VIDEO VIGNETTE: Surgical Pearls for the Direct Anterior Approach

    Surgeons skeptical of the direct anterior approach for total hip arthroplasty (THA) will often say the learning curve is too step and the technique for achieving femoral exposure is too difficult, said Charles A. DeCook, MD, from Arthritis & Total Joint Specialists in Cumming, Georgia.

    Dr. DeCook disagrees, contending that the direct anterior approach is actually simple and reproducible and is effective in recreating hip biomechanics.

    At ICJR’s 3rd Annual Pan Pacific Orthopaedic Congress, Dr. DeCook shared his top surgical pearls for the direct anterior approach.

    For this approach, the surgeon needs to appreciate the ischiofemoral, iliofemoral, and pubofemoral ligaments. These ligaments are released in a simple T-capsulotomy, which amounts to releasing about 270° around the femur.

    Femoral releases in the direct anterior approach generally happen inside the trochanter, Dr. DeCook said, but many surgeons new to the approach get turned around and are unsure where the greater trochanter is located. He showed the location in his video, and noted a key point in the anatomy: The superior capsule is sitting on top of the rotators.

    Using electrocautery, the superior capsule is divided at the 12 o’clock position, revealing the 3 rotators: the obturator externus, the conjoint tendon, and the piriformis. These tendons are typically left intact and generally do not need to be released.

    Real-time feedback is important for improving cup positioning, femoral offset, and leg length, Dr. DeCook said, and it helps to better restore normal hip biomechanics. Fluoroscopic images are easy to obtain with the direct anterior approach, he said, because the patient is in the supine position during the procedure.

    Dr. DeCook uses a computer-based targeting device with fluoroscopy to optimize anteversion and inclination of the cup. He also uses this to overlay actual results on his preoperative template and to do reverse templating intraoperatively to more accurately determine offset and leg length.

    Click the image above to watch Dr. DeCook’s presentation.