MUSCULAR DAMAGE AFTER THA: TRANSGLUTEAL VS ANTERIOR APPROACH
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1 MUSCULAR DAMAGE AFTER THA: TRANSGLUTEAL VS ANTERIOR APPROACH Fabian Kalberer Department of Orthopedics, Balgrist University of Zurich
2 CHANGING PATIENT S EXPECTATIONS
3 RESIDUAL WEAKNESS, LIMP and PAIN Pfirrmann CWA et al Radiology, 235, 2005
4 Pfirrmann et al. Radiology 2005, 235: 562 Alteration of Abductor tendons and muscles 1 year after THR ( conventional lateral approach ) N = 25 Non symptomatic N = 39 symptomatic > 1 year after THR no pain no limp Full abd. strength > 1 year after THR pain limping weakness
5 CONVENTIONAL THR residual structural alterations Asymptomatic Symptomatic 32% 62% Pfirrmann et al. Radiology 2005, 235: 562
6 ANTERIOR APPROACH FOR THR Avoid interference with hip musculature Stable construct facilitates early mobilization Avoids structural? alterations in the musculature and tendon Better short and long-term function
7 ABDUCTOR TENDONS AND MUSCLES ASSESSED AT MR IMAGING 1 YEAR AFTER AMIS A.K. Bremer, F. Kalberer, C. Pfirrmann, C. Dora Department of Orthopaedics University of Zurich, Balgrist Zürich, Switzerland
8 STUDY DESIGN STUDY GROUP (n=25) Inclusion: consecutive series > 1 year after AMIS-THA Exclusion: prior surgery lumbar spine pathology CONTROL GROUP ASYMPTOMATIC (n=25)* Inclusion: > 1 year after conventional THA no pain no limp full abd. strength *Pfirrmann et al., Radiol 235: , 2005
9 METHODS: IMAGE ANALYSIS* anterior lateral posterior defect diameter signal *Pfirrmann et al., Radiol 235: , 2005
10 TENDON DEGENERATION Normal Insertion Tendon Degeneration
11 METHODS: BURSA
12 METHODS: FAN - SIGN Normal Insertion Avulsion
13 METHODS: FATTY ATROPHY (grade 0-4*) Gluteus medius Gluteus minimus *Goutallier, Clin Orthop 304: 78, 1994 *Zanetti, Invest Radiol 33: 163, 1998
14 METHODS: ABDUCTOR STRENGTH lateral position 0 abduction, 0 flexion, 0 rotation
15 PATIENTS Gender (m/f) study control p n=25 n=25 10/15 14/11 >0,05* Age 70,4 (±9,85) 60,3 (±14,3) >0,05** Side (l/r) 12/13 13/12 >0,05* *Chi-square test, **unpaired t-test
16 RESULTS: TENDON DEFECTS study n=25 control n=25 p* anterior 0 2 0,14 lateral 0 4 0,03 posterior 0 0 *Chi-Square-Test
17 *Chi-Square-Test RESULTS: TENDON DIAMETER study n=25 abnormal control n=25 abnormal p* ant 8 21 <0,001 lat 5 24 <0,001 post 0 1 0,31
18 *Chi-Square-Test RESULTS: SIGNAL ALTERATIONS study group n=25 abnormal control group n=25 abnormal p* ant ,02 lat 6 22 <0,001 post 2 5 0,22
19 RESULTS: BURSA - FAN SIGN study n=25 present control n=25 present p* bursa 2 8 0,034 fan 0 4 0,037 *Chi-Square-Test
20 RESULTS: FATTY ATROPHY GLUTEUS MEDIUS study group n=25 control group n=25 Mann-Whitney U Test
21 RESULTS: FATTY ATROPHY GLUTEUS MINIMUS study group n=25 control group n=25 Mann-Whitney U Test
22 RESULTS: ABDUCTOR STRENGTHS side of MIS - THA n=25 opposite side n=25 p* 4,8 kg (±2,9) 4,4 kg (±3,2) 0,56 *T-test for equality of means, two-tailed
23 LIMITATIONS historic control group unknown preoperative soft tissue damage number
24 ANTERIOR APPROACH FOR THR Avoid interference with hip musculature Stable construct facilitates early mobilization Avoids structural alterations in the musculature and tendon Better short and long-term function
25 The Search for Traces..
26 TRACES Which Approach was used?
27 TRACES Transgluteal Approach Gluteus medius / Gap in Fascia / Hypertrophy of the Tensor
28 TRACES... Which Approach was used?
29 TRACES... Posterior Approach: Quadratus / Internal Obturator / Piriformis
30 TRACES... Case: Courtesy T. Stähelin MD, Univ. Lausanne Which Approach was used?
31 TRACES... Case: Courtesy T. Stähelin MD, Univ. Lausanne Roettinger Approach: Tensor / Gluteus medius anterior
32 TRACES... Case: Courtesy C. Dora MD Which Approach was used?
33 TRACES... Case: Courtesy C. Dora MD Anterior Approach (AMIS): Almost no traces
34 CHANGING SURGEONS MIND
35
36 RESULTS: TENDON DIAMETER study n=25 control n=25 p* normal abnormal normal abnormal ant <0,001 lat <0,001 post ,31 *Chi-Square-Test
37 RESULTS: SIGNAL ALTERATIONS study group n=25 control group n=25 p* normal abnormal normal abnormal ant ,02 lat <0,001 post ,22 *Chi-Square-Test
38 RESULTS: BURSA - FAN SIGN study n=25 control n=25 p* absent present absent present bursa ,034 fan ,037 *Chi-Square-Test
39 M I S THR : WHAT DOES IT MEAN? Avoid interference with hip musculature Stable construct facilitates early mobilization Avoids structural alterations in the musculature? Better short and long-term function
40 MUSCULAR DAMAGE AFTER THR: Transgluteal versus anterior approach Fabian Kalberer Department of Orthopaedics University of Zurich, Balgrist Zürich, Switzerland
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