Hip Arthrodesis Takedown via the Direct Anterior Approach

Kristoff Corten

Cigdem Sarac

Introduction

Patients with a spontaneous or surgically fused hip usually experience impaired functionality affecting the adjacent joints. Patients also may experience problems in daily activities due to impaired range of motion, leg length discrepancy, or limping.¹ A conversion to total hip arthroplasty (THA) may be a solution to these problems but is often challenging due to many potential problems (Table 28.1).²^,³^,⁴^,⁵^,⁶^,⁷^,⁸^,⁹^,¹⁰^,¹¹

TABLE 28.1 The Literature Results Showing a Significantly High Infection and Dislocation Rate After Conversion From a Fused Hip Toward Total Hip Arthroplasty

Author	N	Follow-up (y)	Approach	Infection (%)	Dislocation (%)	Revision rate (%)	Loosening (%)	Nerve injuries (%)	HO (%)
Jauregui et al²	1104	2.5-17.3	Not defined	5.3%	2.6%	12%	6.2%	4.7%	0%
Çalbõyõk et al³	17	6.7	Lateral or posterior	17.6%	11.8%	n/a	n/a	17.6%	17.6%
Celiktas et al⁴	28	3.3	Posterior	2.5%	0%	0%	0%	0%	0%
Fernandez-Fairen et al⁵	48	10	Posterior/anterolateral	4.2%	0%	23%	6.3%	2%	10%
Hamadouche et al⁶	45	8.5	Lateral	2%	0%	0%	0%	2%	0%
Kim et al⁷	86	10.2	Posterior	4.7%	4.7%	16%-18%	52%-58%	3.5%	n/a
Peterson et al⁸	30	2	Lateral/posterior/anterior	3%	7%	23%	16.7%	0%	0%
Reikeras et al⁹	55	5	Lateral/posterior	n/a	n/a	12.7%	3.7%	n/a	n/a
Tamaki et al¹⁰	9	5.2	Anterior	0%	11%	0%	0%	0%	0%
Villanueva et al¹¹	20	3	Posterior	0%	5%	10%	5%	5%	0%

Patients who underwent hip arthrodesis most often had this performed at a very young age for many potential indications, such as avascular necrosis, destructive rheumatoid arthritis, or septic arthritis. Hip arthrodesis bears the benefit that it precluded a joint replacement in young patients in an era in which THA was not as well established as today. However, hip arthrodesis is at long term also borne with multiple problems, including spine-related problems, knee arthritis, and leg length discrepancy.¹ In addition, many of our contemporary patients are seeking an active lifestyle and therefore often request a conversion to THA.

Conversion from a fused hip toward a fully mobile THA could be a solution but has been associated with many potential complications.²^,³^,⁴^,⁵^,⁶^,⁷^,⁸^,⁹^,¹⁰^,¹¹ The most problematic issue is the atrophy of the hip deltoid including the abductors. These muscles are the most important stabilizers of the hip joint and support a swift gait pattern. However, most often, these muscles have not been used normally for many years in arthrodesis cases. Problems such as a persistent Trendelenburg gait pattern or instability of the joint can occur.¹^,²^,³^,⁴^,⁵^,⁶^,⁷^,⁸^,⁹^,¹⁰^,¹¹ Therefore, violation of the periarticular muscles should be prevented at all times in order to minimize the risk for these complications. This is one of the major advantages of the DAA. In addition,
access to the anterior column and the fused hip can be swiftly achieved in a muscle-sparing way through the Smith-Peterson interval, leaving it easier to remove anteriorly located plates and other fusion material.

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