Name: the transition to an anterior-based muscle sparing approach improves early postoperative function but is associated with a learning curve
Uploaded: 2022-09-07T12:30:00.000+00:00
Duration: 9 min 51 s
Description: Watch this Scientific Journal Video about The Transition to an Anterior-Based Muscle Sparing Approach Improves Early Postoperative Function but is Associated with a Learning Curve at JoVE.com

The authors have no acknowledgments.

An institutional review board approved this retrospective study (IRB 00060819) of deidentified prospectively collected data.The protocol followed the guidelines approved by the human institutional review board of Adventist Health Lodi Memorial. A written informed consent was obtained from the patients before the procedure.
NOTE: As a representative patient, the clinical course of a 78-year-old male with left hip pain is described. His symptoms included a 2 year history of left groin pain aggravated by activity, night pain not adequately relieved by anti-inflammatory medication, and limitations of daily activities. The Oxford Hip Score at his initial clinic visit was 22 points, and the Hip Disability and Osteoarthritis Outcome Score (HOOS Junior) was 53 points. X-rays revealed primary left hip osteoarthritis (Figure 1).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/63948/63948fig01.jpg" /> 
Figure 1: AP radiograph of the pelvis focused low on the symphysis. The left hip demonstrates typical characteristics of end-stage osteoarthritis. <a href="https://www.jove.com/files/ftp_upload/63948/63948fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
1. Diagnosis, assessment, and plan
<ol>
	<li>Left hip osteoarthritis 
	NOTE: Due to failed conservative treatment, the patient was offered left total hip replacement using the ABMS approach.
	<ol>
		<li>Use the AP-Pelvis x-ray with the 2.5 cm radiographic calibration marker for preoperative planning (Figure 2).</li>
		<li>Measure the distance from the trochanteric fossa to the planned femoral neck resection to restore equal leg length. Fit adequate component sizes to the bony contours to restore femoral offset.</li>
	</ol>
	</li>
</ol>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/63948/63948fig02.jpg" /> 
Figure 2: Planning THA. The planning of left THA begins with calibrating the radiograph to the metal ball of 2.5 cm diameter. Next, the preoperative leg length difference is measured (0.7 mm in this example). The appropriately sized acetabular component (blue) is positioned to restore the center of rotation. The appropriately sized femoral component with the ideal femoral offset (green) is positioned within the proximal femur to correct for any leg length difference. The distance between the trochanteric fossa and the planned femoral neck resection is measured (5.9 mm in this example). <a href="https://www.jove.com/files/ftp_upload/63948/63948fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
2. Surgical preparation
<ol>
	<li>Starting 5 days before surgery, ask the patient to perform daily skin cleansing using chlorhexidine washing solution. Before surgery, meet the patient in the preoperative holding area and mark the correct hip side with a skin marker.</li>
	<li>After the induction of general anesthesia with inhalation anesthetics and the confirmation of its success by the maintenance of stable vital signs, position the patient in a lateral decubitus position with the operated hip facing up. Perform sterile prepping and draping. Cover the exposed skin with iodine-impregnated adhesive.</li>
	<li>Wrap a sterile elastic bandage around assistant 1&#39;s waist to create a belt. The belt serves to hold a sterile mayo-stand cover, which is attached to the belt with two non-penetrating clamps (= kangaroo bag). The kangaroo bag maintains a sterile environment when the leg is dropped behind the patient.</li>
	<li>Position the surgeon in front of the patient and assistant 1 and assistant 2 behind the patient. Position assistant 1 more distal than assistant 2 to maneuver the leg during surgery.</li>
	<li>Mark the incision:
	<ol>
		<li>Palpate and mark the proximal border or greater trochanter (GT) and the anterior border of the proximal femur. Palpate the anterior border of the gluteus medius (GM) fascia, which is tighter than the fascia overlying the tensor fasciae latae muscle.</li>
		<li>Starting 2 cm distal to the GT, make a line along the anterior border of the proximal femur and then slightly turn anterior along the anterior border of the GM fascia, stopping 6 cm proximal to the GT. The incision length is 8 cm.</li>
	</ol>
	</li>
</ol>
3. Surgical procedure
<ol>
	<li>Instruct assistant 1 to abduct the hip. Incise the skin sharply with a #10-blade following the previously made skin mark. Cut down to the fascia with a knife and use a clean lap sponge to expose the fascia.</li>
	<li>The fascia is pierced by a bundle of vessels (= perforating vessels).&#160;Identify these perforating vessels as they pierce through the fascia. These vessels locate the interval between the GM and tensor fasciae latae (TFL). Distally open the fascia parallel to the orientation of the fascial fibers, and curve anteriorly at the mid-portion of the incision, staying posterior to the perforating vessels.</li>
	<li>Use finger palpation at the greater trochanter to dissect the muscle plane between the TFL anteriorly and the gluteus muscles posteriorly. Run a finger along the GM toward the GT. Then, let the finger drop anteriorly into the space between the GM and TFL. Once the finger is in the space, palpate the femoral neck and posterior portion of the femoral neck by elevating the gluteus medius and minimus posteriorly.</li>
	<li>While assistant 1 is holding the hip abducted, place a curved Hohmann retractor (Nr. 17) over the posterior neck outside the capsule to retract the glutei muscles. Then, place a straight Hohmann retractor (Nr. 7) over the anterior neck outside the capsule under the TFL and the reflected head of the rectus femoris tendon.</li>
	<li>Instruct assistant 1 to slightly externally rotate the hip and make an H-shaped capsulotomy using electrocautery with the bar of the H longitudinally along the femoral neck. Ensure that the distal line of the H is far lateral connecting the tip of the GT and medially around the neck to release the capsule and clean out the trochanteric fossa and intertrochanteric ridge.</li>
	<li>Using electrocautery, go through the entire capsule proximally toward the head and acetabular rim, which is felt as a step with an electrocautery tip. At the acetabular rim, turn the electrocautery 90&#176; and release the capsule along the acetabular rim medially and laterally.</li>
	<li>Reposition the retractors underneath the capsule with the assistant holding the leg in abduction. While assistant 1 increases the external rotation and extension, make a subcapital femoral neck cut oblique from proximal to distal to facilitate the lift of the distal femur once the cut is complete.</li>
	<li>Hold the anterior retractor (Nr. 7 retractor) and, with a key elevator positioned at the osteotomy site, level the femoral neck into the surgical field while assistant 1 hyperextends the hip to &#34;dislodge&#34; the osteotomy. Instruct assistant 1 to place the leg in the kangaroo bag and externally rotate the hip so that the patella is pointing upward and the tibia is perpendicular to the floor.</li>
	<li>Reposition the Nr. 17 retractor over the GT and clean up the trochanteric fossa from the soft tissue using electrocautery.</li>
	<li>Instruct assistant 1 to adduct the hip so that the femoral neck is elevated more out of the wound. Identify the femoral neck cut at the planned level distal to the trochanteric fossa. Ideally, use a template to mark out the neck cut using electrocautery. Then, perform a neck cut using an oscillating saw.</li>
	<li>Cut the medial neck first and then proceed to the lateral neck, paying attention not to violate the GT. Remove the free bone piece of the femoral neck with an osteotome and grasper.</li>
	<li>Remove the Hohmann retractors, and instruct assistant 1 to place the leg out of the bag in a neutral position on the mayo stand to allow hip abduction and slight flexion.</li>
	<li>Place Nr. 15 or Nr. 17 retractors over the posterior acetabulum. The Nr. 15 retractor is wider than the Nr. 17 retractor but with comparable shape and curvature. Then, place the Nr. 7 retractor over the anterior acetabulum. Push through the capsule with the spike.</li>
	<li>Remove the femoral head with the Hohmann retractor and grasper. Push on the inferior part of the head to dislodge it superiorly. Then, use a grasper to remove the head. Remove the labrum using a long knife, and incise the inferior capsule if it is in the hemisphere of the acetabulum.</li>
	<li>Ream the acetabulum to an appropriate size, starting 1 mm smaller than the planned cup diameter. Then, insert the final acetabular component in 40&#176; abduction and 10&#176;-15&#176; anteversion. Insert the final polyethylene liner by manually placing it within the acetabular component and then impacting the liner in the acetabular component to engage the locking mechanism.</li>
	<li>While assistant 1 places the leg in the kangaroo bag and externally rotates the hip to 90&#176;, place a two-prong retractor under the postero-medial aspect of the femoral neck and the Nr. 17 retractor over the GT. Then, instruct assistant 1 to extend and adduct the hip.</li>
	<li>If needed, perform release along the anterior portion of the GT to deliver the femur out of the wound. Then, open the proximal femur with a box cutter and canal finder.</li>
	<li>Broach to an appropriate size and length and place the final stem with templated offset.</li>
	<li>Perform a trial reduction with a trial head. To reduce the hip, instruct assistant 1 to apply slight traction and internally rotate the hip while the surgeon uses a head-pusher to guide the ball into the socket. Check the hip for anterior and posterior stability. Place the Nr. 17 retractor over the posterior acetabulum to visualize the hip. Perform a shuck test in longitudinal and lateral traction.</li>
	<li>To dislocate the hip, place a bone hook around the neck, and instruct assistant 1 to apply traction and external rotation. Remove the trial head. Irrigate the cup, insert the final head, and reduce the hip.</li>
	<li>Replace the Nr. 17 retractor outside the capsule. Reapproximate the capsule with a nonabsorbable suture.</li>
	<li>Repair the gluteal fascia with a synthetic braided absorbable suture while the leg is in slight abduction and external rotation. Close the subcutaneous tissue with a 2-0 braided absorbable suture and skin with sterile skin staples.</li>
</ol>

<ol>
	<li>Melman, W. P., Mollen, B. P., Kollen, B. J., Verheyen, C. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=First+experiences+with+the+direct+anterior+approach+in+lateral+decubitus+position:+Learning+curve+and+1+year+complication+rate.">First experiences with the direct anterior approach in lateral decubitus position: Learning curve and 1 year complication rate.</a> Hip International. 25 (3), 251-257 (2015).</li><li>Rottinger, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+MIS+anterolateral+approach+for+THA.">The MIS anterolateral approach for THA.</a> Orthopade. 35 (7), 708-715 (2006).</li><li>Bertin, K. C., R&#246;ttinger, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anterolateral+mini-incision+hip+replacement+surgery:+A+modified+Watson-Jones+approach.">Anterolateral mini-incision hip replacement surgery: A modified Watson-Jones approach.</a> Clinical Orthopaedics and Related Research. 429, 248-255 (2004).</li><li>Civinini, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+anterior-based+muscle-sparing+approach+to+the+hip:+The+&amp;#34;other&amp;#34;+anterior+approach+to+the+hip.">The anterior-based muscle-sparing approach to the hip: The &amp;#34;other&amp;#34; anterior approach to the hip.</a> International Orthopaedics. 43 (1), 47-53 (2019).</li><li>De Geest, T., Fennema, P., Lenaerts, G., De Loore, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Adverse+effects+associated+with+the+direct+anterior+approach+for+total+hip+arthroplasty:+A+Bayesian+meta-analysis.">Adverse effects associated with the direct anterior approach for total hip arthroplasty: A Bayesian meta-analysis.</a> Archives of Orthopaedic and Trauma Surgery. 135 (8), 1183-1192 (2015).</li><li>Christensen, C. P., Karthikeyan, T., Jacobs, C. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Greater+prevalence+of+wound+complications+requiring+reoperation+with+direct+anterior+approach+total+hip+arthroplasty.">Greater prevalence of wound complications requiring reoperation with direct anterior approach total hip arthroplasty.</a> The Journal of Arthroplasty. 29 (9), 1839-1841 (2014).</li><li>Leiberman, J. R., Berry, D. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Advanced Reconstruction: Hip 2. , (2018).</li><li>Delanois, R. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Rottinger+approach+for+total+hip+arthroplasty:+Technique,+comparison+to+the+direct+lateral+approach+and+review+of+literature.">The Rottinger approach for total hip arthroplasty: Technique, comparison to the direct lateral approach and review of literature.</a> Annals of Translational Medicine. 5, 31 (2017).</li><li>Martin, R., Clayson, P. E., Troussel, S., Fraser, B. P., Docquier, P. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anterolateral+minimally+invasive+total+hip+arthroplasty:+A+prospective+randomized+controlled+study+with+a+follow-up+of+1+year.">Anterolateral minimally invasive total hip arthroplasty: A prospective randomized controlled study with a follow-up of 1 year.</a> The Journal of Arthroplasty. 26 (8), 1362-1372 (2011).</li><li>Laffosse, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Learning+curve+for+a+modified+Watson-Jones+minimally+invasive+approach+in+primary+total+hip+replacement:+Analysis+of+complications+and+early+results+versus+the+standard-incision+posterior+approach.">Learning curve for a modified Watson-Jones minimally invasive approach in primary total hip replacement: Analysis of complications and early results versus the standard-incision posterior approach.</a> Acta Orthopaedica Belgica. 72 (6), 693 (2006).</li><li>Chen, D., Berger, R. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Outpatient+minimally+invasive+total+hip+arthroplasty+via+a+modified+Watson-Jones+approach:+Technique+and+results.">Outpatient minimally invasive total hip arthroplasty via a modified Watson-Jones approach: Technique and results.</a> Instructional Course Lectures. 62, 229-236 (2013).</li><li>Rottinger, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+anterolateral+surgical+approach+for+total+hip+arthroplasty:+early+clinical+results.">Minimally invasive anterolateral surgical approach for total hip arthroplasty: early clinical results.</a> Hip International. 16, 42-47 (2006).</li><li>de Jong, L., Klem, T. M., Kuijper, T. M., Roukema, G. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+minimally+invasive+anterolateral+approach+versus+the+traditional+anterolateral+approach+(Watson-Jones)+for+hip+hemiarthroplasty+after+a+femoral+neck+fracture:+an+analysis+of+clinical+outcomes.">The minimally invasive anterolateral approach versus the traditional anterolateral approach (Watson-Jones) for hip hemiarthroplasty after a femoral neck fracture: an analysis of clinical outcomes.</a> International Orthopaedics. 42 (8), 1943-1948 (2018).</li><li>M&#252;ller, M., Tohtz, S., Dewey, M., Springer, I., Perka, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evidence+of+reduced+muscle+trauma+through+a+minimally+invasive+anterolateral+approach+by+means+of+MRI.">Evidence of reduced muscle trauma through a minimally invasive anterolateral approach by means of MRI.</a> Clinical Orthopaedics and Related Research. 468 (12), 3192-3200 (2010).</li><li>Kawarai, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Does+the+surgical+approach+influence+the+implant+alignment+in+total+hip+arthroplasty?+Comparative+study+between+the+direct+anterior+and+the+anterolateral+approaches+in+the+supine+position.">Does the surgical approach influence the implant alignment in total hip arthroplasty? Comparative study between the direct anterior and the anterolateral approaches in the supine position.</a> International Orthopaedics. 41 (12), 2487-2493 (2017).</li><li>Batailler, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Total+hip+arthroplasty+using+direct+anterior+approach+and+dual+mobility+cup:+safe+and+efficient+strategy+against+post-operative+dislocation.">Total hip arthroplasty using direct anterior approach and dual mobility cup: safe and efficient strategy against post-operative dislocation.</a> International Orthopaedics. 41 (3), 499-506 (2017).</li><li>D'Arrigo, C., Speranza, A., Monaco, E., Carcangiu, A., Ferretti, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Learning+curve+in+tissue+sparing+total+hip+replacement:+Comparison+between+different+approaches.">Learning curve in tissue sparing total hip replacement: Comparison between different approaches.</a> Journal of Orthopaedics and Traumatology. 10 (1), 47-54 (2009).</li><li>Rothwell, A. G., Hooper, G. J., Hobbs, A., Frampton, C. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+analysis+of+the+Oxford+hip+and+knee+scores+and+their+relationship+to+early+joint+revision+in+the+New+Zealand+Joint+Registry.">An analysis of the Oxford hip and knee scores and their relationship to early joint revision in the New Zealand Joint Registry.</a> The Journal of Bone and Joint Surgery. British Volume. 92 (3), 413-418 (2010).</li><li>Devane, P., Horne, G., Gehling, D. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Oxford+hip+scores+at+6+months+and+5+years+are+associated+with+total+hip+revision+within+the+subsequent+2+years.">Oxford hip scores at 6 months and 5 years are associated with total hip revision within the subsequent 2 years.</a> Clinical Orthopaedics and Related Research. 471 (12), 3870-3874 (2013).</li><li>Alexander, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Augmented+reality+for+acetabular+component+placement+in+direct+anterior+total+hip+arthroplasty.">Augmented reality for acetabular component placement in direct anterior total hip arthroplasty.</a> The Journal of Arthroplasty. 35 (6), 1636-1641 (2020).</li></ol>

The authors have nothing to disclose.

Minimally invasive surgery (MIS) has gained interest in all fields of surgery due to the faster recovery, lower blood loss, and improved perioperative pain control. THA has adopted MIS to increase hip stability and enhance post-operative mobilization. The ABMS approach utilizes the muscle interval between the tensor fasciae latae and the gluteus medius muscles but without incising or detaching the muscles and tendons. A surgeon considering transitioning to the ABMS approach would be well advised to attend a cadaver cours...

In total hip arthroplasty (THA), the surgical approach serves to visualize the acetabulum and proximal femur and to prepare the acetabulum and proximal femur for safe and stable implantation of the prosthetic components1. An ideal surgical approach in THA provides adequate exposure while minimizing the risk of damage to the muscles, blood vessels, and nerves and the risk of postoperative instability.
The anterior-based muscle-sparing (ABMS) approach in THA utilizes the muscle interval popularized by Sir Reginald Watson-Jones in 19302. The ABMS approach avails itself of the intermuscular plane between the tensor fasciae latae (TFL) and the gluteus medius (GM) to gain access to the hip joint. The abductor muscles are preserved and not detached during this approach. As the ABMS approach is anterior to the GM and to the greater trochanter (GT), it is similar and shares the advantages of the direct anterior approach (DAA)-being muscle sparing. Even though the ABMS approach can be performed with the patient in a supine position, many surgeons prefer the lateral decubitus position based on its original description3.
The ABMS, like the DAA, has multiple operative and early postoperative benefits. The exposure of the acetabulum is excellent, which facilitates optimal positioning of the acetabular component. Functional recovery is faster in the early postoperative period due to there being less muscle damage and, consequently, lower dislocation rates4.
The reported disadvantages of the DAA are damage to the lateral femoral cutaneous nerve (LFCN), the need for a special operating table, wound healing problems, and more limited exposure to the femur5,6. By avoiding these disadvantages, the ABMS has since its introduction in 2004&#160;routinely been utilized in European countries, and has recently attracted more attention in North America3. Motivated by 1) the concept of a muscle-sparing approach, which negates the necessity of post-operative precautions7, 2) the ability to perform the surgery in a lateral decubitus position, which allows stability evaluation maneuvers familiar to a surgeon performing THA through the posterior approach (PA), 3) avoiding intra-operative fluoroscopy8, 4) the increased anatomical distance to the LFCN in comparison to the DA, and 5) the further lateralized incision, which avoids wound-healing complications caused by overhanging soft-tissue, surgeons might decide to transition to the ABMS approach.
However, surgeons considering transitioning to the ABMS approach for THA are concerned about whether transitioning will ultimately improve patient outcomes and about the learning curve associated with the transition. Accordingly, the first cohort of 30 THAs, which were implanted by a single surgeon using the ABMS approach, was analyzed and compared to results gained from 30 THAs implanted by the same surgeon through the PA immediately before the transition. The present study tested 1) whether early patient-reported outcomes improved in the ABMS group in comparison to the PA group and 2) whether the surgical time and complication rate decreased with the number of THAs performed.

<table><tbody><tr><td>30&amp;deg; Offset Masterloc Broach handle L</td><td>Medacta</td><td>01.10.10.461</td><td></td></tr><tr><td>30&amp;deg; Offset Masterloc Broach Handle R</td><td>Medacta</td><td>01.10.10.460</td><td></td></tr><tr><td>3D Printed Acetabular Component</td><td>Medacta</td><td>01.38.058DH</td><td></td></tr><tr><td>ACE Wrap 6 in</td><td></td><td>140700</td><td></td></tr><tr><td>Acetabular Liner</td><td>Medacta</td><td>01.32.4048HCT</td><td></td></tr><tr><td>AMIS 2.0 Genera Tray</td><td>Medacta</td><td>01.15.10.0294</td><td>Curved cup impactor</td></tr><tr><td>AMIS 2.0 General Tray</td><td>Medacta</td><td>01.15.10.0293</td><td>Screw driver for cup impactor</td></tr><tr><td>Anterior Auxillery</td><td>Medacta</td><td>ALAUX</td><td></td></tr><tr><td>Biolox Ceramic Head</td><td>Medacta</td><td>01.29.214</td><td></td></tr><tr><td>Chloraprep 26 mL</td><td>BD</td><td>301185</td><td></td></tr><tr><td>Drape Mayostand</td><td>Cardianal</td><td>7999</td><td></td></tr><tr><td>Ethibond Size 5</td><td>Ethicon</td><td>103831</td><td></td></tr><tr><td>Femoral Neck Elevator</td><td></td><td>3006</td><td></td></tr><tr><td>Femoral neck elevator</td><td></td><td>01.15.10.0037</td><td></td></tr><tr><td>Ioban</td><td>3M</td><td>15808</td><td></td></tr><tr><td>Ketorolac 30 mg/mL</td><td>SN</td><td>MED00575</td><td></td></tr><tr><td>Masterloc Inst (MLOCINS)</td><td>Medacta</td><td>01.39S.301US</td><td></td></tr><tr><td>Masterlock Femoral Stem</td><td>Medacta</td><td>01.39.408</td><td></td></tr><tr><td>Mpact General (MPACT)</td><td>Medacta</td><td>01.32S.300US</td><td></td></tr><tr><td>Mpact Liner Trial face changing/offset</td><td>Medacta</td><td>01.325.305</td><td></td></tr><tr><td>Mpact Liner Trial face changing/offset</td><td>Medacta</td><td>01.325.305</td><td></td></tr><tr><td>Mpact liner trial flat/hooded</td><td>Medacta</td><td>01.32S.301</td><td></td></tr><tr><td>Mpact liner trial flat/hooded</td><td>Medacta</td><td>01.32S.301</td><td></td></tr><tr><td>Mpact Reamers (MPACT)</td><td>Medacta</td><td>01.32S.101US</td><td>Regular hemi reamers swapped out for Half-Moon Reamers</td></tr><tr><td>Single Prong Acetabular Retractor, Extra Deep</td><td></td><td>6570-01</td><td></td></tr><tr><td>Single Prong Acetabular Retractor, Standard</td><td></td><td>6570</td><td></td></tr><tr><td>Single Prong Broad Acetabular Retractor</td><td></td><td>6320</td><td></td></tr><tr><td>Stapler Kine Proximate Plus 35 W</td><td>Ethicon</td><td>52686</td><td></td></tr><tr><td>Tranexamic acid 1 g</td><td>SN</td><td>MED01071</td><td></td></tr><tr><td>Unger Narrow Hohmann</td><td></td><td>3002</td><td></td></tr><tr><td>Vicryl 1 CTX</td><td>Ethicon</td><td>143836</td><td></td></tr><tr><td>Vicryl 2-0 CT2</td><td>Ethicon</td><td>9174</td><td></td></tr></tbody></table>

the transition to an anterior-based muscle sparing approach improves early postoperative function but is associated with a learning curve

Surgeons considering transitioning to an anterior-based approach for THA are concerned about the learning curve and the reported marginal clinical benefit. Accordingly, the first cohort of THAs, which were implanted by a single surgeon using the anterior-based muscle-sparing approach (ABMS), was analyzed. The goal of the study was to test 1) whether patient-reported outcomes improved and 2) whether the complication rate decreased with the number of THAs performed. A retrospective cohort study on the first 30 primary THA cases (27 patients) of one surgeon (January 2021-April 2021) using the ABMS approach was conducted. These 30 THAs were compared to 30 primary THA cases (30 patients) done immediately prior to the transition by the same surgeon (September 2020-December 2020) using the posterior approach (PA). The Oxford Hip Score (OHS), Hip Disability and Osteoarthritis Outcome Score (HOOS Junior), and Forgotten Joint Score (FJS) obtained 6 weeks and 6 months after surgery were compared. In addition, three consecutive groups based on equal numbers of THAs were compared for the incidence of complications and surgery time. At 6 weeks after THA, the OHS was 6 points higher after the ABMS approach (p = 0.0408), and the OHS was comparable at 6 months. The HOOS Junior and FJS were similar at 6 weeks and 6 months after surgery.&#160;In the first 10 THAs using the ABMS approach, one patient had a greater trochanter fracture, and one patient had an intraoperative proximal femur fracture. No further immediate interoperative or postoperative complications occurred. Surgery time significantly reduced with the number of THAs performed. Transitioning from the PA to the ABMS approach is associated with a learning curve, which is limited to the first 20 cases. The effect of improved clinical outcomes is apparent within the early postoperative period. After 6 months, THA patients do well regardless of the approach.

At 6 weeks after THA, the mean OHS was 35 points after the ABMS approach and 29 after the PA (p = 0.0408). The HOOS and FJS did not differ significantly 6 weeks after THA between the ABMS approach and PA. At 6 months after THA, no differences in outcome scores were observed (Table 1).
In the first 10 THAs using the ABMS approach, one patient had a greater trochanter fracture treated with a tension band suture, and one patient had an intraoperative proximal femur fracture treat...

Watch this Scientific Journal Video about The Transition to an Anterior-Based Muscle Sparing Approach Improves Early Postoperative Function but is Associated with a Learning Curve at JoVE.com

The Transition to an Anterior-Based Muscle Sparing Approach Improves Early Postoperative Function but is Associated with a Learning Curve

The anterior-based muscle-sparing approach for total hip arthroplasty (THA) is associated with a learning curve. However, the improved clinical outcome in the early post-operative phase makes the consideration to transition worthwhile.

Surgeons considering transitioning to an anterior-based approach for THA are concerned about the learning curve and the reported marginal clinical ...

the-transition-to-an-anterior-based-muscle-sparing-approach-improves

Research

JoVE Journal

Medicine

2.5K Views.  University of Würzburg. Dit protocol demonstreert en belicht de techniek en fijne kneepjes van de anterieure spiersparende benadering, afgekort ABMS, voor totale heuparthroplastiek. De ABMS-aanpak stelt de chirurg in staat om op efficiënte wijze totale heuparthroplastieken uit te voeren in de laterale decubituspositie, waarbij de voordelen van de posterieure benadering en de directe anterieure benadering worden gecombineerd. Chirurgen die overstappen op de EBMS-benadering moeten zich vertrouwd maken met de mate van...

Video: The Transition to an Anterior-Based Muscle Sparing Approach Improves Early Postoperative Function but is Associated with a Learning Curve

Single-stage Dynamic Reanimation of the Smile in Irreversible Facial Paralysis by Free Functional Muscle Transfer

Unilateral facial paralysis is a common disease that is associated with significant functional, aesthetic and psychological issues. Though idiopathic facial paralysis (Bell&#8217;s palsy) is the most common diagnosis, patients can also present with a history of physical trauma, infectious disease, tumor, or iatrogenic facial paralysis. Early repair within one year of injury can be achieved by direct nerve repair, cross-face nerve grafting or regional nerve transfer. It is due to muscle atrophy that in long lasting facial paralysis complex reconstructive methods have to be applied. Instead of one single procedure, different surgical approaches have to be considered to alleviate the various components of the paralysis.
The reconstruction of a spontaneous dynamic smile with a symmetric resting tone is a crucial factor to overcome the functional deficits and the social handicap that are associated with facial paralysis. Although numerous surgical techniques have been described, a two-stage approach with an initial cross-facial nerve grafting followed by a free functional muscle transfer is most frequently applied. In selected patients however, a single-stage reconstruction using the motor nerve to the masseter as donor nerve is superior to a two-stage repair. The gracilis muscle is most commonly used for reconstruction, as it presents with a constant anatomy, a simple dissection and minimal donor site morbidity.
Here we demonstrate the pre-operative work-up, the post-operative management, and precisely describe the surgical procedure of single-stage microsurgical reconstruction of the smile by free functional gracilis muscle transfer in a step by step protocol. We further illustrate common pitfalls and provide useful tips which should enable the reader to truly comprehend the procedure. We further discuss indications and limitations of the technique and demonstrate representative results.

The use of the masseteric nerve as donor nerve represents a single-stage alternative to the criterion standard two-stage procedure of cross-facial nerve grafting and free muscle transfer in facial paralysis. We provide a detailed description to safely perform this technique with a gracilis muscle transfer and discuss indications and limitations.

Unilateral facial paralysis is a common disease that is associated with significant functional, aesthetic and psychological issues. Though idiopathic ...

Structured Motor Rehabilitation After Selective Nerve Transfers

After severe nerve injuries, selective nerve transfers provide an opportunity to restore motor and sensory function. Functional recovery depends both on the successful re-innervation of the targets in the periphery and on the motor re-learning process entailing cortical plasticity. While there is an increasing number of methods to improve rehabilitation, their routine implementation in a clinical setting remains a challenge due to their complexity and long duration. Therefore, recommendations for rehabilitation strategies are presented with the aim of guiding medical doctors and therapists through the long-lasting rehabilitation process and providing step-by-step instructions for supporting motor re-learning.
Directly after nerve transfer surgery, no motor function is present, and therapy should focus on promoting activity in the sensory-motor cortex areas of the paralyzed body part. After about two to six months (depending on the severity and modality of injury, the distance of nerve regeneration and many other factors), the first motor activity can be detected via electromyography (EMG). Within this phase of rehabilitation, multimodal feedback is used to re-learn the motor function. This is especially critical after nerve transfers, as muscle activation patterns change due to the altered neural connection. Finally, muscle strength should be sufficient to overcome gravity/resistance of antagonistic muscles and joint stiffness, and more functional tasks can be implemented in rehabilitation.

Here, we present a protocol for the motor rehabilitation of patients with severe nerve injuries and selective nerve transfer surgery. It aims at restoring the motor function proposing several stages in patient education, early-stage therapy after surgery and interventions for rehabilitation after successful re-innervation of the nerve&#8217;s target.

After severe nerve injuries, selective nerve transfers provide an opportunity to restore motor and sensory function. Functional recovery depends both on ...

Three-dimensional Navigation-guided, Prone, Single-position, Lateral Lumbar Interbody Fusion Technique

Lateral interbody fusion provides a significant biomechanical advantage over the traditional transforaminal lumbar interbody fusion due to the large implant size and optimal implant position. However, current methods for lateral interbody cage placement require either a two-staged procedure or a single lateral decubitus position that precludes surgeons from having either full access to the posterior spine for direct decompression or comfortable pedicle screw placement.
Herein is one institution's experience with 10 cases of a prone single-position approach for simultaneous access to the anterior and posterior lumbar spine. This allows both lateral lumbar interbody cage placement, direct posterior decompression, and pedicle screw placement, all in one position. Three-dimensional (3D) navigation is utilized for increased precision in both approaching the lateral spine and interbody cage placement. The traditional blind psoas muscle tubular dilation was also modified. Tubular retractors and lateral vertebral body retractor pins were used to minimize the risks to the lumbar plexus.

The single-position, prone, lateral approach allows for both lateral lumbar interbody placement and direct posterior decompression with pedicle screw placement in one position.

Lateral interbody fusion provides a significant biomechanical advantage over the traditional transforaminal lumbar interbody fusion due to the large ...

Neuroscience

Therapy Interventions for Upper Limb Amputees Undergoing Selective Nerve Transfers

Targeted Muscle Reinnervation (TMR) improves the biological control interface for myoelectric prostheses after above-elbow amputation. Selective activation of muscle units is made possible by surgically re-routing nerves, yielding a high number of independent myoelectric control signals. However, this intervention requires careful patient selection and specific rehabilitation therapy. Here a rehabilitation protocol is presented for high-level upper limb amputees undergoing TMR, based on an expert Delphi study. Interventions before surgery include detailed patient assessment and general measures for pain control, muscle endurance and strength, balance, and range of motion of the remaining joints. After surgery, additional therapeutic interventions focus on edema control and scar treatment and the selective activation of cortical areas responsible for upper limb control. Following successful&#160;reinnervation of target muscles, surface electromyographic (sEMG) biofeedback is used to train the activation of the novel muscular units. Later on, a table-top prosthesis may provide the first experience of prosthetic control. After fitting the actual prosthesis, training includes repetitive drills without objects, object manipulation, and finally, activities of daily living. Ultimately, regular patient appointments and functional assessments allow tracking prosthetic function and enabling early interventions if malfunctioning.

This work presents a protocol to enhance prosthetic function after selective nerve transfer surgery. Rehabilitation interventions include patient information and selection, support of wound healing, cortical re-activation of sensory-motor areas of the upper limb, training of selective muscle activation, prosthetic handling in daily life, and regular follow-up assessments.

Targeted Muscle Reinnervation (TMR) improves the biological control interface for myoelectric prostheses after above-elbow amputation. Selective ...

Modified Posterior Vertebral Column Resection for Patients with Thoracolumbar Kyphotic Deformity

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may cause severe thoracolumbar kyphotic deformity, often accompanied by intractable low back pain or compression of the spinal cord, leading to severe neurological symptoms or even paralysis. If conservative treatment cannot relieve the symptoms or correct the deformities, surgical treatment is usually needed. For severe kyphotic deformity, reconstruction of the physiological curvature and rigid fixation determine the prognosis of the patients. Osteotomy and orthopedics are the standard procedure for deformities with severe compression of the front and middle column, but the trauma to the patients is high, with a long operation time and massive blood loss. To avoid these disadvantages, we have developed a modified technique to remove the diseased vertebra unilaterally. In this technique, we use a modified trephine to resect the vertebral columns like in the pedicle screw technique by adding a locking instrument that can restrict the trephine to lower the risk of osteotomy and shorten the surgery time and blood loss.

We describe a modified technique for resecting the posterior vertebral column unilaterally based on a modified trephine for patients with thoracolumbar kyphotic deformity.

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may ...

Procedure for Targeted Muscle Reinnervation for Treating Postamputation Pain

Targeted Muscle Reinnervation: Surgical Protocol for a Randomized Controlled Trial in Postamputation Pain

Over the past decade, the field of prosthetics has witnessed significant progress, particularly in the development of surgical techniques to enhance the functionality of prosthetic limbs. Notably, novel surgical interventions have had an additional positive outcome, as individuals with amputations have reported neuropathic pain relief after undergoing such procedures. Subsequently, surgical techniques have gained increased prominence in the treatment of postamputation pain, including one such surgical advancement - targeted muscle reinnervation (TMR). TMR involves a surgical approach that reroutes severed nerves as a type of nerve transfer to &#34;target&#34; motor nerves and their accompanying motor end plates within nearby muscles. This technique originally aimed to create new myoelectric sites for amplified electromyography (EMG) signals to enhance prosthetic intuitive control. Subsequent work showed that TMR also could prevent the formation of painful neuromas as well as reduce postamputation neuropathic pain (e.g., Residual and Phantom Limb Pain). Indeed, multiple studies have demonstrated TMR&#39;s effectiveness in mitigating postamputation pain as well as improving prosthetic functional outcomes. However, technical variations in the procedure have been identified as it is adopted by clinics worldwide. The purpose of this article is to provide a detailed step-by-step description of the TMR procedure, serving as the foundation for an international, randomized controlled trial (ClinicalTrials.gov, NCT05009394), including nine clinics in seven countries. In this trial, TMR and two other surgical techniques for managing postamputation pain will be evaluated.

Author Spotlight: Advancements and Challenges in Surgical Treatments for Postamputation Pain

The protocol outlines the surgical procedure&#160;for the treatment of postamputation pain using Targeted Muscle Reinnervation (TMR). TMR will be compared with two other surgical techniques, specifically Regenerative Peripheral Nerve Interface (RPNI) and neuroma excision, followed by immediate burying within muscle under the context of an international, randomized controlled trial.

Over the past decade, the field of prosthetics has witnessed significant progress, particularly in the development of surgical techniques to enhance the ...

Combination of Anatomical Plates and Rotator Cuff Reinforcement for Minimally Invasive Treatment of Greater Tuberosity Fractures of the Humerus

Greater tuberosity fractures of the humerus can be challenging to manage due to their complex anatomy and the potential for compromised shoulder function. We present a novel technique for treating greater tuberosity fractures utilizing specialized anatomical plates and rotator cuff reinforcement. The technique involves the use of an anatomically T-shaped plate designed specifically for the greater tuberosity region of the humerus, allowing for precise fixation and stability. Additionally, rotator cuff reinforcement is performed using sutures to enhance structural integrity and promote early mobilization. The simplified process is as follows: After administering anesthesia, a 3 cm incision is made along the lateral aspect of the shoulder to precisely expose the fracture site of the greater tuberosity. A suture of size 5 is skillfully threaded through the tough rotator cuff tendon to securely attach the proximal humerus to the anatomical plate after the greater tuberosity has been reduced. Intraoperative fluoroscopy is utilized to verify the accurate positioning of plates and screws. After ensuring everything is correct, the surgery concludes.

Here, we present a protocol to utilize anatomical plates alongside rotator cuff reinforcement in a minimally invasive surgery to efficiently treat humerus greater tuberosity fractures, promising quicker healing and improved stability.

Greater tuberosity fractures of the humerus can be challenging to manage due to their complex anatomy and the potential for compromised shoulder function. ...

Innovative Video-Based Tool for Precision Assessment and Rehabilitation of LBP

Biomechanical Changes Related to Low Back Pain: An Innovative Tool for Movement Pattern Assessment and Treatment Evaluation in Rehabilitation

Low back pain (LBP) is a highly prevalent disorder frequently related to biomechanical alterations. Movement pattern assessments have a role in the rehabilitation management of patients with LBP; however, a precise assessment is challenging in routine clinical settings. Thus, this study aims to assess the biomechanical alterations related to LBP through the development and application of an innovative assessment tool named CameraLab. Patients with LBP were assessed through a video analysis system. The movement pattern assessment tool includes a touchscreen interface and four high-velocity cameras, enabling real-time data acquisition during movement assessments. The cameras capture dynamic movements, facilitating a thorough examination of motor function. A video analysis software application is employed for precise angle assessments and joint tracking. Three patients with LBP were assessed, demonstrating positive results in pain intensity, functional independence, and overall well-being. The integration of advanced technology highlighted the movement pattern alterations and contributed to tailored rehabilitation strategies. The study offers a paradigm shift toward precision rehabilitation. This innovative approach provides valuable insights into the biomechanical changes related to LBP, fostering a deeper understanding for clinicians and paving the way for effective personalized interventions in the management of LBP.

This study shows the role of an innovative tool for assessing and treating biomechanical alterations in low back pain (LBP) patients. Three LBP patients demonstrated improved pain intensity and functional independence post-assessment. The technology aids in tailored rehabilitation strategies, offering insights into LBP biomechanics for personalized interventions.

Low back pain (LBP) is a highly prevalent disorder frequently related to biomechanical alterations. Movement pattern assessments have a role in the ...

Surgical Approach and Complications of Stand-alone Lateral Trans-Psoas Interbody Fusion

Interbody fusion of the lumbar spine is a standard procedure for symptomatic degenerative lumbar spine disease if conservative treatment fails. Surgical decompression and fusion of the segment can be achieved using several different techniques. Over the last decades, minimally invasive techniques, such as lateral interbody fusion (LLIF), have been developed to reduce tissue damage and complications and allow quicker patient recovery. With growing popularity, indications for LLIF have expanded to treat spinal deformities and foraminal/central stenosis. Mechanically, it allows for an unsurpassed fixation through the left-to-right apophyseal ring placement of the cage. LLIF utilizes a minimally disruptive retroperitoneal corridor and includes both trans-psoas and pre-psoas approaches. For the pre-psoas approach, the risk of damage from manipulation of the intramuscular lumbar plexus is reduced compared to a trans-psoas approach. However, increased risks of major vascular, ureteral, bowel injury and sympathetic plexus damage are reported.
This article aims to provide a detailed and comprehensive guide on stand-alone lateral trans-psoas interbody fusion, including its indications, surgical procedure, potential complications, and outcomes based on a decade of experience from a single center.

Interbody fusion of the lumbar spine can be achieved surgically using different techniques. Minimally invasive techniques, including lateral interbody fusion, have been developed within recent decades to reduce rates of complications and allow for quicker patient recovery. We provide insight into stand-alone lateral trans-psoas interbody fusion, highlighting potential complications and pitfalls.

Interbody fusion of the lumbar spine is a standard procedure for symptomatic degenerative lumbar spine disease if conservative treatment fails. Surgical ...

Techniques for Lower Trapezius Transfer Using Achilles Allograft in Irreparable Posterosuperior Rotator Cuff Tears

The management of irreparable rotator cuff tears presents significant challenges, particularly in active individuals experiencing functional limitations, such as reduced forward elevation and deficits in both external and internal rotation. Traditional latissimus dorsi (LD) tendon transfer has shown effectiveness in reducing pain associated with posterosuperior cuff tears but often yields inconsistent functional outcomes. This is largely due to the LD's primary role as an internal rotator, which limits its capacity to restore normal shoulder biomechanics. To address these limitations, the lower trapezius (LT) tendon transfer, augmented with an Achilles allograft, has emerged as an alternative to enhance external rotation, leveraging the LT's line of pull, which closely resembles that of the infraspinatus muscle.
This protocol outlines a modified surgical technique for LT tendon transfer with Achilles allograft augmentation, detailing patient positioning, tendon harvest, graft preparation, arthroscopic passage, and fixation methods. The protocol emphasizes key anatomical landmarks to minimize neurovascular injury and enhance graft integration. Postoperative care includes a 3 month immobilization period followed by a structured rehabilitation program to facilitate functional recovery.
This procedure is indicated for a specific patient group requiring improved external rotation and is biomechanically advantageous over the LD transfer. Though additional studies are warranted to confirm its efficacy in broader patient populations, early clinical outcomes suggest that LT transfer with Achilles allograft could offer superior biomechanical alignment and improved external rotation.

Here, we describe a modified technique for lower trapezius tendon transfer using an Achilles allograft in the treatment of massive posterosuperior rotator cuff tears.

The management of irreparable rotator cuff tears presents significant challenges, particularly in active individuals experiencing functional limitations, ...

The Transition to an Anterior-Based Muscle Sparing Approach Improves Early Postoperative Function but is Associated with a Learning Curve

Samenvatting

Meer video's verkennen

Hoofdstukken in deze video