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The SuperPATH Total Hip Replacement Approach

Beverly Hills Total Hip Replacement SurgeonDr. Meier is one of only a few surgeons in the United States offering the superior capsular percutaneously assisted or “SuperPATH” total hip technique. Among minimally invasive approaches to the hip, this is a newer, groundbreaking approach that is considered not only minimally invasive but “micro-invasive.” Unlike other techniques, with SuperPATH, no muscles or tendons are cut, the hip is never dislocated, the leg is held in a natural position throughout the procedure and the implants are assembled with the prosthesis being built inside the body using a “ship in a bottle” technique. Because of these innovations, patients are normally able to walk within hours of the surgery, experience far less pain, and often go home the same day of surgery or the next day.

Due to the micro-invasive techniques used in the procedure, patients enjoy a faster recovery and require less formal post-operative rehabilitation, which allows them to get back to their normal activities much sooner. Patients also enjoy a much lower risk of complications with the SuperPATH approach. In the following article, Dr. Meier explains why he prefers to use the SuperPATH hip replacement technique having had years of experience with all the different total hip approaches.

Why I Prefer the SuperPATH Hip Replacement Technique – Steven W. Meier, MD

The SuperPATH technique is a minimally invasive hip replacement approach that utilizes a “superior capsular” surgical interval and is “percutaneously assisted.” Instead of traditional techniques, which are typically more invasive and involve approaching the hip joint posteriorly (from behind), the SuperPATH technique accesses the joint capsule superiorly (from above), avoiding detachment of the external rotator muscles that the hip depends on for stability. This is sometimes referred to as a “Northern Approach,” which ensures that SuperPATH patients are not prone to postoperative dislocation as they can be with other methods.

Also, in contrast to traditional techniques that require one large incision, the SuperPATH method uses a much smaller main incision thanks to the use of an accessory portal (2nd incision measuring approximately ½ inch) located one hand’s width away from the main incision down the side of the thigh. While the femur can be accessed easily through the small main incision, specially designed instruments are then inserted through a narrow metal tube in the accessory portal at a perfect angle to prepare the socket.

Los Angeles Orthopedic Hip InjuryIn my opinion, of all hip replacement techniques, the SuperPATH technique is truly the least invasive and least traumatic. Less tissue damage occurs during surgery so patients experience much less postoperative pain and have a much faster recovery. Since no muscles are cut and the joint capsule is anatomically repaired, no activity restrictions are imposed on patients after surgery as other techniques require. SuperPATH allows for all of the benefits that minimally invasive surgery provides without the downsides of other techniques. Some minimally invasive hip techniques actually lead to more muscle damage than standard approaches when surgeons struggle to work in tight and awkward spaces. This can also result in incorrect placement and poor alignment of implants that can compromise joint function and longevity. Through the use of custom-designed instruments and the accessory portal, the SuperPATH system allows surgery to be performed without any struggling or straining on delicate tissues.

Unlike many other surgical approaches, the SuperPATH technique does not require the hip to be dislocated during the surgery. Also, unlike most other techniques, the leg is not held in unnatural, twisted positions during the procedure. The traditional posterior approach requires the leg to be held in extreme internal rotation for most of the procedure. The direct anterior approach requires that the leg is held in extreme lateral rotation. These awkward leg positions can strain the soft tissues supporting the hip resulting in increased postoperative pain and longer recovery of muscle function. These abnormal positions can also pinch blood vessels, increasing the risk of complications such as deep venous thrombosis (blood clot). With SuperPATH, the leg rests in a natural position throughout the procedure and there is never any need to exert undue strain on the bones or soft tissues.

Because of the anatomy of the posterior of the hip, the SuperPATH technique is easily extendable so while the exposure can be made as small as desired, it can also be extended without limitation as required by unusual patient anatomy or if a complication like femoral fracture occurs. I prefer to have a good backup plan to easily manage unplanned surprises if and when they do occasionally occur. The SuperPATH technique gives the surgeon the flexibility to handle patient-specific challenges when they arise, unlike other minimally invasive approaches. This approach also lends itself well to revision surgery where the incision can be made as small as possible or extended as necessary for difficult cases.

With some other minimally invasive techniques, surgeons “cherry-pick” patients with “ideal” anatomy as candidates because of approach limitations. Patients that are very muscular or otherwise “too heavy” may not qualify for the total hip replacement, for example. A great thing about SuperPATH is that it is a minimally invasive technique that does not discriminate. It can be used on everyone.

Also, SuperPATH provides such great access to the hip while being minimally invasive that there is no restriction on the types of implants and components that can be used. Different patients have different needs and with SuperPATH, the surgeon is able to select and use exactly the most appropriate type of implant system for each patient and not have the surgical approach dictate and restrict which components can be used, as with other methods.

Since SuperPATH is related to the traditional posterior hip approach, which most surgeons are formally trained in, learning the SuperPATH technique is quite natural, allowing for a relatively short learning curve. This allows an experienced surgeon to gradually convert to the SuperPATH technique while realizing consistently good outcomes for their patients, unlike other minimally invasive techniques that have a long and steep learning curve, requiring the surgeon to “practice” on many patients before achieving mastery. Learn more about traditional hip surgery at WebMD.com.

Downsides to the Direct Anterior Approach

The direct anterior hip approach has gained considerable popularity as a minimally invasive technique within the last couple of years. Advocates of this approach have been attracted to the less invasive nature of it and the decreased risk of postoperative dislocation when compared to the traditional posterior approach. While the direct anterior approach offers a number of benefits versus traditional techniques, I have found that it is also associated with a number of significant drawbacks.

One major downside of the direct anterior approach is that the surgical exposure is made through a very restricted and tight anatomic interval. Because the surgical opening is restricted by anatomic structures above and below, there is no room to extend the exposure if needed. There are a number of reasons why a surgical approach may need to be extended intra-operatively, such as in muscular patients, overweight patients, or if the bone becomes fractured during the preparation of the femur and needs to be repaired.

Due to the limited access to the hip that the direct anterior approach provides, the lower extremity must be held in an extreme position of extension and external rotation on a traction table throughout the procedure. This places a tremendous amount of stress on the muscles, tendons, and ligaments supporting the hip and can lead to additional postoperative pain. These extreme forces have been associated with unintentional injury to other body parts, including sprains and fractures to the knee and ankle.

The direct anterior approach can be prone to wound healing problems largely because of the location of the incision in the front of the thigh. Patients can also suffer from permanent thigh numbness after surgery since the incision lies in the territory of a sensory nerve called the lateral femoral cutaneous nerve.

Also as a result of the limited access inherent in the direct anterior technique, normal femoral implants whose design has been perfected and stood the test of time cannot be used. Femoral implants are modified with shortened stems so they can fit into the restricted surgical interval. It is unknown whether these modified implants will perform as well as the standard non-modified implants for which long-term success has been studied. It will be a matter of time to find out whether patients who have undergone direct anterior hip replacements will have comparable long-term results.

The anterior approach is inherently unfamiliar to most surgeons who are usually formally trained on the posterior approach. Because the anterior approach is so foreign, it takes a surgeon a long time to become comfortable and facile with it, needing to practice on many patients. That means it may take the surgeon a long time to realize optimal results for their patients.

Summary of SuperPATH

In summary, it has been my experience that, among all the different surgical approaches to the hip, the SuperPATH technique provides the best balance of benefits with none of the downsides inherent in other techniques. SuperPATH provides the ideal combination of being minimally invasive and minimally traumatic while allowing the surgeon to use any type of implant system with universal applicability to all patients. This combination of attributes allows the surgeon to achieve the best possible outcomes with the most rapid recovery and the lowest incidence of complications.

Call 310.736.2793 or fill out the online contact form to learn more about SuperPATH treatments and get started on the road to recovery today.

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