Two-incision Total Hip Arthroplasty Research Articles

Is two-incision approach superior to the mini-posterior approach in total hip arthroplasty?: a meta-analysis.

Whether there is any clinical superiority for the two-incision total hip arthroplasty (THA) over the mini-posterior THA remains controversial. The present meta-analysis aimed to comprehensively compare the clinical outcomes between the two mini-invasive THAs. Two authors searched the database of Web of Science, PubMed, EMBASE and Cochrane Library to screen eligible studies individually. The quality evaluation of included studies was performed according to the principle of risk-of-bias of the Cochrane Library. The pooled results were analysed by Review Manager 5.3 software. A total of seven prospective studies (including five randomized controlled trials) with 423 hips were finally included for meta-analysis. The pooled results revealed that the mini-posterior THA outperformed the two-incision THA in shortening operative times, reducing blood loss and postoperative fracture risks, while no significant difference was found between the two surgery methods with respect to HSS scoring, SF-12 scoring, postoperative function recovery and other postoperative complications. Based on the pooled results, we suggested the mini-posterior THA as a preferable choice for patients suffering from severe advanced hip diseases.

A 6 to 10 Years Follow-Up Study Comparing Two-incision Total Hip Arthroplasties in Patients with Osteonecrosis of the Femoral Head or Hip Dysplasia

Two-incision total hip arthroplasty (THA) has a steep learning curve and might increase the risks of implant malposition and perioperative complications in difficult cases. Whether dysplasic hip or osteonecrosis of the femoral head (ONFH) would have different results by the two-incision technique remains unreported. From 2003 to 2010, 159 hips in 151 patients (68 female and 83 male) treated with the two-incision THA were included. Cases were divided into two groups with ONFH in 99 hips and dysplasia in 60 hips. The inclusion criteria for hip dysplasia were a Sharp's angle more than 43° and coverage of the femoral head less than 75%. Clinical data and radiological measurement were retrospectively analyzed. The ONFH patients had younger age (48.5 ± 12.8 years) with male predominance (74%) while the dysplasic patients had older age (62 ± 12 years) with female predominance (76%). There were no differences in preoperative functional score, operation time, blood loss, wound size, and length of hospital stay between groups. The ONFH group had bigger cup size ( p = 0.028) but similar stem size ( p = 0.072) as compared with the dysplasia group. The cup inclination angle was 43.7° ± 4.8° and 42.8° ± 5° ( p = 0.25) and the cup anteversion angle was 17.6° ± 7.6° and 14.2° ± 8.2° ( p = 0.009), in the ONFH and the dysplasia group, respectively. At the final follow-up, there were three revisions cases (one septic loosening in the dysplasia group and two periprosthetic fractures in the ONFH group). No dislocation was noted in the study cohort. We had overall 99.4% cup and 98.1% stem survival rate with the two-incision THA. The only differences were the bigger cup size and the more anteverted cup position in the ONFH hips as compared with the dysplasic hips. The two-incision THA seemed to be successful for patients with ONFH or dysplasic hips.

Risk factors associated with complications following total hip arthroplasty using the two-incision technique

Background:The frequency of the complications following total hip arthroplasty (THA) using the two-incision technique is well documented. However, few reports have analyzed the preoperative patient–related factors associated with the complications. The purpose of this study was to estimate the incidence of early complications following primary two-incision THA and to define the risk factors associated with perioperative complications.Materials and Methods:The subjects of this retrospective study were 1218 consecutive patients who underwent primary two-incision THA. The incidence of hip dislocation, stem subsidence, intraoperative femoral fracture, and nontraumatic postoperative femoral fracture was evaluated. The association between complications and preoperative patient–related factors, including gender, obesity, Crowe classification, age, body mass index (BMI), and morphological parameters of the proximal femoral medullary cavity, were investigated.Results:The incidences of complications were dislocation (1.1%), stem subsidence (0.9%), intraoperative femoral fracture (1.2%), and postoperative femoral fracture (0.7%). Obesity (BMI > 30) influenced the occurrences of stem subsidence and postoperative femoral fractures ( p = 0.0001, p = 0.019). Crowe classification significantly correlated with intraoperative femoral fractures (Grade II: odds ratio (OR) 4.63, 95% confidence interval (CI), 1.32–15.6; Grade III and IV: OR 8.96, 95% CI, 2.2–34.94). Additionally, the outer diameter of the femur 10 cm below the lesser trochanter tended to be small in patients who developed a femoral fracture.Conclusions:The early complication rate was comparable to other methods used in uncemented THA. It is necessary for patients with risk factors revealed in this study to pay careful attention or consider other surgical approaches to avoid complications. Further studies considering femur morphology are required.

Long-term outcome of two-incision total hip arthroplasty with intraoperative imageless navigation for cup placement: A concise followup, at ten to twelve years, of a previous report

Background: We previously reported at a minimum follow-up of one-year results of the use of imageless navigation for cup placement in primary two-incision total hip arthroplasties (THA). The purpose of the present report is to update that study and report the ten to twelve-year outcomes. Materials and methods: Twelve consecutive patients underwent minimally invasive two-incision (MIS-2) THA done by a single experienced surgeon between September 2003 and January 2005. A retrospective chart review was performed to investigate clinical assessment (the Harris hip score [HHS] and the Western Ontario and McMaster University Osteoarthritis Index [WOMAC] scale), radiographic analysis, the complications and survivorship. Results: At the latest follow-up evaluation, the HHS and WOMAC scale were 95.4 and 96.5 points respectively. There were no radiographic evidence of definite loosening. Injury to the lateral femoral cutaneous nerve occurred in 4 hips. There were no dislocation, no periprosthetic joint infection or fracture. The 10- year Kaplan-Meier analysis revealed 100% survival rate with revision for any reason as the end point. Conclusion: This study demonstrated that imageless navigation system for the two-incision THA give excellent long-term results.

Comparison of Minimally Invasive Total Hip Arthroplasty versus Conventional Hemiarthroplasty for Displaced Femoral Neck Fractures in Active Elderly Patients.

Fractures of the femoral neck in elderly patients can be treated by internal fixation, hemiarthroplasty, or total hip arthroplasty (THA), and the treatment modality used should be determined on the basis of considerations of the degree of fracture displacement, age, functional demands, and the risk factors for surgery and anesthesia. We studied 85 active elderly patients who underwent minimally invasive two-incision THA or conventional bipolar hemiarthroplasty (BHA) within 2 weeks of injury for the treatment of acute displaced femoral neck fractures. Patients were followed up for a minimum of 24 months. The average operation times were 70 minutes in the THA group and 46 minutes in the BHA group (p=0.002), and average blood losses during the perioperative period were 921 cc and 892 cc, respectively (p=0.562). In the THA group, the average postoperative Harris hip score was 88.3 and the average Western Ontario and McMaster University score was 28.8, whereas in the BHA group the corresponding scores were 80.4 (p=0.006) and 32.5 (p=0.012), respectively. There were 2 cases of hip dislocation in the THA group, and 2 cases in the BHA group underwent conversion to THA. Our short-term follow-up results were better for minimally invasive two-incision THA than for conventional BHA for the treatment of acute displaced femoral neck fractures in active elderly patients.

Modified minimally invasive two-incision total hip arthroplasty using large diameter femoral head

Background:Minimally invasive (MI) total hip arthroplasty (THA) is an alternative to standard THA, but has created much controversy among orthopedic surgeons. The authors modified the original minimally invasive two-incision THA technique and used large-diameter (32 mm, 36 mm) ceramic-on-ceramic articulation.Materials and Methods:One hundred and seventy patients that underwent unilateral MI two-incision THA were retrospectively reviewed, and surgical morbidity, functional recovery, radiological properties, and complications were assessed.Results:Mean Harris hip score (HHS) improved from 41.8 to 96.1 at last followup, and mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score from 66.2 to 26.9. The mean lateral opening angle of the acetabular component was 38.2° and the mean stem position was valgus 1.9°. There was an intraoperative femur fracture and one revision surgery due to stem subsidence. No patient had dislocation.Conclusions:Our data suggest that this modified technique combined with large ceramic femoral head is safe and reproducible in terms of achieving proper implant positioning and early functional recovery.

Two-incision versus modified Watson-Jones total hip arthroplasty in the same patients-- a prospective study of clinical outcomes and patient preferences

The two-incision technique and the modified Watson-Jones technique use muscular intervals and avoid muscle cutting in total hip arthroplasty (THA). However these two techniques have not been compared. A prospective randomized study of clinical outcomes and patient preferences was performed in 20 patients who had a two-incision THA in one hip and a modified Watson-Jones THA in the other between January 2004 and August 2007. The 20 patients were randomized equally to the two-incision first or the modified Watson-Jones first group. After the second surgery, patients were asked about their preferences for one of the two techniques and clinical results were analyzed. After a minimal follow-up of 2 years, there were no differences in the hospital course, clinical results, functional outcomes, and radiographic results between techniques. However more patients (70%) preferred the two-incision side to the modified Watson-Jones side in the first 6 months regardless which procedure was performed first. Given the similarity of these two techniques in cup implantation and with only a difference in femoral stem implantation, we think that the difference in patient preferences in the early postoperative period might be related to the surgical dissection and manipulation of the hip with the modified Watson-Jones technique.

A Prospective Randomized Trial of Mini-Incision Posterior and Two-Incision Total Hip Arthroplasty

A Prospective Randomized Trial of Mini-Incision Posterior and Two-Incision Total Hip Arthroplasty

A Prospective Randomized Trial of Mini-incision Posterior and Two-incision Total Hip Arthroplasty

The two-incision approach to THA has been controversial, with some authors reporting its use is associated with a rapid recovery whereas others report no differences in outcomes and a higher risk of perioperative complications secondary to increased surgical complexity. We therefore compared early postoperative variables including pain, length of stay, functional recovery, complications, and complexity of the mini-posterior and two-incision approaches to THA. We prospectively enrolled 72 patients scheduled for THA and randomized them into two groups: mini-incision posterior approach and the two-incision approach. Preoperative teaching, anesthetic protocols, implants used, and rehabilitation pathways were identical for both groups. All variables were assessed at a maximum of 1 year postoperatively. All key outcomes were similar in the two groups: mean visual analog scale (VAS) scores for pain during the first 3 postoperative days and the first 6 weeks, total narcotic requirements in the hospital and during the first 6 weeks, mean length of stay (51 hours versus 48 hours), and mean Harris hip scores and SF-12 scores. Achievement of functional milestones was similar between the two groups. There was one reoperation in each group. Mean operative time was longer for patients in the two-incision group (98 minutes versus 77 minutes), however the accuracy of component positioning was similar. We found no differences in perioperative outcomes between these two approaches for THA. Variables other than the surgical approach including perioperative protocols, patient expectations, and the patient's general health may have a greater effect on outcomes such as pain during the early postoperative period, functional recovery, and length of hospital stay. The use of small incisions for THA was safe as was a shortened hospital stay in selected patients.

Bilateral simultaneous two-incision minimally invasive total hip arthroplasty

BackgroundThis study aimed to assess the feasibility of bilateral simultaneous minimally invasive two-incision total hip arthroplasty in terms of clinical and radiological outcomes, complications, and patient satisfaction. MethodsA total of 62 patients, ages 24-69 years, were operated on with bilateral simultaneous minimally invasive total hip arthroplasty using a modified two-incision technique, after which they were followed for an average 41 months. The acetabular component was inserted through part of the Watson-Jones approach, and a femoral component was inserted through a space between the gluteus medius and piriformis tendon. ResultsThe mean duration of surgery was 180.4 min, and the mean perioperative blood loss was 1513.2 ml. There were no intraoperative complications. Postoperative periprosthetic fracture occurred in two patients and delayed infection in one patient. The average Harris Hip Score improved from 41.8 to 95.3. The WOMAC score improved from an average of 66.2 to 5.0. The average lateral opening angle of the acetabulum was 40°, and the angle of anteversion was 12°. All the femoral components were implanted in neutral to 5° valgus position. ConclusionsBilateral simultaneous minimally invasive total hip arthroplasty using a modified two-incision technique gave satisfactory clinical, radiological, and functional results. Efforts should be made to prevent perioperative peripros-thetic fractures.

Slower Recovery After Two-Incision Than Mini-Posterior-Incision Total Hip Arthroplasty

It has been claimed that the two-incision total hip arthroplasty technique provides quicker recovery than other methods do. To date, however, there have been no studies that have directly compared the two-incision technique with another method in similar groups of patients managed with the same advanced anesthetic and rehabilitation protocol. We posed the hypothesis that patients managed with two-incision total hip arthroplasty would recover faster than those managed with mini-posterior-incision total hip arthroplasty and designed a randomized controlled trial specifically (1) to determine if patients recovered faster after two-incision total hip arthroplasty than after mini-posterior-incision total hip arthroplasty as measured on the basis of the attainment of functional milestones that reflect activities of daily living, (2) to determine if the general health outcome after two-incision total hip arthroplasty was better than that after mini-posterior-incision total hip arthroplasty as measured with Short Form-12 (SF-12) scores, and (3) to evaluate the surgical complexity of the two procedures on the basis of the operative time and the prevalence of early complications. Between November 2004 and January 2006, seventy-two patients undergoing total hip arthroplasty were randomized to two treatment groups: one group was managed with the two-incision technique, and the other group was managed with the mini-posterior-incision technique. The two-incision group comprised thirty-six patients (twenty men and sixteen women) with a mean age of sixty-seven years and a mean body mass index of 28.7. The mini-posterior-incision group comprised thirty-six patients (twenty men and sixteen women) with a mean age of sixty-six years and a mean body mass index of 30.2. All patients received the same design of uncemented acetabular and femoral components and were managed with the same comprehensive perioperative pain management and rapid rehabilitation protocol. Operative times and complications were recorded. At two months and one year, all patients were assessed with regard to functional outcome and general health outcome. The patients in the two-incision group recovered more slowly than did those in the mini-posterior-incision group as measured on the basis of the mean time to discontinue a walker or crutches, to discontinue all walking aids, and to return to normal daily activities. The clinical outcome as measured on the basis of the SF-12 scores was similar at both two months and one year postoperatively. The two-incision total hip arthroplasty was a more complex surgical procedure, with a mean operative time that was twenty-four minutes longer; however, the rate of complications (2.8%; one of thirty-six) was the same in the two groups. Our hypothesis that the two-incision technique for total hip arthroplasty would substantially improve the short-term recovery after total hip arthroplasty compared with the mini-posterior-incision technique was not proved; instead, the patients managed with the mini-posterior-incision technique had the quicker recovery.

Mayo Experience with Two-Incision Total Hip Arthroplasty: The Added Technical Difficulty Has Not Been Rewarded

Minimally invasive (MIS) two-incision total hip arthroplasty (THA) was initially described as a revolutionary approach to total hip replacement in which no muscles or tendons were cut. Surgeon-developers of the MIS two-incision THA reported rapid recovery with few complications in highly selected groups of patients. However, there were no comparative studies reported by the surgeon-developers comparing the two-incision approach to any other method of THA in similar groups of patients using the same advanced anesthetic and rehabilitation protocols. At the Mayo Clinic our step-by-step research approach concerning MIS two-incision THA has included anatomical and clinical studies evaluating muscular damage, intraoperative and postoperative complications, subjective results, and functional results based on objective measurements including comprehensive gait analysis and strength testing. Our analysis of the accumulated data suggests that there are no scientific data that the two-incision technique provides better functional results than other approaches to THA, for many surgeons the prevalence of complications is high, the technique cannot be done without routinely damaging the abductor muscles, and patients who have had a THA with both techniques preferred a miniposterior THA to the two-incision THA.

Minimally Invasive Two-Incision Total Hip Arthroplasty: Is the Second Incision Necessary?

This article refutes the need for the posterior incision in minimally invasive two-incision total hip replacement. A description of how the Smith-Petersen, direct anterior, approach can be used to expose and implant the femoral components is given. Data from a prospective comparison of direct anterior and modified Hardinge approaches is presented. Seventy-nine patients in matched groups were analyzed. There was no difference between the groups in average body mass index, surgical time, incision length, hospital stay, pain, blood loss, or complications. At the six-month follow up evaluation slightly better outcomes were seen for the direct anterior approach when compared to the direct lateral approach. Limiting exposure to the anterior incision eliminates soft tissue and muscular damage. Other concerns such as intraoperative fractures, stem malpositioning, and prolonged surgeries are not seen with the direct anterior technique. Minimally invasive total hip arthroplasty can be performed safely with excellent results using the direct anterior incision alone.

Anterior Approach Total Hip Arthroplasty: The Heuter Interval

The authors report on outcomes from a consecutive series of 450 total hip arthroplasty patients who underwent surgery with a single-incision anterior approach to the hip joint. This approach is relevant to minimally invasive two-incision total hip arthroplasty, since the anterior portion of the two-incision technique is identical to that described here. Complications with the single incision technique, including thigh sensory changes and periprosthetic femur fractures, are reported, and the authors discuss how these may be avoided. In the authors' experience with total hip arthroplasty through the anterior approach, patients report reduced postoperative pain and experience more rapid recovery, with less surgical scarring.

Slower Recovery After Two-Incision Than Mini-Posterior-Incision Total Hip Arthroplasty

It has been claimed that the two-incision total hip arthroplasty technique provides quicker recovery than other methods do. To date, however, there have been no studies that have directly compared the two-incision technique with another method in similar groups of patients managed with the same advanced anesthetic and rehabilitation protocol. We posed the hypothesis that patients managed with two-incision total hip arthroplasty would recover faster than those managed with mini-posterior-incision total hip arthroplasty and designed a randomized controlled trial specifically (1) to determine if patients recovered faster after two-incision total hip arthroplasty than after mini-posterior-incision total hip arthroplasty as measured on the basis of the attainment of functional milestones that reflect activities of daily living, (2) to determine if the general health outcome after two-incision total hip arthroplasty was better than that after mini-posterior-incision total hip arthroplasty as measured with Short Form-12 (SF-12) scores, and (3) to evaluate the surgical complexity of the two procedures on the basis of the operative time and the prevalence of early complications. Between November 2004 and January 2006, seventy-two patients undergoing total hip arthroplasty were randomized to two treatment groups: one group was managed with the two-incision technique, and the other group was managed with the mini-posterior-incision technique. The two-incision group comprised thirty-six patients (twenty men and sixteen women) with a mean age of sixty-seven years and mean body mass index of 28.7. The mini-posterior-incision group comprised thirty-six patients (twenty men and sixteen women) with a mean age of sixty-six years and a mean body mass index of 30.2. All patients received the same design of uncemented acetabular and femoral components and were managed with the same comprehensive perioperative pain management and rapid rehabilitation protocol. Operative times and complications were recorded. At two months and one year, all patients were assessed with regard to functional outcome and general health outcome. The patients in the two-incision group recovered more slowly than did those in the mini-posterior-incision group as measured on the basis of the mean time to discontinue a walker or crutches, to discontinue all walking aids, and to return to normal daily activities. The clinical outcome as measured on the basis of the SF-12 scores was similar at both two months and one year postoperatively. The two-incision total hip arthroplasty was a more complex surgical procedure, with a mean operative time that was twenty-four minutes longer; however, the rate of complications (2.8%; one of thirty-six) was the same in the two groups. Our hypothesis that the two-incision technique for total hip arthroplasty would substantially improve the short-term recovery after total hip arthroplasty compared with the mini-posterior incision technique was not proved; instead, the patients managed with the mini-posterior-incision technique had the quicker recovery.

Minimally Invasive Two-Incision Total Hip Arthroplasty for Treating Acute Displaced Femoral Neck Fractures in Active Elderly Patients

Purpose: The purpose of this study was to evaluate the short term follow-up results of minimally invasive (MI) two-incision total hip arthroplasty (THA) for treating acute displaced femoral neck fractures in active elderly patients. Materials and Methods: We performed a retrospective review of 39 cases (average age: 72 years old, range: 60 years and above) of elderly patients who underwent MI two-incision THA within 30 days of their injury for treating displaced acute femoral neck fracture s. They were followed up for a minimum of 12 months. Clinical evaluation was done by comparing the pre-injury and postoperative daily activities, the Harris Hip score (HSS) and the Western Ontario and McMaster University (WOMAC) score. The radiographs were checked to evaluate for implant alignment and periprosthetic abnormalities. The postoperative complications were analyzed. Results: The average postoperative HSS was 88.3 and the average WOMAC s core was 28.8. All the patients were able to walk without any assistive device. One patient had a HHS of less than 70. There were 2 dislocations but there was no recurrence. Radiographically, there was no case with a limb length discrepancy of more than 5mm. The femoral stems did not reveal any subsidence of more than 5mm. Other complications such as osteolysis, infection, neurologic injury and intraoperative periprosthetic fracture were not noted. Especially, no patient complained of any groin pain, which often occurs after bipolar hemiarthroplasty. Conclusion: The short term follow-up results were good for MI two-incision THA to treat acute displaced femoral neck fractures in active elderly patients, and these procedures were done by an experienced hip surgeon.

Two-Incision Total Hip Arthroplasty: The Hackensack Experience

Two-incision total hip arthroplasty (THA) represents a unique approach to THA in which muscle planes are preserved and no muscles are cut. It is a reliable and reproducible technique when performed properly in the appropriately selected patient. This technique affords the potential for earlier return to activities and possibly less postoperative pain, thus resulting in a more gratifying surgical experience. A single surgeon’s initial experience of 400 two-incision THAs is presented. There was a significant decrease in operative time, fluoroscopic usage, and complication rates as more comfort and experience were gained with this technique. Modifications to the original technique are presented.

The Two Incision Total Hip Arthroplasty: Technique and Results

The two-incision technique for total hip arthroplasty (THA) has evolved rapidly over the past decade with the aid of training courses, new instrumentation, and cadaver laboratories. We describe our technique, choice of implants, and outcomes using this method. While there is clear evidence of a learning curve for two-incision THA, the number of complications and operative times both declined after the 20th case in our series. We conclude that, with appropriate training, both in the laboratory and with surgeon experience, two-incision THA can be a safe alternative to more invasive hip replacement surgery.

Early Results of Two-Incision Total Hip Arthroplasty: Experience with 250 Consecutive Cases at Saint Louis University

Minimally invasive total hip arthroplasty (THA) has been performed at Saint Louis University School of Medicine since 2000. This study is a critical appraisal of the early outcomes and complications observed in a series of the first 250 consecutive total hip arthroplasty procedures using the Zimmer MIS 2-Incision technique (MIS-2). Despite some published reports indicating high complication rates with this technique, our experience indicates that the complication rates are lower than many series using traditional hip exposures. Our findings show that the MIS-2 technique is useful and need not be restricted to younger patients with a small body habitus. Evolutionary improvements in the surgical technique and pitfalls of the procedure are discussed. Despite its demonstrated advantages, MIS-2 THA remains a challenging technical alteration from traditional total hip operative methods.

Early Results of Minimally Invasive Two-Incision Total Hip Arthroplasty: A Review at 24-Month Follow-Up

With a growing interest from patients in minimally invasive total hip replacements, more follow-up reports on two-incision minimally invasive total hip arthroplasty (MI-THA) are needed to help define risks, patient criteria, and adequate training measures. This study reports early results of 125 two-incision MI-THAs (minimum 2 years). The average age of the patients was 62.4 years, their average body mass was 27, all had Dorr B or better bone, and none had previous hardware. Average hospital was stay was 1.2 days. There were two (1.6%) major complications: one femoral nerve neuropraxia and one periprosthetic fracture occurred when a patient fell 4 weeks after the primary THA, necessitating reoperation. There were 15 (12%) total complications, excluding 38 (30.4%) cases with lateral femoral nerve parathesias, of which all were resolved or of little consequence at 24 months. The authors believe this minor complication is an element of the surgery and that prospective patients be advised of it. Results suggest that two-incision MI-THA may permit earlier function than standard THAs and can be performed with an acceptable complication rate when done on select clients by specially trained hip specialists.