Kazuhiro Oinuma

Total hip arthroplasty by a minimally invasive, direct anterior approach.

ZusammenfassungOperationszielImplantation einer Hüfttotalendoprothese über einen direkten vorderen Zugang zum Hüftgelenk mit minimaler Traumatisierung des umgebenden Gewebes.IndikationenKonventionelle Totalendoprothetik des Hüftgelenks ungeachtet des Alters oder der Knochenqualität.KontraindikationenDestruktion des proximalen Femurs bei Tumor oder Fraktur.Ausgeprägte Dysplasie oder Hüftluxation.Übergewicht (Body-Mass-Index [BMI] > 30 kg/m2) ist besonders während der Lernkurve als relative Kontraindikation zu werten.OperationstechnikRückenlage des Patienten mit der Möglichkeit der Hyperextension des Hüftgelenks in der Tischmitte, um die Darstellung des Femurs zu erleichtern.Vorderer Hautschnitt von 6–9 cm Länge, beginnend etwa 2 cm lateral und 5 cm distal der Spina iliaca anterior.Inzision der Faszie, stumpfes Präparieren des intermuskulären Raums zwischen dem Musculus tensor fasciae latae und dem Musculus sartorius. Ausschneiden der vorderen Kapselanteile.Osteotomie des Femurhalses, Entfernung des Kopfes. Fräsen des Azetabulums und Implantation der Pfanne. Darstellung des Femurs durch Hyperextension, Adduktion und Außenrotation des Beins, Inzision der hinteren Kapsel zur leichteren Vorverlagerung des Femurs. Vorbereiten des Implantatlagers und Implantation des Schafts.Ergebnisse116 Hüften bei 111 Patienten wurden zwischen August 2004 und Dezember 2005 mit der vorgestellten Technik operiert. 17 Patienten wurden aufgrund von Frakturen oder ausgeprägter Dysplasie (Crowe 3 und 4) ausgeschlossen. Das Durchschnittsalter der Patienten betrug 62,5 Jahre (46–84 Jahre), der durchschnittliche BMI lag bei 23,1 kg/m2 (18,1–37,7 kg/m2). Die Implantation der Totalendoprothese der Hüfte wurde bei allen Patienten sicher bewerkstelligt. Wesentliche intraoperative Komplikationen mit Verfahrenswechsel kamen nicht vor. Die durchschnittliche Operationszeit betrug 79 min (45–150 min). Die Operationsdauer verkürzte sich im Lauf der Studie. Die durchschnittliche präoperative Bewertung nach der Skala der Japanischen Orthopädischen Vereinigung (JOA) lag bei 47,2 Punkten (18–63 Punkte) und verbesserte sich 3 Monate nach der Operation auf durchschnittlich 92,3 Punkte (67–100 Punkte; p < 0,001). Bei der letzten Nachuntersuchung nach durchschnittlich 17 Monaten (9–26 Monate) betrug die Punktzahl 94,2 (72–100).AbstractObjectiveImplantation of a total hip replacement device through a direct anterior approach to the hip joint with minimal trauma to adjacent tissue.IndicationsAll conventional total hip replacements, irrespective of age and bone quality.ContraindicationsDestruction of the proximal femur (tumor, fracture).Severe dysplasia and hip dislocation.Morbid obesity (body mass index [BMI] > 30 kg/m2) can be a relative contraindication during the learning curve.Surgical TechniqueSupine position of the patient on the operating table with the possibility of hyperextension in the mid-table in order to facilitate femoral exposure.Anterior incision, 6–9 cm long, starting approximately 2 cm lateral and 5 cm distal of the anterior iliac spine.Incision of the fascia, blunt preparation in the intermuscular space between tensor fasciae latae muscle and sartorius muscle. Excision of the anterior parts of the capsule.Osteotomy of the femoral neck, removal of the head. Reaming of the acetabulum and implantation of the acetabular component. Exposure of the femur by hyperextension, adduction and external rotation of the leg, incision of the posterior capsule for easy anteriorization of the femur. Reaming and implantation of the femoral component.Results116 consecutive hips in 111 patients were operated on between August 2004 and December 2005. 17 patients were excluded due to fracture or severe dysplasia (Crowe 3 and 4). Mean age was 62.5 years (range, 46–84 years), mean BMI amounted to 23.1 kg/m2 (range, 18.1–37.7 kg/m2).The implantation of a total hip replacement device could be accomplished safely in all patients. No severe intraoperative complication requiring a change of the planned procedure or any additional surgical measures was noted. Mean surgical time was 79 min (45–150 min). The operative time was decreasing gradually during the study period.The mean preoperative Japanese Orthopaedic Association (JOA) score of 47.2 points (range, 18–63 points) improved to 92.3 points (range, 67–100 points) at 3 months postoperatively (p < 0.001) and 94.2 (range, 72–100 months) at the latest follow-up at an average of 17 months (range, 9–26 months).

Hip dysfunction-related urinary incontinence: a prospective analysis of 189 female patients undergoing total hip arthroplasty.

Patients reporting that their symptoms of urinary incontinence have decreased after total hip arthroplasty can be encountered in orthopedic practice. In this questionnaire‐based study, we prospectively evaluated the symptoms of urinary incontinence before and after total hip arthroplasty. The International Consultation on Incontinence Questionnaire‐Short Form was used to prospectively evaluate these symptoms in 189 consecutive female patients undergoing total hip arthroplasty. The patients were asked to fill in a questionnaire before and 3 months after surgery. A decrease in the International Consultation on Incontinence Questionnaire‐Short Form score of ≥1 point was defined as an improvement, whereas an increase of ≥1 point was defined as worsening. A total of 81 (43%) patients reported urinary incontinence before total hip arthroplasty. At 3 months after surgery, symptoms of urinary incontinence were improved in 64% of these patients, remained unchanged in 32% and worsened in 4%. Mean International Consultation on Incontinence Questionnaire‐Short Form score in patients with urinary incontinence before surgery significantly improved from 6.0 to 3.5 (P = 0.0002). These findings suggest a relationship between hip joint function and pelvic floor function, and consequently a hip dysfunction‐related urinary incontinence.

Total Hip Arthroplasty with Subtrochanteric Shortening Osteotomy for Crowe Grade 4 Dysplasia Using the Direct Anterior Approach

Between September 2006 and June 2011, 1521 primary total hip arthroplasties were performed using the direct anterior approach on a standard surgical table. In 12 hips, subtrochanteric shortening osteotomy was required. Full weight bearing was allowed 1 week after surgery. The mean follow-up period was 3.7 years. All patients limped preoperatively, but no patient had a positive Trendelenburg or Duchenne limp at the last follow-up. On the basis of our findings, we believe that the direct anterior approach is a safe and reproducible technique for total hip arthroplasty with subtrochanteric shortening osteotomy in the case of Crowe grade 4 dysplasia. It allows the steady recovery of the abductor muscles, a shorter period to postoperative partial weight bearing, and elimination of limping.

Total Hip Arthroplasty after Previous Acetabular Osteotomy: Comparison of Three Types of Acetabular Osteotomy.

To compare surgical results of total hip arthroplasty (THA) following acetabular osteotomy, operative records of 13 hips following Chiari osteotomy (Chiari group), 22 hips following rotational periacetabular osteotomy (RAO; RAO group), 16 hips following shelf acetabuloplasty (Shelf group), and 2475 hips without previous osteotomy (Control group) were retrospectively reviewed. The operative time was significantly longer in the RAO group than in the Control group. Bulk bone augmentation was required more often in the Chiari and RAO groups than in the Control group. An early migration of the acetabular cup occurred in 2 hips in the RAO group. RAO made conversion to THA more complicated than did the Chiari osteotomy or the shelf acetabuloplasty.

Epidemiology of Dislocation Following Direct Anterior Total Hip Arthroplasty: A Minimum 5-Year Follow-Up Study.

BACKGROUND The cumulative mid- to long-term risk of dislocation following total hip arthroplasty is considerably greater than has been reported in short-term studies. We retrospectively investigated the epidemiology of first-time dislocation following total hip arthroplasty using 28-mm heads through the direct anterior approach in patients with hip dysplasia who were followed up for more than 5 years. METHODS The operative records of 871 hips in 790 consecutive patients were reviewed to determine the incidence of postoperative first-time dislocation. RESULTS The mean follow-up duration was 7.8 (range, 5.6-11.7) years. The direct anterior approach was used for all hips. Postoperative dislocation was observed in 8 hips (0.92%) in 8 patients. First-time dislocation occurred during the first 3 weeks in 6 hips (75%). The cumulative risk of postoperative dislocation was 0.69% at 1 month, 0.80% at 1 year, and 0.93% at 5 years. One patient underwent revision surgery for recurrent dislocation within the first month due to malalignment of the cup. CONCLUSION Our findings demonstrated that the direct anterior approach limits the time of dislocation to the very early postoperative period; that is, the risk of a first-time dislocation after the first month is considerably low. Preserving muscular structures may contribute to continuous dynamic stability of the hip, which could explain the slight increase in the cumulative risk of first-time dislocation.

An anatomic study of the impressions on the greater trochanter: bony geometry indicates the alignment of the short external rotator muscles.

In this study, 44 hip regions from 25 embalmed cadavers were dissected to identify the bony landmarks on the greater trochanter, which indicate the individual short external rotator muscle insertions. Micro-computed tomography (micro-CT) images were obtained to identify the bony impressions on the greater trochanter. Then, the soft tissues were removed and their insertions were identified to assess correlation with micro-CT images. Bony landmarks indicating the insertions and the running course of the piriformis muscle, the obturator internus muscle, and the obturator externus muscle were identified on the greater trochanter in all specimens. These findings could be helpful for preserving muscles during capsular release in the anterior approach because the alignment of the short external rotator muscles can be estimated preoperatively using CT images.

Cementless Tapered-Wedge Stem Length Affects the Risk of Periprosthetic Femoral Fractures in Direct Anterior Total Hip Arthroplasty

BACKGROUND Although the popularity of the direct anterior approach for total hip arthroplasty has increased, the femoral procedure in this approach is considered technically challenging, and one of the most frequent complications reported was periprosthetic femoral fractures. The present study aimed to identify factors for predicting the risk of periprosthetic femoral fractures after using stems with a cementless tapered-wedge design through the direct anterior approach. METHODS We retrospectively assessed the medical records of 686 patients (851 hips) who underwent primary total hip arthroplasty using a single stem with a cementless tapered-wedge design having a short or standard length option. The direct anterior approach on a standard operating table was used for all hips. Multivariate logistic regression analysis was performed to identify the independent predictors of intraoperative and early postoperative periprosthetic fractures. RESULTS Seventeen periprosthetic femoral fractures (2.0%) were observed, including 10 intraoperative (1.2%) and 7 postoperative (0.8%) fractures. The occurrence rate of fractures using short stems was significantly higher compared with that using standard stems. The multivariate logistic regression analysis revealed that only stem length was significantly associated with periprosthetic fractures. CONCLUSION Our results indicate that the stem design affects the risk of periprosthetic femoral fractures.

Total hip arthroplasty through a direct anterior approach for fused hips

Introduction Conversion to total hip arthroplasty (THA) from a fused hip is a challenging procedure because of the technical difficulties involved. Here we report the surgical procedure and the early clinical outcome of conversion THA from a fused hip through a direct anterior approach. Methods 9 consecutive THAs following hip fusion were performed in 9 patients. Of these, 6 patients had undergone surgical hip fusion and 3 patients had nonsurgical fusion. Results The mean time interval between fusion and THA was 29.7 years. The mean follow-up period was 5.2 years. All THAs were performed using a direct anterior approach on a standard surgical table. The mean operative time was 68.7 minutes. The mean intraoperative blood loss was 377 g. All acetabular components were placed within Lewinneks safe zone. The mean Japanese Orthopaedic Hip Score significantly improved from 54.0 to 73.2. One early anterior dislocation occurred and was treated conservatively. No revision surgery was required. Conclusions The direct anterior approach allows for an accurate and less invasive implantation of the total hip components.

Acetabular revision using a Kerboull-type reinforcement device through direct anterior approach:

Background: The direct anterior approach has gained popularity in total hip arthroplasty (THA) over the past decade. However, there are few reports that describe the use of this approach for cases of complex revision. The purpose of this study was to report the surgical procedure and early clinical results of acetabular revision in the presence of bone defects using a Kerboull-type reinforcement device through the direct anterior approach. Methods: Eleven patients who had undergone acetabular reconstruction using a Kerboull-type reinforcement device for aseptic or septic loosening bone defects were enrolled. All procedures were performed using the direct anterior approach on a standard operating table. The mean age was 71.8 years, the mean period from initial surgery to revision THA was 14.5 years, and the mean follow-up period was 19.8 months. Results: The Kerboull-type acetabular reinforcement device with cemented cup combined with allogenic femoral head bone grafts was used in all hips. The mean operative time and intraoperative blood loss were 148 min and 743 g, respectively. None of the patients required allogeneic blood transfusion. One patient required revision surgery 11 months postoperatively because of device displacement. No other major or minor orthopedic complications were observed. Conclusion: The direct anterior approach allows for less invasive acetabular reconstruction using a Kerboull-type reinforcement device.

Natural Remission of Major Periprosthetic Osteolysis following Total Hip Arthroplasty with Metal-on-Metal Bearings

The natural course of adverse events following the use of metal-on-metal (MoM) bearings in total hip arthroplasty (THA) is not well known. In this article, we report the case of a patient with asymptomatic major acetabular osteolysis following MoM THA that diminished gradually without any surgical intervention. A 58-year-old male underwent one-stage bilateral MoM THA for bilateral osteoarthritis. Four years after THA, major acetabular osteolysis developed in his right hip without any local or systemic symptoms. The patient underwent a careful radiographic and clinical observation without any surgical intervention because he did not want to undergo revision surgery. The lesion gradually diminished after 7 years, and most of the osteolytic area was replaced by newly formed bone at 10 years. He continues to be followed with no evidence of cup loosening or migration. Our observation suggests that a periprosthetic osteolytic change related to the use of MoM bearings has the potential for natural remission.