The Direct Anterior Approach to Hip Reconstruction

CHAPTER 44 Highly Efficient Direct Anterior Approach: The Pathway to Outpatient Hip Replacement 373

Once the proximal deep fascia is split, a large Hohmann retractor is placed outside the capsule over the superior femoral neck. The blunt cobra retractor is then used to tease the indirect or “reflected” head of the rectus femoris off of the anterior capsule and then is slid deep to it around the inferior femoral neck. We leave the reflected tendon intact whenever possible. Care should be taken in this step not to pierce through the rectus muscle because this may place the femoral nerve at risk of injury. The DeWitte retractor is then placed deep to the rectus tendon on the anterior acetabular rim. The anterior capsule should be exposed at this point. A FIGURE 44.1 The patient is positioned supine on a standard radiolucent operating table with an extender (Steris 3080-R Amsco Surgical Table), and the pubic symphysis is aligned over the break in the table.

thorough anterior capsulectomy is then performed using electrocautery, and the retractors are moved intracapsu larly around the femoral neck. Neck Osteotomy and Femoral Head Extraction With the femoral neck exposed, the saw blade is placed at the templated neck resection level and checked fluoro scopically ( Figure 44.6 ). Ensure the leg is in neutral rotation FIGURE 44.2 With the drape cut on the operative side to uncover the ASIS and anterior thigh, a sterile iodoform drape is folded on the nonsticky side and applied posteriorly to seal off the buttocks, posterior thigh, and groin on the operative side. A second sterile iodoform drape is placed anteriorly to allow for a secure seal and free mobility of the limb.

A FIGURE 44.3 A, The ASIS is identified and used as a reference for positioning of the skin incision. Using the skin marker, a line is drawn from the ASIS to the center of the patella. The incision commences two fingerbreadths distal and two fingerbreadths lateral to the ASIS and is made parallel to a line drawn from the ASIS to the center of the patella for 8 to 10 cm distally. B, Fluoroscopic guidance is used to check positioning and draw a line along the superior aspect of the femoral neck. This line should bisect the previously marked incision at the junction of the distal one-third and the proximal one-third. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024 B