Posterior versus direct anterior approach in revision hip arthroplasty using Kerboull-type plate

Satisfactory clinical and radiographic outcomes following revision total hip arthroplasty by direct anterior approach using primary femoral stems at 2-8 years of follow-up

INTRODUCTION

To report clinical and radiographic outcomes of revision total hip arthroplasty (THA) through the direct anterior approach (DAA) using primary stems.

MATERIALS AND METHODS

The authors assessed a consecutive series of revision THAs operated by DAA using primary (cemented and uncemented) stems between 1/1/2010 and 30/06/2017. The initial cohort comprised 47 patients (50 hips), aged 65 ± 10 years with BMI of 25 ± 4 kg/m2. Clinical assessment included modified Harris Hip Score (mHHS) and satisfaction with surgery. Radiographic assessment included radiolucent lines > 2 mm, bone remodelling, cortical hypertrophy, pedestal formation, and osteolysis. Linear regression analyses were performed.

RESULTS

Of the 50 hips (47 patients) in the initial cohort, intraoperative complications that did not require re-revision occurred in 5 hips. At a follow-up of > 2 years: 5 hips (10%) were lost to follow-up and 3 hips (6%) required stem re-revision, leaving a final cohort of 42 hips (40 patients). Postoperative complications that did not require re-revision occurred in 4 hips (8%). At 4.3 ± 1.6 years, post-revision mHHS was 89 ± 14 (range 47-100) and 38 patients were satisfied or very satisfied with revision surgery. Bone remodelling was observed in 8 hips (16%), cortical hypertrophy in 6 hips (12%), grade I heterotopic ossification in 7 hips (14%), and grade II in 1 hip (2%). There were no cases of radiolucent lines, pedestal formation, or osteolysis. Regression analyses revealed that post-revision mHHS was not associated with any variable.

CONCLUSIONS

Revision THA performed through the DAA using primary stems grants satisfactory clinical and radiographic outcomes at a minimum follow-up of two years.

A low dislocation rate after revision total hip arthroplasty performed through the anterior approach

BACKGROUND

Dislocation is a major complication in revision total hip arthroplasties. This study aimed to evaluate the dislocation rate, complications, and functional scores of revision total hip arthroplasty performed through the direct anterior approach.

METHODS

Between January 2014 and March 2020, 84 patients undergoing revision total hip arthroplasty were retrospectively reviewed. All operations were performed through the direct anterior approach. At the final follow-up, incidences of dislocation, reoperation, acute deep infections, periprosthetic fractures and psoas impingement were assessed. The median postoperative Oxford Hip Score was also calculated.

RESULTS

At revision surgery, the mean age was 66 ± 12 years (range, 28-91). During an average follow-up of 4.2 ± 1.2 years, reoperation rate for major complications in the non-infected revisions was 15% (n = 11), including five acute deep infections (7%), four periprosthetic fractures (5%), one dislocation and one psoas impingement (1%). The median postoperative Oxford Hip Score was 39 (interquartile range = 14).

CONCLUSION

In our series, revision total hip arthroplasty through direct anterior approach was associated with a very low dislocation rate, acceptable complication rates and good functional results. Our results suggest that this procedure is safe and reliable.

TRIAL REGISTRATION

Ethical approval for this study was obtained, before enrollment of the first participant, by CUB Erasme's research ethics committee (P2020/323) and C.H.U Ambroise Paré's research ethics committee.

Satisfactory clinical and radiologic outcomes with a new shorter and modular stem for end-stage hip osteoarthritis: an international prospective multicentre pilot study

Introduction: This multicenter prospective cohort study aimed to assess the safety and clinical and radiologic performance of the CLS® BreviusTM Stem with Kinectiv® Technology. Material and Methods: A total of 222 consecutive subjects, recruited in five different centers, qualifying for primary total hip arthroplasty (THA), were enrolled in the study. All the subjects received the CLS® BreviusTM Stem with Kinectiv® Technology. All the enrolled study subjects underwent pre-operative clinical and radiographic evaluation. Additionally, all subjects underwent post-operative clinical, functional and radiographic evaluations at 6 months and 1, 2, 3, and 5 years. These evaluations included implant survival, pain and functional performance (Harris Hip Score [HHS], University of California, Los Angeles [UCLA] Activity Score, Oxford Hip Score), subject quality-of-life (EQ-5D), radiographic parameters, complications, and concentration of metal ions (aluminum and titanium) in blood. Results: No revisions were performed during the follow-up period. Of the 222 patients, only 76 completed the 5-year follow-up. Only 7 and 5 patients had aluminum and titanium 5-year evaluations, respectively. All the clinical parameters showed an overall improvement in the overtime measured with ANOVA for repeated measures; furthermore, the clinical scores showed a statistically significant improvement at 5 years with respect to pre-operative value (p < 0.001). Aluminum and titanium showed no variation for repeated measures at different time points (p > 0.05). A total of six complications were reported, of which only two were hip-related. Conclusions: The function of the CLS® BreviusTM Stem with Kinectiv® Technology indicated that subject well-being significantly increased following THA regardless of age, gender, BMI, previous surgery, primary diagnosis, and lifestyle.

The direct anterior approach to the hip: a useful tool in experienced hands or just another approach?

The direct anterior approach (DAA) to the hip was initially described in the nineteenth century and has been used sporadically for total hip arthroplasty (THA). However, recent increased interest in tissue-sparing and small incision arthroplasty has given rise to a sharp increase in the utilization of the DAA. Although some previous studies claimed that this approach results in less muscle damage and pain as well as rapid recovery, a paucity in the literature exists to conclusively support these claims. While the DAA may be comparable to other THA approaches, no evidence to date shows improved long-term outcomes for patients compared to other surgical approaches for THA. However, the advent of new surgical instruments and tables designed specifically for use with the DAA has made the approach more feasible for surgeons. In addition, the capacity to utilize fluoroscopy intraoperatively for component positioning is a valuable asset to the approach and can be of particular benefit for surgeons during their learning curve. An understanding of its limitations and challenges is vital for the safe employment of this technique. This review summarizes the pearls and pitfalls of the DAA for THA in order to improve the understanding of this surgical technique for hip replacement surgeons.

Evaluation of Direct Anterior Approach for Revision Total Hip Arthroplasty: A Systematic Review

The direct anterior approach (DAA) is an established approach for total hip arthroplasty (THA) but has been sparingly tried for revisions. The purpose of this study was to examine the available literature in order to consolidate information available on revision THA using the DAA. A PubMed, Embase, and Scopus search was performed using relevant keywords. Studies reporting on patients undergoing revision THA using DAA were included for analysis. In a review of the literature, nine studies matched the pre-decided inclusion criteria with 319 hip joints undergoing revision THA. Mean follow-up of all included studies was 34 months. The indications of revision after primary THA in decreasing order were aseptic loosening (53%), prosthetic joint infection (20.7%), peri-prosthetic fracture (16.9%), dislocation (7.2%), psoas impingement (1.9%), polyethylene wear (1.2%), pain (0.6%), and instability (0.3%). Of the 319 revisions evaluated, 107 underwent a stem revision, 142 underwent cup revision, 49 underwent a combined revision, and 21 underwent isolated liner/head change. A statistically significant improvement in functional score (P<0.05) was observed for all studies reporting on functional outcomes. A low complication rate (51/319, 16.0%), which includes dislocation (12), infection (12), loosening of the acetabular shell (5), peri-prosthetic fractures (6), haematoma (4), and transient nerve palsy (6), was reported. Based on available level III-IV evidence, DAA appears to be a reliable alternative for revision of the failed hip arthroplasty with acceptable complication rates. Evidence of a higher quality is needed to further characterize its role in revision scenarios.

Pelvic discontinuity: a challenge to overcome

Pelvic discontinuity (PD) has been a considerable challenge for the hip revision arthroplasty surgeon. However, not all PDs are the same. Some occur during primary cup insertion, resembling a fresh periprosthetic fracture that separates the superior and inferior portions of the pelvis, while others are chronic as a result of gradual acetabular bone loss due to osteolysis and/or acetabular implant loosening.

In the past, ORIF, various types of cages, bone grafts and bone cement were utilized with little success. Today, the biomechanics and biology of PD as well as new diagnostic tools and especially a variety of new implants and techniques are available to hip revision surgeons. Ultraporous cups and augments, cup-cage constructs and custom triflange components have revolutionized the treatment of PD when used in various combinations with ORIF and bone grafts. For chronic PD the cup-cage construct is the most popular method of reconstruction with good medium-term results.

Dislocation continues to be the leading cause of failure in all situations, followed by infection. Ultimately, surgeons today have a big enough armamentarium to select the best treatment approach. Case individualization, personal experience and improvisation are the best assets to drive treatment decisions and strategies.

Cite this article: EFORT Open Rev 2021;6:459-471. DOI: 10.1302/2058-5241.6.210022

Total hip arthroplasty with reconstruction of acetabulum through direct anterior approach for metastatic bone disease of acetabulum combined with pathological proximal femoral neck fracture: A case report

Most surgical treatment options for metastatic acetabular lesions involve variants of total hip arthroplasty (THA). However, these are technically complex reconstructions performed in very frail patients, and previous reports indicate complications such as dislocation, deep infection, aseptic loosening, and intraoperative death. A 73-year-old man presented to the emergency department at our hospital with right hip pain following a fall. He had undergone nephrectomy for the treatment of right kidney cancer at the age of 68 years. Four years after the nephrectomy, multiple lung metastases, pelvic bone metastases, and right femoral head and neck bone metastases were found. A radiograph of the hip joint showed a pathological proximal femoral fracture with a radiolucent lesion of the acetabulum. THA with acetabular reconstruction using a Kerboull-type (KT) plate through the direct anterior approach (DAA) was performed. After removal of the femoral head, curettage of the metastatic acetabular dome lesion was carefully performed under fluoroscopic guidance. After the KT plate was placed, cementation of the metastatic acetabular dome lesion was performed, and an optimally sized polyethylene liner was fixed with cement. A cemented stem was inserted after confirming the hip joint stability. At the 14-month follow-up, he could walk steadily without any complications and his modified Harris hip score was 100. The DAA conserves soft tissue because it is an intermuscular approach. Accordingly, postoperative recovery is fast and thus associated with a low dislocation rate and effective pain reduction. The acetabulum with metastatic disease was reconstructed using a KT plate for hip joint stability. Bone with metastatic disease that appears adequate at the time of THA may become incompetent after a few years. THA with acetabular reconstruction using a KT plate through the DAA was an effective treatment for metastatic bone disease of the acetabulum combined with pathological proximal femoral neck fracture.

Revision Arthroplasty Through the Direct Anterior Approach Using an Asymmetric Acetabular Component

Despite increasing numbers of primary hip arthroplasties performed through the direct anterior approach (DAA), there is a lack of literature on DAA revision arthroplasty. The present study was performed in order to evaluate outcomes and revision rates after revision through the DAA using an asymmetric acetabular component with optional intra- and extramedullary fixation. In a retrospective cohort study, we analyzed prospectively collected data of 57 patients (61 hips, 43 female, 18 male) who underwent aseptic acetabular component revision through the DAA with the abovementioned implant system between January 2015 and December 2017. The mean follow-up was 40 months (12–56). Survival rates were estimated using the Kaplan–Meier method. All complications were documented and functional outcomes were assessed pre- and postoperatively. Kaplan–Meier analysis revealed an estimated five-year implant survival of 97% (confidence interval CI 87–99%). The estimated five-year survival with revision for any cause was 93% (CI 83–98%). The overall revision rate was 6.6% (n = 4). Two patients had to undergo revision due to periprosthetic infection (3.3%). In one patient, the acetabular component was revised due to aseptic loosening four months postoperatively. Another patient suffered from postoperative iliopsoas impingement and was treated successfully by arthroscopic iliopsoas tenotomy. Two (3.3%) of the revised hips dislocated postoperatively. The mean Harris Hip Score improved from 35 (2–66) preoperatively to 86 (38–100) postoperatively (p < 0.001). The hip joint’s anatomical center of rotation was restored at a high degree of accuracy. Our findings demonstrate that acetabular revision arthroplasty through the DAA using an asymmetric acetabular component with optional intra- and extramedullary fixation is safe and practicable, resulting in good radiographic and clinical midterm results.