c:\documents and settings\lorenzo bertolin\documenti\milano 8 10 10
TRANSCRIPT
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ACCESSO ANTERIORE
E MODULARITA’
Enrico Sartorello
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Ortopedia Bassano
Sprengler (1878)
Bardenheur (1907)
Depuy de Frenelle (1924)
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Ortopedia Bassano
M.N. Smith-Petersen
J Bone Joint Surg 31A, 40 -49,1949
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Ortopedia Bassano
R. Judet
J Bone Joint Surg 32B, 166 -173,1950
via d’ accesso di Hueter
letto ortopedico
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Ortopedia Bassano
J.M. Matta (2002)
Matta JM. Bilateral THA. Orthopedics; 25:1224; 2002
T. Siguier (1993)
Siguier T, Siguier M, Brumpt B . Mini-incision anterior approach does not increase dislocations rate. A study of 1037 total hip replacements. Clin Orthop Relat Res;386: 85-92; 2001
F. Laude
Lesur E, Laude F . Arthroplastie totale de hanche par voie antérieure et son évolution mini-invasive. In: Encycl Med Chir Techniques Chirurgicales Orthopédie-Traumatologie. Paris: Elsevier SAS;44-667-B; 2004
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tempo femorale
• extrarotazione 90°• iperestensione > 40°• adduzione 20°- 30°
tempo acetabolare
• flessione 15°
Ortopedia Bassano
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F. Laude
Maitrîse Orthopèdique 178, 6-11, 2008
Ortopedia Bassano
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capsula elemento di trazione
F. Laude
Maitrîse Orthopèdique 178, 6-11, 2008
Ortopedia Bassano
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letto di trazione• Scuola di Judet (F)• Matta (Boston)
arto libero• Böhler (Linz)• Nogler (Innsbruk)• De Witte (Aalst)• Siebenrock (Bern)• Stürup (Copenhagen)• Hungerford (Baltimore)• Myers (Colorado Springs)
Ortopedia Bassano
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Ortopedia Bassano
doppio arto libero
Krismer M, Nogler M, Rachbauer F. Direct, anterior, single incision approach. In: Hozac W, Krismer M,Nogler M, Bonutti PM, Rachbauer F, Schaffer JL, Donnelly W, eds. Minimal invasive total joint arthroplasty. Berlin Heidelberg New York: Springer, 2004
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caratteri di mininvasività
• nessuna disinserzione muscolare
• ridotte perdite ematiche
• ridotto dolore postopratorio
• precoce recupero funzionale
Ortopedia Bassano
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Unità Operativa di Ortopedia
e TraumatologiaPrimario R. Bisson
ULSS n. 8 Ospedale di Castelfranco Veneto
Pitiè-Salpetriére - Clinique AragòParigi
1990 - 1995
Castelfranco Veneto2001 - 2004
Asiago - Bassano del Grappa (VI)2005 - 2010
Ortopedia Bassano
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Ortopedia Bassano
• posizione del paziente
• strumentario dedicato
• morfologia impianto
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Ortopedia Bassano
Kennon R, Keggi JM, Westmore RS, Zatorski L, Keggi KJ. Anterior approach total hip beyond the minimally invasive technique. J Bone Joint Surg Am; 86 : 91-97; 2004
la trazione dell’arto non si mostra elemento
indispensabile
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Ortopedia Bassano
sartoriotensore
fascia lata
retto del femore
ileo-psoas
piccolo gluteo
medio gluteo
n. gluteo sup. n. femorale
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8 - 10 cm in direzione del margine rotuleo lat.
°SIAS
2 dita distale e 2 dita laterale alla SIAS
*
Ortopedia Bassano
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Ortopedia Bassano
sartorio
tensore fascia lata
n. femoro-cut.
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si dissocia il ventre del tensore della fascia lata
dalla faccia interna della fascia
Ortopedia Bassano
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Ortopedia Bassano
la trazione mediale del sartorio
espone il retto del femore
riposizionare il retrattore mediale
caricando sartorio e retto del femore
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fascia innominata copre
branca ascendente a. circonflessa lat.
Ortopedia Bassano
legare
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Ortopedia Bassano
capsula elemento di trazione
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Ortopedia Bassano
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Ortopedia Bassano
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Ortopedia Bassano
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Ortopedia Bassano
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Ortopedia Bassano
tendenza a verticalizzare ed antivergere
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Ortopedia Bassano
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Ortopedia Bassano
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adduzione elemento fondamentale
Ortopedia Bassano
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progressività traslazione per evitare impegno apice trocantere sulla colonna acetabolare posteriore
3. iperestensione - adduzione
4. leva apice trocantere per elevarlo
1. extrarotazione
2. uncino solleva il femore
Ortopedia Bassano
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Ortopedia Bassano
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Ortopedia Bassano
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Ortopedia Bassano
stelo senza spalla trocanterica
risparmio inserzioni glutee
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Ortopedia Bassano
ripristino parametri morfo-funzionali
sostituzione articolare
ricostruzione articolare
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evitare• anchilosi• pregressa chirurgia• coxa profunda• osteofitosi marcata• displasia
obesità non controindicazione
nei pazienti muscolosi più difficoltosa esposizione del femore
Ortopedia Bassano
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novembre 2005 - settembre 2010
228 impianti letto di trazione
121arto libero
107
Ortopedia Bassano
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78 casi < 400 cc
37 casi 400 - 800 cc
(115 casi)
(prime 6 ore di emorecupero)
Ortopedia Bassano
perdita media 470 cc
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Ortopedia Bassano
64 casi 1° giornata
35 casi 2° giornata
16 casi 3°- 5° giornata
(115 casi)
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Ortopedia Bassano
• fratture trocantere 2
• fratture calcar 2
• lussazioni 1
• calcificazioni eterotopiche 0
• infezioni 0
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Ortopedia Bassano
frattura gran trocantere
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frattura calcar
Ortopedia Bassano
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Ortopedia Bassano
• malposizionamento stelo 5
• malposizionamento coppa 2
• sottodimensionamento stelo 4
• dismetrie (10 -15mm) 8
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malposizionamentoionamento stelo
Ortopedia Bassano
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sottodimensionamento stelo
Ortopedia Bassano
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Ortopedia Bassano
ipermetria arto( 10 ~ 15 mm )
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perdite ematiche 900 cc.
deambulazione 3° giornata
Ortopedia Bassano
♀ 67 a
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Ortopedia Bassano
♀ 50 a
perdite ematiche 800 cc.
deambulazione 2° giornata
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vantaggi
• nessuna disinserzione muscolare
• ridotte perdite ematiche
• ridotto dolore
• minor incidenza lussazioni
Ortopedia Bassano
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svantaggi
• rischio lesione n. femoro cutaneo
• consequenzialità gesti chirurgici
• curva apprendimento
Ortopedia Bassano
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anca orientata anteriormente
accesso anteriore più logico
Ortopedia Bassano
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grazie