- QU'EST CE QUE LA MINI ARTHROTOMIE DE GENOU OU DE HANCHE ? explications, film et photos

C'est une technique dite "mini invasive " c'est a dire moins agressive que la méthode traditionnelle. Il s'agit de diminuer la taille de l'incision, de diminuer l'agressivité du geste chirurgical..

Les avantages sont simples : +++

- moins de douleurs
- moins de prise médicamenteuse
- moins de section musculaire
- moins de pertes sanguines
- moins de risques infectieux
- moins de risques de luxation
- réadaptation plus rapide
- pas ou peu de rééducation

J'ai développé ma technique en 1996, présenté celle ci lors des journées Lyonnaises de la hanche en 2003.J'ai organisé le premier congrès de mini arthrotomie en France , à Grenoble Je suis référent et consultant pour la société BIOMET inc. pour les mini arthrotomies de hanche et de genou.

Mon protocole post opératoire pour les prothèses de hanche est simple : sauf avis contraire ( exception dans certains cas particuliers ..) , TOUS les mouvements sont autorisés. PAS de limitation des amplitudes . PAS de coussin entre les jambes après l'opération. PAS de position interdite. AUTORISATION de croiser les jambes.

TECHNIQUE DE MINI ARTHROTOMIE DE HANCHE EN IMAGE :

incision en arriere dans la fesse

abord direct en regard du haut du fémur

sortie de la tete du fémur

préparation du cotyle dans le bassin

idem-

enfoncement de la tige fémorale

verification de l'ensemble, on voit la tête prothétique

fermeture

cicatrice " discrète "

====> LE FILM =

TECHNIQUE DE MINI ARTHROTOMIE DE GENOU :

ouverture a coté de la rotule qui est dessinée au stylo

   pénétration dans l'articulation

   préparation de la coupe du fémur puis du tibia

mise en place de prothèse d'essai pour valider

   prothèse définitive

   fermeture , dicrète

   cicatrice a distance

   bonne flexion ..

vue de face de la cicatrice en hyperflexion

POSTERIOR MINIMAL INVASIVE PROCEDURE FOR HIP ARTHROPLASTY

Dr Jean Pierre LANTUEJOUL, MD

Clinique BELLEDONNE, GRENOBLE, FRANCE

For some time there has been renewed interest in mini-incisions in all the

fields of the orthopedic surgery. From the beginning of the century to its end , the

proverb « large incision , large surgeon » has been succeeded by « small incision,

large surgeon ».

The goal is not to argue about the interest of such a method, but simply to describe its

tricks and pitfalls.

The realisation of this technique of empirical and personal inspiration was carried out

on a continuous series of more than 1600 THP , within a degenerative framework,

over the last 8 years. The incision of 5 to 7 cm in 99% of the cases allows a posterior

approach.

A. HISTORY:

Effectiveness is the base of surgery, but the concept of « less aggresiveness » is a

modern idea. Mentality has changed and well-being represent the essential concept of

the end of this century in all the fields of our society.

Appearance of new technologies such as computers in operative theaters ,an

increasing activity and cost of medicine, have definitely pushed surgeons to consider

health as an economic activity and to think about new concepts. In a certain way,

arthroscopy has marked the beginning of the less aggressive procedure .

The real turn for the MIS procedure was in 2000 with the publication of a two incision

anterior MIS approach by BERGER, Chicago, in association with a famous

orthopaedic company. Then , the MIS procedures have been organized as a business

market, confirming - if it was necessary - that politics, insurance, medical doctors and

patients were ready for that.

Every actor saw its own benefit :

-companies for the promotion of their prostheses and their specific procedure

of implantation.

-surgeons who saw a direct interest for their patients, and for increasing their

activity.

-medical insurance for the decreasing cost .

-and finally the patients always avid for innovations and wellbeing.

Since this time, a lot of MIS procedure has been published : single or double incision

, anterior ou posterior, with or without computer… and with various point of view.

But if most surgeons agree that the post operative comfort is better and that the patient

recovers faster with such a procedure, it is necessary to be aware of the risks and

pitfalls and it requires many tricks to avoid them.

B. TRICKS:

The patient is installed in lateral decubitus, but always a bit anteriorly, so that the

patient does not slide posteriorly during the manipulation. In such a situation , the

acetabulum becomes difficult to expose , condemning automicatilly the surgeon to

increase the incision. Two supports are used on the pelvis and the sacrum firmly. The

technique may be carried out by two people: the surgeon, and his assistant.

The centering of the incision is the first important point : the top of the great

trochanter is the reference center. The incision follows the virtual line of the MOORE

postero external approach, but shortened . The line of incision is 3 cm on both sides

top, half way between the anterior and posterior edges (fig 1 ). After resecting the

fascia lata, the dissection is done in the direction of fibres, and sometimes beyond

that, under the scar 1 cm further. The large gluteus is dissected in the direction of its

fibres.

fig. 1

The second important point is the exposure : A Charnley frame is used then to retract

the fascia lata (fig.2). This material is compact and hidden, not very traumatic and

specially robust : it allows a direct view of the acetabulum, and compresses are not

hooked by it during manipulations.

fig.2

The goal is to be as economic as possible on the resection of the pelvi trochanteric

muscles, and it’s only necessary to cut the piriformis, the gemellus and the upper part

of the quadratus. This represent a real « mini arthrotomy ». Whatever, if the quadratus

wasn’t dissected enough, the dislocation will complete it

Then , the dissection can be done classically along the posterior edge of the great

trochanter, without need for any explanation. The capsule is divided in the axis of the

femur to preserve a capsular fragment, which will be used to protect the elements

located behind during the operation, and later on to give a good proprioception and

stability to the prosthesis.

Once the head is dislocated, the femoral neck is exposed, Hohman being placed in

contact with neck to locate the height of cut, and especially to go

down and to verticalise the scar in order to resect the neck without damaging the skin,

and with a perfect location (fig.3). The extraction is sometimes difficult when the

neck is very stocky or long : in that situation it may be possible to cut the neck in two

stages: first just under the femoral head , and then, without capsule, the femoral head

raise spontaneouslyand then , secondly the neck may be cut where the surgeon has

decided to.

fig.3

Usually the reference point for the height of cut is the small trochanter. During a MIS

procedure,the small trochanter is hidden and with such a philosophy a Hohman must

be placed in contact with it to locate it, and then ,adapted to the template the height of

cut is choosed. While the mini incision limitate the exposure, it’s probably better to

change of philosophy and locate the height of cut from the center of rotation :in that

situation , the center of the femoral head is in front of the surgeon making easier the

choice of the height of cut..

.

At this stage, the exposure of the acetabulum is managed with two pins : a first

Steinman nail is positioned to push back the capsular fragment on the posterior wall,

to offer protection to the elements located behind and then to expose the acetabulum.

A second nail is inserted into the anterior wall to raise the medius gluteus, the fold

and to expose the acetabulum anteriorly this time (fig.4)

fig.4

Now, the role of the assistant is essential - it is the fruit of experience -

for different reasons : hard traction of the leg to give a better exposure

of the acetabulum, to introduce more easily the reamer or to extract it.

Internal rotation of the femur to release the acetabulum or to facilitate

the extraction of the reamer while erasing the great trochanter.

After preparation of the acetabulum, reaming can be carried out as

usual. The prior insertion of the two nails appears at this stage

important also to protect the soft parts: the reamer is guided, and slips

over these two nails to reach the acetabulum without any trauma. Hohman can be

placed indifferently on the former or the posterior wall to better expose the

acetabulum. A straight or a curved reamer handle may be used indifferently, but with

a straight branch handle , the assistant must tract hardly on the axis of the leg to erase

the great trochanter and the femur and facilitate the slope of the reamer (fig.5,6)

fig.5, 6

The preparation of the femoral canal is certainly the second most important point after

the centering of the incision : it remains as usual, generally without technical tricks

except among very muscular patients for whom the approach is deep BUT there are

never any constraints between the rasp, the skin, the retractor and the femur because

each uncontrolled constraint may be responsible for a fracture of the femur during or

after the operation. This complication is the most frequent after a MIS procedure.

To avoid this particular problem, the femoral canal must be raised while moving the

leg and positionning one knee in front of the other one. That’s why it’s especially

important not to put a cushion between the two legs.

As the patient is installed in lateral decubitusthere is a natural verticalisation of the

femur, facilitating the direct introduction of the rasp. It can also be improved by the

use of a femoral elevator ( fat depressor ). A straight rasp handle allows the minimum

of constraint between both elements which is also fondamental. At least,the use of a

Hohman turns out to be very useful in exposing the Merckel and verify the good

positionning of the definitive rasp: it is placed along side to release it (fig. 7,8,9)

fig.7 fig.8

fig. 9

In the very muscular patient, it is useful to make use of a specific material to raise the

femur, and to lower the skin, protecting it indirectly (fig.10). A femoral elevator

makes it possible to prepare the femur without the rasp causing cam effects on the

patients do not present particular difficulties. It is better to use a deeper Charnley

frame.

fig.10

The implantation of the final implants is carried out according to the usual

procedure, with or without cement, with a straight or a curved handle indifferently for

the acetabulum, but as for the preparation of the acetabulum with a hard traction of

the leg if the handle is straight. A guide for the anterversion is especially interesting to

avoid a blocking of the stem while introducing it. In that situation , it’s always

difficult with such a small arthrotomy to extract the stem and re introduce it again.

The choice of a stem with an extraction kit may be relevant.

The assistant moreover gives the anteversion to facilitate the introduction of the stem

and limite the constraints. As for the preparation of the femoral canal, during the

introduction of the stem , the neck push again the skin which may lead to a

fragilisation of the bone and a fracture during or after surgery.

Closing can be carried out according to the preferences and habits of each

surgeon: capsular closing, reintegration of the pyriformis, a trochanterian rod

, and a cerclage can be positioned on the Merckel if necessary.

C - PITFALLS:

The centering of the incision is an essential phase : too far forward,

and the great trochanter obstructs, too far behind and the acetabulum

moves away, condemning in both cases the surgeon to increase. The

whole procedure depends on finding the reference point for the

incision

But the anatomical conditions may cause a pitfall : a short neck or a coxa vara

requires a different centering of the incision , generally a bit lower so thatit is in front

of the acetabulum.A long neck means the contrary. A coxa profunda doesn’t represent

a contraindication, just a difficulty, because of the great trochanter, generally huge ,

which obstruct the acetabulum.

Finally, the best solution is probably to decrease gradually the incision to be

accustomed to the procedure.

The reaming of the acetabulum may also represent a delicate phase :the great

trochanter may represent a danger because it is huge and it may push the reamer

against the posterior wall and injure it . The ovalisation of the acetabulum is the direct

consequence of that situation ,with all the difficulties of implantation of the cup it

represent. In order to avoid this avoid, it’s important to center at the beginning the

reaming of the acetabulum by starting with the smallest reamer , and by pushing the

reamer against the anterior wall. A Hohman placed anteriorly may facilitate this

procedure.

The resection of the osteophytes may also be difficult with such a small opening :

not really visible , they may be forgot. The use of a Hohman applicated on both wall

facilitate their visibility and their extraction.

It is necessary to be wary of the positioning of the acetabulum because the

instrumentation of the final implantation comes up against the lower part of the

scar: “verticalisation” of the acetabulum can occur if one does not pay atttention. The

use of a curved handle to impact the definitive acetabulum is interesting at this stage.

As the principal risk at the beginning of the experience is the fracture of the femur,

and that the Merckel is hidden by the muscles, the systematic verification of it is

necessary.

Finally, the principal difficulty is the centering of the incision , the principal risk is the

fracture of the femur, and the principal trap is the malpositionning of the cup.

Conscious of that, many tricks facilitate the procedure and make it easy. At least,

the objective advantages of such a method are difficult to highlight because there are

as many practices and techniques as there are surgeons. It is logical to think that the

pain, blood loss, duration of the operation, and risk of sepsis decrease. But what about

the rate of dislocation or the survival rate which depends on so many factors? From a

subjective point of view, it appears that the patient recovers faster and the post-

operative comfort is better. Finally, the patients admire and marvel at the appearance

of the scar.

The posterior mini incision of the hip is a technique which will not revolutionize hip

surgery for "visible"advantages. It requires not only experience on behalf on the

surgeon, but also of his assistant, and the technique is not without its difficulties and

traps, which should be known in order to be avoided.

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