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The Outcomes of Small-Incision Total Hip Arthroplasty Using Modifications of Existing Surgical Approaches
The Outcomes of Small-Incision Total Hip Arthroplasty Using Modifications of Existing Surgical Approaches Aidin Eslam Pour, MD, Javad Parvizi, MD, FRCS, and Richard H. Rothman, MD, PhD Total hip arthroplasty has evolved over the past few decades. Minimally invasive hip arthroplasty has been introduced to the orthopedic community, and it has stirred controversy with respect to the purported benefits over the conventional approaches. Studies done by the pioneers or by exprienced surgeons demonstrate that minimally invasive techniques can improve the immediate outcomes of total hip arthroplasty. Less blood loss, shorter hospitalization, and faster return to normal life are potential benefits of any minimally invasive surgery. However, the majority of those studies implement changes in the intraoperative and postoperative protcols that may independently affect the outcome of THA. The literature lacks proper prospective studies that compare conventional and minimally invasive total hip arthroplasty and the effect of different rehabilitation protocols on the outcome. Also, the results of different approaches for minimally invasive hip arthroplasty remain to be studied. The purpose of this report is to review the results of reported short-term outcomes and complications of small-incision total hip replacements performed with several modifications of existing surgical approaches. Semin Arthro 16:194-197 © 2005 Elsevier Inc. All rights reserved. KEYWORDS minimally invasive total hip arthroplasty, outcome, conventional hip arthroplasty
A
fter being introduced by Sir John Charnley in 1961, thousands of total hip arthroplasties (THA) have been done successfully all over the world.1 It has improved the quality of life and relieved the pain of patients who have been diagnosed with debilitating hip disorders. Orthopedic surgeons and implant manufacturers have strived to improve the quality, outcome, and durability of THA and minimize complications of this otherwise successful procedure. Introduction of modern prostheses, newer techniques, and better postoperative rehabilitation programs are the result of these efforts. Over the past decade, less invasive procedures based on laparoscopic and arthroscopic principles have been developed, which have inspired orthopedic surgeons to perform THA through smaller incisions. Very generally, minimally invasive total hip arthroplasty can be described as a procedure that has less impact on a patient’s life. Blood loss, trans-
Rothman Institute of Orthopedics at Thomas Jefferson University, Philadelphia, PA. Address reprint requests to Richard H Rothman, MD, PhD, Rothman Institute, 925 Chestnut Street, Philadelphia, PA 19107. E-mail: [email protected]
194
1045-4527/05/$-see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.sart.2005.10.006
fusion needs, and rehabilitation time are minimized in an ideal minimally invasive surgery. To achieve this goal, the disruption of muscles and periarticular soft tissue is minimized to the extent practically possible. At the very least, a smaller incision with a cosmetically better postsurgical scar is expected.
Surgical Techniques There are several different approaches for doing the minimally invasive total hip arthroplasty. Each is a modification of a previously used, standard surgical approach. The anterolateral and posterolateral approaches are the two most common approaches for standard total hip replacement. The anterolateral (Hardinge) approach was first introduced in 1982.2 The advantages of this approach are reduced risks of leg length discrepancy, sciatic nerve damage, and dislocation because of the preservation of restraining posterior hip tissues. The anterolateral approach provides an excellent acetabular and femoral exposure and a good surgical visualization. To perform a minimally invasive total hip using the above approach, the patients are placed in the supine position,
Modifications of existing surgical approaches for small-incision total hip arthroplasty which makes possible an easy and accurate leg length check after component positioning. An incision ranging from 6 to 10 cm based on patients body mass index, local muscle and fat tissue mass, and anatomy is made to expose the hip joint. The incision can be extended at either end if needed to improve acetabular and femoral exposure. Modified retractors and impactors are designed to provide excellent surgical visualization and component positioning through the limited incision.
Patient Selection Many orthopedic surgeons believe that the patient selection is very important to achieve satisfactory results in minimally invasive total hip arthroplasty. Generally, the limited incision length is not considered ideal for patients who need a complex operation. Patients whose body mass index is more than 30 kg/m2 and those who have more muscular or fat tissue around the hip joint are not the ideal candidates for this operation.
Results of Studies Chimento and coworkers3 studied minimally invasive total hip arthroplasty through the anterolateral approach. They randomized patients into conventional (32 patients) and mini-incision (28 patients) groups. They reported a significant decrease in intraoperative (P ⫽ 0.003) and total blood loss (P ⫽ 0.009). The authors reported no difference in radiographic analysis of the outcome of the operations concerning component positioning and cement grading. Complication rates in cohorts were the same. With respect to rehabilitation, there was no significant difference in cane usage in the follow up, but they reported less limping in the mini-incision group (P ⫽ 0.04). They found no significant difference between two cohorts regarding other potential benefits of minimally invasive hip replacement, including less blood transfusion, shorter hospitalization, and less narcotic need for postoperative pain management. Howell and coworkers,4 in a prospective study published in 2004, reported a significant reduction in perioperative blood loss in the minimally invasive anterolateral approach for THA but no difference in the postoperative hemoglobin drop. The hospital length of stay was significantly less with the minimally invasive THA group, even correcting for patient comorbidities. The authors also reported an increase in the operative time for minimally invasive hip replacement. They believed that the operative time would decrease with further experience. Berger5 reported less intraoperative blood loss and a shorter hospitalization period with minimally invasive THA using a lateral approach. The author reported no significant difference with respect to operative time between the two approaches. In that prospective study, fewer patients from the minimally invasive THA group were discharged to rehabilitation centers after surgery.
195
Other Approaches Posterior Approach Some studies reported significant differences between conventional and minimally invasive THA done through the posterior approach in terms of blood loss,6,7 operative time,8 shorter hospitalization,6 and functional scores.8,9 On the other hand, some studies comparing conventional and miniincision total hip arthroplasty have shown no major differences in the conventional and small-incision approaches with respect to blood loss,8-10 length of operation,7,10 blood transfusion needs,7,9,10 postoperative pain,9 hospitalization period,8-10 and functional scores.7
Direct Lateral Approach De Beer and coworkers10 studied minimally invasive hip arthroplasty through a direct lateral approach in a prospective matched study. They found less surgical blood loss (P ⫽ 0.004) in the mini-incision group but reported no significant difference between the two cohorts concerning other potential benefits of minimally invasive hip replacement.
Modified Anterior Approach Kennon and coworkers11 reported less soft tissue disruption and reduced operative time and blood loss in their retrospective review of patients who underwent a modified anterior approach minimally invasive hip arthroplasty. They believed this approach to have fewer complications intra- and postoperatively.
Hospital Cost Bertin,12 in a pilot study of 20 patients, compared conventional and abridged outpatient incision total hip arthroplasty in a matched group of patients. All patients were operated through a posterolateral approach. They reported a decrease in hospital costs averaging $4000 and total average reimbursement of $1155. They concluded that performing an outpatient minimally invasive total hip arthroplasty would be financially beneficial.
Rehabilitation Role A faster rehabilitation protocol can possibly affect the results of total hip arthroplasty through either a standard or a small incision approach. With a rapid protocol, patients can begin the postoperative physical therapy in a few hours after the surgery, which should expedite discharge from the hospital. Patients may need special medications to prevent nausea and dizziness after the operation to be able to begin ambulation. Progression from walker to cane may be achieved within a few days after total hip arthroplasty. Berger and coworkers13 studied the role of an accelerated rehabilitation protocol after minimally invasive total hip replacement in a prospective study. All patients were operated through a two-incision approach, and 97% of them were discharged to home the same day. They reported
A. Eslam Pour, J. Parvizi, and R.H. Rothman
196 the rapid rehabilitation protocol to be safe and effective in terms of quicker functionality and return to work using their methods.
Component Positioning Optimal component positioning has been an important concern in performing minimally invasive total hip arthroplasty. A smaller incision may possibly affect the optimal component position, thereby contributing to complications such as leg length discrepancy, dislocation, and periprosthetic fracture. Woolson and coworkers14 reported a higher incidence of component malposition in a radiographic review of components after minimally invasive total hip arthroplasty. They found more acetabular outliers (the goal range was 30 to 50°) in the minimally invasive THA group (P ⫽ 0.04). The prevalence of femoral component varus positioning or poor fit and fill in this group of patients was higher (P ⫽ 0.02). Dorr15 reviewed the outcome of minimally invasive total hip arthroplasty through a posterior approach. In 11% of the patients, the socket inclination was considered an outlier, outside the ideal inclination angle of 25 to 45°, and 8% of the sockets were out of the desired anteversion range of 15 to 30°. With respect to femoral component positioning, 90% of the femoral stems were within 3° of neutral position, and 8% of the stems were in 4 to 5° of varus positioning. One femoral implant was in 6° of varus relative to the femur, and this hip was associated with a lateral femur fracture. Hartzband6 suggested that the risk of vertical cup placement in small-incision hip replacement may be greater in the early phases of a surgeon’s learning curve with minimally invasive surgery. Accordingly, he recommended using a customized, dog-legged acetabular inserter to avoid component malposition. The author also suggested a posterior starting position to ream the femoral canal and cautioned against levering of the acetabular reamer on the posterior aspect of the acetabulum to avoid component malpositioning. Some studies have not reported any significant difference between the conventional and mini-incision approaches in the postoperative radiographic evaluation of the components.8-10,16-18 These studies have shown that minimally invasive total hip arthroplasty does not necessarily jeopardize the component positioning.
Complications of Minimally Invasive Hip Arthroplasty Woolson and coworkers14 showed more wound complications in patients who went through a minimally invasive total hip arthroplasty. They found no significant difference between conventional and mini-incision hip replacement concerning other complications. Fehring and Mason19 reported disastrous complications after minimally invasive total hip replacement in three patients. In one case, a segmental defect in the dome of the acetabulum was created during minimally invasive surgery done through a 9-cm incision. In another case, multiple dis-
locations occurred soon after a minimally invasive hip arthroplasty done through the anterolateral approach (length of incision, 8 cm). The cup was positioned vertically, and multiple revision procedures were necessary. In the third case, nonunion and comminution of an inadvertent greater trochanteric fracture following a two-incision minimally invasive hip replacement led to a severe Trendelenburg lurch. Contrasting data in several other studies3,4,9,18 have demonstrated no statistically significant difference in complication rates comparing the standard and small incision total hip arthroplasties.
Conclusion The minimally invasive total hip arthroplasty has emerged in an effort to shorten the hospital length of stay and to speed recovery and return to daily activities. Cosmetic results, although important, should not be considered the primary goal of the minimally invasive total hip arthroplasty procedures. The literature is lacking sufficient prospective studies to compare mini-incision versus conventional total hip replacements through the various surgical approaches and to assess the independent effects of modified rehabilitation protocols on the outcomes. Most of the studies cited in this report were done by experienced, high-volume orthopedic surgeons. Many of these present retrospectively collected data or report on a single cohort of patients. Finally, although the early results of minimally invasive total hip arthroplasty have been reported, the long-term outcomes remain to be critically evaluated.
References 1. Charnley J: Arthroplasty of the hip. A new operation. Lancet 1(7187): 1129-1132, 1961 2. Hardinge K: The direct lateral approach to the hip. J Bone Joint Surg Br 641:17-19, 1982 3. Chimento GF, Pavone V, Sharrock N, et al: Minimally invasive total hip arthroplasty: a prospective randomized study. J Arthroplasty 202:139144, 2005 4. Howell JR, Masri BA, Duncan CP: Minimally invasive versus standard incision anterolateral hip replacement: a comparative study. Orthop Clin North Am 352:153-162, 2004 5. Berger RA: Mini-incision total hip replacement using an anterolateral approach: technique and results. Orthop Clin North Am 352:143-151, 2004 6. Hartzband MA: Posterolateral minimal incision for total hip replacement: technique and early results. Orthop Clin North Am 352:119-129, 2004 7. Goldstein WM, Branson JJ, Berland KA, et al: Minimal-incision total hip arthroplasty. J Bone Joint Surg Am 85A(Suppl 4):33-38, 2003 8. Wright JM, Crockett HC, Delgado S, et al: Mini-incision for total hip arthroplasty: a prospective, controlled investigation with 5-year follow-up evaluation. J Arthroplasty 195:538-545, 2004 9. Ogonda L, Wilson R, Archbold P, et al: A minimal-incision technique in total hip arthroplasty does not improve early postoperative outcomes: a prospective, randomized, controlled trial. J Bone Joint Surg Am 874: 701-710, 2005 10. de Beer J, Petruccelli D, Zalzal P, et al: Single-incision, minimally invasive total hip arthroplasty: length doesn’t matter. J Arthroplasty 198: 945-950, 2004 11. Kennon RE, Keggi JM, Wetmore RS, et al: Total hip arthroplasty through a minimally invasive anterior surgical approach. J Bone Joint Surg Am 85A(Suppl 4):39-48, 2003 12. Bertin KC: Minimally invasive outpatient total hip arthroplasty: a financial analysis. Clin Orthop Relat Res 435:154-163, 2005
Modifications of existing surgical approaches for small-incision total hip arthroplasty 13. Berger RA, Jacobs JJ, Meneghini RM, et al: Rapid rehabilitation and recovery with minimally invasive total hip arthroplasty. Clin Orthop Relat Res 429:239-247, 2004 14. Woolson ST, Mow CS, Syquia JF, et al: Comparison of primary total hip replacements performed with a standard incision or a mini-incision. J Bone Joint Surg Am 86A:1353-1358, 2004 15. Berry DJ, Berger RA, Callaghan JJ, et al: Minimally invasive total hip arthroplasty: development, early results, and a critical analysis. Presented at the Annual Meeting of the American Orthopaedic Association, Charleston, South Carolina, USA, June 14, 2003. J Bone Joint Surg Am 85A:2235-2246, 2003
197
16. Hart R, Stipcak V, Janecek M, et al: Component position following total hip arthroplasty through a miniinvasive posterolateral approach. Acta Orthop Belg 711:60-64, 2005 17. Sculco TP: Minimally invasive total hip arthroplasty: in the affirmative. J Arthroplasty 194(Suppl 1):78-80, 2004 18. Sculco TP, Jordan LC, Walter WL: Minimally invasive total hip arthroplasty: the Hospital for Special Surgery experience. Orthop Clin North Am 352:137-142, 2004 19. Fehring TK, Mason JB: Catastrophic complications of minimally invasive hip surgery: a series of three cases. J Bone Joint Surg Am 87A:711-714, 2005
A
fter being introduced by Sir John Charnley in 1961, thousands of total hip arthroplasties (THA) have been done successfully all over the world.1 It has improved the quality of life and relieved the pain of patients who have been diagnosed with debilitating hip disorders. Orthopedic surgeons and implant manufacturers have strived to improve the quality, outcome, and durability of THA and minimize complications of this otherwise successful procedure. Introduction of modern prostheses, newer techniques, and better postoperative rehabilitation programs are the result of these efforts. Over the past decade, less invasive procedures based on laparoscopic and arthroscopic principles have been developed, which have inspired orthopedic surgeons to perform THA through smaller incisions. Very generally, minimally invasive total hip arthroplasty can be described as a procedure that has less impact on a patient’s life. Blood loss, trans-
Rothman Institute of Orthopedics at Thomas Jefferson University, Philadelphia, PA. Address reprint requests to Richard H Rothman, MD, PhD, Rothman Institute, 925 Chestnut Street, Philadelphia, PA 19107. E-mail: [email protected]
194
1045-4527/05/$-see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.sart.2005.10.006
fusion needs, and rehabilitation time are minimized in an ideal minimally invasive surgery. To achieve this goal, the disruption of muscles and periarticular soft tissue is minimized to the extent practically possible. At the very least, a smaller incision with a cosmetically better postsurgical scar is expected.
Surgical Techniques There are several different approaches for doing the minimally invasive total hip arthroplasty. Each is a modification of a previously used, standard surgical approach. The anterolateral and posterolateral approaches are the two most common approaches for standard total hip replacement. The anterolateral (Hardinge) approach was first introduced in 1982.2 The advantages of this approach are reduced risks of leg length discrepancy, sciatic nerve damage, and dislocation because of the preservation of restraining posterior hip tissues. The anterolateral approach provides an excellent acetabular and femoral exposure and a good surgical visualization. To perform a minimally invasive total hip using the above approach, the patients are placed in the supine position,
Modifications of existing surgical approaches for small-incision total hip arthroplasty which makes possible an easy and accurate leg length check after component positioning. An incision ranging from 6 to 10 cm based on patients body mass index, local muscle and fat tissue mass, and anatomy is made to expose the hip joint. The incision can be extended at either end if needed to improve acetabular and femoral exposure. Modified retractors and impactors are designed to provide excellent surgical visualization and component positioning through the limited incision.
Patient Selection Many orthopedic surgeons believe that the patient selection is very important to achieve satisfactory results in minimally invasive total hip arthroplasty. Generally, the limited incision length is not considered ideal for patients who need a complex operation. Patients whose body mass index is more than 30 kg/m2 and those who have more muscular or fat tissue around the hip joint are not the ideal candidates for this operation.
Results of Studies Chimento and coworkers3 studied minimally invasive total hip arthroplasty through the anterolateral approach. They randomized patients into conventional (32 patients) and mini-incision (28 patients) groups. They reported a significant decrease in intraoperative (P ⫽ 0.003) and total blood loss (P ⫽ 0.009). The authors reported no difference in radiographic analysis of the outcome of the operations concerning component positioning and cement grading. Complication rates in cohorts were the same. With respect to rehabilitation, there was no significant difference in cane usage in the follow up, but they reported less limping in the mini-incision group (P ⫽ 0.04). They found no significant difference between two cohorts regarding other potential benefits of minimally invasive hip replacement, including less blood transfusion, shorter hospitalization, and less narcotic need for postoperative pain management. Howell and coworkers,4 in a prospective study published in 2004, reported a significant reduction in perioperative blood loss in the minimally invasive anterolateral approach for THA but no difference in the postoperative hemoglobin drop. The hospital length of stay was significantly less with the minimally invasive THA group, even correcting for patient comorbidities. The authors also reported an increase in the operative time for minimally invasive hip replacement. They believed that the operative time would decrease with further experience. Berger5 reported less intraoperative blood loss and a shorter hospitalization period with minimally invasive THA using a lateral approach. The author reported no significant difference with respect to operative time between the two approaches. In that prospective study, fewer patients from the minimally invasive THA group were discharged to rehabilitation centers after surgery.
195
Other Approaches Posterior Approach Some studies reported significant differences between conventional and minimally invasive THA done through the posterior approach in terms of blood loss,6,7 operative time,8 shorter hospitalization,6 and functional scores.8,9 On the other hand, some studies comparing conventional and miniincision total hip arthroplasty have shown no major differences in the conventional and small-incision approaches with respect to blood loss,8-10 length of operation,7,10 blood transfusion needs,7,9,10 postoperative pain,9 hospitalization period,8-10 and functional scores.7
Direct Lateral Approach De Beer and coworkers10 studied minimally invasive hip arthroplasty through a direct lateral approach in a prospective matched study. They found less surgical blood loss (P ⫽ 0.004) in the mini-incision group but reported no significant difference between the two cohorts concerning other potential benefits of minimally invasive hip replacement.
Modified Anterior Approach Kennon and coworkers11 reported less soft tissue disruption and reduced operative time and blood loss in their retrospective review of patients who underwent a modified anterior approach minimally invasive hip arthroplasty. They believed this approach to have fewer complications intra- and postoperatively.
Hospital Cost Bertin,12 in a pilot study of 20 patients, compared conventional and abridged outpatient incision total hip arthroplasty in a matched group of patients. All patients were operated through a posterolateral approach. They reported a decrease in hospital costs averaging $4000 and total average reimbursement of $1155. They concluded that performing an outpatient minimally invasive total hip arthroplasty would be financially beneficial.
Rehabilitation Role A faster rehabilitation protocol can possibly affect the results of total hip arthroplasty through either a standard or a small incision approach. With a rapid protocol, patients can begin the postoperative physical therapy in a few hours after the surgery, which should expedite discharge from the hospital. Patients may need special medications to prevent nausea and dizziness after the operation to be able to begin ambulation. Progression from walker to cane may be achieved within a few days after total hip arthroplasty. Berger and coworkers13 studied the role of an accelerated rehabilitation protocol after minimally invasive total hip replacement in a prospective study. All patients were operated through a two-incision approach, and 97% of them were discharged to home the same day. They reported
A. Eslam Pour, J. Parvizi, and R.H. Rothman
196 the rapid rehabilitation protocol to be safe and effective in terms of quicker functionality and return to work using their methods.
Component Positioning Optimal component positioning has been an important concern in performing minimally invasive total hip arthroplasty. A smaller incision may possibly affect the optimal component position, thereby contributing to complications such as leg length discrepancy, dislocation, and periprosthetic fracture. Woolson and coworkers14 reported a higher incidence of component malposition in a radiographic review of components after minimally invasive total hip arthroplasty. They found more acetabular outliers (the goal range was 30 to 50°) in the minimally invasive THA group (P ⫽ 0.04). The prevalence of femoral component varus positioning or poor fit and fill in this group of patients was higher (P ⫽ 0.02). Dorr15 reviewed the outcome of minimally invasive total hip arthroplasty through a posterior approach. In 11% of the patients, the socket inclination was considered an outlier, outside the ideal inclination angle of 25 to 45°, and 8% of the sockets were out of the desired anteversion range of 15 to 30°. With respect to femoral component positioning, 90% of the femoral stems were within 3° of neutral position, and 8% of the stems were in 4 to 5° of varus positioning. One femoral implant was in 6° of varus relative to the femur, and this hip was associated with a lateral femur fracture. Hartzband6 suggested that the risk of vertical cup placement in small-incision hip replacement may be greater in the early phases of a surgeon’s learning curve with minimally invasive surgery. Accordingly, he recommended using a customized, dog-legged acetabular inserter to avoid component malposition. The author also suggested a posterior starting position to ream the femoral canal and cautioned against levering of the acetabular reamer on the posterior aspect of the acetabulum to avoid component malpositioning. Some studies have not reported any significant difference between the conventional and mini-incision approaches in the postoperative radiographic evaluation of the components.8-10,16-18 These studies have shown that minimally invasive total hip arthroplasty does not necessarily jeopardize the component positioning.
Complications of Minimally Invasive Hip Arthroplasty Woolson and coworkers14 showed more wound complications in patients who went through a minimally invasive total hip arthroplasty. They found no significant difference between conventional and mini-incision hip replacement concerning other complications. Fehring and Mason19 reported disastrous complications after minimally invasive total hip replacement in three patients. In one case, a segmental defect in the dome of the acetabulum was created during minimally invasive surgery done through a 9-cm incision. In another case, multiple dis-
locations occurred soon after a minimally invasive hip arthroplasty done through the anterolateral approach (length of incision, 8 cm). The cup was positioned vertically, and multiple revision procedures were necessary. In the third case, nonunion and comminution of an inadvertent greater trochanteric fracture following a two-incision minimally invasive hip replacement led to a severe Trendelenburg lurch. Contrasting data in several other studies3,4,9,18 have demonstrated no statistically significant difference in complication rates comparing the standard and small incision total hip arthroplasties.
Conclusion The minimally invasive total hip arthroplasty has emerged in an effort to shorten the hospital length of stay and to speed recovery and return to daily activities. Cosmetic results, although important, should not be considered the primary goal of the minimally invasive total hip arthroplasty procedures. The literature is lacking sufficient prospective studies to compare mini-incision versus conventional total hip replacements through the various surgical approaches and to assess the independent effects of modified rehabilitation protocols on the outcomes. Most of the studies cited in this report were done by experienced, high-volume orthopedic surgeons. Many of these present retrospectively collected data or report on a single cohort of patients. Finally, although the early results of minimally invasive total hip arthroplasty have been reported, the long-term outcomes remain to be critically evaluated.
References 1. Charnley J: Arthroplasty of the hip. A new operation. Lancet 1(7187): 1129-1132, 1961 2. Hardinge K: The direct lateral approach to the hip. J Bone Joint Surg Br 641:17-19, 1982 3. Chimento GF, Pavone V, Sharrock N, et al: Minimally invasive total hip arthroplasty: a prospective randomized study. J Arthroplasty 202:139144, 2005 4. Howell JR, Masri BA, Duncan CP: Minimally invasive versus standard incision anterolateral hip replacement: a comparative study. Orthop Clin North Am 352:153-162, 2004 5. Berger RA: Mini-incision total hip replacement using an anterolateral approach: technique and results. Orthop Clin North Am 352:143-151, 2004 6. Hartzband MA: Posterolateral minimal incision for total hip replacement: technique and early results. Orthop Clin North Am 352:119-129, 2004 7. Goldstein WM, Branson JJ, Berland KA, et al: Minimal-incision total hip arthroplasty. J Bone Joint Surg Am 85A(Suppl 4):33-38, 2003 8. Wright JM, Crockett HC, Delgado S, et al: Mini-incision for total hip arthroplasty: a prospective, controlled investigation with 5-year follow-up evaluation. J Arthroplasty 195:538-545, 2004 9. Ogonda L, Wilson R, Archbold P, et al: A minimal-incision technique in total hip arthroplasty does not improve early postoperative outcomes: a prospective, randomized, controlled trial. J Bone Joint Surg Am 874: 701-710, 2005 10. de Beer J, Petruccelli D, Zalzal P, et al: Single-incision, minimally invasive total hip arthroplasty: length doesn’t matter. J Arthroplasty 198: 945-950, 2004 11. Kennon RE, Keggi JM, Wetmore RS, et al: Total hip arthroplasty through a minimally invasive anterior surgical approach. J Bone Joint Surg Am 85A(Suppl 4):39-48, 2003 12. Bertin KC: Minimally invasive outpatient total hip arthroplasty: a financial analysis. Clin Orthop Relat Res 435:154-163, 2005
Modifications of existing surgical approaches for small-incision total hip arthroplasty 13. Berger RA, Jacobs JJ, Meneghini RM, et al: Rapid rehabilitation and recovery with minimally invasive total hip arthroplasty. Clin Orthop Relat Res 429:239-247, 2004 14. Woolson ST, Mow CS, Syquia JF, et al: Comparison of primary total hip replacements performed with a standard incision or a mini-incision. J Bone Joint Surg Am 86A:1353-1358, 2004 15. Berry DJ, Berger RA, Callaghan JJ, et al: Minimally invasive total hip arthroplasty: development, early results, and a critical analysis. Presented at the Annual Meeting of the American Orthopaedic Association, Charleston, South Carolina, USA, June 14, 2003. J Bone Joint Surg Am 85A:2235-2246, 2003
197
16. Hart R, Stipcak V, Janecek M, et al: Component position following total hip arthroplasty through a miniinvasive posterolateral approach. Acta Orthop Belg 711:60-64, 2005 17. Sculco TP: Minimally invasive total hip arthroplasty: in the affirmative. J Arthroplasty 194(Suppl 1):78-80, 2004 18. Sculco TP, Jordan LC, Walter WL: Minimally invasive total hip arthroplasty: the Hospital for Special Surgery experience. Orthop Clin North Am 352:137-142, 2004 19. Fehring TK, Mason JB: Catastrophic complications of minimally invasive hip surgery: a series of three cases. J Bone Joint Surg Am 87A:711-714, 2005