MAASH Technique for Total Hip Arthroplasty: A Capsular Work
Dislocation and leg length discrepancy are major complications following total hip arthroplasty (THA). Many surgical approaches for THA have been described, but none suggest a capsular incision that assures good exposure while maintaining adequate capsule integrity in closure.
Modified anterolateral approach for stable hip (MAASH) is a modification of the classical Hardinge approach, but specifically preserves the anterior iliofemoral lateral ligament and pubofemoral ligament excising the “weak area” of the capsule, in the so called “internervous safe zone” and introducing the “box concept” for the anterior approach to the hip. This is the main difference of the MAASH approach. This technique can be used as a standard for all THA standard models, but we introduce new devices to make it easier.
From November 2007 to May 2012, data were collected for this observational retrospective consecutive case study. We report the results of 100 THA cases corresponding to the development curve of this new concept in THA technique.
MAASH technique offers to hip surgeons, a reliable and reproducible THA anterolateral technique assuring accurate reconstruction of leg length and a low rate of dislocation. Only one dislocation and six major complications are reported, but most of them occurred at the early stages of technique development.
MAASH technique proposes a novel concept on working with the anterior capsule of the hip for the anterolateral approach in total hip arthroplasty, as well as for hemiarthroplasty in the elderly population with high dislocation risk factors. MAASH offers maximal stability and the ability to restore leg length accurately.
Keywordship arthroplastyhip approachanterior hip capsuleTHA stabilityleg length discrepancyhip capsule anatomy
The optimal choice of surgical approach for total hip arthroplasty (THA) in the adult population is still a subject for debate. There is no sufficient data to affirm whether one surgical procedure is better than another . Many approaches for THA are described. The posterior , posterior mini-incision , lateral transtrochanteric approach , direct lateral approach , anterolateral approach , and anterior approach  are among those procedures, but many other modifications have been reported in the literature. Surgeon preference and orthopedic “schools” have influenced the current procedures for THA.
Complications following THA include dislocation, leg length limb discrepancy, deep vein thrombosis (DVT) and infection. The incidence of these major complications is low , but for patients with high expectations, any complication can be devastating. Complications also result in problematic economical impact  and often result in malpractice litigation.
The modified anterolateral approach for stable hip (MAASH) is a modification of the classical Hardinge approach that we have been developing since November 2007. We designed these modifications in order to eliminate the occurrence of dislocation , improving our ability to restore leg length accurately and optimizing the acetabular cup position. Our aims in this report are primarily to describe a surgical technique that provides specific stability for the primary THA while accurately re-establishing exact leg length. Secondly, we have assessed our learning curve in the development of the technique analyzing surgical timing, accuracy of cup orientation, and complication rates.
MAASH technique is not indicated in those cases where a lengthening of the lower limb is expected such in developmental dysplasia (Crowe III or IV ) or for most revision arthroplasties. The main indications for this technique include THA for osteoarthritis, avascular necrosis, childhood diseases resulting in degenerative joint disease but minimal deformity, lesser degree dysplasia (Crowe I or II) , and hip fractures.
The patient is placed in the lateral decubitus position. Skin incision is placed along the midline of the greater trochanter in a length of 90 mm from proximal to distal.
Once the anterior hip capsule is exposed, the middle third (subdividing the capsule in thirds) is excised as a rectangle-shaped piece of tissue of 10 mm along the femoral neck axis, which corresponds to the internervous and weak area of the anterior hip capsule (Fig. 1a–c).
Placing a pair of “66 retractors” (Exactech Inc., Florida, USA) and using two Steinman pins placed in superior acetabulum rim, at 5 and 7 o’clock, allow a circumferential exposure of the acetabulum (Fig. 4). If it is difficult to place the retractors, the surgeon should check the femoral neck osteotomy because it maybe too long or not properly angled. Once the acetabular cartilage is removed and the bone is ready to receive the THA cup, we incise the transverse acetabular ligament to widen the access for the cup and then impact the acetabulum cup in place. On average, we advocate for 40°±5° of abduction angle and 0° to 10° of anteversion . Screw fixation may be added if necessary.
Postoperative rehabilitation plan following MAASH THA is programmed as follows: 6 h after the procedure, thromboprophylaxis with low-molecular-weight heparin is started and maintained during 30 days. The patient is free to move the limb. Full weight bearing and walking-assisted program starts 12 h after the surgery, and it is finished 72 h with training to climb up and down stairs. We called this period, “THA weekend” because we operate on Friday and the patient is discharged on Monday afternoon. A home physical therapy program for 4 weeks is carried out, and patients can recover full activity, on average at 8 weeks.
Patients and Methods
From 6th November 2007 to 25th may 2012, we performed at our institution 100 cases of anterior approach and THA. We use the data of these 100 cases to make our statistical analysis.
Of those 100 cases (94 patients and 6 cases double THA), 51 were women, mean age of 70.4 years old (50–82), and 49 were men, mean age of 63.6 years old (40–82). Twelve cases underwent THA due to hip fracture, and 88 patients were referred from the National Health System for osteoarthritis of the hip. This study is an observational transverse retrospective consecutive case study. Six nonspecific hip surgeons of the orthopedic and traumatology department of our public hospital and the chief of the Human Anatomy Department at University were involved in this project.
THA for primary hip osteoarthritis
Secondary hip osteoarthritis (avascular necrosis, some childhood diseases, low degree dysplasia (Crowe I or II) )
Stage I. Starting point: we proceeded with the Hardinge approach as itself (November 2007–November 2008), 28 cases
Stage II. Development of the “45 rule” (December 2008–October 2010), 32 cases
Stage III. Introduced the “box concept” as a capsular work: MAASH approach itself (November 2010–February 2012), 31 cases
Stage IV. Mammoth tusk retractor was developed (March 2012–May 2012), nine cases.
For the statistical analysis, chi-square and Fisher’s exact tests were used to test for rate differences in different groups (SPSS, IBM v20, evaluation version).
MAASH technique is, in summary, a “capsular work” for anterior THA. Our aims in describing this new concept for the anterior approach were to maintain those main ligamentous structures to allow keeping the intrinsic stability of the capsule and giving the exact leg length to the operated limb, following a primary total hip arthroplasty .
We had one case of dislocation (1%) due to wrong positioning of the cup at 55.3° of inclination. That case was carried out on the early second stage of MAASH development and was replaced. Risk factors for THA instability are surgical approach, capsular repair, soft tissue tension, component malpositioning, femoral head size, impingement, and surgeon experience , and a large economical burden following an unstable THA is about $74 million annually . We agree with the results reported in many papers in the literature that converge around 1% rate in anterior approach THA dislocation .
Other authors report dislocation rates of 2.18% for anterolateral approach .
MAASH technique does not excise the entire anterior capsule in order to preserve enough ligament elements (LIFL and PFL) keeping the capsule intrinsic stability following “the box concept” (Fig. 2a, b). We do not check soft-tissue tension to choose the femoral head insert because the tension comes from the capsule ligament remnants. Instead of testing the regular head trials, we follow the equator rule. We assess the prosthetic femoral head provisional implant relative to the superior acetabular rim, and if the center (equator line) of the head trial is in line with the acetabular cup rim , this is the right size of the definitive prosthesis head implant (Fig. 7b). We perform the “equator rule” since May 2011 with excellent results of leg length impairment, close to 2 mm on average. We strongly recommend this maneuver because MAASH technique is extremely stable, and it is very difficult to dislocate when THA components are assembled. Surprisingly from the beginning, our results in terms of leg length discrepancy were good on average. We can accept <6 mm of lengthening , but we observed that with MAASH technique, the average from the first stage was 4.48 mm and at the last 2.37 mm, close to the anatomical restoration . By drawing the ischiatic line through both lesser trochanter, we measured the leg limb impairment using the IMPAX® (Agfa-Gevaert Group) computer program. No X-ray in surgical theatre  is needed to assure the right leg length.
There are several modifications of the Hardinge approach [3, 7, 16, 18, 22, 26], variations of the classical posterior approaches even minimally invasive surgery, and direct anterior approaches  for THA, but a specific capsular area excision is described by the MAASH approach. According to Kampa et al. , we found that our capsular excision respects the internervous safe zone preserving the proprioceptive and nociceptive structures, and this fact is the main protection against dislocation. Ligaments of the capsule can be shortened, as it occurs in extension plus rotations of the lower limb as a “sandwich effect,” but not enlarged. Preserving the maximal anterior capsule ligament but excising the MIFL along the weak area tissue of the anterior hip capsule allows surgeons accessing the hip joint, keeping the THA stability due to capsular and soft tissue balancing and assuring an accurate length of the operated limb. This is “the box concept,” which is the main contribution to the THA surgery that MAASH has done. It is not able to perform the “box concept” on the posterior capsule because there does not exist a soft spot and the disposition of the ligament fibers is oblique. We think that this fact should drive in a posterior instability of the capsule.
We described four stages concerning the development of this work. The first and the second stages are related to the transition of the classical Hardinge approach to the MAASH. Therefore, the procedure time, complications, and poor accuracy at placing the acetabulum cup mainly occurred at that time. Later on, we improved our results favored by the modification in our THA equipment hardware and the more experience in the approach that we achieved. We tried to place acetabulum cup at 40°±5° of abduction angle and 0–10° of cup anteversion. Analyzing our results throughout MAASH development, we reduced the abduction angle from 51.9° to 35.5° and the anteversion of the cup from more than 25° to close to 0° (Figs. 13 and 14). Wearing rates of the acetabular cups seem to be less in <40° of abduction angle, and this is important to reduce the reoperation index in THA . From the second stage to the fourth, we have decreased our complication rate to zero . Six major complications were identified: one THA dislocation, one acetabular cup loosening, two deep infection (Enterococcus faecalis and Staphylococcus Epidermidis), one obturator nerve palsy and a deep vein thrombosis. Among the minor complications, 12 cases underwent transfusion of red blood cells due to postoperative anemia, two great trochanter, and one calcar fracture. A series in the literature related to anterior approach for THA reported 16% of postoperative anemia . It is statistically proved in our study (p = 0.012) when surgery time exceeded 100 min, and it is doubled if surgery goes beyond 120 min (Fig. 12)
Although we have modified some retractors and designed the “mammoth tusk retractor” (Exactech Inc., Florida, USA), any hip prosthesis system can be used with MAASH technique but always being conscious that it could be difficult to reduce and assemble the THA components because of the “great stability”.
Several lacks and weaknesses in this study can be found. This is an observational retrospective consecutive case study without case control. Instead of this, we compared the results with the current literature. In this study, we present this new anterior approach for the hip, analyzing the stability, leg length impairment, and complications following a THA. We do not report patient satisfaction forms or scores because this would be an issue to treat in another study, which is currently in development.
In conclusion, the MAASH technique is a modified anterior capsular approach for the anterolateral approach in primary total hip arthroplasty. It is also an excellent technique for hemiarthroplasty in the elderly population with high dislocation risk factors. Ligaments of the capsule are incised but not elongated, preserving the anterior hip capsule stability. With the MAASH technique, we achieve maximal stability and leg limb length close to anatomical restoration. We excise the weak area of the anterior hip capsule, preserving the lateral iliofemoral and pubofemoral ligaments and keeping intact the intrinsic stability of the capsule related to the “box concept.”
Conflict of Interest:
Albert Broch, MD, is a paid consultant for Exactech Inc. FL, USA, outside the work. Antoni Salvador, MD, is a paid consultant for Exactech, FL, USA, outside the work. Felipe G. Delgado, MD, is a paid consultant for Exactech, FL, USA, outside the work. Francisco Reina, MD, PhD; David Torras, MD; Lluís Ximeno, MD, PhD; and Francesc García, MD, have declared that they have no conflict of interest.
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5).
Informed consent was obtained from all patients for being included in the study.
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