The DAA has gained popularity in the United States over the past 20 years, becoming the approach incision of choice for more than 50% of arthroplasty surgeons in some surveys.¹ There is an abundance of international literature that supports the DAA as an effective and safe way to perform both primary and revision THAs, and it has also been shown to have several advantages over other approaches such as faster and less painful recovery, less muscle damage, fewer dislocations, and simpler limb length assessment during surgery.² The popularity of the DAA in the United States has influenced the community of hip arthroplasty surgeons in Costa Rica, especially the younger ones, to become increasingly interested in incorporating it into their surgical practices.

In the past 3 years, there have been some isolated attempts to perform this procedure; however, until now, no surgeon has incorporated it into their normal practice because of the large number of limitations in our health system that had made learning this technique difficult. These limitations include the lack of specialized equipment, the lack of surgeons experienced in DAA hip arthroplasty who can serve as mentors for those who are overcoming the learning curve, and the difficulty in finding suitable cases from which to start. This chapter summarizes our experience incorporating the DAA as our preferred approach for the majority of primary THAs. In addition, we review what we consider the main limitations in our health system (in a developing country) and the suggested ways in which to overcome them.

Since the 1940s, Costa Rica has been committed to the social welfare of its population. One of the pillars of achievements in this field was the founding of the Caja Costarricense del Seguro Social (Costa Rican Social Security Fund). This is a government institution that is responsible for providing access to health care to more than 90% of the population. More than 80% of knee and hip arthroplasties are performed in the public health system, and most arthroplasty surgeons work for Caja Costarricense del Seguro Social. Despite its near universal coverage, the public health system has been plagued with a series of difficult challenges, including long queues (ie, waits) for surgery, which can be up to 4 years in some cases. Furthermore, because the wait is also long for many patients to access orthopaedic consultation, they often present with very advanced disease. These may include cases with severe deformity (eg, severe erosive changes, limb length discrepancies, protrusio defects, severe ankylosis, and extreme hypertrophic arthrosis; Figure 57.1). These scenarios lead to complex primary hip arthroplasty, and this pattern is also seen with cases of osteonecrosis that often have late presentations for surgery, leading to technically demanding reconstructions due to severe head collapse and neglect (Figure 57.2). Traditionally, the posterolateral approach has been the most widely used in the country, with a few exceptions in which some surgeons use the anterolateral approach. To date, no surgeon in Costa Rica has performed a fellowship in a DAA hip center.

As residents, we were trained in the posterolateral approach. Later on, I (J.A.D.L.O.) trained in the direct lateral approach during my fellowship in knee and hip arthroplasty at the Hospital Clínic in Barcelona, Spain. However, I did not continue this approach in my practice because of the known risks of abductor weakness, heterotopic ossification, and persistent limp. These are clearly issues related to violating the abductor mechanism through the direct lateral approach and have been well reported in the literature. Because of these concerns, for the first several years of my practice, I performed THA using the posterolateral approach with very good results. Since 2014, I performed a transosseous repair of the external rotators, which, together with the proper placement of the femoral and acetabular components, allowed me to obtain good joint stability. However, despite these good results, there were some situations that I found difficult to resolve.

The first major obstacle I had to face was the fact that in Costa Rica DAA THA was almost an unknown surgery. Recently trained surgeons knew of its advantages as reported in scientific articles, but there was no one in our country with formal training who had mastered the technique and had the ability to teach it to others. There was extensive knowledge of the Smith-Petersen approach in the field of pediatric orthopaedic surgery;
however, this scenario was vastly different from adult hip surgery.

At that time, there were several myths about the DAA that had permeated our guild, obscuring the view of this new technique. On the one hand, its advantages were minimized, and on the other hand, there was a widespread misconception that it was impossible to perform it without a specialized traction table. All this discouraged those surgeons who were interested in the learning process and generated a negative perception around it in the peer surgical community.

In 2018, I received an invitation from Dr. Hari Bezwada to attend the International Congress for Joint Reconstruction’s 7th Annual DAA Hip Course in Houston, TX. At that moment, I knew that was my opportunity to have direct contact with experts in the field and to discover the best way to start my first cases in the safest way and minimize my learning curve. The course was very revealing in many ways because it allowed me to clarify many basic concepts regarding the selection of the first cases from which to start, possible complications during the learning curve, the necessary basic equipment, tips, and tricks of the approach, and the different ways of performing it (ie, with or without traction table, with or without fluoroscopy, etc.). Furthermore, the course program included a cadaver workshop in which I had the opportunity to be guided by expert surgeons in performing this approach. This was my first real contact with an arthroplasty course of this type, and it completely changed my outlook; although I was aware that there was still a long way to go, I convinced myself that it was an applicable technique in my country. Perhaps most importantly, I suddenly had a clear mental scheme on how best to start incorporating this approach into my practice.

The second obstacle was the lack of specialized equipment for the anterior approach. Until that time, no commercial interest in the approach had been generated by implant vendors; therefore, there were no offset broach handles or retractors designed specifically for this procedure in Costa Rica. We only had straight instruments used for posterolateral and anterolateral approaches. Also, there were no specialized traction tables or leg positioning systems in the entire country. As a result, hard work had to be done outside the operating room before starting the first cases. One important step was to find adequate equipment, convincing the vendors to introduce their specific anterior approach instruments to the country. Utilizing online videos and courses was helpful, and then contacting those surgeons was another valuable resource. Also, some “homemade” retractors were manufactured, similar to those used in the United States but smaller and svelter to better accommodate the generally smaller anatomic build of patients in our country (Figure 57.3). Finally, educating all the persons involved in the process, including our nurses, operating room staff, anesthesiologists, and surgery assistants, helped to achieve a more cooperative environment because everyone was aware of the advantages of the new technique.

The third obstacle was finding suitable patients to start with due to institutional limitations and patient-specific factors. The Costa Rican Social Security System is currently fighting against long waiting lists for surgeries; in the largest health care centers, these queues reach several thousand patients, which implies a waiting time for THA surgery that can be up to 4 years. In addition to this, patients often postpone surgical treatment for a long time and only seek consultation when they suffer extreme pain and are diagnosed in most advanced stages of arthritis. These factors make it difficult to find an “easy” case to start with because the primary arthroplasties are usually fairly complex cases. Most patients with osteonecrosis presented with advanced collapsed femoral heads and very short femoral necks, thus moving away from the ideal starting patient with a long and valgus neck, which allows more working distance between the femur and the pelvis (Figure 57.4). In order to overcome this obstacle, we had to prioritize some of the patient selection criteria and ignore some others that were not as applicable to our environment as is explained later.