Prof. Dr Jörg Holstein is a leading authority in the field of hip and knee replacement surgery. His expertise ranges from minimally invasive techniques to the use of artificial joints of the highest standard. His specialist knowledge, gained through many years of experience and close collaboration with leading experts in Europe and the USA, has earned him international recognition. With almost 15 years of service at the University Hospital of the Saarland in Homburg, where he was also responsible for trauma, hand and reconstructive surgery as Deputy Director of the Clinic, he has had a significant influence on orthopedic surgery.
Since qualifying as a specialist 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 the latest treatment methods.
For Prof. Dr Holstein, the individual patient is at the heart of his medical practice. His commitment to providing each patient with a tailor-made treatment plan led him to the ETHIANUM Private Clinic in Heidelberg in October 2018. Here, he can concentrate fully on the individual needs of his patients and offer them treatment tailored to their specific situation. 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 treats patients with statutory health insurance.
In addition to his clinical work, Prof. Dr Holstein is active in various professional societies, where he plays a key role in the development of the orthopedic field. 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 learnt a great deal about the so-called AMIS technique, a specialized method in hip arthroplasty.
Hip replacement has revolutionised 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 to alleviate hip pain and restore mobility. This spectrum of methods and innovations promises tailored 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, a route to the joint must be chosen. The AMIS technique is a specialized access technique that allows access to the hip without damaging major structures and, above all, the muscle groups. Unlike the standard technique, the muscles are not cut. Instead, a natural gap in the muscles is utilized, and the muscles are held aside at this point like curtains, so that the operation can then be performed through this gap. This requires special surgical instruments as well as a special 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 in a sort of 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 start of our conversation, and emphasises:
“A huge advantage is the minimal blood loss, precisely because muscle tissue does not need to be cut and the anterior access 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 was not until the early 2000s that it became possible to utilize the anterior approach through the development of special instruments and implants for endoprosthetics.”
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 technique (Anterior Minimally Invasive Surgery) 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 post-operative recovery. Patients who have undergone surgery using the AMIS technique often report less post-operative pain and a quicker return to mobility. “Thanks to this particularly gentle technique, the patient is often back on their feet on the day of the operation and can usually leave the clinic after three to four days with walking aids. In most cases, inpatient rehabilitation is no longer necessary. In addition, the risk of dislocation is much lower – that is, the risk of the femoral head popping out of the socket. This is because the hip-stabilizing muscles are hardly affected, and the joint capsule is only opened during the operation, not removed. As for the duration of the operation, the AMIS technique requires a little more time for preparation, as the muscle layers must be identified and carefully mobilized. By comparison, standard surgery takes an average of 45 minutes; with the AMIS technique, the procedure takes around 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 is 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 the technique. That number has now increased significantly. There is actually a regional north-south divide. In southern Germany, the percentage of AMIS operations is quite high – here in Heidelberg, for example, we are a large, established center for the AMIS technique. However, I am convinced that the technique will continue to spread across all regions of Germany. The AMIS technique does not incur any additional costs compared to the standard procedure. In this respect, there are no issues regarding cost coverage by health insurance providers,” states Prof. Dr Holstein.
The AMIS technique, an innovative procedure in hip arthroplasty, offers numerous advantages.
In general, the AMIS technique can be used on almost all patients with hip osteoarthritis. “There are, however, a few exceptional cases where the AMIS technique is not particularly suitable, for example if a patient has had complicated previous operations. Patients with very strong muscles or who are obese always present a particular 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 almost every patient,” explains Prof. Dr Holstein.
A comprehensive assessment by an orthopedic surgeon 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 following surgery.
Preoperative planning and imaging play a crucial role in the application of the AMIS technique in hip replacement surgery.
Advanced imaging techniques such as X-rays, magnetic resonance imaging (MRI) or computed tomography (CT) allow surgeons to analyze the patient’s hip joint in detail. Prof. Dr Holstein explains: “Planning always plays an important role, whether with or without the AMIS technique. This is because prior visualization allows potential challenges or specific features of the hip joint to be identified, which 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 planning so that the final results are exactly as I envisage them. This naturally also includes determining the optimal position and alignment of the hip components.”
As with any surgical method, there are potential risks and complications associated with the use of the AMIS technique in hip arthroplasty 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 is lower after using the AMIS technique, for example, and the very gentle incision made during the operation also reduces the risk of post-operative bleeding. There is one minor potential complication that should be mentioned. A cutaneous nerve runs along the thigh, sometimes referred to as the ‘jeans nerve’, as this nerve can be affected when wearing tight jeans. As the nerve is located close to the surgical site, it may be stretched during the operation, which can then result in a slight tingling sensation below the scar. However, this is not particularly bothersome and is usually reversible,” adds Prof. Dr Holstein. Postoperative care plays an important role. Regular check-ups during the rehabilitation phase allow potential problems to be identified and treated at an early stage.
The use of the AMIS technique in hip replacement surgery has gained in 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, further education and specific programs for surgeons to train them in this technique. I myself work as a consultant surgeon for colleagues who wish to familiarize themselves with the AMIS technique. Courses are offered for this purpose, including at an anatomical institute. Trainees can also come to my clinic to observe my operations as assistants. I also travel to their clinics as a consultant to perform AMIS operations together with them. “You can only call yourself an experienced AMIS surgeon once you have performed several hundred operations – personally, I can look back on a four-figure number,” explains Prof. Dr Holstein.
Of course, hip replacement surgery has developed significantly over the last few decades. As for 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 certainly a double-edged sword. Ultimately, the patient’s well-being must always come first, and ideally, healthcare should be accessible to everyone.”
Dear Professor Dr Holstein, thank you very much for your time and for this fascinating information on the AMIS technique!
