44: Highly Efficient Direct Anterior Approach: The Pathway to Outpatient Hip Replacement

David A. Crawford

Keith R. Berend

Adolph V. Lombardi Jr

Introduction

THA is an extremely successful surgery, having been coined “the operation of the century.” ¹ Despite the success of THA, surgeons continue to pursue techniques to further decrease complications and improve outcomes. One of the main targets for ongoing innovation is improving acetabular component positioning and allowing a more rapid postoperative recovery. To this end, the surgical approach for THA, specifically the DAA, has garnered much attention over the past two decades. ² ^, ³

Background

During the early popularization of DAA THA, specialized tables were used to aid in surgery exposure and limb manipulation. ⁴ These tables (eg, the Hana table [Mizuho OSI, Union City, CA, USA]) can help facilitate hip extension, external rotation, and adduction for femoral exposure. However, special tables are expensive, may lengthen the operative time due to setup time and positioning, can complicate checking hip range of motion and stability, require a circulating nurse to position the leg during the surgery, and can lead to equipment-related fractures. ⁴ As a result, alternative DAA techniques have evolved that do not need such tables. ⁵

The advantages of using a standard table DAA technique include a simple setup, ease of assessing hip stability, and optimizing desired leg lengths. This technique has been shown to be effective and safe and to allow rapid recovery in multiple publications. ^6-11 A recent systematic review comparing a traction table with a standard table demonstrated that the use of the standard table had less blood loss, a shorter operative time, and fewer intraoperative fractures. ³ This chapter describes a technique of performing the DAA in the supine position with both legs draped free on a standard radiolucent operative table with the use of a table-mounted femoral elevator.

Equipment

The specialized equipment needed for the DAA technique is summarized in Table 44.1.

Table 44.1

Specialized Equipment Needed for the DAA Technique

Equipment
Microplasty anterior supine intramuscular instrumentation (Zimmer Biomet, Warsaw, IN, USA)
Femoral elevator/double-pronged retractor (Part #31-555531 [Zimmer Biomet])
Cobra retractor (Part #31-555532 [Zimmer Biomet])
Large Hohmann retractor (Part #31-555533 [Zimmer Biomet])
Mueller acetabular retractor (Part #31-555534 [Zimmer Biomet])
DeWitte retractor (Part #31-555535 [Zimmer Biomet])
One surgical technologist (ST)
Two surgical assistants to aid with holding retractors (ST or registered nurse) and with manipulating the leg for proximal femoral exposure (physician assistant or fellow)
Standard radiolucent operating table with an extender at the foot (Steris 3080-R Amsco Surgical Table)
Drapes (Medline Industries)
Two large drapes, three plastic U-drapes, bilateral limb T-drape (Item DYNJP8006), one impervious split drape (Item SPT-2455A), two impervious stockinettes, three cotton stockinettes, and C-arm cover
Two sterile iodoform sticky drapes (Ioban 2 Antimicrobial Incise Drape [3M, St. Paul, MN, USA])
Coban self-adherent wrap (3M)
Fluoroscopy and radiologic technician
Two 90° retractors
Tonsil hemostat
Oscillating saw
Threaded Steinmann pin
Atraumatic offset acetabular reamers
Table-mounted femoral elevator (Omni-Tract Femur Elevator System [Integra LifeSciences, Princeton, NJ, USA])
Padded Mayo stand
Femoral starter rasp
Single and dual offset broach handles—right and left
Hip skid/head reducer
Closure: 0-0 knotless, barbed monofilament suture (Quill Monoderm [CorzaMedical, Westwood, MA, USA]); 2-0 knotless, barbed, monofilament suture (Quill Monoderm); and cyanoacrylate tissue adhesive (Dermabond [Ethicon Inc., Bridgewater, NJ, USA])
Periarticular injection: 30 mL bupivacaine 0.5%, 0.5 mL epinephrine 1:1000
1 g vancomycin powder

Patient Positioning and Draping

The patient is positioned supine on a standard radiolucent operating table (Steris 3080-R Amsco Surgical Table [STERIS Corporation, Mentor, OH, USA]) with the extender at the foot of the bed. No bump is placed beneath the pelvis to ensure it remains truly supine throughout the procedure. The pubic symphysis is aligned over the break in the table, which allows appropriate hyperextension of the hip during femoral exposure and preparation. A nonsterile plastic U-drape is placed around the operative limb (Figure 44.1). The operative limb preparation extends just proximal to the iliac crest, whereas the contralateral limb is only prepped up to the groin. Two sterile plastic U-drapes are placed circumferentially around the operative limb. Both legs are covered by impervious sterile stockinettes, and this is followed with a bilateral lower extremity drape (DYNJP8006 [Medline Industries, Inc., Northfield, IL, USA]).

Figure 44.1

The patient is positioned supine on a standard radiolucent operating table with an extender (Steris 3080-R Amsco Surgical Table), and the pubic symphysis is aligned over the break in the table.

The drape is cut on the operative side to uncover the anterior superior iliac spine (ASIS) and the anterior thigh. A sterile iodoform drape is folded on the nonsticky side and applied posteriorly to seal off the buttocks, posterior thigh, and groin on the operative side. A second sterile iodoform drape is placed anteriorly to allow for a secure seal and free mobility of the limb (Figure 44.2). Three cotton stockinettes are applied to the operative leg, which will later be sequentially removed during femoral preparation and trialing.

Figure 44.2

With the drape cut on the operative side to uncover the ASIS and anterior thigh, a sterile iodoform drape is folded on the nonsticky side and applied posteriorly to seal off the buttocks, posterior thigh, and groin on the operative side.

A second sterile iodoform drape is placed anteriorly to allow for a secure seal and free mobility of the limb.

Surgical Exposure

The ASIS is identified and used as a reference for positioning of the skin incision. Using the skin marker, a line is drawn from the ASIS to the center of the patella. Medial to this line delineates the area of potential neurovascular risk. The incision commences two fingerbreadths distal and two fingerbreadths lateral to the ASIS and is made parallel to the marked line for 8 to 10 cm distally. Care should be taken not to cross inguinal tissue folds proximally because wound complications may more easily arise. Fluoroscopic guidance is used to confirm appropriate incision location. A line is drawn along the superior aspect of the femoral neck, which should generally cross the junction of the distal one-third and proximal one-third of the previously marked incision (Figure 44.3). The position of the superior femoral neck reference line will vary with proximal femoral anatomy.

Figure 44.3

A, The ASIS is identified and used as a reference for positioning of the skin incision. Using the skin marker, a line is drawn from the ASIS to the center of the patella. The incision commences two fingerbreadths distal and two fingerbreadths lateral to the ASIS and is made parallel to a line drawn from the ASIS to the center of the patella for 8 to 10 cm distally. B, Fluoroscopic guidance is used to check positioning and draw a line along the superior aspect of the femoral neck. This line should bisect the previously marked incision at the junction of the distal one-third and the proximal one-third.

The incision is carried down through the subcutaneous tissue to the fascia covering the tensor fascia lata (TFL). The muscle deep to the TFL has a distinguishing purple hue as opposed to the whiter fascia covering the sartorius medially (Figure 44.4). Multiple perforating vessels going from lateral to medial into the fascia covering the TFL provide another characteristic feature of the direct anterior interval. Be mindful that, in more obese patients, the subcutaneous anatomy tends to direct the dissection too lateral. Once the TFL fascia is identified, the fascia is incised in line with the incision. A pickup can then be used to grasp the medial side of the cut fascia while blunt finger dissection is used to separate the muscle from the fascia. Stay within the TFL fascia to minimize risk of injury to the lateral femoral cutaneous nerve.

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