Exposure, visualization challenges of direct anterior THA linked with femoral perforations
There was a 0.4% intraoperative femoral perforation rate 12 years in a single-surgeon series in which the direct anterior approach was used for primary total hip arthroplasty, according to a presenter.
The incidence did not reduce over time, William G. Hamilton, MD, said at the American Association of Hip and Knee Surgeons Annual Meeting.
“Femoral perforation with the anterior approach can occur due to challenge with exposure and visualization,” he said.
Hamilton and colleagues studied the complication of femoral perforation that occurred relative to implantation of the same design DePuy Synthes hip stems in 3,973 cases of anterior primary THA performed between 2009 and 2021. In all, the chart review showed there were 16 femoral perforations in men and women.
The quality of the patients’ bone was distributed fairly equally among the cases, according to Hamilton.
“It might be of interest that there were right and six left hips. If you’re a right-handed surgeon, the right hip is more difficult to broach,” Hamilton, an Orthopedics Today Editorial Board Member, said.
“Intraoperatively, all of these cases were identified by fluoroscopy or direct vision. Most of these were fluoroscopy with the broach in situ,” he said, noting in cases a perforation occurred, he has redirected the broach and implanted a primary stem successfully.
Hamilton said in some of these cases he changed from a flat tapered wedge to a longer dual-tapered design stem with or without adding a cable.
“I don’t think the stem makes much of a difference. The point here is that all stems are subject to this potentially and this is also possible to do with both the manual and mechanical broach technique,” he said.
Risk factors for femoral perforation include anything that impedes direct access to the femoral canal or a patient’s body habitus. The BMI in four of these patients, “so a quarter of our patients,” exceeded 40 kg/m2, which makes visualization and access to the canal difficult, Hamilton said.
Postoperative restrictions Hamilton gave the patients were either 50% weight-bearing or protective weight-bearing.
“With mean follow-up of about 2 years, we found no revisions or reoperations, thankfully. o femoral fractures no loosening. All stems appeared osseointegrated on postop radiographs and the outcome scores were normal,” he said.
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Kinney MC, et al. Paper 23 Presented at: American Association of Hip and Knee Surgeons Annual Meeting. Nov. 11-14, 2021; Dallas (hybrid meeting).
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