---
title: 'Anterior Hip with Peter Sharkey, MD'
type: 'lecture'
url: 'https://doc.social/lectures/anterior-hip-with-peter-sharkey-md'
published: '2021-05-07'
author: 'SwiftPath Program'
specialty: 'Hip and Knee'
transcript: 'yes'
---

# Anterior Hip with Peter Sharkey, MD

## Summary

Dr. Peter Sharkey performs an Anterior Hip Replacement.

## Transcript

2,080 words · 13 min · 2 speakers · automatically transcribed (aws-transcribe) and not checked by a person; it may contain errors, particularly in names, drugs and dosages. The recording is the source.

[0:04] Speaker 1: Hi, 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.
[0:30] Speaker 1: We'll talk a little bit about some of those advantages and some of the nuances of the procedure.
[0:35] Speaker 1: Um, working with me today
[0:37] Speaker 2: is Doctor Lance Montgomery from Laguna Hills. I do Hip, Knee, and Shoulder Surgery, and I'll be assisting today.
[0:44] Speaker 1: So as you can see, this patient is in the supine position.
[0:47] Speaker 1: And 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.
[1:11] Speaker 1: And we're going just anterior to that to make the exposure. OK, do we have a knife?
[1:19] Speaker 1: So 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.
[1:33] Speaker 1: What I like to do is identify.
[1:39] Speaker 1: Where the tensor is.
[1:41] Speaker 1: Because the fascia gets quite thin usually up around the area of the tensor.
[1:45] Speaker 1: So 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.
[2:12] Speaker 1: And 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.
[2:29] Speaker 1: And
[2:31] Speaker 1: Allows you to
[2:33] Speaker 1: Dislocate it Hip much more easily.
[2:36] Speaker 2: You use a cob elevator to elevate the fascia
[2:39] Speaker 2: muscle belly. You know,
[2:40] Speaker 1: usually you don't have to. In this particular case, it is a little more adherent than you typically see.
[2:47] Speaker 1: Um, but what I'm trying to do is find that interval.
[2:51] Speaker 1: Between the
[2:55] Speaker 1: Cancer in the gluteus.
[2:58] Speaker 1: It's important that you get in the right interval.
[3:02] Speaker 1: Which 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.
[3:12] Speaker 1: The tensor and you have a knife there. Usually we'd use a bowie for this.
[3:21] Speaker 1: So I'm putting this up.
[3:24] Speaker 1: Over the top of the
[3:26] Speaker 1: Femur uh.
[3:32] Speaker 1: Near the pier Forest fossa.
[3:38] Speaker 1: OK, so I'm retracting.
[3:41] Speaker 1: The, uh, gluteus this way, and then I'm gonna come right down onto the Hip capsule.
[3:48] Speaker 1: And
[3:49] Speaker 1: What.
[3:55] Speaker 1: And then another one, another blunt cobra. OK, and so now we're seeing the Hip capsule here.
[4:01] Speaker 1: Similar to the Anterior approach, we're looking down on the Hip capsule.
[4:05] Speaker 1: And now I'll take of pickups and a knife. Can you see that here, the anterior Hip capsule in here.
[4:12] Speaker 1: So where's the
[4:13] Speaker 2: spike of that uh enter
[4:15] Speaker 2: retractor.
[4:16] Speaker 1: It's, you can put it all the way over the top if you flex this up. Let me flex this a little bit.
[4:22] Speaker 1: You 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.
[4:32] Speaker 1: A 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.
[4:41] Speaker 1: Yeah, so now you had a pretty good exposure there.
[4:46] Speaker 2: How often do you excise the capsule?
[4:48] Speaker 1: Usually 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.
[5:01] Speaker 1: And 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.
[5:13] Speaker 2: Are you preserving the labrum at this point?
[5:15] Speaker 1: Yes, 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.
[5:24] Speaker 1: OK, and I'm reset these retractors, make sure they're inside the capsule, and then we'll take the saw.
[5:33] Speaker 1: So what I'll do here now is I'll feel right at the base.
[5:38] Speaker 1: Of the trochanter here feeling right at the base of the trochanter and I'll just make an approximate neck cut.
[5:47] Speaker 1: I 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.
[5:58] Speaker 1: And
[6:05] Speaker 1: So that's the cut on the neck, and if you take the Hip and then rotate it around a little bit, usually.
[6:13] Speaker 1: You can
[6:15] Speaker 1: Orient his head. Let me have a cup.
[6:19] Speaker 1: We 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.
[6:30] Speaker 1: An 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.
[6:41] Speaker 1: And 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.
[6:52] Speaker 2: So if you have difficulty getting the head out, do you recut the neck a little
[6:54] Speaker 1: shorter? Yeah, sometimes you have to. Another pointed home.
[6:58] Speaker 1: Tell you what.
[7:03] Speaker 1: Do 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.
[7:10] Speaker 1: That goes about like that knife again. I got it.
[7:15] Speaker 1: And 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.
[7:35] Speaker 1: A very good press fit. I'll go 360 degrees.
[7:42] Speaker 1: And come right out to the
[7:45] Speaker 1: Edge of the uh
[7:49] Speaker 1: And 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.
[8:02] Speaker 1: And 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.
[8:21] Speaker 2: Great exposure.
[8:22] Speaker 1: Yeah, it's
[8:24] Speaker 1: And 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.
[8:36] Speaker 1: Uh, 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.
[8:44] Speaker 1: Reamer, yeah,
[8:46] Speaker 2: I got a 44 on. Is that good to start?
[8:48] Speaker 1: Yeah, um, yeah, 44 is fine.
[8:52] Speaker 1: So again, if you're going to be doing Outpatient Surgery.
[8:56] Speaker 1: You know, you want stuff that's easy to use, simple instruments, reproducible instruments.
[9:02] Speaker 2: Are you using fluoroscopy to assist with?
[9:05] Speaker 1: You 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.
[9:20] Speaker 1: So, 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.
[9:41] Speaker 1: And 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.
[9:54] Speaker 1: You can usually get.
[9:56] Speaker 1: OK, you get the liner. Why don't put a 32 in it. OK, so put the trial liner in.
[10:02] Speaker 1: A 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.
[10:17] Speaker 1: It'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.
[10:28] Speaker 1: So 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.
[10:34] Speaker 1: And I am going to
[10:37] Speaker 1: Take the knife.
[10:39] Speaker 1: Or do anything in the back of the uh
[10:44] Speaker 1: Back area here so it's much more versatile than a knife to doing this is very similar to doing the DA Approach.
[10:55] Speaker 1: But
[10:56] Speaker 1: I'm going to just remove a little bit of the capsule here.
[11:00] Speaker 1: Just thin it out a bit.
[11:05] Speaker 1: And
[11:06] Speaker 1: Now what we're looking at here.
[11:09] Speaker 1: You can see here we're looking right in at the posterior capsule.
[11:15] Speaker 1: And
[11:16] Speaker 1: As Jackie pushes down on that leg, as she pushes down, and I take this all the way down to the bone.
[11:24] Speaker 1: You'll see this give.
[11:27] Speaker 1: See how that just shifted and sometimes, you know, I'm a big patient. I will have to use an offset, um.
[11:34] Speaker 1: I'll have to use an offset.
[11:37] Speaker 1: Per 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.
[11:47] Speaker 1: You 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.
[12:01] Speaker 1: Just, 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.
[12:18] Speaker 1: Loosening 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.
[12:32] Speaker 1: Yeah, 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.
[12:43] Speaker 2: You use a collarless
[12:44] Speaker 2: stem.
[12:45] Speaker 1: Yes, 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.
[12:58] Speaker 1: So to reduce this, pretty straightforward, um, we just lift that leg.
[13:05] Speaker 1: Take this out.
[13:07] Speaker 1: And then I just lift the fas up in there like that and then bring the foot over.
[13:15] Speaker 1: And then we just need somebody to give it a little pull at the end.
[13:18] Speaker 1: And you're in, yep, you're in.