Iliofemoral Approach Research Articles

In-out-in technique for acetabular fractures: is it really good?

We have read the article “A safe technique of anterior column lag screw fixation in acetabular fractures” by Sen et al. with great interest [1]. We congratulate the authors for describing such a novel technique and obtaining excellent results in their patients. The in-out-in technique looks promising in terms of no requirement for an image and avoiding articular penetration during screw insertion. However we have some questions and concerns about this technique which is stopping us from using it in our patients. The iliofemoral approach was used in the majority of cases and the lateral femoral cutaneous nerve was preserved and retracted medially. This nerve is commonly damaged in this approach [2]. In how many cases of their series were the authors able to preserve it? In the current scenario where there is ongoing debate regarding optimal fixation of a transverse fracture with one or two plate , the author is using only two screws with plate and sometimes without plate. We feel that screws alone are not sufficient and they should be supplemented with plate. The authors noted that two screws may be placed in the anterior column through this safe corridor, if room is available. With the anatomical constraints of the bony thickness of the anterior column, it is difficult to insert two screws. Hong et al. established that the transverse section of the anterior column is triangular in shape and the path for the lag screw placement is 10.5 ± 0.8 mm in diameter. They recommended that it is possible to safely insert only one 6.5-mm lag screw in the anterior acetabular column [3]. Chen et al. suggested that the anterior column in males would accommodate a 6.5-mm lag screw very well, but this does not apply to all females. The use of a 6.5-mm screw in females might violate the bony margin and should only be used after careful evaluation of the dimensions of the anterior column. Inserting two screws in such a narrow space is indeed technically difficult [4]. Two screws alone were used in six patients out of whom two were females. We have doubts about the hold of such screws. Would the authors elaborate whether they inserted 4.5-mm or 6-mm screws in such cases? In one of the cases three screws were inserted. The combined diameter of the three screws would be more than the diameter of the anterior column (10.5 ± 0.8 mm). It is technically not possible to insert three screws in the anterior column. How the authors managed to do this is beyond our understanding. What was the post-op protocol following this technique? Does this protocol differ depending upon whether fixation was with screw alone or with screw and plate? Safe and successful application of this technique is critically dependent upon the surgeon’s ability to insert the guide wire and drill in an accurate direction. Multiple attempts at drill bit or screw insertion in such a narrow corridor of cancellous bone may create a void and will affect the purchase of the final screws. To achieve reduction and fixation of the acetabular fracture using screws, the corridors of bone through which these screws pass must contain sufficient cancellous and cortical bone to allow safe passage of the necessary drill bits and screws, and to obtain sufficient fixation to achieve adequate acetabular stability [5]. The anterior superior iliac spine was osteotomised and after finishing the surgery was fixed back to the Ilium with two small fragment screws. However Fig. 5b shows that it was fixed with only one screw. Although the current series comprised predominately young patients, who have a good bone stock, do Sen et al. recommend this technique in osteoporotic patients? We once again congratulate the authors for describing this technique and the excellent results they have obtained.

Comminuted quadrilateral plate fracture fixation through the iliofemoral approach

Comminuted quadrilateral plate fracture with medial displacement is a technically difficult fracture to treat. Minimal bone stock, proximity to the hip joint with limited surgical access, and difficulty in obtaining a stable fixation at this area, contribute to the surgical challenge of open reduction and internal fixation. Fixation of a medial buttress plate in an infrapectineal fashion is a well-described technique to address such fractures. However, this plate alone may be inadequate to buttress all the fragments in a grossly comminuted quadrilateral plate fracture. An additional spring plate is often placed underneath the infrapectineal plate to hold the fracture fragments. Conventionally, these spring plates are fixed to the ilium superiorly while the other end buttresses the quadrilateral plate when placed underneath the infrapectineal reconstruction plate. The standard ilioinguinal approach and modified Stoppa approach have been described for the surgical access to the quadrilateral plate. Both the approaches have some limitations in addressing quadrilateral plate fracture. The ilioinguinal approach requires extensive dissection and mobilisation of inguinal neurovascular bundle. The modified Stoppa approach does not permit visualisation of the entire anterior column and the hip joint. The authors, in this article, describe the fixation of the comminuted quadrilateral plate fracture through the iliofemoral approach combined with a medial ilioinguinal window. The technique involves fixation of a spring plate (Allis T-plate) at right angle to the infrapectineal buttress plate (90°–90° plate construct). The vertical limb of the T-plate is fixed to the iliopectineal eminence whereas the horizontal limb buttresses the quadrilateral plate Hence, this technique addresses fractures of both the iliopectineal eminence and the quadrilateral plate. Other than that, the iliofemoral approach permits direct visualisation of the entire anterior column and the hip joint without the necessity to dissect the ilioinguinal neurovascular structures.

A safe technique of anterior column lag screw fixation in acetabular fractures

Conventional anterior column lag screw fixation in acetabular fracture is a difficult technique that has potential risks of vascular injury, hip joint penetration and excessive radiation exposure. We propose a safe technique of anterior column lag screw fixation (in-out-in technique) and present the outcome. Twenty-seven acetabular fractures were operated through an iliofemoral approach, where the 'in-out-in technique' of lag screw fixation was a part of the surgical procedure. The technique involved insertion of a malleolar screw (4.5 mm) or 6.5 mm partially threaded cancellous screw from the outer side of the iliac wing, 0.5-1 cm posterior and inferior to the anteroinferior iliac spine. The screw comes out of the bone surface to re-enter into the anterior part of iliopectineal eminence, and finally gains purchase in the lateral part of superior pubic ramus. The screw fixation procedure was under direct visualization without resorting to an image intensifier. The average follow-up of the patients was at 18.6 months (range 12-36 months). No loss of reduction, joint penetration or visceral and neurovascular injury were documented. The average duration of surgery was 70 min and blood loss was 290 ml. All fractures were united after an average period of 2.8 months. Excellent to good functional outcome was observed in 24 patients (88 %), on evaluation with Merle D'Aubigne and Postel score at the latest follow-up. We conclude that the 'in-out-in technique' is a safe and effective method of anterior column lag screw fixation in acetabular fractures. It provides rigid stability and minimizes surgical duration, radiation exposure and intra-operative complications.

THE APPLICATION OF ANTERIOR ILIOFEMORAL APPROACH IN TOTAL HIP REPLACEMENT IN HUE UNIVERSITY HOSPITAL

Background: Total hip replacement using mini-invasive approach including the anterior iliofemoral approach technique has become popular in Vietnam and all over the world in treating hip diseases. Including the anterior iliofemoral approach. This research is to assess the result of the total hip replacement using the anterior iliofemoral approach. Materials and method: A prospective study on 32 patients at Orthopaedics Deparment of Hue University Hospital that meet the criteria of selection. The outcome after 3 months and 6 months follow up is assessed using Charnley criteria. Surgical approach, surgical technique, blood transfusion, post operative complications, and postoperative X-Ray are also assessed on these patients. Results: Surgical incision length is 9.6±1.9cm. The lower and cross-legged techniques are applied on 100% patients. Average time of operation: 108.4 ± 12.4 minutes. 15.6% needs blood transfusion in and after operation. There are no complications during operation. Inicision superficial infection rate is 3.1%. Post operative X-Rays show good result. Average time of hospital stay: 12.1±8.1 days. 3 months follow up rate is 93.4%, 6 months rate is 50%. Charnley’s very good and good result after 3 moths is 73.3%, after 6 months is 75.0%. Conclusion: The total hip replacement using the anterior iliofemoral approach has more than 70.0% Charnley’s very good and good result after 3 months and 6 months follow up. There are no complications during operation. Time of operation and post operation are short. Incision gives good exposure for intraoperative manipulations.

Anterior hip subluxation following fixation of a T-shaped acetabular fracture through an extended iliofemoral approach

We report the case of a 34-year-old female patient who, six week following her acetabular fracture ORIF through an extended iliofemoral approach, presented with anterolateral incomplete dislocation of the femoral head. In the absence of joint incongruence as demonstrated on radiographs and CT images, a capsular tightening was performed via the anterior Hueter approach. This capsular plasty stabilized the hip for 2 years, but gradual osteoarthritis deterioration resulted in the need for arthroplasty. At the 2-year follow-up, this secondary arthroplasty showed satisfactory result. The substantial muscle exposure of the lateral aspect of the acetabulum and the circumferential capsulotomy related to the use of the iliofemoral approach were retained as factors promoting this complication. In case early postoperative mobilization is impossible, temporarily maintaining the limb in abduction and flexion can be recommended after an extended iliofemoral approach with circumferential capsulotomy.

A Transepiphyseal Fracture of the Femoral Neck in a Child With 2 Widely Displaced Salter-Harris III Fragments of the Capital Femoral Epiphysis

To our knowledge, this is the first report of a transphyseal fracture of the femoral neck with a fracture of the capital femoral epiphysis involving 2 widely displaced Salter-Harris III fragments in a child. Preoperative surgical lateral radiographs of the hip of a 14-year-old boy clearly showed an anteriorly dislocated femoral head fragment. However, the overlapping ischium, soft tissue, and an anteriorly dislocated femoral head fragment caused a posteriorly dislocated fragment of the split femoral head to be overlooked on the radiographs. The emergent nature of the injury resulted in the performance of an open reduction without further imaging studies. Based on the initial evaluation, an anterior iliofemoral approach was chosen, which made it difficult to locate the posteriorly dislocated main fragment of the split femoral head. This case highlights that plain radiographs do not always provide adequate information for such injuries. Computed tomography or magnetic resonance imaging should be employed to enable accurate diagnosis and appropriate treatment for fracture-dislocations of the pediatric hip.

Die operative Behandlung der Azetabulum-T-Fraktur über eine chirurgische Hüftluxation oder einen Stoppa-Zugang

Anatomic reduction and stable fixation by means of tissue- preserving surgical approaches. INDICATIONS Displaced acetabular fractures. Surgical hip dislocation approach with larger displacement of the posterior column in comparison to the anterior column, transtectal fractures, additional intraarticular fragments, marginal impaction. Stoppa approach with larger displacement of the anterior column in comparison to the posterior column. A combined approach might be necessary with difficult reduction. CONTRAINDICATIONS Fractures > 15 days (then ilioinguinal or extended iliofemoral approaches). Suprapubic catheters and abdominal problems (e.g., previous laparotomy due to visceral injuries) with Stoppa approach (then switch to classic ilioinguinal approach).Surgical hip dislocation: lateral decubitus position. Straight lateral incision centered over the greater trochanter. Entering of the Gibson interval. Digastric trochanteric osteotomy with protection of the medial circumflex femoral artery. Opening of the interval between the piriformis and the gluteus minimus muscle. Z-shaped capsulotomy. Dislocation of the femoral head. Reduction and fixation of the posterior column with plate and screws. Fixation of the anterior column with a lag screw in direction of the superior pubic ramus. Stoppa approach: supine position. Incision according to Pfannenstiel. Longitudinal splitting of the anterior portion of the rectus sheet and the rectus abdominis muscle. Blunt dissection of the space of Retzius. Ligation of the corona mortis, if present. Blunt dissection of the quadrilateral plate and the anterior column. Reduction of the anterior column and fixation with a reconstruction plate. Fixation of the posterior column with lag screws. If necessary, the first window of the ilioinguinal approach can be used for reduction and fixation of the posterior column.During hospital stay, intensive mobilization of the hip joint using a continuous passive motion machine with a maximum flexion of 90 degrees . No active abduction and passive adduction over the body's midline, if a surgical dislocation was performed. Maximum weight bearing 10-15 kg for 8 weeks. Then, first clinical and radiographic follow-up. Deep venous thrombosis prophylaxis for 8 weeks postoperatively.17 patients with a mean follow-up of 3.2 years. Ten patients were operated via surgical hip dislocation, two patients with a Stoppa approach, and five using a combined or alternative approach. Anatomic reduction was achieved in ten of the twelve patients (83%) without primary total hip arthroplasty. Mean operation time 3.3 h for surgical hip dislocation and 4.2 h for the Stoppa approach. Complications comprised one delayed trochanteric union, one heterotopic ossification, and one loss of reduction. There were no cases of avascular necrosis. In two patients, a total hip arthroplasty was performed due to the development of secondary hip osteoarthritis.

Biventricular ICD Implantation Using the Iliofemoral Approach: Providing CRT to Patients with Occluded Superior Venous Access

A 32-year-old woman with a history of nonischemic dilated cardiomyopathy, left bundle branch block, left ventricular ejection fraction of 0.15, and New York Heart Association Class III congestive heart failure, despite optimal medical treatment, was referred for cardiac resynchronization therapy with implantation of an implantable cardioverter defibrillator. The patient had prior chemotherapy for non-Hodgkin's lymphoma and was shown to have chronic total occlusion of the superior vena cava (SVC) by magnetic resonance imaging. Cardiac resynchronization was accomplished with an iliofemoral approach without complications resulting in marked clinical improvement. We conclude that the iliofemoral approach allows transvenous implantation of cardiac resynchronization therapy in patients with superior vena cava occlusion.

Operative management of acetabular fractures: a retrospective analysis of 46 cases

Objective To discuss our experience of diagnosing and treating acetabular frac-tures. Methods From January 1999 to December 2006, a total of 48 acetabular fractures in 46 patients were treated surgically, including 18 hips of Type A, 22 hips of Type B, and 8 hips of Type C. Ilioinguinal approach was adopted in 6 hips, Kocher-Langenbeck approach in 27 hips, combined an-terior and posterior approach (Ilioinguinal plus Kocher-Langenbeck) in 13 hips, and extended iliofemoral approach in 2 hips. Results Anatomical reduction was obtained in 32 hips (66.7%), satisfactory reduction in 11 hips (22.9%) and poor reduction in 5 hips(10.4% ). All the cases were followed up for 4 months to 4 years, with an average of 29 months. They were evaluated according to D'Aubigne and Postel criteria for joint functions. Twenty-six hips were rated as excellent, 9 hips as fine, 9 hips as fair and 4hips as poor. The good-excellent rate was 72.9%. Conclusions CT three-dimensional reconstruction is a great help for a doctor to make accurate diagnosis of the type of complex acetabular fractures and thus select an appropriate operative approach. Preoperative simulation in vitro on a pelvic specimen also helps a doctor reduce operative time and improve operative rcsuhs. Maximal anatomical reduction and good internal fixation are es-sential for satisfactory outcome. Key words: Acetabular; Fractures; Fracture fixation,internal

Experiences with Wagner's hip joint cup endoprosthesis. Indication, results complications

In the last 5 years the authors have installed Wagner hip joint cup prostheses in 260 patients. Of these, 211 were implanted with an iliofemoral approach after Smith-Petersen, severing the pelvitrochanterian musculature, and 49 with a lateral approach after Watson-Jones, modified after Harris, with temporary ablation of the trochanter major. Altogether, 160 of the patients thus treated were followed up 3, 6, 18, 24, 30 and 36 months after surgery. The most common postoperative complication, found in 36% of those examined, was periarticular calcification, which was rated as severe in 5%, moderate in 15% and slight in 16%. Even though the periarticular ossifications did not necessarily lead to severe restrictions of movement, the patients with severe and moderate calcifications who were examined after 3 years were found to have a reduction of function of approx. 24% in flexion and extension, approx. 50% in abduction and adduction and approx. 57% in internal and external rotation compared with preoperative findings. In contrast, patients with no significant periarticular ossifications were found to have a definite improvement in motility 3 years after surgery as compared to their preoperative conditions. Further important complications were 2 infections, 3 fractures of the neck of the femur, 3 slipped prostheses and 23 cases of loosening of the prosthesis. The number of loosened prostheses (9% of those examined) represents a marked increase as compared to the loosening rate with conventional total hip replacements.(ABSTRACT TRUNCATED AT 250 WORDS)

The results of Chiari pelvic osteotomy in adolescents with a brief literature review.

Chiari medial displacement osteotomy is a procedure that uses the cancellous bone of the ilium to contain the femoral head and bear weight. It is the most contraversial osteotomy of the hip joint. This study was therefore conducted to determine the results of this osteotomy with mid-term follow-up in children. From 1995 to 2004, 20 Chiari pelvic osteotomies (in 18 patients) were performed. There were 15 male and 3 female patients. The average age at operation was 12.6 years and the mean follow-up was 54 months. The operative technique was as described by Chiari. An iliofemoral approach was used without utilizing a traction table. If there was anterior or anterolateral uncoverage of the femoral head, bone graft augmentation was performed. The angle of the osteotomy averaged 12 degrees , with the distance from the acetabulum averaging 3.2 mm. The average displacement was 42%. Of the 20 Chiari osteotomies, 11 were categorized as excellent, 8 as good and one as fair in terms of clinical and radiological results. Student's t test statistics showed improvements in all radiologic parameters of the hip joint (Sharp angle, center-edge angle and coverage of the femoral head). Graft resorption was observed in 25% of the patients. There are very rare indications of Chiari osteotomy in patients younger than 10 years. Because of the high rate of graft resorption, Chiari osteotomy should be the last treatment option when there is anterior or anterolateral uncoverage of the hip joint.

Long-Term Results in Surgically Treated Acetabular Fractures Through the Posterior Approaches

The long-term results of surgically treated displaced acetabular fractures using the posterior approaches and the possible role of the greater trochanteric osteotomy in the development of heterotopic ossification (HO) are still somehow controversial despite extensive publications. Seventy-five patients with an acetabular fracture and displacement of at least 3 mm were surgically treated during a 6-year period. The duration of the follow-up was from 10 to 15 years, with a mean of 12.5 years. The over-all satisfactory clinical result, grouping together the excellent and good results, was 80%. There was a good correlation between clinical and radiologic results. The most common complication was HO, observed in 19 patients (25.3%). The extended iliofemoral approach had the greater incidence of HO (40%), whereas the least was observed in the Kocher-Langenbeck approach with osteotomy of the greater trochanter (21.4%). Moreover, posttraumatic osteoarthrosis was observed in eight patients (10.7%) and osteonecrosis of the femoral head in six (8%). Surgical treatment of the acetabular fractures aiming at anatomic reduction of the acetabulum and congruency with the femoral head is the prerequisite for a favorable functional outcome in the long term. In most cases, the Kocher-Langenbeck approach is adequate. Trochanteric osteotomy is indicated only for fractures extending toward the anrerior column and this facilitates exposure, anatomic reduction, and fixation. No statistically significant difference was found between the surgical approach and heterotopic bone formation.

Posterior wall osteotomy to facilitate reduction of complex acetabular fractures

Acetabular fractures have long been a challenge for the experienced orthopaedic surgeon. Displaced fractures are known to be best treated by anatomical reduction and stable fixation. The quality of the reduction strongly correlates with the eventual outcome. It is essential during the operation to obtain adequate exposure of the fracture in order to aid reduction and fixation. The choice of exposure is critical, and is largely dictated by the fracture pattern. The decision is relatively straightforward with single column fractures; posterior column fractures require a posterior approach and anterior column fractures require an anterior approach. The situation becomes a great deal more complex when both columns are involved. There are situations when the acetabular fracture is so displaced that both columns require direct attention. This can be achieved by various different approaches. A double sequential, double simultaneous or an extensile approach such as the extended ilio-femoral or triradiate approach can be used. All of these techniques require lengthy surgery times with large dissections, significantly increasing the potential risks for the patient.

Nouvelle variété de fracture postéro-supérieure de l’acétabulum: Stratégie thérapeutique à propos d’un cas

We report a new variety of acetabular fracture. This posterosuperior fracture affected the acetabular roof and the iliac wing as other superior fractures and presented a supplementary fracture line disjoining the major part of the posterior wall. Two our knowledge, in a series of 940 fractures of the acetabulum, Letournel alone described two cases of superior fractures involving the roof with a slightly anterior fracture line in the iliac wing but with an intact posterior wall in both cases. The patient was treated by osteosynthesis via the iliofemoral approach described by Judet-Letournel. This approach was warranted to achieve simultaneous exposure of both columns and the posterior wall which was separated from the proximal fragment by a secondary fracture line. At six months, the functional result was considered good as assessed by the Postel-Merle-d’Aubigné score. This case widens the Letournel classification and emphasizes the importance of computed tomography to evaluate, in superior fractures of the acetabulum, the volume of the posterior wall fragment and its continuity with the cranial portion of the acetabulum and the iliac wing. For fixation, the surgical approach must be chosen individually according to the position of the fracture lines visualized on the preoperative computed tomography.

MicroHip: a minimally invasive procedure for total hip replacement surgery. A modified Smith-Peterson approach

In this article we present the surgical technique of our anterior minimally invasive approach to the hip joint. This is aligned along an interneural plane and makes the approach truly minimally invasive. This technique is performed in a lateral decubitus position on a normal operating table; there is not a need for a specific orthopaedic or fracture table. As leg traction is not necessary, this enables the approach to be used routinely. Most of the instruments used for this procedure are standard instruments, only the acetabular reamers and positioners are angulated and specifically designed. The angled instruments (MI – minimally invasive) are especially useful when performing hip replacement in obese patients. An excellent view of both the acetabulum and the proximal femur can be obtained through an incision of only 6-8 cm, using this MI approach. The approach follows the interval between the tensor fascia lata muscle and the sartorius muscle using a section of the anterior iliofemoral approach described by Smith-Peterson. No tendon or muscle is cut or detached. The joint capsule is split and preserved in toto. The hip joint is not dislocated and we perform the osteotomy of the femoral neck in-situ. To date we have performed over 500 MicroHip™ operations. We have not observed any nerve lesions or fractures of the trochanter. Our experience to date shows that the method we have developed allows us to operate reliably on virtually any patient. Preliminary results also show that important factors like length of stay, pain, blood loss and return to work can be reduced significantly. The MicroHip™ technique is being used by more and more different clinics all over the world and can be applied with success after suitable training.

Langzeitergebnisse nach Azetabulumfrakturen unter Berücksichtigung von heterotopen Ossifikationen

Arthrosis, necrosis of the femoral head and heterotopic ossification (HO) tend to decline the outcome of acetabular fractures despite of good fracture reduction. In this study functional outcome and degree of HO were analyzed due to fracture type and surgical approach. The aim of this study is to delineate wether minimization of soft tissue damage increases the functional outcome. 55 patients with surgically treated acetabular fractures (mean age: 40.4 (20-81) years, male 43, female 12) where retrospectively evaluated with a mean follow-up of 7.7 (4.4-12.3) years. Fractures were classified according to the Orthopaedic Trauma Association (OTA), functional outcome was scored by D'Aubigné-Postel and the degree of HO was defined by Brooker's classification. Following the OTA the distribution of fractures was: A-24 (44 %), B-23 (42 %) and C-8 (15 %). Mean D'Aubigné Index (max. 18 points) was 15.2, distributed to fracture type: A-15.9, B-15.0 and C-13.6. 32 % of all heterotopic ossifications were classified as Brooker 0, 10 % as Brooker 1, 29 % as Brooker 2 and Brooker 3 each, whereas Brooker 4 ossifications were not observed. 2/3 of the severe ossifications were observed using extended approaches or in case of type C fractures. The iliofemoral approach showed the tendency of fewer ossifications compared to extended approaches. Decrease of soft tissue damage during acetabular surgery plays an important role to improve outcome. Due to the higher risk of wrong implant position and insufficient reduction using a soft tissue sparing approach, we recommend a CT scan postoperatively to evaluate reduction and osteosynthesis.

Periacetabular Osteotomy for Treatment of Acetabular Dysplasia through Iliofemoral approach

Periacetabular Osteotomy for Treatment of Acetabular Dysplasia through Iliofemoral approach

MicroHip: A minimally invasive procedure for total hip replacement surgery A modified Smith-Petersen approach

In this article we present the surgical technique of our anterior minimally invasive approach to the hip joint. This is aligned along an interneural plane and makes the approach truly minimally invasive. This technique is performed in a lateral decubitus position on a normal operating table; there is no need for a specific orthopaedic or fracture table. As leg traction is not necessary, this enables the approach to be used routinely. Most of the instruments used for this procedure are standard instruments; only the acetabular reamers and positioners are angulated and specifically designed. The angled instruments (MI minimally invasive) are especially useful when performing hip replacement in obese patients. An excellent view of both the acetabulum and the proximal femur can be obtained through an incision of only 6-8cm, using this MI approach. The approach follows the interval between the tensor fascia lata muscle and the rectus muscle using a section of the anterior iliofemoral approach described by Smith-Petersen. No tendon or muscle is cut or detached. The joint capsule is split and left in place. The hip joint is not dislocated and we perform the osteotomy of the femoral neck in situ. To date we have performed over 500 MicroHip operations. We have not observed any nerve lesions or fractures of the trochanter. Our experience to date shows that the method we have de-veloped allows us to operate reliably on virtually any patient. Preliminary results also show that important factors like length of stay, pain, blood loss and return to work can be reduced significantly. The MicroHip technique is being used by more and more different clinics all over the world and can be applied with success after suitable training.

MicroHip: A Minimally Invasive Procedure for Total Hip Replacement Surgery: A modified Smith-Petersen approach

In this article we present the surgical technique of our anterior minimally invasive approach to the hip joint. This is aligned along an interneural plane and makes the approach truly minimally invasive. This technique is performed in a lateral decubitus position on a normal operating table; there is no need for a specific orthopaedic or fracture table. As leg traction is not necessary, this enables the approach to be used routinely. Most of the instruments used for this procedure are standard instruments; only the acetabular reamers and positioners are angulated and specifically designed. The angled instruments (MI minimally invasive) are especially useful when performing hip replacement in obese patients. An excellent view of both the acetabulum and the proximal femur can be obtained through an incision of only 6-8cm, using this MI approach. The approach follows the interval between the tensor fascia lata muscle and the rectus muscle using a section of the anterior iliofemoral approach described by Smith-Petersen. No tendon or muscle is cut or detached. The joint capsule is split and left in place. The hip joint is not dislocated and we perform the osteotomy of the femoral neck in situ. To date we have performed over 500 MicroHip operations. We have not observed any nerve lesions or fractures of the trochanter. Our experience to date shows that the method we have de-veloped allows us to operate reliably on virtually any patient. Preliminary results also show that important factors like length of stay, pain, blood loss and return to work can be reduced significantly. The MicroHip technique is being used by more and more different clinics all over the world and can be applied with success after suitable training.

Operative management of complex acetabular fractures of Letournel classification

目的 探讨 Letournel分型复杂髋臼骨折的诊断和治疗.方法 75例 Letournel分型复杂髋臼骨折,术前经骨盆 CT三维重建明确诊断分型后,分别采用前、后入路,前后联合入路及笔者改良的髂股入路显露并复位 ,AO重建钢板内固定.结果随访 6个月～ 8年 ,平均 3年 10个月 ,按关节功能 D' Aubigne和 Postel 6分法及 X线片表现 Epstein标准评价,优 34例,良 28例, 可 8例,差 5例,优良率为 82.57%.结论术前完善的影像学资料、骨盆模型标本的体外模拟、使用合理的手术入路、术中尽可能的解剖复位及 AO重建钢板内固定是获得良好结果的基础。