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site du Docteur                       Jean Pierre LANTUEJOUL

site du Docteur Jean Pierre LANTUEJOUL

chirurgie orthopedique hanche genou ligament croisé menisque grenoble chirurgien docteur jean pierre lantuejoul total hip arthroplasty prosthesis total knee prosthesis MIS ambulatoire

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 :



P4220002.jpg incision en arriere dans la fesse


P4220005.jpg abord direct en regard du haut du fémur


DSC00498.JPG sortie de la tete du fémur


P4220021.jpg  préparation du cotyle dans le bassin


 DSC00485.JPG   idem-



P4220042.jpg  enfoncement de la tige fémorale


P4220057.jpg  verification de l'ensemble, on voit la tête prothétique



P4220059.jpg  fermeture


 200209302209557.jpg  cicatrice " discrète "




====>   LE FILM =

 

 

 








TECHNIQUE DE MINI ARTHROTOMIE DE GENOU :




200210012032868.jpg  ouverture a coté de la rotule qui est dessinée au stylo

 
200210012032734.jpg   pénétration dans l'articulation


IMG_4244.JPG   préparation de la coupe du fémur puis du tibia


200210012033537.jpg  mise en place de prothèse d'essai pour valider


IMG_4303.JPG   prothèse définitive


200210012033681.jpg   fermeture , dicrète


DSC00118.jpg   cicatrice a distance


DSC00007_1.jpg    bonne flexion ..


DSC00008_1.jpg  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 

anterior 

surface of the neck, which can weaken it. Contrary to a generally accepted idea, obese 

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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Early complications of primary total hip replacement performed 

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The mini-incision: occasionally desirable, but rarely necessary. 

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"Minimally invasive" total hip arthroplasty. 

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