Updated: 8/19/2022

THA Approaches

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Flashcards
2
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Questions
12
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Evidence
11
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Videos / Pods
33
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  • Introduction
    • Surgical approach may be dictated by
      • surgeon preference
      • prior incisions
      • obesity
      • risk for dislocation
      • implant selection
      • degree of deformity
    • Standard approaches
      • direct anterior
      • anterolateral
      • direct lateral
      • posterolateral
    • Extensile approaches
      • trochanteric osteotomy
    • "Minimally invasive" approaches
  • Direct Anterior Approach
    • Overview
      • increasingly popular approach with good long-term results
      • uses interval between tensor fascia lata and sartorious
    • Advantages
      • decreased dislocation rate when compared to posterior approach in numerous studies
      • abductor mechanism not violated (compared to anterolateral exposure)
        • No difference in gait biomechanics at 3 months compared to other approaches
      • unsupported advantages include
        • decreased muscle damage
        • decreased pain
        • quicker recovery
    • Disadvantages
      • steep learning curve
        • complication rates decrease after 100+ procedures
      • surgical site infection rates increased in obese patients with large abdominal panni
      • femoral exposure can be challenging
        • may require a special operating room table for increased exposure
      • lateral femoral cutaneous nerve paresthesias
      • intraoperative fracture rate thought to be higher
  • Anterolateral Approach
    • Overview
      • less commonly used approach for arthroplasty secondary to violation of abductor mechanism and post-operative limp
      • uses interval between tensor fascia lata and gluteus medius
    • Advantages
      • lower dislocation rate than posterior approach
    • Disadvantages
      • violates abductor mechanism
        • may lead to postoperative limp
  • Direct Lateral Approach
    • Overview
      • less commonly used approach for arthroplasty secondary to violation of abductor mechanism and postsa-operative limp
      • no true interval
        • splits gluteus medius and vastus lateralis
    • Advantages
      • lower dislocation rate than posterior approach
      • allows access to both anterior and posterior hip joint without osteotomy
    • Disadvantages
      • violates abductor mechanism
        • may lead to postoperative limp
      • heterotopic ossification is common
  • Posterolateral Approach
    • Overview
      • most common approach for primary and revision arthroplasty
      • no true interval
    • Advantages
      • abductor mechanism not violated
      • excellent exposure of both femur and acetabulum
      • easily converted to more extensile exposures both proximally and distally
    • Disadvantages
      • dislocation rates may be higher than anterior exposures
      • risk reduced with repair of capsule and short external rotators
  • Extensile Approaches
    • Trochanteric osteotomy
      • overview
        • 3 types
          • standard trochanteric osteotomy
          • trochanteric slide
          • extended trochanteric osteotomy
        • useful for difficult primary and revision hip arthroplasty
      • advantages
        • excellent acetabular exposure
        • useful for component removal
      • disadvantages
        • complications include
          • non-union
          • heterotopic ossification
          • trochanteric bursitis
          • abductor weakness
        • extended trochanteric osteotomy requires diaphyseal engaging stem
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(OBQ18.83) A 61-year-old man with left hip OA presents to clinic for persistent left hip pain despite a trial of conservative therapy. The decision is made to proceed with total hip arthroplasty via a direct anterior approach. Which of the following correctly describes the superficial internervous plane of this approach?

QID: 212979

Rectus femoris (femoral n.) & tensor fascia lata (superior gluteal n.)

7%

(147/2254)

Tensor fascia lata (femoral n.) & sartorius (superior gluteal n.)

9%

(205/2254)

Rectus femoris (femoral n.) & gluteus medius (superior gluteal n.)

1%

(21/2254)

Sartorius (femoral n.) & gluteus medius (superior gluteal n.)

1%

(20/2254)

Sartorius (femoral n.) & tensor fascia lata (superior gluteal n.)

82%

(1848/2254)

L 1 A

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(OBQ15.206) A 70-year-old male returns to your clinic having decided to pursue hip replacement for his intractable pain. Which of the following scenarios is associated with the greatest risk of dislocation following primary total hip arthroplasty?

QID: 5891

Smith-Peterson approach with failed capsular repair

13%

(277/2175)

Watson-Jones approach with direct penetration of iliospoas with retractors

3%

(64/2175)

Hardinge approach with acetabular cup placement in 40 degrees of abduction

4%

(88/2175)

Direct anterior approach with 15 degrees of anteversion

3%

(73/2175)

Moore approach to the hip with capsulectomy

76%

(1655/2175)

L 4 B

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(OBQ06.89) A minimal-incision technique with an incision no more than 10 centimeters has which of the following advantages compared to a standard incision for a total hip replacement?

QID: 200

lower post-operative visual analogue pain score

5%

(204/4116)

less transfusion requirement

3%

(109/4116)

shorter length of stay

4%

(149/4116)

better cosmetic result

87%

(3587/4116)

less pain medication requirement

1%

(56/4116)

L 2 C

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(OBQ06.232) During a minimally invasive approach to total hip arthroplasty a femoral periprosthetic fracture occurs. Which of the following steps is crucial to properly treat this complication?

QID: 243

Transitioning to an extensile approach to adequately visualize and reduce the fracture

92%

(3496/3796)

Limiting post-operative weight bearing

4%

(164/3796)

Switching to a cemented femoral stem to avoid the stresses created during press-fit fixation

3%

(104/3796)

Delaying the arthroplasty until the fracture has healed

0%

(5/3796)

Supplementing the fracture with autograft

0%

(12/3796)

L 1 C

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Evidence (11)
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EXPERT COMMENTS (7)
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