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1、Review Article Direct Anterior Approach for Total Hip Arthroplasty: Indications, Technique, and Results Abstract Thedirectanteriorapproach(DAA)tothehipwasinitiallydescribedinthe 19th century and has been used sporadically for total hip arthroplasty (THA). In the past decade, enthusiasm for the appro
2、ach has been renewed because of increased demand for minimally invasive techniques.Newsurgicalinstrumentsandtablesdesignedspecificallyfor use with the DAA for THA have made the approach more accessible to surgeons. Some authors claim that this approach results in less muscle damageandpainaswellasrap
3、idrecovery,althoughlimiteddataexistto support these claims. The DAA may be comparable to other THA approaches, but there is no evidence 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 b
4、een well described.However,theincidenceofthesecomplicationsdecreaseswith greater surgeon experience. A question of keen interest to hip surgeons andpatientsiswhetherthe DAA resultsinimprovedearlyoutcomesand long-term results comparable to those of other approaches for THA. T raditionally, elective t
5、otal hip ar- throplasty (THA) has been done with one of two approaches, direct lateral or posterior. Several years ago, in conjunction with increased demand for minimally invasive surgery, other approaches began to be used more frequently. Some of these approaches, specificallythetwo-incisionapproac
6、h, enjoyed only limited use. The direct anterior approach (DAA) to the hip appears to have greater longevity in terms of its popularity. Making use oftheHueterintervalbetween the tensor fascia latae (TFL) and sartorius muscle to expose the hip, the DAA uses a true internervous, intermuscularplane.Pr
7、oponents claimthattheapproachisassociated with less muscle damage and pain as well as rapid recovery after hip ar- throplasty.1-3Most US surgeons familiarity with the approach is limited, but these claims have gen- erated intense interest in the DAA. Many who are now using this approach for hip arth
8、roplasty have learned to do so after completion of formal orthopaedic training, typi- cally at courses sponsored by indus- try. Implant manufacturers, hoping to capitalize on the DAAs popular- ity, have introduced new instrument sets and even surgical tables spe- cifically designed for use with the
9、DAA. However, unique complica- tions associated with the DAA have been described, and no data dem- onstrate that the DAA is associated with improved long-term outcomes. An understanding of the history and development of this approach, the surgical technique, and its outcomes will help the surgeon be
10、tter evaluate the role of the DAA in contemporary hip arthroplasty. September 2014, Vol 22, No 9595 Zachary D. Post, MD Fabio Orozco, MD Claudio Diaz-Ledezma, MD William J. Hozack, MD Alvin Ong, MD From the Rothman Institute, Thomas Jefferson University, Egg Harbor Township, NJ. Dr.Postoranimmediate
11、familymember has received research or institutional support from DePuy and serves as a paid consultant to Smith 22: 595-603 http:/dx.doi.org/10.5435/ JAAOS-22-09-595 Copyright 2014 by the American Academy of Orthopaedic Surgeons. Copyright?the American Academy of Orthopaedic Surgeons. Unauthorized r
12、eproduction of this article is prohibited. History Carl Hueter, a prominent German academic surgeon, first described the anterior approach to the hip in his 1881publication,DerGrundriss der Chirurgie (The Compendium of Surgery).4Hence, the DAA is often referred to as the Hueter approach or as utiliz
13、ation of the Hueter interval. The approach is more commonly known by the description published bySmith-Petersen5in1917.His description and frequent use of the DAA for mold arthroplasty exposed Americansurgeonstotheapproach.5,6 In 1950, French surgeons Judet and Judet7also described the use of the DA
14、A for hip arthroplasty. OBrien8 reported on his satisfactory experience with the DAA for hip arthroplasty in 1955. In the late 1950s and early 1960s, Charnleys low-friction arthro- plasty and the use of the trochanteric osteotomy gained popularity as a reli- able and reproducible approach for THA. S
15、ubsequently, the DAA became less popular for hip arthroplasty, and most orthopaedic residents learned the technique as a way to treat hip infec- tion in children. In 1980, Light and Keggi9published the first American experience on the use of the DAA for modern THA in a series of 104 procedures. The
16、mean surgical time was 65 minutes, and the procedure required a transfusion of an average of 1.9 units of blood. No intra- operative complications were re- ported. The mean length of hospital stay was 12.8 days. The use of a modified version of the original Smith-Petersen approach has only recently
17、gained popularity.10,11A description of a DAA performed on a hip fracture table increased interest in this well-established approach for THA.12However, it was the search for less invasive surgical approaches that generatedrealenthusiasm for the approach.13Many surgeons continue to use a fracture tab
18、le, but others per- form the procedure using a standard operating room (OR) table.11,14,15 Indications and Contraindications Indications for the use of the DAA are similar to those for THA. As with more traditional approaches, certain patient factors make this approach challenging. Recently, the Ame
19、rican AssociationofHipandKneeSurgeons Evidence-based Committee recom- mended against elective THA in patients with a body mass index (BMI) .40.16This recommendation applies to the use of the DAA, as well. Although obesity can make any THA approach difficult, subcutaneous fat in the anterior hip regi
20、on tends to be minimal compared with other as- pects of the hip (posterior and lateral). Thus, it has long been our practice to encourage weight loss before THA is performedinpatientswithaBMI.40. Patients with a large abdominal pan- niculus, particularly those with tissue that overlaps the upper thi
21、gh, present an additional challenge when using the DAA. This overlapping tissue can create a moist environment that can result in chronic skin irritation or fungal infection. In our experience, these patients are prone to wound problems and require extra vigilance to ensure proper healing of the ski
22、n incision. Careful consideration also should be given to patients with a history of previous hip surgery or retained instrumentation. It is not possible to removeplatesfromthelateralaspect of the femur through this approach, but screws are easily removed with addi- tional small incisions. If the ne
23、ed arises, distal or proximal extension of the dis- section can be performed. However, this is challenging for surgeons with limited experience. Therefore, in pa- tients who require more extensive sur- gery(eg,femoralshorteningosteotomy, acetabularaugmentation)atthetimeof THA,theuseofanotherapproach
24、may be warranted unless the surgeon has extensive experience with straightfor- ward cases. However, given sufficient experience with primary procedures, many surgeons use the DAA for all THAs, including revision procedures. Anatomy Theanterioraspect ofthehiphasfew palpable landmarks, and many criti-
25、 cal structures must be noted. The anterior superior iliac spine (ASIS) is the most easily identified structure. Typically, this bony prominence is palpable at the lateral aspect of the abdomen, superior to the level of the pubis. The ASIS is the anterior-most tip of the iliac crest and is the origi
26、n for the sartorius muscle and the inguinal ligament. The pubis is typi- cally palpable at the midline. TheoriginoftheTFLmuscleandthe anterior origin of the gluteus medius musclearelateraltotheASIS(Figure 1). The lateral femoral cutaneous nerve (LFCN) runs under the inguinal lig- ament and over the
27、surface of the sartorius and TFL muscles. The neu- rovascularbundlecontainingthe femoral artery and vein as well as the femoral nerve lies medial to the sar- torius muscle. Knowledge of the neu- rovascular bundles location is critical during all portions of the DAA. The rectus femoris muscle lies de
28、ep to the sartorius and TFL muscles and is divided proximally into two heads: direct and reflected. The direct head originates from the anterior inferior iliac spine, whereas the reflected head originates from the anterior lip of the acetabulum.Thegluteusminimus muscle originates from the iliac wing
29、 and rests alongthe anterolateral aspect of the hip capsule. This muscle inserts on the lateral aspect of the greater trochanter with the gluteus medius, making up the abductor complex. The vastus lateralis and vastus intermedius muscles lie deeper still, originating fromtheanterioraspectofthefemura
30、t Direct Anterior Approach for Total Hip Arthroplasty: Indications, Technique, and Results 596Journal of the American Academy of Orthopaedic Surgeons Copyright?the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. theintertrochantericline.Theiliopsoas
31、 muscle and tendon initially lie anterior to the hip capsule but then pass to the medial side of the femoral neck and insert on the lesser trochanter. A thorough familiarity with hip anatomy is critical to avoid complications dur- ing the DAA. Patient Positioning The DAA is typically done with the p
32、atient in the supine position. At our institution, the patient is positioned on a traditional OR table with the pelvis placed on a small bump that is placedtransversetotheORtableand is centered at the level of the ASIS (Figure 2). The bump is approxi- mately 3 inches thick and measures 8 by 15 inche
33、s. The bump provides a small amount of femoral extension, which facilitates broaching and cre- ates a space where the femur can displaceduringexposureofthe acetabulum. The pelvis must be level when resting on the bump. Failure to achieve a level pelvis after bump placement can result in relative ant
34、e- version or retroversion of the acetab- ulum,potentiallydisorientingthe surgeonduringsurgery.Intraoperative assessment of pelvic alignment is rec- ommended before final cup insertion, with the ASIS and pubis used to establish coronal orientation. Some surgeons prefer to place the bump and position
35、 the patients ASIS at the flexion point of the OR table, which allows extension of the pelvis during surgery. This position lowers the leg, improving the angle for insertion of the femoral component. In our prac- tice, when we plan to flex the bed during surgery, we check this flexion point before s
36、terile preparation of the leg (Figure 3). The patient is placed on either the far left or right side of the OR table based on the surgical hip (ie, left side for the left hip, right side for the right hip) to allow the maximum amount of room for positioning of the surgical leg during surgery. In add
37、ition, an extra arm board is placedoppositethesurgicalhipatthe footofthetable(Figure 4). This extra arm board provides additional room to maneuver the legs during surgery. Finally, leg length is assessed to ensure that the shoulders and hips are aligned when the patient is positioned straight on the
38、 table. Impervious plastic drapes are used to isolate the surgical field, and sterile skin preparation can commence. OR Tables TheuseofspecialORtableshashelped topopularizetheDAAforTHA.These tables are most commonly used in the setting of fracture care. However, many surgeons have found them to be h
39、elpful for the DAA to the hip. These tablesallowthepatienttobepositioned supine with both legs placed in supportive boots. There is no contact between the table and the patient distal to the pelvis, and a radiolucent Figure 1 Intraoperative photograph demonstrating the anatomic dissection of the ant
40、erior aspect of the hip. The Hueter interval can be seen between the tensor fascia latae and the sartorius muscles. ASIS = anterior superior iliac spine (Courtesy of Stryker, Kalamazoo, MI.) Figure 2 Photograph demonstrating patient positioning for the direct anterior approach for total hip arthropl
41、asty. A bump is centered under the anterior superior iliac spine. Zachary D. Post, MD, et al September 2014, Vol 22, No 9597 Copyright?the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. platform can be placed under the pel- vis. Intraoperatively, t
42、he surgical leg can be extended, adducted, and exter- nally rotated to facilitate exposure of the proximal femur and placement of the femoral stem. In addition, a hook can be attached to the table in a sterile fashion during surgery to help elevate the proximal femur. The radiolucent nature of a fra
43、cture table allows the surgeon to easily obtain intraoperative radiographs to guide positioning of THA components. However, special tables do represent a substantial cost and have been associated with unique complications(eg,anklefractures)that are not traditionally associated with THA.12In addition
44、, the use of these tables is associated with additional requirements such as the use of radi- ation gowns for surgeons using radi- ography and more extensive patient positioning, which adds time to the procedure,especiallyearlyinthe learning curve. At our institution, we prefer to use a standard OR
45、table. Surgical Technique The incision typically begins approxi- mately3cmdistaland3cmlateraltothe ASIS. For most patients this point lies near the groin crease (Figure 5). Alter- natively, the incision can be centered over the body of the TFL muscle if the muscle is easily palpable. From the starti
46、ng point, the incision progresses distally and laterally over the TFL and is carried down to the level of the fascia over the TFL (Figure 6). It is critical to confirmthelocationoftheTFLmuscle. Typically, several perforating vessels enter the muscle at the mid portion of the body and are used to con
47、firm the correct location. Another method is to digitally dissect proximally to the ASIS and confirm through palpation that one is lateral to the ASIS. The fascia of the TFL muscle is split in line with the muscle fibers. The medial edge of the fascia is then dis- sectedfromthemuscleandafatstripis s
48、een(Figure 7). Blunt digital dissection is performed superiorly and medially, following the fat strip over the supe- rior aspect of the femoral neck. A blunt retractor is placed over the extracapsular superior neck. Another sharp retractor is placed medial to the TFL muscle and over the lateral edge
49、 of the femur, just distal to the inter- trochanteric ridge. Careful dissection is performed to separate the TFL from the sartorius muscle. Several large vessels lie between these two muscles (divisions of the ascending branch of the lateral femoral circumflex artery) andmustbecarefullyligated(Figure8). Once the muscles are safely sepa- rated, a second blunt retractor is placedovertheextracapsularinferior portion of the femoral neck. The anterior fat over the hip capsule is now visible. A rongeur is used to re- move some of this fat to permit visu- alization of the capsule. A bump can t