John M. Keggi, MD Connecticut Joint Replacement Institute - - PowerPoint PPT Presentation

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John M. Keggi, MD Connecticut Joint Replacement Institute - - PowerPoint PPT Presentation

Sep 15, 2022 225 likes •1.03k views

Direct Anterior Approach THA All the Rage - For All the Right Reasons John M. Keggi, MD Connecticut Joint Replacement Institute Disclosures Smith & Nephew - Consultant OmniLife Science - Consultant & Royalties Medtronic -

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Direct Anterior Approach THA All the Rage - For All the Right Reasons

John M. Keggi, MD

Connecticut Joint Replacement Institute

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Disclosures

  • Smith & Nephew - Consultant
  • OmniLife Science - Consultant &

Royalties

  • Medtronic - Consultant
  • Concept Design and Development
  • Corin - Institutional support
  • JISRF - Institutional support
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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
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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...”

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“Mini-Posterior” Approaches

  • PATH, SuperPATH, SuperCap
  • “Direct Posterior” Approach - DPA

Core features of the DAA For the last 40 years

  • Spare IT Band
  • Release Conjoined tendon only
  • Gluteal - sparing
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Safety

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

  • Dislocation rate ==> Low
  • Relieves anterior capsular contracture
  • Posterior sling of capsule/rotators
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Two-Incision Confusion

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banff

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

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JBJS 2003 Ant THR

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Complications

  • Dislocation: 0.1%
  • Fracture requiring fixation: 1%
  • DVT + PE: 0.8%
  • 2132 patients

– Body wt: 80 to 450 pounds

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Soft Tissue & Vascularity

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

– Fluoro table – Standard OR bed – XR Cassette options

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AAKHS Data -DA

  • 2008 -- 8%
  • 2009 -- 12%
  • 2010 -- 16%
  • ICJR-- 25% of surgeons with >50 THA/yr

– 2012

  • 2016 —AAHKS 34%
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Regarding Tables….

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Regarding Tables…

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Instruments

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Extensile

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Revision THA - Standard Bed

  • 468 revisions
  • 3% dislocation
  • 2.5% infection
  • 5.8% fracture requiring fixation
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Safety

  • There is no

circumstance that you cannot manage safely from the anterior approach

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  • Cup positioning
  • “Safe Zone”
  • Soft tissue concerns
  • Functional recovery

Current Literature

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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

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  • Prospective, multi-center study
  • 1000 pts, 17 centers
  • AD and Approach were independent risk

factors

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

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

  • Impingement ==> early failure

– Neck notching – Component fracture

  • Excessive inclination => Early wear,

metalosis, osteolysis in MOM bearing

  • Best cup position 35-45 degrees
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AJO Oct 2014

Cup Angle - Peak Contact Stress

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  • Case series: 2 PA surgeons, 1 DA surgeon
  • CPK & TNF-alpha

JBJS 2011; 93:1392

Soft Tissue

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CK Levels

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  • 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

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  • 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

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  • Significantly quicker in single leg stance, loss of

limp, walking speed and weaning from assistive device

JOA 24(5), 2009

Functional Recovery

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  • 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

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  • 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

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  • Single surgeon, 22 pts
  • 11 PA (after >2000 pts)
  • 11 DA (after 1st 100 DA pts)
  • DA: Improved IR/ER at 6 & 12 mo (no △ PA)
  • DA: Improved peak extension moment at 6 mo.
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  • Single surgeon, 17 AL, 16 DA
  • 6 & 12 wk gait analysis vs pre-op GA
  • DA: 6 wks - Single leg support & stride time
  • DA: Faster improvements in most parameters
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  • 50 pts PA; 1st 50 DA pts; Next 50 DA pts
  • Single surgeon series
  • Identical pre-emptive pain protocols
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  • 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
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DA PA

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  • 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)
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Pain Control

J Ortho Res 2015

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DAA Outcomes

  • A Large Randomized Trial of Direct

Anterior and Mini-Posterior THA: Which Provides Faster Recovery?

  • AAHKS 2016
  • Taunton, Trousdale, Sierra, Kaufman,

Pagnano

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DAA vs mPA

  • Discontinue walker: 10 d vs 14.5 d
  • DC all gait aids: 18 d vs 23 d
  • DC opiods: 9 d vs 14 d
  • Stairs with gait aid: 5 d vs 10 d
  • Walk 6 blocks: 20.5 d vs 26 d
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Impingement

  • Arthroscopy
  • Mini Open Direct Anterior
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Impingement

  • Surgical Dislocation

– Anterolateral – Trochanteric osteotomy

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Mini-Open FAI

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Hip Resurfacing

March 2010

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Rehab/Post-op Considerations

  • Avoid supine straight leg

raises

  • “Toes above the nose”
  • NSAID for pain and HO

prophylaxis

  • Figure 4 for shoes and

socks

  • Sex: Patient on the

bottom

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JBJS Sept 2015, Grob, et al. JOA 2014

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JOA 2014

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Direct Anterior Advantages

  • Simplicity of set up
  • Extensile capability
  • Muscle recovery
  • Marketability
  • Cup position
  • Versatility
  • Stability
  • Safety
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Thank You