Min-Invasive Hip Tech-lo by fjzhxb

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									A practical

approach to Minimally Invasive Hip Surgery.
posterior approach

Minimally Invasive Surgery: Minimizing everything but the outcome
Since the inception of joint arthroplasty, implants and
procedures have been scrutinized and modified in an effort to optimize long-term survivorship. With Biomet’s 1992 introduction of the Repicci™ Unicondylar Program, focus began to shift to the “invasiveness” of joint arthroplasty—the trauma involved and the speed at which patients could leave the hospital and resume normal activities.

Microplasty Minimally Invasive Hip Program, the practical alternative for Minimally Invasive Hip Surgery.
™

Today’s well informed patient has made minimally invasive total hip arthroplasty one of the most demanded procedures in orthopedics. To satisfy this demand, Biomet offers the Microplasty™ Minimally Invasive Hip Program. The focus of this program is to provide surgeons with practical, reproducible minimally invasive hip replacement techniques and the instrumentation necessary to perform them. In addition, Biomet offers surgeons the opportunity to learn these techniques from other surgeons who are well versed in performing them. Biomet’s intention is to assist surgeons in enhancing their practices while offering patients, payers and employers the potential benefits of minimally invasive total hip arthroplasty: • Less blood loss • Less muscle disruption • Less postoperative pain • Shorter hospital stay • Quicker rehabilitation • Smaller incision • Less resource utilization by payers • Lower costs for employers • Quicker return to productivity

The Microplasty™ Minimally Invasive Hip Program provides the opportunity for surgeons to learn this minimally invasive total hip replacement technique in the operating rooms of other experienced surgeons.

From a long-term perspective,
Biomet hip prosthetic designs have provided exceptional performance. Due to well thoughtout, original philosophies, Biomet implant designs have resulted in superior long-term clinical results. Proven design philosophies such as the titanium alloy composition, 3° bi-planer taper and circumferential porous plasma spray inherent in Biomet’s press-fit prostheses continue to stand the test of time. With Biomet’s clinically proven femoral prostheses and the advent of alternative bearing surfaces Bi-Metric,® Mallory-Head,® and Taperloc® Stems such as Biomet’s M2a-38™ implant which combines an ultra high range-of-motion with an ultra low rate of wear, even young active patients may experience greater longevity from primary hip replacements.

Minimizing the invasiveness of total hip replacement
is at the core of Biomet’s Microplasty™ Program. This brochure details an effective minimally invasive posterior approach technique and presents the instrumentation that makes it not only possible…but also practical.

Biomet provides the

M2a-38™ Implant

surgeon with everything required to optimize the patient experience from start to finish.

Microplasty™ Instrumentation

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Femoral Resection Retractor 1 is positioned beneath the femoral neck at the resection level to shield and protect soft tissues during resection. Narrow and Wide Double-pronged Hohmann Retractors 2 A 2 B allow for enhanced exposure of the acetabulum by angling up and away from the wound to avoid impeding visualization while levering against the acetabular rim to gain joint access. Offset Retractors 3 L 3 R (left and right) allow the surgeon to reach around a small skin incision to lever against bony anatomy, retracting tissues and improving visualization. Femoral Elevators 4 A 4 B (large and small) are placed around the femur to protect the soft tissues and to provide excellent exposure for preparing the femur.

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Self Retaining Retractors are easy to manipulate, holding the wound open while minimizing the need for an awkward abundance of hand held retractors. Fiber Optic Lighting provides the surgeon with his preference of lighting methods that fully illuminate the wound without getting in the way. Curved Acetabular Reamer Shaft avoids skin impingement, allowing for proper acetabular preparation with minimal tissue disruption.

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Microplasty™ total hip instrumentation makes performing the minimally invasive posterior approach technique quite practical, allowing for enhanced visualization and accessibility while minimizing soft tissue disruption. Simplicity, functionality and efficiency—which are designed into the Microplasty™ total hip instrumentation—allow for maximal results with minimal O.R. time. Uniquely designed acetabular reamer and impactor handles curve around the incision, allowing for firm reaming and component placement. Retractors are shaped to avoid obscuring the surgeon’s view. Sequential numbering facilitates a smooth flowing procedure while assisting communication between the surgeon and the O.R. staff. Microplasty™ total hip instrumentation turns an otherwise challenging procedure into a practical, reproducible minimally invasive experience.

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Atraumatic Acetabular Reamers have teeth located along a narrow band, allowing for aggressive cutting and easy wound insertion without injuring surrounding tissues. Curved Acetabular Cup Impactor allows for impaction of the acetabular cup with the proper version through a smaller incision while avoiding soft tissue impingement.

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10) Straight Broach Handle provides for firm, controlled broaching and easy access to the canal while avoiding the surrounding tissues. 11) Provisional Head Clamp firmly holds the provisional or prosthetic femoral head while facilitating placement through a small incision. 12) Femoral Head Remover simplifies removal of the femoral head through a small incision.

Surgical Technique Introduction
Technique Highlights • Intraoperative conversion from this minimally invasive procedure to a standard posterior approach procedure is accomplished by simply extending the incision. • This technique is typically accomplished using a 2–3 inch transverse incision, even for extremely obese or muscular patients. • During the entire procedure, care is taken to minimize surgical trauma to the surrounding tissues. Less tissue dissection results in less blood loss, less pain and quicker recovery. • The gluteus maximus muscle is split and spread apart rather than being cut. • The quadratis femoris is spared. The following minimally invasive technique was originated by Scott Katzman, M.D. and is rooted in the long-established posterior approach. Unlike many techniques which involve only a small incision but apply standard methods beneath the incision, this is truly a “minimally invasive” technique. The uniquely modified approach and instrumentation allow the surgeon to accomplish a much less traumatic procedure through a two to three inch incision. While this minimally invasive surgical technique is specific to the Taperloc,® other Biomet hip prostheses may be implanted using the Microplasty™ Total Hip Instrumentation. Contact your Biomet representative for more information.
Reaming the Acetabulum

Impacting the Acetabular Component

Repicci,™ Microplasty,™ Exact,™ Biomet,® Bi-Metric,® Mallory-Head,® Taperloc,® M2a-38,™ and RingLoc® are trademarks of Biomet, Inc. This brochure describes the surgical technique used by Scott Katzman, M.D. Biomet does not practice medicine and does not recommend this or any other surgical technique for use on a specific patient. The surgeon who performs any implant procedure is responsible for determining and using the appropriate techniques for implanting the prosthesis in each individual patient. Biomet is not responsible for selection of the appropriate products and or surgical technique(s) to be used on any individual patient.

Surgical Technique
Positioning Position the patient in a true lateral position using two Montreal positioners or a pegboard, stabilizing the pelvis to facilitate use of the “minimally invasive” posterior approach. Incision Location Location of the incision is critical to the accomplishment of this minimally invasive procedure. Initially flex the hip to 90°. Then adduct and abduct from neutral to about 30–40° while palpating for the tip of the greater trochanter. Repeat this exercise as necessary until the precise location of the greater trochanter is determined (Figure 1). Mark the tip of the trochanter with the hip flexed at 90°. The axis of the femur in this position represents the ideal location and orientation to optimize exposure for preparation of the femur and acetabulum while minimizing incision size and muscle disruption. Draw a line beginning at the tip of the greater trochanter and extending 1–2" toward the buttocks and extended distally 1⁄2–1", resulting in an incision approximately 2–3" in length (Figure 2). The incision orientation should be transverse in nature.

Figure 1

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Incision/Resection Incise the patient over the previously marked line through the skin and subcutaneous tissue to the gluteus maximus. Gently spread the fibers of the gluteus maximus along the longitudinal lines using a finger or Cobb elevator as not to cause bleeding (Figure 3). Spread fibers posteriorly the length of the incision and approximately 1" distal to the incision. A small portion of the iliotibial tract may be split distally to gain necessary exposure with larger patients. Position a self-retaining retractor deep into the gluteus muscle fibers with the open end toward the buttocks (Figure 4). Use a finger to palpate the piriformis and joint capsule. Identify the sciatic nerve and pack a mini lap or Raytech posteriorly to protect the nerve and improve capsule visualization (Figure 5). Cut the piriformis with a Bovie cautery and extend the cut through the external rotators, including the superior gemellus, obturator internus and inferior gemellus, stopping at the upper part of the quadratus femoris which is not normally resected (Figure 6). Incise the capsule using a “T” shaped incision across the femoral head and down the neck of the femur. External rotator muscles and capsule may be tagged for later repair by using a #1 Ethibond stitch and a Kieth needle. Reflect the capsule and piriformis tendon posteriorly to protect the sciatic nerve. The suture should exit the skin beneath the wound so as to avoid entanglement in the small opening with future instrumentation.

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Figure 4

Sciatic Nerve

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Gluteus Maximus Inferior Gemellus Obturator Internus

Quadratus Femoris

Superior Gemellus Piriformis

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Dislocate the hip by internally rotating the leg. Place the Femoral Resection Retractor 1 underneath and perpendicular to the shaft of the femur just proximal to the lesser trochanter to protect surrounding tissues (Figure 7). Use a fingerbreadth below the femoral head or above the lesser trochanter to indicate the resection level. Resect the femoral head with an oscillating saw blade and remove the head using the Cork Screw (Figure 8). Acetabular Exposure Place the tip of the Narrow Hohmann Retractor 2 A toward the anterior portion of the acetabulum to facilitate exposure (Figure 9). An alternative or additional Wide Double-pronged Hohmann Retractor 2 B may be used in some cases to further enhance exposure. Use a scalpel to clear soft tissue from around the rim of the acetabulum. Using the Curved Acetabular Reamer Driver, insert the Atraumatic Reamers into the wound with the smooth sides against the skin edges and sequentially ream the acetabulum to the appropriate size and position (Figure 10). Proper anteversion and inclination may be more easily accomplished by loosening the selfretaining retractor to relieve tension on the skin, thereby allowing more flexibility on the distal aspect of the incision.
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Impact the trial cup using the curved acetabular impactor. Check cup stability and orientation. Once appropriate sizing and anteversion is confirmed, use the curved impactor to place the final component (Figure 11). Femoral Preparation Flex the hip to 90° and internally rotate the leg. Place the appropriate left or right Offset Retractor 3 L or 3 R perpendicular to the femoral shaft, beneath the neck at the level of the lesser trochanter to avoid the quadratis femoris while retracting soft tissue. Place the Femoral Elevator Retractor 4 A or 4 B that best accommodates patient anatomy and exposure beneath the femoral shaft at the neck cut, in line with the femoral shaft to lift the femur and protect the proximal skin edge of the incision (Figure 12). With a T-handle, insert a canal finder down the shaft to determine appropriate shaft position. If desired, a lateralizing reamer may be used to assist in preparing the femur for proper component placement. Palpate the lesser trochanter to establish proper version and, using the Exact™ Straight Broach Handle, sequentially broach the femur until solid fit is achieved (Figure 13). Apply the magnetic trunnion and provisional head to the broach.

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The Trial Head Placement Clamp may be used to facilitate provisional head placement (Figure 14). Reduce the hip and check leg length, stability and range of motion through flexion, adduction and internal rotation, modifying offset option (standard or lateralized) and neck length as necessary. Once final offset is determined and sizing is achieved, place final components and again check for appropriate range of motion and stability. Wound Closure Approximate the gluteus maximus with a simple #1 Vicryl stitch. If the tensor fascia lata was released, it may also be repaired with a #1 Vicryl stitch. Depending upon the type of post operative anticoagulation chosen, a drain use may or may not be required.
Figure 14

Preoperative X-Ray

Postoperative X-Ray

Ordering Information – Microplasty Total Hip Instrumentation
™

General Instrument Case 595251

Curved Acetabular Impactor 31-555521

General Instrument Case:

Retractor Case 595252

Neck Resection Retractor (1) 31-555516 Hohmann Retractor (2A) 31-555511 Narrow Hohmann Retractor (2B) 31-555510 Wide Offset Retractor (3R) 31-555514 Right Offset Retractor (3L) 31-555515 Left Femoral Elevator (4A) 31-555512 Large Femoral Elevator (4B) 31-555513 Small

Retractor Instrument Case:

Acetabular Reamer Case 595250

Curved Acetabular Reamer Driver 31-555520

Acetabular Reamer Case:

Straight Exact™ Broach Handle 31-555500 Provisional Head Clamp 31-555530 Acetabular Version Guide 31-434545 Cork Screw 425420

Curved Reamer Driver Handle Attachment 31-555522 Atraumatic Acetabular Reamers (Standard Set) 31-555544 44mm 31-555545 45mm 31-555546 46mm 31-555547 47mm 31-555548 48mm 31-555549 49mm 31-555550 50mm 31-555551 51mm 31-555552 52mm 31-555553 53mm 31-555554 54mm 31-555555 55mm 31-555556 56mm 31-555557 57mm 31-555558 58mm 31-555559 59mm 31-555560 60mm 31-555561 61mm 31-555562 62mm 31-555563 63mm 31-555564 64mm 31-555565 65mm 31-555566 66mm 31-555567 67mm 31-555568 68mm 31-555569 69mm 31-555570 70mm

Koros Self Retaining Retractor Set 31-555590

Fiber Optic Snake Light (115 x 3.5mm) 31-555506 Snake Light Adaptor 31-555505

Optional Instruments:

Bifurcated Fiber Optic Cable 31-555502 Fiber Optic Snake Light (175 x 3.5mm) 31-555507

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SM

P.O. Box 587, Warsaw, IN 46581-0587 • 574.267.6639 ©2003 Biomet Orthopedics, Inc. All Rights Reserved web site: www.biomet.com • eMail: biomet@biomet.com Form No. Y-BMT-818/061503/K


								
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