Prof. Dr. med. Jörg Holstein is a leading authority in the field of hip and knee arthroplasty. His expertise ranges from minimally invasive techniques to the use of artificial joints of the highest quality. His expertise, gained through many years of experience and close collaboration with leading experts in Europe and the U.S., has earned him international recognition. With nearly 15 years of service at the Saarland University Hospital in Homburg, where he also served as deputy director of the Department of Trauma, Hand, and Reconstructive Surgery, he has had a significant impact on orthopedic surgery.
Since passing his board certification in orthopedics and trauma surgery in 2010, Prof. Dr. Holstein has continuously expanded his expertise through additional qualifications. His areas of specialization include specialized orthopedic surgery, specialized trauma surgery, hand surgery, manual medicine/chiropractic therapy, physical therapy and balneology, emergency medicine, and radiological diagnostics. This comprehensive range of qualifications underscores his medical expertise and enables him to help his patients achieve a better quality of life using state-of-the-art treatment methods.
For Prof. Dr. Holstein, the individual patient is at the center of his medical practice. His commitment to providing each patient with a tailored treatment plan led him to the ETHIANUM Private Clinic in Heidelberg in October 2018. Here, he can focus entirely on the individual needs of his patients and offer them treatment tailored to their specific situations. At the same time, he continues to serve as head of the Endoprosthetics Department at Salem Hospital, a teaching hospital affiliated with Heidelberg University, where he also cares for patients with public health insurance.
In addition to his clinical work, Prof. Dr. Holstein is active in various professional societies, where he plays a key role in advancing the field of orthopedics. His contribution to research is reflected in an extensive list of publications and reinforces his outstanding reputation among his peers. The editorial team of the Leading Medicine Guide spoke with the expert in hip and knee arthroplasty and learned a great deal about the so-called AMIS technique, a specialized method in hip arthroplasty.
Hip replacement surgery has revolutionized the treatment of hip problems and improves the quality of life for millions of people worldwide. From traditional to state-of-the-art minimally invasive techniques, there is a wide range of methods that help alleviate hip pain and restore mobility. This spectrum of methods and innovations promises individualized solutions for a variety of patient needs.
The AMIS technique (Anterior Minimally Invasive Surgery) is a method of hip replacement that differs from conventional procedures in terms of its approach and technical procedures.
“In order to implant an artificial hip joint at all, an access route to the joint must be chosen. The AMIS technique is a specialized access method that allows surgeons to reach the hip without damaging major structures—and, most importantly, without damaging the muscle groups. Unlike the standard technique, the muscles are not cut. Instead, a natural gap between the muscles is utilized, and the muscles are held aside at this point like curtains, allowing the surgeon to operate through this gap. This requires special surgical instruments as well as a specialized operating table. On this table, the leg to be operated on is secured to a mobile unit. “This means the patient’s foot is clicked into a binding on the table, similar to a ski boot, so that the prosthesis can be inserted safely and precisely into the correct position,” explains Prof. Dr. Holstein, describing the AMIS technique at the beginning of our conversation, and emphasizes:
“A huge advantage is the minimal blood loss, precisely because muscle tissue does not have to be cut and the anterior incision is very small. In fact, the anterior approach was developed as early as the 19th century by a German surgeon, Carl Hueter, but was initially used for other procedures. It wasn’t until the early 2000s that the anterior approach could be utilized for joint replacement surgery, thanks to the development of specialized instruments and implants.”
This technique requires special training for surgeons to make the most of the benefits of this minimally invasive method. “A certain amount of experience is required to use the AMIS technique. The surgeon’s learning curve is definitely longer with this technique, but the benefits for the patient are immense,” comments Prof. Dr. Holstein.
The AMIS (Anterior Minimally Invasive Surgery) technique in hip arthroplasty is a modern approach to hip replacement surgery that offers significant advantages over conventional methods.
The AMIS technique has several positive effects on the postoperative course. Patients who have undergone surgery using the AMIS technique often report less postoperative pain and a faster return to mobility. “Thanks to this particularly gentle technique, patients are often back on their feet on the day of surgery and can usually leave the hospital after three to four days with walking aids. In most cases, inpatient rehabilitation is no longer necessary. In addition, the risk of dislocation—that is, the risk of the femoral head popping out of the acetabulum—is much lower. This is because the hip-stabilizing muscles are hardly affected, and the joint capsule is only opened during surgery, not removed. As for the duration of the surgery, the AMIS technique requires a little more time for preparation, as the muscle layers must be identified and carefully mobilized. By comparison, the standard surgery takes an average of 45 minutes; with the AMIS technique, the procedure takes about 60 minutes, and in very complex cases, up to 90 minutes—though this does not cause any additional “stress” for the patient. “In principle, both general anesthesia and spinal anesthesia are possible,” explains Prof. Dr. Holstein.
More precise positioning of the implant is, of course, also crucial in the AMIS technique for the long-term stability and function of the artificial hip joint. “It’s fair to say that the AMIS technique is evolving. When I started working with the AMIS technique in 2013, there were only a handful of doctors in Germany who were actually using it. That number has since increased significantly. There is, in fact, a regional north-south divide. In southern Germany, the percentage of AMIS surgeries is quite high—here in Heidelberg, for example, we are a large, well-established center for the AMIS technique. However, I am convinced that the technique will continue to spread throughout all regions of Germany. The AMIS technique does not incur any additional costs compared to the standard procedure. In this respect, it also poses no problem in terms of coverage by health insurance companies,” states Prof. Dr. Holstein.
The AMIS technique, an innovative procedure in hip replacement surgery, offers numerous advantages.
In general, the AMIS technique can be used for nearly all patients with hip osteoarthritis. “There are, however, a few exceptional cases in which the AMIS technique is not as well-suited, such as when a patient has had complicated prior surgeries. Patients with very strong muscles or who are obese always present a special challenge for any surgeon and are more difficult to operate on. But in principle, as I said, the AMIS technique can be used without any problems on nearly every patient,” explains Prof. Dr. Holstein.
A comprehensive evaluation by an orthopedic specialist or surgeon is crucial to determine whether the AMIS technique is the best choice for a particular patient or whether alternative procedures are more suitable. This individualized approach makes it possible to ensure the optimal treatment for each patient and a successful recovery after surgery.
Preoperative planning and imaging play a crucial role in the application of the AMIS technique in hip replacement surgery.
Using advanced imaging techniques such as X-rays, magnetic resonance imaging (MRI), or computed tomography (CT), surgeons can analyze the patient’s hip joint in detail. Prof. Dr. Holstein explains: “Planning always plays an important role, whether or not the AMIS technique is used. This is because prior visualization allows us to identify potential challenges or unique features of the hip joint that must be taken into account during the procedure. I know how large the implant will be, the patient’s leg length is measured, and during the operation I can compare everything with the plan to ensure that the final results turn out exactly as I envision them. This naturally also includes determining the optimal position and alignment of the hip components.”
As with any surgical method, the use of the AMIS technique in hip replacement surgery involves potential risks and complications that must be taken into account.
Possible risks include infections, bleeding, damage to blood vessels or nerves, hip dislocations, thrombosis, or problems related to anesthesia. “Because the patient is back on their feet more quickly, the risk of thrombosis, for example, is lower after using the AMIS technique, and the very minimally invasive incision during surgery also reduces the risk of postoperative bleeding. There is one minor potential complication that should be mentioned. A cutaneous nerve runs along the thigh; it is sometimes called the ‘jeans nerve’ because this nerve can be affected when wearing tight jeans. Since the nerve is located close to the surgical approach, it can be stretched during the operation, which may result in a slight tingling sensation below the scar. However, this is not overly bothersome and is usually reversible,” adds Prof. Dr. Holstein. Postoperative care plays an important role. Regular checkups during the rehabilitation phase allow potential problems to be identified and treated early on.
The use of the AMIS technique in hip replacement surgery has gained importance in recent years.
The AMIS technique requires specialized education and training. “There are reference centers that specialize in the use of the AMIS technique in hip replacement surgery. These facilities offer training courses, continuing education, and specific programs for surgeons to teach them this technique. I myself work as a consulting surgeon for colleagues who want to familiarize themselves with the AMIS technique. Courses are offered for this purpose at an anatomical institute, among other places. Trainees can also come to my clinic to observe my surgeries as assistants. In addition, I also travel to their clinics as a consulting physician to perform AMIS surgeries together with them. “You can only call yourself an experienced AMIS surgeon once you’ve performed several hundred surgeries—personally, I’ve performed a four-digit number of them,” explains Prof. Dr. Holstein.
Of course, hip replacement surgery has advanced significantly over the past few decades. When asked whether there is still room for improvement, Prof. Dr. Holstein comments: “Robotics is certainly a topic of interest. But for experienced surgeons, the benefits are rather limited. As far as the AMIS technique is concerned, the method is already very sophisticated. What will certainly change is the overall setting. The trend is toward outpatient surgery, very similar to the American system, even if this is definitely a double-edged sword. Ultimately, the patient’s well-being must always come first, and ideally, medical care should be accessible to everyone.”
Dear Professor Dr. Holstein, thank you very much for your time and for this fascinating information about the AMIS technique!
