The Zimmer® MIS™ Anterolateral Hip Procedure A Muscle-Sparing Approach to THA

1. The Zimmer� MIS� Anterolateral Hip ProcedureA Muscle-Sparing Approach to THA Opening slide � stress the �muscle sparing� part.Opening slide � stress the �muscle sparing� part.

2. Objectives Discuss the history of minimally invasive surgery in terms of evolution, definitions, approaches, and classification schemes Identify the unique characteristics of the Zimmer MIS Anterolateral THA procedure Discuss in detail the stages and key elements of the Zimmer MIS Anterolateral THA surgical procedure Define the Five Acts of leg positioning and describe how they relate to the various stages of the surgical procedure Review the objectives for the course in order to set expectations for the participants. Ask the participants if they have any questions on the objectives.Review the objectives for the course in order to set expectations for the participants. Ask the participants if they have any questions on the objectives.

3. Objectives (cont.) Discuss clinical data obtained from procedure to date Define the advantages and disadvantages of the Zimmer MIS Anterolateral THA procedure as they relate to THA in general Identify and discuss key concerns in the overall continuum of care related to the Zimmer MIS Anterolateral THA procedure Objectives continued. Ask for questions.Objectives continued. Ask for questions.

4. Minimally Invasive Surgery: History, Evolution, Definitions, and Approaches This section will discuss the history of minimally invasive surgery as it relates to medical advances as well as to THA.This section will discuss the history of minimally invasive surgery as it relates to medical advances as well as to THA.

5. Minimally Invasive Surgery:Evolution in THA Procedures Maximally invasive 60s/70s Moderately invasive 80s/90s Minimally invasive Turn of the century Advent of modern THA in 60s/70s with large incisions � better view with larger incision. Time has shown a decrease not only in the size of incision, but in the trauma to soft tissue. Transition to next slide is from history to evolution throughout medicine.Advent of modern THA in 60s/70s with large incisions � better view with larger incision. Time has shown a decrease not only in the size of incision, but in the trauma to soft tissue. Transition to next slide is from history to evolution throughout medicine.

6. Maximally Invasive Surgery Typically Provides: Wide Exposure Neurovascular protection Confident implant placement Straightforward � benefits of traditional approach to total joint arthroplasty.Straightforward � benefits of traditional approach to total joint arthroplasty.

7. What is the Minimally Invasive THA? Length of Incision? Length of capsule incision. Amount of muscle trauma! Amount of bone loss! Content here is more rhetorical. Meant to stimulate thought process as to why a surgeon would want to venture into minimally invasive procedures. Can ask participants what they think to generate early discussion in session. Key point: length of incision is not important�lack of tissue trauma is. Too small of an incision can actually result in more tissue trauma.Content here is more rhetorical. Meant to stimulate thought process as to why a surgeon would want to venture into minimally invasive procedures. Can ask participants what they think to generate early discussion in session. Key point: length of incision is not important�lack of tissue trauma is. Too small of an incision can actually result in more tissue trauma.

8. Minimally Invasive THA Classification Eponymous Modified Watson Jones Modified Smith Peterson Modified Moore Keggi/Mears/R�ttinger �does not connote much meaning Historically, the various approaches have been classified by the inventor�s name. This does not necessarily provide for a concise, systematic method of determining what is occurring surgically.Historically, the various approaches have been classified by the inventor�s name. This does not necessarily provide for a concise, systematic method of determining what is occurring surgically.

9. Minimally Invasive THA Classification Proposal Direction Number of incisions Method of deep dissection A better way to classify the various THA approaches is by these categories. Briefly cover each of these characteristics Let participants know you will cover each of these in detail on subsequent slides.A better way to classify the various THA approaches is by these categories. Briefly cover each of these characteristics Let participants know you will cover each of these in detail on subsequent slides.

10. Minimally Invasive THA Classification Direction is the key Gluteus Medius is the signpost Anterior Anterolateral Lateral Posterior Glut Med represents a dividing point between anterior and posterior minimally invasive surgery approaches. Anterior approaches are anterior to medius, posterior behind, and lateral through the medius. Transition to next slide on number of incisions.Glut Med represents a dividing point between anterior and posterior minimally invasive surgery approaches. Anterior approaches are anterior to medius, posterior behind, and lateral through the medius. Transition to next slide on number of incisions.

11. Minimally Invasive THA Classification Number of incisions Single Incision � acetabular/femoral preparation through one incision Two incisions � acetabular preparation through anterior incision and femur preparation through posterior incision In addition to approach direction, minimally invasive THA procedures can be further classified by number of incisions. Cover each of these briefly. Key message is difference between single and dual-incision approaches. Literature has even defined a three-incision approach (Keggi).In addition to approach direction, minimally invasive THA procedures can be further classified by number of incisions. Cover each of these briefly. Key message is difference between single and dual-incision approaches. Literature has even defined a three-incision approach (Keggi).

12. Minimally Invasive Surgery THA Method of Deep Dissection is key Do you divide or go between the muscles and tendons? Traditional � Cut Mini Anterolateral � Cut less MIS Anterolateral � Spare Spare: to refrain from doing harm Merriam Webster�s Dictionary Traditional and mini Direct lateral/Anterolateral procedures divide or split muscles, while others spare by going around the entire muscle. Key: Anterolateral is a muscle-sparing approach.Traditional and mini Direct lateral/Anterolateral procedures divide or split muscles, while others spare by going around the entire muscle. Key: Anterolateral is a muscle-sparing approach.

13. Minimally Invasive THA Classification Method of Deep Dissection Anterior - Muscle Sparing Anterolateral - Muscle Sparing Lateral - Muscle Cutting Posterior - Muscle Cutting Two-incision - Muscle Sparing To further expand upon this notion, here is a breakdown of muscle-splitting vs. muscle-sparing. Any questions? To further expand upon this notion, here is a breakdown of muscle-splitting vs. muscle-sparing. Any questions?

14. Introduction to the Zimmer MIS Anterolateral THA Procedure Transition slide to preface surgical technique section. Covers Transition slide to preface surgical technique section. Covers

15. The MIS Anterolateral Approach A single incision Muscle sparing approach to the hip Interval between the anterior border of the gluteus medius and the posterior border of tensor fascia lata. Minimally invasive modification conceived by Heinz R�ttinger, M.D. from the Orthop�dische Chirurgie M�nchen (O.C.M.) Munich, Germany in 2003 Cover key bullet points. Identify appropriate location of interval. We�ll discuss how to identify this interval when we get to the surgical technique portion of the program.Cover key bullet points. Identify appropriate location of interval. We�ll discuss how to identify this interval when we get to the surgical technique portion of the program.

16. The MIS Anterolateral Approach � Overview Features and benefits the AL procedure. Precursor to the surgical procedure � each of these will be covered in greater detail. (This slide is not meant as a comparison to other procedures)Features and benefits the AL procedure. Precursor to the surgical procedure � each of these will be covered in greater detail. (This slide is not meant as a comparison to other procedures)

17. The MIS Anterolateral Approach � Overview (cont.) Continuation of previous slide�s material. (Again, no comparison to other procedures). Reinforces advantages of AL approach.Continuation of previous slide�s material. (Again, no comparison to other procedures). Reinforces advantages of AL approach.

18. The MIS Anterolateral Key Principles Before delving into the full surgical technique, it is important to understand the three key principles of the AL approach that help lead to success. Each of these will be covered in detail on subsequent slides. This is more of a transition slide into the full surgical procedure section. Before delving into the full surgical technique, it is important to understand the three key principles of the AL approach that help lead to success. Each of these will be covered in detail on subsequent slides. This is more of a transition slide into the full surgical procedure section.

19. MIS Anterolateral Procedure The Five Leg Positions Skin and Capsular Incisions/Closure Transcapital Neck Cut Definitive Neck Cut Acetabulum Femur Procedure�s success is predicated on leg position. These five acts of leg positioning represent the crucial aspects of the procedure. We cannot overemphasize the importance of this concept. Cover each and state you will go into detail on following slides. We will review these in greater detail after you have been exposed to the individual steps of the surgical procedure.Procedure�s success is predicated on leg position. These five acts of leg positioning represent the crucial aspects of the procedure. We cannot overemphasize the importance of this concept. Cover each and state you will go into detail on following slides. We will review these in greater detail after you have been exposed to the individual steps of the surgical procedure.

20. Importance of leg position. Assistant can work with you or against you.Importance of leg position. Assistant can work with you or against you.

21. Surgical Technique for the Zimmer MIS Anterolateral THA Procedure 1. Transition slide.1. Transition slide.

22. The MIS Anterolateral Surgical Considerations Discuss the content here as the main components of the surgical procedure. You can read them for yourselves, but each of these is a different aspect of the procedure.Discuss the content here as the main components of the surgical procedure. You can read them for yourselves, but each of these is a different aspect of the procedure.

23. Templating Measure down from the �Saddle� Other anatomical references Lesser trochanter can usually be palpated for cross reference Key: saddle � dependable and repeatable landmark.Key: saddle � dependable and repeatable landmark.

24. Surgical Technique Table set up Trumpf Jupiter table or Maquet Skytron table attachments Local custom modification Must be able to drop the leg off of the table for femoral preparation. These are suggested table types/modifications. Others may exist.Must be able to drop the leg off of the table for femoral preparation. These are suggested table types/modifications. Others may exist.

25. Patient and Table Preparation Patient in direct lateral position Securely held on table Leg support modified to allow posterior leg positioning Surgeon works on anterior side Surgeon on anterior aspect of patient could be new for many surgeons. Slight adjustment period as a result. Discuss with participants that it is not an overwhelming adjustment. (Add your own anecdotal experiences and learning curve before you were comfortable � i.e., how many cases.)Surgeon on anterior aspect of patient could be new for many surgeons. Slight adjustment period as a result. Discuss with participants that it is not an overwhelming adjustment. (Add your own anecdotal experiences and learning curve before you were comfortable � i.e., how many cases.)

26. Draping Drape can become unstable Sterile bag Something to be aware of. Bag concept may be new to participants.Something to be aware of. Bag concept may be new to participants.

27. Team Positioning Surgeon Anterior 1st Assistant Distal/Posterior 2nd Assistant Posterior Recommend two assistants for early cases especially. Learning curve and skilled assistants may allow for one only. First assistant is key as they will be manipulating leg position. Assistants don�t need to see what�s occurring with AL procedure. Educate assistants to avoid excessive retraction. Assistant can work with you, or against you, especially with leg positioning.Recommend two assistants for early cases especially. Learning curve and skilled assistants may allow for one only. First assistant is key as they will be manipulating leg position. Assistants don�t need to see what�s occurring with AL procedure. Educate assistants to avoid excessive retraction. Assistant can work with you, or against you, especially with leg positioning.

28. Skin Incision and Intermuscular Interval We covered this briefly in an earlier slide. Transition to following slide � refreshes learner�s memory on incision and interval. We covered this briefly in an earlier slide. Transition to following slide � refreshes learner�s memory on incision and interval.

29. Skin Incision Identify greater trochanter and anterior superior iliac crest Extend incision from anterosuperior aspect of greater trochanter about 8cm to a point 2-4cm posterior to the ASIS Discuss actual technique of identifying the interval and incision site. Cover these aspects on the picture. Tendency is to go distally with incision, which creates difficulty in locating interval and you end up going through the medius. Extend incision over greater trochanter if desired � affords better exposure without disrupting underlying tissues.Discuss actual technique of identifying the interval and incision site. Cover these aspects on the picture. Tendency is to go distally with incision, which creates difficulty in locating interval and you end up going through the medius. Extend incision over greater trochanter if desired � affords better exposure without disrupting underlying tissues.

30. The Interval 1. Reinforces previous slides with a look at the deeper structures.1. Reinforces previous slides with a look at the deeper structures.

31. The Interval Locate the anterior-superior of the greater trochanter. There will commonly be a slight divergence of the gluteus medius and the tensor fascia lata in this region. This is where you insert your finger/thumb to identify the intermuscular plane and separate the two muscles. Note the leg position of neutral to slight abduction to relax the gluteus medius.Locate the anterior-superior of the greater trochanter. There will commonly be a slight divergence of the gluteus medius and the tensor fascia lata in this region. This is where you insert your finger/thumb to identify the intermuscular plane and separate the two muscles. Note the leg position of neutral to slight abduction to relax the gluteus medius.

32. Capsular Exposure The Instruments Retractors numbered for ease of use Optimized radius to be gentle to muscle Retractors are specifically designed to minimize soft tissue trauma and maximize exposure. Remember that excessive retraction can lead to decreased visibility and potential tissue damage.Retractors are specifically designed to minimize soft tissue trauma and maximize exposure. Remember that excessive retraction can lead to decreased visibility and potential tissue damage.

33. The Interval Simple representation of the retractor positions.Simple representation of the retractor positions.

34. Capsulotomy A �Z� shaped capsular incision with two flaps is created Slight internal hip rotation Neutral to slight hip abduction Ability to extend lateral capsular incision can be critical to obtaining adequate femoral exposure T or H shaped capsular incisions are certainly viable options Key is obviously ability to extend lateral capsular incision so that you can adequately expose the femur.Key is obviously ability to extend lateral capsular incision so that you can adequately expose the femur.

36. Femoral Neck Exposure Retractors are replaced inside the capsule Retractor 1 is placed inferiorly, under the femoral neck. Retractor 3 is placed superiorly, under the femoral neck. Clears the capsule and soft tissue from the field of view. Retractor 1 is placed inferiorly, under the femoral neck. Retractor 3 is placed superiorly, under the femoral neck. Clears the capsule and soft tissue from the field of view.

37. Referencing The �Saddle� Other anatomical references Lesser trochanter can usually be palpated for cross reference Referencing slide. Double-checking pre-operative templating. Ensures neck cuts will be accurate. Speak to what you are using in particular as facilitator. Key: saddle � dependable and repeatable landmark. Use sawbones to illustrate. Lesser trochanter accessed by placing leg in �figure-of-4� position.Referencing slide. Double-checking pre-operative templating. Ensures neck cuts will be accurate. Speak to what you are using in particular as facilitator. Key: saddle � dependable and repeatable landmark. Use sawbones to illustrate. Lesser trochanter accessed by placing leg in �figure-of-4� position.

38. First Neck Osteotomy Femoral head and neck are taken out in two pieces First �neck� cut is in articular portion of femoral head Direct blade inferior Externally rotate maximally to approximately 60? or to allowable range of motion Key: proximal neck cut needs to be into articular portion of the head - near the equator. Inferior blade direction helps avoid cutting into the posterior acetabulum. Note leg position.Key: proximal neck cut needs to be into articular portion of the head - near the equator. Inferior blade direction helps avoid cutting into the posterior acetabulum. Note leg position.

39. Neck-Head Disassociation Place Cobb elevator in the first neck cut Move leg into extension and external rotation and lever with Cobb elevator to disassociate femoral neck from residual head and deliver neck into incision Neck will now be parallel to the floor Leg position is transitioning during this step. Key: be sure that proximal neck cut is complete before attempting to disassociate the head from the neck; otherwise, you risk longitudinal fracture of the neck.Leg position is transitioning during this step. Key: be sure that proximal neck cut is complete before attempting to disassociate the head from the neck; otherwise, you risk longitudinal fracture of the neck.

40. Definitive Femoral Neck Cut(s) Hip and leg are rotated 90? externally with thigh parallel to the floor Slight hip flexion may help and saw must be adjusted accordingly Retractors placed more distal on neck Osteotomy - Identify references Oblique portion based on preoperative plan for angle and position Horizontal portion medial to trochanter Key: femur should be horizontal to the floor. Move retractors distally from previous cut positions. Note: osteotomy references. Note: Make the vertical cut 1st � to avoid migrating into greater trochanter with angled cut. Key: femur should be horizontal to the floor. Move retractors distally from previous cut positions. Note: osteotomy references. Note: Make the vertical cut 1st � to avoid migrating into greater trochanter with angled cut.

41. Femoral Head Removal Proximal positioned first osteotomy facilitates easier removal Reinforce equator cut with first osteotomy facilitates head removal. Different methods to extract head (e.g., clamp, Steinmann pin, etc.). External rotation of the femur moves it out of the field of vision for easier removal of head.Reinforce equator cut with first osteotomy facilitates head removal. Different methods to extract head (e.g., clamp, Steinmann pin, etc.). External rotation of the femur moves it out of the field of vision for easier removal of head.

42. Initial neck cut near the equator of the femoral head. Dissociation of the head from the neck with an osteotome. Note the leg position with the hip in external rotation. The definitive neck cut is made. The neck piece is removed. The remaining femoral head piece is then removed.Initial neck cut near the equator of the femoral head. Dissociation of the head from the neck with an osteotome. Note the leg position with the hip in external rotation. The definitive neck cut is made. The neck piece is removed. The remaining femoral head piece is then removed.

43. Acetabular Exposure The Instruments Retractors

44. Acetabular Exposure Note placement of retractors on outside of acetabulum in anterior and posterior positions.Note placement of retractors on outside of acetabulum in anterior and posterior positions.

45. Acetabular Preparation The Instruments Offset reamer handle, low profile reamers and offset cup positioner Show instruments to class. Ask for questions. Offset reamer handle is not required. Do not exclusively rely on alignment frame for cup position � potential to over-antevert the cup with this procedure, especially for surgeons accustomed to posterior approaches.Show instruments to class. Ask for questions. Offset reamer handle is not required. Do not exclusively rely on alignment frame for cup position � potential to over-antevert the cup with this procedure, especially for surgeons accustomed to posterior approaches.

46. Acetabular Preparation Note the straight reamer handle � straight or offset can be used. Offset recommended for obese patients to maintain alignment. Leg still in external rotation.Note the straight reamer handle � straight or offset can be used. Offset recommended for obese patients to maintain alignment. Leg still in external rotation.

47. Acetabular Preparation Again, don�t strictly rely on alignment frame due to potential over-anteversion. There is a general tendency based on the view to underestimate anteversion. Use pelvic sawbones model to demonstrate anteversion issues. We�ll cover this in greater detail in the lab session. Please ask if you have questions when performing the procedure.Again, don�t strictly rely on alignment frame due to potential over-anteversion. There is a general tendency based on the view to underestimate anteversion. Use pelvic sawbones model to demonstrate anteversion issues. We�ll cover this in greater detail in the lab session. Please ask if you have questions when performing the procedure.

48. Acetabular reaming (note the use of straight-handled reamer). Use of retractors to protect soft tissue when inserting and removing reamers. Reaming creates good bleeding bone. Additional soft tissue, labrum, and pulvinar are removed. The cup is inserted. The liner is inserted.Acetabular reaming (note the use of straight-handled reamer). Use of retractors to protect soft tissue when inserting and removing reamers. Reaming creates good bleeding bone. Additional soft tissue, labrum, and pulvinar are removed. The cup is inserted. The liner is inserted.

49. Femoral Exposure - Leg Position Foot and leg in a bag on the posterior table Deliver the proximal femur into the incision for instrumentation Moving on to femoral side. Leg position changes significantly to extension, adduction, and external rotation. Ability to achieve desired leg position will be dictated by capsule release (ties back to extending the lateral capsular incision). First assistant can straddle leg to maintain position and hold retractors if necessary.Moving on to femoral side. Leg position changes significantly to extension, adduction, and external rotation. Ability to achieve desired leg position will be dictated by capsule release (ties back to extending the lateral capsular incision). First assistant can straddle leg to maintain position and hold retractors if necessary.

50. Femoral Preparation The Instruments: Angled/offset rasp handles Demonstrate instruments and allow participants to examine. Instruments may depend on system preference. This is the key instrument in set � allows you to avoid proximal incision soft tissue damage and promotes correct rasp orientation. Inadvisable to attempt procedure without this instrument.Demonstrate instruments and allow participants to examine. Instruments may depend on system preference. This is the key instrument in set � allows you to avoid proximal incision soft tissue damage and promotes correct rasp orientation. Inadvisable to attempt procedure without this instrument.

51. Femoral Preparation Retractor placement Retractor 3 inferior and medial to cut femoral neck Elevates femur Retracts tensor & capsule Retractor 1 lateral to posterior, superior tip of greater trochanter Retracts abductors Cover retractor placement. Cover personal experiences with assuring adequate exposure. Note: anterior and lateral capsule remnants will impede complete visualization of femur. Insufficient capsular release increases risk of greater trochanteric fracture related to excessive retraction. Place dull bone hook in canal and lift to appreciate amount of femoral elevation then make capsular incision accordingly.Cover retractor placement. Cover personal experiences with assuring adequate exposure. Note: anterior and lateral capsule remnants will impede complete visualization of femur. Insufficient capsular release increases risk of greater trochanteric fracture related to excessive retraction. Place dull bone hook in canal and lift to appreciate amount of femoral elevation then make capsular incision accordingly.

52. 1. (need moderator notes).1. (need moderator notes).

53. 1. (Need moderator notes).1. (Need moderator notes).

54. Wound closure Adapting capsule suture Deep drain 6 � 24 hours Closure of fascia Subcutaneous suture Intracutaneous suture Use preferred closure methods. Add anecdotal information on your preferences.Use preferred closure methods. Add anecdotal information on your preferences.

55. Surgical Recap: The Five Acts of Leg Positioning 1. Transition slide.1. Transition slide.

56. MIS Anterolateral Procedure The Five Leg Positions Skin and Capsular Incisions/Closure Transcapital Neck Cut Definitive Neck Cut Acetabulum Femur Procedure�s success is predicated on leg position. These five acts of leg positioning represent the crucial aspects of the procedure. We cannot overemphasize the importance of this concept. Cover each and state you will go into detail on following slides. We will review these in greater detail after you have been exposed to the individual steps of the surgical procedure.Procedure�s success is predicated on leg position. These five acts of leg positioning represent the crucial aspects of the procedure. We cannot overemphasize the importance of this concept. Cover each and state you will go into detail on following slides. We will review these in greater detail after you have been exposed to the individual steps of the surgical procedure.

57. Importance of leg position. Assistant can work with you or against you.Importance of leg position. Assistant can work with you or against you.

58. Skin and Capsular Incision Assistant holds leg in neutral to slight hip abduction Relaxes abductors to achieve maximum exposure Mayo Stand Arm Elevator Mayo stand and arm elevator are utilized when only one assistant is available. Create discussion as to what the associated steps of the procedure are related to this leg position.Mayo stand and arm elevator are utilized when only one assistant is available. Create discussion as to what the associated steps of the procedure are related to this leg position.

59. Transcapital Neck Cut Assistant holds leg in neutral ab/adduction slight hip flexion external rotation that anatomy allows Foot in bag Relaxes iliopsoas Provides improved visualization of femoral neck Generate same discussion on associated steps of procedure. Patients with severe arthritis will have restricted external rotation.Generate same discussion on associated steps of procedure. Patients with severe arthritis will have restricted external rotation.

60. Definitive Neck Cut Assistant moves leg into 90? External Rotation Foot in bag Femur parallel to floor Tibia perpendicular to floor Positions femoral neck parallel to floor to visualize cut Generate same discussion on associated steps of procedure. Slight hip flexion may improve visualization here as it relaxes iliopsoas, HOWEVER, you will need to adjust saw angle accordingly.Generate same discussion on associated steps of procedure. Slight hip flexion may improve visualization here as it relaxes iliopsoas, HOWEVER, you will need to adjust saw angle accordingly.

61. Acetabulum Assistant moves leg into Full knee extension Slight external hip rotation Slight hip abduction and hip flexion can help insertion and extraction of reamers Generate same discussion on associated steps of procedure. Assistants do not need to visualize wound exposure.Generate same discussion on associated steps of procedure. Assistants do not need to visualize wound exposure.

62. Femur Assistant moves leg into 90? External Rotation 20? Extension 40 ? Adduction Foot in bag Tibia perpendicular to floor Elevates femur Generate same discussion on associated steps of procedure. Generate same discussion on associated steps of procedure.

63. Closure Assistant moves leg back to initial position Review your methods of closure.Review your methods of closure.

64. Clinical Data Associated With the Zimmer MIS Anterolateral THA Procedure Transition slide. Data included is based on experiences of Heinz Roettinger of Germany. Roettinger previously utilized posterior approach. Most early complications were related to implant selection and learning curve. Now typically uses CLS� stem and Trilogy� cup (primaries only). Also does revision THA with AL. Further North American data is being collected and should be available shortly.Transition slide. Data included is based on experiences of Heinz Roettinger of Germany. Roettinger previously utilized posterior approach. Most early complications were related to implant selection and learning curve. Now typically uses CLS� stem and Trilogy� cup (primaries only). Also does revision THA with AL. Further North American data is being collected and should be available shortly.

65. Clinical data 2 surgeons (03/03 � 2/05) >700 THA Bodyweight 74.5 kg (min. 43 kg, max. 134 kg) BMI 26 (maximum 42) Surgery time 46 minutes Retransfusion volume 302 ml (intraoperative to 6 hrs. postop.) Cover factually. Ask for questions. Add individual, anecdotal experiences as necessary.Cover factually. Ask for questions. Add individual, anecdotal experiences as necessary.

66. Clinical Experience � Early Results >700 patients Excellent early mobilization Decreased pain Excellent abductor function Excellent standard approach (also for revisions) Acceptable learning curve Review of clinical experiences seen so far with MIS Anterolateral THA.Review of clinical experiences seen so far with MIS Anterolateral THA.

67. Clinical Experience�Complications >700 patients 5 postop. periprothetic fractures Caused by a particular femoral component 6 greater trochanter fractures Asymptomatic 2 dislocations of the acetabular component 3 anterior dislocations Increased anteversion of acetabular component (2 revisions) Most of these complications are part of the development of the approach and can be avoided with current instrumentation and techniques. 6 greater trochanteric fractures likely due to insufficient capsular release. 2 dislocations of acetabular component � potentially linked to learning curve and use of screws to stabilize cup early in learning process. 3 anterior dislocations ties back to point that potential exists to over-antevert the cup.Most of these complications are part of the development of the approach and can be avoided with current instrumentation and techniques. 6 greater trochanteric fractures likely due to insufficient capsular release. 2 dislocations of acetabular component � potentially linked to learning curve and use of screws to stabilize cup early in learning process. 3 anterior dislocations ties back to point that potential exists to over-antevert the cup.

68. Greater Trochanteric Fractures No dislocation No muscle insufficiency Likely related to insufficient lateral superior capsular release Videos of patients who received the MIS Anterolateral THA procedure.Videos of patients who received the MIS Anterolateral THA procedure.

69. Discussion: Advantages, Disadvantages, and the Continuum of Care With the Zimmer MIS Anterolateral THA Procedure Transition slide.Transition slide.

70. Where does this new approach fit? Great alternative for surgeons who prefer anterior approaches Advantages Theoretically better early abductor muscle function Lateral femoral cutaneous nerve and lateral femoral circumflex vessel not in operative field Acceptable surgical time No intraoperative x-ray necessary Acetabulum and femur directly visualized Highlight advantages of AL. This is a summary/review of concepts already covered.Highlight advantages of AL. This is a summary/review of concepts already covered.

71. Where does this new approach fit? More Advantages Familiar lateral positioning Compatible with many Zimmer implants Performed through small incision (patient preference) Viable bail out Highlight advantages of AL. This is a summary/review of concepts already covered.Highlight advantages of AL. This is a summary/review of concepts already covered.

72. Where does this new approach fit? For surgeons who prefer posterior approach Many of the aforementioned features with New view of hip Low dislocation rate Time, experience and well designed studies will tell Tie back to why to use minimally invasive procedures. Reinforce key benefits.Tie back to why to use minimally invasive procedures. Reinforce key benefits.

73. Where does this new approach fit? Potential Challenges New surgeon positioning May require two surgical assistants Expect a variable learning curve Initial risk of complications Excessively anteverted cup Insufficient capsular release Varus stem Greater trochanteric fracture Obese and very muscular patients still difficult Highlight some potential challenges with this procedure. Stress and reinforce the capsular release. Highlight some potential challenges with this procedure. Stress and reinforce the capsular release.

74. Discussion Post-Op Care Anesthesia Challenges Leg Position Interval Capsular Incision Acetabulum Femur Patient Outcomes Discuss your experiences and thoughts in these areas.Discuss your experiences and thoughts in these areas.

75. Conclusions This MIS anterolateral approach is intermuscular Potentially little to no delay in rehab Potentially little to no abductor weakness Clinical results are encouraging Summary slide � captures the potential benefits of the procedure and the encouraging results to date.Summary slide � captures the potential benefits of the procedure and the encouraging results to date.

76. Ask for final questions. Summarize any last key points.Ask for final questions. Summarize any last key points.