Abstract

BRITO, Joaquim Soares do; FERNANDES, Pedro  and  TIRADO, António. Abordagem na artroplastia total primária da anca. Rev. Port. Ortop. Traum. [online]. 2014, vol.22, n.4, pp.398-405. ISSN 1646-2122.

Introduction: the minimally invasive anterior approach to the hip was first described by Heuter and Schede to drain tuberculous septic arthritis. In 1947, Robert Judet used it for the first time to perform a total hip arthroplasty. Since it is a minimally invasive inter-muscular approach, it requires only minimal blunt dissection. However, the first results were disappoiting when compared to other approaches, because of technical difficultes performing it, being abandoned for a long time. With the recent enthusiasm over minimally invasive surgery, orthopaedic surgeons started to regain interest in this technique. Objectives: to evaluate clinical and technical results of primary total hip arthroplasties performed by the minimally invasive anterior approach. Material and methods: we performed a retrospective study between February 2010 and May 2013 (n=47). Data was collected from clinical interview and process, radiologic evaluation, and the population was characterized by gender, age, diagnosis, side, days of admission post-op, blood loss and complications during surgery and postoperatively. The follow-up and outcomes were measured by Harris and Oxford Hip Scores. Statistical analysis was made in SPSS v19.0, with a confidence level of 95%. Results: during the study period we performed 47 THA in 47 patients (35 non cemented, 11 cemented and 1 hybrid). All patients had hip arthritis (43 primary arthritis, 4 secondary to avascular necrosis of the femoral head). 22 males and 25 females, with a mean age of 62,4 years (30-91). The mean decrease in hemoglobin 24 hours post-op was 2,8 g/dL (3 patients requiring blood transfusion). The patients were admitted in average 6 days postoperative (2-15). 4 patients had intra-operative complications (iatrogenic fracture), 1 had aseptic loosening of the acetabular cup with prosthetic dislocation 15 days post-op after direct blunt trauma (fall during rehabilitation), with revision also by this approach, 1 had a revision surgery 1 year post-op - aseptic loosening of noncemented acetabular cup, and we had also 2 cases of iatrogenic lesion of the lateral cutaneous femoral nerve, with numbness of the external thigh. 1 patient was excluded of the follow-up (death by other causes). The mean follow-up is 20 months (1-39). We found a mean Harris Hip Score of 92 (excellent) and mean Oxford Hip Score of 44 (full function of the prosthetic joint). Discussion: the main limitations to our study are the small dimension of the sample, its retrospective nature, the short follow-up and the technical demand of the approach, especially the femoral exposure. The most difficult cases are male patients, short, obese and with large musculed thigh. The direct anterior approach allows an earlier rehabilitation (getting the patient out of bed after 24-48 hours post-op), less pain, better funcional status (especially in the first 6 to 12 weeks post op), reduction in the days of admission, less costs and enhanced patient satisfaction. Conclusion: the direct anterior approach to the hip is regaining an important role in total hip arthroplasty, even though it has been described decades ago, because more surgeons are now using minimally invasive techniques. However, more studies with larger patient samples are necessary, and also comparative studies with other approaches to the hip, in order to prove statistically our clinical and empirical evidence. Nonetheless, we have a very positive experience with this technique. It it elegant, effective and with excellent functional results in our patients. It is also very promising.

Keywords : Hip arthroplasty; Robert Judet; direct anterior approach; minimally invasive surgery.

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