Comparison of complications after transtrochanteric and posterolateral approaches for primary total hip arthroplasty

Excision of trochanteric bursa during total hip replacement: Does it reduce the incidence of post-operative trochanteric bursitis?

BACKGROUND

Trochanteric bursitis is a common complication following total hip replacement (THR), and it is associated with high level of disability and poor quality of life. Excision of the trochanteric bursa prophylactically during THR could reduce the occurrence of post-operative trochanteric bursitis.

AIM

To evaluate whether synchronous trochanteric bursectomy at the time of THR affects the incidence of post-operative trochanteric bursitis.

METHODS

This retrospective cohort study was conducted in the secondary care setting at a large district general hospital. Between January 2010 and December 2020, 954 patients underwent elective primary THR by two contemporary arthroplasty surgeons, one excising the bursa and the other not (at the time of THR). All patients received the same post-operative rehabilitation and were followed up for 1 year. We reviewed all cases of trochanteric bursitis over this 11-year period to determine the incidence of post-THR bursitis. Two proportion Z-test was used to compare incidences of trochanteric bursitis between groups.

RESULTS

554 patients underwent synchronous trochanteric bursectomy at the time of THR whereas 400 patients did not. A total of 5 patients (incidence 0.5%) developed trochanteric bursitis following THR; 4 of whom had undergone bursectomy as part of their surgical approach, 1 who had not. There was no statistically significant difference between the two groups (Z value 1.00, 95%CI: -0.4% to 1.3%, P = 0.32). There were also 8 other patients who had both trochanteric bursitis and hip osteoarthritis prior to their THR; all of whom were treated with THR and synchronous trochanteric bursectomy, and 7 had resolution of their lateral buttock pains but 1 did not.

CONCLUSION

Synchronous trochanteric bursectomy during THR does not materially affect the incidence of post-operative bursitis. However, it is successful at treating patients with known trochanteric bursitis and osteoarthritis requiring THR.

Greater trochanteric pain after primary total hip replacement, comparing the anterior and posterior approach: A secondary analysis of a randomized trial

BACKGROUND

Greater trochanteric pain (GTP) after total hip replacement is a common cause of residual lateral hip pain, regardless of the approach used. The goal of our study was to evaluate GTP after a direct anterior approach (DAA) compared to a posterior approach (PA) as well as the clinical outcomes of both approaches and answer the following: 1) What is the incidence of trochanteric pain after primary THA with two different surgical approaches? 2) What is the functional outcome of patients with GTP? 3) What proportion of patients with GTP resort to peritrochanteric injections?

HYPOTHESIS

Our hypothesis is that GTP is present with both approaches but satisfaction is lower with the PA.

PATIENTS AND METHODS

A secondary analysis of a previously published clinical trial with 55 total hip arthroplasty patients randomized in one of two surgical approaches: 27 patients underwent the anterior modified Hueter approach, while the other group of 28 patients were operated using the posterior approach. Study outcomes were Modified Harris Hip Score (MHHS), satisfaction score, pain when lying on the affected side, and requiring an injection. Hip offset, femur lateralization and leg lengthening were measured before and after surgery.

RESULTS

Forty-five patients were available for complete follow-up at a mean of 62 months (range: 48-74). The incidence of GTP was higher in the posterior approach [PA: 6/21 (29%) vs DAA 4/24 (17%)) (p=0.3). Patients operated through a PA experienced more pain [5/21 (24%) of patients; VAS=mean 5.3] when lying on their operated side, compared to DAA patients [2/24 (8%) of patients; VAS=mean 2) (p=0.2)]. However, MHHS, patient satisfaction with surgery, radiological assessment for hip offset, femur lateralization or leg lengthening, and injections required were similar for both approaches. Overall, satisfaction and functional outcome with surgery was significantly lower in GTP patients, regardless of the approach.

CONCLUSIONS

GTP impacts patient satisfaction and functional outcome in total hip arthroplasty patients. PA patients reported more trochanteric pain than DAA patients, which affected their clinical outcome.

LEVEL OF EVIDENCE

III.

Lateral Trochanteric Pain Following Primary Total Hip Arthroplasty: Incidence and Success of Nonoperative Treatment

BACKGROUND

Our study aimed at quantifying the overall incidence of lateral trochanteric pain (LTP) following total hip arthroplasty (THA) and risk based on surgical approach. The success of conservative treatment and potential risk factors for failure of conservative treatment were evaluated.

METHODS

This is a retrospective review of patients who underwent primary THA between 2010 and 2019 and had a postoperative diagnosis of ipsilateral LTP. Chart review revealed patient demographics/comorbidities, preoperative diagnosis, surgical approach, femoral components, and nonoperative treatment modalities. Radiographic analysis was performed to measure leg length discrepancy, femoral offset, and femoral head lateralization.

RESULTS

The incidence of LTP following primary THA was 1.70% (573/33,761) with an average time to diagnosis of 27.3 months. The direct anterior approach demonstrated the highest risk and the direct lateral demonstrated the lowest risk for LTP (P < .001). Also, 82.4% (472/573) were diagnosed greater than 6 months postoperatively (P < .001). Of 573 patients, 95 (16.6%) were treated with physical therapy, home exercises, or oral medications with a success rate of 96.8% (92/95). Remaining 478 (83.4%) were treated with corticosteroid injection (CSI). And 89.5% (428/478) of the CSI cohort demonstrated clinical improvement with 3 or less CSIs. Risk factors for failure of conservative treatment were depression (P = .034), kidney disease (P = .040), and osteoporosis (P = .007).

CONCLUSION

Postoperative LTP after THA is rare with an incidence of 1.70%. The direct anterior approach presented higher risk of LTP. Non-CSI modalities and CSIs were both successful treatment options. In patients with depression, kidney disease, and osteoporosis, conservative treatment may be less efficacious.

Hip Arthroscopy for Diffuse Idiopathic Skeletal Hyperostosis Using a Capsulotomy-First Approach

Diffuse idiopathic skeletal hyperostosis (DISH) is a systematic disease of unknown etiology characterized by ossification at the site of spine and major joints entheses, including the hip. Ossified connective tissue may cause pain and joint stiffness, which may require surgical intervention. The purpose of this study was to investigate the clinical, radiographic, and arthroscopic presentation and surgical outcomes of patients with DISH involving the hips. Fourteen hips in 9 patients (mean±SD age, 63±14 years; range, 35-76 years) with overcoverage of the femoral head by DISH were retrospectively reviewed. For all joints, a transverse, capsulotomy-first approach was performed due to an inability to access the central compartment by traction of the lower extremity. After arthroscopic resection of the ossified lesion, labral reconstruction was performed with an iliotibial band autograft. For clinical evaluation, patient-reported outcome scores (modified Harris Hip Score [mHHS], Nonarthritic Hip Score [NAHS], International Hip Outcome Tool-12 [iHot-12], visual analog scale [VAS] pain score, and VAS satisfaction score) were obtained. Arthroscopically, circumferential labral damage with no or mild articular cartilage damage was observed. Mean NAHS, iHot-12 score, and VAS satisfaction score improved significantly (47 to 56, 43 to 71, and 21 to 72, respectively; P<.05). Mean mHHS and VAS pain score did not reach significance but did improve (65 to 92 and 45 to 78, respectively). Using a transverse, capsulotomy-first approach for arthroscopic hip surgery for patients with DISH yields successful outcomes in patient-reported outcome measures and satisfaction, despite minor gains in hip range of motion. [Orthopedics. 2020;43(5):e369-e377.].

Current Uses of the Transtrochanteric Approach to the Hip: A Systematic Review

BACKGROUND

The indications and technique for the transtrochanteric approach to the hip have evolved greatly since its initial popularization in the 1960s. The purpose of this systematic review was to assess current uses of this approach on the basis of indications, osteotomy technique, trochanteric fixation method, complications, and functional outcome.

METHODS

A comprehensive search of MEDLINE and Embase databases from January 2000 to July 2017 was performed in accordance with the PRISMA guidelines. Articles were divided into 3 major categories on the basis of the type of hip surgery performed: (1) primary arthroplasty, (2) revision arthroplasty, and (3) joint-preserving procedures. Patient data were then analyzed according to these 3 categories.

RESULTS

Seventy-six studies (5,028 hips), mainly of Level-IV evidence, were included. Four types of osteotomy were reported for a variety of indications. Rates of nonunion were 6.0% (303 of 5,028) across all studies, 4.2% (39 of 921) for primary arthroplasty, 6.7% (114 of 1,690) for revision arthroplasty, and 4.4% (56 of 1,278) for joint-preserving procedures. Rates of dislocation were 1.5% (14 of 921) for primary arthroplasty and 4.6% (77 of 1,690) for revision arthroplasty. The rate of osteonecrosis after joint-preserving procedures was 1.1% (14 of 1,278). Rates of deep infection were 1.1% (55 of 5,028) across all studies, 0.1% (1 of 921) for primary arthroplasty, 2.1% (36 of 1,690) for revision arthroplasty, and 0.6% (8 of 1,278) for joint-preserving procedures.

CONCLUSIONS

The transtrochanteric approach remains useful in cases requiring extensile exposure of the acetabulum or femoral medullary canal. However, trochanteric complications continue to pose a clinical challenge.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Total hip arthroplasty using a combined anterior and posterior approach via a lateral incision in patients with ankylosed hips

BACKGROUND

For most patients with severely ankylosed hips, traditional surgical approaches do not provide sufficient exposure during THAs. We report our experience with a combined anterior and posterior approach using a lateral incision for total hip arthroplasty (THA) in patients with severe, spontaneous bony hip ankylosis.

METHODS

Between January 2004 and December 2008, patients with severe, spontaneous bony hip ankylosis underwent THA via a combined anterior and posterior approach using a lateral incision.

RESULTS

We included 47 patients (76 hips) with a mean age of 53 (range 22-72) years in our study. All surgeries were successful, and no significant postoperative complications occurred. The mean operative duration was 1.5 (range 1.3-1.7) hours, and mean blood loss was 490 (range 450-580) mL. The mean duration of follow-up was 5.5 (range 2-11) years. Harris hip score improved from 53 to 88 points postoperatively, and the outcome was good to excellent in 88.37% of cases. Heterotopic ossification occurred in 6 hips, and infection, which resolved with antibiotics, occurred in 1 patient.

CONCLUSION

This combined anterior and posterior approach to THA using a lateral incision in patients with severe, spontaneous ankylosis provides very good exposure, protects the abduction unit and results in good to excellent postoperative recovery.

Distal lengthening of ilio-tibial band by Z-plasty for treating refractory greater trochanteric pain after total hip arthroplasty (Pedersen-Noor operation)

INTRODUCTION

The development of greater trochanteric pain (GTP) after total hip arthroplasty (THA) represents a special category. Despite that treatment is mainly conservative, some patients show poor response and surgical intervention should be considered. We propose a new method consisting of distal lengthening of ilio-tibial band (ITB) by Z-plasty.

MATERIAL AND METHODS

Between March 2004 and June 2006, 12 women with refractory GTP after THA were operated on using distal ITB lengthening. The procedure was done under local anaesthesia on an outpatient basis. The patients were followed up 3-4 months postoperatively by phone interview and at 1-3 years by EQ-5D questionnaire and clinical examination including tenderness evaluation with algometer.

RESULTS

All patients improved significantly (EQ-5D = 0.26 preoperatively vs. 0.67 postoperatively; P < 0.005) except one patient who experienced no change in GTP symptoms. No postoperative complications were reported.

CONCLUSION

We believe that treating patients with GTP after THA by the technique described offers a simple, safe and reliable method.

Comparison of complications in transtrochanteric and anterolateral approaches in primary total hip arthroplasty

Three surgical approaches to primary total hip arthroplasty (THA) have been in use since Charnley popularized the transtrochanteric approach. This study was designed to examine the difference in morbidity between the transtrochanteric approach and the anterolateral approach in primary THA. Information on 891 patients who underwent primary THA performed by a single surgeon was collected prospectively between 1998 and 2003 using a modified SF-36 form, preoperatively, intraoperatively, and at 3 months postoperatively. The transtrochanteric group had higher morbidity and more patients who were dissatisfied with their THA. There was a greater range of motion in the anterolateral group.

Prosthesis survival after total hip arthroplasty--does surgical approach matter? Analysis of 19,304 Charnley and 6,002 Exeter primary total hip arthroplasties reported to the Norwegian Arthroplasty Register

BACKGROUND AND PURPOSE

Controversies still exist about whether there is any effect of operative approach on survival of hip prostheses. We compared long-term survival of primary total hip arthroplasties in a well-defined study population from a national prospective population-based registry with regard to the three most commonly used surgical approaches.

METHODS

We assessed prosthesis survival according to surgical approach (the lateral with or without trochanteric osteotomy, and the posterolateral) for 19,304 Charnley and 6,002 Exeter total hip arthroplasties performed from 1987 to 2004.

RESULTS

For Charnley total hip arthroplasties, lateral approach with trochanteric osteotomy had a lower probability of revision than lateral approach without trochanteric osteotomy (RR=0.6, 95% CI: 0.5-0.8). The lower revision rate was due to fewer revisions for aseptic loosening and dislocation. The differences had declined in the latest time period (1995-2004). We observed no differences between lateral approach without trochanteric osteotomy and posterolateral approach, except that there were more revisions due to dislocation in the posterolateral approach group (RR=1.9, 95%CI: 1.1-3.2). No statistically significant differences were observed for Exeter total hip arthroplasties.

INTERPRETATION

For Charnley prostheses, the lateral approach with trochanteric osteotomy gave a reduced revision risk compared to the other approaches, which was due to fewer revisions for dislocation, and in the first time period also fewer revisions due to aseptic loosening.

Total hip arthroplasty requiring subtrochanteric osteotomy for developmental hip dysplasia: 5- to 14-year results

This study evaluated total hip arthroplasty in patients with developmental hip dysplasia requiring femoral subtrochanteric shortening derotational osteotomy (SDO). Twenty-three total hip arthroplasties that required SDO were evaluated at an average follow-up of 8 years (range, 5-14 years). Clinical and radiographic data were retrospectively reviewed. Four hips (17%) failed requiring revision. Time to revision averaged 4 years (range, 1-8 years) with polyethylene wear and osteolysis etiologic in 3 of 4 failures. Survivorship was 75% at 14 years. Subtrochanteric SDO provided reliable correction of dysplastic femoral deformity, facilitated hip reduction at the anatomic center, and demonstrated predictable union in all cases. Wear-induced osteolysis was the major reason for revision, probably due to the relatively thin polyethylene liners required for the small acetabular components used in young, active patients.

Greater trochanteric pain after total hip arthroplasty: the incidence, clinical outcome and associated factors

We evaluated any residual pain around the hip joint 11 to 23 months post-surgery in 172 consecutive patients who underwent total hip arthroplasty (THA) for primary or secondary osteoarthritis during 2002 at Sundsvall Hospital, Sweden. Patients with suspected greater trochanteric pain (GTP) were matched with controls from the same cohort. The two groups were assessed with the Western Ontario and McMaster Universities Arthrosis Index (WOMAC) and were examined for localised tenderness over the trochanteric area by algometer. The pre- and postoperative radiographs including femoral offset were evaluated. We found that 21 patients (12%) had GTP with a male to female ratio of 1:6. The WOMAC index revealed a reduction in the clinical outcome in this group. An associated factor of significance was postoperative uncorrected lengthening of the operated limb equal to or more than one centimetre. We found no correlation between the prevalence of GTP and body weight or length, femoral offset or size of the prosthetic components used.

Recurrent instability after total hip arthroplasty: beware of subtle component malpositioning

Most patients exhibiting instability after total hip arthroplasty can be treated nonoperatively. However, instability may become recurrent and require surgical intervention. Abductor insufficiency and component malpositioning constitute two of the most important causes of recurrent instability, although the exact cause may not be identifiable in some patients. There is relative scarcity of reports in the literature regarding the outcome of surgical intervention for recurrent instability; however, it is known that surgical intervention is likely to have a better outcome in patients for whom the cause of recurrent instability can be identified. We hypothesized that component malpositioning, which may be subtle in some cases, is the cause of recurrent instability for many patients. The outcomes of revision arthroplasty in 93 patients who were treated at our institution for recurrent instability were reviewed. Component malpositioning was found to be the major cause of recurrent instability in this successfully treated cohort.