Anterior Hip with Peter Sharkey, MD

Speaker 1Hi, I'm Doctor Pete Sharkey from Philadelphia at the Rothman Institute, and today my team and I are going to demonstrate an anterior-based muscle sparing Approach to the Hip with the patient in the supine position. It's a modification on the direct Anterior approach. There are certain advantages to this Approach that I like, and I use it routinely for Hip Replacement Surgery. And as we go through the procedure today.

Speaker 1We'll talk a little bit about some of those advantages and some of the nuances of the procedure.

Speaker 1Um, working with me today

Speaker 2is Doctor Lance Montgomery from Laguna Hills. I do Hip, Knee, and Shoulder Surgery, and I'll be assisting today.

Speaker 1So as you can see, this patient is in the supine position.

Speaker 1And what I'm going to do here is first mark out the greater trochanter. And usually what we'll do is make the incision just anterior to the trochanter. So, a little bit further laterally, uh, I think there's a much lower risk of injury to the lateral femoral cutaneous nerve. So that's roughly the incision. And again, this would be the trochanter.

Speaker 1And we're going just anterior to that to make the exposure. OK, do we have a knife?

Speaker 1So I'm going to make it a little longer than probably would be needed for somebody with this much adipose tissue, but just for visualization purposes, when we do the procedure and film it, I think you'll be able to see better.

Speaker 1What I like to do is identify.

Speaker 1Where the tensor is.

Speaker 1Because the fascia gets quite thin usually up around the area of the tensor.

Speaker 1So we'll just expose this a little bit and you can see there's a change in the thickness of the tissue here. So this is the muscle belly of the tensor and I'd like to go through the iliotibial band here only because when I close, I think it gives me a better closure in terms of being able to achieve hemostasis and I also inject the joint afterwards with 3 g of transyxemic acid mixed with vancomycin.

Speaker 1And this gives you a good seal if you sew this up first. So what I'll do is, you know, it's easy to sew up here by just retracting, but it's important to get a good release on this, uh, iliotibial band because that really loosens up the tissue.

Speaker 1And

Speaker 1Allows you to

Speaker 1Dislocate it Hip much more easily.

Speaker 2You use a cob elevator to elevate the fascia

Speaker 2muscle belly. You know,

Speaker 1usually you don't have to. In this particular case, it is a little more adherent than you typically see.

Speaker 1Um, but what I'm trying to do is find that interval.

Speaker 1Between the

Speaker 1Cancer in the gluteus.

Speaker 1It's important that you get in the right interval.

Speaker 1Which is, I haven't been able to identify it yet. And again, uh, now we're in the right interval. So I'm just splitting this interval up between.

Speaker 1The tensor and you have a knife there. Usually we'd use a bowie for this.

Speaker 1So I'm putting this up.

Speaker 1Over the top of the

Speaker 1Femur uh.

Speaker 1Near the pier Forest fossa.

Speaker 1OK, so I'm retracting.

Speaker 1The, uh, gluteus this way, and then I'm gonna come right down onto the Hip capsule.

Speaker 1And

Speaker 1What.

Speaker 1And then another one, another blunt cobra. OK, and so now we're seeing the Hip capsule here.

Speaker 1Similar to the Anterior approach, we're looking down on the Hip capsule.

Speaker 1And now I'll take of pickups and a knife. Can you see that here, the anterior Hip capsule in here.

Speaker 1So where's the

Speaker 2spike of that uh enter

Speaker 2retractor.

Speaker 1It's, you can put it all the way over the top if you flex this up. Let me flex this a little bit.

Speaker 1You can bring this all the way over the top. I actually just popped it into the joint, but if you, if you want to go all the way over the top, a little bit.

Speaker 1A little bit Rikier doing that, but as long as you do it in a very controlled fashion, you can even get a little better exposure on it.

Speaker 1Yeah, so now you had a pretty good exposure there.

Speaker 2How often do you excise the capsule?

Speaker 1Usually all the time. It sort of defies the logic that the capsule is critical for Hip stability because I will tell you the dislocation rate is extremely low. I just think component position.

Speaker 1And getting soft tissue tension, the appropriate soft tissue tension without increasing the length of the leg, probably trumps the capsule. So then we'll do this portion of the capsule.

Speaker 2Are you preserving the labrum at this point?

Speaker 1Yes, it usually it is preserved. I have to take that out separately at the end. Again, that's just the anterior portion of the capsule.

Speaker 1OK, and I'm reset these retractors, make sure they're inside the capsule, and then we'll take the saw.

Speaker 1So what I'll do here now is I'll feel right at the base.

Speaker 1Of the trochanter here feeling right at the base of the trochanter and I'll just make an approximate neck cut.

Speaker 1I just estimate it because we can always adjust it afterwards. It's not marking too well, but I know roughly where I want to go.

Speaker 1And

Speaker 1So that's the cut on the neck, and if you take the Hip and then rotate it around a little bit, usually.

Speaker 1You can

Speaker 1Orient his head. Let me have a cup.

Speaker 1We can reorient this so that I can get a corkscrew right down the middle of it. If you get the corkscrew straight up the neck or straight up the head.

Speaker 1An easy way to get that head out of there, and it's actually pretty a traumatic because the head is spinning inside the socket. Just hold that shake for a minute. See how the head turns like that and it just tears the ligament.

Speaker 1And then you just usually pull it straight out, so it's pretty a traumatic, you know, and you don't have to dick around, yeah, OK, hold that like that.

Speaker 2So if you have difficulty getting the head out, do you recut the neck a little

Speaker 1shorter? Yeah, sometimes you have to. Another pointed home.

Speaker 1Tell you what.

Speaker 1Do you have another pointed one? OK, good. You got that. Got it. And then you just let the weight of this drop down on the arm.

Speaker 1That goes about like that knife again. I got it.

Speaker 1And I'm just gonna finish splitting some of the capsule here so we can get the retractor right up against the labrum. So now you get a pretty good view here of the labrum. You can see it going all the way around. I'll take a pick up again. What I try and do for these is, you know, to make sure I get a uh.

Speaker 1A very good press fit. I'll go 360 degrees.

Speaker 1And come right out to the

Speaker 1Edge of the uh

Speaker 1And we're just about ready to ream. I'm just gonna clean up this. You can see the Ileosoas 10. I don't know if you can see it in the camera, but it's right there. It's just a little capsule still on the, uh, over the top of the ileosois.

Speaker 1And you should be able to see if you have a blunt, then you just have one of these blunt cobras. Oh, I got it right here. You can see the transverse as tibular. I'm not going to have to leave this here, Jake, unless you want to, but you can see the, yeah, so you get a pretty good view here. You can see the transverse asstibular ligament right there.

Speaker 2Great exposure.

Speaker 1Yeah, it's

Speaker 1And it's, you know what's nice about it too is it's, it's easily extensile, you know, and the Anterior approach is extensile too. It's just a little trickier, you know, to, this is very easy. You could turn this into a.

Speaker 1Uh, Direct lateral or harding very, very easily, which I've done if I've gotten into trouble. So there's our exposure. OK. Do you have the uh.

Speaker 1Reamer, yeah,

Speaker 2I got a 44 on. Is that good to start?

Speaker 1Yeah, um, yeah, 44 is fine.

Speaker 1So again, if you're going to be doing Outpatient Surgery.

Speaker 1You know, you want stuff that's easy to use, simple instruments, reproducible instruments.

Speaker 2Are you using fluoroscopy to assist with?

Speaker 1You know, I haven't been. If I get in trouble, of course, I always bring it in, but if I'm, you know, if I feel a little disoriented or it's a complicated Hip, but most of the time, um, I don't need to do it most of the time.

Speaker 1So, because the patient's supine, the orientation's pretty easy. Just put the cup in where you want it, and then if you look, the patient's tilted up a little bit, but if you look from the side, you can see we've probably got about 15 degrees of an aversion here, maybe 20, somewhere in that range. And then in terms of abduction, you just look down the midline.

Speaker 1And you know this would be probably 45, maybe 40. Obviously this would be up at 90, that would be down to 0. So, you know, using that method and just knowing the patient's orientation and space.

Speaker 1You can usually get.

Speaker 1OK, you get the liner. Why don't put a 32 in it. OK, so put the trial liner in.

Speaker 1A very good locking mechanism on this cup. These teeth are very, very long, which allows you to release the capsule up into this groove, but also they're very, very stout and sharp, so they're easy to get in.

Speaker 1It's easy to get it into the right spot, but then, um, they don't bend either. They hold up extremely well, and you're not constantly replacing them.

Speaker 1So I'll leave that retractor in just for a minute, and the only thing I'm going to do here is put the bone hook in for a moment.

Speaker 1And I am going to

Speaker 1Take the knife.

Speaker 1Or do anything in the back of the uh

Speaker 1Back area here so it's much more versatile than a knife to doing this is very similar to doing the DA Approach.

Speaker 1But

Speaker 1I'm going to just remove a little bit of the capsule here.

Speaker 1Just thin it out a bit.

Speaker 1And

Speaker 1Now what we're looking at here.

Speaker 1You can see here we're looking right in at the posterior capsule.

Speaker 1And

Speaker 1As Jackie pushes down on that leg, as she pushes down, and I take this all the way down to the bone.

Speaker 1You'll see this give.

Speaker 1See how that just shifted and sometimes, you know, I'm a big patient. I will have to use an offset, um.

Speaker 1I'll have to use an offset.

Speaker 1Per brooch to do this, but you can see here, here, and if you want, you can do the femur. We'll just use a curette to open that up.

Speaker 1You can see here even using regular instruments with just capsular releases, no muscle releases, um, just going in that interval, you get some of the cortex, yeah, that's all I do.

Speaker 1Just, just like as if we're doing any Other total Hip. One of the problems with the DA is a recent study came out showing great results with the DA Approach, but there's a higher incidence of calcar fractures and also loosening.

Speaker 1Loosening of the femoral component early aseptic loosening, and that's probably because you're using offset brooches and things like that which make it a little harder to get an optimal press fit as you put this in.

Speaker 1Yeah, I worry more when you, when you don't have the visualization. You can't always see if it cracks or not, you know. So there's a stem down in there and then let's see the uh.

Speaker 2You use a collarless

Speaker 2stem.

Speaker 1Yes, I do. I like it better to have the collarless. Let's try a lateral and see. It's a, it's a male. He's probably gonna be more likely to be a lateral, and then maybe I'm sure we can do that.

Speaker 1So to reduce this, pretty straightforward, um, we just lift that leg.

Speaker 1Take this out.

Speaker 1And then I just lift the fas up in there like that and then bring the foot over.

Speaker 1And then we just need somebody to give it a little pull at the end.

Speaker 1And you're in, yep, you're in.