Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
Hip Unit, Orthopedic Department, Ziekenhuis Ooost-Limburg Genk, Schiepse Bos 6, 3600, Genk, Belgium.
Oper Orthop Traumatol. 2022 Jun;34(3):203-217. doi: 10.1007/s00064-022-00767-6. Epub 2022 Jun 9.
Acetabular revision arthroplasty and osseous defect management through the direct anterior approach (DAA) with or without proximal extension.
Aseptic or septic component loosening, periacetabular osseous defects, pelvic discontinuity, intrapelvic cup protrusion, anterior pseudotumors, iliopsoas tendonitis, polyethylene wear or iliopsoas abscess.
Clinically relevant gluteal tendon lesions, active infection, morbid obesity, large abdominal pannus, ASA (American Society of Anesthesiologists) score > III, inguinal skin infection.
Electrocautery dissection is recommended to dissect the Hueter interval and to debulk pericapsular scar tissue. At all times during capsular debulking, it should be made sure not to damage the iliopsoas tendon or the neurovascular bundle. A stepwise releasing sequence can facilitate dislocation of the prosthesis. Most cases can be revised via the standard DAA but certain circumstances require an intra- or extrapelvic extension. Access to the anterior gluteal surface of the ilium can be provided using a "tensor snip". More posterior access is provided by the extensile extrapelvic approach described by Smith-Petersen. The intrapelvic Levine extension offers access to the entire visceral surface of the ilium and large parts of the anterior column.
Patient revised via the intra- or extrapelvic extension and patients suffering from extensive soft tissue or osseous defects should undergo postoperative weight-bearing restrictions with 20 kg for 6 weeks.
Based on our studies, there is no limitation on the type of acetabular implant that can be used in DAA revision arthroplasty. Moreover, virtually all types of periacetabular osseous defects can be managed through the approach and its extensions. Acetabular revision arthroplasty via the DAA and its extensions is safe and can result in good midterm results.
通过直接前入路（DAA）进行髋臼翻修和骨缺损处理，可选择或不选择近端延长。
无菌或感染性部件松动、髋臼周围骨缺损、骨盆不连续、盆腔内杯突岀、前假性肿瘤、髂腰肌肌腱炎、聚乙烯磨损或髂腰肌脓肿。
临床相关的臀肌腱病变、活动性感染、病态肥胖、大腹部赘肉、ASA（美国麻醉医师协会）评分＞III 级、腹股沟皮肤感染。
建议使用电烙解剖来解剖 Hueter 间隙并去除囊周瘢痕组织。在进行囊周松解的过程中，始终要确保不损伤髂腰肌肌腱或神经血管束。采用逐步松解的顺序可以促进假体脱位。大多数病例可以通过标准的 DAA 进行翻修，但某些情况下需要进行骨盆内或骨盆外延长。可以使用“张量剪”提供到髂骨前臀侧表面的通路。更靠后的通路可以通过 Smith-Petersen 描述的扩展骨盆外通路提供。盆腔内的 Levine 延长提供了对整个髂骨内脏面和大部分前柱的访问。
通过骨盆内或骨盆外延长进行翻修的患者和患有广泛软组织或骨缺损的患者应在术后 6 周内限制负重，负重 20kg。
根据我们的研究，在 DAA 翻修关节成形术中，没有对髋臼植入物类型的限制。此外，几乎所有类型的髋臼周围骨缺损都可以通过该入路及其延长来处理。通过 DAA 和其延长进行髋臼翻修关节成形术是安全的，可以获得良好的中期结果。
