Abstract
Introduction
Rottinger published a description of an anterior muscle sparing approach to the hip. It utilizes the same muscle interval as the classic WatsonJones approach between the gluteus medius laterally and tensor fascia lata medially. However, this technique has the disadvantage of needing asplit table and a sterile bag to mobilize the operative leg as extension, adduction and external rotation are the key points for femoral preparation. This study describes our experience for an equivalent of the Watson Jones approach with a simplified technique for the femoral preparation.
Material and Methods
Incision starts 1cm distal and 3cm posterior to the ASIS and continues distally for about 8–10 cm along the straightline joining the lateral edge of the patella. It can be extended proximally or distally if necessary. The surgeon is placed posteriorly and the assistant anteriorly. The hip is dislocated with extension and external rotation to osteotomize the femoral neck. During the preparation of the acetabulum the femur is pushed posteriorly with internal rotation. Steinman pins are placed around the acetabulum to improve visualization for reaming and implanting theacetabular components. The femur is then exposed in a simplified way. The operated limb remains on the table. It is adducted above the contralateral limb and rotated outward to allow the femoral metaphysis to protrude. The foot is placed on the edge of the table beside the assistant, the knee is maintained with 45° flexion. The hip capsule is released postero-laterally to improve the femur exposure using Hohman retractors without cutting the short external rotator muscles. Femoral preparation is performed in this position. Once the appropriate implant is selected, the desired head trials are placed. The hip is reduced and the length and stability can be checked with the leg free. In case of isolated cup revision, the femoral head can be conserved. In case of femoral revision, a femorotomy can be easily performed due to the possibility of extended and stable exposure of the femur. Table 1 summarizes the main data of the series.
Results
Mean operative duration was 57mn for primary THP (SD 10mn) and 124mn for revisions (SD 28mn). Table 2 summarizes the main complications according to the time line after the first implantation. High BMI patients and exposure of the acetabulum were never a problem; moreover this technique is very attractive for isolated cup revisions. Complications were mainly focused on femoral preparation due to a suboptimal use of the retractors for the exposure (4/13 fracture cases). Poor bone quality (old patients) was responsible for the 9 additional fractures. False route were observed in 4 curved femurs. 3 nerve compressions were due to excessive pressure on the knee by the assistant. Using short stems facilitates femoral exposure and reduces operative time.
Conclusions
Hip approaches have been modified throughout the years in attempts to improve patient outcomes. This simplified technique did not induceunusual morbidity or mechanical problems. The benefit in terms of operative time and complications is significant in comparison with our previous experience using a fracture table.
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