1. ICJR Cleveland Clinic: How I do the Direct Anterior Approach with a table Stefan Kreuzer, MD Houston, Texas Memorial Bone and Joint Clinic

2. Disclosure and Disclaimers: Consultant to Stryker Consultant to Makosurgical Consultant to Corin Principal of IOT Some of the x-rays may contain off label use of implants

4. Total hip replacement has been one of the most successful operations of the 20 th century Where Have We Been?

6. Posterior: Woolson et al Methods: –consecutive THA –3 surgeons –Posterior approach Results: –Increased wound complication –Acetabular malposition –Poor fit and fill in MIS group Conclusion: Their study did not support the benefit of MIS posterior approach. Woolson et al, JBJS 2004

8. Direct Anterior: Berend et al Methods –372 direct lateral versus 258 DAA –Regular surgical table –HHS and activity score Results –DA had better HHS (0.0000) and improved activity scores (0.03) at 6 weeks. –Ave hospital stay 1.8 versus 2.0 days. –DA went home more often (0.04) Conclusion: –“DA has better HHS, LE activity score, with no increase in complications.” JBJS, Berend et al Dec. 2009

9. AAHKS meeting 2010, Dallas With show of hand, how many surgeon are doing the direct anterior approach: 2008:5% 2009:9% 2010:16%

10. 1) Implant position: Harvard Study At Massachusetts General Hospital, only 36.9% of cups were in the desired zone of placement. Malchau, et al" 39th Annual Course, MGH/BWH, Advances in Arthroplasty, October 2009. Harvard Medical School, Boston

11. Can we improve implant position? ?

12. The patient of today

13. 2) Bone Conservation? Living longer More active Having surgery earlier More obese

14. Can we be more bone preserving? ?

15. Anterior Approach for THR: Technique of Robert Judet Hueter Approach (short Smith-Pete) Performed on Orthopaedic Table or leg holding device Recently popularized by Dr. Matta

17. Anterior Approach (one incision) Incision (6-10 cm) -Smith-Petersen approach Interval - Tensor fascia lata and sartorius/rectus femoris Releases - None really C-arm is not required Special table attachment

18. Anterior Approach (one incision) Incision (6-10 cm) -Smith-Petersen approach Interval - Tensor fascia lata and sartorius/rectus femoris Releases - None really C-arm is not required Special table attachment

19. Anterior Approach (one incision) Incision (6-10 cm) -Smith-Petersen approach Interval - Tensor fascia lata and sartorius/rectus femoris Releases - None really C-arm is not required Special table attachment

20. Anterior Approach (one incision) Incision (6-10 cm) -Smith-Petersen approach Interval - Tensor fascia lata and sartorius/rectus femoris Releases - None really C-arm is not required Special table attachment

23. $187'000

26. $38'000

28. 1) Can we Improve implant position?

29. Computer Navigation: Computer navigation has not advanced for total hip arthroplasty as it has for total knee arthroplasty: - Ease of incorporation - Accuracy and Precision - Addition of overall operative time A majority of THA’s are done through a posterior or lateral approach - Anterior approach accommodates pelvic trackers better due to patient position

30. Questions: Does computer navigation in conjunction with the direct anterior approach.... improve cup position ? improve leg length determination ? add surgical time ?

31. Method Retrospective review of 300 patients Most recent 150 conventional compared to first 150 navigated THA comparing: Leg Length Discrepancy (LLD) Cup Angle Total Surgical Time (Incision to final reduction)

32. Surgical Time AuthorConv.Nav.P-valueNajarian105124190.006 Kalteis758380.002 Kreuzer6156-5<0.0001

33. AuthorConv.Nav.P-valueNajarian105124190.006 Kalteis758380.002 Kreuzer6156-5<0.0001

34. Leg length: Conventional 6.2mm std 9.0 Range:-8 to 13 Computer navigation 4.4mm std 6.4 Range:-7 to 9

35. Cup Angle AuthorAngle Safe Zone P-value Kalteis Conv 43.7 (29-57) 14/300.004 Nav 43.2 (33-50) 28/30 Najarian Conv. 47.5 (37-70) 46/53<0.01 Nav 45.5 (30-56) 45/47 Kreuzer Conv 36 (19-52) 131/150<0.0001 Nav 41 (32-54) 145/150

36. Cup Angle AuthorAngle Safe Zone P-value Kalteis Conv 43.7 (29-57) 14/30 Nav 43.2 (33-50) 28/3046% Najarian Conv. 47.5 (37-70) 46/53 Nav 45.5 (30-56) 45/4787% Kreuzer Conv 36 (19-52) 131/150 Nav 41 (32-54) 145/15087%

37. Cup Angle AuthorAngle Safe Zone P-value Kalteis Conv 43.7 (29-57) 14/300.004 Nav 43.2 (33-50) 28/3093% Najarian Conv. 47.5 (37-70) 46/53<0.01 Nav 45.5 (30-56) 45/4796% Kreuzer Conv 36 (19-52) 131/150<0.0001 Nav 41 (32-54) 145/15097%

38. Conclusion Navigation is easily incorporated when using the DAA Surgical time decreased Cup angle is comparable to conventional and more precise LLD is better than conventional and more precise More work needed but preliminary results promising

40. 2) Can We Be Bone Conserving?

41. What do we mean with Bone Conserving? Less bone resection More anatomic reconstruction of the hip joint More Physiologic loading of the proximal femur

42. What Implants did we use?

43. Physiologic Loading of Proximal Femur Long stems transfer less load to the bone, resulting in stress shielding A neck preserving stem transfers more load to the proximal femur due to its reduced overall stem length and proximal geometry. It minimize periprosthetic bone loss by optimizing prox. femoral loading and resecting less bone There was no significant difference (p < 0.05) between strain energy density of implanted MiniHip vs. intact femur, i.e. MiniHip loads physiologically

44. Physiologic Loading of Proximal Femur

45. Where Are We Going next?

46. Thank you.

47. Thank you