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Five Years of Experience in Hip Navigation Using a Mini-invasive Anterior Approach

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Abstract

For the past 10 years, we have used a minimally invasive anterior approach with a specially designed operating table for hip replacement surgery. After 5 years, we introduced computer-assisted navigation technology to perform the procedure. Our goal was to produce the short-term advantage of accelerated functional recovery associated with the minimally invasive approach along with the long-term benefit of improved implant alignment.

This study compares the results of cup positioning in conventional surgery (40 patients) vs navigated surgery (38 patients).

Hip replacement surgery has been a standard orthopedic procedure for more than 40 years. Although patient outcomes have improved over time, a percentage of failure attributable to surgical approach and imprecise implant placement remains. This results in pain, difficulties in achieving normal gait, persistent limping, and implant dislocation and wear.^1-5

For 10 years, we have used a minimally invasive approach striving to preserve periarticular structures to facilitate faster recovery. The use of computer-assissted technique, combined with a minimally invasive approach, allows for reduced recovery time and improved prosthetic longevity.

Materials and Methods

We have used the Plasmacup and Excia stem (B. Braun Aesculap, Tuttlingen, Germany) for primary hip replacements since 2002, on patients younger than age 70 years. A total of 147 prostheses were implanted between 2002 and 2006, and all prostheses were fitted using a minimally invasive approach based on Hueter’s method and modified by Jean Judet and Robert Judet for the implantation of acrylic prostheses. This approach required a revised orthopedic table (Figure 1).^6,7

In this procedure, an incision between 6 and 8 cm was made with the hip in flexion from the anterior iliac crest to the external edge of the patella. The approach led directly to the tensor of the facia lata, where the aponeurosis was incised. From the internal edge, it was relatively easy to find the gap between the facia lata and the sartorius muscle that protects the cutaneous femoral nerve. The anterior capsule was therefore exposed and easy to excise (Figure 2). The femoral head was dislocated in advance, and the neck resection carried out according to preoperative planning.

The acetabulum was completely exposed, and by putting the leg into hyperextension and adduction on the table, the femur was well positioned for the preparation.

No muscle was disinserted, and no tendon was cut; however, the anterior circumflex artery was coagulated.

Our goal was to test the reproducibility of the OrthoPilot navigation system (B. Braun Aesculap) in improving implant precision of the acetabular cup by alternating our surgical method between the conventional and navigated procedures.

At study end, 40 prostheses were implanted using a conventional approach and 38 using a navigated approach. A single surgeon performed all procedures. All patients younger than 70 years were included in the study, and sex, weight and pathologic type were not considered in patient selection.

The OrthoPilot system is based on the Lewinnek plane, easily referenced with the patient in supine position.⁸

In addition, we recorded the plane of the table and compared it with Lewinnek’s plane and were thereby able to specify the pelvic tilt.

Postoperative control of the cup position was achieved using tomodensitometry, which accounts for differences in pelvic tilt while the patient is on the examination table vs the operating table.⁹ Inclination and anteversion were measured simultaneously, from the operated side and, as reference, from the nonoperated side.

Results

We have reported the advantages of a minimally invasive approach in orthopedic surgery.¹⁰

To assess the improvement in the cup position using navigated surgery, we compared anteversion of the cup between the operated and the nonoperated sides in both the navigated group and the conventional surgery group (Table 1). No relevant differences between the operated side and the nonoperated side in the group that underwent conventional surgery were found. In contrast, anteversion clearly reduced in the group that underwent the navigated procedure, thereby diminishing the risk of anterior luxation.

Second, the results of inclination and anteversion were compared between the two groups (Table 2). The means do not show a significant difference, but the standard deviation in the navigated group shows less variance. Although an experienced surgeon would not likely make major errors in the conventional positioning of the cup, navigation clearly makes the positioning more reproducible, reducing any outliers.

Discussion

The minimally invasive approach in hip replacement surgery is well advanced. Our 10 years of experience with the anterior approach and use of computer-assisted navigation to guide placement of the implant have led us to review the immediate advantages of a minimally invasive approach and the long-term benefit of more precise implant positioning. Further, we investigated whether navigation actually provided greater precision.

Although experienced surgeons are able to place hips correctly, providing good medium- to long-term results, there are still a number of outliers, showing significant deviations. This may lead to higher complications such as dislocation and wear.

Kalteis and colleagues report good positioning of the cup with higher reproducibility in the navigation group.¹¹

It must be taken into account that we still have relatively limited experience in this field. Our study did not consider a number of parameters such as the position of the pelvis in relation to the angle of the lumbar spine¹² or the health of the patient.

Only the supine position has been used as point of reference. A study on the relations between the position of the acetabulum, including the orientation of the spine, is in progress at our institution.

Furthermore, the use of tomodensitometry for postoperative measurement of the acetabulum has limitations. A comparison of the figures obtained by the computer at the end of surgery and those obtained by using tomodensitometry postoperatively shows a constant and proportional difference due to the tilt of the pelvis. Therefore, we conclude that the figures are not reliable in absolute values. Nonetheless, they may be useful as relative values for a comparison between navigated and nonnavigated surgery.

Conclusion

The use of a minimally invasive anterior approach supported by navigation offers an immediate advantage of quicker functional rehabilitation and the long-term benefit of better positioning of the implant. Also, the comparison of conventional and navigated cup placement shows a higher reproducibility in the navigated group.

References

1. Morrey BF. Instability after total hip arthroplasty. Orthop Clin North Am. 1992 Apr;23(2)237-248.
2. Barrack RL. Dislocation after total hip arthroplasty: implant design and orientation. J Acad Orthop Surg. 2003 Mar-Apr;11(2):89-99.
3. Kennedy JG, Roger SZ WB, Soffe KE. Effect of acetabular component orientation on recurrent dislocation, pelvic osteolysis, polyéthylène wear and component migration. J Arthroplasty. 1998;13:550-534.
4. Coventry MB, Beckenbaugh RD, Nolan DR, Ilstrup DM. 2012 total hip arthroplasties: a study of post-operative course and early complications. J Bone Joint Surg Am. 1978:60:217-220.
5. Lewineck GE, Lewis JL, Tarr R, Compere CL, Zimmermann JR. Dislocation after total hip replacement arthroplasties. J Bone Joint Surg Am. 1978;60:217-220.
6. Judet J, Judet R. The use of an artificial femoral head for arthroplasty of the hip joint. J Bone Joint Surg Br. 1950 May;32-B(2):166-173.
7. Judet J, Judet H. Voie d’abord antérieure dans l’arthroplastie totale de hanche. Presse Méd. 1985; 14:1031-1033.
8. Kiefer H, Othman A. OrthoPilot total hip arthroplasty workflow and surgery. Orthopedics. 2005;Oct;28(10 Suppl):s1221-s1226.
9. Blendea S, Eckman K, Jaramaz B, Levison TJ, Digioia AM III. Measurements of acetabular cup position and pelvic spatial orientation after total hip arthroplasty using computed tomography/radiography matching. Comput Aided Surg. 2005 Jan;10(1):37-43.
10. Siguier T, Siguier M, Brumpt B. Mini incision anterior approach does not increase dislocation rate: a study of 1037 total hip replacements. Clin Orthop Relat Res. 2004 Sep;(426)164-173.
11. Kalteis T, Haudel M, Herold T, Perlick L, Baethis H, Grifka J. Greater accuracy in positioning of the acetabular cup by using an image free navigation system. Int Orthop. 2005 Oct;29(5):272-276. Epub 2005 Aug 5.
12. Lazennec JY, Charlonn, Gorin M, et al. Hip-spine relationship: a radio anatomical study for optimisation in acetabular cup positioning. Surg Radiol Anat. 2004; 26:134-136.

Author

Dr Judet is from the Clinique Jouvenet, Paris, France.

Correspondence should be addressed to: Henri Judet, Clinique Jouvenet, 6 Square Jouvenet, 75016 Paris, France.

Dr Judet has received financial compensation from B. Braun Aesculap.