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Total Hip Arthroplasty by the Direct Anterior Approach Using a Neck-preserving Stem

Safety, efficacy and learning curve

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Abstract

Background

The concept of femoral neck preservation in total hip replacement (THR) was introduced in 1993. It is postulated that retaining cortical bone of the femoral neck offers triplanar stability, uniform stress distribution, and accommodates physiological anteversion. However, data on safety, efficacy and learning curve are lacking.

Materials and Methods

We prospectively assessed all patients who were operated for a THR with a short neck preserving stem (MiniHip) between 2012 and 2014. The safety and learning curve were assessed by recording operative time; stem size; and adverse events including periprosthetic fracture; paresthesia; and limb length discrepancy (LLD). The cohort was divided into equal groups to assess the learning curve effect, and the cumulative sums (CUSUM) test was performed to monitor intraoperative neck fractures. For assessment of efficacy, Oxford Hip Score (OHS) and Short Form-36 (SF-36) scores were compared preoperatively and postoperatively.

Results

138 patients with median age 62 years (range 35–82 years) were included with a median followup of 42 months (range 30–56 months). The minimum followup was 2.5 years. The OHS, SF-36 (physical and mental component) scores improved by a mean score of 26, 28, and 27 points, respectively. All patients had LLD of <10 mm (1.9 mm ± 1.3). Adverse events included intraoperative neck fracture (n = 6), subsidence (n = 1), periprosthetic fracture (n = 1), paresthesia (n = 12), and trochanteric bursitis (n = 2). After early modification of the technique to use a smaller finishing broach, the CUSUM test demonstrated acceptable intraoperative neck fracture risk. The second surgery group had a reduced risk of intraoperative neck fracture (5/69 vs. 1/69 P = 0.2), reduced operative time (66 vs. 61 min, P = 0.06), and increased stem size (5 vs. 6, P = 0.09) although these differences were not statistically significant.

Conclusions

The MiniHip stem is safe alternative to standard THR with good functional outcomes but with a learning curve for the surgical technique, implants sizing, and the risk of intraoperative neck fractures.

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References

  1. Cross M, Smith E, Hoy D, Nolte S, Ackerman I, Fransen M, et al. The global burden of hip and knee osteoarthritis: Estimates from the global burden of disease 2010 study. Ann Rheum Dis 2014;73:1323–30.

    Article  PubMed  Google Scholar 

  2. Capello WN, D’Antonio JA, Jaffe WL, Geesink RG, Manley MT, Feinberg JR. Hydroxyapatite-coated femoral components: 15-year minimum followup. Clin Orthop Relat Res 2006;453:75–80.

    Article  PubMed  Google Scholar 

  3. Meding JB, Galley MR, Ritter MA. High survival of uncemented proximally porous-coated titanium alloy femoral stems in osteoporotic bone. Clin Orthop Relat Res 2010;468:441–7.

    Article  PubMed  Google Scholar 

  4. Pivec R, Johnson AJ, Mears SC, Mont MA. Hip arthroplasty. Lancet 2012;380:1768–77.

    Article  PubMed  Google Scholar 

  5. Bourne RB, Rorabeck CH. A critical look at cementless stems. Taper designs and when to use alternatives. Clin Orthop Relat Res 1998;355:212–23.

    Article  Google Scholar 

  6. Khanuja HS, Vakil JJ, Goddard MS, Mont MA. Cementless femoral fixation in total hip arthroplasty. J Bone Joint Surg Am 2011;93:500–9.

    Article  PubMed  Google Scholar 

  7. Engh CA, Bobyn JD, Glassman AH. Porous-coated hip replacement. The factors governing bone ingrowth, stress shielding, and clinical results. J Bone Joint Surg Br 1987;69:45–55.

    Article  CAS  PubMed  Google Scholar 

  8. Lavernia C, D’Apuzzo M, Hernandez V, Lee D. Thigh pain in primary total hip arthroplasty: The effects of elastic moduli. J Arthroplasty 2004;19 7 Suppl 2:10–6.

    Article  PubMed  Google Scholar 

  9. Patel RM, Stulberg SD. The rationale for short uncemented stems in total hip arthroplasty. Orthop Clin North Am 2014;45:19–31.

    Article  PubMed  Google Scholar 

  10. Benedetti MG, Berti L, Frizziero A, Ferrarese D, Giannini S. Functional recovery after hip resurfacing and rehabilitation. J Sport Rehabil 2012;21:167–74.

    Article  PubMed  Google Scholar 

  11. Su EP, Sheehan M, Su SL. Comparison of bone removed during total hip arthroplasty with a resurfacing or conventional femoral component: A cadaveric study. J Arthroplasty 2010;25:325–9.

    Article  PubMed  Google Scholar 

  12. Khanuja HS, Banerjee S, Jain D, Pivec R, Mont MA. Short bone-conserving stems in cementless hip arthroplasty. J Bone Joint Surg Am 2014;96:1742–52.

    Article  PubMed  Google Scholar 

  13. Lachiewicz PF. Metal-on-metal hip resurfacing: A skeptic’s view. Clin Orthop Relat Res 2007;465:86–91.

    PubMed  Google Scholar 

  14. Posada OM, Tate RJ, Grant MH. Toxicity of cobalt-chromium nanoparticles released from a resurfacing hip implant and cobalt ions on primary human lymphocytes in vitro. J Appl Toxicol 2015;35:614–22.

    Article  CAS  PubMed  Google Scholar 

  15. Mannan K, Freeman MA, Scott G. The Freeman femoral component with hydroxyapatite coating and retention of the neck: An update with a minimum followup of 17 years. J Bone Joint Surg Br 2010;92:480–5.

    Article  CAS  PubMed  Google Scholar 

  16. Pipino F, Molfetta L. Femoral neck preservation in total hip replacement. Ital J Orthop Traumatol 1993;19:5–12.

    CAS  PubMed  Google Scholar 

  17. Rajakulendran K, Field RE. Neck-preserving femoral stems. HSS J 2012;8:295–303.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Daniel J, Pradhan C, Ziaee H, McMinn DJ. A clinicoradiologic study of the Birmingham Mid-Head Resection device. Orthopedics 2008;31 12 Suppl 2. pii: http://orthosupersite.com/view.asp?rID=37186.

    Google Scholar 

  19. Waller C. The Silent Hip ‘Neck Only’ prosthesis in total hip replacemen. Prospective study with a minimum 2-year follow up. Clinical and radiographic review. Orthop Proc 2012;94-B Suppl XXIII: 227.

    Google Scholar 

  20. Ettinger M, Ettinger P, Lerch M, Radtke K, Budde S, Ezechieli M, et al. The NANOS short stem in total hip arthroplasty: A mid term followup. Hip Int 2011;21:583–6.

    Article  PubMed  Google Scholar 

  21. Carlsson LV, Albrektsson BE, Albrektsson BG, Albrektsson TO, Jacobsson CM, Macdonald W, et al. Stepwise introduction of a bone-conserving osseointegrated hip arthroplasty using RSA and a randomized study: I. Preliminary investigations-52 patients followed for 3 years. Acta Orthop 2006;77:549.

    Article  PubMed  Google Scholar 

  22. Kim YH, Kim JS, Joo JH, Park JW. A prospective short-term outcome study of a short metaphyseal fitting total hip arthroplasty. J Arthroplasty 2012;27:88–94.

    Article  PubMed  Google Scholar 

  23. Molli RG, Lombardi AV Jr., Berend KR, Adams JB, Sneller MA. A short tapered stem reduces intraoperative complications in primary total hip arthroplasty. Clin Orthop Relat Res 2012;470:450–61.

    Article  PubMed  Google Scholar 

  24. Morrey BF, Adams RA, Kessler M. A conservative femoral replacement for total hip arthroplasty. A prospective study. J Bone Joint Surg Br 2000;82:952–8.

    Article  CAS  PubMed  Google Scholar 

  25. Falez F, Casella F, Panegrossi G, Favetti F, Barresi C. Perspectives on metaphyseal conservative stems. J Orthop Traumatol 2008;9:49–54.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Wittenberg RH, Steffen R, Windhagen H, Bücking P, Wilcke A. Five-year results of a cementless short-hip-stem prosthesis. Orthop Rev (Pavia) 2013;5:e4.

    Article  Google Scholar 

  27. Schmidutz F, Graf T, Mazoochian F, Fottner A, Bauer-Melnyk A, Jansson V. Migration analysis of a metaphyseal anchored short-stem hip prosthesis. Acta Orthop 2012;83:360–5.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Nowak M, Nowak TE, Schmidt R, Forst R, Kress AM, Mueller LA. Prospective study of a cementless total hip arthroplasty with a collum femoris preserving stem and a trabeculae oriented pressfit cup: Minimun 6-year followup. Arch Orthop Trauma Surg 2011;131:549–55.

    Article  PubMed  Google Scholar 

  29. Kendoff DO, Citak M, Egidy CC, O’Loughlin PF, Gehrke T. Eleven-year results of the anatomic coated CFP stem in primary total hip arthroplasty. J Arthroplasty 2013;28:1047–51.

    Article  PubMed  Google Scholar 

  30. Ender SA, Machner A, Pap G, Hubbe J, Grashoff H, Neumann HW. Cementless CUT femoral neck prosthesis: Increased rate of aseptic loosening after 5 years. Acta Orthop 2007;78:616–21.

    Article  PubMed  Google Scholar 

  31. Ender SA, Machner A, Pap G, Grasshoff H, Neumann HW. The femoral neck prosthesis CUT. Three- to six-year results. Orthopade 2006;35:841–7.

    Article  CAS  PubMed  Google Scholar 

  32. Ishaque BA, Gils J, Wienbeck S, Donle E, Basad E, Stürz H. Results after replacement of femoral neck prostheses-thrust plate prosthesis (TPP) versus ESKA cut prosthesis. Z Orthop Unfall 2009;147:79–88.

    Article  CAS  PubMed  Google Scholar 

  33. Corner JA, Rawoot A, Parmar HV. The thrust plate prosthesis in the treatment of osteoarthritis of the hi. Clinical and radiological outcome with minimum 5-year followup. Hip Int 2008;18:88–94.

    Article  CAS  PubMed  Google Scholar 

  34. Schmidutz F, Steinbrück A, Wanke-Jellinek L, Pietschmann M, Jansson V, Fottner A. The accuracy of digital templating: A comparison of short-stem total hip arthroplasty and conventional total hip arthroplasty. Int Orthop 2012;36:1767–72.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Wedemeyer C, Quitmann H, Xu J, Heep H, von Knoch M, Saxler G. Digital templating in total hip arthroplasty with the Mayo stem. Arch Orthop Trauma Surg 2008;128:1023–9.

    Article  PubMed  Google Scholar 

  36. Zeh A, Pankow F, Röllinhoff M, Delank S, Wohlrab D. A prospective dual-energy x-ray absorptiometry study of bone remodeling after implantation of the Nanos short-stemmed prosthesis. Acta Orthop Belg 2013;79:174–80.

    PubMed  Google Scholar 

  37. Lazarinis S, Mattsson P, Milbrink J, Mallmin H, Hailer NP. A prospective cohort study on the short Collum Femoris-Preserving (CFP) stem using RSA and DXA. Primary stability but no prevention of proximal bone loss in 27 patients followed for 2 years. Acta Orthop 2013;84:32–9.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Götze C, Ehrenbrink J, Ehrenbrink H. Is there a bone-preserving bone remodelling in short-stem prosthesis? DEXA analysis with the Nanos total hip arthroplasty. Z Orthop Unfall 2010;148:398–405.

    Article  PubMed  Google Scholar 

  39. Jerosch J, Grasselli C, Kothny C. Early and midterm clinical results with the MiniHip short stem replacement. Dtsch Arzte Verlag Orthopädie und Unfallchirurgie Praxis, 2012;1:202.

    Google Scholar 

  40. Jerosch J, Grasselli C, Kothny PC, Litzkow D, Hennecke T. Reproduction of the anatomy (offset, CCD, leg length) with a modern short stem hip design — A radiological study. Z Orthop Unfall 2012;150:20–6.

    Article  CAS  PubMed  Google Scholar 

  41. Schmidutz F, Beirer M, Weber P, Mazoochian F, Fottner A, Jansson V. Biomechanical reconstruction of the hip: Comparison between modular short-stem hip arthroplasty and conventional total hip arthroplasty. Int Orthop 2012;36:1341–7.

    Article  PubMed  PubMed Central  Google Scholar 

  42. van Oldenrijk J, Molleman J, Klaver M, Poolman RW, Haverkamp D. Revision rate after short-stem total hip arthroplasty: A systematic review of 49 studies. Acta Orthop 2014;85:250–8.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Dorr LD, Faugere MC, Mackel AM, Gruen TA, Bognar B, Malluche HH. Structural and cellular assessment of bone quality of proximal femur. Bone 1993;14:231–42.

    Article  CAS  PubMed  Google Scholar 

  44. Pijls BG, Dekkers OM, Middeldorp S, Valstar ER, van der Heide HJ, Van der Linden-Van der Zwaag HM, et al. AQUILA: Assessment of quality in lower limb arthroplasty. An expert Delphi consensus for total knee and total hip arthroplasty. BMC Musculoskelet Disord 2011;12:173.

    Article  PubMed  PubMed Central  Google Scholar 

  45. McTighe T, Keggi J, Stulberg D, Keppler L, Brazil D, McPherson E. Total hip stem classification system. Reconstr Rev 2014;4:823–849.

    Google Scholar 

  46. Petis S, Howard JL, Lanting BL, Vasarhelyi EM. Surgical approach in primary total hip arthroplasty: Anatomy, technique and clinical outcomes. Can J Surg 2015;58:128–39.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Redmond JM, Gupta A, Hammarstedt JE, Petrakos AE, Finch NA, Domb BG. The learning curve associated with robotic-assisted total hip arthroplasty. J Arthroplasty 2015;30:50–4.

    Article  PubMed  Google Scholar 

  48. Wang J, Higuchi F. Application of Dall-Miles cable grip system for transtrochanteric osteotomy. Kurume Med J 1997;44:1–6.

    Article  CAS  PubMed  Google Scholar 

  49. Healy WL, Iorio R, Clair AJ, Pellegrini VD, Della Valle CJ, Berend KR. Complications of total hip arthroplasty: Standardized list, definitions, and stratification developed by the Hip Society. Clin Orthop Relat Res 2015;474:357–64.

    Article  PubMed Central  Google Scholar 

  50. Sink EL, Leunig M, Zaltz I, Gilbert JC, Clohisy J; Academic Network for Conservational Hip Outcomes Research Group. Reliability of a complication classification system for orthopaedic surgery. Clin Orthop Relat Res 2012;470:2220–6.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Lim CR, Harris K, Dawson J, Beard DJ, Fitzpatrick R, Price AJ. Floor and ceiling effects in the OHS: An analysis of the NHS PROMs data set. BMJ Open 2015;5:e007765.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Ware JE Jr. John E. Ware Jr. on health status and quality of life assessment and the next generation of outcomes measurement. Interview by Marcia Stevic and Katie Berry. J Healthc Qual 1999;21:12–7.

    PubMed  Google Scholar 

  53. Biau DJ, Milet A, Thévenin F, Anract P, Porcher R. Monitoring surgical performance: An application to total hip replacement. J Eval Clin Pract 2009;15:420–4.

    Article  PubMed  Google Scholar 

  54. Gaski GE, Scully SP. In brief: Classifications in brief: Vancouver classification of postoperative periprosthetic femur fractures. Clin Orthop Relat Res 2011;469:1507–10.

    Article  PubMed  Google Scholar 

  55. Dettmer M, Pourmoghaddam A, Kreuzer SW. Comparison of patient-reported outcome from neck-preserving, short-stem arthroplasty and resurfacing arthroplasty in younger osteoarthritis patients. Adv Orthop 2015;2015:817689.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Russo MW, Macdonell JR, Paulus MC, Keller JM, Zawadsky MW. Increased complications in obese patients undergoing direct anterior total hip arthroplasty. J Arthroplasty 2015;30:1384–7.

    Article  PubMed  Google Scholar 

  57. Lombardi AV Jr., Berend KR, Adams JB. A short stem solution: Through small portals. Orthopedics 2009;32. pii: http://orthosupersite.com/view.asp?rID=42833.

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Research, School of Medicine, University of Notre Dame Australia, Darlinghurst, Sydney, New South Wales, Australia

    Aditya Khemka, Omar Mograby, Sarah J. Lord & Munjed Al Muderis

  2. Department of Orthopaedics, Norwest Private Hospital, Bella Vista, Sydney, New South Wales, Australia

    Aditya Khemka & Munjed Al Muderis

  3. National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia

    Sarah J. Lord

  4. Department of Epedemiology, Rural Clinical School, University of Notre Dame Australia, Fremantle, Sydney, New South Wales, Australia

    Zelda Doyle

  5. Department of Orthopaedics, The Australian School of Advanced Medicine, Macquarie University, Sydney, New South Wales, Australia

    Munjed Al Muderis

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  1. Aditya Khemka
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Correspondence to Aditya Khemka.

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Khemka, A., Mograby, O., Lord, S.J. et al. Total Hip Arthroplasty by the Direct Anterior Approach Using a Neck-preserving Stem. IJOO 52, 124–132 (2018). https://doi.org/10.4103/ortho.IJOrtho_314_16

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  • DOI: https://doi.org/10.4103/ortho.IJOrtho_314_16

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