Volume 05 / Issue 03 / September 2017
Page 38
boa.ac.uk
JTO Features
Operations I no longer do... Conventional posterior approach for total hip replacement John Timperley The moment of change occurred 18 months ago when I was learning to carry out total hip arthroplasty through a direct anterior approach (DAA). My driver for learning DAA was that whilst the conventional posterior approach gives the best exposure and, arguably, the best function and PROMS scores following total hip replacement, most centres, including my own, report a dislocation rate in excess of 1%.
Whilst this is not a common complication it can lead to further hospital admissions and adverse psychological consequences for the patient. Most centres also restrict the patient’s activity for the first six weeks and assess them for aids, such as chair and toilet raises. I hoped we could avoid this.
John Timperley
My experience with DAA was not a happy one. I visited multiple surgeons on several continents, carried out multiple cadaver courses and was formally mentored by three experienced DAA surgeons. Anecdotally I could not detect any early benefit, I did not observe the operation to be truly tendon-sparing, even in the most experienced hands, and there was an unacceptable
incidence of patients complaining of groin pain. I abandoned DAA after 20 cases. I re-learned the anatomy of the hip. The trochanteric attachment of the short external rotators has recently been studied in detail.
Usually Obturator Internus is inserted in a more caudal, anterior and medial position than Piriformis.1 The short external rotators have been shown to act together as a Quadriceps Coxae, which functions as a primary abductor and extensor of the hip from flexed positions2, being important when rising from seated and in propulsion. It became apparent that hip arthroplasty could be performed leaving all the tendons, except Obturator Externus, intact. In Exeter we developed a technique appropriate for all routine primary THR in which we Save Piriformis And (Obturator) Internus with Repair of (Obturator) Externus (the SPAIRE technique). An approach is developed in the interval between the Inferior Gemellus and Quadratus Femoris (Figure 1) >>
Figure 1: The interval is developed between the Inferior Gemellus and Quadratus Femoris