The Indian Direct Anterior Approach Experience

Rajesh Malhotra

Deepak Gautam

Sahil Batra

Introduction

The originally described Hueter’s approach has regained its recognition among surgeons as well as patients as DAA for total hip arthroplasty (THA).¹^,²^,³ The growing volume of literature has substantiated several benefits of DAA, including less blood loss, reduced pain, shorter hospital stay, low incidence of dislocation, and high-quality postoperative function.⁴^,⁵^,⁶^,⁷^,⁸ This has not only made DAA attractive for patients who demand this approach but also compelled the surgeons to switch from an alternate surgical approach. However, it is relatively less commonly performed in developing nations like India as compared with Western countries.

The major hindrance, in addition to its steep learning curve, is a theoretical “requirement” for a special table and dedicated instrumentation, as such a table is almost uniformly unavailable in India, as in most other parts of the developing world. This renders it a technically demanding procedure with added expense. The acceptability is now increasing after recognizing the essential benefits associated with this approach. Also, this approach is slowly being adopted by an increasing number of surgeons who are becoming aware of DAA as a consequence of a large number of workshops and cadaveric courses conducted within and outside the country, fellowship programs, as well as formal training by experienced surgeons. Even microteaching, surgical videos, and educational simulation have played a major role in training the surgeons in this approach.

The majority of orthopaedic surgeons in developing nations do not receive formal training in the direct anterior approach. Therefore, the surgeons can familiarize themselves with the surgical technique through published work as well as surgical videos and assisting surgeons adept at the approach to mitigate the learning curve, minimize complications, and achieve a favorable outcome. Critically evaluating radiographs, following up patients, and revisiting the surgical videos after every surgery for the first 50 cases can help them achieve their goals.

The authors have also gone through the process of learning, unlearning, and relearning from mistakes. The learning curve starting with performing one case a day lasting for 2 to 2.5 hours initially has now abated and given way to performing more than 80% of primary THAs by DAA, sometimes even performing six cases in a day and occasionally even simultaneous bilateral THA with DAA.

This chapter elaborates how and why a high-volume tertiary care center arthroplasty team in India transitioned from the conventional posterior approach to DAA. We discuss herewith the developments leading to the transition in 12 key steps leading to recognition, acceptability, as well as the ultimate merit of DAA as a reliable approach for THA in our setting.

Twelve Key Steps

Step 1: First Direct Anterior Approach During the Conference

The very first THA via DAA in the authors’ institution was performed along with the team of surgeons including the senior author (RM) during a live demonstration surgery in an arthroplasty conference by the invited faculty in the year 2012. To the authors’ knowledge, it was not only the first time a DAA was used for THA in India but also the first time a bilateral THA via DAA was performed in a rare case of bilateral fracture neck of femur under the same anesthesia. The delegates and the assisting surgeons from India got exposure to the technique from each surgeon along with the tips and tricks for DAA. Although the experience was well appreciated, it was not enough to diminish hesitation and reluctance among the surgeons to go back to their hospitals and perform THA using this approach. A newer technique, lack of formal training, and lack of willingness to change from the familiar approach used routinely remained major deterrences to adoption. The surgeons were still unsure if they could transition to this new approach without compromising the safety of the patients.

Step 2: Subsequent Direct Anterior Approach by the Invited Surgeons

Being at the premiere teaching institution in India (the All-India Institute of Medical Sciences [AIIMS]), the authors have had the privilege of inviting foreign faculty
for guest lectures and watch and assist them perform surgeries after securing temporary registration in the national medical register solely for academic purpose. Initiated and stimulated to learn DAA, the senior author invited overseas faculty who routinely used DAA to perform live demonstration surgeries and educate the surgeons, residents, and fellows about pearls and pitfalls of DAA. The residents were also encouraged to prepare and present seminars on different approaches to the hip for THA including DAA. These preliminary steps continued to compound the interest the authors had to inculcate DAA in their practice.

Step 3: Experience With Two-Incision Minimally Invasive Surgery for THA (Figure 58.1A-C)

FIGURE 58.1 Photograph showing the exposure of left femoral neck through the first incision of the two-incision minimally invasive surgical technique (A). Removal of the femoral head (B). Broaching of the femur through the second incision (C).

While DAA had yet to become popular in India, the senior author (RM) was trained in the two-incision minimally invasive surgery (MIS) approach for THA. He started regularly performing surgeries with this approach. The anterior incision of the two-incision MIS was 5 to 6 cm long and was followed by the midline incision of the femoral neck under fluoroscopic guidance.⁹ The deeper dissection to expose the anterior capsule and acetabulum was essentially similar to the DAA. This eased the acetabular preparation for the authors while performing THA by DAA. However, the femoral preparation was still a challenge as it required judicious releases to deliver the femur and prevent instability from inadvertent overrelease.

Step 4: Difficulty in Performing THA by Posterior Approach in Patients With Severe Abduction Deformity of Hips (Figure 58.2A and B)

FIGURE 58.2 Radiograph of pelvis of a patient with inflammatory arthritis showing bony ankylosis of both hips in wide abduction (A). Positioning of the same patient for posterior approach (B).

Abduction deformities of hips are seen in a small subset of patients with spondyloarthropathies, which happen to be more common in India. The patients presenting with severe deformities usually belong to the lower middle class family without access to appropriate and timely treatment. Moreover, many of these patients are not insured and have to bear the cost of treatment themselves. Severe bilateral abduction deformity renders placing the patient in lateral position difficult for the posterior approach. Often, in an attempt to position the patient in lateral decubitus, iatrogenic fractures may occur involving contralateral neck of femur, clavicle, and even spine.¹⁰ These patients additionally have extension and external rotation deformities, presenting formidable challenge in accessing the femoral neck for osteotomy in the posterior approach and posing a risk of sciatic nerve injury. Prior to adopting DAA, we used a dual approach to overcome the challenges. First, an in situ neck cut was made in a supine position via the anterior incision to render the hips mobile and make adduction and internal rotation possible. Second, the patient was positioned lateral and the THA performed via the posterior approach. Patients with extension contracture required Z-plasty of gluteus maximus to achieve hip flexion postoperatively and enable patients to sit.¹¹ DAA allowed supine positioning of the patient with abduction contracture mitigating the risk of fractures while providing ready access to the anterior neck in the presence of external rotation deformity.

Step 5: Management of Patients With Neglected Hip Fractures—Need of Circumferential Hip Surgeon (Figure 58.3A and B)

FIGURE 58.3 Photograph of a patient with hip arthritis showing skin lesion in the posterolateral (A) and posterior (B) aspects of the hip. Such lesions were a hindrance for a posterior approach.

There is a significant burden of femoral neck fractures in our ever-increasing population of elderly with poor health. Those from the low socioeconomic status and residing at remote areas often present late for treatment following a fracture of neck of femur.¹² Poor awareness; inability to access health care, often entailing a journey of nearly 100 km; treatment by local osteopath or quacks; and inability to afford the cost of treatment often lead to late presentation of a patient who is bedridden for a long time and may also present with decubitus sores.¹³ Hip arthroplasty is indicated to treat the fracture, mobilize the patient, and reduce the risk of further aggravation of decubitus sores. However, the posterior location of the decubitus sore in these patients often makes them unsuitable for a posterolateral incision. A circumferential hip surgeon can utilize the alternate approach for hip arthroplasty, and DAA is truly invaluable in these cases. In the authors’ practice, patients with fracture neck of femur were the initial subjects to THA via DAA. While the soft tissues around the hip in fracture neck of femur are lax and patulous, femoral mobilization is possible with limited need for release of pubofemoral and medial iliofemoral ligaments. Also, the DAA combats the higher risk of dislocation reported in these patients. Hence, fractured neck of femur was an ideal indication for transitioning from posterior approach to DAA for THA, inclusive of the neglected cases. These conditions were similar to those of the patients presenting with chronic inflammatory skin lesion (noninfective) in the posterior aspect of the hip where the incision is to be made. These patients were better managed with the anterior approach as the lesions need not be touched by the incision.

Step 6: Indian Culture and Total Hip Arthroplasty (Figure 58.4A and B)

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