The Direct Anterior Approach to Hip Reconstruction

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SECOND EDITION

The Direct Anterior Approach to Hip Reconstruction

SECOND EDITION

Editor-in-Chief Lee E. Rubin, MD, FAAOS, FAAHKS, FAOA Associate Professor of Orthopaedic Surgery Chief, Division of Adult Reconstruction Chief, Yale-New Haven Hospital Total Joint Replacement Program

Program Director, Yale Arthroplasty Fellowship Department of Orthopaedics and Rehabilitation Yale University School of Medicine New Haven, Connecticut

Senior Editors B. Sonny Bal, MD, MBA, JD, PhD Chief Executive Officer & President

Associate Editors H. John Cooper, MD

Associate Professor of Orthopedic Surgery Columbia University Irving Medical Center New York Presbyterian Hospital New York, New York Kristoff Corten, MD, PhD Hip Unit Orthopedic Department Ziekenhuis Oost-Limburg, Genk Associate Professor Department of Rehabilitation Sciences University of Hasselt Hasselt, Belgium Heuppraktijk/European Hip Clinic Herselt, Belgium Park Medisch Centrum Rotterdam, The Netherlands Jeremy M. Gililland, MD, FAAOS, FAAHKS Chief of Orthopaedic Surgery, George E. Whalen VA Medical Center Director of Research for Adult Reconstruction Service Associate Professor of Orthopedic Surgery Division of Adult Reconstruction University of Utah Salt Lake City, Utah Theodore Manson, MD, MS Clinical Professor of Orthopaedic Surgery University of Maryland Baltimore, Maryland

SINTX Technologies Salt Lake City, Utah Joseph T. Moskal, MD, FAAOS, FAAHKS, FAOA, FACS Professor and Chairman Department of Orthopaedic Surgery

Virginia Tech Carilion School of Medicine (VTCSOM) Chief and Fellowship Director, Adult Reconstruction (Hip and Knee) Carilion Clinic and VTCSOM Associate Professor University of Virginia Medical School Associate Professor Edward Via College of Osteopathic Medicine Chairman, Department of Orthopaedic Surgery Carilion Clinic Senior Vice President, Carilion Clinic Roanoke, Virginia Editor Emeritus Kristaps Juris Keggi, MD, Dr Med (hc) (deceased) Professor Emeritus Yale University School of Medicine Department of Orthopaedics and Rehabilitation New Haven, Connecticut

J. Bohannon Mason, MD Adult Reconstructive Surgery

OrthoCarolina Hip and Knee Center Professor of Orthopedic Surgery Atrium Musculoskeletal Institute Charlotte, North Carolina

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To our Mentors You have taken significant personal time and effort to guide our individual development as physicians, as orthopaedic surgeons, and as leaders. Thank you, as you have encouraged us to reach our full potential; you have implored us to “press on” and drive the evolution of hip surgery forward through the pursuit of excellence in clinical care closely paired with scientific research. To our Trainees Your tireless work as students, orthopaedic surgery residents, and adult reconstruction fellows is an inspiration to each of us as authors and editors of this text. We recognize and honor the importance of your training and the impact it will have on the future of our profession. We celebrate your bright future with this work, which we hope will elevate each of you and be an enduring guide for the future. To our Families For each of our parents, spouses, and children, thank you for your unending support during the many years of our education and training, for your understanding of the unique demands of our professional calling, for your grace in allowing us the many long days and late nights in the care of our patients, and for allowing us the significant time required to complete this text as a gift to the next generation of surgeons. To our Patients We are truly grateful to the many thousands of patients who place their collective trust in our hands each year. We strive for perfection every day, work to make continuous improvements over time, and we are deeply indebted to your belief and confidence in our abilities. We hope this text serves to improve the care of patients around the world in the many years and decades ahead.

To Jamie, Grey, and Matthew Rubin, Marilyn and Richard Rubin, Carole and Bill Labell, and Isrella and Howard Abrams: I am deeply grateful for your lifetimes of love and support. To Kris Keggi, Michael Ehrlich, and Gary Friedlaender, I will be forever grateful for your mentorship and friendship. To Ed Akelman, Mary O’Connor, Ted Blaine, Jon Grauer, and Lisa Lattanza, thank you for believing in me and for helping to guide my personal and professional growth at every stage of my academic career. Lee E. Rubin, MD, FAAOS, FAAHKS, FAOA Dr. Kris Keggi and I conferred many years ago at a meeting and shared our vision of a book dedicated to anterior hip surgery. The first edition proved to be remarkably successful. Other books addressing anterior hip surgery have since appeared, a testimony to how a classic approach to the hip joint has been increasingly adopted in the modern era, thanks to new implants and instruments, a rich collaboration among peers, and the tireless dedication to teaching by pioneering surgeons, such as Drs. Joel Matta and Kris Keggi, to whom we owe a special debt of gratitude. On behalf of the editorial team, I want to convey a special thank you to Dr. Lee E. Rubin, who undertook the herculean task of updating the first edition of our book, even with his busy professional responsibilities. With Lee’s leadership, we expanded and updated the contents, while encompassing the experience and perspectives of international scholars into this 2nd edition. With new authors and section editors, this refreshed work should serve surgeons worldwide, and help improve patient outcomes. Since the first edition, while my career has taken new directions into law and corporate management, at heart I will always be an orthopaedic surgeon, and proudly so. No words can properly acknowledge the generous support and encouragement of my wonderful family, from parents, to children, and above all, my wonderful wife Dana. My gratitude and respect also go out to my fellowship mentor Dr. William Harris, and to the late Dr. Bill Allen at the University of Missouri, whose quiet guidance and support built my arthroplasty career, and sparked a lasting interest in ceramic biomaterials. B. Sonny Bal, MD, MBA, JD, PhD To my beloved wife, Pam, whose unwavering support has been the foundation upon which I have built my career and pursued my passion for orthopaedic surgery. Your constant encouragement, patience, and understanding have been my guiding light, and I dedicate this textbook to you. Thank you for being my rock and standing by my side throughout this journey. To my mentors, Drs. Louis Ripley, Bob Pruner, Gwo Wang and Les Borden, whose invaluable guidance and expertise shaped me into the orthopaedic surgeon I am today. Your wisdom, mentorship, and belief in my abilities were instrumental in my development and success. I am forever grateful for the opportunities you provided and the knowledge you imparted. This textbook is a testament to your dedication and commitment to the advancement of orthopaedic surgery, and this work is dedicated to your memory.

And finally, to my entire family, whose unconditional love and support have been a constant source of strength and motivation. This textbook is dedicated to you, as a token of my gratitude for your unwavering support and belief in my abilities. Joseph T. Moskal, MD, FAAOS, FAAHKS, FAOA, FACS Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

In Memoriam

grandfather Luda Bērziņš in Jūrmala, Latvia; established the “Keggi Velo,” a bike race in memory of his father; and was the founder of the Luda Bērziņš Prize. Keggi was the first surgeon to perform total hip arthroplasty using the minimally invasive anterior approach in the 1970s and published his early experi ences and case series for the scientific community. He is widely considered to be the pioneer, innovator, and advocate for the anterior approach in the United States. In 2016, Dr. Keggi collaborated with Drs. Sonny Bal and Lee E. Rubin to publish The Direct Anterior Approach to Hip Reconstruction . He was the recipient of multiple national and interna tional awards and four honorary doctorates. These have included the Latvian Order of the Three Stars in 1993, the V Class Order of the Estonian Red Cross in 1999, the Distinguished Service Medal of the Latvian Physicians Association (the second ever awarded) in 2009, and the Silver Medal of Medical Dignity and Service to Russian Medicine in 2012. He received the George H.W. Bush Lifetime of Leadership Award from Yale University in 2005. In 1994, the Pauls Stradiņš Museum of the History of Medicine and the Latvian Academy of the Sciences awarded him the Pauls Stradiņš Prize. Keggi is an Honorary Member of the Latvian Academy of Sciences (1990) and the Russian Academy of Sciences (1993), and holds honorary degrees from the Riga Stradiņš University (1997) and the University of Latvia (2009). He also received the 2019 Humanitarian Service Award from the Connecticut Orthopaedic Society. He is one of only two non-Russians inducted into the Russian Academy of Sciences for his prowess in medi cine. Keggi spoke six languages fluently, was captain of the Yale fencing team as an undergraduate, and later ran six marathons, competed in master’s rowing events, and was a passionate golfer. Over the course of his life, he nobly served many people and institutions. His work in a MASH unit in Vietnam, numerous contributions to the field of medicine in the United States and his native Latvia, and devotion to veterans were documented in his self-published 2022 memoir, My Century: A Memoir of

Kristaps Juris Keggi, MD

Kristaps Juris Keggi, MD, (1934 2023) was Professor Emeritus at the Yale University School of Medicine, Department of Orthopaedics & Rehabilitation. On July 4, 2023, he passed away peacefully and unex pectedly in his home at age 88. His extraordinary life began in Riga, Latvia on August 9, 1934, when he was born in the family

of surgeon Jānis and Ruta Kegi as the second of four brothers. His grandfather was folklorist, teacher, and pastor Ludis Bērziņš (1870-1965). During World War II, he fled with his family to Germany in 1944 then to the United States in 1949. He studied medicine at Yale University (1951-1959) and completed his surgical internship at the Roosevelt Hospital in New York fol lowed by Residency in Orthopaedic Surgery at Yale-New Haven Hospital in 1965. From 1965 to 1966, he partic ipated in the Vietnam War as a military surgeon, and was stationed with the 173rd Airborne as Chief of Surgery at the 3rd Mobile Army Surgical Hospital in Biên Hòa, Vietnam. In 1966, he rejoined the Yale University faculty as an assistant professor. Dr. Keggi was in clinical practice from 1966 through 2016, performing orthopaedic surgery at both St. Mary’s Hospital (1969-1989) and Waterbury Hospital (1969 2018). He served as the director of Waterbury Hospital’s Orthopaedic Center for Joint Reconstruction and as a Senior Research Scientist at the Yale School of Medicine during that time. In 1989, Dr. Keggi became a Clinical Professor of Orthopaedics & Rehabilitation at Yale University, was elected full professor in the Department at Yale in 2008, was named Elihu Professor of Orthopaedics and Rehabilitation in 2010, and retired from clinical practice to become a Professor Emeritus on December 31, 2016. Since 1987, he regularly visited Latvia, where he per formed demonstration operations, conducted seminars, and delivered numerous lectures both in Latvia and the surrounding Baltic Nations. In 1988, he founded the nonprofit Keggi Orthopaedic Foundation to allow for formal academic exchanges between the United States and the USSR. The organization provided fellowships in advanced orthopaedic surgery at both the Yale School of Medicine and Waterbury Hospital for more than 300 surgeons from the Baltic nations, Russia, and Vietnam. In 1990, he founded the memorial museum of his

War, Peace, and Pioneering in the Operating Room . His life as husband, father, father-in-law, and grandfa ther were also extraordinary. The last few weeks of his life were filled with family activities and events. He attended the college graduation of his twin grandsons, Alexander and Christopher Ford from Fairfield University and the wedding of his granddaughter Julia Hunter in New Orleans. Although no longer able to play golf, he Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

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continued to enjoy his affiliations with the Country Club of Waterbury and Highfield. He was thinking about retiring but maintained that working was his lifestyle of choice. He remained an active father, grandfather, teacher, mentor, healer, and inspiration to all who were fortunate enough to know him. Keggi was preceded in death in March 2022 by his beloved wife of 64 years, Julia Grant Quarles. The couple first met on the steps of Buckingham Palace in London during a tour of Europe in the 1950s. They were

married a year later and ultimately moved to Middlebury, Connecticut in 1969, where Kris and Julie became pil lars of the Middlebury Congregational Church and their broader community. Kris and Julie are survived by their three daughters Catherine Keggi Hunter (Howard), Mara Keggi Ford (Donald), Caroline Saunders Keggi (Connie Wilson) and five grandchildren George Quarles Hunter (Caitlion), Julia Hunter Bookman (Zachary), Christopher Daly Ford, Alexander Walden Ford, and Eliza Hannah Ford.

About the Editors

orthopaedic journals and has published over 140 peer-re viewed scientific articles and book chapters. Dr. Rubin is one of the world’s leading experts in the minimally invasive direct anterior approach (DAA) technique, has been an invited lecturer on multiple con tinents, and has been an invited faculty member for the International Congress for Joint Reconstruction’s Annual DAA Course and the International Master’s Anterior Course for the past 13 years. In 2016, he published the world’s first comprehensive book on anterior hip surgery, The Direct Anterior Approach to Hip Reconstruction , which quickly became a landmark reference used by surgeons around the world, with the second edition of this text reaching print in 2024. Dr. Rubin resides in Connecticut with his wife Jamie along with their two children, and their two rescued beagle mix dogs.

EDITOR-IN-CHIEF Lee E. Rubin, MD, FAAOS, FAAHKS, FAOA

Lee Eric Rubin, MD, is a fellow ship trained, board-certified ortho paedic surgeon, who currently serves as an Associate Professor of Orthopaedics & Rehabilitation with Yale Medicine and the Yale University School of Medicine in New Haven, Connecticut. Originally from New Jersey, Dr. Rubin matriculated as a Presidential

Scholar at Brandeis University and graduated cum laude in 2000. He then graduated with Alpha Omega Alpha distinction from the Tufts University School of Medicine in 2004 and completed Orthopaedic Surgery Residency training at Yale in 2009. This was followed by an adult reconstruction fellowship in 2010 with Dr. Kristaps J. Keggi and the Keggi Orthopaedic Foundation at the Waterbury Hospital in Connecticut. Dr. Rubin spent 5 years in practice with University Orthopedics, Inc. and Lifespan, while serving as Assistant Professor of Orthopaedic Surgery on the fac ulty of the Warren Alpert Medical School of Brown University in Providence, Rhode Island. In this role from 2011 to 2016, he was actively engaged at The Miriam Hospital’s Total Joint Center and was the Rhode Island Arthritis Foundation Chapter’s “Medical Honoree” at the Providence Walk to Cure Arthritis event in 2015. At age 35, Dr. Rubin was selected as one of the “Forty Under 40” by the Providence Business News, becoming the first orthopaedic surgeon to win this honor in Rhode Island. In late 2016, Dr. Rubin was appointed as the Section Chief for Yale University’s Division of Adult Reconstruction and as the Chief of the Yale New Haven Hospital’s Total Joint Replacement Program. He later became the founding Program Director for the Yale Arthroplasty Fellowship, which commenced in August 2021. He was selected as one of Castle Connolly’s & Connecticut Magazine’s in 2019, 2020, 2022, 2023, and 2024. Academically, he has served as a reviewer and editorial board member for a number of prestigious

SENIOR EDITORS B. Sonny Bal, MD, MBA, JD, PhD

Dr. Sonny Bal served as Professor of Orthopaedic Surgery and Adjunct Professor of Material Sciences at the University of Missouri, with over 25 years of clinical experience as an orthopaedic surgeon, and consulting attorney. Dr. Bal has an extensive background in research, with multiple publications in peer- reviewed journals.

Dr. Bal was appointed to the Board of Directors of SINTX Technologies in 2012, and currently serves as the CEO and President of that organization. Most recently, Dr. Bal has served on the Board of Trustees of the OREF (Orthopaedic Research and Education Foundation). He earned his MD from Cornell University along with an MBA from Northwestern University, JD from the University of Missouri, and a PhD in Materials Engineering from the Kyoto Institute of Technology in Japan. He completed his Adult Reconstruction Fellowship at Harvard Medical School with Dr. William Harris in Boston, Massachusetts. Dr. Bal lives in Columbia, Missouri with his wife and four children. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

About the Editors

Joseph T. Moskal, MD, FAAOS, FAAHKS, FAOA, FACS

ASSOCIATE EDITORS H. John Cooper, MD

Joseph T. Moskal, MD, is a native of Brooklyn, New York. He received his BA from the State University of New York at Binghamton, graduat ing summa cum laude and elected to the prestigious Phi Beta Kappa honor society. After receiving his medical degree from Washington University School of Medicine in St. Louis, Missouri, he completed

Dr. Cooper is an associate professor of orthopaedic surgery at Columbia University Irving Medical Center in New York City, with a busy clinical practice focusing on ante rior approach hip arthroplasty and complex anterior revision surgery. An active educator and researcher, he has published over 130 peer-re viewed articles and book chapters

his orthopaedic residency at the University of Virginia Medical Center. He then completed his fellowship in Adult Reconstruction and Total Joint Replacement at the Cleveland Clinic, followed by an Orthopaedic Traumatology fellowship at the Maryland Institute for Emergency Medical Services System in Baltimore. Dr. Moskal joined the medical staff of Carilion Roanoke Memorial Hospital in 1988. He currently serves as chair of the Department of Orthopaedic Surgery and chief of Adult Reconstruction at Carilion Clinic in Roanoke, Virginia. He is also chair and pro fessor of the Department of Orthopaedic Surgery at Virginia Tech Carilion School of Medicine, and associate professor at the University of Virginia Medical School and the Edward Via College of Osteopathic Medicine. He has trained numerous orthopaedic surgery resi dents and more than 25 fellows in adult reconstruction. His multiple honors and awards include membership to Alpha Omega Alpha, the University of Virginia Resident Teaching Award, the Virginia Orthopaedic Society Lifetime Achievement Award, and the American Academy of Orthopaedic Surgery (AAOS) Achievement Award. He is a Fellow of the AAOS, a Fellow of the American Association of Hip and Knee Surgeons (AAHKS), past chair of the AAOS Exhibits Committee, and past chair of the Education Committee for AAHKS. He served as chair and faculty member of the International Congress for Joint Reconstruction Direct Anterior Approach Total Hip Meeting for the past 11 years. Dr. Moskal is the current inaugural co-chair of the International Masters Anterior Course. He is also a member of both the Hip Society and the Knee Society, the highest honors bestowed upon an orthopaedic surgeon in adult reconstruction. Dr. Moskal has authored over 140 publications in ref ereed journals, over 40 published abstracts, and serves as a reviewer for several prestigious orthopaedic jour nals. In addition, he has contributed to over 40 scien tific exhibits at national and international meetings. He is a highly respected teacher, having been invited to be a guest speaker, faculty member, and instructor at both national and international meetings. Dr. Moskal and his wife, Pam, have four children, one grandchild and reside in Roanoke, Virginia.

and regularly participates in national and international meetings. Originally from South Carolina, Dr. Cooper graduated from Duke University with a degree in mechanical engineering and materials science, and then completed his medical education at Columbia University, residency at Lenox Hill Hospital, and fellowship at Rush University Medical Center. Kristoff Corten, MD, PhD

Prof. Dr. Kristoff Corten is a fel lowship trained surgeon who spe cializes in reconstructive surgery of the hip joint. He focused on mus cle-sparing surgery of the hip joint, both for joint preservative and for joint reconstructive procedures. During his doctoral research, he focused on the anatomy of the cap sular releases of the direct anterior

approach. He conducted cadaver and clinical research on the efficient direct anterior (EDA) hip procedure. Prof. Dr. Corten optimized the OR-setting of the DAA. He focused on teamwork, instrument tray reduction, and process optimization. He developed the “Efficient SurgerY” (ESY) concept of which parallel processing is the most important key feature. Prof. Dr. Corten welcomes hundreds of visiting surgeons from all over the world. He is (co-)author of over 80 scientific papers and textbook chapters. He is an invited speaker at many world class meetings. Jeremy M. Gililland, MD, FAAOS, FAAHKS

Dr. Jeremy M. Gililland is fellow ship trained in adult reconstruc tive orthopaedic surgery of the hip and knee, with a focus on direct anterior total hip arthroplasty and revision hip and knee arthroplasty procedures. Prior to his medi cal education, Dr. Gililland stud ied Mechanical Engineering and Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

About the Editors

this background led him to the field of Orthopaedic Surgery, and more specifically into the specialty of total joint arthroplasty. He is now an associate professor of Orthopaedic Surgery at the University of Utah and enjoys training residents and fellows in adult reconstruction. Dr. Gililland’s research interests are focused on the biomechanics of hip and knee replacements, revision joint replacement techniques, the use of intraoperative fluoroscopy to improve implant positioning, and peri prosthetic joint infection. His efforts have resulted in the development of a fluoroscopic navigation system to combat the problem of distortion, and development of a collaborative team of researchers aimed at exploring the heritable risk of periprosthetic joint infections. He has published over 100 papers and book chapters and enjoys teaching on the national and international stage. Theodore Manson, MD, MS

or infections around existing hip and knee replacements and directed the Maryland Statewide Referral System for these patients. He also had a hip and knee replacement practice at St Joseph’s Hospital during this time. Dr. Manson now limits his practice to patients with arthritis and provides treatments ranging from early treatments for arthritis to joint replacement surgery. His research interests include complex revision hip replace ment, periprosthetic fractures, and rapid recovery proto cols following hip and knee surgery. J. Bohannon Mason, MD

J. Bohannon Mason, MD, is an attending surgeon at OrthoCarolina Hip and Knee Center and Professor of Orthopedic Surgery at Atrium Musculoskeletal Institute in Charlotte, North Carolina. He was the Thomas Savage award recipi ent as the most outstanding med ical student in his class at Medical

Dr. Manson received his medi cal degree from Northwestern University School of Medicine and completed his residency in orthopaedic surgery at the Johns Hopkins Hospital. He pursued an additional year of advanced training in the management of complex frac tures at the R Adams Cowley Shock Trauma Center in Baltimore. He

University of South Carolina and completed his intern ship and residency at Duke University Medical Center. He was an Otto Aufranc Fellow in adult reconstructive surgery at New England Baptist Hospital before joining Charlotte Orthopedic Specialists in Charlotte, a predi cate organization to OrthoCarolina, where he continues to practice.

followed with an additional one-year fellowship in total joint replacement at the Hospital for Special Surgery in New York, where he trained in minimally invasive joint replacement, revision joint replacement, and hip and knee surgery. From 2009 to 2019 Dr. Manson was an ortho paedic trauma surgeon at the R Adams Cowley Shock Trauma Center and cared for patients with complex frac tures and multisystem trauma. In addition, he cared for patients from Maryland, Pennsylvania, Delaware, and West Virginia who were referred for complex fractures Dr. Mason has spent more than 20 years in the study and pursuit of tissue-sparing reconstructive surgery of the hip, with particular focus on direct anterior, and has authored numerous studies and delivered more than 150 lectures on related topics. His research interests have focused on early recovery following direct anterior total hip arthroplasty, component orientation, exposure techniques, and the contribution of capsule structures to total hip arthroplasty stability. His influence on the field is additionally expanded through the education of visit ing surgeons, residents, and fellows. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

Foreword

In his recent book Innovators , Walter Isaacson describes some of the common characteristics of inno vators and innovations. Based on my understanding, and I could be mis taken of course, an idea or a product will be considered as a true innova tion only if it improves on the state of the art and provides better life for

endovascular surgery, mostly vascular and cardiac sur geons, have now found themselves in the middle of a shrinking subspecialty. Their skill to handle a #10 knife is not required any more. Interventional radiologists/ cardiologists have come to celebrate the birth of a new profession, and, once again, the patients are the benefi ciaries of these innovations. I realize that to some performing a total hip arthro plasty through the direct anterior approach (DAA) may not be seem as great of a leap as laparoscopic or endovascular surgery. However, one common denomi nator between these innovations does clearly exist. The innovators in orthopaedics also wished to depart from an imperfect status quo. They strived to elevate the pro fession to a different height. Be it the continued limp after direct lateral approach, the high dislocation rate after posterior approach, or whatever the other issues were with the status quo, the innovators chose to travel a different journey. I started performing DAA hip arthroplasty in 2005. I soon realized the difference in outcomes that our patients experienced. I was convinced it was the right solution to many problems, and I set out to perfect the technique in my operating room. I was a proponent of the technique and did not shy away from expressing such devotion. I recall a heated debate in a meeting in Brazil. My opponent, a well-known and respected surgeon and ex-president of the American Academy of Orthopaedic Surgeons, decided to use mockery to argue his points. The moderator of the session, also an ex-president of the American Academy of Orthopaedic Surgeons and clearly not aware of his responsibility of remaining neutral to the debate, also resorted to “humor” to stress his points. I walked off the stage feeling defeated but further devoted to the cause. The DAA has stood the test of time. Based on the 2018 American Association of Hip and Knee Surgeons audience survey, over 40% of surgeon members were using the DAA as their preferred approach for total hip arthroplasty, with the numbers increasing yearly. Over 80% of the adult reconstruction fellows that we gradu ate now embrace the DAA and use it routinely on their patients. The early trickle of high-quality publications that demonstrate the superiority of DAA has now gained cadence and force in the literature.

the beneficiaries/users. Of course, not every innovation fulfills those criteria from the day it is launched. Every innovation undergoes many refinements and modifica tions. Only those that fulfill these criteria survive. I was an intern (house officer) in the United Kingdom when the first laparoscopic cholecystectomy was being performed. I remember we had all lined up to watch the surgery from the “gallery.” The procedure took 4.5 hours and calling the surgery smooth would be far from the truth. The patient stayed in the hospital for 11 days because she had developed postoperative ileus. The ini tial experience with laparoscopic procedures was far from perfect. The numerous “new” complications such as clip ping of bile ducts, liver laceration, and others were being described in case reports and case series. I recall watch ing debates on the podium, with one opponent of lap aroscopic cholecystectomy calling the procedure “a gift from hell.” The opponents of laparoscopy had the upper hand early on. The audience clapped and applauded the opponents of the procedure, and for the most part, the debates were considered a total win for those who opposed laparoscopic techniques. The concept and what it could bring to the patients was clearly a huge milestone in modern medicine. The innovators, those without fear, persevered and contin ued to innovate. They were able to divorce themselves from the emotions and seek a journey that would depart from the status quo. We all know where that story ends. Today, laparoscopic cholecystectomy is performed rou tinely as an outpatient procedure, and the lengthy sub costal incisions or the continued incisional pain is a phenomenon of the past. In fact, laparoscopic technique has become the new “standard of care” in general sur gery for nephrectomy, colectomy, bariatric surgery, and many other operations. There are many examples of such accomplish ments and quantum leaps in medicine and surgery. Endovascular technique is another such example. The disruptive nature of endovascular innovations changed the balance of surgical specialties. Many skeptics of

Even podium debates do not appear to be one sided any more. Many former opponents of the technique now realize the value of this surgical approach. In fact, many established surgeons have converted their practice to use Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

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the DAA to the hip, with reasoning discussed in detail by four expert surgeons in Chapter 3 within the first section of this textbook. Our informed patients continue to seek out surgeons who use this anatomic approach to the hip. The DAA in the world of hip reconstruction, much like laparoscopy and endovascular techniques in surgery, is here to stay. I want to congratulate Drs. Bal, Moskal, and Rubin for putting together this second-edition textbook publi cation. In doing so, they have compiled a great collection of chapters written by authorities in the field that captures

the broad value of the DAA for total hip arthroplasty. This scholarly work comprehensively presents unbiased and valuable perspectives related to the DAA to the hip. I am excited to have a copy of the book on my shelf. Our profession remains indebted to innovators who strive to better the lives of our patients. Javad Parvizi, MD, FRCS Sidney Kimmel School of Medicine Rothman Institute at Thomas Jefferson University Philadelphia, Pennsylvania

Contents

9. Direct Anterior Approach With Modular Table Attachment and Traction Boot . . . . . . . . . 68 Amir Pourmoghaddam; Adam M. Freedhand; Roy I. Davidovitch; and Stefan W. Kreuzer 10. Direct Anterior Approach With the Mizuho OSI Hana Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Steven Mennona; Andrzej Brzezinski; and Stephen Kayiaros 11. Direct Anterior Approach in the Lateral Decubitus Position . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Erik J. Hansen; Benjamin R. Coobs; and John C. Clohisy 12. The Bikini Incision for the Direct Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Jenaro A. Fernández-Valencia; Patrick Weinrauch; Hannes A. Rüdiger; and Michael Leunig 13. Transitioning From Traction to No Traction With the Direct Anterior Approach . . . . . . . . . . 101 Trevor M. Owen

Dedication v In Memoriam vii About the Editors ix Foreword xii Contributing Authors xiv

Section I Introduction SECTION EDITOR: B. Sonny Bal 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Kristaps J. Keggi 2. A Definitive History of the Direct Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 David A. Molho; Neil Pathak; Lee E. Rubin; and Kristaps J. Keggi 3. Why I Switched to the Direct Anterior Approach: Expert Practice Perspectives From Leading Surgeons . . . . . . . . . . . . . . . . . . . . . . 20 William J. Hozack; Keith R. Berend; Jose A. Rodriguez; and Neil P. Sheth Section II Fundamental Direct Anterior Approach Topics SECTION EDITOR: Jeremy M. Gililland 4. Surgical Anatomy of the Anterior Hip and Thigh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 John V. Horberg and Benjamin R. Coobs 5. Indications for the Direct Anterior Approach . . . 37 Kevin Campbell and Christopher E. Pelt 6. Direct Anterior Approach for Hip Replacement: The Learning Curve . . . . . . . . . . . . 44 Hari P. Bezwada 7. Training and Education for the Direct Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Jose A. Rodriguez; Tim P. Lovell; John F. Sloboda; and Joseph T. Moskal 8. Supine Direct Anterior Approach Technique Without Traction . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Section III Intermediate Direct Anterior Approach Topics SECTION EDITOR: H. John Cooper 14. Role of Fluoroscopic Imaging

and Image Guidance . . . . . . . . . . . . . . . . . . . . . . . 109 Preetesh D. Patel; Preston W. Grieco; Jeremy M. Gililland; and Trevor M. Owen 15. Managing Obesity in the Direct Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Andrew Poole; Mazin Ibrahim; Jason Thompson; and Brent Lanting 16. Robotic-Assisted and Computer Navigation in the Direct Anterior Approach . . . . . . . . . . . . 127 David R. Maldonado; Matthew S. Hepinstall; and Benjamin G. Domb 17. Simultaneous Bilateral Direct Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . 136 Juan C. Suarez and Saul Hernandez Rodriguez 18. Avoiding Intraoperative Femur Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Devin Walsh; Anand Patel; Matthew E. Deren; and Eric M. Cohen Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

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19. Cementing the Femoral Stem Using the Direct Anterior Approach: Indications and Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Joseph T. Moskal; Christopher J. Betzle; and John F. Sloboda 20. Direct Anterior Approach in the Lumbar-Sacral Fusion Patient: EOS Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Jenna A. Bernstein; Roy I. Davidovitch; Aaron J. Buckland; and James Slover 21. Direct Anterior Approach in the Young, High-Demand Patient . . . . . . . . . . . . . . . . . . . . . . 175 Jaime L. Bellamy and Dustin J. Schuett Section IV Advanced/Revision Surgery Topics SECTION EDITOR: Kristoff Corten 22. A Modified Extensile Anterior Approach to the Acetabulum and Anterior Column . . . . 183 Kristoff Corten and Joseph T. Moskal 23. Direct Anterior Approach and Its Distal Extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 Michael Nogler and Martin Thaler 24. Head and Liner Revision Surgery via the Direct Anterior Approach . . . . . . . . . . . . . . . . . . 197 Diren Arsoy; Eric M. Cohen; and Lee E. Rubin 25. Removal of the Acetabular Component Through the Direct Anterior Approach . . . . . . 203 Michael Huo; Joel Wells; Peteris Studers; and Ronald Driesen 26. Acetabular Augments, Cage Reconstructions, andCustomTriflanges. . . . . . . . . . . . . . . . . . . . . .209 Lucas Anderson; Steven Donohoe; J. Bohannon Mason; and John L. Masonis 27. Management of Recurrent Instability via the Direct Anterior Approach . . . . . . . . . . . . . . . 219 Nathan Haile; Timothy Kahn; and Jeremy M. Gililland 28. Hip Arthrodesis Takedown via the Direct Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . 227 Kristoff Corten and Cigdem Sarac 29. Hip Resection Arthroplasty via the Direct Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . 235 Murillo Adrados and Lee E. Rubin 30. Replacing the Dysplastic Hip via the Direct Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . 241 John L. Masonis; Frederick Laude; J. Bohannon Mason; and Mark Hood

31. Femoral and Acetabular Osteotomies for the Direct Anterior Approach . . . . . . . . . . . 248 Martin Thaler and Michael Nogler Section V Application of the Direct Anterior Approach Across Orthopedic Specialties SECTION EDITOR: Theodore Manson 32. Trauma: The Use of the Direct Anterior Approach for Hip Fractures . . . . . . . . . . . . . . . . . 257 Gil Ortega; Holly Pilson; Kurtis Staples; and Matthew Baron 33. Trauma: Acetabular Fractures and Pelvic Discontinuity via the Direct Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .268 Theodore Manson 34. Trauma: Conversion of Prior Acetabular and Femoral Surgery via the Direct Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . 277 Michael P. Leslie 35. Trauma: Hip Hemiarthroplasty via the Direct Anterior Approach for Geriatric Fractures . . . . . . . . . . . . . . . . . . . . . . . . . 288 Justin Kuether; Jordan Brand; David A. Molho; and Lee E. Rubin 36. Pediatric Orthopaedics: Use of the Direct Anterior Approach in Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . 296 Adam Y. Nasreddine; David B. Frumberg; and Michael B. Millis 37. Hip Preservation: Surgical Techniques via the Hueter Anterior Approach . . . . . . . . . . . . . . 304 Kenneth Milligan; Paul Beaule; and Frederick Laude 38. Oncology: Tumor Reconstruction of the Hip and Proximal Femur With the Direct Anterior Approach . . . . . . . . . . . . . . . . . . 313 Herrick J. Siegel and Daniel C. Allison 39. Sports Medicine: Mini-Open Direct

Anterior Approach, Management of Femoroacetabular Impingement, and Open-Assisted Arthroscopic Management . . . 320 Elizabeth G. Lieberman; Benjamin R. Coobs; and John C. Clohisy 40. Physical Therapy: Updated Guidelines, Protocols, Restrictions, and Telerehabilitation 325 Sarvang (Sam) Dalal; Stefan W. Kreuzer; and Amir Pourmoghaddam Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

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Section VI Outpatient Arthroplasty and Case Efficiency Using the Direct Anterior Approach SECTION EDITOR: Lee E. Rubin 41. Defining Same-Day Criteria: Knowing When to Change Course . . . . . . . . . . . . . . . . . . . 339 Logan Cooper and Tyler D. Goldberg 42. Multimodal Pain Control, Enhanced Recovery After Surgery, and Rapid Recovery Protocols for the Direct Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . 348 Adam E. Roy; Antonia F. Chen; and Vivek M. Shah 43. Anesthesia and Regional Blockade Techniques for the Direct Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .360 Jinlei Li; Ramya Krishnan; Adriana D. Oprea; and Edward R. Mariano 44. Highly Efficient Direct Anterior Approach: The Pathway to Outpatient Hip Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371 David A. Crawford; Keith R. Berend; and Adolph V. Lombardi Jr 45. Operating Room Efficiency for Preparation, Drape, and Room Utilization With the Direct Anterior Approach . . . . . . . . . . . . . . . . . . 380 Kristoff Corten; Christophe Olyslaegers; and Admir Hadzic 46. Self-Sufficiency for the Direct Anterior Approach: Using Self-Retaining Retractor Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395 Christopher A. Schneble; Trevor M. Owen; Mark J. Powers; and Lee E. Rubin 47. Designing Outpatient Program and Perioperative Support Resources . . . . . . . . . . . . 403 Vivek Singh; Simon Greenbaum; and Roy I. Davidovitch Section VII Literature and Outcomes SECTION EDITOR: J. Bohannon Mason 48. Update on Direct Anterior Approach Literature in 2020 . . . . . . . . . . . . . . . . . . . . . . . . . . 415 Tim P. Lovell; Sebastian Heaven; and Javad Parvizi 49. Direct Anterior Approach Outcome Trends From National Databases . . . . . . . . . . . . . . . . . . . 424 Beau J. Kildow; Joseph M. Statz; and J. Bohannon Mason

50. Patient-Reported Outcomes With the Direct Anterior Approach . . . . . . . . . . . . . . . 431 Wayne Moschetti; Alexander Orem; Samuel Kunkel; and David Jevsevar 51. Delivering “The Patient Experience” With the Direct Anterior Approach . . . . . . . . . . 441 Maiken Jacobs; Matthew M. Levitsky; Jeffrey A. Geller; and Roshan P. Shah 52. Economics, Cost Considerations, and Strategic Program Development Using the Direct Anterior Approach . . . . . . . . . . . . . . . 448 Atul F. Kamath; Linsen T. Samuel; and Mark Froimson Section VIII Future Directions and Conclusion SECTION EDITOR: Joseph T. Moskal 53. Evolution of Stem Design and Direct Anterior Approach–Specific Technologies . . . 461 Robert A. Sershon; Eric M. Cohen; Tyler D. Goldberg; and William G. Hamilton 54. Direct Anterior Approach Research Trends . . . 469 Ajay Premkumar; Edwin P. Su; Bradford S. Waddell; and Alexander S. McLawhorn 55. Legal Liability in Adopting New Technologies in Clinical Practice . . . . . . . . . . . . 480 B. Sonny Bal 56. The Australian Experience: Evaluating Approach-Based Outcomes . . . . . . . . . . . . . . . . 487 Sarah O’Reilly-Harbidge 57. The Costa Rican Experience: Incorporating the Direct Anterior Approach in Global Surgery Practice . . . . . . . . . . . . . . . . . . . . . . . . . . 496 Carlos Ovares-Arroyo; Hari P. Bezwada; and Jimmy Angulo De La O 58. The Indian Direct Anterior Approach Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .505 Rajesh Malhotra; Deepak Gautam; and Sahil Batra 59. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515 Lee E. Rubin; B. Sonny Bal; and Joseph T. Moskal

Role of Fluoroscopic Imaging and Image Guidance Preetesh D. Patel, Preston W. Grieco, Jeremy M. Gililland, and Trevor M. Owen

it is necessary to move that individual before bringing in the unit to obtain imaging. Standard plastic draping of the unit is used; however, it is helpful to add additional sterile draping over the body of the unit to prevent contamina tion of the side of the surgical field. The latch allowing the unit to be rolled to the lateral view is not needed and thus can be covered with this draping. The unit is positioned perpendicular to the patient and can be tilted cranially or caudally to adjust for pelvic tilt. Specialized tables such as the Hana table (Mizuho OSI) can easily accommodate a fluoroscopic unit. However, if using a standard operating room table, one must ensure that the base of the table is positioned such that it does not interfere with the path of the unit and an acceptable pelvis image can be obtained. Other equipment such as electrocautery and suction can be placed at the proximal aspect of the patient on the non operative side to minimize their interference. Technical Tips for Fluoroscopy Image intensifiers can be used throughout the DAA THA surgical procedure to confirm or improve on surgi cal steps. This can be performed with or without special surgical tables or attachments based on surgeon prefer ence. The key steps on how to properly incorporate fluo roscopy to the DAA THA are as follows. Before the procedure, the patient’s leg length discrep ancy (LLD) is assessed. The medial malleoli can be used as a reference and have been established as a valid and reliable landmark for measure. 1 True leg length is a complex interaction between soft tissues, bones, and implants. One must consider any knee and hip contrac tures as well as spinal deformity with subsequent pelvic obliquity when determining the true LLD. The physi cal assessment can then be compared with the patient’s perceived LLD, and a planned limb length correction is formulated. It is our routine practice to ask the patient before surgery of any perceived LLD. Preprocedural Physical Assessment of the Patient’s Leg Length Discrepancy

Key Learning Points ◆ Understand the use (including advantages and limitations) of fluoroscopic imaging and image guidance during a direct anterior approach (DAA) in total hip arthroplasty (THA). ◆ Identify pitfalls as well as tips and tricks when utilizing fluoroscopic imaging. Introduction Accurate component positioning is of the utmost impor tance in THA. Malpositioned implants can lead to dis location, impingement, wear, and early failure. One frequently discussed advantage of the DAA in the supine position is the ease with which fluoroscopic imaging can be used to aid in component positioning, component sizing, assessment of leg length, and offset and to iden tify intraoperative complications such as canal perfora tion or fracture. This visual feedback is provided in real time, and adjustments can be made to improve the final implant position. With the patient in a supine position on a radiolucent table, the pelvis and hip are in an ideal position to obtain routine anteroposterior (AP) imaging with minimal interference from the fluoroscopy unit. This contrasts with procedures performed in the lateral position where the pelvis can roll forward or backward and imaging requires the fluoroscopy unit to be rotated 90°, leading to difficulty accessing the operative field. Equipment and Operating Room Setup Fluoroscopy units come in many configurations and sizes with common image intensifier sizes of 9 and 12 in. We recommend using the larger 12-in units because these will typically allow the surgeon to visualize the entire pelvis on the AP view, providing the most data for the assessment of component positioning, leg length, and offset. Patients with a large body habitus may limit the ability to obtain a full AP pelvis even on the larger units because the image intensifier cannot be brought close enough to the pelvis without impinging on soft tissue. Similarly, anteriorly placed retractors can also limit the ability to bring the unit low enough to obtain the desired view and obscure the hip as well. The fluoroscopy unit is positioned on the nonoperative side of the patient and can be brought in over the patient, limiting interference with the surgical team. If an assistant is used on this side of the table (ie, the nonoperative side),

Preprocedural Fluoroscopy (Pelvic Tilt, Pelvic Rotation, and Leg Length) Once the patient is positioned on the preferred operat ing table, fluoroscopy is performed. An AP pelvis image Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

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