Rubin_The Direct Anterior Approach to Hip Reconstruction, 2e

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CHAPTER 2 A Definitive History of the Direct Anterior Approach

FIGURE 2.2 Duplication of figure from Dr. Keggi and Dr. Light 1980 publication showing the trochanteric slide osteotomy. (Reproduced with permission from Light TR, Keggi KJ. Anterior approach to hip arthroplasty. Clin Orthop Relat Res. 1980;152:255-260.)

trochanteric osteotomy. 26 This technique left the attach ments of the gluteus medius and minimus in continuity with the vastus lateralis and did not disrupt the posterior periosteum and posterior muscles. He repaired it with heavy nylon sutures, treating it as a nondisplaced frac ture, and did not restrict patients’ activity. This osteotomy was rarely needed in the early 1970s (3 of 104 of his first cases) 26 and was no longer necessary after the development of better instrumentation but should not be forgotten as a means of resolving difficult exposures. Keggi first described his anterior approach for THA in a scientific exhibit at the 1977 American Academy of Orthopaedic Surgeons meeting with Dr. Terry R. Light, who was his resident at the time. Keggi pub lished on the anterior approach and “foldback osteot omy” in 1979 with Dr. John P. Fulkerson, another one of his residents, 26 and formally entered the modern peer-reviewed literature with Dr. Light via Clinical Orthopaedics and Related Research in 1980. 4 These early publications were followed by many others on the use of the DAA in a multitude of hip problems. 26,27 His significant seminal contributions to the literature were recently highlighted in a review article entitled

“The Most Influential Papers in DAA to THA,” 28 which included four of Keggi’s articles in the top 50 most influential list. 4,29-31 In addition to his early publications on the anterior approach to THA, Keggi pioneered the early develop ment of anterior approach instrumentation. He worked with biomedical companies to lengthen the straight rasps used for preparing the femur. He took the rasps to a tool shop in Waterbury, CT; hired a metal worker to heat them; and used his own gloved hands to bend the rasps, creating the first known version of single offset broaches. This custom instrumentation better facilitated prepara tion of the femur and set the stage for all future modern anterior broach handle designs. The Keggi Anterior Hip Rasp Set, manufactured by Howmedica, became available in 1978 ( Figure 2.3 ) and was the first commercially available instrumentation specifically designed for DAA THA. This set included nonmodular chrome femoral rasps with single offset and long handles, which facilitated access to the femoral canal for cemented stem preparation in the anterior approach. Later, Keggi also created a dual offset “dog leg” rasp in a similar manner of custom experimentation. 32

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