New A.L.M.I.S Hip Arthroplasty

A.L.M.I.S. [ Antero-Lateral-Minimally-Invasive-Surgery]
The term M.I.S. “Minimally Invasive Surgery” is used for various new hip arthroplasty techniques by using single or dual, anterior, lateral, anterolateral or posterior “mini” skin incision.
The “mini” anterior incision has been established as A.M.I.S. (Anterior – Minimally – Invasive – Surgery) and the Anterolateral as A.L.M.I.S ( Antero – Lateral – Minimally – Invasive – Surgery). Their common feature is small skin incision in combination with minimal muscular intervention.
Their differences are related to technical modifications and intraoperative or postoperative complications.
Despite initial enthusiasm, complications of some of these techniques –i.e. femoral cutaneous nerve injury in A.M.I.S. hip arthroplasty, femoral or ankle fractures from excessive traction or wrong implants’ placement etc. created the need to modify some of these techniques with emphasis on avoiding internal injuries but also on how well implants are placed.
To avoid wrong implants’ placement through small incisions due to limited visibility difficulties, robotic – computer assisted systems were also used. However, the great time required to install these systems while the patient is under anesthesia along with surgery’s complexity, additional problems were created.
In order to avoid these complications, Dr N. Christodoulou – with extensive experience in hip and knee arthroplasties – with the collaboration of Dr K. Dialetis, improved and transformed the French ‘Thomine’ technique into the new A.L.M.I.S. arthroplasty ( Anterior – Lateral – Minimally – Invasive – Surgery). Thus, the new A.L.M.I.S. technique is less invasive and almost bloodless in most cases.
With the new A.L.M.I.S. arthroplasty similar – with small differences – to the so called “Mayo Limited – Minimal Anterior” approach for hip arthroplasty in “Master Techniques in Orthopaedic Surgery”/ USA, the skin incision is small at the lateral region of the upper thigh and internally is not extended at the vastus lateralis muscle and its vessels. Branches of the deep femoral artery are not injured likewise those of the anterior or lateral circumflex artery, neither the upper gluteal vessels and nerves. In most cases, no hip muscle is incised while in most difficult cases only a small part of the gluteus medius muscle insertion is reflected and reattached at the end of the operation which does not affect hip abductive activity. This temporary reflexion decreases medius gluteus muscle fibers’ and upper gluteus nerve branches’ strain and injury.
In addition to that, hip external rotation muscles are not incised i.e. the piriformis muscle. However, according to Clinical Orthopedics and Related Research American Journal formal puplication, piriformis external rotator muscle is injured and incised extensively with anterior type A.M.I.S. and posterior hip arthroplasties.
In particular, at Clinical Orthopedics and Related Reserch: December 2006 – Volume 453, p.p. 293-298 is mentioned that during anterior minimal invasive hip surgery –i.e. A.M.I.S. – Smith Petersen type – the tensor fascia lata muscle has been injured by 31% while reflected tendon of rectus femoris by 12%. In 50% of these referred cases, piriformis muscle was incised to mobilize femoral bone.
Using the latest and most improved biomaterials – such as acetabular prosthesis of biocompatible titan implant Zweymuller type with special peripheral threads instead of screws or acrylic cement- this technique offers direct fuctional rehabilitation even in greatly destroyed hips sush in cases of osteoarthritis secondary to congenital hip disclotation or dysplasia.
Study of Drs Christodoulou and Dialetis, presenting excellent results of applying these pre-mentioned implants in dysplastic or congenital dislocated hips, were published at the American Journal ‘’Clinical Orthopedics and Related Reserch’’, 468:1912-1919,2010 (U.S.A).
Direct intraoperative strong fixation and stability of these titanium special implants allows full wait bearing and gait from even the first day – since there are no other co-existing diseases or problems in other joints – while ascending and descending the stairs within first of second postoperative day, with or without assistance.
These new biocompatible implants provoke also strong and permanent periprosthetic osteointegration without any further problem at the implants and bone intersurface for the rest of the patient’s life.
In conclusion A.L.M.I.S. achieves:
Longevity of the new joint – i.e. it is well known that patients are concerned about how many years will total arthroplasty last.
Minimized bleeding – i.e. patients usually do not need homologous blood transfusion unless they suffer from anemia or are prone to hemorrhage.
Minimized muscular, vascular and neural injuries around the hip incision.
Less surgical time and anaesthesia – i.e. surgery usually does not exceed one hour, lessening thus rate of infection or thrombosis incidence.
Small incision – adjusted to each patient at the lateral non visible part of the femur without stressing soft tissue and forcing strong attraction of the leg at risk of fracture, in a specialized surgical table; exactly like performed at the advertised A.M.I.S. technique.
Rapid patient rehabilitation – i.e. most patients may climb stairs almost immediately after operation while exit hospital within 1-3 days.
Rare or not significant complications compared to other techniques on which heavy may appear like hemorrhage that requires numerous of homologous blood units, thrombosis, dislocations, implants loosening, etc.
Patient operated in her left hip (Total arthroplasty) by using the new ALMIS hip approach !
Clinical Orthopaedics and Related Research: December 2006 – Volume 453 – Issue – pp 293-298. Muscle Damage During MIS Total Hip Arthroplasty: Smith-Peterson versus Posterior Approach. Meneghini, R Michael MD; Pagnano, Mark W MD; Trousdale, Robert T MD; Hozack, William J MD.
“The tensor fascia latae muscle was damaged (mean of 31%), as well as direct head of the rectus femoris (mean 12%) during the Smith-Peterson anterior MIS approach. The piriformis or conjoined tendon was transected in 50% of the anterior approaches to mobilize the femur”
Complications of the direct anterior approach for total hip arthroplasty. Barton C, Kim PR. Orthop Clin North Am 2009, 40:3, 371-375.
High Complication Rate With Anterior Total Hip Arthroplasties on a Fracture Table
Brian A. Jewett & Dennis K. Collis, Clin Orthop Relat Res, 2011, 469(2):503-507
High complication rate with anterior total hip arthroplasties on a fracture table. Jewett BA, Collis DK. Clin Orthop Relat Res. 2011 Feb;469(2):503-7.
High complication rate with anterior t… [Clin Orthop Relat Res. 2011] – PubMed – NCBI
Catastrophic complications of minimally invasive hip surgery. Fehring and Mason, J B J S Am, 2005, 87:711-717.
High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach.
Spaans et al, Acta Orthop. 83(4):342-346, 2012.
Early Complications of Anterior Supine Intermuscular Total Hip Arthroplasty
Chengla Yi et al. Orthopedics, 36, Issue 3: 276-281, 2013.
Direct anterior total hip arthroplasty : complications and
early outcome in a series of 300 cases.
Thomas De Geest, Pieter Vansintjan, Geert De Loore, Acta Orthop. Belg., 2013, 79, 166-173
The new A.L.M.I.S. hip arthroplasty has been successfully applied during last years in Greece at Medical Center of Athens, Iatriko Psychikou Clinic.
International study of Dr N. Christodoulou, K. Dialetis and associates presenting the excellent results of A.L.M.I.S. (modified “Thomine” technique using smaller lateral skin incision) hip arthroplasty has been published [ 2012 ] at “European Journal of Orthopaedic Surgery and Traumatology” – SPRINGER publications.