The Mako ™ robotic arm-assisted total hip arthroplasty using direct anterior approach: surgical technique, skills and pitfals

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Piergiuseppe Perazzini
Michele Trevisan
Paolo Sembenini
Francesco Alberton
Mara Laterza
Alberto Marangon
Bruno Magnan


total hip arthroplasty, robotic technology, direct anterior approach, Mako system, surgical technique


In the last decades many innovations have improved the hip replacement and the hip reconstruction surgery such as the introduction of the robotic-arm assisted surgery associated with the direct anterior approach (DAA). This surgical approach for total hip arthroplasty (THA) is growing in popularity and its effectiveness has been demonstrated to improve patients’ outcomes, especially regarding more accurate implant placement, less post operative pain, faster recovery and lower of prosthesis dislocation risk. The robotic-arm assisted surgery is another really great innovation for the orthopedic surgeons. It allows to create a patient-specific THA pre-operative planning and to perform a much more accurate surgical procedure. This article outlines authors’ surgical technique of performing accurate pre-operative planning and robotic-assisted THA using direct anterior approach based on the experience of 534 patients and to discuss details of this technique. 


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1. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am 2009;91:128e33.
2. Kroell A, Beaule P, Krismer M, et al. Aseptic stem loosening in primary THA: migration analysis of cemented and cementless fixation. Int Orthop. 2009;33:1501–1505.
3. Anakwe RE, Jenkins PJ, Moran M. Predicting dissatisfaction after total hip arthroplasty: a study of 850 patients. J Arthroplasty 2011;26(2):209-13.
4. Lee YK, Yoo JJ, Koo KH, et al. Metal neck and liner impingement in ceramic bearing total hip arthroplasty. J Orthop Res. 2011;29:218–222.
5. Jewett BA, Collis DK. High complication rate with anterior total hip arthroplasties on a fracture table. Clin Orthop Relat Res 2011;469(2):503-7. doi: 10.1007/s11999-010-1568-1.
6. Light TR, Keggi KJ. Anterior approach to hip arthroplasty. Clin Orthop Relat Res 1980;152:255-60.
7. Poehling-Monaghan KL, Kamath AF, Taunton MJ, Pagnano MW. Direct anterior versus miniposterior THA with the same advanced perioperative protocols: surprising early clinical results. Clin Orthop Relat Res 2015;473(2):623-31. doi: 10.1007/s11999-014-3827-z.
8. Rodriguez JA, Deshmukh AJ, Rathod PA, Greiz ML, Deshmane PP, Hepinstall MS, Ranawat AS. Does the direct anterior approach in THA offer faster rehabilitation and comparable safety to the posterior approach? Clin Orthop Relat Res 2014;472(2):455-63. doi: 10.1007/s11999-013-3231-0.
9. Seng BE, Berend KR, Ajluni AF, Lombardi AV Jr. Anterior-supine minimally invasive total hip arthroplasty: defining the learning curve. Orthop Clin North Am 2009;40(3):343-50. doi: 10.1016/j.ocl.2009.01.002.
10. Spaans AJ, van den Hout JA, Bolder SB. High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach. Acta Orthop 2012 Aug;83(4):342-6. doi: 10.3109/17453674.2012.711701.
11. Zawadsky MW, Paulus MC, Murray PJ, Johansen MA. Early outcome comparison between the direct anterior approach and the mini-incision posterior approach for primary total hip arthroplasty: 150 consecutive cases. J Arthroplasty 2014;29(6):1256-60. doi: 10.1016/j.arth.2013.11.013.
12. Domb BG, El Bitar YF, Sadik AY, et al. Comparison of robotic-assisted and conventional acetabular cup placement in THA: a matched-pair controlled study. Clin Orthop Relat Res. 2014;472(1):329-36. doi: 10.1007/s11999-013-3253-7.
13. Dorr LD, Malik A, Dastane M, Wan Z. Combined anteversion technique for total hip arthroplasty. Clin Orthop Relat Res 2009;467(1):119-27. doi: 10.1007/s11999-008-0598-4.
14. Bargar WL, Jamali AA, Nejad AH. Femoral anteversion in THA and its lack of correlation with native acetabular anteversion. Clin Orthop Relat Res 2010;468(2):527-32. doi: 10.1007/s11999-009-1040-2.
15. Imai H, Miyawaki J, Kamada T, Takeba J, Mashima N, Miura H. Preoperative planning and postoperative evaluation of total hip arthroplasty that takes combined anteversion. Eur J Orthop Surg Traumatol. 2016; 26: 493-500. doi: 10.1007/s00590-016-1777-8.
16. Widmer KH, Zurfluh B. Compliant positioning of total hip components for optimal range of motion. J Orthop Res 2004;22(4):815-21. doi: 10.1016/j.orthres.2003.11.001.
17. Hirata M, Nakashima Y, Hara D, Kanazawa M, Kohno Y, Yoshimoto K, et al. Optimal anterior femoral offset for functional range of motion in total hip arthroplastya - a computer simulation study. Int Orthop 2015;39(4):645-51. doi: 10.1007/s00264-014-2538-0.
18. Abdel MP, von Roth P, Jennings MT, Hanssen AD, Pagnano MW. What safe zone? The vast majority of dislocated THAs are within the Lewinnek safe zone for acetabular component position. Clin Orthop Relat Res 2016;474(2):386-91. doi: 10.1007/s11999-015-4432-5.
19. Barrack RL. Dislocation after total hip arthroplasty: implant design and orientation. J Am Acad Orthop Surg 2003;11(2):89-99. doi: 10.5435/00124635-200303000-00003.
20. Dorr LD, Wan Z, Malik A, Zhu J, Dastane M, Deshmane P. A comparison of surgeon estimation and computed tomographic measurement of femoral component anteversion in cementless total hip arthroplasty. J Bone Joint Surg 2009;91(11):2598-604. doi: 10.2106/JBJS.H.01225.
21. Elson L, Dounchis J, Illgen R, et al. Precision of acetabular cup placement in robotic integrated total hip arthroplasty. Hip Int Hip Int 2015;25(6):531-6. doi: 10.5301/hipint.5000289.
22. Paley D. Principles of deformity correction. Berlin Heidelberg: Springer; 2002
23. Marcovigi A, Ciampalini L, Perazzini, Caldora P, Grandi G, Catani F Evaluation of Native Femoral Neck Version and Final Stem Version Variability in Patients With Osteoarthritis Undergoing Robotically Implanted Total Hip Arthroplasty. J Arthroplasty 2019;34(1):108-115. doi: 10.1016/j.arth.2018.06.027.
24. Kiernan S, Hermann KL, Wagner P, Ryd L, Flivik G. The importance of adequate stem anteversion for rotational stability in cemented total hip replacement. Bone Joint J 2013;95-B(1):23-30. doi: 10.1302/0301-620X.95B1.30055.
25. Herrlin K, Pettersson H, Selvik G, Lidgren L. Femoral anteversion and restricted range of motion in total hip prostheses. Acta Radio 1988;29(5):551-3.
26. Yoshimine F. The safe-zones for combined cup and neck anteversions that fulfill the essential range of motion and their optimum combination in total hip replacements. J Biomech 2006;39(7):1315-23. doi: 10.1016/j.jbiomech.2005.03.008.
27. Patel AB, Wagle RR, Usrey MM, Thompson MT, Incavo SJ, Noble PC. Guidelines for implant placement to minimize impingement during activities of daily living after total hip arthroplasty. J Arthroplasty 2010;25(8):1275-81.e1. doi: 10.1016/j.arth.2009.10.007.

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