OROAJ.MS.ID.555557

 

The Modification offers greater visibility and decreased blood loss to the Hip Joint, there by conferring greater stability posteriorly ascompared with the conventional Posterior Approach as described by Austin Moore in 1957. This Modification was devised at a time whenthe cause of dislocation was being blamed on the Posterior Approach to the Hip Joint [1,2] In this Approach, since bone is attached to bone, itconfers greater stability than an ordinary suture through soft tissues and hence reduces dislocation of the Hip Joint [3].

Keywords: Trochanteric Osteotomy; Dislocation.

Introduction

The Posterior Approach is the most commonly usedapproaches to the Hip Joint for Endo prosthesis, total Jointreplacement or Revision Hip Surgery wherein it gives excellentvisibility to the entire joint, when compared to other approachesto the Hip Joint [4]. The author’s original paper [5] written 35years ago presented an original technique designed after takinginto consideration the surgical anatomy of the Hip Joint, whereby the posterior overhanging part of the greater trochanter wasosteotomised to include the short lateral rotators along with theposterior one-thirds of the gluteus medius and the capsule of theHip Joint, which was then turned back as a single flap to expose theacetabulum in detail along with a bloodless exposure. This wasalso confirmed before any clinical application of this approachon cadavers, which concluded greater stability as compared withroutine suture or reattachment of the short lateral rotators.

Technique and Introduction

In all, many approaches to the Hip Joint are described inliterature. The author’s original technique was implementedafter a detailed cadaveric study (Figures 1-3), where the forcesrequired to dislocate the Hip Joint was considerably more whencompared to the routine suture or reattachment of the shortlateral rotators.

Clinical Technique

The patient is placed on the sound side. The skin incisionextends from just distal and lateral to the posterior superioriliac spine towards the lateral edge of the greater trochanter,with a curve in the direction of the fibres of gluteus maximus, and extends down the shaft of the femur for about 10 cm. Thegluteal fascia and the ilio-tibial tract are exposed; the deep fascia incised vertically in the lower part of the incision and the incisionis curved upwards through the middle of the fibres of gluteusmaximus.

The muscles now seen converging on the greater trochanterfrom above downwards are gluteus medius; piriformis; obturatorinternus, flanked by the superior and inferior gaemelli; quatratusfemoris, and the upper edge of the adductor magnus. All thesemuscles lie edge to edge, with the sciatic nerve well away fromthe insertion of the short lateral rotators (Figure 4).

The posterior border of the gluteus medius in the upper partand the quadrate tubercle with the lower border of the quadratefemoris in the lower part is then identified.

The greater trochanter is cut through so that thedetached part includes the insertion of the followingstructures. From below upwards these are quatratusfemoris, obturator internus with the inferior andsuperior gaemelli, piriformis and the posterior third of the fibresof the gluteus medius. The osteotomy extends from the junctionof the posterior third and anterior two-thirds of the lateral borderof the greater trochanter obliquely downwards and posteriorlyto the shaft of the femur just distal to the quadrate tubercle.

The posterior triangular flap containing the overhangingposterosuperior part of the greater trochanter at its apex is thendissected free and turned down to expose the capsule of the hipjoint (Figure 5). The capsule is then incised to expose the joint. Iyer et al. [6] reported on early results in 44 patients who hada hemi-arthroplasty done with no dislocation in this series.

The weakest part of the Hip Joint is the posterior envelopewhich contains the short lateral rotators. This point has beenreinforced by various authors on dislocation of the Hip Joint.There are certain anatomical variations in the tendons ofpiriformis and obturator internus which could result in piriformissparing approaches to the hip [7,8] the most posterior marginsof the piriformis and obturator internus attachments are locatedmore than one-third of the way along the greater trochanter,suggesting that osteotomies would not include these externalrotators in the majority of cases.

A modified dorsal approach with osteotomy of a bone shell withthe attached short external rotator muscles which are resutured,is described. The advantages have been less dislocations, lesssciatic nerve injuries, and an increased operative access.

The Modified Posterior Approach follows the anatomicalintermuscular plan and permits full exposure of both the proximalfemur and the acetabulum. Compared to the literature, preservingthe piriformis tendon seems to be superior to repairing it as isdone in the Southern Approach in terms of dislocation of theEndoprosthesis or THR.

They vary mainly as to whether the deep posteriorcompartment is entered by incising the iliotibial band and thegluteus maximus muscle in line with the axis of the shaft, or byseparating the muscle fibres of the gluteus maximus proximally.They also vary depending on whether the abductors are releasedfrom the greater trochanter and, if released, whether the tendinous attachment is transected or the greater trochanter isosteotomized.

Almost all of the Posterior approaches have the option torelease the abductors, depending on the need for added exposure.After I described this Approach, it was quite encouraging thatmy respected teacher (Mr. F.H. Beddow) in Liverpool, UK did aseries of 220 Primary Total Hip Replacements by my techniqueand noted only 2 dislocations throughout his series.

Beddow and Tulloch reported on their experience using thisapproach in 220 cases of primary total hip replacement in whichthere were only 2 cases of dislocation [9].

Terry Canale [10] does make a reference to this approach intheir chapters on Surgical Approaches and Complications afterTotal Hip Arthroplasty with respect to dislocations [10].

Callaghan et al. [11] mention the advantages of preservingthe original soft tissue attachments of the posterior aspect ofthe hip joint, as obtained with this approach. They also stress onthe excellent exposure of both the acetabulum and femoral shaftachieved with this approach in being applicable to both revisionarthroplasty and complex primary Arthroplasty [11].

Thomas Stahelin et al. [12]have stated that the failure rate ofreinserted short lateral rotators was extremely high at 70% withmajority of failures occurring within the first postoperative day.They also concluded that bone to bone reattachment as done inthis approach is more secure,as proved by the cadaveric study[12].

Deepa lyer (2006) was fascinated by this Orthopaedic Dilemain the elderly that she studied this fracture in detail and noted itsimportance for the junior doctors in training, thereby decreasingmorbidity by early diagnosis and treatment [13].

Robert H. Cofield [14] of Mayo Clinic in Rochester, Minnesota,USA has been using this approach for the last 25 years with noregrets. He is extremely happy using this approach since I presentedit during the Scientific Congress of the Asean OrthopaedicAssociation in Singapore in 1984 [14].

Mayo Clinic conducted a study of 68 consecutive cases by theModified Posterior Approach to the Hip posterior trochantericosteotomy is associated with high union rates and a low rate oflate instability after hip replacement [15].

They concluded one disadvantage of the posterior trochantericosteotomy is the potential for injury to the superior glutealnerve if the gluteus medius muscle split is extended proximallymore than 5 cm from the tip of the trochanter.

The Posterior approach that Moore popularized, and which isoften referred to as the “Southern approach”, is a variation of theoriginal Henry approach and of the modifications subsequentlymade by Kocher, Osborne and Gibson.

The Moore approach is the most commonly used approachfor endoprostheses, total hip arthroplasty, open reduction of hipdislocation, removal of loose fragments in the joint, repair of acetabular fractures, drainage of the hip and vascular muscle pediclegraft procedures.

Here the capsule is sectioned along with the short lateral rotatorsto gain entry into the Hip Joint, thereby leaving the closureof the Hip Joint vulnerable to dislocation.

In procedures in which the femoral head is not sacrificed,such as drainage of the hip, reduction of a posterior dislocation,removal of fragments from the joint, repair of acetabular fractures,or resurfacing procedures, special care must be taken toavoid injury to the medial circumflex and retinacular vessels.

The short external rotator muscles are sectioned close to theedge of the acetabulum, rather than at the insertion in the trochanter,and the capsular incisions are made near the acetabularedge rather than near the attachment of the capsule to the neck.The medial circumflex vessels are at risk during the dissectionnear the attachment of the psoas tendon to the lesser trochanter .

In the Modified Posterior Approach to the Hip Joint, bleedingis minimal, because the plane of cleavage through the gluteusmaximus is through its middle thus leaving intact the branches ofthe superior gluteal artery in the proximal half and branches ofthe inferior gluteal artery in the distal half, and hence there is noneed to worry about the amount of blood lost. Bleeding is furtherreduced as the leash of vessels which lies at the inferior border ofthe short lateral rotators is neither cut nor handled.

The most important advantage is that the sciatic nerve is notisolated at any step in this approach, as corresponding to the levelof the greater trochanter, it lies well medially. Above all, it isfirmly held between the piriformis tendon and the triradiate tendon,when the greater trochanter is turned posteriorly, therebypreventing any movement of the nerve.

With this modified posterior approach to the Hip Joint, thegluteus medius is neither cut at its origin nor insertion, therebyleaving the abductor mechanism intact.

In this Modified Posterior Approach, Union of the trochantericfragment should normally occur, as it is through cancellousbone and in close proximity to the anastomosis in the trochantericfossa.

The concept of trochanteric osteotomy was mainly used indifficult exposures and soft tissue tensioning. ContemporaryTHA accentuates a streamlined approach to surgery and recoverywhile maximizing long-term success. Hamblin estimated that10% to 20% of hips require TO for restoration of normal jointanatomy [16]. Rates of trochanteric osteotomy reflect geographictrends and surgeon preferences.

Trochanteric Osteotomy techniques can be generally dividedinto standard, slide, and repeat osteotomy groups. The standardosteotomy may be oblique or posterior. The standard TO wasoriginally popularized for use in hip arthroplasty by Charnley[17]. After exposure of the hip, a Cushing elevator is insertedfrom anterior to posterior in the interval between the tendonof the gluteus minimus and the superior part of the hip capsule.Next, the origin of the vastus lateralis is elevated from the vastustubercle. The osteotomy cut traverses the sulcus between the lat-eral portion of the origin of the vastus intermedius muscle andthe insertions of the gluteus medius and minimus. The osteotomyis started 1 cm distal to the vastus tubercle and is performed withan oscillating saw or osteotome, which is aimed at the Cushingelevator [18].

Complications of trochanteric osteotomy can be divided intotwo broad categories: those related to osteotomy healing andthose related to the mode of fixation. Nonunion or a fibrous unionof the trochanter is not necessarily a complication with clinicalsignificance. ‘lf the trochanter does not heal by bony bridging,however, associated issues of pain, hardware breakage, or abductordysfunction may manifest as impaired gait, Trendelenburglurch, subluxation, or dislocation of the hip replacement.Even when union of the trochanter occurs, the patient may stillhave problems. Trochanteric pain and bursitis may be related toa prominent trochanter or to irritating hardware. Fraying andbreakage of hardware can lead not only to pain, but also to wearand the need for early revision.

In comparison to the conventional sliding trochanteric orextended trochanteric approach, which are more helpful by improvingbiomechanics of the abductor mechanism in work doneon in difficult primary total hip replacement, or failed total hipreplacements and in well fixed stem components or in previouslyosteotomised trochanters., this modification is adequate to carryout routine work on the hip joint.

Though Surgeons may adopt any approach to the hip joint inwhich they are familiar or trained, this modification may be helpful when the greater trochanter is intact in cases when treating adislocated hip joint, when the blame for the dislocation may beavoided on the posterior approach to the hip joint.

Instability following weakening of the already weak posteriorcapsule and short lateral rotators of the Hip leading to dislocationhas been a cause for concern and controversy in the past. Themain purpose of this modification is to overcome this danger andyet retain the advantages of the posterior approach.

Bleeding is slight in this approach because the plane of cleavagethrough the gluteus maximus is through its middle, whichleaves intact the branches of the superior gluteal artery in itsproximal half and branches of the inferior gluteal artery in its distalhalf. The blood loss is reduced considerably, as the leash ofblood vessels which lies at the inferior edge of the lateral rotatorsis neither cut nor handled.

The other advantage is that the sciatic nerve need not be isolatedat any step in this modification, and corresponding to thelevel of the greater trochanter the sciatic nerve lies well medially.Secondly, it is held between the piriformis and the triradiatetendon when the greater trochanter is turned posteriorly, thuspreventing movement of the nerve.

Union of the trochanteric fragment should occur because theosteotomy is through cancellous bone and in close proximity tothe anastomosis in the trochanteric fossa.With this modification, though turned aside, the gluteus mediusis cut neither at its insertion nor its origin, thus leaving theabductor mechanism intact.

There are certain disadvantages which we have to bear withand which is not in every case treated by this modification, suchas heterotrophic ossification, trochantric Osteotomy where thebone takes more time to unite resulting in non-union or fibrousunion along with greater trochantric bursitis and also breakageof the wires.

Certain unsolved controversies still exist with regards TrochantericOsteotomy as follows:-

1.Although the indications of exposure and soft tissue tensioningare well accepted, the exact application of theseindications is somewhat controversial.
2. Greater trochanteric osteotomy is rarely used in contemporaryhip replacement, and its application is likely relatedto both the type of surgery and the surgeon’s predisposition.Some surgeons apply the approach more liberallythan others. Likewise, the type of internal fixation neededto maximize healing is not universally agreed upon.
3. Based on newly available literature, I would recommendavoiding or removing multifilament cables; this advicewill likely be considered controversia.
4. Various options are available, and surgeon preferencedominates their application
5. Also, newer unproven technologies such as locking platesand nonmetallic tensioning wire may prove beneficial,but objective studies will be required if their usage is tobe endorsed.
In this method of Modified Posterior Approach to the HipJoint, the fixation is carried out in a simple manner using twogauge 18 wires to hold the trochanteric osteotomy and reconstitutethe Hip Joint (Figure 6-8).

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  2. lyer K.M. (2015) Guest Editorial for the Journal of Medical Thesis 3(1):3.
  3. Modified Posterior Approach to the Hip Joint. May 2015, Notion Press(Chennai, lndia).
  4. The Hip Joint. Thieme.
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  8. Charbel D. Moussallem, Fadi A. Hoyek, Jean-Claude F. Lahoud (2012)Incidence of Piriformis Tendon Preservation on the Dislocation Rate of Total Hip Replacement following The Posterior Approach A Seriesof 226 cases*. J Med Liban 60(1): 19-23.
  9. Beddow FH, Tulloch C (1990) Rheumatoid Arthritis Surgical Society-Clinical Experience with the lyer modification of the PosteriorApproach to the Hip. J Bone Joint Surg (Br) 73B(Suppl 11): 164-165.
  10. Campbell’s Operative Orthopaedics, In: S Terry Canale (1992) (9thedn), Volume 1, pp. 140,387,466.
  11. Callaghan, Rosenberg, Rubash (1998) The Adult Hip. Lippincott-Raven, Vol. 1, pp. 700-701,718.
  12. Stahelin, Vienne P, Hershe O (2002) Failure of Reinserted ShortExternal Rotator Muscles after Total Hip Arthroplasty-Thomas. JArthroplasty 17(5): 604-607.
  13. Deepa lyer (2006) The Orthopaedic Enigma: A Simplified Classification.Internet Journal of Orthopaedic Surgery 3(2).
  14. Cofield H Robert (2010) Personal Communication.
  15. Sanchez-Sotelo J, Gipple J, Berry D, Rowland C, Cofield R (2005)Primary hip arthroplasty through a limited posterior trochntericosteotomy. Acta Orthop Belg 71(5): 548-554.
  16. Hamblin DL (1984) Complications of trochanteric osteotomy. In:Ling RSM (Ed.), Complications of total hip replacement. ChurchillLivingstone, New York, USA.
  17. Charnley J (1972) The long-term results of low-friction arthroplastyof the hip performed as a primary intervention. J Bone Joint Surg Br54(1): 61-76.
  18. Charnley J (1961) Arthroplasty of the hip: a new operation. Lancet1(7187): 1129-1132.
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    Figure 1: Device used to test stability of the hip joint showing pelvis fixed and protactors tomeasure the angle of flexion/extension, adduction/abduction and internal/external rotations(Courtesy: Photograph reproduced with the kind permission of Injury/Elsevier).

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    Figure 2: Device used to test stability of the hip joint showing pelvis fixed and protactors tomeasure the angle of flexion/extension, adduction/abduction and internal/external rotations(Courtesy: Photograph reproduced with the kind permission of Injury/Elsevier).

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    Figure 3: Internal rotation torque being applied when the hip joint was standardized toa fixed angle of flexion and adduction (Courtesy:Photograph reproduced with the kindpermission of Injury/Elsevier).

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    Figure 4: Line Diagram showing the osteotomy of the posterior overhanging part of thegreater trochanter: (Courtesy: Line Diagram reproduced with the kind permission of Injury/Elsevier): A: Gluteus Maximus; B: Gluteus Medius; C: piriformis; D: Triradiate tendon; E:Quadratus Femoris; F: Sciatic Nerve; G: Greater trochanter; H: Osteotome.

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    Figure 5: Line Diagram to show that the Osteotomy is completed and the flap retracted,after incising the capsule to expose the Hip Joint, (Courtesy: reproduced with the kindpermission of Injury/Elsevier).

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    Figure 6: Trochanteric Wiring: (Courtesy: reproduced with the kind permission of Injury/Elsevier).

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