MIS Hip Joint Replacement Surgical Technique MIS Hip - Direct...3 MIS Hip Joint Replacement Surgical Technique Patient Positioning Place the patient in the supine position at the operating

MIS Hip Joint Replacement Surgical Technique

Direct Anterior Approach

646_11_LMISH_AST_Rev2_MiS_Hip_Direct_Anterior_SP_US_MIS Hip Joint Replacement Surgical Technique 5/26/11 11:16 AM Page c1

It is Stryker’s mission to deliver state of the art MIS technologies and implantsfor hip and knee arthroplasty, while providing the highest standards of trainingand education for the medical community. Stryker’s ultimate goal is to promotepatient lifestyle recovery supported by responsible science. Stryker willendeavor to invent, develop and deliver procedural simplification throughinnovative technologies that provide greater patient satisfaction and potentiallylead to long-term clinical success.Minimally invasive procedures are those that offer a synergistic combination ofimplant and technique with the potential to improve the surgical experience ofpatient and surgeon.

MIS Hip Joint Replacement Surgical Technique

The decision to perform an MIS procedure is ultimately left to the surgeon'sprofessional medical and clinical judgment. It is the surgeon who must carefullyevaluate each patient to determine if MIS surgery is indeed appropriate. In somecases, the clinical risks that apply to MIS total joint arthroplasty may be greaterthan conventional total joint arthroplasty. Stryker strongly recommends thatsurgeons complete a formalized training program before attempting theseoperative techniques on their own.

Scientific Advice

Michael Nogler, M.D.Martin Krismer, M.D.Medical University Innsbruck,Department of OrthopaedicsAnichstraße 35, A-6020 Innsbruck,Austria

William J. Hozack, M.D. Rothman Institute 925 Chestnut StreetPhiladelphia, PA 19107-4216, USA

Direct Anterior Approach

646_11_LMISH_AST_Rev2_MiS_Hip_Direct_Anterior_SP_US_MIS Hip Joint Replacement Surgical Technique 5/26/11 11:16 AM Page 2

Stryker Direct Anterior MIS Technique Introduction 1

Preoperative Planning and Patient Positioning 2

Patient Positioning 3

The Portal 4

Exposure of the Joint 5

Preparation of the Capsule 10

In Situ Osteotomy and Removal of the Femoral Head 11

Acetabular Exposure 13

Preparation of the Acetabulum 14

Cup Impaction 16

Preparation of the Dorsolateral Capsule 18

Figure 4 Position to Mark Femoral Orientation 19

Exposure of the Femur 20

Opening of the Femoral Canal 23

Rasping the Femur 24

Implantation and Closure 26

Stryker MIS Instrumentation 27

Table of Contents

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1 MIS Hip Joint Replacement Surgical Technique

The Direct Anterior Approach can beused to implant a standard total hipprosthesis using instruments speciallydesigned for minimally invasive surgery(MIS).

A modified Smith-Peterson anteriortechnique allows direct, unimpededaccess to the hip capsule through asingle incision. The approach is madethrough an intermuscular andinternervous plane that spares tissue andleaves the gluteal muscles attached to theileum.

• The capsule may be retained via acapsulotomy using an H-shapedincision or it may be excised

• The femoral neck is osteotomized bytwo sequential cuts

• After the bony disc has beenremoved, the femoral head can beremoved without significant softtissue distraction

• Mobilization of the capsule from thefemur and placement of speciallydesigned retractors to elevate thefemur out of the wound permit directaccess to the femoral canal

Direct Anterior MIS Technique

Please note that this MIS Surgical Technique illustrates the Accolade TMZFfemoral component and the Trident acetabular component as an example.The surgical techniques presented here can be adapted to work with manyStryker Orthopaedics primary femoral and acetabular components. Fordetails specific for the components you choose, please consult theappropriate surgical protocols.

This Direct Anterior Surgical Techniquewas derived from the Stryker InteractiveTraining Program. Within this programare interactive MIS Hip and Kneesurgical techniques that allow you towork and become familiar with Stryker'slatest MIS instruments while applyingthem to computer-animated soft tissueand bone models.

This educational tool is one phase in acomprehensive MIS training programand is designed to help reduce the learningcurve associated with MIS procedures.

To access the Stryker Interactive Training Program, use the linkhttp://learn.healthstream.com/strykerortho/

You can find out more about our MIStraining program by accessing ourwebsite at www.stryker.com


Preoperative planning aids in theselection of the appropriate implant styleand size for the patient's hip pathology.Preoperative X-ray analysis can be usedto evaluate:

• Optimal femoral stem fit• Prosthetic neck length• Neck offset• Acetabular component sizing• Correct location of the osteotomy

Determination of probable implant styleand size can facilitate operating roompreparation by ensuring that theappropriate size selection is available.Anatomic anomalies that could preventthe intra-operative achievement of theestablished preoperative goals may alsobe detected through such planning.

Place the patient in a supine position onthe operating table to create apredictable and stable position. A hipbump can be used to push the hipforward, but it is not required.

When preparing the femoral canal, thepatient will need to be repositioned withthe operative leg placed in externalrotation, adduction, and extension.

Preoperative Planning & Patient Positioning

2Direct Anterior Approach



Patient Positioning

Place the patient in the supine position atthe operating table. A table attachmentopposite to the operated side (such as anarmboard) allows for easier hyperabduction of the opposite leg duringfemoral exposure. Both legs are drapedflexibly (only the operative leg needs tobe sterilely draped, but sterile draping ofboth legs may be helpful for the surgicalexposure). (Fig. 1)

Palpate the anterior superior iliac spineand the greater trochanter. The proximalstarting point is found two fingerbreadths (~ 3 cm) lateral and two fingerbreadths distal to the ASIS. Keep theinitial incision small (6-7 cm) andextend it as needed. For increasedacetabular exposure lengthen distallyand for the femur proximally. Observethat the location of the incision issignificantly more lateral than theoriginal Smith-Petersen interval. Seeanatomic dissection on the next page.(Fig. 2a)

Another technique to find the incisionlocation is to draw a line between theASIS and the GT. The proximal extent ofthe incision starts on this line about halfway between the two landmarks. Theincision should angulate graduallytoward the GT rather than going straightdistal. (Fig. 2b)

Figure 1

Figure 2a

Figure 2b

Table Attachment

Smith-Petersen Interval

Smith-Petersen Interval

6-7 cm

6-7 cm

GT

ASIS


http://literature.ortho.stryker.com/files/LMISH_DVD3_SkinIncision.mp4


The Portal

The lateral femoral cutaneous nerve(LFCN) is in the area of this approach.Placing the incision as described before,protects the nerve. In the area of theincision, vessels perforating the iliotibialband can be found and need to becauterized. (Figs. 3a, 3b)

Avoid cutting into the tensor fasciaelatae (TFL) before precisely locating thecorrect portal. Use your index finger inproximal distal movements to palpatethe interval between the TFL andsartorius. (Fig. 4)

An alternative technique is to identifythe fascia of the gluteus medius muscle.This consistently has a whiter morefascial appearance. The muscleimmediately medial to this is the tensorfascia. (Fig. 5)

Figure 3a

Figure 3b

Figure 4

Figure 5

TFL

LFCNLFCN

Sartorius

TFL

TFL

GluteusMedius

Watson JonesGluteus Medius Facia



Exposure of the Joint - Lateral Retractors

Sharply incise the fascia of the tensor atits midpoint (medial to lateral). (Fig. 6)

Dissect the fascia from the muscularfibres and perform the next steps strictlyunder the fascia. Gently pulling the TFLmuscle fibers laterally beneath the TFLfascia easily reveals the Smith-Peterseninterval – this is identified as a fattylayer. (Fig. 7)

Place the first sharp Narrow Hohmannretractor (1) around the lateral orsuperior neck. Gentle pushing with yourfinger in this area prior to placing theretractor can identify the properretractor location. (Fig. 8)

Place the second sharp NarrowHohmann retractor (2) in the area of the greater trochanter. A rake or Hibbsretractor holds back the medial soft-tissue. (Fig. 9)

Figure 6

Figure 7

Figure 8

Figure 9

1

1

2



Figure 11a

Figure 11b

The anatomic situs shows the proximityof vascular structures and the ascendingbranches of the lateral circumflex vesselswhich have to be cauterized. (Fig. 10)

The ascending branches of the lateralcircumflex vessels need to be identifiedand cauterized, sutured or clipped.These branches are variable in number.(Fig. 11)

Figure 10

Femoral NerveBranches Lateral

Circumflex Vessels

RectusSatorius

Capsule

Iliopsoas

TFL

Artery

Vein



Exposure of the Joint - Medial & Cranial Retractors

Once cauterized, the surgeon can incise afascial layer between the rectus and theTFL. This reveals the lateral vastusmuscle. The fascia between rectus andcapsule is cut with the Colorado Needleor Bovie until the precapsular fat pad isvisible. (Fig. 12)

The hip is flexed during this step. A “soft-spot” which offers very littleresistance can be palpated just proximalto the lateral vastus muscle. Bluntdissection with a finger or Cobb canidentify the proper location for theretractor. (Fig. 13)

Place another retractor (3) medial to the neck, thus retracting rectus andsartorius. This can be either a sharpNarrow Hohmann or blunt NarrowCobra retractor. (Fig. 14)

Figure 12

Figure 13a

Figure 13b

Figure 14

12

1

2

12

Vastus

12

3

Rectus

Capsule



The distal lateral retractor (2) can beremoved for this step. After releasing thestrong fascia under the rectus the Cobb isused to prepare the space around theventral rim of the acetabulum. The hip isflexed during this step. (Figs. 15a, 15b)

Figure 15a

Figure 15b

1

3

1

3



A fourth sharp Narrow Hohmannretractor (4) is placed around the ventralrim. A Light Pipe light attachment tothis retractor can enhance dramaticallyvisualization of the acetabulum. Ifnecessary a further release of the rectusfascia can be performed. The lateraldistal retractor is put back at its primaryposition afterwards. (Fig. 16)

If the retractor is placed perpendicularto the ilioinguinal band and kept underthe ilipsoas muscle, injuries of thefemoral nerve or the vascular bundle canbe avoided. (Fig. 16b)

Figure 16

Figure 16b

1

4

2

3

Rectus

Nerve

Santorius

Pubic Symphysis

Adductor Muscles

Illoinguinalband

ASIS

Fem. Artery

Light Pipe


http://literature.ortho.stryker.com/files/LMISH_DVD3_AnteriorRetractor.mp4


Preparation of the Capsule

If necessary the reflected head of therectus can be incised at its capsularinsertion. This is only necessary in rarecases. (Figs. 18a, 18b)

A non-anatomic description divides thecapsule in a ventral, lateral, dorsal andmedial portion. In Figure 19 acetabularand corresponding femoral attachmentsof these capsular parts are shown.Depending on the stiffness of thecapsule and experience of the surgeonseveral variations of capsulotomies andcapsulectomies can be performed. Allvariations have in common a carefuldetachment of capsular parts from thefemoral neck. If it is intended not toperform a total capsulectomy, werecommend a stepwise capsulotomyfrom 11 o’clock to 6 o’clock. Initially starta partial capsulectomy from 11 o’clock to3 o’clock. The flap from 3 o’clock isdetached from the acetabulum as far aspossible but not resected. Place themedial retractor (3) medial to the neckinside the capsule. (Figs. 19, 20)

Carefully clear the “saddle” betweengreater trochanter and the neck as thisserves as starting point for the neckosteotomy. (Figs. 21a, 21b)

Figure 18a Figure 18b

Figure 19 Figure 20


1

4

3

1

4

3

1

4

3

2

Rectus

Reflected

Head

Acetabulum

12ventral

dorsal

Femur

Femur

Saddle

med

ial lateral6

39

9

3612


http://literature.ortho.stryker.com/files/LMISH_DVD3_AnteriorCapsulectomy.mp4


In Situ Osteotomy and Removal of the Femoral Head

Remove the supero-lateral retractor (1)and place a Blunt Narrow Cobra retractor(5) intracapsularily in order to protect thetip of the greater trochanter during theosteotomy. (Fig. 22)

Perform the definitive osteotomy with aStryker CORE Micro Saw or a standardpower tool with a long and small saw-blade. The proximal osteotomy should be asproximal as possible. Make sure that bothosteotomies are parallel. If a wedge iscreated, removal of the neck might bedifficult.The use of longer saw blades increases the risk of cuts into the acetabulum or thetip of the greater trochanter. (Fig. 23)

Make sure that the first osteotomy iscomplete and perform the secondosteotomy on a line from the saddle of the neck approximately 1 cm distal to the first osteotomy. (Fig. 24)

Use the Cobb or a chisel to mobilize the neck disk. (Fig. 25)

Figure 22

Figure 23

Figure 24

Figure 25

4

2

3

5

4

2

3

4

2

3

4

2

5

3

5


http://literature.ortho.stryker.com/files/LMISH_DVD3_DoubleOsteotomy.mp4


Remove the neck disk with a clamp ortenaculum. Gentle traction on the leg will facilitate this step. (Fig. 26a)

A Femoral Head Extractor corkscrew isused to remove the remaining head. Agentle but constant longitudinal pull isthe best technique for removal of thehead. Anterior acetabular osteophytesmay need to be removed first in order to facilitate femoral head removal. (Figs. 26a, 26b)

These steps can be ameliorated bypulling the leg. (Fig. 27)

Figure 26a

Figure 26b

Figure 26c

Figure 27

4

2

3

5

4

2

3

5

4

2

3

5


MIS Hip Joint Replacement Surgical Technique13

Acetabular Exposure

The ventral retractor (4) is kept in place.Remove all other retractors from theirposition. A sharp Narrow Hohmannretractor (3) is positioned in the middleof the acetabulum and orientatedmedially. Scratch along the bone until softtissue is reached. Now place this retractoraround the transverse ligament. (Fig. 28)

A sharp Narrow Hohmann retractor is placed lateral to the acetabulum (1).Occasionally, it is necessary make a small nick in the capsule to facilitateplacement of this retractor. (Fig. 29)

Remove the remaining parts of thelabrum. (Fig. 30)

Figure 28

Figure 29

Figure 30

4

3

4

1

3

4

1

3


Direct Anterior Approach 14

Preparation of the Acetabulum Method 1

Incise the dorsal capsule (it usually formsa roll) in the middle of the acetabulum.This is at 6 o’clock in the middle of thedorsal portion of the capsule. (Fig. 31)

Place a double pronged BG FemoralElevator (6) at the dorsal rim of theacetabulum. (Fig. 32)

The retractor can either be held by thefirst assistant or weights can be used.(Fig. 33a)

Ream to the correct size using the OffsetReamer Handle. (Fig. 33b)

Figure 31

Figure 32

Figure 33a

Figure 33b

4

1

3

4

61

3

4

6

1

3

4

6 1

3


http://literature.ortho.stryker.com/files/LMISH_DVD3_PosteriorCapsularIncision.mp4

MIS Hip Joint Replacement Surgical Technique15

Preparation of the Acetabulum Method 2

Place the first reamer in the acetabulum.(Fig. 35)

Introduce the Offset Reamer Handle andconnect it to the reamer. (Fig. 36)

After reaming, the first assistant uses aclamp to open the locking mechanism ofthe reamer. The Offset Reamer Handle isdisconnected and removed. Remove thereamer with a Kocher clamp. (Figs. 37a,37b)

Figure 35

Figure 36

Figure 37a

Figure 37b

4

1

3

4

1

3

4

1

3

6

4

1

3

6


Direct Anterior Approach 16

Cup Impaction

After trialing, use the Curved PositionerImpactor to impact the final cup.(Figs. 38a, 38b)

Figure 38a

Figure 38b

4

16

3

4

16

3



If screws are placed or the locking screwis inserted, use a flexible screw driver.(Figs. 39a, 39b)

Insert the liner.

At this point, femoral preparation willoccur. Remove retractors (1 + 6) andleave the anterior (lighted) retractor (4)and optionally the medial retractor (3).Leaving these retractors in place willfacilitate exposure of the femur. (Fig. 40)

Figure 39a

Figure 39b

Figure 40

4

1

3

6

4

1

3

6

4

1

3

6



Preparation of the Dorsolateral Capsule

Put a sharp Narrow Hohmann retractor(1) to the lateral aspect of the greatertrochanter. Put the BG Femoral Elevator(7) between capsule and external rotator.The lateral capsular flap is grasped with a clamp. Use the Colorado Needle todissect the fat-tissue layer between thecapsule and the dorsal group of muscles(piriformis, obturator, gemelli). (Fig. 41a)

In order to ameliorate this step, place theleg in adduction and external rotation.The resection of this capsular flap toincision in the dorsal capsule finalizes the partial capsulectomy from 11 o’clockto 6 o’clock leaving the capsule from 6 o’clock to 11 o’clock in place (see Figure 19). (Fig. 41b)

After removal of the dorso-lateralcapsule, the short external rotators can be seen. (Fig. 42)

Figure 41a

Figure 41b

Figure 42

4

1

3

7

4

1

3

7

Obt Ext.

Rectu

s

Piriform

isGluteus M

inimus

Gluteus M

ediusGemellus Inf.

Gemellus Sup.Obturator Int.Ili

opsoas



Figure 4 Position to Mark Femoral Orientation (optional)

Bring the leg in a “Figure 4” position andplace one retractor medial and one lateralto the femur, thus presenting the calcarwhich is still covered with capsular tissue.(Fig. 43a)

Use two sharp Narrow Hohmannretractors to expose the calcar. Removethe capsular tissue. (Fig. 43b)

Mark the neutral rotation of the femurwith the cautery. (Fig. 44)

Figure 43a

Figure 43b

Figure 44

Calcar

TFL



Exposure of the Femur

Break the leg part of the table by about30°- 40°. (Figs. 45, 46)

A double pronged BG Femoral Elevatorretractor (8) is placed behind the greatertrochanter but in front of the gluteusmedius muscle. A Bone Hook (9) is thenplaced into the calcar area of the femoralneck. A gradual but firm anterior pullwill elevate the femur. The doublepronged BG Elevator is then positionedto hold the femur in its elevated position.Additional releases of the posteriorstructure may be required to achieveproper femoral exposure.

In some cases the tip of the greatertrochanter is placed behind theacetabulum. Therefore, pull the BoneHook first laterally in order to free thegreater trochanter and then pullanteriorly.

Always combine pulling the hook andlevering with the BG Femoral Elevator in order to minimize the forces to thegreater trochanter. (Figs. 47a, 47b)

Figure 45

Figure 46


30˚ - 40˚

8

9

8

9


http://literature.ortho.stryker.com/files/LMISH_DVD3_ProximalFemoralExposure.mp4


The opposite leg is hyper-abducted andthe second assistant externally rotates theleg at the knee. Alternatively, the oppositeleg can be crossed over the operated legand the assistant’s hand in order tosupport external rotation. The operatedleg must be placed with a straight knee in order to reduce muscular force at theproximal femur and to optimize theexposure of the proximal femur. (Figs.48a, 48b)

Figure 48b

Figure 48a



Possible Releases

At the tip of the greater trochanter and in the trochanteric fossa, the attachmentsof gluteus minimus, piriformis, gemellussuperior, internal obturator and gemellusinferior can be found. (Fig. 49)

A sharp Narrow Hohmann retractor (11)is placed at the calcar area proximal tothe iliopsoas tendon. Additionallyanother sharp Narrow Hohmannretractor can be placed laterally at theproximal femur in order to pull back thelateral soft tissue. After exposing thefemur, releases of the above mentionedtendons can be performed, if necessary.(Figs. 50a, 50b)

Figure 50a

Figure 50b

Figure 49

Obt Ext.

Femur

Rectu

s

Iliopsoas

Piriform

isGluteus M

inimus

Gluteus M

edius

Gemellus Inf.

Gemellus Sup.Obturator Int.

811

10

811

10



Opening the Femoral Canal

An angulated Curette is used to carefullyopen and probe the direction of thefemoral canal. (Fig. 51)

A Rongeur can be used to extend theopening in the direction of the greatertrochanter. (Fig. 52)

A proximal Accolade TMZF Starter Raspis used to form the proximal canal.(Fig. 53)

Figure 51

Figure 52

Figure 53



Rasping the Femur

Next, insert the Accolade TMZF Rasp size 0 without significant force into thecanal until the rasp is aligned with thefemur. Once there is full introduction ofthe rasp, hammering can then begin.(Figs. 54a–54g)


Figure 54c Figure 54d

Figure 54e Figure 54f

Figure 54g



The Dual Offset Accolade Rasp Handlecan facilitate the introduction andalignment of the broaches and offers the additional advantage of reducing theexposure needed of the proximal femur.



Implantation and Closure

The final implant is introduced by handand then impacted gently into the canal.A straight bullet nosed Accolade TMZFStem Impactor can be used to impact the femoral stem at a 30 - 45 degree anglein the standard fashion. This insureslateralization of the femoral componentand minimizes the chance of a medialcalcar fracture. (Fig. 56)

The final head is attached. (Fig. 57)

The muscular fascia is sutured. Care istaken to avoid placing sutures too farmedially (remember the LFC nerve isthere). (Fig. 58)

Local anaesthetics can be injectedregionally, based on surgeon preference.(Figs. 59, 60)

Figure 56

Figure 57

Figure 58

Figure 59 Figure 60



Universal Accolade TMZF Stem Impactor

Light Pipe

Accolade TMZF Starter Rasp

BG Femoral Elevator

Stryker MIS Instrumentation

NAV Compatible Dual-Offset Accolade Rasp Handle(Left & Right)

Curved Positioner/Impactor

Offset Reamer Handle

Blundt Narrow Cobra Retractor

Narrow Hohmann Retractor



Direct Anterior Set Contents2124-1700 Right - Nav Compatible Dual-Offset Accolade Rasp Handle 2124-1750 Left - Nav Compatible Dual-Offset Accolade Rasp Handle2124-1899 Universal Accolade TMZF Stem Impactor4200-130-0 Accolade TMZF Starter Rasp48498005 (2) BG Femoral Elevators1440-1130S (3) Narrow Hohmann Retractors1440-1140 (2) Blunt Narrow Cobra Retractors4200-105-0 Direct Anterior THA Case/Tray

Acetabular InstrumentsT6320 Offset Reamer HandleCurved Positioner/Impactor1440-0030 MIS Acetabular Instruments - General Tray1440-1300 Curved Positioner/Impactor1440-1370 Lateral Decubitus Alignment Guide1440-1380 Supine Alignment Guide1440-1310 Trident Cup Tip1440-1320 ABG Cup Tip1440-1328 28mm Poly Insert Tip1440-1332 32mm Poly Insert Tip1440-1336 36mm Poly Insert Tip1440-1328D 28D Ceramic Insert Tip1440-1332E 32E Ceramic Insert Tip1440-1332F 32F Ceramic Insert Tip1440-1336G 36G Ceramic Insert Tip1440-1336H 36H Ceramic Insert Tip1440-1336I 36I Ceramic Insert Tip2112-0000 Ceramic Insert Removal Tool1440-1350 U-Joint Flexible Shaft - Positioner/Impactor

Femoral Instruments5900-0050 T-Handle1440-1010 Femoral Head Extractor1440-1070 Head Impactor1440-1040 Quick Connect Handle1440-1700 Neck Trial Forceps1440-0001 Single High Case1440-0002 Double High Case1440-1080 Light Pipe



Notes:



Notes:




A surgeon must always rely on his or her own professional clinical judgment when deciding whether to use a particularproduct when treating a particular patient. Stryker does not dispense medical advice and recommends that surgeons betrained in the use of any particular product before using it in surgery.

The information presented is intended to demonstrate the breadth of Stryker product offerings. A surgeon must alwaysrefer to the package insert, product label and/or instructions for use before using any Stryker product. Products may notbe available in all markets because product availability is subject to the regulatory and/or medical practices in individualmarkets. Please contact your Stryker representative if you have questions about the availability of Stryker products inyour area.

Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the followingtrademarks or service marks: Accolade, Stryker, TMZF, Trident. All other trademarks are trademarks of their respectiveowners or holders.

Literature Number: LMISH-AST Rev. 2MS/GS 05/11

Copyright © 2011 StrykerPrinted in USA

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MIS Hip Joint Replacement Surgical Technique MIS Hip - Direct...3 MIS Hip Joint Replacement Surgical Technique Patient Positioning Place the patient in the supine position at the operating