Preservation of the articular capsule and short lateral rotator in direct anterior approach to total hip arthroplasty

Abstract

IntroductionIn total hip arthroplasty via a direct anterior approach, the femur must be elevated at the time of femoral implant placement. For adequate elevation, division of the posterior soft tissues is necessary. However, if we damage and separate the posterior muscle tissue, we lose the benefits of the intermuscular approach. Furthermore, damage to the posterior soft tissue can result in posterior dislocation. We investigate that protecting the posterior soft tissue increases the joint stability in the early postoperative period and results in a lower dislocation rate.MethodsWe evaluated muscle strength recovery by measuring the maximum width of the internal obturator muscle on CT images (GE-Healthcare Discovery CT 750HD). We compared the maximum width of the muscle belly preoperatively versus 10 days and 6 months postoperatively. As clinical evaluations, we also investigated the range of motion of the hip joint, hip joint function based on the Japanese Orthopaedic Association hip score (JOA score), and the dislocation rate 6 months after surgery.ResultsThe width of the internal obturator muscle increased significantly from 15.1 ± 3.1 mm before surgery to 16.4 ± 2.8 mm 6 months after surgery. The JOA score improved significantly from 50.8 ± 15.1 points to 95.6 ± 7.6 points. No dislocations occurred in this study.ConclusionsWe cut only the posterosuperior articular capsule and protected the internal obturator muscle to preserve muscle strength. We repaired the entire posterosuperior and anterior articular capsule. These treatments increase joint stability in the early postoperative period, thus reducing the dislocation rate.Level of evidenceTherapeutic, Level IV.

Evaluation of Direct Anterior Approach for Revision Total Hip Arthroplasty: A Systematic Review

“…The DAA for THA has grown in popularity owing to its usage of inter-muscular and inter-nervous plane and the preservation of both the external rotators and the hip abductors 7 22) . Literature shows strong results and advantages, in relation to the dislocation rate and heterotopic ossification, compared with other approaches in both mid to long term 23 24 25 26 27 28) .…”

Using the anterior capsule of the hip joint to protect the tensor fascia lata muscle during direct anterior total hip arthroplasty: a randomized prospective trial

“…After the iliofemoral ligament and the anterior articular capsule be revealed in a DAA, many surgeons open the anterior capsule in a "T" or transverse fashion to expose the hip joint and later close the capsule by suture or not close the capsule after the arthroplasty; both closing or not closing the capsule are widely accepted [5,[18][19][20][21][22]. Although some surgeons believe that the anterior capsule is not important, we have found a new application for this structure.…”

Using the anterior capsule of the hip joint to protect the tensor fascia lata muscle during direct anterior total hip arthroplasty: a randomized prospective trial

“…After the iliofemoral ligament and the anterior articular capsule be revealed in a DAA, many surgeons open the anterior capsule in a "T" or transverse fashion to expose the hip joint and later close the 4 capsule by suture or not close the capsule after the arthroplasty; both closing or not closing the capsule are widely accepted. [5,[18][19][20][21][22] Although some surgeons believe that the anterior capsule is not important, we have found a new application for this structure. We hypothesized that we could protect the TFLM by using the anterior articular capsule as a barrier between the TFLM and the retractors needed for exposure of the joint for the arthroplasty.…”