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The history of surgical access for hip replacement
The history of surgical access for hip replacement
G. O s b o r n e The quest for successful surgical construction of a mobile hip joint, subjected to the vagaries of technical fortune in the last 50 years, bears comparison with a Tolkien adventure story. Now, however, it might be said that the journey is ended and the problems of hip replacement are largely conquered. In the past the milestones of success were not always identified or set evenly and the stages of development were not brightly signalled. The technique of surgical access must always be the servant of the particular prosthetic design and its insertion system. However, whereas the design of the present low friction acetabular sockets and femoral stemmed components has narrowed towards a basically similar standard pattern, the anatomical approaches, through which surgeons insert these comparable items, could not vary more widely with no generally held consensus view. Is this position due to the particular and peculiar anatomy of the hip joint or is it a reflection of the historical development of the surgical approaches? Is it due to strongly held views which are reconcilable and should there be a common surgical approach as there has become a similar design of prosthesis and should this 'best' approach be taught in training? Consideration of the development of surgical access to the hip joint for replacement surgery might outline the problem and help to answer these questions.
arthroplasty was introduced with the promise that new articular cartilage to cover the femoral head would develop if the operation was performed technically successfully. 1 The procedure was widely adopted as the standard treatment for arthrosis of the hip joint but after some years, it had to be accepted that the method was a major surgical failure and the reasons became apparent. 1) The surgery of access was diffficult--using only the vertical limb of the incision which Smith Petersen devised in 1917 (while still a student). 2 This approach went down into the front of the acetabulum, between sartorius and tensor fascia femoris and then between psoas and the rectus muscle. Access and vision were poor and reaming was difficult. The technique was well described by Law and when correctly done, was an artistic exercise; however the average surgeon tended to gain more access by adding some of the more proximal part of the Smith Petersen incision, in which the origins of the gluteus medius and tensor fascia femoris muscles were stripped off the outer blade of the ilium. Much bleeding occurred and a limp developed if the origins of the gluteal muscles failed to heal adequately. 2) The loose cup was a high friction joint and was abandoned because it gave unreliable results even when well performed. However in the 1940s it familiarised surgeons with the Smith Petersen incision and for the first time with routine open hip surgery.
The Smith Petersen Approachh1946 Brought to a war weary British orthopaedic profession by Smith Petersen, in 1946, the operation of cup
The Judet Operation--1949 This method was readily accepted by an orthopaedic profession demoralised by the Smith Petersen failure and was taken up with enthusiasm) The early results
Geoffrey Osborne, M Ch Orth, FRCS, FRCSE, 26 Waterloo Road, Southport, Merseyside PR8 2NF.
Current Orthopaedics(1986) 1, 61-66 © LongmanGroup UK Ltd.
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THE HISTORY O F S U R G I C A L ACCESS F O R H I P R E P L A C E M E N T
of this acrylic hemi-arthroplasty were spectacular and confirmed the merit of replacement of the femoral head as an essential step in hip arthroplasty. Unfortunately the prosthesis was a physical and material design failure and fracture, wear, and reaction to particulate acrylic required removal often within one year of insertion. Judet used a Heuter incision which was similar to a restricted vertical limb of the Smith Petersen incision and needed the assistance of a male orderly concealed under the operating table who manipulated the leg according to instructions!
The Gibson Approach--1950 The Judet prosthesis was an important milestone in the development of arthroplasty and gave consistently early good results until mechanical failure ensued. It became more popular when Gibson of Winnipeg in 1950 described his version of the Kocher approach. 4 Through a posteriorly angled skin incision the fascia lata was divided in front of the gluteus maximus and access to the capsule of the hip was achieved by dividing the attachment of gluteus medius and minimus to the great trochanter. This was essentially an anterior exercise because of the position of the muscles at that level. The capsule was opened anterolaterally and the hip was dislocated forwards. It gave a generally good comparatively blood-less view and easy access for prosthetic insertion.
The McFarland/Osborne Approach--1952 This technique modified the Gibson or Kocher incision when it became obvious that permanent gluteal weakness followed incomplete repair of the divided gluteal trochanteric insertion, s The basic principle of 'gluteal displacement', transferring forward the combined gluteal and vastus lateralis muscles in one sheet offered a wide exposure, good vision and more reliable and secure operative repair than the Gibson. It was not published before 1954 at the end of the discredited Judet prosthetic era and at that time remained an interesting surgical concept shelved for lack of a mechanically adequate prosthetic system.
The Osteotomy Operation It was in the 1950s that siren voices turned scientific thought in the United Kingdom away from the progressive logical development of arthroplasty surgery by a further wave of attention to the simplicity and relative reliability of the osteotomy operation for arthrosis of the hip joint. Developed by Lorenz and powerfully advocated pre-war by Malkin and McMurray,6'7 it usually gave pain relief but with often unpleasant knee and hip stiffness and an ungainly limp. Osteotomy was better than conservative treatment but was discarded each time a potentially more advantageous method emerged such as the cup arthroplasty and the Judet operation.
Under the influence of McFarland, Pauwels and Nissen, S lo osteotomy appeared to come into its own, particularly after fixation devices were developed which allowed external fixation in a plaster spica to be discarded and early mobilisation achieved. Osteotomy dominated the European hip surgery scene for 15 years led by Wainwright, 1~ Muller, 12 the author, and others until the successful results of refinement of early total hip replacement systems could no longer be ignored and the instrumentation became generally available. During this osteotomy era, no open hip surgery was generally done except to femoral neck fractures for which the Austin Moore operation, through the posterior approach, slowly gained acceptance as a necessary alternative to neck fixation.
The Posterior Approach of Austin Moore--1957 By the time total hip replacement became available, this posterior approach was the only one familiar to many orthopaedic surgeons. Lasting credit is owed to Austin Moore for the development in the early 1950s of a femoral prosthetic design and a usually effective shaft fixation system, which is still in u s e . 13 Further credit is owed for the development of the true posterior approach essentially as practised today. Although originally described by Osborne (1931) from an anatomical dissection, 14 and with some similarity to the Kocher approach, Moore gave it the name of the 'southern' approach partly because he moved the skin and maximus incisions more posteriorly and inferiorly and also because he practised in one of the southern states of America. The posterior approach totally preserves gluteus medius and minimus and does not risk impairment of their antigravity power after operation. Access to the posterior capsule was achieved by division of the short rotators and often pyriformis and the quadratus femoris in one sheet turned back over the sciatic nerve, preserved medially. Bleeding from the medial femoral circumflex artery required attention but otherwise the approach was relatively bloodless. The hip was dislocated backwards and an adequate view of the acetabulum was obtained. For the hemiarthroplasty replacement prosthesis of Austin Moore the technique proved ideal and rightly achieved considerable support in the USA and in Britain for subcapital fractures. The posterior approach however remains particularly critical to errors of position of the prosthetic components. Some opinion believes if the short rotator tendons are extensively divided, they never heal adequately and that the strong musculo-tendinous posterior wall which they provide at the back of the hip joint in other exposures such as the anterior, is lost. It is uncompromisingly necessary in the posterior approach to restore the normal femoral neck length and neck shaft angle and essential to restore normal anteversion and avoid pointing the prosthetic head backwards into retroversion. This critical protection
CURRENT ORTHOPAEDICS
against dislocation may be secured more easily by a cemented stem such as the Thompson design, the Moore self locking principle being unreliable in an osteoporotic femoral shaft. The posterior approach however gave the highest incidence of post-operative dislocation when compared with the anterior and lateral approaches. Peter Ring 15 and also Robin Ling 16 have used the posterior approach, successfully for specialised work on the design of prosthetic hip components which reduces the danger of instability and for details of these interesting developments, their writings should be consulted.
The Anterior or Antero-Lateral Approach McKee and Watson Farrar pioneered a design of total hip replacement in 196617 and used the anterior approach previously described by Watson Jones. 18 The approach splits the interval between the tensor fascia lata and gluteus medius through an oblique anterior incision along the femoral neck and down the femoral shaft. Sharp dissection to separate the two muscles is necessary at the iliac attachment. At the trochanter, gluteus medius and minimus require division to open the exposure adequately and to prevent the friable fibres of gluteus medius from damage by retraction. After opening the capsule, care is needed in this approach to avoid femoral shaft fracture when the hip is dislocated anteriorly. Special instruments are necessary to display the acetabulum for reaming and insertion of the cup. Adequate treatment of the femoral shaft needs offset reamers and levers to give sufficient access in difficult cases. The tendency to break false passages into the femoral shaft is greatest in this approach. However, accurate alignment of the cup and femoral prosthesis is more easily obtained and the anterior approach has the lowest incidence of post-operative dislocation. Good access to the acetabulum and femoral shaft require a greater degree of skill and training than the posterior approach but in experienced hands the anterior approach gives useful routine service for hip replacement surgery.
The Charnley Approach Sir John Charnley, the major pioneer of hip replacement surgery, was never a participant in the osteotomy fashion. Following his successful development of compression arthrodesis of the knee, he devoted considerable effort to applying the compression principle to surgical fusion of the hip joint but with limited success. He then developed a form of painless partial fibrous fusion of the hip--'the central dislocation operation'-19 which gave no better results than from the average osteotomy operation. He used for these fusion operations a massive oblique T shaped approach derived from the Brackett incision, z° (Fig. 1). The cross of the T ran from the antero-superior spine towards the ischial tuberosity along Nelaton's line, deeply dividing the tensor fascia lata muscle, the fascia horizontally
Brackett
/
63
Posterolateral
Antero-%% 1 lateral lique
Vertical Mid-lateral
teroerior
Fig. 1 Approaches to the hip joint.
and posteriorly he split the fibres of maximus. The vertical limb of the T shaped incision ran for 6in down the mid lateral line from the tip of the greater trochanter to create two large musculo-fascial flaps. The gluteus medius and minimus insertions were divided from the great trochanter and the whole of the front and lateral side of the hip joint was widely displayed. Finally with stiff hips the upper shaft of the femur was partly avulsed from the side of the pelvis by division of all tight obstructing tissues. The patient's foot could then be put over the opposite shoulder and the axis of the femoral neck pointed directly lateral. This extreme exposure was used to bore out the whole floor of the acetabulum for the central dislocation fusion operation. After Charnley developed the earlier designs of his artificial hip joint he continued to use this same approach which had been developed for the fusion procedures. His concept of surgical access at that time included the following points: 1) An extensive approach dividing all tight structures after dislocation allowed access for unrestricted reaming of the acetabulum and full restoration of femoral length. 2) This major access required the total detachment of the gluteal muscles, division of which was soon replaced by detachment of the trochanter--a method suggested by Harry Platt (after Brackett). Charnley,
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T H E H I S T O R Y O F S U R G I C A L ACCESS F O R H I P R E P L A C E M E N T
following his success with compression arthrodesis of the knee, applied himself with vigour to studying the problems of trochanteric fixation and union, which closure of his extreme exposure demanded. 3) Repair created a massive amount of capsular and intermuscular scar tissue which must have contributed considerably to post-operative stability. 4) As compared with other hip approaches, it was an immense surgical procedure. Many surgeons, while respecting his work on the development of the artificial joint, found the approach a 'tour de force' and unattractive. With development of the use of cement, the concept of the low friction joint and adoption of the small femoral head, the Charnley approach procedure was gradually changed from the early 1960s. He first gave up the posterior limb of the T shaped incision and subsequently used an oblique incision from front to back. Later he changed this to a long straight vertical incision but more recently he adopted and described in his book 'Low Friction Arthroplasty',21 an angled postero-lateral incision which ressembled closely the classical postero-lateral skin incision of Gibson and others, I argued with him many years ago that the ideal hip incision ran posteriorly in the skin and fascia of the buttock, laterally through the glutei and anteriorly into the capsule with the hip dislocating forwards. This apparent paradox takes account of the effect of hip flexion on the tight drum-like gluteal fascia and fascia lata. Straight lateral incisions dividing the gluteal fascia in the mid lateral line provide good deep access when the hip is in extension but as the joint is flexed, a tight wall of posterior fascia and gluteus maximus is drawn across the lower half of the approach and hinders access to the trochanter. Charnley had observed this tightness of gluteus maximus in his description of the central dislocation operation in 1955 but only later appreciated its importance in the approach for hip replacement, allowing a shorter skin incision. The standard Charnley approach, now modified to a straight postero-anterior oblique incision, as practised at Wrightington, is a much reduced and refined exercise as compared with the extensive exposures of the early years. Nevertheless it is the only approach that totally detaches the gluteal muscles from the femur and therefore liberates the femur from these muscles if they become shortened and contracted by longstanding hip disease, deformity and previous surgery. Wide distraction allows revision procedures and accurate restoration of the normal joint geometry with insertion of the prosthetic joint into an ideal position. Long term results appear to reflect rigorous adherence to insertion standards. The penalty for this mechanical precision of the Charnley approach is the problem of trochanteric reattachment. With special training this stage in the closure procedure is usually technically satisfactory but without adequate knowledge of the re-attachment technique, wire breakage, failure of union and post
operative dislocation may occur. Many surgeons however use the Charnley prosthetic hip system and instrumentation but without the Charnley surgical approach and are prepared to accept some instrumental difficultyin order to avoid time consuming trochanteric re-attachment.
The Liverpool Approach The McFarland-Osborne method of'gluteal displacement' in continuity published in 19545 was gradually modified and applied to the operation of hip replacement during the last 10 years by Osborne and Owen in Liverpool on the suggestion of Merryweather and by Hardinge in Wrightington.zz When first practised, the approach swung forward from the back of the trochanter the whole of the gluteus medius and vastus lateralis, along with the confluent sheet of gluteal aponeurosis and trochanteric periosteum and a distinct fragment of bone. In closure the major point of attachment was the tendon of gluteus maximus at the back of the upper femur. The aim of the manoeuvre however was to secure closure by firm suturing, and by the time of publication in 1954 muscle splitting of half of vastus lateralis was practised followed later by splitting of gluteus medius to leave enough attached fibres posteriorly for a firm direct closure. Later, at the time of resuscitation of this approach on the suggestion of Merryweather in 1975, splitting of the gluteal muscles up to the superior gluteal nerve supply was established as safe and allowed secure repair. The present Liverpool technique has the following steps (Fig. 2): 1) Lateral position on the table. With the hip and leg flexed forward and the buttock falling backwards, in this attitude, the acetabulum is nearer the skin surface than in any other position and unobstructed illumination is easily achieved. 2) A postero-lateral angled skin incision is made dividing the fascia lata vertically behind the tensor and is then carried into the upper fibres of gluteus maximus. 3) The gluteus medius muscle is split rather more than one inch from its posterior margin which can be identified with a finger behind the prominent edge of the tip of the trochanter. This portion of gluteus medius contains tendinous tissue which is attached to the trochanter and should be preserved in continuity. The split in the medius muscle is continued with diathermy through the trochanteric fascia over the face of the greater trochanter passing just behind and below its greatest prominence to curve into the vastus lateralis muscle below, leaving about a third of the muscle posteriorly. Spicules of bone or a small single fragment are detached with an osteotome to create a powerful fibro-muscular osseous sheet, which later can be drawn back into its original position at closure. 4) This gluteal 'bucket handle' flap is dissected forwards with diathermy dividing the remaining attachments of the gluteus medius, the insertion of gluteus
CURRENT ORTHOPAEDICS
65
\ olr / Fig. 2 The Liverpool approach to the hip joint.
minimus and the ligaments and capsule of the hip joint, all in one sheet. It opens a wide window into the front of the hip joint, the flexed position of which allows the muscles to become increasingly slackened as the gluteal flap is detached and facilitates forward retraction. 5) Closure requires a 1 mm braided polyester suture passed through two transverse drill holes in the body of the trochanter. Although gluteus minimus is partly adherent to medius, it is important that at least one suture is passed through the tendon of minimus to secure it firmly to the front of the trochanter. The split in vastus lateralis is closed by inversion and oversewing and the posterior tendon of medius is sutured to the gluteal flap now restored into normal position. No closure of the split in the gluteal muscle fibres is necessary. Any bone fragments are locked back in their original position if possible and if some lengthening of the neck of the femur has taken place then closure needs to be carried out with the leg held in abduction and extension. 6) The fan-shaped gluteus medius has horizontal fibres anteriorly but radiating fibres vertically above and behind the hip joint. In the anterior approaches, it is the front half of the intact medius which hampers deep exposure and obstructs reaming of the femoral shaft. Division through the tendinous insertion and resuture of this front part of gluteus medius, up to the vertical fibres helps to overcome this difficulty. Hardinge, 1982, elegantly describes an approach similar to the Liverpool approach but makes a rather more anterior division of medius and divides the gluteal tendon downwards into vastus lateralis in front of the bony lateral peak of the trochanter in a line not too different from the extended anterior approach. 22 There may be little preference between the Hardinge and the Liverpool approach provided sufficient of the gluteus medius and minimus muscle is moved forward to facilitate joint exposure and the musculo-tendinous flaps leave adequate tissue for repair and closure. Most replacement surgery can be carried out
through the Liverpool approach including some revision surgery. Where severe neck shortening is present restoration of the normal gluteal attachment may be impossible and imperfect repair risks permanent gluteal weakness. For such difficult cases the Charnley operation is advisable. 21
Summary Three approaches, as currently practised, have emerged from the historical development of hip , replacement. The posterior approach is the simplest technique to learn, but precision and experience is needed to avoid post-operative dislocation. The anterior (antero-lateral) approach gives a more limited exposure and needs training to avoid certain operative difficulties. The lateral approach-i The Liverpool lateral approach is easy to perform, gives an excellent exposure but is more extensive than the anterior or posterior methods and closure is more time consuming. ii The Charnley lateral approach is the most extensive, gives the widest exposure but needs more time for trochanterie repair. Exceptionally difficult cases are probably better done by the Charnley approach in skilled hands. For primary hip replacement by trained surgeons, all approaches give satisfactory results. Adequate exposure to avoid common technical problems requires study of the details of each approach to allow correct positioning of the joint components, the proper retensioning of the pelvi-femoral fascial structures and the management of mechanical difficulties of reduction. Similarity between the superficial layers of the lateral and posterior approaches suggests that a trend towards uniformity may develop.
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THE HISTORY OF SURGICAL ACCESS FOR HIP REPLACEMENT
References 1. Smith-Petersen M N 1948, Evolution of mould arthroplasty of the hip joint. Journal of Bone and Joint Surgery 30B: 59-75 2. Smith Petersen M N 1949, Approach to and exposure of the hip joint for mold arthroplasty. Journal of Bone and Joint Surgery 31A: 40-46 3. Judet R, Judet J 1949, Essais de reconstruction prothetique de la hanche apr6s resection de la tete femorale. Journal de Chirurgi 65:17 4. Gibson A 1950, Posterior exposure of the hip joint. Journal of Bone and Joint Surgery 32B: 183-186 5. McFarland B, Osborne G 1954, Approach to the hip: a suggested improvement on Kocher's method. Journal of Bone and Joint Surgery 36B: 364-367 6. Malkin S A 1936, Femoral osteotomy in treatment of osteoarthritis of the hip. British Medical Journal i: 304 7. McMurray T P 1939, Osteoarthritis of the hip joint. Journal of Bone and Joint Surgery 21:1-11 8. McFarland B 1957, 7e Congres International de Chirurgie Orthop6dique. Imprimerie des Sciences, Brussels, p 811 9. Pauwels F 1959, Directires nouvelles pour le traitement chirurgical de la coxarthrose. Revue de Chirurgie Orthop6dique 45:681 702 10. Nissen K I 1960, The arrest of early primary osteoarthritis of the hip. Journal of Bone and Joint Surgery 42B: 423-424 11. Wainwright D 1971, Intertrochanteric osteotomy--its place in the treatment of degenerative disorders of the hip. Journal of Bone and Joint Surgery 53B: 154-155
12. Muller M E 1973, Part I. Intertrochanteric osteotomy in the treatment of the arthritic hip joint. In Tronzo R G (ed) Surgery of the hip joint. Lea and Febiger, Philadelphia 13. Moore A T 1957, The self-locking metal hip prosthesis. Journal of Bone and Joint Surgery 39A: 811 827 14. Osborne R P 1931, The approach to the hip joint: a critical review and a suggested new route. British Journal of Surgery 18:49 15. Ring P A 1974, Total replacement of the hip joint. Journal of Bone and Joint Surgery 56B: 44-58 16. Ling R 1983, Complications of total hip replacement. Churchill Livingstone, Edinburgh 17. McKee G K, Watson-Farrar J 1966, Replacement of arthritic hips by McKee-Farrar prosthesis. Journal of Bone and Joint Surgery 48B: 245-259 18. Watson-Jones R 1935-6, Fractures of the neck of the femur. British Journal of Surgery 23:787 19. Charnley J 1955, Stabilisation of the hip by central dislocation. Journal of Bone and Joint Surgery 37B: 514515 20. Brackett E G 1912, A study of the different approaches to the hip joint with special reference to the operations for curved trochanteric osteotomy and for arthrodesis. Boston Medical and Surgical Journal 166:235-242 21. Charnley J 1979, Low friction arthroplasty. Springer Verlag, Berlin 22. Hardinge K 1982, The direct lateral approach to the hip. Journal of Bone and Joint Surgery 64B" 17-19
G. O s b o r n e The quest for successful surgical construction of a mobile hip joint, subjected to the vagaries of technical fortune in the last 50 years, bears comparison with a Tolkien adventure story. Now, however, it might be said that the journey is ended and the problems of hip replacement are largely conquered. In the past the milestones of success were not always identified or set evenly and the stages of development were not brightly signalled. The technique of surgical access must always be the servant of the particular prosthetic design and its insertion system. However, whereas the design of the present low friction acetabular sockets and femoral stemmed components has narrowed towards a basically similar standard pattern, the anatomical approaches, through which surgeons insert these comparable items, could not vary more widely with no generally held consensus view. Is this position due to the particular and peculiar anatomy of the hip joint or is it a reflection of the historical development of the surgical approaches? Is it due to strongly held views which are reconcilable and should there be a common surgical approach as there has become a similar design of prosthesis and should this 'best' approach be taught in training? Consideration of the development of surgical access to the hip joint for replacement surgery might outline the problem and help to answer these questions.
arthroplasty was introduced with the promise that new articular cartilage to cover the femoral head would develop if the operation was performed technically successfully. 1 The procedure was widely adopted as the standard treatment for arthrosis of the hip joint but after some years, it had to be accepted that the method was a major surgical failure and the reasons became apparent. 1) The surgery of access was diffficult--using only the vertical limb of the incision which Smith Petersen devised in 1917 (while still a student). 2 This approach went down into the front of the acetabulum, between sartorius and tensor fascia femoris and then between psoas and the rectus muscle. Access and vision were poor and reaming was difficult. The technique was well described by Law and when correctly done, was an artistic exercise; however the average surgeon tended to gain more access by adding some of the more proximal part of the Smith Petersen incision, in which the origins of the gluteus medius and tensor fascia femoris muscles were stripped off the outer blade of the ilium. Much bleeding occurred and a limp developed if the origins of the gluteal muscles failed to heal adequately. 2) The loose cup was a high friction joint and was abandoned because it gave unreliable results even when well performed. However in the 1940s it familiarised surgeons with the Smith Petersen incision and for the first time with routine open hip surgery.
The Smith Petersen Approachh1946 Brought to a war weary British orthopaedic profession by Smith Petersen, in 1946, the operation of cup
The Judet Operation--1949 This method was readily accepted by an orthopaedic profession demoralised by the Smith Petersen failure and was taken up with enthusiasm) The early results
Geoffrey Osborne, M Ch Orth, FRCS, FRCSE, 26 Waterloo Road, Southport, Merseyside PR8 2NF.
Current Orthopaedics(1986) 1, 61-66 © LongmanGroup UK Ltd.
61
62
THE HISTORY O F S U R G I C A L ACCESS F O R H I P R E P L A C E M E N T
of this acrylic hemi-arthroplasty were spectacular and confirmed the merit of replacement of the femoral head as an essential step in hip arthroplasty. Unfortunately the prosthesis was a physical and material design failure and fracture, wear, and reaction to particulate acrylic required removal often within one year of insertion. Judet used a Heuter incision which was similar to a restricted vertical limb of the Smith Petersen incision and needed the assistance of a male orderly concealed under the operating table who manipulated the leg according to instructions!
The Gibson Approach--1950 The Judet prosthesis was an important milestone in the development of arthroplasty and gave consistently early good results until mechanical failure ensued. It became more popular when Gibson of Winnipeg in 1950 described his version of the Kocher approach. 4 Through a posteriorly angled skin incision the fascia lata was divided in front of the gluteus maximus and access to the capsule of the hip was achieved by dividing the attachment of gluteus medius and minimus to the great trochanter. This was essentially an anterior exercise because of the position of the muscles at that level. The capsule was opened anterolaterally and the hip was dislocated forwards. It gave a generally good comparatively blood-less view and easy access for prosthetic insertion.
The McFarland/Osborne Approach--1952 This technique modified the Gibson or Kocher incision when it became obvious that permanent gluteal weakness followed incomplete repair of the divided gluteal trochanteric insertion, s The basic principle of 'gluteal displacement', transferring forward the combined gluteal and vastus lateralis muscles in one sheet offered a wide exposure, good vision and more reliable and secure operative repair than the Gibson. It was not published before 1954 at the end of the discredited Judet prosthetic era and at that time remained an interesting surgical concept shelved for lack of a mechanically adequate prosthetic system.
The Osteotomy Operation It was in the 1950s that siren voices turned scientific thought in the United Kingdom away from the progressive logical development of arthroplasty surgery by a further wave of attention to the simplicity and relative reliability of the osteotomy operation for arthrosis of the hip joint. Developed by Lorenz and powerfully advocated pre-war by Malkin and McMurray,6'7 it usually gave pain relief but with often unpleasant knee and hip stiffness and an ungainly limp. Osteotomy was better than conservative treatment but was discarded each time a potentially more advantageous method emerged such as the cup arthroplasty and the Judet operation.
Under the influence of McFarland, Pauwels and Nissen, S lo osteotomy appeared to come into its own, particularly after fixation devices were developed which allowed external fixation in a plaster spica to be discarded and early mobilisation achieved. Osteotomy dominated the European hip surgery scene for 15 years led by Wainwright, 1~ Muller, 12 the author, and others until the successful results of refinement of early total hip replacement systems could no longer be ignored and the instrumentation became generally available. During this osteotomy era, no open hip surgery was generally done except to femoral neck fractures for which the Austin Moore operation, through the posterior approach, slowly gained acceptance as a necessary alternative to neck fixation.
The Posterior Approach of Austin Moore--1957 By the time total hip replacement became available, this posterior approach was the only one familiar to many orthopaedic surgeons. Lasting credit is owed to Austin Moore for the development in the early 1950s of a femoral prosthetic design and a usually effective shaft fixation system, which is still in u s e . 13 Further credit is owed for the development of the true posterior approach essentially as practised today. Although originally described by Osborne (1931) from an anatomical dissection, 14 and with some similarity to the Kocher approach, Moore gave it the name of the 'southern' approach partly because he moved the skin and maximus incisions more posteriorly and inferiorly and also because he practised in one of the southern states of America. The posterior approach totally preserves gluteus medius and minimus and does not risk impairment of their antigravity power after operation. Access to the posterior capsule was achieved by division of the short rotators and often pyriformis and the quadratus femoris in one sheet turned back over the sciatic nerve, preserved medially. Bleeding from the medial femoral circumflex artery required attention but otherwise the approach was relatively bloodless. The hip was dislocated backwards and an adequate view of the acetabulum was obtained. For the hemiarthroplasty replacement prosthesis of Austin Moore the technique proved ideal and rightly achieved considerable support in the USA and in Britain for subcapital fractures. The posterior approach however remains particularly critical to errors of position of the prosthetic components. Some opinion believes if the short rotator tendons are extensively divided, they never heal adequately and that the strong musculo-tendinous posterior wall which they provide at the back of the hip joint in other exposures such as the anterior, is lost. It is uncompromisingly necessary in the posterior approach to restore the normal femoral neck length and neck shaft angle and essential to restore normal anteversion and avoid pointing the prosthetic head backwards into retroversion. This critical protection
CURRENT ORTHOPAEDICS
against dislocation may be secured more easily by a cemented stem such as the Thompson design, the Moore self locking principle being unreliable in an osteoporotic femoral shaft. The posterior approach however gave the highest incidence of post-operative dislocation when compared with the anterior and lateral approaches. Peter Ring 15 and also Robin Ling 16 have used the posterior approach, successfully for specialised work on the design of prosthetic hip components which reduces the danger of instability and for details of these interesting developments, their writings should be consulted.
The Anterior or Antero-Lateral Approach McKee and Watson Farrar pioneered a design of total hip replacement in 196617 and used the anterior approach previously described by Watson Jones. 18 The approach splits the interval between the tensor fascia lata and gluteus medius through an oblique anterior incision along the femoral neck and down the femoral shaft. Sharp dissection to separate the two muscles is necessary at the iliac attachment. At the trochanter, gluteus medius and minimus require division to open the exposure adequately and to prevent the friable fibres of gluteus medius from damage by retraction. After opening the capsule, care is needed in this approach to avoid femoral shaft fracture when the hip is dislocated anteriorly. Special instruments are necessary to display the acetabulum for reaming and insertion of the cup. Adequate treatment of the femoral shaft needs offset reamers and levers to give sufficient access in difficult cases. The tendency to break false passages into the femoral shaft is greatest in this approach. However, accurate alignment of the cup and femoral prosthesis is more easily obtained and the anterior approach has the lowest incidence of post-operative dislocation. Good access to the acetabulum and femoral shaft require a greater degree of skill and training than the posterior approach but in experienced hands the anterior approach gives useful routine service for hip replacement surgery.
The Charnley Approach Sir John Charnley, the major pioneer of hip replacement surgery, was never a participant in the osteotomy fashion. Following his successful development of compression arthrodesis of the knee, he devoted considerable effort to applying the compression principle to surgical fusion of the hip joint but with limited success. He then developed a form of painless partial fibrous fusion of the hip--'the central dislocation operation'-19 which gave no better results than from the average osteotomy operation. He used for these fusion operations a massive oblique T shaped approach derived from the Brackett incision, z° (Fig. 1). The cross of the T ran from the antero-superior spine towards the ischial tuberosity along Nelaton's line, deeply dividing the tensor fascia lata muscle, the fascia horizontally
Brackett
/
63
Posterolateral
Antero-%% 1 lateral lique
Vertical Mid-lateral
teroerior
Fig. 1 Approaches to the hip joint.
and posteriorly he split the fibres of maximus. The vertical limb of the T shaped incision ran for 6in down the mid lateral line from the tip of the greater trochanter to create two large musculo-fascial flaps. The gluteus medius and minimus insertions were divided from the great trochanter and the whole of the front and lateral side of the hip joint was widely displayed. Finally with stiff hips the upper shaft of the femur was partly avulsed from the side of the pelvis by division of all tight obstructing tissues. The patient's foot could then be put over the opposite shoulder and the axis of the femoral neck pointed directly lateral. This extreme exposure was used to bore out the whole floor of the acetabulum for the central dislocation fusion operation. After Charnley developed the earlier designs of his artificial hip joint he continued to use this same approach which had been developed for the fusion procedures. His concept of surgical access at that time included the following points: 1) An extensive approach dividing all tight structures after dislocation allowed access for unrestricted reaming of the acetabulum and full restoration of femoral length. 2) This major access required the total detachment of the gluteal muscles, division of which was soon replaced by detachment of the trochanter--a method suggested by Harry Platt (after Brackett). Charnley,
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T H E H I S T O R Y O F S U R G I C A L ACCESS F O R H I P R E P L A C E M E N T
following his success with compression arthrodesis of the knee, applied himself with vigour to studying the problems of trochanteric fixation and union, which closure of his extreme exposure demanded. 3) Repair created a massive amount of capsular and intermuscular scar tissue which must have contributed considerably to post-operative stability. 4) As compared with other hip approaches, it was an immense surgical procedure. Many surgeons, while respecting his work on the development of the artificial joint, found the approach a 'tour de force' and unattractive. With development of the use of cement, the concept of the low friction joint and adoption of the small femoral head, the Charnley approach procedure was gradually changed from the early 1960s. He first gave up the posterior limb of the T shaped incision and subsequently used an oblique incision from front to back. Later he changed this to a long straight vertical incision but more recently he adopted and described in his book 'Low Friction Arthroplasty',21 an angled postero-lateral incision which ressembled closely the classical postero-lateral skin incision of Gibson and others, I argued with him many years ago that the ideal hip incision ran posteriorly in the skin and fascia of the buttock, laterally through the glutei and anteriorly into the capsule with the hip dislocating forwards. This apparent paradox takes account of the effect of hip flexion on the tight drum-like gluteal fascia and fascia lata. Straight lateral incisions dividing the gluteal fascia in the mid lateral line provide good deep access when the hip is in extension but as the joint is flexed, a tight wall of posterior fascia and gluteus maximus is drawn across the lower half of the approach and hinders access to the trochanter. Charnley had observed this tightness of gluteus maximus in his description of the central dislocation operation in 1955 but only later appreciated its importance in the approach for hip replacement, allowing a shorter skin incision. The standard Charnley approach, now modified to a straight postero-anterior oblique incision, as practised at Wrightington, is a much reduced and refined exercise as compared with the extensive exposures of the early years. Nevertheless it is the only approach that totally detaches the gluteal muscles from the femur and therefore liberates the femur from these muscles if they become shortened and contracted by longstanding hip disease, deformity and previous surgery. Wide distraction allows revision procedures and accurate restoration of the normal joint geometry with insertion of the prosthetic joint into an ideal position. Long term results appear to reflect rigorous adherence to insertion standards. The penalty for this mechanical precision of the Charnley approach is the problem of trochanteric reattachment. With special training this stage in the closure procedure is usually technically satisfactory but without adequate knowledge of the re-attachment technique, wire breakage, failure of union and post
operative dislocation may occur. Many surgeons however use the Charnley prosthetic hip system and instrumentation but without the Charnley surgical approach and are prepared to accept some instrumental difficultyin order to avoid time consuming trochanteric re-attachment.
The Liverpool Approach The McFarland-Osborne method of'gluteal displacement' in continuity published in 19545 was gradually modified and applied to the operation of hip replacement during the last 10 years by Osborne and Owen in Liverpool on the suggestion of Merryweather and by Hardinge in Wrightington.zz When first practised, the approach swung forward from the back of the trochanter the whole of the gluteus medius and vastus lateralis, along with the confluent sheet of gluteal aponeurosis and trochanteric periosteum and a distinct fragment of bone. In closure the major point of attachment was the tendon of gluteus maximus at the back of the upper femur. The aim of the manoeuvre however was to secure closure by firm suturing, and by the time of publication in 1954 muscle splitting of half of vastus lateralis was practised followed later by splitting of gluteus medius to leave enough attached fibres posteriorly for a firm direct closure. Later, at the time of resuscitation of this approach on the suggestion of Merryweather in 1975, splitting of the gluteal muscles up to the superior gluteal nerve supply was established as safe and allowed secure repair. The present Liverpool technique has the following steps (Fig. 2): 1) Lateral position on the table. With the hip and leg flexed forward and the buttock falling backwards, in this attitude, the acetabulum is nearer the skin surface than in any other position and unobstructed illumination is easily achieved. 2) A postero-lateral angled skin incision is made dividing the fascia lata vertically behind the tensor and is then carried into the upper fibres of gluteus maximus. 3) The gluteus medius muscle is split rather more than one inch from its posterior margin which can be identified with a finger behind the prominent edge of the tip of the trochanter. This portion of gluteus medius contains tendinous tissue which is attached to the trochanter and should be preserved in continuity. The split in the medius muscle is continued with diathermy through the trochanteric fascia over the face of the greater trochanter passing just behind and below its greatest prominence to curve into the vastus lateralis muscle below, leaving about a third of the muscle posteriorly. Spicules of bone or a small single fragment are detached with an osteotome to create a powerful fibro-muscular osseous sheet, which later can be drawn back into its original position at closure. 4) This gluteal 'bucket handle' flap is dissected forwards with diathermy dividing the remaining attachments of the gluteus medius, the insertion of gluteus
CURRENT ORTHOPAEDICS
65
\ olr / Fig. 2 The Liverpool approach to the hip joint.
minimus and the ligaments and capsule of the hip joint, all in one sheet. It opens a wide window into the front of the hip joint, the flexed position of which allows the muscles to become increasingly slackened as the gluteal flap is detached and facilitates forward retraction. 5) Closure requires a 1 mm braided polyester suture passed through two transverse drill holes in the body of the trochanter. Although gluteus minimus is partly adherent to medius, it is important that at least one suture is passed through the tendon of minimus to secure it firmly to the front of the trochanter. The split in vastus lateralis is closed by inversion and oversewing and the posterior tendon of medius is sutured to the gluteal flap now restored into normal position. No closure of the split in the gluteal muscle fibres is necessary. Any bone fragments are locked back in their original position if possible and if some lengthening of the neck of the femur has taken place then closure needs to be carried out with the leg held in abduction and extension. 6) The fan-shaped gluteus medius has horizontal fibres anteriorly but radiating fibres vertically above and behind the hip joint. In the anterior approaches, it is the front half of the intact medius which hampers deep exposure and obstructs reaming of the femoral shaft. Division through the tendinous insertion and resuture of this front part of gluteus medius, up to the vertical fibres helps to overcome this difficulty. Hardinge, 1982, elegantly describes an approach similar to the Liverpool approach but makes a rather more anterior division of medius and divides the gluteal tendon downwards into vastus lateralis in front of the bony lateral peak of the trochanter in a line not too different from the extended anterior approach. 22 There may be little preference between the Hardinge and the Liverpool approach provided sufficient of the gluteus medius and minimus muscle is moved forward to facilitate joint exposure and the musculo-tendinous flaps leave adequate tissue for repair and closure. Most replacement surgery can be carried out
through the Liverpool approach including some revision surgery. Where severe neck shortening is present restoration of the normal gluteal attachment may be impossible and imperfect repair risks permanent gluteal weakness. For such difficult cases the Charnley operation is advisable. 21
Summary Three approaches, as currently practised, have emerged from the historical development of hip , replacement. The posterior approach is the simplest technique to learn, but precision and experience is needed to avoid post-operative dislocation. The anterior (antero-lateral) approach gives a more limited exposure and needs training to avoid certain operative difficulties. The lateral approach-i The Liverpool lateral approach is easy to perform, gives an excellent exposure but is more extensive than the anterior or posterior methods and closure is more time consuming. ii The Charnley lateral approach is the most extensive, gives the widest exposure but needs more time for trochanterie repair. Exceptionally difficult cases are probably better done by the Charnley approach in skilled hands. For primary hip replacement by trained surgeons, all approaches give satisfactory results. Adequate exposure to avoid common technical problems requires study of the details of each approach to allow correct positioning of the joint components, the proper retensioning of the pelvi-femoral fascial structures and the management of mechanical difficulties of reduction. Similarity between the superficial layers of the lateral and posterior approaches suggests that a trend towards uniformity may develop.
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THE HISTORY OF SURGICAL ACCESS FOR HIP REPLACEMENT
References 1. Smith-Petersen M N 1948, Evolution of mould arthroplasty of the hip joint. Journal of Bone and Joint Surgery 30B: 59-75 2. Smith Petersen M N 1949, Approach to and exposure of the hip joint for mold arthroplasty. Journal of Bone and Joint Surgery 31A: 40-46 3. Judet R, Judet J 1949, Essais de reconstruction prothetique de la hanche apr6s resection de la tete femorale. Journal de Chirurgi 65:17 4. Gibson A 1950, Posterior exposure of the hip joint. Journal of Bone and Joint Surgery 32B: 183-186 5. McFarland B, Osborne G 1954, Approach to the hip: a suggested improvement on Kocher's method. Journal of Bone and Joint Surgery 36B: 364-367 6. Malkin S A 1936, Femoral osteotomy in treatment of osteoarthritis of the hip. British Medical Journal i: 304 7. McMurray T P 1939, Osteoarthritis of the hip joint. Journal of Bone and Joint Surgery 21:1-11 8. McFarland B 1957, 7e Congres International de Chirurgie Orthop6dique. Imprimerie des Sciences, Brussels, p 811 9. Pauwels F 1959, Directires nouvelles pour le traitement chirurgical de la coxarthrose. Revue de Chirurgie Orthop6dique 45:681 702 10. Nissen K I 1960, The arrest of early primary osteoarthritis of the hip. Journal of Bone and Joint Surgery 42B: 423-424 11. Wainwright D 1971, Intertrochanteric osteotomy--its place in the treatment of degenerative disorders of the hip. Journal of Bone and Joint Surgery 53B: 154-155
12. Muller M E 1973, Part I. Intertrochanteric osteotomy in the treatment of the arthritic hip joint. In Tronzo R G (ed) Surgery of the hip joint. Lea and Febiger, Philadelphia 13. Moore A T 1957, The self-locking metal hip prosthesis. Journal of Bone and Joint Surgery 39A: 811 827 14. Osborne R P 1931, The approach to the hip joint: a critical review and a suggested new route. British Journal of Surgery 18:49 15. Ring P A 1974, Total replacement of the hip joint. Journal of Bone and Joint Surgery 56B: 44-58 16. Ling R 1983, Complications of total hip replacement. Churchill Livingstone, Edinburgh 17. McKee G K, Watson-Farrar J 1966, Replacement of arthritic hips by McKee-Farrar prosthesis. Journal of Bone and Joint Surgery 48B: 245-259 18. Watson-Jones R 1935-6, Fractures of the neck of the femur. British Journal of Surgery 23:787 19. Charnley J 1955, Stabilisation of the hip by central dislocation. Journal of Bone and Joint Surgery 37B: 514515 20. Brackett E G 1912, A study of the different approaches to the hip joint with special reference to the operations for curved trochanteric osteotomy and for arthrodesis. Boston Medical and Surgical Journal 166:235-242 21. Charnley J 1979, Low friction arthroplasty. Springer Verlag, Berlin 22. Hardinge K 1982, The direct lateral approach to the hip. Journal of Bone and Joint Surgery 64B" 17-19