Minimally invasive total hip replacement: the posterolateral approach.
Our experience with the posterolateral mini-incision technique over the last 8 years has shown that total hip arthroplasty can be performed safely and effectively in properly selected patients through a much smaller incision than the one traditionally used. The main advantage of the posterolateral approach compared with other mini-incisions is its simplicity, with shortened operating time as a result. While the surgical time for a posterior approach is an average of 37 to 70 minutes throughout the literature, the 2-incision approach prolongs the surgery by a factor of 2 or 3. Compared with the anterior or 2-incision approach, the posterolateral and anterolateral approaches also have a much lower incidence of perioperative complications, with the rate being similar to rates seen with a standard incision. For the 2-incision technique and the anterior mini-incision approach, perioperative periprosthetic fracture rates of up to 8.7% and 8.4%, respectively, have been described. Surgeons who traditionally used an anterolateral standard approach might prefer an anterolateral mini-incision. The anterolateral mini-incision total hip arthroplasty has demonstrated excellent results; in the past it was suggested that the anterolateral approach has a higher incidence of heterotopic bone formation and impaired early abductor function, but more recent studies show no difference in abductor strength and limping between the anterolateral and posterior approaches. On the other hand, the posterior approach has been associated with an increased risk of postoperative dislocations. We did not encounter an increased incidence of postoperative dislocation at our institution. This might be related to the routine repair of the external rotators and the capsule in all patients. In summary, both the anterolateral and the posterior mini-incision approaches are reasonable alternatives, and surgeons should choose the approach that they feel most comfortable with. Statements in the press and by some members of the orthopedic community suggest that a smaller incision has revolutionized total hip replacement by accelerating the recovery and improving the functional outcome, but most articles in the peer-reviewed literature fail to confirm these hypotheses. Considering that mini-incision total hip replacement has no dramatic clinical benefits other than the cosmetic appeal, the use of mini-incision total hip replacement by the average orthopedic surgeon should be carefully monitored. In the meantime, the patient should be informed about the true merits of the technique, and any marketing that misleads patients' perception of the technique should be avoided. Because the mini-incision leads to results similar to those obtained with the standard approach, we will, encouraged by the enthusiasm of our patients, continue to use this approach.
Bottner
Friedrich
F
Steadman Hawkins Clinic of the Carolinas, Spartanburg, SC, USA. drboettner@email.de
Delgado
Samuel
S
Sculco
Thomas P
TP
D019644:Arthroplasty, Replacement, Hip / Q000379:methods*; D005500:Follow-Up Studies; D006801:Humans; D019060:Minimally Invasive Surgical Procedures / Q000295:instrumentation*; D017060:Patient Satisfaction; D011446:Prospective Studies; D016896:Treatment Outcome