Dominique G. Poitout and Henri Judet (eds.)Mini-Invasive Surgery of the Hip10.1007/978-2-287-79931-0_2

2. Mini-Invasive Approach and Navigation in Total Prosthesis of the Hip

Henri Judet¹

(1)

Department of Orthopaedic, Clinique Jouvenet, 6 Square Jouvenet, 75016 Paris, France

Henri Judet

Abstract

The anterior approach to the hip, initially described by Hueter, has been modified and used by Jean and Robert Judet since 1947 for fixing an acrylic prosthesis rendering this approach completely mini-invasive by avoiding any muscular disinsertion or sectioning of tendons [1]. When we learnt about the possibilities of using the navigation technique for a hip prosthesis using the OrthoPilot system, we decided to combine these two innovations so as to induce a minimum of aggression and a maximum of security while fixing a hip prosthesis.

A study carried out on the positioning of the acetabulum, with or without navigation, as well as a comparison between two navigation systems attempts to validate the accuracy of the procedure.

Keywords

Total hip replacementAnterior approachMini-invasive surgeryNavigation technique

Introduction

We believe that combination of two innovative concepts, the mini-invasive approach and the navigation technique, would revolutionise the surgery of hip prosthesis.

We are quite familiar with the mini-invasive anterior approach [2] since this technique has been used in our practice since 1993. Being a modification of the technique used by Hueter, its principle is based on the nondetachment and non-sectioning of any muscles or tendons [3]. The navigation technique was adopted 6 years ago by the use of the OrthoPilot system developed by the B. Braun–Aesculap laboratory [4] and by the Amplivision system of the amplitude laboratory since 3 years.

In this work, we will describe the technique of the approach and of the navigation. We mention the results of a comparative study with and without navigation for positioning the acetabular part, and we attempt to validate the frame of reference by comparing the two systems of navigation used.

Surgical Technique

Positioning of the Patient

The patient is placed in a dorsal decubitus on the Judet’s orthopaedic table.
A liquid-level gauge enables one to ensure that both limbs are in a horizontal position.
Electrocardiogram electrode aids are fixed on the iliac spine opposite the side to be operated and on the pubis to serve as reference points under the fields during the acquisition of the pelvis plane.
Two helpers are necessary, one on the side of the operator and the other in front of him.
The computer equipped with its camera is placed on the opposite side facing the operator.

Preparation for Navigation

A pin is fixed vertically on the iliac crest at a distance of three fingers behind the anterosuperior iliac spine so as not to hinder future manoeuvres during the introduction of the prosthesis in the femoral diaphysis.
A second pin is placed in the femoral shaft with a bicortical grip and oriented from inside towards the outside on the internal side of the thigh at its inferior third through the medial great in a manner that the diode that it will bear faces the camera in a 90° external rotation.
Both pins will bear passive diodes.
Then the plane of the pelvis (Lewineck’s plane) is acquired from the anterosuperior iliac spine and the pubis.

Mini-Invasive Anterior Approach

The cutaneous incision straddles the hip’s flexion fold in the direction of the anterosuperior iliac spine head of the fibula. It usually runs along a distance of 6–8 cm but may be stretched for obese subjects or for those having a stout muscle structure.
Having pushed back the subcutaneous fat, incision of the superficial aponeurosis of the fascia lata’s tensor is carried out. Following this and between the internal side of this aponeurosis and the muscle body, a natural fatty space is found leading directly to the anterior side of the capsule without causing any damage to tendons or to muscles. The internal edge of the aponeurosis reclining backwards protects the femoral cutaneous nerve that is the main obstacle to this approach.
Only the anterior circumflex pedicle that crosses the incision at its lower part is to be coagulated.

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