Johns Hopkins is one of just a few locations nationwide offering a new hip replacement technique that promises less trauma and faster recovery compared to traditional methods, and is leading efforts to train more surgeons in the procedure.

The superior transverse atraumatic reconstruction (STAR) approach was developed in 2019 by Greek surgeon Eleftherios Tsiridis, specifically to preserve the piriformis muscle and reduce soft tissue trauma while protecting neurovascular structures.

“It removes the need for any muscle dissection or muscle disturbance,” says Savya Thakkar, hip and knee reconstructive surgeon at Johns Hopkins, and a leader in both performing the surgery and in educating other surgeons — at Johns Hopkins and elsewhere — in the technique.

“It’s a faster recovery,” he continues. “It is less painful, and it involves really no precautions to the hip joint after surgery, as long as patients don’t have a fall. They're walking around the same day, and, in appropriate candidates, they go home the same day as well.”

The STAR acronym refers primarily to the surgeon’s point of entry for accessing the hip joint, which is superior to the vastus ridge (a bony prominence at the top of the thigh), and transverses it at a 45-degree angle. Atraumatic refers to the fact that no muscles are cut or damaged during the procedure, and reconstruction refers to the repair of the surgical flap after the new hip is inserted. 

The STAR approach has been gradually gaining traction as surgeons around the world learn how to perform it for total hip arthroplasty. In the U.S., just a handful of medical centers offer it so far, and Johns Hopkins is the only one in Maryland or its surrounding states, says Thakkar.

He is a member of the STAR Approach Foundation co-founded by Tsiridis, an international group that is conducting research and educating surgeons about the procedure. Thakkar is also planning a traveling fellowship that would bring surgeons to Johns Hopkins to learn the technique.

The STAR approach was created as an improvement to the direct superior approach, a minimally invasive posterior method that avoids cutting the iliotibial band and certain external rotators, but does not protect or preserve the piriformis muscle or conjoint tendon.

Another option is the anterior approach, which became popular in recent years because it involves a small incision in the front of the hip, instead of the gluteus maximus. Though the anterior approach is muscle-sparing, it typically requires an X-ray and specialized equipment so that surgeons can work between muscles, and it has a slightly higher risk of infection because the incision goes through the groin, says Thakkar.

The STAR approach does not have those drawbacks, says Thakkar. It protects the piriformis and other short external rotators, does not involve the groin, and does not require use of an X-ray.

In fact, it’s simpler for surgeons, and requires no specialized equipment, he says.

Thakkar says he and the surgeons he has trained at Johns Hopkins have now performed more than 400 such surgeries in the year since Johns Hopkins adopted it. It’s too early to evaluate outcomes over two or five years, but the anecdotal evidence indicates that patients are happy with the procedure. “At the outset, we feel like they’re doing well,” he says.

The STAR approach, he says, is appropriate for patients of any age and with virtually any hip pathology that would benefit from hip replacement. The exception is a revision surgery around a failed implant or fractures around an existing implant, he says, because that could require more extensive dissections.

One of his patients, he says, had one hip replaced with a traditional surgery and the other, more recently, with the STAR technique.

“He said it was a game changer for him because he’s a very active tennis player, and he’s been able to get back to his game at the same intensity, at the same level, a lot faster with a STAR approach than with a standard posterior approach,” says Thakkar.

“Our patients come to us with the expectation that if they’re coming to Hopkins, they should get the latest and the greatest, but also the safest, and things that give them as seamless a recovery as possible.”