The Direct Anterior Approach to Hip Reconstruction

SECTION VI Outpatient Arthroplasty and Case Efficiency Using the Direct Anterior Approach 378

or a transgluteal approach THA. The DAA group had less frequent and less pronounced detachment of the abductor insertion, partial tears and tendonitis of the gluteus medius and minimus, the presence of peritrochanteric bursal fluid, and fatty atrophy of the gluteus medius and minimus. 13 Other surgeons have published on their experience using a technique similar to that described in this chapter. Goebel et al 14 reported that patients treated with DAA THA had less postoperative pain, required less pain medication, had a shorter length of hospital stay, and had a quicker time to full recovery than those treated with more traditional approaches. Restrepo et al 15 compared the direct lateral approach and the DAA THA performed on a regular oper ating table in a prospective, randomized study. In their tech nique, the authors describe incising the reflected portion of the rectus, which is the only modification of the technique described in this chapter. Using numerous validated out come measures, the DAA patients had significantly better improvements at 6 weeks, 6 months, and 1 year. 15 Surgeons may be hesitant to adopt DAA THA because of the reported learning curve associated with this approach. 16,17 We published data on our first 182 DAA THA cases. 11 After 6 months and 37 cases, more than 50% of all primary THAs were performed by the DAA. There was also a drop and then a plateau in operating times (99 vs 69 minutes, P < .05) and intraoperative blood loss at 6 months. There was no difference in the overall complica tion rate (DAA group: 5.4% and less invasive direct lateral [LIDL] group: 10.4%) or the clinically significant com plication rate (DAA group: 2.2% and LIDL group: 7.8%) during this time between patients undergoing the DAA vs the LIDL approach. Conclusion The described standard table, highly efficient DAA tech nique can easily be adopted into a surgeon’s practice. The approach allows for precise component positioning and restoration of limb length and offset and does not require an expensive traction table. This approach has been shown to have low complication rates, with evidence published from our practice to validate the described techniques presented in this chapter. Perhaps most importantly, the rapid recovery observed with this DAA technique is ideal for safely transitioning THA to the outpatient setting. P I TFALLS ◆ The tendency in obese patients is to get too far lateral with the initial approach, so surgeons must remain focused on establishing the correct plane of dissection in these cases. ◆ Failure to identify and cauterize or ligate the circumflex vessels can result in significant blood loss. ◆ A high femoral neck cut will make acetabular exposure and femoral releases more difficult.

Tips and Tricks ◆ Care should be taken not to pierce retractors through the rectus muscle when gaining initial femoral exposure because this may place the femoral nerve at risk of injury. ◆ Ensure the leg is in neutral rotation before femoral neck resection and the blade is positioned directly perpen dicular to the neck. The tendency is to drop one’s hand laterally, leaving a high posterior neck cut. ◆ It is important to have a well-centered anteroposterior pelvis image because errors in tilt and rotation will alter your perceived abduction and anteversion of the acetab ular component. Take-Home Points ◆ DAA THA is a safe procedure with a proven recovery advantage for the patient. ◆ Specialized retractors are helpful for the described DAA technique; a specialized traction table is not. ◆ The femoral exposure depends on the proper dissection of the proximal and superior capsule from the trochanter. ◆ The learning curve and complication rate are well described and can be overcome. REFERENCES 1. Learmonth ID, Young C, Rorabeck C. The operation of the cen tury: total hip replacement. Lancet . 2007;370(9597):1508-1519. 2. Abdel MP, Berry DJ. Current practice trends in primary hip and knee arthroplasties among members of the American Association of Hip and Knee Surgeons: a long-term update. J Arthroplasty . 2019;34(7 suppl):S24-S27. 3. Sarraj M, Chen A, Ekhtiari S, Rubinger L. Traction table versus standard table total hip arthroplasty through the direct anterior approach: a systematic review. Hip Int . 2020;30(6):662-672. doi:10.1177/1120700019900987 4. Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res . 2005;441:115-124. 5. Berend KR, Lombardi AV Jr, Seng BE, Adams JB. Enhanced early outcomes with the anterior supine intermuscular approach in pri mary total hip arthroplasty. J Bone Joint Surg Am . 2009;91(suppl 6):107-120. 6. Berend KR, Kavolus JJ, Morris MJ, Lombardi AV Jr. Primary and revision anterior supine total hip arthroplasty: an analysis of com plications and reoperations. Instr Course Lect . 2013;62:251-263. 7. Crawford DA, Lombardi AV Jr, Berend KR, Morris MJ, Adams JB. The feasibility of outpatient conversion and revision hip arthroplasty in selected patients. Hip Int . 2021;31(3):393-397. doi:10.1177/1120700019894949 8. Berend KR, Lombardi AV Jr, Berend ME, Adams JB, Morris MJ. The outpatient total hip arthroplasty: a paradigm change. Bone Joint J . 2018;100-B(1 suppl A):31-35. 9. Frye BM, Berend KR, Lombardi AV Jr, Morris MJ, Adams JB. Do sex and BMI predict or does stem design prevent muscle damage in anterior supine minimally invasive THA? Clin Orthop Relat Res . 2015;473(2):632-638.

10. Seng BE, Berend KR, Ajluni AF, Lombardi AV Jr. Anterior supine minimally invasive total hip arthroplasty: defining the learning curve. Orthop Clin North Am . 2009;40(3):343-350. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024