1. PATH™ “Percuntaneous Assisted Total Hip Arthroplasty”

2. What is PATH®? PATH is an acronym that stands for Percutaneous Assisted Total Hip Why would a surgeon want to perform the PATH technique? Benefits include Tissue Sparing – that minimizes functional tissue trauma that allows quick patient recovery Less Blood loss Less Pain medication Piriformis Release only technique that saves short external rotators What does all this mean for the patient? Quicker recovery and return to functional mobility

3. Why do MIS or TS techniques?(Minimally Invasive or Tissue Sparing) To minimize functional tissue trauma for immediate post-op mobility!!

4. What are the benefits for the Patient? No blood donation No blood transfusion Reduces the risk of catching an infectious disease More functioning tissue for immediate post-op mobility Short external rotators spared Abductors (medius and minimus) are spared Piriformis release only Reduced dislocation rate Quicker rehabilitation Quicker release from hospital Shorter recovery back to an active lifestyle

5. Pain Management Protocol Medication Regimen for PATH® MIS Study Pre Op Hct and Hgb 2 hours Pre operative Oxycontin 10 mg. P.O. Celebrex 200 mg. P.O. Tylenol 1 gram P.O. General, spinal or epidural anesthesia can be utilized Injection # 1: Into capsule and greater trochanter Marcaine 30cc 0.5% (.25% each hip for bilateral cases) Depo Medrol 80 mg *not in diabetics, immune-compromised or history of infection Toradol 30 mg Injection #2:*change to a second syringe and needle SQ: Marcaine 20 to 30 cc 0.5 % (0.25% each hip for bilateral) Marcaine 30 cc ½ % Post Operative medications may be offered to patient as needed and as tolerated post operative for 48 to 72 hours: Oxycontin 10mg-20mg Bid P.O. Oxycodone 5mg PO Q. 2 hrs Celebrex 200 mg PO BID Tylenol 1 gram 6AM, Noon, 6 PM P.O. Morphine Sulfate or Dilaudid as needed I.M. No Drain Mobilize Patient 4-6 hours weight bearing as tolerated

6. A-Class™ Advanced Metal with BFH® Technology

7. A-Class™ Advanced Metal A-Class Advanced Metal innovation is a patent-pending process that is the solution to the reduction of wear and potentially the reduction of metal ions.

8. A-Class™ SUPERIOR PRODUCT Reduction of wear 90% reduction in initial (run-in) wear 68% reduction in lifetime wear of the implant

9. Run-In versus Steady State Wear Run-In: Surface carbides dislodged, 3rd-body abrasion, high wear rate Steady state: High polish, large contact area, smooth surface, low wear rate New Implant Run-In Wear Steady State

10. A-Class™ SUPERIOR PRODUCT Optimized Bearing System Surface Hardness Component Clearances Sphericity Surface Finish Surface Velocity

11. Optimized Bearing – Key Points Surface Hardness The femoral head is responsible for 80-95% of the wear in a hip bearing system. The differential hardness between the head and the cup reduces metal wear. (the head is harder than the cup) Surface Finish Extremely tight tolerance promotes a reduction in metal wear. Surface Velocity Increased head size creates increased surface velocity. Greater Surface Velocity = Greater Fluid Film Separation Increased fluid film separation decreases metal wear.

12. A-Class™ Advanced Metal Comparison(Tested under different conditions)

13. A-Class™ SUPERIOR PRODUCT Advanced Metal with BFH™ Technology Reduction of dislocation Increased range of motion Increased jump distance

14. A-Class™ SUPERIOR PRODUCT

15. A-Class™ SUPERIOR PRODUCT

16. A-Class™ SUPERIOR PRODUCT An increase of 9.3 mm in jump distance from 36mm to 56mm heads. A range of motion that is substantially greater than the typical competitor’s 130° to 135° range of motion for smaller diameter heads. WMT’s range of motion is 150° to 165 °

17. A-Class™ EASE OF USE Multiple BFH® Technology head sizes 36mm – 56mm Long, medium, and short BFH® Technology neck options Long = +3.5mm Medium = 0mm Short = -3.5mm Multiple PROFEMUR® stem options

18. A-Class™ EASE OF USE Multiple cup options provide Intraoperative flexibility 6mm HA Cup with BFH® 6mm Cup 10mm Cup 6mm Spiked Cup 14mm SUPER-Fix™

19. A-Class™ INNOVATION A-Class™ Advanced Metal BFH® Technology Modular Necks – optimal restoration of normal hip biomechanics Leg length Varus, Valgus Anteversion, Retroversion Your Philosophy, Our Modular Necks.

20. Patient Positioning

21. Peg is positioned proximal to the sacrum

22. Final peg is positioned on lower chest

23. Preliminary leg length is checked using relative knee height

24. Move patient anteriorly on table to permit maximum adduction

25. Pre-operative Planning

26. Pre-op X-ray evaluation

27. Surgical TechniqueHip Exposure

28. Initial Incision Place the hip in 20 to 30 degrees of flexion Foot resting on Mayo to facilitate maximum internal rotation Internal rotation will facilitate maximum exposure of piriformis and conjoined tendon Outline the greater Trochanter Mark the incision posterior to the corner of the greater Trochanter, overlapping 1cm and extending obliquely 30º to 50º to the axis of the patient

29. Expose the fascia over the gluteus maximus Cobb is used to tease apart gluteus maximus muscle fibers ANT POST

30. A cobb elevator separates the muscle for reduced trauma Deeper dissection is continued proximal and posterior to the greater Trochanter Try not to disturb the Iliotibial band/tensor

31. The piriformis tendon is palpated On some occasions the piriformis is difficult to identify Internally rotate the leg for help identification of the piriformis The tip of the greater Trochanter should also be noted

32. The piriformis tendon is released Place blunt Hohmann just above piriformis tendon – deep to the capsular minimus muscle Then release piriformis as close to the attachment of the greater Trochanter as possible Preserve maximum piriformis length Hohmann Retractor

33. Capsular incision Continue to release soft tissues under piriformis to access the capsule After the Piriformis is released a J shaped capusular incision is made Make the capsular incision parallel to the neck axis and obturator internus tendon Intertrochanteric attachments are released Anterior I J Posterior

34. The hip is adducted, flexed, and maximally internally rotated to dislocate the head An anterior acetabulum retractor is placed along inferior neck Hohmann is placed on superior neck The hip is in 45º of flexion and 60º-70º of internal rotation for neck resection The neck is resected Anterior Acetabular Retractor HEAD FOOT

35. Neck Resection Penetrate the anterior cortex to center of the femoral neck with oscillating saw Complete cut with reciprocating saw to minimize soft tissue damage

36. A schantz screw is threaded into the femoral head and used to extract the femoral head

37. Retractor positioning for acetabular exposure Return to approximately 30º flexion, 20º adduction and approximately 30º internal rotation Anterior retractor is placed on anterior rim This retractor should lever on the tip of the greater Trochanter and anterior rim of the acetabulum Anterior Act. Retractor Superior Pin Anterior Rim

38. PINPOINT™ retractor placement PINPOINT™ Posterior Acetabular Retractor is placed posteriorly on the ischium between the capsule and labrum

39. PINPOINT™ retractor placement Insert two Steinmann pins to hold the PINPOINT™ retractor in place Complete the removal of the labrum Superior Posterior

40. PINPOINT™ Retractor & Pins are secured to the ischium SUPERIOR POSTERIOR

41. Conventional reamers have angular constraints preventing optimal bone preparation

42. Percutaneous Portal Hole Location is Determined Find femur and mark with pen Acetabulum Alignment guide should be placed in main incision into socket The handle should be perpendicular to the table Abduction angle is approximately 40º to 45º when alignment guide is straight up out of the wound Cannula should be loaded on the Trocar / cannula inserter Mark entrance point and make initial stab with scalpel with #11 Sharp Trocar External Alignment Guide FOOT HEAD

43. Cannula Placement Trocar is removed and cannula is left in the incision Superior Cannula

44. Cannula location is behind the femur HEAD Anterior FEMUR Posterior FOOT

45. Reaming the Acetabulum

46. Reamer basket is introduced through main incision HEAD FOOT

47. Reaming begins medially to remove any articular cartilage Direct visualization to the acetabulum

48. Abducting (how much?) the leg allows medialization FOOT

49. Reaming at a 40 to 45 degree angle for final socket sizing HEAD FOOT

50. Cup Placement

51. Conventional impactors prevent optimal implant positioning

52. Acetabular component is introduce in-line with incision (just like reamers)

53. Insertion is parallel to the incision then rotated into the acetabulum

54. Rotate cup into position Cup impaction is 40º of abduction and 20º -25º of anteversion using the alignment guide Special consideration should be directed to the patient positioning and bony landmarks for cup placement

55. Version and abduction are verified With the crossbar portion of the handle perpendicular to the patient’s torso, anteversion is approximately 20º 40° 20° 20°

56. Cup Impaction Need another image here of cup impaction

57. Femoral Retractor Placement

58. Retractors are positioned for femoral preparation Remove soft tissue from lateral neck and intertrochanteric wall The gluteus offset retractor is placed over the tip of the greater Trochanter The anterior acetabular retractor is placed over the medial calcar and under the remaining short external rotators HEAD

59. Starting punch / Chisel is impacted lateral to the piriformis The leg should be in 45º -80º of flexion and 45-80º of internal rotation Chisel’s are inserted at the tip of the Greater Trochanter for maximum lateralization of the canal

60. It is important to maintain axial alignment

61. Reamer sleeve prevents skin trauma

62. PROFEMUR® Z Broach design preserves endosteal blood flow potential around the stem

63. Axial inline broaching is performed sequentially

64. Outrigger guide allows alignment check Alignment guide can be used to ensure proper alignment during broaching

65. Modular neck and femoral ball is inserted and the hip is reduced Key note – Metal trial necks can only be used with broaches Plastic trial necks are to be utilized with the final implant

66. Position is checked using tip of the Trochanter and lateral top of trial

67. A bump should be put under the ankle to keep the leg parallel to the table The hip should be stable in full extension and 70-80º external rotation with pressure applied to the posterior aspect of the Greater Trochanter In addition, hip should be stable between 30º and 90º flexion, 30º-50 adduction, 70º-80º internal rotation, as well as 120º flexion in neutral rotation and neutral adduction Inter op x-ray to check position and leg lengths (recommended for first 5 cases)

68. ! Implant stability Stability relies on STEM positioning… …and NECK geometry!!!

69. Leg is positioned for closure

70. Post Op Events Straight leg raise in recovery room Weight bearing – day one Walking halls unassisted day two Leave hospital day two or three No morphine pain pump

71. THANK YOU