Becker's ASC Review

26 Executive Briefing Sponsored by: T he anterior technique has continued to grow in popularity amongst surgeons and patients who are looking for a faster recovery to total hip replacement. The propagation of outpatient total joints has fueled the demand for anterior total hip arthroplasty because of its early postoperative benefits. 1.2.3.4. Minimally invasive anterior approaches that follow an intermuscular and internervous pathway, protecting and preserving periarticular structure, can provide the following advantages for the patient: • Significantly shortened rehabilitation 1 • Faster return to daily activities 2 • Decreased postoperative pain 3 • Immediate postoperative muscle tone preservation 4 • Decreased blood loss 4 • Shorter hospitalization 4 • Reduced risk of dislocation 1, 3, 4 Over the last decade, the adoption of the anterior technique has proliferated and with that, the technique itself has evolved. While the basis of the technique and muscle interval remains the same, the anterior technique takes on many variances based on a surgeon's education and preferences. Soft tissue releases to achieve femoral exposure is one of these variances. According to recently published research, "The key to obtaining femoral exposure is performing sequential capsular and soft tissue releases along the medial aspect of the greater trochanter and femoral neck under tension. This ultimately allows the greater trochanter to clear the posterior wall of the acetabulum. The goal is to release the minimum amount of soft tissue attachments to translate the femur laterally and elevate it up and out of the wound." 5 With the goal to release the minimum amount of soft tissue attachments to preserve joint stability, is it possible to not release any attachments? A few surgeons say yes – for some of their cases. Anterior MIS (AMIS), taught at courses offered by the Medacta Orthopaedic Research and Education (M.O.R.E.) Institute, utilizes special instrumentation, including a mobile leg positioner to assist in femoral exposure. The AMIS technique has a sequential femoral release of the No. 1. Pubo-femoral ligament, No. 2 Ischio-femoral ligament and No. 3 Conjoint tendon (Obturator internus/Superior gemellus). Diagram courtesy of Dr. Frederic Laude, CMC, Paris, France Surgeons, like Thomas Ellis, MD and Tyler Goldberg MD , have refined their AMIS technique and have reached the goal of minimal femoral release. Dr. Tyler Goldberg: After performing more than 1,200 anterior THA's, I became aware of the "no-release technique" from Frédéric Laude . At first, I did not believe it was possible but I know Dr. Laude is a truthful and master surgeon. I was able to visit Dr. Laude in February. I saw the technique first hand and was literally blown away. I, like others, believed for years the key to the technique was the mobilization of the femur. I have come to understand the femoral preparation does not require complete mobilization. It can be broached "down". However, the ability to prepare the femur requires two specific tools that Medacta provides. First, the orthopedic table with mobile leg positioner promotes positioning of the leg into an extended, externally rotated position that is required to access the femur. Second, Medacta's newest, specially-designed "AMIS" broaches clear the skin and allow broaching in a deeper position. Once I learned the technique, I immediately incorporated it into my practice. As I have become more comfortable with the technique, I now only release both ligaments 25 percent of the time. I release only the pubofemoral ligament approximately 50 percent of the time and no releases are 25 percent. The anterior approach is so anatomical I honestly have a difficult time telling which patients I have released or not. I also don't believe we have the tools specific enough to measure such a small change in technique. However, leaving a smaller footprint reconstructing a patient's hip gives me great personal satisfaction. No release anterior technique: No way…yes way

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