Anterior approach total hip arthroplasty with an orthopedic table

Abstract

Total hip arthroplasty (THA) is well documented as one of the most cost-effective surgical interventions in medicine. Over the past 50 years, numerous surgical approaches have been utilized to perform a THA including posterior, mini-posterior, lateral, and anterolateral approaches. In 1996, the senior author began anterior approach (AA) THA with a special orthopaedic table. The impetus for AA THA was to avoid potential problems of existing approaches: dislocation with posterior approach and abductor weakness with anterolateral approach by preserving the abductors, short external rotators, and posterior capsule. The senior author conducted his first course on the technique in 2003 when the special orthopedic table became available. The growth and popularity of AA THA coincided with the availability of an appropriate orthopedic table for the procedure. Since this time, the AA for THA has grown steadily and rapidly - implemented in conjunction with dedicated educational programming for surgeons learning the technique. It was hypothesized that advocating the need for a special table would hinder adoption of the approach. However, the authors believe the reverse to be true. The majority of surgeons performing AA THA today utilize the special orthopedic table. (Internet-based surveys conducted during VuMedi webinars.) Both the technique and the procedure have evolved over the past 20 years, driven by patient demand and equipment innovations. Anterior approach THA has grown in the United States; an AAHKS survey in 2014 indicated 26 % of surgeons utilize the AA for THA. Americans are living longer, more informed due to the Internet, and expect more from health-care providers than previously. With the coincident trends of evidence-based medicine and bundled payment schemes, it is imperative for arthroplasty surgeons to achieve maximum patient satisfaction with minimum cost and complications during THA. Anterior approach THA, with its lack of postoperative dislocation precautions, potential for earlier rehabilitation and decreased length of stay, fits into this new paradigm of health care. With the addition of fluoroscopically guided implant positioning and precise determination of limb length, the AA is a powerful technique for THA. Lastly, the authors would like to clarify the term minimally invasive. The term minimally invasive, in the context of AA, does not refer to the length of the skin incision. Rather, the term more appropriately refers to understanding the function and respecting the integrity of deeper anatomic structures so that their postoperative function is not compromised. This attention to “deep invasion” of human anatomy tends to be followed by improvements in function and pain - regardless of the skin incision. In this chapter, the authors will convey this concept and demonstrate the AA THA technique in a step-by-step manner.