Minimally invasive surgery anterolateral approach in total hip arthroplasty

Abstract

In recent years there has been increasing interest in the concept of limited incision or minimally invasive hip replacement. The proposed advantages include reduced blood loss, shortened operative time, decreased pain, reduced morbidity, shortened hospital stay and accelerated recovery. While there has been a lag in the collection of scientific evidence in support of these proposals, the concept has been enthusiastically received by patients and hip joint replacement through limited incisions is now widely practiced in North America. A variety of classification systems have been proposed (eponymous, approach to the hip, number of incisions etc.) to describe a variety of surgical techniques. One that has attracted attention, because of its potential influence on morbidity and speed of recovery, is the classification of approaches into: a. intermuscular; and b. transmuscular or transtendinous [1]. Examples of the transmuscular or transtendinous approach, in which muscles are detached for exposure and reattached during closure, include the limited incision direct lateral [2] and the limited incision or mini postero-lateraL as popularized by Dorr and by Sculco [4,5]. Examples of the intermuscular approach include the two-incision technique popularized by Mears and Berger [6] although recent cadaveric studies have revealed substantial damage to the muscles and tendons underlying the posterior incision of this surgical technique [7] A more recent proposal has been the adaptation of a limited incision through the natural interval between the posterior border of the tensor fascia lata and anterior border of gluteus medius. This anatomic approach, first described by Sayer in 1876, was popularized by Watson-Jones in 1936 for the management of fractures of the proximal femur, and modified by Roettinger in 2000 for its use in total hip replacement [8]. This truly intermuscular approach has a number of advantages, with particular reference to the two-incision approach developed by Mears and Berger: . Patient positioned lateral, not supine. Single incision, not two. Muscle dissection not blind. Lateral cutaneous nerve not injured. Lateral femoral circumflex vessels not in field. Femoral preparation under direct vision . Trial reduction with broach in place. Fluoroscopy not required. Incision easily extended if needed. © 2007 Springer Medizin Verlag Heidelberg.