Author's Accepted Manuscript

The Direct Anterior Approach for Hip Arthroplasty

John M. Keggi M.D.

PII: S1045-4527(14)00076-5DOI: http://dx.doi.org/10.1053/j.sart.2014.04.007Reference: YSART50596

To appear in:Semin Arthro

Cite this article as: John M. Keggi M.D., The Direct Anterior Approach for HipArthroplasty,Semin Arthro , http://dx.doi.org/10.1053/j.sart.2014.04.007

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The Direct Anterior Approach for Hip Arthroplasty

--Here to Stay--

John M. Keggi, M.D.

Orthopaedics New England

and

The Connecticut Joint Replacement Institute

Author contact:

John M. Keggi, M.D.

Orthopaedics New England

1579 Straits Turnpike

Middlebury, Connecticut 06762

203-598-0700

www.OrthoNewEngland.com

John.Keggi@gmail.com

Abstract

The Direct Anterior Approach, or Hueter’s Approach, has a long history of

successful use in modern hip arthroplasty. It does not require special tools or

expensive equipment. It is suitable for use with all types of hip prostheses and

affords excellent visibility and safety. Positioning of the patient is simple and

manipulation of the limb is minimal. The Direct Anterior Approach is associated

with less muscle damage and an earlier return of function compared to other

approaches. It has an honorable past and a great future as increasing numbers

of surgeons use this approach as their standard for total hip arthroplasty.

The DAA – Here to Stay!

The Direct Anterior Approach (DAA) has gained popularity since it first attracted

widespread attention in the early 2000's. It has moved from a few scattered

centers to most metropolitan areas, academic programs and communities.

Currently, approximately 25% of arthroplasty surgeons use the DAA for hip

arthroplasty at least some of the time and 15 to 20% of arthroplasty surgeons

use the DAA regularly.1 2 The proposition that the DAA is "Here today and gone

tomorrow" misses the richness of the surgical history of the approach and its

tremendous benefits for current and future arthroplasty patients.

The first published description of the anterior approach for the hip is attributed to

Hueter from Germany in 1883.3 In his published work he stated, "... The leg

keeps its tight connection to the pelvis which facilitates rehabilitation..." and "...

Bleeding is so little, that no single ligature has to be done...". Smith-Petersen in

Boston was the first in the English language literature to promote the anterior

approach in 1917 for hip dysplasia work.4 "This incision has not as yet been tried

out in cases other than congenital hip reductions. It seems not improbable that it

may be of value in cases demanding a good exposure of the acetabulum...". By

1949 Smith – Petersen had extensive experience with hip dysplasia and had

begun his work on mold arthroplasty.5 At that time he noted, "in the past the

various approaches to the hip joint have failed to properly expose the acetabulum

and the surgeon's efforts have been directed mainly at partial reconstruction of

the femoral head.". Concurrently, the Judets in Paris had been developing their

acrylic prosthesis for arthroplasty via Hueter's approach as an alternative to the

Whitman reconstruction with which they had had poor results.6 In New York

Thompson was developing his vitallium prosthesis which both he and O'Brien in

St. Louis were implanting using Hueter's approach as well.7 O'Brien noted,

"Hueter's straight anterior incision... does not require any muscle cutting or

detachment, and no postoperative immobilization is needed.".8

In the modern era of low friction total hip arthroplasty the DAA has been used

around the world since at least 1971. Kristaps Keggi in the USA, Stan Schofield

in Australia and Schofield's mentor, George Braddock, in London all began using

this approach in their early arthroplasty experience and continued it throughout

their careers.9 It was presented as a scientific exhibit at the AAOS Annual

Meeting by K. Keggi in 1977 and published in 1980.10 11 His report in 1993

documented his first 1000 cases using uncemented prostheses of many varieties

and designs.12

In the early 2000's the DAA was popularized as a two incision technique that was

reportedly novel and especially minimally invasive.13 Shortly thereafter, however,

reports began to surface of early complications and problems. The two-incision

technique utilized a posterior accessory interval for preparation of the femur and

placement of the femoral component that became associated with fractures and

neurologic complications.14 This was a distinct technique from the standard DAA.

Other variations emerged as well. In the mid-2000’s use of a traction table was

advocated as an adjunct by Siguier and Matta among others.15 16

History not withstanding, the DAA continues to expand in use today for its direct

benefits to patients and surgeons.

The standard DAA utilizes the interval between the Tensor Fascia Lata and

Sartorius muscles, allowing direct access to the hip joint without detachment or

splitting of the gluteal muscles. It can be performed with anterior capsulotomy or

capsulectomy, includes posterior capsulotomy with release of the obturator

internis (conjoint tendon), but most often spares the Piriformis muscle. No

capsular repair is required at closure. It is performed in the supine position on a

standard OR bed (Figure 1) or with the use of a traction table at the surgeon's

discretion.

The DAA is safe, providing good visibility at all times. (Figures 2 and 3) The

sciatic nerve is well away from the surgical field and is not significantly at risk

during the procedure. Similarly, the femoral bundle is well medial to the area of

dissection. The operative limb is generally maintained a neutral position with mild

manipulations of adduction, extension and external rotation. There is no

significant rotation of the limb at the hip such as is associated with other

approaches and which can cause kinking of the femoral vessels with an

increased risk for DVT. Anesthesia care providers often prefer the DAA as it

affords greater access to the patient who is in the supine position throughout the

procedure. Additionally, plain x-ray or fluoroscopy can be performed easily.

The anterior approach is easily extensile proximally and distally. In our

experience revision hip arthroplasty is preferred via the DAA. There is no intra-

operative event or circumstance that cannot be safely managed or that would

require conversion to a posterior or lateral approach. The DAA is also useful for

hip resurfacing.17

The DAA provides good results. Our report in 2003 documented outcomes in

more than 2000 patients of all body sizes with weights ranging from 80 pounds to

450 pounds.18 The dislocation rate was 0.1%. Fractures requiring fixation were

1%. The combined rate of deep venous thrombosis and pulmonary embolism

was 0.8%. A separate report on more than 450 revisions documented a

dislocation rate of 3% with an infection rate of 2.5% and fracture requiring fixation

of 5.8%.19 Nakata compared DAA and mini-posterior approach showing a

quicker return to single leg stance, earlier loss of limp and more rapid weaning

from an assistive device with the DAA.20 In addition cup placement was more

accurate and consistent with the DAA versus mini-posterior (99% vs 91%). DAA

versus direct lateral approach was associated with better physical and mental

outcome scores on the SF-36 and WOMAC assessments for greater than one

year postoperatively.21 Both groups were equal by two years postoperatively.

Other reports document lower early pain scores and more rapid recovery in the

early post-operative period with DAA compared to other approaches.22 23

Compared to the posterior approach, DAA was associated with lower CPK levels,

suggesting less muscle damage.24 A separate MRI study demonstrated less soft

tissue damage with DAA versus the trans-gluteal approaches.25 These findings

were further substantiated in a comparison of five approaches showing least

gluteal damage with DAA.26

Interestingly, in recent years alternative posterior approaches have been

presented including Percutaneous Assisted Total Hip, SuperPATH, SuperCap

and the "direct posterior approach". All of these improvements in posterior

approach surgery highlight their advantages such as sparing of the tibial band,

release of the conjoined tendon only (sparing the Piriformis tendon muscle) and

avoidance of the gluteal musculature. These new features of posterior approach

surgery have been core aspects of the DAA for more than 40 years.

The DAA is a well-established technique for total hip arthroplasty that is

reproducible, safe, easy to set up and is associated with excellent patient

outcome, reduced muscle damage and early functional recovery. The DAA has

a rich history and a bright future, indeed!

List of Figures

Figure 1 Supine position of the patient on a standard operating bed. A small gel

bump has been placed beneath the left sacroiliac joint region of the pelvis.

Figure 2. The DAA affords a clear view of the acetabulum.

Figure 3. With minimal instrumentation the femur is mobilized and easily

visualized for safe preparation.

Disclosure

The author has no disclosures related to the content of this article.

References

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