Advantage of the anterior approach in total hip arthroplasty (topographic-anatomical and computed tomography substantiation)

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Abstract

BACKGROUND: Hip arthroplasty is effectively performed for the elderly population and young people who continue to work and have an active lifestyle. An increase in the number of operations is facilitated by an increase in the prevalence of osteoarthritis and physical inactivity, leading to an increase in BMI and, accordingly, the load on the joints of the lower extremities. The increased volume of hip arthroplasty, the expansion of indications, the decrease in the average age of patients undergoing the intervention, and the related increase in surgical needs point to the need to improve surgical treatment approaches. In the CIS countries, the direct anterior approach is rarely used; in our opinion, it is less traumatic.

OBJECTIVE: To conduct a topographic-anatomical and computed tomographic study to support the advantages of using a direct anterior approach when performing hip arthroplasty.

MATERIALS AND METHODS: The present study included two stages: First, (a) layer-by-layer anatomical preparation of the hip joint area on five sectional complexes to establish accurate anatomical and topographic relationships of the structures of the anterior thigh region and design accesses and (b) hip arthroplasty on 10 biomannequins using two approaches: five operations (direct anterior approach) and five operations (direct lateral approach), and second, evaluation of access to the hip joint in terms of criteria developed by A.Yu. Sazon-Yaroshevich to assess online access.

RESULTS: This study confirmed that the direct anterior approach is less traumatic; its use preserves soft tissues. However, the use of a direct anterior approach requires additional training of endoprosthetic surgeons. The authors recommend executing the first 10–20 endoprostheses on biomanikins to link the risk of problems and to solidify surgical skills at the beginning of the learning curve. The depth of the wound is 20–25% less with the direct anterior approach to the hip joint than with the Harding approach — 101 and 136 mm, respectively.

CONCLUSION: Because the approach to the joint is carried out along the intermuscular gap, no soft tissues, blood vessels, or nerves are damaged during the direct anterior approach. According to its characteristics, the direct anterior approach is optimal for performing hip arthroplasty. Maintaining muscles during the performance of the direct anterior approach allows you to begin early activation and rehabilitation of patients. The adoption of a direct anterior approach is related to improved hip joint functional results in the early postoperative period.

About the authors

Ivan K. Eremin

LLC “Neuro-clinic”

Email: eremindoctor@yandex.ru
ORCID iD: 0000-0002-0992-0706
SPIN-code: 9019-4184

Orthopedic Traumatologist

Russian Federation, Moscow

Egor V. Ogarev

Priorov National Medical Research Center for Traumatology and Orthopedics

Email: evogarev@yandex.ru
ORCID iD: 0000-0003-0621-1047

MD, Cand. Sci. (Med.), Radiologist, Senior Researcher

Russian Federation, Moscow

Armen A. Daniliyants

Pirogov Russian National Research Medical University

Author for correspondence.
Email: armendts@mail.ru
ORCID iD: 0000-0001-6692-0975

Student

Russian Federation, Moscow

Kirill A. Zhandarov

Sechenov First Moscow State Medical University

Email: zhandarov_k_a@staff.sechenov.ru
ORCID iD: 0000-0002-2908-6990

MD, Cand. Sci. (Med.), Assistant Professor

Russian Federation, Moscow

Nikolay V. Zagorodniy

Priorov National Medical Research Center for Traumatology and Orthopedics; Russian Peoples’ Friendship University

Email: zagorodniy51@mail.ru
ORCID iD: 0000-0002-6736-9772
SPIN-code: 6889-8166

MD, Dr. Sci. (Med.), Professor, Corresponding Member of RAS, Traumatologist-Orthopedist

Russian Federation, Moscow; Moscow

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Supplementary files

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2. Fig. 1. Anatomy of the anterior region of the thigh (here and in Fig. 2–8: the photo was taken using cadaver material provided by Ekb_Cadaver_Lab at the Scientific and Educational Medical Center, Yekaterinburg): 1 — inguinal ligament (lig. inguinale), 2 — femoral artery (a. femoralis), 3 — femoral vein (v. femoralis), 4 — iliopsoas muscle (m. iliopsoas), 5 — femoral nerve (n. femoralis), 6 — sartorius muscle (m. sartorius), 7 — great saphenous vein (v. saphena magna), 8 — rectus femoris (m. rectus femoris).

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3. Fig. 2. Anatomy of the anterior thigh: 1 — inguinal ligament (lig. inguinale), 2 — lateral cutaneous nerve of the thigh (lateral femoral cutaneous nerve), 3 — great saphenous vein (v. saphena magna).

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4. Fig. 3. The neurovascular bundle of the anterior region of the thigh: 1 — branching of the femoral nerve, 2 — femoral artery (a. femoralis), 3 — femoral vein (v. femoralis).

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5. Fig. 4. Anatomy of the femoral artery: 1 — femoral artery (a. femoralis), 2 — deep femoral artery (a. femoralis profunda), 3 — lateral artery that circumflexes the femur (a. circumflexa femoris lateralis).

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6. Fig. 5. Anatomy of the anterior region of the thigh, deep layers: 1 — lateral artery that circumflexes the femur (a. circumflexa femoris lateralis), 2 — tailor muscle (m. sartorius), 3 — rectus femoris (m. rectus femoris).

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7. Fig. 6. Anatomy of the gluteal region: 1 — gluteus maximus (m. gluteus maximus), 2 — ilio-tibial tract (tractus ilio-tibialis).

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8. Fig. 7. Anatomy of the gluteal region: 1 — gluteus medius (m. gluteus medius), 2 — piriformis (m. piriformis), 3 — sciatic nerve (n. ischiadicus), 4 — muscle layer, consisting of the upper twin, internal obturator and lower twin muscles (mm. gemmeli sup. et inf., m. obturatorius internus), 5 — square muscle (m. quadratus), 6 — large trochanter (trochanter major).

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9. Fig. 8. Anatomy of the gluteal region: 1 — small gluteal muscle (m. gluteus minimus), 2 — capsule of the hip joint.

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10. Fig. 9. Images of multislice computed tomography, axial sections: a — bone mode, b — soft tissue mode, 1 — measurement of the wound depth in the anterior approach, 2 — measurement of the wound depth in the Harding approach.

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