Minimally invasive total hip replacement

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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.
http://img.medscapestatic.com/pi/meds/ckb/54/29654tn.jpg

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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
0
1
2
3
4
5
6
7
8
9
10
6 weeks 12 weeks 1 year 2 years
VAS pain at motion 1.5 1 0 0
Harris 7.7 9.1 9.6 9.9
VAS satisfaction 9.6 9.6 10 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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0
1
2
3
4
5
6
7
8
9
10
6 weeks 12 weeks 1 year 2 years
VAS pain at motion 1 0 0 0
Harris 8.3 9.5 9.9 9.9
VAS satisfaction 10 10 10 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
https://openi.nlm.nih.gov/detailedresult.php?img=PMC3143982_or-2009-2-e27-g002&req=4

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-1.7
0.9
-1.9
1.5
-2.5
-2
-1.5
-1
-0.5
0
0.5
1
1.5
2
STD MIS
Radiological outcomes
Mean change of
position Medially
Mean change of
position Cranially
Orthop Rev (Pavia). 2013 Dec; 5(4): e31.

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37.7
23.7
39.8
21.8
0
5
10
15
20
25
30
35
40
45
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?pa=URmJ1OJ6kpGaWAiWnspY9Td01cngGy7K0Xf%2FM3gwc%2BD%2Fm65xAqLuxe5rW4
NwbmwdVrJxKJt4DRD8mxYr6kYfOw%3D%3D

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Thank You for Your Attention!