Direct Anterior Approach THA Fact vs. Fiction John M. Keggi, MD - PowerPoint PPT Presentation

Direct Anterior Approach THA Fact vs. Fiction John M. Keggi, MD Connecticut Joint Replacement Institute

Disclosures • Smith & Nephew - Consultant • OmniLife Science - Consultant & Royalties • Medtronic - Consultant • Concept Design and Development • Signature Orthopaedics - Consultant

Disclosures • Safe • Easy • I’ve always done it that way

Myths • New • Unsafe • Building a ship in a bottle • Difficult • Rarely performed • Not possible without a special table • Not possible without special tools • Not extensile • Limited applications beyond THA • No functional difference

Myths • New • Unsafe • Building a ship in a bottle • Difficult • Rarely performed • Not possible without a special table • Not possible without special tools • Not extensile • Limited applications beyond THA • No functional difference

“The Anterior Approach is new!”

Hueter 1883 • “...the leg keeps its tight connection to the pelvis which facilitates rehabilitation...” • “...bleeding is so little, that no single ligature has to be done...”

Smith-Petersen, 1917

• “Hueter’s straight anterior incision... does not require any muscle cutting or detachment, and no postoperative immobilization is needed.”

Direct Anterior THA Kristaps J. Keggi 1971 Scientific exhibit at AAOS, 1977, Las Vegas Clinical Orthopaedics October 1980 Stan Schofield (Melbourne) & George Braddock (London)

“Mini-Posterior” Approaches • PATH, SuperPATH, SuperCap • “Direct Posterior” Approach - DPA • Spare IT Band • Release Conjoined tendon only • Gluteal - sparing Core features of the DAA For the last 40 years

Safety • Good visibility at all times • Sciatic nerve • Femoral bundle • Thrombo-embolism • Anesthesia access • X-ray access

“The Safety Anterior • Good visibility at all times • Sciatic nerve Approach • Femoral bundle • Thrombo-embolism isn’t safe” • Anesthesia access • X-ray access

Two-Incision Confusion

Presentation at Yale Orthopaedic Alumni Meeting in Banff, Canada 1988 banff Two incision anterior approach

JBJS 2003 Ant THR

Complications • Dislocation: 0.1% • Fracture requiring fixation: 1% • DVT + PE: 0.8% • 2132 patients – Body wt: 80 to 450 pounds

Soft Tissue & Vascularity

• Doppler study, 10 pts, DAA THA, Traction table • Non-signif reduction in FA and FV flow • Acetabular & femoral prep and final reduction

Xray capability – Fluoro table – Standard OR bed – XR Cassette options

“It’s like building a ship in a bottle.” “It’s difficult.”

AAKHS Data -DA • 2008 -- 8% • 2009 -- 12% • 2010 -- 16% • ICJR-- 25% of surgeons with >50 THA/yr – 2012 • 2016 — 34%

AAKHS Data -DA • 2008 -- 8% • 2009 -- 12% • 2010 -- 16% • ICJR-- 25% of surgeons with >50 THA/yr – 2012 • 2016 — 34%

“The AAKHS Data -DA Anterior • 2008 -- 8% • 2009 -- 12% Approach is • 2010 -- 16% rarely used” • ICJR-- 25% of surgeons with >50 THA/yr – 2012 • 2016 — 34%

Regarding Tables….

Regarding Tables…. “The Anterior Approach requires a special table.”

Regarding Tables… Cadaver labs

Instruments

Extensile

Extensile “The Anterior Approach can’t be extended.”

Safety • There is no circumstance that you cannot manage safely from the anterior approach

“There is Current Literature no • Cup positioning functional • “Safe Zone” • Soft tissue concerns benefit...” • Functional recovery

Cup Angle - Peak Contact Stress AJO Oct 2014

Cup Positioning • 185 pts, Consecutive series (2003-2005) • Standard OR bed; Xray on POD 1,2 or 3 • 99% of cups properly positioned in the “Safe Zone” • 91% for posterior approach JOA 24(5), 2009

• Single surgeon, 2 series • 100 PA vs 1st 100 DA cases • PA: Greater cup variance • PA: More large heads and lateralized liners

Instability • DA: 2 cases of instability • One revision for instability • PA: 4 cases of instability • 4 revisions for instability

Soft Tissue • Case series: 2 PA surgeons, 1 DA surgeon • CPK & TNF-alpha JBJS 2011; 93:1392

• Less soft tissue damage on MRI at one year post-op • 50 pts (25 each group) • TFL equal changes • Less detachment, tendinitis, tears, fatty atrophy of gluteals Bone & Joint (JBJS-B) 2011

• MIS DA, 2-incision DA, MIS AL, MIS PA, Lat Trans-gluteal • Cadaver study, muscle staining and dissection • Gluteal damage least with DAA Acta Orth 2010; 81(6):696

Functional Recovery • Significantly quicker in single leg stance, loss of limp, walking speed and weaning from assistive device JOA 24(5), 2009

• LOS 22d vs 30d (p=0.03) • Presence of Trendelenburg gait at 3 wks: • 29% vs 67% (p<0.001) • Negative Trendelenburg sign: • 17d vs 25d (p=0.0002) • Single leg stance >5s: • 17d vs 23 d (p=0.0004) • Gait w/cane >200m: • 12d vs 15.5d (p=0.009) Nakata, JOA 24(5), 2009

• Single surgeon, 128 pts, “Fast track” • 2005-2007 • DAA vs Direct Lateral Approach • Physical and mental outcomes SF-36 and WOMAC better at 1 year; equal at 2 years

• 50 pts PA; 1st 50 DA pts; Next 50 DA pts • Single surgeon series • Identical pre-emptive pain protocols

• Single surgeon; 87 randomized pts • Surgical time: 84m vs 60m PA • Blood loss: 391 cc vs 191 cc PA • LOS: 2.3d vs 3.0d PA

DA PA

• Single surgeon, randomized trial, 51 pts • (experience of 2000 PA, 500 DAA) • Equal stairs, shoes/socks, up/go at 6 wks • Walking aide: 33d vs 43d (p=0.03) • LOS: 1.4d vs 2.0d (p= 0.01) • Pain relief: HHS-PS 27.8 vs 20.7 (p=0.04)

Pain Control J Ortho Res 2015

Impingement • Arthroscopy • Mini Open Direct Anterior

“The Impingement Anterior • Arthroscopy Approach is • Mini Open Direct Anterior limited to total hips.”

Impingement • Surgical Dislocation – Anterolateral with trochanteric osteotomy – vs DAA

Mini-Open FAI

Hip Resurfacing March 2010

Direct Anterior Approach - Fact • Patient and surgeon satisfaction • Simplicity of set up • Extensile capability • Muscle recovery • Marketability • Cup position • Versatility • Stability • Safety

Direct Anterior Approach - Fact • Patient and surgeon satisfaction • Simplicity of set up • Extensile capability • Muscle recovery Thank You ! • Marketability • Cup position • Versatility • Stability • Safety