6/29/2016

1

MIS Anterolateral Hip Procedure

• A single incision

• Muscle sparing approach to the hip

• Interval between the anterior border of the gluteus mediusand the posterior border of tensor fascia lata.

Tensor Fascia Lata

Gluteus Medius

Disclosures

• Smith&Nephew

Why anterolateral?

•Universal Applicability•Direct visualization

•No implant restriction•No hip precautions

6/29/2016

2

Leg positioning

Patient and Table Preparation• Patient in direct lateral position

• Securely held on table

• Leg support modified to allow posterior leg positioning

• Surgeon works on anterior side

6/29/2016

3

6/29/2016

4

Determining the Interval

Tensor Fascia Lata

Gluteus Medius

ASIS

V2

V3

6/29/2016

5

Gluteus Medius

Tensor Fascia Lata

Capsule

V4

Create room with resection

“Saddle”

Lesser Trochanter

6/29/2016

6

V5

V7

V8

6/29/2016

7

V9

V10

Acetabular Preparation

6/29/2016

8

V12

V14

V15

6/29/2016

9

V19

V17

Femoral Exposure - Leg Position

6/29/2016

10

V18

Femoral Preparation

V19

6/29/2016

11

V20

V21

V22

6/29/2016

12

V23

V24

V25

6/29/2016

13

V26

V27

6/29/2016

14

6/29/2016

1

Modified AL MIS THA:

Preoperative

Preparation & Patient

Selection

Brian J. McGrory, MD

George Babikian, MD

• This webinar is provided for informational and educational purposes only. The webinar and information contained therein may not be appropriate for all countries and/or jurisdictions. The presentation and information contained within this webinar were prepared exclusively by the [physician presenter] [physicians presenters] and the views and opinions expressed within are those of the [presenter] [presenters] only and do not reflect the position, opinion, or guidelines for clinical care of any other person, institution, scientific association, or product manufacturer. The webinar may contain information on Smith & Nephew products, educational content, and/or demonstrate certain techniques used by the [presenter] [presenters]. Smith & Nephew does not provide medical advice. This webinar is offered for educational purposes only and is not intended to serve as medical advice, nor endorse any named institution. It is the responsibility of operating physicians to determine and utilize the appropriate products and techniques, according to their own clinical judgment, for each of their individual patients. For more information on the application of any products discussed in the presentation, as well as for use, contraindications, and product safety information, please consult the Instructions for Use (IFU) for such product.

• Sources of some images or references may be unknown and/or may be protected by copyright.

• (Singular) The presenter is a paid consultant of Smith & Nephew.• (Plural) The presenters are paid consultants of Smith & Nephew.

Disclosures

• Smith&Nephew

6/29/2016

2

Patient Selection

• Minimal exclusions

• Poor candidates (less than 1%)

– Severe deformity of the proximal femur

– Posterior acetabular deficiency

– Crowe 3/4 DDH

– Prior anterior exposure with marked scarring

• Not excluded (can use any stem/cup)

– Osteoporosis

– Obesity

Patient Education

• Why home is preferable in most cases

• Our statistics vis-à-vis outpatient surgery

• Joint Replacement class

• Pre-op discussion of pain medications,

DVT prophylaxis, wound care, follow-up,

what to do if questions / problems

• What home care to expect, if any

Facility Preparation

• Why home is preferable in most cases

• Our statistics vis-à-vis outpatient surgery

• Joint Replacement class

• Excellent pre-op education / preparation

by physician extender

• Specific home care expectations

• Availability for phone triage

6/29/2016

3

Modified AL MIS THA:

Postoperative

Protocols & Outcome

Data

Brian J. McGrory, MD

George Babikian, MD

Postoperative Protocols

• Multimodal pain protocol

– Lyrica

– Oxycontin / oxycodone

– Celebrex

• DVT prophylaxis

– ASA

• Aquacel dressing

Procedure Volume

Procedure 2013 2014 Total

AL THA 593 742 1335

Bilateral AL THA 15 17 32

Post THA 134 44 178

Revision THA 67 78 145

Total 809 881 1690

*Maine Medical Center Outcomes Data

6/29/2016

4

Length of Stay

Procedure 2013 2014 Total

AL THA 1.37 1.35 1.36

Bilateral AL THA 1.94 1.83 1.88

Post THA 3.10 3.23 3.13

Revision THA 4.15 3.43 3.76

Total 1.90 1.64 1.76

Discharge Destination

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AL THA Post THA AL THA Post THA

2013 2014

Skilled Nursing Facility

Rehab Facility

Home

6,000 AL MIS THA TO DATE

• Aseptic stem loosening, early experience

– stem potting, other brand (5*)

• Infection

– early MSSA (2*), components retained

• Fracture

– calcar (2), troch avulsion (5), B2 (1*)

• Dislocation

– early (1*), late (2)9/918=0.98%

revisions, 2 in

last 500=0.40%

6/29/2016

5

MODIFIED AL MIS THA

• Interval between the anterior border of the gluteus medius and the posterior border of tensor fascia lata.

• Lateral decubitus

• Bertin & Rottinger, CORR, 2004

Gluteus Medius

Tensor Fascia Lata

Benefits of MIS THA

• Faster recovery, less pain, increased

stability, lower blood loss

• Less readmissions / complications

• Lower cost: $34,000 vs $13,000

Consumer Directed Health Plans

• Safe in surgery center setting

• Patient satisfaction / demand

• Overall a more rewarding practice*Surgeon personal experiences

MODIFIED AL MIS THA

• Recent literature:

– Ankle fractures / periprosthetic fractures1

– Table expensive / unavailable2

– Wound problems in obese patients3

– LFCN issues in 1/3-2/3 of patients4

– Difficulty assessing stability5

– Femoral implant lucencies6

• Viable option that addresses these

concerns:

– Modified AL MIS THA

6/29/2016

6

References

1. Clin Orthop Relat Res. 2011 Feb; 469(2): 503–507. Published online 2010 Oct 1. doi: 10.1007/s11999-010-1568-1 PMCID: PMC3018203 High Complication Rate With Anterior Total Hip Arthroplasties on a Fracture Table Brian A.

Jewett, MDcorresponding author and Dennis K. Collis, MD

2. Direct anterior approach for total hip arthroplasty in the lateral decubitus position: our experiences and early

resultsOriginal Research Article In Press, Accepted Manuscript, Available online 7 June 2016 Min Chen, Zheng-

Liang Luo, Xiao-Feng Ji, Peng Cheng, Guo-Lin Tang, Xi-Fu Shang

3. Clin Orthop Relat Res. 2011 Feb; 469(2): 503–507. Published online 2010 Oct 1. doi: 10.1007/s11999-010-1568-1

PMCID: PMC3018203 High Complication Rate With Anterior Total Hip Arthroplasties on a Fracture Table Brian A.

Jewett, MDcorresponding author and Dennis K. Collis, MD

4. The Anatomical Course of the Lateral Femoral Cutaneous Nerve with Special Attention to the Anterior Approach to

the Hip Joint Diana Rudin; Mirjana Manestar, MD; Oliver Ullrich, PhD, MD; Johannes Erhardt, MD; Karl Grob, MD J Bone Joint Surg Am, 2016 Apr 06; 98 (7): 561 -567 . http://dx.doi.org/10.2106/JBJS.15.01022

5. J Orthop Surg Res. 2012; 7: 17. Published online 2012 Apr 25. doi: 10.1186/1749-799X-7-17PMCID: PMC3419665 The direct anterior approach: initial experience of a minimally invasive technique for total hip

arthroplastyOla Hallert,1 Yan Li,corresponding author1 Harald Brismar,1 and Urban Lindgren1

6. J Orthop Surg Res. 2012; 7: 17. Published online 2012 Apr 25. doi: 10.1186/1749-799X-7-17PMCID:

PMC3419665 The direct anterior approach: initial experience of a minimally invasive technique for total hip

arthroplastyOla Hallert,1 Yan Li,corresponding author1 Harald Brismar,1 and Urban Lindgren1

THANK YOU