In any surgical setting, self-sufficiency has the potential to result in increased productivity, reproducibility, and decreased costs, which are particularly relevant in the practice of total hip arthroplasty (THA). There is a great deal of variability among operating room (OR) charges and costs, ranging from $30 to $100/min; however, a more recent US single-state analysis suggests costs are more likely to be in the $36 to $37/min range, with 26.8% of that cost resulting from staff wages.^1,2,3,4,5 As a result, there still remains room for improvement, both with personnel optimization within the OR as well as more efficient use of available OR resources.

The direct anterior approach (DAA) for THA is a safe and reliable procedure,⁶ which in the typical patient creates both a reproducible surgical approach and field of view; however, such an exposure requires appropriate retractor positioning. Once placed, retractors were historically held in place by one or more assistants or a surgical technician. Oftentimes, there can be variation with assistant availability or expertise that can result in variation with help and add increased variability to the procedure. The use of self-retaining retractor systems helps to mitigate these variables by increasing the self-sufficiency of the surgeon, enabling them to create a reproducible workflow with a consistent exposure for each stage of the procedure.

With regard to DAA THA, the need for a consistent workflow is paramount to reproducing the procedure each time. Inexperienced, fatigued, and/or distracted assistants can become a liability for maintaining the safety of the operation, causing the field of exposure to shift and move throughout the procedure. In addition, reliance on extra assistants can lead to a quandary should there be staffing shortages, injuries, or vacations among the experienced team members. Thus, in a busy DAA surgical practice, it has become imperative to establish self-
sufficiency to free up the hands of the surgeon and surgical technician to maintain a steady, continuous workflow. In doing so, the DAA procedure can proceed smoothly and efficiently, especially because the DAA is increasingly being used in the high-performance ambulatory setting.

Several different self-retaining retractor systems have been used for the DAA, including the Phantom MIS Anterior Hip Retractor System (TeDan Surgical Innovations, Sugar Land, TX, USA), Omni-Tract Retractors (Integra LifeSciences, Princeton, NJ, USA), the ADAPTABLE Leg Holder (Formerly DJO, now ENOVIS Surgical, Wilmington, DE, USA), the Thompson Total Joint System Frame (Thompson Surgical Instruments, Traverse City, MI, USA), and the Gripper System (MedEnvision, Westerlo, Belgium, EU). Among the available retractor systems and setups, there are no studies to suggest any one single system is superior, and there is a paucity of literature regarding the impact of these systems on surgical practice and efficiency. Because there are subtle differences among them, surgeons can evaluate and choose a self-retaining retractor system setup that meets their individual and institutional preferences.

This chapter presents and discusses three of the existing self-retaining retractor systems that are currently used by several leading DAA surgeons in order to provide the reader with a better understanding of a self-
retaining retractor system’s functional utility, in addition to the potential benefits and disadvantages. In addition, we briefly discuss and illustrate some other interesting self-retaining retractor options available on the market that are also useful for a DAA surgeon.

The Thompson Total Joint System frame consists of a base rail clamp (Elite II Rail Clamp, Thompson Surgical Instruments) that attaches to the bed on the contralateral side of the table with two cam joints for angled crossbar attachment. These two crossbar attachments provide the option to use various attachment arms using clip-on clamps to attach them to the frame. In the setup demonstrated in Figure 46.1 (courtesy of Dr. Lee E. Rubin), angled crossbar attachments were used to provide secure clamp points for the various retractors. After the initial setup with the rail clamp and the angled crossbar attachments, the base of the retractor system is prepared to hold the various retractors throughout the procedure with the use of Cam II Clip-On Blade Adapters (Thompson Surgical Instruments). Once the surgical exposure is completed, these retractors then
stay in place and maintain consistent soft tissue tension. In addition, they maintain a steady field of view for the surgeon and provide the means to then share this same view with a resident or fellow who is learning how to perform the DAA operation, thereby improving the teaching quality of the procedure.

After the initial DAA dissection through the superficial soft tissues followed by the fascial incision and hip capsulotomy (or capsulectomy as desired), two Cam II Clip-On Blade Adapters are tightened onto two cobra retractors and placed along the medial femoral neck just proximal to the lesser trochanter and expose the lateral femoral neck by being placed over the posterolateral acetabular labrum, acting to protect the abductor muscles from the oscillating saw during the femoral neck cut. In addition, a third Thompson cobra retractor is placed over the anterior-medial brim of the acetabulum to facilitate exposure of the intra-articular space. Next, an additional long, curved, toothed Balfour retractor blade (25 × 115 mm) is used medially to retract the rectus off of the anterior rim, thereby increasing inferomedial exposure (Figure 46.2). This custom retractor is known locally as the Rubinator blade (Figure 46.3). After the femoral neck cut, further exposure of the acetabulum is performed and retractors are repositioned to garner adequate acetabular exposure and expose the transverse acetabular ligament, which is then used as a native ligamentous landmark for anatomic guidance of acetabular cup positioning (Figure 46.4).

After acetabular reaming and cup placement are completed, attention is then turned to positioning the proximal femur for a posterior-lateral capsular release to aid in exposure and femoral elevation for broaching and implant preparation. A Thompson cobra retractor is placed along the medial femur proximal to the insertion of the iliopsoas at the level of the lesser trochanter and distal to the insertion of the short external rotators. Next, a curved single-prong hip blade is placed under the posterolateral femur behind the greater trochanter to elevate the femur for preparation of the canal (Figure 46.5).