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



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


David A. Crawford

Keith R. Berend

Adolph V. Lombardi Jr





Key Learning Points



  • Femoral exposure during direct anterior approach (DAA) total hip arthroplasty (THA) can be accomplished without the aid of a specialized traction table.


  • Leg length and hip stability can readily be checked using our described technique.


  • DAA THA performed with this described method is safe and allows for rapid patient recovery.


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.6,7,8,9,10,11 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.










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]).







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.







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.