DUAL INCISION HIP REPLACEMENT ST. CLOUD HOSPITAL, ST. CLOUD, MINNESOTA Broadcast November 16, 2004

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1 DUAL INCISION HIP REPLACEMENT ST. CLOUD HOSPITAL, ST. CLOUD, MINNESOTA Broadcast November 16, 2004 NARRATOR A new technique in dual incision MIS hip replacement surgery is redefining the way surgeries are performed. During this live webcast from St. Cloud Hospital in St. Cloud, Minnesota, surgeons will perform a dual incision hip replacement with Stryker navigation. This technique is allowing surgeons to better align implants, see more clearly, and to instantly adjust to the unique anatomies of different individuals without the use of a fluoroscope. When we added surgical navigation, we further assured ourselves that the components were going in in the appropriate position, without exposing us or the operating team to any other radiation from fluoroscopy. NARRATOR This new technique may also shorten the learning curve for surgeons. In conventional hip replacements, the patient is placed in a lateral position. With dual incision approaches, surgeons had to reorient themselves to a supine position. I think that was creating a lot of problems with positioning the components and difficulty in the surgical approach, so we first developed this to do it in a lateral position. I think that greatly eliminated a lot of the problems. NARRATOR At any time throughout this program, you may questions directly to the physicians by clicking the MDirectAccess button on the screen. Good afternoon. Welcome to St. Cloud Hospital s live surgical webcast. Today you will be observing a live two-incision minimally invasive total hip replacement, performed using the Stryker navigation system. My name is Dr. Frank Kolisek. I m from

2 Indianapolis, IN, and I get the honor to moderate this session. Dr. Joe Nessler from St. Cloud will be the surgeon performing the operation for you today. Dr. Nessler, will you please introduce us to your OR team? Thanks, Frank. Our OR team today includes Jerry Nelson. He s my orthopedic physician s assistant, standing to the left of me. We have Robine Evans, our surgical scrub tech. Tara Hyde, another surgical scrub tech assisting us today. Cindy Levadowski, who is the nurse in charge of the whole orthopedic service, is standing across there. Desiree Huker, who is our circulating nurse for the case today. Up at the top of the bed we have Mark Kramer, our anesthetist who will be with us for the duration of the case. Frank Nellen is our anesthesiologist, who was here earlier to induce the patient s spinal anesthetic. I think we re ready to get started. Frank, go ahead and let me know what you want to see. Thanks. I think before we start talking about just the basic concept of what s going on, why don t you show us exactly where you re going to make your skin incision, what landmarks you re looking at, and pretty much just orient the audience, please. What we re doing here, with this technique, we re keeping the patient in a lateral or side lying position, which is different than some of the other two-incision techniques, with the patient lined up on the side. Patient s hip is over here, patient s knee here, foot down here. What we do is look at the kneecap or patella, look at the outer edge of the kneecap and go to the little bump that s on the front of your hip, called the anterosuperior spine. We draw a line between those two and what we want to do is go about 2 cm or so lateral to that with our incision. We base our incision up and down based on the greater trochanter or the big bump on the side of the hips, so people can feel the side of their hips there, called the greater trochanter. We re going to make an incision right there so we get right down on that muscle interval to stay in between the major muscles in the front of the hip. How much of your incision is distal to the tip of the greater trochanter and how much is proximal? About 90% of it is distal to the tip of the trochanter. I start just at the tip or a little above it. If you go a little above the tip of the trochanter, it makes it easier while we re doing our trial reductions and putting our components in at the end, on the femur. We re going

3 to go ahead and make the incision here. This incision will vary, depending on the size of the patient and how muscular they are, anywhere from 4-5 cm up to I m going to ask you to make it a little longer today simply because I want to be able to get the camera down in there and see. Otherwise, the people watching this won t get anything from it, so don t show off for us. The incision length 1 cm or so either way doesn t make any difference. It s what we re doing underneath. So this isn t something that we re doing for cosmetic reasons to make small incisions. This is done to try and get people recuperating quicker and minimize trauma to the underlying muscles. I think while you re working there, I m going to go ahead and expound on that just a little bit because I think there s a lot going on out there in the world right now and everybody s talking about skin incisions. I actually heard a physician describe to me at one time, he stated that he makes the skin incision as short as possible but as long as necessary. I think that is just a wonderful take-home message because it can really make a big difference in the operation, just by going ahead and extending the skin incision. I agree with what Dr. Nessler said and I think that s a bullet point for the audience. It s not the length of skin incision as much as it is what you re doing down beneath the skin. I think that s an important point to keep in mind. You ve just gone through the skin and subcutaneous tissue? I ve just gone through the skin and subcu. We see the tensor fascialata, which is the muscle we re going to pull to the side, and the sartorius medially is the muscle we re going to stay to the lateral portion of. What I m doing is just bluntly dissecting with my fingers. In most cases, you don t have to make an incision with the knife or cautery. I ve just popped through between those muscles, so my finger is actually on the patient s hip joint and I can feel the ball of his ball and socket joint right there on the tip of my finger, without cutting through any muscles or detaching any muscles from the hip joint. Let me make sure we ve got that. You put your finger bluntly down between the sartorius medially and the tensor fascia femoris laterally.

4 Correct. With the skin incision where it s placed, to stay away from side of the side nerves, you occasionally will have to dissect a little skin flap medially to get in that interval. Now, what we re going to use here is I usually use a head-mounted light. What we re going to show you today is a light pipe that Stryker makes that mounts directly onto the retractor to aid in visualization of some of these small wounds. The other thing we re going to do here, and this approach is crucial to try and maintain control of any bleeders. We have little branches here from the recurrent branch of the circumflex that I either will cut into and then Jerry will tag and we ll cauterize or he sometimes tries to find these ahead of time right in this little fatty interval so we can go ahead and cauterize them before starting any bleeders. While you re working, let s back up just a little bit. Can you give us any tips about trying to avoid the lateral femoral cutaneous nerve? First, I think the problems with the lateral femoral cutaneous nerve with these anterior approaches probably are overblown. Most of the patients, even if they have any transient numbness, and that s what it usually is, if they have any, is transient, don t complain of it. I see more people complain of numbness after knee replacements than they do after hip replacements. Do you factor that into your preoperative education? Yeah. Patients know that they might have some thigh numbness. Most of them don t have any and if you place the incision out more lateral, like we do, you ll only get small branches instead of the main nerve. I think that s a good point, being a little bit further lateral, and I also think it s a nice analogy, talking about knee replacement. I think everybody can go home next week, when you do your next total knee, and if you tell your patient they re going to be a little numb lateral to the longitudinal anterior skin incision, they seem to accept it and they say, yup, doc, you were right. Then when it sort of comes back, it s not a big deal. We can go back to the camera on my helmet, if we can, and here he s got the branches, this little vascular bundle with vein and artery from the recurrent branch of that lateral

5 circumflex. We re just going ahead and cauterizing it, which allows us to open that interval a little better. Tell us where the lighted pipe retractor is located. The lighted pipe retractor up here is located along the superior femoral neck, so you can see we just did blunt finger dissection and this is hip joint capsule right here that my cautery is on, so we re right on the hip joint capsule. This muscle you see here is a little kind of wimpy, flimsy portion of the reflective head. Some people will have a big reflective head. Some people will have a small reflective head. In a lot of procedures, people just excise that with the capsule or here we re just going to peel it off medially with the capsule. So with this left hip, we were back on your helmet retractor, looking directly at that retractor. To the right of it is the greater trochanter. You re above the superior neck and to the left of it is the femoral head, correct? Correct. And then you re going to incise the capsule and put the retractor inside the capsule, along the superior neck? Well, what I m going to do is I excise most of this anterior and superior capsule. I know that s still a controversial area with people talking about if they need to excise or incise and repair, but the dislocation rate with this procedure, even with complete excision, is very, very low. We have 231 patients now and we do not have any postoperative dislocations in this group of patients. That s doing an anterior capsulectomy.

6 Yes, anterior capsulectomy and some superior. This one s going to be a little tough here. He s got a lot of hypertrophic osteophytes and a very stiff hip, so that s going to make it a little more challenging. We had a nice, easy loose one earlier this morning, which would ve probably been a great one to do on a live surgery, but this one s going to be a little more challenging. Not to mention the fact that this guy s a muscular male. His body mass index is 31. He s 58 years old and he s quite active. Yes. He had to recently start using a cane for activity. He was using a recumbent bike and a tread climber. He has had to stop all those activities and he was just doing swimming now because of the disability from his hip arthritis, so the hope is to get him back to using his recumbent bike and a tread climber and whatever other activities he wants to do. The retractor that you re putting in right now, is that at the inferior neck? Yes, inferior neck. What we do to try and protect the muscles and take the tension off the TFL is abduct that leg quite a bit. Let s make sure the cameras can see that bump underneath the patient s leg so the hip is abducted. Can everybody see that? I think that s a, you know, this might be a reasonable time to talk about the supine versus the lateral position and I ll just throw my 2 cents in. I went over to New Zealand with Gary Haymond and learned how to do this technique with the supine position. I was always a posterolateral approach surgeon from the lateral decubitus position and I have to tell you, learning how to look at things differently was quite a challenge, looking not only from the front, but trying to get your orientation when the patient s laying on their back. I also found that the buttock occasionally would get in my way and you had to try to get that bump underneath the iliac crest and sort of cock them up a little bit and then I have to admit Dr. Nessler told me, you know, you dummy, why don t you put them on their side, like you re used to anyway. It s actually an easier operation. So I went back to the cadaver lab, did that a couple of times, and I have to admit that Joe was right, it is a lot easier in the lateral approach.

7 I don t actually recall calling you a dummy, though, Frank. Did I? It was probably worse than that. So you re still taking the capsule out. Yes, I m taking the capsule. What I like to do is, I have another Homan retractor. I ve actually placed it under the TFL, toward the inferior wound and I actually grabbed some of the vastus intermedius, just to retract away because I like to look all the way to the capsular attachment at the base of the vastus intermedius. That allows you to pick the neck up? Right. It allows me to cut it low enough with the blade. As you know, it s a very forgiving stem. A neck cut is not crucial. It s not a collared stem. It s a mid zone, wedge fit stem, so if your neck cut is a few mm short, your stem s going to be up a little. If your neck cut s a few mm long, your stem s going to be down a little and it functions just fine. This just helps us identify where we re going to make that cut. I m trying to get all of the superior capsule. If I don t get this now, it s going to give us fits when we try and do our trial reduction and put our head on or slide the prosthesis in, so now I m going to switch the superior retractor to a Benetype. I m going to make a couple of comments that you just set up there. #1, making a comment about that superior capsule. It is mandatory to get that because when you see Dr. Nessler later on go to the posterior incision to get down to the femur for the femoral stem, you have to be able to pull through that superior capsule. If you go ahead and do a capsulectomy, that makes it a lot easier and it allows you to get in without impinging on the trochanter and getting into varus and getting into trouble. You would agree that the common mistake early on, trying this procedure, is the tendency to cut the femoral neck a little bit too long and then it gets in the way of your acetabulum? Yeah. I right away made sure I started cutting them short enough so I could get to the acetabulum. It s a nightmare sometimes, once you cut it and you don t have that head holding things still, it s really hard to re-cut it, so you really want to get that cut right the first time if you can.

8 I have had to recut it several times and I will tell you, from my experience, if you cut the neck and you really do believe you cut it where you templated it, yet the femoral neck is still in the way of the acetabulum, I can guarantee your neck cut is too long, so you may as well cut more. I agree. So now we re ready. Basically a lot of people are concerned about how we pick our orientation. What we do is, we can see the insertion on my helmet cam, the insertion of the vastus intermedius in that vastus ridge, and we basically make our osteotomy parallel to that. We make sure we use a reciprocating saw and we stop short of the trochanter and then we come down from the top of the femoral neck to complete that, kind of make that hockey stick shaped osteotomy. After we ve made that, we just make a second osteotomy wherever to go ahead and take out a wedge of femoral neck to give us some room to work. How close is that retractor on the right, down around the ischium? The one right in front here? That s right around the inferior femoral neck right now, so that s right on the femoral neck. How about the one in the 2:00 position, to your far right? This one up here is along the lateral femur, just below the vastus ridge, below the greater trochanter. It s just holding the vastus intermedius and the tensor out of the way. Out of the way of the neck, so you can cut it. Right. Now I m going to go ahead and make my cut. We re going to stop that cut there and then we re going to come up here. We ve got to be careful not to hit our navigation. We haven t talked about that yet, but we have some navigation pins in.

9 Can you tell us what kind of a blade you re using? If you re like me, you have no idea; you just know it cuts. I just know it s the right blade. It s a recip saw. Stryker has two types and we use the thicker one. It has a little less flop when we re cutting. Now you can see, if you look at my helmet cam, we made that first osteotomy... Tell us how you started. I started from inferomedial, right at the tip of the sucker. Then we extended it up, stopped short of the trochanter, then came from the superior neck down to meet that, so that s that little hockey stick shaped osteotomy. Now we re going to make another one right here and just take a wedge of that femoral neck out. Hockey stick. That s probably where you got that head cam. It s a goalie cam with the NHL on it. That s right because they re not using them this year. Normally we try and see if we can take this out in one piece. Usually if people are watching, we can t, but we ll try. It always makes you look good when the head comes out in one piece, but I ll tell you, whether or not the head comes out in one piece has nothing to do with your surgical technique. You can be doing any approach. Sometimes it s just hard to get out. I m just trying to get the femoral neck section out in one piece first. Then we ll worry about the head. But it looks like I ve got a complete osteotomy. Sometimes we get what s called an incomplete osteotomy of Nelson. That s my assistant. I blame everything on him. The nice thing is that he doesn t have a mike on so he can t refute anything we say today. So now we ve got that out. There s the little wedge that we ve taken out. This just gives us more room and we can see the cut surface here, where the femoral head is. What

10 we re going to do is take out these retractors. Whenever we can remove retractors and not pull on muscle, because these are all relative things, these muscle spreaders, and they don t go without bruising and banging up some muscles. If anyone tells you they can do any of these operations without any damage to any muscle, they re kidding themselves. What I just did is I put a drill hole in the head. Now I m just going to screw in the corkscrew. This is what I m going to use along with what looks like a big glorified shoe horn. We re going to pull this head out because you know in these procedures you can t dislocate them in situ typically, so what we re going to do here is I m going to go ahead and slide this into the joint, behind the femoral head. That s the femoral head skid? Yeah, that s the skid. Now, with a little traction by the assistant, normally we can just gently lever and the head pops right out. Boy, that was good. Fortunately it popped out for the camera. Sometimes you work a little harder at doing that. That came out nice. What I d like to do now...this is something I ve just recently been noticing that helps quite a bit, get that leg again into a little abduction and rotation. It helps get the femur away and it takes the tension off the TFL so we don t have to strain on it and stretch it too much. That s one of the things if you make incisions too small, you might not cut the muscle, but then you re going to damage it by stretching it and tearing it, so it does the same thing. It does the same amount of damage or sometimes worse, so you want to make sure you re minimizing all of that all the time. So we have that one with the light pipe in there again. Now I ve got two of those Homan retractors in there. This is another thing that s kind of controversial. Most people we talk to, with the types of two-incisions that have been talked about a done the most, they talk about this is a blind procedure. You can t see anything. You can t see the acetabulum. If we go to my helmet cam, if you

11 can look, I ll show you. We can see here s the entire posterior wall, posterior labrum. We can see the superior acetabulum. We can see anterior with osteophyte. We can see inferior, where there s big osteophytes on the x-ray, and this is the transverse ligament, so we can see 360 o around that entire acetabulum. With the muscle-sparing approach, we re not talking about a 1.5 incision; we re talking about an incision that doesn t cut any muscle but still allows us to see everything under direct visualization, so we re still doing a safe procedure, unlike something that s blind. That s the other thing. Because we re seeing everything, we don t have to use fluoroscopy and we don t use fluoroscopy for this procedure. Even before we started using navigation, we were not using fluoroscopy. We did it under direct visualization, so navigation is a tool that you could put in with any surgical approach, MIS or standard. I m going to ask you one more question, then I m going to read a couple that we ve received through . Don t forget, everybody out there that s watching, you can in a question and hopefully we can get to it, but you do have a great visualization of the socket there. How often would you say you need a curved acetabular reamer versus a straight? I use it all the time. Which one? The curved, because if I make my incision maybe an inch longer distally, I could get a straight one in, but I think if I use the curved, I don t have to fight the tissues to put it in and out. I know you like to use the straight one, but your interval is a little different. You re using the Watson Jones and I think that s a little easier to use the straight one through the interval you re using. Either way, would you agree it s just a matter of the skin incision? It s a matter of skin incision placement.

12 Right. I think for people that are more comfortable with the straight reamer, just make your skin incision 2 cm long distally and use a straight reamer and you ll be fine, so I don t think it s necessary to have to use some of the other items. Here s one question that came in. Am I supposed to read this like Letterman or something? Anyway, it says how long does it take for the navigation system to be set up for the operation? Why don t you comment on...i was here, I ll comment. I was watching you do it. I think it basically took 3-4 minutes in order to place the pins in the iliac crest. It took about 90 seconds in order to validate the left and right anterosuperior iliac spines and the pubic tubercle. It took about another 90 seconds to put a pin in the distal lateral femur, so I think as far as pin placement and navigating the validation points for the pelvis, with overestimating, was less than 10 minutes and I was sitting here watching it, so I think that s the answer to the question. Would you agree with that, Dr. Nessler? I would agree. I think I add maybe a total of, with everything we do, I could say minutes. The navigation of the hip, if people are familiar with doing it with the knee, is much simpler and quicker with the hip than it is with the knee now. Even though the knee was the first thing out, I think they re already ahead of the knee with the hip navigation. Another question that came through the says do you ever use cement with this type of procedure? No. If I m going to use cement, which I don t very often, I ll do a mini one-incision approach. With my approach here, I think it s best and safest done with uncemented components. What I would do now is, while you re reaming, I ve got a computer screen up here. I think everybody can see these four questions and I think, from the standpoint of just trying to define things, I think a reasonable definition that the country s sort of coming to for minimally invasive surgery is there s two types of different minimally invasive surgeries. One is a limited incision. The other is more of a muscle sparing, so I think this procedure you re watching today is truly a minimally invasive muscle sparing type of approach. The other approaches are muscle sparing mini-incision posterolateral, miniincision anterolateral, and then the direct anterior. I think those are probably the four most popular minimally invasive hip surgeries being performed today. On the second question, I want to point out the word potential, as there have not been any truly prospective randomized studies, but certainly everybody talks and uses common sense, and I ve always thought that common sense is not so common. The bottom line is,

13 if we do less soft tissue dissection, if we release fewer muscles, the thought process is that maybe we can have an earlier return to function and maybe we can have less pain in the early postoperative period. I think not only this technique but others, we still have to prove that in very well controlled prospective studies, but anecdotally, there s numerous reports in the literature, as well as other comments. I think the potential risks of this procedure, would you agree with this, Dr. Nessler, they re no different than a regular standard total hip replacement, potential nerve damage, vascular damage, malposition, fracture. Would you agree? Correct. At least on my data, we re gathering it now. We have 231 patients to date and I m not seeing, at least in my hands, with this technique, any different complication rate. We do know, at least in terms of some things that have been talked about in the literature with other techniques, dislocation rate and things like that, it actually seems to be quite low here. As I said before, we have had none out of 231 and no deep infections either, which was another concern. People who were skeptics would always mention that as a potential. The other comment, I think you re a little bit of an exception to the rule, is it true you basically do this procedure on all comers? And your heaviest patient is 380 pounds? Right. Probably about 95 or so percent of the patients that I see are candidates for this, unless they have some type of deformity. I had one patient earlier this morning that had some significant femoral and acetabular deformity that I did not feel was a candidate for this, so that s one of the few single incisions that I ll do. This has now become my preferred method of replacement. Let s comment about the learning curve. While we re mentioning that, this is a good time to talk about it. I was at the office meeting last week, two weeks ago, whenever it was, November 3, 4, 5, but anyway, it was apparent to me that I think most people agreed in the audience that the learning curve for this two-incision technique may be as high as 40 hips. Can you comment on what you think? Well, I think it s going to depend. Each surgeon s going to have to decide what they re comfortable with and I think it s going to be dependent on technique, so I think when they re talking about it, they obviously weren t talking about this technique. They were talking about some of the variations of the two incisions, but one of the things I was

14 hoping with this technique is that we re actually going to be able to, because we haven t changed the patient s position and other things, that we re able to get this down to a more reasonable learning curve. So you think the reason the learning curve may be less with this technique is because you don t have to get used to x-rays or fluoro, different patient position? Yeah, I think because we don t have to use x-ray or fluoro and the fact that we re using a stem, at least on the femoral side, that I think is easier to insert and put in through this approach, I think a combination of the patient positioning, the technique, incision placement, and the prosthetic choice makes this something that can be a little easier and more reproducible, I think, at an earlier stage. I have to just, as a different train of thought or whatever, I will tell you that I think it might not be 40 but I think it s more than 2 or 3. I think it s something that s not going to be a cookbook approach. Not everybody can drive a race car 240 miles an hour around the Indy 500 track. It s just that simple. So I think everybody needs to do the appropriate cadaver training, whatever appropriate means. I think people need to scrub in to a live operation that they re not doing and assist and then they have to look in the mirror and see what their comfort level is and they have to be able to look at their patient and to be honest with their patient as far as what their experience is, so I think those are valid points. I think the people that have had the best experience are people that have been able to scrub in, have surgical assisting experience, and then also do cadaver work as well. What we have on here now, Frank, we re close to the last reamer and we ve put the navigation. We ve determined the frontal plane of the pelvis preoperatively and now you can see, we can real time decide where we re reaming, you know, pick out. I usually like to pick between 40 and 45 o of inclination. The anteversion is not going to be cookbook. This is just another tool. I have to go based on the patient s anatomy. I think the patient s anatomy looks good right about here. That will point me to about 22 o of anteversion. You know, I m usually between 15 and 30, o most of the time. I like that. So we know we ve been reaming in the right direction. Now we re just going to go ahead and do our final reaming and place our cup. We ll confirm our position when we do our final placement of our cup.

15 So the main point is that you re doing the procedure as you normally would, using all of your appropriate visual cues of the patient s own anatomy after you removed all the osteophytes, putting the reamer in there about the way it should go and the way that you ve always done it, and then verifying it with the navigation and hoping that they re close. Correct. If they re way off, you ve got to determine what s wrong. Is there something wrong with your navigation? Has a pin moved or shifted? Are you disoriented with the anatomy? I like that and I think we re pretty well down to medial wall. He s got a fairly shallow acetabulum. He had a little dysplastic process going on. Now, I m using the trident PSL, which is actually 1.8 mm oversized, so in hard bone on a young guy like this, I ll often ream up another mm, at least the periphery. I just want to make sure everybody understands that. So basically, if you re going to put in a 56 mm trident PSL socket, you ream up to 57 and put the 56 socket in and you re still interference fitting 0.8 mm, is that correct? Right. I had a patient this morning with pretty soft bone, so on a 54, I just reamed to 54 and the bone was soft enough to accept that almost 2 mm press fit. I actually have gone the other way. I actually over-ream everybody, soft or hard, and even in the soft bone, that interference fit of 0.8 is still adequate for the socket to seat, whereas when I did not do it and I thought the bone was soft and it turned out not to be too soft, my socket would hang up and I d be too far lateral, so I over-ream everybody. I think for the majority of patients, I do the same thing. Yu can see here, we re kind of holding up on a little soft tissue. So now we have the acetabulum reamed. On the helmet cam now, you can look. We can see this entire rim of the acetabulum. Here s inferior, posterior acetabulum, superior, anterior. I ll still get some of that soft tissue out of the way. Then anteroinferior. That medial wall, we haven t penetrated. We ve got good bleeding bone, so I think that s a good acetabular preparation. I m going to clean up a little more soft tissue.

16 So you don t even put a retractor over the anterior wall at all. No. This one right here is right over the anterior lip, this one right in the front of the patient that I m pointing to with my cautery right now. Is that anteroinferior? That s anteroinferior. I don t put up anything high, just those two retractors. Sometimes I ll take them out and only go with one and a hand-held. I ll irrigate that out with a little saline, then what I do here, I like to put this on by hand. You see we have a little impaction bolt in here. This is your final socket. This is my final socket. It s an arc deposit. It s got hydroxyappetite, so bone grows in on it and attaches to it, very successful socket. I ll slide it in. Again, concerns of some people dragging bacteria in off the skin. We make sure we can slide it in without dragging anything off the skin, making sure there s no muscle behind it, no soft tissue behind it. Once I get it in position, I use the curved handle. Basically this acts as a Tommy bar to grab that bolt and then I move the cup into position. Now that I ve got it moved into position, to be able to navigate it accurately, because this is not attached solidly, I take out this bolt and I will screw in our navigation handle, so I ll take this out. Now, if you were not using navigation, you could go ahead and drop the socket in with that curved handle. Right. So now I m going to attach my straight navigated...and I ll screw this into the dome hole. You can see I ve got the incision shortened inferiorly, so it s tough to go straight in with this, but once I have it down there, I don t have to fight the soft tissues. Now I m going to get it into position about where I think I want to have it and then I m going to put the navigation on.

17 Now, if you had a heavy patient and you couldn t get down to the appropriate abduction, you would just extend your skin incision a couple of cm? Correct. Okay, now we re going to look at this. Show the live screen up top, the computer screen. Now we have the live screen. That s showing the position I have it, so I want to bring that inclination down. I like to keep less than 45 in there, about 25-30, so that looks clinically like good position. The readings there look good, so we re going to just hold onto those tractors so they don t recline off when I hit them. Okay, we ll put them on again just to make sure we haven t moved. It varies a few degrees, but we re going to want to go now and completely seat this. We re still up a bit. Okay, let me see if we re down. On good hard bone like this, you ve got to pound pretty hard sometimes to get that cup seated. And you over-reamed a millimeter. And I over-reamed a millimeter. Now our position there is pretty good. I maybe might want to bring it up to 40 or so. I was just at New England Baptist. Those guys, Berenbaum was talking about liking and accepting around 30 o abduction. I think that s maybe a little more than I usually take, but he likes o and certainly I agree that s better than getting up at 55 o. What do you like, Frank? I like between 40 and 45 and I like 20-25, but again, I think it really depends on the patient s anatomy, but given your choices of going toward 50 or toward 30, I think going toward 30 would be better. I think we ve got what you like here, 41 inclination, 22 anteversion. That looks good with the anatomy. If you look on my helmet cam again, can you see the sucker tip there? It s right in one of the screw holes and we re down on bone, so we re fully seated here.

18 We re completely down, so I like that. We re going to accept that and we re going to record that position now, so now we re done with navigation until we check the leg length and offset, so that s a nice tool to kind of give you more assurance that what you re looking at with the anatomy is right. With this, in doing the two-incision, you re moving the patient around a lot. That pelvis moves. If I were to just look at the table and the floor and the room for landmarks, I would think I m retroverted, when I m really 20- some degrees of anteversion. I think that s an important point because I think without navigation, using this technique, the tendency is to over-antevert the sockets. Yeah, so you have to be very conscious of looking at your anatomical landmarks with this and making sure. I can t tell you how many times I thought it was 20 and it s 35 of anteversion. It really does throw you off. I m a guy who always puts screws in. How about you, Frank? That rim-loaded socket? You don t need any screws. You re just spending money and wasting time. My rep likes me for it, though. While you re putting that screw in, basically this guy s 58, he s very active, as we had talked about, and doesn t sit around a lot. Who do you choose to put these ceramic on ceramic bearings in, which is what we re using today? I don t think the whole answer is in. I think the ceramic on ceramic is going to be the thing to use and on people that are lower demand and older that I know something like

19 ceramic on a cross-linked plastic or metal on cross-linked plastic is more than likely going to last their entire life, I don t want to take a chance with some of the newer technologies, but a young active guy, a big guy like this that s going to put a lot of demands on the hip, I think the potential added benefit of having a bearing surface that wears so little, you know, kind of offsets any potential unknowns that we have we these surfaces. I would agree. I use ceramics in the younger, active patients as well. The key word is younger and who knows what younger means. I mean, there s 56-year-olds that don t do anything and there s 56-year-olds that play doubles tennis. One s active and one s not, so it s more of activity level, I would agree, and it appears...and I hate to start mentioning people that were in on the ceramic on ceramic study because there were a lot of them and I ll miss a few, but I often talk to Dr. Cappello and Dr. D Antonio and it appears that we don t have the femoral head fracture problem that we had with the ceramic years ago, before they went away, so it looks like the science may have finally caught up and we re able to put these in younger, active people without the significant risk of head fracture. The preoperative x-rays showed a big inferior osteophyte. Again, one of the things people say if you re doing these muscle-sparing approaches is that you can t do a normal hip replacement. Here we re going ahead and we re taking all that inferior osteophyte, so we re not compromising any of the normal arthroplasty principles that we ve been doing for years and years with standard approaches. That s what I like about this. If we can do this and we don t have to compromise our principles that we ve been practicing, we should be okay, so I m just taking out all that osteophyte, which is going to limit motion potentially. For the lay watchers out there, osteophytes are just big bone spurs and that s just a big bone spur that came, if you look at my helmet cam, it came back from the inferior or undersurface of the patient s hip joint, so those are things that limit motion. I want to mention a few more things. We ve got 17 or 20 minutes left of live feed, so I think there s probably got to be some people out there just dying to ask a few of these questions. Let me first off, on the slide I have up, let s talk about the Accolade stem. The reason I want to talk about it is because do you find it easier to go through the gluteus muscle to get into the femur when you re only using a rasp rather than having to also ream the femoral canal? Absolutely. We ll see that in a second here. The femoral preparation usually doesn t take very long, so we should be able to get that entire femoral preparation in and we re going

20 to put the insert in now. We ve taken the extra time to clear all the soft tissues, so this is the ceramic, if we look at my helmet cam, the ceramic bearing surface that we re going to place. It s metal encapsulated. It takes care of some chipping problems that might have occurred in the early phases of development of these ceramic sockets, so what we re going to do now is... So basically with this technique, on the femoral side, we try not to use cement. We don t really recommend that. We recommend potentially going to an implant that minimizes femoral preparation. We do not believe that you have to go with an extremely coated implant. Correct. The other thing is a lot of the technique talk about having to use high walled or elevated rim liners instead of nutraliners. I like nutraliners. I think if you have to use anything else, you re compromising your implant position. With this, I have never used an elevated rim liner. I ve always used 0 o. I would agree with that. I think when you re finished, you ought to be able to look at the x-ray and not know what surgical approach you used to put the implant in. We re just looking now to make sure we ve got all of the capsule out of the way. At this point we externally rotate the leg. There s a little capsular attachment that was at the base of the neck that s still holding up here. I want you to show us on your head cam the femoral neck through that anterior incision. The reason I want you to is because I ve had the opportunity to crack three femoral necks, just that little red line, and you can actually look through the anterior incision and see the femoral neck. Through the anterior incision, you can put a cable around the proximal femur and then go ahead and broach and drive your stem in through the posterior incision and it works fine. Right. Typically you don t even, if you do that, you don t have to extend your incision, even, so this is the entire Calcar proximal femur trochanter over here, so you can see everything. If you need to, like the patient I had this morning, she was rheumatoid arthritis, steroid-dependent, those that are very osteopenic, oftentimes even with standard

21 approaches, I would place a prophylactic Dahlmile cable or wire and I certainly still do that with this approach as well. I ll make a comment about that. Dr. Nessler said that 95-99% of his patients he does this technique on. I have to tell you, I still chicken out and pick the lower body mass indexes, which you can t find very often in Indiana, and I also like to see Type A or B Larry Doerr femoral bone stock because I don t like the osteopenic femur for this approach, and I do not prophylactically Dahlmile the femur, but I have had the occasion to put three on there, simply because of the intraoperative crack that I really would not have been able to see on plain x-ray or fluoro because it s that little bitty red line. So what we do now, with the legs in a figure-4, which is another advantage of this lateral approach, what I m doing is I m taking a guide wire just to go into the proximal femur. I m doing that so I know where my incision s going to be and I tell people it s triangulation. It s basically a brain stem function. If you can put your fingers together, you can even close your eyes and put your hands underneath the table and you can bring your fingers together, so if you can do that from the posterior aspect of the wound and anteriorly, the one inside the anterior wound is at the tip of the trochanter, so you re just aiming for that. You can hit that about 95% of the time and I told one of the guys from New Jersey the other day, one of the engineers, you know Stu Atcheson, don t you, Frank? Yeah. I told him even engineers could probably hit the tips of their fingers together about 50% of the time. So they could even pass the field sobriety test. That s not bad. So all I do is open up the skin and subcu. I don t go into the muscle. I take a T-handled awl. I m using this so I can puncture the capsule and tendon right at the tip of the trochanter and basically what we re doing is going in right at the posterior edge, kind of percutaneously going through the gluteus maximus and the gluteus medius. The minimus is usually anterior to this and we did a nice cadaver dissection showing that, showing the

22 completely preserved piriformis, external rotators, gluteus medius, and just kind of a hair of a percutaneous puncture through the gluteus medius on a dissection we did out in Boston last week after they had presented some unpublished data from Mayo showing cadaver studies showing a lot of muscle damage with the two-incision approach, but you ve got to remember that s a different two-incision approach with a different patient position and a different implant design altogether than this one, so that s something we re probably going to be hearing more about this next year. We ve just got to realize that all of these approaches aren t the same. I think there s a lot of variables and I think it s like, you know, there s too many balls up in the air. I think it s going to take a little bit more time for some of the dust to settle, so to speak. Just as a comment here, while you re putting that in, I oftentimes, see you re doing the left hip and you re left-handed, but for the right-handed people, I ve got my right hand on that drill and I ve got my left hand in the anterior incision, like you do. You ve got your right hand in the anterior incision and you re feeling with your fingertip that go directly into the femoral canal and you can even look up front to see it go in. You re saying you have a preference on the side that you do that, Frank? No. I thought you were trying to tell me that only lefties should do this surgery. No, no. So what I m doing is I take a lateralizer from our old cemented sets to lateralize the femur, since we don t have direct visualization with a box chisel or cookie cutter, like we would normally. I ll use these one piece broaches. This is a custom. Let me interrupt you. I want to go back to that lateralizer. I want to put an exclamation mark behind what you said. You have to use the lateralizer or you will not get that cortical femoral neck bone away from the medial side of the greater trochanter. It will

23 kick you in the varus and you will break the femur. That has nothing to do with this technique. You can do it filleted open however you want. If you don t get that bone... So we re just broaching now, Frank, and we re going to go up. These are some custom one-piece broaches. They re straight broaches that you need to use for this. You can t use your standard curved broaches. We ll show those in a second, when we do our trial reduction. (no audio from Dr. Kolisek here) We re going to do that here since we re ceramic on ceramic. This is one I still do a trial, so I use those one-piece just to broach. If I m going to do a trial, then my last one I ll put in. I ll use the modular handle. They have the standard. This is an extra long one that s built for navigation as well. We re not navigating the femoral component on this, so I m going to put this in and Jerry is always feeling anteriorly to make sure that we re down and he says we are. He ll feel it and we re going to look at it right now. (no audio) We re going to irrigate. Then after we get this in here, we ll switch to my helmet cam and we ll be able to see the broach in the proximal femur. Okay, you can go to my helmet cam. You can see that broach. We can see the entire Calcar. We don t see any fractures. We re going to go ahead and put a trial head and neck on. This is always fun, so if you want to watch me struggle, you can go to the wide shot. What about tricks for putting the trial neck on? Remove the bolster from beneath the leg so it s adducted. Externally rotate. Yes. I use a little neck grabber...

24 Little bit of longitudinal traction? Yup, then a couple of prayers down here too. A couple of hail Marys and we ve got it. So basically what Dr. Nessler is doing right now is he has the neck trial forcep around the neck trial. He has the trial femoral head on the neck trial and he s going to attach those to the Accolade broach that s within the femoral canal and then he will longitudinally pull on the leg and internally rotate and reduce the hip in order to do a trial reduction to get a stable intraoperative range of motion test and then he ll coordinate this with the offset in leg length, based on the Stryker navigation system. Is that what you re doing? That s right. I just want to make sure I m in the right ball park before I put the real stem in. So in other words, if you think your standard neck length is working well with the 0 ball on your trial reduction, then you re comfortable going straight to your stem because if you have to be +4 or -4, you re fine. Exactly. So we re going to get this down here. I think we may actually be down. Let s go ahead and pop it in. We re in. Believe it or not, we actually got that trial neck on. It s a little snug. He was extremely stiff ahead of time, but what you ll see all the time, since you haven t disrupted this muscular envelope, you can take them to hyperabduction, external rotation, hyperextension, and they will not dislocate. These are very, very stable. I do not have any dislocations either and I do not use any abduction pillows or anything, just let them get up and start walking. Can you talk about your post-op rehab briefly, while you re checking this? Postoperatively, we get them up out of bed tonight, let them move around the room as tolerated. Most of them are to a cane by tomorrow. Some of the older, more debilitated patients may take a week or so, but most people by 2 weeks are getting off the cane

25 completely. Some of them get off the cane within the first 4-5 days. That may be a little quick. Do you pretty much just let them go at their own pace and whatever happens happens? Absolutely. This tells me we re 3 mm short and 2 mm medialized, so this is good. I m going to put this real stem in and probably put a 0 on and I m going to get him right dead on, probably within 1 mm of where he was before the surgery. So you would agree, if you got a stable intraoperative range of motion and did not overlengthen the leg, then you re fine? Correct. I would agree. 3 mm short is wonderful. That was with a -4, so we re going to put a 0 on, so we re going to probably be within 1 mm of his virgin length. I m going to put this handle back on and snap it on. Look at that, Frank. Every time you put that together, it goes together right away, right? Right. A little irrigation and we re ready to put the stem in and then we re basically ready to close. Now make a comment about putting the real femoral stem in. What I m referring to, as you know, is now you ve got a neck on the prosthesis that has to go through some of the fascial layers to get down. Tell us how you handle that.

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