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Early Complications of Primary Total Hip Replacement Performed with a Two-Incision Minimally Invasive Technique

Bal, B. Sonny MD, MBA; Haltom, Doug MD; Aleto, Thomas MD; Barrett, Matthew MD

Journal of Bone & Joint Surgery - American Volume: November 2005 - Volume 87 - Issue 11 - p 2432–2438
doi: 10.2106/JBJS.D.02847
Scientific Articles

Background: Total hip replacement performed through a small incision theoretically results in less trauma to the underlying structures, reduced blood loss, less pain, and a shorter hospital stay, but it may result in increased complications, particularly early in a surgeon's experience with a new technique. In the present study, we reviewed the early results of two techniques involving the use of smaller incisions; specifically, we evaluated one series of primary total hip replacements that had been performed through two small incisions and another series of total hip replacements that had been performed through a single small incision.

Methods: Eighty-nine consecutive primary total hip replacements were performed with use of the two-incision technique as described by Mears and Berger; all procedures were performed without cement and with use of fluoroscopic guidance. Outcomes data were reviewed at a minimum of six months following the procedure. The results of these procedures were retrospectively compared with those of a historical control series of ninety-six total hip replacements that had been performed by the same surgeon with use of a single mini-incision technique. No special attempt was made to discharge any patient early from the hospital. In preparation for the use of the two-incision technique, the surgeon attended a two-day seminar that included cadaveric training and mentoring by surgeons who had experience with this technique.

Results: In the two-incision group, nine patients (nine hips; 10%) required repeat surgery because of a femoral fracture that had been identified postoperatively (two hips), dislocation (one hip), a wound complication (two hips), or subsidence and loosening of the femoral implant (four hips). Twenty-two patients (twenty-two hips; 25%) sustained an injury of the lateral femoral cutaneous nerve, and one patient (one hip) had a neuropraxia of the femoral nerve. In the comparative series of ninety-six total hip arthroplasties that had been performed with use of a single mini-incision and a direct lateral exposure of the hip joint, the overall complication rate was 6% (six of ninety-six) and the reoperation rate was 3% (three of ninety-six). The rate of complications associated with the two-incision technique decreased significantly as the surgeon gained experience with the procedure (p = 0.0202).

Conclusions: Although total hip arthroplasty with use of the two-incision technique was performed by a surgeon who was experienced in the performance of total hip replacement surgery with use of a single small incision, the rates of complications and repeat surgery associated with the two-incision technique initially were very high. While the rate diminished with increasing experience, total hip replacement with use of two incisions and fluoroscopic guidance is a technically demanding procedure that may be associated, especially initially, with higher rates of complications and repeat surgery.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

1 Department of Orthopaedic Surgery, School of Medicine, University of Missouri, MC213, DC053.00, One Hospital Drive, Columbia, MO 65212. E-mail address for B.S. Bal:

Copyright 2005 by The Journal of Bone and Joint Surgery, Incorporated
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