DIRECT SUPERIOR HIP APPROACH IN TOTAL HIP ARTHROPLASTY. Anil Thomas, MD Adult Reconstruction Peachtree Orthopedics Atlanta, GA

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1 DIRECT SUPERIOR HIP APPROACH IN TOTAL HIP ARTHROPLASTY Anil Thomas, MD Adult Reconstruction Peachtree Orthopedics Atlanta, GA

2 Disclosures None

3 Direct Superior Approach History and development of the approach Principles of the approach Anatomy and surgical technique Indications and outcomes

4 History Part of the spectrum in the evolution of the posterior approach. Dr. Stephen Murphy (superior capsulotomy; SuperCap) and Dr. Brad Penenburg (percutaneously assisted total hip; PATH) developed this approach in the early 2000s. Dr. James Chow had later merged the two techniques (Direct Superior/SuperPATH). Subsequently, other groups had produced instrumentation for similar approaches with some variations in technique. Stryker DS Direct Superior The SPAIRE Approach

5 Principles of the Approach Spare the short external rotators or minimize its dissection/release. Spare the iliotibial band. Anatomic repair of the hip capsule.

6 Anatomy

7 Anatomy/Surgical Technique

8 Surgical Technique Positioning: Lateral decubitus

9 Surgical Technique Anterior retraction of gluteus medius and minimus Release of piriformis (optional) Exposure of hip capsule

10 Surgical Technique Arthrotomy Typically in interval between minimus and piriformis

11 Preoperative Templating B Penenberg. JBJS Am Broach size and depth of seating based on distance from greater trochanter.

12 Surgical Technique In-line reaming of femoral canal. Establish trough for broach in superolateral femoral head and neck. Broach with femoral neck intact.

13 Surgical Technique In-situ femoral neck cut

14 Surgical Technique Acetabular exposure B Penenberg. JBJS Am 2008.

15 Surgical Technique PATH/SuperPATH SuperCap/Direct Superior B Penenberg. JBJS Am Acetabular exposure and preparation

16 Surgical Technique DS SuperCap Acetabular cup impaction PATH/SuperPATH

17 Surgical technique PATH/SuperPATH Acetabular cup impaction B Penenberg. JBJS Am 2008.

18 Surgical technique Final assembly and reduction

19 Surgical Technique Capsular closure

20 Postop XRay

21 Indications Primary osteoarthritis AVN Degenerative joint disease associated with hip dysplasia Posttraumatic arthritis Inflammatory arthropathy (rheumatoid arthritis, SLE, psoriatic arthritis)

22 Outcomes Penenberg et al 2008 reported on a series of 250 THA with minimum 2 year follow up. Mean Harris Hip Score had improved from 47 to 95. Average cup abduction 42 deg (30-55) and average anteversion 31 deg (22 to 40 deg). Average LOS was 3 days and 83% of patients were using a cane at time of discharge. No dislocations, nerve injuries, wound complications, or VTE. 2

23 Outcomes Murphy et al (CORR 2006) published his early results on 185 total hip replacements performed via the superior capsulotomy hip approach. Average Merle d Aubigne scores improved from 10.9 (preop) to 16.9 (postop; maximum 18). There was one acute postoperative dislocation and one intraoperative greater trochanteric fracture requiring ORIF. 1 More recently, review of his 2,140 THAs performed with this technique demonstrated overall 3 dislocations (0.14%), one acute superficial wound complication requiring I&D, and no acute deep infections.

24 Outcomes Chow et al (2011) reported on his experience with the SuperPATH technique in first 330 cases. There was one high energy traumatic postoperative dislocation. Otherwise, no other incidences of instability or dislocation. No wound infections or perioperative mortalities. 7 Qureshi and Chow (2016) found that brake reaction times (BRT) returned to preop levels by postop day 2, compared to 2-6 weeks in previous studies. 10

25 Outcomes Qureshi et al (2016) published his results on the first 100 THA using SuperPATH technique. No dislocations and 86% were ambulating without any walking aid at 2 weeks. 4 Rasuli et al (2015) reported on 100 THA by PATH and SuperPATH methods. There was one dislocation 6 weeks postoperatively (1%). Otherwise no wound or neurovascular complications. 5 Roger et al (2015) demonstrated no dislocations, nerve injuries, or wound complications in his series of 135 THAs by direct superior technique of hip replacement. 8

26 Outcomes Chow et al looked at in-hospital costs associated with SuperPATH (419) vs all other THAs within the hospital system (1673). The SuperPATH group had shorter LOS (1.2 vs 2.6 days), lower 30 day readmission (0.4% vs 2.9%), and lower discharge to SNF (1.6% vs 20.8%). 11 Recently, Murphy et al had reviewed CMS spend data on superior hip approach vs. other THA in Massachusetts, and found an average cost savings of almost $7,000 per episode. 13 SB Murphy. AAHKS Annual Meeting 2017

27 Benefits Preservation of short external rotators Vaarbakken et al (2014) showed that the piriformis, obturator internus, and gemelli muscles function as the primary abductor and extensor in the position of hip flexion. This is important when standing from a seated position. 15 Kim et al (2008) retrospectively analyzed 670 hips divided into three groups. The group with preservation of the external rotators in posterior THA had no dislocations versus 3.9% and 5.3% dislocation rate in the short external rotator repair and non-repaired groups, respectively. 9 Preservation of IT band TFL/IT band plays a role in hip abduction

28 Benefits Preservation of hip capsule Numerous studies have demonstrated reduce dislocation rate in posterior THA with capsular repair Anatomic studies demonstrate mechanoreceptors within the hip capsule that are important for proprioception and stability. 12 Femoral preparation with the neck intact and in-situ femoral neck osteotomy further reduces soft tissue trauma that may be associated with femoral head dislocation prior to osteotomy. 3 Reduced risk calcar fracture in broaching with femoral neck intact Cadaveric study in 2010 demonstrated higher load to failure when broaching with the femoral neck intact versus broaching after the osteotomy. 14 Ability to extend incision to standard posterior approach

29 Limitations Learning curve Rasuli et al had shown that it is around 40 cases. 5 Instrumentation dependent However, it can be adopted to different implant manufacturers.

30 Conclusion Direct superior approach is a safe and effective method in performing total hip arthroplasty. More studies are needed to describe its safety/efficacy and follow outcomes.

31 Thank you.

32 Reference 1. Murphy SB, et al. THA Performed using Conventional and Navigated Tissue-preserving Techniques. Clin Orthop Relat Res : Penenberg B, et al. Percutaneously Assisted Total Hip Arthroplasty (PATH): A Preliminary Report. J Bone Joint Surg Am : Murphy SB. Technique of Tissue-Preserving, Minimally-Invasive Total Hip Arthroplasty using a Superior Capsulotomy. Operative Techniques in Orthopedics Vol 14: Qurashi S, et al. SuperPATH Minimally Invasive Total Hip Arthroplasty An Australian Experience. Reconstructive Review (2): Rasuli K, Gofton W. Percutaneously assisted total hip (PATH) and Supercapsular percutaneously assisted total hip (SuperPATH) arthroplasty: learning curves and early outcomes. Ann Transl Med (13): Lee PYF, et al. Details of Tendon-Sparing Posterior Approach in Hemiarthroplasty in the Treatment of Displaced Intracapsular Neck of Femur Fracture. J Arthritis (3). 7. Chow J, et al. Modified micro-superior percutaneously-assisted total hip: early experiences & case reports. Curr Rev Musculoskelet Med : Roger DJ, Hill D. Minimally Invasive Total Hip Arthroplasty Using a Transpiriformis Approach. Clin Orthop Relat Res : Kim YS, et al. Modified Posterior Approach to Total Hip Arthroplasty to Enhance Joint Stability. Clin Orthop Relat Res : Qurashi S, et al. Driving After Microinvasive Total Hip Arthroplasty. J Arthroplasty Chow J, Fitch D. In-Hospital costs for total hip replacement performed using the supercapsular percutaneously-assisted total hip replacement surgical technique. Int Orthop : Moreas MRB, et al. The characteristics of the mechanoreceptors of the hip with arthrosis. Journal of Orthopaedic Surgery and Research : Murphy SB. The Superior Hip Approach: Clinical Experience, Economic Results. AAHKS Annual Meeting Kurtz W, et al. Comparison of Load to Failure and Calcar Strain for Two Press-Fit Femoral Stem Implantation Techniques in Matched Cadaver Femora During Simulated Impaction. ORS Vaarbakken K, et al. Lengths of the external hip rotators in mobilized cadavers indicate the quadriceps coxa as a primary abductor and extensor of the flexed hip. Clin Biomech (7): Suh KT. A posterior approach to primary total hip arthroplasty with soft tissue repair. Clin Orthop Relat Res : Browne JA, Pagnano MW. Surgical technique: a simple soft-tissue- only repair of the capsule and external rotators in posterior-approach THA. Clin Orthop Relat Res : Pelluci PM, et al. Posterior approach to total hip replacement using enhanced posterior soft tissue repair. Clin Orthop Relat Res : Chiu FY, et al. The effect of posterior capsulorraphy in primary total hip arthroplasty. J Arthroplasty : Weeden SH, et al. The Early Dislocation Rate in Primary Total Hip Arthroplasty Following the Posterior Approach With Posterior Soft-tissue Repair. J Arthroplasty : 2003.