Rubin_The Direct Anterior Approach to Hip Reconstruction, 2e

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SECTION I Introduction

treatment of slipped capital femoral epiphysis. 20 Halsted’s method of granting significant autonomy to certain resi dents on major operations was passed to Yale orthopedics by Chief and Professor Wayne O. Southwick, who was a mentor to Kristaps Keggi and was frequently cited say ing, “You can do it, Kris.” In the operating room, Keggi always gloved his left hand first, not because he was left-handed but as an indi cation of his surgical lineage to Hopkins via Southwick and Halsted. He had been taught this practice in medical school by surgeons who had been trained by surgeons trained by Halsted himself as both a show of pride and respect to the father of American surgery. Kristaps Juris Keggi (1934-2023) Kristaps Juris Keggi was born in Latvia and came to the United States at the age of 15 years as a World War II ref ugee. His maternal grandfather, Ludvigs Ernest Berzins, was a renowned professor and theologian and educator at the University of Latvia; Keggi has said “his ideals have left a profound impression on me.” 21 Keggi’s passion for medicine stemmed from his father Dr. Janis (John) Keggi, a general surgeon, who at the end of his own residency in Latvia was sent by his mentor, Professor Paulis Stradins, to visit major surgical centers in Germany and Vienna. Janis Keggi then spent a year in Denmark researching tissue cultures. Professor Stradins was Latvian but was trained in Saint Petersburg (Czarist Russia) and at the Mayo Clinic (Minnesota). Less than 2 years after his arrival in Brooklyn, NY, Keggi was enrolled in Yale College and received his Bachelor of Arts degree in 1955. He was on the varsity fencing team, serving as captain in 1955. He then grad uated from the Yale University School of Medicine in 1959. After 2 years of general surgical internship and res idency in New York at the “old” Roosevelt Hospital, he returned to Yale for his orthopedic residency under Dr. Wayne Oren Southwick, who was the inaugural chair of orthopedics when it first became an independent depart ment in 1958. After completing his residency at Yale in 1964, Dr. Keggi served 2 years on active duty in the United States Army Medical Corps. During the first year of active duty, he was on the teaching staff of the Beaumont General Hospital on the Mexican border in El Paso, TX. He operated on the spine and performed elective reconstruc tion of joints, including femoral osteotomies, cup arthro plasties, and hip fusions. Most of the second year of his active duty (1965-1966) was in Vietnam with the 3rd Mobile Army Surgical Hospital treating wounds of the extremities, among them high-velocity gunshot wounds of the proximal femur and hip. Most of the wounded were members of the 173rd Airborne Brigade, 1st and 25th Infantry Divisions, Special Forces, and the rare, exceptional Marine.

Keggi was inspired by a meeting with Major Barbara Stimpson, MD, a Vassar graduate from a prominent Yale family. In 1940, she became the first female surgeon to be certified by the American Board of Surgery. 22 She was a pioneering orthopedic surgeon, with work on fracture fixation and multidisciplinary management. Her 1939 textbook, A Manual of Fractures and Dislocations , was a standard text at the time. 22 She was a decorated surgeon in World War II with combat zone service in the Royal British Army Medical Corps; she was turned down by the American Army Medical Corps due to gender. In the summer of 1966, Keggi returned to Connecti cut and remained on the Yale faculty until the end of his life, operating at the Waterbury or Yale New Haven Hospitals. He performed trauma cases while building an elective practice. His elective practice centered on the spine and reconstruction of the hip, with osteotomies, resections, fusions, and anterior approach Smith-Petersen cup mold arthroplasty. His reconstructive cases were per formed through a variety of approaches to the hip. He was on Yale faculty from 1966 to 1969 and moved to private practice in Waterbury, CT, from 1969 to 2018, retaining a postgraduate year three adult reconstruction resident rotation during that time. He later returned again as a full time Yale faculty member from 2008 to 2017 and retired from clinical practice on December 31, 2017. In 1970, Keggi was among the first in Connecticut to perform Charnley’s cemented, low-friction arthroplasty. The transtrochanteric approach, with its associated reat tachment of the trochanter, was technically frustrating; the wires would tear through gloves, and nonunion rates were up to 17%. 23,24 After approximately 40 cases using this approach, he discussed the problem with colleagues, including Dr. Roderick Habink Turner at New England Baptist Hospital, who also felt “we could do better in the United States.” Dr. Turner was also a Tufts School of Medicine professor and authored more than 50 publica tions in his career. 25 Keggi was well versed in the surgical approach to the hip throughout his training and military experience in Vietnam. In 1971, he started performing THA with out a trochanteric osteotomy through an anterolateral approach; soon after, he performed the first total hip

replacements in the United States through a DAA. In the DAA for THA, he noticed that acetabular expo sure was relatively easy. Femoral exposure was, and has remained, the challenge. He advocated a slightly curved incision for easier exposure of the femur (shallow, upside down “C”). In simple cases, he was able to obtain expo sure after an anterior capsulectomy, the application of Cobra retractors, and a bone hook to pull the femur into view. In more challenging exposures, he would extend the skin incision, release the tensor fascia lata from the ante rior iliac crest, transect the posterior capsule, and release the short external rotators ( Figure 2.2 ). 4 For extremely tight or deformed hips, he developed a “foldback” digastric Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024