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.

Keywords: Anterior hip arthroplasty, Anterior supine intramuscular approach, Total hip arthroplasty, Direct anterior approach

Core tip: This review captures the most important concepts of direct anterior total hip arthroplasty as described by numerous surgeons’ experiences with the procedure. It compares variations in surgical exposure and arthroplasty techniques, while identifying key elements of the anterior hip anatomy for performance of safe and efficient surgery. The review divides anterior hip arthroplasty into six distinct elements, citing the most relevant pearls and pitfalls of previous publications and the most relied upon surgical methods. This concise summary can be beneficial to any level of surgeon desiring to enhance their understanding of direct anterior total hip arthroplasty.