Becker's ASC Review

27 Executive Briefing Dr. Thomas Ellis: I initially started minimizing releases for two reasons. I worried the posterior retractor could cause iatrogenic injury to the gluteus medius tendon, and I had broken the posterior calcar with the medial femoral retractor. During my visit with Dr. Laude, I learned that one can perform a total hip with minimal releases and retraction. This required not elevating the femur during femoral preparation. Initially this was an unnatural view of the femur, but as I became more comfortable with the approach, I realized the femoral exposure was excellent. Medacta provides two instruments that make this technique possible: an orthopedic table and mobile leg positioner to manipulate the leg and specially designed broaches to clear the soft tissue and pelvis during femoral preparation. Additionally, the surgery can be performed utilizing only a modified Charnley style retractor — also provided by Medacta — if a capsular preservation technique is utilized. I learned this technique in a stepwise fashion. Initially, I performed my standard releases (pubofemoral, ischiofemoral and external rotators) but did not elevate the femur or utilize a posterior femoral retractor. As I became more comfortable with this femoral view, I avoided releasing the external rotators, and then the ischiofemoral ligament. Now, I rarely use a medial retractor and instead will gently push the femur medially to facilitate clearance of the femoral broach handle. One advantage of not elevating the femur is that more external rotation can be achieved which facilitates exposure. In cases where removal of lateral femoral bone is necessary to insert the femoral component, release of some of the posterior capsule and rotators is necessary, otherwise the soft tissue blocks the broach and stem. I still routinely release the pubofemoral ligament since I believe this improves acetabular visualization and allows lateral translation of the femur during femoral preparation. I now release the pubofemoral ligament only in about 60 percent of cases, add a release of the ischiofemoral ligament 30 percent of cases and in 10 percent I release all three structures. I almost never place a posterior or medial retractor. I believe not placing the retractors prevents iatrogenic gluteus medius injuries and fractures to the posterior calcar. I agree with [Dr. Goldberg] that it's hard to objectively measure clinical benefits of minimal releases. However, in my experience, limiting soft tissue releases does not compromise my femoral exposure, minimizes bleeding and decreases surgical time. With time and experience, performing anterior total hip replacements without soft tissue releases in the majority of cases is a very achievable goal. The Medacta Orthopaedic Research and Education (M.O.R.E.) Institute was created to provide continuous support to professionals in the field of Research and Education and improve patient outcomes. If you would like to learn more about educational opportunities offered by the M.O.R.E. Institute please contact Medacta USA (customerservice@medacta.us.com) or your local Medacta representative. The AMIS surgical technique and instrumentation was developed by. Dr. Frédéric Laude (Paris, France) with the collaboration of Medacta International. References: 1. Dora C. Minimalinvasive Zugänge an der Hüfte. Orthopäedie Mitteilungen 6/07, 574-576. 2. Laude F. Total hip arthroplasty through an anterior Hueter minimally invasive approach. Interact Surg (2006) 1: 5-11. 3. Vasina PG, Rossi R, Giudice GM, Palumbi P. Hip arthroposthesis through the anterior minimally invasive approach. Sphera 2010;6(12) – Speciale Ortopedia. 4. Jayankura M, Roty M, Potaznik A, Rooze M, Cermak K, Remy P, Gillard B, Biltiau N, Schuind F. Isokinetic and isometric muscle strength recovery after total hip arthroplasty implanted by direct anterior approach. Podium presentation at the 10th Annual Congress of the EFORT, Vienna, Austria, June 3-6, 2009. 5. Moskal JT, Capps SG, Scanelli JA. Anterior muscle sparing approach for total hip arthroplasty. World J Orthop 2013; 4: 12-18. Medacta® International is a world leading manufacturer of orthopedic implants, neurosurgical systems, and instrumentation. Medacta's revolutionary approach and responsible innovation have resulted in standard of care breakthroughs in hip replacement with the AMIS® system and total knee replacement with MyKnee® patient matched technology. Over the last 10 years, Medacta has grown dramatically by taking a different approach and placing value on all aspects of the care experience from design to training to sustainability. Medacta is headquartered in Castel San Pietro, Switzerland, and operates in over 30 countries. To learn more about Medacta International, please visit www.medacta.com or follow @Medacta on Twitter. "With time and experience, performing anterior total hip replacements without soft tissue releases in the majority of cases is a very achievable goal." — Dr. Thomas Ellis

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