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

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 - Consultant • Concept Design and Development • Corin - Institutional support • JISRF - Institutional support

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

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...”

“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

Stability • Dislocation rate ==> Low • Relieves anterior capsular contracture • Posterior sling of capsule/rotators

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

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

Regarding Tables….

Regarding Tables…

Instruments

Extensile

Revision THA - Standard Bed - 468 revisions - 3% dislocation - 2.5% infection - 5.8% fracture requiring fixation

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

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

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

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

• 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

Hard bearings • Impingement ==> early failure – Neck notching – Component fracture • Excessive inclination => Early wear, metalosis, osteolysis in MOM bearing • Best cup position 35-45 degrees

Cup Angle - Peak Contact Stress AJO Oct 2014

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

CK Levels

• 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

• 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.

• 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

• 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

DAA Outcomes • A Large Randomized Trial of Direct Anterior and Mini-Posterior THA: Which Provides Faster Recovery? • AAHKS 2016 • Taunton, Trousdale, Sierra, Kaufman, Pagnano

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

Impingement • Arthroscopy • Mini Open Direct Anterior

Impingement • Surgical Dislocation – Anterolateral – Trochanteric osteotomy

Mini-Open FAI

Hip Resurfacing March 2010

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 74

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JBJS Sept 2015, Grob, et al. JOA 2014

JOA 2014

Direct Anterior Advantages • Simplicity of set up • Extensile capability • Muscle recovery • Marketability • Cup position • Versatility • Stability • Safety

Thank You