Total Hip Arthroplasty: Direct Anterior Approach Using a Specialized Table
Ran Schwarzkopf, MD, MSc
Roy Davidovitch, MD
Dr. Schwarzkopf or an immediate family member serves as a paid consultant to or is an employee of Intelijoint and Smith & Nephew; has stock or stock options held in Gauss Surgical and Intelijoint; has received research or institutional support from Smith & Nephew; and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons and the American Association of Hip and Knee Surgeons. Dr. Davidovitch or an immediate family member has received royalties from Radlink and Schaerer Medicall; serves as a paid consultant to or is an employee of Exactech, Inc., Medtronic, Radlink, and Schaerer Medical; and has stock or stock options held in Radlink.
INTRODUCTION
The history of anterior approach hip surgery dates back to a description by Carl Heuter in Der Grundriss der Chirurgie (The Compendium of Surgery), which was published in 1881.1 Judet then described the first anterior approach for hip arthroplasty in 1950 and then in 1985 described the anterior approach hip arthroplasty using a specialized table that he developed.2,3 For a variety of reasons, chief among them being the difficulty in femoral access and the popularity of the Charnley transtrochanteric approach, the anterior approach to total hip arthroplasty never attained widespread popularity.4 In 2005, however, Matta published his series of anterior approach total hip arthroplasty cases on a specialized table with excellent results, which arguably stimulated a new interest in the technique.5
In today’s era of same-day surgery and minimally invasive techniques, the anterior approach for total hip arthroplasty has experienced a resurgence of interest among surgeons and patients alike. With refinements in technique and the addition of specialized instruments and operating tables, utilization of the anterior approach continues to rise in both the United States and worldwide. The proposed benefits of an accelerated recovery and the elimination of postoperative precautions serve as the basis for much of the recent popularity of the anterior approach total hip arthroplasty. Others cite complications during the steep learning curve, the costs associated with acquiring specialized operating table, and doubt as to the actual role the procedure plays in accelerated recovery.
We describe here our technique for fluoroscopically assisted anterior approach total hip arthroplasty using a specialized table.
VIDEO 58.1 Direct Anterior Approuch Using a specialized table. Roy Davidovitch, MD; Dylan Lowe, BSc; Ran Schwarzkopf, MD, MSc (15 min 29 s)SURGICAL TECHNIQUE
Preoperative templating is performed on images that are corrected for magnification errors. Proper implant sizes and implant position are planned. Consideration is given to the bony anatomy, the quality of bone, and leg length that needs to be achieved before the proper implant size and position is decided.
Patient Positioning and Preparation
After the patient is appropriately anesthetized (spinal regional anesthesia is the preferred method at our institution), the patient is placed on a specialized radiolucent orthopedic table. A variety of specialized tables are now commercially available and all have their various advantages and disadvantages. Common to all of these tables, however, is the ability to fix the surgical extremity in external rotation and extension during femoral prep as well as radiolucency, allowing for fluoroscopic imaging if the surgeon so chooses. The patient is positioned in such a way that a well-padded perineal post engages the perineum. No traction is applied to either leg at this point. The site is prepped with chlorhexidine from the umbilicus to the knee; the surgical site is draped, allowing for manipulation of the entire extremity throughout the procedure. A fluoroscopy unit is draped and brought into the surgical field (Figure 1).
Surgical Anatomy and Approach
Our preference is for a vertical skin incision although a “bikini” style incision is used on heavier patients or patients particularly interested in cosmesis. The prominences of the anterior superior iliac spine (ASIS) and the greater trochanter are marked. A line is drawn connecting the ASIS and the greater trochanter palpable prominences. A vertical line starting 2 cm lateral and 1 cm distal to the first line is drawn toward the lateral border of the patella (Figure 2). The length of the typical incision is
approximately 8 to 10 cm. The dissection is carried down to the fascia overlying the tensor muscle. The direction of the underlying muscle fibers should be from the ASIS to the lateral side of the knee. The fascia is then incised over the tensor muscle. The tensor muscle is then bluntly separated from its fascia using finger dissection. The interval between the tensor muscle laterally and the rectus muscle medially is developed. The femoral neck is then palpated at the proximal aspect of the wound and a blunt cobra retractor is placed around the superior aspect of the femoral neck capsule, retracting the tensor muscle proximally. The interval between the tensor and sartorius muscle is developed distally and a deep cerebellar retractor is placed. Care is taken not to penetrate the loose layer of tissue septum underneath these muscles. The ascending branch of the lateral circumflex artery is identified (Figure 3). The vessels are then isolated and electrocautery is used to achieve hemostasis. Then the fascial septum is divided. The thick fibrofatty layer of tissue overlying the anterior capsule is elevated off the capsule with care being taken not to violate the capsule. After the capsule is freed of the tissue anterior to it, another blunt cobra retractor is placed inferior to the femoral neck. A complete view of the anterior capsule is essential before the anterior capsulectomy is performed. An anterior retractor placed over the anterior acetabular rim may aid in this exposure. We routinely do not use this retractor and use it only after cup placement if any overhanging anterior acetabular osteophytes are noted. The capsule is then incised along the center of the femoral neck from the intertrochanteric line laterally to the labrum medially. The capsulectomy is then performed along the acetabular rim medially both superior and inferior to the line of incision of the capsule. The acetabular labrum is excised anteriorly to facilitate the extraction of
the femoral head. Laterally the capsule is excised from the intertrochanteric line. The superior capsule is then released from the superior part of the trochanter. The position of the cobra retractors is then changed and placed over and under the femoral neck within the capsule.
approximately 8 to 10 cm. The dissection is carried down to the fascia overlying the tensor muscle. The direction of the underlying muscle fibers should be from the ASIS to the lateral side of the knee. The fascia is then incised over the tensor muscle. The tensor muscle is then bluntly separated from its fascia using finger dissection. The interval between the tensor muscle laterally and the rectus muscle medially is developed. The femoral neck is then palpated at the proximal aspect of the wound and a blunt cobra retractor is placed around the superior aspect of the femoral neck capsule, retracting the tensor muscle proximally. The interval between the tensor and sartorius muscle is developed distally and a deep cerebellar retractor is placed. Care is taken not to penetrate the loose layer of tissue septum underneath these muscles. The ascending branch of the lateral circumflex artery is identified (Figure 3). The vessels are then isolated and electrocautery is used to achieve hemostasis. Then the fascial septum is divided. The thick fibrofatty layer of tissue overlying the anterior capsule is elevated off the capsule with care being taken not to violate the capsule. After the capsule is freed of the tissue anterior to it, another blunt cobra retractor is placed inferior to the femoral neck. A complete view of the anterior capsule is essential before the anterior capsulectomy is performed. An anterior retractor placed over the anterior acetabular rim may aid in this exposure. We routinely do not use this retractor and use it only after cup placement if any overhanging anterior acetabular osteophytes are noted. The capsule is then incised along the center of the femoral neck from the intertrochanteric line laterally to the labrum medially. The capsulectomy is then performed along the acetabular rim medially both superior and inferior to the line of incision of the capsule. The acetabular labrum is excised anteriorly to facilitate the extraction of
the femoral head. Laterally the capsule is excised from the intertrochanteric line. The superior capsule is then released from the superior part of the trochanter. The position of the cobra retractors is then changed and placed over and under the femoral neck within the capsule.
 FIGURE 1 Intraoperative photograph. Fluoroscopy unit draped and brought into the surgical field. |
 FIGURE 2 Intraoperative photograph. The surgical incision is marked by a vertical line starting 2 cm lateral and 1 cm distal to the line drawn connecting the anterior superior iliac spine and the greater trochanter and drawn toward the lateral border of the patella. |
 FIGURE 3 Intraoperative photograph. The ascending branch of the lateral circumflex artery is identified. |
The Lateral Femoral Cutaneous Nerve and Possible Dyasthesia
The lateral femoral cutaneous nerve arises form L2 and L3 nerve roots and merges on the lateral border of psoas. It then travels under the inguinal ligament, overlying the sartorius and under the fascia. The lateral femoral cutaneous nerve then divides into anterior and posterior branches. The anterior branch pierces the fascia about 8 to 10 cm below the ASIS and supplies the skin over the anterior and lateral part of the thigh. The posterior branch traverses posteriorly and supplies the skin of the posterior thigh. In the current surgical technique, the fascial incision is placed over the tensor muscle. This is lateral to the course of the nerve. The anterior sensory branch of the nerve may be subject to traction neurapraxia on the medial and distal end of the incision.
Potential Pitfalls
Developing the proper surgical interval is essential. There are perforating vessels on the fascia of the tensor fascia muscle coursing from posterior to anterior. This helps in identifying the tensor muscle. Once the interval is developed, there should be muscle on the lateral side and fatty tissue on the medial side. If there is muscle encountered on both sides, there is a high chance of being in the wrong interval.
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