A Definitive History of the Direct Anterior Approach

David A. Molho

Neil Pathak

Lee E. Rubin

Kristaps J. Keggi

Introduction

We explore the motivations that drew surgeons and patients to the direct anterior approach (DAA). We begin with Carl Hueter’s 1881 description¹ and then delve into how the surgical principles of William Stewart Halsted and Harvey Williams Cushing influenced the development of the DAA. Publications by Marius Nygaard Smith-Petersen in the early 20th century described his motivations for using this approach.² Using a transtrochanteric approach in the 1960s, Sir John Charnley³ made major advances in total hip arthroplasty (THA). By 1980, Kristaps Keggi published on the DAA for THA.⁴ In 1985, Jean Judet published work on the DAA in THA using a specialized fracture table.⁵ This technique was then transmitted to Emile Letournel, who, in turn, trained Joel Matta. Matta helped make a specialized fracture table commercially available, taught surgeons to use it for DAA THA, and published on this topic in 2005.⁶^,⁷ A list of key historical DAA THA articles in chronological order is provided in Table 2.1. Since then, the DAA has gained popularity among surgeons and patients. The literature and surgical tools continue to expand and make DAA more accessible, although the rationale behind its success was described over a century ago by Carl Hueter.

TABLE 2.1 Illustrative Table on History of Landmark Publications Related to Direct Anterior Approach Total Hip Arthroplasty

Year	Author(s)	Title	Journal/publisher/meeting
1883	Hueter	Grundriss der Chirurgie, 2nd edition	FCW Vogel
1917	Smith-Petersen	A new supra-articular subperiosteal approach to the hip joint	J Bone Joint Surg Am
1977	Keggi & Light	The anterior approach to total hip replacement	American Academy of Orthopaedic Surgeons Annual Meeting
1980	Light & Keggi	Anterior approach to total hip replacement	Clin Orthop Relat Res
1985	Judet & Judet	Anterior approach in total hip arthroplasty	Press Med
1993	Keggi et al	Anterior approach to total hip replacement: surgical technique and clinical results of our first one thousand cases using non-cemented prostheses	Yale J Biol Med
2003	Kennon et al	Total hip arthroplasty through a minimally invasive anterior surgical approach	J Bone Joint Surg Am
2004	Kennon et al	Anterior approach for total hip arthroplasty: beyond the minimally invasive technique	J Bone Joint Surg Am
2005	Matta et al	Single-incision anterior approach for total hip arthroplasty on an orthopedic table	Clin Orthop Relat Res
2009	Berend et al	Enhanced early outcomes with the anterior supine intermuscular approach in primary total hip arthroplasty	J Bone Joint Surg Am
2012	Nogler et al	The direct anterior approach to the hip revision	Oper Orthop Traumatol
2016	Bal et al	The direct anterior approach to hip reconstruction	SLACK Incorporated

The advantages of the anterior oblique approach are: (1) Only one muscle, the vastus, is injured; for this reason the leg keeps its tight connections to the pelvis, which facilitates rehabilitation. (2) Bleeding is so little that no single ligature has to be done.¹

Carl Hueter (1838-1882)

Carl Hueter was born in Marburg, Germany, in 1838. In Marburg, his father was a practicing gynecologist. Hueter began medical school at the age of 16 years in 1854. Early in his career, he served as an apprentice to both Virchow and Langenbeck and later worked at the Anatomic Institute in Paris (1861-1863) where he studied orthopedic anatomy.⁸ His extensive study ultimately led to
the 1000+-page textbook titled Compendium of Surgery (published in 1881; Figure 2.1), which included the earliest known written description of the anterior approach to the hip.¹ Dr. Hueter used this surgical approach to resect the femoral head in cases of septic arthritis.

FIGURE 2.1 Illustration from Hueter’s textbook.

(Reprinted from Hueter C. Grundriss der Chirurgie. 2nd ed. FCW Vogel; 1883.)

Marius Nygaard Smith-Petersen (1886-1953)

In the spring of that year [1916] I assisted in an open reduction of a congenital dislocation of the hip. The hip was exposed through a Kocher incision; it was bloody; it was brutal. The patient survived by a very narrow margin… There must be some other way of exposing the hip.⁹

Smith-Petersen was born in Grimstad, Norway, in 1886 and emigrated to the United States (Milwaukee, WI) at the age of 16 years. He completed 1 year of undergraduate studies at the University of Chicago and then completed the rest of his undergraduate years at the University of Wisconsin (graduated in 1910). He completed medical school at Harvard and subsequently enrolled at the Peter Bent Brigham Hospital in Boston as a general surgery intern under the guidance of neurosurgeon Harvey Williams Cushing.⁹^,¹⁰ Some of his innovative work involved spinal osteotomy, femoral neck fracture fixation, and mold interposition hip arthroplasty. In 1917, at the age of 31 years, Smith-Petersen wrote the following:

The incision just described seems to offer an easy approach to the acetabulum without injury to important structures… 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 good exposure of the acetabulum – arthrodesis for instance.²

Smith-Petersen is credited with popularizing the anterior approach to the hip in the United States, first describing it in 1917 for the treatment of congenital hip dislocation.²^,¹¹ He also used a proximal extension of the incision, traveling posteriorly along the iliac wing, which also allowed exposure to the outer table of the ilium. He used this for the treatment of congenital hip dislocation, vitallium mold arthroplasty, and femoroacetabular impingement. In a vivid article, he described how he coined the approach.⁹ He credits the principles he learned from Dr. Harvey Cushing, including “respect for structures and structural planes.” He described a Kocher approach used for congenital hip dislocation as “bloody and brutal.”

He was inspired by the delicate nature of Cushing’s cerebellar exposures. Each structure was reflected intact and “never in shreds.”⁹ The day after witnessing a Kocher approach performed for congenital hip dislocation, 31-year-old Smith-Petersen obtained a cadaver and experimented with the anterior approach. He showed the specimen to his chief of orthopedics, Dr. Elliott Gray Brackett, who thought the new approach was promising. Dr. Brackett brought the specimen to the American Orthopaedic Association meeting. Smith-Petersen received a letter 1 year later from a surgeon who was now using his approach and stated he would use no other approach. Smith-Petersen most likely developed the approach independently, unaware of Carl Hueter’s description of the interval.⁹ Smith-Petersen described how he developed the approach as follows: “I had a new way of exposing the hip joint” and makes no reference to Hueter’s description.⁹ He told his senior colleague, Dr. Roy Abbott, “there must be some other way of exposing the hip.” Abbott’s response was, “Why don’t you figure one out?”⁹

He treated hip arthritis with the mold arthroplasty. He used his anterior approach to interpose a prosthetic cup between the femoral head and the acetabulum. This was intended to be removed 2 years later with the goal of having created a smoother surface. Early glass mold components shattered within the joint, so he transitioned to newer vitallium alloy implants (having learned about this new material from his dentist), which allowed for permanent implantation. Using histologic data, he determined
fibrocartilage underwent metaplasia to form hyaline cartilage after implantation.⁹ He died at the age of 65 years, several days after performing his vitallium mold hip arthroplasty on famous radio and TV star Arthur Godfrey.¹²

William Stewart Halsted (1852-1922)

William Stewart Halsted is considered by some to be the “father of modern surgery.”¹³ He was born in 1852 in New York City and was homeschooled until the age of 10 years. He attended Yale College (class of 1874) and was captain of the football team. He then matriculated to medical school at the Columbia University College of Physicians and Surgeons, where he graduated among the top 10 students in his class.¹⁴ His career took him from New York Hospital to Johns Hopkins Hospital. As an educator, he instilled strong surgical principles into all those he trained at Johns Hopkins in the early 20th century. He made strides in local anesthesia, hernia surgery, mastectomy, surgical instrumentation, and modern surgical training programs. He was a champion of new antiseptic techniques that stemmed from Lister and Pasteur. Halsted spread several of his surgical principles, including hemostasis, careful anatomic dissection, exact approximation of tissues during closure, and gentle handling of tissues.

Halsted was an active, daring surgeon in New York before his cocaine addiction, which started after his research on cocaine’s local anesthetic properties.¹³ After inpatient treatment and rehabilitation at the Butler Hospital in Providence, RI, Halsted returned to the practice and teaching of surgery in Baltimore at Johns Hopkins. He became a very slow, compulsive operator, in contrast to his early years in New York. His medical students quietly referred to his lengthy hospital rounds as “shifting dullness.”¹³ Halsted gave certain Hopkins residents autonomy to do major and innovative operations on their own. A number of his trainees went on to revolutionize new fields of surgery. Harvey Williams Cushing and Walter Dandy would make great strides in neurosurgery, and William Young would have a great impact in the field of urology.

Harvey Williams Cushing (1869-1939)

Harvey Williams Cushing was a Yale College graduate (class of 1891) and baseball varsity athlete. His medical training was completed at Harvard Medical School, where he earned his MD degree in 1895. He served as a surgical intern at Massachusetts General Hospital. Over the span of his career, he was a pioneering neurosurgeon, cerebral pathologist, and Pulitzer Prize-winning biographer.¹⁵ Halsted’s influence is evident in Smith-Petersen’s description of Cushing’s exposure of the cerebellum. This was the inspiration for Smith-Petersen’s work on the anterior approach to the hip.⁹

The teachings of Dr Harvey Cushing – respect for structures and structural planes – were directly responsible for a new approach to the hip joint… .The cerebellum exposure, by reflection of muscle flaps with their periosteal attachments, was probably the one that gave me the idea of combining the anterior hip approach with the periosteal reflection of muscles from the lateral aspect of the ilium.⁹

—Smith-Petersen (1948)

Sir John Charnley (1911-1982)

Sir John Charnley was a British orthopedic surgeon who was born in 1911. His father was a chemist, and his mother was a nurse. Taking an early interest in the sciences, he went on to study medicine at the Victoria University of Manchester.¹⁶ He is credited with using a transtrochanteric approach for exposing the hip and pioneered the development of cemented THA in the 1960s after developing the prosthetic acetabular socket.

The operation is performed through a lateral exposure by elevating the greater trochanter. At the end of the operation the trochanter is reattached to the outer surface of the femur … The patient is splinted with the leg in abduction for three weeks, and is allowed to take full weight on the hip five weeks after the operation. Recent experiences suggest that plaster is not essential… . The average stay in hospital is eight weeks.³

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