Orthostatic retractor placement reduces operating time and post-operative inflammatory response during the learning curve of anterior approach THA

Abstract

Introduction: Handheld retractor placement (HHRP) is prone to repetitive repositioning. This could lead to muscle damage especially during a procedure with a steep learning curve. In an attempt to minimize retractor repositioning during the learning curve of direct anterior approach (DAA) total hip arthroplasty (THA), we used a table mounted orthostatic retractor placement (ORP) device.

Purpose: To investigate whether ORP would reduce the extent of muscle damage, OR-time and post-operative inflammatory response.

Materials and methods: 29 Patients were operated by 2 surgeons who randomly used HHRP or ORP during their learning curve of DAA THA. There were 14 patients in a control group who were operated by an experienced surgeon. Blood levels of Creatine Kinase (CK), C-Reactive Protein (CRP), Hemoglobin (Hb), Lactate Dehydrogenase (LDH) and Erythrocyte Sedimentation Rate (ESR) were measured at 1 h pre- and 24 and 48 h post-operatively.

Results: The mean OR-time was 67 and 50 min in the HHRP and ORP cohort, respectively (p < 0,001). Post-operative CRP levels were significantly higher in the HHRP cohort at 24 h (HHRP 60.64 mg/L (25.20-143.20); ORP 34.67 mg/L (9.30-71.20)) (p = 0.003) and 48 h post-operatively (HHRP 154.54 mg/L (65.90-369.00); ORP 81.60 mg/L (21.30-219.40) (p = 0.004). The post-operative Hb-levels were significantly lower in the HHRP cohort at 24 h (HHRP 11.11 g/dL (9.10-12.30); ORP 11.37 g/dL (8.80-14.00)) (p = 0.0008) and 48 h (HHRP 10.86 g/dL (9.50-12.00); ORP 11.25 g/dL (8.60-14.10)) (p = 0.03). Post-operative ESR levels were significantly higher in the HHRP cohort 48 h post-op (HHRP 45.21 mm/h (14.00-83.00); ORP 23.73 mm/h (2.00-73.00)) (p = 0.004). No significant differences were found for the CK and LDH levels at any time postoperatively. There were no complications in any group.

Conclusion: The use of an orthostatic retractor placement device allows for reducing the OR-time, post-operative blood loss and post-operative inflammatory response during the learning curve of DAA THA.

Keywords: Direct anterior approach; Efficiency; Learning curve; Orthostatic retractor positioning reduces operating time and post-operative inflammatory response during the learning curve of anterior approach THA; Outcomes; Total hip arthroplasty.

Fig. 1

Consort diagram.

Fig. 2

(a) The patient is installed supine on a regular OR table with both legs draped free. This allows for easy leg length and stability testing at the end of the procedure. (b) The retractors are held in a stable position by the ORP device (Gripper™, MedEnvision, Belgium). (c) The surgeon can conduct the procedure with the help of 1 scrub nurse, even for the femoral broaching. After the stepwise capsular releasing sequence, the femur can be sufficiently elevated so that hyperextension is not required. The surgeon can conduct the surgery with the scrub nurse on the contra-lateral side of the table.

Fig. 3

The anterior capsule is exposed by means of 4 retractors.

Fig. 4

(a) The anterior flap is created and (b) the corkscrew is put inside the femoral head. (c) The neck is osteotomized and (d) the head is extracted.

Fig. 5

(a) The transverse acetabular ligament (TAL) is visible after proper retractor placement. Fluoroscopy is not required due to a superb visualisation of the acetabulum and the reaming. (b) Reaming with a straight reamer is done. (c) The socket is inserted. (d) Overview of the OR set-up. (e) The ceramic liner is inserted.

Fig. 6

(a) The bone hook pulls the femur in the lateral direction and the retractor is put at the level of the release. (b) The leg is put underneath the contralateral leg and adducted and externally rotated. (c) Lateral and (d) superior view of the femur. (e) The final stem is inserted. (f) The femoral head is applied.

Fig. 7

The CRP, ESR and Hb blood levels.