The Anterolateral Minimal/Limited Incision Intermuscular Approach

CHAPTER 12 The Anterolateral Minimal/Limited Incision Intermuscular Approach






The ultimate goal for arthroplasty surgeons is to provide patients with a state of the art total hip arthroplasty with excellent fixation and a durable bearing surface, allowing outstanding function that meets patient expectations. Recovery should be short and rehabilitation rapid so as to optimize transition through the entire experience.


Exposure is an important facet of the surgery and determines the extent to which the soft tissue envelope is compromised. If soft tissue damage can be kept to a minimum, then recovery and rehabilitation should be rapid. In the past, surgeons performed large exposures to aid component placement and protect neurovascular structures. Recently though, the concept of minimally invasive surgery has come to the fore. As a consequence, surgeons have had to re-evaluate the techniques they use and decide whether they adopt these new minimally invasive surgical techniques. There are many proposed advantages. However, it has yet to be proven that minimally invasive techniques will have the same impact in joint arthroplasty as they have had in other surgical applications. A number of minimally invasive surgical techniques have been described and a classification system has been advanced to clarify and simplify our understanding of this group of techniques. This classification defines whether the approach involves a single incision or multiple incisions, the type of approach or plane of entry into the hip (anterior, anterolateral, posterior, or combined), and finally, the method of deep dissection (either intermuscular or transmuscular).


In this chapter we describe the single-incision, anterolateral intermuscular technique for total hip arthroplasty. This anatomic approach was first described by Sayer in 1876 and was popularized by Watson-Jones for the management of fractures of the proximal femur in 1936. It was subsequently modified by Roettinger for its use in total hip arthroplasty. It is a single-incision intermuscular approach to the hip using the anterolateral interval between the posterior border of the tensor fascia lata and the anterior border of the gluteus medius and has recently been described in the literature.


This approach has many clear advantages. First, it is truly an intermuscular approach into the joint with no disruption of the abductor musculature and its associated morbidity. It allows good access to both the femur and the acetabulum to allow accurate placement of components and, with the use of specialized minimally invasive surgical instrumentation, avoids any potential damage to the abductor musculature during retraction. With minimal muscular disruption and a strong capsular repair, this approach is inherently stable and the risk of dislocation is minimized. Fluoroscopy is avoided as in other minimally invasive surgical techniques, and direct visualization allows precise component positioning.




PREOPERATIVE PLANNING


Preoperative templating is performed on anteroposterior radiographs of the pelvis and on a lateral view of the hip. The specific objectives of preoperative planning include calculation of any leg length discrepancy and restoration of appropriate femoral offset, and determination of component sizes. Three important measurements are taken to aid intraoperative decision making for the femoral osteotomy and seating of the component (Fig. 12-1). The first measurement is the distance from the saddle of the neck (the superior surface of the femoral neck at the base of the medial face of the greater trochanter) to where the definitive osteotomy is to be performed. The second measurement is the distance from the lesser trochanter to the medial point of the femoral osteotomy. The last measurement is from the tip of the greater trochanter to the shoulder of the prosthesis in its final location. Strict adherence to these measurements allows precise placement of components with minimal error and without compromising of stability.



Mar 10, 2016 | Posted by in Reconstructive surgery | Comments Off on The Anterolateral Minimal/Limited Incision Intermuscular Approach

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