Direct Anterior Approach Arthroplasty Text Book

© 2016 SLACK, Incorporated
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B. Sonny Bal, MD, JD, MBA
Professor of Orthopedic Surgery
School of Medicine
University of Missouri Health System
Columbia, Missouri
Lee E. Rubin, MD
Assistant Professor of Orthopaedic Surgery
Division of Adult Reconstruction
Warren Alpert Medical School of Brown University
University Orthopedics, Inc
Providence, Rhode Island
Kristaps J. Keggi, MD, Dr Med (hc)

Professor of Orthopedics and Rehabilitation
Yale University School of Medicine
New Haven, Connecticut

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Library of Congress Cataloging-in-Publication Data

Names: Bal, B. Sonny, editor. | Rubin, Lee E., 1978- , editor. | Keggi,
Kristaps Juris, 1934- , editor.
Title: The direct anterior approach to hip reconstruction / [edited by] B.
Sonny Bal, Lee E. Rubin, Kristaps J. Keggi.
Description: Thorofare, NJ : SLACK Incorporated, [2016] | Includes
bibliographical references and index.
Identifiers: LCCN 2016006598 (print) | LCCN 2016007303 (ebook) | ISBN
9781630910273 (hardback : alk. paper) | ISBN 9781630913519 (e-book) | ISBN
9781630913526 (Web ready)
Subjects: | MESH: Arthroplasty, Replacement, Hip--methods | Hip
Injuries--surgery | Hip Joint--surgery
Classification: LCC RD772 (print) | LCC RD772 (ebook) | NLM WE 862 | DDC
617.5/810592--dc23
LC record available at http://lccn.loc.gov/2016006598
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Dedication
We are grateful to the many expert authors and surgeons who have contributed their work for this
text, and to SLACK Incorporated for their support and guidance throughout the publication pro-
cess. This text is the first to comprehensively encapsulate the training process for the direct anterior
approach (DAA) from novice to expert, and it will serve to educate future generations of residents,
fellows, and surgeons to the benefit of patients around the world.
The publication of this text represents the culmination of a celebrated career in orthopedic sur-
gery and hip reconstruction for Dr. Kristaps J. Keggi. For many years throughout my training at
Yale, he talked with me at length about his lifelong vision to author a definitive text on the DAA.
Unfortunately, the size and scope of such a visionary project kept it perennially out of reach. Dr. Sonny
Bal and I are truly honored to bring this project to fruition. Dr. Keggi has been a role model and an
inspiration, showing us the very best of what can be achieved with selfless service both to our patients
and to the orthopedic profession. As his “Final Fellow,” I am privileged to have known him extensively
as a mentor, partner, and friend. In the spirit of celebration, we wish to dedicate this text in honor of
Dr. Keggi's life and career.
Lee E. Rubin, MD

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Contents
Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
About the Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii
Contributing Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xv
Foreword by Larry Dorr, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii
Section I Basic Direct Anterior Approach Surgical Technique . . . . . . . . . . . 1
Chapter 1 Applied Anatomy of the Anterior Hip and Thigh . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Blake E. Peterson, MD and Brett D. Crist, MD
Chapter 2 Indications for the Direct Anterior Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

R. Presley Swann, MD, MS and Christopher E. Pelt, MD
Chapter 3 Managing Single and Multiple Incisions in Direct Anterior Hip Surgery . . . . . . . 21
Scott A. Ritterman, MD; Kristaps J. Keggi, MD, Dr Med (hc);
and Lee E. Rubin, MD
Chapter 4 Primary Total Hip Arthroplasty Using the Hana Table . . . . . . . . . . . . . . . . . . . . . 39

Navid M. Ziran, MD and Joel M. Matta, MD
Chapter 5 Extensile Approach to Anterior Hip Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Chapter 6 Anterior Supine Intermuscular Total Hip Replacement . . . . . . . . . . . . . . . . . . . . . 77

Keith R. Berend, MD; Nathan J. Turnbull, MD; Robert E. Howell, MD; and
Adolph V. Lombardi Jr, MD, FACS
Chapter 7 Tips and Tricks for Overcoming the Direct Anterior Approach
Learning Curve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Benjamin Domb, MD and Timothy Jackson, MD
Section II Intermediate Direct Anterior Approach Techniques . . . . . . . . . . 105
Chapter 8 Understanding the Risks in New Technologies . . . . . . . . . . . . . . . . . . . . . . . . . . 107

B. Sonny Bal, MD, JD, MBA and Lawrence Brenner, JD
Chapter 9 Direct Anterior Total Hip Arthroplasty in the Lateral Decubitus Position . . . . . .115
Wietse P.R. Melman, MD; Markus C. Michel, MD;
and Cees C.P.M. Verheyen, MD, PhD

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viii Contents
Chapter 10 Direct Anterior Total Hip Replacement With Leg Positioning

System and Fluoroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Adam M. Freedhand, MD; Preetesh D. Patel, MD; and Eric M. Slotkin, DO
Chapter 11 Computer Navigation and Robotics in Anterior Hip Reconstruction . . . . . . . . . 135

David Dodgin, MD; E. Matthew Heinrich, MD;
and Joseph T. Moskal, MD, FACS
Chapter 12 Transitioning to Direct Anterior Total Hip Replacement . . . . . . . . . . . . . . . . . . 149

Blake E. Peterson, MD; Joseph Morgan, MD; and
Chapter 13 Specialized Instruments for the Direct Anterior Approach. . . . . . . . . . . . . . . . . . 161

Dan Gerscovich, MD; Anthony S. Unger, MD; Evan Smith, MD;
Kristaps J. Keggi, MD, Dr Med (hc); and Lee E. Rubin, MD
Chapter 14 Specialized Retraction for Direct Anterior Total Hip Arthroplasty . . . . . . . . . . . 175
Daniel C. Allison, MD, MBA and Timothy McTighe, Dr HS (hc)
Section III Advanced Adult Reconstructive Techniques . . . . . . . . . . . . . . . . 193
Chapter 15 Avoiding, Recognizing, and Treating Complications of the

Direct Anterior Hip Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Mohan S. Tripathi, MD and Stephen Kayiaros, MD
Chapter 16 How to Identify and Correct Technical Errors With

the Direct Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Michael P. Ast, MD and Hari P. Bezwada, MD
Chapter 17 Head and Liner Revision Surgery via the Direct Anterior Approach . . . . . . . . . . 223
Scott A. Ritterman, MD; Matthew E. Deren, MD; and Lee E. Rubin, MD
Chapter 18 Simultaneous Bilateral Direct Anterior Approach

Total Hip Arthroplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Stefan Kreuzer, MD, MSc and Amir Pourmoghaddam, PhD
Chapter 19 Acetabular Direct Anterior Approach Revision Surgery . . . . . . . . . . . . . . . . . . . . 239

Jonathan Yerasimides, MD
Chapter 20 Anterior Approach Femoral Revision Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

Michael Nogler, MD, MA, MSc

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Contents ix
Section IV Direct Anterior Approach Across Orthopedic Specialties:

Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Chapter 21 Direct Anterior Hip Surgery in Pediatric Patients . . . . . . . . . . . . . . . . . . . . . . . . 263

Jonathan R. Schiller, MD; Philip McClure, MD; and Lee E. Rubin, MD
Chapter 22 Management of Developmental Dysplasia of the Hip With

the Bernese Periacetabular Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Atul F. Kamath, MD; Reinhold Ganz, MD; and Michael Leunig, MD
Section V Direct Anterior Approach Across Orthopedic Specialties:

Sports/Hip Preservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Chapter 23 Limited Exposure Direct Anterior Approach for

Treatment of Femoroacetabular Impingement . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Lee E. Rubin, MD; Joseph A. Gil, MD; and Scott A. Ritterman, MD
Chapter 24 Addressing Acetabular and Femoral Lesions in Hip Impingement With

Garrett Davis, MD, MBA, MS and Javad Parvizi, MD, FRCS
Section VI Direct Anterior Approach Across Orthopedic Specialties:

Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
Chapter 25 Management of Acetabular Fractures in the Elderly With

Direct Anterior Hip Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Steve Papp, MD; Wade Gofton, MD; Derek Butterwick, MD;
Allan Liew, MD; and Paul E. Beaulé, MD
Section VII Direct Anterior Approach Across Orthopedic Specialties: Adult

Reconstruction/Hip Preservation . . . . . . . . . . . . . . . . . . . . . . . . 317
Chapter 26 Proximal Femur-Preserving Hip Reconstruction With

Section VIII Direct Anterior Approach Across Orthopedic Specialties:

Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Chapter 27 Tumor Reconstruction of Hip and Proximal Femur With

the Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Herrick J. Siegel, MD and Daniel C. Allison, MD, MBA

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x Contents
Section IX Direct Anterior Approach Across Orthopedic Specialties:

Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
Chapter 28 Patient Rehabilitation After Direct Anterior Hip Surgery . . . . . . . . . . . . . . . . . . 347

Sarvang Dalal, PT, DPT, MSPT, MTC, FAAOMPT and
Amir Pourmoghaddam, PhD
Section X Direct Anterior Approach Across Orthopedic Specialties:

Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Chapter 29 Anesthesia for the Direct Anterior Approach to Total Hip Arthroplasty . . . . . . . 369
Anjali O. Rozario, MD and Stavros G. Memtsoudis, MD, PhD
Section XI Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Chapter 30 Multi-Center Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383

Harman Chaudhry, MD and Mohit Bhandari, MD, PhD, FRCSC
Chapter 31 Current Direct Anterior Approach Outcomes Literature Review . . . . . . . . . . . . . 389

Tim P. Lovell, MD
Chapter 32 Training and Educating Others About Direct Anterior Hip Surgery . . . . . . . . . . 397
John A. Scanelli, MD and Joseph T. Moskal, MD, FACS
Chapter 33 Understanding Short Femoral Stem Design and Application in Direct Anterior
Approach Total Hip Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
Timothy McTighe, Dr HS (hc) and Daniel C. Allison, MD, MBA
Section XII Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
Chapter 34 In Closing: The Future of Direct Anterior Hip Surgery. . . . . . . . . . . . . . . . . . . . 435

Lee E. Rubin, MD; B. Sonny Bal, MD, JD, MBA;
and Kristaps J. Keggi, MD, Dr Med (hc)
Financial Disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439

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Acknowledgments
Many thanks are due to the wonderful pioneers like Joel Matta and Kris Keggi, who patiently
taught me the principles of anterior hip surgery, and to my mentor William Harris who always encour-
aged questioning and thinking, that has served me so well in medicine and beyond. Thanks to the
wonderful staff at the University of Missouri, especially my nurse colleague Linda Landry, who opened
their hearts and operating rooms to help me develop new operations and techniques, and guided me
as a surgeon. A special gratitude to my patients who always trusted me, and who keep teaching me the
art of medicine. The staff at SLACK Incorporated were always there to help in finishing this book,
which could not have been possible without the generous contribution of so many superb, passionate
authors. Most of all, I thank my wonderful family, especially my wife Dana, who keeps making my
impossible dreams come true.
Thanks are first due to the patients who have entrusted me with their care and to the many
supremely talented nurses, techs, and staff at both Rhode Island Hospital and The Miriam Hospital
in Providence. I have been inspired by the energy and enthusiasm of the Brown University Orthopedic
Residents, blessed by my outstanding office staff Jeri, Sonia, Courtney, and Stephanie, and privileged
to work with Dr. Michael Ehrlich and my partners at University Orthopedics. I owe a lifetime of grati-
tude for the unending support of my loving parents and family, as well as for my wife and children:
Jamie, Abigail, and Matthew; you are the center of my world.
Lee E. Rubin, MD
The arrival of Wayne O. Southwick, MD to Yale in the fall of my fourth year of medical school
must be acknowledged as the beginning of my surgical, orthopedic, and teaching career. Dr.
Southwick's inspired teaching, encouragement, and enthusiasm for innovative thinking has been the
foundation for the productive lives of more than a generation of his students and residents. It was fun
and exciting to have been one of them.
In the course of my years as a Yale University Orthopaedic Surgeon, I have worked with over 150 of
our residents and more than 250 foreign fellows. All of them have taught me as much as I have taught
them. The list of their names is long and their career achievements have been astounding. Terry Light,
MD, future President of the American Osteopathic Association, was with me as a resident when we
developed the DAA and presented it to the American Academy of Orthopaedic Surgeons as a scientific
exhibit in Las Vegas during the 1977 meeting. More than 35 years later, I was privileged to have Lee
Rubin, MD as a resident and fellow. Dr. Rubin is well on his way to a spectacular surgical and aca-
demic career—it is his dedicated, hard work that has made this book possible and I owe him thanks
beyond a simple acknowledgement.
Gary Friedlaender, MD, who has been the chair of the Yale University Department of Orthopaedic
Surgery for over 35 years, has always been very supportive of our work. There are so many others, but
John Barrasso, MD, now a United States senator from Wyoming, Marlene Demaio, MD, Captain in
the United States Navy, and Andrew Moore, MD, Colonel in the United States Air Force have been
great friends and inspirational with their own service at home and abroad. The foreign fellows of the
Keggi Orthopaedic Foundation, among them Dr. Valdis Zatlers, who later became the President of
Latvia, have long been encouraging us to write the DAA book, and I hope they will find it of use in
their work.
It was a privilege to have served in the United States Army and the 3rd Mobile Surgical Hospital
(“MASH”) in Vietnam. War has always been a “School for Surgeons.” The wounded of the 173rd
Airborne Brigade and the First Infantry Division (“The Bloody Red One”) are frequently on my
mind. Taking care of their hip wounds in particular, made such peace-time procedures as the DAA a
relatively simple process.

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xii Acknowledgments
None of our daily work and achievement would be possible without the dedicated work of the
nurses, technicians, nurses aides, secretaries, orderlies, and others who are with us in the clinics, hos-
pitals, and operating rooms of The Waterbury Hospital and Yale-New Haven Hospital. They deserve
my respect and gratitude.
Last, but not least my love and thanks go to my family. If “surgeons are born,” I must give credit to
my surgeon father and if “teaching is in the genes,” I must thank my maternal grandfather, a scholar,
theologian, and educator of renown who like his grandson, 2 generations later, was the recipient of the
Order of Three Stars and an Honorary Doctorate from the University of Latvia. My wife, children,
and grandchildren have always been a support and have made it possible for me to press on with life,
orthopedic surgery, teaching, and the DAA.

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About the Editors
B. Sonny Bal, MD, JD, MBA is an arthroplasty surgeon, who was one of the early adopters of
anterior total hip arthroplasty. Dr. Bal has an academic appointment at the University of Missouri
in Columbia, Missouri. In addition to clinical work, he is active in materials science research at the
Missouri University of Science & Technology at Rolla, Missouri, and heads a silicon nitride ceramic
manufacturer located in Salt Lake City, Utah. Dr. Bal is also an attorney and active in medico-legal
education and consulting work.
Originally from New Jersey, Lee E. Rubin, MD matriculated as an undergraduate Presidential

Scholar at Brandeis University, Waltham, Massachusetts and graduated Cum Laude in 2000. He
then graduated with Alpha Omega Alpha distinction from the Tufts University School of Medicine,
Boston, Massachusetts in 2004. Dr. Rubin completed his orthopedic training at Yale University, New
Haven, Connecticut in 2009, followed by an Adult Reconstruction Fellowship focused on the Direct
Anterior Approach with Dr. Kristaps J. Keggi and the Keggi Orthopedic Foundation in Connecticut
in 2010.
Dr. Rubin is presently affiliated with University Orthopedics, Inc and is an Assistant Professor
of Orthopedic Surgery on the faculty of the Warren Alpert Medical School of Brown University in
Providence, Rhode Island. He is actively engaged in numerous clinical research projects through The
Miriam Hospital’s Total Joint Center, Providence, Rhode Island, and has published over 50 scientific
posters, papers, and book chapters. He is a Fellow of the American Academy of Orthopaedic Surgery
(AAOS), a Fellow of the American Association of Hip and Knee Surgeons (AAHKS) an active member
of the Orthopaedic Research Society (ORS), and is a Faculty Member of the International Congress
for Joint Reconstruction (ICJR).
In 2013, Dr. Rubin was selected and awarded as one of the Forty Under 40 in Rhode Island by the
Providence Business News. In 2013, he was elected to serve on the Executive Committee of the Rhode
Island Orthopedic Society (RIOS), and was invited to serve on the Board of the Yale Orthopaedic
Association in 2016. He is an editorial board member and reviewer for a number of prestigious ortho-
pedic journals, is actively involved with the Rhode Island Chapter of the Arthritis Foundation, and
was the Chapter’s Medical Honoree at the Providence Walk to Cure Arthritis event in 2015. He lives
outside of Providence, Rhode Island with his wife and 2 children.
Kristaps J. Keggi, MD, Dr Med (hc) is the Elihu Professor of Orthopaedics and Rehabilitation at the
Yale University School of Medicine in New Haven, Connecticut. Dr. Keggi was born in Latvia and
arrived in America as a World War II refugee at the age of 15 years. With the exception of 2 years of
general surgical training at the “Old” Roosevelt Hospital in New York City and 2 years of military
service with the United States Army in Texas and Vietnam (3rd Surgical Hospital, Army, Mobile), Dr.
Keggi has been associated with Yale College and Yale University since 1951. First, he attended Yale
as an undergraduate and medical student, later trained as a Yale orthopedic resident, and ultimately
joined the teaching faculty of the university, a post he holds to the present day.
Dr. Keggi completed his orthopedic training in 1964 and was practicing and teaching ortho-
pedic surgery for more than 5 years when the Charnley Low Friction Arthroplasty was brought to
the United States. He was among the first in Connecticut to perform this procedure in its classical
transtrochanteric manner. Based on his training with Wayne O. Southwick, MD, who encouraged
innovative thinking, he rapidly moved to utilize the less traumatic Direct Anterior Approach. With the
help of Terry Light, MD, his resident at the time, he presented the DAA technique for total hip arthro-
plasty (THA) and published his early results as a Scientific Exhibit at the 1977 Meeting of the AAOS
in Las Vegas. Subsequently, in October of 1980, he published the results in Clinical Orthopaedics and
Related Research, thereby becoming one of the first American surgeons to publish on the DAA for

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xiv About the Editors
THA. Continuously since that era, the DAA has been his primary approach for all simple and complex
hip arthroplasty procedures.
Over the course of a career spanning over 50 years, Dr. Keggi has improved the lives of thousands
of patients, has taught over 150 Yale residents, and has hosted more than 250 international fellows
brought to Yale and The Waterbury Hospital from Latvia, Estonia, Lithuania, Russia, Ukraine,
Georgia, Belarus, Kazakhstan, Uzbekistan, Tajikistan, Sweden, Germany, and Vietnam. He is the
author of numerous publications on total hip surgery, has lectured at multiple meetings and locations,
and has visited sites around the world to teach and perform DAA hip replacements.
During his career, Dr. Keggi has received numerous Yale teaching awards, honorary degrees from
Universities around the world, and has been honored with the Latvian Order of the Three Stars in
1993, the V Class Order of the Estonian Red Cross in 1999, the Distinguished Service Medal of the
Latvian Physicians Association (the second ever awarded) in 2009, and the Silver Medal of Medical
Dignity and Service to Russian Medicine in 2012. He was granted honorary memberships in both the
Latvian Academy of Science in 1990 and the Russian Academy of Science in 1993. One of his great-
est honors was to have received the George H.W. Bush Lifetime of Leadership Award from his alma
mater, Yale University, in 2005.

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Contributing Authors
Daniel C. Allison, MD, MBA (Chapters 14, 27, Mohit Bhandari, MD, PhD, FRCSC
33) (Chapter 30)
Assistant Professor of Surgery Division of Orthopedic Surgery
Assistant Director of Orthopedic Oncology McMaster University
Cedars-Sinai Medical Center Hamilton, Ontario, Canada
Clinical Associate Professor of Orthopedic
Lawrence Brenner, JD (Chapter 8)
Surgery
Partner
University of Souther California Keck School of
Medicine Bal Brenner Law Firm
Co-Director of Orthopedic Oncology Chapel Hill, North Carolina
Children's Hospital of Los Angeles Derek Butterwick, MD (Chapter 25)
Los Angeles, California Royal Inland Hospital
Michael P. Ast, MD (Chapter 16) Kamloops, British Columbia, Canada
Orthopedic Surgeon Harman Chaudhry, MD (Chapter 30)
Mercer Bucks Orthopaedics Division of Orthopedic Surgery
Director, Outpatient Joint Replacement McMaster University
Mercer County Surgery Center Hamilton, Ontario, Canada
Lawrenceville, New Jersey
Brett D. Crist, MD (Chapters 1, 5)
Director, Robotic Assisted Joint Replacement
Program Department of Orthopaedic Surgery
Robert Wood Johnson University University of Missouri
Hospital—Hamilton Columbia, Missouri
Hamilton Township, New Jersey Sarvang Dalal, PT, DPT, MSPT, MTC,
Paul E. Beaulé, MD (Chapter 25) FAAOMPT (Chapter 28)
Professor of Surgery Memorial Hermann Sports Medicine &
Rehabilitation
University of Ottawa
Houston, Texas
Head Division of Othropadeic Surgery
The Ottawa Hospital Garrett Davis, MD, MBA, MS (Chapter 24)
Ottawa, Ontario, Canada Rosenberg Cooley Metcalf Orthopaedic Clinic
Park City, Utah
Keith R. Berend, MD (Chapter 6)
Joint Implant Surgeons Matthew E. Deren, MD (Chapter 17)
White Fence Surgical Suites Resident in Orthopedic Surgery
New Albany, Ohio Rhode Island Hospital
Providence, Rhode Island
Hari P. Bezwada, MD (Chapter 16)
Director, Marjorie G. Ernest Total Joint Center David Dodgin, MD (Chapter 11)
of Excellence Orthopaedic Specialists of Austin
Capital Health System Texas Institute for Hip and Knee Surgery
Princeton Orthopaedic Associates Austin, Texas
Princeton, New Jersey

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xvi Contributing Authors
Benjamin Domb, MD (Chapter 7) Stephen Kayiaros, MD (Chapter 15)

American Hip Institute Department of Orthopaedic Surgery
Westmont, Illinois Robert Wood Johnson Medical School
Hinsdale Orthopaedics Rutgers—The State University of New Jersey
Hinsdale, Illinois New Brunswick, New Jersey
University Orthopaedic Associates, LLC
Adam M. Freedhand, MD (Chapter 10)
Somerset, New Jersey
University of Texas Health Science Center at
Houston Stefan Kreuzer, MD, MSc (Chapters 18, 26)
Houston, Texas Memorial Bone & Joint Clinic
Reinhold Ganz, MD (Chapter 22) Department of Orthopedic Surgery
Professor Emeritus University of Texas
University of Berne Houston, Texas
Berne, Switzerland Michael Leunig, MD (Chapter 22)
Dan Gerscovich, MD (Chapter 13) Chief of Hip Surgery
George Washington University Orthopedics Department of Orthopedic Surgery
Washington, DC Schulthess Klinik, Zürich, Switzerland
Joseph A. Gil, MD (Chapter 23) Allan Liew, MD (Chapter 25)

Resident in Orthopedic Surgery Director of Orthopaedic Trauma
Rhode Island Hospital The Ottawa Hospital
Providence, Rhode Island Assistant Professor
University of Ottawa
Wade Gofton, MD (Chapter 25) Ottawa, Ontario, Canada
The Ottawa Hospital
Ottawa, Ontario, Canada Adolph V. Lombardi Jr, MD, FACS (Chapter 6)
President of Joint Implant Surgeons, Inc.
E. Matthew Heinrich, MD (Chapter 11) Clinical Assistant Professor
Orthopaedic Specialists of Austin Department of Orthopaedics
Texas Institute for Hip and Knee Surgery The Ohio State University
Clinical Associate Professor Attending Surgeon
University of Texas Medical Branch Mt. Carmel Health Systems
Galveston, Texas Attending Surgeon
Robert E. Howell, MD (Chapter 6) White Fence Surgical Suites
Southern Orthopaedic Surgeons Columbus, Ohio
Montgomery, Alabama Tim P. Lovell, MD (Chapter 31)
Timothy Jackson, MD (Chapter 7) Providence Medical Group
Congress Orthopedic Associates Spokane, Washington
Pasadena, California Joel M. Matta, MD (Chapter 4)
Atul F. Kamath, MD (Chapter 22) Saint John's Health Center
Assistant Professor Hip and Pelvis Institute
Department of Orthopedic Surgery Santa Monica, California
University of Pennsylvania Philip McClure, MD (Chapter 21)
Philadelphia, Pennsylvania Fellow in Pediatric Orthopedic Surgery
Texas Scottish Rite Hospital
Dallas, Texas

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Contributing Authors xvii
Timothy McTighe, Dr HS (hc) (Chapters 14, 33) Javad Parvizi, MD, FRCS (Chapter 24)
Executive Director James Edwards Professor of Orthopaedic
Joint Implant Surgery & Research Foundation Surgery
Editor-in-Chief Sidney Kimmel School of Medicine
Reconstructive Review Rothman Institute at Thomas Jefferson
Chagrin Falls, Ohio University
Philadelphia, Pennsylvania
Wietse P.R. Melman, MD (Chapter 9)
Department of Orthopedic Surgery and Preetesh D. Patel, MD (Chapter 10)
Traumatology Cleveland Clinic Florida
Isala Hospital Weston, Florida
Zwolle, the Netherlands Christopher E. Pelt, MD (Chapter 2)
Stavros G. Memtsoudis, MD, PhD (Chapter 29) Department of Orthopaedic Surgery
Department of Anesthesiology University of Utah School of Medicine
Hospital for Special Surgery—Weill Cornell Salt Lake City, Utah
Medical College
Blake E. Peterson, MD (Chapters 1, 5, 12)
New York, New York
Department of Orthopedic Surgery
Markus C. Michel, MD (Chapter 9) University of Missouri
Specialist in Orthopedic Surgery, FMH Columbia, Missouri
Alpha Clinic
Amir Pourmoghaddam, PhD (Chapters 18, 26,
Zürich, Switzerland 28)
Joseph Morgan, MD (Chapter 12) Medical Research Scientist
Department of Orthopedic Surgery Memorial Bone and Joint Research Foundation
University of Missouri Department of Orthopaedic Surgery
Columbia, Missouri University of Texas Health Science Center at
Houston
Joseph T. Moskal, MD, FACS (Chapters 11, 32) Houston, Texas
Chairman
Department of Orthopedic Surgery Scott A. Ritterman, MD (Chapters 3, 17, 23)
Chief of Adult Reconstruction Resident in Orthopedic Surgery
Carilion Clinic Rhode Island Hospital
Professor and Chair Providence, Rhode Island
Department of Orthopedic Surgery Anjali O. Rozario MD (Chapter 29)
Virginia Tech Carilion School of Medicine Hospital for Special Surgery
Roanoke, Virginia New York, New York
Michael Nogler, MD, MA, MSc (Chapter 20) John A. Scanelli, MD (Chapter 32)
Full Professor of Experimental Orthopedics George Washington University Hospital
Medical University of Innsbruck Washington, DC
Innsbruck, Austria
Jonathan R. Schiller, MD (Chapter 21)
Steve Papp, MD (Chapter 25) Assistant Professor of Orthopedic Surgery
Assistant Professor The Warren Alpert School of Medicine of
University of Ottawa Brown University
Director of Clinical Services Providence, Rhode Island
Division of Orthopaedic Surgery
The Ottawa Hospital
Ottawa, Ontario, Canada

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xviii Contributing Authors
Herrick J. Siegel, MD (Chapter 27) Nathan J. Turnbull, MD (Chapter 6)

University of Alabama at Birmingham Medical Florida Orthopaedic Associates
Center DeLand, Florida
Birmingham, Alabama
Anthony S. Unger, MD (Chapter 13)
Eric M. Slotkin, DO (Chapter 10) Clinical Professor Orthopedic Surgery
Orthopedic Associates of Reading, Ltd George Washington University Medical Center
West Reading, Pennsylvania Washington, DC
Evan Smith, MD (Chapter 13) Cees C.P.M. Verheyen, MD, PhD (Chapter 9)
Resident Department of Orthopedic Surgery and
George Washington University Traumatology
Washington, DC Isala Hospital
Zwolle, the Netherlands
R. Presley Swann, MD, MS (Chapter 2)
Methodist Sports Medicine Jonathan Yerasimides, MD (Chapter 19)
Indianapolis, Indiana Norton Healthcare
Louisville, Kentucky
Mohan S. Tripathi, MD (Chapter 15)
Department of Orthopedic Surgery Navid M. Ziran, MD (Chapter 4)
Robert Wood Johnson Medical School Saint John's Health Center
Rutgers—The State University of New Jersey Hip and Pelvis Institute
New Brunswick, New Jersey Santa Monica, California
Marina Del Rey Hospital
Cedars-Sinai Affiliate
Marina Del Rey, California

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Foreword
It was 1966 and Kris Keggi had returned from the Vietnam War, and was settled in his career
home, Yale University, at a time when John Charnley and his group were starting to teach total hip
replacement (THR) to a worldwide audience using the trochanteric osteotomy and transfer approach.
However, surgeons were already tiring of trochanteric complications and some were exploring the
use of the posterior approach. That approach would become popular because surgeons at the leading
orthopedic hospitals, Hospital for Special Surgery in New York, Brigham in Boston, and Mayo Clinic
were adopting it. In New Haven, Connecticut in 1972 an energetic, motivated, young orthopedic
surgeon gazed through his bright blue eyes at a patient lying supine on his operating table. He reached
out for a scalpel and made an anterior incision into the hip! It would be 3 decades before his life’s pas-
sion would become accepted.
Keggi’s innovative approach to THR had been introduced before by Smith-Petersen in the United
States and Judet in France, but this was a different operation. It required exposure and preparation
of both the acetabulum and the femur. In his civilian training and practice with Wayne Southwick,
Kris had used all the standard approaches to the hip. During his wartime service in Vietnam, he was
exposed to exposures beyond any standards, such that he knew them all; but his instinct chose the
anterior approach, and he spent his early years refining the operation, designing instruments, and
teaching his students.
The contemporary author Malcolm Gladwell has studied human reactions to events in 2 of his
books: The Tipping Point and Blink. He might have described Keggi’s decision to operate anteriorly as
instinctive, and not muddled by an overload of information. Too much research might have deterred
him from being a pioneer. Pioneers take risks others won’t, and that trait can’t always be explained.
But Keggi’s pioneering work did not receive acceptance because the context was not favorable. THR
had too many problems to be solved so it could not be concerned with another new approach, and
the innovator was not a “connector” or “salesman” in Gladwell’s definition. Non-cemented fixation,
“cement disease,” infection, dislocation, revision surgery, wear, and osteolysis dominated the thoughts
of those doing research. Furthermore, Hardinge’s anterior lateral approach became popular because
it divided the gluteus medius muscle which made it an easier operation. The thought of cutting the
gluteus medius made many surgeons shudder, but dislocation was lessened and that was incentive
enough for those who adopted it.
Around 1996, there was another surgeon who was energized by exploring techniques, and who did
not shy away from difficult operations. Joel Matta was already an international leader in acetabular
fracture surgery, and he began to use a modified technique for the hip replacement via the anterior
approach. That was his early passion, and I witnessed it when Emile LeTournel came to Los Angeles
as a visiting professor and I helped host him. An orthopedic friend of mine had a patient with an
acetabular fracture, and he called me for help fixing it. I took LeTournel with me and asked him to
operate. Joel and I were both young surgeons affiliated with USC at that time and he asked to come
along. LeTournel used his inguinal approach, and was well into this approach when the operating
room supervisor rushed into the room screaming for him to stop. There was no permission from the
state for him to operate. Fortunately, my friend was the Chief of Staff and LeTournel finished. As he
laid down his scalpel he looked up and asked with a stone face, “Are the Gendarmes at the door?”
During this operation I saw Matta’s eyes intently watch LeTournel operate and I knew this was more
than an operation for him. It was an epiphany. His drive to excel in his profession, and be the best, was
evident. He made it clear that acetabular fractures were his territory going forward, and I only smiled
since THR was my passion. LeTournel became Matta’s mentor, and Joel ultimately replaced him in
the acetabular arena after Emile’s death.
If you are an acetabular surgeon you soon have patients who need a THR. Matta’s time in France
exposed him to the Judets, and their history. He was comfortable around the anterior hip because
many of the acetabular fractures were fixed anteriorly. He knew the anatomy, and the Judet approach
for hip surgery with a table suited him fine. He would bring this technique to the United States.
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xx Foreword
Unlike Kris Keggi, the context was right for Joel Matta. In fact, it was a perfect storm. In the eye of
that storm was Richard Berger of Rush University in Chicago who pioneered the 2-incision approach
which used a second incision for the femur to substitute for the difficult femoral exposure with the
DAA. His surgical skill allowed him to perform this operation successfully, but few could match it.
However, Berger’s innovation was more than an approach. He revolutionized pain management, and
was the first to routinely send patients home on the same day of hip replacement. Surgeons associated
this rapid recovery with the short-incision anterior approach Berger used but didn’t want to do the
2-incision method.
Gladwell described a person’s mental thinking to new information as “instinctive” or “deliberate.”
I have used different terms which essentially mean the same: surgeons are either creative or managers.
At the time of a revolution, the creators of the revolution need managers to accomplish their ideas.
It is rare for a person to have both creative and manager instincts so it is not unusual that 2 leaders
emerge to accomplish success of new ideas. Berger is creative, and his risk-taking personality will try
new ideas with Gladwell’s thin slices of information as was defined in Blink. Matta too is a risk taker,
but his pioneering methods are much more deliberate. So the uproar around the 2-incision technique
created an opening for the DAA, and Matta was prepared to fill it with his meticulous table method.
In Gladwell’s Tipping Point, he described the need for “Connectors,” “Mavens,” and “Salesmen” to take
a new initiative over the tipping point. Matta’s enthusiasm, optimism and passion for this approach,
combined with his deliberate planning of a step-by-step teaching method, made him the perfect
Salesman. Companies which saw an opportunity to engage surgeons by teaching the DAA were the
Mavens who had the persuasion to promote the technique, and the Connectors were the early adopters
(surgeons) who spread the word that the operation worked.
The tipping point was secured by a phrase which became the battle cry for the Mavens and
Connectors. No muscle cut. It evolved from the original concept of the Judets that their approach
preserved muscle. Matta described his use of the DAA as “no muscles detached from the bone.” This
description galvanized surgeons and patients. “No muscle cut” was a brilliant marketing phrase and
surgeons could visualize this because the gluteus medius muscle was not cut, and there was not always
a need to cut some of the external rotators. The DAA became a movement, and the public joined in.
Surgeons in every city became Gladwell’s Majority because they understood the impact on patients of
this approach which gave promise to less violation of their body, early to home and early to function
with protection against dislocation. For those who joined the movement it was an exciting revolution.
During this same time period of the mid-2000s, Tom Sculco innovated the mini-posterior
approach and its results mirrored the DAA. I began sending patients home the same day in 2005 using
the mini-posterior operation and published our experience with it. With posterior capsular repair, as
pioneered by Paul Pellici at the Hospital for Special Surgery in New York, and the use of larger 32 mm
to 40 mm femoral heads, dislocation with the posterior approach was also decreased to 1% or less,
and dislocation precautions were relaxed. But there were no Mavens for this approach, and it did not
reach a tipping point as was seen with the DAA. Posterior approach surgeons shortened their incisions,
adopted multi-modal pain management and discharged patients on Day 2, but most still prescribed
dislocation precautions. There was not an early Majority who became excited about the mini-posterior
incision. Posterior surgeons did not exude an air of confidence about their incision that their DAA
colleagues did.
As soon as the DAA reached the tipping point, many surgeons wanted to perform this method,
but did not want the additional time, money and inconvenience of the traction table. A school rose in
Europe and the United States to adopt Keggi’s method, or modify it, so no traction table was neces-
sary. This feature made the operation more attractive to new surgeon adopters. My impression is that
this school is the choice for almost all new adopters of the DAA.
The DAA is no longer a new exciting revolution. It has matured into one of the 3 accepted inci-
sions surgeons choose: DAA, anterior-lateral, or posterior. The DAA has grown from minimal routine
usage by surgeons in 2000 to approximately 25% in 2016, but has been stable between 24% to 26%
for the last 2 years in the annual AAHKS surgeons survey. The internet still promotes this operation

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Foreword xxi
as superior in rapid recovery and postoperative pain; but I think the growth has plateaued, at least
temporarily, because there is no research which conclusively confirms the superiority declared on the
internet.
What is the future of the DAA operation? When operations mature in orthopedics, the growth no
longer accrues by conversion of established surgeons. Meetings which promote one incision or another
are really confirmation for those who are dedicated to that approach. The real growth must come from
adoption by graduating residents. The benefits and methods for early discharge and rapid recovery are
well established now, and younger surgeons will want to know that they are providing stable long-term
results for their patients. So there must be longer-term results published, like the recent publication by
us of 10 year results with the mini-posterior incision. A focus on the graduating young surgeons will
require the teachers in academic centers to be training them with the DAA. If the residents are trained
with the posterior approach, those who choose a joint fellowship must be incentivized to choose a fel-
lowship in a DAA center.
Orthopedics does not have a Hall of Fame. We have heroes, and surgeons choose role models to
follow. It is with gratitude that I thank the followers of Kris Keggi for editing this comprehensive,
superbly organized textbook, and dedicating it to him. He is the innovator for DAA for THR. I believe
that Kris is correct in his expectation, stated in his introduction, that this textbook will be the “Bible”
for DAA surgeons. It will be the primary reference for those who want to understand this operation,
and adopt it, for at least the next 2 to 3 generations of surgeons. Eventually someone will edit it to
update it, but it will always be the reference for the principles of this operation. It will be the book
that describes the evolution of this approach for THR with the innovator (Keggi), and the manager
(Matta), both contributing to it which makes it a historical book.
Personally, I want to thank Kris Keggi for honoring me, a leader of the posterior mini-incision
approach, by asking me to write this foreword. I am a surgeon. I have spent my career dedicated to
improving outcomes for THR, as reflected in my published works. My research has allowed me to
meet thousands of surgeons around the world. What I know from this experience is that surgeons per-
form best when they have confidence in what they do, when they deeply believe that their methods are
best, and they passionately want everyone to do what they do. This is why I know that DAA surgeons
will continue to grow their approach. They may ultimately prove it to be superior. The direct anterior
approach is an important and lasting contribution to our orthopedic profession.
Larry Dorr, MD
Keck Medical Center of University of Southern California
Department of Orthopedics
Los Angeles, California

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Introduction
The Direct Anterior Approach (DAA) for total hip arthroplasty (THA) has been my only approach
for all primary and revision THA surgeries since the early 1970s. Over the past 40 years of clinical
practice, I have regularly published my experiences and shared the lessons learned from the DAA. I
have been fortunate to care for many thousands of individuals and educate generations of residents and
fellows, all with the DAA as the central focus of my hip surgery practice.
Despite a rapidly expanding body of clinical literature on the DAA, there has never existed a single
resource for the teaching and learning of the DAA, making it perennially difficult to standardize
the educational aspects of the approach and share it with other surgeons. For the first time, we have
assembled a group of expert authors from around the world to help contribute toward establishing a
comprehensive volume on the DAA. I wish to offer my experience from a lifetime of clinical practice;
that experience has formed the vision for this project.
The following notable cases should be of interest and serve as a starting point for understanding the
DAA and its evolution over the past 40+ years.
The first case is a 42-year-old male whose hip I replaced with a cemented prosthesis in 1973. He is
now 83 years old and has done amazingly well for more than 4 decades, golf being his major avoca-
tion. He was among our first total hip patients performed through the DAA and his case was one of
those originally presented at the Annual Meeting of the American Academy of Orthopaedic Surgeons
in 1977 in Las Vegas (Figure 1).1,2
The second case is a Mittelmeier ceramic-on-ceramic hip used in 1983 in a 48-year-old female with
degenerative arthritis secondary to acetabular dysplasia. The result has been clinically “perfect” (in her
words) for more than 30 years and her x-rays continue to show the implant to be stable without any evi-
dence of ceramic wear. Her case was included in the only successful series of Mittelmeier hips reported
in the United States.3–7 The success of these implants was based on the DAA, which made it possible
to expose, manually ream the acetabulum, and then screw in the monoblock ceramic prosthesis with
what amounted to very simple instruments of that era. With proper positioning of the acetabulum, the
long, skirted femoral head component also performed well when inserted through the DAA (Figure 2).
The third case is from our series of hip resurfacings originally published in 1983.8 These early
resurfacings did well for a few years but failed because of the thin, cemented acetabular shells. These
resurfacings were easily placed with the DAA, but fell out of favor due to the unreliable implant mate-
rials of that era. More recently, we have avoided “modern” resurfacing devices because of our ongoing
concerns about using metal-on-metal articulations. This 62-year-old female was resurfaced in 1982
and was subsequently revised in 1987 (Figure 3).
The fourth case is a typical patient of the present era, who at age 60 years expects a new hip to lead
an active life for many years to come. A non-cemented, short, intertrochanteric, space-filling stem hip
was performed through the DAA in 2014. The patient went home less than 48 hours after surgery and
was back to normal activities within 3 weeks. She is the direct beneficiary of the legacy of the DAA,
including 4 decades of surgical experience, better perioperative care, a variety of improved implants
designed for the DAA, and commercially manufactured DAA instruments and retractors used during
the procedure.9–12 In direct contrast, none of these things existed in the 1970s, and their availability
now allows cases such as hers to be performed across the United States and around the world. For the

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xxiv Introduction
A C
Figure 1. (A) Preoperative image 1973. (B) Immediate postoperative image 1973. (C) Follow-up image 2014.
A B
Figure 2. (A) Postoperative image 1983. (B) Follow-up image 2014.
majority of our patients with common hip osteoarthritis, the choice of their femoral component is
based on the geometry of the proximal femoral anatomy. We do, however, use the DAA in all complex
cases and deformities (Figure 4).13,14
The fifth case is a 50-year-old male with multiple social problems, spinal stenosis, and end-stage
bilateral osteoarthritis of the hips. Three different posterior approach surgeons had refused his case,
expressing both fear of dislocations and also inability to reach the anterior osteophytes. His right hip
was totally ankylosed in 50 degrees of flexion, left hip fixed in 35 degrees with slight motion. The
anterior approach, while less than simple in this instance, allowed the removal of all the osteophytes,
insertion of the components through single incisions and the correction of the flexion contractures.
The bilateral replacements were performed sequentially during one operation. He was able to walk a
few steps with assistance 2 days after the operation and at 2 months was ambulating with a cane. DAA
naturally lends itself to bilateral replacements performed during a single operation for carefully selected
patients in the hands of experienced surgeons (Figure 5).13
The sixth case is a muscular, obese male weighing 300 pounds. The hip was exposed and excised
through a short, anterior incision. The acetabular preparation was difficult because of the “flat”
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Introduction xxv
C
Figure 3. (A) Post- resurfacing. (B) Post- revision with
non- cemented acetabulum and Zweymuller-type stem.
(C) Immediate postoperative lateral image.
configuration of the bony acetabulum and a large labral, ganglion cyst in its dome (unrecognized
before surgery). The acetabulum was reamed and the multi-hole acetabular prosthesis was inserted
using a straight reamer and cup inserter retrograded through a short accessory stab wound just distal
and lateral to the main incision. Because of the cyst, 4 screws were used to achieve total stability of the
acetabular construct. The femoral canal was prepared and the femoral prosthesis inserted through a
secondary short incision (K-Spot) made over the origin of the gluteus medius. They were passed from
this incision through the interner vous interval of the superior and inferior gluteal nerves.15,16 It may
also be of interest to note that our heaviest DAA patient was 450 pounds at the time of surgery. While
there is debate about caring for patients at the extremes of health, the DAA lends itself toward effective
surgical management when no other realistic option exists to treat the patient (Figure 6).
Our seventh case is an 18-year-old male with a failed, painful, acetabular reconstruction of a high
congenital dislocation. His case illustrates an example of the DAA as we have used it for management
of congenital hip dislocations.17–19 The sciatic nerve did not need to be exposed. The femoral neuro-
vascular bundle was protected by the iliopsoas muscle and tendon retracted medially. The acetabulum
and femur were prepared and the prostheses safely inserted. His pain relief was immediate, his gait
improved dramatically, and he returned to both his food-service job and school in 3 weeks (Figure 7).

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xxvi Introduction
A B
Figure 4. (A) Preoperative image March 2014. (B) Three months postoperative image June 2014.
B
A
Figure 5. (A) Preoperative pelvis image March 2014. (B) Postoperative pelvis image June 2014.
The eighth case is an example of the revisions that can be performed through the DAA.20–24 If
needed, release of the tensor fascia lata and hip abductors from their iliac origins can be performed
to expose acetabular defects. Suprapelvic access is possible and if there is concern about intrapelvic
vascular or visceral injuries, the abdomen can be draped free for rapid exposure of the injured struc-
tures. Extension of the incision along the lateral thigh allows access to the entire femur for a variety
of cortical windows and osteotomies. The short, secondary incisions can also facilitate comprehensive
femoral and acetabular preparation with decreased soft tissue damage (Figure 8).

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Introduction xxvii
B
A
Figure 6. (A) Preoperative image 2014. (B) Six months postoperative image.
The DAA is effective for routine, primary THA, but allows for acetabular and femoral revisions
and periprosthetic femoral shaft failures. We have used the posterior approach to the hip only to
remove plates and screws from previous procedures. Posterior hardware removal through scar tissue in
the area of the sciatic nerve has been a much more challenging procedure than the subsequent DAA
THA itself. Typically, we have staged these 2 procedures and every time we perform one, we feel for-
tunate to be able to perform total hip replacements and revisions through the DAA.
Sir John Charnley’s Low Friction Total Hip Arthroplasty was revolutionary in its time and we
started using it in 1970, but his transtrochanteric approach had numerous pitfalls and began an evolu-
tion toward less invasive, muscle-sparing surgical techniques that led to the utilization of the DAA
for THA. The interner vous and intermuscular plane of the DAA is the culmination of that evolution
for THA, and continues to be improved through the renewed efforts of a new generation of younger,
energetic, outcome-driven surgeons who aim to find new ways to continue improving THA for their
patients.
It is my hope that this comprehensive text and its associated videos will serve to organize and illus-
trate the many details of the DAA for the ultimate benefit of patients everywhere. In publishing this
work in conjunction with my coeditors, we aim to provide the first-ever definitive text on the DAA
in order to organize and standardize the learning, teaching, and utilization of the DAA for residents,
fellows, and practicing orthopedic surgeons around the world.
As I finish this chapter, I continue on with my surgical practice at the age of 80. I am grateful to
my coeditors for assembling such an esteemed group of experts from around the world to contribute
toward the success of this work. Indeed, The Direct Anterior Approach to Hip Reconstruction represents
the summation of my 40 years of hip surgery. I truly hope this work will stand for decades and genera-
tions to come as the authoritative resource on the DAA.

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xxviii Introduction
C
Figure 7. (A) Preoperative pelvic image. (B) Immediate post-
operative image. (C) Three months postoperative image.
1. Keggi KJ, Light T. The anterior approach to total hip replacement. American Academy of Orthopaedic Surgeons,
Annual Meeting; 1977. Las Vegas, NV.
2. Light T, Keggi KJ. Anterior approach to total hip replacement. Clin Orthop Relat Res. 1980;(152):255-260.
3. Keggi KJ. Cementless ceramic hip replacement, the anterior approach [video]. Glaxo-Masters of Surgery Series;
1985.
4. Keggi KJ, Friedlaender G, Kalnberz VK, Southwick WO. US/USSR Orthopaedic Exchange. SICOT Meeting;
September, 1990. Montreal, Canada.
5. Hoffinger SA, Keggi KJ, Zatorski LE. Primary ceramic hip replacement: a prospective study of 199 Hips.
Orthopedics. 1991;14(5):523-530.
6. Huo MH, Martin RP, Zatorski LE, Keggi KJ. Cementless total hip arthroplasties using ceramic-on-ceramic
articulations in young patients: a minimum 5-year follow-up study. J Arthroplasty. 1996;11(6):673-678.

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Introduction xxix
A B
C D
Figure 8. (A, B) Preoperative right femur images. (C, D) Immediate postoperative right femur images. The
horizontal screw in the posterior, inferior acetabular wall was never visible and to avoid major acetabular
injury, it was left in place.

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xxx Introduction
7. Huo MH, Martin RP, Zatorski LE, Keggi KJ. Total hip replacements using the ceramic Mittelmeier prosthesis.
Clin Orthop Relat Res. 1996;(332):143-150.
8. Hendrikson RP, Keggi KJ. Anterior approach to resurfacing arthroplasty of the hip: a preliminary experience.
Conn Med. 1983;(47):8-12.
9. Kennon RE, Keggi JM, Wetmore RS, Zatorski LE, Huo MH, Keggi KJ. Total hip arthroplasty through a mini-
mally invasive anterior surgical approach. J Bone Joint Surg Am. 2003;(85-A Suppl 4):39-48.
10. Kennon RE, Keggi JM, Keggi KJ. The anterior approach to hip arthroplasty: the short, single minimally invasive
incision. Op Tech in Orthop. 2004;14(2):94-101.
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mally invasive technique. J Bone Joint Surg Am. 2004; (86-A Suppl 2):91-97.
12. Keggi KJ, Keggi JM, Kennon RE. Minimal incision total hip arthroplasty via the anterior approach. Curr Op in
Orthop. 2005;16(1):10-13.
13. Lorenze M, Huo MH, Zatorski LE, Keggi KJ. A comparison of the cost effectiveness of one-stage versus two-
stage bilateral total hip replacement. Orthopedics. 1998;21(12):1249-1252.
14. Keggi KJ, Rubin LE. Total hip arthroplasty with the anterior surgical approach using one or two incisions.
Seminars in Arthroplasty. 2008;19(2):175-179.
15. DiCaprio MR, Huo MH, Chan PS, Zatorski LE, Keggi JM, Keggi KJ. Total hip arthroplasty in the obese.
American Academy of Orthopaedic Surgeons, Annual Meeting; March, 2001. San Francisco, CA.
16. Huo MH, Zurauskas A, Zatorska LE, Keggi KJ. Cementless total hip replacement in patients with developmental
dysplasia of the hip. J South Orthop Assoc. 1998;7(3):171-179.
17. Flanagin BA, Dushey CK, Rubin LE, Keggi KJ. Total hip arthroplasty followed by traction and delayed reduction
for Crowe IV developmental dysplasia of the hip. J Arthroplasty. 2013;28(6):1052-1054.
18. Huo MH, Zukauskas A, Martin RP, Keggi KJ. Cementless total hip replacement in patients with developmental
dysplasia. American Academy of Orthopaedic Surgeons, Annual Meeting; February, 1995. Orlando, FL.
19. Barrasso J, Keggi KJ. Simplified reaming of the deformed femoral canal in total hip surgery. Orthop Rev.
1983;(12):111-112.
20. Huo MH, Elliott AJ, Keggi KJ. Periprosthetic infection in total hip replacement: management with temporary
prostheses and antibiotic impregnated cement between stages. J Orthop Tech. 1994;2(3):93-102.
21. Huo MH, Keggi KJ. Periprosthetic femoral fracture treatment with an intramedullary extension sleeve. J Orthop
Tech. 1994;2(4):191-196.
22. Huo MH, Cox M, Zatorski LE, Keggi KJ. Oblique femoral osteotomy in cementless total hip arthroplasty. A
prospective consecutive series with minimum 3 year follow-up. J Arthroplasty. 1995;10(3):319-327.
23. Grey MA, Keggi KJ. Revision total hip arthroplasty in a centenarian: a case report and review of the literature.
J Arthroplasty. 2006;21(8):1215-1219.
24. Keggi KJ. Hip revisions with the Zweymuller prostheses. Society for Arthritic Joint Surgery, Annual Meeting;
October, 1995. Santa Fe, NM.
Please see video on the accompanying website at

www.healio.com/books/daavideos

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Section I
Basic Direct Anterior Approach
Surgical Technique

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1
Applied Anatomy of the
Anterior Hip and Thigh
The ascending branch of the lateral femoral circumflex artery must be identified and
coagulated/ligated to minimize blood loss.
Injury to the lateral femoral cutaneous nerve (LFCN) injury should be avoided by
identifying the correct tissue plane.
Avoid injury to the obturator externus to preserve postoperative hip stability.
Understand the relationship of the iliopsoas and femoral nerve to the anterior acetabu-
lum when placing anterior acetabular retractors.
The direct anterior approach (DAA) to the hip has gained recent popularity for per-
forming total hip replacement. It allows both intermuscular and interner vous exposure
to the hip joint independent of size/location of the skin incision. The DAA was first
documented in 1883 by Carl Hueter1,2 and later by Marius Smith-Petersen.3,4 An advan-
tage of the DAA is preservation of the posterior capsule, thereby obviating postoperative
restrictions, and speeding recovery after hip replacement. This chapter reviews the basic
anatomy that is relevant to safe execution of DAA total hip replacement.
Table 1-1 summarizes the relevant anterior hip and thigh musculature, including each
muscle’s origin and insertion, innervation, and blood supply. Palpation of relevant bony
Bal BS, Rubin LE, Keggi KJ, eds.
The Direct Anterior Approach to Hip Reconstruction (pp 3-9).
© 2016 SLACK Incorporated.

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4 Chapter 1

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Applied Anatomy of the Anterior Hip and Thigh 5
Figure 1-1. Superficial landmarks for DAA surgery. (Copyright 2016 by The
Curators of the University of Missouri, a public corporation. Reprinted with
permission.)
landmarks (ie, the ASIS, pubic symphysis, greater trochanter and inguinal crease) is pos-
sible even in obese patients, thereby guiding incision placement (Figure 1-1).
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6 Chapter 1
Figure 1-2. Intraoperative markings of the skin incision, and

superior extension of the approach. The ASIS is noted by the
circle.
Figure 1-3. Intraoperative photograph showing the

interval between vastus lateralis and rectus femoris,
with the superficial layer between TFL and sartorius
being retracted.
Incision placement is centered over the tensor fascia lata (TFL) muscle, which is located
about 2 to 3 cm lateral and 1 cm distal to the ASIS (Figure 1-2).5 The TFL is a large
muscle belly that originates broadly from the ASIS and anterior iliac crest, coalescing
over the greater trochanter into the iliotibial band and inserting into Gerdy’s tubercle at
the tibia (see Table 1-1). Even in obese patients, the TFL belly is identifiable by internally
rotating the hip. By retracting the TFL laterally, the interval between it and the sartorius
is entered to gain access to the deeper musculature and anterior hip capsule.
The Hueter approach uses the skin incision over the TFL muscle belly in order to stay
lateral and distal to the branches of the LFCN that are between the tensor and sartorius.
The LFCN arborizes into a gluteal branch and a femoral branch; these extend laterally
from the main trunk. These branches are at risk over the entire length of the incision,
particularly from 24 to 92 mm distal to the ASIS.6 The rate of LFCN neurapraxia,
while clinically insignificant, can be as high as 81% after the DAA total hip arthroplasty
(THA).7
The deep anatomy is between the vastus lateralis and rectus femoris (Figure 1-3). The
arcade of vessels arising from the ascending branch of the lateral femoral circumflex artery
(usually a 3 vessel complex) should be ligated or cauterized effectively; other wise, bleeding
will compromise further steps. Note that the rectus femoris has 2 origins: a direct head off
the ASIS and an indirect head off the superior acetabulum and hip capsule. The indirect
head along with the iliocapsularis muscle should be elevated off the capsule and superior
rim of the acetabulum to gain capsular exposure (Figure 1-4). The iliocapsularis is a

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Figure 1-4. Illustration showing femoral neck exposure with the ascend-
ing branches of the lateral femoral circumflex artery crossing the surgical
field. (Copyright 2016 by The Curators of the University of Missouri, a
public corporation. Reprinted with permission.)
muscle of variable size that originates from the ASIS spine and anteromedial hip capsule.
The insertion of the muscle is the femur along the intertrochanteric line and the capsular
reflections just distal to the lesser trochanter. The muscle is thought to assist in anterior
capsular control and stability of the hip joint.8
Safe acetabular exposure requires knowledge of the periacetabular anatomy. A spiked

retractor is placed anteriorly, near or over the superior ramus, thereby placing the femoral
neurovascular structures and the iliopsoas tendon at risk. The posterior retractor is placed
within the capsule and superficial to the labrum and poses less risk. An inferior retrac-
tor (if used) is placed outside the transverse acetabular ligament and places the obturator
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8 Chapter 1
vessels and nerves at risk. If retractors are removed and replaced during surgery, placement
should be in the same location next to the bone, to avoid injury to the adjacent structures
at risk.
The risks of retractor placement in THA have been described.9,10 Shubert et al used
preoperative CT scans and cadaveric dissection to study retractor placement around the
acetabulum. They found that a retractor over the superior ramus is within 1 cm of the
femoral neurovascular bundle.10 McConaghie et al also investigated the relationships
between hip retractor placement and neurovascular structures.9 The anterior retractor
should be placed under the iliopsoas, but can end up with the femoral nerve directly super-
ficial to it. If the retractor is repositioned during surgery, care must be taken to ensure
that it is between the bone and psoas tendon, thereby protecting the femoral neurovascu-
lar bundle. Careless retractor placement can lead to the femoral nerve slipping under the
retractor tip and getting compressed.10
The inferior retractor, under the transverse acetabular ligament, often comes into direct
contact with the obturator nerve and/or vessel as pressure is applied to gain acetabular
exposure.9 To minimize injury to the obturator neurovascular bundle, the retractor should
have a blunt, short tip, with the least amount of retraction applied as needed for exposure.
In our experience, the anterior, superior, and posterior retractors suffice for excellent visu-
alization without placing the obturator structures at risk. Injury to the obturator nerve can
be difficult to diagnose, often manifesting as weakness in hip adduction, groin pain, and
limited medial thigh numbness.
Femoral vein compression occurs during posterior total hip replacement, leading to dis-
tal venous dilatation and endothelial damage, with attendant increase in deep vein throm-
bosis (DVT) risk. This can occur during deep hip flexion and internal rotation required
for joint dislocation.11 Mednick et al showed that during DAA-based total hip replace-
ment, while limb position did not affect femoral venous flow, anterior retraction in the
acetabulum or around the calcar with a spiked retractor can occlude femoral venous blood
flow. Even so, the limited retraction needed during DAA total hip surgery may contribute
to the low risk of DVT reported in the literature.12 In 2132 patients, for example, Kennon
et al found only 8 patients (0.0038%) who suffered a venous thromboembolic event13; a
marked decrease from traditional rates of 1% to 6%.14
Safe femur exposure during DAA requires complete capsular release of the proximal
femur to at least the piriformis insertion. Insufficient releases lead to compromised expo-
sure, and contribute to the risk of fracture from overzealous retraction. The extent of
proximal femoral releases is patient specific, depending on flexibility of each hip. Release
of the posterior and superior capsule and the obturator internus is helpful in femoral
elevation from the wound.15 The obturator externus is an impor tant medial restraint that
should be preserved to avoid hip instability.16

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The ascending vascular leash of the lateral femoral circumflex artery must be defini-
tively identified and controlled to avoid blood loss and poor exposure.
LFCN injury can be minimized by lateral incision placement and by careful tissue
plane selection.
Avoid releasing the obturator externus tendon during femoral exposure to lessen the
risk of hip instability.
Understand the relation of the iliopsoas and femoral nerve versus the anterior acetabu-
lum; a cadaver dissection will be very helpful for the novice surgeon.
Postoperative weakness in hip adduction, groin pain, and a limited zone of medial
thigh numbness can indicate an iatrogenic obturator nerve injury.
1. Hueter C. Fünfte abtheilung: die verletzung und krankheiten des hüftgelenkes, neunundzwanzigstes
capitel. In: Hueter C, ed. Grundriss der chirurgie. 2nd ed. Leipzig, Germany: FCW Vogel; 1883: 129–200.
2. Rachbauer F, Kain MS, Leunig M. The history of the anterior approach to the hip. Orthop Clin North Am.
2009;40(3):311-320.
3. Smith-Petersen MN. A new supra-articular subperiosteal approach to the hip joint. J Bone Joint Surg Am.
1917;s2–15:592–595.
4. Smith-Petersen MN. Approach to and exposure of the hip joint for mold arthroplasty. J Bone Joint Surg
Am. 1949;31A(1):40-46.
5. Matta JM, Shahrdar C, Ferguson T. Single incision anterior approach for total hip arthroplasty on an
orthopaedic table. Clin Orthop Relat Res. 2005;441:115-124.
6. Ropars M, Morandi X, Huten D, Thomazeau H, Berton E, Darnault P. Anatomical study of the lateral
femoral cutaneous nerve with special reference to minimally invasive anterior approach for total hip replace-
ment. Surg Radiol Anat. 2009;31(3):199-204.
7. Goulding K, Beaulé PE, Kim PR, Fazekas A. Incidence of lateral femoral cutaneous nerve neurapraxia after
anterior approach hip arthroplasty. Clin Orthop Relat Res. 2010;468(9):2397-2404.
8. Ward WT, Fleisch ID, Ganz R. Anatomy of the iliocapsularis muscle: relevance to surgery of the hip. Clin
Orthop Relat Res. 2000;374:278–285.
9. McConaghie FA, Payne AP, Kinninmonth AWG. The role of retraction in direct nerve injury in total hip
replacement: an anatomical study. Bone Joint Res. 2014;3(6):212-216.
10. Shubert D, Madoff S, Milillo R, Nandi S. Neurovascular structure proximity to acetabular retractors in
total hip arthroplasty. J Arthroplasty. 2015;30(1):145-148.
11. Binns M, Pho R. Femoral vein occlusion during hip arthroplasty. Clin Orthop Relat Res. 1990;(255):168-172.
12. Mednick RE, Alvi HM, Morgan CE, Stover MD, Manning DW. Femoral vein blood flow during a total
hip arthroplasty using a modified Hueter approach. [published online ahead of print December 17, 2014].
J Arthroplasty. 2015;30(5):786-789. doi: 10.1016/j.arth.2014.12.015.
13. Kennon RE, Keggi JM, Wetmore RS, Zatorski LE, Huo MH, Keggi KJ. Total hip arthroplasty through a
minimally invasive anterior surgical approach. J Bone Joint Surg Am. 2003;85-A:39-48.
14. Dorr LD, Gendelman V, Maheshwari AV, Boutary M, Wan Z, Long WT. Multimodal thromboprophylaxis
for total hip and knee arthroplasty based on risk assessment. J Bone Joint Surg Am. 2007;89(12):2648-2657.
15. Matsuura M, Ohashi H, Okamoto Y, Inori F, Okajima Y. Elevation of the femur in THA through a direct
anterior approach: cadaver and clinical studies. Clin Orthop Relat Res. 2010;468(12):3201-3206.
16. Crist BD, Ivie CB, Bal BS. Total hip replacement with use of a direct anterior approach. A critical analysis
review. JBJS Reviews. 2014;2(6):e4.

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2
Indications for the
Direct Anterior Approach
R. Presley Swann, MD, MS and Christopher E. Pelt, MD
Understand the indications and contraindications for direct anterior approach (DAA)
total hip arthroplasty (THA).
Distinguish between straightforward vs complex cases using radiographic and clinical
criteria.
Understand the learning curve when transitioning from a posterior hip practice to the
DAA.
Identify potential solutions to addressing some of the more common challenging
cases.
THA is very successful, but complications such as hip instability, leg length discrepancy,
and abductor dysfunction/gait disturbances continue to manifest at a finite incidence. The
DAA method has been advocated to address some of these shortcomings of traditional (ie,
posterior) THA.1 DAA THA gained popularity as surgeons were attracted to minimally
invasive arthroplasty.2,3 Critics point to limited outcomes in the literature, such as retro-
spective reviews, and statistically underpowered randomized trials from a single center to
contend that DAA THA presents no advantages over traditional methods.4–6 Proponents
believe that DAA offers less muscle damage and a lower risk of hip dislocation,7–9 leading
to fewer patient restrictions, quicker recovery,3 and quicker hospital discharge.10 Long-
term outcomes beyond 6 months may not be different, although, one study has suggested
that improved gait mechanics may be enduring with DAA THA.11 DAA THA has
introduced some new complications, such as ankle fractures,4 meralgia paresthetica,12 and

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12 Chapter 2
Figure 2-1. DAA in obese patient; note greater

lateral soft tissue mass compared to the thin-
ner anterior tissues.
a learning curve requiring >100 operative cases.10,13 Masonis et al previously described a

step-wise learning approach to overcome the learning curve.14 Understanding the indi-
cations and contraindications, as well as identifying challenging cases, should help the
novice surgeon adapt DAA for THA surgery in a safe and reproducible manner.
As for any primary THA, the indications for DAA include pain, functional limitation,
stiffness, and radiographic arthritis or deformities that have failed nonoperative measures.
Certain prior surgeries may be conducive for DAA; for example, existing anterior inci-
sions from a periacetabular osteotomy can be leveraged toward DAA THA.
Contraindications to the DAA THA are similar to any THA (ie, hip arthroplasty
may not be indicated in the setting of severe medical disease wherein the risk of surgery
outweighs the expected benefit, patient noncompliance, or local or systemic infections).
Obesity (BMI >40 kg/m 2) may be considered a relative contraindication to THA given
a higher risk of complications. For example, infection risk is increased from 1.8% to 9.1%
in the morbidly obese, when compared to non-obese pateints.15 On the other hand, DAA
THA may be easier in the obese patient since the fat layer in the anterior thigh is thin-
ner than that found laterally4 (Figure 2-1). Even so, higher rates of wound complications
occur in obese patients, possibly because of the thinner dermis along with the groin flex-
ion crease, which can lead to moisture retention, motion, and irritation to the incision16
(Figure 2-2). An obese abdominal pannus can exacerbate skin irritation and maintain a
moist environment, harbor fungal infections, and delay wound healing. Nystatin powder
can treat groin flexion crease irritation if identified preoperatively. If identified during
surgery, it is best to consider alternative approaches to avoid placing a surgical incision
near a potentially contaminated groin.
Obese abdominal pannus can also impede placement of instruments, particularly dur-
ing femoral preparation. The most challenging abdominal deformity is a tense, distended
belly, often seen in the metabolic syndrome male patient. Other anatomic conditions, such
as existing hip and knee flexion contractures can make the DAA approach challenging,
in terms of patient position and manipulation of the leg. Spinal fusions and other spine
pathologies such as ankylosing spondylitis may pose additional risks.

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Indications for the Direct Anterior Approach 13
Figure 2-2. Wound complication from DAA,

showing incision placement. In this referral to
our institution, the incision is too medial and
curves into the groin crease, thereby compli-
cating healing.
Relative contraindications to DAA for hip replacement can include severe acetabular
deformity, significant acetabular bone loss, posterior column incompetence or fracture,
the possible need for posterior column plating, retained hardware that is inaccessible from
an anterior approach, or pelvic discontinuity. On the femoral side, prior surgeries, defor-
mity, bone deficiency, retained hardware that is inaccessible through the anterior incision,
and cases requiring long straight diaphyseal engaging stems can pose challenges, but do
not necessarily mandate an alternative approach. Many of these concepts will be addressed
elsewhere in this text and can be tackled after sufficient experience and training. For
example, retained lateral plates cannot be easily removed via the DAA, but retained femo-
ral neck screws can easily be removed with a small accessory lateral incision.
Proximal or distal extension of the approach and additional releases can, and should
be used to address many primary, complex primary, and even revision DAA THA opera-
tions, although this may not be a suitable strategy for the surgeon with limited experience.
With increased experience and confidence, many surgeons use the DAA for all THA
surgery, including revision procedures. Understanding the learning curve can help expe-
dite this transition.

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14 Chapter 2
Figure 2-3. Blue lines show the neck shaft

angle, higher values will be easier for DAA THA.
Yellow lines show the ilium-to-ischium ratio—
measuring the distance of the widest portion
of the ilium and the apex of the ischia—a
ratio >3:1 represents difficulty in accessing
the femur with the obstructing iliac wing. This
radiograph also shows large anteriorly facing
iliac wings. The green line is collinear with the
femoral canal; note the obstructing wide ilium.
The red line shows a shortened neck. All of
these factors predict a difficult case.
For some surgeons, the learning curve continues long enough that it becomes a
circle.
—John W. Goodfellow16
Surgical learning curves are an art, and rarely a simple linear process. Each patient is
unique, with memorable anatomy, or a particularly challenging surgical nuance. As a sur-
geon takes on more difficult cases, DAA THA may prove time consuming and frustrat-
ing when compared to the familiarity of the standard posterior approach learned during
the formative, residency years. Early on, expect longer case times and potentially increased
blood loss. Patient selection can help early success and confidence building, with advance-
ment to more challenging cases to prevent surgeon frustration, operating-room acceptance
of change, and most importantly, the execution of safe surgery for the patient.
Radiographic variables can help identify the challenging cases. Femoral neck length,
neck shaft angle, protrusio acetabuli, ilium morphology, and inner ischial distance are a
few examples of helpful radiographic features (Figure 2-3). Kreuzer et al identified 2 sta-
tistically significant, helpful measurements in planning DAA THA. Authors found that
the distance from the anterior superior iliac spine (ASIS) to the superior lateral aspect of
the acetabulum was 67 mm in difficult cases vs 90 mm in the easier cases. Also, the dis-
tance from the greater trochanter to the ASIS was 93 mm in difficult cases and 86 mm
in easier cases.18
Longer, valgus femoral necks allow more working room within the hip capsule, and
are going to require minimal releases. Shorter varus femoral necks can prove challenging,
with tight capsules that require extensive releases of the short external rotators for femo-
ral exposure. Protrusio hips create a relative shortening of the hip capsule and external
rotators and can behave like coxa breva (structural shortening of the femoral neck), even
if the femoral neck appears long. Coxa profunda is defined as the acetabular fossa being
medial to the ilioischial line whereas protrusio acetabuli is defined as the femoral head
being medial to the ilioischial line. Each of these disease patterns should be recognized as
predictors of a more difficult exposure during DAA.

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Figure 2-4. Progression of the learning curve

for DAA THA.
Ilium morphology may be helpful (ie, a wide iliac wing will make it difficult to instru-
ment the femur; see Figure 2-3). When measuring the ilium-to-ischium ratio, values
>3:1 indicate a wide ilium with a potentially medial acetabulum that will present chal-
lenges in femoral component insertion. Similarly, large iliac wings directed anteriorly (the
so-called Mickey Mouse pelvis) is another quick radiographic clue toward a tough case.
When combined with large males, particularly with large abdomens and small posteriors,
these radiographic findings can suggest some of the most difficult cases for femoral prepa-
ration. Plan on more aggressive and extensive proximal femoral releases, more adduction
of the femur, and the use of double offset femoral broaches. Femoral releases that help
elevate the femur include superior and lateral capsule, posterior capsule, and if needed, the
tensor fascia lata. External rotator release including and beyond the obturator internus will
not help further with femoral elevation, and the most useful release is that of the superior
lateral capsule, based on cadaveric observations.19
During the first 25 to 30 cases, exercise discretion in patient selection, and leverage
knowledge of the equipment, the table selected for exposure, the patient anatomy, and/or
personnel expertise to execute safe DAA THA. The ideal patient selection begins with
thin females with minimal deformity and long valgus neck angles. The next progression
is thin males with long necks to adapt your release techniques and accommodate the
increased muscle mass. Obese patients are the next progression with long necks to master
the approach, incision placement, and wound management. Coxa breva cases or those
with mild dysplasia or related deformity can then be tackled in thin patients, as a step-
wise progression. To identify coxa breva, measure the vertical distance from the trochanter
to a line across the top of the femoral head. Distances of ≤ 23 mm in men and ≤ 16 mm
in women indicate the presence of coxa breva.20 Finally, some DAA surgeons may never
proceed with cases beyond a comfort point, while others will continue learning and
take on increasingly tough cases with dysplasia, straight stems, revisions, and the like.
An algorithmic approach to stepwise progression in learning DAA THA is outlined in
Figure 2-4; this strategy will minimize surgeon anguish and technical hardship during
the learning curve with judicious patient selection.

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16 Chapter 2
Figure 2-5. Abdominal pannus taped out of the

way (upper right hand corner).
Figure 2-6. Alternative incision placement, as

shown, can avoid potential wound problems
by steering clear of the abdominal pannus and
the groin crease.
Obesity and the Abdominal Pannus

In addition to the previous observations, intraoperative taping of the pannus to pull it
up and over toward the contralateral side allows access to the incision area (Figure 2-5).
Alternative incision placement, such as a horizontal “bikini incision” that follows
Langerhans lines and avoids crossing the flexion crease can be helpful (Figure 2-6).
Postoperative care with compression shorts or abdominal binders can help keep the
abdomen away from the wound, with less moisture and mechanical irritation. Similarly,
using an occlusive silver impregnated dressing like Aquacel (ConvaTec) that remains in
place for 2 weeks postoperatively, can keep the wound safe and dry. Proximal pole wound
dehiscence is usually superficial and amenable to negative pressure vacuum therapy or
wet-to-dry dressings. If the wound is not superficial, drainage approaching 7 days should
be addressed in the operating room to avoid a prosthetic joint infection.

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Coxa Breva or Acetabular Protrusio

Because of the shortened distance between the femur and acetabulum, femoral head
removal will be easier with a segmental femoral neck osteotomy combining both a sub-
capital and a basicervical femoral neck cut. Excising a 1 cm segment of neck bone will ease
access in these cases, and facilitate head removal. During femoral exposure, the femur may
remain tight against the acetabular rim. If so, increased capsular release off the posterior
femur, including piriformis and posterior and superior capsule, will help. Further, release
of the tensor muscle off of the ilium can aid in the exposure of the femur, particularly
if getting instrumentation collinear with the femoral canal is a challenge. This can be
achieved with partial muscle fiber release, a tenotomy, or an osteotomy of the iliac crest.
These techniques are described elsewhere in this text.
Dysplasia/Version Issues on the Femur

Modular stems (such as the S-ROM [DePuy Synthes]) or other similar straight or
diaphyseal-engaging stems can be placed via DAA. However, this often requires more
extensile releases off the femur. Even so, there may be challenges related to getting the
reamers and other straight instruments collinear with the femoral canal. Increased risk of
intraoperative fracture is a concern. The surgeon should use discretion when considering
the DAA for these cases, and if in doubt, use alternative approaches.
Bone Loss
Bone grafting and the placement of augments can be done through the anterior
approach. In these cases, assessment of bony deficiencies preoperatively can help plan
the approach. If the bone loss is anterior, superior, or even posterosuperior, the DAA is
amenable to placing augments and bone grafting. The reflected head of the rectus can be
released for widened exposure as well as a tensor tenotomy off of the ilium to aid in further
acetabular exposure if necessary. However, more sizable posterior deficiencies and need for
augmentation will call for a posterior approach to the hip.
Spine Disease
Assessment of the patient’s spine will help plan cup positioning. Patient position for
DAA THA may be advantageous for patients with spine disease. Degenerative disk dis-
ease, relative lumbar kyphosis, or the so-called flat back syndrome can increase pelvic tilt
and therefore increase the relative anteversion of the acetabulum. The DAA approach
allows the surgeon to decrease some of the acetabular version, reducing dislocation risk.
Standing preoperative x-rays can help plan where the patient holds the pelvis in space, and
intraoperative fluoroscopy should match this orientation. This can be done by adjusting
the image intensifier toward a pelvic outlet view, so that the image matches the amount
of outlet on the standing AP pelvis while positioning the cup.
Cemented Stems
Cemented stems require the same releases that are needed for femoral preparation with
press fit stems. The placement of the cement restrictor, canal preparation, pressurization
of the cement, and placement of the stem are similar to other hip approaches. Offset stem

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18 Chapter 2
impactors that are used for cementless components may often be used to implant cemented
stems (eg, Summit Stem System [DePuy Synthes]), and can maintain stem position while
the cement cures. Flexible restrictor insertion handles can also help with mantle prepa-
ration. Cement delivery via the gun injector allows loading, injecting, and pressurizing
the mantle much in the same way as is done via other approaches so long as the femoral
exposure and releases are adequate for the case. Care should be taken to ensure enough
lateralization proximally to avoid varus stem positioning.
Calcar Fractures
Calcar fractures, when properly identified, are easily fixed with cerclage wires or cables.
Extend the inferior portion of the incision to visualize the proximal femur and place
retractors. Pass wires or cables around the femur, above and/or below the lesser trochanter.
Place wires/cables adjacent to bone, and deep to the vastus lateralis origin laterally, and the
vastus intermedius origin anteriorly. Wire placement is easier with the femoral lift off, no
traction, and the leg placed in either neutral or external rotation. This skill should be prac-
ticed in cadaver dissection, since calcar fractures often manifest during the learning curve.
DAA THA offers improved early rehabilitation, lower dislocation rates, and more
accurate implant positioning. However, the method has unique challenges. The learning
curve can be eased with careful surgical technique and patient selection. By an incremen-
tal adoption of the approach and recognizing the difficult cases ahead of time, a surgeon
can safely learn, all the ways to performing revision THA. The various techniques offered
in this chapter can help address patient conditions that other wise might preclude the
DAA approach.
While indications for DAA THA are similar to other methods, the learning curve
algorithm mandates limited case selection early on.
Recognize clinical and radiographic variables that can help safe patient selection.
Easier cases include thin, flexible, female patients with a long, valgus femoral neck.
More difficult are heavier males with a BMI >30; a short, varus femoral neck; and a
wide ilium with narrow ischium distance.
In addition to cadaver surgery, consider attending an advanced DAA course, followed
by a site visit to an experienced, high-volume DAA surgeon to understand the tips
and techniques described in this chapter.

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1. Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an
minimally invasive anterior surgical approach. J Bone Joint Surg Am. 2003;85(Suppl 4):39-48.
3. Kennon R, Keggi JM, Zatorski LE, Keggi KJ. Anterior approach for total hip arthroplasty: beyond the
minimally invasive technique. J Bone Joint Surg Am. 2004;86(Suppl 2):91-97.
4. Barrett WP, Turner SE, Leopold JP. Prospective randomized study of direct anterior vs postero-lateral
approach for total hip arthroplasty. J Arthroplasty. 2013;28(9):1634-1638.
5. Mayr E, Nogler M, Benedetti MG, et al. A prospective randomized assessment of earlier functional recov-
ery in THA patients treated by minimally invasive direct anterior approach: a gait analysis study. Clin
Biomech. 2009;24(10):812-818.
6. Taunton MJ, Mason JB, Odum SM, Springer BD. Direct anterior total hip arthroplasty yields more
rapid voluntary cessation of all walking AIDSL a prospective, randomized clinical trial. J Arthroplasty.
2014;29(9 Suppl):169-172.
7. Bremer AK, Kalberer F, Pfirrmann CW, Dora C. Soft-tissue changes in hip abductor muscles and tendons
after total hip replacement: comparison between the direct anterior and the transgluteal approaches. J Bone
Joint Surg Br. 2011;93(7):886-889.
8. Bergin PF, Doppelt JD, Kephart CJ, et al. Comparison of minimally invasive direct anterior versus pos-
terior total hip arthroplasty based on inflammation and muscle damage markers. J Bone Joint Surg Am.
2011;93(15):1392-1398.
9. Meneghini RM, Pagnano MW, Trousdale RT, Hozack WJ. Muscle damage during MIS total hip arthro-
plasty: Smith-Petersen versus posterior approach. Clin Orthop Relat Res. 2006;453:293-298.
10. Nakata K, Nishikawa M, Yamamoto K, Hirota S, Yoshikawa H. A clinical comparative study of the direct
anterior with mini-posterior approach: two consecutive series. J Arthroplasty. 2009;24(5):698-704.
11. Maffiuletti NA, Impellizzeri FM, Widler K, et al. Spatiotemporal parameters of gait after total hip replace-
ment: anterior versus posterior approach. Orthop Clin North Am. 2009;40:407-415.
12. Lovell TP. Single-incision direct anterior approach for total hip arthroplasty using a standard operating
table. J Arthroplasty. 2008;23(7 Suppl):64-68.
13. Anterior Total Hip Arthroplasty Collaborative Investigators, Bhandari M, Matta JM, et al. Outcomes fol-
lowing the single-incision anterior approach to total hip arthroplasty: a multicenter observational study.
Orthop Clin North Am. 2009;40(3):329-342.
14. Masonis J, Thompson C, Odum S. Safe and accurate: learning the direct anterior total hip arthroplasty.
Orthopedics. 2008;31(12): Suppl 2.
15. Dowse M, Choony P. Obesity is a major risk factor for prosthetic joint infection after primary hip arthro-
plasty. Clin Orthop Relat Res. 2008;466(1):153-158.
16. Christensen CP, Karthikeyan T, Jacobs CA. Greater prevalence of wound complications requiring reopera-
tion with direct anterior approach total hip arthroplasty. J Arthroplasty. 2014;29:1839-1841.
17. Goodfellow JW, O'Connor J, Dodd CAF, Murray DW. Unicompartmental arthroplasty with the Oxford
knee. Oxford, United Kingdom: Oxford University Press; 2006: 117-128.
18. Kreuzer S, Stulber J. Predicting difficulty of femoral preparation in the direct anterior approach to the
hip. Published abstract ORS 2012 Orthopaedic Proceedings. J Bone Joint Surg Br. 2011;93B(Supp IV):419.
19. Matsuura M, Ohashi H, Okamoto Y. Elevation of the femur in THA through a direct anterior approach:
cadaver and clinical studies. Clin Orthop Relat Res. 2010;468(12):3201-3206.
20. Standard SC. Treatment of coxa brevis. Orthop Clin North Am. 2011;42(3):373-387.

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3
Managing Single and
Multiple Incisions in
Direct Anterior Hip Surgery
Scott A. Ritterman, MD; Kristaps J. Keggi, MD, Dr Med (hc);
and Lee E. Rubin, MD
The direct anterior approach (DAA) generally consists of a single incision leading
to the Smith-Petersen interner vous interval between the sartorius and tensor fascia
lata (TFL), but accessory incisions can facilitate acetabular or femoral preparation for
virtually any hip implant system.
Five types of accessory incisions will be presented and discussed in relation to their
specific roles in supplementing the primary DAA incision for specific contingencies.
The DAA to the hip was first described by German surgeon Carl Hueter in his 1881
work, Der Grundriss der Chirurgie (Compendium of Surgery). Hueter described an inci-
sion that started halfway between the anterior superior iliac spine (ASIS) and the greater
trochanter. The incision was carried caudally parallel to the lateral edge of the sartorius
muscle, allowing access to the interval between the sartorius and the TFL, which could
be developed bluntly.
Even at this early time, Hueter noted the muscle-sparing advantages of the DAA.
Dr. Marius N. Smith-Petersen of Massachusetts General Hospital popularized the DAA
in the United States in the 1920s and 1930s, and used it throughout his prolific career.
Smith-Petersen notably described a proximal extension of the incision, which travelled
posteriorly along the iliac spine to gain greater exposure to the outer table of the ilium,

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22 Chapter 3
Figure 3-1. Clinical image of a right hip prepared for DAA surgery. The primary
longitudinal incision is marked (1) and is placed distal and lateral to the ASIS.
The distal accessory “stab” incision for straight reamer access to the acetabu-
lum is marked (2). The proximal accessory incision for femoral preparation is
marked (3) and is marked with a transverse orientation for cosmetic healing
with Langer’s skin lines. This incision can also be made longitudinally by
preference.
as well as unfettered access to the hip joint to aid in the open reduction of congenital hip
dislocations, treatment of femoral acetabular impingement, and for glass and Vitallium
cup mold arthroplasties of that era.1
There are numerous descriptions of the DAA for hip arthroplasty in the contemporary
literature.2–4 We present the primary single-incision approach used in our institution with
several additional incision modifications mentioned. Each of these incisions represents an
additional option for the treating surgeon. The expert DAA surgeon must understand
how to use each of these incisions as well as when to selectively utilize an additional acces-
sory incision to help optimize exposure, implant placement, and successful completion of
the operation for a variety of patient pathologies and morphologies.
The primary DAA incision is placed just lateral to the border of the sartorius muscle
and the plane is developed between the fascia of the sartorius and the TFL. Modifications
of the DAA skin incision used today still continue to use this same fascial interval to
access the interner vous route to the hip joint. Straight (Figure 3-1), curvilinear, or oblique
(Figure 3-2) incisions are typically placed 1 to 3 cm distal and 1 to 5 cm lateral to the
ASIS. The incision may be placed directly over the intermuscular/interner vous plane,
as in the traditional description or may be centered over the medial third of the TFL
muscle belly. Lateral placement of the skin incision can avoid the groin crease and any

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Managing Single and Multiple Incisions in Direct Anterior Hip Surgery 23
Figure 3-2. Oblique skin incision used for DAA.
overhanging pannus. This position allows adequate exposure of the hip joint and protec-
tion from the lateral femoral cutaneous nerve as well as medial femoral structures.
Alternatives to the straight single incision exist. Keggi et al utilize an oblique incision
centered on the femoral neck (Figure 3-3) which can be used in combination with 1 or
2 accessory incisions described later.5 Leunig presented the use of a “reverse oblique,” also
known as the bikini skin incision, to help improve skin cosmesis during DAA THA.6 In
each of these variants, the fascial dissection is nearly identical and utilizes the interner-
vous plane of the DAA beneath the initial skin incision. Note that the bikini incision
may have inherent limits on its ability to create extensile exposure if needed, as it is not
extensile. Accordingly, the bikini incision is perhaps best suited to well-selected cases of
thin patients with supple soft tissues.
Keggi’s original curvilinear incision (Figure 3-4) used a portion of the larger, extensile
Smith-Petersen exposure. Keggi’s DAA incision, first described at an American Academy
of Orthopaedic Surgeons scientific exhibit in 1977,7 was subsequently published in 19803
and was originally designed to facilitate the insertion of the femoral component. It has
undergone many modifications, with the latest version being an oblique incision centered
directly over the femoral neck. The orientation of the incision is designed to mirror the
obliquity of the lateral femoral cutaneous nerve (LFCN) branches, which are equally
oblique after their passage over the sartorius, therefore reducing the risk of LFCN injury
during exposure.
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24 Chapter 3
Figure 3-3. Oblique skin incision shown with placement of accessory proximal
and distal incisions.
The skin incision is carried down through subcutaneous tissue until the fascia overlying
the TFL muscle is exposed sufficiently to ensure the LFCN is not injured. The LFCN
follows a highly variable course out of the pelvis to supply sensation to the skin of the
superior-lateral thigh. The nerve crosses under the inguinal ligament an average of 1.4 cm
distal to the ASIS and 1 cm deep to the ligament itself but may even exit the pelvis lateral
to the ASIS.8
Several anatomic variants take the nerve laterally over the body of the TFL muscle
belly between 1 and 5 cm distal to the ASIS, placing it within the operative field. In
general, we split the tensor fascia under direct vision with the electrocautery for 4 to 6 cm,
then use blunt finger dissection to extend this split longitudinally both proximally and
distally, to further reduce the risk of iatrogenic injury to the main trunk or arborizing
branches of the LFCN.
Numbness or paresthesia resulting to injury to the LFCN can be seen in 15% or more
of patients undergoing THA via the DAA. Numbness and paresthesia typically improve
over time but may persist in some patients, without any effect on the motor function of
the limb. LFCN paresthesia does not appear to affect functional outcomes.9 In our experi-
ence, the most lateral branch of the LFCN is most often at risk during DAA THA, and
can be difficult to identify during the procedure. Inadvertent stretching or transection of

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Figure 3-4. Illustration of the original curved anterior incision used for THA
by Dr. Keggi in 1977, with placement of fascial incision in the right side of
the image. (Reprinted with permission from Keggi KJ, Light TR. The anterior
approach to total hip replacement. Clinical Exhibit Booth 1477: 44th Meeting
of the AAOS; 1977. Las Vegas, NV.)
this branch will not affect the main trunk of the LFCN, leading to a numb lateral thigh
but intact sensation over the balance of the anterior thigh. These findings do not have
any impact on the other wise satisfactory outcomes of hip arthroplasty performed through
the DAA.
An incision is made in the fascia overlying the TFL muscle and is continued proxi-
mally and distally the length of the skin incision. An Allis clamp can be used to grasp the
medial edge of the fascia and a finger can be used to bluntly separate the fascia from the
underlying TFL muscle belly along its medial edge. Alternatively, the TFL muscle belly
may be split, leaving a small cuff (approximately 1 cm) medially to protect the LFCN
and thereby facilitating closure.5 This TFL split technique has been the longstanding
preference of Dr. Keggi to further minimize the risk of direct trauma to the more medial
LFCN during DAA THA, and can be a helpful variation to improve hip joint exposure
in patients with a bulky TFL or significant muscularity.
At the superior extent of this fascial incision on the medial aspect of the TFL, a finger
can palpate the femoral neck and a blunt-tipped cobra retractor can then be placed superi-
or to the femoral neck and outside the joint capsule. At this point, care should be taken to
delicately dissect through the tissue of the anterior hip, using blunt dissection to identify
and then cauterize the ascending branches of the lateral femoral circumflex vessels that
invariably cross the surgical field. These may either be ligated with suture or cauterized
and care should be taken or significant bleeding may be encountered. Often, 3 distinct
vessels can be identified, but sometimes one is deep and distal to the others, requiring
caution and diligence during dissection to avoid bleeding complications early in the case.

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26 Chapter 3
Fibers of the indirect head of the rectus femoris muscle can be identified on the anterior
aspect of the hip joint capsule. The hip should be flexed slightly by either elevating the
leg on the traction table or elevating the knee if the leg is draped free. This slight relax-
ation of the rectus femoris will allow easier separation between its fibers and the anterior
hip capsule. These fibers of the indirect head of the rectus should be separated from the
capsule using either an elevator or electrocautery. The rectus muscle should be mobilized
until sufficient room exists to place a finger and then an additional blunt cobra retractor
inferiorly on the neck, allowing excellent visualization of the joint capsule from vastus
ridge to the pelvic attachment of the iliofemoral ligament. The anterior joint capsule is
covered by fat, which should be removed bluntly with a Cobb elevator or with a rongeur to
improve direct exposure prior to capsular management. A double bent Hohmann retrac-
tor can be placed medially along the anterior rim of the acetabulum to elevate the rectus
femoris and anterior soft tissues and to enhance visualization during the single-incision
approach for DAA THA.
Anterior capsulotomy can then be performed as an inverted T-shaped or L-shaped inci-
sion, or the anterior capsule may be removed to enhance visualization. The capsulotomy
should be taken from the vastus ridge proximally through the labrum. Transverse exten-
sions of the capsulotomy provide increased visualization and allow the cobra retractors to
be moved to similar positions inside the joint capsule, around the femoral neck. The pos-
terior capsule is initially retained and protected. At this point, the entire femoral neck and
shoulder are exposed. In-situ femoral neck cuts are preferred and are used first to remove
a sub-capital section of femoral neck and then facilitate head removal. Alternatively, cir-
cumferential capsular release about the proximal femur can be undertaken to dislocate
the hip anteriorly prior to the femoral neck osteotomy, but the utility of this additional
dislocation step has not been clearly established.10
To allow further exposure of the acetabulum the femur must be mobilized laterally.
Capsular release off the medial aspect of the femur, proximal to the lesser trochanter,
must be undertaken. The femur is externally rotated and the iliopsoas tendon insertion
can be palpated inferior to the medial capsule; this capsular tissue is then dissected off
the femur. Continued external rotation of the leg as this tissue is released enhances visu-
alization and puts the capsular tissue under tension during release. Cautery is used and
is strongly recommended over scissors, as the medial capsular release can endanger the
medial femoral circumflex artery and cause profuse hemorrhage during this step. The
capsular release is performed directly on the calcar insertion to further minimize the risk
of this complication.
Once the proximal femur is adequately mobilized, the acetabulum must be properly
exposed. A posterior acetabular retractor can be placed against the posterior wall to retract
the TFL muscle belly posteriorly, and a gauze sponge is used to protect the muscle belly
during retraction. Additional pointed retractors are placed superiorly at the anterior wall
elevating the rectus femoris. Retractors can be placed inferiorly along the transverse ace-
tabular ligament if needed. The acetabulum can then be prepared in a standard fashion.
If the acetabulum is deep or the exposure is limited for acetabular visualization, the
single-incision DAA can be extended distally for additional exposure as needed. Often

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Figure 3-5. Surgical photo demonstrating use of the distal/lateral accessory

incision to facilitate placement of a straight acetabular reamer shaft and
basket in a right hip.
just 1 to 2 cm of additional distal skin incision results in a noticeable improvement in

DAA visualization into the acetabulum. The tensor fascia split is extended with longitu-
dinal blunt dissection beneath the skin extension to facilitate additional direct visualiza-
tion of the acetabulum. Care must be taken not to damage the neurovascular leash to the
vastus intermedius while expanding distal exposure, as these terminal motor branches of
the femoral nerve are in close proximity to the primary DAA incision and are at direct
risk during this step.11
Offset reamers can be used to minimize muscle damage during single-incision DAA
acetabular preparation and cup insertion. In some cases, the physical bulk of the anterior
thigh may cause the surgeon to excessively antevert the reamers and cup; awareness is
needed and care should be taken to avoid this error. An offset basket reamer and an offset
cup impactor are both used via the single-incision DAA and represent our current prefer-
ence, typically obviating the need for an additional incision for acetabular instrumentation
during routine DAA THA. Importantly, note that the offset impactor may not transmit
impaction force as directly as a typical straight impactor handle; practice is needed when
using this tool. A straight impactor can be used for final seating when placing a cup in
sclerotic bone.
Alternatively, an accessory distal incision can be used to insert a straight, long reamer or
cup inserter handles. This is planned at a 45-degree abduction and 20-degree anteversion
angle, corresponding to a longitudinal central axis emanating from the ideal cup position.
This is an option often selected to facilitate straight reamer preparation in heavier patients
with extensive soft tissue obesity. In this scenario, the anterior thigh obesity tends to force
the reamer handle anteriorly and can cause premature loss of the anterior rim and column
during acetabular instrumentation.
The secondary incision for acetabular preparation is approximately 2 to 3 cm long and
is placed distal and lateral to the primary DAA incision. The larger the patient, the more
distal this accessory incision should be. The straight reamer shaft is inserted from the
main DAA incision and out of the stab wound laterally, then connected to a power driver.
The basket reamers are then dropped into the acetabulum for reaming (Figure 3-5).
Similarly, for cup insertion using this accessory incision, the inserter handle is
brought from lateral to medial into the primary DAA incision. The final cup is then
screwed onto the straight inserter and impacted into the acetabulum (Figure 3-6).
Knowledge and use of this accessory incision allows the use of smaller incisions and a

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28 Chapter 3
Figure 3-6. Surgical photo demonstrating positioning for straight threaded

impactor shaft and final acetabular component via the distal/lateral acces-
sory incision in a right hip.
more minimally-invasive-DAA technique even when managing obese or very muscular

patients. Recently, cannulated positioning guides have been developed to help facilitate
the accurate placement of this incision.
Preparation of the femur for broaching is often cited as the most difficult part of the
DAA THA operation.10 Soft tissue release from the medial aspect of the calcar should
already have been undertaken, by the time the acetabular cup insertion is completed.
Independent of whether a fracture table is used or not, the proximal femur has to be
elevated through the surgical wound. To do this, several steps must be taken.
Soft tissue should be dissected off the posterior aspect of the cut face of the femoral
neck both laterally at the shoulder and posteriorly, just cephalad to the location of the
short external rotators. This is best accomplished with electrocautery while the leg is being
externally rotated. Bending the cautery tip facilitates this release off the posterior aspect
of the femur. Maintaining proximity to bone is critical to avoid an injury to the medial
femoral circumflex artery behind the hip.
As the soft tissue restraints are being released from the posterior-lateral proximal
femur, a large manual bone hook around the lateral proximal femoral shaft or a hydraulic
femur elevator (if using a traction table) can be used in conjunction with a trochanteric
elevator placed posteriorly on the greater trochanter. These tools should be engaged to
be able to use it to progressively lift the proximal femur out of the wound, and this step
directly helps facilitate the postero-lateral capsular sleeve releases when performing a
single-incision DAA THA. Hip extension and leg adduction are also essential for expo-
sure and subsequent instrumentation of the proximal femur.
Mobilizing the proximal femur may require extensive soft tissue release; exposure and
femoral elevation may be inadequate in obese or muscular patients. For these reasons, a
secondary incision for femoral preparation can greatly aid in femoral broaching and final
prosthesis placement, in selected patients.
Difficulty in preparing the femoral canal during DAA THA led to the creation of
a secondary incision placed on the lateral thigh just proximal to the greater trochanter
(Figure 3-7). Originally, this accessory stab incision was used to place a bony plug into

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Figure 3-7. Site selection of proximal accessory incision for femoral prepara-
tion in a right hip.
Figure 3-8. Insertion of straight femoral broach via proximal K-spot incision
for femoral preparation in a right hip. Note the longitudinal incision place-
ment in this case compared to the orientation planned in Figure 3-1.
the femoral canal for cement pressurization, and later for placement of a plastic canal
restrictor for stem cementation during hybrid THA. These bone and metal plugs, or later
silicone canal restrictors, were difficult to pass into the femoral canal using long, straight
metallic insertion devices through the small DAA single incision, leading to the need for
the accessory incision. Later, this secondary incision was adapted for femoral reaming
and broaching with straight handle instruments (Figure 3-8) and prosthesis insertion
(Figure 3-9).12
Difficulty is often encountered during elevation of the proximal femur through the sur-
gical wound, especially for severely contracted hips in obese or muscular patients. The sec-
ondary incision for femoral preparation allows direct access in line with the femoral canal,
just posterior to the TFL and anterior to the gluteus medius (Figure 3-10). This incision
was originally used and described by Gerhard Küntscher who pioneered intramedullary
femoral nailing during World War II.13 Küntscher advocated intramedullary nailing for
long bone fractures. His trochanteric nails were inserted through this approach, anterior
to the abductor tendons.
In recognition of Dr. Küntscher, we refer to this second incision as the K-spot. We
routinely utilize this second incision for DAA THA cases, but it is important to note that

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30 Chapter 3
Figure 3-9. Insertion of final femoral component with a straight threaded

insertion handle via the proximal K-spot incision in a right hip.
Figure 3-10. Illustration of the right hip demonstrating the position of access
for the K-spot posterior to the TFL muscle and anterior to the gluteus medius
for linear access to the femoral canal.

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Figure 3-11. Straight broach handles (DePuy Orthopaedics).

The handle on the right is the standard straight handle. On
the left, is a custom broach handle, with an extended length
and reversed clamp connection point. This longer handle is
of par ticular use for the proximal secondary K-spot incision
in larger patients, as it facilitates handle detachment from
the broach in situ for intraoperative trialing of the THA. The
handles are positioned in the photo as viewed for potential
use on a right hip. The reversed clamp orientation of the left
handle is specifically designed to allow opening and closing
away from the patient’s body during the procedure.
the original nomenclature of this refers back to Dr. Küntscher’s work. Dr. Keggi became
familiar with Küntscher nailing during his residency at Yale from 1961 to 1964, and later
used a modification of this femoral access technique to facilitate femoral component inser-
tion during DAA as described here, particularly for large, muscular, or obese patients.
Use of the secondary K-spot incision for straight femoral reaming and broaching is
not simple and can be difficult to teach and learn. Femoral stems can be inserted directly
through this incision using straight threaded impactors. Surgeons performing DAA THA
should be aware of this secondary incision and be prepared to use it in selected cases.
With improved knowledge of and use of a systematic femoral release sequence, the need
for secondary incisions has faded over time. Of note, extra-long, straight broach handles
with the attachment point reversed can be of additional value when considering use of the
accessory K-Spot incision for femoral preparation in heavy patients (Figure 3-11).
Of note, in 2003, Dr. Richard Berger presented the use of a 2-incision less-invasive
THA technique that was branded and patented by the Zimmer Corporation.14 As sur-
geons across the country tried to adopt this challenging approach to THA, bony and
soft tissue complications mounted, prompting most surgeons to abandon this in favor of
traditional posterior or lateral surgical approaches. Although the concepts of Dr. Berger’s
technique were sound, the technique proved hard to teach and incorporate into routine
practice, underscoring the additional challenges of using accessory incisions for femoral

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32 Chapter 3
Figure 3-12. Preoperative skin marking for a DAA THA on a right hip, showing
the primary DAA incision marked distal and lateral to the ASIS. The proximal/
lateral incision is marked in line with the curvature of the extensile exposure.
Only a limited portion of this incision is planned for intrapelvic access to an
ilacus hematoma during a revision THA via the ilioinguinal window.
preparation and implantation. Limited exposure and visualization can compromise the
surgery if proper training is not ensured prior to adopting these techniques.
Ideally, the primary DAA incision placement is designed to be extensile. Proximally,

the incision can be carried up to the ASIS and then curved posterolaterally, inferior to the
iliac crest. This iliofemoral exposure is similar to the original description by Dr. Smith-
Petersen and may be required for grafting or cage reconstruction.5 The iliac origins of
the TFL, gluteus medius and minimus can all be exposed and released if necessary, while
the neurovascular pedicle innervating the superior gluteal artery and nerve are carefully
protected upon their more posterolateral exit from the greater sciatic notch. Accordingly,
complete lateral iliofemoral exposure is available via the DAA when needed to provide
access to the entire outer wall of the pelvis back to the sciatic notch. This iliac exposure
technique will be addressed in greater detail in the chapter on acetabular revision, and
can also be facilitated by an iliac crest osteotomy 15 to preserve the iliotibial band origin.
In cases requiring intrapelvic access beneath the iliacus, another accessory incision
can be utilized to create an ilioinguinal window (Figures 3-12 and 3-13). This incision

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Figure 3-13. Final skin closure following use of the ilioinguinal window inci-
sion over the proximal/lateral iliac crest. The 2 incisions can be connected for
an extensile iliofemoral exposure, but here are created as 2 working windows
to maintain a minimally invasive technique.
is created proximally and laterally over the iliac crest and utilizes the lateral ilioinguinal
window for access beneath the iliacus to gain access to the inner pelvic table and ilacus
fossa. This can be useful in rare cases for immediate retrieval of lost femoral head trials,
which can escape over the anterior pelvic rim along the psoas tendon during trialing if the
tight rectus tendon acts as a bowstring to separate the trial head from the neck. Typically,
these heads end up in the iliac fossa beneath (or adjacent to) the iliacus muscle and can be
retrieved with this accessory incision. Additionally, drainage of intrapelvic, juxta-articular
fluid collections, infections, or hematomas, can be accessed and evacuated with this lateral
window.
Distally, the extensile DAA incision (Figure 3-14) can be carried down the thigh later-
ally toward the knee, then back over the midsagittal aspect of the knee joint, helping to
facilitate total femoral prosthetic replacement. This anteriorly-based incision can also be
carried further down the anterior tibia, ankle, and foot toward the second ray, for manage-
ment of extensive trauma or necrotizing fasciitis of the lower extremity.16 While use of the
DAA for these indications is rare, these options should become familiar to DAA surgeons
and used in contingency planning for extreme cases. More detail is provided within this

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34 Chapter 3
Figure 3-14. Illustration demonstrating the distal creation of the extensile

DAA exposure in a right hip.
text in Chapters 5 and 27. Comprehensive femoral exposure and extension to the knee can
and should be practiced in the anatomy lab prior to clinical use.
When additional access to the femoral canal is planned or determined to be needed
during a DAA procedure, a fourth type of accessory incision can be used to create a lat-
eral working window to the femur. This type of secondary lateral incision can be used
effectively to address specific needs such as cannulated lateral screw removal, femoral per-
foration during broaching, osteotomy to remove a distal cement plug, or to place cerclage
cables around the femur prior to impacting stems with diaphyseal fixation.
Lastly, a fifth and final accessory DAA incision can be utilized to create access to the
intra-abdominal cavity (Figure 3-15). Although rarely utilized, surgeons should remember
that an advantage of the supine patient position during DAA THA is immediate access to
the abdomen for emergent management of inadvertent vascular injury. Certainly this is a
rarity for routine primary THA, but may be needed during acetabular revision surgery if
the pelvic vessels are injured. The supine position used for the DAA is the only surgical

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Figure 3-15. Illustration demonstrating the use of an accessory incision to gain

intra-abdominal access for contingency management of a vascular injury
caused by errant screw placement.
approach to the hip that can allow intra-abdominal access within the surgical field for
contingency purposes without repositioning or redraping the patient. Additionally, this
type of intra-abdominal accessory incision may have a role or for management of geriatric
pelvic and acetabular trauma, as combined fracture fixation and simultaneous THA may
have an expanded future role for selected patients.
The DAA uses the intermuscular and interner vous plane between the sartorius (femo-
ral nerve) and the TFL (superior gluteal nerve) and has become a versatile, extensile,
reliable, and safe approach for both primary and revision THA. Though not required,
specialized instruments, traction tables, and new techniques have created a renewed inter-
est in this classic approach, and made surgeon adoption easier.

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36 Chapter 3
Most important are the muscle-sparing principles of the DAA. The hip abductors,
extensors, and posterior external rotators are all generally preserved. These important
dynamic stabilizers of the hip joint are left intact and when components are paced accu-
rately, patients may not require postoperative motion precautions.17 Like other approaches
to the hip, excellent clinical results have been demonstrated with the DAA.
Knowledge of the DAA should include functional understanding of the single-incision
technique. The surgeon should know when and how to expand the field of view as needed
for both acetabular and femoral exposure. Surgeons should also know how to accomplish
proximal and distal extension of the primary DAA incision, and have awareness of the
4 types of accessory incisions that can further improve access to, and instrumentation of,
the acetabulum, femur, iliac fossa, and lateral femoral shaft.
Judicious and expert use of these secondary incisions can enable the DAA surgeon to
become more proficient, versatile, and prepared for the variety of pathology that can be
encountered in the operating room. The use of secondary incisions can help a novice DAA
surgeon gain further proficiency. Practice is required when considering use of multiple or
accessory incisions, and adequate cadaver and clinical training is essential to ensure safe
outcomes.
Slightly lateral placement of the primary DAA incision may help protect the main
trunk of the LFCN, but may still compromise the most lateral sensory nerve branch.
The resulting thigh numbness is not clinically significant and does not impair hip
function.
Distal extension of the primary DAA incision can improve direct exposure and visu-
alization of the acetabulum during primary THA.
Proximal extension of the primary DAA incision can assist with upward femoral
mobilization during primary THA or during femoral revision surgery.
Two carefully placed accessory incisions can help with straight acetabular or femoral
instrumentation, respectively, in selected cases. Two additional accessory incisions are
also useful for technical versatility; these can assist with intrapelvic access via a lateral
ilioinguinal window, and lateral accessory incisions can provide useful access to the
femoral shaft.
A fifth accessory incision can be used to gain intra-abdominal access for vascular
emergency situations encountered rarely during supine DAA hip reconstruction, but
may be more of a risk during complex revision DAA THA.
1. Rachbauer F, Kain MSH, Leunig M. The history of the anterior approach to the hip. Orthop Clin North
Am. 2009;40:311–320. doi:10.1016/j.ocl.2009.02.007.
orthopaedic table. Clin Orthop. 2005;441:115–24.
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15. Ziran NM, Sherif SM, Matta JM. Safe surgical technique: iliac osteotomy via the anterior approach for
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4
Primary Total Hip
Arthroplasty Using
the Hana Table
Navid M. Ziran, MD and Joel M. Matta, MD
Anterior approach (AA) total hip arthroplasty (THA) is a tissue-sparing proce-

dure with minimal deep soft-tissue dissection and no compromise to the abductor
mechanism.
The use of a special orthopedic table, such as the Hana table (Mizuho OSI) can
facilitate AA THA, but is not necessary.
Femoral exposure is the most technically challenging component of the procedure and
is aided by the orthopedic table.
Fluoroscopic guidance may provide the surgeon more precise determination of ace-
tabular component anteversion/inclination and matching of limb length /offset to the
contralateral extremity.
Since the initial 2003 surgeon course, the AA for THA has grown steadily and rapidly.
In 2003, less than 1% of United States surgeons utilized AA for THA while a survey at the
American Association of Hip and Knee Surgeons 2014 meeting indicated 26% of surgeon
attendees utilized the AA. The past 2 to 3 years have demonstrated strong surgeon inter-
est in this technique with over 800 surgeons per year receiving training at the American
Academy of Orthopaedic Surgeons, International Congress for Joint Reconstruction or
industry sponsored venues on primary and revision AA.
The senior author began AA to avoid the potential problems of existing approaches:
dislocation with posterior approach and abductor weakness with anterolateral approach.


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40 Chapter 4
AA avoids these potential issues by preserving the abductors, short rotator tendons, and
the posterior capsule.1-4
The primary purpose of the orthopedic table is to enhance access to the femur with
a secondary benefit of improved acetabular exposure.1,2 The orthopedic table can also
enhance accuracy and stability of the pelvis and hip position during intraoperative image
intensification.5-9
Today, most AA surgeries are performed with an orthopedic table or leg positioning
device2,3,5,10,11,12 though many are also performed on a standard operating room (OR)
table.13-16 Supine position and a radiolucent table, used by most AA surgeons, affords the
advantage of rapid and accurate information from image intensification regarding cup
position, leg length and offset.7,8,12,15,17
In this chapter, the authors present AA THA as performed by the senior author start-
ing in 1996 and undergoing refinements up to the present day. As in most surgical tech-
niques the “devil is in the details,” and it is the authors’ wishes that these details, along
with the AA THA technique as a whole, are both conveyed to the reader.
AA THA can be performed on a standard OR table, but is facilitated with the use
of a special orthopedic table. The Hana table provides control over lower extremity
positioning, and the femoral hook-lift enhances femoral exposure and provides sta-
bility during femoral broaching. One surgical assistant is necessary when using this
technique.
Special retractors designed for AA THA also greatly facilitate the procedure. These
retractors are sometimes provided by the manufacturers of the implants.
Preoperative templating of implant sizes should be performed on either hard copy or
digital radiographs.
The surgeon should confirm inventory of available implants. Both authors also have
the following instruments/systems available: (1) a flexible reaming set to ream the
femoral canal, (2) cerclage cables and a plating system to repair iatrogenic femur frac-
tures, and (3) a femoral component with a larger anterior-posterior width for patients
with larger metaphyseal canals and less cancellous bone.
Fluoroscopy allows precise implant positioning but is not necessary.
A touchscreen imaging hardware/software system (Galileo Positioning System
[GPS; Radlink]) can provide more quantitative data to the surgeon during implant
placement.
Positioning and Draping

The patient is brought to the OR and anesthesia is administered. Either general or
regional anesthesia can be administered. The patient is transferred to the Hana table.

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Primary Total Hip Arthroplasty Using the Hana Table 41
Figure 4-1. Supine position with a perineal post and lower extremities
secured to the table for left total hip arthroplasty.
A padded perineal post is placed and the patient is slid down against the post. The arms
are placed at 70 to 80 degrees in abduction with padding placed under bony prominences
and no pressure on the ulnar nerve. The patient’s feet are placed in padded liners and
then inserted into the Hana table boots. The boots are attached to the table spars and
locked into position. The table spars should be flexed approximately 5 to 10 degrees.
The legs should be internally rotated approximately 15 degrees in order to maximize the
radiographic appearance of neck offset and visualize the “bulge” of the tensor muscle.
The gross traction should be locked on both sides. Hair should be clipped from the mid-
thigh, groin, and abdomen. The abdomen (approximately up to the xyphoid) and hip
should be prepped and draped to the mid-thigh. The authors prefer to use ChloraPrep
(BD Worldwide) solution. Patient positioning is shown in Figure 4-1.
Surgical Exposure
The landmarks of the AA are the anterior superior iliac spine (ASIS) and the top of the
greater trochanter. The incision begins approximately 1 cm distal and 3 cm lateral to the
ASIS directed obliquely distal and posterior toward the anterior border of the femur. If the
patient is thin, the bulge of the tensor can be visualized, especially with the leg in slight
internal rotation. The incision is ideally located at the junction of the posterior 1/3 and
anterior 2/3 portion of the tensor (Figure 4-2). Sharp dissection is performed down to the
fascia of the tensor. The subcutaneous tissue can be gently finger dissected proximally
and distally, but not anteriorly or posteriorly; too much subcutaneous dissection can create
dead space for a potential fluid collection.
There are some anatomic clues to ensure that the surgeon is over the tensor muscle.
First, the fascia over the tensor muscle is more translucent than the iliotibial band, which
is more posterior. Next, there is frequently a small fascial perforating vessel directly over
the tensor fascia that needs to be coagulated. The fibers of the tensor muscle should be
parallel to the skin incision (Figure 4-3).
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42 Chapter 4
Figure 4-2. The incision for AA THA. The landmarks are the ASIS and the
greater trochanter. The proximal extent of the incision is started 3 cm lateral
and 1 cm distal to the ASIS and directed obliquely over the bulge of the ten-
sor toward the proximal femur.
Figure 4-3. After the skin incision, the fascia over the tensor muscle is
exposed. The fascia is typically translucent with an accompanying vein pierc-
ing the fascia. The iliotibial band is posterior and typically thicker than the
tensor fascia.
The tensor fascia is sharply incised in-line with the skin incision and extended slightly
proximal and distal to the skin incision. An Allis clamp is placed over the anterior aspect
of the fascia and the tensor fascia lata (TFL) muscle is gently finger dissected medially,
both proximally and distally, as shown in Figure 4-4. There is a definite plane medially,

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Figure 4-4. After the tensor fascia is incised, the tensor muscle is bluntly dis-
sected off the fascia medially, both superiorly and inferiorly.
Figure 4-5. A cobra retractor is placed lateral to the femoral neck. The
retractor is placed distal and lateral to the AIIS. If muscle is identified
medial to the retractor, it is typically the gluteus minimus.
as the tensor is contained in a fascial “pillow.” At this point, the anterior inferior iliac spine
(AIIS) can be palpated. The lateral femoral neck is distal and directly posterior to the
AIIS. In hips with significant arthritis/wear or short femoral necks, the position of the
lateral femoral neck may be different (ie, more proximal). At this point, a cobra retractor
is placed lateral to the femoral neck and medial to the tensor and the gluteus minimus
(Figure 4-5). Sometimes, a small portion of the gluteus minimus is located medial to the
cobra. If this occurs, the retractor should be re-placed medial to the gluteus minimus.

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44 Chapter 4
Figure 4-6. A Hohmann retractor is placed posterior to the rectus femoris

around the medial femoral neck. A Hibbs retractor is placed distal to the
cobra and retracts the tensor in order to visualize the lateral femoral circum-
flex vessels.
Next, the reflected head of the rectus femoris is identified along the anterior neck
capsule. A sharp Hohmann retractor is then placed with its tip on the femoral neck and
placed under the rectus femoris onto the anteromedial neck. The anterior neck capsule is
now exposed. A Hibbs retractor is placed on the distal aspect of the tensor muscle retract-
ing it laterally to expose the lateral femoral circumflex vessels. Figure 4-6 shows the cobra
around the lateral neck, the Hohmann around the medial neck, and the Hibbs retractor
gently retracting the distal tensor to expose the lateral femoral circumflex vessels.
There may be several leashes of the lateral femoral circumflex vessels; these leashes can
be coagulated or suture ligated. Figure 4-7 demonstrates transection of the coagulated lat-
eral femoral circumflex vessels. The vests fascia is then released using Mayo scissors—this
frees up the vastus lateralis and more, importantly, helps to mobilize the tensor muscle.
Meticulous and efficient initial exposure is key to the rest of the procedure. The initial
AA approach exposure takes approximately 5 to 10 minutes.
After the initial exposure, an L-capsulotomy is performed of the anterior neck cap-
sule using a cautery knife. Proximally, the cut is made lateral to the AIIS. Distally, the
surgeon can palpate the anterior tubercle of the vastus intermedius origin on the greater
trochanter—the cut should be aimed toward the lateral aspect of this protuberance. The
cut should then proceed inferomedially along the vastus ridge, proximal to the vastus
intermedius muscle. The anterior and lateral capsule limbs are then tagged with #1 Vicryl
(Ethicon) suture. A cobra retractor replaces the Hohmann retractor along the medial neck
on the inside of the capsule. The cobra on the lateral neck capsule is placed inside the
capsule. The hip joint should now be exposed (Figure 4-8).

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Figure 4-7. The lateral femoral circumflex vessels are clamped and cauterized
or ligated. There is sometimes a distal leash of these vessels that also needs
to be cauterized.
Figure 4-8. The joint is exposed after an L-capsulotomy.
Femoral Head Dislocation

A small Hohmann is placed under the anterior capsule along the anterior acetabular
rim to expose osteophytes and/or ossified labrum. These ossifications are removed using
a 0.5-inch straight osteotome. Three turns of traction are applied to the extremity and
should open up the joint. If the joint does not open, ensure that the foot is properly placed

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46 Chapter 4
Figure 4-9. (A) After approximately 3 turns of traction, a skid is placed in the
superior joint space and levered to separate the head and acetabular roof.
(B) The skid is placed around the medial aspect of the femoral head into the
acetabulum.
in the boot and the contralateral lower extremity gross traction is locked. A skid is then
placed first superior to the head (Figure 4-9) and then medial to the head.
A corkscrew is then advanced into the center of the femoral head. During initial inser-
tion, the corkscrew can be angled, but its final position should be perpendicular to the
floor (Figure 4-10). This angle is important so that when the head is dislocated and the
corkscrew handle is externally rotated, it does not damage the tensor muscle. The rotation
is unlocked and the leg is externally rotated about 25 degrees. Dislocation is performed by
pushing the head out with the skid and pulling the head “up and out” with the corkscrew
(Figure 4-11). It is important to pull the head “up and out” in one maneuver. The authors

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Figure 4-10. The corkscrew is drilled into the femoral head so it is perpendicu-
lar to the floor.
A
Figure 4-11. Femoral head dislocation is performed by pulling the
head “up and out” rather than pure external rotation. The skid is
used as counter-leverage to push the head out during this maneuver.
(continued)
find that general anesthesia facilitates head dislocation compared to spinal anesthesia. If
the head does not come out, a 0.75-inch curved osteotome can be used to cut the liga-
mentum teres. Head dislocation can be difficult. Particular attention should be placed
on placement of the corkscrew in the center of the head, muscle relaxation, and utilizing
proper technique to pull the head out (“up and out” vs pure external rotation). Another
option is to cut the neck in situ without dislocation, and then remove the head. It is the

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48 Chapter 4
D
Figure 4-11 (continued). The anterior wall is not at risk for fracture, and
the surgeon should ensure that the rotation is unlocked.

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Figure 4-12. The head is dislocated and rotated approximately 90 degrees.

Care should be taken to avoid injury to the tensor by the corkscrew by
excessive rotation. A small Hohmann is placed between the inferomedial hip
capsule (green arrow) and vastus lateralis. The inferomedial capsule is cauter-
ized until the surgeon can visualize and/or palpate the lesser trochanter. The
iliopsoas tendon should not be released.
authors’ preference, however, to dislocate and relocate prior to the neck cut because this
enhances femoral mobility and later femoral exposure.
Neck Osteotomy and Femoral Head Extraction

After dislocation, the leg is externally rotated approximately 90 degrees. A small
Hohmann is placed along the inferomedial neck anterior to the neck capsule and deep to
the vastus lateralis and intermedius. The remaining inferomedial neck capsule attachment
is taken off the bone with cautery (Figure 4-12). The lesser trochanter should be palpable
or visible afterwards. The hip joint is then reduced with internal rotation. Two cobras,
placed lateral and medial to the femoral neck, should be re-placed along with a Hibbs
retractor. The transverse portion of the femoral neck cut is then performed based on the
template (Figure 4-13). The saw should be aimed slightly posteromedial to avoid injury
to the greater trochanter. The longitudinal aspect of the neck cut (through the saddle) is
completed with a 0.5-inch straight osteotome. After the cut, the head is rotated out while
leaving the posterior cobra in place to protect the tensor muscle (Figure 4-14).
Acetabular Exposure and Reaming

To expose the acetabulum, 2 retractors are utilized—1 anterior and 1 posterior. The
anterior retractor is a Hohmann with a 90-degree bend in the handle and is placed with
the tip over the distal half of the anterior rim and distal to the pectineal eminence. A
cobra retractor is placed along the posterior rim of the acetabulum. The posterior retrac-
tor is placed inside the posterior capsule outside the labrum. The labrum, along with any
osteophytes, are then removed. The inferior capsule is longitudinally incised. Reaming

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50 Chapter 4
Figure 4-13. With the hip reduced, the femoral neck is osteotomized
according to the template. Typically, the saw blade is directed postero-
medial to avoid injury to the greater trochanter. An osteotome is used to
complete the cut through the neck saddle.
Figure 4-14. The femoral head is delivered by “rotating” it out of the

acetabulum. The sharp edges of the femoral neck should be directed
away from the tensor muscle. Sometimes, the ligamentum teres is still
attached and can be detached with a 0.5-inch curved osteotome.

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Figure 4-15. The pelvis is leveled using the fluoroscope. The following
landmarks are used to ensure a level pelvis: the coccyx should point
toward the pubis, the obturator foramen should be the same size/shape,
and the ilioischial line should bisect the teardrop in approximately the
same location.
is started with a 42-mm reamer in nearly all cases. The reamer is directed medial rather
than proximal and slightly anterior to posterior with the handle above the horizontal 10 to
15 degrees. The reamer is typically not directed in the direction of later cup insertion
but rather more transverse. Medial osteophytes should be excised with the initial reamer.
Sequential reaming is performed until within 1 to 2 mm of the templated cup size.
Before reaming to the final template size, fluoroscopy is used to (1) ensure the surgeon
has reamed medially enough, (2) check the proximal-distal position of the reamer and
eventual cup position, and (3) estimate the eventual cup size based on the reamer position.
The pelvis should first be checked to ensure it is level.
The image should be centered over the pelvis and the following markers can be used
to ensure a level pelvis:
The coccyx should point toward the pubic symphysis.
The obturator foramina should appear identical (height/shape).
The location of the ilioischial lines relative to the teardrop should be the same.
The table is tilted to the right or left until these landmarks are matched (Figure 4-15).
The C-arm image should also be rotated until the pelvis appears level (the transverse ana-
tomic line is horizontal). The fluoroscope is then centered over the acetabulum to avoid
parallax, and the reamer position is checked (Figure 4-16A).
Once the surgeon is satisfied with the reamer size, torque feedback, and appearance
on fluoroscopy, the actual cup is placed. The Radlink GPS software is utilized to ensure

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52 Chapter 4
Figure 4-16. Final acetabular reaming is done using fluoro-

scopic guidance. (A) The acetabulum should be centered
under the fluoroscope to minimize parallax. The acetabular
cup is placed using the fluoroscope coupled with Radlink GPS
software to ensure satisfactory inclination and version. (B) The
surgeon can enter in his or her preferred goal for acetabular
cup inclination and anteversion. (continued)
accurate cup placement. Prior to placing the acetabular component, the desired values
for acetabular inclination and version are entered on the Radlink GPS surgeon checklist
computer program (Figure 4-16B). Both authors prefer to place the cup in 40 to 45 degrees
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Figure 4-16 (continued). (C, D) The ellipse shown on the screen will
correspond to the entered numbers. (continued)
of inclination and 20 to 25 degrees of anteversion. Next, using Radlink, a reference line is

established from the apex of the teardrop and tangential to the pelvic brim. This reference
line eliminates potential for errors with measurements of inclination due to slight varia-
tions in image rotation. The visualized ellipse is then placed over the fluoroscopic image
of the cup (Figures 4-16C and 4-16D). The surgeon can make subtle adjustments to the
inclination and anteversion to match the radiographic image of the rim of the cup to the
digital ellipse.
For surgeons new to the AA, it is common to place the cup with too much inclina-
tion and anteversion. The typical orientation of the inserter handle is more parallel to the
floor as well as the long axis of the patient (see Figure 4-16C) than the surgeon expects.
After the cup is placed, the hole eliminator is screwed in (if using a single-hole cup) and
the polyethylene liner is impacted. The cup should have a good circumferential fit. The
implanted cup and fluoroscopic image are shown in Figures 4-16E and 4-16F.
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54 Chapter 4
Figure 4-16 (continued). E and F show the implanted cup and liner with
the corresponding fluoroscopic image.
In young patients with more lumbar lordosis, the senior author prefers slightly less
anteversion and inclination. As these younger patients age, their lordosis and pelvic tilt
may decrease (the pelvis flexes more), creating more “effective” anteversion and inclination
over time. The position of the pelvis is also different from lying to standing; the pelvis
extends upon supine positioning and is more flexed upon standing. Pelvic flexion poten-
tially contributes to more effective anteversion, although this precise quantity is unknown.
Lordosis can be estimated from the shape of the obturator foramen—patients with
more lordosis have more pelvic tilt, and hence, more obliquity to the obturator foramen
and therefore a smaller superior-inferior dimension seen on x-ray.

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Femoral Exposure and Preparation

Femoral exposure is the key to a successful surgery and adequate exposure is criti-
cal. The Hana table utilizes a specially designed femoral hook that mounts to a support
assembly and lift on the table.
To expose the proximal femur, the leg is placed in slight internal rotation to facilitate
hook placement under the proximal femur at the level of the vastus ridge. The hook helps
“deliver” the proximal femur, protects the tensor muscle, and supports the femur during
broaching.
The gross traction is released. The foot is then externally rotated to 120 degrees with
the patella facing laterally at 90 degrees. The rotation is then locked; it is critical that gross
traction and all fine traction are released before the leg is extended and adducted to avoid
inadvertent strong traction (Figure 4-17A), as this maneuver can potentially cause patient
injuries. After the leg is extended and adducted, a retractor is placed along the postero-
medial neck (Figure 4-17B). Another retractor is placed behind the greater trochanter.
The hook is placed in the support assembly (bracket), and the bracket is raised until there
is adequate tension to the proximal femur. The lateral neck capsule is pulled medially and
sharply released off the medial aspect of the greater trochanter and the gluteus minimus
(Figure 4-18A). Remnants of the lateral neck are removed with a rongeur, and posterior
retinacular vessels are coagulated prophylactically using the Aquamantys (Medtronic)
device (Figure 4-18B). At this point, the obturator internus and piriformis are visualized
on the medial aspect of the greater trochanter; the obturator externus tendon is sometimes
visible medial to the greater trochanter (Figure 4-19). If the proximal femur lacks mobil-
ity, the piriformis and obturator internus can be sharply incised along their insertion on
the medial greater trochanter—this can improve the mobility of the femur with little
morbidity since these rotators do not “recoil” and will heal in their anatomic positions.
Preserve the obturator externus tendon. This tendon has a direct medial pull on the proxi-
mal femur and provides the most resistance to hip dislocation.
Femoral Broaching and Trialing

Broaching should be initiated adjacent to the posterior femoral cortex (Figure 4-20A).
In order to avoid penetrating the lateral cortex, the surgeon’s hand should be directed
toward the floor (valgus) to ensure that the stem is going down the intramedullary canal
(Figure 4-20B). Palpation of the knee can be done to ensure that the broach is heading in
the right direction. The authors prefer to maintain the native neck version during broach-
ing. The path of the broach should not be altered significantly in order to maintain the
same line-to-line path. For the inexperienced surgeon, there is a potential danger to per-
forate the posterolateral cortex of the metaphysis. The authors’ femoral stem preference is
a non-cemented broach only stem. Sequential broaching is performed to the template size.
The surgeon can usually hear a change in the sound of mallet impaction as the broach
has a tighter fit. The broach should not be rotated during insertion or withdrawal so that
there is a satisfactory cancellous bone mantle. The goal should be a solid metaphyseal fit
(Figure 4-21).
The calcar should be adequately visualized during broaching, especially as the broach
size approaches that of the template, to avoid a potential fracture. Once the appropriate
broach size is determined, the trial neck and head are placed, and the hip is reduced.

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56 Chapter 4
B
Figure 4-17. (A) During femoral exposure, the affected leg is externally
rotated during extension and adduction. (B) The hook and the postero-
medial retractor during femoral exposure are shown.
The fluoroscope is used again to check that the pelvis is level using the previously
mentioned landmarks. It is then centered over the contralateral hip. The rotation of the
contralateral femur should be determined by (1) the position of the lesser trochanter and
(2) the overlap of the medial cortex of the anterior and posterior facets of the greater tro-
chanter. The rotation of the proximal femur, including the position of the lesser trochanter

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B
Figure 4-18. (A) The lateral neck capsule is incised off the gluteus minimus
down to the level of the bone. (B) An Aquamantys is utilized to cauterize
retinacular vessels after releasing the lateral neck capsule.

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58 Chapter 4
Figure 4-19. The piriformis (yellow arrow), obturator internus (green

arrow), and obturator externus (blue arrow) are demonstrated in this
photograph. The piriformis and obturator internus can be sharply incised
to improve mobilization of the proximal femur.
and overlap of the anterior/posterior greater trochanter facets is matched to the contralat-
eral side (Figure 4-22). The purpose of the internal rotation is to visualize the maximum
neck offset; thus, the proximal femurs should be slightly internally rotated to maximize
this offset. The femur should be adducted or abducted as well to match the contralateral
side, since this can affect limb length. The surgeon should attempt to eliminate as many
confounding imaging and positioning variables to replicate the opposite side. The Radlink
GPS software will superimpose the contralateral hip image to match limb length and
offset (Figure 4-23).
It is important for the surgeon to know the difference between the global offset (distance
between the proximal femur shaft axis to the inferior aspect of the teardrop line) and
femoral offset (distance between the proximal femur shaft axis to center of femoral head
rotation). When overlaying the images, if global offset is decreased, this may be due to
medialization of the acetabular component; it is more important to match up the femoral
offset rather than the global offset. In addition to offset, leg length should also be matched.

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Figure 4-20. (A) Broaching should be initiated parallel to the posterior

femoral cortex. (B) The surgeon should push the broach down toward
the floor (green arrow) during broaching to prevent violation of the lat-
eral femoral cortex.
Final Implantation
Once leg length and offset are matched, the hip is dislocated, the femoral hook/retrac-
tors are placed, and the calcar is planed. The trial implants are removed and the final
implants are placed. The stem should be impacted with light blows until seated at the
calcar. The final head should be placed on the stem and gently impacted (Figure 4-24).
Before reduction, the cup should be checked and irrigated for any soft tissue interposition.
The hip is reduced (Figure 4-25) and a final fluoroscopy is taken. The wound is irrigated.

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60 Chapter 4
Figure 4-21. The femoral trial stem is placed.
Figure 4-22. After confirmation of a level pelvis, the hips are visualized
using the fluoroscope.
Wound Closure
Wound closure is performed by tying the 2 capsule sutures together (Figure 4-26A).
The fascia is closed with 2-0 Vicryl (Figure 4-26B). The skin is closed with 2-0 Vicryl, a
3-0 Monocryl (Ethicon) subcuticular stitch, and Dermabond (Ethicon; Figure 4-26C). A
sterile dressing is applied.

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B
Figure 4-23. (A, B) Using the Radlink GPS software, the greater trochanter
and inferior aspects of the teardrop are marked on the native hip and the
trial hip. (continued)
Approach Extension
The approach can be extended proximally toward the ASIS and curving along the
posterior border of the iliac crest to expose the tensor origin and/or the inner table of the
ilium. The incision can be extended distally if access to the femoral shaft is necessary.
The vastus lateralis can be elevated and perforating veins should be ligated. This extensile
exposure provides the surgeon potential access for revision arthroplasty, which is discussed
in Chapter 5. Revision exposure may include an osteotomy although detailed and specific
revision techniques are beyond the scope of this chapter.

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62 Chapter 4
D
Figure 4-23 (continued). (C, D) These images are then digitally overlaid to
match leg length and offset.
Postoperative Rehabilitation
Patients are weight bearing as tolerated and receive physical therapy postoperative day
zero, if possible. During physical therapy, patients are instructed on gait training and
muscle strengthening. There are no hip dislocation precautions and range of motion is as
tolerated. Patients should avoid excessive physical activity during the first 2 weeks.

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Figure 4-24. The actual femoral component and head are placed.
Figure 4-25. The hip joint is reduced and visualized to ensure a

concentric reduction.

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64 Chapter 4
Figure 4-26. (A) The capsule is closed with the tagged Vicryl
suture. (B) The tensor fascia is closed with #1 Vicryl running
suture. (C) The skin is closed with 3-0 Monocryl and Dermabond.

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In over 3000 consecutive, unselected primary AA THAs performed by the senior

author, the following complications occurred: 4 hip dislocations (0.13%), 2 deep infec-
tions (0.06%), 1 case of femoral neurapraxia (0.03%), 2 cases of partial sciatic nerve palsy
(0.06%), 7 greater trochanter fractures (0.23%), and 3 ankle fractures (0.1%).1 The major-
ity of these complications occurred during the first 500 cases by the senior author (from
1996 to 2004).
In a multi-center study that examined 5090 consecutive primary procedures from 2006 to
2013 by 5 surgeons, the overall perioperative complication rate was 1.93% (manuscript
in preparation). Intraoperative complications included 41 intraoperative femur frac-
tures (0.8%) including 29 (0.57%) calcar fractures, 9 (0.18%) greater trochanter frac-
tures, and 3 (0.06%) femoral shaft fractures. Postoperative complications included:
15 (0.29%) superficial infections; 5 (0.10%) deep infections; 12 (0.24%) dislocations;
8 (0.16%) hematomas; 3 (0.06%) cases of cellulitis; 7 postoperative femur fractures
including 3 (0.06%) greater trochanter fractures, 2 (0.04%) calcar fractures, and
2 (0.04%) femur fractures; 2 (0.04%) sciatic nerve palsies; 1 (0.02%) peroneal nerve palsy;
and 1 (0.02%) intrapelvic bleed.18
The number of partial and total hip replacements in the United States in 2012 was
452,615.19 The growth rate is expected to continue as it has in the past. THAs per-
formed in the Medicare population have demonstrated a 1.3% year over year growth from
2005 to 2011.20
Coincident with the increased demand for THA in the United States, the health care
climate is also evolving with greater emphasis on “pay-for-performance” paradigms. The
authors feel that AA THA fits into this evolving climate for several reasons: (1) improved
acetabular cup positioning, (2) accurate restoration of limb length and offset, (3) minimal
soft-tissue trauma with preservation of the external rotators, (4) minimal postoperative
pain, and (5) low dislocation rate.
The use of the Hana orthopedic table facilitates the AA THA procedure for the sur-
geon. Use of the Radlink GPS system offers the surgeon a more precise assessment of
implant position. Proximal femoral exposure is key to an excellent outcome. The authors
would like to communicate the following important anecdotal details that may facilitate
the procedure:
In obese patients, the correct skin incision may be difficult to identify. If the patient
has a large pannus, the surgeon can retract the pannus (ie, by taping to the table) prior
to prepping and draping the patient.
If the approach does not look quite right, the surgeon is advised to stop and reassess
the anatomy.
In degenerative hips with significant proximal migration, do not cut the direct head of
the rectus femoris attachment to the AIIS. Normal bony landmarks can be distorted
in these cases.

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66 Chapter 4
Avoid injuring the tensor muscle during the procedure, particularly by excessive
retraction or during removal of the femoral head (sharp prominences of the neck can
injure the tensor).
If the neck cut is too long and in the way of the acetabulum, the surgeon can exter-
nally rotate the leg to improve exposure rather than re-osteotomizing the neck.
Ensure all fluoroscopic views of the acetabulum are centered to avoid any parallax
distortion; the image should be rotated so the pelvis image is level to the floor.
To improve exposure of the proximal femur, the obturator internus and piriformis can
be sharply released of their attachment on the greater trochanter. These tendons do
not recoil and maintain their continuity as a “flap.” If proximal femur exposure is still
an issue, the incision can be extended proximally and a small portion of the tensor
origin can be released. Another option to facilitate exposure is an iliac osteotomy.21
To avoid broaching through the lateral femoral cortex, keep the broach handle pushed
down toward the floor. Avoid excessive rotation of the broach during insertion and
withdrawal to ensure a tight cancellous bone mantle.
Greater trochanter fractures can be prevented by aiming the oscillating saw postero-
medial during the neck osteotomy. A reciprocating saw can also be used. Another
potential cause of greater trochanter fractures is excessive tension from the femoral
hook. The excessive tension from the soft tissues (gluteus medius, piriformis, obtura-
tor internus) can avulse the greater trochanter.
AA THA is a tissue-sparing procedure that facilitates accurate implant positioning

with minimal soft-tissue compromise.
Potential postoperative benefits include earlier rehabilitation, no need for dislocation
precautions, and lower wear due to more accurate implant placement.
Although a special orthopedic table and fluoroscopy facilitate the procedure, they are
not necessary.
Meticulous and efficient initial exposure is key to the rest of the AA THA procedure.
Like many orthopedic procedures, the surgical details are the initial hurdles in AA
THA.
The authors would like to thank Lisa Hutchinson Gable and Danielle Berberian Kelley
for their assistance.

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1. Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for THA on an orthopaedic table.
CORR. 2005;441:115-124.
2. Matta JM, Ferguson TA. The anterior approach for hip replacement. Orthopedics. 2005;28:927-928.
Orthop Clin of North Am. 2009;40:329-342.
4. Mast NH, Matta JM. Simultaneous bilateral supine AA THA: evaluation of early complications and short-
term rehabilitation. Orthop Clin North Am. 2009;40:351-356.
5. Masonis J, Thompson C, Odum S. Safe and accurate: learning the direct anterior THA. Orthopedics.
2008:31(12 suppl 2):pii.
6. Moskal JT. Anterior approach in THA improves outcomes: affirms. Orthopedics. 2011;34:e456-e458.
7. Bourne MH, Mariani EM. A comparison between direct anterior surgery of the hip and anterolateral surgi-
cal approaches to THA: postoperative outcomes. Poster presented at: American Academy of Orthopaedic
Surgeons Annual Meeting; March 9-13, 2010. New Orleans, LA.
8. Masonis JL, Ruffolo M, Odum SM, Mason JB, Fehring TK. Effect of surgical approach and intra-operative
imaging on acetabular component alignment in THA. Paper presented at: American Association of Hip
and Knee Surgeons Annual Meeting; November 2012. Dallas, TX.
9. Vail TP, Mariani EM. Approaches to primary total hip arthroplasty. JBJS Am. 2009:91(suppl 5):10-12.
10. Judet R, Judet T. Technique and results with the acrylic femoral head prosthesis. JBJS Br. 1952;34:173-180.
11. Mast NH, Laude F. Revision total hip arthroplasty performed through the Hueter interval. JBJS Am.
2011;93(suppl 2):143-148.
approach for THA. J Arthroplasty. 2013;28(9):1634-1638.
13. Yi C, Agudelo JF, Dayton MR, Morgan SJ. Early complications of anterior supine intermuscular total hip
arthroplasty. Orthopedics. 2013;36(3):e276-e281.
14. Torkos M, Gimesi C, Toth Z, Bajzik G, Magyar A, Szabo I. Comparative results of half year follow-up
after primary total hip arthroplasty with minimally invasive anterior and direct lateral approach. JBJS Br.
2012;94(suppl xxxvvii):124.
15. Berend KR, Lombardi AV, Seng BE, Adams JB. Enhanced early outcomes with the anterior supine inter-
muscular approach in primary THA. JBJS Am. 2009;91(suppl 6):107-120.
approach with mini-posterior approach: two consecutive series. J Arthroplasty. 2009;2495):698-704.
17. Wegman BM, Aleto TJ, Aggarwal A, Bal BS. Making the case for anterior total hip arthroplasty. Semin
Arthroplasty. 2012;23(3):149-154.
18. Barnett SL, Peters DJ, Hamilton W, Ziran NM, Gorab RS, Matta JM. Is the anterior approach safe? Early
complication rate associated with 5090 consecutive primary total hip arthroplasty procedures performed
using the anterior approach. J Arthroplasty. 2015;S0883-5403(15)00607-5. doi: 10.1016/j.arth.2015.07.008.
19. Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project (HCUP) 2012
national inpatient sample. http://hcupnet.ahrq.gov. Accessed May 2, 2016.
20. Nwachukwu BU, McCormick F, Provencher MT, Roche M, Rubash HE. A comprehensive analysis of
Medicare trends in utilization and hospital economics for total knee and hip arthroplasty from 2005 to
2011. J Arthroplasty. 2015;30(1):15-18.
21. Ziran NM, Sherif SM, Matta JM. Safe surgical technique: iliac osteotomy via the anterior approach for
revision hip arthroplasty. Patient Saf Surg. 2014;8:32.

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5
Extensile Approach to
Anterior Hip Surgery
Proximal extension can be performed via a combined iliofemoral approach to expose

the entire acetabulum.
Distal extension can be achieved via a direct lateral approach to the femur, exposing
the entire femur.
Selective osteotomy of the anterior superior and/or inferior iliac spines improves expo-
sure to the anterior column/acetabulum and allows for bone-to-bone healing.
This chapter will guide the reader through the steps necessary to extend the direct
anterior approach (DAA) exposure proximally and distally. Surgeons should know these
techniques, since they are useful when placing acetabular reconstruction cages, tri-flange
components, pelvic reconstruction plates, an extended trochanteric osteotomy, and
implantation of tumor prostheses for limb salvage operations.
The extent of the DAA exposure over the pelvis and thigh can be seen in Figures
5-1 and 5-2, which detail the skin incision extensions and muscular intervals both proxi-
mally and distally about the hip. Practically, the extensile DAA approach can be carried
distally to the knee joint. In theory, the approach can continue even further distally to the
second ray of the foot for rare cases involving necrotizing fasciitis.


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70 Chapter 5
Figure 5-1. Illustration demonstrating the skin incision of the direct anterior
approach (solid line) with planned skin incision for the extensile measures
(dotted line). (Copyright 2016 by The Curators of the University of Missouri, a
public corporation. Reprinted with permission.)
Figure 5-2. Illustration depicting the muscular interval for the extensile
measures of the anterior approach. (Copyright 2016 by The Curators of the
University of Missouri, a public corporation. Reprinted with permission.)
Proper preparation includes preoperative planning for an extensile exposure. When

draping the patient proximally and distally, generous amounts of the thigh and iliac crest
should be sterile and maintained within the final field for exposure as necessary. Based on
the individual case, the surgical field should extend from the inferior rib cage to the ipsi-
lateral lower extremity distal to the knee. This allows access to the entire hemipelvis and
femur. Surgical preparation to the toes is commonly practiced at many institutions for the
DAA, incorporating the entire lower extremity into the sterile field. Additionally, sterile
preparation of the foot may reduce contamination of the stocking as it is applied to the
leg. An orthopedic traction table can be used but is not necessary.1 Fluoroscopy, a variety
of hip and pelvic retractors, and femoral elevators are useful to facilitate this technique.
Proximal Extension
Extension of the standard DAA begins with extending the skin incision to the anterior
superior iliac spine (ASIS). Just medial to the ASIS, one must be careful to avoid injury to
the lateral femoral cutaneous nerve (LFCN). The DAA approach blends into an extended
iliofemoral approach 2 that affords exposure of both the anterior and posterior columns.
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Extensile Approach to Anterior Hip Surgery 71
This allows for revision of acetabular components, plating of pelvic discontinuity, place-
ment of structural metal augments, and use of salvage components such as an acetabular
reconstruction cage or tri-flange implants.
The authors prefer placing the skin incision just inferior to the iliac crest to minimize
irritation by pants or belts; this is shown proximally in Figure 5-1 as a dotted black
line. This incision is taken down to the aponeurosis between the gluteus and abdominal
muscles over the iliac crest. The fascia is subperiosteally elevated from the iliac crest with
the abdominal muscles and the iliacus muscle is elevated off of the inner table of the ilium
to place a blunt Hohmann retractor safely along the quadrilateral surface. This achieves
access to the entire inner table of the ilium and the sacroiliac joint if necessary. Access to
the superior ramus and anterior column is achieved by elevating the iliopsoas muscle with
a blunt elevator. During closure, if it is difficult to primarily repair the abductor muscles
to the abdominal fascia with sutures, multiple 3.5-mm suture anchors may be placed into
the iliac crest and used to repair the fascia in order to minimize risk of muscle herniation.
To access the outer table of the ilium and posterior column, the gluteus muscles are
elevated off the outer table of the ilium with a Cobb elevator and electrocautery as needed.
The goal is to stay subperiosteally to minimize tissue disruption. Alternatively, an iliac
crest osteotomy can be performed to allow for bone-to-bone healing for the abductor
origin. This may be considered in patients that appear to have poor quality soft tissue
attachment. The osteotomy is completed with an osteotome or small oscillating saw.
The bone fragment is mobilized with the abductors. Though a combination of sharp and
blunt dissection, this dissection is carried down to the roof of the acetabulum and greater
sciatic notch. This provides visualization of the posterior column and posterior wall. The
osteotomy is fixed with multiple independent 3.5-mm cortical screws and may be up to
50 or 60 mm in length if they are directed toward the pelvic brim.
Elevating the abductors off of the outer table of the ilium has a high incidence of het-
erotopic ossification (HO) when used for complex acetabular fracture repair.3 The use of
medications, like indomethacin, or radiation has been shown to be useful and should be
considered.4,5 Our preference is to use a one-time prophylactic dose of radiation (7 Gy)
to minimize the risk of HO done either preoperatively if the patient has known risk
factors, like previous HO formation, or within 72 hours of surgery.6 Although this does
pose a potential risk of nonunion or inhibit potential arthroplasty ingrowth and wound
healing problems, the 72-hour window minimizes this concern. Prophylactic radiation
also removes the concern over patient medication compliance when daily nonsteroidal
anti-inflammatory drugs (NSAIDs) are used for 6 weeks. However, both NSAIDs and
prophylactic radiation have been shown to be successful.7
Exposure of the anterior column is achieved with or without an osteotomy of the ASIS
and anterior inferior iliac spine (AIIS). Limited visualization of the anterior column can
be achieved by simply elevating the iliopsoas muscle. However, osteotomy of the ASIS
readily mobilizes the sartorius and inguinal ligament medially, allowing for reflection of
the muscle belly away from the anterior acetabulum. Prior to osteotomy, the tensor fascia
lata (TFL) muscle must be elevated off the outer table of the ASIS. The TFL and sarto-
rius interval must be opened distally as well. Care should be used to avoid injury to the
LFCN that varies in its course. Typically it is up to 1.5 cm medial to the ASIS; however,
the nerve can range from slightly lateral to the ASIS to up to 6 cm medial to the ASIS
at the inguinal ligament.8 We recommend pre-drilling the hole for later screw fixation
prior to making the osteotomy to ensure anatomic reduction and facilitate fixation later.

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72 Chapter 5
Figure 5-3. Illustration depicting the superior extension of the anterior

approach to the hip with ASIS and AIIS osteotomies for complete exposure of
the acetabulum and pelvis. (Copyright 2016 by The Curators of the University
of Missouri, a public corporation. Reprinted with permission.)
Typically, a 3.5-mm cortical screw measuring 50 to 60 mm is used to fix the ASIS oste-
otomy, but having a 3.5-mm screw set with lengths up to 110 mm is advised. If additional
rotational stability is required and known prior to osteotomy, 2 2.7-mm cortical screws
can be used—one going from anterior to posterior and one going from the ASIS into the
inferior ilium toward the pelvic brim. Screw lengths may be up to 50 to 60 mm. However,
these screw pilot holes are typically not pre-drilled, but rather drilled after the osteotomy
is reduced after the arthroplasty is complete.
The ASIS osteotomy fragment should be at least 1 cm in length and the osteotomy is
typically performed with a micro-oscillating sagittal saw. An osteotome can be used to
complete the osteotomy medially if there is concern for injuring the LFCN. Once the
osteotomy is complete, this fragment along with the sartorius and inguinal ligament are
separated from the underlying rectus and retracted medially. A blunt Hohmann retractor
can be placed over the superior ramus to provide exposure to the anterior portion of the
hip. The anterior column of the acetabulum can be identified and accessed. Further access
to the anterior hip can be achieved by osteotomy of the AIIS. Pre-drilling and perform-
ing the osteotomy of the AIIS is essentially done in the same fashion as the ASIS. Once
this is complete, the rectus with its bony insertion can be reflected medially, providing
access to the entire anterior column and wall of the acetabulum for structural augment
or plate placement. Fluoroscopy may be helpful to ensure accurate placement of the AIIS
osteotomy and later fixation. Alternatively, the direct head of the rectus femoris may be
ligated and repaired with sutures (usually a #5 nonabsorbable suture) or suture anchors
(typically 3.5 or 4.5 mm screw-type anchors). However, suture alone may be less reliable
for healing potential because healing is dependent upon tendon-to-tendon healing instead
of bone-to-bone healing. Figure 5-3 demonstrates the extensile acetabular exposure.

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Figure 5-4. Skin incision showing extensile DAA from the iliac crest down to
the foot.
Distal extension of the DAA extends slightly laterally on the thigh and coalesces into
the extensile lateral approach to the femur. The distal limb of the direct anterior incision
is extended along the TFL as it becomes the iliotibial (IT) band (see Figures 5-1 and 5-2).
Maintenance of the layers of muscle and their overlying fascia throughout this dissection
is important. Identifying and closing these layers at the end of the case can help to reduce
postoperative hematoma and incidence of muscle herniation through the fascia.
Directly underlying the IT band, the fascia of the vastus lateralis is identified. It is ideal
to try to keep as much of the vastus muscle belly together and avoid splitting it. Rather
than splitting the fibers, the muscle fibers can be elevated from the posterior muscular
septum with a Cobb elevator, which preserves the muscle’s anterior innervation. Use of an
Allis clamp on the vastus fascia can help facilitate separation of the muscle and septum.
The muscle belly is bluntly elevated up anteriorly as dissection continues posteriorly until
the femur is reached. Throughout this dissection, large perforating vessels to the vastus
may be encountered posteriorly and must be sequentially ligated with suture, coagulation,
or vessel clips. A large Bennett or Hohmann retractor can be placed around the anterior
shaft of the femur to retract the vastus muscle belly out of the field of view.
This dissection can be taken distally as needed, and can extend over the anterior knee
for access to the knee joint during total femur replacement. Direct access to the entire
femur can be achieved. If desired, the exposure can continue along the entire lower
extremity including the foot, allowing comprehensive access to the entire lower extrem-
ity for debridement of necrotizing fasciitis (Figure 5-4). Distal to the knee, the exposure
becomes the extensile anterolateral exposure of the leg9 and the extensile Böhler approach
to the ankle and foot along the axis of the fourth ray.10 Ultimately, the surgeon skilled
in using the extensile elements of the DAA has complete access from the inner table of

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74 Chapter 5
the pelvis to the toes for specific surgical contingencies. This type of extension is rarely
needed in clinical practice, but the principles of intermuscular dissection, recognition of
relevant anatomy, and minimizing soft tissue trauma are consistent with the advantages of
the DAA approach that surgeons are familiar with for use with primary THA.
In cases where a well-fixed femoral component requires revision via DAA, the entire
vastus lateralis muscle belly can be elevated from the lateral femur, and an extended tro-
chanteric osteotomy can be performed. The leg is internally rotated and the osteotomy
performed from posterior to anterior, preserving the digastric muscle attachments on the
trochanteric fragment, which is then moved anteriorly for access to the femoral canal. The
osteotomy is then repaired as usual with cerclage wires or a trochanteric plate.
Femoral Nerve
Retractors placed anteriorly and medially around the acetabulum should be between
the bone and the iliopsoas tendon to protect the femoral nerve. The femoral nerve lies
just anterior and medial to the psoas tendon. Aberrant retractor placement can result
in damage to the femoral nerve, particularly when the hip is in extension as this brings
the femoral nerve more posterior and directly on to the iliopsoas tendon.11 To avoid this
complication, ensure that the retractor is placed directly on bone and that the hip is flexed
sufficiently to remove the tension of the anterior soft tissues.
Lateral Femoral Cutaneous Nerve

The LFCN branches are at risk with the DAA as described in Chapter 1. In addition,
with proximal extension of the incision along the iliac crest, the main trunk of the LFCN
is at risk, often just medial to the ASIS. However, its position can vary and may be up
to 6 cm medial to the ASIS.8 Dissection in this area requires vigilance and patience to
protect the LFCN.
Greater Sciatic Notch

With continued posterior and superior extension, the greater sciatic notch can be
exposed. Careful placement of blunt retractors, use of elevators, and electrocautery around
the greater sciatic notch are necessary to protect the contents of the notch. Contents of
the greater sciatic notch include not only the sciatic nerve, but also the superior and infe-
rior gluteal neurovascular bundles, the recurrent pudendal neurovascular bundle, and the
posterior cutaneous nerves to the thigh. Meticulous retractor placement in the notch is
needed at all times, and blunt retractors are generally recommended. If any of the multiple
vascular bundles present are injured, it can be very challenging to obtain hemostasis due to
retraction of the vessels into the pelvis. Hip flexion brings the sciatic nerve closer to the
bony structures of the pelvis that increases the risk of injury and should be avoided during
the dissection and retraction.

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The extensile DAA exposure to the hip allows for direct access to the anterior and pos-
terior column, anterior and posterior acetabular walls, and to the entire femur. Anatomical
structures at risk can be protected with vigilance and patience. Most importantly, a thor-
ough understanding of the relevant anatomy are essential before embarking on the major
dissections described in this chapter. If the proximal iliofemoral exposure to the outer
table of the ilium is used, prophylaxis against heterotopic ossification prophylaxis should
be considered.
Manrique et al described the use of an approach very similar to that described in
this chapter as an option for revision hip arthroplasty.12 Although no specific data were
presented, the authors proposed this approach as a safe and effective means for revision
surgery. Nogler et al described the use of DAA for hip revision with varying degrees of
extensile measures being made depending on the pathology that is addressed.13 They
found reasonable success with 81 % of patients doing well at 1-year follow-up. Mast and
Laude presented a retrospective case series of 51 patients that underwent revision hip
arthroplasty through a DAA with relatively minor extensile measures.14 Kennon et al
reported their experience with 468 revision total hips, with very low complication rates
and successful treatment of femoral, acetabular, and both-component revisions.15 Details
on using extensile DAA for periacetabular osteotomy, acetabular component revision, and
femoral component revision surgery are addressed elsewhere in this text. Our goal was to
illustrate and discuss the anatomic rationale and safety principles of distal and proximal
extension of the DAA technique, when so required by individual patient needs.
Revision arthroplasty can be performed via the extensile DAA, which allows for
access to the entire acetabulum and femur.
The main trunk of the LFCN is at risk during the proximal extension and needs to
be identified and isolated to avoid injury.
The transition of the exposure to the lateral approach distally requires careful eleva-
tion of the vastus lateralis muscle fibers off of the posterior intermuscular septum to
minimize damage.
Osteotomy of the ASIS and AIIS can allow for complete exposure to the anterior
acetabulum and provide bone-to-bone healing.
Thorough familiarity with the anatomy, patience, and appropriate surgical tools and
assistance are essential for the extensile approach described in this chapter. While
this general principle applies to any surgical operation, the DAA extensile technique
requires recognition of specific anatomic relationships at different locations in the
pelvis and lower limb for safe execution.

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76 Chapter 5
2. Letournel E, Judet R. Fractures of the Acetabulum. Elson RA, ed. New York, NY: Springer; 1993.
3. Griffin DB, Beaulé PE, Matta JM. Safety and efficacy of the extended iliofemoral approach in the treat-
ment of complex fractures of the acetabulum. J Bone Joint Surg Br. 2005;87(10):1391-1396.
4. Johnson EE, Kay RM, Dorey FJ. Heterotopic ossification prophylaxis following operative treatment of
acetabular fracture. Clin Orthop Relat Res. 1994;(305):88-95.
5. Moed BR, Letournel E. Low-dose irradiation and indomethacin prevent heterotopic ossification after
acetabular fracture surgery. J Bone Joint Surg Br. 1994;76(6):895-900.
6. Kölbl O, Knelles D, Barthel T, Kraus U, Flentje M, Eulert J. Randomized trial comparing early postopera-
tive irradiation vs. the use of nonsteroidal anti-inflammatory drugs for prevention of heterotopic ossifica-
tion following prosthetic total hip replacement. Int J Radiat Oncol Biol Phys. 1997;39(5):961-966.
7. Kölbl O, Knelles D, Barthel T, Raunecker F, Flentje M, Eulert J. Preoperative irradiation versus the use of
nonsteroidal anti-inflammatory drugs for prevention of heterotopic ossification following total hip replace-
ment: the results of a randomized trial. Int J Radiat Oncol Biol Phys. 1998;42(2):397-401.
8. Majkrzak A, Johnston J, Kacey D, Zeller J. Variability of the lateral femoral cutaneous nerve: an anatomic
basis for planning safe surgical approaches. Clin Anat. 2010;23(3):304-311.
9. Rüedi TP, Buckley R, Moran CG, eds. AO Principles of Fracture Management. 2nd ed. New York, NY:
Thieme (Stuttgart); 2007.
10. Herscovici D, Jr, Sanders RW, Infante A, DiPasquale T. Böhler incision: an extensile anterolateral approach
to the foot and ankle. J Orthop Trauma 2000;14(6):429-432.
11. Bal BS, Crist BD. Anterior supine hip arthroplasty: primary surgical approach with extensile options. Video
J Orthopaedics. 2013;4080. www.vjortho.com/2013/08/anterior-supine-hip-arthroplasty-primary-surgical
-approach-with-extensile-options/. Published August, 2013. Accessed January 11, 2016.
Ann Transl Med. 2014;2(10):100.
13. Nogler M, Mayr E, Krismer M. The direct anterior approach to the hip revision. Oper Orthop Traumatol.
2012;24(2):153-164.
14. Mast NH, Laude F. Revision total hip arthroplasty performed through the Hueter interval. J Bone Joint
Surg Am. 2011;93(Suppl 2):143-148.
mally invasive technique. J Bone Joint Surg Am. 2004;86-A(Suppl 2):91-97.

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6
Anterior Supine Intermuscular
Total Hip Replacement
Keith R. Berend, MD; Nathan J. Turnbull, MD; Robert E. Howell, MD;

and Adolph V. Lombardi Jr, MD, FACS
Femoral exposure during direct anterior approach (DAA) total hip arthroplasty
(THA) can be accomplished without the aid of a specialized traction table.
Leg length and hip stability can readily be checked using our anterior supine inter-
muscular (ASI) technique.
Our data show that DAA THA performed with our method is safe and allows for
rapid patient recovery.
With successful outcomes, a relatively low complication rate, and the aging demo-
graphic of United States citizens, the demand for THA is expected to increase in the
future.1 These data, combined with concerns for quality, and lower health care costs, have
driven an interest in less invasive THA techniques. The DAA is a minimally invasive
technique for THA. The interner vous and intermuscular planes were described by Carl
Hueter in 18812 and the attendant techniques have since been replicated and modified.
Smith-Petersen3,4 described a variation in 1917 that involved detaching the tensor fascia
lata (TFL) from the iliac crest. In general, most modifications relate to the length and
location of the incision as well as manipulation of the TFL. In 1950, Judet 5 described
performing THA using DAA with a traction table. In 1980, Light and Keggi6 published
the first American experience using the same technique, without a traction table, substi-
tuting a bump under the sacrum and using accessory incisions when needed.7,8 Since these
pioneering efforts, other studies have shown DAA to be safe and effective in THA.9–27

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78 Chapter 6
At the start of the 21st century, the DAA using a specialized traction table gained
popularity through published studies by Siguier et al.25 and Matta et al19 These tables
(eg, Hana [Mizuho OSI]) can help facilitate hip extension, external rotation, and adduc-
tion for femoral exposure. However, special tables are expensive, lengthen operative time
due to set up time and positioning, can complicate checking hip range of motion and
stability, require a circulating nurse to position the leg during the surgery, and can lead to
equipment-related fractures.19 As a result, alternative DAA techniques have evolved that
do not need such tables.
In this chapter we describe our technique of performing the DAA in the supine posi-
tion with both legs draped free on a standard radiolucent operative table with the use of
a table-mounted femoral elevator. The advantages of using this ASI technique include a
simple set-up and ease of checking hip stability and leg lengths. Since we implemented the
technique for primary THAs in 2007, it has proven safe, with accelerated recovery over
our earlier less-invasive direct lateral approach (LIDL).12 In 258 patients who underwent
primary THA via the ASI approach, vs 372 via the LIDL, more ASI patients were dis-
charged directly to home (87% vs 79%, p = 0.04). Further, at 6 weeks postoperatively, ASI
patients had higher mean lower extremity activity scales (8.6 vs 8.0; p = 0.03).
We use the ASI technique for primary THA and for revision surgery to address
polyethylene wear, metal-on-metal bearing complications, recurrent dislocation, aseptic
loosening of the acetabular component, loosening of the femoral component, and peri-
prosthetic femoral fractures. Between June 2007 and April 2015, 1006 patients underwent
1164 revision THA operations at our institution. Of these, 12% (140 of 1164) were done
via the ASI approach while 88% (1021 of 1164) were done via the direct lateral approach.
A posterior approach was used in only 3 patients, all of whom had undergone prior arthro-
plasty done elsewhere and had existing posterior-placed incisions.
The specialized equipment needed for the ASI technique is summarized in Table 6-1.
The patient is supine on a standard radiolucent operating table (Steris 3080-R Amsco
Surgical Table [Steris Corporation]) with the extender at the foot of the bed. The pubic
symphysis is aligned over the break in the table. This allows appropriate hyperextension of
the hip during femoral exposure and preparation. A non-sterile plastic U-drape is placed
around the operative limb (Figure 6-1). The operative limb is prepped in its entirety just
proximal to the iliac crest while the contralateral limb is only prepped up to the groin. Two
sterile plastic U-drapes are placed circumferentially around the operative limb. Both legs
are covered by impervious sterile stockinettes and this is followed with a bilateral lower
extremity drape (Item: SPT-8630A [Medline Industries, Inc]).

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Anterior Supine Intermuscular Total Hip Replacement 79

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80 Chapter 6
Figure 6-1. The patient is positioned supine on a standard radiolucent

operating table with extender (Steris 3080-R Amsco surgical table, Steris
Corporation, Mentor, OH), and the pubic symphysis is aligned over the break
in the table.
The drape is cut on the operative side to uncover the anterior superior iliac spine (ASIS)
and anterior thigh. A sterile iodoform drape is folded on the non-sticky side and applied
posteriorly to seal off the buttocks, posterior thigh, and groin on the operative side. A sec-
ond sterile iodoform drape is placed anteriorly to allow for a secure seal and free mobility
of the limb (Figure 6-2). Three cotton stockinettes are applied to the operative leg.
The ASIS is identified and used as a reference for positioning of the skin incision.
Using the skin marker, a line is drawn from the ASIS to the center of the patella. The
incision commences 2 finger breadths distal and 2 finger breadths lateral to the ASIS and
is made parallel to the marked line for 8 to 10 cm distally. Fluoroscopic guidance is used
to draw a line along the superior aspect of the femoral neck. This line should bisect the
previously marked incision (Figure 6-3).
The incision is carried down through the subcutaneous tissue to the fascia covering the
TFL. The muscle deep to the TFL gives it a distinguishing purple hue as opposed to the
whiter fascia covering the sartorius medially (Figure 6-4). Multiple perforating vessels
going from lateral to medial into the fascia covering the TFL provide another characteris-
tic feature of the direct anterior interval. Once identified, the fascia is incised in line with
the incision. A pickup can then be used to grasp the medial side of the cut fascia while
blunt finger dissection is used to separate the muscle from the fascia.
A right-angle retractor is used to retract the TFL laterally while the rectus is retracted
medially with an additional right-angle retractor. The circumflex vessels are then identi-
fied by piercing the deep fascia in the distal portion of the exposure with a tonsil and then
using blunt finger dissection to split the fascia proximally (Figure 6-5). The finger will

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Figure 6-2. With the drape cut on the operative side to uncover the ASIS and
anterior thigh, a sterile iodoform drape is folded on the non-sticky side and
applied posteriorly to seal off the buttocks, posterior thigh, and groin on the
operative side. A second sterile iodoform drape is placed anteriorly to allow
for a secure seal and free mobility of the limb.
then encounter resistance at the level of the circumflex vessels. The vessels can then be
coagulated or ligated. The remaining deep fascia can then be divided using electrocautery.
Once the proximal deep fascia is split, the #7 retractor is placed outside the capsule over
the superior femoral neck. The #6 retractor is then used to tease the indirect or “reflected”
head of the rectus femoris off the anterior capsule and then is slid deep to it around the
inferior femoral neck. The #9 retractor is then placed deep to the rectus tendon on the
anterior acetabular rim. The anterior capsule should be exposed at this point. Precapsular
fat can be removed using a rongeur. A thorough anterior capsulectomy is then done using
the electrocautery, and the #6 and #7 retractors are moved intracapsularly around the
femoral neck.
With the femoral neck exposed, the saw blade is placed at the templated neck resection
level and checked fluoroscopically (Figure 6-6). Once the neck resection level is con-
firmed, the first of 2 osteotomies is completed. A second more proximal osteotomy is then
made and the intervening napkin ring of bone is removed using a threaded Steinmann
pin. The remaining femoral head is then removed using the same technique. Care must be
taken to protect the TFL muscle belly both from the retractors during exposure and from
the sharp bone edges on the cut surface of the femoral head during extraction.

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82 Chapter 6
Figure 6-3. (A) The ASIS is identified and used as a reference for positioning of
the skin incision. Using the skin marker, a line is drawn from the ASIS to the
center of the patella. The incision commences 2 finger breadths distal and
2 finger breadths lateral to the ASIS and is made parallel to a line drawn from
the ASIS to the center of the patella for 8 to 10 cm distally. (B) Fluoroscopic
guidance is used to check positioning and draw a line along the superior
aspect of the femoral neck. This line should bisect the previously marked
incision.

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Figure 6-4. The incision is carried down through the subcutaneous tissue to
the fascia covering the TFL, which has a distinguishing purple hue due to the
underlying muscle, as opposed to the whiter fascia covering the sartorius
medially. The fascia is incised in line with the incision using blunt finger dis-
section is to separate the muscle from the fascia.
Figure 6-5. The TFL is retracted laterally while the rectus is retracted medially
using right angle retractors. The circumflex vessels are identified by pierc-
ing the deep fascia distally with a tonsil and using blunt finger dissection to
split the fascia proximally until resistance is encountered at the level of the
circumflex vessels. The vessels are coagulated or ligated. The remaining deep
fascia is then divided using electrocautery.

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84 Chapter 6
Figure 6-6. (A) With the femoral neck exposed, the saw blade is placed at the
resection level determined by preoperative templating. (B) The position of
the saw blade is checked with fluoroscopy.

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With the femoral head and neck removed, the #6 retractor is placed over the anterior
wall of the acetabulum retracting the rectus femoris muscle. The #7 retractor is placed
superolaterally on the ilium, while the #8 retractor is placed inferiorly behind the posterior
wall of the acetabulum. The inferior capsule may be incised to enhance exposure but one
must be careful not to damage the immediately deep iliopsoas tendon. Any remaining
acetabular labrum and soft tissue in the cotyloid fossa is sharply removed.
The initial reamer is one size smaller than the templated cup size. Reaming is then
done under fluoroscopic guidance to allow for appropriate cup depth and position (Figure
6-7). Using fluoroscopic guidance, the corresponding sized cup is impacted into place.
Screws may be placed in the cup for additional fixation. The final polyethylene liner is
then impacted into the cup.
The femoral hook attachment for the table-mounted femoral elevator is placed around
the femur, from lateral to medial, and proximal to the gluteus maximus sling. The well
leg is placed on a padded Mayo stand while the foot of the table is lowered to approxi-
mately 45 degrees combined with 15 degrees of Trendelenburg to allow for appropriate
hip hyperextension.
With the table appropriately positioned, the table-mounted femoral elevator is secured
and the femoral hook is attached. The operative hip is then adducted and extended to
place gentle tension on the capsule. The #8 retractor is placed medial to the cut femoral
neck and the #5 retractor is placed around the anterosuperior aspect of the greater tro-
chanter. Electrocautery is then used to tease the capsule off the inner aspect of the greater
trochanter from anterosuperior to posterior, while the hip is gently adducted, extended,
and externally rotated to deliver the femoral neck into the wound (Figure 6-8). When the
release is complete, the operative leg should end up in a lazy figure-four position posi-
tioned under the well leg and between the assistant’s legs (Figure 6-9). The table-mounted
femoral elevator is then used to lift the femoral neck out of the wound.
The lateral aspect of the femoral neck is used as the starting point to open the canal
with the box osteotome. A femoral starter rasp is then used to confirm the longitudinal
axis of the femur. The femur is then sequentially broached to an appropriate sized femo-
ral implant. With the femoral broach in place, any remaining femoral neck is removed
using the calcar planar. The hip is then trialed starting with the shortest available neck
length. The operative leg is brought out of the figure-4 position while removing the now
contaminated outer stockinette. This must be done anytime the leg is brought out of the

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86 Chapter 6
Figure 6-7. (A) In most patients acetabular preparation is done with a single
reamer that is one size smaller than the templated cup size. (B) Reaming is
performed under fluoroscopic guidance to allow for appropriate cup depth
and position.

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Figure 6-8. For femoral preparation, the table is repositioned, the bone eleva-
tor is secured to the table, and the hook is positioned around the femoral
shaft. The operative hip is adducted and extended to place gentle tension
on the capsule, and additional retractors are placed. The capsule is teased off
the inner aspect of the greater trochanter from anterosuperior to posterior
using electrocautery, while the hip is gently adducted, extended, and exter-
nally rotated to deliver the femoral neck into the wound.
Figure 6-9. When capsular release is complete, the operative leg is maneu-
vered into a lazy figure-4 position under the patient’s well leg and between
the assistant’s legs. The femoral neck is lifted out of the wound using the
table-mounted elevator.

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88 Chapter 6
Figure 6-10. Leg length equality can be easily assessed using direct compari-
son.
figure-4 position. The hip is reduced using internal rotation and traction with a hip skid
placed deep to the rectus femoris.
Hip stability is checked dynamically with combined hip external rotation and exten-
sion. Leg length can be checked using direct comparison to the well leg (Figure 6-10) or
fluoroscopy. To check the leg length radiographically, an alignment rod is placed at the
level of the ischial tuberosities on an appropriately rotated anteroposterior image of the
pelvis. Leg length can then be assessed by examining the relationship between the align-
ment rod and the 2 lesser trochanters. At this point, the final stem size and neck length
are selected.
The hip is dislocated using a bone hook combined with hip extension and external
rotation. The retractors are placed back in the original position with the leg in the
figure-4 position. The femoral trial is removed and the final femoral component is then
placed. The final head component can be placed at this time or the hip can be retrialed to
verify neck length before selecting the final component. After the final components are
implanted, the operating table is returned to the flat position, the final cotton stockinette
is removed from the leg, and a new sterile impervious split drape is placed over the table
for closure.
After thorough irrigation of the hip joint, 1 g vancomycin powder is placed deep in
the wound. The TFL and subcutaneous tissue is then closed using 0-0 knotless, barbed
monofilament suture. The skin is closed in a subcuticular fashion using 2-0 knotless,
barbed monofilament suture and cyanoacrylate tissue adhesive. The incision is dressed
with a clear adhesive dressing.

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Patients are discharged from the hospital or our outpatient surgery center when they
have accomplished physical therapy goals. We use a rapid recovery protocol, 28 and approx-
imately 90% of patients are discharged on the day of or the day after surgery. They may
shower immediately and can remove their clear dressing in 3 to 5 days. A walker is used
for assistance with ambulation for approximately 2 weeks and then they may transition to
a cane for 2 more weeks. At that point, they may ambulate without any assistance.
Bergin et al13 measured creatine kinase levels following THA with either the DAA or
the mini-posterior approach, and the levels were 5.5 times higher after the mini-posterior
approach. Furthermore, Bremer et al14 used MRI scans to evaluate soft tissue damage to
the abductor musculature of patients 1 year after a DAA-based or a transgluteal-approach
THA. The DAA group had less frequent and less pronounced detachment of the abduc-
tor insertion, partial tears and tendonitis of gluteus medius and minimus, the presence of
peritrochanteric bursal fluid, and fatty atrophy of gluteus medius and minimus.
Using a technique similar to ours, Goebel et al,15 in a retrospective study, reported
that patients treated with ASI THA had less postoperative pain, required less pain medi-
cation, had a shorter length of hospital stay, and had a quicker time to full recovery than
those treated with more traditional approaches. Restrepo et al 23 compared the direct
lateral approach and the DAA THA performed on a regular operating table in a prospec-
tive, randomized study. In their technique, the authors describe incising the reflected
portion of the rectus, which is the only modification of the technique described in this
chapter. Using numerous validated outcome measures, the DAA patients had signifi-
cantly better improvements at 6 weeks, 6 months, and 1 year. At 2 years, results were
the same. Lastly, Barrett et al 27 published another prospective, randomized study. They
performed the DAA on a fracture table, and found that patients required less postopera-
tive pain medication, half-day shorter hospitalization, and had higher functional scores
at 1 and 3 months than patients undergoing a posterolateral approach. These functional
differences disappeared at 1 year. They also found less variability in acetabular cup ante-
version in the DAA THA group.
In our experience, THA done with the DAA technique as described here showed
improved outcomes when compared to our legacy LIDL approach, described earlier.12
The DAA patients had a higher rate of hospital discharge directly to home as well as
improved lower-extremity activity scale scores at 6 weeks. In addition, the complication
rates did not differ significantly between groups. In another paper, involving 1035 con-
secutive ASI THAs, we focused on the complication and reoperation rate.29 A majority
(95.3%) were primary THA cases, followed by revision procedures (4.3%), resurfacing
arthroplasties (0.2%), and conversions of failed open reduction and internal fixation
for femoral fractures (0.2%). The overall transfusion rate was 5%. There were 3 (0.3%)
intraoperative calcar cracks and 1 canal (0.1%) perforation, all of which were treated with
cerclage cables. Six (0.6%) wound complications required debridement, 4 (0.4%) lateral
femoral cutaneous nerve paresthesia had not resolved at 12 months postoperatively, and
there was 1 (0.1%) femoral nerve palsy. At up to 56 months after surgery, there were
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90 Chapter 6
25 revisions (2.4%). The most common reason for revision was periprosthetic femoral
fracture occurring 9 times (0.9%), followed by metal-on-metal bearing complications that
occurred in 5 patients (0.5%), dislocation in 4 patients (0.4%), cup and stem loosening in
2 patients (0.2%), isolated cup loosening in 2 patients (0.2%), and 1 incident each of infec-
tion, cup malposition, and femoral subsidence (0.1%).
Although surgeons may hesitate to adopt DAA THA because of the learning curve,
we have published data on our first 182 ASI THA cases.24 After 6 months and 37 cases,
more than 50% of all primary THAs were performed by the ASI approach. There was
also a drop and then a plateau in operating times (99 minutes vs 69 minutes, p < 0.05) and
intraoperative blood loss at 6 months. There was no difference in the overall complication
rate (ASI group: 5.4%, LIDL group: 10.4%) or the clinically significant complication rate
(ASI group: 2.2%, LIDL group: 7.8%) during this time between patients undergoing the
ASI vs the LIDL approach.
ASI DAA THA is a safe procedure with a proven recovery advantage for the patient.
Specialized retractors are needed for the ASI DAA technique; a specialized traction
table is not.
The femoral exposure depends on proper dissection of the proximal/superior capsule
from the trochanter.
The learning curve and complication rate are well described and can be overcome.
Additional research is necessary to compare various DAA techniques and assess the
long-term outcomes of these approaches.
1. Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United
States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780.
2009;40(3):311-320.
3. Smith-Petersen MN. A new supra-articular subperiosteal approach to the hip joint. Am J Orthop Surg.
1917;15:593.
4. Smith-Petersen MN. Approach to and exposure of the hip joint for mold arthroplasty. J Bone Joint Surg.
1949;31A:40.
5. Judet J, Judet R. The use of an artificial femoral head for arthroplasty of the hip joint. J Bone Joint Surg.
1950;32B:166.
6. Light TR, Keggi KJ. Anterior approach to hip arthroplasty. Clin Orthop. 1980;152:255.
7. Kennon RE, Keggi JM, Wetmore RS, et al. Total hip arthroplasty through a minimally invasive anterior
surgical approach. J Bone Joint Surg Am. 2003;85(Suppl 4):39-48.
9. Alecci V, Valente M, Crucil M, et al. Comparison of primary total hip replacements performed with a
direct anterior approach versus the standard lateral approach: perioperative findings. J Orthop Traumatol.
2011;12(3):123-129.
10. Bhandari M, Matta JM, Dodgin D, et al. Outcomes following the single-incision anterior approach to total
hip arthroplasty: a multicenter observational study. Orthop Clin North Am. 2009;40(3):329-342.

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11. Bender B, Nogler M, Hozack WJ. Direct anterior approach for total hip arthroplasty. Orthop Clin North
Am. 2009;40(3):321-328.
12. Berend KR, Lombardi AV Jr, Seng BE, et al. Enhanced early outcomes with the anterior supine intermus-
cular approach in primary total hip arthroplasty. J Bone Joint Surg Am. 2009;91(Suppl 6):107-120.
13. Bergin PF, Doppelt JD, Kephart CJ, et al. Comparison of minimally invasive direct anterior versus posterior
total hip arthroplasty based on inflammation and muscle damage markers. J Bone Joint Surg Am. 2011;
93(15):1392-1398.
after total hip replacement: comparison between the direct anterior and the transgluteal approaches. J Bone
Joint Surg Br. 2011;93(7):886-889.
15. Goebel S, Steinert AF, Schillinger J, et al. Reduced postoperative pain in total hip arthroplasty after
minimaly-invasive anterior approach. Int Orthop. 2012;36 (3):491-498.
16. Horne PH, Olson SA. Direct anterior approach for total hip arthroplasty using the fracture table. Curr Rev
Musculoskelet Med. 2011; 4(3):139-145.
table. J Arthroplasty. 2008;23(7):64-68.
Orthopedics. 2008;31(12):pii.
20. Moskal JT. Anterior approach in THA improves outcomes. Affirms. Orthopedics. 2011;34(9):e456-e458.
21. Nakata K, Nishikawa M, Yamamoto K, et al. A clinical comparative study of the direct anterior with mini-
posterior approach: two consecutive series. J Arthroplasty. 2009;24(5):698-704.
22. Oinuma K, Eingartner C, Saito Y, at al. Total hip arthroplasty by a minimally invasive, direct anterior
approach. Oper Orthop Traumatol. 2007;19(3):310-326.
23. Restrepo C, Parvizi J, Pour AE, et al. Prospective randomized study of two surgical approaches for total hip
arthroplasty. J Arthroplasty. 2010;25(5):671-679.
24. Seng BE, Berend KR, Ajluni AF, et al. Anterior-supine minimally invasive total hip arthroplasty: defining
the learning curve. Orthop Clin North Am. 2009;40(3):343-350.
25. Siguier T, Siguier M, Brumpt B. Mini-incision anterior approach does not increase dislocation rate: a study
of 1037 total hip replacements. Clin Orthop Relat Res. 2004;426:164-173.
26. Yerasimides JG. Use of the Fitmore hip stem bone-preserving system for the minimally invasive anterior-
supine approach in hip replacement. Am J Orthop. 2010;39(10):13-16.
28. Berend KR, Lombardi AV Jr, Mallory TH. Rapid recovery protocol for peri-operative care of total hip and
total knee arthroplasty patients. Surg Technol Int. 2004;13:239-247.
29. Berend KR, Kavolus JJ, Morris M, et al. Primary and revision anterior supine total hip arthroplasty: an
analysis of complications and reoperations. Instr Course Lect. 2013;62:251-263.


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Tips and Tricks for
7
Overcoming the
Learning Curve
Benjamin Domb, MD and Timothy Jackson, MD
The learning curve associated with direct anterior approach (DAA) total hip arthro-
plasty (THA) is related to complications that should be recognized and that can be
avoided by careful planning and execution.
Exposure is the most difficult part of DAA THA, and successful exposure is espe-
cially critical to the success of the operation and prevention of complications.
Recognizing key steps along the learning curve will allow surgeons to learn DAA
THA in a safe, efficient manner.
This purpose of this chapter is to summarize helpful hints to help navigate the steep
learning curve of DAA THA. The learning curve for DAA THA is that phase of sur-
geon learning when complications occur at a higher incidence; the volume of cases in
the learning curve may be as low as 20 cases, or as high as 100 cases before proficiency
is achieved.1,2 During the learning curve, a surgeon can expect longer operative times,
more blood loss, and complications such as calcar fracture, greater trochanter fracture,
and cortical perforations.1-4 The techniques discussed here are meant to serve as a series
of important, practical tips and tricks to navigate the learning curve so that DAA THA
can be performed in a safe, reproducible manner.


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94 Chapter 7
Figure 7-1. Schematic of the position of equipment in the operating room.
Marked differences exist in technical difficulty when performing DAA THA in

larger, heavier male patients, as opposed to thin females. Since muscles are neither cut
nor released during surgery, judicious and careful retraction throughout the procedure is
necessary. A male with tight, large muscles will require more retraction with less visual-
ization than a female with smaller muscles. This was confirmed in a study by Frye et al
that showed increased muscle damage with increasing BMI and male gender.5 Likewise,
acetabular reaming and cup placement require more force and judgment to ensure accu-
racy in patients with sclerotic, tough bone.6 Finally, in large patients with tight hip con-
tractures, femoral exposure and broaching is very difficult, with increased risk of canal
perforation and varus stem placement.
Proper patient positioning includes C-arm position relative to table position, patient
orientation on the table, and positioning of operating room personnel (Figure 7-1). These
concepts hold true regardless of the specific equipment used in any operating room for
DAA THA. The table should be positioned in the room such that there is room for the
designated table operator to easily manipulate the leg during the case. The fluoroscopy
C-arm should be perpendicular to the table so that images can be quickly obtained with
a simple in/out movement of the boom. The fluoroscopy monitor should be positioned
across the patient toward the foot.

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Tips and Tricks for Overcoming the Direct Anterior Approach Learning Curve 95
Figure 7-2. Anteroposterior radiograph showing neutral position. The coc-

cygeal tip to symphysis (line), obturator foramina symmetry, and teardrop
(asterisk) can be used to determine malrotation and excessive tilt.
As the patient is positioned, the pelvis can tilt forward. To avoid error, table and/or
C-arm position may need to be adjusted during the case. Using the coccyx, pubis sym-
physis, obturator foramina, tear drop, and ischial spine as landmarks can help identify
rotational or tilt discrepancies (Figure 7-2). As the surgery progresses, the patient will
tend to tilt to the operative side, therefore table and/or C-arm adjustments should be made
accordingly. The arm on the operative side can be either abducted or placed over the chest
to allow for more room for an assistant. The feet should be in neutral alignment to slight
internal rotation.
The DAA can be performed through a small incision, especially in thinner, smaller
patients. The longitudinal incision generally starts 2 cm lateral and 1 cm distal to the
anterior superior iliac spine (ASIS; Figure 7-3). A carefully placed incision can allow for
smaller overall incision length. For reaming of the acetabulum, the distal part of the inci-
sion will be pulled distally and compressed medially. For femoral exposure and broaching,
the proximal aspect of the incision will be placed under tension.
Avoid medial placement of the incision. Even in larger patients, the muscular interval
between the rectus and tensor fascia lata (TFL) can often be palpated. The skin incision
should be placed 2 to 4 cm lateral to this interval in a slightly oblique fashion. Do not hesi-
tate to extend the incision to relax tension on the wound, improve exposure, or facilitate
the surgery. Ultimately, the length of the incision is less crucial to the result than how the
tissues are managed beneath it.

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96 Chapter 7
Figure 7-3. The ASIS is drawn on the skin. The incision begins 2 cm lateral
and 1 cm distal to the ASIS. The incision proceeds distally in an oblique fash-
ion, parallel but lateral to the interval between the TFL and rectus femoris. In
small patients, a 3-inch incision is usually all that is needed.
While the decision to preserve or excise the capsule is controversial, initial preservation
and careful dissection of the capsule during the exposure can help along the way. Initial
capsule exposure is done by placement of blunt cobra retractors superior to the femoral
neck (under the abductors) and inferior to the femoral neck (under the rectus femoris).
Sharp-point retractors can be used but are not necessary and, with the risk of an aberrant
retractor placed in the femoral artery, are to be discouraged.
The indirect head of the rectus can be seen extending superolaterally, just superficial to
the capsule. This reflected tendon is incised longitudinally in line with the rectus fibers to
allow for improved anterior exposure of the acetabulum and should be repaired upon com-
pletion of surgery. After identification of the capsule, a longitudinal cut into the capsule
is performed using electrocautery, followed by extension of this capsulotomy in an H-type
fashion parallel to the acetabular labrum and just off the insertion into the femur. Make
sure to release the inferomedial capsule from the femur; this step will improve visualiza-
tion. The medial and lateral capsular limbs are tagged with a heavy suture. The tagging
suture on the medial side can be used as a means to expose the soft tissues for placement
of acetabular reamers without having to place retractors each time you insert a reamer.
The lateral tagging suture is used as a retractor as well and can be used during femoral
exposure to identify your plane between the capsule and overlying abductors. Depending
on preference, these sutures can be tied together to repair the original capsulotomy, or
removed with the capsule if a capsulectomy is preferred.
The femoral neck cut can be guided by anatomic landmarks and most surgeons will
be comfortable with creating a cut based on preoperative templating and anatomic

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landmarks. Most instrument sets have a guide that can be placed over the proximal aspect
of the femur and used to plan the angle of the neck cut. This basicervical cut is often a
45-degree angle related to the femoral shaft anatomic axis. The height of the cut can be
determined by measuring the distance from the lesser trochanter, which can be palpated,
but not as easily visualized, for direct measurements.
Many experienced DAA surgeons also advocate for a second in-situ osteotomy in the
subcapital position at the femoral head-neck junction. This cut allows a napkin-ring of
neck bone to be removed and can make femoral head removal easier. A common mistake
is to make these 2 cuts (subcapital and basicervical) too close together, thereby removing
a very small ring of femoral neck. If used, the 2-cut technique should allow at least 1 cm
of bone to be removed to facilitate ease of exposure and head removal.
Fluoroscopic guidance can be used to mark out the position of the cut (Figure 7-4).
With appropriate positioning of the C-arm, place the cautery tip in the presumed loca-
tion of the neck cut. Angle the long cautery tip in line with the cut. Use fluoroscopy to
dynamically adjust the height and angle of the cut. When the correct height and angle are
obtained, mark the line for the cut using the electrocautery. After removal of the head,
if you have difficulty with inserting acetabular reamers, stop and recheck the level of the
neck cut on fluoroscopy. If needed, address appropriately by creating an additional basi-
cervical neck resection to facilitate acetabular exposure.
Once the femoral head is removed, 2 or 3 retractors are used for acetabular exposure.
In the right hip, for example, the first retractor is placed anteriorly, aiming the tip of the
retractor medially and placing in the 4 o’clock position just medial to the iliopsoas notch.
A sharp retractor is placed posteriorly at the 9 o’clock position. An additional pointed
retractor can be placed anterosuperiorly for labral resection (Figure 7-5, showing left hip).
With this exposure, the remaining ligamentum teres and labrum can be removed before
reaming. The transverse acetabular ligament and cotyloid fossa should be exposed and
clearly visible as reference landmarks prior to initiating acetabular instrumentation.
The leg should be held in approximately 30 to 40 degrees of external rotation with

traction applied to maximize the working space for instrumentation of the acetabulum.
The inferior capsule can obstruct instrument placement. Often a simple capsular cut, or
episiotomy, will relax this tissue. Most surgeons prefer to ream inferomedially at first with
a smaller reamer (Figure 7-6A). This helps identify the true medial wall of the medial
acetabulum. Progressively larger reamers are inserted, assuring that the newer reamer gets
as far medially as the previous reamer and then adjusted to ream superiorly (Figure 7-6B).
A problem that can arise is not getting the reamer completely in medially but reaming
superiorly. This creates a double cavity and can affect cup stability. This can be avoided
by a smooth, continuous transition from the medially directed reaming to superior ream-
ing. Superior reaming continues until the subchondral sclerotic line seen on preopera-
tive imaging is completely removed to assure there is not a cortical fit superiorly. Using

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Figure 7-4. A neck cut using fluoroscopy. The cautery is placed in line with
the expected cut and an image is taken. (A) An example of a high neck cut
with improper angle is shown. (B) Image of a more appropriate neck cut that
matches that of preoperative templating. The superior part of the neck cut
extends into the insertion point of the femur broaches.
even-numbered reamers can help as these are generally used less frequently and may be
sharper to penetrate thick sclerotic bone. Additionally, using offset reamers in heavier
patients and employing fresh batteries to drive the reamer motor can aid in acetabular
preparation.

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Figure 7-5. A sharp-tipped cobra retractor is placed on the anterior acetabular

rim, penetrating the capsule. Another sharp retractor is placed posterior to
the labrum. There is usually a sulcus between the capsule and labrum poste-
riorly so penetrating the capsule is not typically necessary. The labrum can
be visualized deep in the wound, just beneath the anterior (top) retractor.
As with using offset reamer handles, offset impactor/insertion handles can help cup
placement. Ensure that all soft tissue is clear, and use the anterior capsular stitch for
retraction and exposure. A posterior retractor is placed behind the acetabulum. If the
incision is small, a retractor and the cup may not fit simultaneously. In this case, traction
on the anterior capsular stitch and a simple 2-finger posterior retraction of the TFL can
expose the acetabulum. Once the cup is seated in the socket medially, while holding this
pressure medially, redirect the inserter to the appropriate inclination and anteversion. Use
fluoroscopy to confirm the tilt and version of the cup before beginning cup impaction
and seating.
Femoral exposure during DAA THA can be difficult. Maximally externally rotate the
leg, avoiding excessive force. Pass the femoral hook laterally around the proximal femur
and hold manually or attach to the Hana (Mizuho OSI) table to help elevate the femur.
The leg can then be extended to the floor and adducted underneath the contralateral leg.
The hook is attached to the elevating device and lifting mechanism is activated to hold
the femoral position obtained by manual lifting.
The first retractor placed is on the posterior cortex of the femoral neck to lateralize
the femur. The posterior capsule can be further exposed and released by placing a blunt
cobra retractor between the capsule and the abductors. While maintaining traction on the
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Figure 7-6. Acetabular reaming. (A) The small- diameter reamer is placed into
the acetabulum and is initially aimed medial. Reaming is done at this angle
to assure the cup is as medial as templated. (B) Sequentially larger reamers
are inserted and directed superiorly to the same position as the cup will be
inserted. Inclination and anteversion are noted and adjustments made under
fluoroscopic guidance.

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tagging sutures, additional release of capsule from the acetabulum and posterior part of
the proximal femur is done with electrocautery. Sometimes this will result in a palpable
release. Once adequate soft tissue is removed from the entry point and the posterior cap-
sule is adequately released, remove the cobra retractor and place a long pointed retractor
lateral to the greater trochanter. The trochanter is now oriented posteriorly. This retractor
stabs through the abductor muscle/tendon unit, thus, a pointed instrument is necessary.
With gentle but firm pressure on this retractor, the proximal femur entry point should be
elevated enough to begin broaching. Always lateralize the entry point and proximal bone
in order to prevent varus stem placement (Figure 7-7).
When using the Hana table, after implants are in place, the hip can be reduced with
close cooperation of the assistant manipulating the table. If the table attachment was
used to lift the femur, lower this to release the hook first. From the extended, externally
rotated, adducted position, have the table operator elevate to neutral with maintenance of
external rotation. With a head pusher to help guide the hip in, have the table operator pull
gross traction and internally rotate to reduce the hip. If there is difficulty, do not force hip
reduction. If the hip cannot be reduced, avoid releasing traction with continued internal
rotation; this can place the trial head in the pelvis. To dislocate, place a bone hook around
the trial neck while the assistant applies traction and external rotation.
Despite the learning curve related to DAA THA, the previously discussed steps can
ease execution, while the surgeon builds confidence. These pointers are offered in hopes
of making the operation safe and consistent early on. The most important tip is to avoid
obese and muscular patients during the early part of the curve as the surgical exposure and
associated releases will be inherently more difficult in this population.
The learning curve for the DAA approach to THA is associated with increased blood
loss, longer operative times, and a higher risk of complications. Focusing on the expo-
sure steps can help reduce the risk of complications during the learning curve.
Before attempting live surgery, gain experience with cadavers and seek specialized
training from surgeon mentors.
There are multiple steps that can critically affect the execution of DAA THA, such
as patient positioning, use of fluoroscopy, capsule management, and exposure to the
acetabulum and femur.

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B
Figure 7-7. The proximal femur lifting hook is placed around the proximal
femur while the leg is in the neutral position prior to external rotation and
extension. The leg is then externally rotated approximately 120 degrees,
extended, and adducted. (A) The femur is lifted by the hook and attached to
the table attachment. Next, a Mueller-type retractor is carefully placed on the
posterior cortex. (B) The last retractor is a long single pointed device placed
lateral to the greater trochanter, which is now oriented posterior.
Femoral exposure requires posterolateral capsule release from the femur. A visual and
palpable release may occur if tension is placed on the femur while performing capsule
release. Do not begin femoral broaching until adequate exposure is ensured.
Start with thin, flexible patients early on to ease exposure to the acetabulum and
femur.

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1. Goytia RN, Jones LC, Hungerford MW. Learning curve for the anterior approach total hip arthroplasty.
J Surg Orthop Adv. 2012;21(2):78-83.
Orthopedics. 2008;31(12 Suppl 2):pii.
3. Lee G-C, Marconi D. Complications following direct anterior hip procedures: costs to both patients and
surgeons. Arthroplasty. 2015;30(98):98-107
4. Barnett SL, Peters DJ, Hamilton WB, Ziran NM, Gorab RS, Matta JM. Is the anterior approach safe? Early
complication rate associated with 5090 consecutive primary total hip arthroplasty procedures performed
using the anterior approach. Arthroplasty www.sciencedirect.com/science/article/pii/S0883540315006075.
Published July 11, 2015. Accessed February 29, 2016.
5. Frye BM, Berend KR, Lombardi AV, Jr, Morris MJ, Adams JB. Do sex and BMI predict or does stem
design prevent muscle damage in anterior supine minimally invasive THA? Clin Orthop Relat Res.
2015;473(2):632-638.
6. Hallert O, Li Y, Brismar H, Lindgren U. The direct anterior approach: initial experience of a minimally
invasive technique for total hip arthroplasty. J Orthop Surg Res. 2012;7:17.

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Section II
Intermediate Direct Anterior
Approach Techniques

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8
Understanding the Risks
in New Technologies
B. Sonny Bal, MD, JD, MBA and Lawrence Brenner, JD
Understand the professional risk exposure that is associated with the learning and
execution of new technologies, specifically, new surgical techniques.
Understand how surgeon conduct, as it relates to new learning, also implicates the
hospital, through legal principles and judicial reasoning.
Understand strategies that can be executed at the professional and at the enterprise
level, to reduce and mitigate legal risk associated with the introduction of new tech-
nologies, such as direct anterior approach (DAA) total hip arthroplasty (THA).
In their 2013 New England Journal of Medicine article, authors Birkmeyer et al1 studied
bariatric surgeons to see if there was a relationship between their proficiency and skill
vs their clinical outcomes. Twenty bariatric surgeons were enrolled in the study. Video
recordings were made of each surgeon performing a laparoscopic gastric bypass operation.
Videos were then examined by independent, blinded peers who rated surgeon technical
skills on a standard rating scale. Authors then looked for a relationship between surgeon
skill scores, and risk-adjusted complication rates using a prospective, clinical-outcomes
registry that had more than 10,000 patients. Not surprisingly, surgeons in the bottom
quartile of surgical skills had a longer duration of surgery, more complications, higher
rates of reoperation and patient readmissions, and increased patient mortality, when com-
pared to the top quartile of surgeons in the study.
While peer rating of surgical skills may quantify a surgeon’s proficiency, a different
issue arises when a new skill, such as DAA THA, is introduced to surgeons. A generally

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accepted standard for a new surgery technique has been its reproducibility (ie, the abil-
ity of other surgeons to learn and safely reproduce the operation in their practices). The
inherent assumption in this standard is that all willing surgeons can master the new tech-
nique, albeit at different learning speeds. As hip surgery has become more specialized, less
invasive methods have been promoted. One element of surgeon self-examination relates
to a candid appraisal of one’s skill set to see if the benefits of adopting the new technique
outweigh the risk created in learning it. This appraisal can be facilitated by understanding
the legal liability arising from physician actions.
Aside from professional negligence risk that is familiar to surgeons, enterprise risk should
also be considered in adopting new technology. The present era of increased transparency
in medicine, information technology, and consumer empowerment demands more data
from medical practitioners. Health care payers are focused on outcomes, quality, and cost
measures. Should a hospital therefore recognize and react to the different outcomes of
its surgeons, in light of the findings of Birkmeyer et al1 that show variations in quality
depending on surgeon skill? If a surgeon has complications related to the DAA, and such
complications occur at a higher incidence than other standard methods of THA, then
should the hospital be held liable for the complications?
This is a hard question that is inescapable in the new world of health care, with its focus
on outcomes, quality, and safety. To answer, we will first examine the legal foundations
that created hospital liability for the acts of its medical staff. This is especially relevant
at a time when more physicians are accepting a practice model as a hospital or corporate
employee.2
The legal doctrine known as respondeat superior creates legal liability for an employer
for the negligent acts of its employees. This common-law doctrine was established in 17th
century England, and has been adopted in the United States as a fixture of a branch of law
called agency law. Agency law helps define the legal relationship between an employer and
its employees. It provides a better chance for an injured party to recover damages, because
under respondeat superior the employer is liable for the injuries caused by an employee who
is working within the scope of his or her employment relationship.
Thus, if a surgeon-employee injures a patient during DAA, the application of the
respondeat superior doctrine is relatively straightforward. For injuries arising out of physi-
cian conduct during the scope of employment, courts have little trouble finding that the
hospital (ie, the employer), should be held liable as well. But, respondeat superior does
not address the conduct of those surgeons who are independent (ie, not employees of a
hospital). Having privileges at a hospital does not create or imply an employer-employee
relationship. Still, an independent surgeon must formally apply for privileges and the
hospital must clearly delineate the scope of his or her hospital practice. Credentialing is
the process of applying for and being accepted to a hospital medical staff. Privileges, or
privileged delineations, are the physician or surgeon’s permissible scope of practice within
a hospital. How does the legal system create hospital liability for the actions of medical
staff members who are not hospital employees?

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Understanding the Risks in New Technologies 109
In 1965, the legal ruling in an Illinois case called Darling v. Charleston Community
Memorial Hospital created hospital liability for physician negligence.3 From Darling
onward, US courts have recognized and enforced a doctrine called “Hospital Corporate
Liability,” which creates a direct duty of a hospital to ensure the competency of its medical
staff, as well as appropriate limitations on a medical staff member’s privileges.
In Darling, an 18-year-old boy broke his leg during a football game. He was seen in the
emergency room and the on-call doctor placed the leg in a cast. Compartment syndrome
ensued and went unrecognized, until, at a different hospital, a below-knee amputation was
performed. Plaintiffs presented a new legal theory that the hospital was responsible for
ensuring that patients were treated by competent medical staff members. Agreeing with
this premise, the Darling court said that the trial evidence revealed that “. . . the hospital
failed to review Dr. Alexander’s work . . . its failure to do so was negligence. On the evi-
dence before it, the jury could reasonably have found that [the hospital] was [negligent].”3
The defense that the hospital does not treat the patient, and does not act through its
doctors and nurses, but undertakes instead simply to procure them to act upon their own
responsibility, was soundly rejected by the court.
In the years that followed the Darling ruling, other legal cases upheld the doctrine of
hospital corporate liability. In Elam v. College Park Hospital,4 a podiatrist performed neg-
ligent surgery. It was discovered that the hospital peer-review committee had voiced con-
cerns about the podiatrist’s incompetence and lack of qualifications, but had never alerted
the hospital administration of these concerns. Applying hospital corporate liability, the
Elam court held that “the hospital owed a general duty to ensure the competency of its
medical staff and to evaluate the quality of medical treatment rendered to its patients.”4
More recent litigation has expanded hospital corporate liability to examine the granting
of privileges, especially as they relate to new surgical procedures, such as DAA. The intro-
duction of laparoscopic cholecystectomy is instructive in this regard. Experienced general
surgeons who wanted to learn this operation worked on swine cadavers during weekend
courses. The learning curve was steep; surgeons accustomed to direct visualization needed
new skills and aptitude related to indirect vision and different tactile feel through an
endoscope. In the large volume of lawsuits that followed iatrogenic bile duct injuries, the
hospitals were invariably named as defendants. The argument invoked the legal principles
established in Darling (ie, that the hospitals should be held liable because they had erred
in allowing surgeons to perform laparoscopic cholecystectomy without establishing that
the surgeons were qualified, competent, and proficient to do the operation).
While the Darling ruling may make sense, it has an undesirable side that creates risk
for the individual surgeon. In a highly competitive medical marketplace, for example,
surgeons who lack economic or political power can unjustly lose medical staff membership
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or have their privileges limited by competitors. Such competitors may assert that removal
of an orthopedic surgeon off the staff is a legal responsibility under hospital corporate
liability. But the actual motives may be driven by economic interests rather than improved
quality. Accordingly, it is important for hospitals to have in place due process procedures,
and even outside, independent evaluators, to protect the interests of medical staff who are
targeted by competing surgeons who have more political or economic clout in the hospital
system.
Darling imposed upon the hospital a duty to oversee its medical staff; a failure to do so
has been viewed by courts to be a breach of the hospital’s standard of care.3 That standard
now extends to hospital peer-committees whose members may unfairly target a colleague
to restrict his or her privileges. This scenario commonly occurs when a practicing surgeon
learns a new method, such as DAA, and encounters complications that then trigger a
peer-review action. In addition to these considerations, the doctrine of hospital corporate
liability invokes the informed consent process since hospitals have a duty to ensure that
surgeons properly tell patients about the risks and alternatives for new procedures. We will
examine the complex and often difficult questions that arise from these legal requirements
and interpretations.
In the pharmaceutical industry, injuries from new drugs can create significant liabil-
ity. In 2014, for example, a US federal court jury ordered Osaka, Japan-based Takeda
Pharmaceutical Co (Takeda) and Indianapolis-based Eli Lilly & Co to pay a combined
$9 billion in punitive damages after finding that the companies hid the cancer risks of
their prescription diabetes medication, Actos.5 The Actos verdict is typical of a long trend
of major monetary judgments against drug manufacturers whose new drugs end up caus-
ing injury.6,7 These legal cases teach us that all so-called medical advancements, whether
pharmaceutical or other wise, can carry special risks of legal liability.
As physician-author Nortin Hadler has noted, “Ten percent of all drugs approved
for marketing by the FDA between 1975 and 1999 were subsequently either withdrawn
because of adverse reactions or labeled with a Black Box, indicating special hazards.”8 This
type of liability also relates to new orthopedic technologies, such as metal-on-metal total
hips that ended up creating significant liability exposure for several orthopedic implant
vendors.
In summary, new operative techniques, such as the DAA, can be associated with an
increased risk of complications, especially during the learning phase. These complications
create direct liability risk for the orthopedic surgeon. In addition, complications can trig-
ger an allegation that the hospital failed in its duty to ensure surgeon competence, profi-
ciency, and qualifications consistent with the hospital corporate liability arising from the
Darling decision. This liability, on the part of the hospital, is distinct from vicarious liabil-
ity, which normally arises when the physician is an employee of the hospital, such that
physician misconduct is imputed to the hospital-employer under agency law principles.

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In terms of hospital credentialing and privileging, there are 3 aspects about surgi-
cal performance that a hospital must monitor to avoid invoking hospital corporate
liability. These include the competency, proficiency, and qualifications of staff surgeons.
Implementing these properly can reduce liability exposure for the hospital and its physi-
cians, while improving patient safety and the quality of clinical outcomes.
New techniques such as the DAA usually require a different set of surgical skills,
aptitudes, and instruments. Proper training and mentoring may be required to declare
the surgeon capable of doing DAA for the first time. As such, a weekend cadaver course
or watching an experienced surgeon during a visit may not be sufficient preparation for
tackling an actual case independently, at least for some surgeons.
Even if a surgeon who is new to DAA can execute the steps competently, he or she
will lack proficiency, which is a skill acquired through experience. Familiarity with an
operation is not the same as proficiency, and no surgeon is proficient in the early cases of
a new procedure. Advances in surgery and technology will always lead to a lack of pro-
ficiency, while the learning curve is overcome by the surgeon. The law does not excuse
a hospital or surgeon from legal liability arising from an injury that occurred during the
early stages of a new operation or implant. In other words, there is no safe haven under
the law that excuses complications associated with learning and mastering a new opera-
tion. Accordingly, the burden is upon the hospital to assure not only that its medical staff
is competent with new technologies, but also that the staff is proficient. Within hospital
settings, proficiency often extends not only to the orthopedic surgeon but also to the
entire operating room team.
The exact qualifications for safely executing a novel operation are difficult to define,
particularly in an orthopedic setting. With DAA THA, a learning curve of 50 to
100 cases has been cited by some authors.9,10 While the hospital is responsible for verify-
ing sufficient qualification of the surgeon to attempt a new operation, the training mission
is often delegated to industry-sponsored courses that may vary in quality and consistency.
To avoid legal claims from errors related to novel procedures and technology, a hospital
must assure that the orthopedic surgeon is competent, proficient, and qualified. Difficult
as this task may appear, the suggestions that follow may be helpful.
Hospital corporate liability was invoked during the litigation that followed failed lapa-
roscopic cholecystectomies. General surgeons learned the new operation during industry-
sponsored weekend courses where they operated on swine subjects.11 They then operated
on human patients, often lacking competence, proficiency, and the qualifications for the
new operation. Hospitals were sued for the failure to provide proctorship for the initial
surgical procedures. The evidence showed the limited nature of training and also showed
that many general surgeons were simply unable to acquire the skills needed to perform the
operation in the 2-dimensional endoscopic field of view.11
Applying these principles to DAA, should an orthopedic surgeon adopt DAA after
an industry course without the hospital proctoring his or her performance? While this

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remains an unresolved and vexing issue for hospital administrators, there is plenty of guid-
ance in law. An administrator could logically conclude that any procedure with a learning
curve can subject the hospital to liability, as the litigation experience with the adoption of
laparoscopic cholecystectomy demonstrated. Concern on the part of the hospital is proper
whenever an orthopedic surgeon performs outside the scope of what he or she learned in
residency training. Conversely, if the surgeon was introduced to the operation in question
during residency training, and/or was further exposed to that operation during specialized
fellowship training, then the risk of liability exposure related to insufficient training may
be mitigated.
This question is further compounded by the complicating variable of surgeon age. Is
there a higher duty on the part of the hospital to monitor, for example, a 75-year-old
orthopedic surgeon, who for business reasons wants to begin performing DAA total hips,
when compared to a 35-year-old surgeon with the same intentions, and identical level of
inexperience with DAA? Astute lawyers could probably make that argument forcefully.
Another point in regards to new learning, such as DAA, relates to the informed con-
sent process. All too often, the informed consent process relating to a new operation is no
different than a routine review of the known risks, with a description of the operation and
its purported benefits. However, to make an informed decision about a novel operation
or new technology, the patient needs more information. For example, the patient must be
aware of the new risks created by the operation. This may be very difficult in the early
adoption of an operation, when widespread enthusiasm may drive adoption well before any
long-term data concerning the safety and efficacy are known. Thus, the synthetic anterior
cruciate ligament replacements introduced in the mid-1970s ultimately failed, as did the
silastic toe joint prostheses introduced in the 1980s, and the troubles with metal-on-metal
total hips are following the same trend.12,13
With new operations, hospitals may be at risk for making unwarranted assumptions
about the informed consent process. The first assumption is that orthopedic surgeons have
good data about the risks of new technology. The second assumption is that all orthopedic
surgeons may be equally equipped to safely perform new technologies. Finally, hospitals
may assume that they can safely delegate the informed consent process to the orthopedic
surgeon. All these assumptions may, in fact, be entirely incorrect. A hospital may have
an independent obligation to tell the patient that the risks of the new surgical procedure
are uncertain, or unknown. It may also have an obligation to tell the patient about the
background and qualifications of the surgeon, and that of the operating team who will be
providing surgical support for the new technologies.
In reality, market pressures often conspire to achieve the exact opposite; hospitals often
advertise that their surgeons are the first to perform an operation such as DAA, or use
the latest robot to perform total knee surgery. Like so many issues in law and medicine,
the legal liability exposure created by new technologies is often in conflict with marketing
and economic considerations. Online searches for minimally invasive DAA total hips will
identify thousands of hospitals, surgeons, and orthopedic practices that compete for the
consumers’ attention. There is little doubt that competition in orthopedic surgery is often
driven by the ability to demonstrate superiority; this is often achieved by marketing new

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technologies to attract patients. Therefore, there is an economic incentive for hospitals and
surgeons to overstate the advantages of new technologies to obtain a market advantage
over their respective competitors.
At the end of the day, market pressures can conspire to create increased liability risk
for surgeons and hospitals alike. The precise relationship between patient exposure and
response to marketing and advertising vs the integrity and credibility of the informed
consent process is a complex subject, and outside the scope of this chapter. Suffice it
to say that balancing the economic advantages of adopting surgical methods like DAA
THA vs the legal risks created for surgeons and hospitals is a challenging task. Surgeons
and hospitals should work together to identify and institute quality control measures and
disclosure processes to ensure safe outcomes and honest disclosure to the patient.
Hospital orthopedic departments or divisions should provide a working definition

for novel surgical techniques and new surgical technologies. The definition for novel
surgical techniques should address those techniques that invoke a learning curve. The
definition of new surgical technologies should include technologies that are truly dif-
ferent and not simply enhancements of existing technologies.
If a staff surgeon wants to perform a novel operation, or adopt a new technology
consistent with the previous definition, he or she should apply for a new privilege to
do so. The hospital should have well-defined protocols in place (eg, proctoring the
first 10 procedures) and literature that supports the procedure before granting the new
privilege.
For new technologies and operations, the patients should be informed of the per-
ceived benefits of the procedure, the known risks, and the knowledge that every new
technology has special hazards that may not be foreseeable during the early phases of
implementation and adoption.
Patients undergoing novel surgical procedures or receiving new technologies should be
carefully monitored for complications, as well as positive outcomes.
Some form of pattern analysis of this monitoring and oversight process should be
conducted to assess both the benefits and unforeseen complications of the procedure
or technology.
1. Birkmeyer JD, Finks JF, O’Reilly A, et al; and Michigan Bariatric Surgery Collaborative. Surgical skill and
complication rates after bariatric surgery. N Engl J Med. 2013;(15):1434-1442.
2. Belde DM. Physician employment in an era of health reform: using shared ideals to achieve social interests.
Health Prog. 2012;93(2):62-71.
3. Darling v. Charleston Community Memorial Hospital, 33 Ill.2d 326, 211 NE 2d 253, 14 ALR 3d 860 (1965).
4. Elam v. College Park Hospital, 132 Cal. App. 3d 332; 183 Cal Rptr. 156 (1982).
5. Feeley J, Matsuyama K. Takeda. Lilly jury awards $9 Billion over Actos risks. Bloomberg.
www.bloomberg.com/news/articles/2014-04-07/takeda-actos-jury-awards-6-billion-in-punitive-damages.
Published April 8, 2014. Accessed April 14, 2014.

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6. Harris G, Berenson A. Lilly said to be near $1.4 billion U.S. settlement. The New York Times.
www.nytimes.com/2009/01/15/business/15drug.html?_r=0. Published January 14, 2009. Accessed
February 23, 2016.
7. Hilts P. Jury awards $6.4 million in killings tied to drug. The New York Times. www.nytimes.com/
2001/06/08/us/jury-awards- 6.4 -million-in-killings-tied-to-drug.html. Published June 8, 2001. Accessed
January 8, 2016.
8. Hadler N. Worried Sick: A Prescription for Health in an Overtreated America. Chapel Hill, NC: University
of North Carolina Press; 2008.
9. Berend KR, Lombardi AV, Seng BE, Adams JB. Enhanced early outcomes with the anterior supine inter-
muscular approach in primary total hip arthroplasty. J Bone Joint Surg Am. 2009;91(Suppl 6):107-120.
10. Seng BE, Berend KR, Ajluni AF, Lombardi AV. Anterior-supine minimally invasive total hip arthroplasty:
defining the learning curve. Orthop Clin North Am. 2009;40:343-350.
11. Southwick AF. Hospital liability. Two theories have been merged. J Leg Med. 1983;4:1–50.
12. US Food and Drug Administration. Recalls. www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/
ImplantsandProsthetics/MetalonMetalHipImplants/ucm241770.htm. Published July 2, 2014. Accessed
April 21, 2015.
13. Drugwatch. Hip Replacements. www.drugwatch.com /hip -replacement /. Published 2015. Accessed
April 21, 2015.

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9
Direct Anterior
Total Hip Arthroplasty in the
Lateral Decubitus Position
Wietse P.R. Melman, MD; Markus C. Michel, MD;
and Cees C.P.M. Verheyen, MD, PhD
The direct anterior approach (DAA) in the lateral decubitus position provides excel-
lent visibility for exposure of both the femur and acetabulum.
Adoption of the lateral decubitus approach does require special training and education.
A femoral implant with a low shoulder or an anatomical stem is recommended when
using this approach.
DAA total hip arthroplasty (THA) is advantageous in terms of faster recovery from
surgery, less blood loss, more precise cup placement, less muscle damage, and lower dislo-
cation risk.1–6 Disadvantages of DAA THA are damage to the lateral femoral cutaneous
nerve (LFCN) and prolonged operating times and high complication rates, particularly
during the early learning curve for new adopters of the technique. Many of the reported
femoral complications are attributable to difficulties in femoral exposure, leading to com-
plications such as fracture and canal perforation.7–15
In the majority of studies describing DAA THA, the patient is positioned supine, with
or without traction to the operative leg.1,8–20 However, the operation can be done in the
lateral decubitus position as well.21 A major theoretical advantage of this position is that
it requires less effort to expose the femur during surgery while the leg is simply positioned
in hyperextension, adduction, and external rotation. This position provides easier access
to the femoral canal compared with the supine position and completely avoids any possible
iatrogenic complications due to leg traction.

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Figure 9-1. The patient is positioned in the lateral decubitus position. A strong
posterior support is needed in order to prevent the pelvis from tilting.
The DAA in lateral decubitus position can be done on any standard operating table,
using standard total hip replacement instruments. We use Stulberg positioners (Innomed)
to prevent the pelvis from tilting. Special angulated acetabular reamers and cup impactors
may be helpful in obese or muscular patients. We use straight handle broaches for the
femur. Retractors without sharp points are advised, like the Subtilis retractors (Accuratus).
The patient is positioned in a lateral decubitus position, with the posterior foot part of
the table removed; a split table is preferred to enable this step. A strong support for the
back of the patient is needed in order to prevent the pelvis from tilting. The position of
the surgeon is in front of the patient (Figure 9-1). A line (typically 8 to 10 cm) is drawn
from the middle of the anterior border of the greater trochanter to the anterior iliac crest.
The actual length of the incision is not impor tant (Figure 9-2).
The subcutaneous tissue is dissected down to the level of the fascia. The border of the
iliotibial band (ITB) can then be accessed; the incision is not placed on the very border
of the ITB but 2 to 3 mm lateral to it, therefore, within the ITB. This is for 2 reasons.
Primarily, the border of the ITB is easier to suture when closing than the sometimes fine
fascia of the tensor muscle. Secondly, the superficial LFCN of the thigh can be avoided
by proceeding with the blunt dissection of the tensor muscle from underneath the fascia.
The LFCN may be close, but it always runs superficially to the fascia.
The first blunt retractor is placed on the capsule, lateral to the femoral neck in order to
keep all musculature lateral and therefore resulting in excellent access to the femoral neck.

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Direct Anterior Total Hip Arthroplasty in the Lateral Decubitus Position 117
Figure 9-2. Specific landmarks are used for the incision: the middle of the
anterior border of the greater trochanter and the anterior superior iliac crest.
Next, the sartorius and rectus femoris muscle are mobilized medially and the tensor and
abductor muscles are mobilized laterally with an additional blunt retractor. The anterior
neck capsule is covered with a thin double layer of fascia containing the yellow fat pad
in the middle, which is excised. A longitudinal incision of the superficial layer should be
followed by a blunt dissection of the yellow fat pad, moving it medially together with the
elevated reflected rectus tendon; these are held in place by repositioning of the second
medial retractor.
The dissection is thus in the intermuscular and interner vous plane between the ten-
sor and gluteus medius muscles on the lateral side, and the sartorius and rectus femoris
muscles on the medial side. The capsule is incised in a T-shaped manner lateral to the
insertion of the reflected rectus tendon with the distal incision on the intertrochanteric
line (Figure 9-3). It is recommended to dissect the capsule from the intertrochanteric line
in an inside-out technique to avoid the main branches of the medial femoral circumflex
artery posteriorly. The recurrent and ascending branches of the lateral femoral circumflex
artery, which runs along the deeper surface of the tensor muscle, need to be coagulated or
ligated prior to capsular exposure.
The blunt retractors are then placed around the femoral neck within the joint capsule
and the femoral neck osteotomy is performed in situ. To dislocate and remove the femoral
head, a double-corkscrew technique is used. The first corkscrew is inserted in an anterior-to-
posterior direction into the lateral femoral neck and used to flip the femoral neck toward
the surgeon. Second, the corkscrew is then repositioned into the longitudinal axis of the
cut femoral neck toward the head and is used to twist the head several times around its
longitudinal axis, until it is completely loose, allowing removal of the head at this point.
Occasionally, it is helpful to cut a 1 cm slice of the femoral neck to facilitate removal of
the femoral head in a tight or ankylosed hip joint.
After removing the femoral head there will be an excellent 360-degree view of the
acetabulum, which is further enhanced by adding a third double-bent Hohmann retrac-
tor at the lateral insertion of the transverse acetabular ligament (TAL), so as to move the
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118 Chapter 9
Figure 9-3. The capsule is incised in a T-shaped manner lateral to the insertion
of the reflected rectus tendon.
femur distally and protect the cut femoral neck. The TAL, which is an important local
landmark for controlling anteversion of the cup, should be identified and preserved when-
ever possible. When implanting the acetabular component, surgeons should be aware that
in the lateral decubitus position the pelvis tends to adduct and, combined with the impact
of version on radiographical inclination, this means the surgeon should aim for an opera-
tive inclination of approximately 35 degrees in order to achieve a 45-degree angle on the
postoperative anteroposterior radiograph.
For preparation of the femur, a blunt retractor should be placed over the tip of the
greater trochanter before the leg is transferred posteriorly into a sterile bag (Figure 9-4).
By means of this retractor, the tensor muscle is flipped over the greater trochanter and
the trochanter is mobilized with the tip of the retractor medially in order to prevent the
femur from impinging against the lateral acetabular rim. In most hips (approximately
95%), no specific additional releases are needed. In extremely restricted hips the following
3 releases can be performed in order:
Release of the lateral/posterior capsule from the greater trochanter
Release of the piriformis tendon
Partial release of the proximal tensor muscle origin from the anterior iliac crest (inter-
muscular fibers)
Good access to the femur is required before broaching in order to ascertain the correct
entry point for the specific implant. The most common error is to start broaching too
medially so the broach will be in varus, which increases the risk of undersizing, fracturing
the calcar and producing varus malalignment. After implantation of all components, the
capsule is closed with a few single stitches. Using a running suture to the fascia followed
by skin closure. Postoperative mobilization is started the first day after surgery or prefer-
ably the same afternoon under supervision of a physiotherapist.

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Figure 9-4. Patient positioned on a split table with one leg support removed
facilitating easy positioning for femoral access.
As with every new procedure, there is a learning curve. Complication rates may be
higher in the early adoption period of DAA THA.22 Special training and education in
order to protect both surgeons and patients from unnecessary risks are required. Learning
the DAA systematically as a resident or orthopedic surgeon may negate an initial higher
rate of complication, but this concept applies to all other hip approaches as well.15
In the absence of a traction table, the number of trochanteric fractures seems to be
relatively low when using this specific approach. The overall rate of complications such as
infection and early revision surgery is comparable to other hip approaches, when using a
femoral stem with a low shoulder or an anatomical profile.22,23 We analyzed one surgeon’s
first 182 procedures, comparing 3 consecutive time periods based on an equal number of
surgical procedures. The technical complication rate and operating time improved signifi-
cantly between the 3 consecutive groups. Initial complication rate was high but decreased
significantly in time and was acceptable certainly in the third group of our cohort.
Early on, we used a straight, uncemented stem with a non-curved shoulder; this non-
anatomical design was not conducive to DAA THA and we abandoned it after only
7 cases. The overall infection rate was 0.5% at 1 year after surgery, and the overall survival
rate was 98.4%.22 Overall dislocation rate seems to be low; a cohort of 216 consecutively
operated patients showed a low dislocation rate of 0.4% over 5 years.23
DAA THA in the lateral decubitus position has the advantage of a more familiar
patient position for most hip surgeons and easier femoral exposure. No traction table is

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120 Chapter 9
needed. Since the orientation of the pelvis remains familiar to surgeons accustomed to
the lateral decubitus position, cup positioning and femoral stem version may be easier to
implant, with more accurate positioning of components. Despite these advantages, there
are still a limited amount of data available on the lateral decubitus approach for DAA
THA and more comparative research will be needed to expand this knowledge base into
the future. At this stage, there are no data available comparing the DAA in lateral decubi-
tus position to the DAA supine. Even so, DAA THA in itself is competitive to the other
standard procedures due to the preservation of muscle and use of the interner vous plane
into the hip joint for improving the postoperative recovery for the patient.23
Special training and education are needed to perform DAA THA in the lateral posi-
tion, to minimize the risk of complications.
Femoral exposure is easier in the lateral decubitus DAA THA since the leg is simply
positioned in hyperextension, adduction, and external rotation. This position provides
easier access to the femoral canal when compared with the supine-positioned patient
and no traction table is needed.
Femoral implants optimized for DAA THA are preferred (ie, femoral stems with a
low-profile shoulder or an anatomical design) in order to minimize the risks of tro-
chanteric fracture and stem malposition.
Currently there is no evidence that the DAA THA in the lateral decubitus position
has benefits over the same operation in the supine position, but further investigation
will be warranted based on our positive experience using this technique.
1. Rodriguez JA, Deshmukh AJ, Rathod PA, et al. Does the direct anterior approach in THA offer faster
rehabilitation and comparable safety to the posterior approach? Clin Orthop Relat Res. 2014;472(2):455-463.
2. Schweppe ML, Seyler TM, Plate JF, Swenson RD, Lang JE. Does surgical approach in total hip arthro-
plasty affect rehabilitation, discharge disposition, and readmission rate? Surg Technol Int. 2013;23:219-227.
2011;93(15):1392-1398.
5. Alecci V, Valente M, Crucil M, Minerva M, Pellegrino CM, Sabbadini DD. Comparison of primary total
hip replacements performed with a direct anterior approach versus the standard lateral approach: periopera-
tive findings. J Orthop Traumatol. 2011;12(3):123-129.
6. Moskal JT, Capps SG, Scanelli JA. Anterior muscle sparing approach for total hip arthroplasty.
World J Orthod. 2013;4(1):12-18.
Am. 2009;40(3):321-328.
8. Goulding K, Beaulé PE, Kim PR, Fazekas A. Incidence of lateral femoral cutaneous nerve neuropraxia after
9. Light TR, Keggi KJ. Anterior approach to hip arthroplasty. Clin Orthop Relat Res. 1980;(152):255-260.
10. Oinuma K, Eingartner C, Saito Y, Shiratsuchi H. Total hip arthroplasty by a minimally invasive, direct
anterior approach. Oper Orthop Traumatol. 2007;19(3):310-326.

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12. De Geest T, Vansintjan P, De Loore G. Direct anterior total hip arthroplasty: complications and early
outcome in a series of 300 cases. Acta Orthop Belg. 2013;79(2):166-173.
13. Spaans AJ, van den Hout JA, Bolder SB. High complication rate in the early experience of minimally inva-
sive total hip arthroplasty by the direct anterior approach. Acta Orthop. 2012;83(4):342-346.
14. Jewett BA, Collis DK. High complication rate with anterior total hip arthroplasties on a fracture table. Clin
Orthop Relat Res. 2011;469(2):503-507.
15. Müller DA, Zingg PO, Dora C. Anterior minimally invasive approach for total hip replacement: five-year
survivorship and learning curve. Hip Int. 2014;24(3):277-283.
16. Rachbauer F, Krismer M. Minimally invasive total hip arthroplasty via direct anterior approach. Oper
Orthop Traumatol. 2008;20(3):239-251.
17. Berend KR, Lombardi AV Jr, Seng BE, Adams JB. Enhanced early outcomes with the anterior supine
intermuscular approach in primary total hip arthroplasty. J Bone Joint Surg Am. 2009;91(Suppl 6):107-120.
18. Laude F. Total hip arthroplasty through an anterior Hueter minimally invasive approach. Interact Surg.
2006;1(1-4):5-11.
19. Nam D, Sculco PK, Su EP, Alexiades MM, Figgie MP, Mayman DJ. Acetabular component positioning
in primary THA via an anterior, posterolateral, or posterolateral-navigated surgical technique. Orthopedics.
2013;36(12):e1482-e1487.
table. J Arthroplasty. 2008;23(7)(Suppl):64-68.
21. Michel MC, Witschger P. MicroHip: a minimally invasive procedure for total hip replacement surgery
using a modified Smith-Petersen approach. Ortop Traumatol Rehabil. 2007;9(1):46-51.
22. Melman WP, Mollen BP, Kollen BJ, Verheyen CC. First experiences with the direct anterior approach
in lateral decubitus position: learning curve and 1 year complication rate. Hip Int. 2015;25(3):191-292.
doi: 10.5301/hipint.5000221.
23. Michel MC, Pierre W. THR by direct anterior approach (DAA): five year results including gate analysis.
J Bone Joint Surg Br. 2011;93-B(Suppl II): 153.


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Direct Anterior Total
10
Hip Replacement With
Leg Positioning System
and Fluoroscopy
Adam M. Freedhand, MD; Preetesh D. Patel, MD;
and Eric M. Slotkin, DO
How to properly position the ARCH table (Innovative Orthopaedic Technologies) for
direct anterior approach (DAA) total hip arthroplasty (THA) surgery
How to identify the functions of the ARCH table
How to apply the functions of the ARCH table extension to the appropriate steps of
a DAA THA
How to utilize fluoroscopy during DAA THA
How to properly interpret intraoperative fluoroscopy images
DAA is a classic surgical approach; since its description by Carl Hueter over a century
ago, it was used for THA only sporadically until recently.1,2 Interest in DAA THA has
been driven by its muscle-sparing technique that supports less invasive surgery 3
and the supine position allows the surgeon to assess pelvic position more easily. The
supine position also facilitates the use of fluoroscopy to assess component size and posi-
tion. Proponents of special tables or leg positioning systems cite their ease of use and the
need for fewer assistants. The ARCH Leg Positioning System (Innovative Orthopaedic
Technologies) is a device that can be used with a standard operating room table to main-
tain leg position during DAA surgery.
Component position affects the longevity and performance of THA.4 Malpositioning
and soft tissue imbalance can lead to dislocation risk, impingement, accelerated


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124 Chapter 10
Figure 10-1. The ARCH table attachment.
polyethylene wear, and early revision surgery.5,6 Numerous studies have described the
ideal acetabular position, but few have addressed the variability and dynamic nature of
the true pelvic orientation unique to each patient.7–10 Intraoperative patient positioning
affects the ability to accurately estimate pelvic tilt and rotation. Many technologies have
been utilized to improve component positioning and surgical outcomes, including robot-
ics, navigation systems, and fluoroscopy.10 Recreation of preoperative patient-specific pel-
vic tilt and neutral rotation with the use of fluoroscopy during the surgical procedure can
improve component orientation.11–13 In addition, fluoroscopy can be utilized to improve
and confirm various aspects of the surgical procedure and may help reduce complication
risk, especially during the learning curve.
The ARCH system (Figure 10-1) is a freestanding attachment for a standard operating
table that was designed for leg positioning during DAA THA. It can also be used during
other orthopedic procedures (ie, hip arthroscopy, hip fractures, and femoral neck open
reduction internal fixation). This table attachment is draped outside of the sterile field
and can be controlled by an assistant (Figure 10-2). The ARCH extension allows for leg
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Direct Anterior Total Hip Replacement With Leg Positioning System and Fluoroscopy 125
Figure 10-2. The ARCH leg position device utilized during surgery.
rotation, extension, flexion, adduction, and abduction. Movements are calibrated in mil-
limeters or degrees and allow for reproducible leg positioning during DAA surgery. The
table extension is amenable to intraoperative fluoroscopy with a portable C-arm intensifier
unit (Figure 10-3).
Specific steps for the safe use of the ARCH extension system include the following:
Patient positioning and draping: The patient is placed supine on a standard operating
room table. The operative leg is secured in the ARCH device and the contralateral leg
placed in a well leg holder. The ARCH should be positioned approximately 52 inches
(matching its radius) from the center of rotation of the hip to minimize unintentional
traction or compression of the leg with changes in position. The leg should be in a
neutral anatomic position.

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126 Chapter 10
Figure 10-3. Intraoperative view of full pelvis.
Surgical exposure: During the approach to the hip, the leg is held in a neutral position
without any traction. Capsular exposure and the surgical release of the medial capsule
from the femoral calcar can be facilitated with external rotation of the leg to deliver
the lesser trochanter toward the surgeon. Specific capsular releases are dependent on
surgeon preference; however, no additional releases are necessary to perform in order
to maximize the ARCH device use.
Neck osteotomy and femoral head extraction: The femoral neck osteotomy is made with
the foot in the neutral position and should be made with a single- or double-osteotomy
perpendicular to the femoral neck. After completion of the osteotomy, approximately
40 mm of traction and 40 degrees of external rotation (the 40/40 position) is applied
to displace the osteotomy and gain access to the head fragment. The femoral head
is then extracted with a corkscrew device, taking care to protect the surrounding
muscles from any sharp bone edges.
Acetabular exposure: Deep retractors are placed on the acetabular rim, while maintain-
ing the 40/40 position with the ARCH device. Mild traction can be applied during
acetabular reconstruction to facilitate exposure. After acetabular preparation and
implantation of the socket, traction is released and the leg is brought back to the
neutral position.
Femoral exposure: Capsular releases are begun with the leg in the neutral position with-
out traction. The greater trochanter must clear the lateral margin of the acetabulum
prior to leg positioning for femoral preparation. A combination of external rotation,
extension, and adduction of the leg allows access to the proximal femur. Sequential

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and appropriate capsular releases must be done to reduce stresses on the proximal
femur before stem preparation; these steps are addressed elsewhere in this text.
Femoral preparation: The ARCH device keeps the leg in external rotation, extension,
and adduction for broaching of the femur. The most common positions are 90 degrees
of external rotation, 30 degrees of extension, and 30 degrees of adduction; however,
these may be varied for surgeon preference.
Trial reduction: Position for trial reduction is accomplished by taking the leg out of
adduction, bringing the leg back up to a position parallel to the floor, and placing it in
50 degrees of external rotation. The assistant should announce changes in position or
traction in measurement units displayed on the ARCH device. The surgeon reduces
the hip by applying pressure digitally or with a head pusher, taking care to quantify
the traction that was required to achieve reduction. The soft tissue tension and the
amount of traction required for reduction helps the surgeon assess the restoration of
leg length and offset.
Component position and stability testing: The operative leg is brought into 90 degrees of
external rotation prior to dislocation. With proper component position there should
be no impingement of the neck trial on the acetabular component. With a bone hook
on the trial neck pulling anterior and lateral, traction is applied and the amount of
distraction required to dislocate the hip helps quantify the stability of the reconstruc-
tion. Removing the foot from the traction device, may aid the surgeon in dynamically
assessing posterior stability, although most surgeons performing DAA THA omit
this maneuver. Limb length and femoral offset restoration can be confirmed with the
use of fluoroscopy, as described in the next section.
Stem insertion: After dislocation of the trials the leg is put back in the position used
for femoral broaching for final implantation of the stem. Femoral head implantation
on the taper trunnion or re-trailing with a femoral head can be done at this point.
Wound closure: The leg is maintained in a neutral and reduced position without trac-
tion during closure of the fascia and skin.
Image intensifiers can be used throughout the DAA THA surgical procedure to con-
firm or improve on surgical steps with or without the use of a special table or attachments.
The use of fluoroscopy during the surgical procedure is recommended to aid with the
following surgical steps:
Preoperative assessment of pelvic orientation
For pelvic rotation, the goal is to recreate a neutral pelvis by assessing the symmetry
of the obturator foramina and ischial spines, as well as alignment of the coccyx
with the pubic symphysis. This may be accomplished by manually repositioning
the pelvis or changing the direction of the fluoroscopy beam.
Functional acetabular component positioning is accomplished by recreating the
preoperative pelvic tilt. The goal is to replicate the patient’s preoperative pelvic tilt
on a standing anteroposterior pelvis image when they change to a supine position
on the operating table with the use of the fluoroscopy unit. Attention is paid to the

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128 Chapter 10
Figure 10-4. Preoperative assessment of limb length discrepancy.
position of the coccyx relative to the pubic symphysis and the appearance of the
obturator foramen on the preoperative standing image. The fluoroscopy unit can
be maneuvered or angled cephalad or caudad to recreate the image.
Preoperative assessment of limb length discrepancy (Figure 10-4)
By interpreting the intersection point of a radiopaque rigid bar across the pelvis
(authors use an alignment rod from a total knee set), the surgeon is able to deter-
mine the length and offset. Restoration of these parameters aid to restore normal
hip biomechanics.
Confirmation of femoral neck osteotomy length (Figure 10-5)
According to preoperative templating, the level of femoral neck resection can be
confirmed intraoperatively. A common tendency is to errantly under-resect the
femoral neck compared to preoperative templating and therefore leave too much
neck behind on the femur. This can complicate acetabular preparation. Fluoroscopy
can likewise assist in visualizing and confirming the final acetabular component
position (Figure 10-6).
Component alignment, offset, and limb length (Figure 10-7)
Post-procedure intraoperative fluoroscopic analysis of the surgical corrections
may confirm the recreation of preoperative planning and hip biomechanics. It
has been reported that 83.9% of patients have between 10 degrees posterior and
10 degrees anterior pelvic tilt.14,15 Therefore, 15% of patients have excessive ante-
rior or posterior pelvic tilt, which can affect socket positioning if not recognized.
In addition, pelvic rotation can change during surgery, thereby complicating the
interpretation of intraoperative radiographs. Failure to recognize a change in pelvic
rotation during surgery can contribute to positioning errors. Correction of the iliac

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Figure 10-5. Femoral neck osteotomy.
Figure 10-6. Assessment of final acetabular component position during

impaction.
oblique image may be accomplished by turning the fluoroscopy beam toward the
surgical side to recreate a neutral pelvic image. Figures 10-8 and 10-9 illustrate
the perceived acetabular version interpretation changes as a result of alterations in
intraoperative pelvic views.

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130 Chapter 10
Figure 10-7. Assessment of final component alignment, offset, and limb

length.
Figure 10-8. Changes in acetabular positioning for an inlet and outlet view
of the pelvis.
Parallax is another phenomenon that can contribute to errors. It occurs due to vari-
ability in the radiograph beam offset and centralization and will also cause differences
in the interpretation of the image. In Figure 10-10, for example, note how moving the
C-arm beam cephalad or caudad will change surgeon perception of the true acetabular
version. To maintain consistency in the intraoperative images, the surgeon must be aware
of the position of the fluoroscopy beam and attempt to maintain that position as the unit
is brought in for imaging throughout the case.

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Figure 10-9. Changes in acetabular positioning for an iliac and obturator

oblique view of the pelvis.
Figure 10-10. Difference in acetabular cup positioning as the fluoroscopy unit

moves in a caudad-cephalad direction. In the cephalic direction, the cup
position appears more anteverted. In the caudad direction, the cup position
appears less anteverted.
Two previous case-series studies have reported the accuracy of component position-
ing performed through the various approaches with the patient positioned in the lateral
decubitus position.16,17 The first study utilized a narrowed safe-zone acetabular position
defined at 30 to 45 degrees inclination and 5 to 25 degrees anteversion and found that
both criteria were accomplished in only 47% of the cases.16 The second study, when using
the same target safe-zone criteria, demonstrated that only 38% of acetabular components
met both criteria.17 The surgeons in these studies used traditional anatomic landmarks
for component placement.
Another study compared fluoroscopically-assisted DAA THA to the posterior
approach without radiographic guidance.18 Authors concluded that intraoperative fluo-
roscopy led to deceased variability of acetabular component version; however, they were
unable to differentiate whether that decreased variability was due to a learning curve
involving the approach or the use of fluoroscopy itself.
A retrospective review of 780 primary fluoroscopically-assisted DAA THAs designed
to evaluate the efficacy of intraoperative fluoroscopy, and the learning curve associated

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132 Chapter 10
with the use of fluoroscopy has been reported.19 In this study, 718 THAs (92.1%) fell
within the targeted acetabular inclination range, 723 THAs (93%) fell within the targeted
acetabular anteversion range, and 698 THAs (89.5%) simultaneously met both criteria.
Over the 4-year study period, the distribution of components simultaneously meeting
target range criteria for both inclination and anteversion improved yearly for each sur-
geon (Surgeon A: 2010—68.1%; 2011—78.9%; 2012—91.4%; 2013—97.4%; Surgeon
B: 2011—80.8%; 2012—89.6%; 2013—94.1%). These data suggest that a learning curve
exists for both the interpretation of fluoroscopy and in the execution of DAA THA itself.
An advantage of DAA THA is that it can be performed with the patient in the supine
position, such that a table extension and fluoroscopic imaging can be used to reduce errors
and improve component positioning. Specifically, the ARCH table extension, in our
experience, has allowed reliable and reproducible limb positioning during DAA THA.
Fluoroscopy helps mimic preoperative pelvic tilt and neutralize pelvic rotation, as well as
provide real-time interpretation of key steps to the surgical procedure. Accurate interpre-
tation of fluoroscopic imaging data requires the understanding of important changes in
both patient and C-arm positioning, and those can affect the interpretation of images. In
addition to the learning curve associated with DAA THA, published data suggest that
there may be a learning curve associated with the interpretation of intraoperative fluoros-
copy as well.
The ARCH leg positioning device allows for positioning of the leg in rotation, flex-
ion/extension, and adduction/abduction.
All functions of the ARCH leg positioning device are calibrated such that limb posi-
tion can be quantified during DAA surgery, thereby facilitating reproducibility from
one step to another.
The C-arm projections of pelvis anatomy depend on patient positioning, as well as
pelvic rotation and tilt. Failure to recognize positioning variability can increase the
likelihood of errors in the interpretation of intraoperative images.
Parallax is the difference in the apparent position of the components between dif-
ferent C-arm placements. This can affect proper interpretation of the intraoperative
fluoroscopy image and the surgeon must be vigilant of this source of error.
Component malposition can contribute to early failures in THA, and fluoroscopy is
an easily accessible tool that can help optimize component orientation, especially dur-
ing the learning curve phase of DAA utilization.

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1. Smith-Petersen, MN. Arthroplasty of the hip. J Bone Joint Surg Am. 1939;21(2):269-288.
2. Light, TR, Keggi KJ. Anterior approach to hip arthroplasty. Clin Orthop Relat Res. 1980;152:255-260.
2011;93(15):1392-1398.
4. Wan Z, Boutary M, Dorr LD. The influence of acetabular component position on wear in total hip arthro-
plasty. J Arthroplasty. 2008;23:51-56.
5. D’Lima DD, Urquhar AG, Buehler KO, et al. The effect of the orientation of the acetabular and femo-
ral components on the range of motion of the hip at dif ferent head-neck ratios. J Bone Joint Surg Am.
2000;82:315-321.
6. Dorr LD, Wan Z. Causes of and treatment protocol for instability of total hip replacement. Clin Orthop
Relat Res. 1998;355:144-151.
7. Lewinnek GE, Lewis JL, Tarr R, et al. Dislocation after total hip replacement arthroplasties. J Bone Joint
Surg Am. 1978;60:217-20.
8. Harris WJ. Advances in surgical technique for total hip replacement: without and with osteotomy of the
greater trochanter. Orthop Clin North Am. 1980;146:188.
9. Woo RY, Morrey BF. Dislocations after total hip arthroplasty. J Bone Joint Surg Am. 1982;64(9);1295-1306.
10. McCollum DE, Gray WJ. Dislocation after total hip arthroplasty: causes and prevention. Clin Orthop.
1990;260:159-170.
11. Anda S, Svenningsen S, Grontvedt T, et al. Pelvic inclination and spatial orientation of the acetabulum: a
radiographic, computed tomographic and clinical investigation. Acta Radiol. 1990;31:389-394.
12. DiGiola AM, Jaramaz B, Blackwell M, et al. The Otto Aufranc Award. Image guided navigation system to
mea sure intraoperative acetabular implant alignment. Clin Orthop Relat Res. 1998;355:8-22.
13. Lembeck B, Mueller O, Reize P, et al. Pelvic tilt makes acetabular cup navigation inaccurate. Acta
Orthopaedica. 2005;76(4):517-523.
14. Siebenrock KA, Kalbermatten DF, Ganz R. Effect of pelvic tilt on acetabular retroversion: a study of pelves
from cadavers. Clin Orthop Relat Res. 2003;407:241-248.
15. Zhu J, Wan Z, Dorr LD. Quantification of pelvic tilt in total hip arthroplasty. Clin Orthop Relat Res.
2010;468:571-575.
16. Callanan MC, Jarrett BS, Bragdon CR, et al. Risk factors for cup malpositioning. Clin Orthop Relat Res.
2011;469;319-329.
17. Barrack RL, Krempec JA, Clohisy JC, et al. Accuracy of acetabular component position in hip arthroplasty.
J Bone Joint Surg Am. 2013;95:1760-1768.
18. Rathod PV, Bhalla S, Deshmukh AJ, et al. Does fluoroscopy with anterior hip arthroplasty decrease
acetabular cup variability compared with a nonguided posterior approach? Clin Ortho Relat Res.
2014;472:1877-1885.
19. Slotkin EM, Patel PD, Suarez JC. Accuracy of fluoroscopic guided acetabular component positioning dur-
ing direct anterior total hip arthroplasty. J Arthroplasty. 2015;30(9 Suppl):102-106.

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11
Computer Navigation
and Robotics in
Anterior Hip Reconstruction
David Dodgin, MD; E. Matthew Heinrich, MD;
and Joseph T. Moskal, MD, FACS
The use of adjunctive technology to enhance the accuracy of component position dur-
ing total hip arthroplasty (THA) has evolved rapidly over the past 2 decades.
Surgeons considering the direct anterior approach (DAA) can gain improvements in
both accuracy and precision related to cup placement and leg length correction when
using computer navigation.
The results of DAA THA with computer navigation have demonstrated that there is
no longer a routine need for fluoroscopic guidance.
Computer navigation (NAV) and robotic-assisted THA each offer certain advantages
and disadvantages for the surgeon and patient, and each technique must be carefully
evaluated prior to adoption by anterior hip surgeons.
Fluoroscopic navigation for increased reconstructive accuracy and precision during

DAA THA has been advocated by several authors. However, most arthroplasty surgeons
are not familiar with intraoperative fluoroscopy for routine THA in the lateral position. In
2005 when DePuy/BrainLab wrote some of the earliest software for THA, it presented an
alternative to fluoroscopy. This technology was subsequently adapted to DAA THA, with
the goal of maintaining the same level of accuracy as with the fluoroscopically-assisted
technique, without adding time to the procedure.


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Computer navigation systems often use the anterior pelvic plane as a reference for ante-
version and the anterior superior iliac spine (ASIS) for inclination. This has led to slower
utilization trends by reconstructive surgeons and particularly for the approaches that have
the patient in a lateral position. Having the patient in a supine position makes registration
significantly easier and has even lead to reports of decreased operative times compared
to DAA THA using traditional fluoroscopy for navigation.1 There have been studies to
question the validity of using the anterior pelvic plane (also known as the frontal pelvic
plane) for cup placement based upon the pelvic plane’s variability with standing, supine,
and sitting positions as studied in x-rays of patients in these various positions.2 Other
studies have shown low frontal plane variability with various subject positions using navi-
gation registration and improved accuracy and precision when looking at cup inclination
and anteversion.3–5
We began using fluoroscopy and computer navigation in tandem to evaluate both
technologies simultaneously. Cup inclination and leg length were consistent and precise,
but this was not the case with regard to cup anteversion. This had to do with difficulty
in registering the pubic symphysis and the ASIS in obese patients. In such patients,
alternative references should be used to determine cup anteversion, such as the transverse
acetabular ligament (TAL), which is a proven, consistent landmark for determining socket
anteversion. Using TAL either visually or as a digitized reference with navigation leads to
consistent accuracy in both cup inclination and anteversion.6
Our initial data from 2005 with computer navigated DAA THA is summarized in
Table 11-1. Later, when we could digitize the plane of the TAL for anteversion, we aban-
doned fluoroscopy for acetabular component positioning in favor of computer navigation
alone.
Not only are operating times less with computer navigation, but the mean cup inclina-
tion and its standard deviation are also comparable to fluoroscopy.1 Based on these data,
we believe that computer navigation can suffice in DAA THA, without the need for
concurrent fluoroscopy. DAA surgeons can increase surgical efficiency with computer
navigation, and avoid wearing the lead aprons that are needed during fluoroscopy, inde-
pendent of whether or not a special traction table is used for the operation.

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Computer Navigation and Robotics in Anterior Hip Reconstruction 137
Acetabular component placement in THA can be adversely influenced by poor visual-

ization of the acetabulum and surrounding anatomy, increased patient body mass index,
inaccuracies of external mechanical guides, and inability to consistently obtain and main-
tain precise patient positioning during the procedure.7 The use of the DAA in combina-
tion with imageless NAV ensures better acetabular component placement by addressing
these variables.
Proponents of minimally-invasive THA (MIS THA) claim that the benefits of using a
truly interner vous and intermuscular interval include less pain, reduced blood loss, shorter
postoperative stays in the hospital, and quicker return to function due to muscle preserva-
tion.8–10 Opponents of MIS THA are concerned with the additional risks due to increased
poor visualization of the hip and surrounding anatomy, risks such as thromboembolism,
infection, neurovascular injury, femoral fracture, and component malposition.11–13 By
incorporating NAV along with MIS THA, the additional risks created by poor visualiza-
tion are addressed and better acetabular component placement is achieved.1,4–6,14,15
A meta-analysis of randomized controlled studies found that NAV improves the
precision of acetabular cup placement by decreasing the number of outliers (outliers:
NAV 10.7% vs freehand placement 41.8%14). While there was no statistical difference in
acetabular component placement between NAV vs conventional methods, the incidence
of outliers in terms of cup position was reduced with NAV (outliers: NAV 19.25% vs
conventional 37.66%) and the incidence of postoperative hip dislocation was significantly
reduced (dislocations: NAV 1.03% vs conventional 2.49% 6).
Other authors have also reported good outcomes with NAV-assisted DAA. Kruezer
et al believe that the DAA facilitates MIS THA because of supine patient positioning,
and shorter operative times with NAV-assisted DAA vs conventional THA.1 Nogler et
al found that both NAV and DAA independently reduced variability in acetabular cup
placement, and when combined and the reduction in variability persisted.4,5
Preoperative Planning
The surgeon new to computer navigation will encounter a lot of information. Surgeons
should have a good idea as to the beginning leg position and the reconstructive goal. As an
example, notice the radiographic leg length in Figure 11-1 is short on the operative side.
As long as this is consistent with patient perception and objective leg length evaluation in
the office, one can plan the reconstruction to include some leg length increase.
Registration
Pins are placed in the iliac crest (Figure 11-2). This can be done ipsilaterally or contra-
laterally based on surgeon preference. The authors here have found ipsilateral placement
easier to visualize for the computer and are able to avoid array interference during femoral
broaching fairly easy. Another drill hole is placed in the distal femur; this acts as a con-
sistent reference point to measure leg lengths during the reconstruction (Figure 11-3).

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138 Chapter 11
Figure 11-1. Preoperative radiographic templating and planning to determine

correct stem offset and neck resection level and identify radiographic leg
length discrepancies. It is impor tant in this planning phase to correlate any
radiographic leg length differences to the clinical scenario for proper adjust-
ments if needed during surgery. Usually, leg length increases are conserva-
tive with the computer and about a 3 to 5 mm increase would be acceptable
in this case, as long as the patient looked short on clinical exam as well. In the
event that you are not navigating the femoral component, offset planning is
crucial in this stage to choose the correct stem design and neck option. In this
case, the template does not fully medialize the cup to the medial wall and if
the cup is actually placed fully medialized to the wall then it may be neces-
sary to increase the offset of the stem.
Registration of the ASIS and pubic symphysis is performed to establish the frontal pelvic
plane (Figures 11-4 and 11-5).
Acetabular Placement and Transverse Acetabular

Ligament Registration
Once the acetabulum is registered and prepared for cup implantation, the cup is placed
and navigated into position. The TAL is often visualized and the cup face made parallel
to it during implantation. Alternatively, the TAL plane can be digitized and saved into the
computer with a trial prior to cup placement, then the cup navigated back to that antever-
sion number on final implantation (Figure 11-6 through 11-8).
Leg Length Determination

After hip reduction with trials, determine the leg length position relative to the start-
ing position. For instance, the computer will tell you if the leg length is a negative mm
value (short), a 0 mm value (equal), or a positive mm value (long). In Figure 11-9, we see
the reconstruction is 3 mm longer than the baseline prior to surgical instrumentation,

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Figure 11-2. Two threaded pins are placed in the iliac crest to enter between
the tables. They will solidly fix the pelvic array to the ileum. In the face of
osteoporotic bone, check the array of your navigation system to see if they
will accept a larger diameter pin. In this case, the pins are placed in the ipsilat-
eral side. One can also place the pin on the contralateral side, but the authors
prefer to keep every thing on the operative side and have learned to avoid
the pins and clamp during femoral preparation.
Figure 11-3. The same pin that is used in the ileum is used to drill a unicorti-
cal hole in the distal femur. This hole will act as a stable and direct bony
landmark for leg length determination throughout the case. This procedure
has been performed with very little comorbidity over the past 10 years in
the author’s practice. Occasional mild bruising and even less occasional mild
pain have been reported in the first 1 to 2 weeks postoperatively in a paucity
of cases. No pin site fractures have ever occurred in the authors' practice from
this procedure.

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140 Chapter 11
Figure 11-4. Registration of the left ASIS is performed. This landmark can be
somewhat elusive in the obese patient. If these anatomic points are regis-
tered poorly, you can see inaccurate inclination angles for the acetabular
component. This process is not difficult in most patients and takes very little
time.
Figure 11-5. Registration of the right ASIS is performed for this planned
left THA. With this system the left ASIS is registered first regardless of the
planned operative side. Even through the drapes, the ASIS is typically readily
available.

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Figure 11-6. Once registered, the approach is carried out. The neck cut is
made and the head is removed. There is typically a registration process of
the inside of the acetabulum, which is efficiently completed, and then ream-
ing and cup placement is carried out. Navigation of the reaming process has
proven to be unnecessary and time consuming in the authors' practice and
thus has been eliminated from the workflow. However, these navigation
workflows are fully customizable and you can include as much or as little as
desired. We have found over the years that navigated acetabular reaming
does not add valuable information to the case as the acetabular anatomy is
easily visualized through the anterior approach.
Figure 11-7. The navigation screen for cup placement will look something like
this with nearly all systems. Inclination and frontal pelvic plane anteversion
are usually displayed. Seating depth can be navigated if desired but again
found to be unnecessary typically. With no-hole cups, one may want to con-
sider seating depth but would have to at least register the last reaming depth
to do so. This actually doesn’t add very much time and can be useful when
using cups without screw holes.

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142 Chapter 11
Figure 11-8. Final cup placement shows a well- covered anterior rim of the
cup and a cup face that is parallel to the plane of the TAL. This happens to
be the preferred method of anteversion determination in most cases except
dysplastic cases. In this par ticular case, the author used the well-registered
frontal pelvic plane for anteversion guidance as seen on the previous cup
placement screen in Figure 11-7.
consistent with the preoperative planning which shows some existing leg length shorten-
ing (Figures 11-9 and 11-10).
Final Evaluation
At the end of the case, one can take a flat plate radiograph by placing a flat x-ray plate
on the leg spars of the orthopedic table, using a portable x-ray machine. One can also use
1 to 2 seconds of fluoroscopy if desired to have confirmation and correlation of the com-
puter data and what you will see on postoperative x-rays (Figures 11-11 through 11-13).
This is especially important in the beginning of a surgeon’s experience with computer
navigation as it allows the numbers being interpreted to be correlated with the x-ray view
and can provide confidence in the new information presented. This also allows simulta-
neous visualization of the stem alignment and is offset if stem navigation was not used
during the navigation of the case.
Stem Alignment and Offset Navigation

Stem navigation can be added to the computer navigation process by changing the
workflow on the system and providing more preregistration information. Typically navi-
gation arrays must be fixed on the distal femur and/or additional tracker devices attached
to the stem to allow stem alignment and femoral-pelvic offset to be measured. Some
systems allow a generic femoral offset to be measured relatively efficiently by digitizing
points on the proximal and distal femur to provide femoral offset information only. In
order to navigate stem varus and valgus, you must attach a tracker to the stem or have the
dimensions of the stem in question stored in the computer software for reference.

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Figure 11-9. In this case example, the added leg length to the preoperative sit-
uation is 3 mm. This was within the preoperative template plan and if stable,
will be accepted. If global subluxation occurs without impingement and the
preoperative offset has been reproduced, then more length is needed given
the preoperative shortening of the diseased hip. Of course, routine stability
evaluation should be performed to exclude neck impingement in the func-
tional range of motion planes and component adjustments can be made if
necessary. Femoral offset at this point is usually confirmed with an AP pelvis
film or quick fluoroscopy shot. Alternatively, the surgeon can navigate the
femur for this information as discussed in the body of the chapter.
Figure 11-10. Now, after femoral preparation, the author will check leg length
by going back to the lateral cortex drill hole and placing the tip of the pointer
into it. The computer is looking for the position of the tip of the pointer and
therefore the angle of the pointer with the femur is kept relatively perpen-
dicular but exact angles are not clinically impor tant for accurate leg length
measurements.

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144 Chapter 11
Figure 11-11. In the event that the surgeon would like to take an x-ray while
using the orthopedic table, the plate can be placed on the leg spars under
the pelvis for radiographic evaluation.
Figure 11-12. A standard x-ray is then taken with protective temporary drap-
ing and lowering of the bed to obtain proper magnification.
In our experience, with DAA THA using the orthopedic table, single x-ray image or
a simple generic registration process can evaluate femoral alignment and offset, when
compared to the more time-consuming exercise of multiple trackers for the same deter-
minations. The orthopedic table allows for very efficient use of x-ray or fluoroscopy for
stem alignment and femoral-pelvic offset compared to the contralateral hip, with very
little time added to the case. Conversely, we have found that cup position and leg length
are very accurate with computer navigation. On a traditional flat OR table, intraoperative
x-ray may be cumbersome; in this setting, computer navigation of femoral stem alignment
and offset may be more advantageous.

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Figure 11-13. The result of the x-ray is shown. The cup was placed just shy of
the medial wall as it was template and therefore the offset is within accept-
able range of the preoperative position. The radiographic leg length is
corresponding to the navigated 3 mm leg length increase. Stability checks
are performed and final stem implantation with leg length confirmations is
performed.
Arguments for or against the use of computer navigation in conjunction with DAA
THA may be related to unfamiliarity, costs, and related variables. Accordingly, the use
of fluoroscopy navigation during DAA THA is still very popular. Although fluoroscopy
navigation is usually somewhat less efficient than computer navigation, it can be just as
accurate and precise as computer navigation in the hands of a well-trained surgeon.
The use of robotic assistance for DAA THA may increase in the future, but this tech-
nology is more expensive than computer navigation. Functionally, the robot is very accu-
rate and precise given that it uses a fundamentally image-based technology. We predict
that this technology may see increased adoption as costs decline and software accuracy
and ease-of-use are improved. At present, robotic technology can be very time consuming
but also can be used efficiently with experience, even with the orthopedic table.
When using an orthopedic traction table or attachment, the foot is not readily avail-
able for leg length comparison but the pelvis is accessible. Therefore, the combination of
computer-guided cup alignment and leg length determination, with x-ray or fluoroscopic
confirmation of femoral stem offset and femoral component alignment, is an accurate and
time efficient method. When traditional OR tables are used for DAA THA, both lower
extremities are available for direct manual leg length comparison. Even so, we believe
that the precision in computer navigation leg length determination is superior to visual
estimation, and we therefore advocate the use of computer navigation in all DAA THA,
whether done on a traction table or other wise.

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146 Chapter 11
Computer navigation can be a time efficient, accurate, and precise measurement tool
for acetabular component inclination, femoral component alignment, femoral-pelvic
offset, and leg length determination in DAA THA, whether using an orthopedic
table or traditional OR table.
Acetabular cup anteversion is not always accurately or precisely predicted by computer
navigation. Alignment using anatomic identification such as the TAL plane should
be considered for a more functional cup anteversion determination or if there is any
question of the registration accuracy of the frontal pelvic plane.
Robotic-assisted THA is theoretically more accurate and precise for cup inclination as
well as anteversion planning and positioning than computer navigation, reflecting the
inherent accuracy difference between image-based and imageless navigation systems.
Robotic THA requires preoperative CT data and has a steep learning curve when
compared to computer navigation. So far, robotic THA has not matched the very
accurate leg length determination that computer navigation is able to offer.
With major orthopedic vendors interested in guidance technologies, we predict that
intraoperative component guidance, whether image-based or not, will continue to
grow and the use of computers and/or robotics will become popular in the future.
1. Kreuzer S, Leffers K. Direct anterior approach to total hip arthroplasty using computer navigation. Bull
NYU Hosp Jt Dis. 2011;69(Suppl 1):S52-S55.
2. Pinoit Y, May O, Girard J, Laffargue P, Ala Eddine T, Migaud H. Low accuracy of the anterior pelvic plane
to guide the position of the cup with imageless computer assistance: variation of position in 106 patients.
Rev Chir Orthop Reparatrice Appar Mot. 2007;93(5):455-460.
3. Mayr E, Kessler O, Prassl A, Rachbauer F, Krismer M, Nogler M. The frontal pelvic plane provides a valid
reference system for implantation of the acetabular cup: spatial orientation of the pelvis in dif ferent posi-
tions. Acta Orthop. 2005;76(6):848-853.
4. Nogler M, Mayr E, Krismer M, Thaler M. Reduced variability in cup positioning: the direct anterior surgi-
cal approach using navigation. Acta Orthop. 2008;79(6):789-793.
5. Nogler M, Kessler O, Prassl A, et al. Reduced variability of acetabular cup positioning with use of an image-
less navigation system. Clin Orthop Relat Res. 2004;(426):159-163.
6. Moskal JT, Capps SG. Acetabular component positioning in total hip arthroplasty: an evidence-based
analysis. J Arthroplasty. 2011;26(8):1432-1437.
7. DiGioia AM, Jaramaz B, Blackwell M, et al. The Otto Aufranc Award. Image guided navigation system to
mea sure intraoperative acetabular implant alignment. Clin Orthop Relat Res. 1998;(355):8-22.
8. Chimento GF, Pavone V, Sharrock N, Kahn B, Cahill J, Sculco TP. Minimally invasive total hip arthro-
plasty. J Arthroplasty. 2005;20(2):139-144.
9. Rachbauer F, Krismer M. Minimally invasive total hip arthroplasty via direct anterior approach. Oper
Orthop Traumatol. 2008;20(3):239-251.
10. Reininga IH, Zijlstra W, Wagenmakers R, et al. Minimally invasive and computer-navigated total hip
arthroplasty: a qualitative and systematic review of the literature. BMC Musculoskelet Disord. 2010;11:92.
11. Berry DJ, Berger RA, Callaghan JJ, et al. Minimally invasive total hip arthroplasty. Development, early
results, and a critical analysis. Presented at the annual meeting of the American Orthopaedic Association,
Charleston, SC, June 14, 2003. J Bone Joint Surg Am. 2003;85-A(11): 2235-2246.
12. Pagnano MW, Leone J, Lewallen DG, Hanssen AD. Two-incision THA had modest outcomes and some
substantial complications. Clin Orthop Relat Res. 2005;(441):86-90.

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13. Woolson ST, Mow CS, Syquia JF, Lannin JV, Schurman DJ. Comparison of primary total hip replacements
performed with a standard incision or a mini-incision. J Bone Joint Surg Am. 2004;86-A(7):1353-1358.
14. Gandhi R, Marchie A, Farrokhyar F, Mahomed N. Computer navigation in total hip replacement: a meta-
analysis. Int Orthop. 2009;33(3):593-597.
15. Kalteis T, Handel M, Herold T, Perlick L, Baethis H, Grifka J. Greater accuracy in positioning of the
acetabular cup by using an image-free navigation system. Int Orthop. 2005;29(5):272-276.

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12
Transitioning to
Direct Anterior
Total Hip Replacement
Blake E. Peterson, MD; Joseph Morgan, MD;
and B. Sonny Bal, MD, JD, MBA
Most arthroplasty surgeons are familiar with direct, rather than indirect, visualization
of the operative field during total hip arthroplasty (THA).
Modifying the direct anterior approach (DAA) to facilitate unhindered, direct visual-
ization of the relevant anatomy at each step can contribute to safe and rapid adoption
of the technique by surgeons already familiar with other standard approaches.
Authors present a step-wise, logical approach to executing DAA THA, with instru-
ments already used in other total hip techniques and avoiding the use of intraoperative
fluoroscopy entirely.
The 2-incision THA technique has been developed and modified as a minimally-
invasive method with less pain and earlier hospital discharge.1–3 The technique is dif-
ficult, however, with limited visualization of the surgical field, leading to complications
and abandonment of the operation by many surgeons.4–6 Today, few, if any, surgeons still
perform the 2-incision THA technique that was described by Berger.1
One reason for early complications with 2-incision THA, despite the sporadically-
reported good results, was insufficient training of arthroplasty surgeons. Traditional
THA approaches have emphasized open, expansive exposure and visualization of the
relevant anatomy with direct, tactile feedback. Hip joint dislocation, for example, is part

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150 Chapter 12
of most standard lateral decubitus THA methods, and other steps, such as acetabular
reaming and femoral preparation are done under direct, unfettered vision. The tactile feel
of tissues, reaming, impaction of guides, and related biomechanical steps also guide the
surgeon during the early experience. Later, these steps become part of experience, muscle-
memory, and acquired art of performing safe, predictable THA surgery.
The 2-incision THA entails fluoroscopic, rather than direct, visualization and the
tactile feedback is absent or very different than standard THA. It may be possible to
master the 2-incision technique, but only after a steep learning curve marked with com-
plications.7 In the authors’ experience, after overcoming the learning curve, a consecutive
series of over 250 primary 2-incision THAs showed predictable outcomes, with consistent
patient satisfaction, low complication rates, and implant positioning that was similar to
standard, open techniques.8
One pitfall in executing 2-incision THA relates to the potential for misinterpreta-
tion of intraoperative fluoroscopic data. Minor changes in pelvic position during surgery
can alter the fluoroscopic appearance of the socket and reamer, for example. Likewise,
fluoroscopically-guided preparation of the femur and assessment of femoral stem size is
novel for the arthroplasty surgeon accustomed to traditional approaches. In comparison,
orthopedic trauma surgeons use fluoroscopy routinely during pelvic surgery and may be
more comfortable with it. Early in our experience with 2-incision THA, satisfactory fluo-
roscopy images intraoperatively were sometimes contrary to what was seen on postopera-
tive x-rays; this difference related to a lack of familiarity with interpreting fluoroscopic
data or inability to compensate for changes in pelvic position.
Our transition to safe 2-incision THA required a change in the original Berger opera-
tion1 to a direct-vision variation that did not rely on fluoroscopy and was closer to the
DAA procedure described by Keggi et al9 This allowed direct visualization of socket posi-
tion and its relation to the acetabular anatomy ensuring accurate cup placement in the safe
zone advocated by Lewinnek et al10 Moreover, direct vision of the proximal femur reduced
the risk of stem malposition, proximal femur fracture, and sizing errors.8
The first step in making the leap to DAA THA is identification of an experienced
mentor. A site visit with exposure to at least 4 or 5 total hip replacements is advisable. We
prefer using the Hana fracture table (Mizuho OSI); this requires training and familiarity
with the technology, especially the femur hook system that permits power-operated eleva-
tion and exposure of the proximal femur. Cadaver training, attendance at a specialized
DAA course, and a thorough review of the thigh anatomy are also requisite steps before
making the transition. Practical steps to ensure patient safety, in addition to technique
reliability and consistency, are listed as follows.
We prefer to use the Hana fracture table for DAA THA because the device is like a
retractor that can help exposure and reduce the need for human retraction. The surgi-
cal team should be very familiar with the table and its various controls to ensure patient

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Transitioning to Direct Anterior Total Hip Replacement 151
Figure 12-1. Simplified draping with a hip frac-

ture plastic drape.
safety and proper positioning. Operating room personnel and/or the implant representa-
tive should also receive training in safe patient positioning and leg manipulation during
surgery. Proper padding and securing of the feet is an important step. With experience,
patient positioning on the Hana table is faster and easier than lateral decubitus positioning
for posterior THA.
Once the thigh is prepped, a large, iodine-impregnated, self-sticking plastic isolation
drape that is commonly used for hip fracture fixation will isolate the field in one step
(Figure 12-1). This drape design is large enough to ensure a sterile field almost over the
entire patient. Over this layer we place a large abdominal paper drape with the opening
positioned over the thigh. The pouch built into the plastic drape is pulled out over the
opening in the abdominal drape. This completes the draping step, with the exception of
smaller drapes placed over the upper limbs, if necessary.
The upper extremities are placed to the sides or crossed over the chest and secured.
Any overhanging abdominal pannus should be securely taped out of the way. Surgeons
accustomed to the complex rituals of draping the leg in the lateral decubitus position will
appreciate the simplicity of DAA draping. For bilateral operations, one can repeat the
draping step on the opposite hip following completion of the first hip, or prep and drape
both sides simultaneously.
Before draping, the assistant should manipulate the leg to make sure the foot is secured
properly, and that the limb can be moved freely. Ensure that both legs are in comparable
positions; slight hip flexion of about 5 degrees will ease later retraction. Palpate both
patellae to get a sense of existing leg lengths. Operate the motorized hook spar on the
table to ensure that it works.
Proper incision placement for DAA THA has been addressed by many authors11–13;
we have found more wound healing problems if the incision crosses the inguinal crease.
Avoid this problem by curving the proximal part of the incision laterally (Figure 12-2).
With the anterior superior iliac spine identified by palpation, the proximal extent of the
incision should be about 2 to 3 cm lateral and distal to this anatomic point, and at least
10 to 15 cm in length to allow direct vision. Recovery from DAA THA is independent of
incision length, and for the arthroplasty surgeon accustomed to direct (not fluoroscopic)
vision, it is safer to have a longer incision, at least early in the learning experience.

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152 Chapter 12
Figure 12-2. Curved incision (right hip) avoids crossing ingui-

nal crease and leads to fewer wound healing problems.
The fascial split must be done over the tensor fascia lata (TFL) muscle belly; the easi-
est way to ensure this is to retract the subcutaneous tissues and identify the muscle belly
through the thin, translucent fascia. Retraction is facilitated by having one assistant stand
on the opposite side of the surgeon and another standing next to the surgeon toward the
head of the table. With experience, one assistant will suffice. If the fascial layer appears
white and feels relatively firm, the dissection is too far lateral and exposure will be diffi-
cult. In that case, it is best to work further medial and identify the proper point of making
the fascial incision, before retracting the tensor laterally with a cobra retractor.
It is possible to inadvertently stray medial to the sartorius muscle, close to the neurovas-
cular bundle containing the femoral artery and nerve. If this happens, subsequent lateral
retraction will be harder, with increased risk of femoral nerve palsy. Accordingly, take
time to confirm that initial entry is in the proper plane. One tip is to extend the incision
distally, if in doubt, and observe the course of the sartorius as it separates from the TFL.
Another tip is that retraction of the TFL with a cobra retractor placed lateral to the hip
capsule is a very easy step, occurring in natural anatomic planes. Difficulty encountered
with this step may indicate retractor placement medial to the sartorius muscle, and this
error must be corrected.
The rectus muscle is elevated off the anterior hip capsule and retracted medially. Early
on, it is easiest to detach the reflected head of the rectus muscle origin from the capsule
and the acetabular rim, in favor of proper visualization of the acetabular rim. A tag suture
can be used to easily identify the rectus tendon, for later reattachment to the lateral cap-
sular flap, if deemed necessary, although in our experience, detachment of the reflected
rectus origin has had no noticeable impact on clinical recovery.
Some surgeons have observed more blood loss with DAA hip replacement, when com-
pared with other methods.14 Even experienced surgeons may encounter sporadic cases
with greater blood loss than expected. This phenomenon probably relates to insufficient
preemptive control of the vascular leash of the ascending branches of the lateral circum-
flex artery. First, this group of blood vessels must be identified before further dissection

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Figure 12-3. Identify and coagulate the cir-

cumflex vessels, shown here (right hip) at the
cautery tip. Failure to preemptively address
this leash of vessels will lead to increased
blood loss.
(Figure 12-3). Second, when the surgeon is satisfied that the vessels have been sufficiently
coagulated, a useful tip is to double the amount of cautery time. The reason is that the
vessels are usually larger and more numerous than they appear. Incomplete coagulation
(authors have not found it necessary to ligate the vessels), premature division of the vessels,
and their retraction into the adjacent muscles will lead to a steady ooze, more difficult
exposure, and increased blood loss.
Even after coagulation, a vigilant eye must be kept on wound oozing; the source is usu-
ally the location of the lateral circumflex vessels. If bleeding continues, retract individual
muscle bellies and identify the bleeding lumen of the vessels before repeat coagulation.
Alternatively, a retracted bleeding vessel can be over-sewn with a needle-stitch. Patience
at this stage will improve the rest of the operation and avoid a later struggle to gain vision
in a bleeding field. It is also useful to return to recheck these vessels at the end of the
case as the joint is closed. This will ensure that there is no ongoing bleeding following
the procedure.
Following capsular dissection, the femoral head and neck will come into view. Have the
assistant rotate the leg a few times to get oriented to the anatomy. Further exposure will
usually require excision of at least a part of the hip capsule that is fibrotic and thickened.
In hips that have undergone a previous arthroscopy, expect a more difficult capsular dis-
section. To gain safe exposure, remove as much of the capsule as is needed. The effect
of capsular repair on hip stability following DAA total hips is unclear. The use of large
diameter heads (32 and 36 mm), in addition to proper anatomic implant positioning using
the DAA, results in very low dislocation risk. In our experience, postoperative anterior
total hip dislocation has occurred at a rate of about 1/500 cases following DAA THA.
Once the hip joint is exposed, have the assistant rotate the leg externally. This relieves
tissue pressure, eases further dissection, and optimizes exposure. Also, the movement of
the femoral neck and head serves to orient the surgeon to the anatomy. We usually chisel
out 3 to 5 mm of the superior lateral acetabular rim at this stage. This rim is overgrown
with osteophytes in many patients or is prominent from underlying hip impingement
anatomy. The calcified labrum is adherent to the acetabular rim, and chiseling off the rim
will facilitate the next step (ie, anterior dislocation of the femoral head).

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154 Chapter 12
Figure 12-4. Identification of the lesser tro-

chanter (left hip) assists in femoral cut accu-
racy, and offers an easy landmark to guide
further surgery. Here, level of resection is mea-
sured off the lesser trochanter and marked
with a purple pen. The femoral head has been
dislocated using a corkscrew.
Ensure that the hip capsule is sufficiently released medially over the femoral head; a
scalpel or cautery can help with this step. Drill and thread a corkscrew into the externally-
rotated femoral head, and simply lift it up and out anteriorly, while the assistant applies
gentle traction to the limb. We prefer the dislocation step since surgeon visualization is
improved. Also, femoral head dislocation is a familiar step to arthroplasty surgeons accus-
tomed to other standard approaches. In addition to improving direct visualization, it has
been our experience that anterior dislocation of the femoral head partially peels away the
posterior capsule, thereby making subsequent femoral exposure easier.
Many surgeons template the femoral neck cut in relation to the position of the lesser
trochanter. Accordingly, exposure of the lesser trochanter is desirable, as a reference point
and to ensure medial capsular release, which is necessary to safely expose the proximal
femur for stem insertion. After the lesser trochanter is identified, a ruler can measure up
to the planned level of the femoral neck cut (Figure 12-4). We begin the femoral neck cut
medially, using a reciprocating saw. This cut is angled up and laterally to join a second ver-
tical cut that is placed medial to the greater trochanter. Operating under direct vision—in
a manner familiar to surgeons accustomed to other THA approaches—facilitates safety
and confidence building during the learning phase of DAA total hip surgery.
Preparation of the acetabulum begins with placement of spiked retractors (preferably

illuminated) around the acetabulum. The surgeon should obtain circumferential vision of
the acetabulum to ensure safe preparation. With practice, a pair of Gelpi retractors can
be positioned at 90 degrees to each other for retraction, with the sharp end of one such
retractor placed inside the osteotomized femoral neck to help retract it.

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A B
C D
Figure 12-5. Placement of a hemispherical guide into native socket (right hip) allows accurate placement
of an accessory thigh portal to introduce a cannula through which reamer handles are placed. Once the
cannula is introduced, the reamers are placed in the acetabulum, and then connected to a handle passed
through the cannula.
Accessory incisions can be used to facilitate acetabular reaming. Orthopedic vendors

(eg, Microport) have special acetabular instruments designed for this purpose. These
instruments allow a hemispherical guide to be placed in the native acetabulum, which
then guides accessory incision placement just anterior to the femur. Through this skin
opening, a special cannula is passed and a reamer is dropped into the acetabulum. The
reamer is then engaged to a keyed reamer handle placed through the cannula and reaming
is performed under direct vision, with no pressure on anterior thigh tissues and no risk of
eccentric reaming of the anterior acetabular wall (Figure 12-5).
The previous steps are recommended to improve safety, minimize surgeon workload,
and avoid the use of complex offset reamers and inserters that may have very different
tactile feedback than straight-handled instruments with which most surgeons are accus-
tomed. When reaming is completed in our method, the acetabular component is dropped
in, and impacted in place with a straight handle passed through the cannula. The poly-
ethylene liner is implanted in the same manner. The cannula is withdrawn, leaving a small
skin opening that can be closed with a few stitches, or even left open.
To ensure proper acetabular position under direct vision, we identify, retain, and refer-
ence the transverse acetabular ligament as a useful landmark for accurate cup antever-
sion.15,16 Second, the circumference of the native socket can guide appropriate acetabular
position, in the absence of anatomic anomalies. Third, standard outriggers connected to
straight impactor handles can guide the surgeon to 45 degrees of abduction and 15 degrees
of anteversion of the cup. Fine adjustments to a seated cup can be made with a bone tamp

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156 Chapter 12
Figure 12-6. Cautery points to saddle of greater

trochanter, stripped of soft tissue attachments.
This level of release is needed for safe femoral
mobilization and visualization.
and mallet applied to the cup edges. The cup’s seating depth against the acetabular dome
can be directly palpated through the cup insertion hole centrally and additional impaction
can be applied if needed.
With modern press-fit cups, there is little need for acetabular screw placement, espe-
cially in light of the well-known risks of errant acetabular screws.17 The method of ace-
tabular component placement described here leads to easier learning for the novice DAA
THA surgeon and avoids intraoperative imaging.
Maximally internally rotate the femur and slide the appropriate-sided femoral hook
around the femur, adjacent to the proximal insertion of the vastus. After this step, maxi-
mally externally rotate the femur to allow capture of the proximal femur by the hook.
Secure the hook to a hole in the elevator and raise the elevator until the tissues are under
slight tension. With no traction, lower the foot, while in external rotation, about one-
third of the way to the floor. Next, place a lighted Hohmann retractor around the lesser
trochanter (the anterior part of this structure was subperiosteally exposed earlier). Ensure
the medial capsule is sufficiently peeled off, while preserving the insertion of the iliopsoas
onto the lesser trochanter. Place a large Hohmann retractor or femoral elevator (several
orthopedic implant manufacturers make an instrument specifically for this step) outside
the superior hip capsule, thereby lifting up the proximal femur slightly. A surgical sponge
placed between the retractor and the skin edges will protect the skin and avoid wound
problems.
Starting laterally, the hip capsule must be released off the femur with a long cautery
blade, bent as necessary. The release must be carried posteromedially, far enough to clear
the so-called saddle of the greater trochanter (Figure 12-6). At every step, the assistant
should gently externally rotate the femur; an incremental gain in external rotation can be
seen under direct vision as the capsular release progresses. Also, a visible lifting of the
proximal femur and its delivery into the surgical field will occur when the last bit of cap-
sular release is completed. In the author’s experience, if these steps are carried out under
direct vision, and each step is executed with care and patience, the risks of trochanteric
fracture are minimal.

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Figure 12-7. Insertion of a short, modular stem

is ideal for anterior THA. Such stems are avail-
able from a number of vendors.
Figure 12-8. Final insertion of a modular neck;

modularity of the neck segment allows fine
adjustment of leg lengths and hip offset. Note
direct visualization of the calcar and proximal
femur.
In patients with long-standing hip contractures or heavy thigh musculature, have the
assistant adduct the leg slightly, and have the scrub tech push in on the ipsilateral patella
gently; both moves will improve proximal femoral visualization. This visualization must
be gained before attempting femoral preparation. The key is to proceed stepwise, method-
ically, and with patience to gain exposure. No retractor should ever be used to force expo-
sure; the proximal femoral release in DAA total hips is an art in that it demands surgeon
attention to soft tissue detail. Finally, in some hips, lowering the bone hook slightly from
its maximum elevated position can relax tissues just enough to allow another few degrees
of external rotation that can make all the difference.
Once the femur is sufficiently exposed, use a sharp, curved, handheld awl to identify
the femoral canal. Each broach should be worked back and forth by hand, opening the
canal and lateralizing the opening. This step, done under direct vision, will avoid the
risk of inadvertent canal perforation. We broach for a short stem design, taking care to
lateralize the broach every time it is impacted into the femur to help achieve proper stem
position (Figure 12-7).
We prefer to use a modular neck stem (Preserve, Microport Orthopedics); although with
concerns about neck modularity, a fixed-neck version may be used as well (Figure 12-8).
The modular neck allows fine-tuning of version, leg lengths, and offset. Insert a trial

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158 Chapter 12
head, remove all retractors, and have the assistant internally rotate the leg 5 to 10 degrees
before raising the foot. At this stage, insert a small bone hook around the prosthetic neck;
this simple step gives the surgeon control over the hip reduction, achieved with gentle
traction and internal rotation. During this step, place a finger on the trial head, to avoid
it being dislodged and lost in the tissues.
Leg lengths are readily checked by comparing patella positions, and maximum external
rotation of the leg checks for anterior hip stability. The value of flexing the hip to check
for posterior hip stability, or checking for “shuck” laxity is variable and uncertain; we do
not use these steps. If offset and leg length are restored, based on careful presurgical plan-
ning, and accurate execution of intraoperative surgical steps, then hip stability is never an
issue. Increasing leg lengths in a misguided attempt to improve stability will lead to an
unhappy patient.
After final checks, particularly to check for any residual bleeding, closure is straightfor-
ward. An advantage of the DAA approach is that the fascia lata is not disrupted, thereby
avoiding the tedious repair of this structure common to other approaches. Subcutaneous
stitches must be kept to a minimum and branches of the lateral femoral cutaneous nerve
should be kept away from sutures to minimize the risk of thigh numbness.
Our first 89 fluoroscopically-assisted, 2-incision minimally-invasive THAs (MIS

THAs) were associated with a steep learning curve and complications.4 We reported
even minor, transient thigh numbness as a complication, although this phenomenon is
now an accepted and clinically insignificant side-effect of DAA surgery. The subsequent
250 2-incision MIS THAs had very satisfactory outcomes; during this learning, we had
adopted each of the steps described previously.8 Peer-review journals of the era were keen
to publish complication data, but proved considerably less enthusiastic about publishing
any good outcomes from the 2-incision experience.
When the transition to single-incision DAA THA was made, the strategy of direct
visualization of each surgical step ensured satisfactory outcomes from the outset. A recent
comparison between DAA surgeons at our institution (one arthroplasty surgeon who
relied on direct vision as described here, and one trauma surgeon who relied on fluoros-
copy) showed comparable accuracy in acetabular component position.18
A step-wise THA DAA method based on familiar instruments, sufficient vision, and
avoiding intraoperative fluoroscopy is easier to learn.
A mentorship with a senior, experienced hip surgeon, cadaver training, attendance
at a DAA course, and knowledge of anatomy are essential preparatory steps before
embarking on DAA THA.

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Recovery from DHA THA is independent of incision length; the incision should be
as long as needed to assure sufficient visualization of the anatomy.
Direct visualization of each surgical step, in our experience, is as good as intraopera-
tive fluoroscopy.
1. Berger RA. Total hip arthroplasty using the minimally invasive two-incision approach. Clin Orthop Relat
Res. 2003;417:232-241.
2. Berger RA, Duwelius PJ. The two-incision minimally invasive total hip arthroplasty: technique and results.
3. Berger RA. The technique of minimally invasive total hip arthroplasty using the two-incision approach.
Instr Course Lect. 2004;53:149-155.
4. Bal BS, Haltom D, Aleto T, Barrett M. Early complications of primary total hip replacement with a two-
incision minimally invasive technique. J Bone Joint Surg Am. 2005;87(11):2432-2438.
5. Feinblatt JS, Berend KR, Lombardi AV Jr. Severe symptomatic heterotopic ossification and dislo-
cation: a complication after two-incision minimally invasive total hip arthroplasty. J Arthroplasty.
2005;20(6):802-806.
6. Pagnano MW, Leone J, Lewallen DG, Hanssen AD. Two-incision THA had modest outcomes and some
substantial complications. Clin Orthop Relat Res. 2005;441:86-90.
7. McMinn DJ, Daniel J, Pynsent PB, Pradhan C. Mini-incision resurfacing arthroplasty of hip through the
posterior approach. Clin Orthop Relat Res. 2005;441:91-98.
8. Bal BS, Barrett MO, Lowe J. A modified two-incision technique for primary total hip replacement.
Seminars in Arthroplasty. 2005;16(3):198-207.
10. Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR. Dislocations after total hip-replacement
arthroplasties. J Bone Joint Surg Am. 1978;60(2):217–220.
11. Post ZD, Orozco F, Diaz-Ledezma C, Hozack WJ, Ong A. Direct anterior approach for total hip arthro-
plasty: indications, technique and results. J Am Acad Orthop Surg. 2014;22(9):595-603.
15. Fujita K, Kabata T, Maeda T, et al. The use of the transverse acetabular ligament in total hip replacement:
an analysis of the orientation of the trial acetabular component using a navigation system. Bone Joint J.
2014;96-B(3):306-311.
16. Inoue M, Majima T, Abe S, et al. Using the transverse acetabular ligament as a landmark for acetabular
anteversion: an intra-operative mea surement. J Orthop Surg (Hong Kong). 2013;21(2):189-194.
17. Valle AG, Zoppi A, Peterson MG, Salvati EA. Clinical and radiographic results associated with a modern,
cementless modular cup design in total hip arthroplasty. J Bone Joint Surg Am. 2004;86-A(9):1998-2004.
18. Peterson BE, Crist BD, Aleto TJ, Bal BS. The use of fluoroscopy in aiding acetabular cup position in direct
anterior total hip arthroplasty. Podium presentation at: International Congress for Joint Reconstruction,
2nd Annual Pan Pacific Orthopaedic Congress; July 22-25, 2015. Kona, HI.

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13
Specialized Instruments for
the Direct Anterior Approach
Dan Gerscovich, MD; Anthony S. Unger, MD; Evan Smith, MD;

Kristaps J. Keggi, MD, Dr Med (hc); and Lee E. Rubin, MD
During direct anterior approach (DAA) total hip arthroplasty (THA), selection of
an operative table plays an important role in patient positioning and overall surgical
technique.
Specialized instruments for DAA THA have evolved from the earliest days of THA,
when only a limited number of straight acetabular gouges and straight femoral rasps
were available.
A surgeon should assemble a basic set of instruments for DAA THA that might
include, for example, curved retractors, large bone hooks, a femoral spoon, and curved
scissors.
Complete modular reaming and broaching sets are now available from nearly every
orthopedic implant manufacturer to assist with DAA THA.
Since Judet described his anterior hip approach in the 1950s to “avoid all damage
to muscle and bone,”1 there has been an increased interest in muscle sparing surgery.
Originally described by Hueter in 1881, the approach is through a true intermuscular
and interner vous plane, found between muscles innervated by the femoral and superior
gluteal nerves, respectively. Variants include the Smith-Petersen extensile approach and
the 2-incision approach to THA.2 As the DAA approach for THA does not violate any


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162 Chapter 13
Figure 13-1. Original image of the 1978 Howmedica Keggi Anterior Hip Rasp
Set. (Reprinted with permission from Waterbury Hospital OR Archive.)
hip musculature, the operative field can be deep, and specialized instruments have been
developed to help with surgical exposure.
Judet and Judet in the 1950s used straight instruments with a 15-cm incision.1 Modern
instruments are longer, narrower, and have offset or curved handles to relieve stresses on
the surrounding soft tissues and allow comfortable retraction and better visualization.
With input from pioneering early DAA surgeons, an orthopedic vendor (Howmedica)
offered a set of non-modular, single offset, cast chrome femoral rasps that were sold start-
ing in 1978 as the Keggi Anterior Hip Rasp Set. This was the first standardized set of com-
mercially available instruments made specifically for DAA THA (Figure 13-1).
Despite improvement and standardization in femoral broach offset in the 1970s
and 1980s, the broach rasps remained too long and posed risks for femoral perforation
during initial femoral canal instrumentation. To address this, modern starter broaches
are a part of nearly every instrument set today. Next, the broach handles were rounded
and difficult to impact effectively, so new strikeplates were developed to improve impact
force delivery and help the surgeon achieve more meticulous control of anteversion. This
became an essential feature of the instruments as press-fit femoral fixation demanded
greater accuracy during the femoral broaching process.
Later on, modular attachments for femoral preparation became available as manufac-
turing methods improved. The Bio Fit modular DAA broach handles were produced by
the Richards Corporation in 1982 for the United States launch of the Mittelmeier Hip
System (Figure 13-2). Rasps gave way to broaches to compact bone in preparation for
press-fit stem fixation and sizing options improved and expanded.
In addition to the customized options in metal surgical instruments, there has been an
evolution of adjunctive technologies in lighting, tissue protection, and patient positioning.
When considered together, these tools have dramatically improved visualization of the
acetabulum and femur, thereby allowing surgeons to use smaller incisions during DAA
THA and deliver the benefits of true minimally invasive surgery (MIS).3

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Specialized Instruments for the Direct Anterior Approach 163
Figure 13-2. Earliest known modular single offset broach handles used for the
DAA, developed by Dr. Keggi in conjunction with the Richards Corporation
for the United States release of the Mittelmeier Hip System in 1982. (Reprinted
with permission from Waterbury Hospital OR Archive.)
Figure 13-3. Maquet ALPHASTAR Radiolucent

Table (Getinge Group), with illustration lines
demonstrating the ability to extend the bed
downward at the hip joint.
Many surgeons perform the DAA on standard tables with soft tissue releases to deliver
the femur for broaching and preparation. Examples of these include a regular operat-
ing room (OR) bed, a radiolucent Maquet table (Figure 13-3), or a regular table with an
ARCH leg extension (Innovative Orthopaedic Technologies). The setup includes placing
a bump or gel pad underneath the pelvis, ending at the ischium, and lowering the bottom

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164 Chapter 13
Figure 13-4. Patient positioned on Maquet bed

in preparation for a left DAA THA. Note the
gel bump is beneath the ischium, allowing the
gluteal tissues to fall away from the anterior
field.
half of the bed to allow extension at the hip joint; the patient’s hip is positioned at the
break in the table (Figure 13-4). Some surgeons prefer positioning the operating table so
that the upper half is in Trendelenburg and the lower half is in reverse Trendelenburg.4
An accessory arm-board is placed lateral to the nonoperative (contralateral) leg to allow
abduction of that leg and thereby facilitate adduction of the operative leg for femoral
preparation.5
Fracture tables can simplify and standardize delivery of the proximal femur for broach-
ing. These tables suspend the legs in traction boots and allow motorized manipulation of
the operative leg to expose the proximal femur. The most common model includes the
Hana (Mizuho OSI) traction table. The ARCH and the AMIS (Medacta) mobile leg
positioners are extensions to a standard table and allow traction, rotation, and manipula-
tion of the operative leg in a method similar to fracture tables.
Utilizing a radiolucent table or a fracture table also provides the potential advantage of
obtaining spot radiographs, or dynamic fluoroscopic evaluation of trials and implants for
leg length and position. In some hands, these specialized tables can provide advantages
over a standard table, but they are more expensive and can lead to complications such as
ankle injuries and neurapraxias.6 The costs of acquiring both a new fracture table and a
large diameter high-resolution fluoroscopic machine may be prohibitive for some small
hospitals. Thus, consideration for learning how to effectively utilize standard tables pro-
vides needed simplicity and cost-effectiveness when adopting DAA THA.
In addition to the instrument development efforts mentioned, curved cobra retractors

are another tool that can help protect soft tissues and allow DAA THA through a shorter
incision length.4 Other special instruments include the spoon-shaped retractor device,
which utilizes a long moment arm to easily leverage the osteotomized femoral head out
from the acetabulum (Figure 13-5). This equipment is relevant since studies have shown
increased muscle and soft tissue damage using standard operative sets for the minimally
invasive DAA THA.7 Current DAA-specific retractors are longer and narrower to access
the deep acetabulum and allow ease of retraction. Hibbs retractors are ideal for retraction
of muscle bellies and protection of the tensor fascia lata (TFL). After exposure of the hip

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Figure 13-5. Femoral spoon used for femoral

head extraction from the acetabulum (Jarit
#225-425).
Figure 13-6. Innomed Unger anterior total hip instruments set.
capsule, curved cobra retractors and double-bent Hohmann retractors can improve visu-
alization. Instrument sets with retractors named after the anatomic site where they should
be used are also now available commercially (eg, anterior femoral neck retractor, posterior
femoral neck retractor, anterior acetabular retractor, and posterior acetabular retractor).
Complete DAA-specific instrument sets such as the Unger Set (Innomed) include wide
and narrow, single- and double-prong Hohmann retractors, rat tail rasps, cobras, offset
retractors, and femoral neck elevators (Figure 13-6). There are self-retaining retractor
systems like the Surgical Phantom (TeDan) and the Integra (Omnitract). Additionally,
surgeons can obtain long rongeurs and long scissors for reaching deep areas around the
acetabulum. Jorgensen-type scissors or a long, curved thoracic Mayo scissors are particu-
larly useful for helping cut the ligamentum teres for femoral head extraction during DAA
THA (Figure 13-7).

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166 Chapter 13
Figure 13-7. Examples of long curved scissors

useful for DAA THA. Top: curved cooley scis-
sors (Jarit #305-120), 8¾" (222 mm). Bottom:
long thoracic Mayo scissors.
Figure 13-8. Offset acetabular reamer handle

(Greatbatch Medical).
Figure 13-9. Offset acetabular cup impactor

(Greatbatch Medical).
After acetabular exposure with the instruments described above, offset modular ace-
tabular reamers (Figure 13-8) and cup inserters (Figure 13-9) are useful to position the
cup without restraint from the tensor and often bulky lateral thigh musculature. If using
straight reamers, the bulk of the anterior thigh during DAA THA can quickly cause
premature or excessive reaming of the anterior wall and anterior column. In addition,
the thigh tends to push the straight reamer and acetabular inserter toward the ceiling,
potentially leading to increased anteversion when placing the final implant. Using offset
handles can improve visualization by negotiating over the thigh musculature and allowing
for a more direct insertion angle to ensure proper cup placement and reaming.
Offset impactor handles can sacrifice force transmission during implant seating com-
pared to straight impactor handles,8 so surgeon awareness of the relative impaction force
needed to place the implants comes with practice and experience with these instruments.
Regardless of how the acetabulum is prepared, the implant is generally inserted in approx-
imately 15 to 20 degrees of anteversion and 40 to 45 degrees of abduction. Meticulous
attention must be paid to matching the native anteversion and achieving anterior coverage
of the shell by native bone, so as to avoid the potential for iliopsoas tendon impingement
and subsequent pain.

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Figure 13-10. Wixson bone hook, 50-mm curve

(Innomed #5920).
Figure 13-11. Trochanteric elevator (Innomed

#6450).
For femoral exposure, either a manual bone hook (Figure 13-10) or fracture table
motorized attachment is helpful. Adducting and externally rotating the leg and dropping
the foot of the bed to extend the hip assists with proximal femoral exposure. Utilizing a
sharp cobra or a double-pronged bent Hohmann on the medial aspect of the femur and a
Hibbs retractor initially for lateral soft tissue retraction, a femoral elevator (the trochanteric
elevator; Figure 13-11) with or without extended prongs allows for further delivery.
The pubofemoral and ischiofemoral ligaments are released via cautery to further elevate
the femur into the operative field while protecting the iliopsoas. If exposure is difficult, it
is advantageous to lower the foot of the bed to further extend the femur and ensure ade-
quate adduction has been achieved. Numerous options are available for femoral elevators,
including both manual retractors and table-mounted lift devices, and these can range from
simple hooks to specialized suspension systems. Commercial vendors, such as Innomed
produce many surgeon-specific femoral elevators and bone hooks.
The femoral canal is approached with a box cutter then a small sharp broach (eg, the
“chili pepper”) to open the proximal cancellous bone. Next, a rat tail rasp (Figure 13-12)
can be used to safely probe and define the canal. Sequential broaching is performed and
directed with a posterior and lateral force, being mindful to aim the broach tips anteriorly
into the native femoral bow. Femoral broaches include numerous options in handle geom-
etry: simple straight handles exist along with handles that feature single- and double-
offset as well as right- and left-side specific handles (see Figure 13-12). There are also
a variety of strikeplates to ease femoral positioning, improve version control, and avoid
errant striking (Figure 13-13). The wider, T-shaped strikeplate is particularly useful; it
is easier to strike squarely with a mallet and can be used universally on either the left or
right hip, thus simplifying the instruments needed for this step (Figure 13-14). Lastly,

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168 Chapter 13
Figure 13-12. Femoral rat tail rasp

options.
Figure 13-13. Femoral broach handle options (DePuy), Left to right: double-
offset handle for left hip broaching, T-handle single-offset broach, standard
single-offset broach, and double-offset handle for right hip broaching.
there are angled and straight options for stem impaction to help seat the final press-fit
femoral implant.
In cases where a tight femoral canal is encountered, as in younger patients with Dorr
Type A bone, femoral reaming may be needed to help open and widen the canal to accept
the broaches and femoral stem. In this situation, flexible femoral reamers are useful
(Figure 13-15). After accessing the femoral canal with starter broach and/or femoral rasp,
a ball-tipped guidewire is advanced down the canal. Next, the reamers are inserted in a
curvilinear fashion and reamed by 0.5-mm increments until the desired canal diameter
is reached, usually 13 to 14 mm. The reamer and wire are then removed and broaching
is used to prepare the canal as per the preoperative template. Careful attention is needed
during the reaming process to pass the reamer tips distal to the most proximal femoral
cancellous bone in order to preserve that important metaphyseal bone for controlling stem
rotation.

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Figure 13-14. Closer profile view of the strike-

plate options for the single- offset broach
handle. Note the threads in the strikeplate
hole for use with a slap-hammer extractor if
needed.
A
Figure 13-15. (A) Placement of flexible reamer on the ball-tip guidewire
(BixCut Reamer System [Stryker Corporation] in preparation for right hip
femoral canal preparation. (continued)
Even with LED lights, OR lighting may be insufficient during DAA THA.
Traditional surgical headlamps can be used without helmets, and surgical helmets can

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170 Chapter 13
B
Figure 13-15 (continued). (B) Angled insertion of flexible reamer head and
shaft into the femoral canal of the right hip via DAA. Note the trochan-
teric elevator laterally, the sharp cobra medially, and the bone hook laterally
around the proximal femur to facilitate exposure.
now be outfitted with battery-powered head-lamp attachments (eg, T-5 Helmet [Stryker])
to help improve visualization.
Lighted retractors are available as part of many Innomed instruments, whereby a
lighted cord can be attached to the reusable metal retractor for static lighting into the
wound. Lighted retractors can be static as mentioned or used as a disposable, adherent,
lighted strip (Lumitex [Strongsville]) that can be secured to standard DAA retractors for
direct lighting into the acetabulum. Surgical lighting companies such as Invuity also now
offer disposable lighted suction devices (eg, Invuity’s EIGR Saber Waveguide) that can
be readily adapted for DAA THA. Despite the effectiveness of this particular suction
lighting system, the device may add significant expense to the overall costs of the DAA
THA procedure. As more options evolve and pricing becomes increasingly competitive,
these specialized lights for MIS or DAA THA will likely become more commonplace.
We prefer fascial closure with barbed suture, such as #2-0 Quill (Surgical Specialties
Corporation) or #0 V-Loc (Covidien). A Monoderm Quill or #3-0 V-Loc suture is used to
achieve subcuticular cosmetic closure. The skin is closed with skin staples or skin adhesive
and antimicrobial silver Aquacel (ConvaTec) dressing is placed.
Proponents of the DAA claim that there is less muscle damage,7,9 better functional
outcomes,10-12 and better gait dynamics.13-15 Select studies have found lower blood loss,
less narcotic usage, and shorter hospitalization in DAA THA patients,16 while others
have found increased blood loss instead10 and no differences in postoperative pain or
hospital stay.11 Complication rates have been comparable to other approaches, particularly
after overcoming initial learning that entails about 100 procedures.12 Femoral exposure
may be complicated by retained hardware; if so, the lateral decubitus approach is preferred.

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Lacking the appropriate specialized DAA instrumentation should be considered a relative

contraindication for DAA THA today since use of standard or straight instruments may
result in increased tissue trauma, operative time, and complication rates,17-19 as was seen
in the early days of DAA THA. Lastly, large patient size, decreased femoral offset, and
protrusio acetabulum can all make the DAA technique more difficult.20
DAA THA was done in the 1970s and 1980s with limited specialized instrumentation
using a longer incision than what is used today.4 By 1993, accessory incisions were in use,
and for revision surgery, an anteriorly-based digastric trochanteric foldback osteotomy had
been described.21 A variation of this method was later adopted as the posteriorly-based
digastric trochanteric flip osteotomy for anterior surgical hip dislocation.22 Improved
knowledge of femoral releases and better instrument options now allow routine primary
DAA THA to be performed through small incisions with virtually no muscle damage.
While secondary or accessory incisions are useful, they are not needed in routine primary
DAA THA.
A surgeon performing the DAA today has a variety of options available from surgi-
cal table design and patient positioning to femoral bone hooks and offset retractors.
Knowledge of the relevant history behind these advances is essential. These advances
now allow improved exposure, visualization, reaming, femoral preparation and broaching.
Offset handles, reamers, impaction devices, and specialized broaches allow the surgeon to
place components ideally without being restrained by surrounding soft tissue and avoiding
the need for secondary incisions.4
Additionally, recent advances in lighting and tissue protection also enhance visualiza-
tion, dissection, and may limit complications and allow more consistent hardware place-
ment to further improve the outcomes of DAA and expand its indications. Ultimately, the
ideal goal for a modern DAA hip surgeon is to develop expert clinical and technical skills
such that DAA THA can be performed with a basic set of instruments in the operating
room of any hospital, at any time, with any implant system, anywhere in the world.
Understand and recognize the wide variety of specialized instrument options now
available for DAA THA, and practice with these in a cadaver lab prior to use in the
operating room.
Modern instruments, in contrast to the pioneering days of DAA surgery, can protect
the soft tissues and facilitate exposure to improve the safety and reliability of DAA
THA.
Lack of proper instruments may have impeded the widespread adoption of DAA in
the early days. That limitation no longer applies, as modern instrument sets and relat-
ed equipment have been developed specifically to protect tissues, minimize complica-
tion risk, and assist the surgeon in performing DAA THA as a routine procedure.

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1. Judet J, Judet R. The use of an artificial femoral head for arthroplasty of the hip joint. J Bone Joint Surg
Br. 1950;32:166-173.
2. Waldman BJ. Advancements in minimally invasive total hip arthroplasty. Orthopaedics.
2003;26(Suppl 8):833–836
3. Bhargava T, Goytia RN, Jones LC, Hungerford MW. Lateral femoral cutaneous nerve impairment after
direct anterior approach for total hip arthroplasty. Orthopedics. 2010;33(7):472.
4. Keggi KJ, Huo MH, Zatorski LE. Anterior approach to total hip replacement: surgical technique and clinical
results of our first one thousand cases using non-cemented prostheses. Yale J Biol Med. 1993;66(3):243-256
5. Berry D, Lieberman J, Matar W, Hozack W. Direct anterior primary total hip arthroplasty. In: Berry DJ,
Lieberman JR, eds. Surgery of the Hip. Philadelphia, PA: Elsevier; 2011: 236-244.
6. Sariali E, Leonard P, Mamoudy P. Dislocation after total hip arthroplasty using Hueter anterior approach.
J Arthroplasty. 2008;23(2):266-272.
8. Kayiaros S, Rubin LE, Biercevicz A, Limbird R, Paller D. Broach handle offset and impact acceleration
during femoral preparation for total hip arthroplasty. Reconstructive Review. 2013;3(2):41-43.
2011;93(15):1392-1398.
approach for total hip arthroplasty. J Arthroplasty. 2013; 28(9):1634-1638.
11. Restrepo C, Parvizi J, Pour AE, Hozack WJ. Prospective randomized study of two surgical approaches for
total hip arthroplasty. J Arthroplasty. 2010;25(5):671-679.
ery in THA patients treated by minimally invasive direct anterior approach: a gait analysis study. Clin
Biomech (Bristol, Avon). 2009;24(10):812-818.
14. Varin D, Lamontagne M, Beaulé PE. Does the anterior approach for THA provide closer-to-normal lower-
limb motion? J Arthroplasty. 2013;28(8):1401-1407.
15. Maffiuletti NA, Impellizzeri FM, Widler K, et al. Spatiotemporal parameters of gait after total hip replace-
ment: anterior versus posterior approach. Orthop Clin North Am. 2009;40(3):407-415.
tive findings. J Orthop Traumatol. 2011;12(3):123-129
18. Siguier T, Siguier M, Brumpt B. Mini- incision anterior approach does not increase dislocation rate: a study
19. Post ZD, Orozco F, Ledezma CD, Hozack WJ, Ong A. Direct anterior approach for total hip arthroplasty:
indications, technique and results. J Am Acad Orthop Surg. 2014; 22(9):595-603
20. Bender B, Nogler M, Hozack W. Single incision direct anterior approach for total hip arthroplasty. In:
Brown T, Mihalko W. Arthritis and Arthroplasty: The Hip. Philadelphia, PA: Elsevier; 2009: 218-224.
21. Fulkerson JP, Crelin ES, Keggi KJ. Anatomy and osteotomy of the greater trochanter. Arch Surg.
1979;114:19–21.

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22. Ganz R, Gill TJ, Gautier E, et al. Surgical dislocation of the adult hip: a technique with full access to the
femoral head and acetabulum without the risk of avascular necrosis. JBJS Br. 2001; 83(8):1119-1124.


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14
Specialized Retraction
for Direct Anterior Total
Hip Arthroplasty
Daniel C. Allison, MD, MBA and Timothy McTighe, Dr HS (hc)
Specialized retractor systems can facilitate exposure and decrease the need for person-
nel during director anterior approach (DAA) total hip arthroplasty (THA).
Data support the use of the Phantom Minimally Invasive Surgery (MIS) Anterior
Hip Retractor system (TeDan Surgical Innovations, Inc. [TSI] United States Patent
# 8,808,176 B2) both for experienced surgeons who can expedite the operation and
for novice surgeons who may be able to shorten the learning curve.
Since the introduction of DAA to the United States, many studies have demonstrated
the validity of DAA THA using a standard operating table.1-4 Downsides to the tech-
nique include the need for multiple assistants, as well as difficulties with femoral exposure,
which may result in femoral perforation/fracture, soft tissue trauma, and component mal-
position, creating a distinct and potentially lengthy learning curve.5-7
The Phantom MIS technique entails a specialized retractor system that enhances expo-
sure during DAA THA and allows fluoroscopic visualization and prepping of the contra-
lateral limb in the field. This self-retaining system employs the use of adjustable surgical
arms with attachable retractors. The operation can be done on a standard operating table
with minimal additional personnel. The ability to prepare both lower extremities in the
surgical field allows for direct clinical limb length comparison, a more familiar feel of
reduction, soft tissue tension, and complete, dynamic joint range of motion. The manual
femoral elevation system exposes the femur well, while providing controlled forces and
feel of tension, which may decrease soft tissue trauma, nerve stretch, and fracture risk.


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176 Chapter 14
Thus the system provides both excellent acetabular exposure and femoral exposure, while
allowing the use of fluoroscopy for both acetabular and femoral preparation. Additional
advantages include attachable, small LED lighting and high-definition camera systems to
illuminate and film the surgical field.
The equipment includes the following:

A standard operating stable that bends at the knee (Skytron Elite or similar)
TSI Phantom Anterior Retractor System
Standard fluoroscopy unit (if desired)
Surgical assistant
Standard DAA THA instruments and equipment
Patient Positioning, Preparation, and Retractor System Set Up
Secure the head extension piece of a traditional operating room (OR) table to the foot
of the table.
Place the patient supine, centered on the table, with the table’s bending joint
3 inches distal to the level of the patient’s hip joint.
Hindquarter preparation on the operative side, the nonoperative side is prepped to

above the knee. Alternatively, both hindquarters may be prepped for bilateral THA
cases.
Impervious drapes initially secure the perimeter; both lower extremities are covered
with stockinettes, which are then wrapped with Coban.
A traditional hip drape with pouches is passed over both limbs, with a 6-inch slit
cut to accommodate the nonoperative limb (Figure 14-1A); for bilateral cases,
2 U-drapes with a central perineal towel can be used (Figure 14-1B).
The skin is re-prepped with another surgical prep stick, the incision line is marked
with the sterile marking pen, and Ioban is placed to completely cover all skin. Outer
gloves are then changed.
The yellow post clamp (YC) is applied to the nonoperative side of the table 12 in prox-
imal to the hip joint, over the sterile drapes (Figure 14-1C). The trident (T) is placed
over the YC, directed toward the incision, and locked into place, with the red T prong
directed toward the patient’s head and the blue T prong directed toward the patient’s
foot (see Figure 14-1C). The blue elbow (BE) is secured to the distal T (blue) prong,
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Specialized Retraction for Direct Anterior Total Hip Arthroplasty 177
B
Figure 14-1. (A) Example of draping for unilateral case. (B) Example of draping
for bilateral case. (continued)
and the yellow accessory arm (YA) and blue accessory arm (BA) are then secured to
the corresponding middle T (yellow) and BE attachment points, respectively; these
yellow and blue accessory arms will hold retractors on the side opposite the surgeon.
Two options allow a retractor to be placed on the surgeon’s side of the incision:
1. Option 1 (Figures 14-1D and 14-1E):
The red elbow (RE) may be attached to the proximal (red) T prong, which then
attaches to the red accessory arm (RA).
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178 Chapter 14
D
Figure 14-1 (continued). (C) Yellow post clamp and trident application.
(D) Option 1: the additional proximal retractor is placed on the nonoperative
side of the table through the red elbow attachment. (continued)
2. Option 2 (Figure 14-1F)

The purple post clamp (PC) is applied to the side rail operative side of the bed,
12 inches distal to the hip joint, over the sterile drapes.
The ball joint angle arm (JA) is then applied to this mounting post, which then
attaches to the purple accessory arm (PA).
Each accessory arm (blue, yellow, red, purple) is able to hold a retractor in self-
retaining fashion.

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F
Figure 14-1 (continued). (E) Option 1: the additional proximal retractor is
placed on the nonoperative side of the table through the red elbow attach-
ment (another view). (F) Option 2: the additional proximal retractor is placed
on the operative side of the table through the RE attachment.

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180 Chapter 14
B
Figure 14-2. (A) The initial surgical incision. (B) The approach with entry into
the TFL sheath. (continued)
The incision starts 1 cm distal and 2 cm lateral to the anterior superior iliac spine and
extends 8 to 12 cm distally and laterally toward the lateral knee (Figure 14-2A); the
fascia over the tensor fascia lata (TFL) muscle is incised and elevated off of the TFL
muscle medially (staying in this sheath protects the lateral femoral cutaneous nerve
and allows for easy identification of the interval; Figure 14-2B).
The interval between the TFL and sartorius is developed with finger dissection and
held open with a self-retaining Weitlander retractor (abducting the hip will loosen
the TFL and further open this interval), and the lateral femoral circumflex vessels
are identified and ligated (the authors prefer using silk ligature, but electrocautery is
also an option; Figure 14-2C).

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D
Figure 14-2 (continued). (C) Exposure of the superficial interval with ligation
of the lateral femoral circumflex vessels. (D) Exposure of the anterior hip
capsule.
Medially, a straight (20 degrees) Hohmann retractor is placed between the medial hip
capsule and rectus femoris and secured to the YA; laterally, a right-angled Hohmann
retractor is placed between the lateral hip capsule and TFL and secured to the red
(option 1) or purple (option 2) accessory arm see (Figure 14-2D).
The precapsular fat is removed, and the indirect head of the rectus is elevated medi-
ally for capsular exposure; a transverse H-shaped capsulotomy is performed, and the
capsule is then tagged and preserved; alternatively, the capsule may be resected.
Neck Osteotomy and Femoral Head Extraction

Medially, a straight (20 degrees) Hohmann retractor is placed around the medial
femoral neck; laterally a right-angled Hohmann retractor is placed around the lateral
femoral neck.

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182 Chapter 14
B
Figure 14-3. (A) Exposure of the femoral neck and localization of femoral neck
osteotomy. (B) Removal of the femoral head.
The inferomedial femoral neck capsule is released to the level of the lesser trochanter;
palpation of the lesser trochanter, in addition to fluoroscopy, facilitates osteotomy
position (Figure 14-3A).
The oscillating saw is used to create the femoral neck cut. An additional femoral neck
cut can be made 5 to 10 mm proximal to the initial cut, creating an intercalary seg-
ment, which can then be removed to allow for easier head extraction.
The hip joint can be slightly flexed to facilitate delivery of the femur posteriorly.
Posteriorly, a straight (20 degrees) Hohmann retractor is placed between the posterior
femoral head and the femur, carefully delivering the femur further posterior; anteri-
orly a curved (70 degrees) Hohmann retractor is placed between the femoral head and
the acetabulum. A corkscrew or threaded Steinman pin is placed into the femoral head
through the cartilage or femoral neck cortex (Figure 14-3B).
Capsular attachments around the base of the head are released with electrocautery.
Care is taken with rotation not to injure the TFL upon head removal.

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B
Figure 14-4. (A) Acetabular exposure using Option 1 (posterior wall retractor
is secured from the nonoperative side of the table). (B) Acetabular exposure
using Option 2 (posterior wall retractor is secured from the operative side of
the table). (continued)
Acetabular Exposure
A curved (70 degrees) Hohmann retractor is placed over the anterior wall of the
acetabulum (with great care not to over-retract) and secured to the YA.
A curved (70 degrees) Hohmann retractor is placed between the inferior border of
the acetabulum (cotyloid fossa) and transverse acetabular ligament and secured to
the BA.
A straight (20 degrees) Hohmann retractor is placed between the posterior wall of the
acetabulum and the femur and secured to the RA (Option 1 [Figure 14-4A]) or PA
(Option 2 [Figure 14-4B]).

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184 Chapter 14
C
Figure 14-4 (continued). (C) Acetabular exposure and preparation, allowing
fluoroscopy, without any other surgical assistance.
The acetabulum is reamed in the usual fashion. The authors prefer to ream only to the
base of the cotyloid fossa, at 40 degrees abduction, 20 degrees anteversion, without
raising the joint line (closely following native acetabular position); fluoroscopy can be
used as a guide (Figure 14-4C).
Femoral Exposure
If Option 1 was used, the PC is now applied 12 inches distal to the hip joint to the
side rail of the table, over the sterile drapes; the JA is then applied to this mounting
post, which then attaches to the PA, and the RE and RA are removed. The extension
bar (EB) is then placed over the PC.
The legs of the table are dropped 15 to 60 degrees (obtaining extension at the hip);
the nonoperative leg is placed on a well-padded sterile Mayo stand; the operative limb
is adducted and externally rotated, keeping the knee straight to decrease anterior soft
tissue tension.
The femoral hook is carefully placed around the proximal posterior femur from the
lateral direction, distal to the vastus ridge, over the vastus lateralis, hugging the
bone posteriorly. One or two retractors are placed around the medial femoral neck
and secured to the YA and/or BA. The lateral and posterior femoral neck capsule is
released, and the serrated cobra retractor or curved pointed retractor is placed between
the greater trochanter and gluteus medius, retracting the TFL and assisting with
femoral elevation. The femoral hook is attached to the femoral lift (FL), which is
attached to the EB (Figure 14-5A).
The femur is carefully elevated by turning the finger dial on the FL (1 click = 1-mm
elevation). The posterolateral femoral neck capsule is further released under tension;
the conjoined tendon at the medial greater trochanter is identified and either released
fully, released partially, or preserved; the piriformis tendon at the medial tip of the

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A
Figure 14-5. (A) Femoral exposure and preparation, using the Femoral Lift,
without any other surgical assistance. (continued)
greater trochanter and the obturator externus at the distal posterior greater trochanter
are preserved (Figures 14-5B and 14-5C).
The femur is elevated gradually as careful releases are performed, without excessive
tension; the femur is delivered only to the extent necessary for appropriate broach and
stem insertion (Figure 14-5D). Traditional straight broach handles can even be used
with this technique (Figure 14-5E).
Femoral Trialing and Implantation

Femoral component trialing is then performed. Fluoroscopy, manual palpation/feel,
and direct comparison to the prepped contralateral limb all assist with optimal
implant selection (Figure 14-6A).
Femoral stem implantation is then performed with standard technique according to
the type of stem used (Figure 14-6B).

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186 Chapter 14
C
Figure 14-5 (continued). (B) Exposure of the proximal femur and associ-
ated insertions of the obturator internus and superior/inferior gamelli. (C)
Exposure of the proximal femur. (continued)

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E
Figure 14-5 (continued). (D) Femoral broaching with double- offset broach
handle. (E) Femoral broaching with standard straight (non- offset) broach
handle.
Wound Closure
The authors prefer to preserve the hip joint capsule and subsequently close it with
interrupted, braided, absorbable #1 suture (Figure 14-7A).
The fascia over TFL is closed with interrupted, braided, absorbable #0 suture, with
care not to ensnare branches of the lateral femoral cutaneous nerve anteriorly.
The skin is closed with subdermal and subcuticular suture and the soft tissues remain
healthy and free of surgical trauma (Figure 14-7B). The incision is dressed with
incisional sealant (Dermabond [Ethicon US, LLC]) in addition to a skin-friendly
occlusive antimicrobial dressing (Aquacel Ag [ConvaTec, Inc]).
Postoperative Care and Rehabilitation

The patient is treated with protected weight bearing as tolerated with crutches or a
front-wheeled walker if a press-fit femoral stem is used, or full weight bearing as toler-
ated with assistive devices only as needed if a cemented femoral stem is used.

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188 Chapter 14
B
Figure 14-6. (A) Femoral broach and head trialing with contralateral limb
length comparison. (B) Femoral stem implantation.
No hip precautions (anterior or posterior) are instituted.

The sealed, occlusive dressing is left in place and not changed for 7 to 10 days
(patients are allowed to shower).
We reviewed 50 consecutive DAA THA cases done using a standard operating table
and the previously described specialized retractor system by one surgeon, early during
the learning curve. The mean patient age was 67.7 years (range 45 to 97 years), with
35 females and 15 males. The underlying pathology ranged from osteoarthritis (23),
femoral neck fracture (14), congenital dysplasia (6), avascular necrosis (4), and metastatic

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B
Figure 14-7. (A) Preservation and closure of preserved anterior hip joint
capsule. (B) Soft tissue status and incisional length after completion of the
procedure.
carcinoma (3). Follow-up averaged 24 months. Thirty-seven of the cases performed were
total hip arthroplasties, 13 of which were hemiarthroplasties. Thirty-two of the femoral
stems were press fit, the remaining group was cemented, and all cups were press fit. All
patients were allowed to bear full weight immediately with no hip precautions (anterior
or posterior).
Surgical time averaged 116.3 minutes (range 79 to 180 minutes), and estimated
blood loss averaged 223 cc (range 50 to 600 cc), without use of tranexamic acid or pro-
coagulants. The mean number of surgical assistants was 0.9 per case, with 5 (10%) of the
cases using no assistant. Length of stay averaged 2.9 days (range 1 to 5 days). With regard
to femoral releases, some form of conjoined tendon release was performed in 47 of 50 cases
(15 partial release, 32 complete release). Thirty-seven of 50 cases (74%) were performed
without any piriformis release (the remaining 13 cases involved partial piriformis release
in 8, and complete in 5). Radiographic limb length discrepancy averaged 0.2 mm (range
0 to 3.5 mm). Mean radiographic coronal femoral stem alignment was 0.13 degrees with
respect to neutral (range 0 [neutral] to 2 degrees [varus]). In 4 cases (8%), the stem rested

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190 Chapter 14
in 1 degree varus, and in 1 case (2%) the stem rested at 2 degrees varus. The remaining
stems (90%) rested at 0 degrees alignment (including the last 25 cases).
Mean acetabular abduction angle was 39.8 degrees, and in 36 of 37 THA cases (97%),
the cup fell within 35 to 45 degrees. In one case, the acetabular abduction angle was
50 degrees (case #15). With regard to complications, there were no dislocations (0%) and
no infections (0%). There was one intraoperative non-displaced proximal femur fracture
early in the series (case #9) in a patient with severe osteoporosis while implanting a press-
fit femoral stem. This patient was still allowed to bear weight as tolerated without restric-
tions immediately, and healed uneventfully. The patient’s contralateral hip was replaced
later in the series (case #50) using a cemented femoral stem, with no complications. There
was one case of femoral stem subsidence 3 months postoperatively in a patient with severe
osteoporosis in which a press-fit femoral stem was used and immediate weight bearing was
allowed. This case was treated with revision, and there were no further problems. There
was one case of lumbosacral plexopathy, diagnosed by neurology consultation as second-
ary to epidural hematoma caused by traumatic spinal block, which resolved spontaneously
without intervention.
In summary, DAA THA with a standard OR table, and a specialized retractor system
led to acceptable outcomes without undue complications and with shortening of the learn-
ing curve.
Use of a specialized hip retractor system affords surgeons the opportunity to perform
DAA THA with limited assistance on standard operating tables, with many potential ben-
efits when compared to traction-related techniques, such as decreased expense, decreased
storage, compatibility with standard OR equipment, simple mechanics, controlled forces,
improved feel, and ability to prep both legs into the surgical field. Traditional hip arthro-
plasty principles still apply, and careful attention to technique and respect for soft tissues
and bone is required. A retrospective review of surgeries using the Phantom MIS Hip
Retractor system has demonstrated that the system can be safely and effectively applied to
the DAA procedure, even early in the surgeon’s learning curve.
DAA THA without a special OR traction table is a longstanding, proven, and reliable
method, with specific benefits when compared to traction-based systems.
Specialized retractor systems can facilitate the previous technique; specifically, as we
have described in this chapter, the TSI Phantom Anterior Hip Retractor system offers
a safe and effective potential means to improve exposure, shorten the learning curve,
and reduce the need for surgical assistance in DAA hip arthroplasty.

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minimally invasive anterior surgical approach. J Bone Joint Surg Am. 2003;85-A(Suppl 4):39-48.
5. Seng BE, Berend KR, Ajluni AF, Lombardi AV Jr. Anterior-supine minimally invasive total hip arthro-
plasty: defining the learning curve. Orthop Clin North Am. 2009;40(3):343-350.
7. Matsuura M, Ohashi H, Okamoto Y, Inori F, Okajima Y. Elevation of the femur in THA through a direct
anterior approach: cadaver and clinical studies. Clin Orthop Relat Res. 2010;468(12):3201-3206.

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Section III
Advanced Adult
Reconstructive Techniques

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15
Avoiding, Recognizing, and
Treating Complications of the
Direct Anterior Hip Approach
Mohan S. Tripathi, MD and Stephen Kayiaros, MD
Understanding the direct anterior approach (DAA) and how it is applicable to total
hip arthroplasty (THA), especially in terms of complication risk.
A knowledge of the capsular releases necessary to safely and successfully perform
DAA THA.
Recognize and address the common intraoperative complications of the DAA.
THA is one of the most successful procedures for the treatment of painful hip arthritis.
Despite this success, there is a constant drive for improvement in technique and patient
outcomes, and also to seek a reduction in complications. Various surgical approaches to
the hip joint have been described, with the most commonly used ones being the postero-
lateral, anterolateral (Watson-Jones), direct lateral (modified Hardinge), and the DAA. In
comparing these approaches, surgeons have evaluated intra- and postoperative complica-
tions, including dislocation, periprosthetic fracture, nerve injury, and patient satisfaction
scores. Recent interest in minimally invasive techniques for THA over the past 2 decades
has reignited enthusiasm in alternative approaches to the hip. The proposed advantages to
various minimally invasive surgery (MIS) techniques include reduced soft tissue trauma
and blood loss, shorter hospital stay, and a faster time to unassisted ambulation.1–4
Recently popularized, the DAA utilizes a modified-Hueter approach, a true interner-
vous and intermuscular plane between the tensor fascia latae (TFL) and gluteus medius
laterally and the sartorius and rectus femoris muscles medially. The intermuscular and
interner vous plane of this approach protects and avoids violation of the hip abductors and

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196 Chapter 15
the posterior soft tissue structures, so as to preserve the hip deltoid.5 This helps to maintain
normal abductor strength and reduces posterior instability and potential dislocation. This
exposure provides a direct 360-degree view of the acetabulum and anterior inferior iliac
spine (AIIS), which facilitates proper instrumentation and reconstruction. The DAA can
also be performed with a specialized fracture table to facilitate femoral exposure and with
live fluoroscopy to aide in proper implant positioning and restoration of leg lengths and
offset.
Despite the proposed advantages of the DAA, surgeons are confronted with unique
complications associated with this approach. Masonis et al discuss the steep learning
curve to become proficient at the DAA.6 In this single-surgeon series of 300 consecutive
cases, operative time and fluoroscopy time significantly decreased after the first 100 cases.
In addition, there were no calcar fractures reported after the first 62 cases. Woolson et
al reported on the early experience of 5 surgeons utilizing the DAA and found longer
operative times, increased blood loss, and increased revision rates.7 This study highlights
5 community surgeons that adopted the DAA to decrease their dislocation rates from pos-
terior approach THA and compete with other surgeons in the area that were marketing
MIS. It should be noted that none of the surgeons in this study were fellowship trained in
arthroplasty and they all had a low volume of THA cases, with 4 out of the 5 performing
no more than 1 THA per month. Other studies have shown complication rates decrease
once surgeon experience exceeds more than 100 cases, and that complications rates are
actually similar to those of conventional approaches.8 Intraoperative disadvantages of
the DAA include difficulty in straight reaming, achieving satisfactory femoral exposure,
and potential injury to the lateral femoral cutaneous nerve (LFCN). Limited or difficult
surgical exposure heightens the risk of component malpositioning. Fractures of the proxi-
mal femur can also be more common, especially in the hands of the inexperienced DAA
surgeon.
In this chapter, we will review the technique for the DAA as performed at our institu-
tion, with special attention paid to the potential pitfalls and complications for each step,
as well as highlight techniques to avoid and treat them. We will also review the current
literature with respect to each complication and outcomes thereof.
The DAA to the hip is typically performed with the patient in the supine position. At
our institution, we utilize the Hana table (Mizuho OSI), a specialized table that allows
for independent positioning of each leg, including full freedom of rotation, adduction, and
hyperextension, greatly facilitating femoral exposure (Figure 15-1).
The table is radiolucent, and there is no contact between the table and the patient distal
to the pelvis. The patient’s feet are placed into padded boots that are attached to the trac-
tion arm spars of the table. A perineal post is required to stabilize the patient and provide
a counter to the traction applied through the patient’s foot. The perineal post should be
well padded to avoid possible pudendal nerve palsy. To facilitate exposure of the proximal
femur, a surgeon-operated motorized elevator attachment is implemented. A hook-like
retractor is placed around the femur and then attached to the sterile attachment bracket,
which is connected to a non-sterile table support. This allows the surgeon to control the
height of femoral elevation and degree of lateralization.

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Avoiding, Recognizing, and Treating Complications of the Direct Anterior Hip Approach 197
Figure 15-1. The Hana table by Mizuho OSI.
Adequate surgical exposure of the hip can be challenging when using the DAA, espe-
cially for the proximal femur. An anterior incision is made beginning approximately 2 cm
distal and 3 cm lateral to the anterior superior iliac spine. The subcutaneous tissues are
sharply divided and the TFL is identified. The fascia over the TFL is incised in line with
the muscle fibers about 1 cm lateral to the true interner vous plane, the fascia is elevated
medially, and the TFL muscle belly is mobilized laterally. Careful blunt dissection is
performed to separate the TFL from the sartorius muscle medially. Ascending branches
of the lateral femoral circumflex artery are encountered in this interval and can be a sig-
nificant source of bleeding if they are not correctly identified and ligated. Retractors are
placed above and below the hip capsule.
Next, attention is then turned to elevating the rectus off of the anterior capsule. The
indirect head of the rectus is now released. In very muscular males, it may be necessary to
completely release the indirect head as well as part of the direct head to allow for adequate
exposure of the hip capsule and eventual exposure of the acetabulum. The release should
also be aggressive if patients have a preoperative flexion contracture of the hip. This
release is contiguous with the supra-acetabular capsular release (Figure 15-2).
A capsulectomy or capsulotomy is performed to allow for visualization of the femoral
neck. At our institution, we perform an L-shaped capsulotomy, starting on the anterior
rim just distal to the AIIS and extending to the base of the femoral neck laterally, in the
sulcus between the anterolateral neck and greater trochanter. This is commonly referred
to as the saddle. Extension of the distal capsulotomy to the medial femoral neck creates a
medial-based flap of capsule, which is subsequently repaired to the lateral flap to allow for
a soft-tissue layer between the iliopsoas tendon and the anterior acetabular rim.
Several capsular releases are necessary, as the capsule tends to tether the proximal femur
to the acetabulum. The first release is performed medially while slowly externally rotating
the operative leg. The anterior capsule is released off the intertrochanteric ridge as the leg
is externally rotated, until the lesser trochanter is palpated and visualized. This helps to
mobilize the femur as well as helps the surgeon determine the level of the final femoral
neck cut.

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198 Chapter 15
Figure 15-2. Intraoperative exposure of the capsule of a right hip. The 2 cobra
retractors are above and below the hip capsule. A small Hohmann retractor
sits on the anterior acetabular rim, protecting the rectus. The skin, subcuta-
neous tissue, TFL muscle, and fascia are protected by the soft tissue retractor.
The proximal origin of the vastus intermedius muscle is visible inferiorly.
The second critical release is the supra-acetabular capsular release. Beginning at the
superior rim (1 o’clock on a right hip and 11 o’clock on a left hip), the superior capsule
is released off the ilium, at the lateral capsulolabral junction, working in an anterior to
posterior direction (Figure 15-3).
Forceful external rotation of the leg should also be avoided, as this risks causing iat-
rogenic fracture of the femoral shaft or ankle, especially in the setting of a stiff hip with
contractures.5 Exposure will be more challenging in cases of narrow or decreased femoral
offset, a short femoral neck or coxa breva, and protrusio, therefore the releases should be
extensive and liberal. Additionally, care should be taken in placing the lateral acetabular
retractors so as not to risk damage to the superior gluteal nerve and artery as they emerge
from the greater sciatic notch.
With these releases completed, the femoral neck cut is made in situ and a corkscrew is
used to remove the femoral head from the acetabulum. It is usually helpful to make 2 cuts;
the first being a subcapital cut and the second cut being the definitive level of resection,
effectively creating a “napkin ring” of bone that can be removed, which makes femoral
head removal more facile. It is helpful to ensure the 2 cuts allow for removal of a large neck
segment whenever possible, which can make head retrieval significantly easier.
Acetabular exposure is paramount for appropriate reaming and cup placement. The
inferior hip capsule may need to be incised to allow proper retractor placement. After the
cotyloid fat, labrum, and any overhanging osteophytes are removed, the acetabulum can
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Figure 15-3. Intraoperative photo of a right hip depicting the superior acetab-
ular release. The tip of the Bovie marks release of the superior capsule from
the acetabular rim. The dissection is continued in an anterior-to-posterior
direction.
be sequentially reamed. If the inferior capsule is hypertrophic, it should be partly excised

to obtain full visualization of the posterior acetabulum. Usually only 2 retractors are suffi-
cient; a posterior-superior cobra retracts the femur and an anterior-inferior bent Hohmann
retracts the capsule and rectus. The psoas may be partially recessed, lengthened, or
released in cases where exposure is difficult, although this is not commonly required.
Specialized offset acetabular reamers and offset cup inserters can be utilized for proper
reaming and cup positioning; although, we prefer straight instruments whenever pos-
sible. The surgeon needs to exercise caution to ensure controlled concentric reaming.
Excessive anterior force of the femur, especially in a muscular male, may inadvertently
cause reaming away of the anterior wall. Conversely, overcompensation by the surgeon to
counter this force may cause reaming away of the posterior wall. Fluoroscopy can be used
during reaming and cup insertion to gauge the appropriate abduction angle and antever-
sion. Acetabular cup abduction angle can be assessed via goniometric measurement of the
angle subtended by the teardrop line (a horizontal line drawn along the inferior edges of
the right and left teardrops) and the diameter of the ellipse represented by the rim of the
acetabular cup.5 While helpful, dependency on fluoroscopy should be avoided. There is
no substitution for excellent exposure and direct visualization of acetabular and pelvic
anatomy to determine proper reaming and cup placement. The anterior pelvic plane may
also be used as a method to assess abduction and anteversion. This is facilitated with the
pelvis in supine position for the DAA, making the anterior superior iliac spine and pubic
symphysis easily palpable.
Matta et al reviewed their experience with fluoroscopic-guided acetabular reaming
and found 96% of all acetabular components were within the target abduction range of 35
to 50 degrees and 93% of components were within the target anteversion range of 10 to
25 degrees.5 Conversely, Woolson et al reported a greater variation in cup abduction angle,

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200 Chapter 15
with an average angle of 44 degrees (range 33 to 63 degrees).7 Twenty-one percent of these

cups were implanted with an abduction angle greater than 50 degrees, despite fluoroscopic
guidance.7
Placement of an acetabular cup in excessive anteversion may be related to surgeon
experience. In a retrospective review of 300 consecutive THAs via the DAA, De Geest
et al reported 91.6% of all cups were positioned in the target abduction range of 35 to
55 degrees. Of those cups that fell outside of this range, 17 out of 24 were implanted dur-
ing the first 100 patients of the series.9 We try to aim for 40 to 45 degrees of abduction
and try to match the native anteversion of the acetabulum, making sure not to exceed
15 degrees, so as to avoid iatrogenic anterior instability.
We prefer to use several intraoperative landmarks to confirm proper cup placement.
Approximately 1 to 2 mm of the cup should be exposed laterally relative to the superior
rim to ensure an abduction angle of approximately 40 to 45 degrees. Correct antever-
sion can be obtained by positioning the cup so that the inferior margin is parallel to the
transverse acetabular ligament, which should be routinely identified and protected during
exposure. In addition, 1 to 2 mm of the cup should rest deep to the anterior lip so as to
avoid irritation of the iliopsoas tendon sheath.
Femoral exposure and preparation is thought to be the most difficult aspect of the
DAA. Exposure of the femur is initiated by external rotation, adduction, and extension
of the leg, allowing access to the resected portion of the femoral neck. The Hana table
facilitates this position and maintains the leg stationary, serving as a static third assistant.
The superior capsule is now released off the femoral neck posterolaterally, which helps to
elevate the femur anteriorly from a relative posterior position. This release is critical as it
will be nearly impossible to broach the femur if it is not satisfactorily elevated. The release
extends from the junction of the anterior femoral neck and trochanter, around the superior
femoral neck, to the posterolateral femoral neck, directly superior to the piriformis fossa.
This is the so-called 11-to-1-o’clock release (with the apex of the calcar as 6 o’clock). A
proximal femoral hook is placed around the femur, distal to the vastus ridge and is secured
to a bracket mount that is attached to the table; this stabilizes the proximal femur for canal
preparation. The surgeon controls the amount of elevation applied with this hook first
manually and then through a motorized foot pedal (Figure 15-4).
As the release is performed, the femur will become more mobile and be able to elevate
anteriorly. The surgeon first assesses the anterior translation of the femur manually with a
bone hook on the calcar, and then uses the elevating hook attached to the table to stabilize
the femur. Excessive retraction of the proximal femur anteriorly and laterally is known
to cause fractures of the proximal femur and femoral shaft.5, 10–12 Sequential soft tissue
releases, including the capsule, piriformis, and obturator internus if necessary can help
alleviate tension on the femur, thereby reducing fracture risk (Figure 15-5).
Canal preparation is also fraught with potential complication. The canal is accessed
via a box-cutting osteotome. Lateralizing the stem avoids varus malpositioning; this
can be accomplished by resecting the lateral cortical margin of the superior femoral
neck. Currently, many stems are designed to prepare the femur using a broach only
method. Curved, offset broach handles are available to facilitate component positioning.

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Figure 15-4. With the femoral elevating hook around the posterior femur, the
surgeon pulls the femur laterally and anteriorly with the leg in hyperexten-
sion to gauge the amount of tension present. (Inset) The surgeon uses the
foot pedal simultaneously to elevate the bracket to a position that will allow
the hook to be connected without undue tension.
Figure 15-5. After adequate releases have been performed, the

femoral exposure is complete on a right hip. The femoral elevat-
ing hook is now attached to the table and maintains the femur
in a static position. A large bent Hohmann retractor lies posterior
to the greater trochanter, and a Mueller retractor rests on the
medial calcar.

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202 Chapter 15
These offset handles can avoid soft tissue interference while broaching, thus prevent-
ing inadvertent perforation of the posterior or lateral femoral cortex. Perforation of the
femoral cortex during broaching has been reported, particularly in patients with flexion
contractures.10,12 To avoid perforation, a more horizontal, or valgus, insertion angle is
required at the start of broaching so that the broach follows the angle of a femur that
remains in a contracted position.10 Additionally, the tip of each broach should be directed
anteriorly into the femoral bow, and the canal should always be probed with a curved
plastic yankauer or metal suction tip after the starter broach and prior to insertion of
subsequent broaches. This sequence allows verification of medullary entry and can help
avoid perforations.
If perforation does occur, it must be recognized immediately, and the true canal must
be identified and broached. Fluoroscopy can help accomplish this. The final stem should
ideally bypass the perforation by 2 cortical diameters and we also recommend placing
a prophylactic cable distal to the perforation to prevent possible fracture propagation
from a stress riser. In general, the surgeon performing DAA should maintain a constant
vigilance for perforation or calcar fracture, and be prepared for cerclage wire placement.
Practicing the added exposure and placement of cerclage wires should be learned in the
cadaver lab in advance of incorporating the DAA into practice. We routinely have cable
passers and 1.7-mm cerclage cables and crimps available at our total joint center for this
contingency and utilize these as needed during the case proactively whenever a femoral
complication is recognized.
Several authors have described fractures of the proximal femur during elevation and
broaching. Most of these fractures involve the greater trochanter or the calcar. Matta et
al reported a total of 9 fractures of the femur (3 greater trochanter, 2 femoral shaft, and
4 calcar fractures) out of a series of 494 primary THAs performed via the DAA.5 Calcar
fractures were encountered during aggressive broaching of the canal and were unevent-
fully treated with either protected weight bearing or cerclage wiring. Greater trochanter
fractures are attributed to careless broach entry and/or removal, aggressive broaching
or femoral elevation with the hook, or aggressive force exerted with the trochanteric
retractor. These fractures were treated conservatively, with protected weight bearing for
6 weeks, so as to avoid potential soft tissue stripping that would occur with osteosynthesis.
Rüdiger et al evaluated the outcome of patients who sustained proximal femur fractures
during THA via the DAA.13 Thirteen fractures were encountered: 5 metaphyseal frac-
tures treated with cerclage wiring and 8 greater trochanter fractures treated conservatively
with protected weight bearing for 6 weeks. Compared to patients without proximal femur
fractures, patients with proximal femur fractures had no significant difference in either
Western Ontario and McMaster Universities Arthritis (WOMAC) scores or incidence of
Trendelenburg sign or limp. Radiographic analysis at 1 year demonstrated complete bony
consolidation in 7 out of 8 patients with greater trochanter fracture; 1 patient experienced
proximal and posterior displacement. Stem subsidence of 5 and 7 mm was observed in
2 out of 5 patients with metaphyseal fractures; however, the stems demonstrated com-
plete bony integration and patients were asymptomatic and unaware of the resultant
leg length discrepancy.13 The authors surmise that subsidence may have been prevented
with a restricted weight-bearing rehabilitation protocol and have adopted this practice
accordingly.
At our institution, we treat greater trochanter fractures with either suture repair
or protected weight bearing. More worrisome fractures are those that extend into the

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metaphyseal area of the trochanter. These patients should definitely be treated with pro-
tected weight bearing. In addition, a suture anchor may be placed through the fracture
site and anchored to the distal part of the trochanter. The sutures are passed and tied
through the fractured segment. It is often difficult to pass the sutures through the distal
fragment of the trochanter that is fractured; therefore, we often pass the sutures around
the trochanter, through adjacent capsule, periosteum, and abductor fascia, tying the suture
in a pants over vest technique (Figure 15-6).
Calcar fractures are treated with cerclage wiring with a 1.7-mm cable and crimp and
case-specific weight-bearing protocols. We prefer applying the wire in a figure-8 technique,
with a limb of the wire above and below the lesser trochanter (Figure 15-7). Patients
with osteoporosis, especially elderly females, are at highest risk for intraoperative femur
fractures. We have a low threshold to utilize cemented fixation of the femoral stem in
patients with osteoporotic bone or patients with Dorr Type C femora, as this technique
has become more reliable and reproducible then trying to obtain press-fit fixation, and has
virtually eliminated fractures of the femur (Figure 15-8).
Distal fractures, such as ankle fractures, have also been reported. Matta et al observed
3 ankle fractures in their cohort. These fractures are thought to be a result of excessive
external rotation force applied only at the foot and ankle.5 It is vital for the surgeon to be
cognizant of the force used to elevate and rotate the femur, as this can lead to iatrogenic
fracture of the ankle.
Once the final components have been inserted, the wound is thoroughly irrigated.
Closure is performed in a layered fashion. Residual medial and lateral capsule are re-
approximated, as this layer protects the iliopsoas tendon from the anterior lip of the
acetabular cup. Rodriguez et al found that cup anteversion correlates with postoperative
groin pain. As the socket anteversion decreases, anterior implant overhang increases, thus
creating a source of irritation for the iliopsoas tendon. A reduction in the incidence of
groin pain has been observed by adjusting component positioning such that the anterior
lip of the implant is covered by bone.14
During wound exposure and subsequent closure, the LFCN is also at risk for injury due
to its proximity to the surgical site. Injury to this nerve can cause a burning sensation and/
or numbness over the anterolateral thigh, which can be permanent. At our institution, we
do not formally identify the nerve; however, care is taken to avoid inadvertently injuring a
nerve that may lie in an abnormally lateral position. Incidence of this complication varies
greatly in the literature, ranging from 0% to 81%.15–18 Lateralizing the incision over the
muscle belly of the TFN has been found to decrease the incidence of LFCN injury.9 We
have found that placing the incision as lateral as possible avoids encountering the nerve
during the surgical dissection and closure.
A higher than expected incidence of wound complications has also been reported. In a
comparison of wound complication rates between primary THAs performed via the pos-
terior approach vs the DAA, Christensen et al reported that the rate of wound complica-
tion requiring reoperation was significantly higher in patients undergoing THA via the
DAA.19 There were 7 out of 505 (1.4%) DAA THAs that required reoperation: 2 due to
uninfected hematomas, 2 due to infected hematomas, 2 for delayed wound healing, and 1

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204 Chapter 15
Figure 15-6. Postoperative radiograph of a 73-year- old male who sustained

an intraoperative greater trochanter fracture, treated with suture anchor
fixation.
for acute periprosthetic joint infection.19 Jewett et al reported 37 wound complications in

800 cases (4.6%).10 Thirteen were wound infections that required reoperation, while the
remaining 24 were deemed to be non-infectious. There was no effect of the learning curve
on the incidence of wound complication.10 Christensen et al found that 3 wound compli-
cations occurred in the first 100 cases, while another 3 occurred after the 400th case.19

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Figure 15-7. Postoperative radiograph of a 68-year- old female who sustained

an intraoperative calcar fracture of the right hip, treated with cerclage wiring.
She was allowed weight bearing as tolerated and her speed of recovery was
unaffected.
The rate of wound complication may be explained by the differences in skin thickness at
the anterior proximal thigh compared to wounds over the lateral or posterior aspect of the
hip. In addition, patients with significant anterior soft tissue pannus, especially if it over-
hangs the proposed area of the incision, are at significant risk for wound complications,
and we advise against performing DAA in these patients. Increased risk of major and
minor complications following THA has been well documented in obese and super-obese
patients.20,21 Arsoy et al reported inferior outcomes and an overall 52% complication rate
in their series of patients undergoing THA with a BMI > 50.21 In general, we do not rec-
ommend performing DAA in patients with a BMI > 40, as we believe that the procedure
cannot be done safely, and that the risk of intra- and postoperative complications is vastly
higher.
Meticulous hemostasis also needs to be maintained to avoid postoperative hematoma.
Identification and coagulation and/or ligation of the ascending lateral femoral circumflex
vessels is mandatory as these can be a source of significant bleeding. Additionally, cap-
sular vessels can be encountered during release of the anterior capsule along the intertro-
chanteric ridge, especially in hips with inflamed synovium with severe arthritic changes.
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206 Chapter 15
Figure 15-8. Postoperative radiograph of an 80-year- old female with osteo-

porosis. Cemented fixation of the femur was chosen with excellent results.
Branches of the medial femoral circumflex may be encountered when releasing the ilio-
femoral and ischiofemoral ligaments near the lesser trochanter, and the surgeon should be
well aware of this. We have a low threshold to place a deep drain at the time of closure if
there is concern for hematoma. There have been several studies published on the efficacy

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of tranexamic acid (TXA) in reducing blood loss in THA. Protocols for intravenous and
topical administration exist with studies supporting the use of both.22,23 Our protocol is
to administer 1 g of TXA intravenously prior to incision and 1 g at closure unless it is
contraindicated.
Dislocation after THA continues to be a major concern for orthopedic surgeons and
patients. This complication is the topic of much research and deliberation due to its mor-
bidity and the costs associated with its numerous treatments. As such, this complication
has become one of the many benchmarks in comparing various surgical approaches and
techniques. One of the many attractions of the DAA is its muscle-sparing nature. By
preserving lateral and posterior soft tissues, it is proposed that patients would benefit from
faster recovery times and a decreased risk of dislocation.
Dislocation after DAA THA has been reported. In a large prospective series of
1764 DAA THAs, Sariali et al reported 27 (1.5%) dislocations within 2 months of the
index procedure.12 All of these dislocations were anterior dislocations; 2 patients required
revision surgery for recurrent instability.12 The authors surmised that risk factors for dis-
location after DAA THA include high body mass index, younger age, use of a smaller
femoral head, and reduced postoperative hip range of motion. Patients with a diagnosis
of avascular necrosis were 3 times more likely to dislocate than patients requiring THA
for other diagnoses.12
Despite preserving posterior and lateral soft tissue structures, posterior dislocation has
also been reported after THA via the DAA. Jewett et al reported a total of 7 dislocations
in a series of 800 patients (0.88%), with 4 of the dislocations in the posterior direction.10
Sariali et al also compared dislocation rates among the various other surgical approaches
from the available literature.12 On average, dislocation rates vary slightly with respect to
surgical approach: 4% for the posterior approach, 1.6% for the transtrochanteric approach,
2% for the anterolateral approach, and 1% for the DAA.12 Matta et al reported 3 disloca-
tions in a total of 494 patients (0.61%).5 Kennon et al reported a total of 28 dislocations in
their consecutive series of 2132 patients amongst 3 senior surgeons (1.3%).24
Interest in the DAA for THA has increased to accommodate patient demand for MIS
techniques. In conjunction with specialized operating room tables and surgical equip-
ment, this approach is quickly finding itself at the forefront of THA. Improved surgical
and patient outcomes with the DAA have also led to a continuous rise of surgeon enthu-
siasm and more generalized acceptance for the DAA in the arthroplasty community. The
DAA, however, is not without complication and has a potentially steep learning curve.
When performing a THA via the DAA, the surgeon must be ever vigilant to avoid and
recognize complications related to difficulty in exposure and component positioning. A
thorough understanding of the anatomy and the sequential necessary capsular releases
will allow the surgeon to master the approach. Fractures of the femur are still a concern,
as they can significantly affect a patient’s immediate postoperative rehabilitation protocol.

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208 Chapter 15
Meticulous technique and preoperative planning must be pursued to ensure successful

surgical and patient outcomes.
A thorough understanding of hip anatomy is vital to master THA via the DAA and
avoid potential complications, especially during the early learning curve.
Meticulous capsular releases are critical to ensure the approach is performed success-
fully, with an increased emphasis for short femoral necks and muscular male patients,
where femoral exposure may be more difficult.
The key to avoiding complications during THA DAA is to have adequate education
and training before adopting the DAA, and then anticipate the potential for compli-
cations at each step of the surgical exposure and instrumentation.
DAA surgeons should always be vigilant about the potential for proximal femoral
fractures and perforations during the procedure, and should have the equipment on
hand at their total joint center to manage these complications immediately when they
do occur.
1. Howell JR, Garbuz DS, Duncan CP. Minimally invasive hip replacement: rationale, applied anatomy, and
instrumentation. Orthop Clin North Am. 2004;35(2):107-118.
2. Sendtner E, Borowiak K, Schuster T, Woerner M, Grifka J, Renkawitz T. Tackling the learning curve:
comparison between the anterior, minimally invasive (Micro-Hip®) and the lateral, transgluteal (Bauer)
approach for primary total hip replacement. Arch Orthop Trauma Surg. 2011;131(5):597-602.
2011;93(15):1392-1398.
7. Woolson ST, Pouliot MA, Huddleston JI. Primary total hip arthroplasty using an anterior approach and a
fracture table: short-term results from a community hospital. J Arthroplasty. 2009;24(7):999-1005.
anterior with mini-posterior approach: two consecutive series. J Arthroplasty. 2009;24(5):698-704.
Orthop Relat Res. 2011;469(2):503-507.
11. Mast NH, Munoz M, Matta J. Simultaneous bilateral supine anterior approach total hip arthroplasty: eval-
uation of early complications and short-term rehabilitation. Orthop Clin North Am. 2009;40(3):351-356.
J Arthroplasty. 2008;23(2):266-272.
13. Rüdiger HA, Betz M, Zingg PO, McManus J, Dora CF. Outcome after proximal femoral fractures
during primary total hip replacement by the direct anterior approach. Arch Orthop Trauma Surg.
2013;133(4):569-573.

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16. Berend KR, Lombardi AV, Jr, Seng BE, Adams JB. Enhanced early outcomes with the anterior supine
17. Goulding K, Beaulé PE, Kim PR, Fazekas A. Incidence of lateral femoral cutaneous nerve neurapraxia after
total hip arthroplasty. J Arthroplasty. 2010;25(5):671,9.e1.
19. Christensen CP, Karthikeyan T, Jacobs CA. Greater prevalence of wound complications requiring reopera-
tion with direct anterior approach total hip arthroplasty. J Arthroplasty. 2014;29(9):1839-1841.
20. Mason JB, Callaghan JJ, Hozack WJ, Krebs V, Mont MA, Parvizi J. Obesity in total joint arthroplasty: an
issue with gravity. J Arthroplasty. 2014;29(10):1879.
21. Arsoy D, Woodcock JA, Lewallen DG, Trousdale RT. Outcomes and complications following total hip
arthroplasty in the super-obese patient, BMI > 50. J Arthroplasty. 2014;29(10):1899-1905.
22. Wind, TC, Barfield WR, Moskal JT. The effect of tranexamic acid on transfusion rate in primary total hip
arthroplasty. J Arthroplasty. 2014;29(2):387-389.
23. Tuttle JR, Ritterman SA, Cassidy DB, Anazonwu WA, Froehlich JA, Rubin LE. Cost benefit analysis of
topical tranexamic acid in primary total hip and knee arthroplasty. J Arthroplasty. 2014;29(8):1512-1515.
minimally invasive anterior surgical approach. J Bone Joint Surg Am. 2003;85-A(Suppl 4):39-48.

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16
How to Identify and Correct
Technical Errors With the
Michael P. Ast, MD and Hari P. Bezwada, MD
Adoption of a new surgical technique is associated with a learning curve during which
increased surgical time and/or complication rates may be encountered.
Understanding the nature of technical errors is the first step to identifying and pre-
venting them during surgery.
An understanding of how to recognize errors, and treat them expediently, is likewise
imperative when learning a new surgical technique.
Like all other surgical procedures, direct anterior approach (DAA) total hip arthroplas-
ty (THA) is associated with a learning curve. During this time, surgeon unfamiliarity can
lead to a higher risk of complications. Estimates of the learning curve have cited a mini-
mum number between 30 and 50 DAA THA operations.1 Early complications often arise
from technical difficulties that come with changes in spatial orientation, instrumentation,
and anatomical dissection during DAA THA. In this chapter, we will examine how to
avoid, identify, and correct some of the common technical errors that can occur when
modifying the Smith-Petersen approach for performing primary total hip replacement.
One of the most common complications of the DAA for THA is postoperative lateral
femoral cutaneous nerve (LFCN) palsy. The course of the LFCN is over the anterior

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212 Chapter 16
Figure 16-1. Intraoperative photograph showing the fascia overlying the ten-
sor fascia lata (TFL). The blueish tissue to the left on the image is the muscle
belly. The fascial entry should be made with blunt dissection medial to the
tensor to avoid injury to the LFCN.
superior iliac spine and then along the muscle belly of the sartorius. Postoperative thigh
numbness is usually as a result of traction injury from excessive retraction. Dissection
also creates the risk of transection of the main trunk of the nerve in addition to its distal
branches. During the approach, always monitor the location of the sartorius and the rec-
tus femoris and be sure to stay lateral to these structures, since the risk of LFCN palsy
increases if the surgeon strays medial to them.
The skin incision for the DAA should be located just lateral to the true interner-
vous interval, centered over the tensor muscle belly, thereby reducing the risk of injuring
branches of the LFCN (Figure 16-1). This approach is called a modified Smith-Petersen
approach since it does not directly overly the classic Smith-Petersen interner vous interval
between the TFL/sartorius muscles superficially, and the gluteus medius/rectus femoris
muscles deeply. The fascia is elevated off the muscle and finger dissection of the interval
is performed, wrapping around the medial border of the TFL muscle (Figure 16-2).
The most common source of excessive bleeding during DAA THA is from the lateral
femoral circumflex vessels. Located at the distal portion of the exposure, these vessels
must be addressed before the anterior hip capsule can be exposed for the THA. After
placing retractors outside of the capsule, a fat layer is encountered. Careful dissection
through this layer at the distal end of the incision will expose the network of vessels
running transversely across the surgical field. Often, up to 3 vessels are present, but can
vary in their precise position and caliber from one patient to the next. The vessel network
can be suture ligated, clipped, or cauterized, but it is best to address them in a systematic,

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How to Identify and Correct Technical Errors With the Direct Anterior Approach 213
Figure 16-2. Surgical image demonstrating blunt dissection medially around

the tensor muscle into the Smith-Petersen interval.
Figure 16-3. Intraoperative photograph demonstrating the appearance of the

lateral femoral circumflex vessels.
methodical way. If they are ligated and there is still significant bleeding from the area,
trace the lateral branch laterally and you can usually see the ascending branch, which may
need to be ligated or cauterized (Figure 16-3).

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214 Chapter 16
The most common technical error in the neck cut during DAA is to leave too much
residual femoral neck, which can complicate acetabular exposure. It has been recommend-
ed that the femoral neck cut be made under direct fluoroscopy during the early adoption
of this approach. Preoperative templating of the osteotomy location can help identify the
correct resection level. Since the lesser trochanter is not as readily visible as in other hip
approaches, fluoroscopy may be very useful in orienting and locating the femoral neck cut,
especially early on.
Alternatively, the saddle or the lateral portion of the femoral neck as it turns into the
medial side of the greater trochanter can be identified and used as a landmark for the
femoral neck osteotomy (Figure 16-4). The basicervical neck osteotomy is usually at a
45-degree angle related to the femoral shaft with its origin in the center of the lateral
saddle.
Removal of the femoral head can be challenging. A napkin-ring technique is often
used to facilitate femoral neck removal, by making a second, in-situ subcapital neck oste-
otomy at the femoral head-neck junction. This intervening neck fragment is removed to
open space within the hip capsule and help with femoral head extraction (Figure 16-5).
The femoral head can then be removed with a corkscrew or skid. Some authors have also
advocated dislocating the femoral head prior to making the neck cut, which can make
subsequent removal of the cut femoral head from the acetabulum easier.2
Reaming and socket placement during DAA THA can be challenging for surgeons
used to the lateral approach, since the patient position and acetabular appearance are
different. Further, the method of visualizing cup positioning, local landmarks, and ulti-
mate cup orientation may be slightly different in this approach, especially for those more
accustomed to the posterior approach. This is important not only in the reaming and
placement of the component, but also in the evaluation of intraoperative and postoperative
radiographs. Many posterior hip surgeons may be used to aiming for 20 or more degrees
of anteversion in their acetabular component. With the DAA, the goal should be closer to
15 degrees or less. The anterior acetabular lip should be directly visualized along with the
transverse acetabular ligament to provide the surgeon with consistent guides to improve
both the accuracy and precision of cup placement 2,3 (Figure 16-6).
A frustrating early complication observed with the widespread adoption of the DAA
for THA was periprosthetic fracture of the femur, most often involving the greater tro-
chanter.1,4 It is important to understand when these fractures occur and how to prevent
them. The surgeon should protect the greater trochanter during the basicervical femoral
neck osteotomy. Placing a blunt, wide retractor into the saddle of the proximal femur,
which is the area where the femoral neck meets the base of the greater trochanter, will
protect the trochanter from inadvertent injury with the saw blade (see Figure 16-4).
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B
Figure 16-4. (A) Surgical illustration and (B) intraoperative photograph dem-
onstrating position of the retractors medial to the femoral neck and in the
saddle region to protect the surrounding tissue and the greater trochanter
during femoral neck osteotomy.
The trochanter is also at risk during exposure of the femur for reaming. When plac-
ing the leg into hyperextension as well as maximal external rotation, care must be taken
to ensure that the posterior aspect of the greater trochanter does not get caught on the
posterior aspect of the acetabulum. This is a concern when using a proximal femur hook
elevator device, either with a specialized table or mounted onto a standard table. When
elevating the hook, be sure to use manual distraction pressure to initially pull the femur
laterally and elevate it, and then only use the hook to maintain the level of elevation.
Pulling the femur laterally by hand prior to elevation will help ensure the trochanter does
not catch the posterior acetabulum and fracture when forceful elevation is applied for
exposure.

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216 Chapter 16
Figure 16-5. Intraoperative photograph demonstrating the in-situ technique

of segmental femoral neck resection.
Figure 16-6. Intraoperative photograph showing acetabular inserter handle

position relative to the floor, to ensure 10 to 15 degrees of anteversion.
Finally, the trochanter is at risk during femoral preparation. Ensuring appropriate

femoral exposure that allows for lateralization of the femoral component will help avoid
injury at this stage. Ensuring that the leg has been extended, adducted, and externally
rotated is critical prior to initiating broaching. Be sure to fully release the femur as needed
to be able to have a straight shot for broaching the femur, and for placement of the final
component without undue tension on the greater trochanter. A retractor placed over the
top of the greater trochanter can help remind the surgeon of its location, and appropriate
lateralization will allow for safe placement of the stem without lateral cortical perforation.

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Exposing the femur for canal preparation and placement of the final implants is often
the most challenging part of the early adoption period of the DAA for THA. It is also
one of the more important parts of the exposure in order to prevent femoral complications.
Appropriate femoral exposure takes time and patience, especially in the early adoption
period. Do not be afraid to over-release the femur to ensure adequate exposure prior to
beginning femoral preparation.
Appropriate releases begin with the release of the capsular flap the runs between the
lateral acetabulum and the posterior aspect of the femoral neck and greater trochanter.
Sometimes referred to as the capsular sail, this tissue can be completely released off of the
femur to give visibility to the medial side of the greater trochanter and allow appropri-
ate femoral elevation. Further, if necessary, the capsular tissue within the confines of the
greater trochanter can also be released and this should be carried down the medial aspect
of the femoral neck all the way around to the lesser trochanter. Finally, if exposure is still
inadequate, the tendinous attachments of the piriformis and proximal external rotators
can be partially released from the trochanter, which should allow for complete exposure
and delivery of the proximal femur.
When the releases are completed, the entire proximal femoral neck should be easily
visible and broaches should easily be able to be passed into the canal without tension to
achieve the appropriate trajectory (Figure 16-7). Start slightly posterior, angling the tip of
the broach anteriorly up and into the anatomic femoral bow in order to avoid perforation.
The use of a femoral system that does not require straight reamers as well as one with an
offset broach handle will ease femoral canal preparation.5 Always remember that appro-
priate femoral exposure and releases are the most important way to avoid technical errors
during femoral preparation.
The most common technical errors during DAA femoral stem placement entail exces-
sive femoral anteversion, perforation of the femoral canal, and fracture of the calcar. Each
of these errors must be identified intraoperatively to avoid postoperative instability, sub-
sidence, or periprosthetic fracture. When these complications are noted intraoperatively,
they are often amenable to simple steps to prevent further complications.
Excessive femoral anteversion can lead to postoperative instability. It is impor tant to
have appropriate landmarks and references for assessing anteversion intraoperatively. A
good technique is to expose the femur and calcar fully, then assess the position of the
medial epicondyle distally. Then place an electrocautery mark on the calcar that is 0 to
15 degrees anteverted relative to that point, to avoid retroversion or over-anteversion of
the stem. Version errors can arise from the medial soft tissue of the abdomen and proxi-
mal thigh rotating the surgeon's hand in an external direction. Avoid this by ensuring
limb adduction, so that the entry point is more lateral, thereby easing canal access. As the
broaches get larger, excessive anteversion can often remove the trabecular bone from the
anterior femoral neck. When this happens, bone grafting of this anterior femoral neck
defect can help improve stem stability.

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218 Chapter 16
Figure 16-7. Intraoperative photograph showing appropriate fem-

oral exposure and entry that should be achieved prior to broach-
ing the femur.
The simplest bone grafting technique is to take an autologous wedge from either the
cut femoral neck or the femoral head and place it snuggly in the defect after placement
of the final femoral stem implant. If a surgeon notes excessive anteversion, pushing the
broach handle back into a more internally-rotated position, often fighting against the
soft tissue tension, can correct this malposition and the stem will then again be placed
in appropriate anteversion (Figure 16-8). The use of double-offset broaches, especially
in more challenging cases, can be very helpful in avoiding the surrounding soft tissues
and allow the surgeon good access to the appropriate trajectory for broaching the femoral
canal.5
Perforations of the femoral canal or intraoperative proximal femur fracture have been
reported to be as high as 6.5% in some DAA THA series.1 Once it occurs, canal perfora-
tion will be worsened by any further broaching of the femur. As with any other approach
to the femur, there should not be significant resistance when broaching the femoral canal.

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Figure 16-8. Intraoperative photograph showing appropriate femoral ante-

version. Note the trabecular bone loss in the femoral neck (right side of
implant). This can be bone grafted with an autologous bone wedge after
final implant placement.
If a surgeon finds the need for aggressive broaching, or encounters resistance to broach
advancement that is followed by a loss of resistance, this may represent a femoral perfora-
tion or fracture.
Perforations usually arise because the broach is not lateral enough and/or the broach is
in varus. Fluoroscopy should also be used frequently, especially in the early adoption peri-
od, for avoidance of this complication, and expeditious identification of it. An additional
tool is the suction device, as the tip can be inserted down the canal after the initial starter
broach is used to verify canal integrity before subsequent broach insertion. The suction
also is a palpation tool during the broaching process, allowing the surgeon to sound the
canal between broaches and verify the correct position of the stem in real time.
If a perforation is identified with the entry broach or a very short early broach, then
simply reposition the remaining broaches and the final implant down the true canal
should correct the problem without need for further intervention, especially with press-
fit metaphyseal contact stems. If, however, a more distal perforation occurs or there is a
peri-trochanteric fracture noted on fluoroscopy, then cable repair is necessary. One can
also convert to a longer stem design to bypass the defect. Cerclage wires, wire passers, and
multiple stem designs for the DAA should be available to help manage this complication.
Calcar fractures are associated with the use of non-cemented fixation, and to our
knowledge, do not occur with increased incidence during DAA THA, when compared
with other approaches. DAA surgery allows excellent, direct visualization of the calcar. If
a crack is seen, or if the final implant sinks in further than expected, the surgeon should
suspect a calcar fracture. If so, the stem should be backed up, a cerclage cable placed
circumferentially around the femur and tightened, before the implant is impacted down
again. In cases with particularly severe osteoporosis, conversion to a cemented femoral
implant is an option.

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220 Chapter 16
The incidence of postoperative dislocation after DAA THA has been reported to be
between 0.6% and 1.5%.4,6–8 Often, these are anterior dislocations. As with all other
complications mentioned here, intraoperative attention can help avoid this problem. Leg
lengths should be restored, as with any hip replacement. Also, anterior hip stability should
be checked in both limb extension with external rotation and limb flexion with external
rotation (Figure 16-9). Hip laxity can be checked by placing a bone hook into the inserter
well (located on the lateral shoulder of most implants) and pulling laterally to ensure
appropriate offset recreation and abduction tension.
If instability is noted, then the femoral and acetabular components should be checked
for excessive anteversion. It is important to keep in mind the concept of combined ante-
version. This is the total anteversion when the anteversion of the femoral and acetabular
components combined.9 For DAA, the desired combined anteversion is about 30 degrees.
If version is accurate, then check for soft tissue or bony impingement. Commonly, poste-
rior acetabular osteophytes that are not removed can impinge and cause anterior instabil-
ity. If instability is still present, then care should be taken to examine for a fracture of the
greater trochanter and this should be repaired. Finally, the use of larger femoral heads,
elevated liners, and dual-articulation bearings can sometimes help address hip instability;
however, these should never be used as a substitute for appropriate component positioning
and tissue balance.
Use fluoroscopy early and often during the early DAA adoption period.
Do not under-release the femur, especially in the early adoption period, as this may
lead to complications during broaching.
Use canal finders, frequent suction probing, and fluoroscopy to identify and address
any canal fractures or perforations during femoral broaching.
Always assess THA stability intraoperatively and resolve it by ensuring proper com-
bined version, lack of bony impingement, and restoration of proper limb lengths.
1. Woolsen ST, Pouliot MA, Huddleston JI. Primary total hip arthroplasty using an anterior approach and a
2. Yerasimides JA, Matta JM. Primary total hip arthroplasty with a minimally invasive anterior approach.
Semin Arthro. 2005;16:186-190.
3. Biedermann R, Tonin A, Krismer M, Rachbauer F, Eibl G, Stockl B. Reducing the risk of dislocation
after total hip arthroplasty: the effect of orientation of the acetabular component. J Bone Joint Surg Br.
2005; 87(6):762-769.
orthopaedic table. Clin Orthop Rel Res. 2005;(441):115-124.

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B
Figure 16-9. Assessing intraoperative hip stability testing in flexion and exter-
nal rotation, as well as in limb extension and external rotation. Identify and
address any causes of instability.
5. Nogler M, Krismer M, Hozack WJ, Merritt P, Rachbauer F, Mayr E. A double offset broach handle for
preparation of the femoral cavity in minimally invasive direct anterior total hip arthroplasty. J Arthroplasty.
2006;21(8):1206-1208.
of 1037 total hip replacements. Clin Orthop Relat Res. 2004;(426):164-173.

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222 Chapter 16
minimally invasive anterior surgical approach. J Bone Joint Surgery Am. 2003;85-A(Suppl 4):39-48.
J Arthroplasty. 2008;23(2):266-272.
9. Amuwa C, Dorr LD. The combined anteversion technique for acetabular component anteversion.
J Arthroplasty. 2008;23(7):1068-1070.

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17
Head and Liner
Revision Surgery via the
Scott A. Ritterman, MD; Matthew E. Deren, MD; and Lee E. Rubin, MD
The direct anterior approach (DAA) offers straightforward, direct, and anatomic
access to the acetabulum and femoral head for isolated bearing surface exchange.
Structural components must be well-fixed and well-aligned with a proven track rec-
ord to allow consideration of isolated bearing surface exchange.
DAA is extensile; this is an advantage if major bone grafting or revision of either the
femoral or acetabular component is required after intraoperative assessment of the
implant fixation.
Isolated acetabular liner exchange, with or without prosthetic head exchange, is the
most basic revision total hip arthroplasty (THA). Common indications include hip insta-
bility, osteolysis resulting from polyethylene (PE) wear, metal-on-metal (MOM) bearing
failures, trunnion corrosion in metal-on-PE components, and squeaking associated with
ceramic-on-ceramic (COC) components.
Most THAs implanted from the 1970s to 1990s used metal prosthetic heads and con-
ventional PE acetabular liners. The reactive nature of large PE wear particles from this
bearing combination can lead to osteoclast activation and periarticular osteolysis. Isolated
acetabular liner exchange is the treatment of choice when proper indications are met and
the THA components are deemed to be both well-fixed and satisfactorily aligned. The
DAA provides a minimally invasive approach to liner exchange, offers direct access to
the acetabulum, and is extensile for complete component revision if needed. Also, in most
such instances, the DAA can be performed through previously unoperated tissue planes.

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224 Chapter 17
All THA bearing surfaces generate wear particles, and the association between
PE wear and osteolysis is well-established.1,2 Wear rates produced by metal prosthetic
heads on conventional PE have been associated with osteolysis.3 Highly cross-linked
PE (HCLPE) has a significantly lower wear rate than conventional PE.4,5 Despite the
advent of HCLPE in the mid-1990s, osteolysis remains a relevant problem because of the
large numbers of prostheses implanted prior to its development. Additionally, younger
and more active patients receiving joint replacements will likely experience wear-induced
osteolysis and require revision with a higher frequency than older, sedentary patients.
Many patients who present with significant wear and osteolysis are satisfied with the
function of their prosthesis and may not be symptomatic.6 Early intervention in such
patients can allow for a more limited surgical procedure and yield good results if compo-
nents are well fixed, correctly positioned, and carry a solid track record.7,8 The acetabular
shell can be retained, since removal of a well-ingrown shell can entail significant bone loss
and even pelvic discontinuity.9 Surgical treatment options for osteolysis include bearing
exchange with or without bone grafting of bony defects, cementing a HCLPE liner into a
well-fixed acetabular shell, or component revision for malpositioned or loose components.
In some cases, hip instability can be treated with an isolated head and liner exchange.10
Two familiar causes of recurrent instability are component malposition and neuromus-
cular dysfunction. For a malpositioned metal acetabular shell, bearing exchange alone
will not suffice; the shell must be removed and repositioned. Recurrent dislocation due
to neuromuscular causes such as abductor deficiency or other neurological conditions can
be treated with conversion to a constrained liner, provided the components are well-fixed
and well-positioned.
Head and liner exchange also allows use of a larger diameter femoral head that confers
hip stability, even though large heads may produce increased volumetric wear and/or pres-
ent an increased risk of galvanic corrosion at the trunnion.11,12 Some authors recommend
increasing the femoral head diameter during routine bearing exchange to increase the
jump distance and therefore reduce the risk of instability following revision.13 Additional
reasons for bearing exchange include conversion of an existing MOM bearing to ceramic
or metal-on-HCLPE. Revision of COC bearings to an HCLPE liner for squeaking
noises is a viable option with good results.14
The supine patient position during DAA is particularly advantageous during revision
surgery, when operative times may be prolonged. In the lateral decubitus position, for
example, external compression on the down limb has been associated with the develop-
ment of compartment syndrome during lengthy surgical procedures.15
The supine position of the pelvis can also facilitate the correct placement of com-
ponents, especially in revision cases when bony landmarks may be compromised. Leg
lengths are easy to estimate, since the nonoperative leg may be draped free or out of the

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Head and Liner Revision Surgery via the Direct Anterior Approach 225
operative field. The DAA also offers the shortest route to the hip joint in most patients
and is extensile from the medial aspect of the ilium to the lateral aspect of the knee for
contingency purposes.16
An 86-year-old female had worsening right hip pain, and a history of a ceramic-on-
conventional-PE THA performed 10 years earlier. Aspiration was negative for deep infec-
tion. She was unable to walk or bear weight for more than a single step, and preferred to
lay supine with her right hip slightly flexed and externally rotated for comfort.
Radiographs showed well-fixed, press-fit THA implants with a 28-mm alumina
ceramic-PE bearing (Figure 17-1). Prominent osteolytic cysts were present behind the
socket on plain radiographs. Bone scan data showed no loosening of components. MRI
confirmed the presence of osteolytic cysts around the acetabulum and a contiguous mass
of fluid and wear debris extending from the joint into the ilacus and psoas muscles.
Based on these findings, bearing revision via the DAA with component retention was
contemplated.
Since a simple revision may turn into a more complicated operation, DAA revision,
even if for a simple bearing exchange, should be done only after the surgeon has gained
enough experience with primary DAA THA. Additionally, the surgeon should gain
cadaver practice with pelvic and femoral extensile surgery through the DAA pathway.
The operation can be done on a special traction table or a regular table. In regular table
use, a bump is placed under the sacrum ending at the ischium to raise the pelvis, and allow
the posterior gluteal tissues to fall away from the field. Other details of patient position-
ing, bony landmarks, and incision placement have been addressed in previous chapters.
In the present case, a longitudinal DAA incision was marked just distal and lateral to
the anterior superior iliac spine. The extensile incision to the pelvis was marked proxi-
mally, just inferior to the iliac crest, and a second incision was marked centered over the
lateral iliac crest to allow planned intrapelvic access (Figure 17-2). During the DAA, if
needed, the proximal tendon of the tensor fascia lata (TFL) muscle can be released for
1.5 cm from the insertion on the lateral aspect of the ilium for additional exposure. This
release can be carried further posteriorly for extended exposure to the lateral ilium via the
iliofemoral approach but is rarely needed for isolated liner exchange.
The joint is approached and the lateral circumflex vessels are identified and cauterized.
This step is critical if the DAA is a native tissue plane after prior lateral- or posterior-
approach THA. The pseudocapsule is identified and the iliopsoas is carefully protected,
as it can be scarred to the capsule following prior THA surgery. The capsule is incised,
and the external-most layer is preserved for subsequent closure when possible. Aspiration
of the joint just prior to opening capsule can help obtain a fluid sample for microbiology,
which is supplemented by a minimum of 2 additional synovial biopsies for tissue culture,
each taken with a sterile instrument.
In the present case, the joint capsule was grossly distended. Upon incising the capsule,
we discovered synovial fluid under pressure with reactive synovium and macroscopic PE
debris. Pseudocapsular releases off the femur were performed anteriorly at the intertro-
chanteric line, laterally along the shoulder, and medially from the lesser trochanter to
the medial calcar. This 270-degree release allows for lateral mobilization of the femur

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226 Chapter 17
Figure 17-1. Anteroposterior radiograph of the right hip, showing well-fixed

socket and 28-mm ceramic head, with superior acetabular cystic changes.
and dislocation of the hip. Once initial dislocation is achieved, the operative leg can be
adducted and externally rotated, allowing surgical access to the posterior pseudocapsule,
which can then be released if needed.
Leaving the existing ceramic head in place will act to protect the trunnion dur-
ing the liner extraction. After the above dissection, place the leg in a figure-4 position
(Figure 17-3). Then, a cobra retractor is placed laterally against the acetabular wall, and a
gauze sponge is used to pad and protect the femoral neck. Gentle lateral retraction then
depresses the retained stem and head away from the acetabulum. With an anterior cobra
in place with a third medial retractor near the transverse ligament when needed, excellent
360-degree cup exposure is obtained prior to liner removal.
We removed the liner using a screw placed into the PE liner (Figure 17-4) although
other methods can be used as well. Care should be taken to protect the locking mecha-
nism if the cup is to be retained. Once the liner and any acetabular screws are removed,
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Figure 17-2. Preoperative skin incision markings, showing the DAA incisions
used in this case. The more cephalad incision was used to decompress wear
debris fluid not accessible through the joint cavity.
Figure 17-3. Right leg positioned to move the femoral neck and head laterally
while the liner is removed. A sponge is placed over the retained prosthetic
femoral neck and a blunt cobra retractor depresses the stem from the ace-
tabulum for exposure.
cup stability can be assessed manually and bone grafting can be performed via screw holes
or via a portal in the lateral ilium. When placing a new HCLPE liner, consideration can
be given to cementing the liner, especially if the shell is an older design with an unreliable
locking mechanism. Techniques for doing so have been described in the literature.
A 36-mm liner with a 10-degree face-changing feature was selected for this case, as
the prior acetabular shell was slightly over abducted. A view of the entire hip joint is
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228 Chapter 17
Figure 17-4. Liner removed from the shell, with

a screw to lever it out.
Figure 17-5. DAA view of the final trial head in

place against the newly revised HCLPE liner
prior to final ceramic head placement.
shown with a red trial head in place with the leg in neutral position (Figure 17-5). A
bone hook was next used to distract the joint and replace the trial with a 36-mm ceramic
femoral head, with a revision titanium sleeve. Bearing revision using HCLPE liners and
a titanium sleeve delta ceramic head is our current preference whenever indicated. Wound
closure is no different than that described for the primary DAA THA operations, detailed
elsewhere in this text.
In this case, a lateral ilioinguinal approach window was performed as a secondary inci-
sion to gain extra-peritoneal access into the inner pelvic cavity, as the psoas collection
could not be manually drained by digital palpation over the anterior ilium from within the
joint. The collection was palpated and evacuated by a limited lateral ilioinguinal approach
and then closed in layers (Figure 17-6). The patient was allowed to fully weight bear on

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Figure 17-6. Final incisions following closure. A standard DAA working inci-
sion was used for joint exposure and a limited lateral ilioinguinal incision was
used for intrapelvic lesion debridement.
the hip, and she recovered uneventfully, with complete resolution of her symptoms, and
with the ability to ambulate without assistive devices.
The outcomes of bearing exchange have been addressed in some literature reports. For
example, in 24 hips with isolated PE liner exchange, a computer-assisted method mea-
sured regression or resolution of osteolytic lesions.17 Although there were no dislocations,
2 revisions were required for continued osteolysis likely due to the poor track record of
the implants.17 In another series of 35 patients with PE wear and either osteolysis or hip
instability, isolated liner/head exchange was successful in treating instability, although
2 postoperative dislocations occurred in patients with osteolysis.18
Another retrospective review examined 68 cases of liner exchange with or without
femoral component revision.19 Authors found a similar revision rate at 7 years between
the liner exchange group (82 ± 10%), vs the liner exchange and femoral revision group
(84 ± 11%), vs complete acetabular and femoral revision (82 ± 11%). The authors noted that
the 9 dislocations, of which 3 required revision surgery, occurred in patients with a history
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230 Chapter 17
of multiple procedures and acetabular abduction angles of less than 40 degrees, suggesting
the importance of component position.19
Restrepo et al retrospectively reviewed 36 isolated liner exchanges and 31 full acetabu-
lar revisions.20 Acetabular loosening resulted in failure and revision within 5 years in
3 of the isolated liner exchanges, compared to only 1 patient with a full acetabular revi-
sion. They concluded that the full acetabular component be revised in cases of locking
mechanism damage, damage to the cup from the femoral head wear through the liner,
and malposition.20
Cancellous impaction bone grafting was examined in a series of 168 patients with
acetabular defects in complex primary and revision total hip arthroplasty.21 Although
the series lost 30 patients to follow-up or unrelated deaths, the grafting technique proved
successful in radiographic incorporation of the bony defects, resulting in only 2 revisions
for late loosening and 1 revision for instability.21 Koh et al reviewed a series of 45 patients
with complete acetabular revision with 35 patients who underwent cup retention with
cancellous allograft grafting.22 The authors found a statistically significant increase
in concomitant femoral stem revision when the full acetabular shell was revised, with
decreased hospital stay and intraoperative blood loss with liner exchange.22 Of note, the
revision PE liner was cemented into 29 patients and exchanged in only 6 patients. There
were no significant differences in osteolysis progression, failure requiring revision, or
major complications.22
Mall et al examined 40 patients (22 head and liner exchanges, 18 full revisions) using
high-resolution computed tomography to determine if plain radiography underestimated
the healing of osteolytic defects after revision surgery. Through advanced imaging, the
authors demonstrated that complete revisions had increased filling of osteolytic defects
and graft healing compared to component retention with liner exchange.23 The bear-
ing surface exchange group had a higher rate of reoperation (17%) for progression of the
osteolytic lesions and loosening.
Liner and/or femoral head exchange is an ideal starting point for performing revision
THA surgery using the DAA. If complete acetabular component revision becomes nec-
essary intraoperatively, the DAA can be extended. In all cases, acetabular extraction and
revision instruments should be available. Although we use a standard operating room table
for bearing-exchange revision DAA THA, a traction table and fluoroscopy can be used
with slight technique modifications. In our experience, DAA bearing exchange patients
have generally stayed a single night in the hospital, and this type of limited revision may
be performed on an outpatient basis in the future. Literature is starting to emerge regard-
ing revision THA via the DAA, and particularly as the operation is increasingly adopted
among arthroplasty and trauma surgeons.

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DAA-based bearing exchange, when indicated, is a simple progression from primary

THA; the anatomic supine position offers distinct advantages for the surgeon already
facile with primary DAA THA.
The DAA is extensile and will accommodate bone grafting, or complete component
revision, if necessary. Revision instruments should be available in such cases.
Future studies will address the efficacy of bearing exchange through DAA, following
primary THA done with other approaches.
1. Dowd JE, Sychterz CJ, Young AM, Engh CA. Characterization of long-term femoral-head-penetration
rates. Association with and prediction of osteolysis. J Bone Joint Surg Am. 2000;82-A(8):1102–1107.
2. Orishimo KF, Claus AM, Sychterz CJ, Engh CA. Relationship between polyethylene wear and osteolysis
in hips with a second-generation porous-coated cementless cup after seven years of follow-up. J Bone Joint
Surg Am. 2003;85-A(6):1095–1099.
3. Dumbleton JH, Manley MT, Edidin AA. A literature review of the association between wear rate and
osteolysis in total hip arthroplasty. J Arthroplasty. 2002;17(5):649–661.
4. Thomas GE, Simpson DJ, Mehmood S, et al. The seven-year wear of highly cross-linked polyethylene in
total hip arthroplasty: a double-blind, randomized controlled trial using radiostereometric analysis. J Bone
Joint Surg Am. 2011;93(8):716–722.
5. Glyn-Jones S, Thomas GE, Garfjeld-Roberts P, et al. The John Charnley Award: highly crosslinked poly-
ethylene in total hip arthroplasty decreases long-term wear: a double-blind randomized trial. Clin Orthop
Relat Res. 2014; 473(2):432-438.
6. Naudie DDR, Engh CA. Surgical management of polyethylene wear and pelvic osteolysis with modular
uncemented acetabular components. J Arthroplasty. 2004;19(4 Suppl 1):124–129.
7. Adelani MA, Mall NA, Nyazee H, Clohisy JC, Barrack RL, Nunley RM. Revision total hip arthroplasty
with retained acetabular component. J Bone Joint Surg Am. 2014;96(12):1015–1020.
8. Lombardi AV, Berend KR. Isolated acetabular liner exchange. J Am Acad Orthop Surg. 2008;16(5):243–248.
9. Maloney WJ, Herzwurm P, Paprosky W, Rubash HE, Engh CA. Treatment of pelvic osteolysis associated
with a stable acetabular component inserted without cement as part of a total hip replacement. J Bone Joint
Surg Am. 1997;79(11):1628–1634.
10. Salassa T, Hoeffel D, Mehle S, Tatman P, Gioe TJ. Efficacy of revision surgery for the dislocating total hip
arthroplasty: report from a large community registry. Clin Orthop Relat Res. 2014;472(3):962–967.
11. Cross MB, Nam D, Mayman DJ. Ideal femoral head size in total hip arthroplasty balances stability and
volumetric wear. HSS J Musculoskelet J Hosp Spec Surg. 2012;8(3):270–274.
12. Cooper HJ, Della Valle CJ. Large dia meter femoral heads: is bigger always better? Bone Joint J.
2014;96-B(11 Suppl A):23–26.
13. Hamilton WG, Hopper RH, Engh CA, Engh CA. Survivorship of polyethylene liner exchanges performed
for the treatment of wear and osteolysis among porous-coated cups. J Arthroplasty. 2010;25(6 Suppl):75–80.
14. Matar WY, Restrepo C, Parvizi J, Kurtz SM, Hozack WJ. Revision hip arthroplasty for ceramic-on-
ceramic squeaking hips does not compromise the results. J Arthroplasty. 2010;25(6 Suppl):81–86.
15. Cascio BM, Buchowski JM, Frassica FJ. Well-limb compartment syndrome after prolonged lateral decubi-
tus positioning. A report of two cases. J Bone Joint Surg Am. 2004;86-A(9):2038–2040.
16. Keggi JM, Kennon RE, Rubin LE, Keggi KJ. Isolated acetabular liner exchange. J Am Acad Orthop Surg.
2008;16(9):495–496; author reply 496.
17. O’Brien JJ, Burnett RSJ, McCalden RW, MacDonald SJ, Bourne RB, Rorabeck CH. Isolated liner
exchange in revision total hip arthroplasty: clinical results using the direct lateral surgical approach.
J Arthroplasty. 2004;19(4):414–423.

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18. Wade FA, Rapuri VR, Parvizi J, Hozack WJ. Isolated acetabular polyethylene exchange through the antero-
lateral approach. J Arthroplasty. 2004;19(4):498–500.
19. Bidar R, Girard J, May O, Pinoit Y, Laffargue P, Migaud H. [Polyethylene liner replacement: behavior and
morbidity in 68 cases]. Rev Chir Orthopédique Réparatrice Appar Mot. 2007;93(5):461–468.
20. Restrepo C, Ghanem E, Houssock C, Austin M, Parvizi J, Hozack WJ. Isolated polyethylene exchange
versus acetabular revision for polyethylene wear. Clin Orthop Relat Res. 2009;467(1):194–198.
21. Patil N, Hwang K, Goodman SB. Cancellous impaction bone grafting of acetabular defects in complex
primary and revision total hip arthroplasty. Orthopedics. 2012;35(3):e306– e312.
22. Koh KH, Moon YW, Lim SJ, Lee HI, Shim JW, Park YS. Complete acetabular cup revision versus isolated
liner exchange for polyethylene wear and osteolysis without loosening in cementless total hip arthroplasty.
Arch Orthop Trauma Surg. 2011;131(11):1591–1600.
23. Mall NA, Nunley RM, Smith KE, Maloney WJ, Clohisy JC, Barrack RL. The fate of grafting acetabular
defects during revision total hip arthroplasty. Clin Orthop Relat Res. 2010;468(12):3286–3294.


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18
Simultaneous Bilateral
Total Hip Arthroplasty
Bilateral direct anterior approach (B-DAA) offers the ease of supine patient surgery
and avoids change in patient position required when the patient is placed lateral.
Candidates for B-DAA should be selected carefully and the operating room should
be set up with efficiency in mind.
Patient education is an especially impor tant step for patients with B-DAA.
The direct anterior approach (DAA) for total hip arthroplasty (THA) is considered a
less invasive surgical approach, as it leaves hip muscle groups such as hip extensors and
abductors intact.1 In this chapter, we discuss the application of single setting B-DAA
THA. In contrast to staged bilateral surgery, single setting B-DAA can reduce medi-
cal costs and expose the patient to one anesthetic and surgical episode, leading to faster
recovery.2,3 Some authors have cited increased risk with B-DAA done simultaneously,
such as thrombophlebitis4 and heterotopic ossification.5–7 In addition, the need for blood
transfusion may be higher with bilateral THA done simultaneously, compared to staged
bilateral THA,8,9 although some authors have found other wise.10 Finally, patients with
bilateral THA surgeries may need more rehabilitation and may face an increased risk of
reoperation.9
Bilateral THA may be indicated in 10% of the hip arthroplasty patient population.7,11
Both hips can be replaced at the same time, or the operations can be staged (ie, the patient
recovers in between the 2 surgeries). Since bilateral operations done at the same time
entail more surgery,12 contraindications include cardiac disease pulmonary deficiencies,13

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234 Chapter 18
gastrointestinal and renal failures,14 and congenital anomalies such as patent ductus
arteriosus and septal defects.13 Some authors have proposed avoiding simultaneous hip
surgery in patients with any previous coronary vessel disease or anemia.12 Patients with
coronary disease, including heart failure, manifest more postoperative complications
following bilateral joint replacements.15 Likewise, patients with diabetes should also be
selected with caution for bilateral THA.13 These data suggest a careful patient selection
approach when contemplating B-DAA, if complications are to be minimized.
Many prior investigations utilized a lateral decubitus approach to perform simultane-
ous bilateral THA surgeries. Due to the special positioning of the body in the lateral
approach, 2 major concerns arise. First, during patient repositioning for the second THA,
the first incision is under pressure from weight and movement of the freshly-sutured
wound. Second, the mechanical steps during THA, such as impaction of components,
may result in fracture or dislocation of the implants in the initially repaired leg. Therefore,
the bilateral approach should be approached with caution during lateral positioning.
B-DAA offers the advantages of the supine patient position, thereby avoiding these con-
cerns entirely.
Lanting et al reported the outcome of B-DAA in 90 patients (average age of 54 years)
with an average blood loss of 632 mL and low intraoperative and postoperative complica-
tion rate. During 90 cases of B-DAA, only in a single case was the procedure stopped
after the first implantation due to the discovery of an intraoperative arrhythmia.12 The
authors reported an average of 4.5 days length of stay in hospital. In a study by Mast et
al on B-DAA, 147 patients were treated with the average age of 62 years.7 The authors
reported low intraoperative blood loss of 289 mL (range 50 to 900 mL) and average length
of stay of 4 days. The postoperative anemia (hemoglobin [Hgb] < 10 g/dL) was reported
to be the most significant side effect of the surgery with an incidence of 18%.
When considering simultaneous B-DAA THA, one should consider certain patient
factors to avoid complications and poor outcomes. Indications ideally would include bilat-
eral hip disease with relatively few comorbidities, an American Society of Anesthesiology
classification (ASA) of I or II, with a BMI of less than 32 and a motivated patient.16
Since Mast et al have shown an 18% postoperative anemia and a 12% transfusion rate,7
the baseline preoperative Hgb should be >13. Absolute contraindications include a BMI
> 35; ASA III+; patient on chronic blood thinners such as aspirin, Plavix (clopidogrel),
or Coumadin (warfarin); a low Hgb; history of smoking; or a patient taking preoperative
narcotics. Other preoperative factors that may extend the surgical time would be complex
primary cases such as hypertrophic osteoarthritis (OA) or significant heterotopic ossifica-
tion, retained hardware, protrusio acetabulae, and childhood structural hip deformities
that may need additional surgical time to be addressed.
Preoperative medical clearance should be planned before B-DAA THA surgery. The
surgeon should also include detailed preoperative education for the patient and family

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Simultaneous Bilateral Direct Anterior Approach Total Hip Arthroplasty 235
Figure 18-1. Bilateral draping for simultaneous DAA THA. Note the isola-
tion of the perineal area using self-adhesive drapes, and the advantage of
draping both legs free.
regarding the risks of complications such as infection, dislocation, fracture, need for addi-
tional rehabilitation, delays in driving, and the potential need for more pain medication. A
careful assessment of family support should be done to ensure the availability of additional
help postoperatively.
There are several operating room considerations when performing simultaneous
B-DAA THA, such as details of draping, timing sequence of performing the 2 surgeries,
instrument sets, and technical support available. In our practice we obtain 2 anterior-
posterior pelvis x-rays; one after the first hip implant is fully positioned in the femoral
canal and another one after the second hip implant is used for the contralateral hip.
Simultaneous draping can be performed very easily but one must be attentive to the peri-
neal area since that can be a site of contamination (Figure 18-1).
The advantage of B-DAA THA is surgical efficiency, as both hips can be operated
on at the same time, allowing closing of the first hip while starting the approach of the

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236 Chapter 18
Figure 18-2. Photograph of a broach with a low-profile proximal end. If the

femur is prepared first, the broach can be left in place without encroaching
on acetabular preparation.
second hip. Also, final implant choice can be changed if an unexpected issue occurs
while completing the second hip as it relates to leg length or hip stability. Utilizing both
attending co-surgeons and assistants could also be considered, with one surgeon doing the
acetabulum first and the other surgeon doing a femur first technique and then reversing
sides. In addition, to prevent interference of the broaching system while preparing the
acetabulum, a broach system with a low proximal profile may be beneficial (Figure 18-2).
Sequential draping during the procedure can also be done after full completion of
the first side, but requires a time interval between the 2 hips where the surgeon is not
operating. A single instrument set can easily be utilized for both sides; although a second
set can be used as the risk of latent contamination of the instruments is higher. Some
supportive equipment may be of particular benefit, such as autologous cell saver suction,
image intensifier, a bipolar tissue sealant device, and tranexamic acid to reduce the risk of
blood transfusion.7
Of 27 patients who underwent B-DAA since 2005, there were 15 male and 14 female
patients; patient age was 54.7±9.42 years and BMI was 27.97±4.96. One of the patients was
categorized into ASA I, 18 into ASA II, and 8 into ASA III. Four patients were treated
for avascular necrosis and the rest for OA. The functional scores during preoperative and
postoperative collection sessions are summarized in Table 18-1.

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Simultaneous Bilateral Direct Anterior Approach Total Hip Arthroplasty 237
Simultaneous THA can be done very safely via the B-DAA. This method leverages
the full advantages of the supine patient position and avoids the potential complications
related to lateral positioning during bilateral THA done with other approaches. When
properly indicated, simultaneous B-DAA THA can also minimize health care costs
and simplify surgery. In our practice, as an example, 50% of bilateral cases are cash-pay
patients who want to avoid paying for 2 hospitalization bills. The reduced need of physi-
cal therapy, absence of hip precautions, and the shortened recovery time overall, make the
B-DAA is ideal for patients who desire bilateral THA.
Surgeons considering B-DAA THA should have significant prior experience and
expertise in performing unilateral primary DAA THA. In addition, the operating room
staff should be familiar with the patient positioning and unique equipment needs related
to DAA THA to avoid delays or technical problems during the procedure. In between
the 2 replacements, the surgeon and anesthesiologist should communicate, to ensure that
the patient has remained stable. If necessary, the surgeon should be prepared to abort the
second surgery, and the family should be counseled accordingly beforehand.
B-DAA THA, when indicated, offers a lower-cost, simpler method to bilateral hip
surgery that may be ideal for certain patients.
Patient selection, surgeon familiarity and experience, operating room experience, and
thorough preoperative assessment and risk evaluation will ensure good outcomes and
reduce the risk of complications.
Patient and family education is important to make sure that expectations are managed
and that rehabilitation is expedient.

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238 Chapter 18
2. Aghayev E, Beck A, Staub JP, et al. Simultaneous bilateral hip replacement reveals superior outcome and
fewer complications than two-stage procedures: a prospective study including 1819 patients and 5801
follow-ups from a total joint replacement registry. BMC Musculoskelet Disord. 2010;11(1):245.
3. Della Valle CJ, Idjadi J, Hiebert RN, Jaffe WL. The impact of Medicare reimbursement policies on simul-
taneous bilateral total hip and knee arthroplasty. J Arthroplasty. 2003;18(1):29-34.
4. Bullock DP, Sporer SM, Shirreffs TG Jr. Comparison of simultaneous bilateral with unilateral total knee
arthroplasty in terms of perioperative complications. J Bone Joint Surg Am. 2003;85-A(10):1981-1986.
5. Zhang X, Jie S, Liu T, Zhang X. Acquired heterotopic ossification in hips and knees following encephalitis:
a case report and literature review. BMC Surg. 2014;14:74.
6. Sugita A, Hashimoto J, Maeda A, et al. Heterotopic ossification in bilateral knee and hip joints after long-
term sedation. J Bone Miner Metab. 2005;23(4):329-332.
7. Mast NH, Mùnoz M, Matta J. Simultaneous bilateral supine anterior total hip arthroplasty: evaluation of
early complications and short-term rehabilitation. Orthop Clin North Am. 2009;40(3):351-356.
8. Kim YH, Kwon OR, Kim JS. Is one-stage bilateral sequential total hip replacement as safe as unilateral total
hip replacement? J Bone Joint Surg Br. 2009;91(3):316-320.
9. Berend KR, Lombardi AV Jr., Adams JB. Simultaneous vs staged cementless bilateral total hip arthroplasty:
perioperative risk comparison. J Arthroplasty. 2007;22(6 Suppl 2):111-115.
10. Romagnoli S, Zacchetti S, Perazzo P, Verde F, Banfi G, Viganò M. Simultaneous bilateral total hip arthro-
plasties do not lead to higher complication or allogeneic transfusion rates compared to unilateral proce-
dures. Int Orthop. 2013;37(11):2125-2130.
11. Alfaro-Adrián J, Bayona F, Rech JA, Murray DW. One- or two-stage bilateral total hip replacement.
J Arthroplasty. 1999;14(4):439-445.
12. Lanting BA, Odum SM, Cope RP, Patterson AH, Masonis JL. Incidence of perioperative events in single
setting bilateral direct anterior approach total hip arthroplasty. J Arthroplasty. 2015;30(3):465-467.
13. Macaulay W, Salvati EA, Sculco TP, Pellicci PM. Single-stage bilateral total hip arthroplasty. J Am Acad
Orthop Surg. 2002;10(3):217-221.
14. Swanson KC, Valle AG, Salvati EA, Sculco TP, Bottner F. Perioperative morbidity after single-stage bilat-
eral total hip arthroplasty: a matched control study. Clin Orthop Relat Res. 2006;451:140-145.
15. Basilico FC, Sweeney G, Losina E, et al. Risk factors for cardiovascular complications following total joint
replacement surgery. Arthritis Rheum. 2008;58(7):1915-1920.
16. Flugsrud GB, Nordsletten L, Espehaug B, Haveli LI, Engeland A, Meyer HE. The impact of body mass
index on later total hip arthroplasty for primary osteoarthritis: a cohort study in 1.2 million persons.
Arthritis Rheum. 2006;54(3):802-807.

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19
Acetabular Direct Anterior
Approach Revision Surgery
Jonathan Yerasimides, MD
In-situ prosthetic femoral head removal may be easier with a specialized orthopedic
table and requires less femoral capsular release than an anterior dislocation for head
removal.
The trunnion should be placed lateral and posterior to the acetabulum with the leg in
an externally rotated position for acetabular exposure with a retained femoral stem.
Use of fluoroscopy allows for control of reaming and placement of the acetabular
component, if the surgeon is skilled at interpreting fluoroscopic images.
Direct anterior approach (DAA) total hip arthroplasty (THA) has gained popular-
ity, and acetabular revision surgery is usually the first revision experience for most sur-
geons accustomed to the DAA technique.1 Beyond its less invasive nature, DAA offers
very direct exposure of the acetabulum and easy visualization for implant removal and
placement.1–3 When extended, DAA offers revision exposure for both the femoral and
acetabular sides of the hip joint.4 At present, there is limited literature, and a relatively
small number of mentor surgeons who have extensive experience using the DAA for revi-
sion indications. This chapter will address the need to teach revision DAA THA surgi-
cal exposure, focusing on techniques for implant removal and acetabular reconstruction
through the DAA.


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Table: A Hana table (Mizuho OSI) allows for traction to be placed on the leg for
in-situ femoral head removal. It acts as a mechanical assistant for holding the leg in
external rotation to allow the trunnion to sit lateral and posterior to the acetabulum.
Finally, it eases use of fluoroscopy for reaming and positioning of the acetabular
component.
Fluoroscopy: The image intensifier guides reaming and implant positioning. Having a
real time picture of reaming depth, anteversion, and abduction angle can help ensure
ideal cup position even in the face of distorted anatomy. It is also used to radiographi-
cally confirm equal leg lengths at the end of the procedure.
Retractors: Two retractors are needed for acetabular exposure. A single prong bent
Hohmann retractor is placed over the anterior acetabulum. A standard cobra retractor
is placed around the posterior acetabulum.
Explant tool: If the acetabular shell is going to be removed, a specialized cup explant
tool is preferred. Even well-fixed implants can be removed with minimal bone loss.
The standard straight-handle explant tool works very well through the DAA.
Surgical assistant: A single assistant is used, positioned on the opposite side of the table
and reaching over the patient to hold the 2 retractors. If the procedure is performed
on a regular operating room table, a second assistant is required to hold the operative
leg. In teaching programs, the assistant surgeon usually stands on the operative side,
with another assistant on the opposite side.
Patient position on the Hana table, and the placement of the incision have been
addressed by previous authors in this text. It is ultimately important to stay lateral to the
anterior superior iliac spine (ASIS) to avoid dissection directly into the Smith-Petersen
interval. The goal is to come down onto the muscle belly of the tensor fascia lata (TFL),
which can help avoid injury to the lateral femoral cutaneous nerve.5–7 Blunt finger dis-
section can be used to find the Smith-Petersen interval if the index procedure was done
through another approach. If this is a revision of a prior anterior approach, then sharp
dissection must be used to get through the interval, as it will be scarred in. Follow the
interval down to the anterior hip capsule or pseudocapsule. In a virgin dissection, the
lateral femoral circumflex vessels will have to be identified and ligated or cauterized. A
Gelpi retractor is placed in the interval between the TFL and rectus femoris. The anterior
hip capsule is opened in line with the neck of the implant. Tag sutures are placed in the
anterior and lateral capsule flaps as may be done in a primary procedure; the inner half of
a thick capsule will have to be excised for exposure.
Retractors are placed anterior and posterior to the acetabulum. The placement of the
anterior retractor is the most difficult and the key retractor for excellent exposure. Once
the anterior retractor is placed, the anterior and medial capsule can be released from the
medial neck of the femur, which allows the surgical exposure to expand dramatically. Be
careful not to excise the psoas tendon when dissecting the anterior hip capsule. Next,

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Acetabular Direct Anterior Approach Revision Surgery 241
traction is placed through the orthopedic table with the leg in slight internal rotation.
This allows the femoral head to be impacted off with a bone tamp into the acetabulum.
If the leg is in neutral or external rotation, the head will hit the anterior edge of the poly-
ethylene and be difficult to remove. Once the head is disengaged into the acetabulum,
more traction is applied and the bone tamp is used on the anterior edge of the head as the
leg is externally rotated. This causes the head to roll off the trunnion and the leg is fully
externally rotated to 90 degrees. Traction is released and the trunnion is placed postero-
lateral to the acetabulum. The trunnion will not sit completely behind the acetabulum
unless the lateral femoral capsule has been completely released, a step that can be added
if the exposure is not adequate at this point. The head is removed anterior to the neck of
the implant (Figure 19-1).
If there is a screw present in the cup, the polyethylene now needs to be removed. A
3.2-mm drill and a 6.5 mm x 35 mm screw can be used to remove the liner. Drill into the
edge of the liner to assume maximum screw threads into the liner before the tip hits metal.
This will assure the screw doesn’t strip out of the polyethylene before the liner disengages.
If no screws are present, the explant tool is now used to remove the cup. The small blade
is inserted superior, anterior, and posterior; a meticulous effort to work circumferentially
is needed to minimize bone loss upon cup removal. The inferior portion of the cup can be
difficult to access via the DAA, but when the tool is rotated and the long blade is used,
a 270-degree arch of motion is usually more than enough to remove even the most well-
fixed acetabular cup (Figure 19-2).
In the acetabulum with minimal defects or cavitary defects, reaming can then be per-
formed with fluoroscopic assistance as needed. This is an accurate way to control depth
of reaming and positioning of the cup and can greatly assist the novice DAA revision
surgeon. It is absolutely critical that the pelvis is level before the onset of reaming; proper
use of fluoroscopy has been addressed in preceding chapters. Once the proper depth has
been obtained and reaming has been performed out to the acetabular rim, any cavitary
defects can be packed with bone graft. The reamer is placed on reverse to pack the graft
and the cup is inserted under guidance of fluoroscopy. Screws are placed in the cup with
fluoroscopy available to check screw position on oblique views if desired.
A neutral liner is almost always used with this technique, as version and abduction are
controlled by cup insertion under fluoroscopy. Leg lengths are determined using fluo-
roscopy and comparing the operative hip to the contralateral side. Again, to make this
method decisively accurate, the pelvis must be level and the hips must be symmetric with
regards to abduction and rotation.
Most acetabular defects encountered in revision surgery are either cavitary or small
segmental defects. Metal augments can be used when the bone deficiency is so large that
the implant is left unsupported alone.8–12 Porous metal augments are superior to bulk
allografts because they do not resorb and obtain biologic fixation to host bone. Thus, the
acetabular cup and metal augment both achieve biologic fixation, which creates a stable
and durable construct. When planning for a revision with potential metal augmentation,
it is important to know the location of the defect. Through the DAA, access is easily
obtained to the anterior wall, anterior column, superior acetabular dome, and posterior

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242 Chapter 19
C
Figure 19-1. (A) Traction is applied and a bone tamp is used to
disengage the femoral head. (B) The leg is externally rotated
and the trunnion placed lateral and posterior to the acetabu-
lum. (C) The head is removed anterior to the femoral neck.

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C
Figure 19-2. The Explant (Zimmer) tool can access the
(A) superior, (B) posterior, and (C) anterior quadrants of the
acetabulum.

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244 Chapter 19
Figure 19-3. Photograph showing location of incision for DAA acetabular

revision surgery.
superior wall. Access to the posterior column or large defects of the posterior wall are not
easily accessible through this approach.
Access to the superior lateral acetabulum is easily obtained by extending the standard
incision proximally to the ASIS, then curving it laterally to follow the iliac crest. The
dissection is carried through the interval between TFL and rectus femoris and extended
proximally to the ASIS staying in this interval. The TFL can be released off the iliac crest
over a 1- to 2-cm area to allow the muscle to be retracted laterally. It is important not
to take the release too far lateral across the origin of the iliotibial band. The TFL origin
can be easily repaired to the iliac crest with interrupted absorbable suture. No postopera-
tive precautions are employed. The gluteus minimus and medius can be reflected off the
ilium using a Cobb elevator and hip capsule opened, allowing full access to the superior
acetabulum. The muscles are not completely released over their entire origin so no formal
repair is required. This allows access for smaller structural grafts like those needed in
developmental hip dysplasia or larger defects in revision surgery.
Direct access to the inner table of the pelvis and anterior column is a unique feature of
the DAA. The ability to get to this area is impor tant for reconstruction of the Paprosky
IIIB (up and in) acetabular defect. This is a particularly difficult defect for both removal
of failed implants and access for reconstruction of the anterior column. Implant removal
is difficult because the protrusio defect makes femoral mobility extremely difficult to get
access to the cup. Current techniques for reconstruction of these defects include antipro-
trusio cages, cup/cage constructs, and custom cups.11,13 These techniques span the defect,
as access to the anterior column is not possible from traditional surgical approaches.
Through the DAA, direct access of the anterior column is possible for cup removal and
reconstruction. The incision is extended proximally to the ASIS, then curved lateral to
follow the iliac crest (Figure 19-3). The dissection is carried through the interval between
TFL and rectus femoris and extended proximally to the ASIS staying in this interval.
Release the origins of the abdominal muscles from the iliac crest and elevate the iliacus
with a Cobb elevator. The dissection is carried around the ASIS, releasing the sartorius
and inguinal ligament and connecting the proximal dissection to the interval previously

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Figure 19-4. Surgical dissection and anatomy along the iliac crest for extensile
acetabular exposure.
developed between the TFL and sartorius/rectus femoris. Dissection is carried down the
anterior border of the pelvis toward the anterior inferior iliac spine (AIIS). In Paprosky
IIIB defects, the anterior wall of the acetabulum is missing medial to the AIIS along with
the anterior column and the quadrilateral surface of the acetabulum.
Next, the entire inner table of the pelvis is exposed along with the entire proximal
femur (Figure 19-4). This allows the intrapelvic cup to be removed by direct access.
Because of the anterior displacement of the cup into the psoas muscle, this exposure is
still difficult. Flexion of the hip can relax the psoas to allow better exposure. With the
protrusio defect, it is much easier to remove the cup with the femoral component removed.
The trunnion interferes with access and removal of the femoral component allows more
room for both acetabular cup removal and reconstruction.
Access for stem removal can be improved using an iliac wing osteotomy. This allows
the lateral retraction of the TFL and exposure of the proximal femur. The osteotomy
extends from the interspinous notch to the iliac crest anterior to the medius tubercle
(Figure 19-5). This allows the TFL to retract laterally and clears the ASIS for femoral
stem removal and revision. Once the femoral stem is removed, the cup is now exposed
from both distal and proximal and removal is more controlled.
With all implants removed, the remaining bone stock is assessed with a sharp
Hohmann retractor placed into the superior pubic ramus medially and a blunt cobra
placed around the posterior wall. In Paprosky IIIB defects, the posterior wall and col-
umn will be retained, but less that 40% of host bone is available and over half of the
acetabular rim is deficient. The anterior half of the acetabulum and quadrilateral surface

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246 Chapter 19
Figure 19-5. (A) Iliac crest osteotomy for proximal extension of the DAA revi-
sion approach. Iliac wing osteotomy allows the iliac wing and TFL to retract,
facilitating exposure of the proximal femur for stem revision. (B) The oste-
otomy extends from interspinous notch to medius tubercle.
are missing. Reaming is performed under direct visualization until 2-point fixation is
obtained between the ischium and the superior lateral acetabulum. Anterior support is
deficient and the cup will fall through the anterior defect without additional support.
The cup is impacted and screws are placed into the posterior wall and column. Inferior
screws into the ischium are ideal if obtainable. The anterior half of the cup is exposed
without support and an anterior column augment is placed on the inner table of the pelvis
for trialing. A high-speed burr is used to contour the inner table, allowing the augment to
sit against the acetabular cup. The augment is fixed to the inner table of the pelvis with

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E
Figure 19-6. Preoperative radiograph showing ace-
B tabular defect (A), and existing bone deficiency (B),
that is reamed carefully (C), before implantation of
the socket and augment (D), with a postoperative
image of the reconstruction at a 2-year follow-up
(E). With no anterior acetabulum, 2-point fixation
is obtained from the ischium to the superior lateral
acetabulum. The reamed acetabulum has 50% or less
rim available for fixation. The augment is fixed to
the inner table of the pelvis and cement is placed
between the cup and the augment.
screws and bone cement is placed between the augment and cup to provide immediate
stability to the construct (Figure 19-6).
The stem is revised as needed and the iliac wing osteotomy is repaired using 2 4.5-mm
screws. The sartorius and inguinal ligament are repaired to the ASIS using nonabsorbable
suture through a drill hole and the abdominal muscles repaired to the iliac crest. Patients
are toe-touch weight for 8 weeks. No braces or position restrictions are applied.

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248 Chapter 19
The DAA allows access to the entire anterior acetabulum as well as the lateral and
superior acetabulum. The posterior wall and posterior column are not accessible through
this approach. Access to the inner table of the pelvis can aid in difficult implant removal
and anterior column reconstruction in Paprosky IIIB defects. This reconstruction can be
difficult and should only be attempted by surgeons experienced in revision hip arthroplas-
ty and approaches to the inner table of the pelvis. Surgeons may wish to gain experience
with revision DAA THA for head and liner exchange first, then revise loose acetabular
cups, and with this experience, consider performing pelvic column reconstruction through
the DAA.
Direct anterior hip revision surgery offers advantages over other approaches to the hip.
The ability to use fluoroscopy can help to facilitate accurate reaming, and positioning of
the acetabular component is a distinct advantage. By preserving the posterior structures of
the hip, dislocation rates are reduced and, in the author’s practice, dislocation precautions
are not used postoperatively. Leg lengths are well controlled because of a combination of
fluoroscopy checks and the intrinsic stability of the approach established via periarticular
muscle preservation, such that limb lengthening is not needed to gain hip stability, as may
be necessary with other approaches.
In experienced hands, the DAA can be safely used for revision THA. At minimum, if
a surgeon is going to perform primary anterior approach hip arthroplasty, he or she should
be familiar with revision techniques and extensile exposures to the hip. As the demand for
primary hip replacement through this approach grows, revision techniques will need to be
learned and incorporated into a surgeon’s capabilities.
The DAA to the hip is a utility approach to the hip allowing extensile exposure
for revision arthroplasty. Both simple and complex revisions involving the anterior
column are uniquely addressed through the exposure of the inner table of the pelvis.
In the absence of posterior capsule dissection, hips may be more stable and postopera-
tive dislocation precautions can be eliminated in the majority of cases.
The ability to easily use fluoroscopy allowing for precise reaming and implant posi-
tioning is a plus with DAA revisions. Fluoroscopy is also used to confirm leg lengths,
and hip stability does not rely on leg lengthening because of the inherent stability
afforded by the approach.
1. Mast NH, Laude F. Revision total hip arthroplasty performed through the Hueter interval. J Bone Joint
Surg Am. 2011;93(Suppl 2):143-148.
3. Matta JM. Hip joint arthrodesis utilizing anterior compression plate fixation. J Arthroplasty. 1994;9(6):665.

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4. Kumar A, Shair AB. An extended iliofemoral approach for total arthroplasty in late congenital dislocation
of the hip: a case report. Int Orthop. 1997;21(4):265-266.
Am. 2009;40:321-328.
2009;40:311-320.
8. Paprosky WG, Perona PG, Lawrence JM. Acetabular defect classification and surgical reconstruction in
revision arthroplasty. A 6-year follow-up evaluation. J Arthroplasty. 1994;9(1):33-44.
9. Della Valle CJ, Berger RA, Rosenberg AG, Galante JO. Cementless acetabular reconstruction in revision
total hip arthroplasty. Clin Orthop Relat Res. 2004;(420):96-100.
10. Silverton CD, Rosenberg AG, Sheinkop MB, Kull LR, Galante JO. Revision total hip arthroplasty using
a cementless acetabular component. Technique and results. Clin Orthop Relat Res. 1995;(319):201-208.
11. Sporer SM, Paprosky WG. The use of a trabecular metal acetabular component and trabecular metal aug-
ment for severe acetabular defects. J Arthroplasty. 2006;21(6 Suppl 2):83-86.
12. Sporer SM. How to do a revision total hip arthroplasty: revision of the acetabulum. J Bone Joint Surg Am.
2011;93(14):1359-1366.
13. Goodman S, Saastomoinen H, Shasa N, Gross A. Complications of ilioischial reconstruction rings in revi-
sion total hip replacement. J Arthroplasty. 2004;19(4):436-446.


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20
Anterior Approach
Femoral Revision Surgery
Michael Nogler, MD, MA, MSc
In direct anterior approach (DAA) total hip arthroplasty (THA) revision cases,
exposure and removal of the socket is usually straightforward. In order to place larger
implants or reconstructive cages via the DAA, it is necessary to extend the approach
along the ilium.
In order to remove the femoral component and perform an endofemoral revision via
the DAA, it is necessary to get straight access to the femoral cavity; a partial release
of the tensor fascia lata (TFL) origin can help facilitate this exposure.
If access to the femoral diaphysis is needed for implant removal or the treatment of
femoral fracture, the DAA approach can be extended distally and vastus lateralis can
be elevated from its lateral periosteal origin.
Direct anterior hip surgery as it applies to THA has been described over many
decades.1–4 It has gained new attention over the past decade in the United States as sur-
geons have recognized the muscle-preserving benefit.5–9 Using DAA, THA can be done
using minimally invasive concepts through a smaller soft tissue window.10
With increasing adoption of DAA THA, interest in using the approach for revision
surgery has increased. Until recently, few resources existed to guide the advanced learning
needed for surgeons to perform revision THA surgery via the DAA. The supine position
makes access to the acetabular component easy.11 Standard revision techniques (cemented,
uncemented, impaction bone grafting, cages, and augments) can be done safely through
the DAA. When needed, the lateral aspect of the ilium can be exposed to elevate the

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gluteus minimus and/or medius origins, to place plates, cages, or augments against the
iliac bone.6,12,13 Offset tools are required in most cases; a special retraction table can be
used but is not mandatory.6,7,14
Revision femoral surgery requires straight access to the femoral canal and is more dif-
ficult. Straight access is possible by sufficient resection of the joint capsule and a release
of the TFL, to allow use of standard revision tools, implant-specific instruments, and
flexible reamers. If an extended femoral osteotomy is needed, or cerclage fixation of the
femoral canal is necessary, then femoral diaphyseal exposure is required.15 Division of the
junction of rectus femoris and vastus lateralis anteriorly is not recommended as that will
disrupt the nerve supply of vastus lateralis. A posterior approach to vastus lateralis should
be used by splitting the iliotibial band and detaching the vastus lateralis muscle posteriorly
off the femur.6,12,16 With this strategy, unfettered access to the femoral diaphysis is pos-
sible, with only minimal soft tissue retraction.6
The author’s preference is not to use a traction or extension table for any DAA THA
case, primary or revision. Fluoroscopy should be available for any step during the proce-
dure to be used as needed. Therefore, a radiolucent table should be used.
DAA-specific retractors and special acetabular component removal chisels or curved
cutting devices, like the Cup-X system (Innomed), should be available. Reamer handles
and cup impactors should have sufficient offset in order to facilitate access to the acetabu-
lum. An important tool for screw placement is a 90-degree mini-drill that can easily be
introduced to the acetabulum at any desired angle.
For stem removal, offset chisels are helpful; however, existing femoral revision systems
for the most part have been designed with straight instruments. Therefore, in most cases
it is necessary to achieve straight access to the femoral canal, which can be achieved by
doing the partial TFL release. In such a case, the access to the femur is virtually unlimited
and all available standard instruments and implant systems can be used with ease. This
has worked in all the author's cases and an osteotomy of the ilium has not been necessary.
The Cup
The table can be articulated at the hip joint and the leg part can be flexed and the hip
hyperextended. In order to have maximum operative flexibility on the table, we prefer to
drape both legs (Figure 20-1). The incision is about 10 cm long, about 2 to 3 cm lateral
to the anterior superior iliac spine (ASIS), and 1 cm distal to it. Figure 20-2 shows the
overall anatomy of the intermuscular interval.
After placing the retractors carefully, the joint capsule in primary THA or the respec-
tive pseudocapsule in revision THA is visible. In the author’s experience, it works best
to take it out in a stepwise fashion, using the pointed retractors to expose pieces of the
capsule step by step. Removal of the scar tissue is performed until it is possible to dislocate
the hip joint (Figure 20-3).

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Anterior Approach Femoral Revision Surgery 253
Figure 20-1. Patient placed in supine on a standard operating room table,

both legs draped.
Figure 20-2. Intermuscular anatomy of the DAA interval.
After dislocation, the femur with the hip stem in place can be maneuvered to a position
that gives way to the acetabular component. This is achieved by lifting, adducting, and
externally rotating the leg. The trunnion and/or the head are thus place dorsolateral to
the acetabulum. A retractor can be placed posterior to the lateral acetabulum to help push
the stem dorsally (Figure 20-4). For cup removal, offset instruments like chisels or cutting
devices can be used (Figure 20-5).

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254 Chapter 20
Figure 20-3. Removal of the scar tissue until the hip joint can be dislocated.
Figure 20-4. Head and trunnion are placed dorsolateral to the acetabulum.
For cup reconstruction, both cemented and uncemented options can be used. If access
to the ilium is required (such as for the GAP II design [Stryker]), the TFL and gluteus
medius can be pushed laterally and partially elevated off the ilium. A complete detach-
ment is not necessary. The plates of an augmentation ring can be put against the iliac bone
and fixated with screws. A small 90-degree drill facilitates this procedure and is also the
ideal tool for placing screws inside the acetabulum (Figure 20-6).
The Stem
As in primary THA, it is possible to reach down to the entrance of the femoral canal—
or in the case of a revision to the stem—after the head has been removed. In some cases,
as is seen with very loose stems, the basic exposure is sufficient with the standard approach
technique to retrieve the stem, preserve the femoral cortex without requiring osteotomy,

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Figure 20-5. Using an offset chisel to remove the cup.
Figure 20-6. Exposing the ilium and placing plate underneath gluteus and
TFL.
and then replace the stem with a new one by the use of offset instruments (Figure 20-7).
In an endofemoral revision, the use of flexible reamers is required if longer stems are
implanted that demand reaming.
In many cases in which the femoral reconstruction is performed by the use of longer
stems, impaction bone grafting, or modular Wagner-type stems, straight access to the
femoral canal is required. This can be achieved by sufficient release of the capsular scars
and additionally by an incision into the TFL. This partial release, which should never
completely detach the TFL from the ilium, is usually performed 1 cm distal to the ASIS,
an area in which the TFL has a small tendinous portion (Figure 20-8). The author care-
fully avoids releasing the entire TFL as repair is difficult. Release of half of the diameter
at the site of the cut is usually sufficient in order to be able to push the femoral elevator
dorsally.
Use of a curved or straight femoral elevator placed posterior to the greater trochanter
can ease exposure and protect soft tissues. It may not increase the elevation of the proximal

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256 Chapter 20
Figure 20-7. An offset tool is used to retrieve the stem through a standard
incision.
Figure 20-8. Partial TFL release.
femur, but allows the surgeon to push the elevator down more posteriorly (Figure 20-9).
This strategy, combined with the partial TFL release, allows straight access to the femoral
canal, for straight reamers and certain types of revision implants.
As the TFL has been released in its tendinous portion, this stronger tissue and the
anterior portions of the iliotibial fascia can be used to suture the TFL back in situ. The
author does not use a special device for this suture repair, but employs the same techniques
as used in re-fixating the supraspinatus in open shoulder surgery (ie, a Kessler suture). Re-
fixation of the TFL is easier if the leg is abducted.
In cases that require access to the femoral diaphysis, it is possible to split the iliotibial
band. This is done in the direction of its fibers at the anterior border of the TFL, and

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Figure 20-9. Pushing down the partially-released TFL with the double-
pronged femoral elevator.
Figure 20-10. Distal extension to the femoral diaphysis; this figure shows the
relevant anatomy.
the band can be pulled laterally. This exposes the lateral aspect of vastus lateralis. The
vastus lateralis can then be detached from the femoral bone at its posterior border and a
standard straight-lateral access to the femoral diaphysis can be performed (Figure 20-10).
Before reaming, the author favors attaching prophylactic cerclage cables around the femur
to avoid fracture.
Revision THA may not always be elective, but meticulous anatomic knowledge, sur-
geon training, and careful surgical planning for these cases can all help to improve patient
outcomes. Patients may require revision surgery electively, and some may need it urgently,
as with periprosthetic fractures or acute bearing failures. Revision THA is highly diverse
with regard to the clinical situation; the technical challenges presented by the patient’s

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anatomy and prior treatment are to be matched with the variety of technical solutions that
can be employed by the surgeon.
The surgeon should be prepared with a number of different technical options for
removal of the cup and stem, as well as being familiar with technical options for the
reconstruction of both components. A variety of implants should be available during any
given surgery; this is usually more easily achieved in dedicated centers with high numbers
of arthroplasty revision cases.
Surgeons often feel most comfortable with the approach they use as the standard
method for primary THA. Changing to another approach should always be done with
caution. This is as true for the DAA as for all other approaches. The DAA is a very use-
ful approach for revision THA, in the author’s experience. For cups, the DAA offers a
very straightforward, anatomic access to the acetabular component in an intermuscular
interval. The acetabulum is generally easy to approach for revision surgery and there are
few limitations to its utility, with the exception being the need for simultaneous dorsal
plating at the ischium. In this case, placing the patient in lateral decubitus position and
then approaching the acetabulum posteriorly would be more favorable.
For stem revision, a straight-DAA approach to the femoral canal is often needed, and
this can be achieved with offset instruments, and in my experience, even with straight
instruments if the TFL cut is performed. An extensile approach to the femoral diaphysis
is always possible. An extended trochanteric osteotomy of windowing of the femur can be
performed. Therefore, with satisfactory training and clinical experience, the author sees
no special indications or requirements when selecting patients specifically for femoral
revisions via the DAA.
The DAA is a legacy approach to THA and is now popular given its less invasive
nature and reduced soft tissue trauma. It can be applied to revision THA, just as for
primary THA.
Cup revision is usually possible with little to no extension of the approach compared
to primary cases but requires more release of the posterior capsule for the dislocation
of the joint than in a primary case.
A partial TFL incision can be performed in the tendinous origin in order to help
achieve straight access to the femoral canal.
A distal extension and splitting of the iliotibial band longitudinally gives access to the
whole of the vastus lateralis muscle. It can be detached from the femur along its dorsal
border thus granting lateral access to the femoral diaphysis.
1. Hendrikson RP, Keggi KJ. Anterior approach to resurfacing arthroplasty of the hip: a preliminary experi-
ence. Conn Med. 1983;47(3):131-135.
2. Keggi K, Nao M, Zatorski LE. [Anterior approach in hip prosthesis]. Khirurgiia (Mosk). 1995;2:42-48.
3. Keggi KJ, Huo MH, Zatorski LE. Anterior approach to total hip replacement: surgical technique and clinical
results of our first one thousand cases using non-cemented prostheses. Yale J Biol Med. 1993;66(3):243-256.

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Am. 2009;40(3):321-328.
6. Nogler M, Mayr E, Krismer M. [The direct anterior approach to the hip revision]. Oper Orthop Traumatol.
2012;24(2):153-164.
7. Kreuzer S, Leffers K, Kumar S. Direct anterior approach for hip resurfacing: surgical technique and com-
plications. Clin Orthop Relat Res. 2011;469(6):1574-1581.
9. Unger AC, Schulz AP, Paech A, Jurgens C, Renken FG. Modified direct anterior approach in minimally
invasive hip hemiarthroplasty in a geriatric population: a feasibility study and description of the technique.
Arch Orthop Trauma Surg. 2013;133(11):1509-1516.
10. Putzer D, Haselbacher M, Klug S, Nogler M. Assessment of the size of the surgical site in minimally inva-
sive hip surgery. Adv Wound Care (New Rochelle). 2014;3(6):438-444.
11. Nogler M, Hozack W, Fritsch WJ, Mayr E, Krismer M. Cup revision through the direct anterior approach.
Video presented at: AAOS Annual Meeting; 2011. San Diego, CA.
Annals Transl Med. 2014;2(10):100.
13. Oinuma K, Eingartner C, Saito Y, Shiratsuchi H. Total hip arthroplasty by a minimally invasive, direct
anterior approach. Oper Orthop Traumatol. 2007;19(3):310-326.
14. Nogler M, Krismer M, Hozack WJ, Merritt P, Rachbauer F, Mayr E. A double offset broach handle for
preparation of the femoral cavity in minimally invasive direct anterior total hip arthroplasty. J Arthroplasty.
2006;21(8):1206-1208.
15. Nogler M, Hozack W, Fritsch WJ, Mayr E, Krismer M. Stem revision through the direct anterior approach.
Video presented at: AAOS Annual Meeting; 2011. San Diego, CA.
16. Oinuma K, Tamaki T, Miura Y, Kaneyama R, Shiratsuchi H. Total hip arthroplasty with subtrochan-
teric shortening osteotomy for Crowe grade 4 dysplasia using the direct anterior approach. J Arthroplasty.
2014;29(3):626-629.


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Section IV
Direct Anterior Approach Across
Orthopedic Specialties: Pediatrics

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21
in Pediatric Patients
Jonathan R. Schiller, MD; Philip McClure, MD; and Lee E. Rubin, MD
The direct anterior approach (DAA) is well-established in the treatment of septic

arthritis and open reduction of the dysplastic hip in pediatric orthopedic practices.
In contrast to the medial approach, the DAA offers the ability to address capsu-
lar redundancy as well as address any need for pelvic osteotomy through the same
incision.
The DAA can be safely utilized for proximal femoral resection (hip resection arthro-
plasty) for treatment of painful hips in children (and adults) with painful dislocations.
Septic Arthritis of the Hip

Septic arthritis of the hip is a devastating disease that requires emergent treatment.
Objective measures have been developed to identify and stratify the likelihood of intra-
articular sepsis based on laboratory values and clinical criteria.1 Elevated CRP above
20 mg/L is an independent risk factor for septic arthritis and can be used in conjunction
with the classic Kocher Criteria for the diagnosis of septic arthritis.2 Aspiration under
ultrasound guidance is a low-risk procedure that is used at our institution to help make
definitive diagnosis in the at-risk patient. In selected patients, drilling of the proximal


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264 Chapter 21
femur to evaluate and treat for osteomyelitis can be done through the DAA without
modification of the approach.
Developmental Dysplasia of the Hip

Developmental dysplasia of the hip (DDH) is a common pathology in the pediatric
orthopedic practice. DDH includes both congenital dislocation of the hip and delayed hip
dysplasia secondary to neuromuscular imbalance. Depending on the severity of the dys-
plasia, acetabular pathology varies from a shallow acetabulum with increased acetabular
index to a dislocated femoral head with a pseudoacetabulum.
If diagnosed early and the hip is reducible, DDH is generally treated with application of
a Pavlik harness and followed by serial ultrasonographic evaluations to ensure that reduc-
tion is maintained. Transition to an abduction brace may be needed if residual dysplasia
persists after Pavlik harness.3 While the Pavlik harness can be used successfully in the
majority of cases, treatment by closed reduction and casting or open reduction may still
be required. In a series of 720 cases of hip dislocations in 550 children under 1 year of
age, 11% proved to be irreducible in a harness, an additional 9% had persistent dysplasia,
and 5% had some recurrence of dysplasia prior to age 2 years.4 Early treatment reduces
the risk of Pavlik harness failure.5
Both a medial and DAA approach for open hip reduction are available, with advan-
tages to each method. The medial approach, both as initially described by Ludloff and as
modified by Ferguson,6 puts the vascular supply to femoral head at risk and does not allow
access for pelvic osteotomy. Primary advantages of the medial approach are decreased
blood loss, no violation of the iliac apophysis, and direct access to the hypertrophied trans-
verse acetabular ligament.7 As such, it is useful in children below the age of 18 months,
who are less likely to require osteotomy.
The DAA, through a bikini incision, offers the ability to perform pelvic correction,
and avoids the blood supply to the femoral head (Figure 21-1). It has become the pre-
ferred approach for many pediatric orthopedists and has also been described for total
joint arthroplasty.8–10 Some authors have reported superior results through the DAA
in comparison to the medial approach.11 A direct comparison has been described, with
equal incidence of hip avascular necrosis (AVN) between the medial and anterior groups;
although, all DAA patients were Tönnis grade 4, while the medial group was only 25%
grade IV.9
Hip Resection Arthroplasty

The painful spastic hip can benefit from resection arthroplasty that allows for pain
relief, as well as improved hygiene and personal care. Multiple techniques for treatment
of the spastic dislocated hip have been described including simple head resection, resec-
tion with interposition of soft tissue, resection with subtrochanteric osteotomy placing
the lesser trochanter into an articulating position,12 and prosthetic interposition arthro-
plasty.13 The ideal treatment has not been determined, but a trend toward better outcomes
with simple interposition arthroplasty was noted in one comparative study.14

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Direct Anterior Hip Surgery in Pediatric Patients 265
Figure 21-1. Anterior hip surgery in the pediatric patient. Note the excellent
exposure with only a minimum number of instruments. The capsule has
been incised and retracted with sutures to demonstrate the neck. A Cobb
elevator is on the inferior surface of the femoral neck. Metaphyseal access
can easily be gained through this approach if there is concern for proximal
osteomyelitis.
All 3 pediatric procedures described in this chapter can be done on a radiolucent flat
table, as fluoroscopy may be needed for localization or guidance of bony correction. Key

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instruments from our pediatric hip tray are available from a number of vendors; a compre-
hensive pediatric hip tray, containing a variety of instruments, will facilitate the operations
described below and minimize operating room traffic.
Treatment of septic hips through the DAA is simple, and requires only cobra and
Hohmann retractors of appropriate size, and basic instrument sets. Some authors have
recommended leaving a drain in place to evacuate any additional fluid that may re-
accumulate in the early postoperative period.15
In pediatric hip procedures (except hip resection), care should be taken to preserve
the blood supply to the femoral head, as the terminal branches of the medial femoral
circumflex artery (MFCA) can be damaged by aggressive retraction or extension of the
capsulotomy around the superolateral aspect of the femoral neck. In addition, the lateral
femoral circumflex artery (LFCA) should be preserved if possible to minimize vascular
trauma to the thigh. The capsule can be tagged during exposure and should be repaired
whenever possible to preserve the mechanics of the joint in the young patient.
For DAA open reduction of the dysplastic hip, a Cobb elevator should be used to dis-
place the iliac apophysis once it is split to allow later repair, and a series of curved osteo-
tomes may be required to execute a pelvic osteotomy.
For proximal femoral interposition arthroplasty, standard anterior retractors are needed,
especially since the patients are larger in size than infants being treated for DDH. A sagit-
tal saw is employed to make the proximal osteotomy. Closure should include interposition
of soft tissue into the acetabulum to prevent impingement of the residual proximal femur
with acetabulum. Interposition of remaining quadriceps tendon has been advocated16;
however, in our experience, identifying clear muscle planes in these patients can be dif-
ficult. We suture any available tissue into the acetabulum to prevent impingement.
For hip resection arthroplasty via DAA, the joint is exposed in the routine fashion
using a longitudinal or bikini-skin incision of the surgeon's preference. Often, it has been
our experience that prior open reduction of childhood DDH may precede the need for hip
resection later in life, so previous DAA incisions can easily be utilized for hip exposure.
Once exposed, a basicervical osteotomy is created. An additional subcapital osteotomy
can also be used to help make segmental retrieval of a scarred or contracted femoral head
easier in the spastic, contracted patient. Every effort should be made during the DAA
resection technique to preserve the medial capsular attachment (pubofemoral ligament)
to the calcar femorale, as we believe this ligament acts as a tether or “check-rein” to help
limit the amount of proximal migration seen after these cases, which averages 4.27 cm.
Bone wax is applied to the cut face of the femur to limit the possibility of a hemarthrosis
and the capsule and incision are closed in the usual manner.
Postoperatively, the hip resection patient is allowed bed to chair transfers and posi-
tioned upright in a wheelchair or commode as comfort allows. Gentle active and passive
hip movement can limit further contractures, increase hip abduction, promote comfort,
improve sitting posture, and facilitate perineal hygiene. If the patient was previously
ambulatory, he or she may partially weight bear over the first 2 months with assistive
devices and usually have improved ambulatory capabilities by 3 to 4 months postoperative-
ly. A slow but progressive recovery is expected; patients and families should be counseled
that 6 to 12 months may be required for ultimate improvements to be observed following
the hip resection.
Closure of the operations described here is with absorbable suture in a layered fashion.
The skin is closed with a running 3-0 or 4-0 Monocryl (Ethicon), and a dry sterile dressing

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is placed, which should be kept in place for at least 48 hours. Steri-Strips (Nexcare) or
Dermabond (Ethicon) can be used according to surgeon preference.
Early recognition and prompt initiation of treatment is necessary to optimize outcomes

in the setting of developmental dysplasia of the hip. The growth potential of the triradiate
cartilage allows acetabular remodeling, but this effect decreases with age. Conservative
management with a Pavlik harness should be initiated at the time of diagnosis in neonates,
but must be monitored closely for treatment failure. In idiopathic DDH, open reduction is
generally not required before 6 to 12 months of age as closed means are adequate to obtain
a reduction. Open reduction is most often needed after 18 months of age, but should be
in the algorithm for any hip undergoing closed reduction if concentric reduction cannot
be obtained and maintained. Proper use of each technique is required to assure optimal
outcome.
Sequelae of septic arthritis of the hip in children can be severe and are more likely
if treatment is delayed.17–19 If promptly treated by surgical means (arthroscopy, mini-
arthrotomy, etc), good or excellent outcomes are routinely reported.20,21 Prompt recogni-
tion and thorough debridement remain mainstays of successful treatment. Some authors
have advocated serial aspirations; however, this has not become widely accepted.22,23
A review article published by our group describes outcomes after hip resection arthro-
plasty in the pediatric population.24 In that article, 12 clinical papers published from 1981
to 2000 were addressed; 190 patients were treated with hip resection with pain controlled
in 95% and improved sitting ability and perineal hygiene achieved in 96%. Patient satis-
faction with the procedure was reported in 93 patients, with a rate of 82%.
The DAA can be used to address a variety of pediatric hip pathology, and modification
of the skin incision can allow access to the iliac crest and pelvic osteotomy while main-
taining a good cosmetic outcome. In comparison to the direct medial approach, the blood
supply to the femoral head is not directly in the surgical field, theoretically decreasing the
risk of AVN. The option of including pelvic osteotomy becomes more impor tant as patient
age advances, with associated decrease in remodeling through the triradiate cartilage.
For drainage of septic hip, a limited, mini-open DAA can be used, keeping the expo-
sure proximal to the lateral femoral circumflex vessels, and a modified bikini incision can
be used for the young patient based on surgeon comfort and patient size. Adult retractors
may be too large for younger patients, and this needs to be taken under consideration pre-
operatively. Both specialized instruments and close partnership with pediatric anesthesia
are very helpful when considering the DAA for this population.
The painful spastic hip remains a challenging problem for the pediatric and adult hip
surgeon. Improvements in both pain control and sitting ability can be expected following
hip resection arthroplasty. Improved perineal hygiene is also a significant benefit. Review
of the available literature demonstrates an average of 82% satisfaction with the procedure
overall, though pain and sitting tolerance was improved in over 95% of the patients.24

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Variations of the standard DAA can be safely used for open reduction of the dislocated
hip, also allowing concurrent pelvic osteotomy, if needed, in the pediatric population.
Septic arthritis of the hip joint is easily addressed with a short-DAA technique, mini-
mizing morbidity and preserving cosmesis in the young patient.
Proximal femoral hip resection arthroplasty is done for non-ambulatory patients
with spastic hip disease. The DAA offers a more cosmetic alternative to the lateral
approach, while affording the same periarticular soft tissue access.
When the DAA is used for pediatric hip preservation, awareness of the medial femo-
ral circumflex vessels is important. Placement of the lateral retractor directly on the
superolateral femoral neck should be avoided to preserve the ascending blood supply
to the femoral head.
1. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of
the hip in children: an evidence-based clinical prediction algorithm. J Bone Jt Surg. 1999;81(12):1662-1670.
2. Caird MS, Flynn JM, Leung YL, Millman JE, D’Italia JG, Dormans JP. Factors distinguishing sep-
tic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am.
2006;88(6):1251-1257. doi:10.2106/JBJS.E.00216.
3. Gans IB, Flynn JM, Sankar WN. Abduction bracing for residual acetabular dysplasia in infantile DDH.
[Miscellaneous Article]. J Pediatr Orthop. 2013;33(7):714-718. doi:10.1097/BPO.0b013e31829d5704.
4. Harris IE, Dickens R, Menelaus MB. Use of the Pavlik harness for hip displacements. When to abandon
treatment. Clin Orthop. 1992;(281):29-33.
5. Harding MGBBSH, Harcke HT, Bowen JR, Guille JT, Glutting J. Management of dislocated hips
with Pavlik harness treatment and ultrasound monitoring. [Miscellaneous Article]. J Pediatr Orthop.
1997;17(2):189-198.
6. Ferguson AB. Primary open reduction of congenital dislocation of the hip using a median adductor
approach. J Bone Jt Surg. 1973;55(4):671-689.
7. Guille JT, Pizzutillo PD, MacEwen GD. Developmental dysplasia of the hip from birth to six months. J Am
Acad Orthop Surg. 2000;8(4):232-242.
8. Leunig M, Faas M, von Knoch F, Naal FD. Skin crease “bikini” incision for anterior approach total
hip arthroplasty: surgical technique and preliminary results. Clin Orthop. 2013;471(7):2245-2252.
doi:10.1007/s11999-013-2806-0.
9. Bulut M, Gürger M, Belhan O, Batur OC, Celik S, Karakurt L. Management of developmen-
tal dysplasia of the hip in less than 24 months old children. Indian J Orthop. 2013;47(6):578-584.
doi:10.4103/0019-5413.121584.
10. Sales de Gauzy J. Pelvic reorientation osteotomies and acetabuloplasties in children. Surgical technique.
Orthop Traumatol Surg Res. 2010;96(7):793-799. doi:10.1016/j.otsr.2010.07.004.
11. Szepesi K, Szücs G, Szeverényi C, Csernátony Z. Long-term follow-up of DDH patients who
underwent open reduction without a postoperative cast. J Pediatr Orthop Part B. 2013;22(2):85-90.
doi:10.1097/BPB.0b013e32835b7c98.
12. McHale KA, Bagg M, Nason SS. Treatment of the chronically dislocated hip in adolescents with
cerebral palsy with femoral head resection and subtrochanteric valgus osteotomy. J Pediatr Orthop.
1990;10(4):504-509.
13. Gabos PG, Miller F, Galban MA, Gupta GG, Dabney K. Prosthetic interposition arthroplasty for the pal-
liative treatment of end-stage spastic hip disease in nonambulatory patients with cerebral palsy. J Pediatr
Orthop. 1999;19(6):796-804.

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14. Wright PB, Ruder J, Birnbaum MA, Phillips JH, Herrera-Soto JA, Knapp DR. Outcomes after sal-
vage procedures for the painful dislocated hip in cerebral palsy. J Pediatr Orthop. 2013;33(5):505-510.
doi:10.1097/BPO.0b013e3182924677.
15. Wiesel SW. Operative Techniques in Orthopaedic Surgery. Philadelphia, PA: Lippincott Williams & Wilkins;
2011.
16. Castle ME, Schneider C. Proximal femoral resection-interposition arthroplasty. J Bone Joint Surg Am.
1978;60(8):1051-1054.
17. Bennett OM, Namnyak SS. Acute septic arthritis of the hip joint in infancy and childhood. Clin Orthop.
1992;(281):123-132.
18. Fabry G, Meire E. Septic arthritis of the hip in children: poor results after late and inadequate treatment.
J Pediatr Orthop. 1983;3(4):461-466.
19. Lunseth PA, Heiple KG. Prognosis in septic arthritis of the hip in children. Clin Orthop. 1979;(139):81-85.
20. Nusem I, Jabur MKA, Playford EG. Arthroscopic treatment of septic arthritis of the hip. Arthroscopy.
2006;22(8):902.e1-3. doi:10.1016/j.arthro.2005.12.057.
21. El-Sayed AMM. Treatment of early septic arthritis of the hip in children: comparison of results of open arthrot-
omy versus arthroscopic drainage. J Child Orthop. 2008;2(3):229-237. doi:10.1007/s11832-008-0094-0.
22. Givon U, Liberman B, Schindler A, Blankstein A, Ganel A. Treatment of septic arthritis of the hip joint by
repeated ultrasound-guided aspirations. J Pediatr Orthop. 2004;24(3):266-270.
23. El-Sayed AMM. Response to Uri Givon. Re: Treatment of early septic arthritis of the hip in children:
comparison of results of open arthrotomy versus arthroscopic drainage. J Child Orthop. 2008;2(6):497.
doi:10.1007/s11832-008-0137-6.
24. Rubin LE, Murgo KT, Ritterman SA, McClure PK. Hip Resection Arthroplasty. JBJS Rev. 2014;2(5).
doi:10.2106/JBJS.RVW.M.00060.


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Management of Developmental
22
Dysplasia of the Hip
With the Bernese
Periacetabular Osteotomy
Atul F. Kamath, MD; Reinhold Ganz, MD; and Michael Leunig, MD
The Bernese periacetabular osteotomy (PAO) has been used for over 30 years to
address structural deformity in young patients with acetabular dysplasia without
major cartilage damage.
The modified direct anterior approach (DAA) and PAO technique described here
offer unique advantages: preservation of the posterior column adds to the stability
of the hemipelvis and protection of the sciatic nerve, preservation of the acetabular
blood supply, maintenance of the hip abductor musculature, and maintenance of the
integrity of the birth canal.
The juxta-articular osteotomy planes of the Bernese PAO offer a surgeon the ability
to correct the deformity correction about an ideal center of rotation.
While maximizing joint stability, coverage and congruency, the final intraoperative
acetabular position must be determined with the goal of establishing an impingement-
free range of motion (ROM).
The goal of pelvic osteotomy is to address biomechanical and structural abnormalities

that can lead to secondary osteoarthrosis under improper loading conditions. In patients
with acetabular dysplasia, improved coverage and/or congruity may be achieved through
reorientation of the acetabulum into an ideal position.1 By improving these loading con-
ditions, the static and dynamic instability patterns seen with hip dysplasia can be appro-
priately countered. While reorienting the osteotomy fragment and increasing the femoral
head coverage improve load distributions across the joint, the amount and direction of

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272 Chapter 22
B
Figure 22-1. (A) Preoperative anteroposterior pelvis radiograph of a patient
with bilateral acetabular dysplasia. (B) Anteroposterior pelvis radiograph
obtained 20 years post-bilateral PAO. The fixation hardware from the right
hip had been previously removed after osteotomy healing.
correction required for optimal off-loading varies among patients. Therefore, there may
be an ideal correction for each patient, and precisely establishing this correction remains
the most critical, and perhaps most demanding, part of the procedure.
The most frequent indication for performing the Bernese PAO is acetabular dysplasia
in an adolescent or adult 2 with correctable deformity, preserved ROM, and minimal to
no hip arthrosis (Figure 22-1). The procedure may be executed safely in patients older
than 10 years of age. Patients may be suitable candidates for the procedure based on the
degree of arthrosis, as well as other factors such as activity level, expectations, obesity, and
systemic conditions. Contraindications to PAO include subluxation resulting in a femoral
head within a neo-acetabulum, advanced osteoarthrosis (eg, Tönnis Grade 2 or 3), a mis-
match between a smaller acetabular radius and that of the femoral head, which may cause
worsening of joint congruity after reorientation and severe restrictions in ROM.

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Management of Developmental Dysplasia of the Hip 273
Prior to surgery, a thorough history and physical examination is required, including a

careful assessment of gait, leg lengths, and ROM. Radiographic study should include an
anteroposterior view of the pelvis (without excessive tilt and without rotation to one side
or the other) and a true lateral view. Optional views include a Dunn view (eg, 45-degree
projection) and a false profile view.3 A functional abduction view, with the hip in inter-
nal rotation, may indicate the amount of correction possible and resulting congruency.
A magnetic resonance imaging (MRI) study, with or without intra-articular contrast,
may be obtained to evaluate labral damage, cartilage status, and periarticular tissues.
The patient’s age, body mass index, level of activity, and functional goals must also be
incorporated into a decision to pursue surgical intervention. Surgical instruments and the
equipment needed for performing the PAO are listed in Table 22-1.
Patient Positioning and Draping

The patient is placed in the supine position on a radiolucent table. The ipsilateral upper
limb may be placed across the chest, and bony prominences are well-padded. Fluoroscopic
views should be confirmed prior to definitive prep and draping of the limb. Access to
above the level of the iliac crest of the operative hemipelvis and down to the ipsilateral
foot must be included within the prepped field. Neuromonitoring leads may be secured to
the involved extremity before final sterile draping.
Surgical Exposure
A modified Smith-Petersen DAA, with preservation of the abductor musculature, is
utilized. A curvilinear skin incision, centered about the anterior superior iliac spine (ASIS),
extends proximally along the iliac crest and distally along the interner vous interval of the
tensor fascia lata (TFL) and sartorius muscles. The fascia over the TFL is incised in line
with the muscle fibers, protecting the lateral femoral cutaneous nerve (LFCN) during the
distal superficial exposure. The TFL muscle belly is separated from the fascial envelope
bluntly and retracted laterally; slight abduction may make this separation easier.
The ASIS is then osteotomized, preserving the origin of the sartorius and ilioinguinal
ligament on the mobile fragment. The externus oblique muscle aponeurosis is reflected
from the iliac crest, and a subperiosteal plane is developed for access to the inner pelvis
down to the pelvic brim; the periosteum on the medial surface of the iliac crest is elevated
along with the iliacus muscle using straight and angled, long, Cobb-type elevators. If
bleeding is encountered from the iliolumbar artery as it penetrates the iliac crest, the arte-
rial orifice may be exposed and occluded with bone wax.
The deep distal exposure is competed by reflecting the rectus tendon from the anterior
inferior iliac spine (AIIS), preserving a bed of tendon for later repair. As the deep fascia
is opened distally, the pedicle to the TFL (encompassing the recurrent branches of the
lateral circumflex artery) is exposed; this pedicle is freed, mobilized, and preserved. By
dissecting the iliocapsularis muscle off the anterior hip capsule, an interval is developed
medially under the iliopsoas tendon. The hip may be flexed up on a radiolucent tri-
angle (or rested upon a foot bump) at this time to relax the anterior soft tissues further.

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Completion of the dissection between the iliocapsularis, especially at its inferolateral

border, allows the surgeon to palpate the calcar femoris through the capsule as well as the
anterior surface of the ischium using closed scissors. Medial dissection exposes the ilio-
pectineal bursa; the bursa is opened. Further subperiosteal exposure of the quadrilateral
surface and pubic root allows for placement of a sharp Hohmann into the pubis, medial
to the iliopectineal eminence.
Periacetabular Osteotomies
Following the hip capsule inferiorly, the ischium is palpated with scissors. The ischium
is triangular in shape with the base posterior. The infracotyloid groove, along with the
obturator foramen medially and hamstrings origin laterally, is identified. The tips of the
scissors should be kept proximal to the obturator externus muscle, and this scissor trajec-
tory then guides the placement of a specialized, curved, bifid acetabular osteotome. The
osteotome is positioned within the infracotyloid groove, and its position may be verified
in anteroposterior and oblique fluoroscopic projections.
The inferior retroacetabular osteotomy begins at the infracotyloid groove and progres-
ses toward the midpoint of the ischial spine in both medial and lateral limbs. The oste-
otomy is begun on the medial side, with the osteotome handle aimed toward the patient’s
contralateral shoulder. For the lateral osteotomy, the sciatic nerve should be relaxed, with
the limb abducted, the hip extended and the knee in slight flexion, to minimize the risk of
nerve injury during the lateral osteotome pass. Both tactile and aural feedback is critical in
assuring that the osteotome is within bone, as well as to prevent violation of the posterior
column. The ischial osteotomy is an incomplete osteotomy, with depth to about 2.5 cm;
it is important to cut the thicker medial cortex, while the thinner lateral cortex may break
in a controlled fashion during the final osteotomy expansion maneuvers.
Hip flexion and adduction aids in exposure of the superior pubic ramus. The perios-
teum is incised along the superior cortex, and square-tip small retractors are placed around
the posteroinferior and posterosuperior aspects of the pubic ramus to encircle the bone
and to protect the obturator nerve. Adequate circumferential release of the periosteum
must be ensured to allow later fragment mobility, especially in younger patients with thick
periosteum. A spiked Hohmann retractor is impacted into the superior cortex at least 1 to
2 cm medial to the most medial extent of the iliopectineal eminence, in order to retract
the iliopsoas and the femoral neurovascular bundle medially. The pubic osteotomy is initi-
ated with a thin wafer of the anterior cortex to ease further orientation of the osteotome

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276 Chapter 22
and to avoid fissuring of the medial cortex during deeper penetration of the osteotome.
The osteotome is directed posteromedially in an angle of 45 degrees. In doing so, the
osteotome will exit posteromedial to the obturator nerve.
The ischial spine is identified with a reverse Eva retractor (eg, Subtilis Pelvis Lever,
Accuratus AG, item AC 24.51.42) placed on the most posterior inside of the ischial spine,
after subperiosteal presentation of the quadrilateral surface. The lateral cortex of the ilium
is accessed along the interspinous crest by detaching a small portion of the periosteum
and insertion of a second reverse Eva retractor into the greater sciatic notch. This tunnel
along the outer table protects the abductor muscles during the iliac osteotomy. The level of
this iliac osteotomy is at a sufficient distance from the acetabulum in order to decrease the
chance of injury to the supra-acetabular branch of the superior gluteal artery and acetabu-
lar arcade. Furthermore, a larger bone bridge allows for better purchase of the Schanz
screw during reduction, as well as to minimize the chance of joint surface violation while
performing the second limb of the retroacetabular osteotomy.
A high-speed burr is used to make a target hole approximately 1 cm superolateral to
the pelvic brim; alternatively, an osteotome may be used to mark this eventual vertex of
the 120-degree osteotomy limbs. The iliac cut is then made with an oscillating saw, first
along the medial cortex, and then, with the lower extremity abducted and the musculature
protected with the reverse Eva, into the lateral cortex. The posterior column cut is made
(this cut can be monitored with fluoroscopy) at an angle of 120 degrees to the iliac cut;
the osteotomy is begun in the medial cortex using a straight osteotome. The cut is then
completed with a straight osteotome that is passed in a distal direction, and with an angled
osteotome that is passed from medial to lateral in sequential steps. Tactile and aural feed-
back is important at this step, as subtle bone displacement may occur during progressive
osteotomy maneuvers. The sequence and location of the periacetabular osteotomy seg-
ments are depicted in Figure 22-2.
A laminar spreader is placed into the iliac osteotomy site; a second laminar spreader
may be placed in the second limb of the retroacetabular osteotomy to effect the final dis-
placement. Any residual tethering of the posterior column osteotomy may be freed under
direct vision with an angled bifid osteotome from inside. During this maneuver, the hip
is again extended and abducted to relax the sciatic nerve.
Acetabular Correction
A Schanz screw is placed in the supra-acetabular region, and the mobility of the frag-
ment is tested. Final freeing of the fragment is achieved with a downward and inward
move of the Schanz screw and an inward turn of the spreader placed at the vertex of the
supraretroacetabular osteotomy at the same time. The lack of complete mobility neces-
sitates that the surgeon review 3 problematic sites: (1) the pubic osteotomy and accompa-
nying periosteum, (2) the posterior cortex at the 120-degree osteotomy vertex point, and
(3) the inferior retroacetabular cut. Mobility is again verified, with the ability to flip the
fragment.
The reorientation is then performed, keeping in mind the ideal fragment position to
optimize joint loading conditions and to maintain ROM about an ideal center of hip
rotation. For the more common hip dysplasia morphology, the acetabulum is usually
repositioned with a combination of internal rotation, forward tilt/extension, and medial
translation. Adjunctive reorientation tools may include a ball-spike pusher, Weber clamp,

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Figure 22-2. The location of the periacetabular osteotomy segments, outlined with a black line on a
sawbones pelvis model, as viewed from the (A) lateral and (B) medial aspects of the hemipelvis. The
osteotomy cuts are numbered (1 to 4) in order of description in the text. The osteotomy of the ASIS (*)
has been described previously as part of the surgical exposure.
small bone hook, or a second Schanz screw. Provisional fixation is maintained with sev-
eral terminally threaded or smooth Kirschner wires; the surgeon may choose to place
2 antegrade wires and 1 retrograde wire.
A properly projected anteroposterior pelvic radiograph, centered over the symphysis
pubis, should be taken. This radiograph must be critically evaluated for the final lateral
center-edge angle, acetabular inclination, adequate medial translation and position of the
teardrop, restoration of Shenton’s line, and acetabular version. This formal intraoperative
radiograph is used in lieu of fluoroscopic imaging alone in order to visualize the fine bony
detail necessary to determine the final correction. Furthermore, the authors do not rou-
tinely use intraoperative fluoroscopy during performance of the osteotomy steps. A well-
exposed and well-positioned radiograph is sufficient to assess intraoperative correction,
and the authors do not feel that additional advanced imaging studies (eg, 3-dimensional
computed tomography) are required.
ROM is dynamically assessed to rule out secondary femoroacetabular impingement
or for evidence of residual instability. Free hip flexion should be 90 degrees. Definitive
fixation is achieved using 3 or 4 3.5 mm/4.5 mm cortical screws in antegrade and/or retro-
grade fashion. There is variability in the screw lengths, depending on the patient anatomy,
degree of correction, and trajectory of the screws. Fluoroscopic images can confirm that
the acetabular reduction is maintained. A final intraoperative radiograph is used to assess
the correction, including with definitive fixation hardware in place.

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278 Chapter 22
An arthrotomy is performed to evaluate the labral integrity and the femoral head-neck
junction. Labral debridement vs repair (with possible augmentation) is performed, depend-
ing on the characteristics of the labral tear and quality of tissue. Osteochondroplasty using
a curved osteotome and a burr may be performed at this time at the sites of femoroac-
etabular impingement. A preoperative MRI study can guide the decision to perform
arthrotomy and intra-articular work at the time of PAO.
Wound Closure
After thorough irrigation of the joint and surgical field, the capsular incision is closed.
The prominent aspect of the anterior acetabular fragment is trimmed with an oscillating
saw and is used to fill the iliac osteotomy site. The rectus tendon is repaired with non-
absorbable suture back to the AIIS origin. The ASIS fragment is repositioned and fixed
with a small-fragment screw or non-absorbable suture through drill holes in the ilium.
Deep and superficial wound drains may be placed, although the authors do not use drains
routinely at present, as a matter of preference. The fascia over the iliac wing, as well as
distally over the tensor, is closed. The remainder of the superficial DAA wound is closed
in a routine, layered fashion.
Postoperative Care and Rehabilitation

Mobility and weight-bearing status depend on whether the PAO has been performed
alone or in conjunction with other procedures, such as femoral osteotomy and/or surgical
hip dislocation. With maintenance of the posterior column and with good bone quality,
partial weight bearing (15 kg) is prescribed for the first 4 to 6 weeks. A continuous pas-
sive motion machine may be employed, especially if intra-articular work is performed;
this step is a matter of surgeon preference. Routine deep venous thrombosis prophylaxis
(eg, low molecular weight heparin or aspirin) is used for the first 6 weeks. Heterotopic
ossification prophylaxis is not routinely used.
At 4 weeks, abduction strengthening exercises (first standing and then laying on the
opposite hip) is allowed, along with a stationary bike. Active flexion of the hip joint is
prohibited for 6 weeks to protect the reattached sartorius and rectus femoris muscles. At
8 weeks postoperatively, the patient is assessed clinically and radiographically. By this
time, healing is usually sufficient for full weight bearing, and full muscular strengthen-
ing can be started. Flexion strength may take up to 6 months to return, and complete
bony union will take several months to achieve. The majority of patients have pain-free
hip ROM at 8 to 12 weeks, depending on the extent of correction achieved. Patients
may generally return to sports activity between 6 to 12 months, but patients with severe
preexisting abductor and other functional weakness may take up to 1 year for complete
rehabilitation.
The Bernese PAO has been applied to complex acetabular dysplasia cases for more
than 30 years.4 While it remains a technically demanding procedure,5–7 the potential
to improve the natural history of hip dysplasia is well-demonstrated in mid- and long-
term clinical studies.8–10 Refinements in surgical technique and patient indications, in

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combination with the application of key femoroacetabular impingement concepts, have

increased the understanding of hip pathomorphology and the parameters for acetabular
reorientation.11
Compared with a number of other pelvic osteotomy techniques, the Bernese PAO
maintains the posterior column. By not violating the posterior column, prolonged immobi-
lization and/or extensive pelvic fixation methods are obviated, and there remains inherent
stability and good potential for union of the mobile fragment to the residual pelvis. There
is variability in the reported non-union rate,12 which may be related to certain patient
factors like bone quality, timing of mobilization, full advancement of weight bearing,
and smoking status. The juxta-articular osteotomy planes also maintain the dimensions
of the true pelvis and effect a powerful correction about an ideal center of hip rotation
(Figure 22-3). With medialization of the hip joint, the abductor lever arm is maximized
and joint reaction forces are decreased. A systematic review of PAO studies published in
2009 highlighted a major complication rate of 6% to 37%,12 most likely related to the
surgical learning curve in the individual studies. The conversion rate to THA was 0% to
17% in the literature included for systematic review.12
Since its initial description, the PAO surgical technique has undergone various modi-
fications.13 The original approach involved stripping of the abductors from the iliac crest
during the iliac wing/supra-acetabular osteotomy. Protecting the abductors and utilizing
the DAA for hip exposure not only preserves muscle function, but also decreases the
risk of osteonecrosis due to compromised acetabular vascular supply: obturator, superior
and inferior gluteal arteries, and capsular contributions to acetabular perfusion. Initially,
the bone cuts were performed from both sides of the iliac wing; the bone cuts are now
predominantly performed from the inner aspect of the pelvis to further preserve the
abductors. More recently, it has become apparent that hip flexion strength is decreased
postoperatively, and thus a rectus-sparing DAA PAO technique has been advocated,14
which leaves the direct and indirect heads of the rectus femoris attached. It remains
unclear whether this modification solves the issue of residual hip flexion deficits, and the
authors have concern regarding the possibility of injury to the most proximal branches of
the femoral nerve during osteotomy of the pubis. Further study will be needed to establish
consensus on this point.
Other modifications to the original surgical technique include a 2-incision technique,15
in which the ischial osteotomy was performed under direct visualization. The primary
disadvantage of this technique involves dissection of the external rotators posteriorly,
which may endanger the medial femoral circumflex artery blood supply to the femoral
head. Additional variations to the technique include various minimally invasive incisions,
including a trans-sartorial approach.16 Other investigators have presented the use of hip
arthroscopy at the time of PAO to evaluate the articular cartilage and to address labral
pathology.17
The femoral head in a dysplastic hip may have a decreased head-neck offset and lateral
flattening from a hypertrophic gluteus minimus. When the acetabulum is reoriented in a
position of excess lateral and/or anterior coverage, secondary femoroacetabular impinge-
ment may occur. Impingement has been recognized as a potential cause for continued

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280 Chapter 22
Figure 22-3. (A) Preoperative

anteroposterior pelvis radio-
graph of a patient with right
hip residual Legg- Calve-Perthes
disease and acetabular dyspla-
sia. (B) Immediate postopera-
tive and (C) final follow-up right
hip radiographs status post-
pelvic reorientation osteotomy,
relative head-neck lengthen-
ing and osteochondroplasty
through a surgical dislocation
approach, and subtrochanteric
derotational osteotomy.
B C
pain after PAO. As a result, an arthrotomy has been incorporated for evaluation and
correction of intra-articular impingement; MRI study preoperatively may guide the deci-
sion to perform arthrotomy at the time of PAO. Careful recognition of acetabular version
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(eg, avoidance of iatrogenic retroversion) during the correction also helps to minimize
secondary impingement.
Finally, it must be stated that any surgeon initially undertaking PAO should have
extensive experience with concepts of both DAA surgery and hip-preserving surgery, as
well as with specialized equipment and advanced training in this technique. The opera-
tion is a major intervention and has a number of technical steps that must be executed
properly to ensure a good result. While PAO represents a highly effective technique for
patients with dysplasia, risks associated with the procedure remain. Ideally, PAO may be
performed by higher volume joint-preserving surgeons, at specialized centers devoted to
hip preservation, to minimize the risks associated with this complex procedure.
The Bernese PAO is one of several acetabular osteotomies to address structural defor-
mity in patients with dysplasia, from approximately age 10 years (safely executed after
closure of the triradiate cartilage) to adolescents and young adults.
The PAO technique involves a modified Smith-Petersen approach.
Advantages of the Bernese PAO include preservation of the load-bearing posterior
column of the hemipelvis, preservation of the acetabular blood supply, maintenance
of the hip abductor musculature, safeguarding integrity of the birth canal, and the
ability to correct deformity about an ideal center of rotation.
The procedure is technically demanding, yet offers reproducible results with good
long-term survivorship in patients with preserved cartilage.
Pelvic osteotomy should be considered as a preferred alternative to arthroplasty in the
young, active patient with correctable structural deformity of the hip.
1. Leunig M, Siebenrock KA, Ganz R. Rationale of periacetabular osteotomy and background work. Instr
Course Lect. 2001;50:229-238.
2. Ganz R, Klaue K, Vinh TS, Mast JW. A new periacetabular osteotomy for the treatment of hip dysplasias.
Clin Orthop Relat Res. 1988;(232):26-36.
3. Clohisy JC, Carlisle JC, Beaulé PE, et al. A systematic approach to the plain radiographic evaluation of the
young adult hip. J Bone Joint Surg Am. 2008;90(Suppl 4):47-66.
4. Clohisy JC, Schutz AL, St John L, Schoenecker PL, Wright RW. Periacetabular osteotomy. A systematic
literature review. Clin Orthop Relat Res. 2009;467(8):2041-2052.
5. Thawrani D, Sucato DJ, Podeszwa DA, DeLaRocha A. Complications associated with the Bernese periace-
tabular osteotomy for hip dysplasia in adolescents. J Bone Joint Surg Am. 2010;92(8):1707-1714.
6. Peters CL, Erickson JA, Hines JL. Early results of the Bernese periacetabular osteotomy: the learning curve
at an academic medical center. J Bone Joint Surg Am. 2006;88(9):1920-1926.
7. Hussell JG, Rodriguez JA, Ganz R. Technical complications of the Bernese periacetabular osteotomy. Clin
Orthop Relat Res. 1999;(363):81-92.
8. Steppacher SD, Tannast M, Ganz R, Siebenrock KA. Mean 20-year follow-up of Bernese periacetabular
osteotomy. Clin Orthop Relat Res. 2008;466(7):1633-1644.
9. Troelsen A, Elmengaard B, Søballe K. Medium-term outcome of periacetabular osteotomy and predictors
of conversion to total hip replacement. J Bone Joint Surg Am. 2009;91(9):2169-2179.

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10. Matheney T, Kim YJ, Zurakowski D, Matero C, Millis M. Intermediate to long-term results follow-
ing the Bernese periacetabular osteotomy and predictors of clinical outcome. J Bone Joint Surg Am.
2009;91(9):2113-2123.
11. Siebenrock KA, Leunig M, Ganz R. Periacetabular osteotomy: the Bernese experience. Inst Course Lect.
2001;50:239-245.
12. Clohisy JC, Schutz AL, St John L, Schoenecker PL, Wright RW. Periacetabular osteotomy: a systematic
literature review. Clin Orthop Relat Res. 2009;467(8):2041-2052.
13. Leunig M, Ganz R. Evolution of technique and indications for the Bernese periacetabular osteotomy. Bull
NYU Hosp Jt Dis. 2011;69(Suppl 1):S42– S46.
14. Novais EN, Kim YJ, Carry PM, Millis MB. The Bernese periacetabular osteotomy: is transection of the
rectus femoris tendon essential? Clin Orthop Relat Res. 2014;472(10):3142-3149.
15. Bernstein P, Thielemann F, Günther KP. A modification of periacetabular osteotomy using a two-incision
approach. Open Orthop J. 2007;1:13-18.
16. Søballe K, Troelsen A. Approaches and perioperative management in periacetabular osteotomy surgery: the
minimally invasive transsartorial approach. Instr Course Lect. 2013;62:297-303.
17. Domb BG, LaReau J, Redmond JM. Combined hip arthroscopy and periacetabular osteotomy: indications,
advantages, technique, and complications. Arthrosc Tech. 2014;3(1):e95-e100.


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Section V
Across Orthopedic Specialties:
Sports/Hip Preservation

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Limited Exposure Direct
23
Anterior Approach for
Treatment of Femoroacetabular
Impingement
Lee E. Rubin, MD; Joseph A. Gil, MD; and Scott A. Ritterman, MD
Mini-open direct anterior approach (DAA) arthrotomy can facilitate surgical treat-
ment of femoroacetabular impingement (FAI) from femoral neck osteochondral
prominence (“cam” lesions), degenerative hip labral tears, or previously-placed
hardware.
Experience with cadaver dissection and live surgery will facilitate safe exposure in a
small surgical field with the described method.
Conversion to a total hip replacement, if necessary, will require knowledge of revision
DAA total hip arthroplasty (THA) techniques. Surgeons should gain familiarity
with such before utilizing the mini-open modification of the operation.
In a hip practice, previously-placed surgical hardware can sometimes require removal

before conversion to THA.1 In patients with FAI and preserved joint space, treatment
may be limited to the management of hip impingement or labral disease. Osteochondral
lesions leading to FAI are often located on the anterior femoral neck, where they are
accessible by the DAA method. Published evidence suggests that DAA may be effec-
tive in joint-preserving surgery, designed to ameliorate the symptoms of FAI. Thus, a
cadaveric study showed that surgical exposure was adequate with both the DAA and the
Hueter interval for joint preserving surgery.2 Another report described a mini-open hip
arthrotomy with arthroscopic visualization of the hip joint.3
Trevino-Garza et al4 reported on 117 hips that had osteochondroplasty though a mini-
open DAA technique; patients were improved at 2 years with no arthritis or minimal

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286 Chapter 23
arthritis on radiographs. Ribas et al reported in 20075 and in 2010 6 on the outcomes of

mini-anterior DAA for the treatment of symptomatic FAI in 105 patients; clinical scores
were statistically improved in patients with Tönnis Grades 0 and 1 hip degeneration.
These data also showed that only 14 of 24 patients with Tönnis Grade 2 hip osteoarthritis
obtained pain relief, suggesting that patient selection and timeliness of surgical interven-
tion may affect the outcomes of hip preservation surgery.
Cloihsy et al7 reported in 2010 on arthroscopically-assisted mini-open DAA osteo-
chondroplasty for FAI; scores and functional outcomes were improved, with reductions
in the alpha angle in 35 hips. Their method was to assess and treat the so-called central
compartment disease of the articular cartilage and labrum with arthroscopy, followed by
removal of impinging lesions at the femoral head-neck junction through a mini-DAA
arthrotomy. Twenty-nine of the 35 patients thus treated had at least a 10-point improve-
ment in the modified Harris Hip Score (HHS), and 71% of the patients had an HHS of
> 80 points at the 2 year follow-up visit. Authors observed that this method is less invasive
than open surgical hip dislocation. Other reports have also supported the arthroscopic-
assisted mini-DAA method in hip preservation surgery.8-11
Parvizi et al12 reported on the outcomes of mini-DAA in femoroacetabular osteo-
plasty for the treatment of FAI, without hip dislocation or arthroscopy. At 2 years, in
149 patients, objective measures such as the Short Form-36 (SF-36), Western Ontario
and McMaster Osteoarthritis Index (WOMAC), UCLA activity, modified HHS, and
Super Simple Hip Scores were significantly improved. Eighteen reoperations were done,
with 11 conversions to THA, and 1 hip resurfacing; all for progressive arthritis. A subset
of the data on mini-open DAA for FAI included athletic patients (59 patients, 66 hips),13
who achieved similar clinical improvements. Of the athletic subgroup, 55% of patients
returned to their specific preoperative sports. Authors observed a 20% incidence of thigh
numbness (meralgia paresthetica) but symptoms resolved after 1 year.
There are few reports concerning mini-open DAA hip arthrotomy for FAI treatment
with retained hardware from prior pediatric hip surgery. One case series addressed open
surgical hip dislocation for management of FAI caused by loose bodies related to synovial
chondromatosis.14 In this chapter, we present an illustrative case to show how mini-open
DAA can be used to address FAI, when previous hardware and impinging femoral osteo-
chondral lesions are present.
The mini-open DAA hip arthrotomy for FAI can be done on a standard operating
table with fluoroscopy. A universal screw removal kit is necessary, along with hex and
locking-star drive screwdrivers in various sizes. Locking pliers or heavy needle drivers
should be available to grasp hardware.
A retractor set designed for DAA is helpful, although a general tray of hip retractors,
such as cobra and Hohmann retractors, can also suffice. A standard arthroscopic hook-
probe is helpful to probe the undersurface of the labrum for tears. A round 5-mm burr
is needed to shave down femoral neck impinging lesions. Bone wax applied manually
after debridement can limit bleeding and reduce the risk of hematoma and ectopic bone
formation.

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Limited Exposure DAA for Treatment of Femoroacetabular Impingement 287
Figure 23-1. Radiograph showing anterior prominence of the screw head with
osteochondral lesion at the anterior femoral head-neck junction.
The surgeon should attempt to preserve the lateral circumflex femoral vessels; these
demarcate the inferior limit of dissection in mini-open DAA. The leash of vessels should
be protected from avulsion during the capsular exposure. In contrast, these vessels are
routinely ligated and divided during THA performed with DAA.
In the limited field available with mini-open DAA, a headlight and/or lighted retrac-
tors are helpful in visualization. Hemostasis must be maintained meticulously so the
operative field remains dry and offers the best exposure.
A 30-year-old female had left hip pain aggravated by sitting and riding her horse.
She worked as a bartender, was recently married, and had delivered her first child. At
age 12 years, she had undergone in-situ anterior hip pinning with an 8.0-mm screw for
slipped capital femoral epiphysis (SCFE).
On examination, she had an antalgic gait pattern. Seated, hip internal rotation was
<10 degrees vs 30 degrees on the contralateral side, with reproduction of groin pain with
the FADIR maneuver (flexion, adduction, internal rotation) and the FABER maneuver
(flexion, abduction, external rotation). External rotation of both hips was 80 degrees, with
no pain in the contralateral right hip.
A lateral hip radiograph (Figure 23-1), showed the prominent screw head in the ante-
rior femoral neck, with a healed grade I SCFE slip of <30 degrees and osteochondral

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288 Chapter 23
Figure 23-2. Screw head is seen protruding from the anterior femo-
ral neck and the suction tip is pointing to the osteochondral lesion
at the proximal femoral head-neck junction. (Orientation: Cephalad
is to the right, and caudad to the left of the photograph.)
overgrowth at the anterior femoral head-neck junction proximal to the screw head. The
hip joint space was well preserved on both sides.
The patient underwent a mini-open DAA hip arthrotomy, positioned supine with a
gel bump under the ipsilateral sacrum to elevate the hip. The limb was draped free to
allow for intraoperative range of motion (ROM). The previous anterior hip incision was
re-utilized and the anterior hip capsule was exposed and cut with an inverted T-shaped
arthrotomy.
The capsulotomy began along the intertrochanteric line distally and was extended from
distal to proximal along the anterior femoral neck to avoid iatrogenic labral injury with the
scalpel blade during the proximal dissection. Once the labrum was exposed, the proximal
capsular exposure was extended horizontally to create an H-shaped capsular exposure.
Reactive synovitis overlying the screw head was excised; pathology showed benign
fibrocollagenous synovium with degenerative changes and mild chronic inflamma-
tion. The labrum was examined directly with an arthroscopic hook probe to assess for
undersurface tearing or detachment. Focal globular degeneration at the anterior-superior
labrum was visualized grossly, but no tearing was identified.
The screw head (Figure 23-2) was cleared of surrounding bone and removed using
grasping pliers and screwdrivers. The resultant bony defect was debrided with a small
angled curette and filled with pelletized calcium phosphate bone graft substitute, which
was impacted into place. Next, the anterior femoral head neck junction was identified by
limb rotation and direct visualization, and a 5.0-mm round burr was used to restore nor-
mal femoral head-neck offset and eliminate the impingement onto the anterior labrum.
Debrided bone was covered with bone wax to discourage bleeding, adhesions, and
ectopic bone formation. Hip mobility after surgery showed flexion of 130 degrees,
with internal rotation of 45 degrees with the hip flexed to 90 degrees. No anterior hip
impingement or labral elevation was identified during direct visualization through the

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Figure 23-3. Four months postoperatively, the graft has healed and the joint
space is intact.
hip arthrotomy or via palpation at the conclusion of the case. The capsule and reflected
head of the rectus femoris tendon were repaired with 0-Vicryl and the wound was repaired
cosmetically with subcutaneous 2-0 Vicryl and subcuticular 3-0 Monocryl (Ethicon) fol-
lowed by Dermabond Advanced Skin Glue (Ethicon).
Crutches were prescribed for 4 weeks with partial weight bearing and early active hip
ROM. The patient was able to gradually resume routine activities, including full return
to work by 2 months and horseback riding at 4 months. Physical therapy targeted early
ambulation, active abduction, and hip flexion, with gradual stretching for restoring
internal and external rotation. Pelvis radiograph (Figure 23-3) at 4 months showed the
incorporation of the synthetic bone graft substitute with no recurrence of the anterior
osteochondral lesion on lateral views.
At the 6-month follow-up, the patient had a non-antalgic gait with symmetric, painless
movement in both hips, with flexion to 130 degrees, internal to 30 degrees, external to
80 degrees, and no pain with hip maneuvers.
Careful preoperative selection of patients with little or no radiographic evidence of

hip osteoarthritis is important for achieving improvements in function with hip preserv-
ing surgery. An accurate history, review of prior treatments and surgical records, and
high-quality radiographs will ensure adequate preoperative preparation. MRI scanning
can help resolve discrepancies between normal radiographs and a symptomatic hip. A
diagnostic injection of a local anesthetic into the hip joint can be helpful in the work-up.

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290 Chapter 23
Counseling the patient of the possible need for future THA is important, and the sur-
geon should know how to perform THA through DAA re-exposure using existing inci-
sions. Hip preservation surgery in patients with existing arthritis should be approached
with caution, since residual pain may frustrate the surgeon and patient. Re-utilization
of the existing anterior scar that was previously used for hip preservation is cosmetically
appealing and a relatively easy strategy in converting to a THA.
The DAA technique is facile, allowing a number of interventions that are the subject of
this book, including FAI debridement, hardware removal, as well as primary and revision
THA. Mini-DAA is suitable for septic hip decompression, open biopsy or joint explora-
tion, foreign body removal, and treatment of FAI. Fluoroscopy and arthroscopy can be
used selectively to improve exposure if needed. Limited dissection to preserve the lateral
circumflex femoral vessels will reduce the morbidity of the operation and improve early
recovery.
The mini-open DAA avoids the morbidity of surgical hip dislocation and attendant
complications like trochanteric non-union, avascular necrosis, and prolonged recovery.
The technique is expeditious in experienced hands, using minimal equipment, and usu-
ally <2 hours operative time. This is an advantage over hip arthroscopy, which can take
longer, and require both a traction table and live fluoroscopy, with attendant risks to the
patient and surgeon.
Clinical results have shown success with FAI debridement and related hip-
preservation surgical techniques with mini-open DAA when hip disease is limited
to Tönnis Grades 0 or 1. The majority of patients can expect to resume preoperative
athletic sports and activity levels.
Mini-open DAA is an attractive alternative to the morbidity of open surgical hip
dislocation and hip arthroscopy. Mini-open DAA allows intraoperative testing and
limb ROM assessment to calibrate the extent of osteochondroplasty.
When planning hardware removal with mini-DAA, implant identification, satisfac-
tory radiographs, intraoperative fluoroscopy, and a variety of screw and hardware
removal instruments should be available. Bone-grafting of residual femoral neck
defects can preserve bone stock and avoid stress risers.
During mini-open DAA, avoid placement of the lateral retractor directly on the
superolateral femoral neck, to avoid damaging the retinacular blood vessels to the
femoral head. This retractor is best placed over the posterolateral joint between the
capsule and the labrum using a sharp-pointed cobra retractor to avoid iatrogenic
femoral head osteonecrosis.

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1. Polkowski GC, Callaghan JJ, Mont MA et al. Total hip arthroplasty in the very young patient. J Am Acad
Orthop Surg. 2012;20(8):487-497.
2. Malik AK, Chou DT, Witt JD. Anterior approaches to the hip for the treatment of femoro-acetabular
impingement: a cadaveric study. Hip Int. 2010;20(4):482–488.
3. Sekiya JK, Wojtys EM. Hip arthroscopy using the mini-open approach. Oper Tech Sports Med.
2002;10(4):200-204.
4. Trevino-Garza O, Rivas-Fernandez M, Marin-Pena O, et al. Treatment of femoro-acetabular impingement
by a minimally invasive approach. Results at 2 years follow-up. Acta Ortop Mex. 2009;23:57.
5. Ribas M, Marin-Penna OR, Regenbrecht B, et al. Hip osteoplasty by an anterior minimally invasive
approach for active patients with femoroacetabular impingement. Hip Int. 2007;17:91-98.
6. Ribas M, Ledesma R, Cardenas C, et al. Clinical results after anterior mini-open approach for femoroac-
etabular impingement in early degenerative stage. Hip Int. 2010;20(Suppl 7):36.
7. Clohisy JC, Zebala LP, Nepple JJ et al. Combined hip arthroscopy and limited open osteochondroplasty
for anterior femoroacetabular impingement. J Bone Joint Surg Am. 2010;92(8):1697-1706.
8. Clohisy JC, McClure JT. Treatment of anterior femoroacetabular impingement with combined hip arthros-
copy and limited anterior decompression. Iowa Orthop J. 2005;25:164-171.
9. Laude F, Sariali E, Nogler A. Femoroacetabular impingement treatment using arthroscopy and anterior
approach. Clin Orthop Relat Res. 2009;467:747-752.
10. Hartmann A, Günther KP. Arthroscopically assisted anterior decompression for femoroacetabular impinge-
ment: technique and early clinical results. Arch Orthop Trauma Surg. 2009;129:1001-1009.
11. Srinivasan SC, Hosny HA, Williams MR. Combined hip arthroscopy and limited open osteochondroplasty
for anterior femoroacetabular impingement: early patient reported outcomes. Hip Int. 2013;23(2):218–224.
12. Parvizi J, Huang R, Diaz-Ledezma C et al. Mini-open femoroacetabular osteoplasty. How do these patients
do? J Arthroplasty. 2012;S1-27(8):122-125.
13. Cohen SB, Huang R, Ciccotti MC et al. Treatment of femoroacetabular impingement in athletes using a
mini-direct anterior approach. Am J Sports Med. 2012;40(7):1620-1627.
14. Abolghasemian M, Kuzyk P, Masdari Z et al. Hips with synovial chondromatosis may display the features
of femoroacetabular impingement. J Bone Joint Surg Am. 2014;96(2):e11 1-6.


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Addressing Acetabular and
24
Femoral Lesions in
Hip Impingement With the
Garrett Davis, MD, MBA, MS and Javad Parvizi, MD, FRCS
Mini-open direct anterior approach (DAA) hip arthrotomy for the management of
cam, pincer, and labral lesions provides excellent visualization with both subjective
and objective improvement in patient outcomes.
This method is best for younger patients (< 40 years) with minimal arthritis of the hip
(< Tönnis Grade 2) and no dysplasia who have failed the nonoperative management.
Patients with labral tear and femoroacetabular impingement (FAI) need to be evalu-
ated thoroughly to exclude other causes of hip pain as incidental labral tear and FAI
is common.
FAI is believed to be secondary to abutment between the proximal femur and the
acetabular rim. This arises from morphological abnormalities affecting the acetabulum
and/or the proximal femur.1 Loss of normal femoral head sphericity is thought to lead
to reduction in anterolateral joint space clearance, which subsequently leads to repetitive
impingement. This abnormality leads to labral tear, chondral separation, and eventual
degenerative arthritis of the hip.2 FAI is a condition that is most commonly diagnosed in
young and active patients.3
Reduced joint clearance may occur from abnormal acetabular or femoral morphology.
The prominence of the anterior acetabular rim may be the result of acetabular retrover-
sion, protrusio acetabula, or overcorrection after periacetabular osteotomy. The decreased
femoral head-to-neck ratio may also be secondary to prior slipped upper femoral epiphysis,
previous Legg-Calve-Perthes disease, or idiopathic development of the degenerative cam

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lesion on the anterosuperior femoral neck. There is a growing evidence that FAI is one of
the predominant risk factors for the development of osteoarthritis of the hip.4,5
FAI and related hip pathology were originally described by Ganz et al, who proposed
a surgical treatment through open hip dislocation and femoroacetabular osteoplasty
(FAO).4,6 While this procedure provided excellent exposure, it was associated with com-
plications related to the trochanteric osteotomy.7 This led to the consideration of less
invasive approaches, such as the hip arthroscopy as well as the mini-open DAA surgery.
The latter refers to DAA through a smaller (< 4 cm) length incision. The procedure avoids
the need for osteotomy or muscular detachment, permitting a faster rehabilitation for the
patient. It allows for excellent access to the hip joint. The mini-open FAO does not have
the steep learning curve associated with more invasive techniques for treating FAI.
Surgical management for FAI should be considered in young patients who present with
groin and/or buttock pain that is unresponsive to activity modification and nonsteroidal
anti-inflammatory drug therapy and who also have appropriate clinical and radiological
findings consistent with FAI. Radiographic parameters for the diagnosis of FAI include
an abnormal alpha angle > 60 degrees on anteroposterior, cross-table lateral, Dunn’s, or
frog-leg lateral views.8–10 Patients with FAI may also require cross-sectional studies such
as MR-arthrography to evaluate the labrum and the articular cartilage. Patients undergo-
ing MR-arthrography may also receive diagnostic injection of local anesthetics. Patients
with concurrent spine disease and/or other pathologies may require further work up and
evaluation by a specialized team prior to surgical intervention. Incidental labral tear and
FAI can exist in asymptomatic patients; thorough patient evaluation will ensure that FAI
is truly the cause of hip symptoms.
Successful surgical management of FAI requires removing the impingement lesions

(cam and/or pincer), stabilizing the acetabular cartilage, and ideally restoring the labral
seal.11 A standard operating table is used. A gel pad bump is used for patient position-
ing. DAA hip retractors are recommended. A sharp curved retractor with a light-source
(Retractor Light Strip [DePuy]) is used over the anterior acetabular wall to assist with
lighting and improved visualization. A blunt nerve hook can be used for assessment of the
labrum. A round 5-mm burr is used for removal of the cam lesion. Labrum is repaired to
the acetabular rim with the use of anchor sutures. A 45- or 90-degree pick can be used
for micro-fracture, when necessary. Bone wax is typically applied to the debrided femoral
neck area at the end of the case to help obtain hemostasis.
A 21-year-old male had pain in his left hip for 1 year that had been progressively wors-
ening. He described his pain as constant. His symptoms were limiting his activities and
precluding him from participating in sports. Radiographs (Figure 24-1) demonstrated
both a cam and pincer lesion, with an alpha angle of 63 degrees.
On clinical examination he was found to have 110 degrees of flexion and -10 degrees
of internal rotation. He had a positive impingement test (pain with flexion, adduction,

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Addressing Acetabular and Femoral Lesions in Hip Impingement with the DAA 295
Figure 24-1. Frog lateral view showing anterior

cam and pincer lesion in a 21-year- old patient.
and internal rotation),12 as well as a positive FABER (flexion, abduction, external rota-
tion) test.
Patient underwent a mini-open DAA FAO. A spinal anesthetic was used. The patient
was placed supine on a standard operating room table. A padded gel bump was placed
under the patient at the midpoint of the patient’s anterior superior iliac spine (ASIS).
Plastic draping was then used to seal off the perineum as well as the foot prior to prepping.
The hip was brought through a full range of motion (ROM) under anesthesia. This was
documented and compared to the patient’s ROM at the conclusion of the case.
The ASIS was identified prior to incision. A marking pen was used to mark a 4 cm
incision starting 2 cm distal and lateral to the ASIS and directed to the head of the fibula
(Figure 24-2).
A standard DAA was utilized using the interval between the sartorius and tensor fascia
lata (TFL), incising lateral to the sartorius through the perimysium overlying the TFL
in line with the muscle fibers. A blunt Hohmann retractor was passed over the superior
femoral neck. The rectus muscle was retracted medially to expose the underlying capsule
of the hip. The ascending branches of the lateral femoral circumflex artery (LFCA) are
usually distal to the incision and not encountered with this approach. However, in some
patients these vessels may need to be ligated or coagulated. A second blunt Hohmann was
then placed distally around the femoral neck capsule.
The muscle belly of the rectus femoris was gently elevated from the hip capsule using
a Cobb elevator. A sharp curved retractor with an attached light was passed over the
anterior acetabular wall, resting on the upper portion of the anterior inferior iliac spine.
Flexion of the hip during placement of this retractor helps to ensure the femoral head is
not engaged.
A long-handled knife was then used to perform an I-shaped capsulotomy starting from
the intertrochanteric line to the femoral head, with care being exercised not to incise the
labrum. Exposure of as much of the labrum as possible is recommended. Both Hohmann
retractors were then replaced around the inferior and superior aspect of the femoral neck
on the inner aspect of the capsule.

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296 Chapter 24
Figure 24-2. Prepped hip, showing ASIS, and incision placement.
The anterior superior aspect of the acetabulum was debrided. The labrum was then
evaluated using a blunt nerve hook (Figure 24-3). The labrum was then detached, along
with a thin wafer of bone, approximately 2 mm in width over the anterior acetabular wall.
Care should be taken to avoid over-resection as this can lead to instability. It is also impor-
tant to ensure that there is not associated acetabular retroversion and posterior acetabular
under-coverage.
An assistant then applied axial traction to the leg in order to provide slight distraction
of the hip. A Cobb elevator was then placed in the interval between the detached labrum
and the femoral head. Note, that the Cobb is gently advanced into the joint space and
the femoral head is held distracted. Acetabular cartilage was then assessed at this point
using a blunt nerve root retractor to probe the acetabular cartilage. Delaminated carti-
lage should be excised and removed back to a stable rim using a long-handled knife. A
90-degree dental pick can be used at this time for microfracture in areas of full thickness
cartilage loss, a strategy that has shown improvement in patient reported outcomes and
return to play in athletes.13,14
The Cobb was removed from joint space and the femoral head was reduced. The ante-
rior wall of the acetabulum was trimmed to expose bleeding bone. Three suture anchors
(Twinloop Bioabsorbable Anchors [Stryker]) are then placed evenly spaced along the
superior aspect of the acetabulum, avoiding penetration of the hip joint. Non-absorbable
Ethibond (Ethicon) suture was passed through the labrum and the labrum was reat-
tached to the anterior acetabular wall, with care made to tie the knots outside the joint
(Figure 24-4).

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Figure 24-3. Blunt nerve hooked placed into the tear of the anterior supe-
rior aspect of patient’s labral tear. (Orientation for all surgical photographs:
Patient head to the left; foot to the right)
Figure 24-4. Three suture anchors used to repair the labrum. Note the sutures
are placed outside the joint.

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298 Chapter 24
Figure 24-5. Burring of the femoral head cam lesion with a 5-mm burr.
Attention was then turned to the femoral cam lesion. A curved osteotome was used to
define the abnormal cartilage approximately 15 mm from the labral edge. The cam lesion
can often be differentiated from normal cartilage by its discoloration and frayed cartilage.1
A 5-mm burr or an osteotome was then used to remove the cam lesion, typically to the
depth of 5 mm (Figure 24-5). The posterior-inferior aspect of the femoral neck can be
better accessed by placing the patient’s operative leg in a figure-4 position.
The hip was then flexed to assess normal joint clearance as well as the resolution of
impingement. The patient was found to have 20 degrees of internal rotation. A digit was
placed into the area of the debrided cam lesion, after which the hip is brought through
flexion and internal rotation to assess for any additional impingement. Bone wax was then
placed in the area of the burred femoral neck to help with hemostasis.
The hip capsule was then repaired using 2 absorbable sutures. Hemostasis was obtained
and the perimysium of the TFL-sartorius interval was then closed with absorbable suture.
Superficial skin and fat were closed using absorbable suture. The incision was dressed
with an Aquacel (ConvaTec) dressing kept on for 7 days. Postoperative anteroposterior
and Dunn radiographs (Figure 24-6) were obtained and the patient was allowed to mobi-
lize with full weight bearing with crutches use for 1 week. Aspirin 81 mg twice a day for
2 to 4 weeks is typically used as prophylaxis against venous thromboembolism.15

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Figure 24-6. Frog lateral view showing correction of

the FAI deformity when compared to Figure 24-1.
Early experience with mini-open DAA FAO has demonstrated patient improvement in
Modified Harris Hip, Western Ontario and McMaster Osteoarthritis Index (WOMAC),
and UCLA activity scores. Patients have also been found to have clinical improvement in
their flexion and internal rotation (19 degrees and 9 degrees, respectively).16–19
Relative contraindications to mini-open DAA FAO include Tönnis Grade 2 or greater
degree of arthritis, age greater than 40 years, and radiographic evidence of hip dyspla-
sia, which has been shown to be associated with poor clinical outcomes with mini-open
FAO.20 Absolute contraindications include posteroinferior femoral or labral lesions,
Tönnis Grade 3 or 4 radiographic arthritis, as well as hip pain not clearly localized to the
joint.
Mini-open DAA provides excellent visualization of hip pathology in patients with

FAI. Early data have demonstrated excellent results in the appropriate surgical candidates
with patients experiencing less pain and improved ROM of affected hips. Patients over
the age of 40 years and those with Tönnis Grade 2 or greater arthritic changes have less
reliable results; thus, selection of patients for this procedure is highly dependent on sur-
geon knowledge and experience. Detailed and accurate surgical technique is needed to
safely debride cam and pincer lesions and to repair labral tears. Stabilization of acetabular
cartilage and restoration of the labral seal are important in improving patient outcomes.

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Mini-open DAA FAO provides excellent visualization of both the cam and pincer
lesions.
Patients show improvements in both functional scores and ROM following mini-open
DAA hip arthrotomy for FAI.
Successful surgical treatment of FAI requires removing the impingement lesion (cam
and/or pincer), stabilizing the acetabular cartilage, and restoring the labral seal.
1. Lavigne M, Parvizi J, Beck M, Siebenrock KA, Ganz R, Leunig M. Anterior femoroacetabular impinge-
ment: part I. Techniques of joint preserving surgery. Clin Orthop Relat Res. 2004;(418):61-66.
2. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabu-
lar cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg
Br. 2005;87:1012-1018.
3. Clohisy JC, Baca G, Beaulé PE, et al. Descriptive epidemiology of femoroacetabular impingement: a North
American cohort of patients undergoing surgery. Am J Sport Med. 2013;41:1348-1356.
4. Ganz R, Parvizi J, Beck M, Leunig M, Nötzli H, Siebenrock KA. Femoroacetabular impingement: a cause
for osteoarthritis of the hip. Clin Orthop Relat Res. 2003;(417):112-120.
5. Harris WH. Etiology of osteoarthritis of the hip. Clin Orthop Relat Res. 1986;(213):20-33
6. Ganz R, Gill TJ, Gautier E, Ganz K, Krügel N, Berlemann U. Surgical dislocation of the adult hip a tech-
nique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone
Joint Surg Br. 2001;83:1119-1124.
7. Matsuda DK, Carlisle JC, Arthurs SC, Wierks CH, Philippon MJ. Comparative systematic review
of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement.
Arthrosc— J Arthrosc Relat Surg. 2011;27(2):252-269.
8. Barton C, Salineros MJ, Rakhra KS, Beaulé PE. Validity of the alpha angle mea surement on plain
radiographs in the evaluation of cam-type femoroacetabular impingement. Clin Orthops Relat Res.
2011;469:464-469.
9. Meyer DC, Beck M, Ellis T, Ganz R, Leunig M. Comparison of six radiographic projections to assess
femoral head/neck asphericity. Clin Orthop Relat Res. 2006;445:181-185.
10. Nötzli HP, Wyss TF, Stoecklin CH, et al. Ovid: the contour of the femoral head-neck junction as a predic-
tor for the risk of anterior impingement. J Bone Joint Surg Br. 2002;84:556-560.
11. Bardakos N V, Vasconcelos JC, Villar RN. Early outcome of hip arthroscopy for femoroacetabular impinge-
ment. J Bone Joint Surg Br. 2008;90-B:1570-1575.
12. Ganz R, Leunig M, Leunig-Ganz K, Harris WH. The etiology of osteoarthritis of the hip: An integrated
mechanical concept. I Clin Orthop Relat Res. 2008;466:264-272.
13. McDonald JE, Herzog MM, Philippon MJ. Return to play after hip arthroscopy with microfracture in elite
athletes. Arthrosc— J Arthrosc Relat Surg. 2013;29:330-335.
14. Karthikeyan S, Roberts S, Griffin D. Microfracture for acetabular chondral defects in patients
with femoroacetabular impingement: results at second-look arthroscopic surgery. Am J Sports Med.
2012;40(12):2725-2730.
15. Tischler EH, Ponzio DY, Diaz-Ledezma C, Parvizi J. Prevention of venous thromboembolic events follow-
ing femoroacetabular osteoplasty: aspirin is enough for most. Hip Int. 2014;24:77-80.
16. Chiron P, Espié A, Reina N, Cavaignac E, Molinier F, Laffosse JM. Surgery for femoroacetabular impinge-
ment using a minimally invasive anterolateral approach: analysis of 118 cases at 2.2-year follow-up. Orthop
Traumatol Surg Res. 2012;98(1):30-38.
17. Parvizi J, Huang R, Diaz-Ledezma C, Og B. Mini-open femoroacetabular osteoplasty. How do these
patients do? J Arthroplasty. 2012;27(8 suppl):122-125.

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18. Ribas M, Ledesma R, Cardenas C, Marin-Peña O, Toro J, Caceres E. Clinical results after ante-
rior mini-open approach for femoroacetabular impingement in early degenerative stage. Hip Int.
2010;20(Suppl 7):S36-S42.
19. Treviño-Garza O, Rivas-Fernández M, Marín-Peña O, Esteban-Ledezma R, Vilarubias-Guillament JM.
[Treatment of femoro-acetabular impingement by a minimally invasive approach. Results at 2 years follow-
up]. Acta Ortop Mex. 2009;23:57-69.
20. Huang R, Peters C, Erickson J, Stewart RPJ. Femoroacetabular impingement: predictors of surgical failure.
Poster presented at: American Academy of Orthopaedic Surgeons Annual Meeting; February 7-11, 2012.
San Francisco, California.


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Section VI
Orthopedic Specialties: Trauma

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25
Management of Acetabular
Fractures in the Elderly With
Steve Papp, MD; Wade Gofton, MD; Derek Butterwick, MD;
Allan Liew, MD; and Paul E. Beaulé, MD
Acetabular fractures in the elderly often occur after low-energy trauma and tend to
have different patterns than seen in younger patients with high-energy trauma.
Typically, there is increased involvement of the anterior column, quadrilateral plate
comminution, medialization of the femoral head, and marginal impaction.
Poor prognostic factors for open reduction and internal fixation (ORIF) include pos-
terior wall comminution, marginal impaction of acetabulum, femoral head impaction
fracture, and hip dislocation.
Conversion to total hip arthroplasty (THA) following index acetabular ORIF may be
needed in up to 22% of patients.
THA performed post-acetabular fracture yields good clinical results; however, in the
acute setting, THA must be combined with stable fracture fixation.
With an aging population in the United States and Canada, the incidence and burden
of fragility fractures that occur in osteopenic bone is on the rise.1 More specifically, in
patients over the age of 60, the incidence of acetabular fractures has increased over the
past quarter of a century.2 While the majority of acetabular fractures in young adults
occur as a result of high-energy trauma, falls from a standing height account for 50% of
such fractures in patients > 60 years of age, a higher incidence than all injuries sustained
in motor vehicle accidents for the same demographic.2 When associated with high-energy


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306 Chapter 25
mechanisms, acetabular fractures can be accompanied by abdominal and chest injuries,

which can be especially devastating in elderly patients.3,4
In high-energy trauma, acetabular fracture patterns are typical of those described by
the Letournel classification.2,5 However, osteopenic patients who fall on their side typi-
cally experience an impact through the greater trochanter, which results in an anterome-
dial force, fracturing and displacing the anterior column and quadrilateral plate. The
femoral head then medializes with the anterior column and impacts the posteromedial
portion of the roof. At times, the femoral head can be impacted and damaged by an intact
acetabulum. This mechanism results in certain features of geriatric acetabular fractures,
which include anterior column displacement, quadrilateral plate involvement, medializa-
tion of the femoral head, and superomedial roof impaction.6 The anterior column poste-
rior hemitransverse (ACPHT) fracture pattern is the classic osteopenic acetabular fracture
that tends to display all these features.7,8
Radiographic evaluation should include an anteroposterior pelvis view and obturator

and iliac oblique Judet views. Fractures are then classified according to the Letournel
classification of acetabular fractures to assist in treatment planning.9 The fracture can be
further investigated with CT scans and 3D reconstructions to gain a better understanding
of the affected anatomy. Radiographic signs associated with a poor outcome are posterior
wall comminution, marginal impaction, the so-called gull sign indicating superomedial
roof impaction, hip dislocation, impaction injuries to the femoral head, femoral head or
neck fractures, and pre-existing arthritic changes in the injured hip.2,10
Anglen et al described the gull sign, which refers to a specific type of marginal impac-
tion of osteopenic bone resulting in superomedial dome impaction from medialization of
the femoral head.6 In their series, all fractures with this radiographic finding experienced
inadequate reduction or early loss of reduction, medial subluxation of the femoral head,
and medial/superior joint narrowing. These findings were later confirmed by Laflamme
et al in a series of 21 patients where 6 patients with the gull sign had a poor reduction and
progressed to early THA.11 These findings were contradicted by Helfet et al, who found
no association between the gull sign and the need for subsequent arthroplasty, and who
concluded that the failures were related to the overall quality of the fracture reduction.12
A 67-year-old male fell onto his right side after losing control of his bicycle. He was
retired, living with his wife, had no significant medical comorbidities, and was active on
a daily basis. His x-rays and CT scan showed a displaced acetabular fracture. The fracture
involved the anterior column of the acetabulum and displacement of the quadrilateral
plate. There was also acetabular roof impaction, showing the gull sign. The posterior
column remained intact (Figure 25-1).

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Management of Acetabular Fractures in the Elderly With Direct Anterior Hip Surgery 307
A B
D
Figure 25-1. Anteroposterior pelvis and CT scans
demonstrating acromioclavicular fracture with
superomedial dome impaction, quadrilateral plate
displacement, and medial subluxation of the femoral
head. Note intact posterior column in this case.
Conservative treatment may be an option for specific fractures and/or in patients who
cannot undergo surgery. The success of nonoperative treatment relies on fracture stability,
joint congruity, and minimal intra-articular displacement. Thus, fractures with < 2 mm
of displacement, an intact roof arc angle of 45 degrees, and 10 mm of subchondral ring
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308 Chapter 25
intact on CT are suitable for non-surgical management in patients who are otherwise able
to mobilize.13,14
Conversely, nonsurgical management of displaced, unstable, or incongruent fractures
with nonoperative management yields poor results. Historically, closed reductions were
achieved and maintained via lateral trochanteric or longitudinal skeletal traction and pro-
longed bed rest, which reduced only 56.3% (18/32) of displaced fractures resulting in 44%
(14/32) poor clinical outcomes.15 In a review of 25 patients over the age of 65 years, 30%
experienced poor results, resulting in severe pain with ambulation or incapacitation, when
acetabular fractures were managed nonsurgically.16 Despite these data, nonsurgical man-
agement may be the only reasonable option in patients who are medically unfit for surgery
or have minimal functional demands.16 In this scenario, a short course of immobilization
for pain control may be necessary, but the goal should be early mobilization with protected
weight bearing to minimize the morbidity associated with bed rest.7
While it has been suggested by Tile et al17 that attempts at osteosynthesis of geriatric
acetabular fractures are futile because of poor bone quality, Letournel et al have reported
76% (44/58) good to excellent outcomes in patients > 60 years of age, in whom acetabular
fractures were addressed surgically.18 Matta et al reported that achieving a reduction with
< 3 mm of intra-articular congruity was the key variable in achieving good clinical results
in acetabular fractures.13 However, it may be more difficult to obtain anatomic reduction
in fractured osteopenic bone. Clinical series have reported achieving anatomic reduction
in 44% (13/29) patients > 60 years of age and 58% (26/45) in patients > 55 years of age with
acetabular fractures, respectively.13,19
In general, the fracture pattern will dictate the surgical approach required for fixa-
tion. Direct anterior surgery is often useful in approaching certain injuries. In geriatric
fractures involving the anterior column and displacement of the quadrilateral plate, the
anterior intrapelvic Stoppa approach 20-22 provides direct access and visualization of these
fragments for reduction and fixation. If the fracture calls for acute total hip arthroplasty
(THA), then the 2 preferred approaches are the posterior approach 23,24 and the Levine
modification of the anterior approach.25 In choosing a surgical approach, access to fixa-
tion of the fracture to provide enough stability for the acetabular component placement as
well as access to the femur for broaching must be taken into consideration.
The Stoppa approach has gained popularity for treating acetabular fractures from an
anterior abdominal approach.26 The approach offers significant advantages over the clas-
sic techniques, such as the ilioinguinal approach. It has been shown to offer increased
visualization of the fracture,27 better windows for clamp placement,22 and better fixation
options to deal with quadrilateral plate fractures.28-30 In cases with dome impaction, the
surgeon may be able to reduce this impaction directly through the Stoppa approach.31,32
The surgeon stands on the side opposite to the acetabular fracture, with the patient in
the supine position. First, a transverse incision is made approximately 1 to 2 cm above the

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pubic symphysis. The skin and subcutaneous tissue are mobilized off the deeper fascia in
the midline to allow generous exposure of the midline raphe of the rectus abdominus. The
linea alba is cut from the level of the symphysis and extended proximally. The proximal
extension should be generous for easy soft tissue retraction. The space of Retzius anterior
to the bladder is carefully developed. The bladder should be palpated bluntly and gently
pushed away from any superficial structures, keeping in mind that adhesions can put the
bladder at risk of injury. Once the bladder is freely dissected, a combination of a malleable
retractor to protect the bladder and a Deaver retractor under the femoral neurovascular
structures will allow visualization of the pelvis (Figure 25-2A).
The rectus abdominus fascia should be dissected away from the pubic rami superiorly,
leaving its anterior attachment on the pubic body, and a Hohmann retractor can be placed
over the medial portion of the pubic rami. Next, the periosteum and iliopectineal fascia
are released from the pubic rami. Commonly, the corona mortis, a vascular anastomosis
between the internal and external iliac system, will be encountered. These vessels must
be ligated or clipped. The iliopsoas muscle can now be lifted and used to protect the
femoral vessels. The Deaver or Hohmann retractor can be slid under this muscle allow-
ing for visualization of the anterior column. With controlled elevation of the periosteum,
the dissection can go as far as the sacroiliac (SI) joint posteriorly. Following exposure of
the anterior column, the quadrilateral plate and posterior column can be exposed. During
dissection into the true pelvis, the obturator nerve should be identified and protected. The
obturator internus can be released at this stage, exposing the quadrilateral plate, posterior
column, and majority of the ischial spine.
Fracture reduction begins with disimpaction of the medialized femoral head via
lateral traction using a Shanz pin in the proximal femur allowing lateralization of the
femoral head back under the intact dome. Through the lateral window of the ilioinguinal
approach, reduction and lag screw/plate fixation of high anterior column fractures can be
completed. Deformity correction often requires internal rotation of the anterior column;
anti-glide plate techniques can be very useful in achieving and maintaining the reduction
without blocking the reduction of the medial articular fragments or quadrilateral plate.
Reduction of impacted roof fragments and the quadrilateral plate can be done through
the ilioinguinal (often through a cortical window) or the Stoppa approach (often through
the fracture line).
Achieving rigid fixation of the quadrilateral plate can be difficult.5 Attempts at but-
tressing the quadrilateral plate through the ilioinguinal approach via a spring plate or
T-plate placed under a pelvic reconstruction along the pelvic brim can result in late
displacement. Direct buttressing of the quadrilateral plate can be achieved through the
Stoppa approach. The quadrilateral plate fragment can be mobilized, and after reduc-
tion of the impacted dome fragment, subchondral screws can be placed above the dome.
Laflamme et al treated 21 elderly patients with quadrilateral plate displacement and
protrusion, using a contoured infrapectinal pelvic reconstruction plate placed through the
Stoppa window with 2 screws just anterior to the SI joint and 2 screws into the superior
pubic ramus; significant loss of reduction occurred in only 2 patients.33
The posterior column can also be reduced through the Stoppa approach. The pelvic
offset clamp can be used and one tine is placed on the ischial spine or carefully through
the greater sciatic foramen. The other tine is placed on the pelvic brim or pubic symphysis.
The posterior column can be stabilized with an intrapelvic plate or with posterior column
screws placed through the lateral window 34 (Figures 25-2B and 25-2C). The results of

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310 Chapter 25
C
Figure 25-2. (A) Illustration of visualization of the pelvis
through a Stoppa approach. (B) Placement of offset
clamps to reduce both the anterior and posterior col-
umns through this approach. (C) Placement of pelvic
brim plate and posterior column screws. Quadrilateral
plates may also be used through this approach.

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A B
C D
Figure 25-3. The following images demonstrate the reduction and fixation of the patient in Figure 25-1.
(A) The superomedial dome fragment is reduced via a bone tamp through the lateral approach in this
case. (B) Judet obturator oblique view demonstrates anterior column plate fixation. (C) AP pelvis showing
final reduction with plate fixation on both the quadrilateral plate and anterior column. (D) The final fluo-
roscopic picture, postoperative x-ray, and CT scan are also seen.
surgical fixation of acetabular fractures in patients > 55 years of age were summarized in
a 2014 review article that cited 8 studies; acceptable fracture reduction of up to 3-mm
displacement occurred in 86.2% of the cases, with anatomic reduction in 45.3%, and con-
version to THA in 22.4% of the cases (Figure 25-3).35
Indications for acute THA in acetabular fracture management have not been fully
developed, but generally include the poor prognostic factors for fixation as a reason to give
consideration to acute THA. In each case, the surgeon must decide whether successful
reduction and fixation can be done in a reasonable amount of time. If not, arthroplasty can
be considered. General indications for acute THA include severe comminution, femoral
head lesions, dome impaction with gull wing impaction injuries involving > 40% of the
dome, femoral head/neck fractures, and pre-existing severe degenerative arthritis.23
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312 Chapter 25
Surgical goals when approaching such a fracture include achieving rigid stabilization
such that an acetabular component can be inserted with good initial stability to allow
healing and long-term stability of the component. Achieving these goals involves over-
coming many technical challenges and one should be careful not to assume that THA is
a simpler solution to a complex fracture pattern as it can be as difficult, if not more so,
than ORIF.
Several techniques of fracture reduction and stabilization of the acetabulum (cables,
ORIF, or percutaneous screws) can be used prior to performing acute THA. During
reduction, the goal is not to achieve anatomic reduction, but to reduce the columns such
that they will provide stability to the acetabular component. Efforts should be made to
utilize a single incision for both procedures to reduce OR time and blood loss. Those
surgeons comfortable with the direct anterior approach (DAA) THA technique may
elect to use the Levine modification of the Smith-Petersen approach. However, this is an
extended approach, different than the standard DAA used for primary hip arthroplasty.
Surgeons taking on this approach must be comfortable with anterior approaches and
fixation techniques of anterior acetabular fractures. Surgeons with expertise in acetabu-
lar fractures (trauma training) and surgeons with expertise in arthroplasty (arthroplasty
training) may even combine their experiences and perform this procedure as co-surgeons.
The DAA for THA in patients with an acetabular fracture should only be used in the
setting of isolated anterior column or associated ACPHT injury.25
The patient is placed in the supine position, preferably using a radiolucent positioning
table. Appropriate equipment includes a standard pelvic fixation set (small fragment pelvic
reconstruction plates, pelvic reduction instruments) and a DAA THA set (offset reamers,
impactors, broaches). The acetabular component would normally be a porous metal cup
with screw augmentation. A cage cup should be available in case stable acetabular com-
ponent fixation cannot be achieved. Perioperative antibiotics are administered. Cell Saver
(Haemonetics) is considered in these cases routinely.
The incision is made from the iliac crest, curving and running just lateral and distal to
the anterior superior iliac spine (ASIS) and continuing distally over the tensor fascia lata
(TFL) muscle 5 cm distal to the level of the symphysis. The abdominal muscle insertions
are released from the proximal iliac crest. The sartorius and direct head of the rectus
femoris are also released. The TFL muscle is retracted laterally and the rectus is retracted
medially, while protecting the lateral femoral cutaneous nerve. Deep to the fascia of the
rectus, the dissection reaches the plane between the gluteus medius tendon and the cap-
sule of the hip joint. A blunt Hohmann is placed under the psoas tendon to gain full access
to the hip capsule. The upper fibers of the vastus intermedius and a portion of the iliocap-
sularis muscle take origin from the anterior capsule and are released distally and medially.
Once the exposure is completed, there should be full visualization of the hip capsule,
ASIS, pelvic brim, and false pelvis. Through this approach, the anterior column fracture
can be stabilized. The femoral head should be lateralized and disimpacted and the anterior
column fracture reduced. This can be stabilized with a plate screw construct. Typically
the plate is placed within the internal iliac fossa, lateral to the sacroiliac joint and over the
anterior column and wall fracture, securing the fracture with fixation over the pectineal

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Figure 25-4. (A) 72-year- old male with protrusio type

acetabular fracture after low- energy mechanism.
(B) Levine approach showing dissection plane where
the abdominal muscles are elevated with sarto-
rius and direct head of the rectus released. (C) The
patient was treated with anterior column fixation
and an acute THA using a GAP cup through a Levine
all anterior approach.
eminence. The quadrilateral plate can be stabilized with a 3.5-mm cortical screw inserted
from the outer aspect of the pelvic bone25 (Figure 25-4).
Once the pelvis has been stabilized, gentle acetabular reaming is done, with morselized
bone autograft used to fill defects. This can often be obtained as autograft from the
femoral head or allograft. The metal socket is then impacted in the appropriate abduction
and anteversion. In this setting, supplemental multidirectional screw augmentation for
the socket will add to initial socket stability. Next, the leg is externally rotated, extended,
and adducted for femoral preparation. Reaming and/or broaching are done per DAA
routine and the femoral component is inserted. Leg lengths and appropriate position are
confirmed with intraoperative imaging. Solid closure of the abdominal muscle insertions
onto the iliac crest should be emphasized. This high-stress area should be closed solidly
in layers to avoid any dehiscence. We over-sew the proximal abdominal musculature.
Postoperatively, patients are limited to 30 lbs weight bearing for 8 weeks. No specific hip
precautions are needed.

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314 Chapter 25
Delayed THA, when done for post-traumatic arthritis in failed ORIF of acetabu-
lar fractures or in deformed bone with malunion, should be approached with caution.
Technical hurdles include scarring, heterotopic bone, retained hardware, acetabular defor-
mity, acetabular non-union, low-grade infection, and avascular necrosis of the femoral
head.36 Acetabular support may prove difficult, and the results of cemented fixation are
generally poor. Lewallen et al reported on 55 cemented THA cases done for failed acetab-
ular fixation; 50% rate of acetabular components were radiographically loose and 15% had
been revised.37 Weber et al reported on 63 conversion THA cases done for failed acetabu-
lar ORIF; of 41 cemented implants, 15 (36.6%) were loose and 9 had been revised.38
Press-fit fixation may fare better. Bellabarba et al reported on 30 patients with post-
traumatic osteoarthritis, treated with cementless acetabular components and noted a 97%
Kaplan-Meier 10-year survival rate.39 In that series, 15 patients had a previous failed
ORIF and 15 had failed nonoperative treatment for acetabular fractures. Patients with
previous ORIF had significantly longer operating room times, more blood loss, and
higher transfusion rates; however, given the restored pelvic anatomy, there was a decreased
need for bone grafting. Component survival based on revision surgery or radiographic
loosening was similar between the acetabular fracture patients vs a comparable group of
patients who underwent primary THA.39
Acetabular fractures in the elderly patient may be more frequently encountered as the
population ages. ORIF can provide acceptable outcomes when a concentric, congruent
joint reduction is obtained. Satisfactory reduction and fixation can be achieved through a
Stoppa approach, although subsequent conversion to THA may be as high as 22%.35 For
selected patients, ORIF may be combined with acute THA using extended approaches
such as the Levine modification of the DAA. Sufficient surgical training, experience,
judgement, and detailed preoperative planning will allow the surgeon to choose the best
approach to achieve acceptable results.
Non-surgical management is appropriate in fractures where joint congruence is

maintained.
Choice of surgical exposure should be selected based on capacity to stabilize the frac-
ture with or without associated total hip replacement.
The Stoppa approach can be used as adjunct to stabilize the quadrilateral plate.

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1. Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic
fractures. Osteoporos Int. 2006;17(12):1726–1733.
2. Ferguson TA, Patel R, Bhandari M, Matta JM. Fractures of the acetabulum in patients aged 60 years and
older: an epidemiological and radiological study. J Bone Joint Surg Br. 2010;92(2):250–257.
3. Hill BW, Switzer JA, Cole PA. Management of high-energy acetabular fractures in the elderly individuals:
a current review. Geriatr Orthop Surg Rehabil. 2013;3(3):95–106.
4. Bible JE, Wegner A, McClure DJ, et al. One-year mortality after acetabular fractures in elderly patients
presenting to a level-1 trauma center. J Orthop Trauma. 2014;28(3):154–159.
5. Dana C, Mears MP. Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone.
J Am Acad Orthop Surg. 1999;7(2):128-141.
6. Anglen JO, Burd TA, Hendricks KJ, Harrison P. The “gull sign”: a harbinger of failure for internal fixation
of geriatric acetabular fractures. J Orthop Trauma. 2003;17(9):625–634.
7. Henry PDG, Kreder HJ, Jenkinson RJ. The osteoporotic acetabular fracture. Orthopedic Clinics of NA.
2013;44(2):201–215.
8. Butterwick D, Papp S, Gofton W, Liew A, Beaulé PE. Acetabular fractures in the elderly: evaluation and
management. J Bone Joint Surg. 2015;97(9):758–68.
9. Beaulé PE, Dorey FJ, Matta JM. Letournel classification for acetabular fractures. Assessment of interob-
server and intraobserver reliability. J Bone Joint Surg Am. 2003;85-A(9):1704–1709.
10. Zha G-C, Sun J-Y, Dong S-J. Predictors of clinical outcomes after surgical treatment of displaced acetabular
fractures in the elderly. J Orthop Res. 2012;31(4):588–595.
11. Laflamme GY, Hebert-Davies J, Rouleau D, Benoit B, Leduc S. Internal fixation of osteopenic acetabular
fractures involving the quadrilateral plate. Injury. 2011;42(10):1130–1134.
12. Carroll EA, Huber FG, Goldman AT, et al. Treatment of acetabular fractures in an older pop-
ulation. J Orthop Trauma. http://journals.lww.com /jorthotrauma /Abstract /2010/10000/Treatment _of
_ Acetabular_ Fractures _in _ an _Older.7.aspx. Published October 2010. Accessed January 6, 2016.
13. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed
operatively within three weeks after the injury. J Bone Joint Surg Am. 1996;78(11):1632–1645.
14. Olson SA, Matta JM. The computerized tomography subchondral arc: a new method of assessing acetabu-
lar articular continuity after fracture (a preliminary report). J Orthop Trauma. 1993;7(5):402–413.
15. Sen RK, Veerappa LA. Long-term outcome of conservatively managed displaced acetabular fractures.
J Trauma. 2009;67(1):155–159.
16. Spencer RF. Acetabular fractures in older patients. J Bone Joint Surg Br. 1989;71(5):774–776.
17. Marvin T, ed. Fractures of the Pelvis and Acetabulum. Baltimore, MD: Lippincott Williams & Wilkins;
2003.
18. Letournel E. The treatment of acetabular fractures through the ilioinguinal approach. Clin Orthop Relat
Res. 1993;(292):62–76.
19. Miller AN, Prasarn ML, Lorich DG, Helfet DL. The radiological evaluation of acetabular fractures in the
elderly. J Bone Joint Surg Br. 2010;92(4):560–564.
20. Cole JD, Bolhofner BR. Acetabular fracture fixation via a modified Stoppa limited intrapelvic
approach. Description of operative technique and preliminary treatment results. Clin Orthop Relat Res.
1994;(305):112–123.
21. Sagi HC, Afsari A, Dziadosz D. The anterior intra-pelvic (modified Rives-Stoppa) approach for fixation of
acetabular fractures. J Orthop Trauma. 2010;24(5):263–270.
22. Sands SS, Sagi HC. Open reduction of geriatricacetabulum fractures using a Stoppa exposure. YOTOR;
2011;21(4):272–275.
23. Mears DC, Velyvis JH. Acute total hip arthroplasty for selected displaced acetabular fractures. J Bone Joint
Surg. 2002;84A(1):1–9.
24. Herscovici D, Lindvall E, Bolhofner B, Scaduto JM. The combined hip procedure: open reduction internal
fixation combined with total hip arthroplasty for the management of acetabular fractures in the elderly.
J Orthop Trauma. 2010;24(5):291–296.
25. Beaulé PE, Griffin DB, Matta JM. The Levine anterior approach for total hip replacement as the treatment
for an acute acetabular fracture. J Orthop Trauma. 2004;18(9):623–629.

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26. Guy P. Evolution of the anterior intrapelvic (Stoppa) approach for acetabular fracture surgery. J Orthop
Trauma. 2015;29(Suppl 2):S1–5.
27. Bible JE, Choxi AA, Kadakia RJ, Evans JM, Mir HR. Quantification of bony pelvic exposure through the
modified Stoppa approach. J Orthop Trauma. 2014;28(6):320–323.
28. Collinge CA, Lebus GF. Techniques for reduction of the quadrilateral surface and dome impaction when
using the anterior intrapelvic (modified Stoppa) approach. J Orthop Trauma. 2015;29(Suppl 2):S20–24.
29. Shazar N, Eshed I, Ackshota N, Hershkovich O, Khazanov A, Herman A. Comparison of acetabular
fracture reduction quality by the ilioinguinal or the anterior intrapelvic (modified Rives-Stoppa) surgical
approaches. J Orthop Trauma. 2014;28(6):313–319.
30. Hammad AS, El-khadrawe TA. Accuracy of reduction and early clinical outcome in acetabular fractures
treated by the standard ilio-inguinal versus the Stoppa/iliac approaches. Injury. 2015;46(2):320–326.
31. Laflamme G-Y, Hebert-Davies J. Direct reduction technique for superomedial dome impaction in geriatric
acetabular fractures. J Orthop Trauma. 2014;28(2):e39– e43.
32. Casstevens C, Archdeacon MT, d’Heurle A, Finnan R. Intrapelvic reduction and buttress screw stabiliza-
tion of dome impaction of the acetabulum: a technical trick. J Orthop Trauma. 2014;28(6):e133–137.
33. Laflamme GY, Hebert-Davies J, Rouleau D, Benoit B, Leduc S. Internal fixation of osteopenic acetabular
fractures involving the quadrilateral plate. Injury. 2011;42(10):1130–1134.
34. Kistler BJ, Sagi HC. Reduction of the posterior column in displaced acetabulum fractures through the
anterior intrapelvic approach. J Orthop Trauma. 2015;29(Suppl 2):S14–19.
35. Daurka JS, Pastides PS, Lewis A, Rickman M, Bircher MD. Acetabular fractures in patients aged > 55 years:
a systematic review of the literature. Bone Joint J. 2014;96-B(2):157–163.
36. Sierra RJ, Mabry TM, Sems SA, Berry DJ. Acetabular fractures: the role of total hip replacement.
Bone Joint J. 2013;95-B(11 Suppl A):11–16.
37. Romness DW, Lewallen DG. Total hip arthroplasty after fracture of the acetabulum. Long-term results.
J Bone Joint Surg Br. 1990;72(5):761–764.
38. Weber M, Berry DJ, Harmsen WS. Total hip arthroplasty after operative treatment of an acetabular frac-
ture. J Bone Joint Surg Am. 1998;80(9):1295–1305.
39. Bellabarba C, Berger RA, Bentley CD, Quigley LR, et al. Cementless acetabular reconstruction after
acetabular fracture. J Bone Joint Surg Am. 2001;83-A(6):868–876.

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Section VII
Orthopedic Specialties: Adult
Reconstruction/Hip Preservation

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26
Proximal Femur-Preserving
Hip Reconstruction With the
The surgeon must understand appropriate patient selection criteria for hip resurfac-
ing or neck-preserving implants, especially when using the direct anterior approach
(DAA).
Clinical advantages of supine patient positioning and accuracy of implant placement
apply equally well when DAA is used for short stems and/or hip resurfacing.
Knowledge of the surgical steps for hip resurfacing and neck-preserving implants
when using the DAA are important to the success of these demanding procedures.
Total hip arthroplasty (THA) is a well-accepted treatment for end-stage hip osteo-
arthritis.1–3 The DAA is generally thought to be less invasive than other hip surgical
approaches.4,5 Preservation of femoral neck bone during THA may protect the proximal
anatomy and anteversion of the femur, and allow more physiologic loading to the healthy
femur (Figure 26-1).6 Hip resurfacing arthroplasty (HRA) is an alternative to THA, and
it preserves the femoral neck entirely.7–9
Accurate restoration of the femoral head center and leg lengths are among the advan-
tages of HRA. Preservation of the femoral neck may ease future revision surgery after
HRA. Proximal femoral loading is closer to the natural femur with HRA when compared
to THA.10 HRA may also be associated with better outcomes in cases complicated by
sepsis, with a lower incidence of thromboembolic events, when compared to THA.11
HRA is usually done with a posterior approach, requiring sacrifice of the short exter-
nal rotators. The posterior approach is known to compromise hip stability and result in

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320 Chapter 26
Figure 26-1. Distribution of compressive strains in femoral cortex in

(A) intact femur, (B) femur implanted with a neck-preserving stem
(MiniHip [Corin]), and (C) femur implanted with a non–neck-preserving
stem. A neck-preserving stem results in more physiological distribution
of forces in femoral cortex.
abnormal gait patterns after THA.12,13 DAA is advantageous in preserving hip muscu-
lature, especially the extensors and hip abductors that control gait and balance.14 DAA
can also preserve blood supply to the femoral head from the medial femoral circumflex
artery.15 While the gluteus-medius splitting approaches may also preserve femoral head
blood supply, they can result in an abductor limp after surgery.16 The preservation of
proximal femoral bone is also achievable, in part, during THA with various designs of
short, neck-preserving femoral stems (Figure 26-2).
Patients selected for HRA are generally young and active.17 Since implant stability
relies on the strength of the proximal femur, an age cutoff may be used (eg, males age
< 65 years and females < 55 years) and intraoperative observation can verify adequate bone
quality.8 If proximal femur bone stock is insufficient, a backup conventional stem should
be used instead.
A Surface Arthroplasty Risk Index (SARI) has been introduced to assess the suitability
of an individual patient for HRA, based on 4 variables: (1) femoral head cysts > 1 cm, (2)
patient weight < 82 kg, (3) history of proximal femoral surgery, and (4) UCLA score > 6.18
In this grading system, a SARI score of greater than 3 suggests increased risk of early
failure after HRA.
With proximal femoral preservation, DAA is more challenging since the femoral head
or neck will obstruct the view of the acetabulum. Capsular releases will be more difficult

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Proximal Femur-Preserving Hip Reconstruction With the Direct Anterior Approach 321
B
Figure 26-2. Two types of commercially avail-
able neck-preserving stems. (A) The stem
A is contained only in the femoral neck, and
(B) the stem extends into the metaphyseal
femoral canal.
as well. The young age of the patients means that surgical exposure itself will be harder
due to the heavier musculature. We prefer the use of a radiolucent table with an ARCH
extension (Innovative Orthopedic Technologies), which is a leg-holding device that facili-
tates leg positioning during surgical exposure (Figure 26-3).
Fluoroscopic image intensifier (C-arm) and special instruments can help during DAA
HRA. A standard goniometer with long arms can ensure proper angle of pin placement.
The hip tray should include double-bent Mueller retractors, a Ranawat retractor, and
long-bent Hohmann retractors for exposure. We use a bipolar tissue sealer (Aquamantys,
Medtronic) to reduce blood loss during surgery. For exposure, the general rule is that hip
flexion, posterior capsular releases, and posterior and lateral displacement of the femur
will help acetabular exposure and instrumentation. Femoral preparation is facilitated by
external rotation, extension, and different degrees of adduction.
After routine DAA exposure as described in other chapters, a pocket is created between
the gluteus medius and minimus muscle groups, and the iliac wing to house the femoral
head during acetabular preparation. After a capsulotomy is performed, 3 capsular releases
are performed: (1) inferior capsular release along the medical calcar to the lesser trochan-
ter, (2) superior capsular release between the labrum and the femoral head, and (3) piri-
formis fossa release for the posterior capsule in the piriformis fossa. Rotating the femoral
head will facilitate these releases.

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322 Chapter 26
Figure 26-3. ARCH table extension for

easier leg positioning during DAA
THA.
The femoral head is dislocated and placed into a previously created soft tissue pocket
superiorly. Additional posterior capsular releases are performed in a semi-blind manner
to mobilize the femur superiorly and laterally and move it out of the way of the acetabu-
lum. The assistant pushes the thigh to displace the femur posteriorly to allow acetabular
preparation. Acetabular preparation is done by placing the reamer basket into the acetabu-
lum followed by connecting a thin shaft straight reamer onto the reamer basket in situ.
Likewise, the acetabular component is placed manually and then connected to the inserter
in situ. We use C-arm fluoroscopy to verify implant position.
The operation is similar for neck-preserving, short femoral stems. A subcapital femoral
neck cut is made, and the retained neck is carefully protected during surgery to avoid
crushing injury to it. After releases, a double-bent Mueller retractor can be placed over the
cut femoral neck to depress it from the field and expose the acetabulum. A conventional
offset reamer can be used and an image intensifier is not necessary, in our experience.
Navigation can also easily be incorporated into this technique, if desired.
For femoral implantation in HRA, we use the image intensifier to guide accurate guide
pin placement, and we further confirm the neck angle with a sterile goniometer with long
arms (Figure 26-4). The goal is to avoid varus pin placement. After preparation of the
femoral head as per manufacturer’s instrumentation and instructions, the trial resurfacing
component is checked again with the C-arm before cementing in the final component.
If short-stem THA is to be performed instead, the femoral neck is entered with a sharp-
entry awl followed by a canal finder and/or curved rasp and subsequent broaching. The
surgeon should understand the proximal femoral anatomy, especially the anteversion of
the femoral neck, in order to avoid canal perforation. Before final stem placement, we bone
graft the canal with autologous reamings from the acetabulum to gain further stability.

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Figure 26-4. Pin placement for HRA is facilitated by C-arm

imaging during DAA.

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324 Chapter 26
Figure 26-5. HRA, with contralateral neck-preserving THA; both done using
the DAA technique.
During closure, our preference is to use silver impregnated dressings (eg, Silverlon).
All procedures are done under spinal anesthesia in addition to a local infiltration of a
pain cocktail or Exparel (bupivacaine; Pacira Pharmaceuticals Inc). Figure 26-5 shows an
x-ray view of a HRA in place, with a contralateral short-stem THA; both operations were
accomplished using DAA.
Retention of the femoral head during HRA, or native femoral neck during short-stem
THA, leads to additional technical challenges when the DAA is used. Even surgeons
experienced with primary DAA THA with standard implants should approach these
procedures with caution, and only after gaining familiarity and experience with DAA. As
others have suggested, given the learning curve associated with DAA, surgeon training is
important before embarking on live surgery.19 For HRA specifically, cadaveric dissection,
instrumentation practice, and observations of actual surgery are highly recommended.8

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Adequate capsular releases and appropriate surgical exposure are even more critical,
and more challenging, when utilizing the DAA for HRA and short-stem THA where
the femoral neck is preserved.
Approach-specific instrumentation, an image intensifier, a specialty table, and back-
up plans with standard instruments/implants should be available before attempting
DAA-based HRA or neck-preserving THA.
Since these operations can prove to be challenging, surgeons should have significant
DAA THA case experience with standard implants, and additional training with
proctorship/mentorship, before embarking on independent, live-patient surgery.
rapid voluntary cessation of all walking AIDS: a prospective, randomized clinical trial. J Arthroplasty
2014;29(9 Suppl):169-172. doi:10.1016/j.arth.2014.03.051.
2. Rathod PA, Orishimo KF, Kremenic IJ, Deshmukh AJ, Rodriguez JA. Similar improvement in
gait parameters following direct anterior & posterior approach total hip arthroplasty. J Arthroplasty
2014;29(6):1261-1264. doi:10.1016/j.arth.2013.11.021.
3. Dorr LD, Maheshwari AV, Long WT, Wan Z, Sirianni LE. Early pain relief and function after posterior
minimally invasive and conventional total hip arthroplasty. A prospective, randomized, blinded study.
J Bone Joint Surg Am. 2007;89(6):1153-1160. doi:10.2106/JBJS.F.00940.
4. Kreuzer S, Leffers K, Kumar S. Direct anterior approach for hip resurfacing: surgical technique and com-
plications. Clin Orthop Relat Res. 2011;469(6):1574-1581. doi:10.1007/s11999-010-1698-5.
5. Nakata K, Nishikawa M, Yamamoto K. A clinical comparative study of the direct anterior with mini-posterior
approach two consecutive series. J Arthroplasty 2009;24(5):698-704. doi:10.1016/j.arth.2008.04.012.
6. Pipino F, Molfetta L. Femoral neck preservation in total hip replacement. Ital J Orthop. http://europepmc.org
/abstract/MED/8567257. Published 1993. Accessed April 23, 2013.
7. Vail TP, Mina CA, Yergler JD, Pietrobon R. Metal-on-metal hip resurfacing compares favorably with THA
at 2 years followup. Clin Orthop Relat Res. 2006;453:123-131. doi:10.1097/01.blo.0000238852.08497.92.
8. Shimmin A, Beaulé PE, Campbell P. Metal-on-metal hip resurfacing arthroplasty. J Bone Joint Surg Am.
2008;90:637-654. doi:10.2106/JBJS.G.01012.
9. Schmalzried TP. Why total hip resurfacing. J Arthroplasty 2007;22(7):57-60. doi:10.1016/j.arth.2007.05.050.
10. Kishida Y, Sugano N, Nishii T, Miki H, Yamaguchi K, Yoshikawa H. Preservation of the bone min-
eral density of the femur after surface replacement of the hip. J Bone Joint Surg Br. 2004;86:185-189.
doi:10.1302/0301-620X.86B2.14338.
11. Treacy RBC, McBryde CW, Pynsent PB. Birmingham hip resurfacing arthroplasty. J Bone Joint Surg—
Ser B. 2005;87(2):167-170. doi:10.1302/0301-620X.87B2.15030.
12. Madsen MS, Ritter M a., Morris HH, et al. The effect of total hip arthroplasty surgical approach on gait.
J Orthop Res. 2004;22:44-50. doi:10.1016/S0736-0266(03)00151-7.
13. McMinn DJW, Daniel J, Ziaee H, Pradhan C. Posterior surgical approach for hip resurfacing arthroplasty.
Tech Orthop. 2010;25(1):56-66. doi:10.1097/BTO.0b013e3181d2a987.
14. Matta J, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an ortho-
paedic table. Clin Orthop. 2005;(441):115-124. doi:10.1097/01.blo.0000194309.70518.cb.
15. Beaulé PE, Campbell P, Lu Z, et al. Vascularity of the arthritic femoral head and hip resurfacing. J Bone
Joint Surg Am. 2006;88(Suppl 4):85-96. doi:10.2106/JBJS.F.00592.
16. Masonis JL, Bourne RB. Surgical approach, abductor function, and total hip arthroplasty dislocation.
Clin Orthop Relat Res. www.ncbi.nlm.nih.gov/pubmed/12461355. Published December, 2002. Accessed
January 24, 2015.

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17. Beaulé PE, Antoniades J. Patient selection and surgical technique for surface arthroplasty of the hip. Orthop
Clin North Am. 2005;36:177-185. doi:10.1016/j.ocl.2005.01.001.
18. Beaulé PE, Dorey FJ, Le Duff MJ, Gruen T, Amstutz HC. Risk factors affecting outcome of metal-on-
metal surface arthroplasty of the hip. Clin Orthop Relat Res. 2004;(418):87-93.
19. Benoit B, Gofton W, Beaulé PE. Hueter anterior approach for hip resurfacing: assessment of the learning
curve. Orthop Clin North Am. 2009;40(3):357-363. doi:10.1016/j.ocl.2009.02.002.

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Section VIII
Orthopedic Specialties: Oncology

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27
Tumor Reconstruction of
Hip and Proximal Femur
With the Anterior Approach
Herrick J. Siegel, MD and Daniel C. Allison, MD, MBA
The direct anterior approach (DAA) may be used for biopsy, tumor resections, and
complex revisions.
Understanding the pertinent anatomic landmarks and vital structures is essential.
Extensile approaches may be utilized and exposure of the entire femur may be
accomplished.
Advantages of the anterior approach include preservation of posterior soft tissue
envelope, preservation of the gluteus muscles, neurovascular access, and facilitated
imaging.
Nononcologic femoral resections may be successfully accomplished with the use of a
standard operating room (OR) table or with the use of a specialized fracture table (ie,
Hana [Mizuho OSI] or ARCH tables [Innovative Orthopedic Technologies]).
Endoprosthetic reconstruction following femoral resections for oncologic and

Nononcologic etiologies has gained wide acceptance.1–3 The extensile DAA to the proxi-
mal femur may be used to address a wide range of oncologic and nononcologic causes of
massive femoral bone loss. The approach may be extended distally to expose the entire
femur4,5 (Figure 27-1). Oncologic conditions include primary bone sarcomas, metastatic
disease, lymphoma, and myeloma. Nononcologic indications for femoral endoprosthetic
reconstruction include periprosthetic fractures, chronic femoral non-unions, revision total
hip arthroplasty, and comminuted osteoporotic fractures.6 Relative contraindications for
primary bone sarcomas include soft tissue mass extension around the greater trochanter

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330 Chapter 27
Figure 27-1. Standard DAA with extensile approaches indicated with lines A
and B. B is more classic extension; however, for anterior compartment tumor
involvement line A may be used.
and soft tissue mass extension adjacent to the sciatic nerve or notch. The advantages of
DAA resections include supine patient positioning, facilitated intraoperative imaging,
anterior column acetabular exposure, and femoral neurovascular bundle/adductor com-
partment access.7
In oncologic cases, the anatomic location and the extension of a soft tissue component
often dictates the necessary approach. Femoral resections in oncology include malignant
bone sarcomas (ie, osteosarcoma, Ewing sarcoma, chondrosarcoma) and metastatic dis-
ease (renal, thyroid, breast, prostate, and lung are most common). Myeloma, lymphoma,
and aggressive benign bone tumors (ie, giant cell tumor, aneurysmal bone cyst) may also
require femoral resection and reconstruction. Biopsy tracts and areas involved with prior
surgical procedures for treatment of sarcomas are often incorporated into the resection.8
Traditional approaches to the proximal femur have included the posterior approach and
anterolateral approach, both which are generally performed in the lateral decubitus posi-
tion.9 In contrast, the patient is positioned supine during DAA, and both lower extremi-
ties are draped into the surgical field. Musculoskeletal tumor (MSTS) IIB bone sarcomas
are high-grade extracompartmental malignancies (osteosarcoma, Ewing sarcoma); how-
ever, low and intermediate chondrosarcoma often present as MSTS type IA (confined to
the bone) and amenable to the DAA.10 Although a universally acceptable bone margin
has not been established, most orthopedic oncologists use a minimum of 2 cm. With
pathologic fractures from metastatic disease, myeloma, and lymphoma, the margin of
resection is variable and the tumor treatment is highly dependent on chemotherapy and/
or radiation.11,12
The important aspects of hip reconstruction for oncology surgery include safe expo-
sure, good soft tissue preservation when possible, joint stability, and a durable construct.13
Available endoprosthetic implants included cemented, uncemented, and hybrid fixa-
tion, such as a combination of cemented and biologic fixation. The DAA can be used
at the proximal portion of the femoral resection. Utilizing a muscle-sparing approach
that avoids injury to the lateral femoral cutaneous nerve (LFCN) has several advantages
including posterior tissue envelope preservation.14 If the greater trochanter is uninvolved
with tumor, it may be preserved and left in continuity with the vastus origin by utilizing
a trochanteric slide osteotomy. This is easily accomplished with the DAA and once the

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Tumor Reconstruction of Hip and Proximal Femur With the Anterior Approach 331
trochanter is osteotomized, the proximal femur can be elevated and exposed.15 The glu-
teus maximus tendon may be released for further femoral elevation and the sciatic nerve
will passively translocate posteriorly with the release of the gluteal sling.
Whichever approach is selected for oncologic resection, it should be performed by a
fellowship-trained orthopedic oncologist and the resection margin should not be compro-
mised by the approach.8 Radiographs, MRI, and CT scans can be used to help provide
3-dimensional understanding of the tumor margins and help with detailed surgical plan-
ning. There are no studies in the literature, as yet, looking at functional outcome as it
relates to the surgical approach to the proximal or total femur replacement, although the
use of a synthetic mesh (ie, Marlex) has been reported to improve stability and reduce the
incidence of dislocation.2,13
The patient may be positioned supine on a fracture table (ie, Hana table) or a standard
radiolucent table preferably with the ability to extend the hip. The standard operative table
is preferred, since it allows direct access to the contralateral extremity and the freedom
to move the lower extremity independent of the table and without a fracture boot. The
advantage of the fracture table is the assistance of the hook table attachment that assists
with femoral elevation. The patient is prepped from above the anterior iliac spines bilater-
ally and a sterile towel/drape is placed in the perineum and covered with an impervious
sticky drape (ie, Ioban). Bilateral lower extremities are prepped and sterile stockinettes
and cobans are applied distal to the planned resection.
Fluoroscopy is essential in directing not only the femoral resection, but also position-
ing of implants and leg lengths. The proximal extent of the incision utilizes the tensor
fascia lata (TFL) envelope, which reduces the risk of injury to the LFCN. If additional
medial exposure is needed or the sartorius muscle requires resection, the LFCN may be
exposed and protected or injected with local anesthetic and incised, if necessary. A lighted
suction tip and/or retractor system is helpful for deep dissection. Unless contraindicated,
the patient is given 1 g of intravenous tranexamic acid 30 minutes prior to the incision to
reduce intraoperative blood loss. A bipolar hemosealant device (Aquamantys [Medtronic])
is also used in the majority of cases to assist with coagulation.
Direct anterior hip instrumentation is preferred. This includes 2 Mueller retractors,
2 cobra retractors, 2 double-angle Hohmann retractors, 1 T-handle bone hook, and
1 Lane bone holder. If hardware or implant removal is planned, preoperative planning is
important to assure that specific screwdrivers are available and the necessary allografts
and cables are available for reconstruction. If a cemented implant is planned, 2 to 3 bags
of low viscosity cement are recommended, depending on canal diameter. A bone plug and
canal prep kit may help reduce the risk of fat embolism and improve the consistency of
the cement mantle. In nononcologic femoral resections, cell saver is used and preoperative
hemoglobin is optimized with iron infusion or erythropoietin. Depending on the level of
femoral resection and soft tissue loss, closure is usually accomplished primarily without
the use of soft tissue flaps. The TFL is often well-preserved, even if it has to be released
proximally. The trochanteric slide is preferred and may be secured to the proximal portion

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332 Chapter 27
of the prosthesis with No. 5 nonabsorbable suture. Some endoprosthetic systems have an
option for a trochanteric side plate buttress (ie, Stanmore) that acts as a large washer in
which the preserved greater trochanter is compressed against a hydroxyapatite-coated
implant.
Vascular studies (ie, angiography) may be performed intraoperatively in the supine posi-
tion and if necessary, muscle flap donor sites (including the rectus abdominis muscle) may
be easily harvested by a plastic surgeon. Deep and superficial drains may be used, based
on surgeon preference. An abduction pillow is used for gluteal rest and patients are gener-
ally weight bearing as tolerated with a walker for 6 weeks and then advanced to a cane.
Case 1
A 31-year-old male with an enlarging left thigh mass had a low impact motorcycle inju-
ry 6 months prior to presentation to an orthopedic oncologist. The initial treatment plan
was physical therapy and anti-inflammatory medication. The mass continued to grow and
he went back to his primary care doctor who diagnosed him with a painful lipoma. The
pain continued and he eventually presented to an emergency room with severe onset of
exacerbated pain. Imaging studies showed a pathologic mid-shaft distal femur fracture.
He was treated with a retrograde femoral nail. His immediate postoperative course was
unremarkable; however, at 4 months postoperatively, he was still unable to weight bear
and radiographs showed massive bone loss extending from the fracture site proximally.
He was referred to an orthopedic oncologist; biopsy was consistent with leiomyosarcoma
of bone. His staging studies were negative for distant disease.
The patient underwent preoperative chemotherapy and radiation, followed by total
femoral resection. The DAA was utilized proximally and the mass was resected en bloc
with the vastus intermedius (see Figures 27-1 and 27-2). A total femoral replacement was
placed through an extended anterior approach, and the knee was reconstructed using a
modular rotating hinge (Figures 27-3 and 27-4). The soft tissues were closed primary
with closure of the TFL, sartorius, and iliotibial band (Figure 27-5). The final closure
consisted of drain placement, subcutaneous layer closure, and staples (Figure 27-6). The
surgical margins were negative and the patient was able to ambulate unassisted 2 months
postoperatively. At 2 years postoperatively, he has no evidence of disease and is monitored
at 6-month intervals with PET/CT scans.

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Figure 27-2. Total femur resection; patient posi-

tioned supine for procedure. DAA interval was
used proximally with preservation of posterior
capsule. Trochanteric osteotomy is necessary when
resected proximal femur through this approach.
Figure 27-3. Hip reconstruction using

multiple suture anchors placed cir-
cumferentially around acetabulum to
anchor soft tissues including residual
labrum and capsule. Bipolar was used
in this case to improve hip stability.

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334 Chapter 27
Figure 27-4. Preparation of tibia during total femur replacement. Tension is

relieved on the neuromuscular bundles by shortening the extremity during
preparation.
Figure 27-5. Soft tissue closure of TFL, sartorius, and iliotibial band after total
femur reconstruction.
Case 2
A 46-year-old male with osteosarcoma of the proximal left femur with a large anterior
soft tissue component presented with pain and inability to ambulate (Figure 27-7). The
mass was not involving the TFL and extended medially into the adductor compartment
and distally into the vastus intermedius (Figure 27-8). The patient’s staging studies were
negative for metastasis and he underwent a preoperative course of chemotherapy. The soft
tissue involvement was extensive and there was concern regarding soft tissue coverage and
the preoperative plan included a soft tissue flap. The patient underwent a wide resection

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Figure 27-6. Final closure of wound after extensive reconstructive surgery for
tumor.
Figure 27-7. Gross, pre-surgical appearance of osteosarcoma of the left thigh.
Figure 27-8. Resection of mass; the TFL was not involved in the tumor,
which had invaded the medial adductor compartment and the distal vastus
intermedius.

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336 Chapter 27
Figure 27-9. (A) Wide resection of the tumor, and (B) endoprosthetic recon-
struction of the femur.
with endoprosthetic femoral reconstruction (Figure 27-9). The DAA was utilized proxi-
mally and the incision was extended distally for vascular exposure. A rectus abdominis
soft tissue flap was performed by plastic surgery (Figure 27-10). The patient’s surgical
margins were negative. He was able to ambulate unassisted at 3.5 months and is currently
disease free 3 years postoperatively.

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B
Figure 27-10. (A) Soft tissue reconstruction with rectus abdominis flap, and
(B) skin closure with assistance from plastic surgery.
Case 3
A 65-year-old female with metastatic breast cancer and pathologic fracture of her right
proximal femur. She underwent internal fixation of her left femur prior to referral to
orthopedic oncology. Unfortunately, she later sustained a pathologic acetabular fracture
with hip dislocation. The hardware in her right proximal femur failed with pull-out of a
recon intramedullary nail. She then underwent a girdlestone procedure and placement of
antibiotic cement (Figure 27-11). She was then seen by an orthopedic oncologist for joint
salvage and reconstruction. An infection work up was negative and the patient was taken
to the OR for proximal femoral endoprosthesis and acetabular reconstruction using porous
metal augments.
A DAA was used with partial release of the TFL from the iliac crest to allow for the
proximal femur to be superiorly translated into the surgical field and additional exposure
of the acetabulum. A short segment proximal femoral replacement with a hydroxyapa-
tite collar for bone ingrowth at the host-implant junction was cemented into the femur
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338 Chapter 27
Figure 27-11. Proximal femur resection in patient with metastatic cancer and
failure of total hip reconstruction.
(Stanmore; Figure 27-12). A bipolar prosthesis was used with a smooth, uncoated proxi-
mal body to reduce soft tissue irritation around the trochanter (Figure 27-13). The patient
was full weight bearing 1 day postoperatively and was ambulating comfortably with a cane
3 months postoperatively (Figure 27-14). At her 1.5-year follow-up, she was ambulating
without assistive devices and was living independently.
The clinical outcome for femoral resections for oncologic etiologies is dependent on
the extent of bone and soft tissue resection. Patients with bone sarcomas (ie, osteosar-
coma and Ewing sarcoma) are treated with pre- and postoperative chemotherapy (with
the exception of chondrosarcoma). Immunosuppression and myelosuppression puts these
patients at high risk for infection and wound complications. Metastatic disease patients are

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Figure 27-12. A short segment proximal femoral replacement with a hydroxy-

apatite collar for bone ingrowth at the host-implant junction.
Figure 27-13. A bipolar prosthesis was used with a smooth, uncoated proximal
body, to reduce soft tissue irritation around the trochanter.

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340 Chapter 27
Figure 27-14. AP of right hip showing proximal femur of replacement implant

with augmented acetabular reconstruction and constrained liner in patient
without abductor function.
also frequently immuno- and myelosuppressed. Rehabilitation for these patients is often
complex and prolonged by multiple variables, including extent of disease and additional
comorbidities.
Early return to activities of daily living and independence is the goal of the procedure;
in the majority of patients, this goal is accomplished with the DAA. Dislocation remains a
significant risk of the proximal femur resections; however, with the use of bipolar compo-
nents and preservation of the gluteal muscles, this risk is significantly reduced. There are
no current studies in the literature describing the use of the DAA in orthopedic oncology.
The use of the DAA in oncology has evolved from the anterior extensile approaches used
in total hip revision surgery. While the location of a primary bone tumor dictates the best
approach for resection, the TFL fascial envelope may be reflected for enhanced exposure

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of the proximal femur and femoral head. The approach may also be extended proximally
along the iliac crest to expose the anterior column of the acetabulum. Indications for this
approach in orthopedic oncology include intracompartmental bone sarcoma (MSTS type
IA or IIA), metastatic disease without posterior soft tissue mass extension, and aggressive
benign bone tumors of the proximal femoral with significant bone destruction (ie, giant
cell tumor, aneurysmal bone cyst).
The potential advantages of DAA surgery in orthopedic oncology include supine posi-
tion, which may assist with airway control and ventilation; improved hip stability when
the abductors are preserved; muscle preservation (muscles are released from the femur
but not divided); intraoperative imaging as needed to assist with planned bone resection
and leg length determination; and access to femoral neurovascular bundle, with ability to
perform an angiogram on the radiolucent table. Oncologic outcome has been reported to
be dependent on multiple variables including chemotherapy response, margin status, pres-
ence of metastatic disease, tumor size (larger, worse prognosis), anatomic location (axial or
central location, worse prognosis), and grade (high grade, worse prognosis).
Extensile DAAs continue to evolve. While the primary advantage of DAA has been
described in primary total hip arthroplasty, revision hip arthroplasty surgeons have found
success with extensile variations of DAA, as described elsewhere in this book. The supine
position has many advantages, including ventilation, vascular and airway access, facili-
tated intraoperative imaging, soft tissue releases without division of muscle, preservation
of the posterior capsule and gluteal/iliotibial band sleeve, and ease of leg length com-
parison. DAA instrumentation and lighted retractor/suction tips are helpful in assisting
with femoral and acetabular exposures. With short proximal femur resections, a standard
10-cm incision may be used. The proximal femur is delivered into the surgical field view
with manipulation of the extremity and the acetabular view is unobstructed. Restoration
of the patient’s anatomy is easier because of the supine position, and leg lengths may be
checked either by comparing the medial malleoli or the Galeazzi test.
With the extensile DAA, the entire femur may be exposed. The direction of the distal
extent of the incision is determined by whether the femoral neurovascular bundle will
need to be exposed. The safest extension is laterally along the iliotibial band with either
division or periosteal elevation of the vastus lateralis. If a total femur is performed, split-
ting the vastus lateralis is preferred and if the proximal femur is replaced, the vastus may
be elevated from anterior to posterior and the muscle left intact.
Postoperative recovery protocol is generally the surgeon’s preference; however, the
majority of patients may fully weight bear immediately with the use of assistive devices
and abductor sparing exercises. With the use of a bipolar implant, the patient’s range of
motion is not restricted; however, if an unconstrained total hip is performed, posterior
precautions are used for 12 weeks. The postoperative protocol for the total femur includes
6 weeks of postoperative knee bracing to limit quadriceps stretching; however, weight
bearing is as tolerated. This protocol will vary based on length of resection, soft tissue
resection, and the surgeon’s experience.
Primary bone sarcomas should be referred to a fellowship-trained musculoskeletal
oncologist prior to biopsy. Appropriate oncologic techniques should be followed to avoid

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contamination of adjacent soft tissue. A wide margin should be the goal of all pri-
mary bone sarcomas. Type of approach and reconstruction is highly surgeon specific.
Utilization of the DAA for endoprosthetic or megaprosthetic femur and hip reconstruc-
tion is an advanced, but powerful, technique that requires extensive DAA experience and
significant expertise in both equipment selection and oncologic surgery.
The DAA to the hip may be used in selected tumor resections involving the proximal
femur. The approach is extensile and may be used to expose the entire femur.
Advantages of DAA for oncology include the supine position, neurovascular access,
leg length comparison, intraoperative imaging for implant positioning and bone cuts,
and easier access to knee for total femur replacement.
Disadvantages of DAA for oncology include difficulty in resecting posterior soft
tissue extension (especially near the sciatic nerve), difficulty resecting tissue around
the greater trochanter, and increased potential for wound complications if the TFL is
involved with tumor and requires resection.
Primary bone sarcomas should be managed by a fellowship-trained orthopedic oncol-
ogist and preferably the patient should be referred prior to performing initial biopsy.
Metastatic disease may be resected through a DAA; however, embolization should be
considered preoperatively, especially for renal and thyroid metastasis.
Specialized DAA instrumentation is helpful, and the proximal exposure is highly
dependent on the surgeon’s ability to elevate the femur for exposure.
A radiolucent table with hip extension is recommended. The fracture table should
only be used by those experienced with its use for the DAA approach for hip replace-
ment, and only in short proximal resection, just below the lesser trochanter. The
fracture table may be helpful for femoral elevation/retraction; however, it should be
operated only by experienced personnel to prevent patient injury.
1. Bernthal NM, Greenberg M, Heberer K, Eckardt JJ, Fowler EG. What are the functional outcomes of
endoprosthetic reconstructions after tumor resection? Clin Orthop Relat Res. 2015; 473(3):812-819.
2. Ahlmann ER, Menendez LR, Kermani C, et al. Survivorship and clinical outcome of modular endopros-
thetic reconstruction for neoplastic disease of the lower limb. J Bone Joint Surg Br. 2006;88B:790-795.
3. Savvidou OD, Mavrogenis AF, Sakellariou V, et al. Salvage of failed total hip arthroplasty with proximal
femoral replacement. Orthopedics. 2014; 37(10):691-698.
4. Glassman AH. Exposure for revision: total hip replacement. Clin Orthop Relat Res. 2004;(420):39-47.
Review.
5. Stiehl JB. Extensile anterior column acetabular reconstruction in revision total hip arthroplasty. Semin
Arthroplasty. 1995;6(2):60-67.
6. Parvizi J, Sim FH. Proximal femoral replacements with megaprosthesis. Clin Orthop Relat Res.
2004;420:169-175.
7. Lietman SA. A novel surgical approach for complex destructive acetabular malignancies. J Surg Oncol.
2009;99(6):379-381.

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8. Enneking W, Maale GE. The effect of inadvertent tumor contamination of wounds during the surgical
resection of musculoskeletal neoplasms. Cancer. 1981;47:1251-1256.
9. Donati D, Zavatta M, Gozzi E, et al. Modular prosthetic replacement of the proximal femur after resection
of a bone tumour— a long term follow up. J Bone Joint Surg Br. 2001;83B:1156-1160.
10. Enneking WF, Spanier S, Goodman MA. A system for surgical staging of musculoskeletal sarcoma. Clin
Orthop Relat Res. 1980;153:106-120.
11. Hattori H, Mibe J, Yamamoto K. Modular megaprosthesis in metastatic bone disease of the femur.
Orthopedics. 2011;34(12):e871-e876
12. Veth RP, Nielsen HK, Oldhoff J, et al. Megaprostheses in the treatment of primary malignant and meta-
static tumors in the hip region. J Surg Oncol. 1989; 40(3):214-218.
13. Morris HG, Capanna R, Del Ben M, Campanacci D. Prosthetic reconstruction of the proximal femur after
resection for bone tumors. J Arthroplasty. 1995;10(3):293-299.
Ann Transl Med. 2014;2(10):100.
15. Berend KR, Kavolus JJ, Morris MJ, Lombardi AV Jr. Primary and revision anterior supine total hip arthro-
plasty: an analysis of complications and reoperations. Instr Course Lect. 2013;62:251-263.


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Section IX
Orthopedic Specialties: Rehabilitation

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28
Patient Rehabilitation After
Sarvang Dalal, PT, DPT, MSPT, MTC, FAAOMPT

and Amir Pourmoghaddam, PhD
Direct anterior approach (DAA) total hip arthroplasty (THA) recovery consists of
3 rehabilitative phases, and the surgeon and therapist should work together to ensure
patient safety and quick recovery.
Resistance tubing bands are an important part of functional rehabilitation by permit-
ting movements in multiple anatomical planes and by utilizing benefits of both open-
and closed-kinetic chains.
Straight leg raise (SLR) exercises should be avoided since they can cause iliopsoas
tendonitis after DAA THA.
Primary THA is the ultimate surgical option to help patients with painful hip osteo-
arthritis (OA).1–3 Rehabilitation following any major joint replacement surgery is an inte-
gral part of the recovery process.4,5 A variety of hip replacement protocols are used based
on surgeon preference and guided by the specific surgical approach. Standard methods
(posterior, lateral approaches) to THA have well-recognized postoperative limitations and
restrictions that are unique to each type of surgery and based on known patterns of soft-
tissue trauma and the attendant risk of hip instability.6 The rehabilitation process can vary
considerably depending on the surgical technique, and few common standards may exist
to guide the physician, patient, or therapist as to the optimal course.
Patient rehabilitation following DAA THA involves a carefully designed physical
therapy program based on 4 major criteria. First, tissue healing properties must be taken
into consideration when designing a proper time-based implementation of stretching and

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strengthening exercises. Second, patient-specific tolerance must be considered for the

progression and advancement of difficulty of exercises. Third, to prevent postoperative
complications, pre-surgical factors such as previous joint replacements, femoral fracture,
neurological disorders, or ligamentous laxity should be considered. Fourth, weight-bearing
status will dictate which postoperative exercises must be avoided or delayed.
In this chapter, we describe a preoperative and a 3-phase postoperative rehabilitation
protocol that has been optimized for patient recovery after primary DAA THA. Our goal
is to help standardize the DAA recovery pathway so that these rehabilitation principles
can be used by other surgeons and physical therapy professionals, keeping the previous
4 recovery criteria in mind.
Pain and joint dysfunction lead to the inhibition of periarticular muscles.7 Severe
muscular atrophy can occur, for example, in the gluteus medius and external rotators in
patients with hip osteoarthritis.7 Preoperative strengthening of hip muscles, when possi-
ble, is therefore desirable to improve postoperative THA recovery. We recommend that
patients attend a preoperative joint replacement class in which surgery, expectations, goals,
and milestones can be discussed. In addition, a preoperative outpatient physical therapy
evaluation is advisable to identify patient-specific joint dysfunctions, weaknesses, aberrant
movement patterns, flexibility, and strength deficits.
Pre-surgical patient evaluation will contribute to identifying the optimal rehabilitative
program for each patient. Hip range of motion (ROM) is usually limited with OA pre-
operatively,8 thus stretching can be of benefit, particularly since preoperative hip ROM
has been shown to be a predictor of postoperative hip ROM.9 We recommend isometric
quad sets, isometric hamstring sets, isometric hip adduction, isometric gluteal sets, and
side-lying hip abduction for preoperative strengthening. Stretching exercises for the quad-
riceps, hamstring, piriformis, psoas, and iliotibial band (IT) can also increase preoperative
hip flexibility. Generalized low-impact aerobic exercises, reconditioning, and weight loss
can improve daily function and reduce pain in OA patients.10
We organize postoperative physical therapy for DAA THA into 3 distinct phases
(Table 28-1). All of the postoperative physical therapy exercises are specially designed
to avoid the possibility of anterior hip dislocation in limb extension and external rota-
tion. Certain exercises were omitted from the DAA THA protocol based on the relevant
anatomy to avoid irritation of the iliopsoas muscle/tendon unit. Specifically, SLR and hip
flexion with resistance tubing are avoided as these exercises may aggravate anterior hip
pain and dysfunction. Furthermore, for patients who elect to use a stationary bike, the
authors strongly recommend against strapping or clipping the feet into pedals to avoid
overuse of the iliopsoas.

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Patient Rehabilitation After Direct Anterior Hip Surgery 349
Phase 1 (0 to 6 weeks)
The first exercise phase starts 0 to 6 weeks postoperatively and consists of gentle exer-
cises including isometrics in which joint angles and muscle length are held constant (ie, no
visible movement in the target limb during the exercise). Each of these isometric exercises
can be held for 5 seconds and should be performed for approximately 20 to 30 repetitions
depending on patient tolerance.

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350 Chapter 28
Figure 28-1. Isometric gluteal sets.
Figure 28-2. Isometric quad sets.
Isometric gluteal sets are performed by squeezing the buttocks together while in supine
position to strengthen gluteus maximus as shown in Figure 28-1.
Patients are also instructed to perform isometric quad sets by squeezing the thighs
and pushing the back of the knee down into the mat as shown in Figure 28-2. The feet
are simultaneously dorsiflexed to improve the contraction. This exercise strengthens the
quadriceps
Isometric adductors are performed by squeezing a ball or a pillow in between the thighs
as demonstrated in Figure 28-3.
Isometric hamstring sets can be performed by pressing the heel into the mat while
keeping the knees flexed and attempting to pull the heels toward the buttocks as shown
in Figure 28-4.
Hip abduction exercises play a crucial role in normalizing proper gait pattern and reduc-
ing a Trendelenburg gait or abductor lurch.11,12 These are demonstrated in Figure 28-5.

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Figure 28-3. Isometric adductor.
Figure 28-4. Isometric hamstring set.
Active hip abduction is allowed and encouraged in Phase 1. Abduction is generally

performed starting in a supine position to eliminate the resistance from gravity by sliding
the hip outwards away from the body in about a 30- to 45-degree angle. Hip abduction is
then progressed to a side-lying position against gravity after 2 to 3 weeks.
In the standing position, the hamstring can be strengthened by performing hamstring
curls. This exercise is performed by bending the operative leg at the knee while keeping
the hip straight, as demonstrated in Figure 28-6. The femur should be parallel to the
opposite leg.
The patient can also perform hip abduction to approximately 30 to 45 degrees in a
standing position as shown in Figure 28-7. If the patient is weight bearing as tolerated,
then the patient can stand on the operative leg and abduct the nonsurgical leg. This will
also promote weight bearing on the operative side and strengthening the abductors in a
closed chain approach.

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352 Chapter 28
Figure 28-5. (A) Side-lying hip abduction position to overcome

Trendelenburg gait due to abductor weakness. (B) Trendelburg posi-
tion is shown.
The patient can also perform standing heel raises to increase gastrocnemius strength
as shown in Figure 28-8.
In addition, ankle pumps are also recommended 10 times/hour to aid in deep vein
thrombosis (DVT) prophylaxis as shown in Figure 28-9, particularly in the early postop-
erative period.
Spine stabilization is an important part of the lumbopelvic complex and interregional
dependence. Core muscle stability can provide a solid foundation onto which extremi-
ties can function more effectively. Specifically, we recommend the abdominal drawing-in
maneuver that was developed by Richardson et al which produces a co-contraction of the
transverse abdominus and multifidus.13–16 In this exercise, patients are instructed to “draw
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Figure 28-6. Standing hamstring curl.
up and in the lower part of the abdomen toward spine without the movement of the trunk
or pelvis.”15
Phase 2 (After 6 weeks)

The second phase of physical therapy rehabilitation after DAA THA begins at the
6-week postoperative period. Based on the properties of tissue healing and post-surgical
scar formation, stretching and flexibility exercises can be initiated in this phase. Some
studies have suggested that the dislocation rate is less with DAA THA when compared
to the traditional posterior approach,17 permitting earlier initiation of flexibility exercises.
The stretching exercises are generally performed with 3 repetitions each lasting approxi-
mately 30 to 45 seconds. The patient will perform supine-positioned hamstring stretching
in which the opposite knee can be bent if the patient has a history of low back pain (LBP)
as shown in Figure 28-10.
Quadriceps stretching can be performed in a prone position. A pillow can be placed
under the abdomen for patients suffering LBP. This exercise is depicted in Figure 28-11.
Another option for patients who cannot sustain the prone position is to perform quadri-
ceps stretching in a side-lying position.

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354 Chapter 28
Figure 28-7. Standing hip abduction.
The piriformis stretch can be performed by keeping the nonsurgical leg in a straight
position while crossing the surgical leg over the nonoperative leg and pulling across
(Figure 28-12).
External rotation stretching can be performed by placing the ankle of the surgical leg
just below the knee of the nonsurgical leg as depicted in Figure 28-13. This stretch helps
with improving external rotation ROM that is required in daily activities, such as with
putting on shoes and socks. External rotation stiffness can be common after DAA THA,
so incorporating this flexibility regimen can have lasting benefits for normalizing hip
function in Phase 2.
To help prevent iliopsoas dysfunction postoperatively, a gentle hip flexor stretch is
performed. The beginner position for this stretch is performed by flexing the nonsurgi-
cal hip and straightening out the surgical hip and knee as shown in Figure 28-14A. The
advanced version of the stretch is performed by keeping the nonsurgical hip and knee
flexed and placing the surgical leg carefully off the side of the supporting bed or table
as demonstrated in Figure 28-14B. In the advanced version, the psoas is stretched more
because the surgical leg is located below the horizontal line and is further pulled down by
gravity off the side of the table.
Phase 2 also includes an important component that involves strengthening of the surgi-
cal leg with elastic tubing. To achieve a satisfactory recovery status, rehabilitation of the
affected limb should be performed in all anatomical planes (ie, sagittal, frontal/coronal,

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Figure 28-8. Calf raises.
Figure 28-9. Ankle pumps to prevent DVT.
and transverse planes). Many activities such as biking, elliptical, walking, or running are
primarily performed in the sagittal plane. However, elastic tubing engages the musculature
of the lower body in all 3 planes. Hip extension that is performed in the sagittal plane aims
to strengthen the posterior hip, musculature including gluteus maximus and hamstrings

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356 Chapter 28
Figure 28-10. Supine hamstring stretch.
Figure 28-11. Quadriceps stretching in prone position.
as shown in Figure 28-15A. This extension, however, should be limited to 20 degrees in

order to avoid hip hyperextension that may increase the risk of hip dislocation.
Hip abduction that is performed in the frontal (coronal) plane is prescribed to enhance
lateral muscle strength, including gluteus medius and minimus, and is generally per-
formed within 30 to 45 degrees of abduction (Figure 28-15B). Hip adduction (frontal/
coronal plane) is performed by pulling the surgical leg toward the midline and avoiding
the surgical leg to cross in front of the stance leg. This exercise is performed to strength-
en the adductor medial muscle group including adductor magnus as demonstrated in
Figure 28-15C. A standard walker is used to further support the patient and to provide
additional balance and safety during the performance of hip tubing exercises.
Side-lying hip external rotation that is performed in the transverse plane strengthens
the hip rotator musculature (Figure 28-16). However, the performance of hip flexion with
tubing is discouraged to avoid iliopsoas dysfunction that can lead to significant anterior

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Figure 28-12. Piriformis stretching.
Figure 28-13. External rotation stretching.
hip pain and discomfort, specifically after DAA THA. Most commercial-grade elastic
tubing is manufactured in different color-coded strengths; thus, we usually start with a
light resistance and progress gradually to tubing with higher resistance. Patients start the
exercise with 15 repetitions and after each week the number of repetitions is increased in
increments of 5 repetitions until the patient can perform 30 successful repetitions. Next,
we increase the resistance of the tubing and repeat the aforementioned process starting
with 15 repetitions. These tubing strength exercises are recommended to be performed
every other day.
An important concept in joint rehabilitation is to strengthen the surgical limb in both
an open- and closed-kinetic chain format, since both are used in daily living activities.
During an open-kinetic chain activity, the distal limb is free to move and the task is per-
formed without weight bearing. Conversely, in closed-kinetic chain activities the distal
limb is fixed and the task is performed while weight bearing and involves co-contraction

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358 Chapter 28
Figure 28-14. Hip flexor stretching. (A) The beginner position; (B) the stretch-
ing in the advanced condition.
of muscles. We recommend that these exercises to be performed bilaterally by standing

on the nonsurgical leg for DAA THA open-kinetic strengthening, and by standing on
the surgical leg to perform THA closed-kinetic chain strengthening. Therefore, the elas-
tic tubing allows for the patient to strengthen the limb in both open- and closed-kinetic
chains. However, loading the nonoperated hip may not always be feasible if that limb is
also affected by severe osteoarthritis.
Single leg stance exercises are also performed in the second phase to improve proprio-
ception and balance as shown in Figure 28-17.18 This set of exercises is usually started on
a level surface and can later be progressed to an unstable surface like a foam pad or disc.

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A B
Figure 28-15. (A) Hip tubing strengthening exer-
cise demonstrates hip extension with tubing.
(B) Extension beyond 20 degrees should be avoided.
(C) Hip abduction with tubing.

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360 Chapter 28
Figure 28-16. Side-lying external rotation with tubing.
Figure 28-17. Single leg stance.

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Phase 3 (After 10 weeks)

The third phase of postoperative DAA THA physical therapy starts no earlier than
10 weeks. In this phase, the patient should continue a combination of the flexibility stretch-
ing exercises as well as strengthening exercises from the previous 2 phases. However, the
isometric exercises are substituted with machine-based strengthening. For example, the
patient can perform the leg-press machine as shown in Figure 28-18A instead of isometric
quad set exercises. The patient is instructed to perform the hamstring curl using a weight
machine (Figure 28-18B) instead of isometric hamstring sets. A leg squatting machine
such as the Total Gym machine (Total Gym Fitness LLC; Figure 28-18C) is also recom-
mended to facilitate both the eccentric and concentric phases in a functional manner. The
leg press, hamstring-curl machine, and Total Gym are used in our clinic with a single leg
(operative side) in order to target the weakened muscles in that par ticular limb and prevent
the nonoperative side from engaging and compensating for any weaknesses. Patients also
perform a mini-wall slide exercise to allow functional squat-based strengthening of the
lower extremity as depicted in Figure 28-18D.
We also recommend performing an exercise using a resistance band that is placed
around the legs just above the malleoli while the patient walks sideways to improve hip
abductor strength in the frontal plane (Figure 28-19).
Finally, the patient performs hip hikes as shown in Figure 28-20 by standing on the
operative leg and contracting the ipsilateral musculature, which results in sideways pelvic
tilt and slight elevation of the opposite hip.
Physical therapy rehabilitation following DAA THA plays an important role in the
recovery of patient function. In this chapter, we categorized the postoperative rehabilita-
tion protocol into 3 distinct phases based on postoperative duration, tissue healing, patient
tolerance, surgical considerations, and weight-bearing status. The treatment begins with
isometric exercises and progresses to machine-based activities. The flexibility exercises
can be utilized to improve postoperative hip ROM. The concept of strengthening in
sagittal, frontal, and transverse planes is important to selectively involve different hip and
pelvic musculature. As this rehabilitative program is designed to incorporate muscular
strength, flexibility/ROM, and balance, we recommend that patients should continue the
aforementioned program at least for 1 year postoperatively. Furthermore, patients are also
encouraged to gradually introduce and incorporate general aerobic conditioning into their
exercise routine.
Our rehabilitative protocol utilizes both principles of open- and closed-kinetic chains.
Specific to DAA THA, SLR should be avoided in order to prevent irritation of the ilio-
psoas. Lastly, as some patients elect to use a stationary bike during recovery, we suggest
that the feet not be strapped or clipped into pedals. If a patient develops iliopsoas tendon
dysfunction, we recommend a physical therapy consultation and treatment approach
that consists of iliopsoas stretching, soft tissue mobilization of iliopsoas, and, if needed,
eccentric-only iliopsoas strengthening.

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362 Chapter 28
A B
C
Figure 28-18. Phase 3 exercises.
DAA THA rehabilitation can be divided into 3 phases based on the principles of tis-
sue healing, postoperative time period, and patient ability.
Postoperative physical therapy exercises are designed to avoid combined hip extension
with external rotation (dislocation precaution).
Hip physical therapy exercises should be performed in the sagittal, frontal, and
transverse planes of the body. Hip abductor strengthening is crucial to reducing a
Trendelenburg or abductor lurch gait pattern.

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Figure 28-19. Sideways walking with an elastic band.
Figure 28-20. Hip hikes exercise.

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364 Chapter 28
THA rehabilitation should include both open- and closed-kinetic chain exercises to
retrain the body functionally.
Avoid SLR exercises as they may aggravate the iliopsoas and can result in painful
tendinitis.
The authors would like to thank Dr. Marius Detmer and Ms. Carolyn Zo Mendoza,
PT (Shooting without Limits Photography) for their assistance with producing the images
in this chapter.
1. Taunton MJ, Mason JB, Odum SM, Springer BD. Direct anterior total hip arthroplasty yields more rapid
voluntary cessation of all walking AIDS: a prospective, randomized clinical trial. J Arthroplasty. 2014;29(9
Suppl):169–172. doi:10.1016/j.arth.2014.03.051.
gait parameters following direct anterior & posterior approach total hip arthroplasty. J Arthroplasty.
2014;29(6):1261–1264. doi:10.1016/j.arth.2013.11.021.
3. Dorr LD, Maheshwari AV, Long WT, Wan Z, Sirianni LE. Early pain relief and function after posterior
minimally invasive and conventional total hip arthroplasty. A prospective, randomized, blinded study.
J Bone Joint Surg Am. 2007;89(6):1153–1160. doi:10.2106/JBJS.F.00940.
4. Coulter CL, Scarvell JM, Neeman TM, Smith PN. Physiotherapist-directed rehabilitation exercises in the
outpatient or home setting improve strength, gait speed and cadence after elective total hip replacement: a
systematic review. J Physiother. 2013;59(4):219–226. doi:10.1016/S1836-9553(13)70198-X.
5. Freburger JK. An analysis of the relationship between the utilization of physical therapy ser vices
and outcomes of care for patients after total hip arthroplasty. Phys Ther. 2000;80(5):448–458.
http://ptjournal.apta.org/content/80/5/448.short. Accessed December 13, 2014.
6. Blom AW, Rogers M, Taylor AH, Pattison G, Whitehouse S, Bannister GC. Dislocation following total
hip replacement: the Avon Orthopaedic Centre experience. Ann R Coll Surg Engl. 2008;90(8):658–662.
doi:10.1308/003588408X318156.
7. Rasch A, Byström AH, Dalen N, Berg HE. Reduced muscle radiological density, cross-sectional
area, and strength of major hip and knee muscles in 22 patients with hip osteoarthritis. Acta Orthop.
2007;78(4):505–510. doi:10.1080/17453670710014158.
8. Hurwitz DE, Hulet CH, Andriacchi TP, Rosenberg a G, Galante JO. Gait compensations in patients
with osteoarthritis of the hip and their relationship to pain and passive hip motion. J Orthop Res.
1997;15(4):629–635. doi:10.1002/jor.1100150421.
9. Lavernia C, D’Apuzzo M, Rossi MD, Lee D. Is postoperative function after hip or knee arthroplasty
influenced by preoperative functional levels? J Arthroplasty. 2009;24(7):1033–1043. doi:10.1016/j.
arth.2008.09.010.
10. Felson DT. Weight and osteoarthritis. J Rheumatol. 1995;22:7-9.
11. Krautwurst BK, Wolf SI, Heitzmann DWW, Gantz S, Braatz F, Dreher T. The influence of hip abductor
weakness on frontal plane motion of the trunk and pelvis in patients with cerebral palsy. Res Dev Disabil.
2013;34(4):1198–1203. doi:10.1016/j.ridd.2012.12.018.
12. Kendall KD, Cat C, Patel C, et al. Steps toward the validation of the Trendelenburg test: the effect of
experimentally reduced hip abductor muscle function on frontal plane mechanics. Clin J Sports Med.
2013;23(1):45–51.
13. Park S-D, Yu S-H. The effects of abdominal draw-in maneuver and core exercise on abdominal mus-
cle thickness and Oswestry disability index in subjects with chronic low back pain. J Exerc Rehabil.
2013;9(2):286–291. doi:10.12965/jer.130012.

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14. Teyhen DS, Bluemle LN, Dolbeer JA, et al. Changes in lateral abdominal muscle thickness dur-
ing the abdominal drawing-in maneuver in those with lumbopelvic pain. J Orthop Sports Phys Ther.
2009;39(11):791–798. doi:10.2519/jospt.2009.3128.
15. Richardson C, Jull G, Hodges P, Hides J. Therapeutic Exercise for Spinal Segmentalstabilization in Low Back
Pain. Toronto, ON, Canada: Churchill Livingstone; 1999.
16. Hodges PW. Core stability exercise in chronic low back pain. Orthop Clin North Am. 2003;34(2):245–254.
www.ncbi.nlm.nih.gov/pubmed/12914264. Accessed November 4, 2014.
17. Horne PH, Olson SA. Direct anterior approach for total hip arthroplasty using the fracture table. Curr Rev
Musculoskelet Med. 2011;4(3):139–145. doi:10.1007/s12178-011-9087-6.
18. Rasool J, George K. The impact of single-leg dynamic balance training on dynamic stability. Phys Ther
Sport. 2007;8(4):177–184. doi:10.1016/j.ptsp.2007.06.001.

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Section X
Orthopedic Specialties: Anesthesia

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29
Anesthesia for the
Direct Anterior Approach to
Anjali O. Rozario, MD and Stavros G. Memtsoudis, MD, PhD
Anesthesia for direct anterior approach (DAA) total hip arthroplasty (THA) includes
medical optimization of the patient prior to surgery, then generating an individual-
ized intraoperative plan and postoperative analgesic strategy. This process requires
communication between the anesthesiologist, surgeon, perioperative physicians, and
the patient.
While there are choices for anesthesia in DAA THA, an increasing body of evidence
suggests that the use of neuraxial anesthesia (NXA) may be associated with better
perioperative outcomes.
Postoperative pain management is best achieved with a multimodal approach, includ-
ing epidural or intravenous patient-controlled analgesia (PCA), peripheral nerve
blockade, or periarticular injection.
Choosing an anesthetic plan for DAA THA requires consideration of each patient’s
medical comorbidities, as well as a discussion with the surgeon, patient, and perioperative-
care providers as to the specific goals of care. The ideal approach should involve a multi-
disciplinary strategy aimed at medical optimization of the patient prior to surgery, per-
formance of a safe anesthetic with a view to reducing perioperative complication risks,
and successful treatment of postoperative pain. The ultimate goal of this team-oriented
strategy is to ensure safe surgery, rehabilitation, and recovery. In this chapter, we will dis-
cuss the perioperative anesthetic care of the patient undergoing DAA THA and elaborate
on the available literature on anesthetic techniques and outcomes.

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Surgical anesthesia for DAA THA can be provided both with a general or neuraxial
technique or a combination thereof. Currently, the majority (approximately 75%) of joint
arthroplasties in the United States are being performed under general anesthesia (GA).1
Despite this practice, a growing body of evidence suggests favorable perioperative out-
comes with neuraxial techniques. The following is a brief discussion of both methods.
GA involves the administration of medication rendering the patient unconscious.
Placement of an endotracheal tube or a laryngeal mask airway is required to protect the
patient’s airway and support ventilation. The patient will require opioid and non-opioid
analgesics for pain control, which are initiated while the patient is still under anesthesia.
Advantages of GA include the ability to control ventilation in patients with severe base-
line respiratory impairment or airway obstruction, utilization when neuraxial anesthesia is
contraindicated, and practitioner comfort. Disadvantages include the hemodynamic stress
associated with induction and emergence, cardiovascular depression by anesthetics, airway
manipulation in patients with possible difficult airway, and increased narcotic require-
ments postoperatively when compared to regional anesthesia.2 Complications are rare but
include oropharyngeal damage, aspiration pneumonia, pneumothorax, and hypoxemia
secondary to inability to ventilate and intubate.
NXA includes spinal, epidural, or combined spinal-epidural techniques. Required
equipment includes a standard spinal or combined spinal-epidural tray, topical antiseptic
solution, local anesthetic, and use of surgical cap, mask, and sterile gloves to minimize
risk of infection. The spinal technique involves an injection of local anesthetic into the
intrathecal space, resulting in dense sensory and motor blockade at the level of the nerve
roots. For longer procedures, or for patients who may not tolerate the rapid sympathec-
tomy caused by a spinal injection, catheter-based anesthesia can dose or re-dose the epi-
dural space. Postoperatively, patients with epidural catheters in place are able to receive
local anesthestic infusions or bolus doses for analgesia. The advantages include avoidance
of airway manipulation and maintenance of spontaneous ventilation, which is critical in
patients with underlying pulmonary disease who may be difficult to wean from mechani-
cal ventilation.1,3,4
NXA is associated with decreased intraoperative blood loss and transfusion require-
ments,1,5 lower incidence of deep venous thrombosis,6 lower rates of infection,7,8 lower
catecholamines and physiologic stress,9 and better postoperative pain control with greater
hemodynamic stability. One disadvantage of NXA is potential hemodynamic instability
caused by sympathectomy, particularly with spinal anesthestic. Some patients may not
be candidates for NXA secondary to coagulopathy, prior spinal instrumentation, obesity,
local skin breakdown or infection, and unwillingness by patients to cooperate. A rare but
devastating complication, epidural hematoma, can occur, particularly in the setting of
coagulopathy or anticoagulant use.10
GA is always a back-up option for NXA, when the situation demands. In suit-
able patients, controlled hypotensive anesthesia can also be used. In this technique, an
epidurally-mediated sympathectomy decreases arterial blood pressure, while a simultane-
ous intravenous infusion of adequate fluids and epinephrine maintain heart rate, stroke
volume, central venous pressure, and blood flow to the lower extremity. The overall effect
is a decrease in surgical bleeding with preservation of cardiac output.11

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Anesthesia for the Direct Anterior Approach to Total Hip Arthroplasty 371
A number of pain management approaches have proven effective in patients after THA.
While enteral and parenteral medications, peripheral nerve blocks, and neuraxial tech-
niques are available, a multimodal approach appears to be the most effective strategy for
pain management. Opioid-based and nonsteroidal anti-inflammatory drugs (NSAIDs)
are an important component of postoperative analgesia. Combination medications reduce
overall opioid dosages and are highly effective. Additionally, anticonvulsants and steroids
may be helpful adjuncts. THA patients are generally very good candidates for regional
anesthetic techniques, thus minimizing their need for opioids and their numerous side
effects.
For patients expected to have significant pain after surgery, patient-controlled epidural
analgesia (PCEA) may be used. Patients receive an infusion of dilute local anesthetic with
or without opioids or additives and may receive self-administered bolus doses via an auto-
mated pump. With the use of PCEA, overall opioid requirements are decreased, thereby
minimizing side effects including sedation, respiratory depression, nausea, decreased
bowel motility, and development of dependence. The timing of initiation of postoperative
anticoagulation and removal of the catheter are important considerations. The use of anti-
thrombotics or thrombolytics may be contradicted in regional anesthesia, and guidelines
vary considerably by drug. Close communication among care providers can ensure patient
safety and avoid complications such as epidural hematoma.12
A number of peripheral nerve blockade procedures may be utilized for postoperative
pain control. Typically ultrasound-guided or nerve-stimulator techniques are used to iden-
tify the neural target prior to injection of local anesthetic, thereby increasing efficacy and
decreasing incidence of intravascular injection and subsequent local anesthetic systemic
toxicity. Based on the desired duration of action, specific local anesthetics and adjuvants
may be chosen. In addition to single-shot administration of local anesthetic, placement
of a perineural catheter with patient-controlled regional anesthesia (PCRA) may provide
a longer duration of postoperative pain control. Alternatively, additives and long-acting
formulations can be used to prolong the analgesic duration.
The lumbar plexus block, also referred to as the psoas compartment block, is a tech-
nique that targets the L1 to L4 roots of the lumbar sympathetic plexus that lie within
the fascial sheath of the psoas muscle (Figure 29-1). Arising from the plexus are the
superficial sensory iliohypogastric (L1), ilioinguinal (L1), genitofemoral (L1 and L2), and
lateral femoral cutaneous (L2 and L3) nerves, as well as the combined motor and sensory
femoral (L2 to L4), and oburator nerves (L2 to L4). Blockade of these nerves can be used
for hip and knee procedures as they combine to cover the distribution of the anteromedial
and anterolateral thigh, knee, and medial-lower extremity distal to the knee, as well as
involved osteotomes.13 Given the anatomic depth of the target (approximately 8 cm) and
volumes of local anesthetic required, the procedure is not without serious risks, including
intravascular injection (aorta, inferior vena cava) and cardiovascular and respiratory col-
lapse, epidural or intrathecal injection with resulting sympathectomy or total spinal anes-
thesia, renal or bowel puncture, retroperitoneal hematoma, infection, or nerve injury.14 A
risk-benefit analysis and consideration of the anesthesiologist’s experience level with the
procedure should take place before choosing this technique.

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372 Chapter 29
C
Figure 29-1. Lumbar plexus block. (A) The practitioner first
identifies the iliac crest and L4 spinous process. The posterior
superior iliac spine (PSIS) can help define the appropriate
distance from midline. (B) The block needle is advanced
perpendicular to the patient 3 to 4 cm lateral to the spinous
process at the corresponding level, or two-thirds the distance
between the L4 spinous process and PSIS at the iliac crest.
(C) Correct placement is confirmed by quadriceps muscle
twitch with the nerve stimulator technique.

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Figure 29-2. Ultrasound- guided femoral nerve block. (A) A linear ultrasound
probe is placed in a parallel orientation in the femoral crease, and an
insulated stimulating needle is advanced lateral to the femoral artery (or
approximately 1 cm lateral and inferior to the pulsation of the femoral artery).
(B) The femoral nerve lies lateral to the femoral artery, below the fascia iliaca
and superficial to the iliopsoas muscle. If the nerve-stimulator technique is
used, quadriceps contraction may be observed as the needle approximates
the nerve.
Femoral nerve blockade provides analgesia to the anteromedial thigh and articu-
lar capsule, with the medial aspect of the distal lower extremity and foot also affected
(Figure 29-2). Studies have shown similar analgesia to lumbar plexus block after hip
arthroplasty.15 The concern over motor blockade and possible hindrance of early post-
operative ambulation can be overcome with appropriate physical therapy assistance. The
fascia iliaca block is performed in a more lateral position, at approximately two-thirds the

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374 Chapter 29
A B
Figure 29-3. Fascia iliaca block. (A) Needle insertion

is lateral to the femoral artery at approximately two-
thirds the distance toward the ASIS, or (B) 2 cm infe-
rior and medial to the ASIS (needle insertion point at
circled cross). (C) The nerve lies deep to the fascia lata
and fascia of the iliacus muscle at the junction with
the sartorius muscle.
distance from the pubic tubercle toward the anterior superior iliac spine (ASIS), deep to
the fascia lata and fascia of the iliacus muscle and at the junction with the sartorius muscle
(Figure 29-3). This block also targets the femoral nerve, but additionally covers the cuta-
neous anterolateral thigh via the lateral femoral cutaneous nerve, which may be helpful in
the treatment of incisional pain or after femoral neck fracture. The obturator nerve may
be affected to varying degrees depending on volume and spread of local anesthetic. Several
recent prospective randomized trials have shown varying benefits of this block, from no
difference in pain intensity scores,16 to improved pain control over parenteral opioids dur-
ing lateral positioning for spinal anesthetic, decreased opioid consumption postoperatively,
and improved patient satisfaction.17
A number of strategies may be used by the surgeon intraoperatively to optimize
postoperative pain control, including incisional and/or periarticular infiltration with
local anesthetic, opioids, and NSAIDs. Epicapsular catheters with local anesthetic infu-
sions have been shown to significantly improve postoperative pain. In one prospective

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randomized double-blinded placebo-controlled study of 76 patients having direct lateral

approach THA under spinal anesthesia, patients who were randomized to an epicapsular
infusion of ropivacaine 0.3% vs saline demonstrated less morphine consumption in the
first 48 hours postoperatively (45.4 ± 9.5 vs 69.7 ± 9.6; P <0.0001).18 Patients also had
improved pain scores at rest and in motion on the first postoperative day. Other studies
have shown less convincing results, with another prospective randomized, double-blind,
placebo controlled study showing no difference in pain scores and patient satisfaction after
THA when infiltration of ropivacaine, ketorolac and epinephrine, and infusion of ropiva-
caine 0.2% was added to the standard analgesic regimen.19 Importantly, if the patient has
already received NXA or regional anesthesia, consideration of appropriate dosing must be
given to avoid local anesthetic toxicity manifested by altered mental status, seizures, and
cardiovascular collapse. Communication with the anesthesiologist helps to ensure delivery
of a safe amount of local anesthetic.20
With advances in orthopedic surgical techniques and technology, as well as the increas-
ing societal demands for THA, anesthetic techniques will continue to evolve for this pro-
cedure. No single ideal anesthetic method exists, and customized planning must take into
account the medical comorbidities of the patient in order to reduce the risk of developing
serious perioperative complications such as myocardial ischemia or infarction, pneumo-
nia, respiratory failure, thromboembolism, infection, sepsis, and death.21 A recent data
review of 382,236 patients undergoing primary hip or knee arthroplasty in the United
States between 2006 and 2010 revealed that 11% received NXA alone, 14.2% combined
neuraxial-regional, and 74.8% GA alone.1 A number of large, retrospective cohort studies
and meta-analyses have examined morbidity and mortality benefits in patients undergoing
THA under NXA vs GA.2,3,6,22 Although conflicting data have emerged, recent studies
have demonstrated benefits of specific techniques based on the individual patient.
The most clear advantages of regional anesthesia are the prevention of postoperative
respiratory complications including hypoxia, reintubation and postoperative ventilation,
intensive care admission, and pneumonia.3,4 These complications appear to be more
prevalent in older patients and those with underlying pulmonary disease. In one review
of 795,135 patients undergoing total hip and total knee arthroplasties, 26.1% of the
patients suffered from major pulmonary complications.1 Also at elevated risk are patients
with underlying obstructive sleep apnea (OSA), who have a higher incidence of postop-
erative mechanical ventilation, critical care admission, and prolonged inpatient length of
stay after joint arthroplasty performed under GA.23 Patients with diagnosed or risk for
OSA benefit from overnight observation in a monitored setting with respiratory therapy
involvement. Patients with continuous positive airway pressure masks should be instructed
to bring them the day of surgery.
From a cardiac standpoint, various studies have shown no difference in myocardial
ischemic events or infarction between regional anesthesia and GA.1,5,6 The risk of post-
operative deep venous thrombosis and pulmonary embolism, however, is significantly
lower with the use of NXA, with one large meta-analysis of patients undergoing elective
THA showing an odds ratio of 0.27 (95% CI 0.17 to 0.42) and 0.26 (95% CI 0.12 to
0.56), respectively.6 Several large studies have also demonstrated less surgical blood loss

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376 Chapter 29
and lower perioperative transfusion rates with NXA.1,5 For patients with significant car-
diovascular disease who may not tolerate anemia and hemodynamic shifts associated with
perioperative bleeding, NXA may be advantageous.
Infection rates are significantly lower in patients receiving neuraxial anesthetics, as
compared to GA alone. In one study of patients receiving THA, the odds ratio of infec-
tion with GA vs NXA alone was 1.45 (adjusted 95% CI 1.27 to 1.65). The systemic anti-
inflammatory impact of local anesthetics has been implicated.7 The relative attenuation
of systemic stress response and improved glycemic control have also been described.8,9
The incidence of postoperative falls based on anesthetic technique has been examined
in depth, with new evidence showing less of an association with regional anesthesia than
previously estimated. In one large retrospective cohort study of 190,000 patients under-
going elective total knee arthroplasty, the fall incidence was higher with GA vs NXA
with GA vs NXA alone (1.6% vs 1.5% and 1.3%, P = 0.0018). For patients who received
a peripheral nerve block, fall incidence was not significantly different than the overall
incidence (1.58% vs 1.62%, P = 0.6933).24 Although studies have shown higher inpatient
fall rates with continuous lumbar plexus block infusions as compared to non-continuous
or no blockade, rates are no higher than those universally reported after lower extremity
joint arthroplasty.25 In general, falls in the postoperative orthopedic population are higher
when compared to the postoperative population at large, suggesting that appropriate post-
operative precautions should be instituted for all patients.26
A comparison of anesthetic technique and length of hospital stay has shown only mod-
est differences. One retrospective cohort study showed only a 0.6 day shorter length of stay
with regional anesthesia vs GA for hip fracture (95% CI, -0.8 to -0.4, P<0.001) and no
difference in 30-day mortality rates.22 Another study of 5870 propensity-score matched
surgical patients receiving either regional anesthesia or GA demonstrated a 4.3 hour dif-
ference in median time to discharge (67.6 vs 71.9 hours, respectively).27
Some authors have raised concern that regional anesthesia may increase the risk for
associated complications including but not limited to urinary retention, epidural hemato-
ma formation, and neurapraxias. One literature review describes retention rates from 18%
to 49% with THA.28 Both general and regional anesthetics can contribute to pathology,
including sedative-hypnotics, anticholinergics, vasopressors, opioids, and neuraxial local
anesthetics. Certain factors common in the orthopedic population, including advanced
age and bladder dysfunction or urinary obstruction, can predispose patients to retention.29
Regardless of the technique chosen, strategies to identify and treat symptoms should be
in place. Recent evidence suggests routine placement of bladder catheters for THA under
NXA may not be necessary. One randomized prospective study of 200 patients under-
going THA under spinal anesthesia showed no difference in rates of urinary retention,
or length of stay with indwelling vs intermittent catheterization postoperatively, with a
statistically insignificant lower urinary infection rate in the latter group.30
With respect to epidural hematoma formation or compressive lesions after NXA,
a study of 100,000 orthopedic patients showed the rate of occurrence was small
(0.07/1000; 95% CI, 0.02 to 0.13/1000). All of these patients were taking at least one
drug that potentially impaired coagulation; no persistent nerve damage was identified.10
Similarly, the risk of neurologic complications after both NXA and regional anesthesia
has been shown to be low at <0.04% and 3%, respectively.31 However, if a practitioner
identifies specific risk factors, or if the patient is unwilling to accept this potential risk,
then regional anesthesia is best avoided.

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Lastly, studies comparing anesthetic technique and the development of postoperative

delirium and cognitive dysfunction have not consistently shown a clear benefit of one
technique over another.32–35 However, the avoidance of benzodiazepines and postopera-
tive narcotics, early mobilization, preservation of sleep-wake cycles, and the maintenance
of hemodynamic stability may be important in the prevention of postoperative delirium,
regardless of the type of anesthetic employed.
By using a multimodal analgesic approach that includes procedural techniques and

pharmacologic methods, successful pain control can be achieved after DAA THA to
help promote patient recovery.
Regional anesthesia plays an important role in the treatment of this patient popula-
tion. Based on practitioner comfort and patient eligibility, regional techniques should
be strongly considered for use as increasing evidence suggests improved perioperative
outcomes in selected patients.
A variety of local anesthetic-based techniques exist to potentially augment the deliv-
ery of anesthesia for DAA THA, including PCEA, lumbar plexus block, femoral
nerve block, fascia iliaca block, as well as incisional and/or periarticular infiltration.
1. Memtsoudis SG, Rasul R, Suzuki S, et al. Does the impact of the type of anesthesia on outcomes differ by
patient age and comorbidity burden? Reg Anesth Pain Med. 2013;39(2):112-119.
2. Patorno E, Neuman MD, Schneeweiss S, Mogun H, Batemen BT. Comparative safety of anesthetic type
for hip fracture surgery in adults: retrospective cohort study. BMJ. 2014;348:g4022.
3. Guay J, Choi PT, Suresh S, Albert N, Kopp S, Pace NL. Neuraxial anesthesia for the prevention of
postoperative mortality and major morbidity: an overview of Cochrane systematic reviews. Anesth Analg.
2014;119(3):716-725.
4. Popping DM, Elia E, Marret E, Remy C, Tramer MR. Protective effects of epidural analgesia on pulmonary
complications after abdominal and thoracic surgery: a meta-analysis. Arch Surg. 2008;143(10):990-999.
5. Guay J. The effect of neuraxial blocks on surgical blood loss and blood transfusion requirements: a meta-
analysis. J Clin Anesth. 2006;18(2):124-128.
6. Mauermann WJ, Shilling AM, Zuo Z. A comparison of neuraxial block versus general anesthesia for elec-
tive total hip replacement: a meta-analysis. Anesth Analg. 2006;103(4):1018-1025.
7. Hollmann MW, Durieux ME. Local anesthetics and the inflammatory response: a new therapeutic indica-
tion? Anesthesiology. 2000;93(3):858-875.
8. Marchant MH Jr, Viens NA, Cook C, Vail TP, Bolognesi MP. The impact of glycemic control and diabetes
mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg Am. 2009;91(7):1621-1629.
9. Gottschalk A, Rink B, Smektala R, Piontek A, Ellger B, Gottschalk A. Spinal anesthesia protects against
perioperative hyperglycemia in patients undergoing hip arthroplasty. J Clin Anesth. 2014;26(6):455-460.
10. Pumberger M, Memtsoudis SG, Stundner O, et al. An analysis of the safety of epidural and spinal neuraxial
anesthesia in more than 100,000 consecutive major lower extremity joint replacements. Reg Anesth Pain
Med. 2013;38(6):515-519.
11. Sharrock NE and Salvati EA. Hypotensive epidural anesthesia for total hip arthroplasty: a review. Acta
Orthop Scand. 1996;67(1):97-107.
12. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic
or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based
Guidelines (Third Edition). Reg Anesth Pain Med. 2010;35(1):64-101.

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13. Amiri HR, Zamani MM, Safari S. Lumbar plexus block for management of hip surgeries. Anesth Pain Med.
2014;4(3):e19407.
14. Pousman RM, Mansoor Z, Sciard D. Total spinal anesthetic after continuous posterior lumbar plexus
block. Anesthesiology. 2003;98(5):1281-1282.
15. Ilfield BM, Mariano ER, Madison SJ, et al. Continuous femoral versus posterior lumbar plexus nerve blocks
for analgesia after hip arthroplasty: a randomized, controlled study. Anesth Analg. 2011;113(4):897-903.
16. Shariat AN, Hadzic A, Xu D, et al. Fascia iliaca block for analgesia after hip arthroplasty: a randomized
double-blind, placebo-controlled trial. Reg Anesth Pain Med. 2013;38(3):201-205.
17. Diakomi M, Papaioannou M, Mela A, Kouskouni E, Makris A. Preoperative fascia iliaca compartment
block for positioning patients with hip fractures for central ner vous blockade: a randomized trial. Reg Anesth
Pain Med. 2014;39(5):394-398.
18. Aguirre J, Baulig B, Dora C, et al. Continuous epicapsular ropivacaine 0.3% infusion after minimally inva-
sive hip arthroplasty: a prospective, randomized, double-blinded, placebo-controlled study comparing con-
tinuous wound infusion with morphine patient-controlled analgesia. Anesth Analg. 2012;114(2):456-461.
19. Solovyova O, Lewis CG, Abrams JH, et al. Local infiltration analgesia followed by continuous infusion
of local anesthetic solution for total hip arthroplasty: a prospective, randomized, double-blind, placebo-
controlled study. J Bone Joint Surg Am. 2013;95(21):1935-1941.
20. Weinberg GL. Treatment of local anesthetic systemic toxicity (LAST). Reg Anesth Pain Med.
2010;35(2):188-193.
21. Mantilla CB, Horlocker TT, Schroeder DR, Berry DJ, Brown DL. Frequency of myocardial infarction,
pulmonary embolism, deep venous thrombosis, and death following primary hip or knee arthroplasty.
Anesthesiology. 2002;96(5):1140-1146.
22. Neuman MD, Rosenbaum PR, Ludwig JM, Zubizarreta JR, Silber JH. Anesthesia technique, mortality,
and length of stay after hip fracture surgery. JAMA. 2014;311(24):2508-2517.
23. Memtsoudis SG, Stundner O, Rasul R et al. Sleep apnea and total joint arthroplasty under various types of
anesthesia: a population-based study of perioperative outcomes. Reg Anesth Pain Med. 2013;38(4):274-281.
24. Memtsoudis SG, Danninger T, Rasul R, et al. Inpatient falls after total knee arthroplasty: the role of anes-
thesia type and peripheral nerve blocks. Anesthesiology. 2014;120(3):551-563.
25. Johnson RL, Kopp SL, Hebl JR, Erwin PJ, Mantilla CB. Falls and major orthopaedic surgery with periph-
eral nerve blockade: a systematic review and meta-analysis. Br J Anaesth. 2013;110(4):518-528.
26. Ilfied BM, Duke KB, Donohue MC. The association between lower extremity continuous peripheral nerve
blocks and patient falls after knee and hip arthroplasty. Anesth Analg. 2010;111(6):1552-1554.
27. Bulka CM, Shotwell MS, Gupta RK, Sandberg WS, Ehrenfeld JM. Regional anesthesia, time to hos-
pital discharge, and in-hospital mortality: a propensity score matched analysis. Reg Anesth Pain Med.
2014;39(5):381-386.
28. Darrah DM, Griebling TL, Silverstein JH. Postoperative urinary retention. Anesthesiol Clin.
2009;27(3):465-484.
29. Waterhouse N, Beaumont AR, Murray K, Staniforth P, Stone MH. Urinary retention after total hip
replacement: a prospective study. J Bone Joint Surg Br. 1987;69(1):64-66.
30. Miller AG, McKenzie J, Greenky M, et al. Spinal anesthesia: should everyone receive a urinary catheter?
A randomized, prospective study of patients undergoing total hip arthroplasty. J Bone Joint Surg Am.
2013; 95(16):1498-1503.
31. Brull R, McCartney CJL, Chan VWS, El-Beheiry H. Neurologic complications after regional anesthesia:
contemporary estimates of risk. Anesth Analg. 2007;104(4): 965-974.
32. Slor CJ, de Jonghe JF, Vreeswijk R, et al. Anesthesia and postoperative delirium in older adults undergoing
hip surgery. J Am Geriatr Soc. 2011; 59(7):1313-1319.
33. Vasilevskis EE, Han JH, Hughes CG, Ely EW. Epidemiology and risk factors for delirium across hospital
settings. Best Pract Res Clin Anaesthesiol. 2012;26(3):277-287.

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34. Wu CL, Hsu W, Richman JM, Raja SN. Postoperative cognitive function as an outcome of regional anes-
thesia and analgesia. Reg Anesth Pain Med. 2004; 29(3):257-268.
35. Zywiel MG, Prabhu A, Perruccio AV, Gandhi R. The influence of anesthesia and pain management on
cognitive dysfunction after joint arthroplasty. Clin Orthop Relat Res. 2014; 472(5):1453-1466.


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Section XI
Outcomes

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30
Multi-Center Outcomes
Harman Chaudhry, MD and Mohit Bhandari, MD, PhD, FRCSC
To understand the importance of multi-center research and the logistical challenges

of conducting multi-center research.
Define and understand the importance of patient-important outcomes in multi-center
research.
Identify common disease-specific and generic outcome instruments that can be used
in hip research.
In the era of evidence-based medicine,1 and with an ongoing focus on comparative

effectiveness research to inform decision and policy making, 2 the importance of multi-
center research cannot be overstated. To date, there has been very little such research
conducted on the direct anterior approach total hip arthroplasty (DAA THA), with many
studies focusing on the results of a single surgeon at a single center.3,4 In this type of study
design, a single (or several) expert surgeon may be able to achieve results that few others
can. Although useful information per se, it provides very little information pertaining to
the effectiveness of DAA if utilized more broadly by all orthopedic surgeons performing
a certain hip reconstruction procedure.
One of the largest multi-center endeavors examining DAA THA is a study comprising
9 clinical sites in the United States.5 However, this was a retrospective study, which means
that despite its broader generalizability, the results were prone to biases associated with


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384 Chapter 30
retrospective study designs. These biases include a reliance on administrative databases

for outcomes data and an inability to control for all possible confounding variables (eg,
surgeon experience, disease severity, clinical indication, patient motivation). The future of
DAA clinical research must involve prospective randomized controlled trials of multiple
clinical sites throughout the United States or, more ideally, throughout the world. This
would provide the most unbiased representation of outcomes following hip reconstruction
procedures performed with DAA.
There are many challenges to conducting a multi-center trial.6 Perhaps one of the
most difficult challenges is establishing a network of surgeon collaborators with a similar
interest and motivation to execute a surgical trial that may last several years and require
recruitment of hundreds, if not thousands, of patients. This becomes particularly difficult
when the procedure is performed by only a limited number of surgeons, as may be the
case for DAA THA. One strategy to overcome this is to not limit the trial to geographic
borders and consider expanding the network of collaborators to across the United States,
outside the United States, or even outside North America.
Finite availability of research funding is another challenge. Multi-center efforts are
ambitious undertakings, requiring funds for human resources, site visits, and technol-
ogy, among other costs.6 Government funding seems to be decreasing perennially, while
competition for these limited funds continues to increase.7 Industry provides an important
source for additional funding, especially in cases of innovative approaches requiring novel
instrumentation such as DAA; however, industry funding is also becoming more difficult
to obtain.8 Having multiple collaborators who have been successful in obtaining grants
can help overcome this hurdle.
With limited funding comes the challenge of choosing only those outcome measures
with the highest yield; these include outcomes that are relatively cheap to administer/
collect, responsive to change (ie, able to detect real differences between groups), easy
to administer/collect, facilitate future collation of data (ie, via meta-analyses), and are
patient-important (ie, have relevance to the patient).
Given finite resources, multi-center trials must be designed to and devote most of their
energy to collecting patient-important outcomes. Patient-important outcomes have been
defined as those outcomes that most directly affect patients.9 Of course, the distinction
between what is patient-important and what is not is purely theoretical. In reality, the
outcomes that are important to surgeons are usually important to patients as well (either
directly or indirectly). Similarly, outcomes that are important to patients are almost always
important to surgeons. However, for simplicity, we can divide outcomes into those that
are more surgeon-important and those that are more patient-important, with an implicit
understanding that almost all outcomes exist on a spectrum between both.
Outcome measurements that do not affect patients directly but rather through a path-
way of events (ie, surrogate outcomes) are typically not considered patient-important.10

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Multi-Center Outcomes 385
The typical example of this is a radiographic parameter such as version of the acetabular
cup following THA. If there is a difference in cup retroversion between DAA THA vs
THA through other approaches, this certainly needs to be studied, as it may increase the
incidence of prosthetic dislocation. However, we would argue that large, multi-center
trials must focus on outcomes more directly impacting patients, with only a secondary
focus on such surrogate outcomes. Measuring dislocation rates directly would be an out-
come in this situation that more directly impacts patients. Further, if there are drastic
differences between procedures in terms of radiographic cup version, this issue should
have been identified and addressed in the preliminary investigations prior to the multi-
center trial.
Surgical complications are typically very closely observed by surgeons and are defi-
nitely patient-important, as these directly impact the patient experience with a surgical
procedure. These include deep infections, prosthetic dislocations, intra- and postopera-
tive fractures, and lateral femoral cutaneous nerve palsy. It is imperative that multi-center
trials collect this information, since it relates to the safety of a procedure. However, in
many areas of orthopedic surgery, it is unlikely that a very low rate of complications will
sway decision-making or policy one way or another, unless the existing procedure shows
a very high rate of complications. For instance, THA is already a very safe procedure, and
demonstrating low rates of complications with DAA is unlikely to result in groundbreak-
ing changes in decision-making algorithms or policy.
Measures of function are perhaps the best form of patient-important outcome in ortho-
pedic surgery. This is because almost all patients undergoing an orthopedic procedure are
primarily doing so in order to preserve or restore function. Differences in function directly
impact patients and, furthermore, differences in function between 2 procedures can be
used to advocate very strongly for policy-level changes. However, function that impacts
quality of life is difficult to measure, especially in the setting of many hundreds of patients
in multi-center trials. Surrogate measures such as length of rehabilitation, hip range
of motion, and gait parameters are very crude measures of patient-important function.
We generally advocate for the incorporation of a well-validated disease-specific patient-
reported outcome measure (PROM) as well as a generic PROM. On a broader level, this
not only enables comparisons between different types of hip reconstruction procedures
(via the hip disease-specific PROMs), but also facilitates comparisons among procedures
from various other areas of surgery and medicine (via the generic PROM).11,12
In addition to a consideration of instrument-specific properties, such as reliability and

validity, the choice of a disease-specific PROM is influenced by several factors including
the patient population being evaluated, study resources, how many other questionnaires
are being administered, and familiarity in the field of study. For example, the International
Hip Outcome Tool (iHOT-33) is a 33-item questionnaire that has been shown to be more
responsive to change than many commonly used PROMs; however, many of its ques-
tions are aimed at young athletic patients (eg, cutting/pivoting during athletic activity).13
Therefore, despite the favorable properties of this PROM, it is likely not ideal for study in
a THA population. The Copenhagen Hip and Groin Outcome Score (HAGOS) and the
Hip Dysfunction and Osteoarthritis Outcome Score (HOOS) are other PROMs that are

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likely more ideal for younger or middle-aged patient samples.14,15 Use in elderly popula-
tions would potentially result in low informational yield for the increased question burden.
The Western Ontario and McMaster Osteoarthritis index (WOMAC), Harris Hip
Score (HHS), and Oxford Hip Score (OHS) are PROMs classically used in older popula-
tions with osteoarthritis of the hip. The WOMAC is a 24-item questionnaire measuring
domains of pain, stiffness, and function.16 The HHS is an 8-item questionnaire scored
from 0 to 100.17 The OHS is a 12-item questionnaire measuring function related to the
hip.18 Each item is given a score from 0 to 4, which provides a final summative score out
of 48.
The WOMAC, HHS, and OHS are all well-validated, have adequate responsiveness,
and are of reasonable length for use in large multi-center studies.16–18 However, the HHS
in particular has been shown to have a ceiling effect, which means it is less able to dif-
ferentiate between patient function at the higher levels of function.19 The WOMAC and
OHS likely have some degree of ceiling effect as well.20 A careful consideration of the
content, as well as pros and cons of each instrument, is necessary prior to selecting one for
a multi-center study.
The purpose of using generic PROMs in DAA research is to enable an understand-

ing of the effect of the hip pathology or surgery on a patient’s global quality of life.11
Furthermore, this enables comparison of hip pathology and DAA procedures with other
conditions and procedures—as disparate as a carpal tunnel release or the pharmacologic
treatment of migraines—to help policy-makers understand the comparative impact of
different conditions and procedures on a patient’s quality of life.12 Therefore, we favor
the use of generic PROMs in multi-center research. The Short Form-36 (SF-36) is a
well-validated 36-item generic quality-of-life instrument, measuring 8 domains of quality
of life, each of which is scored on a scale of 0 to 100.21 Another commonly used generic
PROM is the Euro-QoL-5D (EQ-5D), which measures 5 domains of quality of life.22
Multi-center clinical trials are the gold standard of comparative-effectiveness research.

However, given limited resources and complex logistics, surgeons and researchers must
focus on collecting only the highest yield information to inform evidence-based decision
and policy making. Patient-important outcomes are central to this endeavor and include
traditional outcomes such as reoperations, infections, and other complications, as well
as detailed measurements of function using both disease-specific and generic outcome
instruments. In this era of evidence-based medicine and comparative-effectiveness
research, measurement and dissemination of these outcomes will form a central compo-
nent to demonstrating superiority and advancing technology in the field of DAA to hip
reconstruction.

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Multi-Center Outcomes 387
The future of DAA THA clinical research must involve prospective, randomized
controlled trials of multiple clinical sites throughout the United States or, more ide-
ally, throughout the world.
There are multiple challenges to conducting multi-center research, including develop-
ing a collaborative network and finite levels of funding from both government and
industry sources.
Patient-important outcomes are those that directly impact patients.
PROMs of function are high-yield outcome instruments that can be used to quantify
a patient’s level of function.
Incorporation of both disease-specific (eg, iHOT-33, OHS, WOMAC) and generic
(eg, SF-36, EQ-5D) PROMs should be considered in any multi-center study design
for DAA in hip reconstruction.
1. Sackett DL. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312:71.
2. Platt R, Kass NE, McGraw D. Ethics, regulation, and comparative effectiveness research: time for change.
JAMA. 2014;311:1497-1498.
approach for total hip arthroplasty. J Arthroplasty. 2013;28:1634-1638.
rapid voluntary cessation of all walking aids: a prospective, randomized clinical trial. J Arthroplasty.
2014;29:169-172.
5. Anterior Total Hip Arthroplasty Collaborative Investigators; Bhandari M, Matta JM, Dodgin D, et al.
Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observa-
tional study. Orthop Clin N Am. 2009;40:329-342.
6. Mundi R, Chaudhry H, Mundi S, Godin K, Bhandari M. Design and execution of clinical trials in ortho-
paedic surgery. Bone Joint Res. 2014;3:161-168.
7. Mann M, Tendulkar A, Birger N, Howard C, Ratcliffe MB. National Institutes of Health funding for
surgical research. Ann Surg. 2008;247:217-222.
8. Moses H III, Matheson DHM, Cairns-Smith S, George BP, Palisch C, Dorsey ER. The anatomy of medical
research: US and international comparisons. JAMA. 2015;313:174-189.
9. Guyatt G, Montori V, Devereaux PJ, Schunemann H, Bhandari M. Patients at the centre: in our practice,
and in our use of language. Evid Based Med. 2004;9:6-7.
10. Hoang-Kim A, Miclau T, Goldhahn J, Nijman TH, Poolman RW. Patient-important outcome for the
assessment of fracture repair. Injury. 2014;45:S44-S48.
11. Poolman RW, Swiontkowski MF, Fairbank JCT, Schemitsch EH, Sprague S, de Vet HCW. Outcome
instruments: rationale for their use. J Bone Joint Surg Am. 2009;91(Suppl 3):41-49.
12. Dijksman LM, Poolman RW, Bhandari M, Goeree R, Tarride JE, International Evidence-Based
Orthopaedic Surgery Working Group. Money matters: what to look for in an economic analysis. Acta
Orthop. 2008;79:1-11.
13. Mohtadi NGH, Griffin DR, Pederson ME, et al. The development and validation of a self-administered
quality-of-life outcome mea sure for young, active patients with symptomatic hip disease: the International
Hip Outcome Tool (iHOT-33). Arthroscopy. 2012;28:595-610.
14. Thorburg K, Roos EM, Christensen R, Petersen J, Holmich P. The iHOT-33: how valid is it? Arthroscopy.
2012;28:1194-1195.

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15. Thorburg K, Holmich P, Christensen R, Petersen J, Roos EM. The Copenhagen Hip and Groin Outcome
Score (HAGOS): development and validation according to the COSMIN checklist. Br J Sports Med.
2011;45:478-491.
16. Wright JG, Young NL. A comparison of dif ferent indices of responsiveness. J Clin Epidemiol.
1997;50:239-246.
17. Hoeksma HL, Van den Ende CHM, Ronday HK, Heering A, Breedveld FC, Dekker J. Comparison of the
responsiveness of the Harris Hip Score with generic mea sures for hip function in osteoarthritis of the hip.
Ann Rheum Dis. 2003;62:935-938.
18. Fitzpatrick R, Morris R, Hajat S, et al. The value of short and simple mea sures to assess outcomes for
patients of total hip replacement surgery. Quality in Health Care. 2000;9:146-150.
19. Wamper KE, Sierevelt N, Poolman RW, Bhandari M, Haverkamp D. The Harris Hip Score: do ceiling
effects limit its usefulness in orthopedics? Acta Orthop. 2010;81:703-707.
20. Marx RG, Jones EC, Atwan NC, Closkey RF, Salvati EA, Sculco TP. Mea suring improvement follow-
ing total hip and knee arthroplasty using patient-based mea sures of outcome. J Bone Joint Surg Am.
2005;87:1999-2005.
21. SF-36.org. US Population Norms. SF-36. www.sf-36.org /research /sf98norms.pdf. Published 1998.
Accessed January 7, 2016.
22. Picavet HS, Hoeymans N. Health related quality of life in multiple musculoskeletal diseases: SF-36 and
EQ-5D in the DMC3 study. Ann Rheum Dis. 2004;63:723-729.

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31
Current Direct Anterior
Approach Outcomes
Literature Review
Tim P. Lovell, MD
Direct anterior approach (DAA) is the only intermuscular and interner vous approach
to the hip and appears to cause less soft tissue damage than other approaches for total
hip arthroplasty (THA).
DAA THA patients appear to recover faster and easier and have better early outcomes
compared to other approaches.
There is a learning curve for surgeons new to DAA THA and additional training is
strongly encouraged before beginning this technique.
A basic principle in orthopedic surgery is that operations performed via intermuscular

and interner vous planes tend to minimize soft tissue damage. While excellent results for
THA with all of the surgical approaches to the hip joint have been reported in the lit-
erature, the DAA is the only one that utilizes both an intermuscular and interner vous
interval. Some have proposed a skin incision less than 10 cm is a reasonable definition
of a minimally invasive THA.1 This seems rather arbitrary since length of skin incision
mainly relates to cosmetic value. A more reasonable definition of minimally invasive
THA may be one that invokes interner vous and intermuscular planes during surgery.2
The DAA to the hip is the only approach to the hip that meets this criterion. Multiple
authors have proposed that DAA THA offers less soft tissue damage, lower dislocation
risk, better acetabular component alignment, and a faster and easier recovery with better
early outcomes. Here, we will review the literature regarding these claims to help establish
an evidence-based analysis for informed decision making regarding use of the DAA.

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390 Chapter 31
When compared to the popular posterolateral approach (PL), Meneghini and Pagnano
reported more abductor damage with the PL approach than with DAA in a cadaveric
model.3 These authors found a mean of 18% of the gluteus minimus muscle and 23% of
the minimus tendon were damaged in PL approach specimens compared to 8% of the
muscle and 5% of the tendon in the DAA specimens.
One measure of muscle damage may be serum creatinine kinase (CK) levels. Using that
marker, one study reported that DAA led to significantly less muscle damage than the PL
approach, with a 5.5 times increase in CK levels with the PL approach compared to the
DAA in the post-anesthesia care unit, and nearly twice as high cumulatively.4 Another
investigation reported that symptoms of urinary incontinence in female patients were sig-
nificantly improved in patients who underwent DAA THA, when compared to the PL
approach, possibly because of the release of the short external rotators in the PL group.5
Comparing DAA to the anterolateral (AL) approach, Bremer et al found MRI evi-
dence of abductor damage in patients who underwent THA with the AL method.6 MRI
scans of patients who underwent the AL approach showed findings such as detachment
of the abductor insertion, partial tears and tendonitis of the gluteus medius and minimus,
the presence of peri-trochanteric bursal fluid, and fatty atrophy of gluteus medius and
minimus; these findings were significantly less pronounced and less frequent when the
DAA was used.
Next, let us examine the risk of hip dislocation with the DAA method when compared
to other approaches. Sariali et al summarized the reported dislocation rates with the
traditional posterior, anterolateral, and transtrochanteric THA approaches as 4%, 2%,
and 1.6%, respectively.7 In contrast, Horne and Olson reported a 1% dislocation rate for
DAA THA using a fracture table.8 Keggi et al have reported a 1.3% incidence of hip dis-
location in 2132 DAA THA cases9 and Matta et al reported a 0.61% dislocation rate in
494 consecutive DAA THA cases.10 A meta-analysis of 11,810 DAA THA cases found
postoperative hip dislocations occurred in 1.2% of the cases.11 These papers thus demon-
strate an average DAA dislocation rate of 1.03%, a figure that is about 50% lower than
the AL approach and about 75% lower than the posterior approach cited by Sariali et al.
Multiple studies have looked at comparing acetabular component alignment in DAA vs

the PL approach. The majority of studies have found improved and more consistent ace-
tabular component alignment with DAA THA.12–18 There have been some studies, how-
ever, that have not shown a difference.19–21 This is an area requiring further investigation.
In terms of recovery parameters after DAA THA, when compared to the PL approach,
multiple studies have shown less pain,15,22-24 faster early functional recovery,9,14,15,21,22
faster early gait ability,14 shorter hospitalization,15,16,23,24 less narcotic usage,16,23 more
discharges to home,16,23 faster discontinuation of walking assistive devices, 23–25 and
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Current Direct Anterior Approach Outcomes Literature Review 391
higher Harris Hip Scores in the early postoperative period.15,20,24,25 Nearly all of these
studies also report little, if any, discernible differentiation between DAA and PL patients
by 6 months from surgery. At 6 months postoperatively, however, PL approach patients
have been reported to have higher stiffness scores than DAA patients using the Western
Ontario and McMaster Osteoarthritis Index (WOMAC) questionnaire.26 Contradictory
data have not shown a difference in pain, 20 faster early functional recovery,20,27 faster early
gait ability,28 shorter hospitalization, 20 less narcotic usage, 20 more discharges to home, 20
or faster discontinuation of walking assistive devices.20 A meta-analysis of DAA vs PL
approach concluded that given the poor methodological quality of the studies analyzed,
the superiority of DAA THA over other approaches cannot be established with certainty,
such that patient characteristics, surgeon experience, and surgeon and patient preference
should drive the choice of approach, at least until further data are forthcoming.29
In terms of postoperative recovery, DAA THA may be advantageous compared to,
for example, the AL approach. Studies comparing these 2 approaches to THA have
shown that DAA is associated with comparatively less pain, 30,31 faster early return of
hip function,31–33 faster early gait ability,34 shorter hospitalization,30 more discharges to
home,30,33 higher Harris Hip Scores both in the early 33 and late postoperative period,31,32
better range of motion,34 and less blood loss.35
While the majority of studies have described favorable variables associated with DAA
THA, when compared to other approaches, other studies have pointed out the signifi-
cant learning curve for surgeons who are new to the procedure. Two studies specifically
looking at the learning curve have suggested that 50 to 60 cases are necessary to progress
through the learning curve, with possibly fewer cases needed for the higher volume sur-
geon.36,37 These studies were done at a time when meaningful and standardized training
for DAA THA was not yet available. One study found no improvement in the learning
curve after 46 cases, in a clinical setting where only one DAA THA case per week was
being performed.27 These findings may suggest that a relatively slow pace of only one
DAA THA case per week may be insufficient to overcome the learning curve. Another
investigation concluded that morbidly obese or very muscular patients and hips with short
femoral necks or acetabular protrusion can represent challenges that are best avoided dur-
ing the learning curve.38
Complications with DAA have been shown to be higher during the learning curve
for DAA in some studies.27,37-40 Other studies have stated that the complications dur-
ing DAA THA compare favorably to other approaches.36,38,41 Some studies have shown
higher blood loss with DAA, 27 while others have shown less blood loss.35 In terms of
nerve injury, a meta-analysis of 11,810 DAA THA cases from the literature showed a
2.1% incidence of lateral femoral cutaneous nerve palsy, a 0.093% incidence of femoral
nerve palsy, and a 0.068% incidence of peroneal nerve palsy.11 Another study reported

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lateral femoral cutaneous nerve paresthesia occurring in 25% of patients during the learn-
ing curve; this figure dropped to 5% later in the series.42
The meta-analysis citing 11,810 DAA THA cases also found that the reported inci-
dence of intraoperative fractures was 2.3%.11 Other studies have reported metaphyseal
fractures rates of 1% 43 and 1.3%.40 Greater trochanteric fractures have been reported at
rates of 1.7% 43 and 1%.40 In one study, 7 of 8 greater trochanteric fractures healed without
fixation, and metaphyseal fractures healed if they were stabilized by cerclage fixation.43
One study found the risk of delayed periprosthetic femur fractures was 1.7%; authors
cautioned that the early learning curve may be associated with a risk of unrecognized
intraoperative femur fractures during DAA THA.40
In the meta-analysis that captured 11,810 DAA THA cases reported in the literature,
premature revision surgery that occurred within 12 months of the index arthroplasty
manifested at the rate of 1.2% because of component loosening, subsidence, instability,
or leg length discrepancy.11 Another study reported that the complications that occurred
during learning DAA THA were more serious and resulted in more revision surgery than
a control group that underwent THA with the PL approach.37 One study identified a
higher risk of stem under-sizing leading to revision surgery, when the stem design was
changed at the same time the surgeon learned DAA THA, and cautioned against this
combination.44
An elegant summary capturing the high-level view of DAA THA stated the
following:
Minimally invasive total hip arthroplasty based on the Smith-Petersen surgi-
cal interval provides the optimal combination of sufficient exposure, simplicity,
safety, consistency, and preservation of muscle and tendons when compared with
other methods of primary THA. Dissection is entirely within intermuscular
planes, without disruption of tendinous insertions. Trial reduction and consistent
component positioning are possible. Intraoperative fluoroscopy is an option for
the surgeon. The supine patient position is more physiologic for the patient and
anesthesiologist. With proper surgeon training, consistent and safe outcomes are
possible.45
The DAA is the only approach for THA that is truly intermuscular and interner vous.
It appears to cause less soft tissue damage than other approaches for THA.
While a definitive, large randomized study has not been done, the majority of the
data available indicates that once a surgeon is past the learning curve, DAA THA
patients have a lower dislocation risk, better acetabular component alignment, a faster
and easier recovery, and better early outcomes compared to other approaches.
Surgeons should be reminded and remain clinically aware of the learning curve
associated with adoption of the DAA technique and are strongly encouraged to get
additional training and also have satisfactory case volume before using this approach.

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1. Higuchi F, Gotoh M, Yamaguchi N, et al. Minimally invasive uncemented total hip arthroplasty through
an anterolateral approach with a shorter skin incision. J Orthop Sci. 2003;8(6):812-817.
table. J Arthroplasty. 2008;23(7):64-68.
plasty: Smith-Petersen versus posterior approach. Clin Orthop Relat Res. 2006;453:293–298
4. Bergin PF, Doppelt JD, Kephart CJ, et al. Comparison of minimally invasive direct anterior versus posterior
total hip arthroplasty. J Bone Joint Surg Am. 2011;93:1392-1398
5. Baba T, Homma Y, Takazawa N, et al. Is urinary incontinence the hidden secret complications after total
hip arthroplasty? Eur J Orthop Surg Traumatol. 2014;24(8):1455-1460.
6. Bremer AK, Kalberer F, Pfirrmann CWA, Dora C. Soft-tissue changes in hip abductor muscles and tendons
after total hip replacement. Comparison between the direct anterior and the transgluteal approaches. J Bone
Joint Surg [Br]. 2011;93-B:886-889.
J Arthroplasty. 2008;23(2):266–272.
8. Home PH, Olson SA. Direct anterior approach for total hip arthroplasty using the fracture table. Curr Rev
Musculoskelet Med. 2011;4:139–145
9. Kennon R, Keggi J, Wetmore R, Zatorski L, Huo M, Keggi K. Total hip arthroplasty through a minimally
invasive anterior surgical approach. J Bone Joint Surg Am. 2003;85(suppl 4):39-48.
11. Lee G, Marconi D. Primary Hip View ePoster. Paper presented at: American Association of Hip and Knee
Surgeons; November 7, 2014. Dallas, TX.
12. Masonis JL, Ruffolo M, Bates MD, Odum SM, Nogler MM, Fehring TK. Effect of Surgical Approach
Imaging on Acetabular Alignment in Hip Arthroplasty. Poster presented at: American Academy of
Orthopaedic Surgeons; 2014. New Orleans, LA.
13. Deshmukh A, Rodriguez J, Rathod P, Gretz M, Ranawat A. Is there faster recovery after direct anterior
than posterior approach total hip arthroplasty? Paper presented at: American Academy of Orthopaedic
Surgeons; 2013. Chicago, IL
anterior with mini-posterior approach. Two consecutive series. J Arthroplasty. 2009;24(5):698-704.
16. Schweppe ML, Seyler TM, Plate JF, Swenson RD, Lang JE. Does surgical approach in total hip arthro-
plasty affect rehabilitation, discharge, disposition, and readmission rate? Surg Technol Int. 2013;23:219-227.
17. Huddleston J, Leucht P, Greene M, et al. Does surgical approach in total hip arthroplasty influence socket
position and limb length discrepancy? A comparison of the anterior, lateral, and posterior approaches. Paper
presented at: American Academy of Hip and Knee Surgeons Annual Meeting; 2014. Dallas, TX.
18. Patel P, Suarez J, Szubski C, Slotkin E. Accuracy of fluoroscopic guided acetabular component positioning
during direct anterior total hip arthroplasty. Paper presented at: American Association of Hip and Knee
Surgeons Annual Meeting; 2014. Dallas, TX.
19. Nam D, Sculco P, Su E, Alexiades M, Figgie M, Mayman D. Does the direct anterior approach improve
acetabular component positioning and leg length restoration in THA? Poster presented at: American
Association of Hip and Knee Surgeons; November, 2013. Dallas, TX.
20. Poehling-Monaghan KL, Kamath AF, Taunton MJ, Pagnano MW. Direct anterior versus miniposterior
THA with the same advanced perioperative protocols: surprising early clinical results. Clin Orthop Relat
Res. 2015;473(2):623-631.
22. Bhadra AK, Yakkanti MR, Malkani AL. Primary total hip arthroplasty using a direct anterior vs. postero-
lateral approach: a comparative study. Poster presented at: American Academy of Orthopaedic Surgeons;
2012. San Francisco, CA.

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23. Zawadsky MW, Paulus MC, Murray PJ, Johansen MA. Early outcome comparison between the direct ante-
rior approach and the mini-incision posterior approach for primary total hip arthroplasty: 150 consecutive
cases. J Arthroplasty. 2014;29(6):1256-1260.
24. Christensen C, Jacobs C. No differences in patient function six weeks after direct anterior or posterior
THA: a randomized study. Paper presented at: American Association of Hip and Knee Surgeons Annual
Meeting; 2014. Dallas, TX.
25. Taunton M, Mason J, Odum S, Springer B. Direct anterior total hip arthroplasty yields more rapid volun-
tary cessation of all walking aids: a prospective, randomized clinical trial. J Arthroplasty. 2014;29(9)169-172.
26. Maffiuletti N, Impellizzerio F, Wilde K, et al. Spatiotemporal parameters of gait after total hip replace-
ment: anterior vs posterior approach. Orthop Clin N Am. 2009;40:407-415.
27. Spaans AJ, Van Den Hout JAAM, Bolder SBT. High complication rate in the early experience of minimally
invasive total hip arthroplasty by the direct anterior approach. Acta Orthopaedica. 2012;83(4):342-346.
gait parameters following direct anterior & posterior approach total hip arthroplasty. J Arthroplasty.
2014;29(6):1261-1264. doi:10.1016/j.arth.2013.11.021.
29. Higgins B, Barlow D, Heagerty N, Lin T. Primary Hip View ePoster. Poster presented at: American
Association of Hip and Knee Surgeons; November 7, 2014. Dallas, TX.
30. Alecci V, Valente M, Crucil M, et al. Comparison of primary total hip replacements performed with a direct
anterior approach versus the standard lateral approach: perioperative findings. J Orthopaed Traumatol.
2011;12:123–129
31. Bourne MH, Mariani EM. A comparison of direct anterior and lateral THA: postoperative outcomes.
J Bone Joint Surg Am. 2009;91(Suppl 5):10
total hip arthroplasty. J Arthroplasty. 2010;25(5):671-679.e1.
33. Berend K, Lombardi A, Seng B, Adams J. Enhanced early outcomes with the anterior supine intermuscular
approach in primary total hip arthroplasty. J Bone Joint Surg Am. 2009;91(Supplement 6):107-120.
ery in THA patients treated by minimally invasive direct anterior approach: a gait analysis study. Clinical
Biomechanics. 2009;24:812-818.
35. Parvizi J, Rasouli MR, Jaberi M, et al. Does the surgical approach in one stage bilateral total hip arthro-
plasty affect blood loss? Int Orthop. 2013;37(12):2357-2362.
J Surg Orthop Adv. 2012;21(2):78-83.
37. Woolson ST, Pouliot M, Huddleston JI. Primary total hip arthroplasty using an anterior approach and a
fracture table. Short-term results from a community hospital. J Arthroplasty. 2009;24(7):999.
invasive technique for total hip arthroplasty. J Orthop Surg Res. 2012;7:17
39. Bradley GW. Direct anterior approach for hip arthroplasty: an unselected single surgeon experience.
Podium presented at: American Academy of Orthopaedic Surgeons; 2008. San Francisco, CA.
outcome in a series of 300 cases. Acta Orthop Belg. 2013;79(2):166-173
41. Choi L, Barnett SL, Gorab RS, Patel JJ. The perioperative morbidity of the direct anterior approach for
total hip arthroplasty. Poster presented at: American Academy of Orthopaedic Surgeons; 2011. San Diego,
CA.
42. Bhargava T, Goytia R, Jones L, Hungerford M. Lateral femoral cutaneous nerve impairment after direct
anterior approach for total hip arthroplasty. Orthopedics. 2010;33(7):472.
43. Rüdiger HA, Betz M, Zingg PO, McManus J, Dora CF. Outcome after proximal femoral fractures
during primary total hip replacement by the direct anterior approach. Arch Orthop Trauma Surg.
2013;133(4):569-573.

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44. Rivera F, Leonardi F, Evangelista A. Risk of stem undersizing in anterior approach for total hip arthro-
plasty. Paper presented at: American Academy of Orthopaedic Surgeons; 2014. New Orleans, LA.
45. Bal BS, Vallurupalli S. Minimally invasive total hip arthroplasty with the anterior approach. Indian
J Orthop. 2008; 42(3): 301–308. doi:10.4103/0019-5413.41853.

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32
Training and Educating
Others About
John A. Scanelli, MD and Joseph T. Moskal, MD, FACS
In selecting patients, favor thin patients with a flexible hip, a narrow pelvis, and high
native offset, at least early on. Avoid those with muscular thighs, morbid obesity,
minimal hip motion, a wide pelvis, a high-neck shaft angle, and/or coxa valga.
Anticipate the location of blood vessels that contribute to blood loss, and use proactive
hemostasis to control blood loss.
Supine acetabular reaming can be disorienting, leading to errors. Ensure that you have
sufficient training to gain familiarity with this maneuver.
Adequate femoral exposure is difficult during direct anterior approach (DAA) total
hip arthroplasty (THA) and is the source of many errors. Understand the 3-D posi-
tion of the femur, identify the starting point of the femoral canal, and properly use
instruments. These steps take training.
Know how to read C-arm images during surgery, and interpret acetabular and femoral
position from the fluoroscopic images.
This chapter describes the process of educating residents, fellows, and orthopedic
surgeons on the DAA for THA. A step-wise program has been developed to provide a
repeatable method for learning and performing the DAA with an emphasis on under-
standing the nuances of each step to minimize the risk of complications.
Many studies report relatively longer operative times, increased blood loss, and iatro-
genic femur fractures as the frequently encountered complications while learning DAA


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398 Chapter 32
THA. The number of cases before proficiency is achieved with DAA THA ranges from
50 to 100.1–8 The novice surgeon should invest the time to visit experienced surgeons,
practice cadaver dissection, learn the relevant anatomy, understand the equipment needed,
and master the soft tissue releases to minimize risk during the learning phase. A weekend
cadaver course is insufficient and will lead to grief if live DAA THA is attempted on such
abbreviated training. There are no shortcuts.
We have broken DAA THA learning into 12 key and critical steps. This reproducible
method has eased the teaching of DAA THA to residents and fellows, while ensuring
patient safety. The method also provides a framework for making the operation reproduc-
ible for trained orthopedic surgeons looking to adopt the DAA into their practices. This
12-step method has been refined and validated at national cadaver-based courses aimed
at teaching DAA THA to residents, fellows, and orthopedic surgeons and is part of the
curriculum of the annual Anterior Hip Course offered by the International Congress on
Joint Reconstruction. This chapter describes the 12-step teaching protocol in detail.
The surgical approach described here is performed by author preference with a special-
ized fracture table with well-padded boots and a mobile spar that provides traction and
controls rotation of the lower extremity. While fluoroscopy is optional, it is easily per-
formed in the supine position, a clear advantage of the DAA approach. A 12-inch C-arm
image intensifier is recommended over a 9 inch because it captures a wider field of view to
facilitate leg length comparison. Fluoroscopic images of the operative hip can be printed
and overlaid, or an external grid utilized to help guide the surgeon’s decision on how best
to optimize leg length, offset, component orientation, and size.
To elevate the femur sufficiently to prepare the bone requires a lateral hook placed just
proximal to the gluteus maximus insertion that attaches to a hydraulic bracket that moves
independent of the operating table. Iatrogenic femoral shaft fractures can be caused by
attempting to elevate the femur by simply raising the hook through the hydraulic lift. To
avoid this, the surgeon should elevate the femur through the hook by hand and then bring
the hydraulic bracket to the level of the hook, allowing it to be docked. If femoral expo-
sure is not adequate at this point, more soft tissue releases are necessary. Adequate tissue
releases are mandatory before mechanical retraction with the elevator hook.
Double-offset broach handles are helpful to minimize soft tissue trauma while pre-
paring the femur. Any variety of femoral components can be used, although diaphyseal
engaging stems with straight rigid reamers may not be practical for this approach in the
primary setting. These implants require an extensile DAA that may involve an osteotomy
of the anterior superior iliac spine (ASIS) or partial release of the tensor fascia lata (TFL)
off the iliac wing.
The 12-step method is presented, listing each critical step during the DAA THA pro-
cedure. Tips for avoiding common complications during the learning curve are provided.
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Training and Educating Others About Direct Anterior Hip Surgery 399
This serves as a methodological framework for teaching residents and fellows with a step-
wise progression, once proficiency is achieved at a par ticular step along the pathway to
performing the DAA.
Step #1: Preoperative Planning: Patient Selection and

Templating
Patient characteristics are identified that facilitate femoral exposure, which includes
thin patients with a flexible hip, a narrow pelvis, and high native offset. Patients with
muscular thighs, morbid obesity, minimal hip motion, a wide pelvis, and a high neck-
shaft angle can make the femoral exposure more challenging. Deep hips or patients with
acetabular protrusio are not recommended during the learning curve. Abdominal obesity
with a pannus that would rest on the planned skin incision is a relative contraindication for
the DAA. Templating the THA procedure with standardized radiographs helps improve
the accuracy and equipment planning needs for the case. This should be done routinely as
a way to perform the operation prior to reaching the operating room.
Step #2: Prep, Drape, and Skin Incision

The patient is positioned supine on the operating table and the operative limb is draped
to allow easy access to the ASIS, iliac crest, and the posterior border of the greater tro-
chanter. This also allows planned access to the proximal third of the femur, if not the full
length of the femoral shaft. The incision starts proximally 2 cm lateral and 2 cm distal to
the ASIS and continues for 8 to 10 cm distally, aiming for the center of the patella (Figure
32-1). It is generally better to make the incision slightly more lateral than too medial.
Step #3: Fascia Over the Tensor Fascia Lata—Identification of

the Portal
The fascia encasing the TFL muscle is then identified (Figure 32-2). The TFL has a
spectrum of thickness and color. In some patients it is a fairly thin translucent layer with
muscle fibers easily identifiable underneath it, while in other patients it appears thick
and glossy white. Generally, the fascia over the TFL becomes whiter in color relative to
the surrounding tissue going lateral and posterior as it coalesces into the iliotibial band.
There are usually 2 to 3 perforating vessels that are helpful for guiding placement of the
TFL fasciotomy, which is made 1 to 2 cm anterior to these perforators and in line with
the skin incision.
Step #4: Muscle Management—Creating Space Between Tensor

Fascia Lata and Rectus Femoris
An Allis clamp is then attached to the medial flap of TFL fascia and provides
counter-traction as the surgeon’s finger then bluntly sweeps the space between the TFL
laterally and the rectus femoris medially (see Figure 32-2). This allows the surgeon to feel
the correct interval to place a cobra retractor into the space between the gluteus minimus
and hip capsule. This space proximal to the femoral neck between the capsule and the
gluteus minimus can be tight or scarred into place and requires the surgeon to ensure the

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400 Chapter 32
Figure 32-1. Incision placement.

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Figure 32-2. TFL fasciotomy.
minimus is not split after placing the retractor. Flexing the hip can also help relax the soft
tissues enough to place the retractor.
Attention is then turned to the distal aspect of the incision where a Hibbs retractor
is used to retract the rectus muscle belly medially and another Hibbs retracts the TFL
laterally. The fascia encasing the rectus femoris is then incised longitudinally starting

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402 Chapter 32
B
Figure 32-3. Location and cauterization of the ascending branches of the
lateral femoral circumflex vessels.
distally and continuing proximally, taking care to identify and isolate the crossing branch-
es of the lateral femoral circumflex artery that cross perpendicular to the operative field
(Figure 32-3). These vessels are encased in a thin membrane surrounded by fat. Spreading
a tonsil parallel to the vessels or perpendicular to the incision is helpful to identify them.

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These vessels are probably the major source of blood loss early on in the learning curve if
they are not controlled. Extensive cauterization or suture ligation is performed to achieve
this. The vessel ends should be checked throughout the case and just prior to wound
closure as it is not uncommon for some residual bleeding to occur given the large size of
the vessels.
The position of the anterior circumflex vessels relative to the skin incision is a helpful
guide to assess whether the length of the skin incision is appropriate, too proximal, or too
distal. The anterior circumflex vessels should lie in the central portion of the incision.
Often, slight distal skin extension is needed for proper DAA exposure.
Step #5: Capsule Management #1—Show Me the Neck

The pericapsular fat is then identified and a cobra retractor is placed adjacent to the
femoral neck inferiorly. A Bovie or Cobb elevator is gently used to elevate the indirect
head of the rectus femoris off the capsule to allow a double-bent Hohmann retractor to
slide over the anterior rim of the acetabulum. Extreme caution should be taken to keep
the tip of this retractor directly on bone to avoid femoral nerve injury.
If at any point the surgeon experiences difficulty in identifying the correct interval to
access the hip joint, the ASIS is the most reliable landmark to help orient the surgeon.
Sliding a finger underneath the skin, palpating the ASIS directly, and then knowing the
interval should be lateral to this landmark will help guide the surgeon to identify the
correct plane at the outset and avoid going too medial into the neurovascular structures.
One cobra retractor is placed between the gluteus minimus and capsule along the supe-
rior margin of the femoral neck, one cobra retractor is placed along the inferior margin
of the femoral neck medially, and a double-bent Hohmann retractor over the rim of the
acetabulum facilitates the capsulotomy and femoral neck osteotomy.
A capsulotomy or capsulectomy is now performed. If a capsulotomy is desired, this can
be created parallel to the femoral neck along its superior aspect and then the capsule taken
off its insertion along the intertrochanteric line anteriorly toward the lesser trochanter
distally. This is achieved by maximum external rotation of the hip and using electrocau-
tery to release any part of the capsule that inserts along the femoral neck headed toward
the lesser trochanter. This flap is then tagged with a heavy suture to facilitate retraction.
Alternatively, an anterior capsulectomy is performed by incising the capsule parallel to the
femoral neck along its mid-portion, and then creating 2 flaps that are excised proximally
and distally.
Step #6: Neck Osteotomy

The 2 retractors adjacent to the neck are now positioned intracapsular and the saddle
of the femoral neck and the lesser trochanter identified before performing the neck cut
(Figure 32-4). Lap sponges can also be placed adjacent to the neck, behind the cobras, and
tucked around posteriorly to improve the safety of the cut prior to using the saw.
The femoral neck osteotomy can be done before or after dislocating the femoral head.
The advantage to dislocating the hip prior to performing the osteotomy is improved visu-
alization of the proximal femur to facilitate a more accurate neck cut. Caution needs to
be taken when dislocating the hip to avoid ankle fractures. This complication can also be
avoided by controlled rotation of the lower extremity with the surgeon’s hand applying
rotational force through a T-handle attached to a corkscrew embedded within the femoral
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404 Chapter 32
Figure 32-4. Femoral neck exposure prior to osteotomy.
head, and a hand supporting the femur as the un-scrubbed assistant carefully pulls trac-
tion and externally rotates the operative leg.
Complications can also occur during the femoral neck cut. The greater trochanter can
be transected with the saw blade posteriorly or laterally. If the saw blade is angled too
distally, it can cut into the lesser trochanter, which is difficult to visualize with the lower
extremity in neutral rotation. Taking an x-ray with the planned angle of femoral neck
and then marking the planned resection can be helpful. We find that direct visualization
and clearly identifying the saddle of the femoral neck, the intertrochanteric ridge, and
the lesser trochanter are perhaps more reliable than radiographs. The saddle can often be
obscured by capsule or the gluteus minimus, and must be exposed in every case. Using a
pair of forceps to feel for the saddle is helpful if it is not directly visualized. The osteotomy
should not pass lateral to the intertrochanteric ridge to avoid cutting into the greater tro-
chanter. There is a bony prominence on the anterior surface of the femur along this line
that serves as a good reference point to ensure that the neck cut is not completed lateral to
it. Performing the femoral neck osteotomy with the hip reduced and the surgeon’s hand
too vertical can also cut into the greater trochanter posteriorly. If the saw blade passes
posteriorly through the capsule at the planned level of resection, the posterior circumflex
artery can be transected and lead to a significant source of blood loss.
A corkscrew is driven into the femoral head through the outer cortical surface or
through the cut surface of the femoral neck. The handle is rotated several times clock-
wise, spinning it to transect the attachment of the ligamentum teres. If there is difficulty
encountered removing the femoral head, aiming the T-handle toward the patient’s con-
tralateral shoulder to disengage the native head from the socket, removing prominent
anterior rim osteophytes, transecting the ligamentum teres with a hip skid, or removing
a napkin ring segment of bone from the femoral neck are helpful maneuvers. The sharp
edge of bone where the femoral neck cut was made is carefully maneuvered to avoid dam-
aging the TFL muscle during extraction.

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B
Figure 32-5. Acetabular exposure and sequence of retractor placement.
#1—sharp retractor placed superiorly, #2—retractor placed on ischium,
#3—anterior retractor if necessary.
Step #7: Acetabulum: Getting the Socket Right

Three retractors are then used to expose the acetabulum. These are placed anteriorly,
superiorly, and posteriorly (Figure 32-5). If the acetabular exposure is not adequate, use
a finger to palpate for tightness of the rectus fascia distally and release more if necessary
to facilitate retraction of the soft tissues. Understanding the plane of cup inclination and
anteversion is vital. In muscular and obese patients, the tendency is for the thigh to push
the reamer and cup impactor into a vertical position. The surgeon needs to be aware of

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406 Chapter 32
Figure 32-6. Three radiographs illustrating how the

trajectory of the C-arm beam influences the sur-
geon’s interpretation of cup position. The cup did not
move on any of these images but could theoretically
influence the surgeon to change the cup position on
images B and C.
this and apply counter-pressure to the thigh when this is encountered to ensure appro-
priate cup orientation. Offset instruments or accessory incisions can also help with this
critical step.
Accurate interpretation of the radiographs is important to avoid cup insertional errors.
The process requires an understanding of pelvic tilt and rotation. The cup will appear
more anteverted if the image taken is a relative outlet view, or rotated too much toward the
operative hip. The surgeon should assess the vertical and horizontal height of the obtura-
tor foramen and reproduce the shape of the obturator foramen on the C-arm image that
matches the preoperative anteroposterior pelvis radiograph to ensure accurate assessment
of the cup position in 3-dimensional space relative to the pelvis (Figure 32-6).
Step #8: Capsule Management #2—Femur Out and Up

Adequate femoral exposure is often the most challenging part of the DAA. The key to
achieving this is releasing as much soft tissue around the greater trochanter as necessary
to allow the femur to be elevated enough to prepare the bone. The femoral hook is first

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placed just proximal to the gluteus maximus insertion on the femur with the leg in neutral
rotation. A finger is used to palpate the space just above the gluteal sling. With the hook
handle pointed toward the foot and parallel to the thigh, the hook is inserted as the hand
is rotated toward the floor. The hook should slide in easily. If resistance is encountered,
remove it and try again.
We favor a systematic approach to releasing the capsule and short external rotators that
insert along the posterolateral border of the greater trochanter. The initial goal is to clear
the greater trochanter from behind the posterior wall of the acetabulum by translating
the femur laterally and anteriorly, or pulling the femur out and up. The leg is externally
rotated approximately 90 degrees so the greater trochanter is facing toward the proximal
aspect of the incision and the calcar distally. The operative leg is then hyperextended
and adducted and a long curved Hohmann retractor placed behind the greater trochanter
to sufficiently tension these soft tissue attachments. This allows the surgeon to see and
feel the femur move with each structure that is released. Care should be taken with the
amount of force applied through this retractor in patients with soft bone so as not to frac-
ture the greater trochanter.
With the femoral hook in place underneath the femur, the surgeon lifts with the hand
until the soft tissue tension prevents its translation any further. This is not a forceful
maneuver. The goal is to place the soft tissues under tension. The hydraulic lift is then
raised to the level of the hook to dock it and maintain the tension while the release is
performed. Lifting the femur with the hydraulic lift through the hook alone can cause
iatrogenic fracture. A lap pad is useful to clear the overlying fat off the short external
rotators so these structures are more easily identifiable. The posterior capsular insertion
along the greater trochanter is first incised with a Bovie or knife. This is followed by
the piriformis, the gamelli, and then the obturator internus until sufficient exposure is
achieved. Preserving the obturator externus is impor tant for maintaining hip stability and
this tendon should not be released; the obturator externus acts as the most direct medial
pull of the femur to the pelvis.
Step #9: Broaching

The surgeon should assess the femoral neck cut relative to the lesser trochanter with the
femur extended, externally rotated, and adducted before broaching. How does the neck
cut compare to the preoperative template? Is the neck cut too long or too short? Be aware
of the risk of posterior canal perforation. This complication probably occurs because when
the surgeon sees the femoral neck cut perpendicular to the incision, the tendency is for the
surgeon to hold the broach with the tip of it angled more perpendicular to it (ie, toward
the floor or aiming posteriorly). This is avoided by dropping the hand parallel to the thigh
and aiming the tip of the broach up into the anterior bow of the femur. It is important to
remember even though the hip is extended with the leg of the table resting on the floor,
the foot is still raised off the ground several inches. Do not force the broach in if it does
not pass easily. Reassess the neck cut; it could be too high or the broach could be in varus,
such that surgeon’s hand needs to be dropped to parallel the thigh.
Using the suction tip as a probe within the femoral canal during broaching is a help-
ful maneuver to confirm there has been no perforation. If the suction tip suddenly stops
sucking because it has engaged soft tissue, or leaves the canal entirely, perforation has
probably occurred. Radiographs taken with the last broach in place are recommended to

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408 Chapter 32
confirm this. If the femoral stem overlaps the cortical bone on the AP, maintain a high
suspicion for perforation and check a lateral view of the femur. The tendency is for the
perforation to occur proximal enough that simply repositioning the femoral component
down the long axis of the canal is sufficient to achieve adequate fixation to bypass the
defect. Offset broach handles and occasional use of flexible reamers can also facilitate
preparation of the femur.
Step #10: Trials—Long, Short, Stable

A trial reduction is performed and leg length is assessed radiographically. Having the
same person who is managing the table also perform the reduction is most helpful because
the surgeon begins to gauge a sense of how difficult or easy it is to reduce the hip, which
provides clues to leg length. The foot is not routinely removed from the traction bed to
assess stability, although this is possible. It is the authors’ opinion and experience that for
routine cases with no unusual deformity or pathology, if component position is optimized
radiographically, dynamic stability testing is unnecessary.
Step #11: Final Implants and Closure

Once primary stability of the acetabular component, as well as axial and rotational sta-
bility of the stem, is achieved, the wound is thoroughly irrigated and hemostasis obtained
once again. The capsule may be repaired if it was preserved, but this is not necessary if
capsulectomy was performed during exposure. The deep fascia is closed with a #1 Vicryl
and the skin per surgeon preference.
Step #12: Postoperative Management

Dislocation precautions are not routinely utilized and patients are able to fully weight
bear immediately following surgery to tolerance in routine cases. Other aspects of
postoperative management are patient specific and not associated with the approach.
Rehabilitation of the DAA THA patient is discussed in great detail elsewhere in this
textbook.
Early Complications
The DAA is associated with a relatively low risk of dislocation9–11 compared to the
posterolateral approach (PL) and a lower risk of postoperative limp compared to the direct
lateral (DL) approach. Table 32-1 summarizes the first DAA THA cases of a several-
surgeon series with a listing of complications.1–8,11–16 Eight of the 13 studies listed used
an orthopedic table. Five of 13 surgeons reported what they did in preparation prior to
starting the DAA on patients. A total operative-related complication rate of 5.5% and a
reoperation rate of 2.8% are noted. These studies appear to show a correlation with lower
rates of complications where surgeons spent more time preparing themselves prior to
starting the DAA. The surgeon can improve these outcomes by using and understanding
fluoroscopy to optimize component orientation and leg lengths, visiting surgeons who

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are well experienced and routinely perform the DAA, utilizing cadavers, and attending
intensive DAA courses.
Use of Fluoroscopy
There are mixed data supporting the use of fluoroscopy to optimize acetabular com-
ponent position with the DAA compared to other approaches. This difference is likely
attributable to a learning curve with the surgeon’s interpretation of the intraoperative
fluoroscopy images, in particular pelvic tilt and rotation. If these parameters are not
understood, the surgeon can be misled into putting the cup in correctly on the wrong
x-ray. It is the authors’ opinion that fluoroscopy can be a very helpful adjunct for DAA
THA during the learning curve.
Accuracy of Component Placement

Comparing the DAA and PL with and without intraoperative fluoroscopy, the DAA
was associated with more frequent acetabular component placement (78% and 89%)
within the ideal range of anteversion and inclination than the PL (41% and 45%).17
Another study compared rates of ideal cup position between the DAA with fluoroscopy,

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PL without fluoroscopy, and PL with navigation; the data showed that conventional PL
and DAA with fluoroscopy groups were essentially equivalent (70% PL vs 68% DAA),
with a 91% accuracy in the navigated PL group.18 Future studies might directly compare
computer-navigated DAA vs PL for more direct comparison with the impact of approach
when using navigated THA.
Operative Time
Operative time is understandably longer for a new approach compared to others that a
surgeon is more familiar with. Masonis et al showed reduced operative and fluoroscopy
times during the first 100 cases with no significant reduction after 200 cases.2 Despite the
increased operating time, no increase in adverse medical complications, anesthetic-related
complications, or rate of deep infection were reported in one study.3 Seng et al reported
a drop in an average operative time from 99 to 69 minutes after 47 cases.19 Blood loss
decreases as surgeon awareness of regional anatomy increases so that the location of larger
blood vessels can be prophylactically treated. Hospital length of stay (LOS) is shorter
with the DAA8 compared to others; however, the LOS varies mostly by hospital location,
with a shorter LOS in hours from United States hospitals and days in European hospitals.
Discharge to home is more commonly seen compared to the PL8 or DL approach.3 LOS
may not be a valid outcome measure in the elderly in the United States, where federal
Medicare policies mandate a 3-day LOS for all THA patients before proceeding to a
rehabilitation center after their hospitalization.
Iatrogenic Fractures
Iatrogenic femoral fractures are the most frequent complication of concern during the
learning curve. Unrecognized intraoperative periprosthetic fractures are a special con-
cern since they may manifest when the patient ambulates. Minimally displaced greater
trochanter fractures are typically managed nonoperatively; however, a large bony piece of
the greater trochanter that is displaced probably should be reduced and fixed to prevent a
permanent limp. These larger pieces usually require a second incision posteriorly to appro-
priately reduce and fix the greater trochanter back to the proximal femur. It is important
to distinguish between femoral perforation and fracture. Femoral perforations often only
require redirection of the broach down the canal in the correct orientation, while fractures
require either cabling or stem revision.
Lateral Femoral Cutaneous Nerve Injury

Rates of LFCN dysfunction vary considerably (2%9 to 81%20), but most postoperative
LFCN dysfunction represents a benign numbness over the lateral aspect of the proximal
thigh, clinically comparable to a patch of routine lateral knee numbness following transec-
tion of the infrapatellar branch of the saphenous nerve during knee replacement surgery.
The rate of true meralgia paresthetica with DAA THA is extremely low. Making the
fascial incision lateral on the TFL muscle belly significantly reduces this risk.
Muscle Damage
Attempts have been made to quantify muscle damage comparing the DAA after THA
with other approaches using inflammatory biomarkers, MRI scans, and gross inspection

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414 Chapter 32
of cadaveric specimens. Inflammatory biomarkers of muscle damage are less following

DAA compared to the PL in the acute postoperative period.21 A cadaveric study grossly
quantifying muscle damage showed less damage with the PL than DAA.22 MRI evidence
shows less soft tissue damage after THA with a DAA compared to DL.23
The 12-step method was designed as a model to teach the DAA to residents, fellows,
and orthopedic surgeons in a systematic and reproducible way to minimize the risk of
complications with each step. Surgeons can also reduce the risk of complications during
the learning curve by visiting experienced DAA surgeons, attending DAA courses, and
dissecting cadavers to familiarize themselves with the relevant anatomy, exposure, and
releases necessary to safely prepare the bone. Learning and understanding the orientation
of the acetabulum and femur in the supine position is facilitated by cadaver surgery prac-
tice. Knowing where to anticipate potential sources of major blood loss and how to control
them prophylactically is essential. Lastly, knowing how to correctly interpret fluoroscopy
will minimize component malposition.
If you are lost finding the correct interval during initial fascial dissection, palpate,
locate the ASIS underneath the skin, and stay lateral to it.
Isolate and ligate or cauterize the branches of the lateral femoral circumflex artery in
the surgical field. Check on these vessels throughout the case and again just prior to
wound closure to ensure adequate hemostasis is achieved.
Before making the femoral neck osteotomy, palpate the saddle, the intertrochanteric
ridge and lesser trochanter, then mark the neck cut to help improve accuracy.
An outlet view of the pelvis and a wide obturator foramen will show increased ante-
version of the acetabular component. An inlet view and less medial/lateral width of
the obturator foramen will show less anteversion.
Ensure adequate femoral exposure before preparing the femur. The goal is to achieve
sufficient external rotation, lateralization, and elevation of the proximal femur.
Adduct and extend the femur to facilitate exposure, and aim the broach tip anteriorly
into the femoral bow to avoid perforating the canal posteriorly.
2. Masonis J, Thompson C, Odum S. Safe and accurate: learning the direct anterior approach total hip arthro-
plasty. Orthopaedics. 2008;31(12 Suppl 2):129-134.

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4. D’Arrigo C, Speranza A, Monaco E, Carcangiu A, Ferretti A. Learning curve in tissue sparing total hip
replacement: comparison between dif ferent approaches. J Orthop Traumatol. 2009;10(1):47-54.
J Surg Orthop Adv. 2012;21(2):78-83.
Orthop Relat Res. 2011;469(2):503-507.
8. Zawadsky MW, Paulus MC, Murray PJ, Johansen MA. Early outcome comparison between the direct ante-
rior approach and the mini-incision posterior approach for primary total hip arthroplasty: 150 consecutive
cases. J Arthroplasty. 2014;29(6):1256-1260.
total hip arthroplasty. J Arthroplasty. 2010;25(5):671-679 e1.
J Arthroplasty. 2008;23(2):266-272.
11. Siguier T, Siguier M, Brumpt B. Mini-incision anterior approach does not increase dislocation rate. Clin
Orthop Relat Res. 2004;426:164-173.
tive findings. J Orthop Traumatol. 2011;12(3):123-129.
15. Wayne N, Stoewe R. Primary total hip arthroplasty: a comparison of the lateral Hardinge approach to an
anterior mini-invasive approach. Orthop Rev (Pavia). 2009;1(2):e27.
16. Woolson ST, Pouliot MA, Huddleston JI. Primary total hip arthroplasty using an anterior approach and a
17. Masonis JL, Ruffolo M, Bates MD, Odum SM, Nogler MM, Fehring TK. Effect of surgical approach imag-
ing on acetabular alignment in hip arthroplasty. Poster presented at: American Academy of Orthopaedic
Surgeons; 2014. New Orleans, LA.
18. Rathod PA, Bhalla S, Deshmukh AJ, Rodriguez JA. Does fluoroscopy with anterior hip arthroplasty
decreases acetabular cup variability compared with a nonguided posterior approach. Clin Orthop Relat Res.
2014;472(6):1877-1885.
19. Seng BE, Berend KR, Ajluni AF, Lombardi AV Jr. Anterior-supine minimally invasive total hip arthro-
plasty: defining the learning curve. Orthop Clin North Am. 2009;40(3):343-350.
20. Goulding K, Beaulé PE, Kim PR, Fazekas A. Incidence of lateral femoral cutaneous nerve neuropraxia after
2011;93(15):1392-1398.
after total hip replacement. J Bone Joint Surg Br. 2011;93-B(7):888-889.

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Understanding Short Femoral
33
Stem Design and Application
in Direct Anterior Approach
Timothy McTighe, Dr HS (hc) and Daniel C. Allison, MD, MBA
A Stem Classification System is a tool to standardize short femoral stem design and
offer clarity in implant selection and clinical outcomes evaluation.
Certain short, curved, neck-retaining, and metaphyseal design femoral stems ease
implant insertion during direct anterior approach (DAA) total hip arthroplasty
(THA), but these designs are also associated with new learning for the surgeon.
Besides facilitating the DAA, properly inserted short femoral stems may offer other
procedural and biomechanical advantages.
The DAA for THA has evolved into a safe and effective hip replacement technique that
offers many distinct clinical advantages.1 The disadvantages of DAA stem from difficul-
ties with femoral exposure and implantation and the need for learning a new technique.2
Short femoral stem designs have emerged to facilitate femoral preparation and implan-
tation through the DAA. These stems can decrease the amount of femoral release
required for exposure. The curved, neck-sparing arthroplasty (NSA) stems can be intro-
duced medially, reducing the need to remove bone close to the greater trochanter. This
reduces the risk of proximal femur fracture and decreases the need for capsular releases to
achieve adequate femoral exposure (Figure 33-1). In addition, short femoral stems allow


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418 Chapter 33
Figure 33-1. Illustration showing bone saving

zones for a short curved neck sparing stem.
(Reprinted with permission from Joint Implant
Surgery & Research Foundation.)
for shorter incisions, less bone loss, increased ease of future removal, and compatibility
with all canal configurations.3,4
Short femoral stems have been used overseas for at least a decade longer than in the
United States.5-7 Early designs were modifications of current standard cementless stems
in which the diaphyseal portion was truncated. Early data suggested that stable, durable
fixation and excellent clinical outcomes can be achieved with these modifications.3,8,9
Today, a variety of short-stem implants are available with an array of design features, with
limited information to guide the surgeon in terms of design rationale, fixation features,
surgical technique, and clinical outcomes.9,10
Since 2012, the Joint Implant Surgery and Research Foundation (JISRF) has advocated
a femoral stem classification system.10-12 This system is organized by primary stabilization
contact regions, as follows:
1. Head stabilized
a. Hip resurfacing
b. Mid-head stem

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Understanding Short Femoral Stem Design and Application 419
Figure 33-2. Illustration of Biodynamic stem 1983 (Howmedica).

(Reprinted with permission from Joint Implant Surgery &
Research Foundation.)
2. Neck stabilized
a. Short curved neck stabilized stem
b. Short lateral flare engaging neck stabilized stem
c. Neck plugs
3. Short metaphyseal stabilized
a. Short taper stems
b. Bulky or “fit-and-fill” stems
4. Conventional metaphyseal/diaphyseal stabilized (not considered a short stem)
In the previous scheme, implants in groups 2a and 3a are of interest to DAA THA.
Short Curved Neck Stabilized Stem Design

Femoral neck preservation in THA contributes to reduction of torsional and bending
moments on the femoral component.13,14 Surgical advantages of short stems relate to less
canal invasion, reduced bone loss, less soft tissue damage, favorable dislocation rates, and
easier removal in revision situations.15 Professor Pipino from Monza, Italy has innovated
short stems since the late 1970s with the Biodynamic cementless prosthesis (Howmedica/
Stryker Orthopaedics)9,16,17 (Figure 33-2). Several evolutionary variations have followed,

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420 Chapter 33
Figure 33-3. Images of 7 short curved neck-sparing stems.

1. CFP (Waldemar Link)
2. Tissue Sparing Implant (TSI; Signature Orthopaedics Ltd)
3. ARC Bone Preserving Technology (Omni)
4. Muscle Sparing Approach (MSA; Signature Orthopaedics Ltd)
5. MiniHip (Corin Corp)
6. Nanos Neck Preserving Stem (Smith & Nephew)
7. Alteon Neck Preserving Femoral Stem (Exactech, Inc)
(Reprinted with permission from Joint Implant Surgery & Research
Foundation.)
particularly since 2007, that offer a variety of features (Figure 33-3). Published outcomes
with this type 2a, neck-sparing design of femoral stem are summarized in Table 33-1.
Short-Tapered Stem Design

The coronal wedge taper design of femoral stem gains stability from metaphyseal
fit, and the flat design allows some flexibility to adjust version during implantation.
Conventional stems of this design can be shortened to create variations more suited for
DAA THA. These stems require removal of the lateral femoral neck cortex to avoid varus
positioning of the implant. Stability results from a wedge-fit at the meta-diaphyseal junc-
tion of the proximal femur. Medial to lateral cortical contact is essential but the anterior
to posterior fill is often not anatomic. Published outcomes with this type 3a, M/L wedge
design of femoral stem are summarized in Table 33-2. Several such designs are available
in the United States today (Figure 33-4).9,11

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Short femoral stems can be implanted with any DAA technique and generally require
special broaches and trial instrumentation for femoral preparation that applies to the par-
ticular stem. In addition to standard equipment needed for DAA THA, the type 2a stem
insertion requires specialized rasps that cut in both directions and are designed to shape
bone (Figure 33-5). Insertion of the type 3a stems requires truncated M/L taper broaches
that are designed to cut in one direction and tend to compress cancellous bone.
Preoperative planning should include availability of a standard cementless stem system
available for backup in case the short design does not work. X-ray templating is use-
ful if the surgeon is cognizant of errors from inaccurate x-ray images. Template x-rays
should have size markers; and a 20-degree internal rotation view of the femur will usu-
ally allow more accurate measurement of femoral offset and proximal femoral anatomy
(Figure 33-6).48 If the patient cannot internally rotate the affected arthritic hip, template
the uninvolved side or externally rotate the beam to match the externally rotated position
of the patella (which accurately reflects hip rotation).
Type 2a short curved NSA-style stems save most of the femoral neck, and the oste-
otomy level is usually about 8 to 10 mm in the subcapital region. Type 3a-style stems
use a standard neck resection. NSA-style stems fit the femoral neck not the metaphysis

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Figure 33-4. (A) Image of a type 3a stem (Ovation Tribute, Ortho Development
Corporation); this design is essentially a truncated version (25% reduction of
the distal stem tip) of the proven M/L taper. (B) Preoperative and postopera-
tive radiographs of a deformity amenable to correction with the same type
3a stem. (Reprinted with permission from Ortho Development Corporation,
Inc.)
or diaphysis. The precise angle of neck cut is determined with the neck reference guide
for the particular stem design and with the preoperative templates as another guide. For
NSA-type stems, the retained neck is retracted behind a lateral cobra retractor or it can be

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Figure 33-5. Specialized rasp for a neck-sparing implant allows back-and-

forth movement and preparing bone for implantation. (Reprinted with per-
mission from Joint Implant Surgery & Research Foundation.)
depressed inferiorly with an additional retractor to allow visualization of the acetabulum.

The techniques have been addressed elsewhere in this book.
Femoral exposure for short stems is the same as described elsewhere for DAA THA.
The type 2a NSA design of stem may require fewer femoral releases when compared to
standard femoral stems. Preparation for 2a neck-sparing stems is different from conven-
tional, or even type 3a, short metaphysical-style stems. The angle of the osteotomy is
important in the accurate preparation of the femur and final stem alignment. A curved
canal probe or curved starter rasp is used in a back-and-forth motion following the proxi-
mal medial curvature of the femur (Figure 33-7). Rasps are up-sized sequentially, taking

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428 Chapter 33
Figure 33-6. Plain anteroposterior radiographs showing routine view vs

20 degrees of internal rotation. Note: femoral offset increases with internal
rotation. (Reprinted with permission from Joint Implant Surgery & Research
Foundation.)
Figure 33-7. Note rasping along the medial cortex of the femoral neck. The
rasp is moved back and forth to prepare the canal for neck-preserving short
stem. (Reprinted with permission from Joint Implant Surgery & Research
Foundation.)
care to hug the medial cortex, and working toward the lateral side, ensuring that the
instruments stay within the femoral canal.
With a type 2a NSA-design stem, removing approximately 2 mm of additional neck
will open up the cavity for a larger stem size, if the surgeon is between sizes. Insertion of
the definitive stem should be done with gentle impaction, allowing hoop stresses to dis-
sipate before final seating. Some NSA stems have a modular neck design that allows fine-
tuning of version, offset, and neck lengths. However, concerns about fretting corrosion

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have dampened the enthusiasm for modular neck hip implants and have led to product
recalls, although improved engineering and biomaterials may overcome fretting concerns
in modular tapers, especially in short stems with neck-sparing designs.14,49 For example,
finite element analysis modeling comparing levels of neck resection (neck sparing vs con-
ventional) has shown that a neck-sparing resection leads to a 35% reduction in principal
tensile stress and 40% reduction of torsional and bending moments.14
The preparation of the femur for short 3a stems is identical to the traditional broach-
only technique used with M/L tapered stems, with the advantage of less surgical trauma
and avoiding the occasional “hanging up” that can occur in tight diaphyseal femoral
canals. Type 3a stems can end up in varus malposition, however, if the appropriate entry
point to the femoral canal is not identified accurately. In our experience, intraoperative
fluoroscopy can help with accurate coronal and sagittal alignment, as well as confirm
proper proximal medial-lateral fit.
Stem retrieval during revision surgery is an important design consideration. Type 2a
neck-retaining stems ease removal during revision and can sometimes facilitate revision
to a primary stem of a standard design. This is a function of the proximal femoral bone
preservation that is an advantage of Type 2a stems. Type 3a stems are removed in tradi-
tional fashion, though their shorter construct should allow for easier retrieval without the
need for extended trochanteric osteotomy. Subsequent revision surgery will require a stem
with distal fixation.
Wound closure and rehabilitation are similar with short stems, as for other DAA THA
descriptions elsewhere in this book. We prefer protected weight bearing as tolerated with
crutches or a front-wheeled walker for support for the first 4 weeks. If osteoporotic bone
is encountered during surgery, partial weight bearing is prescribed for approximately
6 weeks.
Data suggest that short stems, particularly the Type 2a and Type 3a designs addressed
in this chapter, work well for most routine DAA THA. However, these designs are not
risk free. Shorter stems may be less stable at initial press fit, leading to more aggressive
implantation and the risk of unrecognized fracture. Conversely, if a short stem does
not gain initial stability, the surgeon may be faced with early subsidence and loosening.
Identifying the proper amount of stability requires a new learning curve for surgeons
accustomed to conventional stem designs. Investment in training and the use of intraop-
erative fluoroscopy may help mitigate risk when using the short stems described in this
chapter.
Neck-retaining short stems should be used with caution in cases with thin femoral
necks from osteoporotic bone. These implants are subjected to rotational and cantilever
bending stresses, and osteoporotic bone may suffer fatigue failure when such implants are
loaded during ambulation. While metaphyseal short stems have significantly less surface
contact area compared with conventional-length stems, the clinical data suggest that these

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designs work as well as longer, standard versions of similar design. The JISRF classifica-
tion is a useful tool to recognize and consider each stem design and its respective attributes
and limitations. Future studies will identify patient variables that allow surgeons to pre-
cisely select the best stem for a par ticular DAA THA.
The JISRF stem classification system provides guidelines as to stem stabilization

contact regions to help identify, differentiate, and cata log short stems for DAA THA.
The preservation of the femoral neck reduces both torsional and axial bending
moments, providing improved initial and long-term mechanical implant stability.
Various short stem designs differ in biomechanical features and surgical technique,
often resulting in a distinct learning curve before mastering their implantation.
Early- and mid-term clinical outcomes with the short femoral stems (particularly
Type 2a and Type 3a designs) are encouraging and may offer customized solutions
that are optimized for individual patients in the future.
2. Yi C, Agudelo JF, Dayton MR, Morgan SJ. Early complications of anterior supine intermuscular total hip
arthroplasty. Orthopedics. 2013;36(3):e276-e281.
3. Rubin L, Ritterman S, and McTighe T. “Neck-sparing” total hip arthroplasty. In: Kinov P, ed. Arthroplasty–
Update. Published February 20, 2013. Accessed July 1, 2013. doi:10.5772/56149.
4. McTighe T, Brazil D, Keggi J, et al. Short stems in total hip arthroplasty. Poster presented at: Pan Pacific
Orthopaedic Congress; July, 2014. Waikoloa, HI.
5. The Australian Orthopaedic Association National Joint Replacement Registry. 2012 Annual Report: 66.
6. van der Rijt A, van der Rijt R, Solaiman R. Early experience with MSA™ neck sparing stem via anterolat-
eral approach. Poster presented at: International Society for Technology in Arthroplasty; October, 2012.
Sydney, Australia.
7. McTighe T, Keggi J, Keppler L, et al. The first 1,790 U.S.A. short curved neck sparing stems: clini-
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-surgical-observation.pdf. Accessed January 7, 2016.
8. Tóth K, Sohár G. Short-stem hip arthroplasty. In: Kinov P, ed. Arthroplasty— Update. Published
February 20, 2013. Accessed January 7, 2016. doi: 10.5772/53134.
9. McTighe T. Brazil D, Keggi J, et al. Short-stem designs for total hip arthroplasty. In Callaghan J, Beaulé
P, Clohisy J, Della Valle C, Rosenberg A, Rubash H. The Adult Hip. 3rd ed. Philadelphia, PA: Wolters
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10. McTighe T, Keggi J, Stulberg SD, et al. Total hip stem classification system. Reconstructive Review.
2014;4(2):24-28. doi:10.15438/rr.v4i2.70
11. McTighe T, Stulberg SD, Keggi J, et al. A classification system for short stem uncemented total hip arthro-
plasty. Poster presented at: ISTA; October, 2012. Sydney, Australia. doi:10.13140/RG.2.1.3406.0004.
12. van Oldenrijk J, Molleman J, Klaver M, et al. Revision rate after short-stem total hip arthroplasty. A sys-
tematic review of 49 clinical studies. Acta Orthopaedica. 2014;85(3):250-258
13. Freeman MAR. Why save the neck? J Bone Joint Surg. 1986;68B:346.
14. McTighe T, Brazil D, Clarke I, et al. Metallic modular taper junctions in total hip arthroplasty.
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15. McPherson E, Vaughn B, Keppler L, Brazil D, McTighe T. The incidence of dislocation utilizing a neck
sparing stem in primary THA in community based practices with the posterior approach. Reconstructive
Review. 2015;5(2): 2262-2331. doi:10.15438/rr.5.2.106
16. Rajakulendran K, Field RE. Neck-preserving femoral stems. HSSJ. 2012;8:295–300.
doi:10.1007/s11420-01209302-z
17. McTighe T, Brazil D, van der Rijit A, et al. The science behind a short (neck preserving) curved stem total
hip replacement. Poster presented at: EFFORT 14-4564, 15th EFFORT Congress; June 4-6, 2014. London,
United Kingdom. doi:10.13140/RG.2.1.3141.8406
18. Pipino F, Keller A. Tissue-sparing surgery: 25 years’ experience with femoral neck preserving hip arthro-
plasty. J Orthop Traumatol. 2006;7(1):36–41.
19. Röhrl SM, Li MG, Pedersen E, et al. Migration pattern of a short femoral neck preserving stem. Clin Orthop
Relat Res. 2006;448:73-78.
20. Gill IR, Gill K, Jayasekera N, Miller J. Medium term results of the collum femoris preserving hydroxyapa-
tite coated total hip replacement. Hip Int. 2008;18(2):75–80.
21. Pons M. Learning curve and short-term results with a short-stem CFP system. Hip Int. 2010;20(Suppl 7):S52-57.
22. Wang YS, Liu M, Li JW, et al. [Application of CFP short-stem prosthesis in the treatment of osteonecrosis
of the femoral head]. Zhonghua Yi Xue Za Zhi. 2011;91(47):3320-3323.
23. Briem D, Schneider M, Bogner N, et al. Mid-term results of 155 patients with CFP short stem prosthesis.
Int Orthop. 2011;35(5):655-660.
24. Nowak M, Nowak TE, Schmidt R, et al. Prospective study of a cementless total hip arthroplasty with a
collum femoris preserving stem and a trabeculae oriented pressfit cup: minimum 6-year follow-up. Arch
Orthop Trauma Surg. 2011;131(4):549–555.
25. Kress AM, Schmidt R, Nowak TE, et al. Stress-related femoral cortical and cancellous bone density loss
after collum femoris preserving uncemented total hip arthroplasty: a prospective 7-year follow-up with
quantitative computed tomography. Arch Orthop Trauma Surg. 2012;132(8):1111–1119.
26. Ghera S, Bisicchia S. The collum femoris preserving stem: early results. Hip Int. 2013;23(1):27-32.
27. Kendoff DO, Citak M, Egidy CC, et al. Eleven-year results of the anatomic coated CFP stem in primary
total hip arthroplasty. J Arthroplasty. 2013;28:1047-1051.
28. Lazarinis S, Mattsson P, Milbrink J, et al. A prospective cohort study on the short collum femoris-
preserving (CFP) stem using RSA and DXA: primary stability but no prevention of proximal bone loss in
27 patients followed for 2 years. Acta Orthop. 2013;84(1):32-39.
29. Hutt J, Harb Z, Gill I, Kashif F, Miller J, Dodd M. Ten year results of the collum femoris preserving total
hip replacement: a prospective cohort study of seventy five patients. Int Orthop. 2014;38(5):917-922.
30. Khanduj V, Tek V, Scott G. The effect of a neck-retaining femoral implant on leg-length inequality follow-
ing total hip arthroplasty. J Bone Joint Surg (Br). 2006;88-B(6):712-715.
31. Ahmad R, Kerr HL, Spencer RF. Bone conserving mini hip replacement. J Bone Joint Surg (Br).
2012;94-B(SUPP XLII):14.
32. Jerosch J, Grasselli C, Kothny PC, Litzkow D, Hennecke T. Reproduction of the anatomy (offset, CCD,
leg length) with a modern short stem hip design— a radiological study. Z Orthop Unfall. 2012;150(1):20-26.
33. Götze C, Ehrenbrink J, Ehrenbrink H. Is there a bone-preserving bone remodeling in short-stem prosthesis?
DEXA analysis with the Nanos total hip arthroplasty. Z Orthop Unfall. 2010;148(4):398-405.
34. Ettinger M, Ettinger P, Lerch M, et al. The Nanos short stem in total hip arthroplasty: a mid term follow-
up. Hip Int. 2011;21(5):583-586.
35. Ettinger M, Ettinger P, Ezechieli M, et al. CCD and offset after Nanos short stem in total hip arthroplasty.
Technol Health Care. 2013;21(2):149-155.
36. Zeh A, Pankow F, Röllinhoff M, et al. A prospective dual-energy x-ray absorptiometry study of bone remod-
eling after implantation of the Nanos short-stemmed prosthesis. Acta Orthop Belg. 2013;79(2);174-180.
37. Burt CF, Garvin KL, Otterberg ET, Jardon OM. A femoral component inserted without cement in total
hip arthroplasty. A study of the Tri-Lock Component with an average ten-year duration of follow-up. J Bone
Joint Surg Am. 1998;80(7):952-960.
38. Healy WL, Tilzey JF, Iorio R, Specht LM, Sharma S. Prospective, randomized comparison of cobalt-
chrome and titanium trilock femoral stems. J Arthroplasty. 2009;24(6):831-836.
39. Emerson R, Jones K, Kavolus C, Peyton R, Pietrzak W. Short-term clinical outcomes of the Taperloc™
Microplasty™ stem. White Paper Biomet Publication Form No. BOI0306.0 REV061508.
40. Morrey BF, Adams RA, Kessler M. A conservative femoral replacement for total hip arthroplasty. J Bone
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41. Falez F, Casella F, Panegrossi G, Favetti F, Barresi C. Perspectives on metaphyseal conservative stems.
J Orthop Traumatol. 2008;9(1):49-54.
42. Chen HH, Morrey BF, An KN, Luo ZP. Bone remodeling characteristics of a short-stemmed total hip
replacement. J Arthroplasty. 2009;24(6):945-950.
43. Grupp TM, Weik T, Bloemer W, Knaebel H-P. Modular titanium alloy neck adapter failures in hip
replacement—failure mode analysis and influence of implant material. BMC Musculoskeletal Disorders.
2010;11:3.
44. Lerch M, von der Haar-Tran A, Windhagen H, et al. Bone remodeling around the Metha short stem in total
hip arthroplasty: a prospective dual-energy x-ray absorptiometry study. Int Orthop. 2012;36(3):533-538.
45. The Australian Orthopaedic Association National Joint Replacement Registry. 2012 Annual Report:169.
46. Wittenberg RH, Steffann R, Windhagen H, et al. Five-year results of a cementless short-hip-stem prosthe-
sis. Orthopedic Reviews. 2013;5(1):e4.
47. Dawson-Bowling S, Yeoh D, Edwards H, et al. Ceramic-on-ceramic versus metal-on-polyethylene bearing
surfaces in the ABG II total hip arthroplasty—4–10 year results of a randomised controlled trial. J Bone
Joint Surg (Br). 2012;94-B(Supp XXXIX):27.
48. Schutte D, Barfield W, Conrad J, et al. Predicting errors in offset templating for total hip arthroplasty.
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Review. 2011;1(1):8-16. doi:15438/rr.5.2.108

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Section XII
Conclusion

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34
In Closing
The Future of
Lee E. Rubin, MD; B. Sonny Bal, MD, JD, MBA;

and Kristaps J. Keggi, MD, Dr Med (hc)
This text reflects a milestone in the field of hip reconstruction. For several decades,
the direct anterior approach (DAA) to the hip joint had been used and taught at only a
few locations around the world. For those seeking to learn this technique, there were few
focused resources, and a comprehensive text addressing the approach was lacking. This
made learning DAA, or advancing one’s surgical skillset in DAA surgery, all the more
difficult.
It would be impossible to complete this book without acknowledging the contributions

of the key surgeons in the field of DAA hip surgery. These foundational surgeons have
left their mark on the field and have shaped the evolution of this technique over the past
century.
The earliest documented accounts of anterior hip surgery serve as historical reference
but preceded the development of modern total hip replacement implants in the 1960s. In
Germany in the 1880s, Dr. Carl Hueter first described the surgical approach and docu-
mented his findings, establishing the interner vous and intermuscular plane that continues
to be used to this present day. In France in the 1940s, Dr. Henri Judet developed an ortho-
pedic traction table and became an orthopedic visionary. His legacy was carried forward
both by his son Dr. Robert Judet, who first employed the DAA for acrylic total hip recon-
struction in the 1940s, and also by his grandson, Dr. Thierry Judet. Together, the Judets
are well known for developing some of the earliest instruments for patient positioning,

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436 Chapter 34
traction techniques, and radiographic assessment of the pelvis, all of which have played
key roles in facilitating the DAA procedure.
In Boston during the 1920s and 1930s, Dr. Marius Smith-Petersen used an extensile
version of the DAA for comprehensive access to the hip; with this technique he gained
expertise in performing pediatric hip debridements, cup-mold arthroplasty, and adult
fracture reconstructions about the hip and pelvis.
Following the incorporation of polyethylene acetabular replacement to create a total hip
arthroplasty (THA) by Sir John Charnley in the 1960s, 2 surgeons have played major roles
in the adoption and expansion of the DAA both in the United States and abroad. At Yale
University, early in the 1970s, Dr. Kristaps Keggi was the first surgeon to use the DAA in
the United States for THA. Early on, Keggi created one of the first outcomes databases in
the United States. With a career-long commitment to academics and publication, the first
body of orthopedic literature related to DAA THA was generated by Keggi and continues
to be a rich source of knowledge to this day. Keggi created custom-made retractors, offset
broaches, impactors, and design modifications that are now universally accepted and used
around the world to reduce tissue trauma and ease implant insertion.
In California in the 1990s, Dr. Joel M. Matta, already an expert in acetabular trauma
and fracture reconstruction, adopted the DAA in his practice for fluoroscopic-assisted
THA using a modified version of Dr. Judet’s traction table. Matta brought this variation
of the operation to the US, and worked tirelessly to popu larize it among peer surgeons.
Because of Matta’s ability to develop a teachable, stepwise curriculum for learning the
procedure, the DAA has been increasingly adopted by other surgeons, especially in the
past 10 to 15 years. Matta made numerous implant design improvements, produced out-
comes research, worked to establish DAA educational courses; both with industry, and
also later established an annual comprehensive anterior hip course with the International
Congress on Joint Replacement (ICJR).
Following in the footsteps of these pioneers in DAA, an entire generation of surgeons is

now familiar with the method and has adopted it for primary THA. Whereas the limited
availability of DAA-specific or custom surgical instruments was once an obstruction to
implementing the DAA in practice, such instruments are now commonly available and
are produced by almost every major orthopedic manufacturer worldwide.
It is important to acknowledge the contributions of each of the pioneer surgeons of the
previously mentioned DAA technique, since many surgeons have learned from them. We
believe that a properly trained, modern hip surgeon using the DAA reflects an amalgam
of the many various techniques presented in the preceding chapters, each of which has tar-
geted learning points and take home points. The goal of this text is to allow a surgeon to
proceed along a training pathway from beginner, to intermediate, to advanced, ultimately
achieving comprehensive expertise with the DAA for a wide array of patient conditions,
well beyond simple primary THA.
For a considerable time, there was a difference in opinion within the United States
between those surgeons performing the DAA with and without a traction table. Thus,
surgeons who learned from Dr. Matta and Dr. Keggi, respectively, had justification and
defense of their selected technique, and each variation enjoyed a rich background and

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In Closing: The Future of Direct Anterior Hip Surgery 437
tradition. With time and monitoring of patient outcomes, it has become clear that both
versions of the surgical procedure have pros and cons, and both are viable and effective
options.
Ideally, elements of both techniques can and should be incorporated into one's prac-
tice, and exposure to both options must be an element of comprehensive surgical training
moving forward. With the completion of this text, we feel that a bridge has now been
established between these 2 philosophies. Each has inspired the next generation of great
surgical thinkers, and many of those individuals have presented unique DAA technique
variations within this text.
The demand for knowledge has propelled the DAA into the forefront of modern hip
surgery. Annual audience surveys conducted at the American Association of Hip and
Knee Surgeons (AAHKS) now suggest that over 25% of AAHKS surgeons are using the
DAA, a number that continues to grow annually and will likely rise in the next decade
ahead. Industry estimates also suggest 8% to 10% annual growth in surgeon utilization of
the DAA during this same period. The ultimate impact of the DAA on the world of hip
reconstruction is still evolving, but clearly will play a role in driving improvement moving
forward.
Today, surgeons can apply the DAA toward a wide variety of patients, diseases,
and conditions. Revisions, once thought to be too complex for the DAA, can now be
routinely performed for many indications. Hip joint preservation and fracture care can
be incorporated into a DAA practice with ease, again expanding the horizons for the
DAA in the modern hip practice. The evolution and development of innovations such as
fluoroscopically-guided implant placement and short stems that limit bone removal are a
favorable by-product of the wider adoption of DAA THA.
While several orthopedic product manufacturers were offering DAA surgeon education
and training programs, a single, comprehensive, and objective training course was lacking
for many years. Now, the ICJR’s annual “Anterior Hip Course” will enter its fifth year in
2016, driven by the original vision and leadership of Matta, and now led by other leaders,
such as Drs. Joseph T. Moskal, Stefan Kreuzer, John Masonis, and Michael Nogler. Many of
the energetic faculty teaching that course have contributed to this text, and the diversity
of their expertise is reflected in the technique variations, unique devices, and specific
applications of the DAA to further expand the horizon of this field for our readers.
Moving forward, surgeons are being held responsible for developing and reporting on
quality measures by insurers and government agencies. A desire to improve patient short-
term outcomes will continue to drive surgeons toward adopting truly minimally invasive
surgery techniques and will fuel ongoing interest in the DAA for years to come.
At the present time, nearly all of the many currently available surgical approaches for hip
reconstruction yield similar long-term clinical outcomes at 10+ years and identical implant
durability based on the current generation of implants. If long-term THA outcomes are
similar, then there is no reason why any surgeon should avoid a surgical technique that has
short-term advantages in terms of efficacy, safety, and quality of recovery. With the most
current evidence in hand, DAA is the favored method to help achieve these important
short-term goals. As an example, the literature directly comparing the DAA to posterior

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438 Chapter 34
or anterolateral surgery for THA and hip hemiarthroplasty now makes a clear case for
improved short-term recovery and early outcomes with the DAA, making it an evidence-
based technique choice in the new era of public disclosure of surgical results.
Moving into the future, many exciting developments will shape the practice of hip
surgery and expand the DAA. Implant design will continue to evolve; an improved under-
standing of proximal femoral geometry will create less invasive and more durable stems
with improved bone preservation and early fixation. Biomaterials will evolve, as future
generations of wear-resistant polyethylene and ultra-performance ceramics will further
push the longevity and durability of THA. In doing so, the DAA will combine with
these implants to expand the reliability of THA for patients across the age spectrum and
improve the outcome of THA performed for rare conditions and pathology.
Ultimately, the combined result of accurate THA implant positioning, hip muscle and
bone preservation, enhanced implant fixation, and durable bearing wear will be to reduce
the burden of revision surgery. Although revision was once thought to be inevitable for
young, active patients with severe structural or metabolic hip arthrosis, the future of DAA
THA in the hands of modern surgeons may lead to fewer revision operations, and perhaps
completely eliminate the need for secondary arthroplasty surgery after a well-performed
index operation.
Already, there are many individual surgeons and groups publishing on the DAA.
Pooling of these data along with improved surgeon collaboration will lead to further
developments of the technique. As more surgeons report on the DAA, we will see the
continued evolution of the adult reconstruction field move toward embracing the DAA as
an evidence-based strategy. Importantly, the DAA will be incorporated into the accepted,
mainstream teaching pathway for orthopedic resident and fellowship education, thereby
easing the learning, teaching, and propagation of the technique.
As a specific example, in 2005 at Brown University there were 5 adult reconstruction
specialists; all routinely performed the anterolateral or posterior approach for primary
THA. In late 2015, there are still 5 adult reconstruction specialists on the same core
academic faculty, but now 3 of these 5 routinely perform the DAA for primary THA.
Residents in training are being exposed to this new DAA focus and are seeking to incor-
porate the technique into their future practices. As a result, the present text will serve as
a formal reference for both basic knowledge and skill development, and will hopefully
become a resource for ongoing, lifelong learning, and practice development.
On behalf of our editors, authors, and publisher, we are grateful that you have chosen
to use this text. We hope you will work toward becoming an expert DAA surgeon and
will work to pass your knowledge on to both current colleagues and also to the next gen-
eration of students, residents, and fellows eager to carry on this great tradition into the
future. Perhaps most importantly, we are confident that the skillful use of the DAA will
positively impact patient outcomes around the world. Ultimately, we all share in achieving
that goal.

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Financial Disclosures
Dr. Daniel C. Allison has received royalties from TeDan Surgical Innovations, Inc, Ortho
Development Corporation, and Exactech, Inc; consultant fees from Ortho Development
Corporation and Exactech, Inc; is a paid speaker for ConvaTec, Inc; and is on the surgeon advisory
board for and has stock options from Carbo-Fix Ltd.
Dr. Michael P. Ast is on the speakers bureau of Smith & Nephew and is a consultant for
OrthoAlign, Inc.
Dr. B. Sonny Bal is a consultant to Microport Orthopedics, a design surgeon for ConforMIS
Corporation, and is President and CEO of Amedica Corporation.
Dr. Keith R. Berend is a board/committee member for the Knee Society; is on the edito-
rial/governing board for Reconstructive Review; and received research support from Kinamed,
Orthosensor, Paciria, and Zimmer Biomet.
Dr. Paul E. Beaulé is a consultant for Corin, MicroPORT, and Zimmer Biomet.
Dr. Hari P. Bezwada is an educational consultant for Zimmer Biomet and Ortho Development.
Dr. Mohit Bhandari receives research funding from Stryker and Smith and Nephew.
Dr. Lawrence Brenner has no financial or proprietary interest in the materials presented herein.
Dr. Derek Butterwick has no financial or proprietary interest in the materials presented herein.
Dr. Harman Chaudhry has no financial or proprietary interest in the materials presented herein.
Dr. Brett D. Crist has stock options from Amedica Corporation and Orthopaedic Implant
Company; is a paid consultant for DePuy, KCI, and Microport; is a board member for International
Geriatric Fracture Society and Orthopaedic Trauma Association; is on the editorial board for
the Journal of Orthopaedic Trauma and the Journal of the American Academy of Orthopaedic
Surgeons; and receives research support from Synthes and Wright Medical Technology, Inc.

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440 Financial Disclosures
Dr. Savrang Dalal has no financial or proprietary interest in the materials presented herein.
Dr. Garrett Davis has no financial or proprietary interest in the materials presented herein.
Dr. Matthew E. Deren has no financial or proprietary interest in the materials presented herein.
Dr. David Dodgin has no financial or proprietary interest in the materials presented herein.
Dr. Benjamin Domb has received research grants and support from ATI, Breg, American Hip
Institute, Arthrex, MAKO Surgical, and Pacira; he is a consultant for Arthrex, MAKO Surgical,
and Parcia; he receives royalties from Orthomerica, DTO; and is a stockholder with Stryker.
Dr. Larry Dorr receives royalties from Don Joy Orthopedics on revision knee design and has
stock in Joint Development, LLC.
Dr. Adam M. Freedhand has no financial or proprietary interest in the materials presented
herein.
Dr. Reinhold Ganz received seed money from Examedical S.P.A., Italy.
Dr. Dan Gerscovich has no financial or proprietary interest in the materials presented herein.
Dr. Joseph A. Gil has no financial or proprietary interest in the materials presented herein.
Dr. Wade Gofton received education technology from Microport and Zimmer.
Dr. E. Matthew Heinrich is a consultant for DePuy Medical Education, Medtronic Medical
Education, and DJO Medical Education; receives royalties from DJO Empower Knee Design; and
has stock options with Orthalign Consultant.
Dr. Robert E. Howell is a paid consultant for Zimmer Biomet and DePuy.
Dr. Timothy Jackson has no financial or proprietary interest in the materials presented herein.
Dr. Atul F. Kamath is a consultant for Zimmer Biomet and DePuy.
Dr. Stephen Kayiaros is a stock holder with Pfizer, a consultant for DePuy Orthopedics, and a
reviewer for Reconstructive Review.
Dr. Kristaps J. Keggi receives stock options and IP royalties from OMNI Life Science, Inc, and
is a board/committee member for the Yale Orthopaedic Alumni Organization.
Dr. Stefan Kreuzer receives royalties from Corin Stryker (MAKO), and Zimmer; is on the
speakers bureau for Corin, Stryker (MAKO), and Stryker; is a paid consultant for Corin, Stryker
(MAKO), Stryker, and Medtronic; has stock options from Innovative Orthopedic Technologies;
received research support from Eli Lilly and Cempra Pharmaceutical; is on the editorial/gov-
erning board of the Journal of Arthroplasty; and is a board member for the International Society
for Technology in Arthroplasty, the International Congress for Joint Reconstruction, and the
Memorial Bone and Joint Research Foundation.
Dr. Michael Leunig is a consultant to DePuy and Arthrex, and has received research funding
from the Swiss National Science Foundation.
Dr. Allan Liew has no financial or proprietary interest in the materials presented herein.

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Financial Disclosures 441
Dr. Adolph V. Lombardi Jr is a consultant for Zimmer Biomet, Pacira Pharmaceuticals, and
OrthoSensor; receives royalties from Zimmer Biomet, Innomed, and OrthoSensor; receives
research support from Zimmer Biomet, Pacira Pharmaceuticals, and OrthoSensor; is on the
editorial board for Journal of Arthroplasty, Journal of Bone and Joint Surgery-American, Clinical
Orthopaedics and Related Research, Journal of the American Academy of Orthopaedic Surgeons, Journal of
Orthopaedics and Traumatology, Surgical Technology International, and The Knee; and is on the board
for Operation Walk USA, The Hip Society, The Knee Society, and Mount Carmel Education
Center at New Albany.
Dr. Tim P. Lovell is a consultant for Stryker Orthopedics.
Dr. Joel M. Matta is a paid consultant for DePuy, Invuity Inc, Medtronic Sofamor Danek, and
Stryker; received stock options from Invuity Inc, Medical Enterprises MD LLC, and Radlink
Corp; and received IP royalties from Mizuho OSI.
Dr. Philip McClure has no financial or proprietary interest in the materials presented herein.
Dr. Timothy McTighe has equity in CDD, LLC, consults for Signature Orthopaedics, and
royalties from CDD, LLC.
Dr. Wietse P.R. Melman has no financial or proprietary interest in the materials presented
herein.
Dr. Stavros G. Memtsoudis has no financial or proprietary interest in the materials presented
herein.
Dr. Markus C. Michel has no financial or proprietary interest in the materials presented herein.
Dr. Joseph Morgan has no financial or proprietary interest in the materials presented herein.
Dr. Joseph T. Moskal is a consultant for Stryker and Medtronic, on the speakers bureau for and
receives royalties from DePuy, and has stock options from Invuity.
Dr. Michael Nogler is on the speakers bureau for and receives royalties from DJO and Stryker.
Dr. Steve Papp receives institutional support from Synthes.
Dr. Javad Parvizi has no financial or proprietary interest in the materials presented herein.
Dr. Preetesh D. Patel is a consultant for Stryker, on the speakers bureau for Pacira Pharmaceu-
ticals, and is a stockholder with OtisMed Corporation.
Dr. Christopher E. Pelt is a board/committee member for the American Academy of Orthopedic
Surgeons and the American Association of Hip and Knee Surgeons; and is a paid consultant for
Zimmer Biomet.
Dr. Blake E. Peterson has no financial or proprietary interest in the materials presented herein.
Dr. Amir Pourmoghaddam is on the editorial/governing board for the Journal of Arthroplasty.
Dr. Scott A. Ritterman has no financial or proprietary interest in the materials presented herein.
Dr. Anjali O. Rozario has no financial or proprietary interest in the materials presented herein.
Dr. Lee E. Rubin is a board/committee member of the American Academy of Orthopaedic

Surgeons, the American Association of Hip and Knee Surgeons, the Orthopaedic Research
Society, and the Rhode Island Orthopaedic Society; and is on the editorial/governing board for
Arthroplasty Today and Reconstructive Review.

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442 Financial Disclosures
Dr. John A. Scanelli has no financial or proprietary interest in the materials presented herein.
Dr. Jonathan R. Schiller has no financial or proprietary interest in the materials presented herein.
Dr. Herrick J. Siegel has consultant agreements with Zimmer Bioment, Corin, Aesculap, DJO,
and Stanmore.
Dr. Eric M. Slotkin is a consultant for DePuy-Synthes and Radlink, a speaker for Pfizer, and
has stock options with Radlink.
Dr. Evan Smith has no financial or proprietary interest in the materials presented herein.
Dr. R. Presley Swann has no financial or proprietary interest in the materials presented herein.
Dr. Mohan S. Tripathi has no financial or proprietary interest in the materials presented herein.
Dr. Nathan J. Turnbull has no financial or proprietary interest in the materials presented herein.
Dr. Anthony S. Unger is a consultant for Stryker and Biomet; receives royalties from Innomed
and Biomet; has a share ownership in CDD; and is a reviewer for the Journal of Arthroplasty and
Arthroplasty Today.
Dr. Cees C.P.M. Verheyen has no financial or proprietary interest in the materials presented
herein.
Dr. Jonathan Yerasimides is a consultant for Zimmer Biomet, DePuy, and Medtronic.
Dr. Navid M. Ziran has no financial or proprietary interest in the materials presented herein.

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Direct Anterior Approach Arthroplasty Text Book

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Direct Anterior Approach Arthroplasty Text Book

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© 2016 SLACK, Incorporated

Kristaps J. Keggi, MD, Dr Med (hc)

© 2016 SLACK, Incorporated

Published by: SLACK Incorporated

Library of Congress Cataloging-in-Publication Data

© 2016 SLACK, Incorporated

© 2016 SLACK, Incorporated

Section I Basic Direct Anterior Approach Surgical Technique . . . . . . . . . . . 1

Chapter 1 Applied Anatomy of the Anterior Hip and Thigh . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Chapter 2 Indications for the Direct Anterior Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Chapter 4 Primary Total Hip Arthroplasty Using the Hana Table . . . . . . . . . . . . . . . . . . . . . 39

Chapter 5 Extensile Approach to Anterior Hip Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Chapter 6 Anterior Supine Intermuscular Total Hip Replacement . . . . . . . . . . . . . . . . . . . . . 77

Section II Intermediate Direct Anterior Approach Techniques . . . . . . . . . . 105

Chapter 8 Understanding the Risks in New Technologies . . . . . . . . . . . . . . . . . . . . . . . . . . 107

© 2016 SLACK, Incorporated

Chapter 10 Direct Anterior Total Hip Replacement With Leg Positioning

Chapter 11 Computer Navigation and Robotics in Anterior Hip Reconstruction . . . . . . . . . 135

Chapter 12 Transitioning to Direct Anterior Total Hip Replacement . . . . . . . . . . . . . . . . . . 149

Chapter 13 Specialized Instruments for the Direct Anterior Approach. . . . . . . . . . . . . . . . . . 161

Section III Advanced Adult Reconstructive Techniques . . . . . . . . . . . . . . . . 193

Chapter 15 Avoiding, Recognizing, and Treating Complications of the

Chapter 16 How to Identify and Correct Technical Errors With

Chapter 18 Simultaneous Bilateral Direct Anterior Approach

Chapter 19 Acetabular Direct Anterior Approach Revision Surgery . . . . . . . . . . . . . . . . . . . . 239

Chapter 20 Anterior Approach Femoral Revision Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

© 2016 SLACK, Incorporated

Section IV Direct Anterior Approach Across Orthopedic Specialties:

Chapter 21 Direct Anterior Hip Surgery in Pediatric Patients . . . . . . . . . . . . . . . . . . . . . . . . 263

Chapter 22 Management of Developmental Dysplasia of the Hip With

Section V Direct Anterior Approach Across Orthopedic Specialties:

Chapter 23 Limited Exposure Direct Anterior Approach for

Chapter 24 Addressing Acetabular and Femoral Lesions in Hip Impingement With

Section VI Direct Anterior Approach Across Orthopedic Specialties:

Chapter 25 Management of Acetabular Fractures in the Elderly With

Section VII Direct Anterior Approach Across Orthopedic Specialties: Adult

Chapter 26 Proximal Femur-Preserving Hip Reconstruction With

Section VIII Direct Anterior Approach Across Orthopedic Specialties:

Chapter 27 Tumor Reconstruction of Hip and Proximal Femur With

© 2016 SLACK, Incorporated

Section IX Direct Anterior Approach Across Orthopedic Specialties:

Chapter 28 Patient Rehabilitation After Direct Anterior Hip Surgery . . . . . . . . . . . . . . . . . . 347

Section X Direct Anterior Approach Across Orthopedic Specialties:

Section XI Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381

Chapter 30 Multi-Center Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383

Chapter 31 Current Direct Anterior Approach Outcomes Literature Review . . . . . . . . . . . . . 389

Section XII Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433

Chapter 34 In Closing: The Future of Direct Anterior Hip Surgery. . . . . . . . . . . . . . . . . . . . 435

Financial Disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439

© 2016 SLACK, Incorporated

© 2016 SLACK, Incorporated

© 2016 SLACK, Incorporated

Originally from New Jersey, Lee E. Rubin, MD matriculated as an undergraduate Presidential

© 2016 SLACK, Incorporated

© 2016 SLACK, Incorporated

© 2016 SLACK, Incorporated

Benjamin Domb, MD (Chapter 7) Stephen Kayiaros, MD (Chapter 15)

Joseph A. Gil, MD (Chapter 23) Allan Liew, MD (Chapter 25)

© 2016 SLACK, Incorporated