Trauma: The Use of the Direct Anterior Approach for Hip Fractures
Gil Ortega
Holly Pilson
Kurtis Staples
Matthew Baron
Key Learning Points
The direct anterior approach (DAA) is a safe, biologically friendly, and muscle-sparing approach that can address fracture care of the femoral head and femoral neck.
Anatomical reduction is key for treatment of these fractures, and the DAA highlights excellent visualization of the majority of these injuries.
With the appropriate technical use of reduction aids and implant placement, the DAA can facilitate all of this care with commonly used orthopaedic tables and equipment.
Introduction
The DAA to the hip has been well described. As the number of DAA primary and revision total hip arthroplasty (THA) procedures are increasing, the application of the DAA is becoming more popular among orthopaedic surgeons in treating a variety of hip fracture injuries. The DAA allows surgeons to use the approach for open reduction and internal fixation (ORIF) techniques for several types of hip fractures, including femoral neck fractures, femoral head fractures, and acetabular fractures. Our chapter focuses on using the DAA for femoral neck and head fractures.
Hip Fracture Fixation
The literature regarding the DAA for fracture fixation surgery of the hip continues to evolve with technology, implant development, trends in surgical approach and exposure, and biological and biomechanical considerations. Femoral neck and femoral head fractures continue to be at the forefront of this paradigm given their frequency, necessity, impact on patient health, and continued interest by the general orthopaedic community. In our experiences that are shared in this chapter, we believe the DAA offers the orthopaedic surgeon the ability to achieve important fracture visualization; anatomic reduction; and stable, optimized internal fixation.
As arthroplasty continues to be the mainstay in the United States for displaced femoral neck fractures in the elderly, femoral neck fractures in young to middle-aged patients continue to be a popular topic in the literature given the frequency of nonunion, avascular necrosis, and residual deformity of the lower limb after collapse and shortening of the fracture fragments.1,2,3 Although the optimal fixation construct continues to remain elusive,4 other important questions remain, including the necessity of open reduction.5
The quality of reduction has been of the utmost importance in ensuring good outcome,6,7 and this may indicate an open reduction for adequate treatment. At this junction, a decision on the choice of approach remains. A surgical approach for visualization has been debated between a laterally based approach, the Watson-Jones approach, and a DAA, and the recent literature would suggest that total surgical field exposure and visualization of the femoral neck are significantly higher with the DAA.8 Displaced fractures of the femoral neck in young and middle-aged patients should undergo anatomic reduction and, if necessary, open reduction with superiority given to the DAA; implant selection should be based on surgeon preference and other patient-specific factors including smokers. According to the Fixation Using Alternative Implants for the Treatment of Hip Fractures (FAITH) study,4 there were no differences in reoperation rates in patients with femoral neck fractures when randomized to fixation with a sliding hip screw or cancellous screws only. However, the FAITH study demonstrated that smokers did better when fixed with a sliding hip screw compared with smokers fixed with cancellous screws only.
Femoral head fractures often require ORIF when there is a fracture within the weight-bearing region of significant size or in a position that would impinge or present risk of becoming a loose body within the joint. Therefore, a decision must be made on the surgical approach and whether dislocation of the hip is required. The recent literature has compared surgical approaches (anterior and posterior) but is limited by the lack of control groups and suggests increased heterotopic ossification (HO) with an anterior approach.9
Other considerations may drive the selection of surgical approach, such as the location of the fracture fragment and associated injuries, including acetabular fractures. Considering this, surgical dislocation via a trochanteric osteotomy has gained interest and would necessitate a laterally based approach, but this has shown a significantly increased rate of HO even with prophylactic indomethacin.10 Regardless, most studies suggest similar long-term outcomes regarding the choice of approach necessary to treat the femoral head fracture, and the choice is ultimately up to the treating surgeon. Special consideration for HO prophylaxis should be considered as an adjunct to decrease rates of HO formation when either a DAA or trochanteric osteotomy is performed.
Technical Tips, Tricks, and Pitfalls for Femoral Head and Neck Fractures Using the Direct Anterior Approach
There are a variety of methods to ensure a surgeon’s success in the operative care of femoral neck and head fractures. We believe the DAA allows surgeons to use the advantages of the DAA while optimizing several technical tips and tricks that are demonstrated in the following cases.
Operative planning: When managing femoral head and neck fractures in a patient, it is important to develop an operative plan that considers the prioritization of reduction quality and absolute stability of the femoral head and neck fractures. This may mean a need to change patient positioning or even the type of bed preferred. The surgeon may want to choose the most ideal position, bed, and tools needed to get the most anatomic reduction possible of the femoral neck first. Compromising any of these parameters for the convenience of not having to reposition the patient, reprepare, or change out a table may lead to an unwanted compromise of the reduction or fixation quality.
Operative table choice and setup: We use and recommend a supine position on either a radiolucent table with a small, radiolucent bump (a rolled, large towel works well) under the ipsilateral hip or a hip fracture table, such as the Hana table (Mizuho OSI, Union City, CA, USA).
Radiolucent table advantages: Surgeons may prefer using a radiolucent table with free extremity draping because it provides the surgeon with the ability for full control to manipulate the leg in any plane while trying to obtain the reduction.
Radiolucent table pitfalls: When using a radiolucent table, surgeons might find lateral hip imaging challenging secondary to the table. We recommend prepping in the contralateral leg into the field to allow the contralateral hip to be flexed out of the field of view to enhance the operative lateral hip image. With the operative leg free, the surgeon will oftentimes require an assistant to help pull traction and/or hold the leg to facilitate reduction and internal fixation, which can cause assistant strain.
Hip fracture table advantages: Surgeons may prefer using a hip fracture table because the table can allow the surgeon to hold the leg without an assistant while also being able to fine-tune leg traction and manipulation, which will assist with the reduction and internal fixation. See case 1 demonstrating the use of a hip fracture table.
Hip fracture table pitfalls: Care must be taken to make sure that there is no secondary fracture displacement or traction nerve injury when using a hip fracture table.
Operative approaches for reduction and instrumentation
DAA: First, we recommend starting with the DAA to help visualize the fracture. A T-type capsulotomy is performed with one limb placed parallel to the femoral neck and the other limb perpendicular to the first limb in order help minimize the risk of injury to the femoral head blood supply. We recommend using a scalpel for the capsulotomy to help avoid thermal injury to the cartilage and/or the circumflex vessels. We use two sutures sewn into the capsule superiorly and inferiorly to allow capsule preservation, retraction, and closure. We then use two blunt cobra retractors or narrow Hohmann retractors inside the capsule to help minimize the footprint insult to the blood supply. The hemarthrosis is evacuated, the fracture hematoma debrided, and the fracture inspected.
Additional lateral approach: In cases when the DAA cannot be used as a single approach for both reduction and internal fixation, a second approach window directed via the lateral approach can also be used for reduction aids and instrumentation.
Hybrid anterolateral approach: As described by Vopat et al,11 the DAA can be extended distally and laterally to allow a single approach for both operative reduction and internal fixation. In patients with a body habitus that allows for safe lateralization of the DAA in an S-shaped curve along the lateral proximal femur, femoral neck fractures can be both reduced and stabilized through the same surgical approach.
Operative reduction techniques and instrumentation
Reduction maneuvers and instruments are then decided based on fracture characteristics. Common instruments used for reduction are Kirschner wires for joysticks (Figure 32.1), Weber reduction clamps (Figure 32.2A), modified Weber reduction clamps (Figure 32.2B), and a small bone hook or shoulder hook (Figure 32.2C). For most femoral head fractures, the DAA can be used for both reduction and internal fixation. For some femoral neck fractures in patients who do not have a large body mass index, a single DAA approach can be used for both reduction and instrumentation by lateralizing the DAA incision in an S-shaped curve along the lateral proximal femur as described by Born et al.10 The surgeon can then use a submuscular approach and raise the vastus lateralis superiorly to help enable lateral proximal femur-based instrumentation.Related posts:
A Definitive History of the Direct Anterior Approach
The Bikini Incision for the Direct Anterior Approach
Avoiding Intraoperative Femur Fractures
A Modified Extensile Anterior Approach to the Acetabulum and Anterior Column
Replacing the Dysplastic Hip via the Direct Anterior Approach
Trauma: Conversion of Prior Acetabular and Femoral Surgery via the Direct Anterior Approach
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