Total Arthroplasty of Hip and Knee  Joint

THE NEW A.L.M.I.S. (Antero – Lateral – Minimally – Invasive – Surgery) HIP ARTHRΟPLASTY

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 anaesthesia 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, 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:

  1. longevity of the new joint – i.e. it is well known that patients are concerned about how many years will total arthroplasty last.
  2. Minimized bleeding – i.e. patients usually do not need homologous blood transfusion unless they suffer from anemia or are prone to hemorrhage.
  3. Minimized muscular, vascular and neural injuries around the hip incision.
  4. Less surgical time and anaesthesia – i.e. surgery usually does not exceed one hour, lessening thus rate of infection or thrombosis incidence.
  5. Small incision – adjusted to each patient at the lateral nonvisible 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.
  6. Rapid patient rehabilitation – i.e. most patients may climb stairs almost immediately after operation while exit hospital within 1-3 days.
  7. 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. 

Τhe new A.L.M.I.S. arthroplasty has been successfully applied in several cases in Greece at Athens Medical Groop, Iatriko Psychikou Clinic. More information about the new A.L.M.I.S., adjusted French “Thomine” technique, may be found at url: International study of Dr Christodoulou, K. Dialetis and associates presenting excellent results of A.L.M.I.S. hip arthroplasty technique has been published [ 2012 ] at “European Journal of Orthopaedic Surgery and Traumatology” – SPRINGER publications (2012, Volume 22, Issue 2, pp 167-174 ).

ALMIS Anterolateral Hip Approach Using a Different Table and Legs Position during Femoral Exposure; New Surgical Technique. N. Christodoulou. MOJ Orthopedics & Reumatology, Volume 7, Issue 4, 2017. (USA):



(The preoperative “ROBOTIC”… arthroplasty System)  

In “Athens Medical Group” and especially in “Iatriko Psychikou Medical Center” the new modern presonalized “Custom Knee Arthroplasty” is applied.  This modern knee arthroplasty system is the latest one in navigation technology where personalised custom guides are prepared before surgery for each patient on a model designed from an MRI or Three dimensional CT reconstruction of the patient osteorthritic knee. This allows to the surgeon to place the knee arthroplasty system at the correct position during surgery with minimally invasive technique. The personalized guides have been prepared and designed in detail preoperatively at factory computers – “robots” and not during surgery as it was made until now with the so called “robotic” or “computer assisted” arthroplasty systems.  

This new modern knee arthroplasty system and especially the “SIGNATURE” type, is mainly used in our Orthopedic Clinic. The surgeon, instead of looking with many tools and guides on the patient during surgery to place the implants or by using dificultly installed intraoperative Computer assisted – ” Robot ” system, with a  small incision, minimal invasiveness, very less time and without injuring the canals of the femoral and tibial bones, places very easily the ideal implants at the ideal position. The factory sent also to the surgeon before surgery for study the exact three-dimensional copy of the bony articular surfaces with details of the bones deformity, the osteophytes shade etc. All are designed and programmed with absolute precision before surgery. With this new and revolutionary “CUSTOM” knee arthroplasty system, especialy the “SIGNATURE” type, that we use in our patinets, perfect implants size is selected preoperatively and mechanical axis correction, ideal placement of the implants and maximum range of motion are easily achieved in order the patients to be able to return to their advance activities, sports etc as soon as possible. Similar “preoperatively prepared” – CUSTOM systems, can now be used in difficult cases of knee hemiarthroplasties and hip arthroplasties.

Modern partial knee arthroplasties are also now used with mobile artificial articular surfaces – “artificial meniscus”, for medial compartment of the knee joint lesions and specilal “mini” partial arthroplasties for patello-femoral osteoathritis are in our Center. This is the future of the arthroplasties! Arthroplasties by using preoperatively ready templates, guides and personalized design, small incision and invasiveness, minimal intraoperative procedure, small time anesthesia and sedation without intracanal tibial or femoral bleeding and injury to the bones and perfect placement of implants. The results are 1. ideal postoperative range of motion, 2. ideal correction of the leg, 3. significant reduction of postoperative pain, 4. direct and independent ambulation with full wait bearing, 5. excellent functional outcome and 6. permanent fixation of the implants! All are designed and programmed by computers and  “robots ” preoperatively and not during surgery !

In some patients we use the new partial patellofemoral artrhoplasty (Stryker)