例,髋关节骨性关节炎10例。所有患者使用生物型陶-陶人工关节假体。观察比较两组患者手术时间、术中出血量、切口长度、手术前后肌酸激酶(CK-NAC)、下地活动时间、住院时间、术后假体的外展角及前倾角。比较两组术前及术后12个月Harris评分。结果:所有病例获得随访,时间14～26(18.4±3.6)个月。两组患者术中出血、术后前倾角及外展角比较,差异均无统计学意义(P0.05)。两组病例手术时间、切口长度、术后肌酸激酶、下地时间、住院时间差异均有统计学意义(P0.05)。两组术前及术后12个月Harris功能评分差异均无统计学意义(P0.05)。结论:两种入路人工全髋关节置换术均可获得满意的疗效,OCM入路损伤小,术后康复快,是可靠的手术入路。     

Trochanteric heterotopic ossification after total hip arthroplasty performed using a direct lateral approach

A unique pattern and location of symptomatic heterotopic ossification (HO) was observed in patients having total hip arthroplasty (THA) performed using a direct lateral approach, situated outside the hip capsule, distal, lateral, and anterior to the greater trochanter, designated as trochanteric heterotopic ossification (THO). Radiographs of 1420 consecutive primary total hip arthroplasties were reviewed. Three hundred and seventy hips (26%) developed HO around the hip and greater trochanter. One hundred of these hips (27%) demonstrated THO, without classic HO. Of the 270 cases containing a Brooker component, 110 hips exhibited additional HO (THO). Thus, THO occurred in 210 (14.8%) of 1420 THAs. Two patients required surgical excision of the HO after maturity, gaining full relief without recurrence. Trochanteric heterotopic ossification should be considered as a possible cause of early postoperative pain after THA performed using a direct lateral approach.     

Mini-midvastus versus medial parapatellar approach in TKA: muscle damage and inflammation markers

The purpose of this prospective study was to analyze the biochemical markers of muscle damage and inflammation in patients treated with the mini-midvastus approach or the medial parapatellar approach for total knee arthroplasty. Of 60 patients who underwent unilateral total knee arthroplasty, 30 were treated with the mini-midvastus approach (MMV group) and 30 were treated with the medial parapatellar approach (MPP group). Serum creatine kinase, myoglobin, lactate dehydrogenase, glutamic oxaloacetic transaminase, C-reactive protein, interleukin-6, and interleukin-1β levels were measured preoperatively, immediately postoperatively (except for C-reactive protein level), and on postoperative days 1, 2, and 3. Student's t test, Pearson's chi-square test, and Fisher's exact test were used to compare the outcomes between the 2 groups. Compared with the MPP group, a significant increase in serum creatine kinase level existed in the MMV group on postoperative days 2 (P=.08) and 3 (P=.09) and cumulatively (P=.02). However, significantly elevated C-reactive protein and interleukin-6 levels existed in the MPP group.According to the serum creatine kinase levels, the mini-midvastus approach has no superiority over the medial parapatellar approach in terms of sparing muscle and may cause more muscle damage. Further study is warranted to determine the correlation between biochemical markers and functional deficits.     

Modified direct anterior approach in minimally invasive hip hemiarthroplasty in a geriatric population: a feasibility study and description of the technique

Introduction

The direct anterior approach (DAA) is generally accepted method for minimal invasive arthroplasty of the hip. As good results for total hip arthroplasty are already published, there is a lack of evidence for the implantation of bipolar hip hemiarthroplasty (BHH) in elderly patients with osteoporosis after femoral neck fracture.

Materials and methods

For hip arthroplasty using a direct anterior approach (DAA) in elderly patients with femoral neck fractures, a number of modifications of the original technique are being described. The modified DAA considers in particular the co-morbidity and the bone quality of the geriatric patient population. A consecutive series of 16 hemiarthroplasties using this technique is presented. In all 16 cases, the BHH was implanted in modified DAA technique. Mobility measured by 4-item Barthel Index, pain via visual analogue scale (VAS), duration of surgery, external length of incision and blood loss were evaluated.

Results

There was no major operative complication during the procedures. The pain level decreased from 7 (preoperatively) to 0 at postoperative day 40. The Barthel Index increased from 5 at first postoperative day to 40 at day 40. Early postoperative mobilisation is efficiently accelerated. Mean operating time was 71 min; the medium skin incision length was 8 cm. The mean haemoglobin level decreased from 118 g/dl preoperatively to 101 g/dl at first postoperative day.

Conclusion

The described modifications of the DAA help to implant a BHH gently in elderly patients with increasing risk of complications like iatrogenic fractures, wound or prosthesis infections and haematoma. This will hopefully lead to a faster rehabilitation and lower mortality rate for patients with femoral neck fractures in the future.