Anterior Hueter Approach Research Articles

Total blood loss after hip hemiarthroplasty for femoral neck fracture: Anterior versus posterior approach

IntroductionFemoral neck fractures constitute a public health problem due to significant associated morbidity and mortality amongst the ageing population. Perioperative blood loss can increase this morbidity. Blood loss, as well as the influence that the surgical approach exerts on it, remains poorly evaluated. We therefore conducted a retrospective comparative study in order to: (1) compare total blood loss depending on whether the patients were operated on using an anterior or posterior approach, (2) compare the transfusion rates, operating times and hospital stays between these two groups and, (3) analyze dislocation rates. HypothesisTotal blood loss is greater from an anterior approach following a hip hemiarthroplasty for femoral neck fracture, compared to the posterior approach. Material and methodsThis retrospective single-center comparative study included 137 patients operated on by hip hemiarthroplasty between December 2020 and June 2021, and seven patients were excluded. One hundred and thirty patients were analyzed: 69 (53.1%) had been operated on via the anterior Hueter approach (AA) and 61 (46.9%) via the posterior Moore approach (PA). The analysis of total blood loss was based on the OSTHEO formula to collect perioperative “hidden” blood loss. The risk of early dislocation (less than 6 months) was also analyzed. ResultsTotal blood loss was similar between the two groups, AA: 1626±506mL versus PA: 1746±692mL (p=0.27). The transfusion rates were also similar between the two groups, AA: 23.2% versus PA: 31.1% (p=0.31) as well as the duration of hospitalization, AA: 8.5±3.2 versus PA: 8.2±3.3 days (p=0.54). The operating time was shorter in the PA group (Δ=10.3±14.1minutes [p<0.001]) with a greater risk of early dislocation when the patient was operated on by PA with AA: 9.8% versus PA: 1.4% (p=0.03). ConclusionThis study does not demonstrate any influence of the approach (anterior or posterior) on total blood loss. Transfusion rates and length of hospitalization were similar between the groups with a slightly shorter operating time but a greater risk of early dislocations after posterior hemiarthroplasty in a population at high anesthesia-related risk. Level of proofIII, comparative study of continuous series.

Low rate of periprosthetic femoral fracture with the Hueter anterior approach using stems cemented according to the 'French paradox'.

The aim of this retrospective study was to assess the incidence of early periprosthetic femoral fracture (PFF) associated with Charnley-Kerboull (CK) femoral components cemented according to the 'French paradox' principles through the Hueter anterior approach (HAA) in patients older than 70 years. From a prospectively collected database, all short CK femoral components implanted consecutively from January 2018 to May 2022 through the HAA in patients older than 70 years were included. Exclusion criteria were age below 70 years, use of cementless femoral component, and approaches other than the HAA. A total of 416 short CK prostheses used by 25 surgeons with various levels of experience were included. All patients had a minimum of one-year follow-up, with a mean of 2.6 years (SD 1.1). The mean age was 77.4 years (70 to 95) and the mean BMI was 25.3 kg/m2 (18.4 to 43). Femoral anatomy was classified according to Dorr. The measured parameters included canal flare index, morphological cortical index, canal-calcar ratio, ilium-ischial ratio, and anterior superior iliac spine to greater trochanter (GT) distance. Among the 416 THAs, two PFFs (0.48% (95% confidence interval 0.13 to 1.74)) were observed, including one Vancouver type B2 fracture 24 days postoperatively and one intraoperative Vancouver type B1 fracture. Valgus malalignment and higher canal bone ratio were found to be associated with PFF. This study demonstrated that short CK femoral components cemented according to the French paradox were associated with a low rate of early PFF (0.48%) in patients aged over 70 years. Longer follow-up is warranted to further evaluate the rate of fracture that may occur during the bone remodelling process and with time.

What happens in the medium-term to capsule-thickening plasties for iliopsoas impingement after total hip arthroplasty? Evaluation of 14 procedures at 4 years’ follow-up

IntroductionIn 2015, we described a capsule-thickening technique via an anterior approach for iliopsoas cup impingement. To our knowledge, medium-term results have not been reported. We therefore retrospectively analyzed all cases in the initial series and those since 2015, to assess this original technique over a longer follow-up: (1) to analyze complications, and (2) to assess functional outcome. HypothesisThe study hypothesis was that this surgical solution has a success rate sufficient for it to be included in the therapeutic armamentarium for iliopsoas impingement. Material and methodFourteen patients were included. Nine plasties were in first line, 3 after tenotomy, and 2 after cup exchange. The anterior Hueter approach was used, visualizing anterior cup overhang, sometimes associated with penetration of the anterior capsule, and enabling capsule-thickening by a folded Vicryl™ mesh. Functional results were analyzed. ResultsAt a median 4years’ follow-up (IQR: 2–5; range: 1–9), change over baseline in Oxford score was 7 points (p=0.004), median Medical Research Council thigh flexion strength score was 5 (IQR: 5–5), and 50% of patients (7/14) were satisfied or very satisfied. The major complications rate was 7% (1/14), for 1 irrigation of infected hematoma, cured without recurrence; there was also 1 minor case of injury to the lateral cutaneous nerve of the thigh. Forty-three percent of patients (6/14) exhibited a minimal clinically important difference (MCID) and 64% (9/14) a patient-acceptable symptom state (PASS). Median anatomic overhang on anatomic CT transverse slice was 7mm (IQR: 3–8; range: 0–13). Four patients underwent secondary acetabular component exchange; their median overhang was 7.5mm (IQR: 7–8) compared to 5mm (IQR: 2–8) for the other patients (p-value non-calculable). ConclusionThis surgical option seems interesting when acetabular overhang is not too great, especially as it does not affect flexion strength. Level of evidenceIV.

Outcome of hip resurfacing revision through the Hueter-anterior approach.

The Hueter-Anterior Approach (HAA) with its limited soft tissue and internervous dissection has been shown to be an effective approach for primary total hip and hip resurfacing arthroplasty (HRA). The purpose of this study is to evaluate the clinical outcome of patients requiring revision of HRA to total hip replacement using the HAA, assessing function and complications. We performed a retrospective review of a prospectively maintained research database. Between 2006 and 2015, 555 primary metal-on-metal (MoM) HRAs were performed via the HAA; we identified 33 hips in 30 patients that required revisions for aseptic causes to THA: aseptic loosening of acetabulum in 12 and femoral in 7, 10 for pseudotumour/ALTR, 4 for femoral neck fracture. All revision surgeries were performed through a HAA by a single surgeon who had also performed the index operation. PROMs were collected preoperatively and yearly at various timepoints postoperatively. The mean age at time of revision was 48.9 years (±5.3 SD) for 22 males (67%) and 11 females (33%). The mean time to revision surgery/failure of hip resurfacing was 3.3 years (±2.4 SD). There were 5 major reoperations with 3 infections, 1 acetabular loosening and 1 trunnionosis. There were significant improvements in multiple PROMs. The HAA is a viable surgical approach for revision of HRA with smaller initial HRA acetabular components generally requiring a relatively larger acetabular compoent at time of revision. Patients reported improvement in symptoms and function and a lower risk of subsequent reoperation than what has previously been reported for failed MoM bearings.

Hueter Anterior Approach for Metal-on-Metal Hip Resurfacing Arthroplasty: 555 Cases at a Minimum Five-Year Follow-Up

BackgroundPurpose of this study was to determine implant survivorship and resultant outcomes, including modes of failure, for metal-on-metal hip resurfacing through the Hueter anterior approach (HAA). MethodsRetrospective review of cases from 2006 to 2015, resulted in 555 metal-on-metal hip resurfacing via HAA, mean age 49.4 ± 6.9 years and mean BMI 28.1 ± 5.3. Kaplan-Meier curves were used to assess implant survivorship. Evaluation of technique was based on radiographic assessment of component position at 6 weeks. Patient-reported outcome measures were assessed using 12-Item Short Form Survey 12, University of California Los Angeles activity, Western Ontario and McMaster Universities Osteoarthritis Index, and hip disability osteoarthritis outcome scores. ResultsAt a mean follow-up of 9.18 years, survivorship was 95.0% at 5 years (95% CI: 93.2-96.8 years) and 92.5% at 10 years (95% CI: 90.0-95.0 years); men at 96.1% (95% CI: 94.3-97.9) and 93.8% (95% CI: 91.1-96.5), and women at 88.8% (95% CI: 81.9-95.7) and 85.6% (95% CI: 77.6-93.6), 5 and 10 years, respectively (P = .033). There were 37 revisions to total hips (7%) at a mean time of 3.3 years (SD 2.7). Indications for revision were aseptic loosening of acetabular (n = 12) and femoral component (n = 7) and pseudotumor (n = 6). Radiographic parameters were respectable and consistent, median acetabular inclination angle 41.2° and femoral stem shaft angle 137.7°. Patient-reported outcome measure scores significantly improved and remained stable at 2 and 5 years postoperatively. ConclusionAlthough choice of surgical approach should always be based on surgeon’s technical expertise, this study has shown that HAA is safe and effective for hip resurfacing. Mindful attention to long-term metal ion exposure must still be considered.

Treatment of femoroacetabular impingement by arthroscopy versus anterior mini-open approach: Case-control study of a continuous series of 91 cases at a mean 4.6 years’ follow-up

IntroductionFemoroacetabular impingement is a frequent cause of hip pain, and can be managed by conservative surgery. Many studies assessed postoperative course, but none compared operative techniques within a given population. We therefore conducted a retrospective case-control study comparing the minimally invasive anterior Hueter approach versus arthroscopy, assessing difference in 1) functional gain and 2) complications and 3) analyzing the impact of labral or cartilage lesions on functional scores. HypothesisClinical results do not differ between the mini-open and arthroscopic approach. Material and methodBetween 2007 and 2018, 91 hips in 84 patients were treated for femoroacetabular impingement: 69/91 (75.8%) cam effect, 6/91 pincer effect (6.6%) and 16/91 mixed (17.6%). Fifty-five were treated by arthroscopy and 36 by the Hueter mini-open approach. There were 20 female and 71 male hips. Mean age at surgery was 32 years (range, 17–55 years). Potential predictive factors comprised Nötzli alpha angle, labral/cartilage lesion and type of surgery. ResultsMean follow-up was 4.6 years (range, 1–16 years), with no loss to follow-up. The arthroscopy and Hueter groups showed no differences in functional improvement on Oxford-12 score (gain, −6.7±5.9 versus −6.2±8.1 (p=0.73), Postel Merle d’Aubigné (PMA) score (gain, 1.3±1 versus 1.1±0.9; p=0.41), operative time (75 versus 67min; p=0.16), or alpha angle correction (−10.9±12.9 versus −9.8±7.1; p=0.22). Complications did not differ: 1/55 severe complications after arthroscopy (1 definitive femoral nerve palsy) versus 4/36 non-severe complications after Hueter (3 cases of dysesthesia in the lateral cutaneous nerve of the thigh, 1 rectus femoris enthesopathy) (p=0.15). Labral lesions (37/91) did not affect clinical outcome: gain, 1.2±1 versus 1.3±0.9 on PMA (p=0.514) and −7.3±6 versus −6±7.3 on Oxford-12 (p=0.366). Cartilage lesions (27/91) were associated with poorer outcome on PMA (gain, 1±1.1 versus 1.3±0.9; p=002) but not on Oxford-12 (gain, −6.1±7.3 versus −6.7±6.6; p=0.288). ConclusionImpingement correction by the minimally invasive anterior Hueter approach gave clinical results comparable to those of hip arthroscopy in terms of Oxford and PMA scores, alpha angle correction, operative time and complications. Cartilage lesions were associated with poorer clinical results. Level of evidenceIII; retrospective case-control study.

Surgical Technique and Case Series of Total Hip Arthroplasty with the Hueter Anterior Approach for Crowe Type-IV Dysplasia.

Total hip arthroplasty (THA) is being increasingly performed via the Hueter anterior approach (HAA), which has proven benefits with nondysplastic hips; however, little has been published on its outcomes with dysplastic hips, where it can provide better acetabular exposure. We describe our technique for THA via the HAA in hips with Crowe type-IV developmental dysplasia and report the mid-term outcomes of cases that were performed over 5 consecutive years. We retrospectively evaluated a continuous series of 8 hips (6 patients) with Crowe type-IV dysplasia; the patient ages ranged from 44 ± 20 years (range, 17 to 65 years) at the index THA. All of the patients received uncemented implants via the HAA on a traction table to restore the hip center of rotation to the true acetabulum. Femoral head autografts (FHAs) were used to increase acetabular coverage in 6 hips, and subtrochanteric shortening osteotomies (SSOs) were performed in 5 hips. Patients were assessed clinically and radiographically at a minimum follow-up of 2 years. There were no revisions, deaths, dislocations, or infections. Two hips (25%) had intraoperative complications, and 1 hip (13%) had a postoperative complication that required reoperation without implant removal. All of the hips were assessed clinically and radiographically at 4 ± 1 years (range, 2 to 6 years). The modified Harris hip score (mHHS) improved from 33 ± 7 to 90 ± 7, and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) improved from 53 ± 14 to 89 ± 6; the postoperative leg-length discrepancy was 3.2 mm (range, -10 to 20 mm). None of the hips had osteolysis or radiolucent lines of >2 mm. THA via the HAA on a traction table for hips with Crowe type-IV dysplasia yielded satisfactory mid-term outcomes. Both FHA and SSO can be adequately performed via the HAA to help restore the hip center of rotation to the true acetabulum. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Minimally invasive total hip arthroplasty using Hueter's direct anterior approach.

For many years the Hueter anterior approach has been performed exclusively in Paris. Robert and Jean Judet described it for the first time in 1950 in relation to total hip arthroplasty. They started using an orthopaedic surgery table in 1985. The approach was only taught within the capital's orthopaedic units and was relatively unknown before. In the last 10 years there has been widespread renewed interest in this approach which preserves the muscles. The technique is described in detail with its tricks and risks. It appeals to the surgeon in its minimally invasive form and provides particulary effective treatment for the patient.

Direct anterior Hueter approach is a safe and effective approach to perform a bipolar hemiarthroplasty for femoral neck fracture

Background and purpose — The direct anterior (DA) approach in total hip arthroplasty has recently been associated with faster functional recovery than the posterolateral (PL) approach. We hypothesized that the same should hold for the DA approach in bipolar hemiarthroplasty for femoral neck fractures.Patients and methods — 82 patients with a displaced femoral neck fracture and candidates for bipolar hemiarthroplasty were enrolled after IRB approval in this prospective non-randomized comparative study (DA: n = 38; PL: n = 44). The postoperative protocols were similar in both groups. Evaluation included surgical complications, component placement, and early functional outcomes, assessed 6 weeks postoperatively using a timed up-and-go (TUG) test. The incidence of dislocation was assessed by telephone interview at least 1 year after the surgery.Results — The DA-group patients had better results in the TUG test than the PL-group patients 6 weeks after surgery: half were under 19 seconds as opposed to only one third for PL (p = 0.06). We did not record any intraoperative femoral fracture or any lateral femoral cutaneous neuropraxia in the DA group. We observed a significant difference (p = 0.04) in lateral offset between the PL group (4.2 (SD 6.4) mm) and the DA group (−1.6 (SD 8.5) mm). Stem alignment was similar between groups. The dislocation rate for DA patients was lower than for PL patients (1 of 38 cases vs. 9 of 44 cases; p = 0.02).Interpretation — Our findings indicate that relative to the posterolateral approach, the direct anterior approach for bipolar hemiarthroplasty may improve gait in the early postoperative period and decrease the dislocation rate.

Capsulotomy First: A Novel Concept for Hip Arthroscopy

Capsulotomy during hip arthroscopy improves the mobility of arthroscopic instruments and helps gain greater access to key areas of the hip. During the past decade, its use has expanded dramatically as the complexity of hip arthroscopy has advanced. We report a novel approach for hip arthroscopy that consists of performing an extra-articular capsulotomy under endoscopic control before exploration of the hip joint. The principle of this new concept is to replicate an anterior Hueter approach of the hip joint. We describe the surgical technique and discuss its advantages compared with conventional hip arthroscopy techniques using either a peripheral- or central-compartment starting point. This new approach is easy to master, can be performed with a 30° optic system, does not require fluoroscopic assistance, allows a reduction in both the force and duration of traction, and reduces the risk of labral or chondral damage.

Total hip arthroplasty dislocation rate following isolated cup revision using Hueter's direct anterior approach on a fracture table

Instability is a major complication after revision total hip arthroplasty. Studies in the literature have shown that the dislocation rate after primary arthroplasties by anterior approach on a fracture table is satisfactory, but the rate of instability following revision surgery is not known. We hypothesized that the Hueter direct anterior approach would result in a lower rate of postoperative dislocation following revision surgery. This hypothesis was tested in a series of isolated acetabular component replacements. Seventy-three consecutive isolated acetabular component replacements were performed between January 2000 and December 2007. Twelve revisions using constrained liners or dual mobility cups were excluded, thus 61 revisions in 59 patients, mean age 65.8-year-old (range 27-86) were included. The indications for revision arthroplasty were: 51 (83.6%) cases of aseptic loosening, five (8.2%) non-integration of cementless cups, three (4.9%) cases of instability, one (1.6%) case of impingement with the psoas and one (1.6%) case of excessive (3cm) lengthening. Acetabular bone defects were moderate, with 12 stage I, 26 stage II, 19 stage III, and only four stage IV defects on the SOFCOT bone stock deficiency score. There was no acetabular reconstruction in 18 cases, while there were four isolated reconstruction cages and 39 cages with a graft. The replacement cup was cemented in 52 cases and cementless in nine. Inclination and anteversion were measured by the Pradhan method on standard X-rays. Results were evaluated after a mean follow-up of 2.4 years±1.7 years (1-7 years). Four dislocations were observed (6.6%) all anterior and early in the postoperative period (less than 2 months): three patients had a single episode of dislocation and one patient again underwent revision cup replacement by Hueter anterior approach for recurrent anterior dislocation. The only factor associated with a risk of dislocation was a high body mass index: 29.7±0.8 in the group with dislocation compared to 25.6±3.2 in the group without (P=0.008). A high number of prior interventions was also a significant risk factor (P=0.045). On the other hand, there was no difference in cup inclination or femoral offset between the group with dislocation and that without. Although the rate of dislocation is higher than after primary THA by anterior approach, it remains acceptable for revision THA and is similar to rates observed with other approaches. The literature does not clearly establish that one surgical approach is better than another in terms of instability. This study was limited by the absence of CT-scan measurements of component orientation both preoperatively to evaluate the femoral component which is preserved, as well as during follow-up to evaluate cup angle and compare the groups with and without dislocation. The Hueter direct anterior approach is a viable option for isolated cup revision, as long as femoral loosening has been excluded, and the orientation of the preserved femoral component is known. Level IV; retrospective study.

Anterior hip subluxation following fixation of a T-shaped acetabular fracture through an extended iliofemoral approach

We report the case of a 34-year-old female patient who, six week following her acetabular fracture ORIF through an extended iliofemoral approach, presented with anterolateral incomplete dislocation of the femoral head. In the absence of joint incongruence as demonstrated on radiographs and CT images, a capsular tightening was performed via the anterior Hueter approach. This capsular plasty stabilized the hip for 2 years, but gradual osteoarthritis deterioration resulted in the need for arthroplasty. At the 2-year follow-up, this secondary arthroplasty showed satisfactory result. The substantial muscle exposure of the lateral aspect of the acetabulum and the circumferential capsulotomy related to the use of the iliofemoral approach were retained as factors promoting this complication. In case early postoperative mobilization is impossible, temporarily maintaining the limb in abduction and flexion can be recommended after an extended iliofemoral approach with circumferential capsulotomy.

Femoroacetabular Impingement Treatment Using Arthroscopy and Anterior Approach

Femoroacetabular impingement (FAI) has been identified as a common cause of hip pain in young adults. However, treatment is not well standardized. We retrospectively reviewed 97 patients (100 hips) who underwent osteochondroplasty of the femoral head-neck for FAI using a mini-open anterior Hueter approach with arthroscopic assistance. The mean age of the patients was 33.4 years. The labrum was refixed in 40 hips, partially excised in 39 cases, completely excised in 14 cases, and left intact in seven. Six patients were lost to followup, leaving 91 (94 hips) with a minimum followup of 28.6 months (mean, 58.3 months; range, 28.6-104.4 months). We assessed patients clinically using the nonarthritic hip score (NAHS). One patient had a femoral neck fracture 3 weeks postoperatively. At the last followup, the mean NAHS score increased by 29.1 points (54.8 +/- 12 preoperatively to 83.9 +/- 16 points at last followup). Eleven hips developed osteoarthritis and subsequently had total hip arthroplasty. The best results were obtained in patients younger than 40 years old with a 0 Tönnis grade. Refixation of the labrum did not correlate with a higher NAHS score (87 +/- 11 with refixation versus 82 +/- 19 points without) at the last followup. The technique for FAI treatment allowed direct visualization of the anterior femoral head-neck junction while avoiding surgical dislocation, had a low complication rate, and improved functional scores.

Dislocation After Total Hip Arthroplasty Using Hueter Anterior Approach

A prospective study including 1764 hips has been carried out to evaluate the frequency of dislocation while using the Hueter anterior approach and the correlated factors. The dislocation group was compared with the patients without dislocation. We observed 27 dislocations (1.5%). The dislocation rate when using 28 mm head diameter was 0.5%. Two patients underwent a revision for recurrent dislocations. Correlated factors for dislocation were male sex, high body mass index, etiology of osteonecrosis, low head diameter, high bleeding, and low postoperative ROM. Dislocation risk while using Hueter approach is one of the lowest in the literature. The main disadvantages are the necessity for a specific orthopedic table and a more difficult exposure of the femur.