Friday, March 29, 2024
HomeClinical ProceduresMinimally Invasive Total Hip Arthroplasty

Minimally Invasive Total Hip Arthroplasty

Practice Essentials

In addition to conventional surgical approaches, total hip arthroplasty (THA) may be done via minimally invasive surgery (MIS). Minimally invasive THA (MIS-THA) is often portrayed in the lay community and press as involving a small skin incision; actually, it is limited soft-tissue and bony dissection. Existing MIS-THA techniques are based on variations of conventional surgical approaches that have been used by surgeons for decades.

To date, no single technique has been proved superior to the others. The benefits of a shorter incision (see the image below) must outweigh the added technical difficulty caused by reduced visualization. The choice of operative approach depends on surgeon preference and experience.

Minimally invasive total hip arthroplasty. Shown a

Minimally invasive total hip arthroplasty. Shown are skin incisions for direct anterior (black), miniposterior/lateral/anterolateral (dark blue), conventional posterior (dark blue plus red extensions), direct superior (green), and SuperPATH (purple) approaches to hip. Conventional posterior incision is usually 10-25 cm long. Single incisions for minimally invasive approaches are usually less than 10 cm long. In two-incision approach, both incisions are usually less than 5 cm long.

View Media Gallery

Indications and contraindications

A minimally invasive approach may be suitable for the following:

Patients with a straightforward anatomy

Patients who are not obese (ie, body mass index [BMI] lower than 30 kg/m
2)

No absolute contraindications to MIS-THA have been definitively established, but conventional THA is probably a more suitable choice for the following patients:

Patients with pathologic conditions that necessitate enhanced exposure (eg, revision THA, complex primary THA, complete hip dislocation, Crowe type III or IV dysplasia, or severe acetabular protrusion)

Patients who have previously undergone certain surgical procedures (eg, malunion or prior osteotomy or fracture repair requiring removal of hardware)

Patients undergoing surgery involving the use of a cemented prosthesis (eg, for osteoporotic bone, metastatic cancer, metabolic disorder, or femoral anatomy)

Patients with bony ankylosis

Patients with rheumatoid arthritis

Patients with a BMI higher than 30 kg/m
2

Patients with severe hip contracture

Patients who are exceedingly muscular

See Overview for more detail.

Preparation for procedure

A routine preoperative workup is necessary, including the following:

Complete medical workup

Radiography (eg, affected extremity and chest radiographs)

Basic laboratory evaluation (eg, type and screen, complete blood count, basic metabolic panel, and urine analysis if symptomatic

)

Electrocardiography (ECG) for patients older than 50 years

Additional studies, as warranted by any comorbid conditions that may be present

Dental evaluation and treatment for dental diseases should be done before THA is performed; routine cleaning of the teeth should be delayed for several weeks after surgery

Preoperative templating may be used to guide determination of the following:

Implant size

Leg length restoration

Femoral stem offset

The following specialized surgical instrumentation and implants may be helpful during MIS-THA:

Modified versions of conventional instrumentation to access a limited operative field

Additional equipment for visualization (eg, fiberoptic light cables, cutaway reamers, angled reamers and broach handles, Hohmann retractors with light sources, or flexible acetabular reamers)

Special operating room table for hip dislocation (eg, Judet Orthopaedic Table, PROfx Fracture Table, or Jupiter Table)

See Periprocedural Care for more detail.

Procedural technique

The choice of operative approach depends on the surgeon’s preference and experience. The basic surgical approaches to the hip include the following:

Direct anterior approach (eg, modified Smith-Petersen) – Performed in the supine position and uses the internervous plane between the femoral and superior gluteal nerves

Anterolateral approaches (eg, modified Watson-Jones) – Performed in the supine or lateral position and divides the anterior portion of the gluteus medius muscle

Direct lateral approach (eg, modified Hardinge) – Performed in the supine or lateral position and uses the intramuscular interval between the tensor fasciae latae and gluteus medius muscles

Posterior approach (eg, modified Southern) – Performed in the lateral position and divides the gluteus maximus muscle and the short external rotators of the hip (eg, piriformis, superior gemellus, obturator internus, inferior gemellus, and quadratus femoris)

Piriformis-sparing posterior approach – Performed in the lateral position and divides the gluteus maximus, the iliotibial band, and the short external rotators of the hip (eg, superior gemellus, obturator internus, inferior gemellus, and quadratus femoris) except the piriformis

Direct superior approach – Performed in the lateral position and divides the gluteus maximus and the short external rotators of the hip (e.g., piriformis, superior gemellus, obturator internus, and inferior gemellus) while leaving the iliotibial band and quadratus femoris intact

Two-incision approach – Combines an anterior approach to the acetabulum with a posterior approach to the proximal femoral shaft

SuperPATH approach – Performed in the lateral decubitus position and divides the gluteus maximus, medius, and minimus

The complication rate is twice as high for surgeons who perform fewer than 50 MIS-THAs a year, with some suggesting that 40 operative cases are necessary for surgical proficiency to provide outcomes comparable to those of conventional approaches.
​ Complications after MIS-THA are more common in the following individuals:

Patients older than 65 years

Patients with a BMI higher than 30 kg/m
2

Women with osteoporosis

Patients with altered femoral or acetabular anatomy

Common adverse events include the following:

Dislocation

Damage to the sciatic, femoral, or lateral femoral cutaneous nerve

Impaired postoperative wound healing

Hematoma

Infection

See Technique for more detail.

RELATED ARTICLES
- Advertisment -

Most Popular