In 1950, the DAA for hip arthroplasty was first described by Judet using a traction table,¹ and this has remained the predominant technique for many anterior hip surgeons who tout its benefits for femoral and, secondarily, acetabular exposure. However, the approach can be performed safely and efficiently without the use of a special table, a technique that is gaining traction as the DAA continues to gain popularity.²

There are a number of benefits to using a standard operating room (OR) table for the DAA. It requires less capital expenditure on the part of the hospital or surgery center and obviates the need for an unscrubbed and proficient assistant to safely manipulate the leg. It aids in simplifying the workflow for the OR and cleaning staff. In addition, it allows the surgeon to correlate intraoperative and preoperative assessments of leg length and allows for easy dynamic stability testing. The use of intraoperative fluoroscopy has been touted as a major advantage to the DAA and can be used readily with the DAA on a standard table (in conjunction with robotic assistance if desired by the surgeon). A recent meta-
analysis comparing the DAA performed with and without a traction table demonstrated similar early outcomes, with a lower mean operative time, less blood loss, and a lower rate of femoral fracture in the cohort on the standard OR table.³ Lastly, it nullifies the risk of ankle fracture, which has been reported with the use of a traction table.⁴

In this chapter, we illustrate how the DAA is performed at our institutions, with a regular OR table and a table-mounted femoral hook as necessary with both legs draped into the sterile field.

The DAA on a standard OR table can be performed safely and efficiently with relatively few basic instruments. In the authors’ experience, these can generally fit on a single Mayo stand (Figure 8.1). Although most of these instruments are widely available, specialized femoral retractors may aid in safe and reproducible femoral exposure. Additional instruments not pictured in Figure 8.1 are occasionally needed, such as osteotomes and rongeurs that may be necessary to remove acetabular osteophytes. Some surgeons find value in using specialized anterior hip retractors (Figure 8.2), which can aid in the exposure of the acetabulum and elevation of the femur, such as the set designed by one of the authors (A.S.U.).

Most standard OR tables can be used for the DAA. Those commonly used at our institutions include the AlphaStar 1132 (Maquet) and the STERIS 4085 (STERIS). If intraoperative fluoroscopy is to be used (the authors’ preferred technique), the patient should be positioned on the bed so that the fluoroscopy unit can easily access the pelvis without interference from the table base. These positioning requirements often involve sliding the patient distally on the OR table, away from the anesthesiologist. Of note, some OR tables may need to be reversed in order for the base of the bed to accommodate the fluoroscopy unit. There should be no head extension on the OR table, and a foot extension is typically necessary to allow the patient to be shifted to the appropriate position to allow hip extension during femoral exposure. The fluoroscopy unit is positioned on the nonoperative side of the bed. The scrub technician stands at the foot of the bed, and the sterile tables are positioned in an “L” configuration (Figure 8.3).

The authors’ preference is to use two surgical assistants (one on the operative side and the second across the table on the nonoperative side); however, one skilled assistant on the operative side is sufficient to allow for adequate exposure and retraction during the case. Newer, self-retaining retractor systems that allow the case to be performed without surgical assistants are available and discussed elsewhere in this textbook.

The patient is positioned such that the hip joints, which can be approximated by palpating the greater trochanters, are centered over the break of the bed (Figure 8.4). In conjunction with the foot extension, this allows the potential for intraoperative hip extension by using the bed’s “leg down” function. Taller patients may have their feet hanging off the end of the bed by several centimeters, which we have not found to be problematic. We do not routinely place a bump under the pelvis to avoid altering pelvic tilt, although some surgeons find this helpful to allow for hip extension without breaking the bed. If a bump is used, a sacral bump is preferred because this avoids pelvic rotation, keeping the anterior pelvic plane parallel to the floor and helping to avoid cup malposition.

Both legs are prepped and draped, allowing the surgical team easy access to both the operative and the nonoperative sides. Prepping can be performed per institutional protocols. At our institution, both extremities are hung using table-mounted leg holders for skin preparation (Figure 8.5). The operative side is prepped to the umbilicus and the nonoperative side to the groin. We place one sterile half-sheet drape over each of the arms and one under the legs. We then use two impervious split drapes to drape out the operative leg. Both legs are placed into impervious stockinettes, ensuring that the medial malleoli can be palpated. A bilateral extremity drape is then used, and a cutout is made on the operative side to accommodate the surgical field. The hip is sealed with two sheets of Ioban (3M), and we use an additional shower curtain drape to cover the arm boards. The feet, ankle, and legs are then wrapped with Coban (3M) with attention to be able to manually palpate the medial malleoli (Figure 8.6).