+-

Advertisements

Welcome Back

The Hip Talk Discussion Forum was hacked a few weeks back. It has taken me a long time to fix it. The only backup I could use was way back to April 2020. All members and posts up to that date are available. Anything newer has been lost. I am sorry, but that has been the only way to get things up and running again.

Author Topic: Surgeon Explanations to Gantz Approach  (Read 3520 times)

0 Members and 1 Guest are viewing this topic.

Pat Walter

  • Patricia Walter
  • Administrator
  • Hero Member
  • *****
  • Posts: 3785
  • Owner/Webmaster of Surface Hippy
    • Surface Hippy about Hip Resurfacing
Surgeon Explanations to Gantz Approach
« on: October 22, 2011, 03:36:31 PM »
I asked several of the top hip resurfacing surgeons to explain the Gantz approach and why they do or don't use it. It will take a bit of time before all surgeons have time to answer.

Dr. Brooks, Bose, Rogerson and Gross have written information about the Gantz Approach.  I placed all their responses together here

http://surfacehippy.info/hiptalk/index.php?topic=3030.0

I locked their replies so it would be easy for new people to read the responses in one place.  I have left this original discussion so people can continue to comment.

Pat
« Last Edit: November 26, 2011, 03:42:49 PM by Pat Walter »
Webmaster/Owner of Surface Hippy
3/15/06 LBHR De Smet

Pat Walter

  • Patricia Walter
  • Administrator
  • Hero Member
  • *****
  • Posts: 3785
  • Owner/Webmaster of Surface Hippy
    • Surface Hippy about Hip Resurfacing
Dr. Brooks explains the Gantz Approach
« Reply #1 on: October 22, 2011, 03:37:56 PM »
Hi Pat,

You asked about the Ganz approach, which is also known as "surgical dislocation" of the hip for resurfacing.

This was described way back in 2001 by Prof. Reinhold Ganz in Berne, Switzerland. Resurfacing was being done in those days, although not so much by him, and he used it for all kinds of hip surgery from debridement to revision total hips. The key factor is that it is designed to preserve the blood supply to the femoral head. That is irrelevant in hip replacement because the femoral head is getting cut off anyway. In joint preservation procedures like FAI operations, labral repairs, removal of loose bodies etc and in hip resurfacing, it is important that the femoral head blood supply is respected.

Dr Ganz's major contributions have been his descriptions of the blood supply to the femoral head, and of femoroacetabular impingement (FAI) in the development of hip arthritis.

There is little question that the posterior approach routinely damages the blood supply to the femoral head. But there is also little question that this approach yields excellent outcomes in hip resurfacing, and is done by most US surgeons, about 80%. The pioneering surgeons McMinn and Treacy both use the posterior approach.

The early post-op femoral neck fracture risk is 1-2% in men, and 3-4% in women, and since these are likely "fatigue" fractures or accumulated microstresses, I would expect that blood supply is important in preventing them.

Proponents of the anterior approaches, myself included, like to preserve the blood supply to the femoral head. These approaches include the anterolateral (like me), the direct anterior, and Ganz. In that both the femoral neck and the acetabulum face anteriorly, and the common FAI lesions on the femoral neck are anterior, it makes sense to go in that way. If you want to see someone at their front door, why go in the back? Having said this, remember that experienced posterior surgeons have no trouble seeing everything, but a less experienced surgeon would struggle.

In all the anterior approaches, to get to the front of the hip you need to get the abductor muscles out of the way. You can retract them, split them, or cut them, but they have to be moved. 

Ganz cuts through the bone of the greater trochanter, where the abductors attach, moves the bone plus muscle out of the way, and gets in that way. On the way out, then, one has to reattach the bone using hardware: either screws or wires, and protect the bone until it heals by delaying weight-bearing. Of course, any time you cut a bone and put it together, there is a chance that it does not "knit" or heal, just like a fracture. This causes pain, broken or loose hardware, and probably more surgery to fix it.

In the anterolateral approach you can spread the muscles apart, peel them off the trochanter and reattach them, or cut them. It's better to spread them in the line of their fibers, not cut them. This is how I do it. The muscles heal side-to-side, held together, not apart, by contractions. The blood supply is preserved, and I have had only one fracture so far out of 1100+. Knock on wood.

Posterior surgeons, like McMinn and Treacy, and most others too, cut a number of small muscles, ("the short external rotators") and sometimes part or all of gluteus maximus, and repair them on the way out in an end-to-end manner. Where total hips have a tendency to dislocate posteriorly, resurfacing is so stable that it really isn't an issue.

We would view Ganz's approach as being un-necessarily complex, and adding the additional risks of non-healing trochanteric osteotomy or broken hardware to the procedure. If you're concerned with the blood supply, do another, less complex anterior type of approach.

There are indeed circumstances during revision total hip replacements where a trochanteric osteotomy is useful, e.g. for getting out old stems and cement, and then I do it. The method Ganz described of "sliding" the trochanter and leaving it attached to the quadriceps below is how I do it, and hats off to him for that.

I have said this before, but I'll say it again: don't go and talk a surgeon into an approach that you like. He/she should do what they always do. Pick the surgeon. Resurfacing is a difficult operation, so your surgeon has to be comfortable with what they are doing. ANY approach, anterior, posterior, Ganz, etc can give the same excellent results in the hands of the experienced surgeon, using a good device, in an appropriate patient.

Regards,

Peter Brooks MD, FRCS(C)

Cleveland Clinic

Webmaster/Owner of Surface Hippy
3/15/06 LBHR De Smet

obxpelican

  • Hero Member
  • *****
  • Posts: 1489
  • ~Welcome to SixBurgh~
Re: Surgeon Explanations to Gantz Approach
« Reply #2 on: October 22, 2011, 04:51:12 PM »
Thanks Pat, Dr. Brooks did a great job explaining the procedure.

IMHO I just do not see the need of that procedure given how many of the top surgeons in the world use the posterior approach and also given the extra risks associated with the Gantz procedure.  This is kind of what I've been saying all along..... why break bones when you do not have to.


Chuck
Chuck
RH/Biomet U/C Dr. Gross/Lee Webb
8-6-08

Dannywayoflife

  • Hero Member
  • *****
  • Posts: 2507
Re: Surgeon Explanations to Gantz Approach
« Reply #3 on: October 22, 2011, 05:51:09 PM »
Thanks pat that's very interesting. I personally am more concerned by the selection of the surgeon. If Mr Treacy said to me I need to take this approach for reasons xyz then I would accept that he is the surgeon and knows best. I wouldn't be so accepting from a less experienced surgeon though. I think Derrick Mcminn said in an interview he's used all approaches for various reasons but usually uses the posterior.
Thanks once again for the gem info.
Danny
Train hard fight easy
LBHR 10/11/2011 Mr Ronan Treacy Birmingham England
60mm cup 54mm head
Rbhr 54mm head 60mm cup 12/02/15 Ronan Treacy ROH Birmingham England
;)

Anniee

  • Sr. Member
  • ****
  • Posts: 343
Re: Surgeon Explanations to Gantz Approach
« Reply #4 on: October 22, 2011, 07:29:09 PM »
Thank you, Pat!  Very informative!
Annie/ Right Uncemented Biomet 4-20-11/Left Uncemented Biomet 10-12-11/Dr. Gross

newdog

  • Sr. Member
  • ****
  • Posts: 362
  • I am a Gross Hippy!
Re: Surgeon Explanations to Gantz Approach
« Reply #5 on: October 23, 2011, 01:20:06 AM »
Thank you, Pat. That was a really good explanation from Dr. Brooks.
Steve, Dr. Gross bilateral, uncemented Biomet, January 10 & 12, 2011, Columbia S.C.

Luanna

  • Sr. Member
  • ****
  • Posts: 376
Re: Surgeon Explanations to Gantz Approach
« Reply #6 on: October 23, 2011, 03:02:14 AM »
I'd like to hear Dr. Pritchett's opinion. I wonder if he has time to provide his thinking about it? He's been doing this stuff for so many years and he's seen lots of trends and changes and has some unique perspectives on lots of topics.

Luanna
RHR 8/30/2011 - Dr. Pritchett - Stryker Trident Shell /X3 Poly liner acetabular cup. BHR head.

curt

  • Sr. Member
  • ****
  • Posts: 340
  • Runner with the cruddy cartilage
Re: Surgeon Explanations to Gantz Approach
« Reply #7 on: October 23, 2011, 01:41:56 PM »
I echo the sentiments about finding a surgeon with LOTS of procedures under their belt, and a successful track record (i.e. comfortable in talking about any and all revisions that were necessary and why).  It would worry me to remove and reattach bone.  I wonder whether surgeons believe the anterior approach is "easier" to perform, given the great track record of posterior cases.  Easier to the surgeon does not trump a successful outcome (the best possible) for me.  Curt
51 yr, RHBiomet, Dr. Gross, 9/30/11
happy, hopeful, hip-full

Pat Walter

  • Patricia Walter
  • Administrator
  • Hero Member
  • *****
  • Posts: 3785
  • Owner/Webmaster of Surface Hippy
    • Surface Hippy about Hip Resurfacing
Re: Surgeon Explanations to Gantz Approach
« Reply #8 on: October 23, 2011, 03:02:21 PM »
Luanna

I don't know all the surgeons.  If they don't attend the hip resurfacing courses and conferences to learn, teach and stay updated on techniques - then I don't know them personally.  I know all the top surgeons personally and have their personal emails and cell numbers. 

If you would like a reply from Dr. Pritchett, then why don't you ask him to respond next time you visit him.  He can email me or give you a written answer.  Many of the surgeons won't take time to teach while others will.  The surgeons that attend the courses are really very pro hip resurfacing and will help with any information that I need for the website.

Pat
Webmaster/Owner of Surface Hippy
3/15/06 LBHR De Smet

Luanna

  • Sr. Member
  • ****
  • Posts: 376
Re: Surgeon Explanations to Gantz Approach
« Reply #9 on: October 23, 2011, 04:51:22 PM »
Hi Pat,

I'd be happy to give him the question in writing with your email address, site, and contact info. I'll also give it to his care coordinator, Susan. I have my 8 week check-in this coming Wednesday.

He also needs to provide you with updated stats on the number of HRs he has performed to date as it is close to 3,000 now according to Tin who saw him recently. I'll ask him to contact you to update that data as well.

http://www.surfacehippy.info/listofdoctors.php

Cheers,
Luann
RHR 8/30/2011 - Dr. Pritchett - Stryker Trident Shell /X3 Poly liner acetabular cup. BHR head.

Tin Soldier

  • Hero Member
  • *****
  • Posts: 1117
Re: Surgeon Explanations to Gantz Approach
« Reply #10 on: October 24, 2011, 09:15:18 PM »
I calculated about 2800 based on 2600 in Feb 2011 adding about 6 or so per week.  Pritchett's a bit quiet, but last week I saw him and once I started asking technical questions, he provided lots of interesting info.  We talked nothing about my recovery (I have been through this before), but about femoral neck thinning, a proposed joint registry in the US, ASR issues, Barry (NY Times Journalist), metallosis, and a little bit about statistics and dataset sizes.  I wish I could have chatted longer.  He inspires me to want to be an orthopedic surgeon.  My wife recommended that I stick with my day job and keep hobbies like building boats in the back yard. ::)     

BTW - He is well-authored, extremely epxerienced, and he keeps current on HR topics. 
LBHR 2/22/11, RBHR 8/23/11 - Pritchett.

Pat Walter

  • Patricia Walter
  • Administrator
  • Hero Member
  • *****
  • Posts: 3785
  • Owner/Webmaster of Surface Hippy
    • Surface Hippy about Hip Resurfacing
Dr. Rogerson Explains his Opinion about the Gantz Approach
« Reply #11 on: November 04, 2011, 02:05:55 AM »
Dr. Rogerson explains:

I am not enthused about the Ganz trochanteric flip approach for several reasons. It was developed to be less injurious to the femoral blood supply. Koen DeSmet showed that with the modified posterior capsulotomy approach that he, Bose and I use, that the blood supply compromise during surgery is not much different than with a trochanteric osteotomy. Also, the incidence of AVN even with the much more extensive posterior capsular release that McMinn initially used is extremely low. We are now over 600 cases and have not seen a case of AVN.

Problems with any trochanteric osteotomy including the trochanteric flip all relate to injury to the gluteus medius attachment which results in an abductor lurch weak and awkward gait afterward. In this young and very active patient population, one is hard pressed to protect them for 6-8 weeks on crutches so the trochanteric bone can heal. If the patient is even relatively non-compliant, one is left with a lifelong limp that is impossible to fix. That is why the posterior approach became almost universal in America and the Charnley trochanteric osteotomy was abandoned. Paul Beaule recently reported on his series with trochanteric osteotomy and had a significant number of complications relative to the abductor mechanism.

In summary, this "flip" technique is a solution to a problem (AVN) that barely exists with the modified posterior capsulotomy approach and is associated with a significant number of "limps" and restrictions for a very active group of patients.

Dr. John Rogerson
« Last Edit: November 04, 2011, 02:06:17 PM by Pat Walter »
Webmaster/Owner of Surface Hippy
3/15/06 LBHR De Smet

obxpelican

  • Hero Member
  • *****
  • Posts: 1489
  • ~Welcome to SixBurgh~
Re: Surgeon Explanations to Gantz Approach
« Reply #12 on: November 04, 2011, 12:39:11 PM »
It would be interesting to see the stats for the Gantz procedure, in other words how often does the trochanter not heal correctly?  How often do the patients suffer that dreaded lifetime limp?

Pat, have you ever seen the stats for those issues?

Personally I would have gone nuts waiting to put weight on my foot for 6 or 8 weeks. 

Chuck
Chuck
RH/Biomet U/C Dr. Gross/Lee Webb
8-6-08

Pat Walter

  • Patricia Walter
  • Administrator
  • Hero Member
  • *****
  • Posts: 3785
  • Owner/Webmaster of Surface Hippy
    • Surface Hippy about Hip Resurfacing
Re: Surgeon Explanations to Gantz Approach
« Reply #13 on: November 04, 2011, 02:07:21 PM »
I have not seen statistics for people left with limps and problems from the Gantz approach.  I am not sure where to find them.

Pat
Webmaster/Owner of Surface Hippy
3/15/06 LBHR De Smet

Pat Walter

  • Patricia Walter
  • Administrator
  • Hero Member
  • *****
  • Posts: 3785
  • Owner/Webmaster of Surface Hippy
    • Surface Hippy about Hip Resurfacing
Dr. Bose Compares the Posterior Approach to Gantz Approach
« Reply #14 on: November 06, 2011, 01:59:01 PM »
Comments by Dr. Vijay Bose

The ganz trochanteric flip is an excellent approach for doing open FAI surgery, for fixing fracture on the femoral head ( pipkin #) and for doing osteotomy of the femoral neck in post SUFE situations. In these non - arthritic situations a surgical dislocation of the hip is warranted without damaging the blood supply and I employ it routinely for these indications.

However its use in hip resurfacing is a bit of an overkill.
It has been documented without a shadow of doubt that the post approach does not compromise the vascularity of the femoral head in an arthritic hip after resurfacing. Thousands of patients who have crossed the 10 yr mark with the post approach & BHR bear testimony to this.

Doing the ganz for resurfacing is a much more morbid procedure than a standard post approach. Any osteotomy will take more time to heal and recover function. The extended trochanteric osteotomy ( ETO) which is the bigger version of the Ganz flip will take about 6 months for the patient to regain function.

Intuitively the Ganz looks appealing as regards preserving blood supply but this issue is not relevant in an arthritic hip.

with best regards
vijay bose
chennai
« Last Edit: November 06, 2011, 01:59:34 PM by Pat Walter »
Webmaster/Owner of Surface Hippy
3/15/06 LBHR De Smet

 

Recent Posts

Advertisements

Donate Thru Pay Pal

Surface Hippy Gear

Accordion Player Pat Webmaster/Owner

Owner/Webmaster of Surface Hippy

Statcounter

View My Stats

Powered by EzPortal