Favorable Radiographic and Early Postoperative Results with the Inguinal Crease Direct Anterior Total Hip Arthroplasty Bradford Waddell 1,2 MD, Jesse Raszweski 3 BS, Imraan Khan 2 BS, Benjamin Ricciardi 2 MD, Robert Fischer 1 BS, Brian Godshaw 1 MD Edwin Su 2 MD 1 Ochsner Clinic Foundation; New Orleans, Louisiana 2 Hospital for Special Surgery; New York, New York 3 Alabama College of Osteopathic Medicine; Dothan, Alabama
Introduction • The direct anterior approach for total hip arthroplasty (THA) has become more popular – Inter-nervous and inter-muscular planes – Minimal muscle detachment – Few post operative restrictions • Disadvantages of direct anterior THA – Injury to lateral femoral cutaneous nerve (LCFN) – Longitudinal incision • Does not follow Langer’s lines of tension • Can result in less favorable scar appearance.
Introduction • Inguinal crease direct anterior THA – Utilizes oblique incision in inguinal crease – Incision follows Langer’s lines, resulting in favorable scar formation – Leunig et al : low complications and similar results compared to direct anterior THA
Objective To report early results of a direct anterior approach THA through a short oblique incision in the inguinal crease of the groin.
Methods • Retrospective comparative study, 70 consecutive THA performed by the senior author – 29 standard direct anterior incision – 41 oblique inguinal crease incision • Similar prostheses were used • Combined spinal-epidural and hypotensive anesthesia • Direct Anterior THA: – Hana table – Standard approach • Inguinal Crease THA: – Flat table, both legs prepped to assess limb length – Incision: 8cm in inguinal crease with 1/3 medial to ASIS – Femoral preparation: leg is adducted under contralateral leg
Methods • Radiographs and charts were reviewed for – Acetabular cup version and inclination – Heterotopic ossification (HO) formation – Leg lengths – Complications • *Scar appearance was based on a questionnaire including the Vancouver Scar Scale (VSS) (0-13, with 0 being normal skin) • *Patient satisfaction with the scar was assessed using simple scale (Extremely Dissatisfied, Dissatisfied, Neutral, Satisfied, Extremely Satisfied) * Most recent follow-up visit
Results Table 1. Demographic Data by Surgical Approach Inguinal Crease Standard Direct Anterior Anterior P-value Age 59.41 (22-83) 64.6 (46-83) 0.08 Height (cm) 164.9(155-173) 164.5 (144-205) 0.73 Weight (kg) 58.7 (45-72) 62.77 (48-92) 0.004* BMI 21.31 (18-27) 23.05 (19-27) 0.001* Sex (Percent Female) 97.5 82.7 0.03* Mean (range), *Denotes statistical significance
Results Table 2. Radiographic Results and Harris Hip Scores by Surgical Approach Inguinal Crease Standard Direct Anterior Anterior P-value Length Surgery (mins) 92.0 (68-158) 92.6 (61-142) 0.97 Blood loss (cc) 166.9 (100-200) 153.45 (100-250) 0.2 Cup Size 50.4 (48-56) 51.1 (46-58) 0.29 Head Size 33.2 (32-36) 32.5 (28-40) 0.5 Stem Size 4.92 (3-10) 5.58 (4-10) 0.11 Length of Stay (days) 2.15 (1-5) 2.24(1-4) 0.67 Preop LLD (mm) 5.9 (0-30) 4.8 (0-18) 0.39 Post-op LLD (mm) 1.15 (0-4) 2.58 (0-8) 0.008* Cup Inclination (degrees) 37.39 (30-49) 40.1 (33-49) 0.02* Cup Version (degrees) 20.76 (7-28) 16.93 (9-29) 0.01* Preop HHS 60.36 (40-81) 63.35 (49-83) 0.36 Postop HHS 92.61 (61-100) 89.9 (73-100) 0.35 Preop vs Postop HHS p= 2.2x10-17 p= 1.8x10-8 *Denotes statistical significance, LLD=Limb length discrepancy, HHS=Harris Hip Score
Results • Vancouver Scare Scale: – Inguinal crease: 0.68 (range 0 – 3) – Direct anterior: 1.56 (range 0 – 4) – P = 0.015 – Inguinal crease: 44% rated as “0” – Direct anterior: 20.7% rated as “0” – P = 0.045 • Satisfaction: – Inguinal crease: • 87% extremely satisfied • 13% satisfied – Direct anterior: • 32% extremely satisfied • 52% satisfied • 16% dissatisfied
Results • Heterotopic Ossification: – Inguinal crease: 0 – Direct anterior : 2 (Brooker 1) • Lateral Femoral Cutaneous Nerve Numbness: – Inguinal crease: 4 – Direct anterior: 1 – P = 0.17 • No major complications - One case of supra-therapeutic INR in the inguinal incision group requiring reversal - One case of nausea and one case of diarrhea in the standard incision group
Conclusions • Inguinal crease incision for total hip arthroplasty was safe and offered the similar early results compared to the standard direct anterior incision • Incision in the inguinal group more closely resembled normal skin • Overall, patients were more satisfied with the incision appearance after surgery with the inguinal incision
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