BackgroundThe key for successful delivery in minimally-invasive hip replacement lies in the exact knowledge about the surgical anatomy. The minimally-invasive direct anterior approach to the hip joint makes it necessary to clearly identify the tensor fasciae latae muscle in order to enter the Hueter interval without damaging the lateral femoral cutaneous nerve. However, due to the inherently restricted overview in minimally-invasive surgery, this can be difficult even for experienced surgeons.Methods and Surgical TechniqueIn this technical note, we demonstrate for the first time how to use the tensor fasciae latae perforator as anatomical landmark to reliably identify the tensor fasciae latae muscle in orthopaedic surgery. Such perforators are used for flaps in plastic surgery as they are constant and can be found at the lateral third of the tensor fasciae latae muscle in a direct line from the anterior superior iliac spine.ConclusionAs demonstrated in this article, a simple knowledge transfer between surgical disciplines can minimize the complication rate associated with minimally-invasive hip replacement.
Between 2010 and 2012, 28 patients with large bone defects [Anderson Orthopaedic Research Institute (AORI) grade: 21 × F3, 3 × F2, 13 × T3, 8 × T2] underwent total knee revision with impaction bone grafting. The mean follow-up was 27.7 months (range 21-47 months). On average, patients had undergone 2.5 previous revisions. Implant survival was 82.0 % (95 % CI = 62.5 %-92.1 %) for any reason of revision as the endpoint and 93.1 % (95 % CI = 74.5-98.4 %) for aseptic revision as the endpoint. The mean postoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score was 35.4 (range 3.3-101.6, SD ± 26.2). The mean KSS was 70.6 (range 20-100, SD ± 26.8).
Compressive dressing to prevent postoperative hematoma. In cases of tumors affecting load-bearing bones, weight-bearing should be prohibited after biopsy, if there is any fracture risk. Upon receipt of the histopathological results the definitive tumor resection is planned.
Purpose
Delay of elective surgeries, such as total joint replacement (TJR), is a common procedure in the current pandemic. In trauma surgery, postponement is associated with increased complication rates. This study aimed to evaluate the impact of postponement on surgical revision rates and postoperative complications after elective TJR.
Methods
In a retrospective analysis of 10,140 consecutive patients undergoing primary total hip replacement (THR) or total knee replacement (TKR) between 2011 and 2020, the effect of surgical delay on 90-day surgical revision rate, as well as internal and surgical complication rates, was investigated in a university high-volume arthroplasty center using the institute’s joint registry and data of the hospital administration. Moreover, multivariate logistic regression models were used to adjust for confounding variables.
Results
Two thousand four hundred and eighty TJRs patients were identified with a mean delay of 13.5 ± 29.6 days. Postponed TJR revealed a higher 90-day revision rate (7.1–4.5%, p < 0.001), surgical complications (3.2–1.9%, p < 0.001), internal complications (1.8–1.2% p < 0.041) and transfusion rate (2.6–1.8%, p < 0.023) than on-time TJR. Logistic regression analysis confirmed delay of TJRs as independent risk factor for 90-day revision rate [OR 1.42; 95% CI (1.18–1.72); p < 0.001] and surgical complication rates [OR 1.51; 95% CI (1.14–2.00); p = 0.04].
Conclusion
Alike trauma surgery, delay in elective primary TJR correlates with higher revision and complication rates. Therefore, scheduling should be performed under consideration of the current COVID-19 pandemic.
Level of evidence
Level III—retrospective cohort study.
Although there is no clear evidence, minimally invasive hip arthroplasty seems to be associated with slightly higher complication rates compared to standard procedures. Major nerve palsy is one of the least common but most distressing complications. The key for minimizing the incidence of nerve lesions is to analyze preoperative risk factors, accurate knowledge of the anatomy and minimally invasive techniques. Once clinical signs of nerve injury are evident, the first diagnostic steps are localization of the lesion and quantification of the damage pattern. Therefore, clinical assessment of the neurological deficits should be performed as soon as possible. Apart from rare cases of isolated transient conduction blockade or complete transection, the damage pattern is mostly combined. Thus, there can be evidence for dysfunction of nerve conduction (neuropraxia) and structural nerve damage (axonotmesis or neurotmesis) simultaneously. Because the earliest signs of denervation are detectable via electromyography after 1 week, it is not possible to make any reliable prognosis within the first days after nerve injury using electrophysiological methods. This review article should serve as a guideline for prevention, diagnostics and therapy of neural lesions in minimally invasive hip arthroplasty.
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