Direct anterior total hip arthroplasty: Literature review of variations in surgical technique

Abstract

The direct anterior approach to the hip has been suggested to have several advantages compared to previously popular approaches through its use of an intra-muscular and intra-nervous interval between the tensor fasciae latae and sartorius muscles. Recent increased interest in tissue-sparing and minimally-invasive arthroplasty has given rise to a sharp increase in the utilization of direct anterior total hip arthroplasty. A number of variations of the procedure have been described and several authors have published their experiences and feedback to successfully accomplishing this procedure. Additionally, improved understanding of relevant soft tissue constraints and anatomic variants has provided improved margin of safety for patients. The procedure may be performed using specially-designed instruments and a fracture table, however many authors have also described equally efficacious performance using a regular table and standard arthroplasty tools. The capacity to utilize fluoroscopy intra-operatively for component positioning is a valuable asset to the approach and can be of particular benefit for surgeons gaining familiarity. Proper management of patient and limb positioning are vital to reducing risk of intra-operative complications. An understanding of its limitations and challenges are also critical to safe employment. This review summarizes the key features of the direct anterior approach for total hip arthroplasty as an aid to improving the understanding of this important and effective method for modern hip replacement surgeons.

Keywords: Anterior hip arthroplasty; Anterior supine intramuscular approach; Direct anterior approach; Total hip arthroplasty.

Figures

Figure 1

Patient positioning. A: Use of a regular table with bump under the sacrum and ability to lower the distal end of the bed down to afford better femoral exposure. An extra arm board can be placed on the contralateral distal end of the bed to support the contralateral leg while accessing the operative femoral canal; B: Patient positioning on a fracture-type table (Hana table, Mizuho Orthopedics Systems, Inc.).

Figure 2

Surface anatomy for the direct anterior approach. A 6-8 cm oblique incision is typically used by the authors. This incision may be extended proximally and distally as needed along the Smith-Petersen interval for adequate femoral and acetabular exposure.

Figure 3

Selected retractors used for direct anterior approach. From left to right, hip skid for ceramic head reduction, greater trochanteric retractor/elevator, femoral elevator for medial/calcar exposure (front and side views), medial acetabular wall retractor, posterior acetabular wall retractor, and tensor fascia lata retractor.