Snittföring - hur man tar sig in till höften    

Arkan Sayed-Noor Sundsvall/Umeå Sep 2016

Vad är den idealiska approachen?

�  Mjukdelssparande (MIS) �  Adekvat tillgång till femur och acetabulum (med/utan

speciella instrument).

�  Går att förlänga vid behov (intraoperativ komplikation). �  Tillåter intraoperativ undersökning av protesens

stabilitet och rörelseomfång samt benlängdsskillnad. �  Lätt att lära.

Fyra välkända approacher (med flertal modifikationer)

�  Anterior [Smith-Petersen, Hueter]

�  Antero-lateral [Watson-Jones, Rottinger]

�  Lateral (trochanterosteotomi eller myo-tenotomi) [McFarland and Osborne, Hardinge, Gammer]. Känd som Främre snitt

�  Posterior (postero-lateral) [Kocher, Gibson, Langenbeck, Moore]. Känd som Bakre snitt

Främre snitt [McFarland and Osborne, Hardinge, Gammer]

•  Beskrevs först i mitten av 50-talet och modifierades av Hardinge

•  Patient i rygg- eller sidoläge •  Lätt att förlänga vid behov •  Generös tillgång till acetabulum och femur àbra

positionering av komponenterna – undvik C positionering av stammen

•  Ej optimal MIS teknik (trokanterosteotomi eller gluteus myotenotomi)

Främre snitt [McFarland and Osborne, Hardinge, Gammer]

•  Risk för hälta och trokanterömhet (gluteusinsufficiens sek till muskelskada el sup. gluteus nervskada) – verkar inte påverka kliniken

•  Vid trokanterosteotomi (ovanligt) à risk för non-union •  Ger god möjlighet till intraoperativ undersökning av

protesens stabilitet och rörelseomfång samt benlängdsskillnad

•  Relativt kort lärningskurva (15-25)

Bakre snitt [Kocher-Langenbeck, Gibson, Moore].

•  Beskrevs först för 100 år sedan och modifierades av Moore på 50-talet

•  Patient i sidoläge •  Lätt att förlänga vid behov •  Mindre generös tillgång till acetabulum än främre

approach à viss svårighet att positionera cupen. •  Ej optimal MIS teknik (tenotomi av utåt-

rotatorarna)

Bakre snitt [Kocher, Langenbeck, Gibson, Moore].

•  Risk för protesluxation (risken minskar när man

re-suturerar bakre ledkapsel och utåtrotatorerna)

•  Ger god möjlighet till intra-operativ undersökning av protesens stabilitet och rörelseomfång samt benlängdsskillnad

•  Relativt kort lärningskurva (15-25)

Vilket snitt används mest? Havelin et al Acta Orthopaedica 2009

�  Bakre 60% �  Bakre 90%

�  Bakre 24%

Vilket snitt ger bästa resultat, främre eller bakre?

� De tillgängliga jämförande studierna är bristfälliga (dålig design, otillräckligt material eller uppföljning, hög drop-out mm).

�  Resultaten varierar bland artrospatienter

och frakturpatienter.

Artrospatienter

Främre vs. bakre Jolles & Bogoch Cochrane Review 2006

�  Fyra prospektiva studier med begränsat material (n=241) och bristfällig design:

1.  Ingen skillnad på protesluxationsfrekvensen. 2.  Lätt ökad risk för Tredelenburg-hälta med lateral

approach postoperativt men inte efter år. 3.  Ingen skillnad på nervskador. 4.  Ingen skillnad på postoperativ benlängdsskillnad 5.  Ingen skillnad på postoperativ smärta. 6.  Ingen skillnad på operationens slutgiltiga resultat

(outcome), mätt med HHS.

Berstock et al 2015

Kwon et al. Review article Clinical Orthopaedics and Related Research 2006

�  Systematisk review av 11 studier. �  Jämförbar luxationsrisk: Ant.lat : 0.70% Lateral: 0.43% Post.lat: 1.01%

Påverkar det kirurgiska snittet risken för revision pga recidiverande luxation efter höftprotes-kirurgi?

Bakre snitt gav högre risk för revision pga recidiverande luxation (RR 1.3, CI 1.1-1.7)

442 Acta Orthopaedica 2012; 83 (5): 442–448

The risk of revision due to dislocation after total hip arthroplasty depends on surgical approach, femoral head size, sex, and primary diagnosisAn analysis of 78,098 operations in the Swedish Hip Arthroplasty Register

Nils P Hailer1, Rüdiger J Weiss2, André Stark3, and Johan Kärrholm4

1Department of Orthopaedics, Institute of Surgical Sciences, Uppsala University Hospital, Uppsala; 2Department of Molecular Medicine and Surgery, Section of Orthopaedics and Sports Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm; 3Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm; 4Department of Orthopaedics, Institute of Surgical Science, Sahlgrenska University Hospital, Göteborg University, Mölndal, SwedenCorrespondence: nils.hailer@surgsci.uu.se Submitted 12-04-24. Accepted 12-07-06

Open Access - This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the source is credited.DOI 10.3109/17453674.2012.733919

Background and purpose The effects of patient-related and tech-nical factors on the risk of revision due to dislocation after pri-mary total hip arthroplasty (THA) are only partly understood. We hypothesized that increasing the femoral head size can reduce this risk, that the lateral surgical approach is associated with a lower risk than the posterior and minimally invasive approaches, and that gender and diagnosis influence the risk of revision due to dislocation.

Patients and methods Data on 78,098 THAs in 61,743 patients performed between 2005 and 2010 were extracted from the Swed-ish Hip Arthroplasty Register. Inclusion criteria were a head size of 22, 28, 32, or 36 mm, or the use of a dual-mobility cup. The covariates age, sex, primary diagnosis, type of surgical approach, and head size were entered into Cox proportional hazards models in order to calculate the adjusted relative risk (RR) of revision due to dislocation, with 95% confidence intervals (CI).

Results After a mean follow-up of 2.7 (0–6) years, 399 hips (0.5%) had been revised due to dislocation. The use of 22-mm femoral heads resulted in a higher risk of revision than the use of 28-mm heads (RR = 2.0, CI: 1.2–3.3). Only 1 of 287 dual-mobil-ity cups had been revised due to dislocation. Compared with the direct lateral approach, minimally invasive approaches were asso-ciated with a higher risk of revision due to dislocation (RR = 4.2, CI: 2.3–7.7), as were posterior approaches (RR = 1.3, CI: 1.1–1.7). An increased risk of revision due to dislocation was found for the diagnoses femoral neck fracture (RR = 3.9, CI: 3.1–5.0) and osteonecrosis of the femoral head (RR = 3.7, CI: 2.5–5.5), whereas women were at lower risk than men (RR = 0.8, CI: 0.7–1.0). Restriction of the analysis to the first 6 months after the index procedure gave similar risk estimates.

Interpretation Patients with femoral neck fracture or osteo-necrosis of the femoral head are at higher risk of dislocation. Use

of the minimally invasive and posterior approaches also increases this risk, and we raise the question of whether patients belonging to risk groups should be operated using lateral approaches. The use of femoral head diameters above 28 mm or of dual-mobility cups reduced this risk in a clinically relevant manner, but this observation was not statistically significant.

■

Dislocation remains a major problem after primary total hip arthroplasty (THA), and has a considerably negative effect on the quality of life after THA, especially if it is recurrent (Enocson et al. 2009b). Revision due to dislocation accounts for 9% of all revisions of primary THAs in the Swedish Hip Arthroplasty Register (SHAR), and it is therefore the second most common reason for revision after aseptic loosening (SHAR Annual Report 2010). An even higher proportion of revisions due to dislocation—of 26%—has been reported by the Australian National Joint Replacement Registry (2011). Most dislocations occur during the first postoperative year, and up to 50% take place within the first 3 months (Woo and Morrey 1982, Phillips et al. 2003, Meek et al. 2006). The Nor-wegian Joint Register reported that the number of revisions performed due to dislocation has increased over time, possi-bly related to changes in head sizes and surgical approaches during the study period (Fevang et al. 2010).

Several factors have been proposed to influence the risk of dislocation, but many questions still remain unsolved (Meek et al. 2006). Various diagnoses such as femoral neck fracture (Conroy et al. 2008), the posterior approach to the joint, and small femoral head size of the prosthesis are parameters that have been identified as risk factors for dislocation (Furnes et

Påverkar det kirurgiska snittet patient-rapporterat utfall efter höftproteskirurgi?

Bakre snitt gav bättre rörlighet, livskvalité och patienttillfredsställelse (p<0.001)

Frakturpatienter

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184 Acta Orthopaedica 2009; 80 (2): 184–189

Dislocation of total hip replacement in patients with fractures of the femoral neck

A prospective cohort study of 713 consecutive hips

Anders Enocson1, Carl-Johan Hedbeck1, Jan Tidermark1,3, Hans Pettersson2, Sari Ponzer1, and

Lasse J Lapidus1

1Sections of Orthopedics and 2Statistics, Department of Clinical Science and Education, Karolinska Institutet, Stockholm Söder Hospital; 3Department of Orthopedics, Capio St. Göran’s Hospital, Stockholm, SwedenCorrespondence AE: anders.enocson@sodersjukhuset.se Submitted 08-08-27. Accepted 08-10-24.

Copyright © Informa Healthcare Ltd 2009. ISSN 1745–3674. Printed in Sweden – all rights reserved.DOI 10.3109/17453670902930024

Background Total hip replacement is increasingly used in active, relatively healthy elderly patients with fractures of the femoral neck. Dislocation of the prosthesis is a severe complication, and there is still controversy regarding the optimal surgical approach and its influence on stability. We analyzed factors influencing the stability of the total hip replacement, paying special attention to the surgical approach.

Patients and methods We included 713 consecutive hips in a series of 698 patients (573 females) who had undergone a primary total hip replacement (n = 311) for a non-pathological, displaced femoral neck fracture (Garden III or IV) or a secondary total hip replacement (n = 402) due to a fracture-healing complication after a femoral neck fracture. We used Cox regression to evaluate factors associated with prosthetic dislocation after the operation. Age, sex, indication for surgery, the surgeon’s experience, femoral head size, and surgical approach were tested as independent fac-tors in the model.

Results The overall dislocation rate was 6%. The anterolateral surgical approach was associated with a lower risk of dislocation than the posterolateral approach with or without posterior repair (2%, 12%, and 14%, respectively (p < 0.001)). The posterolat-eral approach was the only factor associated with a significantly increased risk of dislocation, with a hazards ratio (HR) of 6 (2–14) for the posterolateral approach with posterior repair and of 6 (2–16) without posterior repair.

Interpretation In order to minimize the risk of dislocation, we recommend the use of the anterolateral approach for total hip replacement in patients with femoral neck fractures.

Different surgical methods are available for the treatment of displaced fractures of the femoral neck (Garden III and

IV): internal fixation (IF), hemiarthroplasty (HA), and total hip replacement (THR). Despite the good results for THR reported in recent randomized controlled trials with regard to the need for revision surgery, hip function (Johansson et al. 2000, Tidermark et al. 2003, Keating et al. 2006), and health-related quality of life (HRQoL) (Tidermark et al. 2003, Blomfeldt et al. 2005, Keating et al. 2006), the proportion of patients treated with a THR in routine healthcare is not as high as would be expected (Bhandari et al. 2005). The risk of dislo-cation may be one major reason why orthopedic surgeons hes-itate to perform a THR. Several studies have confirmed that the dislocation rate after a THR for a femoral neck fracture is considerably higher than what can be expected after a THR for osteoarthritis or rheumatoid arthritis (Woo and Morrey 1982, Berry et al. 2004, Meek et al. 2006). The principal surgical approaches for insertion of a THR are anterolateral (Hardinge 1982) or posterolateral (Moore 1957). The posterior approach can be performed with or without re-attachment of the short external rotators and/or the posterior joint capsule (posterior repair).

The influence of the surgical approach on stability is dif-ficult to evaluate within the context of a conventional random-ized controlled trial since most surgeons have their individual preferences regarding this issue. The best approach is prob-ably randomization by surgeon, or a large prospective cohort trial in which the surgical approach used conforms to the pref-erence of the treating surgeon.

We analyzed factors influencing the stability of a THR within the context of a large prospective cohort trial involving consecutive patients. We payed special attention to the surgi-cal approach used.

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Främre (Hardinge) vs. bakre (Moore) snitt Enocson et al Acta Orthopaedica 2008 & 2009

�  Två prospektiva studier. �  Studie I: Total höftprotes som primär eller sekundär

behandling för dislocerade collum femoris (n=713) opererades med Hardinge snitt (n=463) och Moore snitt (n=250).

�  Studie II: Hemiartroplastik som primär eller sekundär

behandling för dislocerade collum femoris (n=739) opererades med Hardinge snitt (n=431) och Moore snitt (n=308).

Främre (Hardinge) vs. bakre (Moore) snitt Enocson et al Acta Orthopaedica 2008 & 2009

Studierna visade att Moore snitt var den enda faktor

som ökade risken för protesluxation, oavsett om man rekonstruerade bakre strukturerna (ledkaspel och utåtrotatorarna) eller inte (totalprotes, 2% vs. 12% och 14% ― hemiartroplastik , 3% vs. 8.5% och 13%).

Kan man ändra rutinen för snittföring? Svaret är JA

�  4 kirurger lärde ut andra kollegor över 1 årsperiod

�  Minskad luxationsrisk från 8% till 2%

© 2014 Wichtig Publishing - ISSN 1120-7000

Hip Int (2014; :Suppl 10) S7-S1124

S7

An update on surgical approaches in hip arthoplasty: lateral versus posterior approach

Sebastian S. Mukka, Arkan S. Sayed-Noor

Department of Surgical and Perioperative Sciences (Orthopaedics-Sundsvall), Umeå University, Umeå - Sweden

REVIEW

DOI: 10.5301/hipint.5000164

INTRODUCTION

The choice of surgical approach in hip arthroplasty for osteoarthritis (OA) or femoral neck fracture (FNF) patients is a crucial part of preoperative planning. Frequently con-sidered aspects are soft-tissue sparing, accessibility to the proximal femur and acetabulum, prosthetic stability and postoperative pain and function. However, the sur-geon’s preference, usually based on previous experience, remains the main factor in making the final choice.In clinical practice, there are three common approaches to hip arthroplasty, anterior, lateral and posterior. However, several modifications (and therefore new names) have been made to these approaches creating a great amount of confusion in analysing their reported suitability and safety. Furthermore, minimally invasive (MIS) modalities of these approaches have also been described with even more technical variability.In the anterior approach (also known as direct anterior), the interval between the sartorius muscle and tensor facia lata is used to access the anterior joint capsule. The lateral approach (LA) has two main types, the an-terolateral and direct lateral. The former uses the interval

between the tensor facia lata and the anterior margin of the gluteus medius muscle while the latter includes ei-ther osteotomy of the greater trochanter or tenotomy of a variable length of the gluteus medius muscle attach-ment to the greater trochanter to access the anterior joint capsule. Some authors use the term modified anterolat-eral when the surgical dissection includes the release of the distal part of the gluteus medius tendon from the greater trochanter. In both anterolateral and direct lat-eral, supine or lateral decubitus positions can be used. The posterior approach (PA) (also known as posterolat-eral) comprises blunt dissection of the gluteus maximus muscle fibres followed by tenotomy of the hip short ex-ternal rotator muscles with or without tenotomy of the periformis muscle to access the posterior joint capsule. In this approach, the patient lies in the lateral decubitus position.The rate of use of different approaches varies among coun-tries (1). However, the LA and PA are by far the commonest two alternatives in clinical practice both for OA and FNF patients (1-4). In this update, we aim to discuss the avail-able evidence about the advantages and disadvantages of these two approaches.

In this update we searched the literature about the outcome of the lateral versus posterior approach in hip arthoplasty for osteoarthritis (OA) and femoral neck fracture (FNF) patients. The available evidence shows that the use of posterior approach in OA patients is associated with lower mortality and bet-ter functional outcome while the use of lateral approach in FNF patients gives lower dislocation rate. We recommend therefore the use of posterior approach in OA patients and lateral approach in FNF patients.

Keywords: Surgical approach, Lateral, Posterior, Hip arthroplasty, Outcome, Dislocation

Accepted: May 16, 2014

SÅ HÄR TYCKER JAG:

�  När det gäller artrospatienter så går lika bra att lära sig främre eller bakre snitt.

Blir det bakre snitt så ska man rekonstruera bakre strukturerna och använda 32 mm huvud då detta minskar luxationsrisken.

�  När det gäller frakturpatienter så verkar det som att främre snitt ger bättre stabilitet och lika bra kliniskt utfall.

TACK FÖR ER UPPMÄRKSAMHET