The Direct Anterior Approach to Hip Reconstruction

CHAPTER 44 Highly Efficient Direct Anterior Approach: The Pathway to Outpatient Hip Replacement 377

Outcomes We have published numerous articles on our experience with standard table DAA THA. 5-9 In our first publication on this topic in 2009, we found that compared with the less invasive direct lateral approach, the DAA resulted in significantly more patients discharging to home (rather than a skilled nursing facility), significantly higher Harris Hip Scores, and higher lower extremity activity scale scores at 6 weeks postoperatively. 5 In looking at differ ences in acetabular component positioning between these same two approaches by a single surgeon at our institution, we found that the DAA had significantly better component position with less abduction, antever sion, and medialization outliers than the direct lateral approach. 7 In a subsequent publication, we focused on complications and reoperations in 1035 consecutive DAA THAs. A majority of these procedures (95.3%) were primary THA cases followed by revision procedures (4.3%), resurfacing arthroplasties (0.2%), and conver sions of failed open reduction and internal fixation for femoral fractures (0.2%). The overall transfusion rate was 5%. There were 3 (0.3%) intraoperative calcar cracks and 1 canal (0.1%) perforation, all of which were treated with cerclage cables. Six (0.6%) wound complications required debridement, 4 (0.4%) lateral femoral cutaneous nerve paresthesia cases had not resolved at 12 months postop eratively, and there was 1 (0.1%) case of femoral nerve palsy. At up to 56 months after surgery, there were 25 revisions (2.4%). 6 The described DAA approach has shown great suc cess as we have transitioned to primarily outpatient THA. In 2018, we reported on 1472 outpatient THA procedures at a freestanding ambulatory surgery center. Overall, there was a 3.3% overnight stay for medical rea sons, 0.3% incidence of major complication within 48 hours, and 2.2% of patients requiring unplanned care. 8 Furthermore, the described highly efficient DAA tech nique can also be successful in selected cases for outpa tient revision hip arthroplasty. 7 Femoral exposure tends to be the most difficult part of becoming proficient in the DAA, with resulting muscle damage of the TFL being one of the complications of gain ing exposure. We analyzed patient factors that affect the risk of muscle damage in DAA THA and found that increas ing body mass index and male sex are both significant risk factors for muscle damage. Furthermore, as body mass index increased, shorter stem designs resulted in less muscle damage. 10 Even so, the DAA approach likely still results in less muscle damage than other approaches. In an analysis by Bergin et al 12 evaluating the serum markers of muscle damage, they found that creatinine kinase levels were 5.5 times higher after the mini-posterior approach compared with the DAA. Similarly, Bremer et al 13 used magnetic resonance imaging to evaluate soft tissue damage to the abductor musculature of patients 1 year after a DAA-based

FIGURE 44.10 Leg length equality can be easily assessed using direct comparison.

component. After the final components are implanted, the operating table is returned to the flat position, the final cotton stockinette is removed from the leg, and a new sterile impervious split drape is placed over the table for closure. Wound Closure The hip is thoroughly irrigated, 1 g vancomycin pow der is placed deep in the wound, and the periarticular injection is performed. The TFL fascia and subcutane ous tissue are then closed using 0-0 knotless, barbed monofilament suture. The skin is closed in a subcuticular fashion using 2-0 knotless, barbed monofilament suture and cyanoacrylate tissue adhesive. The incision is covered with a clear adhesive dressing. Postoperative Care and Rehabilitation Patients are discharged from the hospital or outpatient surgery center when they have accomplished physical therapy goals, pain is controlled, and they are tolerating oral intake. With the use of a rapid recovery protocol, 12 approximately 94% of our patients are now discharged on the day of surgery. 9 Patients may shower immediately and can remove their clear dressing in 3 to 5 days. A walker is used for assistance with ambulation for approximately 2 weeks, and then they may transition to a cane for 2 more weeks. At that point, they may ambulate without any assistance.

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