Patient Education and Consent

It is imperative to ensure appropriate patient education before either conventional total hip arthroplasty (THA) or minimally invasive THA (MIS-THA). Such education should address the patient’s postoperative expectations, as well as inform the patient regarding the administration of anticoagulation. Preoperative counseling with respect to the patient’s postoperative activity level is left to the discretion of the surgeon.

Preprocedural Planning

Provided that the disadvantages caused by limited visualization during MIS-THA can be overcome, there is no logical reason to use a longer incision and create more surgical trauma if a shorter incision with less trauma would achieve the same end result. The skin incision can limit component insertion. A 10-cm (4-in.) incision is appropriate for inserting a 56-mm acetabular component while avoiding contact between the component and the skin or subcutaneous tissues.^[9]

The most important factors allowing early discharge appear to be related to patient selection, patient motivation, anesthesia, acute pain-management techniques, and the postoperative protocol. The specific operative approach used does not appear to be an independent factor in early discharge. There are no data to indicate how the surgical approach interacts with the other variables in affecting discharge.

Factors such as family education, patient preconditioning, preemptive analgesia, and accelerated preoperative rehabilitation—rather than the surgical technique per se—may play a major role in fostering better outcomes after MIS-THA. Careful scientific study and evaluation are warranted before MIS techniques are widely accepted.

Preprocedural evaluation

No special workup is indicated for MIS-THA patients as compared with conventional THA patients. If the diagnosis of hip disease is in doubt, magnetic resonance imaging (MRI) or a diagnostic injection into the hip joint may be useful. If a fluoroscopically guided hip-joint injection relieves pain, the pathology is probably localized to the intra-articular joint. Careful examination and selected diagnostic modalities may be needed to rule out spinal stenosis, herniated lumbar disk, vascular claudication, incarcerated hernia, meralgia paresthetica, psoas impingement, hip bursitis, transient osteoporosis, malignancy, stress fracture, and other diseases that can mimic the symptoms of hip degeneration.

A routine preoperative workup is necessary, including the following:

Complete medical workup
Radiography (eg, affected extremity and chest radiographs)
Basic laboratory evaluation (eg, type and screen, complete blood count, basic metabolic panel, and urine analysis)
Electrocardiography (ECG) for patients older than 50 years
Additional studies, as warranted by any comorbid conditions that may be present

Dental evaluation and treatment for dental diseases should be done before THA is performed. Routine cleaning of the teeth should be delayed for several weeks after surgery. In older patients with prostate problems or urinary retention issues, urinalysis should be done and cultures obtained to check for urinary infections; any infections diagnosed should be treated before THA.

Because of the limited surgical exposure afforded by MIS-THA, preoperative templating is critical. Templating may be used to guide determination of the following:

Implant size
Leg length restoration
Femoral stem offset

If there is uncertainty about leg lengths, computed tomography (CT) can provide definitive evaluation. The opposite hip joint should be evaluated on the anteroposterior radiograph for comparison of leg lengths and assessment of existing offset relations. In selected patients, other studies (eg, vascular indices, spinal radiographs, MRI of the hip or spine, and evaluation of the ipsilateral knee joint) may be required.

Intraoperative radiographic imaging may or may not be necessary, depending on surgeon experience. Intraoperative radiography may prolong operating time and complicate the procedure, but it may reduce the risk of component malpositioning and facilitate the estimation of leg length.

Equipment

Specialized surgical instrumentation and implants are commonly required for MIS-THA. Because exposure may be limited, MIS-THA may necessitate modification of conventional instrumentation and possibly the use of additional equipment (eg, fiberoptic light cables, cutaway reamers, angled reamers and broach handles, Hohmann retractors with light sources, or flexible acetabular reamers).^{[71, 72, 73]}

Particular operating room tables make certain MIS-THA approaches more accessible and may be required to provide the requisite traction and permit rotation of the lower extremity. For example, a Judet Orthopaedic Table (Tasserit, Sens, France) or a PROfx Fracture Table (OSI, Union City, CA) can facilitate an anterior approach, and a Jupiter Table (Trumpf, Charleston, SC) may be especially suitable for an anterolateral approach.^{[24, 72, 74]}

Monitoring & Follow-up

After an MIS-THA procedure, the patient should be followed at the same time intervals that would be appropriate for a conventional THA. Periodic clinical and radiographic examinations are indicated to monitor for aseptic loosening, wear, and late infection.

Technique

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Media Gallery

Minimally invasive total hip arthroplasty. Shown are skin incisions for direct anterior (black), miniposterior/lateral/anterolateral (dark blue), conventional posterior (dark blue plus red extensions), direct superior (green), and SuperPATH (purple) approaches to hip. Conventional posterior incision is usually 10-25 cm long. Single incisions for minimally invasive approaches are usually less than 10 cm long. In two-incision approach, both incisions are usually less than 5 cm long.
Minimally invasive total hip arthroplasty: two-incision approach. Photograph of right hip in supine position showing outlines of anterior superior iliac spine and greater trochanter. Dotted line marks anterior incision.
Minimally invasive total hip arthroplasty: direct anterior approach. Insertion of acetabular component after acetabular component reaming in supine position.
Minimally invasive total hip arthroplasty: direct anterior approach. Circumferential view of acetabular component is shown with visual confirmation of orientation. Insertion guides and radiographs also may be used to assess positioning.
Minimally invasive total hip arthroplasty: direct anterior approach. View of proximal femur and right hip in supine position, showing lesser trochanter femoral neck resection marked with pen.
Minimally invasive total hip arthroplasty: direct anterior approach. Photograph of right anterior thigh after draping on fracture table. Note metal spar with square holes; this device attaches to fracture table and allows elevation of femur during femoral preparation.
Minimally invasive total hip arthroplasty: direct anterior approach. Left femoral head is dislocated anteriorly before osteotomy of femoral neck.
Minimally invasive total hip arthroplasty: direct anterior approach. Proximal femoral exposure and rasp is introduced into femoral canal facilitated by fracture table via metal spar elevating femur anteriorly.
Minimally invasive total hip arthroplasty: two-incision approach. Surgeon can guide femoral broaches through small posterior incision while palpating through anterior incision.
Minimally invasive total hip arthroplasty: two-incision approach. After wound closure, length of anterior incision is approximately 7.5 cm (3 in.).
Minimally invasive total hip arthroplasty: direct superior approach. Gluteus maximus fascia is incised sharply to expose gluteus maximus muscle.
Minimally invasive total hip arthroplasty: direct superior approach. Gluteus maximus muscle fibers are divided longitudinally, and deep gluteus maximus fascia is divided to expose pericapsular fat; prirformis tendon is detached close to its insertion.
Minimally invasive total hip arthroplasty: direct superior approach. Capsule is incised in inferior aspect of wound; capsulotomy is extended posterior and superior to superior acetabulum.
Minimally invasive total hip arthroplasty: direct superior approach. Hip is dislocated, femoral neck osteotomized, and femoral head removed.
Minimally invasive total hip arthroplasty: direct superior approach. Sharp curved Hohmann retractor is placed over anterior acetabular rim; second bent 90-degree Hohman at inferior margin; 90-degree handheld retractor in superior aspect of wound; and 90-degree sharp Hohmann deep to superior capsule. Optional retractor may be placed on posterior aspect of acetabulum.
Minimally invasive total hip arthroplasty: direct superior approach. Acetabular labrum is excised; acetabulum is reamed. Retractor is placed in inferior aspect of wound to retract quadratus femoris away from proximal femur.

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Author

Derek F Amanatullah, MD, PhD Assistant Professor, Department of Orthopedic Surgery, Stanford University School of Medicine

Derek F Amanatullah, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, American Medical Association, California Orthopedic Association, International Cartilage Repair Society, Orthopaedic Research Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Stanford University; nSight Surgical; PlantarTech; Arthrology Consulting; Radial Medical; Stryker; Exactech; Zimmer-Biomet; DePuy<br/>Received research grant from: NIH-NCATS; OREF; Sparta Health Science; Stanford University<br/>Have a 5% or greater equity interest in: Arthrology Designs (DBA: PlantarTech); Arthrology Consulting; nSight Surgical<br/>Received income in an amount equal to or greater than $250 from: Stryker; Exactech; DePuy; Zimmer-Biomet<br/>Patents: Dynamic Tension Plantar Fasciitis Splint; Cool Cut Cast Saw, Modular Total Knee Design, Augmented Reality in Arthroplasty; Surgical Visualization Systems for: Honoraria: WebMD/Medscape.

Coauthor(s)

Raj J Amin, MD Fellow in Adult Total Joint Reconstruction, Department of Orthopedic Surgery, Stanford University Hospital, Stanford University School of Medicine

Raj J Amin, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Maryland Orthopaedic Association

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Additional Contributors

Paul E Di Cesare, MD

Paul E Di Cesare, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons

Disclosure: Nothing to disclose.

Melvin Joice, MD Resident Physician, Department of Internal Medicine, Massachusetts General Hospital

Disclosure: Nothing to disclose.

Rami M Ezzibdeh Stanford University School of Medicine

Disclosure: Nothing to disclose.

Acknowledgements

B Sonny Bal, MD Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

B Sonny Bal, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Bonesmart.org None Online orthopaedic marketing and information portal; OrthoMind None Social networking for orthopaedic surgeons; Amedica Corporation Stock options and compensation Manufacturer of Orthopaedic Implants; BalBrenner LLC Ownership interest Consulting; Zimmer Royalty Consulting; Medtronic None Consulting; ConforMIS Consulting

William L Jaffe, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Vice Chairman, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases

William L Jaffe, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, Eastern Orthopaedic Association, and New York Academy of Medicine

Disclosure: Stryker Orthopaedics Consulting fee Speaking and teaching

James J McCarthy, MD, FAAOS, FAAP Director, Division of Orthopedic Surgery, Cincinnati Children's Hospital; Professor, Department of Orthopedic Surgery, University of Cincinnati College of Medicine

James J McCarthy, MD, FAAOS, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Orthopaedic Association, Limb Lengthening and Reconstruction Society ASAMI-North America, Orthopaedics Overseas, Pediatric Orthopaedic Society of North America, Pennsylvania Medical Society,Pennsylvania Orthopaedic Society, and Philadelphia County Medical Society

Disclosure: Nothing to disclose.

Steven I Rabin, MD Clinical Associate Professor, Department of Orthopedic Surgery and Rehabilitation, Loyola University, Chicago Stritch School of Medicine; Medical Director, Orthopedic Surgery, Podiatry, Rheumatology, Sports Medicine, and Pain Management, Dreyer Medical Clinic; Chairman, Department of Surgery, Provena Mercy Medical Center

Steven I Rabin, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Fracture Association, AO Foundation, and Orthopaedic Trauma Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Santaram Vallurupalli, MD Resident Physician, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

Disclosure: Nothing to disclose.