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Tissue preserving total hip arthroplasty using superior capsulotomy

Gewebeerhaltende Hüft-TEP-Operation mit superiorer Kapsulotomie

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Abstract

Objective

The goals of a tissue-preserving minimally invasive approach to the hip are to allow early short-term recovery, achieve hip joint stability, minimize muscle strength loss from surgery, spare the peri-articular soft tissues, and allow unrestricted motion in the long term.

Indications

Hip arthroplasty in patients with no pre-existing hardware, with a sufficient space between the acetabular rim and greater trochanter; management of subcapital femoral fractures in older patients.

Contraindications

Protrusio acetabuli. Joint stiffness. This is the main concern when undertaking the superior capsulotomy. Stiffness may result from bone causes, including ankylosis, large osteophytes, bone bridges etc., extra-articular retraction of surrounding soft tissues with capsular contracture of both ligaments and muscles, or a combination of bony and soft tissues causes, resulting in limited adduction. Indeed, maximal adduction is necessary to increase the distance between the apex of the greater trochanter and the superior acetabular edge. In the approach described in the present article, the real limitation is the impossibility to introduce a straight stem through the trochanteric fossa without weakening the trochantericarea. If adduction is restricted, excessive lateralization of the femoral stem would result in postoperative pain and discomfort, especially as we advocate immediate full weight bearing. Even though patients fare better when the trochanteric area is intact, many types of stem such as the GTS (Biomet), or stem Microplasty (Biomet) or even stem Parva (Adler Ortho) may pressurize the internal bone of the trochanteric structures. Therefore, these stems may be implanted in maximal hip adduction. This is the case in coxa profunda or coxa vara, which require more invasive and destabilizing surgical approaches.

Surgical technique

Lateral position, 5–8 cm incision from the tip of the greater trochanter, identification and transaction of piriformis tendon. Anterior mobilization of the gluteus minimus and exposure of the trochanteric fossa. Removal of the superior portion (bone block) of the head and neck, and preparation of the femoral canal. Preparation of the acetabulum. Complete muscle relaxion is helpful to proceed to satisfactory trial reduction.

Postoperative management

Patients may progress to motion and weight bearing without restriction.

Results

From April 2009 to December 2010, the first author operated on 463 patients, 275 for osteoarthrosis of the hip, and 188 for subcapital fractures of the femoral neck. Thereof, 375 (75 %) patients could walk with full weight within 6 h from the operation, and climb stairs 24 h later with low loss of blood, and rapid recovery.

Zusammenfassung

Operationsziel

Ziel des gewebeerhaltenden minimal-invasiven Ansatzes bei der Hüfttotalendoprothesen-(TEP-)Operation sind die frühzeitige kurzfristige Wiederherstellung, das Erreichen der Hüftgelenkstabilität, die Minimierung des operationsbedingten Verlusts an Muskelkraft, die Schonung der periartikulären Weichteile und die Ermöglichung einer langfristig uneingeschränkten Beweglichkeit.

Indikationen

Hüft-TEP bei Patienten ohne vorbestehende Metallimplantate, mit ausreichendem Platz zwischen dem Pfannenrand und dem Trochanter major; Behandlung subkapitaler Femurfrakturen bei älteren Patienten.

Kontraindikationen

Protrusio acetabuli. Gelenksteifigkeit stellt das Hauptproblem bei der Durchführung der superioren Kapsulotomie dar. Die Steifigkeit kann knöchern bedingt sein durch Ankylose, große Osteophyten, Knochenbrücken usw., durch extraartikuläre Retraktion umgebender Weichteile mit kapsulärer Kontraktur von Ligamenten und Muskeln oder durch eine Kombination knöcherner und weichteilbedingter Ursachen, welche die Adduktion einschränken. Die maximale Adduktion ist notwendig, um die Entfernung zwischen der Spitze des Trochanter major und des oberen Pfannenrands zu vergrößern. In dem hier beschriebenen Ansatz liegt die wahre Begrenzung in der Unmöglichkeit, einen geraden Schaft durch die Fossa trochanterica zu schieben, ohne den Trochanterbereich zu schwächen. Ist die Adduktion eingeschränkt, führt die ausgedehnte Lateralisierung des Femurschafts zu postoperativen Schmerzen und Beschwerden, insbesondere da die Autoren die unmittelbare Vollbelastung befürworten. Auch in günstigerer Situation, bei Patienten mit intaktem Trochanterbereich, können viele Schaftarten, wie z. B. GTS (Fa. Biomet), Microplasty (Fa. Biomet) oder der Schaft Parva (Fa. Adler Ortho), auf das knöcherne Innere der Trochanterstrukturen drücken. Diese Schäfte sollten daher bei maximaler Hüftadduktion implantiert werden. Dies ist nötig bei Coxa profunda oder Coxa vara, bei denen stärker invasive und destabilisierende chirurgische Ansätze erforderlich sind.

Operationstechnik

Seitenlage, 5–8 cm lange Inzision von der Spitze des Trochanter major, Identifizierung und Durchtrennung der Sehne des M. piriformis. Anteriore Mobilisierung des M. glutaeus minimus und Darstellung der Fossa trochanterica. Entfernung des oberen Anteils (Knochenblock) von Kopf und Hals sowie Präparation des Femurkanals. Präparation des Azetabulums. Vollständige Muskelrelaxation ist für eine zufriedenstellende Probereposition hilfreich.

Weiterbehandlung

Die Patienten können ohne Einschränkung zu Bewegung und Belastung übergehen.

Ergebnisse

Von April 2009 bis Dezember 2010 operierte der Erstautor 463 Patienten, 275 wegen Hüftarthrose und 188 wegen subkapitaler Fraktur des Schenkelhalses. Von diesen Patienten konnten 375 (75%) innerhalb von 6 h postoperativ mit voller Belastung gehen und 24 h später Treppen steigen, bei geringem Blutverlust und schneller Wiederherstellung.

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Compliance with ethical guidelines

Conflict of interest. N. Capuano, A. DelBurono, and N. Muffulli state that there are no conflicts of interest.

The accompanying manuscript does not include studies on humans or animals.

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Authors and Affiliations

  1. Department of Orthopaedics and Traumatology, San Luca Hospital, Vallo Della Lucania, Italy

    N. Capuano

  2. Department of Orthopaedic and Trauma Surgery, Campus Biomedico University of Rome, Via Alvaro del Portillo, Rome, Italy

    A. Del Buono

  3. Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, E1 4DG, London, UK

    N. Maffulli MD, MS, PhD, FRCS(Orth)

Authors
  1. N. Capuano
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  2. A. Del Buono
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  3. N. Maffulli MD, MS, PhD, FRCS(Orth)
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Corresponding author

Correspondence to N. Maffulli MD, MS, PhD, FRCS(Orth).

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Capuano, N., Del Buono, A. & Maffulli, N. Tissue preserving total hip arthroplasty using superior capsulotomy. Oper Orthop Traumatol 27, 334–341 (2015). https://doi.org/10.1007/s00064-013-0242-7

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  • DOI: https://doi.org/10.1007/s00064-013-0242-7

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