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Minimally Invasive Total Hip Replacement (MITHR)

Students:

For: Guntis Balodis,

Against: Andris Džeriņš

Mentor: Asoc. Prof. Pēteris Studers

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Total hip replacement has been termed as «Operation of Century» as it has revolutionized the treatment of patients with advanced hip disorders1

In 1890, Gluck in Germany reported first total hip replacement from ivory2

In 1960s low friction arthroplasty procedures developed by Sir John Charnley2

Introduction

1. Learmonth DI, Young C, Rorabeck C. The operation of the century: total hip replacement. The Lancet

2007;370:1508-19.

2. Bhan S, Pankaj A. History and evolution of hip arthroplasty. Bhan S, Malhotra R (Ed). Key Issues in Hip

Arthropasty. New Delhi. Mediworld publications 2007.pp.4-10.

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In 2003 Berger popularized the idea of MITHR1

Prof. Frederick Laude in Paris adapted the anterior approach and modified the traction table and tissue retractors to create a truly “minimally invasive approach” 13 years ago1

History of MITHR

1. http://kog.net.au/hip/anterior-minimally-invasive-hip-replacement-surgery-amis-thr

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Minimally invasive technique- total hip replacement performed through an incision that is less than 10 cm in length (6-10cm)

Minimally invasive THA involves a modified surgical dissection that uses internervous planes while minimising any tendon or muscle trauma during the exposure1

Introduction

1. Single-incision, minimally invasive total hip arthroplasty: length doesn't matter. de Beer J, Petruccelli D, Zalzal P,

Winemaker MJ J Arthroplasty. 2004 Dec; 19(8):945-50.

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MITHR: anterolateral approach

Dtsch Arztebl 2006; 103(49):A3333–9 www.aerzteblatt.de

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MITHR: posterior approach

Dtsch Arztebl 2006; 103(49):A3333–9 www.aerzteblatt.de

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MITHR: direct two-incision approach

Dtsch Arztebl 2006; 103(49):A3333–9 www.aerzteblatt.de

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The incision lenght

Total hip arthroplasty through the mini-incision (Micro-hip) approach versus the

standard transgluteal (Bauer) approach: a prospective, randomised study. J

Orthop Surg (Hong Kong). 2014 Aug;22(2):168-72.

13,4 cm

9,3 cm

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MITHR is not suitable for all patients1:Elderly patients

Overweight patients (BMI >30)

Severe acetabular dysplasia

Severe acetabular protrusion

Previous hip operations

Severe hip contracture

Muscular patients

Patient Characteristics for MITHR

1. http://www.arthritis-health.com/surgery/hip-surgery/minimally-invasive-hip-replacement-vs-traditional-hip-replacement

http://www.medscape.com/viewarticle/858818

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Tissue trauma is similar between the groups by assesing cytokine level (Ogonda et al. and Chimento et al. 2012)

Mow et al. Skin and soft tissue damage is caused by the high retractor pressure required for the MIS exposure1

Damage to surrounding tissue

http://emedicine.medscape.com/article/2000333-technique

1. Minimally invasive versus conventional exposure for total hip arthroplasty: a systematic review and

meta-analysis of clinical and radiological outcomes. Smith TO, Blake V, Hing CB. Int Orthop. 2011 Feb;

35(2): 173–184.

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Surgery time

J Arthroplasty. 2014 Oct;29(10):1970-82. doi: 10.1016/j.arth.2014.05.021. Epub 2014 Jun 3.

Minimally invasive surgery

+5 min

Standart approach

+12 min

Orthop Rev (Pavia). 2013 Dec; 5(4): e31

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Hospitalization time

Minimally invasive surgery

+ 1 day

Clin Orthop Relat Res. 2013 Apr; 471(4): 1283–1294.

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There were no statistically significant differences between the exposure methods during THA for complications such as:

infection rates

intra- or postoperative fracture

dislocation rate

deep vein thrombosis

haematoma formation

wound complications

component loosening

Complication rates I

Minimally invasive versus conventional exposure for total hip arthroplasty: a systematic review and meta-

analysis of clinical and radiological outcomes. Smith TO, Blake V, Hing CB. Int Orthop. 2011 Feb; 35(2):

173–184.

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Complication rates II

MI technique has a five times greater rate of iatrogenic lateral femoral cutaneous nerve palsy (p < 0.0001) 1

Femoral nerve palsy may be associated with retractor position2

Reduced operative visibility may increase the potential for nerve injury1

1. Yoon TR, Park KS, Song EK, Seon JK, Seo HY. New two-incision minimally invasive total hip

arthroplasty: comparison with the one-incision method. J Orthop Sci. 2009;14:155–160. doi:

10.1007/s00776-008-1305-8.2. Minimally invasive versus conventional exposure for total hip arthroplasty: a systematic review and

meta-analysis of clinical and radiological outcomes. Smith TO, Blake V, Hing CB. Int Orthop. 2011 Feb;

35(2): 173–184.

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There was no statistically significant difference between the exposure method in respect to:

WOMAC score (p = 0.13)Harris hip score (p=0.06)Oxford Hip score(p = 0.29)SF-36 physical function (p=0.69)

Clinical outcomes

2. Minimally invasive versus conventional exposure for total hip arthroplasty: a systematic review and

meta-analysis of clinical and radiological outcomes. Smith TO, Blake V, Hing CB. Int Orthop. 2011 Feb;

35(2): 173–184.

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6 weeks – 2 years after surgery

6 weeks 12 weeks 1 year 2 years0

1

2

3

4

5

6

7

8

9

10

Standart lateral

VAS pain at motion Harris VAS satisfaction

Orthop Rev (Pavia). 2013 Dec; 5(4): e31.

[0-10] [0-10] [0-10]

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6 weeks 12 weeks 1 year 2 years0

1

2

3

4

5

6

7

8

9

10

Minimally invasive

VAS pain at motion Harris VAS satisfaction

6 weeks – 2 years after surgery

Orthop Rev (Pavia). 2013 Dec; 5(4): e31.

[0-10] [0-10] [0-10]

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Repantis et al. 2014. On discharge, postoperative hematocrit lower in conventional THA patients, but the difference was not statistically significant (p = 0.08)

There was no statistical significant difference in the amount of blood units transfused in the two groups (p = 0.67).

Blood-loss

Repantis T, Korovessis PG. Comparison of minimally invasive approach versus conventional

anterolateral approach for total hip arthroplasty. E J of Orth Surg. Feb 2014.

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Blood-loss

Clin Orthop Relat Res. 2013 Apr; 471(4): 1283–1294.

Minimally invasive surgery

+73 ml

Minimally

invasive

surgery

+59 ml

J Arthroplasty. 2014 Oct;29(10):1970-82. doi: 10.1016

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Woolson et al. 2004. The posterolateral MI group was had a higher percentage of acetabular component malposition (p = 0.04), and poor fit and fill of femoral components (p = 0.004)1

Radiological outcomes

1. Woolson ST, Mow CS, Syquia JF, Lannin JV, Schurman DJ. Comparison of primary total hip

replacements performed with a standard incision or a mini-incision. J Bone Joint Surg.

2004;86:1353–1358.

2. Kim YH (2006) Comparison of primary total hip arthroplasties performed with a minimally invasive

technique or a standard technique: a prospective and randomized study. J Arthroplasty 21: 1092–

1098.

Kim YH 2006. Femoral offset was significantly increased ( p =

0.02) involving the posterolateral approach2

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STD MIS

Radiological outcomes

Mean change of

position Medially

Mean change of

position CraniallyOrthop Rev (Pavia). 2013 Dec; 5(4): e31.

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0

5

10

15

20

25

30

35

40

45

1

1

1

1

STD MIS

Radiological outcomes

Mean inclination Mean anteversion

Orthop Rev (Pavia). 2013 Dec; 5(4): e31.

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The learning curve of the MI anterior approach is more than 46-100 patients

During this learning curve, the complication rate is higher because of the technical difficulties

The complication rate is twice as high for surgeons who perform fewer than 50 MITHRs a year1

Learning curve I

1. Y.M. den Hartog & S.B.W. Vehmeijer (2013) High complication rate in the early

experience of minimally invasive total hip arthroplasty by the direct anterior

approach, Acta Orthopaedica, 84:1, 116-117

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MITHR, when performed by an experienced surgeon, can have results equivalent to conventional THR1

While MITHR can be safe and effective, the evidence does not support making it the standard of care1

The choice of operative approach depends on surgeon preference and experience2

Conclusions

1. A Henderson, J Grahame. Safety and Efficacy of Minimally Invasive Total Hip Arthroplasty. The Internet Journal of

Academic Physician Assistants. 2008 Volume 7 Number 1.

2. Medscape- Minimally Invasive Total Hip Arthroplasty: http://emedicine.medscape.com/article/2000333-overview?

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%2Fm65xAqLuxe5rW4NwbmwdVrJxKJt4DRD8mxYr6kYfOw%3D%3D

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Thank You for Your Attention!