Total Hip Replacement Surgical Approach Health And Social Care Essay

Total Hip Replacement Surgical Approach Health And Social Care Essay The two most commonly used and described approaches to Total Hip Arthroplasty (THA) are the anterolateral and the posterior. The anterolateral or modified Hardinge approach involves a skin incision over the greater trochanter, over or parallel with the shaft of femur. The incision is often curved posteriorly at its proximal end. Dissection is then undertaken to take advantage of the intramuscular plane between the tensor fascia lata and the gluteus medius. In the direct lateral or Hardinge approach, the acetabulum is exposed by a partial or total release of the abductor muscles (gluteus medius and minimus). This was originally achieved by a trochanteric osteotomy or detachment at their greater trochanter insertion3 described by Watson-Jones 4 and then subsequently modified by Charnley.5 The anterolateral or modified Hardinge approach, as used in Tayside, involves detaching the anterior third of the gluteus medius and minimus. This minimises the risk to the superior gluteal nerve and limits damage to the abductors.6 This modification from the original technique was described by Harris7, and Muller.8 The posterior approach involves a skin incision over the posterior aspect of the greater trochanter, proximally following inline with the gluteus maximus and distally the lateral shaft of the femur. A blunt dissection of the gluteus maximus follows emerging posterior to the abductor muscles. The external rotators (piriformis, superior and inferior gemelli and obturator internus) are then detached at the femoral insertion and reflected exposing the capsule and acetabulum.3 It was originally described by Langenbeck, and subsequently Kocher9 and finally Gibson.10 There have been numerous studies but there is still professional disagreement about which approach is the most effective for primary total hip arthroplasty. Many of the studies that have been undertaken over recent years have been considered to be deficient in both quality of study design and quantity of patients in the study sample. The Cochrane review considered four studies sufficient but only one of these included functional outcomes with the Harris Hip score.11 The study in the Cochrane review was done by Barber et al, it was limited in size, 49 patients, with a relatively short follow-up.12 Dislocation rates between these approaches have been looked at in some depth. Many studies have found a difference, while others havent. The difference is often considered minimal if good tissue repair is used in the posterior approach.13,14,15 Where this is the case, the implant has been shown to have half the amount of internal rotation (anteversion) when placed using anterolateral approac h as opposed to the posterior approach.16 This is a retrospective study aiming to use large sample groups to answer the null hypothesis that there is no difference between an anterolateral approach and a posterior approach with regards to functional outcome scores (Harris Hip Score and Trendelenburg Test for primary total hip replacement surgery). It also aims to answer the null hypothesis that there is no difference functionally in patients that suffer post-operative dislocations. To do this it will look at the pre-operative scores and post-operative scores comparing any gain or loss in function for each patient. The reasoning behind using Harris Hip Score and Trendelenburg Test is that these are commonly used, meaning any conclusions can be easily related to clinical practice. Dislocation rates between the two approaches will also be compared. Materials and Methods: The data used within this project was collected under the Tayside Arthroplasty Audit Group (TAAG) database. The objective of the TAAG database is to evaluate the clinical performance of all hip arthroplasties or hip resurfacings in Tayside. Initially there were 8153 cases with data for primary hip arthroplasties (resurfacings were not included), of these 6350 cases had undergone either an anterolateral or a posterior approach to the surgery. For this data the aim was to look at pre-operative Harris Hip score results and Trendelenburg tests and again at 1-year post-operatively. Due to this, the data was further screened to ensure that each patient had a complete set of data for these tests. Some cases didnt have data correctly collected or alternatively were not followed up at 1-year post-operatively. The resulting number of cases was 3416 with 1001 having suffered a complication within the 1-year period after surgery. These complications were medical and surgical. Not all of these co mplications had a direct effect on the function or rehabilitation of the joint. The choice of Harris Hip score and Trendelenburg Testing to test functional ability has been shown to be clinically relevant as a reference tool for assessment of improvement or deterioration of the hip joint, particularly pre-operatively and at 1-year.17,18 The Harris Hip score assesses pain, ability to complete basic tasks, deformity of the joint, and range of movement out of 100. The functional score removes the subjective areas of the full score looking specifically at functional ability out of 47. Trendelenburgs test is specifically looking at abductor deficit, although it has its recognised disadvantages.19 The need for experienced interpretation of the Trendelenburgs test is its main disadvantage, otherwise you can get false-negatives and false-positives very easily. It was considered only relevant to look at results post-operatively at 1-year, as from a patients perspective this is often the expectation of relative normality. From a surgical point of view, secondary complicat ions such as loosening of the prosthesis and deep infection are less likely to be apparent at 1 year but will have presented at 5 years.20 The TAAG database is a rolling audit of all elective hip arthroplasties or resurfacings done in Tayside. Any patient who is undergoing either of these procedures will be considered for inclusion. Exclusion criteria for audit enrolment are a previous total or cemented/uncemented hemi-arthroplasty of the affected hip or inability/unwillingness to participate in the follow up programme. If a patient consents for involvement they will be assessed pre-operatively and post-operatively, this includes radiography to assess prosthesis positioning. Data for Harris Hip Scores and Trendelenburg Test are collected at each assessment. Post-operative follow-up is at 1, 3, 5, 7 and 10 years and then every 2 years thereafter until the prosthesis fails. Operative procedures, local practices, technique used, antibiotic coverage, theatre type, and any other regimes are all recorded. If a patient suffers a complication, details of it, management, and final outcome are all recorded. All data is collected in the same format, if any clinical issues for a patient are found that patient will be referred back to the supervising consultant for review. The data available had a large range of implants used and was also unspecific for consultant surgeon who undertook each procedure. Positive (2)On comparing the difference between pre-operative testing to post-operative testing the groups four possible results were seen. As the outcome for Trendelenburg is categorical, each result was given a value, the pre-operative result was simply added to the post-operative, as is shown in Table 2, giving an option of 1-4. For a negative to negative (1) result the anterolateral group was 59.89% and the posterior group was 51.38%. For a positive to negative result (2) the anterolateral group was 34.39% and the posterior group was 46.40%. This shows the posterior approach corrected a Trendelenburgs positive test in 12.01% more cases than the anterolateral approach. For a negative to positive (3) result the anterolateral group was 3.52% and the posterior group was 0.55%. This shows that the anterolateral approach caused a Trendelenburgs positive test in 2.97% more cases than the posterior approach. For a positive to positive (4) result the anterolateral group was 2.18% and the posterior group was 1.65%. When comparing the two groups as a whole, a statistical significance was found (p=