Over the past decade, the direct anterior approach (DAA) to total hip arthroplasty (THA) has gained significant popularity. During this time, given the mentorship and training patterns within the United States, the majority of these procedures have been performed using a traction table or other leg positioning device. Although they are useful surgical tools, these tables carry significant cost; may require additional nonscrubbed assistants; and are physically large, creating storage and operating room size requirements for the table itself and its associated accessories. Because more procedures are being performed on an outpatient basis in ambulatory surgery centers, cost and space requirements may limit the option to use a traction table. In this chapter, an efficient table-free technique is presented and the necessary modifications required to convert from “on table” (traction table or other leg positioning device) to “off table” (conventional operative table) are discussed. This technique can be used for both primary and revision arthroplasty performed with and without the assistance of image guidance, as well as for simultaneous bilateral THA.

As with any new technique, it is important to identify a mentor who is willing to guide you through the process. Cadaveric dissection is also important in order to learn the appropriate releases and positioning in a safe environment to minimize the learning curve and potential complications. Ideally, a surgeon looking to transition off the table will have both observed and performed the procedure in a cadaver before attempting it on their own.

The off-table technique also improves operating room efficiency, and, by doing so, this change can increase procedure throughput. With this improved efficiency, the decreased direct and indirect costs associated with the use of a specialized table, and the decreased need for human resources (table operator and potentially surgical assistants), the off-table technique can improve the value of the procedures we perform; thus, it continues to gain popularity and allows us to be good stewards of all resources. Additionally, the elimination of specialized tables can expand the applicability and clinical benefits of the DAA to ambulatory surgery centers as well as to hospitals and regions without access to these devices. ¹

In an on-table technique, the room is typically set up with the surgeon and surgical technician on the same (operative) side of the patient with an additional assistant on the opposite side of the table and possibly another assistant on the same side. Depending on the design of the table, the foot end of the table is often required to remain unsterile for access to the controls of the leg positioning device. In this situation, should an assistant be required to change sides of the table, it requires passing this unsterile area, leading to concerns for potential contamination. With an off-table technique, the entire 270° of the table is available and remains sterile. This allows the surgical technician to stand across the table, creating a more ergonomic environment with less exposure to the back side of the physician and surgical assistants (Figure 13.1). Electrocautery and suction can be placed on either side of the patient; however, if fluoroscopic imaging is used, it is recommended to place these items on the same operative side as the surgeon to leave room for the C-arm to access the patient.

The on-table technique requires the use of a special traction table or attached leg positioning device, whereas an off-table technique can be performed on any operative table. Many operative tables designed for prolonged general surgical procedures have thick (10-cm) mattresses intended to prevent posterior pressure areas. These thicker mattresses can lead to the patient sinking down into the cushioning, limiting the space available for draping on the anterior lateral aspect of the hip. It is recommended to use a mattress similar to the typical flat-top fluoroscopic table mattress at around 5 cm thickness (Figure 13.2). If fluoroscopic imaging is desired, it is important to ensure that you have ample access to image the entire pelvis. This can be accomplished by using a table with a “foot slide” option and removing the head extension of the table, placing this at the foot of the table, and sliding the mattress downward. This moves the pedestal supporting the table cranially under the patient’s chest, allowing the C-arm to come in unimpeded. Note that if a heavier patient is slid too far distally, this can lead to tipping of the table, and caution must be taken. It is also useful to add a table extension to the distal contralateral side of the table. This allows additional adduction of the operative limb across the table during femoral exposure. Without this extension, the foot tends to drop below the edge of the mattress, decreasing external rotation and limiting exposure.

To prevent lateral displacement of the patient during adduction of the operative limb, a lateral post or pad is added in the area of the contralateral greater trochanter. Some surgeons find it helpful to “break” the table and extend the foot of the table toward the floor to extend the hip to gain additional exposure to the femoral canal; however, adequate exposure can routinely be obtained with appropriate adduction and external rotation. If the surgeon intends to use this “break” technique, care must be taken to position the patient so the pelvis remains on the static portion of the table and the legs rest on the portion of the table that will extend away. An additional benefit of the standard operative table is the availability to put the rails down on both sides of the table to allow the attachment of positioning devices and static retractors (Figure 13.3). Currently, there are reduced attachment points on most traction tables, limiting the ability to use some devices.