Minimally invasive total hip replacement (MITHR) uses a smaller incision of 6-10 cm compared to the standard incision. While MITHR results in less soft tissue damage and shorter hospital stays, it also has a longer learning curve for surgeons. Early in the learning curve, complication rates are higher for MITHR. With increased experience, surgeons can perform MITHR with outcomes equivalent to conventional THR. However, the evidence does not clearly support making MITHR the standard procedure over the conventional approach. Patient characteristics and surgeon experience should guide the choice of surgical approach.

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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!