PATH® Technique General Precautions

Patient Positioning	Neck Resection
Skin Incision	Portal Placement
Deep Dissection	Cup Impaction
Piriformis / Conjoined Tendon Release	Stem Impaction

Proper surgical procedures and techniques are the responsibility of the medical professional. Each surgeon must evaluate the appropriateness of the procedure based on personal medical training and experience. Wright Medical Technology, Inc. cannot recommend a particular surgical technique suitable for all patients.

Patient Positioning
The lateral decubitus position is utilized, and the patient is secured on a peg board using radiolucent pegs to permit an unobstructed AP pelvis x-ray. In contrast to traditional total hip arthroplasty done in a lateral position, the patient is moved as far forward on the table as possible. This permits maximum adduction of the operated extremity, substantially reducing trauma to the posterior skin edge during femoral preparation and component insertion. Once the patient is secured in the lateral decubitus position, prepping and draping proceed in a standard manner.

Skin Incision
The greater trochanter is palpated and outlined using a marking pen. The Incision Template (20070034) is aligned over the outline, and the incision location is then marked with a marking pen. The length of the skin incision will vary depending on patient size and surgeon experience. When attempting the procedure for the first time, a 4-5 inch skin incision is a reasonable length with which to begin. The incision is made with the hip flexed to approximately 20°-30° and the foot and ankle resting on the corner of a well padded Mayo stand raised to bring the hip to maximum internal rotation. This position exposes the maximum length of the piriformis/conjoined tendon. The incision is placed at the posterior corner of the greater trochanter, overlapping the tip of the trochanter by approximately 1 cm, and extending posteriorly and proximally in an oblique fashion approximately 30° -50° to the long axis of the patient (roughly parallel to the course of the Piriformis tendon).

Deep Dissection
Fascia over the gluteus maximus is incised in line with the wound. Orientation of the muscle fibers is clearly visible. A Cobb elevator may be utilized to longitudinally, gently tease apart the muscle fibers allowing access to the soft tissues overlying the piriformis tendon. This dissection is carried out posterior and proximal to the tip of the greater trochanter and should not disturb the ITB/tensor. Once this opening between gluteus max muscle fibers has been created, the piriformis/conjoined tendon can almost always be palpated. Occasionally the tendon will flatten out in extreme internal rotation making it indistinct. If it is not readily palpated the leg may be slightly externally rotated and the tendon can then be differentiated from adjacent tissue. The tip of the greater trochanter should be located approximately 1 cm from the lower edge of the skin incision (in hips with significant varus the incision may require extension distally).