Why I Switched to the Direct Anterior Approach: Expert Practice Perspectives From Leading Surgeons

William J. Hozack

Keith R. Berend

Jose A. Rodriguez

Neil P. Sheth

Introduction

Change can be hard. Change can be painful. As such, there must be compelling reasons for change. This is particularly so in the setting of a surgical procedure. Every new surgeon entering practice undergoes a learning curve until they gradually achieve consistency and diminish the outlier cases. A surgeon who has achieved mastery in their surgical execution benefits from optimized outcomes and mostly happy patients. As that surgeon begins a new procedure, the learning curve begins all over again, and this is often accompanied by diminished quality outcomes, until the learning curve is overcome and surgical mastery is reestablished.

Numerous studies have examined the learning curve in converting to the direct anterior approach (DAA) for total hip arthroplasty (THA). De Steiger et al suggested that the cumulative percent revision rate progressively declined up to first 100 cases performed, although the percent was not statistically different between 50 cases and 100 cases.¹ On the more cautious note, Stone et al showed that in transitioning from a posterior approach (PA) to the DAA, it took 400 cases before the DAA procedure time became statistically equivalent to the PA procedure time and 850 cases before the DAA procedure time was shorter than the PA procedure time.²

In this chapter, we asked four experienced hip surgeons to identify the reasons for their switch from their previously favored approaches to the hip to the DAA and to highlight some of the pearls and pitfalls in the process. Common experiences among the surgeons include substantial cadaver experience, dedicated and repeated visitation of established DAA surgeons, and a gradual and deliberate focus on team-based transition. Some things were learned by trial and error; for example, some of us initially attempted to suture ligate the femoral circumflex vessels, and the ligature would routinely get knocked off resulting in significant bleeding, such that we now all use electrocautery instead. Each story is personal and individual, and thereby remarkable in its own right.

Expert Practice Perspectives From Leading Surgeons

William J. Hozack, MD

Rothman Institute, Philadelphia, PA

During my training (both residency and fellowship), under the guidance of Dr. Richard Rothman, THA was performed using the classic Charnley supine transtrochanteric approach. As an aside, I could argue that the transtrochanteric approach is one of the original muscle sparing approaches, but I will leave that to another day. As I began my own practice, I transitioned to a modified Hardinge approach (now better known as the direct lateral approach), but still with the patient in the supine position. For me, there are substantial benefits of the supine patient position that continue to be realized even today—pelvic orientation is simplified, stability is easily evaluated, and leg lengths can be measured directly through palpation of the medial malleoli. With the direct lateral approach, patients periodically did have a nagging limp postoperatively for several months, but my practice was very full of satisfied patients. Yet, I knew that the operation could be better.

I was very active in the American Academy of Orthopaedic Surgeons (AAOS) teaching programs during the beginnings of the MIS (minimally invasive surgery) era. I feel several important advances did occur (despite some of the marketing hoopla) because of the emphasis on performing surgery that was less traumatic to the patient (thereby hopefully improving overall functionality), as well as on facilitating a more rapid pain-free recovery. During this time, I became enamored about the possibilities around the DAA for THA. It was a natural transition for me, as I already was using supine patient positioning for THA.

My surgery focus has always been on the exposure (rather than on an x-ray) as my tool to ensure proper component positioning and to minimize complications. As such, I made a deliberate choice to move away from the techniques that advocated for the use of fluoroscopy. Rather, I spent a great deal of time working with and learning from DAA THA techniques espoused by Professor Michael Nogler (supine, regular operating room [OR] table, no x-ray). I made many visits to his facility and worked with him on cadavers and in the OR to refine the surgical procedure. My technique has evolved further over the last 15 years, and I have benefited tremendously from the collective experience of innumerable DAA THA surgeons.

For me, the hardest part of adopting the DAA was that the overall experience at that time was small. At the outset, there were few specifically designed instruments—now I have specific instruments for every step of the operation. The sequence of surgical steps was undetermined—now the sequence is worked down to minute
detail. The exact location of various small “bleeders” was unknown—now I incorporate identification and coagulation of bleeders as specific and deliberate steps. The best placement of each retractor that would minimize muscle trauma had not been fully explored—now the specific timing, location, and even angle of each retractor is fully identified. In the beginning, my surgical times doubled as compared with my familiar and comfortable direct lateral approaches. And yet, the DAA patients had remarkable, sometimes spectacular, early recoveries that encouraged me to keep at it, to get it all worked out.

My transition from direct lateral 100% to direct anterior 100% occurred over a 3- to 4-year period. I chose easy cases first—flexible, minimal deformity, good neck length, valgus neck. Now I do all my primaries (both simple and complex) and all my revisions using the DAA. I have had a positive experience with DAA THA³ and continue to explore the intricacies of the operation (for example, a transverse incision in selected patients⁴). While not entirely attributable to the DAA, I believe that the soft tissue friendliness of DAA THA is a big reason that my THA practice in 2020 is now 50% outpatient or same day discharge.

Keith R. Berend, MD

Joint Implant Surgeons, New Albany, OH

In my residency training, we exclusively performed THA and hemiarthroplasty via a posterior approach. Late in my training, Dr. Tad Vail started working on a less invasive posterior approach or mini incision posterior approach. I had the privilege of training with him and learned how to perform a small-incision, somewhat less invasive, posterior approach.

Upon starting my fellowship with Drs. Tom Mallory and Adolph Lombardi, they exclusively used the direct lateral abductor splitting approach, or what is called a modified Hardinge approach. Initially this was performed through a large incision, and throughout my Fellowship and my first year or so in practice, Dr. Lombardi and I worked toward refining a small-incision or less invasive direct lateral approach. I performed this approach for the first 5 to 6 years of practice, confidently allowing patients to resume normal activities without hip precautions as quickly as possible.

Working at a musculoskeletal specialty hospital, I began to notice that patients from other practices and from other surgeons appeared to be recovering more quickly. We were pushing toward rapid recovery and early discharge. Most patients were able to go home within 24 to 36 hours of surgery; however, my patients tended to be slower with their physical therapy, tended to have more pain, and tended to have a much lengthier recovery than patients of surgeons performing the mini posterior approach within my community. For this reason, I sought to change my approach to total hip arthroplasty.

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