Open Surgical Treatment: Advantages and Potential Complications of Modern Surgical Approaches

Abstract

Although the arthroscopic treatment of hip diseases has experienced enormous popularity with an explosion in surgical techniques and instruments to treat a vast array of pathologies, there are limitations to hip arthroscopy. There are certain conditions that are better addressed through open approaches and certainly many procedures where arthroscopy is not an option, like open reduction and internal fixation of pelvic fracture or total hip arthroplasty (THA). Many open approaches to the hip exist and hip surgeons should be facile with most, if not all, of these approaches. Certain surgical procedures demand the use of a specific approach, for example, the sliding trochanteric osteotomy for surgical dislocation of the hip or a posterior approach for the fixation of a posterior column fracture, but for most procedures, more than one approach can safely and effectively be used. There are specific approaches that are almost exclusively used for pediatric patients and pediatric diseases, such as the Ludloff and Ferguson approaches, that will not specifically be addressed in this chapter. The choice of approach is often based on surgeon comfort level, experience, the need for an extensile approach, or perceived benefits of one approach over another. As most of the reports of complications regarding various approaches to the hip have been reported in relation to THA, data presented in the chapter will necessarily be biased toward hip arthroplasty, but fundamentally similar for any surgery performed through a specific approach.

The zeal for potential benefits of different open approaches can sometimes overshadow the potential complications. In THA, for example, the two-incision approach was touted as a muscle sparing, minimally invasive approach for total hip replacement that resulted in early recovery, reduced pain, and high levels of patient satisfaction. As many surgeons began to adopt this technique and it was critically studied (Della Valle et al., Clin Orthop Relat Res 468:3348–54, 2010), it became clear that these advantages were most likely due to the perioperative management protocols rather than the surgical approach itself and that this approach was associated with higher rates of complications compared to other approaches (Bal et al., J Bone Joint Surg Am 87: 2432–8, 2005). Potential complications of a surgical approach should be clearly understood from the etiology to rates of occurrence so that the surgeon may make the optimal choice of approach for each individual patient.