Abstract
ObjectiveMinimally invasive approach in total hip arthroplasty for the treatment of femoral neck fractures with a hemiarthroplasty.IndicationsFemoral neck fractures of patients without hip osteoarthritis where the acetabulum is still intact.ContraindicationsLesions and infections of the skin in the approach area; hip osteoarthritis; surgeon’s lack of experience with the technique.Surgical techniqueThe direct anterior approach (DAA) uses the Smith–Peterson interval between the tensor fasciae latae (TFL) and the rectus and sartorius muscle. After coagulation of the ascending branches of the femoral circumflex vessels, the capsule is opened. The remaining parts of the femoral neck are removed and osteotomized if necessary. The femoral head is removed with a cork screw. Then the shaft is supported by 2 sharp retractors at the greater trochanter from cranial, and the leg is externally rotated, hyperextended, and adducted. A TFL release can be performed which we also recommend. The femoral canal is opened step by step and extended with rasps which are introduced with the double curved broach handle. Cement and the final implant are introduced and after the trial reduction also the final head. The hip is reduced, the capsule adapted and the wound closed.Postoperative managementFor this approach, there are no approach specific recommendations. Postoperative treatment depends on whether the approach was extended with muscle releases and on the type of reconstruction performed. If the approach was limited to the minimally invasive direct anterior portal, quicker rehabilitation can be expected due to the reduced muscle damage. We prefer mobilization with full weight bearing as tolerated on the next day.
Highlights
The main advantage of the direct anterior approach (DAA) is preservation of the muscular structures, especially the gluteal muscles which remain intact during primary total hip arthroplasty (THA) through this approach
A proximal extension of the skin incision beyond the ASISline is not recommended as the muscles are attached in this area and they represent an inner natural barrier.The red line shows the Lazy S skin incision extension for the approach to the femoral diaphysis.When releasing the tensor fasciae latae (TLF) muscle from the iliac crest, it is necessary to extend the incision to the anterior superior iliac spine (ASIS)
From January 2010 until July 2019, 1158 femoral neck fractures were treated with hemiarthroplasty in the hospital
Summary
The direct anterior approach to the hip was described as early as the 1880s by Carl Hueter [3] and was widely popularized for pelvic and pediatric surgery by Smith Petersen [19]. The main advantage of the direct anterior approach (DAA) is preservation of the muscular structures, especially the gluteal muscles which remain intact during primary total hip arthroplasty (THA) through this approach. – Standard approach to the hip – Preservation of the muscular structures especially gluteal abductional function – Short skin incision – Low blood loss [22] – Faster rehabilitation compared to the anterolateral approach [10] – Lower risk of dislocation compared with the posterior approach [21] – A distal extension of the approach is possible in cases of femoral fractures [20]. – Smaller approach – Technically more demanding – Training and experience necessary – Potential lesion of the lateral femoral cutaneous nerve – Risk of femoral fractures [12] – Specialized instruments are mandatory
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