Direct Anterior Approach for Total Hip Arthroplasty

The direct anterior approach to the hip for total joint arthroplasty has been recommend to have multiple pros compared to other accepted approaches through its use of a natural intramuscular and intra-nervous interval. Recent emphasis on tissue sparing and marginally invasive outpatient joint substitutions has given rise to a notable rise in the utilization of direct anterior total hip arthroplasty (DAA).

If you are suggested a hip replacement, you may be anxious about what lies ahead. That’s normal and expected—but you will be happy to learn that, in terms of result, a hip replacement is one of the most successful operations you can have. Though they sound dramatic and off-putting, hip substitution can be counted upon to dependably deliver pain comfort and reinstate quality of life.

In this blog, Dr Aashish Arbat, India’s leading Robotic joint and hip replacement surgeon, explains direct anterior approach for total hip arthroplasty.

Direct Anterior Approach for Total Hip Arthroplasty

The direct anterior approach  to the hip for total joint arthroplasty has been suggested by Dr Arbat an Orthopedic Doctor in Pune to have multiple benefits compared to other popular approaches through its use of a natural intramuscular and intra-nervous interval. Latest emphasis on tissue economical and minimally invasive outpatient joint replacements has given rise to a notable increase in the utilization of direct anterior total hip arthroplasty (DAA). Proponents of this approach cite better improvement times, lower pain levels, better patient fulfilment along with improved precision on both implant placement/alignment and leg length restoration.

Several variations of the procedure have been detailed and many authors have published their experiences and technical keys to expertly attaining this procedure. Described techniques have been performed using specifically designed instruments and specific fracture tables and intra-operative flouroscopy, however this approach may be performed using a regular table with standard arthroplasty tools with alternative patient positioning and without intraoperative imaging. This analysis abridges several aspects of the direct anterior approach for total hip arthroplasty and its comparison to other well-accepted approaches to recent hip replacement.

Direct anterior approach hip surgical technique

Through the use of a natural intramuscular and internervous interval, the direct anterior approach (DAA) for total hip arthroplasty (THA) has been mentioned to have multiple benefits over other general arthroplasty approaches. The usage of DAA for THA has substantially grown in the West in recent years due to the focus on tissue preservation and minimally invasive joint replacements. However, because of the long learning curve, literature on this approach originating from India has been inadequate, suggesting a limited adoption of this surgical technique by the Indian diaspora of practicing surgeons.

Direct Anterior Approach for Total Hip Arthroplasty: Indications, Technique, and Results

The direct anterior approach (DAA) to the hip was at the initial stage outlined in the 19th century and has been used occasionally for total hip arthroplasty (THA). In the past decade, the zest for the approach has been resumed because of the rise in demand for minimally invasive techniques. New surgical instruments and tables planned particularly for use with the DAA for THA have made the approach more approachable to surgeons. Some states that this approach results in less muscle damage and pain besides rapid recovery, although limited data exist to support these claims.

The DAA may be equivalent to other THA approaches, but there is no substantiation to date that shows improved long-term outcomes for patients. The steep learning curve and complications unique to this approach (fractures and nerve damage) have been well described. However, the incidence of these complications decreases with greater surgeon experience. A question of keen interest to hip surgeons and patients is whether the DAA results in improved early outcomes and long-term results comparable to those of other approaches for THA.

Direct Anterior Approach Hip Precautions

• No hip extension or hip external rotation beyond neutral
• No bridging, no prone lying, and none of the above motions combined
• When the patient is supine, keep the hip flexed at or above 30 degrees
• Pillow under the patient’s knee or raise the head of the bed
• No full bridging
• Do not step backwards with surgical leg
• Do not allow surgical leg to externally rotate (turn outwards)
• Never cross your legs
• Do not turn feet excessively inward or outward
• Do not bend hip more than a right angle

The Direct Anterior Approach to Hip Reconstruction

The Direct Anterior Approach to Hip Reconstruction is a diverse reference text that addresses present-day surgeon interest in reorganization and less invasive surgery.  This resource will support with introductory learning, transitional technical development, and modern revision total hip skills using the direct anterior technique. Accordingly, the text is designed into three sections as follows:

• Basic concepts: Surgical hip anatomy, patient selection, and placement of single, multiple, and extensile incisions for primary total hip arthroplasty
• Intermediate concepts: Adoption of imaging and navigation technologies, use of traction tables to enhance positioning, and presentation of unique instruments and custom devices that have evolved specifically for the direct anterior approach
• Advanced concepts: Using the direct anterior approach for liner and bearing exchanges, acetabular revisions, femoral component revisions, and both component adaptations.

As mentioned by the most acclaimed hip replacement surgeon in Pune, Direct anterior hip replacement is a minimally invasive surgical technique that involves:

• A small incision on the front of the hip.
• Moving muscles aside along their natural tissue planes without detaching tendons.
• Potentially faster recovery and reduced post-operative pain.
• Avoiding cutting major muscles by working between them

Anterior Approach to Hip AO

The anterior approach provides the most direct approach to the anterior aspect of the hip. Many surgeons choose this approach for reduction of femoral head and neck fractures. Frequently the prime surgical approach can be used for treatment of periprosthetic fractures. This is evaluated a greater obstacle from the direct anterior approach. However, it can be comfortably extended to carry out the most fracture surgeries effectively, while maintaining the posterior capsule and short external rotators.

FAQ

Why I no longer do anterior hip replacement?

As a surgeon, Dr Aashish Arbat, a hip replacement doctor in Pune with specialization in hip and knee replacement surgery, patients rely on my expertise. Lately, a patient asked me why I no longer use the anterior approach for total hip replacement.  I paused carrying out this method because in my experience there are no pros to the surgery, rather a number of probable disadvantages.  Simply, I couldn’t pursue to use a procedure that I could not trust to deliver every time.

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