Chapters Transcript Video Live Surgery: ABLE Advanced Anterior Approach- Supine Position featuring Dr. Jeffrey Geller Dr. Jeffrey Geller narrates his technique in a live surgery using the ABLE Approach with a patient in a supine position. This is a left hip where the patient's head is oriented to the top of the screen and the foot is oriented towards the bottom of the screen. You will see the incision is marked out an interior to the interior border of the greater trochanter, just distal to the enter superior iliac spine. The incision is made, a superficial dissection is done down to the area of the fascia, overlying the muscle compartments. What we try to isolate is the border between the tensor fascia lata and the gluteus medius. The T F L is demarcated by a slightly bluish hue to the tissue. And the incision through the FAA is done quite superficially just on the gluteus medius side of the approach. Once we get through the fascia, we spread the tissue a little bit to expose the anterior border of the gluteus Medius muscle. We spread the interval distally to really localize it and find it. There are always some crossing veins and vessels that need to be cauterized to get control of any bleeding. As we use our fingers to digitally spread the tissue and find and develop our muscle. Inter we find the uh border just deep to the gluteus medius on the superior board of the femoral neck and retractors are placed around the thermal neck superiorly and inferiorly. We then place another retractor on the inter medial border of the aceta bum just deep to the rectus femmes, indirect head. This allows us to isolate the capsule overlying the hip joint. Some people choose to do a capsulotomy and tag it for later repair. My approach has been to do a capsulectomy uh so as to improve the overall visualization and mobilization and it is not proven to lead to any increased risk of dislocation, post surgery. So my practice is typically to remove the capsule as a scene here. Once the capsule is adequately removed and visualization is clear at this point, I will mark out with uh Bovi exactly where I want my femoral neck osteotomy to be done based on preoperative templating, you can dissect the capsule immediately uh and palpate where the lesser trochanter is to get a little bit of a better sense. But visualization should be very clear at this point when doing the thermal neck to make sure that we are inside the greater trochanter. After doing the osteotomy, I use an osteotome to lever the femoral head up. I then take a drill and a cork screw into the center center position of the femoral head which allows me to get a good hold of the thermal head and remove it without difficulty. I will then at this point, double check my neck cut on the femoral neck for accuracy and recut as needed. At this point, I'll place retractors around the Aceta bum. In this left hip, we see a curved C type retractor along the interior border of the Aceta bum. Uh I generally use a femoral neck retractor around the posterior border of the aci taul. And in this left hip, the ini retractor is in the nine o'clock position and the poster retractor is in the three o'clock position. If looking at a clock face, we excise. The Lara do a typical reaming. I prefer to use a straight inserter for my aceta bum and orient the cup appropriately. I use the X frame to help with my abduction angle and I'll feel the anterior border of the aceta bum to gauge my anti version angle of the cup. I typically place a screw through the cup and the interior superior region and place a standard lip liner and impact it into place without difficulty. If any osteophytes need to be removed at this point, it can be at this point. Now, we focus on the proximal femur, I will drop the leg of the table approximately 25 to 30 degrees and put the well leg onto a padded male. I'll then put the operative leg in a figure four position which allows external rotation, a deduction and extension to enable exposure of the proximal femoral metaphysis. I'll put the curve, thermal neck retractor around the cow car to give exposure distally in the wound and then a pointed retractor underneath the greater trochanter to help elevate the femur for access. It is important at this point to spend some time learning about the releases. I release the superolateral capsule as well as the peri performance tendon back to the poster aspect of the greater trochanter which helps enable elevation of the femur up and out of the wound with a successful release. There is unencumbered access to the femoral shaft and using any type of stem can be completed with this type of exposure. Once the proximal femur is exposed, we go through the typical steps of preparation including open up the canal with the box osteotome, finding the canal and then broaching. I take care to use the starter chili pepper broach to really lateralize as much as possible and maximize the size of the brooch and stem broaching is then done in the standard fashion. Once we get to the appropriate size broach, I typically use a calcar planner to finish prep of the proximal femur. My typical preference is you to use a collared implant. So I will place the collared trial onto the Broch, a trial femoral head onto the stem and we then go ahead and reduce the hip. I then bring in the fluoroscopy machine to check the sizing of the implant, the position of the acetabular component as well as leg lengths I flatten the table out so I can measure leg lengths clinically with the patient laying down supine on the table. But I then use the bovie cord technique across the inferior aspects of the issue tuberosity to confirm leg lengths in their relationship to the lesser cantors. At this point, I dislocate the hip again, remove the provisional component at this point. The stem is inserted under direct visualization by calcar planting the metastasis. I'm able to visualize the collar of the stem sitting directly onto the cal car of the femur and resting comfortably. I then checked the CAL car for fractures and knowing that the stem has sat down exactly where my brooch was. I placed the final ephemeral head onto the stem. If you so choose, you can do another trial reduction and reassess leg lengths, stability and offset. I've checked the CALC car for fractures at this point. I now I use the lighted sucker tip to make sure there's no debris in the aci taul. And we go ahead and reduce the hip. I check wound edges to make sure there's no muscle damage. Uh And I will once again bring in fluoroscopy, double check my leg lengths both clinically and fluoroscopically uh which is pretty easy to do in the supine position. I do this once again with the Bovi cord technique and then inject local anesthetic into the hip. My closure technique is to use barb sutures in the fas as well as the subcutaneous closure and then do a plastic surgical closure for the skin to help enable faster wound healing and then use a skin glue type based bandage uh for uh ease of post op care for the patient. Patients are then weight bearing as tolerated immediately. I do not invoke any anterior hip precautions with this procedure. And uh I no longer send patients for any formal physical therapy but simply encourage walking uh increasing amount on a daily basis postoperatively, uh which helps enable them to get back to life a little bit quicker. This is the end of the surgical technique. Thank you very much. Published April 24, 2023 Created by Related Presenters Jeffrey Geller, MD Orthopaedic Surgeon View full profile
