ANTERIOR APPROACH MIS TOTAL HIP RELPACEMENT COURSES*
EMILE LETOURNEL INSTITUTE COURSE AND WORKSHOP:
Fractures of the Acetabulum and Pelvis
Letournel in 1984, then the world's foremost expert in the
field conducted the first course: Fractures of the Acetabulum
and Pelvis in Paris, this being the first international
course on the subject. The current course will be the 19th
in this lineage. Despite the death of Professor Letournel,
the course has prospered and developed regarding its content
and faculty. Though it has been frequently imitated it remains
the first and we believe the best.
here to download the complete brochure (PDF)
PRODUCTS DESIGNED BY JOEL M. MATTA,
Pelvic System: Pelvic and Acetabular Plating (click
here to enlarge)
Orthopaedic Table - supine (click
here to enlarge)
Orthopaedic Table - supine w/hip extended (click
here to enlarge)
IN CLINICAL PRACTICE
TO IMPROVE YOUR CLINICAL RESULTS
M. Matta, M.D.
the formula for excellence in orthopaedic clinical practice?
Certainly there is no set formula for all but I will give you
my thoughts based upon what I have learned from others as well
as my personal experience.
a number of ways that excellence can be measured but I think
the most important is by the benefit we provide to our patients
which is our clinical results. Top clinical results exist in
many settings and are not necessarily related to the notoriety
of the surgeon or institution.
recommendation is to pursue the type of practice you have a
passion for. You should find your niche according to your interests
and your abilities. Monetary reward will to a degree direct
our activities however you sell yourself short if you place
money first. In Orthopaedics we can have our “cake and
eat it too”. Our position allows us to enjoy our work
as much as sport, gain personal satisfaction and community recognition,
and in the bargain also be well compensated. I think the key
to all of these benefits however is our passion and commitment
to our work. There are few careers available that combine the
pleasure of both manual and intellectual challenges.
are surgeons and the job we do in the operating room is probably
most important we must also take pride in our one to one skills
with patients. If the patient is able, the more he understands
about his problem the better. Pre and post operative detailed
explanations can help the final result. I also rely on patient
information publications and my own web site to inform the patient
In the acute high energy trauma situation be disciplined regarding
the physical examination. The patient should be completely undressed
and all skin areas visualized. As well as a neurological exam,
palpate and move all extremities that do not have obvious deformity.
Use x-rays liberally.
sub acute or chronic problem listen carefully to the patient.
You need to always assume that the patient is telling the truth
and is not crazy or a “crock”. There are many problems
we don’t yet understand and everyone does not fit neatly
into a category. Many old trauma problems such as mal unions
and non unions require a unique solution that you need to invent.
The extra time you spend in planning and consultation will make
we find ourselves at a loss with patients, particularly those
with chronic pain problems who will often say “you’ve
got do something” or “I can’t live like this”.
The justification for surgical treatment however should not
be based on such desperate reasoning. Surgery should always
have a probability of success when undertaken. You may have
nothing to offer the patient and in that case it is best to
say so. In a few cases I have gone so far as to tell patients
that they should quit seeing doctors before somebody operates.
A large proportion of these difficult patients are chronic narcotic
users. I believe it is our responsibility to limit prescription
of these medications to acute situations or terminal situations
such as neoplasm.
in interpretation of x-rays, CT and MRI. These combined with
the clinical factors provide the main indications for surgery.
Maintain indications for surgery and not just operate because
there is a fracture. The integrity of you and our specialty
suffers with application of faulty indications. Operating without
the proper indication is not just unethical it is an assault.
high quality Orthopaedic surgery is a goal we all aspire to.
Within your chosen niche do everything you can to learn from
the best. Read publications and texts. Attend courses. As we
interpret medical data, large multi center studies can tell
you the standard level of care that is present as an average
across centers. Pay attention also to the results of experienced
and knowledgeable single surgeon series. The large single surgeon
series can represent the level of results that can be obtained
with dedication to the subject.
observe patient care and surgery with the field’s best.
Most orthopedic surgeons are open to this. A corollary to this
is: learn and adopt the best existing techniques before attempting
to modify or develop new ones. In learning a technique, the
technique must be learned and adopted completely in order to
expect the maximum benefit to the patient and in some cases
to avoid disaster. As a resident in 1978 I attended my first
Swiss AO Course. Upon returning home I was delighted to be presented
with a tibial plafond fracture. I operated enthusiastically
but as the months progressed I watched in horror as green bone
fell out of the wound. I had learned how to plate and screw
the bone but not how to make the proper incision and handle
the soft tissues. Acetabular fracture surgery is successful
by a specific combination of the table, patient positioning,
surgical approach, reduction techniques and implants. I have
quite a few visitors who wish only to peer into the open wound.
Learn and adopt the best existing techniques in their entirety
before attempting to modify and develop new ones. This knowledge
will keep you from repeating the mistakes of past failed techniques
and forms the basis of our technical evolution.
created equal as surgeons? Of course not. Surgery is a combination
of intellect and motor skill. I would say that intellect is
by far the most important factor. Understanding the fracture
before surgery, establishing a good plan including set up, approach,
reduction and fixation strategies are the most important factors.
Concentrate your plan more on how you will reduce the fracture
rather than how you will fix it. Reduction is typically a bigger
problem then placing the implant. For a given surgery, one of
several implants may be applicable and your familiarity with
a device may be the reason to use it.
that surgeons are often best judged not by a surgery where everything
goes well but by how they react when things start to go wrong.
I have witnessed “flails” triggered by panic with
the situation going from bad to worse. The high stress of a
problem situation should ideally trigger your mind to a higher
level of focus to deal effectively with the unexpected problem.
Experience and contingent strategies can help.
surgeries we need to critically assess the result. I would say
that a minority of my surgeries are performed completely to
my satisfaction particularly regarding acetabular fractures.
I like to have a think after surgery in the presence of the
post op x-rays regarding how things could have been done a little
is speed in performing surgery. At the beginning of my career
I did not consider speed to be very important but I think it
is an important factor though admittedly not the most important
one. I think speed is a benefit in limiting tissue trauma and
infection. It is also an economic factor for you and the hospital
as well as one that limits the number of patients you can benefit.
During my early years of operating acetabular fractures I was
assisted for the first time by my chief, Gus Sarmiento on a
Kocher-Langenbeck approach to a transverse plus posterior wall
fracture. If you know Gus Sarmiento you know he is not particularly
patient. Gus’s first words at the scrub sink, “Joel,
how long is this going to take?”. My response, “Gus,
relax and get ready for a four hour case.”. His response,
“Four hours, I’ll give you 2!”. The case took
2 hours and the result was as good as my 4 hour cases and from
that time forward similar cases took about 2 hours. On the other
hand you need to take the time necessary to achieve the desired
result. Speed is not a primary goal but should increase progressively
with your years of experience. When you watch a good surgery
go quickly you will not see particularly fast movements but
rather well planned and effective ones.
As an orthopaedic
surgeon you are the organizer and leader of the OR team. Regardless
if you think that you are inherently organized or an obvious
leader type this is your role. I don’t think that personal
charisma or forcefulness is a prerequisite for leading an effective
team. The factors I consider most important are planning, providing
respect, education and encouragement for your team members and
working with the team in a hands on way. The concern you show
for the patient and the commitment you show for achieving an
excellent surgical result will rub off. By all means don’t
be the one who is responsible for delays or your tardiness and
lack of efficiency will also rub off. Leading the team, trying
to improve performance and efficiency is a job that never stops.
complications are inevitable and the indication for any surgery
must be judged in relation to their potential incidence. When
a complication occurs an honest discussion with the patient
at an early time is essential. There is a tendency to feel guilt
and a wish to avoid the inevitable discussion with the patient
and family. It is important to use the word complication and
confront the situation openly and directly. The patient will
at least take comfort that you are still with him in his care
and will do everything possible to take a positive course. Surgical
wound complications such as hematoma and infection are some
of the most difficult to face and potentially harmful to the
patient. Three orthopaedic surgeons can look at a wound regarding
infection and say no, maybe or yes. It is easier to pronounce
a colleague’s wound infected than your own. Saying infection
is present to yourself, the patient, and writing it in the chart
aids in getting on with effective treatment.
often believes in the myth that miracles in medicine are the
norm. The truth is that we treat most problems with significant
limitations of our understanding and that we will look back
at many of our current treatments as primitive. Getting good
results following orthopedic trauma entails great difficulties.
We therefore need to practice with honesty and humility.
that a simple documentation system including diagnosis, treatment,
complications and results is a big help in quality control.
Simple data forms that can be coded in a prospective manner
and entered into a computer data base may not add a great deal
of time and expense. This information can guide the evolution
of your practice methods. To improve results it is very important
to have results to compare to. Changes to improve results are
best addressed to groups of patients or fractures with a high
level of bad results and/or complications.
I like to
give credit to my mentors. In my own career my most important
mentors have been Augusto Sarmiento and Emile Letournel. I take
pride in my own contributions to orthopedic knowledge but recognize
that the huge basis of my practice is what I have learned from
health and lifestyle to be important in my performance as an
Orthopedic surgeon. Some restraint with food and alcohol as
well as exercise benefits you and your patients. I think a mistake
most of us make is not taking enough time off. I once asked
Harald Tscherne how much vacation he took. He answered, “Six
weeks”. I said that must include your educational travel.
“No”, he said, “six weeks vacation”.
None of us would question Prof. Tscherne’s commitment
carefully selected your career and have also passed an extensive
training and selection process to be an orthopaedic trauma surgeon.
The evolution of your practice toward improved clinical results
will make it all the more exciting and rewarding.
BIBLIOGRAPHY OF ARTICLES BY DR. MATTA
- Ferguson, T.A.; Patel, R.; Bhandari, M.; Matta, J.M.: Fracture of the acetabulum in patients aged 60 years and older. J Bone Joint Surg Br. 2010. 92(2):250-7
- Mast, N.H.; Munoz, M.; Matta, J.M: Simultaneous Bilateral Supine Anterior Approach Total Hip Arthroplasty: Evaluation of Early Complications and Short-Term Rehabilitation. Ortho Clinics of North America. 40(3):351-356, July 2009.
- Anterior Total Hip Arthroplasty Collaborative (ATHAC) Investigators: Outcomes Following the Single-Incision Anterior Approach to Total Hip Arthroplasty: A Multicenter Observational Study. Ortho Clinics of North America. 40(3):329-342, July 2009.
- Matta, J.M., Yerasimides J.G.: Table-skeletal fixation as an adjunct to pelvic ring reduction. J Orthop Trauma. 21(9):647-656. Oct 2007
- Matta, J.M. and Kreuzer, S. “Single-Incision Anterior
Approach for Total Hip
Arthroplasty: Smith-Petersen Approach.” Limited
Incisions for Total Hip Arthroplasty.
Ed O’Connor, M.I.
Rosemont, IL: AAOS. 2007. Chpt.1 pp 1-14
J.M.; Mehne, D.K.; Roffi, R.: Fractures of the Acetabulum: Early
Results of a Prospective Study. CLIN. ORTHOP. & REL. RES.,
205:241-250, April 1986.
J.M.; Anderson, L.M.; Epstein, H.C.; Hendricks, P.: Fractures
of the Acetabulum: A Retrospective Analysis. CLIN. ORTHOP.
& REL. RES., 205:230-240, April 1986.
J.M. and Merritt, P.O.: Displaced Acetabular Fractures. CLIN.
ORTHOP. & REL. RES., 1988.
J.M. and Saucedo, T.: Internal Fixation of Pelvic Ring Injuries.
CLIN. ORTHOP. & REL. RES., 242:83-97, 1989.
S.A. and Matta, J.M.: The Computerized Tomography Subchondral
Arc: A New Method of Assessing Acetabular Articular Continuity
After Fracture (A Preliminary Report). J. Orthop. Trauma,
A.J.; Greeno, R.A.; Brooks, L.R.; Matta, J.M.: Prevention of
Deep Vein Thrombosis and Pulmonary Embolism in Acetabular and
Pelvic Fracture Surgery. CLIN. ORTHOP. & REL. RES., 305:133-137,
J.M.: Operative Treatment of Acetabulum Fractures Through the
Ilioinguinal Approach: A 10 Year Perspective. CLIN. ORTHOP.
& REL. RES., 305:10-19, August 1994.
N.; Matta, J.M.; Bernstein, L.: Heterotopic Ossification Following
Operative Treatment of Acetabular Fractures. CLIN. ORTHOP.
& REL. RES., 305:96-105, August 1994.
- Mayo, K.;
Letournel, E.; Matta, J.M.; Mast, J.W.; Johnson, E.E.; Martimbeau,
C.: Surgical Revision of Malreduced Acetabular Fractures. CLIN.
ORTHOP. & REL. RES., 305:47-52, August 1994.
E.E.; Matta, J.M.; Mast, J.W.; Letournel, E.: Delayed Reconstruction
of Acetabular Fractures 21-120 Days Following Injury. CLIN.
ORTHOP. & REL. RES., 305: 20-30, August 1994.
P.; Matta, J.M.: Outcome of Operatively Treated Unstable Posterior
Pelvic Ring Disruptions. CLIN. ORTHOP. & REL. RES., 329:186-193,
J.M.; Dickson, K.F.; Markovich, G.: Surgical Treatment of Pelvic
Nonunions and Malunions. CLIN. ORTHOP. & REL. RES., 329:199-206,
J.M.: Indications for Anterior Fixation of Pelvic Ring Fractures.
CLIN. ORTHOP. & REL. RES., 329:88-96, August 1996.
P.; Dickson, K.F.; Matta, J.M.: Outcome of Rotationally Unstable
Pelvic Ring Injuries Treated Operatively. CLIN. ORTHOP. &
REL. RES., 329:147-151, August 1996.
M.D.; Zinar, D.M.; Matta, J.M.: Neurologic Injuries in Pelvic
Ring Fractures. CLIN. ORTHOP. & REL. RES., 329:28-36,
J.M.; Tornetta, P.: Internal Fixation of Unstable Pelvic Ring
Injuries. CLIN. ORTHOP. & REL. RES., 329:129-140, August
J.M.: Fractures of the Acetabulum: Reduction Accuracy and Clinical
Results of Fractures Operated Within Three Weeks of Injury.
JBJS, 78A:1632-1645, November 1996.
J.M.; Siebenrock, K.A.: Hip Fusion Through an Anterior Approach
with Use of a Ventral Plate. CLIN. ORTHOP. & REL. RES.,
J.M.; Siebenrock, K.A.: Does Indomethacin Reduce Heterotopic
Bone Formation After Operation for Acetabular Fractures? JBJS,
79B #6: 959-963, November 1997.
- Hak, D.J.;
Olson, S.A.; Matta, J.M.: Diagnosis and Management of Closed
Internal Degloving Injuries Associated with Pelvic and Acetabular
Fractures: The Morel-Lavellee Lesion. J. of Trauma: Injury,
Infection & Critical Care, 42 #6, 1997.
R.S.; Stover, M.D.; Matta, J.M.: Late Posterior Instability
of the Pelvis after Resection of the Symphysis Pubis for Treatment
of Osteitis Pubis. JBJS, 80A #7, July 1998.
J.M.; Stover, M.D.; Siebenrock, K.: Periacetabular Osteotomy
Through the Smith-Peterson Approach. CLIN. ORTHOP. & REL.
RES., 363:21-32, June 1999
- Matta, J.M.; Ferguson,
T.A.: The Anterior Approach for Hip Replacement. Orthopedics,
vol 28, no. 9; p. 927-928, September 2005.
Joel M.; Anterior Approach for Total Hip Replacement: Background
and Operative Technique; Chapter 8 pp121-140 in MIS
Techniques in Orthopedics (Scuderi, G.R., Tria, A.J.,
Berger, R.A. editors); copyright Springer Science+Business
- Matta, J.M.; Ferguson, T.A.: The Anterior Approach for Hip
Replacement. Orthopedics, vol 28, no. 9; p. 927-928,
J.G.; Matta, J.M.: Primary Total Hip Arthroplasty with a
Minimally Invasive Anterior Approach. Seminars
in Arthroplasty, vol 16, no.3, p. 186-190, September 2005.
J.M.; Shahrdar, C.; Ferguson, T.: Single-Incision Anterior
Approach for Total Hip Arthroplasty on an Orthopaedic Table. Clin
Orthop Rel Res, no. 441, p 115-124, December 2005.