Introduction

Metal-on-metal hip resurfacing arthroplasty has re-emerged as a viable alternative to traditional total hip arthroplasty for selected patients. Improvements in design technology and in the metallurgy of metal-on-metal bearings have helped solve many of the problems associated with the first generation of metal-on-polyethylene hip resurfacing, such as massive bone loss with cemented acetabular components and high wear rates associated with larger femoral head sizes. Current hip resurfacing systems make use of a hybrid design, with a press-fit acetabular component and a cemented femoral component. Early and midterm results have been favorable and comparable with traditional total hip arthroplasty, although femoral neck fractures continue to be a concern, with osteonecrosis as a leading cause.

The most commonly used approach for hip resurfacing is the posterior approach. This is an extensile approach that provides excellent visualization of the acetabulum as well as of the posterosuperior femoral head–neck junction. However, it has been well documented that the blood flow to the femoral head is compromised, thus putting the area at risk for an osteonecrotic event. Other approaches that are currently being used are the direct lateral approach, surgical dislocation as described by Ganz, and the anterior Hueter approach, each of which preserves the extraosseous blood supply to the femoral head. Since 2006, we have adopted the anterior Hueter approach with the use of an orthopedic traction table, because it represents the only true internervous surgical approach to the hip, with excellent preservation of the soft-tissue envelope.

Indications

• Young patients

Men less than 65 years old

Women less than 55 years old

Relative contraindications

Absolute contraindications

Clinical history

The clinical history of advanced hip arthritis is straightforward, especially for younger patients with no other source of distracting pain (e.g., back pain). Intra-articular hip pain is typically reproducible and felt in the groin area with activity.

Physical examination

The goal of the physical examination is to confirm the clinical history. Pain in the groin area should be reproduced by passively moving the hip joint, which is usually limited with regard to flexion and internal rotation. If the patient has no groin pain with flexion, adduction, and internal rotation, other causes (e.g., back, extra-articular hip pathology) must be sought. True and functional leg-length discrepancies should be carefully assessed.

Imaging and diagnostic studies

Our hip series for evaluating the patient with osteoarthritis of the hip includes a supine anteroposterior pelvic view that is centered on the hips and that shows the proximal femur down to the diaphysis as well as cross-table lateral views, Dunn views, or both (Figure 34-1). These two radiographs are scrutinized to analyze for structural abnormalities (e.g., insufficient femoral head–neck offset), the integrity of the joint space, and periarticular bone. In the rare case of a patient with radiographic osteoarthritis of the hip joint without a typical clinical history or physical examination, we perform an intra-articular anesthetic injection to determine whether the patient’s symptoms are a result of the radiographic hip degeneration.

Figure 34–1 A 42-year-old patient with advanced left hip osteoarthritis. The inset is a cross-table lateral view that assesses the femoral head–neck offset.

Surgical technique

Although the anterior Hueter approach can be performed without a special surgical table, our main experience is with the use of a specialty orthopedic traction table (Figure 34-2). We do not exclude patients on the basis of body mass index or underlying deformity.

Figure 34–2 An orthopedic traction table (Delacroix Device, Maquet-Dynamed, Paris, France) used for anterior-approach total hip arthroplasty. Note the capacity to extend the operated limb with the patient in the supine position.

Patient Positioning (Figure 34-3)

The patient is placed supine on the operative table. The operative leg is placed into a leg-holding device that allows for controlled positioning in three dimensions during surgery. The leg is not draped free but rather attached to the foot holder to allow for traction, internal and external rotation, flexion, extension, abduction, and adduction. Slight internal rotation of the operative leg allows for the better surface delimitation of the interval between the tensor of the fascia lata and the sartorius. The contralateral lower limb is set in 15 degrees of internal rotation and in neutral flexion, extension, abduction, and adduction; it is also placed under tension to serve as a radiographic control for the operated side.

Figure 34–3 The patient in the supine position. The incision is centered at the tip of the greater trochanter; it is 2 cm to 3 cm longer than the incision that is used when performing a total hip replacement.

Exposure

The incision is placed 1 cm to 2 cm posterolateral and 2 cm distal to the anterosuperior iliac spine. The incision is extended distally and posterolaterally toward a line that connects to the fibular head for a total of 6 cm to 10 cm. The subcutaneous tissue is divided with the use of electrocautery until the aponeurosis of the tensor of the fascia lata is identified. The latter is incised longitudinally with a No. 10 blade, with all muscle fibers preserved. Blunt finger dissection is then performed between the medial aspect of the muscle belly (which can sometimes be bipennate) and the aponeurosis. At this point, retractors are placed in between the muscle and its sheath to expose the rectus femoris and the fat that overlies the hip capsule. With the use of electrocautery, this fat is removed to expose the capsule. After incising the fascia over the rectus femoris, blunt dissection is performed to expose the lateral circumflex vessels, which are then ligated and cut. These vessels can bleed briskly, and they deserve attention. Some of the lateral aspects of the rectus femoris and the iliocapsularis muscle can be elevated to maximize the exposure of the hip capsule. It is recommended to release the reflected head of the rectus femoris to facilitate the exposure of the acetabulum. At this point, the capsulotomy is performed with the use of electrocautery from inferomedial to superolateral, and a second transverse capsular incision is made from inferomedial to lateral, leaving a laterally based capsular flap attached to the proximal femur. In some cases, it is preferable to excise the lateral capsular flap to facilitate the delivery of the proximal femur (Figure 34-4). A large cobra retractor is then placed around the proximal femur to retract the tensor muscle laterally, and a blunt Hohmann retractor is placed at the inferomedial femoral neck.

Figure 34–4 A view of the hip joint after capsulotomy.