Direct anterior total hip arthroplasty: Literature review of variations in surgical technique

The direct anterior approach to the hip has been suggested to have several advantages compared to previously popular approaches through its use of an intra-muscular and intra-nervous interval betweenthe tensor fasciae latae and sartorius muscles. Recent increased interest in tissue-sparing and minimallyinvasive arthroplasty has given rise to a sharp increase in the utilization of direct anterior total hip arthroplasty. A number of variations of the procedure have been described and several authors have published their experiences and feedback to successfully accomplishing this procedure. Additionally, improved understanding of relevant soft tissue constraints and anatomic variants has provided improved margin of safety for patients. The procedure may be performed using speciallydesigned instruments and a fracture table, however many authors have also described equally efficacious performance using a regular table and standard arthroplasty tools. The capacity to utilize fluoroscopy intraoperatively for component positioning is a valuable asset to the approach and can be of particular benefit for surgeons gaining familiarity. Proper management of patient and limb positioning are vital to reducing risk of intra-operative complications. An understanding of its limitations and challenges are also critical to safe employment. This review summarizes the key features of the direct anterior approach for total hip arthroplasty as an aid to improving the understanding of this important and effective method for modern hip replacement surgeons.

Bernese periacetabular osteotomy for hip dysplasia: Surgical technique and indications

For young, active patients with healthy hip cartilage, pelvic osteotomy is a surgical option in to address hip pain and to improve mechanical loading conditions related to dysplasia. Hip dysplasia may lead to arthrosis at an early age due to poor coverage of the femoralhead and abnormal loading of the joint articulation. In patients with symptomatic dysplasia and closed triradiate cartilage(generally over age 10), including adolescents and young adults(generally up to around age 40), the Bernese periacetabular osteotomy(PAO) is a durable technique for addressing underlying structural deformity. The PAO involves a modified Smith-Petersen approach. Advantages of the Bernese osteotomy include preservation of the weight-bearing posterior column of the hemi-pelvis, preservation of the acetabular blood supply, maintenance of the hip abductor musculature, and the ability to effect powerful deformity correction about an ideal center of rotation. There is an increasing body of evidence that preservation of the native hip can be improved through pelvic osteotomy. In contrast to hip osteotomy and joint preservation, the role of total hip arthroplasty in young, active patients with correctable hip deformity remains controversial. Moreover, the durability of hip replacement in young patients is inherently limited. Pelvic osteotomy should be considered the preferred method to address correctable structural deformity of the hip in the young, active patient with developmental dysplasia. The Bernese PAO is technically demanding, yet offers reproducible results with good long-term survivorship in carefully selected patients with preserved cartilage and the ability to meet the demands of rehabilitation.

Surgical management of osteonecrosis of the femoral head in patients with sickle cell disease

Sickle cell disease is a known risk factor for osteonecrosis of the hip.Necrosis within the femoral head may cause severe pain,functional limitations,and compromise quality of life in this patient population.Early stages of avascular necrosis of the hip may be managed surgically with core decompression with or without autologous bone grafting.Total hip arthroplasty is the mainstay of treatment of advanced stages of the disease in patients who have intractable pain and are medically fit to undergo the procedure.The management of hip pathology in sickle cell disease presents numerous medical and surgical challenges,and the careful perioperative management of patients is mandatory.Although there is an increased risk of medical and surgical complications in patients with sickle cell disease,total hip arthroplasty can provide substantial relief of pain and improvement of function in the appropriately selected patient.

Impact of gender and race on expectations and outcomes in total knee arthroplasty

BACKGROUND Total joint arthroplasty is one of the most common surgeries performed in the United States with total knee arthroplasty(TKA)being one of the most successful surgeries for restoring function and diminishing pain.Even with the demonstrated success of TKA and a higher prevalence of arthritis and arthritis related disability among minorities,racial and gender disparity remains a constant issue in providing care for the adult reconstruction patient.AIM To assess the role of demographics and expectations on differences in perioperative patient reported outcomes(PRO)following TKA.METHODS One hundred and thirty-three patients scheduled for primary unilateral TKA secondary to moderate to severe osteoarthritis were enrolled in this twoinstitution prospective study.Validated PRO questionnaires were collected at four time points.Statistical analysis was conducted to determine the impact of gender,ethnic background and expectation surveys responses to assess PRO at these time points.RESULTS Females were associated with worse preoperative Knee Injury and Osteoarthritis Outcome Scores(KOOS)for symptoms,pain,and activities of daily living.African Americans were associated with worse KOOS for pain,activities of daily living,and quality of life.Despite worse preoperative scores,no difference was noted in these categories between the groups postoperatively.Additionally,all pre-operative psychometric scales were equivalent across groups except Geriatric Depression scale,which was significantly different between groups within the Race and Age Group(P<0.05).Conversely,Pain Catastrophizing Scale,was significantly different for all subscales and total score within Age Group(P<0.05),and the Magnification,Helplessness subscales as well as the Total score were significantly different between groups for Race and Relationship Status(P<0.01).CONCLUSION We conclude that female and African American patients have lower preoperative KOOS scores compared to white male patients.No postoperative differences in outcomes between these groups.

Direct anterior total hip arthroplasty:Comparative outcomes and contemporary results

Direct anterior total hip arthroplasty has become increasingly more popular among arthroplasty surgeons,in large part due to the use of an intramuscular interval and desire to reduce soft tissue damage.Several studies have now been published comparing the anterior intramuscular to other commonly used approaches,and many studies have published complication rates on large series of patients.Review of comparative studies indicates direct anterior hips tend towards shorter hospital stays and high rates of patients discharged to home.Although some studies show evidence of early benefit in functional outcomes,there is no strong evidence that the anterior approach provides any long term functional improvements compared to other approaches.Additionally,evidence to support reduced damage to soft tissue may not translate to certain clinical significance.Rates of intra-operative femur fracture,operative time and blood loss rates are notably higher for those developing familiarity with this approach.However,when surgeons have performed a modest number of procedures,the complication rates tend to markedly decrease in most studies to levels comparable to other approaches.Accuracy of component positioning also favors the anterior approach in some studies.This review summarizes the available literature comparing the direct anterior to other approaches for total hip arthroplasty and provides a comprehensive summary of common complications.