INDICATIONS/CONTRAINDICATIONS

There has been an increased interest in the anterior approach for total hip arthroplasty (THA) in the United States over the last 5 to 10 years (1). This increased attention has grown from surgeon and patient desires' for rapid recovery, reduced dislocation risk, and increased component accuracy, which have been advocated as benefits of this approach, as well as a multiplicity of economic and marketing pressures, which have influenced surgeons to examine their surgical approach to the hip.

The anterior approach was first described by Smith-Peterson in 1917 (2,3) and used for mold arthroplasties. Heuter modified the classic Smith-Peterson approach, utilizing the inferior limb of the incision, dissecting between the sartorius muscle medially and the tensor muscle laterally and the tensor and rectus muscles deep onto the hip capsule. Judet (4) utilized an anterior approach in conjunction with a traction table for hip procedures including early arthroplasty. Following positive personal experience with the anterior approach for total hip arthroplasty, Joel Matta popularized this approach in the United States, touting the intermuscular, internervous plain to the hip joint as an approach that did not disrupt the abductor or “deltoid muscles” of the hip (5).

While several well-described approaches can be considered for routine total hip arthroplasty, the anterior approach has long been utilized for nonarthroplasty interventions requiring arthrotomy of the hip joint including removing of loose bodies, drainage of sepsis, and fractures of the femoral head. Recently, it has been advocated for patients seeking a more rapid recovery from the surgical trauma of hip arthroplasty.

Although this last point remains controversial, strict indications for anterior total hip arthroplasty do not exist. Relative indications for utilizing an anterior approach

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include patients who are at higher risk for postoperative dislocation. This includes patients suffering neurologic conditions such as multiple sclerosis, prior stroke, or patient factors such as cognitive

impairment, substance abuse, or parkinsonism that may additionally be considered. Patients suffering from collagen vascular disorders such as Ehlers-Danlos or patients with prior hip fusion, particularly those with anteriorly placed hardware, are relative indications for an anterior approach.

Contraindications to the use of anterior approach vary according to the surgeon's experience with extensile techniques employed via this approach and consequently are relative. That said, anterior approach is not generally selected for patients requiring trochanteric osteotomy for exposure or in patients with high-riding developmental dysplasia in which subtrochanteric osteotomy is required. Additionally for some surgeons, arthroplasty situations requiring the use of a straight stems may prove problematic and are a relative contraindication. Revision arthroplasty, when more extensile femoral exposure is required, is a relative contraindication for an anterior approach arthroplasty. Additionally, patients with personal hygiene issues, very large abdominal pannus, or with obvious skin irritation and/or fungal infection in the hip flexion crease are at risk for periprosthetic infection if explored via an anterior approach.

A number of recent studies have reported outcomes comparing direct anterior approach (DAA) THA to other approaches. Nakata et al. (6) reported faster recovery of hip function and gait mechanics with DAA

 

compared to posterior approach THA. A retrospective MRI study comparing DAA to transgluteal approach found better soft tissue response, and another study found decreased creatine kinase, a marker for muscle tissue damage, in patients undergoing DAA compared to posterior approach THA (7,8). In a prospective randomized comparison of DAA to posterior approach, Barrett et al. (9) found improvements in early functional recovery and VAS scores for the DAA group that persisted to 3 months. We conducted a similar prospective randomized trial comparing DAA to miniposterior approach and found earlier cessation of walking aids with the anterior cohort (10). Additionally, Rodriguez et al. (11) found faster functional recovery and comparable safety with DAA compared to posterior approach, yet the functional gains did not persist beyond 2 weeks. The early functional recovery gains were reflected in another case series where hospital length of stay was significantly shorter for the DAA group compared to posterior approach (12). In another prospective series, the outcome variance between anterior and posterior patients undergoing advanced rehabilitation protocols was minimal (13).

Gait analysis has documented minimal difference in gait parameters between anterior and posterior approach patients, but greater postoperative stiffness in patients undergoing posterior approach (14,15). A prospective randomized trial comparing DAA with anterolateral approach found significantly better SF-36, WOMAC, and linear analogue scale assessment scores for the DAA patients, which persisted beyond 6 months (16). Several authors have shown improvement in acetabular component accuracy with the combined use of fluoroscopy and DAA, but without defined clinical benefit (17,18). Improvements in capsular closure and the use of larger heads have reduced the likelihood of instability following posterior approach THA to 1% to 2% some series (19). Many authors have shown equally low rates of dislocation with DAA, yet rates of revision for instability following DAA are 0.1%, superior to posterior THA (20). In contrast to the equivalent safety profiles reported in each of the aforementioned studies, some studies have highlighted technical concerns with DAA, documenting higher intraoperative fracture risk, higher complication risk, and higher blood loss in the early learning series (21,22).

 

PREOPERATIVE PLANNING AND PATIENT SELECTION

In patients with hip disease requiring THA, an anteroposterior standing pelvic x-ray and a Lowenstein lateral radiograph of the hip are obtained. We typically employ digital templating with a standardized magnification marker. Care is taken in the templating process to ascertain ideal component position, beginning first with the acetabular component. The depth and sizing of the acetabular component is patient specific, but generally, we attempt to reproduce the native hip center for each patient. Leg lengths are carefully evaluated, and the effect of stem position, neck resection level, and prosthetic head length are all ascertained and recorded in the preoperative templated plan. With regard to the acetabular component position, templated acetabular component position is noted relative to the patient's radiographic teardrop. This landmark can be easily evaluated intraoperatively with the assistance of fluoroscopy and consequentially reproduced according to the templated plan. Limb length differences (LLDs) are measured on the templated x-ray, referencing a horizontally line at the base of the teardrop of the pelvis on both sides and compared to a line drawn between two fixed femoral references, typically the top of the lesser trochanters. The measured LLD should

 

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be interpreted clinically with attention paid to fixed pelvic obliquity or discrepancies in extremity lengths, which occur below the level of the hip joint. In such instances, clinical measurement of limb inequality with blocks can be helpful. Stem selection, shape, and fill are all contingent upon variances in endosteal anatomy of the patient. Anatomic femoral offset also figures prominently into stem selection. With careful attention to templating, the patient's limb length and femoral offset can be optimized, assisting with abductor mechanics and soft tissue tension.

Patient

Positioning The patient is placed in the supine position on the operative table. We elect to use a specialized operative bed, which allows independent manipulation of the two legs with the ability to flex and extend, abduct, and adduct the operative extremity. There is a central perineal post, which is used as a counter point for traction necessary in dislocation and reduction phases of the surgical procedure as well as to assist in acetabular exposure. The patient's arms are extended at their side, which allows easy access for the anesthetic team. A Mayo stand is brought in from the nonoperative side at the level of the patient's shoulders and kept 6 to 12 inches above the patient's face to facilitate airway management by the anesthetic team throughout the surgical procedure and to serve as a platform for surgical instruments, lavage, cautery, and suction. The patient on the table is typically raised to a height comparable to the upper abdomen of the operative surgeon, which facilitates comfortable a working height and visualization of the surgical field. Gel or foam pads are placed beneath the bony prominence of the upper extremities on the arm boards, and the palms are secured in the supinated position with a Velcro wrap. The protuberant abdomen or pannus of an obese patient is displaced to the nonoperative side using adhesive spray and nonstretch tape, which is secured to the contralateral side of the operative bed.

Draping A nonsterile adhesive U-Drape is applied to the lateral femur and extended medial to the anterior-superior iliac spine by approximately one hand breath. The posterior limb of the U-Drape is brought to the lateral iliac crest posterior to the greater trochanter by similar hand breadth. A second nonsterile plastic drape is applied proximally, connecting the two limbs of the U-Drape 4 to 5 cm above the iliac crest. This field is clipped preoperatively with electric clippers shortly prior to entering the operative theater. The field is cleansed with alcohol removing any emollients or flaking skin. The field is then sterilized with either chlorhexidine solution or iodine/alcohol solution.

A pair of adhesive sterile paper U-Drapes are used to circumscribe the field highlighted above. A bar drape is placed longitudinally over the midaxis of the patient and allowed to cover the non-operative extremity. If necessary to cover the arm board on the operative side, a bar drape can be placed diagonally across the patient's midabdomen and secured to the IV poles. The surgical field is marked for incision position, and the skin is covered with the iodine-impregnated adhesive occlusive barrier drape.

The specialized table that we utilize has a hydraulic lift for a hook that passes beneath the proximal femur, assisting with femoral exposure (see below). A small cut is made in the drapes over the apex of the nonsterile femoral hydraulic lift adapter. The sterile bracket for the femoral hook is placed onto the spicket from the hydraulic lift. The barrier between the drapes and the bracket is sterilely secured circumferentially with a cut strip of the iodine adhesive barrier. Suction and cautery are secured and stored on the Mayo stand over the patient's thorax.

Approach The incision is begun approximately 2 cm lateral to the anterior-superior iliac spine and extends for approximately 10 cm toward the lateral epicondyle of the knee (Fig. 1-1). This incisional position places the skin incision above the anterior margin of the tensor fascia lata muscle. Some variability in positioning of the skin incision is necessary with certain body habitus. In the obese patient, the incision is slightly more lateral on the thigh and extends up to but not across the skin flexor crease. This keeps the incision lateral to the pannus, which can assist in wound healing. Placing the incision 2 cm lateral to the anterior-superior iliac spine reduces the risk of injury to the lateral femoral cutaneous nerve.

The incision is carried down through the subcutaneous tissues to the fascia over the tensor fascia lata muscle. Commonly, two or three small perforators can be visualized exiting through the fascia and should be cauterized. The lateral femoral cutaneous nerve arborizes proximally and remains superficial to the tensor fascia lata muscle fascia. Once this fascia plane is identified, care is taken to avoid dissection at the level of the fascia to avoid

inadvertent dead space creation. The fascia of the tensor fascia lata muscle is opened longitudinally with a No. 20 Beaver blade revealing the

 

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longitudinally oriented fibers of the tensor fascia lata muscle (Fig. 1-2). An Allis clamp is used to grasp the anterior leaf of the fascia, and a cob elevator is used to sweep the muscle off of the anterior medial fascia allowing finger dissection down to the superior femoral neck. A cobra retractor is placed medial to the tensor

fascia muscle over the superior femoral neck. This plane is easily identified and can be verified with the absence of muscular tissue between the retractor and the superior femoral capsule. By opening the fascia of the tensor fascia lata muscle, the sartorius muscle remains medial to the dissection superficially and the rectus femoral muscle can be visualized through the fascia medially deep within the incision lying over the anterior aspect of the femoral head neck junction. A Hibbs right-angle retractor is then placed medially within the wound, and the rectus muscle is retracted medially. A thin band of fascia extends between the rectus and the tensor muscle.

 

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Just deep to this fascia are the ascending branches of the lateral circumflex vessels, which traverse medial to lateral towards the muscle of the tensor fascia lata (Fig. 1-3). Typically, two but occasionally three pairs of vessels are present and should be identified and cauterized. Although suture ligature for these vessels have been advocated by some surgeons, simply cauterizing them with a hemostat adequately assures hemostasis. Just deep to the circumflex vessels lies the pericapsular fat, anterior to the femoral neck. This fatty tissue will often have a more globular appearance and can be used to differentiate this tissue plane. When this pericapsular fat is encountered, a cob elevator is then placed onto the inferior aspect of the femoral neck

elevating the rectus femoris muscle from the anterior capsule of the hip. A second cobra retractor can be placed in this interval between the hip capsule and the rectus femoris. The pericapsular fat can then be excised.

 

 

 

 

FIGURE 1-1 Illustration of incision placement and fascial exposure.

 

 

 

FIGURE 1-2 A,B: Illustration of TFL fascial incision and elevation of TFL fascia.

 

When the tissue planes have been identified down to the anterior hip capsule, the retractors are removed and a tubular tissue protector is placed deep to the tensor muscle and adjacent to the rectus femoris muscle. This tissue protector reduces trauma, particularly to the tensor muscle belly, throughout the remainder of the surgical procedure. The cobra retractors are replaced through the tubular tissue protector onto the superior and inferior hip capsule as before. The capsulotomy incision is made, beginning proximally at the anterior margin of the acetabulum over the anterior-superior femoral neck, and extended laterally to the inner trochanteric ridge at the superior lateral aspect of the femoral neck-greater trochanteric junction (Fig. 1-4). The inferior limb of the capsulotomy is extended along the anterior inner trochanteric ridge just approximal to the vastus

 

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lateralis muscle. A tagged suture is placed at the apex of the anterior leaf of the capsule, and the cobra rectractor is moved intracapsularly. The superior lateral capsule is released at the junction of the greater trochanter allowing visualization of the inflection between the neck and the greater trochanter, and a second capsular suture is placed at this apex. The superior cobra rectractor is also placed within the hip capsule (Fig. 1-5). With the anterior femoral head neck region now exposed, the extremity is externally rotated approximately 80 degrees, which places the inferior hip capsule under tension. The electrocautery is used to release the inferior hip capsule off of the anterior calcar to the midcoronal plane. Palpation of the medial calcar assures completion of this release. The hip is then returned to a neutral rotation, and the inferior cobra retractor is replaced with a Mueller retractor, which provides improved visualization of the anterior medial head neck region.

 

 

 

 

FIGURE 1-3 Identification (A) and cautery (B) of ascending branch of circumflex vessels.

 

 

 

FIGURE 1-4 Outline of anterior hip joint capsulotomy.

 

Unlike other approaches to the hip that often reference the lesser trochanter for the femoral neck osteotomy selection, DAA utilizes the lateral neck-greater trochanteric reflection as a constant point of comparison to the templated neck resection level. The appropriate neck resection level can be scored on the anterior aspect of the femur with the electrocautery. Fluoroscopy can be utilized to better localize the osteotomy level if desired. The femoral neck resection is typically performed with either a tissue protecting saw or a single-sided reciprocating saw (Fig. 1-6). The cut is performed with traction on the extremity, which allows the osteotomized proximal femoral head segment to recess into the acetabulum following the osteotomy. A corkscrew can be driven into the proximal

 

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femoral neck segment allowing manipulation and removal of the femoral head (Fig. 1-7). To assist in rupturing the ligamentum teres, circular motion of this fragment is useful. Occasionally, excessive osteophytes or marked protrusion may require a napkin ring osteotomy of the femoral neck to assist with femoral head removal.

 

 

 

 

FIGURE 1-5 Illustration of completed anterior capsulotomy and ligation of ascending circumflex vessels.

 

 

 

FIGURE 1-6 Illustration of femoral neck osteotomy.

 

 

 

 

 

FIGURE 1-7 Illustration of corkscrew utilized to remove femoral head.

 

Acetabular Preparation With the femoral head removed, traction in generally released from the extremity and the extremity is allowed to externally rotate approximately 60 degrees. External rotation of the femur lateralizes the anterior margin of the cut distal femoral segment, allowing better visualization through the wound into the acetabulum. The first acetabular retractor is a curved Hohmann-like retractor, which is placed between the anterior labrum and the hip capsule over the anterior column. Care is taken to achieve accurate placement of this retractor as placement too deep could injure the femoral nerve. The second acetabular retractor, also a curved Holman-like retractor, is placed within the hip capsule posteriorly, lateral to the posterior labrum. This can be secured to the femoral lift for hands free retractor. It is helpful to release the superior capsule from the anterior-superior acetabular margin for approximately 4 to 8 mm, allowing inversion of the proximal hip capsule. The posterior acetabular labrum can then be easily visualized and sharply excised. A third retractor, a straight, sharp Hohmann retractor, can be placed just anterior to the transverse acetabular ligament between the hip capsule and anterior labrum. With these two anterior retractors in place, the anterior labrum and pulvinar are easily visualized and removed (Fig. 1-8). Any overriding anterior osteophytes can also be removed at this time with a curved half inch lambotte osteotome.

 

 

 

FIGURE 1-8 Illustration and clinical photo of acetabular exposure achieved for proper acetabular preparation.

 

 

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FIGURE 1-9 A: Illustration of acetabular reamer placement and clinical photo of fluoroscopy setup for acetabular reaming. B: Fluoroscopic image obtained during reaming of acetabulum.

 

The third, inferior Hohmann retractor, is removed prior to acetabular reaming. Slight traction is applied to the extremity, and offset acetabular reamers are typically employed (Fig. 1-9).

Femoral Preparation Following impaction of the acetabular component (Fig. 1-10), attention is directed to the exposure of the femur. With traction released and the extremity in neutral rotation, the femoral lift hook is placed between the lateral abductor musculature and the lateral proximal femur. This fascial plane is easily palpable and does not require dissection. Without elevation of the femur, the extremity is externally rotated to 120 to 140 degrees on the leg spar of the specialized table. A sharp Hohmann retractor is placed over the medial calcar just medial to the lesser trochanter,

 

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tensing the medial capsular attachment to the calcar. The electrocautery is used to further release this inferior capsular attachment, allowing palpation of the lesser trochanter. When the lesser trochanter can be easily palpated, the release is complete. A Mueller retractor is placed medial to the femoral neck, and the leg is extended and adducted. The proximal capsular suture is then placed under tension, and the space between the anterior-superior capsule and the greater trochanter is exposed with a curved Hohmann retractor placed over the anterior lateral trochanter. The plain between the superior capsule and the gluteus minimus can then be identified, and the capsule is reflected off of the lateral neck between the lateral neck and the greater trochanter. Once this has been released to the posterior proximal aspect of the femoral neck, the superior capsular release is complete. The superior capsule is maintained and held medial to the femur with a sharp Hohmann placed over the posterior proximal femur just distal to the piriformis notch.

 

 

 

 

FIGURE 1-10 Illustration of acetabular component in place.

 

At this time, the proximal femur can be elevated into the wound with the assistance of the hydraulic femoral lift (Fig. 1-11). The surgeon should manually elevate the femur and use the femoral lift to match the manual positioning to avoid excessive pressure on the proximal femur and greater trochanter.

To improve visualization of the lateral proximal femur, the conjoint tendon and piriformis tendon are often released. This may not be necessary in all patients. This release is performed with the electrocautery at the posterior margin of the femoral neck proximal to the neck resection level and extending proximally towards the greater trochanter, traversing the conjoint tendon and the piriformis tendon. Commonly, when these tendons are released, further elevation of the femur will occur. A Mueller retractor can then be placed deep to the tensor

muscle over the tip of the greater

 

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trochanter fully exposing the proximal femur. The remnants of the piriformis conjointed tendon attachments to the femur within the piriformis fossa can be cleared with the electrocautery.

 

 

 

 

FIGURE 1-11 A: Illustration of proper femoral exposure and proper externally rotated position of patient's leg during femoral preparation. B: Clinical photograph of proper femoral exposure.

 

At this time, the proximal femur should be well visualized and may be accessed for broaching with curved or offset broach handles. The lateral femur is opened with a combination of a box osteotome and a rongeur. A lateralizing broach may be utilized to avoid positional varus. Broaching is initiated with a curve broach handles and graduated until secure broach position is obtained. Femoral anteversion is judged by comparison of the anatomic neck orientation to the epicondylar axis, which is palpable at the knee, typically striving for 15 to 20 degrees of anteversion. With the broach in place, trial reduction can be performed and fluoroscopy can be utilized to assist in assuring accurate component position, offset, and leg length. The extremity can be taken through arc of motion to confirm stability if desired. The authors typically examine the hip for stability in extension with 90 degrees of external rotation. If leg length is appropriately restored and femoral-acetabular component positions appropriately oriented, the extremity will be stable at 90 degrees of external rotation (Fig. 1-12).

Following placement of final components, the wound is copiously irrigated and the hip capsule is repaired with absorbable sutures (Fig. 1-13). The thin fascia of the tensor muscle is reapproximated with a running absorbable suture, and subcutaneous closure is absorbable sutures. Subcuticular closure is performed with a 4-0 monofilament absorbable suture, and the skin edges are sealed with a cyanoacrylate adhesive.

 

 

 

FIGURE 1-12 A: Clinical photograph of femoral broach placement with curved broach handle. B: Illustration of final femoral component in place.

 

 

 

 

 

FIGURE 1-13 Illustration of anterior hip joint capsular closure with suture.

 

 

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Postoperative Management A silver-impregnated inclusive dressing is applied to the wound and maintained for 7 to 10 days postoperatively. Patients are allowed to weight-bear to tolerance immediately and are typically ambulated on the surgical ward the evening of surgery. Patients may graduate from use of a walker to a cane when they have sufficient confidence. Progression of physical therapy goals is gradual over the first 4 weeks and accelerated subsequently after early osseous integration of the implants occurs. Parenteral narcotics are used sparingly throughout the first 24 hours only. Venous thrombosis and embolic prophylaxis are typically are treated using aspirin or Coumadin, selected based on patient risk profiles, and is continued for 28 days postoperatively.

 

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12. Zawadsky MW, Paulus MC, Murray PJ, et al.: Early outcome comparison between the direct anterior approach and the mini-incision posterior approach for primary total hip arthroplasty: 150 consecutive cases. J Arthroplasty 29(6): 1256-1260, 2014. doi: 10.1016/j.arth.2013.11.013.

     

     

13. Poehling-Monaghan KL, Kamath AF, Taunton MJ, et al.: Direct anterior versus miniposterior THA with the same advanced perioperative protocols: surprising early clinical results. Clin Orthop Relat Res 473(2): 623-631, 2015.

     

     

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18. Rathod PA, Bhalla S, Deshmukh AJ, et al.: Does fluoroscopy with anterior hip arthroplasty decrease acetabular cup variability compared with a nonguided posterior approach? Clin Orthop Relat Res 472(6): 1877-1885, 2014. doi: 10.1007/s11999-014-3512-2.

     

     

19. Jameson SS, Mason J, Baker P, et al.: A comparison of surgical approaches for primary hip arthroplasty: a cohort study of patient reported outcome measures (PROMs) and early revision using linked national databases. J Arthroplasty 29(6): 1248-1255, 2014. doi: 10.1016/j.arth.2013.11.027.

     

     

20. Sariali E, Leonard P, Mamoudy P: Dislocation after total hip arthroplasty using Hueter anterior approach.

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