Direct Anterior Approach for Total Hip Arthroplasty

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This article describes the surgical technique for total hip arthroplasty using the single-incision direct anterior approach. The authors believe the direct anterior approach has significant advantages, including minimal soft tissue trauma, resulting in faster postoperative mobilization and rehabilitation. The small incision scar also results in better cosmesis.

Section snippets

Indications/contraindications

Indications for using the minimally invasive technique comprise moderate degenerative changes in the hip joint of various etiologies requiring total hip replacement. The ideal patient is a flexible, non-muscular patient with a valgus femoral neck and good femoral offset. Not every surgeon can perform the minimally invasive procedure, because it requires excellent manual skills and knowledge of anatomy, as well as experience in performing conventional hip joint surgery so that the operator can

Positioning and draping

A standard operating table is used. The table can be broken at the level of the hip joint to hyperextend both legs. The patient is positioned in the supine position, and the operative leg is draped. The supine position achieves a stable pelvis and allows easy measurement of leg length. The opposite leg is supported by an additional arm board that is attached to the table, making hyperabduction of the opposite leg during femoral exposure easier. The authors drape only the operated leg, but some

Skin incision

The position of the skin incision is determined by palpating the anterior superior iliac spine (ASIS) from below. From this point, measure 3 cm laterally and 3 cm distally to find the starting point and orientate the incision along the longitudinal axis of the TFL muscle. Keep the initial incision small (8–10 cm), but do not hesitate to extend it as needed (Fig. 1). Lengthen the incision distally to increase acetabular exposure and proximally to increase exposure of the femur. The site of the

Intermuscular portal

The lateral femoral circumflex nerve and its branches lie along the surface of the sartorius muscle. As an additional step to protect the lateral femoral circumflex nerve, the authors recommend incising the TFL sharply at its midpoint for the length of the muscle and performing a strictly subfascial exposure. Elevation of the medial aspect of the superficial TFL fascia reveals a fat layer medially. This fat layer defines the Smith Peterson interval.

Inserting an index finger posteriorly at this

Anterior capsulectomy

Start the capsulectomy with a cut laterally along the axis of the femoral neck. Distally, be sure to remove the entire capsule, but do not cut into the lateral vastus, which will cause bleeding. Try to cut as far proximally as possible. This ventral capsular flap can be kept in place or removed completely. The inferior or medial retractor then is placed inside the capsule around the femoral neck. In rare cases, if necessary, the reflected head of the rectus can be incised at its capsular

Double osteotomy

Remove the superolateral retractor and place a blunt retractor intracapsularily to protect the tip of the greater trochanter during the osteotomy. Typically, a double osteotomy is performed without dislocating the hip joint. Use the “saddle” between the greater trochanter and the neck as a starting point for the second osteotomy. Perform the definitive osteotomy with a microsaw or a standard power tool using a long, small saw blade. The proximal osteotomy should be done as proximally as

Acetabulum exposure

For the acetabular preparation, additional light is helpful and can be achieved using a head-mounted light or by placing a localized light source in the wound. While the anterior retractor remains in place, the medial (sharp or blunt) retractor is placed in the area of the transverse ligament medial and inferior to the acetabulum. Incising the medial or inferior capsule facilitates placement of this retractor. Another sharp retractor is placed inside the capsule in the area of the

Reaming of the acetabulum

Standard reamers can be used, but it is extremely helpful to have an offset reamer handle available. The offset reamer handle allows reaming in the correct orientation. Ream the acetabulum to the correct size using the offset reamer.

Cup implantation

After the trial, use the curved cup impactor to place the cup. The use of a curved cup impactor is essential for achieving the correct cup orientation (Fig. 4). If screws are placed, or a locking screw is inserted, use a flexible screw driver.

Leg positioning and proximal femoral exposure

Place the operated leg in hyperextension, adduction, and externally rotation. The table is broken by about 30° to 40° to accomplish hyperextension. The opposite leg is abducted and placed on the arm board. Alternatively, the opposite leg can be crossed over the operated leg and the assistant's hand to support external rotation. Leave the anterior retractor in place, and remove all other retractors. Grasp the lateral capsular flap with a clamp, and place the femoral elevator behind this flap.

Broaching of the femoral canal

An angled curette is used to open and probe the direction of the femoral canal carefully. A rongeur can be used to extend the opening in the direction of the greater trochanter. Always use the smallest broach available, and always use a double-offset broach handle to broach the femoral canal. Using minimal force, insert the broach handle by hand into the open canal. When the broach is completely aligned with the femur, tap it with the hammer. The double-offset design of the broach handle eases

Implantation, reduction, and wound closure

The final femoral component should be inserted by hand into the space created by the broaches. A straight impactor cannot be used in the standard fashion. Instead, it should be placed into the femoral stem impaction hole at an angle of 30° to 45°. Angling a standard blunt impactor by 45° directs the forces correctly and completes impaction of the stem. Alternatively, a custom angled impactor can be used. This technique minimizes the risk of medial calcar fracture and ensures lateralization of

Perioperative management

Sufficient postoperative analgesia is essential. Mobilization is possible within the first 24 hours. When the minimally invasive direct anterior portal approach is used, the reduced muscle damage should result in faster rehabilitation. Whether full weight bearing is allowed is based on the surgeon's preference and the design of the implant being used. The authors' preference is for weight bearing as tolerated.

Complications

In comparison with open approaches in general, the direct anterior approach preserves muscle structures well. Complications involving muscular damage, especially dislocation, should not be expected using this approach, if implants are placed correctly.24 There is almost no risk of injuring the sciatic nerve, but the femoral nerve is exposed to a higher risk of injury because it lies close to the surgical field. Careful use and placement of the curved retractors avoids damage to this nerve. To

Discussion

The anterior approach has the advantage of preventing injury to muscles and their attachments to the pelvis and femur, helping restore their normal tension immediately on completion of the surgery. Uninjured muscles and muscle attachments significantly improve the dynamic muscular stabilization of the hip joint. An important advantage of this approach in complicated cases (eg proximal femur fractures) is easy access to proximal femur that can be obtained by extending the incision distally, as

Summary

Minimally invasive single-incision direct anterior approach surgery is completed through an 8- to 10-cm incision positioned 3 cm distal and lateral to the ASIS. The skin incision is placed more laterally in this approach to protect the branches of the LFCN. Access to the joint capsule is achieved through the interval between the TFL and gluteus medius; the rectus femoris of the quadriceps femoris muscle and the sartorius fat layer defines the Smith Peterson interval. If the retractor is placed

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      To apply a strict definition to the term ‘MI THA’, we specified that no muscle or tendon should be detached from their insertion and no muscle should be dissected as occurs during an intramuscular approach. The only two approaches meeting these criteria are the direct anterior approach and the modified Watson-Jones approach [3,5]. The direct anterior approach utilises the interval between the tensor fascia lata and sartorius superficially with the deep interval between gluteus medius and rectus femoris [18,19].

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