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Direct anterior approach for total hip arthroplasty using the “bikini incision”

Direkter vorderer Zugang zur Implantation einer Hüftendoprothese unter Verwendung der „Bikini-Inzision“

  • Surgical Techniques
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Operative Orthopädie und Traumatologie Aims and scope Submit manuscript

Abstract

Objective

The classic skin incision for direct anterior approach (DAA) total hip arthroplasty (THA) is usually placed over the belly of the tensor fasciae latae (TFL) muscle parallel to the axis of the lower extremity. In the “bikini incision” technique however, a more horizontal skin incision is used and placed parallel to the skin creases, which largely corresponds to the skin’s tension lines to prevent hypertrophic scarring and optimize cosmetic outcomes.

Indications

Primary or secondary osteoarthritis, femoral neck fracture, aseptic acetabular component loosening with sufficient bone stock and without the need for proximal extension of the approach, head and/or liner exchange.

Contraindications

Complex primary or revision THA requiring extensile distal and/or acetabular exposure, revision with pre-existing longitudinal DAA incision, inguinal skin infection.

Surgical technique

The skin incision, located three fingerbreadths distal to the anterior superior iliac spine (ASIS), is orientated parallel to the groin crease. One third of the incision is medial and two thirds lateral to the ASIS. Subcutaneous dissection should only be performed in the lateral two thirds of the incision to protect the main branches of the lateral femoral cutaneous nerve (LFCN). The fascia lata is opened as far lateral over the muscle belly as possible to leave the LFCN untouched within its fascial sheet. The stepwise procedure consists of three key steps: capsular exposure, capsular release, and component insertion. The approach allows for an excellent 360° exposure of the acetabulum. The femur is aligned along the incision during femoral elevation and adduction. With this technique, DAA hip arthroplasty can be performed in a less-invasive way providing best possible functional and cosmetic outcomes.

Postoperative management

No restrictions in ambulation or range of motion. Deep vein thrombosis prophylaxis.

Results

In a prospective series of 532 consecutive patients undergoing 613 primary THA with a bikini-incision in 2017, a good clinical outcome with a 2.3% incidence of wound-related problems was observed. In particular, obese patients can also benefit from the technique.

Zusammenfassung

Operationsziel

Die klassische Hautinzision zur Implantation einer Hüfttotalendoprothese über den direkten anterioren Zugang wird über dem M. tensor fasciae latae angelegt und folgt in etwa der Längsachse der unteren Extremität. Bei der „Bikini-Inzision“ wird die Haut jedoch durch eine etwas horizontalere Schnittführung eröffnet, wobei die Inzision parallel zur inguinalen Hautfalte angelegt wird und damit im Wesentlichen den Hautspannungslinien folgt, um eine hypertrophe Narbenbildung zu vermeiden und für ein optimales kosmetisches Ergebnis zu sorgen.

Indikationen

Primäre oder sekundäre Osteoarthrose, Schenkelhalsfraktur, aseptische Pfannenlockerung ohne wesentlichen Knochendefekt und ohne Notwendigkeit einer proximalen Erweiterung des Zugangs, Kopf- und/oder Inlaywechsel.

Kontraindikationen

Komplexe Primärendoprothetik oder Wechseleingriffe, die einer distalen und/oder proximalen Erweiterung des Zugangs bedürfen, Revisionseingriffe mit vorbestehenden kreuzenden Narbenzügen, Infektionen im Bereich der Inguinalfalten.

Operationstechnik

Der Hautschnitt wird 3 Fingerbreit distal der Spina iliaca anterior superior (ASIS) angelegt und ist parallel zur Leistenfalte ausgerichtet. Ein Drittel der Inzision befindet sich medial und 2 Drittel lateral der ASIS. Die subkutane Dissektion sollte nur in den lateralen 2 Dritteln der Inzision erfolgen, um die Hauptäste des N. cutaneus femoris lateralis (LFCN) zu schützen. Die Fascia lata wird so weit lateral wie möglich über dem Muskelbauch eröffnet, um den LFCN in seiner Faszienschicht unberührt zu lassen. Die übrige Operation besteht im Wesentlichen aus 3 Schritten: Exposition der Kapsel, Kapsel-Release und Implantation der Komponenten. Der Zugang ermöglicht eine hervorragende 360°-Exposition des Azetabulums. Das Femur wird während dessen Elevation und Adduktion entlang der Inzision ausgerichtet. Mit dieser Technik ist eine minimalinvasive Implantation der Hüftendoprothese über den direkten anterioren Zugang gewährleistet bei gleichzeitig bestmöglichen funktionellen und kosmetischen Ergebnissen.

Weiterbehandlung

Keine Einschränkungen hinsichtlich des postoperativen Bewegungsumfangs bzw. der Belastungsfähigkeit. Prophylaxe tiefer Beinvenenthrombosen.

Ergebnisse

In einer prospektiven Studie mit 532 Patienten, bei denen 613 primäre Hüfttotalendoprothesen über den direkten vorderen Zugang mit einer Bikini-Inzision im Jahr 2017 implantiert wurden, waren gute klinische Ergebnisse mit einer Inzidenz postoperativer Wundheilungsstörungen von lediglich 2,3 % festzustellen. Insbesondere können auch adipöse Patienten von dieser Technik profitieren.

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Authors and Affiliations

  1. Hip Unit, Orthopedic Department, Ziekenhuis Oost-Limburg Genk, Limburg, Belgium

    Kristoff Corten MD, PhD

  2. Heuppraktijk, Herselt, Belgium

    Kristoff Corten MD, PhD

  3. Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany

    Boris Michael Holzapfel MD, PhD , FEBOT

  4. Reconstructive Surgery of the Hip, Hip Unit, Ziekenhuis Oost-Limburg, Genk, Ziekenhuis Maas en Kemp, Maaseik , Belgium

    Kristoff Corten MD, PhD

Authors
  1. Kristoff Corten MD, PhD
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  2. Boris Michael Holzapfel MD, PhD , FEBOT
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Corresponding author

Correspondence to Kristoff Corten MD, PhD.

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Conflict of interest

K. Corten and B.M. Holzapfel declare that they have no competing interests.

For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.

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M. Rudert, Würzburg

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R. Himmelhan, Mannheim

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Supplementary Information

Video online: This video explains the efficient direct anterior approach for total hip arthroplasty (THA) using the bikini incision. The procedure consists of 3 major parts: capsular exposure, capsular release and component insertion. The procedure is conducted through the bikini incision and can be done by 1 surgeon and 1 scrub nurse (or assistant). (Courtesy of K. Corten, Belgium. All rights reserved.)

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Corten, K., Holzapfel, B.M. Direct anterior approach for total hip arthroplasty using the “bikini incision”. Oper Orthop Traumatol 33, 318–330 (2021). https://doi.org/10.1007/s00064-021-00721-y

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  • DOI: https://doi.org/10.1007/s00064-021-00721-y

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