Safe surgical technique: iliac osteotomy via the anterior approach for revision hip arthroplasty
© Ziran et al.; licensee BioMed Central Ltd. 2014
Received: 30 April 2014
Accepted: 27 June 2014
Published: 9 September 2014
Robert Judet first performed hip arthroplasty via the anterior approach (AA) in 1947 on an orthopaedic table. Our center has a near 20-year experience on more than 3500 patients operated by AA hip arthroplasty. While primary AA total hip arthroplasty techniques have been discussed in the literature, revision AA total hip arthroplasty techniques are relatively new. The current article in the Journal′s "Safe Surgical Technique" series describes the successful application of an adjunctive iliac osteotomy to improve femoral exposure in two selected patients undergoing AA revision hip arthroplasty. The potential risk/complications of an iliac osteotomy include iatrogenic fracture, malunion/nonunion, infection, and pain. These potential risks should be weighed against the potential benefits of improved surgical exposure and/or risks of other revision techniques. Future prospective longitudinal studies will be helpful to determine efficacy and risk profile compared to other revision techniques.
Robert Judet performed the first hip arthroplasty on an orthopaedic table (Judet-Tasserit table) through the anterior approach in 1947 at Hospital Raymond Poincaré in Garches, France . Judet termed the approach the Hueter interval and utilized the intermuscular plane between the sartorious and the tensor fascia lata. The senior author began performing total hip arthroplasty via the anterior approach (AA) in 1996 on a special orthopaedic table which was derived from the original Judet-Tasserit table. The results of the first 437 consecutive, unselected patients who had 494 primary total hip arthroplasty surgeries done through the AA were published in 2005 . Other groups have also published positive outcomes on large series of patients after AA total hip arthroplasty ,. More recently, revision total hip arthroplasty via AA has become an area of investigation.
Mast et al.  and Kennon et al.  have both reported positive results using the Hueter interval for revision hip arthroplasty. This article, however, expands on the Levine modification (proximal extension of the AA) discussed in the Mast article and demonstrates a method to improve proximal femur exposure for revision surgery. In most cases, revision of the acetabular cup via AA is not as challenging. Femoral exposure, however, can be challenging due to either broach obstruction by the anterior superior iliac spine (ASIS)/ilium, large musculature, and/or a poor trajectory down the axis of the femur. For cases in which an AA primary hip arthroplasty was performed and the femoral component fails, many surgeons feel more comfortable with revision surgery via the posterior approach. If the surgeon desires to revise the femoral component via the AA, there are described techniques to facilitate femoral exposure and/or implant removal. To improve femoral exposure, the surgeon can extend the AA proximally and detach the tensor. Other techniques to aid in femoral implant removal include distal AA extension with femoral corticotomy, extended trochanteric osteotomy, and anterior femoral osteotomy (verbal communication, J. Matta, M.D.). The purpose of the iliac osteotomy is to improve exposure of the proximal femur via the AA with minimal soft-tissue morbidity. Since bony healing tends to be less morbid than soft tissue healing (i.e. tensor detachment), the authors feel this technique is an option to facilitate exposure for AA revision hip arthroplasty.
The hip joint is then dislocated using gentle traction and external rotation. The head is removed by "tapping" it off the trunion. Another method to remove the head is in situ removal of the head with the joint reduced. In this method, the hip is left reduced and the head is impacted off the neck using the native cup as counter-pressure. The neck is then "pulled" out from the head. After head removal and dislocation, the hook is placed near the vastus ridge under the proximal femur with the leg in internal rotation.
Exposure - frequently, there is a crossing vein overlying the tensor fascia which provides an anatomic cue to the surgeon.
Exposure – the lateral hip capsule retractor is placed in a "pocket" distal and lateral to the anterior inferior iliac spine.
Exposure - attention should be spent on thorough exposure and release of the neck capsule. If a previous anterior approach was performed, this portion of the surgery can be a limiting factor due to granulation tissue. Specific attention should be paid to release of the neck capsule off the intertrochanteric line to the inferomedial neck.
Dislocation - the patient should have complete muscle relaxation. Dislocation can be performed by either method described in the text. Head removal can also be challenging, and the surgeon should ensure that the appropriate instrumentation is available in the OR prior to the procedure.
Iliac osteotomy – a complete iliac osteotomy should be ensured utilizing an osteotome from the internal iliac fossa (Figure 6C) to prevent iatrogenic fracture.
Case study #1
Case study #2
Revision anterior approach arthroplasty is a field in evolution as techniques to facilitate exposure and extract implants are introduced. Such techniques include: proximal extension of the anterior approach with detachment of the tensor origin on the iliac crest, distal extension of the incision with a femoral corticotomy, or an extended trochanteric osteotomy. The index procedure discusses proximal extension of the incision with exposure of the internal ilium. The purpose of the iliac osteotomy is to facilitate exposure and instrumentation of the proximal femur that would otherwise be impeded by the ilium and/or a large tensor muscle. In cases where the ilium is a mechanical impediment to the broach handle, dual-offset broaches handles have been utilized although they are not co-axial with the femoral canal.
In the described technique, the osteotomized ilium is retracted posteriorly along with the tensor attachment; the proximal femur is thereby exposed with no mechanical impedance either to the proximal femur or to a straight, co-axial trajectory down the femoral canal. Compared to detachment of the tensor as a strategy for femoral exposure, the osteotomy provides relief from both soft tissue and bone impediments while not disrupting the soft tissues of the hip deltoid. Soft-tissue morbidity associated with tensor origin detachment may compromise hip function (flexion, abduction) versus the high union rate of an iliac osteotomy.
If, during revision of the femoral component, it is necessary to expose the distal femur, the incision can be extended distally. The deep dissection can be performed posterior (subvastus) to the vastus lateralis with cauterization or ligation of the venous perforators near the bone. The vastus lateralis is elevated anteriorly and the distal femur is exposed. Iatrogenic fracture fixation can be performed with this extended approach. If cement removal is necessary, the surgeon can perform either a corticotomy or an extended trochanteric osteotomy through this approach.
There are limitations of this technique. First, the surgeon should be comfortable with the anatomy around the pelvis and acetabulum. While not part of the approach, the lateral femoral cutaneous nerve runs lateral in the sartorious, and if the surgeon is not careful detaching the sartorious/inguinal ligament off the ASIS, it can be injured. Next, the iliac osteotomy should include the origin of the tensor – anterior to the gluteus medius tubercle extending into the interspinous notch as shown in Figure 5B. Iatrogenic fracture can occur if the osteotomy is not completed. The external abdominal oblique aponeurosis and sartorious/inguinal ligament should be adequately repaired to the tensor fascia lata and ASIS, respectively. Because we have only described two cases with limited follow-up, the potential for other complications is unknown.
This article describes a technique, which may aid the surgeon in performing revision of the femoral component through the AA. The authors recognize that femoral component revision surgeries are not always best performed via the AA; this article describes a potentially helpful technique via the AA to facilitate femoral exposure and minimize soft-tissue compromise. Hip capsule release, muscle relaxation, and understanding of pelvic anatomy are key aspects of this procedure. Further prospective studies on this technique should be performed to determine its morbidity and efficacy compared to other revision techniques.
Written informed consent was obtained from the patients for publication of this article.
NMZ and SS provided the drafts of the manuscript. NMZ provided the intraoperative pictures. JMM and NMZ commissioned the line-art. JMM innovated the technique, performed the surgeries, edited the manuscript, and provided oversight. All authors read and approved the final version of this article.
The authors would like to acknowledge Shirley Coleman (medical illustrator, Los Angeles, CA) for all the line-art illustrations. All photographic images were obtained with patient consent.
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