The Direct Anterior Approach to Hip Reconstruction

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

xii