Hip Resurfacing News - Surgical Approaches

Navigation Reduces the Learning Curve in Resurfacing Total Hip Arthroplasty

nospam@example.com (Patricia Walter) — Tue, 09 Oct 2007 05:59:54 -0700

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Clinical Orthopaedics & Related Research. 463:90-97, October 2007.
Cobb, Justin P FRCS; Kannan, Vijaraj MD; Brust, Klaus MD; Thevendran, Gow MD

Abstract:
Hip resurfacing is a novel technique with a substantial learning curve resulting in poor outcomes for many patients. We asked whether navigation would influence this learning curve and accuracy of implantation. Twenty medical students earning their degree in surgical technology participated in a randomized trial. We provided instruction about the surgical technique, including the use of conventional instrumentation, the use of a computed tomography-based planner for hip resurfacing, and a navigation system. The 20 students were then split into three groups undertaking these tasks in three different orders. Synthetic femurs replicated normal, osteoarthritis, slipped capital femoral epiphysis, and coxa valga. The mean error using the conventional method to insert a guidewire was 23[degrees]; using the computed tomography plan method it was 22[degrees]; and using navigation was 7[degrees]. Students produced similar accuracy, even in their first attempt, on difficult anatomy when provided navigation. Motivated students rapidly achieved an expert level of accuracy when provided with navigation. Learning a conventional method first did not improve performance, even in difficult cases. Our data suggest navigation may play an important role in reducing the learning curve in hip resurfacing arthroplasty and other tasks in arthroplasty in which a high degree of accuracy is clinically important.

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Anterior Approach for Hip Resurfacing

nospam@example.com (Patricia Walter) — Tue, 09 Oct 2007 06:04:59 -0700

Surgical Approaches for Hip Resurfacing
Peter Brooks MD
Cleveland Clinic

Most hip replacement and resurfacing surgery in the USA, about 80%, is performed through a posterior approach. About 20% of US hip surgeons prefer some variation of an anterior approach (antero-lateral, direct lateral, trans-gluteal, or true anterior). Anterior approaches are also more common in Europe and Canada.

In the posterior approach, the incision, dissection, and dislocation of the hip joint are all performed posteriorly (toward the buttock). The large gluteus maximus is split, and the gluteus medius and minimus muscles (hip abductors) are retracted, but not cut. A number of smaller muscles, the “short external rotators” including piriformis, obturator internus, gemelli, quadratus, and obturator externus, are cut, and the tendon of gluteus maximus may also be partially divided. With these out of the way, the posterior hip capsule is incised, and the hip is dislocated posteriorly by turning the foot toward the ceiling. The acetabulum and femoral head are then resurfaced, the muscles and capsule are repaired, and the incision closed.

In the direct lateral approach, (or trans-gluteal approach as it is also known), the incision is on the side of the hip, and from there the dissection proceeds towards the front of the hip joint. The hip abductors (gluteus medius and minimus) are split in the line of their fibers, peeled off the greater trochanter of the upper femur in continuity with upper fibers of the vastus lateralis, and retracted anteriorly, allowing the anterior capsule to be cut, and the hip to be dislocated anteriorly, with the foot pointing down to the floor. During closure, these muscles all tend to lie back where they belong, and since they have not been cut across their fibers, there is no tendency for their repair to pull apart. The antero-lateral approach is similar, but retracts or detaches, rather than splits, the abductors.

The true anterior approach can be adapted to hip resurfacing, actually better than for hip replacement, since exposure to the shaft of the femur is difficult (and not needed in resurfacing). It is not popular among surgeons who operate on adults, but is fairly common in pediatric orthopedics.

Different approaches have different issues. The posterior approach is very well known in the USA, and BHR developers Mr McMinn and Mr Treacy use it routinely as well. Theoretically it should have a higher dislocation rate, due to the fact that dislocation almost always occurs posteriorly, and this approach disrupts all the potential restraints to posterior dislocation. But dislocation after hip resurfacing is much less of a problem than it is with hip replacement, due to the very large head size. The blood supply to the femoral head stands a greater chance of damage through the posterior approach, since that is where the vessels mostly are. The important hip abductors (gluteus medius and minimus) are left completely intact.

The direct lateral (trans-gluteal) approach has the advantage of a lower dislocation rate, and less likelihood of damage to the blood supply of the femoral head. In addition, no muscles are actually cut across; they are just split, or teased apart in the line of their fibers, which should lead to more reliable healing. The exposure of the socket is a “straight shot”, since the acetabulum is an anteriorly facing structure. The disadvantages are that there is nonetheless surgical trauma to the abductors which, if substantial, could cause a limp. There are also reports of heterotopic ossification, although this may occur with any approach.

The true anterior approach can be associated with injury to a sensory nerve responsible for the side of the thigh (lateral femoral cutaneous nerve), and the location of the incision in the groin is not the cleanest part of the body. It is also by far the least commonly used of these incisions for adult hip surgery, so at least for the time being, we do not have a lot of data.

The main thing to keep in mind is that any of these surgical approaches can work just fine. All have been modified in many ways as surgeons find better ways to do things. The most important thing for a patient to decide is who will do their surgery, not how it will be done. The surgeon, drawing on his or her own training, experience and beliefs, will decide what works best in their hands.

Dr. Rogerson Compares the Posterior Approach & Gantz Approach

nospam@example.com (Patricia Walter) — Sun, 06 Nov 2011 08:21:35 -0700

I am not enthused about the Ganz trochanteric flip approach for several reasons. It was developed to be less injurious to the femoral blood supply. Koen DeSmet showed that with the modified posterior capsulotomy approach that he, Bose and I use that the blood supply compromise during is not much different than with a trochanteric osteotomy. Also, the incidence of AVN even with the much more extensive posterior capsular release that McMinn initially used is extremely low. We are now over 600 cases and have not seen a case of AVN.

Problems with any trochanteric osteotomy including the trochanteric flip all relate to injury to the gluteus medius attachment which results in an abductor lurch weak and awkward gait afterward. In this young and very active patient population, one is hard pressed to protect them for 6-8 weeks on crutches so the trochanteric bone can heal. If the patient is even relatively non-compliant, one is left with a lifelong limp that is impossible to fix. That is why the posterior approach became almost universal in America and the Charnley trochanteric osteotomy was abandoned. Paul Beaule recently reported on his series with trochanteric osteotomy and had a significant number of complications relative to the abductor mechanism.

In summary, this "flip" technique is a solution to a problem (AVN) that barely exists with the modified posterior capsulotomy approach and is associated with a significant number of "limps" and restrictions for a very active group of patients.

Dr. John Rogerson

Dr. Gross discusses the Gantz vs other surgical approaches

nospam@example.com (Patricia Walter) — Sat, 26 Nov 2011 08:46:01 -0700

Approaches in hip resurfacing

The path that surgeons choose to arrive at the hip joint is called the "approach". There are many different basic approaches used for hip resurfacing. None has been proven to be superior to others based on valid scientific research. Basically, I recommend that a surgeon use the method that he/she is already most comfortable with when performing standard total hip replacement and modify it as needed for the more complex hip resurfacing operation. My preferred approach is the posterior. This is used in at least 70% of hip resurfacings done worldwide. The next most common approach is the lateral (two versions: anterior-lateral and direct-lateral). Finally the direct anterior and the Ganz (or trochanteric, or internal dislocation) approach are far less commonly used. All of these approaches are adapted slightly by different surgeons.

Continue reading "Dr. Gross discusses the Gantz vs other surgical approaches "

Dr. Brooks Compares theGanz Approach vs Other Surgical Approaches

nospam@example.com (Patricia Walter) — Fri, 04 Nov 2011 14:12:26 -0700

Hi Pat, You asked about the Ganz approach, which is also known as "surgical dislocation" of the hip for resurfacing. This was described way back in 2001 by Prof. Reinhold Ganz in Berne, Switzerland. Resurfacing was being done in those days, although not so much by him, and he used it for all kinds of hip surgery from debridement to revision total hips. The key factor is that it is designed to preserve the blood supply to the femoral head. That is irrelevant in hip replacement because the femoral head is getting cut off anyway. In joint preservation procedures like FAI operations, labral repairs, removal of loose bodies etc and in hip resurfacing, it is important that the femoral head blood supply is respected. Dr Ganz's major contributions have been his descriptions of the blood supply to the femoral head, and of femoroacetabular impingement (FAI) in the development of hip arthritis. There is little question that the posterior approach routinely damages the blood supply to the femoral head. But there is also little question that this approach yields excellent outcomes in hip resurfacing, and is done by most US surgeons, about 80%. The pioneering surgeons McMinn and Treacy both use the posterior approach.
Continue reading "Dr. Brooks Compares theGanz Approach vs Other Surgical Approaches"

Dr. Bose Compares Posterior Approach to Gantz Approach

nospam@example.com (Patricia Walter) — Sun, 06 Nov 2011 08:15:44 -0700

Comments by Dr. Vijay Bose

The ganz trochanteric flip is an excellent approach for doing open FAI surgery, for fixing fracture on the femoral head ( pipkin #) and for doing osteotomy of the femoral neck in post SUFE situations. In these non - arthritic situations a surgical dislocation of the hip is warranted without damaging the blood supply and I employ it routinely for these indications.

However its use in hip resurfacing is a bit of an overkill. It has been documented without a shadow of doubt that the post approach does not compromise the vascularity of the femoral head in an arthritic hip after resurfacing. Thousands of patients who have crossed the 10 yr mark with the post approach & BHR bear testimony to this.

Doing the ganz for resurfacing is a much more morbid procedure than a standard post approach. Any osteotomy will take more time to heal and recover function. The extended trochanteric osteotomy ( ETO) which is the bigger version of the Ganz flip will take about 6 months for the patient to regain function.

Intuitively the Ganz looks appealing as regards preserving blood supply but this issue is not relevant in an arthritic hip.

with best regards vijay bose chennai

Bloodless Hip Surgery at GSMCH India

nospam@example.com (Patricia Walter) — Wed, 19 Mar 2008 10:15:20 -0700

Bloodless hip surgery at GSMCH

Link http://www.punjabnewsline.com/content/view/9315/38/

Tuesday, 18 March 2008

CHANDIGARH: Bloodless hip surgery would be performed at the Gian Sagar Medical College and Hospital, near here, with an internationally acclaimed orthopaedic surgeon Gursharan Singh Chana visiting the hospital regularly every two months.

Disclosing this here Tuesday, Dr Sukhwinder Singh, vice-chairman of the Gian Sagar Educational and Charitable Trust, said that Dr Chana, who is settled in the United Kingdom, would visit the GSMCH every two months.

He would train orthopaedic surgeons in bloodless hip surgery for which a 15-day training course would be organized every two months.

Dr Sukhwinder Singh said that Gursharan Singh Chana, a doctor of Indian origin, would deliver a lecture on minimal invasive surgery for total hip replacement and hip resurfacing at the Gian Sagar Medical College and Hospital on March 20.

He said that Dr Chana would interact with the faculty of the GSMCH on March 20 morning and in the evening he would address orthopaedic surgeons of Patiala. On March 21, he would be interacting with orthopaedic surgeons of Chandigarh and on march 22 he would have an interactive session with orthopaedicians of Ludhiana.

Dr Sukhwinder Singh said that an internationally acclaimed orthopaedic surgeon, Dr Chana has devised a minimally invasive approach to hip joint to carry out total hip replacement and hip resurfacing. He has devised Chana reamer handle to allow accurate surgery of the hip joint.

Dr Chana is presently working as a consultant orthopaedic surgeon at the Royal Orthopaedic Hospital, NHS Trust Birmingham, since October 2002.

Dr Chana has the vast experience of carrying out the over 2500 total hip replacements, over 2000 total knee replacement, over 1500 hip resurfacing, 200 hip replacements using minimally invasive surgical approach, 200 hip resurfacings using minimally invasive hip resurfacing.

Over the last two years he has been involved in developing instrumentation and implants for hip resurfacing procedure to be carried out using a minimally invasive approach through Comis Orthopaedics, a company based in Yorkshire.

The implant is being used currently in the U.K. This implant is the only one of its kind that can be delivered using a minimally invasive approach with obvious benefits of early discharge from hospital, blood transfusion is not necessary in 95 per cent of patients and the patients tend to return to normal activities at an earlier stage compared to patients who undergo open surgery. The average incision size is 7 cm. with this approach as opposed to 20 cm. using an open approach.

Nigel Church Right Cormet Resurfacing with Dr. Kreuzer

nospam@example.com (Patricia Walter) — Fri, 10 Apr 2009 05:11:18 -0700

I am a 55 year old male. I have been active all my life in various sports which ultimately led to my hip cartilage damage. I had my right hip resurfaced using the anterior approach November 2007 by Dr. Stefan Kreuzer, a Birmingham hip. In Feb of this year, Dr Kruezer resurfaced my left hip with a Cormet.

I am almost two months into the recovery and I am almost back to full strength. There is still some numbness around the incision area, but I know from experience that will improve over time.

Dr. Kruezer is clearly constantly learning and improving as my second recovery is a few weeks ahead of my first.

My hospital stay was two days, I was walking the day of the surgery. I went home and used the walker for three days and never needed a cane. A week after my resurfacing, I was walking completely unassisted and even resumed normal activities like shopping, etc. Road biking is my passion, after one month I was training on a stationary bike; at five weeks I was back to riding my road bike albeit carefully; last weekend at eight weeks, I rode 80 miles in just over 4 hours.

I would strongly advise anyone considering hip resurfacing to find out if they are suitable for the anterior approach.

Nigel Church