A Novel Technique to Detect Femoral Shaft Perforation during Direct Anterior Total Hip Arthroplasty

Abstract

Despite its popularity, the direct anterior approach for hip arthroplasty is not without complications. Intraoperative femoral shaft perforation using this approach ranges from 0.8% to 7%. A missed perforation can lead to fracture with the need for further surgery if not detected intraoperatively. We describe a reproducible and cost-effective technique using a plastic Yankauer suction handle to help identify proximal femoral perforations during direct anterior total hip arthroplasty. Careful attention to the visual, tactile, and auditory feedback provided by the suction handle can help ensure the cortical continuity of the proximal femur. Familiarity with relevant surgical anatomy, improving surgical technique, and scrutinizing implant positioning helps minimize the risk of complications during the direct anterior approach.

Minimizing complications in bikini incision direct anterior approach total hip arthroplasty: A single surgeon series of 865 cases

“…The modified vessel sparing bikini anterior approach, namely a horizontal incision over the lateral groin crease, was utilized in all cases [35,42]. A superolateral Table 1 Overview of complications found in our series (851 hips with average 3.9 years follow-up) and results from published studies on DAA and bikini incision DAA THA [11,20,35] Calcar fracture 3 (0.35) 0.3-1.5% [20,35,40] Stem subsidence 3 (0.35) 0.2-0.7% [35,40] Trochanteric fracture 3 (0.35) 2.3% [29] Femoral fracture 4 (0.47) 0.12%-0.45% [19,29] Leg length discrepancy 2 (0.23) 0.2% [35] Deep vein thrombosis 3 (0.35) 0.8-1.35% [11,30] Permanent neuropraxia (LFCN) 3 (0.35) 1.2-11% [25,33,35] Transient neuropraxia (LFCN) 55 (6.4) 15-81% [17,20,45] Canal perforation 0 0.8-9% [16,52] Trochanteric capsular window was utilised preserving the ascending branches of the circumflex femoral vessels. A dedicated fracture table or intraoperative radiography was not routinely used in any of the cases.…”

“…We did not come across any cases of lateral cortical perforation. Perforation is a known complication of DAA due to incorrect trajectory of femoral broaching [16].…”

Late Femoral Component Revision for Femoral Canal Perforation

“…Nine of these patients were asymptomatic and without signs of mechanical failure at an average follow-up of five years. The incidence, complications, and clinical consequences of the complication with the use of modern technique and cementless components have not been well-described in the literature [1], but there has been some more recent descriptions and recommended techniques for preventing the complication as a specific risk to the direct anterior surgical approach [4,[8][9].…”

“…Femoral perforation is a rare complication of total hip arthroplasty with an incidence that has not been delineated in the literature [1][2][3]. Most of the existing literature on the topic focuses on the prevention and management of complications in the intraoperative and immediate postoperative periods [1][2][3][4][5][6][7]. Patient risk factors for femoral perforation include previous surgery, hip dysplasia, and osteoporosis [2].…”

“…Surgical factors predisposing to femoral perforation include poor exposure and the use of a long-stemmed implant [3]. When recognized in the intraoperative setting, treatment involves removal of the existing component and bypassing the cortical defect with a longer stemmed component [1][2][3][4][5]. Alternatively, a standard component may be placed in the appropriate position and the cortical defect can be reinforced with a strut graft or plate and screw device [7].…”