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
enfoncement de la tige fémorale
verification de l'ensemble, on voit la tête prothétique
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
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
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
-surgeons who saw a direct interest for their patients, and for increasing their
-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.
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
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.
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
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)
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)
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)
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
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
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
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
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
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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