Less Invasive Modified “Thomine et al” Limited and adaptable to Subgroin Thigh Diameter Lateral Hip Approach.

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In this study, a modified “Thomine et al” lateral hip approach is described. This modified lateral hip approach developed by the first author ( NAC) in order to eliminate even more the side effects of an transguleal approach, is characterized except of no extending into the vastus lateralis muscle by that a) the skin incision is adaptable to about 20% of the pre-operative subgroin diameter of the thigh, b) the temporary during surgery elevation of the anterior 1/3 mechanically not very important for abduction part of gluteus medius is adapted in width to surgical and local difficulties and c) two 6mm in diameter external fixator pins are temporary placed over the acetabulum rim to protect stably without using retractors or pins the elevated part of gluteus medius muscle, the tensor fascia lata and gluteus maximus muscle during acetabulum reconstruction. The operative time, hospital stay, peri-operative blood loss, post-operative Trendelenburg gait, walking ability, Harris score and peri-operative complications between two groups of operated patients, one using this approach and one other in which the Hardinge traditional approach was used, are studied. The purpose of our study was to review our initial experience with this modified “Thomine et al” lateral hip approach, with the intent of implementing a randomized controlled trial if the approach could be shown as safe and effective.

SURGICAL TECHNIQUE

The patient is positioned on the operating table in the lateral position with the affected side up. The pelvis and torso are firmly secured to the operating table with a rigid stabilization system. No special tables are used for this approach. The hip is prepared and draped using contemporary techniques that would allow the affected leg to be draped free and to be mobile in front of the table during the surgical procedure. The initial skin incision is adapted in length to about 20% of the subgroin pre-operative thigh diameter of each patient made on a longitudinal or slightly anterior curbed lateral line with 1/2 proximally and 1/2 distally of the tip of greater trochanter. After longitundinal fascia lata incision an automatic soft tissue retractor is used to open the interval between the tensor fascia lata and the gluteus maximus. The trochanteric bursa is incised to demonstrate the anterior and posterior borders of the gluteus medius and the vastus lateralis. The anterior one third of gluteus medius muscular insertion – depended on the sufficiency of the posterior remaining intact tendinous insertion of gluteus medius muscle and the local difficulties to reconstruct the hip joint due to local obesity, strong muscular patient system, long acetabular or femoral head diameters or great acetabular deformation – is elevated from the greater trochanter by using cautery knife. In every case more than 4 cm of posterior tendinous insertion of gluteus medius is left intact to stabilize intra-operatively and post-operatively the hip joint (Fig. 1). The incision proximally between the anterior elevated and posterior remaining part of gluteus medius is directed to its fibers interval to about 3 to 5cm in maximum, according the patient height, in distance from the tip of the greater trochanter to avoid injury to superior gluteus nerve branches. In very lax patients with small thigh subgroin diameter and small femoral heads we estimate intra-operatively by using trial retractors, if isolated anterolateral approach between hip abtuctors and tensor fascia lata is enough to reconstruct the joint without additional partial abductors elevation. Gluteus minimus is elevated and carefully reflected also. By using anterior and posterior thin Hohmann retractors in the musculocapsular interval a reversed “Τ” capsulotomy is performed. In continuance, placing the thin Hohmann retractors under the open capsule anterior and posterior and over the femoral head anterior dislocation of the hip joint is performed by adduction, external rotation and flexion. During the dislocation process another wide Hohmann’s retractor is placed posterior to the greater trochanter in order to retract behind the greater trochanter the gluteus maximus muscle and to protect from traction the posterior intact part of gluteus medius muscle and facilitate the hip dislocation. If dislocation is difficult previous subcapital osteotomy of the femur is made. Final femoral neck osteotomy is made at a level determined by preoperative planning. Using an oscillating saw, the femoral neck is cut at an angle of approximately 45° relative to the long axis of the femur and at an anteverted angle at about 15°. Haemostatic wax is temporary placed at the osteotomised femoral neck to eliminate the femoral neck bleeding. Two 6mm external fixators pins were temporary carefully placed 1 to 1.2 cm over the acetabular rim at about 10 and 2 o’clock and 30 degrees inclination into the iliac bone neck to protect the temporary elevated anterior part of the gluteus medius and the gluteus minimus, the tensor fascia lata in front and the gluteus maximus posteriorly during cup preparation (Fig. 2). Two Hohmann retractors are also placed to observe and prepare the acetabulum at about 5 o’clock on posterior and at about 7 o’clock on anterior acetabular ring displacing the femur posteriorly. The leg is kept externally rotated, adducted and flexed during acetabular preparation. Careful distal traction on the femur using a hook retractor or MIS hip cobra type retractors may help acetabular exposure in difficult cases. In difficult cases the approach is extended to the anterolateral interval between gluteus abductors muscles and tensor fascia lata and not proximally to avoid superior gluteus nerve injury. In this case careful ligation of anterior branches of lateral circumflex artery is needed to avoid excessive bleeding.

In difficult cases eccentric MIS reamers are use to facilitate the cup preparation. Femoral reconstruction is made in the flexed, external rotated and adducted hip position with the leg posed in a draped bag in the front side of the table using an elevating wide retractor placed posteriorly to the greater trochanter which levers the femoral bone out of the wound to protect the posterior part of gluteus medius muscle by traction. Using trial Zweymuller [34] stems in different deepness into the femoral canal and different lengths in the trial heads, stability of the hip is estimated in the reduction position under control of combined movements of a) extension, external rotation and adduction or b) full internal rotation, adduction and flexion. So, in some cases of dysplastic or low dislocated hips with a superior placement of the cup at the better bone stock position, elevating of the rectangular Zweymuller distally fixed stem into the femoral canal is used in combination with different head/neck lengths giving as a result not only the stability of the hip but sufficient level and strength of the remaining intact strong posterior part of gluteus medius muscle. [4] After final components implantation the hip is reduced and range of motion and leg lengths are confirmed. The reflected part of abductors is repaired to the greater trochanter with strong Vicryl stitches. Sometime, additional stitches are posed between abductors and vastus lateralis muscles insertion to reinforce the suture. The fascia lata, subcutaneous tissues and skin are sutured in place (Fig. 3A-J). For the first 6 weeks, patient begins walking with canes assistance and full weight bearing.

Patients and Methods

The study was completed at orthopedic department of Karpenissi Hospital, Karpenissi, Greece. Between October 2006 and September 2007, we implanted 55 patients (64 hips), 8 males (9 hips) and 47 women (55hips), with primary osteoarthritis using the bloodless and modified lateral Thomine et al (TA) hip approach with a rectangular titanium biologically fixed stem in combination with a Bicon Zweymuller [34] cup (Plus Orthopaedics AG/Smith & Nephew, Aurau, Switzerland) after a learning curve of about 3 years. We retrospectively reviewed also a second group of 88 patients (97 hips), 9 men (12 hips) and 79 women (85 hips), operated by total hip arthroplasty for hip osteoarthritis between February 2003 and March 2005 using a traditional lateral Hardinge approach (HA). These HA cases were the last cases of a total number of 702 patients operated in our clinic using the Hardinge lateral hip approach. In this study there are not included revision THA or high hip dislocation operated cases. The mean age of the 55 TA patients was 63.4 years (range, 49 – 82.3 years ) and the mean age of the 88 HA patients was 64.8 ( range, 42 – 84.2 years ) at the time of surgery. The skin incision length in the TA group of patients was 12cm (range: 8 to 15cm) corresponded to about 20% of the preoperatively estimated subgroin diameter of each patient. The mean subgroin thigh diameter was measured 59 cm (range: 42 το 74cm). The skin incision in the HA group of patients was 18cm (range, 16 to 24cm) not preoperatively estimated and not related to the subgroin diameter of each patient. Clinical and radiological parameters and complications were recorded pre-and postoperatively in both groups and the collected data concerning operative time, hospital stay, peri – operative blood loss, walking ability, postoperative Trendelenburg gait at 3 months and one year, Harris hip score at one year and peri-operative complications were compared between the two groups. In HA group of patients, data of the personal archive envelope of each patient was used. All patients were operated on by the same surgeon (NAC).

RESULTS

The hospital stay was 4 ± 1.2 days for TA approach patients and 6 ±2.1 days for HA patients. The mean operative time was estimated at 68 min (range, 55 to 81min) in the TA group and 72 min (range, 60 to 85 min) in the HA group. The mean volume of autologous blood transfusion was 245±75 ml in TA group and 515±130 ml in HA group of patients and the difference was statistically significant (95%, confidence interval). Not any TA patient needed complementary homologous blood transfusion more than one unit but on the contrary 11(12.5%) patients in the HA group needed complementary two or more homologous (allogenic) blood units. The preo-operative haematocrit and haemoglobin values of 38.7±9% and 12.8±0.6% respectively were transformed to 32.8±6% and 10.9±0.7% at first post-operative day and 30.9±2.2% and 10.1±1% the third post-operative day in the TA group of patients. The pre-operative haematocrit and haemoglobin values of 39.1±9% and 12.6±0.6% respectively were transformed to 28.6±6% and 10.1±1.1% at first post-operative day and 29.1±2.2% and 09.8±1% at the third post-operative day in the HA group of patients. The pre-operative Trendelenburg sign positive in 7 hips in TA group and in 13 hips in HA group was ameliorated in all cases postoperatively except one TA and three HA cases in very obese patients with many difficulties to reconstruct the hip joint, abductors muscles injury by traction from retractors during surgery and mal-technique. In other 2 (3.63%) TA cases and 9 (10.22%) HA cases a positive Trendelenburg sign, underlined with an average of 5°, was observed at 3 months pos-operatively but no significant difference was found between the operative and non operative side at one year. Two patients (3.62%) in TA group and 8 patients (9.09%) in HA group needed walking assistance of one cane at the opposite side after the usually used period of two post-operative months. None of the patients used both canes assistance after two post-operative months. The mean Harris hip score at one year followup was 88.7 (range, 62 -100) for TA patients and 87.9 (range, 59-100) for HA cases. One greater trochanter avulsion, one temporary sciatic nerve paresis, 3 superficial hematomas, one superficial infection, one brooker III ossification and one more than 1.5 cm leg lengthening case were the complications in the TA group of patients and 2 greater trochanter avulsions, 2 temporary sciatic nerve paresis, 2 early and 2 late dislocations, one serious pulmonary embolism case needed Emergency Unit, 2 Brooker III ossifications, 2 more than 1.5 cm leg lengthening cases and one revision at 2 years for metal-on-metal osteolysis were the complications in the HA group of patients. No any case of skin necrosis was observed in both groups (Table 1).

DISCUSSION

In Hardinge type or similar splitting transgluteal approaches reflection of portion of the abductors with a sleeve of vastus lateralis attached is performed either through the fascia or in modification bone removed from the greater trochanter. The divided abductors have then been repaired during incision closure. Although excellent results are reported using these approaches [2, 6, 7, 8, 11, 25, 26, 29, 30, 31] complications concerning damage to the superior gluteal nerve, postoperative limb or ossification problems are mentioned in some other works. [16, 18, 24] If the division of the gluteus medius is limited to a safe area extending 3 to 5 cm in maximum, according to the height of each patient and the local difficulties to reconstruct the joint, proximal to the tip of greater trochanter, the possibility of superior gluteal nerve injury is minimized. [6, 7, 31] The MIS approaches seem to eliminate the complications of traditional extensile exposures and attempt to facilitate more rapid rehabilitation of patients after surgery. But, mainly, in anterior or anterolateral MIS approaches there are usually difficulties to reconstruct the joint especially in obese patients and injury of lateral femoral cutaneous nerve or anterior or lateral circumflex artery branches can be occurred. Also hyperextension and excessive traction of the leg is needed on a special table or robotic systems for implants positioning elongating operative time and consequence peri-operative complications. Elevated rates of complications concerning femoral or ankle fractures and unsuitable implants positioning are reported by many authors. [1, 9, 14, 23] In the anterior or anterolateral traditional or MIS also approaches a postoperative dysmorphic skin scar also is sometime present in the frontal most usually visible part of the pelvis and thigh annoying young women while bathing or swimming or in time of erotic commingling. [21, 33] Minimal invasive surgery (MIS) is rather an evolution not a necessity. It is the evolutionary result of various parameters which day by day keep improving. We chose the Hardinge approach several years ago and as our experience progressed we tried to make smaller incisions and less soft tissue damage. Then when using “Thomine et al”[31] approach we were ready technically to apply a new modified lateral limited and adaptable hip approach. We take graduated steps to minimize the skin and soft tissue damage in order to reduce the complications reported in traditional lateral hip approaches or the complications of the recently used MIS approaches.

Our bloodless modified “Thomine et al” [31] (TA) hip approach is characterized except of no extension into the vastus lateralis by a) skin incision of about 20% of the subgroin diameter of the thigh to avoid the MIS standard mini incision of < 8-10cm problems in obese or muscular patients, b) careful and adaptable in width elevation of the anterior 1/3 bloodless and mechanically non very significant for hip abduction. [7, 15, 31] part of gluteus medius muscle according to local difficulties to reconstruct the hip joint and c) use of two 6mm in diameter external fixator pins over the acetabulum rim to protect stably without retractors possible soft tissue injury. This surgical technique is different from “Thomine et al” [31] and “Soni” [29] approach due mainly to absence of skin incision similarity for all cases and that the anterior elevated part of the gluteus medius is adapted in width to each different case to avoid surgical difficulties and soft tissue injury. In all cases the posterior 2/3 or at minimum 4 cm insertion of the posterior important for abduction ability and hip stability part of gluteus medius remains intact during surgery. [6, 7, 31] The main question in our study was if this modified approach is safe and effective in reconstruction of the hip joint without the serious problems of traditional lateral approaches related to Trendelenburg gait and postoperative limb.

The absence of Trendelenburg gait or limb problems in the majority of our cases in three months and one year post-operatively is probably related to the careful avoidance of superior gluteus nerve injury branches and protection of the posterior part of gluteus medius muscle by stably fixed during acetabular reconstruction 6mm in diameter external fixator pins. The elevation of the trochanteric region using a wide rectractor during hip dislocation and during femoral reconstruction is related also with the absence of greater trochanter fractures or posterior part of gluteus medius traction injury. Our Trendelenburg positive cases are mainly related to irregular abductors muscles traction injury in obese patients. In difficult cases, if muscular incision is extended during surgery, some branches of superior gluteus nerve may be damaged but they are related mainly to the anterior part of medius gluteus internal rotation insufficiency and not to the abduction hip ability. This probably explains the absence of limp problems in the majority of patients with lateral transgluteal approaches. [6,25,26,30,31] In difficult cases it is preferable to elevate and reinsert carefully more in width anterior part of the gluteus medius instead of make many irregular muscles and skin traction injuries form a restricted and difficult approach. The anterior part of gluteus medius is the main internal rotational component of the abductors and the posterior part the most important for hip abduction component and this part remain intact during a careful lateral transgluteal approach. [5, 7, 12, 31] The low blood loss rates in our cases seem to be related to the avoidance of lateral circumflex artery injury and are in accordance with the results of “Thomine et al” traditional approach. [6, 7, 31] The observed more peri-operative bleeding in traditional Hardinge approach cases is mainly related to the injury of the lateral circumflex artery branches in the anterior 1/3 of the vastus lateralis muscle as also to the accompanied extensive for all cases skin or other soft tissue incisional injury. The total also peri-operative complications rates in the adaptable TA approach cases are also very low mainly due to avoidance of excessive surgical difficulties to reconstruct the joint and by eliminating the anesthesia and surgical time. There are more complications in non adaptable MIS skin incisions. [19] There were not observed skin necrosis problems in our cases by avoiding excessive skin traction injuries. The skin surgical scar in the lateral side of the thigh even a little more extensive is more acceptable especially by young women. On contrary, in other MIS approaches with a mini not adaptable skin incision, cicatrization, skin necrosis and dysmorphic scars are usually present. [10, 17, 19, 21] Τhe bloodless “Thomine at al” [31] modified and adaptable to the subgroin diameter lateral hip approach has the advantages of minimal blood loss, limited operating time, low complications rates, early rehabilitation and no permanent Trendelenburg or limb problems in patients. The efficacy of our limited hip approach is comparable to other recently used lateral MIS hip approaches. [13, 22] It can be easy and safely used without special tables, without traction or hyperextension leg problems and without need of excessive exposure to x-rays from robotic systems to control the implants position and without long time surgery dependent complications. It can be used in all cases of total hip arthroplasties except revision surgery or high congenital hip dislocation cases in which more extensive approaches usually are needed. It is maybe more muscles invasive than other MIS hip approaches but not invasive in any important vessels branch, avoiding bleeding and surgical time loss for ligation processes, not difficult, more safe, not complicated and without accompany of any visible anterior or anterolateral anti-aesthetic skin scar. Nowadays with the help of the technology and new improved surgical tools we are still working to improve the results of this surgical approach to the patients and their rehabilitation.

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Christodoulou Nikolaos, MD, PhD. http://www.christodoulou-n.blogspot.com/ E-mail: chnortho@yahoo.gr Orthopedic Surgeon - Doctor of Orthopedics, University of Athens - 20 years Chief Clinical Director of Orthopedic Karpenissi Hospital Department- « Ancient Résident des Hôpitaux de Paris ( A-Paré ) », Actually Director of one of the Hip and Knee Reconstructive Surgery Departments in 'White Cross" Therapeutic Private Hospital, Papadiamantopoulou 16 & Sisini 1 street, 11528, Athens, Greece. Οut patinets Clinic, Tuesday and Thirsday, 4-7 p.m., Tel. : 210-7214156, 6950-563656, 6932-665965, 210-6013410. http://www.lefkos-therapeftiko.gr/ . Orthopedic Surgeon : Hip and Knee arthroplasties, ΙΑΣΩ General Hospital, Messogion 264. Athens. Monday and Wensday, 6.30-8.30 p.m. (Out patients Clinc, R. 120, 1st floor), tel.: 6932.665965, Secretary: 6950.563656. Special Surgery: Hip and knee arthroplasties, Surgical correction of leg - foot deformities, Special arthroplasties for congenital hip dislocation cases.
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