Aims

The purpose of this study was to analyze the incidence of the different ultrasound phenotypes of developmental dysplasia of the hip (DDH), and to determine their subsequent course.

In recent years, the direct anterior approach (DAA) has become a standard approach for primary total hip arthroplasty (THA). With the increasing use of the DAA in primary cases also more and more revision surgeries are performed through the same interval. With ability to extend the DAA interval proximally and distally, loose cups, loose stems, and even periprosthetic femoral fractures (PPF) can be treated. Especially, PPF are devastating complications causing functional limitations and increased mortality. Therefore, we conducted a study to report the outcome of surgical treatment of PPF with the DAA interval.

We report on the one year complications and mortality in 40 cases with a mean clinical follow-up of 1.5 years. Mean age of patients was 74.3 years. Fractures were classified as Vancouver B2 (36), and B3 (N=4). In 14 cases, a standard stem was used, and in 26 cases a modular revision stem. In 30 cases, a distal extension +/- tensor release was used, in 4 cases a proximal tensor release was done, and in the remaining 6 cases revision could be performed without extension of the approach.

Median cut/suture time was 152 minutes (IQR 80 – 279). The overall complication rate in our patient group was 12.5%. 2 patients died in the first three months after operation. One patient had a transient femoral nerve palsy, which completely recovered.

The DAA interval to the hip for the treatment of PFF showed similar results compared with other approaches regarding mortality, complications, fracture healing, dislocation rate and clinical results. We conclude that femoral revision in case of PPF in the DAA interval is a safe and reliable procedure. Each Vancouver type of periprosthetic fracture can be treated by use of this approach.

Background

Processing of allografts, which are used to fill bone defects in orthopaedic surgery, includes chemical cleaning as well as gamma irradiation to reduce the risk of infection. Viable bone cells are destroyed and denaturing proteins present in the graft the osteoconductive and osteoinductive characteristics of allografts are altered. The aim of the study was to investigate the mechanical differences of chemical cleaned allografts by adding blood, clotted blood, platelet concentrate and platelet gel using a uniaxial compression test.

Introduction

BAG-S53P4 has similar mechanical properties as cortical bone tissue and can be used as an additive to bone allografts. The aim of this study was to evaluate the effect of adding BAG-S53P4 to chemically treated allografts with controlled grain size distribution.

Summary

Study showed a simple acetabular placement plane formed by pelvic landmarks. The plane was adjusted by changing one of the landmarks to a fixed value for best representing the native acetabular orientation based on CT generated 3D pelvi

A cleaning process reduces the contamination risk in bone impaction grafting but also modifies the grain size distribution. The cleaned allograft shows a higher mechanical stability than the untreated group.

In revision total hip replacement, bone loss can be managed by impacting porous bone chips. The bone chips have to be compacted to guarantee sufficient mechanical strength. To improve the safety of bone grafts and to reduce the risk of bacterial and viral contamination, cleaning processes are used to remove the organic portion of the tissue while maintaining its mechanical characteristics.

A cleaning procedure described by Coraca-Huber et al. was compared to untreated allografts by performing a sieve analysis, followed by an uniaxial compression test. Differences in grain size distribution and weight loss during the cleaning procedure were compared to data from literature. Yield stress limits, flowability coefficients as well as initial density and density at the yield limit of the two groups were determined for each group over 30 measurements. The measurements were taken before and after compression with an impaction apparatus (dropped weight).

The cleaning process reduced the initial weight by 56%, which is comparable to the results of McKenna et. al. Cleaned allograft showed a 25% lower weight of bone chips sized > 4 mm compared to data from a previous study.

The cleaned bone chips showed a statistically significant (p > 0.01) higher yield limit to a compression force (0.165 ± 0.069 MPa) compared to untreated allograft after compaction (0.117 ± 0.062 MPa). The flowability coefficient was 0.024 for the cleaned allograft and 0.034 for the untreated allograft.

Initial density as well as the density at the yield limit was higher for the untreated allografts, as the sample weight was twice as high as in the cleaned group, to compensate for the washout of the organic portion. The cleaned bone grafts showed a higher compaction rate, which was 31%, compared the the untreated group with a compaction rate of 22%.

The cleaned allograft showed a higher compaction rate, which means that the gaps between the single grains are filled out with smaller particles, resulting in better interlocking. In the untreated allograft the interlocking mechanism is hindered by the organic elements. This observation is confirmed by a reduced flowabillity and a higher yield stress limit. The loss of weight as well as a higher compaction rate implies that more cleaned graft material is needed to fill bone defects in hip surgery. Sonication may damage the bone structure of the allograft and reduce the size of the particles.

In the last years custom-fit cutting guides using magnetic resonance imaging (MRI) were introduced by orthopedic surgeons for total knee arthroplasty (TKA). One of the advantages of these shape-fitting jigs is the possibility to transfer the preoperative planning of the TKA directly to the individual patient's bone. However, one has to be aware, that the jigs are designed for single-use and have to be custom made by an external manufacturer. This increases the cost of implantation and unlinks the surgeon from this process. In addition a potentially necessary adjustment of the preoperatively planned implant size and position in a surgical situation is not possible.

The purpose of our development was to combine the advantages of custom-fit cutting guides as a 3-D-computer-assisted planning tool with the option to adjust and improve the preoperative planning and the jig in the actual surgical situation. In addition no outside jig manufacturing would occur in this concept. This leaves the surgeon in control of the entire process.

The purpose of this study was to examine the reliability of this screw-based shape – fitting system. In order to do this we assessed the inter- and intra-observer reliability of the recurrent placement of the plate on a set of bone samples with preset screws.

We developed a plate with the dimension of 66 × 76 × 10 mm, containing 443 threaded holes. A connector for further instrumentation is mounted on the proximal part of the plate,. As the plate and the screws are made of aluminum and steel, sterilization is possible.

After computer tomography (CT) scans were taken from three human femoral bones, eight to nine variably positioned screws (50.45 mm length, 2.75 mm diameter), reversibly fixed by locknuts, formed an imprint of a bone's surface. For calculating precise screw positions, a computer-based planning software was developed resulting in a three-dimensional reconstruction of the bony surfaces. The plate was integrated in the 3-D reconstruction software. With a defined distance to the distal part of the femurs, allowed the proper length and position of the screws to be calculated. These calculations were transferred to the screws on the real plate.

In the next step the plate was positioned on the bony surface and after reaching the planned position the plate's connector was rigidly fixed to the bone. The plate was removed to give place to link saw jigs to the connector.

Planning and setting of the plate and the screws were conducted on three femoral bones.

Examinations were performed by five investigators with ten repetitions on each bone with three distinct plates. Intra- and inter-observer variability was assessed by measuring the variation in plate position between the trials.

The jigs were placed in a mean frontal tilting (medial to lateral) of 0.83°. The mean axial tilting (proximal to distal) was 1.66° and the mean shift on the axis from proximal to distal 8.48 mm. The shift and the tilting were significantly bone dependent but not user dependent. Compared with previous studies the deviation from the mechanical axis were comparable with conventional TKA (2.6° and 0.4°), computer assisted TKA (1.4° and 1.9°) and Custom-fit TKA (1.2°).

We developed a preoperative planning system for TKA that allows a transfer of the planning and the calculated imprint of the bones surface on a grid-plate during surgery by the surgeons themselves. Neither external manufacturers to create a fixed device nor a navigation system is necessary. Results showed the functioning of the screw – based shape fitting technique within the accuracy mentioned above. These findings are encouraging to do further research to examine the ideal number of screws to offer a perfect fitting.

INTRODUCTION

While standard instrumentation tries to reproduce mechanical axes based on mechanical alignment guides, a new “shape matching” system derives its plan from kinematic measurements using pre-operative MRIs. The current study aimed to compare the resultant alignment in a matched pair cadaveric study between the Shape Match and a standard mechanical system.

In minimally invasive direct anterior total hip arthroplasty double offset broach handles are used, in order to facilitate the preparation of the femoral canal. The maximum value of the main force peak and the impulse of two types of double offset broach handles (A European version, B American version) were compared to a single offset broach handle (S). Results have demonstrated that the highest values of the main force peak and force impulse were found in the single offset broach handle. Broach handle A had higher impulse values and lower maximum force values compared to broach handle B. In double offset broach handles less energy is transmitted to the tip. Broach handle A has a lower force peak than B and therefore a reduced risk of bone fracture.

In Total Hip Arthroplasty (THA) bone loss is recovered by using compacted porous bone chips. The technique requires the morsellised allograft to be adequately compacted to provide initial stability for the prosthesis in order to prevent early massive subsidence and to induce bone remodeling. Therefore the bone grafts provide initial stability and an environment in which revascularization and incorporation of the graft into the host skeleton may occur. Acetabular reconstruction with impacted morsellised cancellous grafts and cement leads to satisfactory long-term results. In the acetabular impact-grafting procedure, a hammer and an impaction stick is used for manual compaction. Another technique uses a hammer driven by compressed air, which could lead to higher density and improved stability of bone chips in the acetabulum. The aim of this study was to compare two different compaction modes for bone impaction grafting for the acetabulum. The hypothesis was that a pneumatic impaction method would produce less variable results than the manual impaction mode and lead to better compaction results of the bone chips in less time.

Bone mass characteristics were measured by force and distance variation of a penetrating punch, which was lowered into a plastic cup filled with bone chips. For each compaction method and for each time interval (0, 3, 6, 9, 12, 15 and 30 [s] of compaction time) 30 measurements of force and distance variations were taken. From the measurements of force and distance variations bulk density, contact stiffness, impaction hardness and penetration resistance were calculated before and after the established time intervals of compaction. Since not all data was normally distributed the non-parametric U-Test was used for comparison of the two impaction methods. Particle size distribution was determined using sieve analysis according to Din 18123 standard after the compaction experiments.

Results have shown that the pneumatic method leads to higher values in impaction hardness, contact stiffness and bulk density and is more suitable to increase the primary stability of the implant. The differences in bulk density, impaction hardness and contact stiffness where statistically significant (p<0.01). No significant differences were found between the two different methods concerning the penetration resistance. The coefficient of uniformity C_u, calculated from the particle size distribution determined by the sieve analysis, has a value of 3.8.

The particle size distribution is comparable to the results published in literature. Pneumatic impaction achieves higher density values in less time with less force applied and results in more reproducible outcomes when used. It reduces therefore the risk of bone fracture, as smaller peak forces are used for less time. However for optimal osteointegration it is not recommended to achieve maximum density. Further clinical studies should determine a reference value for optimal growth-in of osteocytes. Manual impaction shows more variable results and depends much on the experience of the surgeon. The pneumatic hammer is therefore a suitable tool to standardize the impaction process for acetabular bone defects.

The current decade has seen a marked rise in popularity of minimally invasive hip replacement, done through a variety of surgical approaches. A specific downside to the direct anterior approach includes the significant difficulty getting a “straight shot” down the femoral canal for either straight, nonflexible reaming or broaching as with standard approaches. Improper alignment in the femoral canal can lead to sub-optimal load transfer and thus compromised fixation. The femoral broach and stem insertion path for this approach is best described as a curved one, rather than the typical straight path. Some femoral components appear to be more suitable to this technique due to their geometries. The purpose of the study was to describe the effects that the single geometric parameter, stem length, has on its insertion path into the femoral canal. Due to the potential introduction of human error associated with repetitively performing a specific motion, both a physical study and a computer generated analysis were conducted.

For the physical portion of the study, a femoral implant body of generic fit and fill geometry was designed and manufactured. The length of the stem was varied from 40 mm to 100 mm in 10 mm increments. A medium sized synthetic femur (Sawbones, Pacific Labs, Seattle, WA) was machined to match the volume of the full length stem. The insertion path constraints were defined such that the stem had to maintain the greatest allowable insertion angle while still making contact on both the medial and lateral side of the canal during translation in the X direction. To reduce the variability in applying the constraints, a single author conducted the insertion procedure for each length stem while the path was videotaped from a fixed position directly in front of the setup. The most proximal lateral point of the stem was tracked through the insertion path and the X, Y coordinates were recorded at a frequency of 2 FPS. The area under this curve, referred to as the minimum insertion area (MIA), was calculated.

For the computer generated portion of the study, a CAD model of the standard length Omnifit^® (Stryker Orthopaedics) was utilized. The stem was modified to create 5 additional models where the length was progressively shortened to 65%, 55%, 45%, 35%, and 25% of original length or 91mm, 77mm, 63mm, 49mm, and 35mm respectively. The femur was created from a solidified mesh of a computed tomography (CT) scan with the canal virtually broached for a full length stem. The models were each virtually assembled within the femoral canal with the similar constraints as the physical study. Again, the most proximal lateral point of the stem was tracked through the insertion path with the coordinates recorded and the MIA was calculated.

There was a non-linear relationship between stem length and the MIA with the rate of change decreasing as the stem length decreased. That is, the greatest decrease in MIA was between the standard length and next longest length in the computer simulation. It was noted that marked change in MIA began to subside between the 77mm and 63mm stems and continued this trend of having less influence onward through to the shorter lengths. Although the results of the physical study showed a higher variability than the computer generated portion, it does confirm the results of the computer generated study.

Minimizing the trauma associated with THR has led most of the above authors to the direct anterior approach. However, the femoral broach and stem insertion path is best described as a curved one, rather than the typical straight path used in other approaches. This curved insertion path also has benefits for other approaches since the broaches and stem can be kept away from the abductors, minimizing the potential injury to them. Shorter stem length makes this curved insertion path easier to perform. This is the first study to describe the effect that stem length has on its insertion path into the femoral canal. As expected, the physical portion of the study showed more variability than the computer generated portion. However, the physical and computer studies correlated well, with shorter stem lengths clearly allowing a more curved insertion path. The improvement tapered off in stem lengths below 63mm. This length correlates well with the other attempts at a shorter stem. This study provides quantitative data to help with shorter stem design and possible computer navigated insertion paths.

Taper locking connection has been widely used in orthopedic implant devices. The long term successful clinical results indicated it is a safe and effective structural component. The common materials used are solid titanium and cobalt chromium alloys. Recently, foam metal materials showed promising results of bony in-growth characteristics and became the excellent choices for the orthopedic implants. Clinically it is desirable to taper lock the foam metal component to other structural components. To date there is no data for the foam metal being used directly in taper connection. The purpose of this study was to investigate the static locking strength of the taper junctions made of titanium foam metal comparing to that of conventional solid titanium material.

(5) 43mm long and 4mm thick sleeve were machined internally with 17mm major diameter and 3° included taper angle for each 70% porosity CP titanium foam metal and solid Ti6AL4VELI alloy materials. (10) Solid Ti6AL4VELI alloy stems were machined with OD geometry matching the ID of the sleeves. All components were inspected, cleaned and assembled to (5) pairs of each sleeve material combinations with 2224N axial compression force. Each assembled specimen was mounted on MTS Bionix test machine for torque resistance test. The angular displacement at 0.1 degree/sec was applied to the stem when sleeve was rotationally locked. The maximum torque resistance was recorded. The specimen was then re-assembled with 2224N axial compression force. Axial push out test was performed by loading at smaller end of the stem when the opposite end of sleeve was supported. The maximum push out force was recorded. Procedures were repeated for all foam metal and solid metal specimens. The taper interface surfaces were visually inspected to compare two types of sleeve materials.

The average torque resistance for foam metal and solid tapers were 20.4Nm (SD=3.68) and 21.7Nm (SD=3.72) respectively (p=0.59). The average axial locking forces were 2035.7N (SD=201.11) for foam metal taper and 1989.3N (SD= 451.84) for solid taper (p=0.839). There was no visual difference observed for tested stem outer and sleeve inner surfaces of foam metal and solid metal pairs.

This study suggested that the foam metal sleeve is capable to have comparable taper locking strength as the conventional solid taper components under dry static condition. The study indicated that the contact area does not significantly influence the friction locking. This is in agreement with the friction force definition which depends only on the coefficient of friction and normal contact force.

In revision total hip replacement, bone loss can be managed by impacting porous bone chips. In order to guarantee sufficient mechanical strength, the bone chips have to be compacted. The aim of this study was to determine in an in vitro simulation whether the use of a pneumatic hammer leads to higher primary stability than manual impaction. Bone mass characteristics were measured by force and distance variation of a penetrating punch, which was lowered into a plastic cup filled with bone chips. From these measurements bulk density, contact stiffness, impaction hardness and penetration resistance were calculated for different durations of impaction.

We found that the pneumatic method reached higher values of impaction hardness, contact stiffness and bulk density suggesting an increase in stability of the implant. No significant differences were found between the two different methods concerning the penetration resistance. The pneumatic method might reduce the risk of fracture in vivo, as force peaks are smaller and applied for a shorter period. Results from manual impaction showed higher variability and depend much on the experience of the surgeon. The pneumatic hammer is a suitable tool to standardise the impaction process.

High tensile stress has been considered as a contributing factor to the rim fracture of polyethylene acetabular cup liner. We performed the 3 D Finite Element Analysis (FEA) to compare the stress patterns at the polyethylene liner rim as a function of polyethylene thicknesses and whether or not rim was supported by the titanium acetabular shell extension. Two 3.1 mm thick generic 52 mm titanium alloy acetabular shells with and without 2 mm high rim support extension were modelled. Six corresponding Ultra High Molecular Weight Polyethylene (UHMWPE) liners with inner bearing diameters ranging from 22 mm to 44 mm and same outer diameters, were fixed in the shells. A 2 450 N load was applied through the corresponding CoCr femoral heads to the rims of liners while the acetabular shells were fixed on the outer spherical surface. The FEA was performed in half body of the assembly. The maximum principal stresses at the rim regions of UHMWPE liners were recorded.

The results showed that in all rim supported conditions, the maximum principal stress were in compressive patterns, a preferred pattern to reduce the potential polyethylene liner fracture. In rim unsupported conditions, the stresses was in tensile on the internal bearing surface when polyethylene liner thickness was bellow 5 mm, or was bellow 9 mm if the average maximum principal stress cross the rim was considered.

We conclude that the metal rim support changes the stress pattern in the rim region of UHMWPE liner to compressive for all liner thicknesses. The stress pattern turns to tensile, or there will be a higher potential for rim fracture, if UHMWPE liner is unsupported and the polyethylene rim thickness is less than 9 mm.

Although components used this study did not include the locking details which add higher stress concentrations, the trend of stress patterns should follow the results found in this study.

Background and purpose: Implantation of the femoral component at 10 to 15 degrees of anteversion is recommended in total hip arthroplasty. Surgical guidelines suggest that the lower leg be positioned horizontally or vertically with the knee flexed to 90° (figure of four). By constructing a perpendicular axis (a “figure-of-four” axis) to the lower leg, anteversion of the stem is approximated. This study was performed to validate the figure-of-four axis as a reliable intraoperative tool to approximate the retrocondylar line as reference for stem version.

Method: In 21 cadavers placed supine on an operating table, the lower legs were aligned to the horizontal plane. Using a box column drill, Steinmann nails were inserted perpendicular to the lower leg into the medial epicondyles. The Steinmann nails were replaced by cannulated titanium screws, representing the figure-of-four axis. The femoral neck axes, retrocondylar lines and the figure-of-four axes were determined using CT images of the specimen.

Results: The median version of the femoral neck axis was anteversion of 9.8° (IQR 4.5°–15.1°). The median figure-of-four axis showed a deviation of 0.5° (IQR −2.1°−2°) in relation to the retrocondylar line, whereas the median difference of the axis in relation to the femoral neck axis was 9.5° (IQR −13.6° – −2.1°).

Interpretation: The figure-of-four axis, being nearly parallel to the retrocondylar line, is a valid indirect method to determine stem version intraoperatively in patients without varus/valgus deviations of the knee.

Introduction: Minimally invasive total hip arthroplasty has evoked substantial controversy with regard to whether it provides superior outcomes compared with conventional total hip arthroplasty. The objective of this study was to compare the results of a minimal invasive direct anterior approach (MIDA) with those of a conventional lateral transgluteal approach (CLT).

Methods: 120 patients (120 hips) admitted for unilateral total hip arthroplasty were randomized to undergo surgery via minimal invasive direct anterior or conventional lateral transgluteal approach. Patients with a body mass index of more than 35, previous hip surgery, preoperative neurological deficits and with an age of more than 80 years were excluded. Two surgeons performed all procedures. To estimate muscle damage serum creatinkinase was assessed. Blood loss was calculated according to Rosencher by comparing preoperative to postoperative hematocrit. Postoperative pain and the ability to perform the activities of daily living were recorded in a dairy via modified WOMAC first on a daily basis, then on each second day and finally once a week for a total of 12 weeks. WOMAC questionnaire and SF-36 were administered at 6 weeks and 3 months follow-up.

Results: The groups were similar demographically. Patients in MIDA group had significantly less total blood loss (p = 0.006), postoperative blood levels of creatinine kinase were significantly lower (p = 0.001). Operative time was similar in both groups, we found no difference in component placement. Physical component summary of SF-36 at 12 weeks follow-up showed a significant benefit for the MIDA group. Averaged modified WOMAC scores and their pain and function subscores demonstrated a clear advantage on every recorded day during the first 12 weeks for MIDA. Median WOMAC sum score and respective pain as well as function subscores were better in the MIDA group at 6 and 12 weeks follow up.

Conclusions: A minimally invasive direct anterior approach is superior to a conventional lateral transgluteal approach with regard to blood loss and muscle trauma, resulting in better health related quality of life in the first three months after operation.

Purpose of the study: The anterior rim of the arthroplasty cup can overhang the bone in certain situations: oversized cup, insufficient anteversion, insufficient ace-tabular reaming, cylindrospherical reaming overriding the acetabular opening. The straight or concave shape of the anterior wall of the acetabulum also affects prosthetic overhang. The purpose of this anatomic study was to use a navigation system to quantify, in vitro, the height of the iliopubic psoas notch.

Material and methods: Sixty-eight acetabuli from 34 cadaver pelvi free of osteoarthritis (13 male and 21 female) were analyzed using the Stryker™ hip navigation system. Morphological data were collected for mathematical processing which defined the diameter and the center of the articular surface.

Results: Considerable intra- and inter-individual differences in the shape of the acetabular rim were noted and quantified, particularly concerning the psoas notch. When the lateral view of the acetabular rim is projected onto a plane it produces a succession of three summits and three valleys explaining the difficulty encountered in obtaining a precise mean plane for the acetabular opening.

Discussion: More or less pronounced protrusion of the cup could explain potentially painful anterior impingement of the psoas, especially for certain types of acetabular morphology.

A complete cement mantle is important for the longevity of a total hip replacement. In the minimally-invasive direct anterior approach used at the Innsbruck University hospital, the femoral component has to be inserted into the femoral canal by an angulated movement. In a cadaver study, the quality and the extent of the cement mantle surrounding 13 Exeter femoral components implanted straight through a standard anterolateral transgluteal approach were compared with those of 13 similar femoral components implanted in an angulated fashion through a direct anterior approach. A third-generation cementing technique was used. The inner and outer contours of the cement mantles was traced from CT scans and the thickness and cross-sectional area determined.

In no case was the cement mantle incomplete. The total mean thickness of the cement mantle was 3.62 mm (95% confidence interval 3.59 to 3.65). The mean thickness in the group using the minimally-invasive approach was 0.16 mm less than that in the anterolateral group. The distribution of the thickness was similar in the two groups. The mean thickness was less on the anteromedial and anterolateral aspect than on the posterior aspect of the femur.

There is no evidence that the angulated introduction of Exeter femoral components in the direct anterior approach in cadavers compromises the quality, extent or thickness of the cement mantle.

Successful total knee arthroplasty (TKA) is dependent on the correct alignment of implanted prostheses. Major clinical problems can be related to poor femoral component positioning, including sagittal plane and rotational malalignment. A prospective randomized study was designed to test whether an optical navigation system for TKA achieved greater implantation precision than a non navigated technique. The primary variable was rotation of the femoral component in the transverse plane measured from post operative radiographs and CT images. Sixty-four patients were included in the study. All patients received the Duracon total knee prosthesis. The patients were randomly divided into two groups; Group C patients underwent conventional TKR without navigation, Group N patients underwent TKR using a computer assisted Knee Navigation System. Analysis revealed that patients in Group N had significantly better rotational alignment and flexion angle of the femoral component than patients in Group C. In addition, superior post operative alignment of the mechanical axis, posterior tibial slope, and rotational alignment was achieved for patients in Group N. The use of a navigation system provides improved alignment accuracy. Specifically, it can help to avoid femoral malrotation and errors in axial alignment.

Introduction: In a prospective clinical study the feasibility of total hip arthroplasty via a minimal invasive single incision anterior approach was analyzed. 100 consecutive patients with no exclusion criteria (52 females, 48 males, mean age 65.6 yrs) were included. 19 patients showed a BMI > 30.

Material and Methods: The patients were placed in a supine position on the OR table. After skin incision the interval between sartorius, tensor fasciae latae, rectus femoris and glutaeus medius/minimus was split to bluntly expose the anterior aspect of the hip joint capsule. No muscle had to be dissected. Following capsular incision the neck was osteotomized in-situ. After reaming a cemented or cement-less cup was inserted. The calcar was elevated with a hook to the level of skin incision. By placing special two-pronged retractor between the inserting abductor tendons and the greater trochanter the broaching of the femoral medullar canal could be easily performed. Followed by implanting a cemented or cement less stem.

Results: The median incision length was 6.75 cm. Median angle of cup inclination was 44.1 and 0 of varus/ valgus position for the stem. Blood loss was significantly reduced. The rehabilitation was fast (mean WOMAC score 90.4 at 6 weeks) and patients showed only little postoperative pain. No dislocations or nerve palsies occurred. The complication rate was low with one fissure of the proximal femur, one perforation of the acetabulum and one deep infection.

Conclusion: The study demonstrated that blood loss, postoperative pain and hospitalization time were reduced with a correct placement of the implants. The rehabilitation was quicker. Therefore we state that the minimal invasive anterior approach is safe and lead to advantages for the patients.