Abstract: Minimally invasive surgical techniques are an
extremely important part of modern day hip replacements. The most significant progress all over the world
in the evolution of total hip replacement is that the procedure can be done
with less invasive techniques which allow the
patient to recover and therefore mobilise early. These techniques require minimum
handling to prevent
damage to periarticular soft tissues and preservation of bone substance to the
maximum extent possible,which helps conserve bone mass and avoid damage
to soft tissues,to thus allow faster
restoration of hip function.

 

I had devised
an Approach to the Hip Joint `Modified Posterior Approach to the Hip Joint’
in 1981,when there
were increasing reports
of dislocation of the Hip
Joint using the conventional posterior Approach as described by Austin Moore
in 1957(Ref.no.1) due mainly
to the weak
capsule of the Hip Joint
posteriorly,when I was working with
my teacher late Geoffrey V Osborne
who had himself
described the Osborne
McFarland Approach to the Hip Joint..This term was coined
by my respected teacher,Mr.F.H.Beddow,Senior

Consultant,University of Liverpool,UK,who had himself done
about 220 Primary
Total Hip Replacements by my technique along with 2 dislocations.(Ref.no.2).

Considerable mention and citations of this Modified
Posterior Approach were appreciated from 1981 till today.Mark Coventry
did concur with the concept
of this approach in imparting more stability posteriorly
postoperatively,as compared to all other posterior approaches to the hip joint
described since 1874,which either divide the short external
rotators or pass between them which thereby
increase the risk of postoperative dislocation of the hip.(Refr.No:3)

Hedley
et al have devised a modification of the posterior approach to the hip joint
in which the short
lateral rotators are resutured during
closure of the hip joint.However they do not have any experience with
this approach.(Refr.No:4)

Citation along with appreciation by James
Shaw(Ref.no.5), Terry Canale(Ref.No.6) in Campbell’s Operative
Orthopaedics,9th Edition,1992, Callaghan,Rosenberg and Rubash(Ref.no7)in
The Adult Hip,1998,till Thomas Stahelin et al(Ref.no.8) mentioned in extensive studies on the resuture and reattachment of the short
lateral muscles by using
markers many years ago and came
to the conclusion that nearly
70% of the failures occurred on the first
post-operative day itself. Robert H.Cofield of Mayo Clinic in Rochester,Minnesota,USA has been using this approach
for the last 25 years with no regrets.He
is extremely happy using this approach since I presented it during the
Scientific Congress of the AseanOrthopaedic Association in Singapore in 1984. Mayo Clinic conducted a study of 68 consecutive cases
by the Modified Posterior Approach
to the Hip Joint.There were

no cases
of late instability. Posterior approach to the hip joint through
a posterior trochanteric osteotomy is associated with high union
rates and a low rate of late
instability after hip replacement.(Refr.No:9)

I had long drawn out interactions with
Dr.John O’Donnell of Australia,who is extremely
comfortable saying that I continue to use DAA
for my hip replacements, and I have
been very happy with it that I cannot imagine
changing to any other approach
now.I developed an interest in the Direct
Anterior Approach to the Hip Joint and have used
in initially in Hemiarthroplasty in a few cases with
a radical change
in my thinking of this
Approach,which is helpful to the patient
tremendously,as there is no need
to osteotomise the
greater trochanter and hence
avoids any complications related to the union of the greater trochanter,such as non-union or fibrous union,but most importantly prevents
dislocation of the Hip Joint
which was the main purpose
of me devising the Modified
Posterior Approach to the
Hip Joint,which I had been
using till today.
Due to these
multiple simple advantages offered by this
Approach,I would encourage this Direct Anterior Approach to the
Hip Joint to the newer generation of Orthopaedic Surgeons
wherever feasible,though it has a steep
learning curve in the initial
stages.

The most effective surgical approach for the Hip Joint remains
controversial,as the Hip joint
is likened to a motorway
roundabout with numerous
different approaches and exits. There are more than 100 different approaches to the Hip Joint
described in literature(Fig.no.1).

 

Fig.No,.1:
Courtesy:Figure reproduced with the kind permission of Hiran Amarasekera(Ref.no.10),Consultant Orthopaedic
Surgeon/Orthopaedic Research Fellow, PhD Student, Warwick
Medical School, University of Warwick, UK from the book Arthroplasty

– Update”ISBN 978-953-51-0995-

 

 

Direct
anterior approach (DAA)
has become popular
in the United states of America for past
one decade as “minimally invasive muscle sparing approach” The first description(Ref.no.11) of the direct anterior
approach to the hip joint(Fig.no.2)

 

Figure
no.2:Hueter’s original publication

which provides an excellent exposure
to the acetabulum, in primary
or a revision total hip arthroplasty,which In contrast with
conventional techniques, and hence direct anterior approaches (DAA)
has gained popularity among the orthopaedic hip surgeons world
over and patients for earlier recovery and mobilization.

This
has progressed to such a point that
some patients are able to have their
surgery done as an outpatient procedure without any hospital
admission,as mentioned in my book
“Hip Joint in Adults: Advances and Developments”https://www.crcpress.com/Hip-Joint-in-Adults-

Advances-and-Developments/Iyer/p/book/9789814774727

 

 

in chapter 18 as “Total
hip in a day, setup
and early experiences in outpatient hip surgery”, by

 

Dr. med. Manfred
Krieger and and
Dr. med. IlanElias.Wiesbaden,Frankfurt,Germany. (Ref.no12)

 

 

This is a chapter written wherein the Total Hip can
be done as an outpatient procedure without any in-patient addmission(Fig.no.3) on selected patients
as a day case,without having any fear of dislocation.

 

 

 

 

 

Fig.no.3- Intra-op single incision
anterior approach(Courtesy:Figure reproduced with kind
permission of Dr. ILAN ELIAS
and Dr. MANFRED
KRIEGER,Frankfurt, Germany)

Outpatient total hip replacement (THR)
procedures are increasing in the orthopedic surgery community, especially in the USA,
Scandinavia, and the Benelux countries. This was presented at the 10th Int. Conference of Arthroplasty in Madrid,Spain on December 04-05, 2017.

Krieger and Elias,
were the first
authors to report
setup and first
clinical experiences of ambulatory and very fast track
THR in Germany.
From June 2016
until August 2017
they have treated 41 patients
(22female/19male, average age 60years) who
underwent primary total hip replacement surgery at the orthopaedic surgery day clinic
of the GPR Hospital
Rüsselsheim,
Germany with a direct anterior
approach and all under general
anesthesia. All patients were carefully selected and enrolled in the so called “Hip-in-a-Day” program.

Dr.John O’Donnell of Australia
uses a fracture table(Fig.no.4) for DAA(Ref.no.13)

 

 

 

 

 

 

 

FIG 4. Patient
positioned for right
Total Hip Replacement(“Courtesy:With the
kind permission of Dr.John
O D’onnell,Associate Professor, Hip Arthroscopy Australia)

Direct anterior hip replacement is considered as a minimally invasive surgical technique. The anterior approach
for hip replacement is a tissue-sparing technique designed to follow both an
intermuscular and an internervous path(Fig.no.5)

 

 

FIG 5:The
approach is both intermuscular and interneural(With kind permission Medacta,through
Dr.John O’Donnell.Associate Professor, Hip Arthroscopy Australia).The blue line
is the line of the approach, passing between the Rectus femoris and Sartorius,
innervated by the Femoral nerve, and the TFL and Gluteal muscles, innervated by
the Gluteal nerves.

This approach
provides a direct visualization of the acetabulum and the anterior iliac spine
landmarks to allow reference for appropriate cup positioning as It utilizes
anterior internervous and intermuscular plane.

In fact,I am particularly happy
by its use immensely so much so that I have published a small book on the `The Direct Anterior Approach to the Hip
Joint’ by Lambert Academic Publishing,Germany
on 10/1/2018 as seen on this link-

.http://www.morebooks.de/bookprice_offer_db8f09846d5a8fd2554724ccd204ec799af88311?

I have tried to
get accustomed to this DAA by initially as I was accustommed to the Modified
Posterior Aproach to the Hip Joint and by doing a few cases of Hemiarthroplasty
by the DAA as shown in figure 3,and am fully convinced of the usefulness of
this Approach to the Hip Joint for the newer generation of Orthopaedic Surgeons
in the world,because of multiple advantages.

This
DAA can be used in

 

1. Outpatient procedure as in certain
advanced centres in Frankfurt, Germany. 2. The
Direct Anterior Approach in Hemiarthroplasty.

(2a)
DAA is an approach more useful for bipolar hemiarthroplasty for femoral neck
fracture in elderly
patients than THA in terms
of the early
acquisition of walking
ability due to muscle preservation and the low dislocation rate(Ref.no.14).

(2b)
Hip replacement is the most common treatment for displaced femoral
neck fractures in the elderly,
and minimally invasive surgery is popular
in the field
of orthopaedic surgery. Hemiarthroplasty for hip fractures can be performed safely and effectively via the direct anterior approach with good functional
outcome and high patient satisfaction.(Ref.no.15)

3. Direct Anterior Approach in Primary Total Hip Arthroplasty.

 

(3a)
Primary total hip arthroplasty using
the anterior approach
allows for superior recovery.(Ref.no.16)

(3b) It is able to perform this procedure in the lateral
decubitus position on an ordinary operation table(Ref.no.17)

4. Direct Anterior Approach in
Revision Hip Arthroplasty.

 

(4a) Revision THA can be successfully performed through the DA approach.
The DA

approach does not split muscles,
as in other approaches, and
studies have demonstrated improved strength, proprioception and healing in the
postoperative period .The acetabular exposure can
be facilitated by capsular release
and correct placement of retractors. Distal
and proximal extension of the incision,
as well as a femoral
extended trochanteric osteotomy (ETO) are helpful
to increase femoral
exposure.(Ref.No.18)

(4b)
Revision total hip arthroplasty through
the direct anterior approach is technically challenging but offers some
advantages in exposure of the acetabulum(Ref.no.19)

I give full credit to Dr.John O’Donnell,Australia for
having introduced me to this fascinating
Direct
Anterior Approach which
was dormant in 1981 when
I described the Modified
Posterior Approach to the Hip joint.

 

 

 

Dr.John O
D’onnell,MBBS,FRACS,FA(Orth)A,Associate Professor, Hip Arthroscopy
Australia,Past President,International Society of Hip Arthroscopy,Australian
Hip Joint Preservation Surgery Society,Past President and Associate
Professor,Melbourne University and Bond University is also the Convener and
Host, Melbourne ISHA ASM 2018,and would encourage all Orthopaedic Surgeons
worldwide to attend the same.

 

  

 

Hueter’s
Anterior Approach to the Hip Joint

 

Abstract: Minimally invasive surgical techniques are an
extremely important part of modern day hip replacements. The most significant progress all over the world
in the evolution of total hip replacement is that the procedure can be done
with less invasive techniques which allow the
patient to recover and therefore mobilise early. These techniques require minimum
handling to prevent
damage to periarticular soft tissues and preservation of bone substance to the
maximum extent possible,which helps conserve bone mass and avoid damage
to soft tissues,to thus allow faster
restoration of hip function.

 

I had devised
an Approach to the Hip Joint `Modified Posterior Approach to the Hip Joint’
in 1981,when there
were increasing reports
of dislocation of the Hip
Joint using the conventional posterior Approach as described by Austin Moore
in 1957(Ref.no.1) due mainly
to the weak
capsule of the Hip Joint
posteriorly,when I was working with
my teacher late Geoffrey V Osborne
who had himself
described the Osborne
McFarland Approach to the Hip Joint..This term was coined
by my respected teacher,Mr.F.H.Beddow,Senior

Consultant,University of Liverpool,UK,who had himself done
about 220 Primary
Total Hip Replacements by my technique along with 2 dislocations.(Ref.no.2).

Considerable mention and citations of this Modified
Posterior Approach were appreciated from 1981 till today.Mark Coventry
did concur with the concept
of this approach in imparting more stability posteriorly
postoperatively,as compared to all other posterior approaches to the hip joint
described since 1874,which either divide the short external
rotators or pass between them which thereby
increase the risk of postoperative dislocation of the hip.(Refr.No:3)

Hedley
et al have devised a modification of the posterior approach to the hip joint
in which the short
lateral rotators are resutured during
closure of the hip joint.However they do not have any experience with
this approach.(Refr.No:4)

Citation along with appreciation by James
Shaw(Ref.no.5), Terry Canale(Ref.No.6) in Campbell’s Operative
Orthopaedics,9th Edition,1992, Callaghan,Rosenberg and Rubash(Ref.no7)in
The Adult Hip,1998,till Thomas Stahelin et al(Ref.no.8) mentioned in extensive studies on the resuture and reattachment of the short
lateral muscles by using
markers many years ago and came
to the conclusion that nearly
70% of the failures occurred on the first
post-operative day itself. Robert H.Cofield of Mayo Clinic in Rochester,Minnesota,USA has been using this approach
for the last 25 years with no regrets.He
is extremely happy using this approach since I presented it during the
Scientific Congress of the AseanOrthopaedic Association in Singapore in 1984. Mayo Clinic conducted a study of 68 consecutive cases
by the Modified Posterior Approach
to the Hip Joint.There were

no cases
of late instability. Posterior approach to the hip joint through
a posterior trochanteric osteotomy is associated with high union
rates and a low rate of late
instability after hip replacement.(Refr.No:9)

I had long drawn out interactions with
Dr.John O’Donnell of Australia,who is extremely
comfortable saying that I continue to use DAA
for my hip replacements, and I have
been very happy with it that I cannot imagine
changing to any other approach
now.I developed an interest in the Direct
Anterior Approach to the Hip Joint and have used
in initially in Hemiarthroplasty in a few cases with
a radical change
in my thinking of this
Approach,which is helpful to the patient
tremendously,as there is no need
to osteotomise the
greater trochanter and hence
avoids any complications related to the union of the greater trochanter,such as non-union or fibrous union,but most importantly prevents
dislocation of the Hip Joint
which was the main purpose
of me devising the Modified
Posterior Approach to the
Hip Joint,which I had been
using till today.
Due to these
multiple simple advantages offered by this
Approach,I would encourage this Direct Anterior Approach to the
Hip Joint to the newer generation of Orthopaedic Surgeons
wherever feasible,though it has a steep
learning curve in the initial
stages.

The most effective surgical approach for the Hip Joint remains
controversial,as the Hip joint
is likened to a motorway
roundabout with numerous
different approaches and exits. There are more than 100 different approaches to the Hip Joint
described in literature(Fig.no.1).

 

Fig.No,.1:
Courtesy:Figure reproduced with the kind permission of Hiran Amarasekera(Ref.no.10),Consultant Orthopaedic
Surgeon/Orthopaedic Research Fellow, PhD Student, Warwick
Medical School, University of Warwick, UK from the book Arthroplasty

– Update”ISBN 978-953-51-0995-

 

 

Direct
anterior approach (DAA)
has become popular
in the United states of America for past
one decade as “minimally invasive muscle sparing approach” The first description(Ref.no.11) of the direct anterior
approach to the hip joint(Fig.no.2)

 

Figure
no.2:Hueter’s original publication

which provides an excellent exposure
to the acetabulum, in primary
or a revision total hip arthroplasty,which In contrast with
conventional techniques, and hence direct anterior approaches (DAA)
has gained popularity among the orthopaedic hip surgeons world
over and patients for earlier recovery and mobilization.

This
has progressed to such a point that
some patients are able to have their
surgery done as an outpatient procedure without any hospital
admission,as mentioned in my book
“Hip Joint in Adults: Advances and Developments”https://www.crcpress.com/Hip-Joint-in-Adults-

Advances-and-Developments/Iyer/p/book/9789814774727

 

 

in chapter 18 as “Total
hip in a day, setup
and early experiences in outpatient hip surgery”, by

 

Dr. med. Manfred
Krieger and and
Dr. med. IlanElias.Wiesbaden,Frankfurt,Germany. (Ref.no12)

 

 

This is a chapter written wherein the Total Hip can
be done as an outpatient procedure without any in-patient addmission(Fig.no.3) on selected patients
as a day case,without having any fear of dislocation.

 

 

 

 

 

Fig.no.3- Intra-op single incision
anterior approach(Courtesy:Figure reproduced with kind
permission of Dr. ILAN ELIAS
and Dr. MANFRED
KRIEGER,Frankfurt, Germany)

Outpatient total hip replacement (THR)
procedures are increasing in the orthopedic surgery community, especially in the USA,
Scandinavia, and the Benelux countries. This was presented at the 10th Int. Conference of Arthroplasty in Madrid,Spain on December 04-05, 2017.

Krieger and Elias,
were the first
authors to report
setup and first
clinical experiences of ambulatory and very fast track
THR in Germany.
From June 2016
until August 2017
they have treated 41 patients
(22female/19male, average age 60years) who
underwent primary total hip replacement surgery at the orthopaedic surgery day clinic
of the GPR Hospital
Rüsselsheim,
Germany with a direct anterior
approach and all under general
anesthesia. All patients were carefully selected and enrolled in the so called “Hip-in-a-Day” program.

Dr.John O’Donnell of Australia
uses a fracture table(Fig.no.4) for DAA(Ref.no.13)

 

 

 

 

 

 

 

FIG 4. Patient
positioned for right
Total Hip Replacement(“Courtesy:With the
kind permission of Dr.John
O D’onnell,Associate Professor, Hip Arthroscopy Australia)

Direct anterior hip replacement is considered as a minimally invasive surgical technique. The anterior approach
for hip replacement is a tissue-sparing technique designed to follow both an
intermuscular and an internervous path(Fig.no.5)

 

 

FIG 5:The
approach is both intermuscular and interneural(With kind permission Medacta,through
Dr.John O’Donnell.Associate Professor, Hip Arthroscopy Australia).The blue line
is the line of the approach, passing between the Rectus femoris and Sartorius,
innervated by the Femoral nerve, and the TFL and Gluteal muscles, innervated by
the Gluteal nerves.

This approach
provides a direct visualization of the acetabulum and the anterior iliac spine
landmarks to allow reference for appropriate cup positioning as It utilizes
anterior internervous and intermuscular plane.

In fact,I am particularly happy
by its use immensely so much so that I have published a small book on the `The Direct Anterior Approach to the Hip
Joint’ by Lambert Academic Publishing,Germany
on 10/1/2018 as seen on this link-

.http://www.morebooks.de/bookprice_offer_db8f09846d5a8fd2554724ccd204ec799af88311?

I have tried to
get accustomed to this DAA by initially as I was accustommed to the Modified
Posterior Aproach to the Hip Joint and by doing a few cases of Hemiarthroplasty
by the DAA as shown in figure 3,and am fully convinced of the usefulness of
this Approach to the Hip Joint for the newer generation of Orthopaedic Surgeons
in the world,because of multiple advantages.

This
DAA can be used in

 

1. Outpatient procedure as in certain
advanced centres in Frankfurt, Germany. 2. The
Direct Anterior Approach in Hemiarthroplasty.

(2a)
DAA is an approach more useful for bipolar hemiarthroplasty for femoral neck
fracture in elderly
patients than THA in terms
of the early
acquisition of walking
ability due to muscle preservation and the low dislocation rate(Ref.no.14).

(2b)
Hip replacement is the most common treatment for displaced femoral
neck fractures in the elderly,
and minimally invasive surgery is popular
in the field
of orthopaedic surgery. Hemiarthroplasty for hip fractures can be performed safely and effectively via the direct anterior approach with good functional
outcome and high patient satisfaction.(Ref.no.15)

3. Direct Anterior Approach in Primary Total Hip Arthroplasty.

 

(3a)
Primary total hip arthroplasty using
the anterior approach
allows for superior recovery.(Ref.no.16)

(3b) It is able to perform this procedure in the lateral
decubitus position on an ordinary operation table(Ref.no.17)

4. Direct Anterior Approach in
Revision Hip Arthroplasty.

 

(4a) Revision THA can be successfully performed through the DA approach.
The DA

approach does not split muscles,
as in other approaches, and
studies have demonstrated improved strength, proprioception and healing in the
postoperative period .The acetabular exposure can
be facilitated by capsular release
and correct placement of retractors. Distal
and proximal extension of the incision,
as well as a femoral
extended trochanteric osteotomy (ETO) are helpful
to increase femoral
exposure.(Ref.No.18)

(4b)
Revision total hip arthroplasty through
the direct anterior approach is technically challenging but offers some
advantages in exposure of the acetabulum(Ref.no.19)

I give full credit to Dr.John O’Donnell,Australia for
having introduced me to this fascinating
Direct
Anterior Approach which
was dormant in 1981 when
I described the Modified
Posterior Approach to the Hip joint.

 

 

 

Dr.John O
D’onnell,MBBS,FRACS,FA(Orth)A,Associate Professor, Hip Arthroscopy
Australia,Past President,International Society of Hip Arthroscopy,Australian
Hip Joint Preservation Surgery Society,Past President and Associate
Professor,Melbourne University and Bond University is also the Convener and
Host, Melbourne ISHA ASM 2018,and would encourage all Orthopaedic Surgeons
worldwide to attend the same.