Hemiarthroplasty of the hip using the direct anterior approach

Abstract

Objective: Minimally invasive approach in total hip arthroplasty for the treatment of femoral neck fractures with a hemiarthroplasty. Indications: Femoral neck fractures of patients without hip osteoarthritis where the acetabulum is still intact. Contraindications: Lesions and infections of the skin in the approach area; hip osteoarthritis; surgeon’s lack of experience with the technique. Surgical technique: The direct anterior approach (DAA) uses the Smith–Peterson interval between the tensor fasciae latae (TFL) and the rectus and sartorius muscle. After coagulation of the ascending branches of the femoral circumflex vessels, the capsule is opened. The remaining parts of the femoral neck are removed and osteotomized if necessary. The femoral head is removed with a cork screw. Then the shaft is supported by 2 sharp retractors at the greater trochanter from cranial, and the leg is externally rotated, hyperextended, and adducted. A TFL release can be performed which we also recommend. The femoral canal is opened step by step and extended with rasps which are introduced with the double curved broach handle. Cement and the final implant are introduced and after the trial reduction also the final head. The hip is reduced, the capsule adapted and the wound closed. Postoperative management: For this approach, there are no approach specific recommendations. Postoperative treatment depends on whether the approach was extended with muscle releases and on the type of reconstruction performed. If the approach was limited to the minimally invasive direct anterior portal, quicker rehabilitation can be expected due to the reduced muscle damage. We prefer mobilization with full weight bearing as tolerated on the next day.