the direct anterior approach: here today, gone tomorrow—affirms

Author's Accepted Manuscript

The Direct Anterior Approach: Here Today, GoneTomorrow – Affirms

Brad L. Penenberg MD, Antonia Woehnl MD

PII: S1045-4527(14)00075-3DOI: http://dx.doi.org/10.1053/j.sart.2014.04.006Reference: YSART50595

To appear in:Semin Arthro

Cite this article as: Brad L. Penenberg MD, Antonia Woehnl MD, The Direct AnteriorApproach: Here Today, Gone Tomorrow – Affirms,Semin Arthro , http://dx.doi.org/10.1053/j.sart.2014.04.006

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The Direct Anterior Approach: Here Today, Gone Tomorrow – Affirms

Brad L. Penenberg, MD, and Antonia Woehnl, MD

Brad L. Penenberg, MD

Director, Hip and Knee Section, Cedars-Sinai Medical Center, Los Angeles, CA

Antonia Woehnl, MD

Research Fellow, Cedars-Sinai Medical Center, Los Angeles, CA

Research from: Cedars-Sinai Medical Center, Los Angeles, CA

Dr. Penenberg has the following financial disclosures: Royalties: Microport Orthopedics;

Stock holder: Radlink Imaging

Address reprint requests to:Brad L. Penenberg, MD

Director, Hip and Knee Section, Cedars-Sinai Medical Center, Los Angeles, CA

120 South Spalding Drive, Suite 400

Beverly Hills, CA 90212, USA

Phone: 310.860.3470, Fax: 310.659.2724

Email: [email protected]

"I believe in everything until it's disproved. So I believe in fairies, the myths,

dragons … it all exists, even if it's in your mind."

John Lennon

There has been great enthusiasm for minimally invasive surgery (MIS) or accelerated

recovery total hip arthroplasty (THA) over the last decade. This has perhaps been driven

by economic imperatives as well as the decreasing average age of the THA patient and

the need to return to work.1 The first glimpse at what accelerated recovery might look

like was afforded by the two-incision approach to THA introduced in 2000.2,3 In spite of

the fact that dramatic improvement in immediate postoperative function could occur with

this approach, there was a difficult learning curve and a higher than acceptable

complication rate.2,4,5 It appears to have been all but abandoned. In the last 7 to 8 years

an approach to the hip that was first described in 1883 and then in 1917 by Smith-

Peterson, has received renewed interest.6-8

The initial appeal, of what is now referred to as the Direct Anterior approach

(DA), was the idea that, for the first time, a THA could be performed without cutting any

muscle or tendon. We were lead to believe preserving all of these structures was why

patients appeared to recover faster. Over the last year it has come to light that, in a very

high percentage of these cases, both tendon and capsular release are performed in order to

access the femoral canal safely.9,10 In spite of these additional releases, advocates

continue to see early return to function and feel that traditional hip precautions are not

necessary. There appears, however, to be an abundance of data that describes the

difficult learning curve prior to becoming proficient with this approach.11-15 The surgeon

new to this procedure can expect the occurrence of trochanteric fractures, wound

problems, and lateral femoral cutaneous nerve injury.11-13,16-18 19-24 It has even been

acknowledged that because of the location of the incision and the nature of the skin in

this area wound problems can persist beyond the learning curve.16 There have also been

admonitions to avoid larger patients and patients with lower offset hip.12,25-27 Industry

sources (Zimmer, DePuy, Stryker, Biomet, Microport Ortho) have claimed that in spite of

ongoing educational initiatives market penetration of the Direct Anterior approach has

remained level at about 20% of surgeons.

Emerging Alternative

Of interest to the remaining 80% of us (and probably many in that 20%) is the fact

that there appears to be a growing body of evidence in support of the fact that a highly

modified, or a Direct Posteriortm (DP) approach, can achieve all of the same goals as the

Direct Anterior approach, but without the risk. 28-33 The DP is essentially a sub-segment

of the traditional Moore, Gibson, or Kocher Langenbeck approach. Risk is mitigated by

the fact that, at any point in this procedure, it is possible to simply extend the dissection

and return to familiar landmarks (Figure 1b). The DPtm, an emerging alternative to the

DA, is typically performed in the familiar lateral decubitus position. The skin incision

travels obliquely a distance of approximately 3 to 6 inches from the posterior corner of

the greater trochanter (Figure 1a). The approach is essentially trans-gluteal. The

iliotibial band is not incised, but gluteus maximus fibers are gently teased apart. The

conjoined tendon is then identified by palpation and incised (as described for the DA).9

Obturator externus tendon and piriformis tendon are preserved in most cases and the

quadratus muscle is preserved in all cases (Figure 2).33

Mythology of the Direct Anterior Approach

The very visible nature of the DA, as it is marketed (by industry and surgeons)

and offered as a “new and unique technique” along with its imprecise comparisons to

“the posterior approach”, has resulted in a number of misconceptions (Figure 3).19 As

these promotional efforts continue, the superiority of the DA versus anything else,

especially anything “posterior” has come to be based on supposition and perhaps wishful

thinking, rather than data. The available database of peer-reviewed publications does not

support the fact that most of the attributes associated with the DA are unique to the

DA.28,30-32,34 In order to better understand where marketing and promotion leave off and

fact exists this paper presents the most notable misrepresentations of the Direct Anterior

approach.

Myth 1: The DA is the only alternative to result in accelerated recovery.

There is a growing body of data that demonstrates “accelerated recovery” with scaled

down or modified posterior approaches. The Direct Posterior approach, for example, has

resulted in an equally accelerated recovery with length of stay after THA of two days or

less and a mean time to cane of 5 days.28,30-34 When DA versus DP data are compared

there was no difference in early functional outcome.35,36

Myth 2: The DA is the only option permitting “no precautions” postoperatively.

As it turns out soft tissue preservation, capsular preservation and repair, and careful

attention to intraoperative range of motion testing have permitted the lifting of

postoperative precautions, even when a posterior approach is used. Studies with between

250 to 700 patients have been found to result in a dislocation rate of 0.0% to 0.4%

without the use of hip precautions after primary THA.28,30,37

Myth 3: The DA will be safe and precise after the “learning curve” of 50 cases.11-15

Advocates of the DA who publish this data on learning curves are usually surgeons with

a case volume of 200 hips per year or more. However, recent studies have found their

learning curve to include between 100 and 200 cases with complication rates of up to

16%.11-13,15,16,24 Wound healing complications for example were observed throughout one

series of 800 cases (4.6%).16 Figures 4 to 8 represent cases that were referred to the senior

author (BLP) within the past 12 months as complications from the Direct Anterior

approach. In each instance the surgeon told the patient that he had performed more than

100 DA cases (Figures 4 - 8).

Myth 4: The DA is indicated for all patients regardless of body habitus and type of

hip disease.12,25-27,38

Apparently, because of the difficulty achieving femoral access, it is recommended that

surgeons new to the technique avoid patients with large BMI and low offset.

Myth 5: The DA has a lower dislocation rate than “the” posterior approach.

Data pertaining to modern THA, with preservation and repair of the posterior capsule and

careful range of motion testing report dislocation rates identical to, or lower than, those

reported for the DA. It is important to realize that the high dislocation rates ascribed with

a broad stroke to the “posterior approach” appear in publications reporting on the

traditional posterior approach.13,16,18,27,28,37,39-43

Myth 6: It is essential to invest in costly capital equipment to achieve the results of

the DA.28,30-32,34

Numerous advocates of both approaches have described comparable results with and

without using a specialized table (fracture table, HANA table, etc)44,45

Myth 7: The DA is performed without cutting any tendons or the posterior joint

capsule.9,10

Over the last year, as authors beyond the technique developers have begun to report their

experience with the DA, it is becoming clear that modifications are being applied. To

access the femoral canal many surgeons advocating the DA have clearly indicated in

recent publications that tendon and capsule releases are frequently performed, affecting

the conjoined tendon in up to 71% and the piriformis tendon in 7%.9,46

Myth 8: A surgeon who does not perform the DA is a second-class citizen.

This of course is a subjective conclusion, but what else is a patient or a referring

physician supposed to believe if a fair and balanced story is not told (Figures 3 and 9).19 I

would suggest that it is appropriate for any surgeon interested in performing THA, to

become comfortable with the idea that he may have “chosen not to do that anterior

approach.” There is an abundance of data to support that choice and we should be

prepared to educate our patients regarding the true state of the art.

Conclusions

When we apply something new, the goal is to improve the outcome. Why choose

an option almost guaranteed to result in a life altering complication as it is being learned?

It is the only logical, if not the ethical choice, to favor an option that allows improvement

in surgical technique and outcome, but with the safety of knowing that the result can be

no worse than one’s baseline. Unlike the Direct Posterior approach, the Direct Anterior

approach does not offer a readily extensile option that permits the surgeon to return to

familiar territory and a “comfort zone” if a point of uncertainty occurs during the new

procedure.

It is clear that the DA can work but it presents a high-risk transition for most

surgeons. Once it becomes more widely understood that the advantages offered by the

Direct Anterior and Direct Posteriortm are equal, there is an excellent chance that the

Direct Anterior approach will be gone tomorrow.

References

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navigated tissue-preserving techniques. Clin Orthop Relat Res 453:160-7, 2006

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Brad L. Penenberg, MD, and Antonia Woehnl, MD

In recent years there has been a wave of enthusiasm for the DA. Its appeal centers around

the possibility of performing a THA “without cutting muscle or tendon.” This allegedly

provides the benefit of accelerated recovery, reduced dislocation rate, and absence of

postoperative precautions. However, literature shows that the price to the patient can be

unacceptably high. This paper provides some perspective on this risk and presents a safe

alternative (DPtm), which can achieve similar clinical results. The readily extensile DP

gives the surgeon new to the technique an opportunity to minimize risk associated with

the learning curve.

Key Words: total hip arthroplasty, direct anterior approach, direct posterior approach


Brad L. Penenberg, MD, Antonia Woehnl, MD

CAPTIONS

Figure 1 – Skin Incision for Direct Posterior

Figure 1a – The incision for the Direct Posteriortm approach (yellow, ITB intact) begins at

a point approximately 1 cm distal to the posterior corner of the greater trochanter. It is

directed posteriorly, 45˚ to the long axis of the patient. It typically spans a distance of

approximately 10 cm.

Figure 1b – For the beginner, carrying the DPtm incision more distally immediately

provides access to a more familiar landscape. The surgeon new to this approach has the

opportunity to stay in his or her comfort zone at all times. It is possible to scale down as

comfort and patient safety dictate.

ITB – iliotibial band, GMax – gluteus maximus, CT – conjoined tendon, P – piriformis,

sg – superior gemellus, oi – obturator internus, ig – inferior gemellus, OE – obturator

externus, QF – quadratus femoris

Figure 2 – Preferred Tendon Release

In the preferred version of the Direct Posteriortm approach, after incising the gluteus

maximus fascia, the fibers of the muscle are carefully teased apart. At a point

approximately 1 cm distal to the tip of the greater trochanter, the conjoined tendon can

almost always be palpated. Overlying fat is removed using electrocautery and suction.

The tendon can then be visualized as it courses beneath the posterior edge of the greater

trochanter. This is distinct from the piriformis, which inserts at the tip of the greater

trochanter. The CT is released beneath the edge of the trochanter as close to its insertion

as possible. In most instances, all remaining external hip rotators and the ITB can be

spared.33

ITB – iliotibial band, GMax – gluteus maximus, GMed – gluteus medius, GMin – gluteus

minimus, CT – conjoined tendon, P – piriformis, sg – superior gemellus, oi – obturator

internus, ig – inferior gemellus, OE – obturator externus, QF – quadratus femoris, gt –

greater trochanter, lt – lesser trochanter, c - capsule

Figure 3 – Newspaper Articles Making Inaccurate Comparisons

This New York Times article (March 18, 2013) leaves the reader with the impression that

the anterior approach is uniquely capable of “helping patients recover more quickly,”

return to cycling, lifting weights, etc, and “feel like I never had surgery.” It incorrectly

states that the dislocation rate is lower than with “the posterior” approach.

Figure 4a and 4b – Fluoroscopic Images with DA

This 44 year-old woman underwent bilateral DA. Figure 4a shows the limited

intraoperative view when using fluoroscopy during the DA. Figure 4b shows the

postoperative anteroposterior pelvic radiograph indicating a cup inclination of minus two

degrees on the right and of 68 degrees on the left side.

Figure 5 – Intraoperative Peritrochanteric Fracture during DA

This 58 year-old woman presented to the senior author 11 months following an attempted

THA via the DAA. The operating surgeon told the patient he had performed more than

300 such procedures. She suffered an intraoperative peritrochanteric fracture. She

required repositioning in order for the surgeon to switch to an extensile posterolateral

approach in attempt to fix the fracture and salvage a “routine” primary THA. She

remained wheelchair bound for 8 months as the femoral component slowly subsided and

it became clear she needed revision surgery.

Figure 6a and 6b – Intraoperative Trochanteric Fracture and Femoral Neuropathy

with Brooker III+ HO

This 62 year-old male, cardiologist and former cyclist, underwent a DA by a surgeon who,

according to the patient had “a lot of experience with this approach.” He presented to the

senior author at 10 months postoperatively with extensive heterotopic ossification and

flexion to 40 degrees. He suffered an intraoperative trochanteric fracture described by

the operating surgeon as inaccessible for fixation. He also suffered a femoral neuropathy

that he was told was responsible for the weakness that lead to a fall the day after surgery.

He was told that it was this fall that lead to his re-operation 3 days postoperatively

because of femoral subsidence.

Figure 7 – Wound Healed by Secondary Intention after DA

Thin skin in this area can lead to wound problems.16 This wound was left to heal by

secondary intention. It closed 18 days after surgery.

Figure 8a and 8b Trochanteric Fracture and Inadequate Fixation

This 89 year-old severely osteopenic female suffered a trochanteric fracture during the

course of her THA via a DA approach. Incision was extended and ORIF was attempted.

She was referred to the senior author because of severe limp and limited ambulation 1

year postoperatively.

Figure 9 – Misleading Publication Title Comparing DA to “The” Posterior

Approaches19

Articles such as this fail to differentiate that all “posterior approaches” are not the same.

This creates confusion unless the reader takes the time to read carefully thru this article

and realize this is a comparison to the “traditional posterior approach.” There is no

acknowledgement that modifications of this approach might be comparable to DA.

Fig 1A

Fig 1B

Fig 4A

Fig 4B

Fig 6

6A

Fig 6

6B

Fig 7

7

Fig 8

8A

Fig 8

8B

the direct anterior approach: here today, gone tomorrow—affirms

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