Direct anterior total hip arthroplasty: Literature review of variations in surgical technique

Abstract

The direct anterior approach to the hip has been suggested to have several advantages compared to previously popular approaches through its use of an intra-muscular and intra-nervous interval between the tensor fasciae latae and sartorius muscles. Recent increased interest in tissue-sparing and minimally-invasive arthroplasty has given rise to a sharp increase in the utilization of direct anterior total hip arthroplasty. A number of variations of the procedure have been described and several authors have published their experiences and feedback to successfully accomplishing this procedure. Additionally, improved understanding of relevant soft tissue constraints and anatomic variants has provided improved margin of safety for patients. The procedure may be performed using specially-designed instruments and a fracture table, however many authors have also described equally efficacious performance using a regular table and standard arthroplasty tools. The capacity to utilize fluoroscopy intra-operatively for component positioning is a valuable asset to the approach and can be of particular benefit for surgeons gaining familiarity. Proper management of patient and limb positioning are vital to reducing risk of intra-operative complications. An understanding of its limitations and challenges are also critical to safe employment. This review summarizes the key features of the direct anterior approach for total hip arthroplasty as an aid to improving the understanding of this important and effective method for modern hip replacement surgeons.

Using the anterior capsule of the hip joint to protect the tensor fascia lata muscle during direct anterior total hip arthroplasty: a randomized prospective trial

“…After the iliofemoral ligament and the anterior articular capsule be revealed in a DAA, many surgeons open the anterior capsule in a "T" or transverse fashion to expose the hip joint and later close the capsule by suture or not close the capsule after the arthroplasty; both closing or not closing the capsule are widely accepted [5,[18][19][20][21][22]. Although some surgeons believe that the anterior capsule is not important, we have found a new application for this structure.…”

“…This approach is favored by surgeons, because it utilizes the intermuscular plane, thereby avoiding the need to transect any of the periarticular muscles. Moreover, this approach is favored because it provides adequate exposure of the acetabular side [1][2][3][4][5]. Several studies have reported that DAA decreases the duration of hospital stay and increases the percentage of patients discharged home due to the lesser operative trauma which permits a more rapid recovery [5][6][7][8][9].…”

Total hip arthroplasty

“…This approach increases the risk of nerve damage and may not be suitable for certain patient's anatomy because of the limited access to the posterior column. 6…”

Using the anterior capsule of the hip joint to protect the tensor fascia lata muscle during direct anterior total hip arthroplasty: a randomized prospective trial

“…Moreover, this approach is favored because it provides adequate exposure of the acetabular side. [1][2][3][4][5] Several studies have reported that DAA decreases the duration of hospital stay and increases the percentage of patients discharged home due to the lesser operative trauma which permits a more rapid recovery. [5][6][7][8][9] Whether DAA is actually superior to other surgical approaches, however, remains controversial.…”

“…[1][2][3][4][5] Several studies have reported that DAA decreases the duration of hospital stay and increases the percentage of patients discharged home due to the lesser operative trauma which permits a more rapid recovery. [5][6][7][8][9] Whether DAA is actually superior to other surgical approaches, however, remains controversial. Due to some concerns of less adequate exposure caused by difficulty elevating of proximal femur, some complications can occur during the operation, such as contusion of periarticular muscles, injury to the anterolateral femoral cutaneous nerve, and fractures around the prosthesis.…”