K.Mohan Iyer, Senior Consultant Orthopaedic Surgeon, Bangalore, India. Email: email@example.com
K.Mohan Iyer (2017), The direct anterior approach to the hip joint. Int J Sur & Trans Res. 1:6, 49-52. DOI: 10.25141/2476-2504-2017-6.0049
Minimally invasive surgical techniques is an important component of modernday hip replacements. The most significant progressin
the evolution of total hipreplacement is that the procedure can be done with much less invasive techniques whichallow the patientto
recover and therefore mobilise early. These techniques requireminimum handling to prevent damage to periarticular soft tissuesand
preservation ofbone substance to the maximum extent possible,which helps conserve bone mass andavoid damage to soft tissues,
which allows faster restoration of hip function.
I had devised an Approach to the Hip Joint `Modified Posterior Approach to the Hip Joint’https://www.amazon.com/Modified-Posterior-Approach-HipJoint/dp/3330336870/ref=sr_1_1?s=books&ie=UTF8&qid=1503829887&sr=1-1&keywords=lambert+academic+publishingmodified+posterior+approach+to+the+hip+joint,in
1981, along with the mentorship of aBiomedical Engineer Dr.
Martin Elloy,PhD attached, to the University of Liverpool,UK,at
a timewhen there were considerable reports of dislocation of the
hip joint using the conventionalposterior Approach as described by
Austin Moore in 1957(Ref.no.1).
With interactions with Dr.John O’Donnell of Australia,who is
extremelycomfortable sayingthat I continue to use DAA for my
hip replacements, and I have been very happy with it that Icannot
imagine changing to any other approach now.I developed
an interest in the DirectAnterior Approach to the Hip Joint and
have used in initially in Hemiarthroplasty in a fewcases with a
radical change in my thinking of this Approach,which is helpful
to the patienttremendously,in that there is no need to osteotomise
the greater trochanter and henceavoids any complications related
to the union of the greater trochanter,such as non-union orfibrous
union,but most importantly prevents dislocation of the Hip Joint
which was the mainpurpose of me devising the Modified Posterior
Approach to the Hip Joint,which I had beenusing till today. Due
to these multiple simple advantages offered by this Approach,I
wouldnot hesitate to recommend this Direct Anterior Approach
to the Hip Joint to the newergeneration of Orthopaedic Surgeons
wherever feasible. The most effective surgical approach for the
Hip Joint remains controversial,as the Hip jointis likened to a motorwayroundabout with plenty of different approaches and exits.
Thereare more than100 different approaches to the Hip Joint de
scribed in literature (Fig.no.1)
Figure 1: Courtesy:Figure reproduced with the kind permission of HiranAmarasekera(Ref.no.2),Consultant Orthopaedic Surgeon/Orthopaedic Research Fellow, PhDStudent, Warwick Medical School, University of Warwick, UK from the book Arthroplasty -Update”ISBN978-953-51-0995-
Direct anterior approach (DAA) has become popular in thUnitedstates of America for pastone decade as “minimally invasive muscle sparing approach” The first description(Ref.no.3)
of the direct anterior approach to the hip joint(Fig.no.2)
Figure 2: Hueter’s original publicationwhich provides an excellent exposure to the acetabulum, in primary or a revision total hiparthroplasty,whichIn contrast with conventional techniques, and hence direct anteriorapproaches (DAA) has gained popularity among theorthopaedic hip surgeons and patientsfor earlier recovery and mobilization.
This has progressed to such a point that some patients are ableto have their surgery doneas an outpatient procedure without
any hospital admission,as mentioned in my book “HipJoint inAdults:Advances and Developments” https://www.crcpress.
book/9789814774727 in chapter 18 as ``Total hip in a day, setup and early experiencesin outpatient hip surgery”,by Dr. med.
Manfred Krieger and and Dr.med. Ilan Elias,Wiesbaden,FrankfurtGermany(Ref.no.4).This
is achapter written wherein the Total Hip canbe done as an outpatientprocedure without any in-patient addmission(Fig.no.3) on selectedpatients as a day case,without any fear of dislocation.
Figure 3: Intra-op single incision anterior approach(Courtesy:Figure reproduced with kindpermission of Dr. ILAN ELIAS and Dr. MANFRED KRIEGER,Frankfurt, Germany) The Direct Anterior Approach can be helpful in
- Outpatient procedure as in certain advanced centres in Frankfurt,Germany.
- The Direct Anterior Approach in Hemiarthroplasty.
- Direct Anterior Approach in Primary Total Hip Arthroplasty.
- Direct Anterior Approach in Revision Hip Arthroplasty In fact,I am particularly happy by its use immensely so much sothat I am coming out with asmall book on the `The Direct AnteriorAproach
to the Hip Joint’ by Lambert AcademicPublishing,Germany in early
Dr.John O’Donnell of Australia who uses a fracture table(Fig.no.4) for DAA(Ref.no.5)
Figure 4: Patient positioned for right Total Hip Replacement(“Courtesy:With the kindpermission of Dr.John O D’onnell,Associate Professor,Hip Arthroscopy Australia)Direct anterior hip replacement is considered as a minimally invasive surgical technique. Theanteriorapproach for hip replacement is a tissue-sparing technique designed to followboth an intermuscular and an internervous path(Fig.no.5)
Figure 5:The approach is both intermuscular and interneural((With kind permissionMedacta,through Dr.John O’Donnell.Associate Professor, Hip ArthroscopyAustralia).The blue line is the line of the approach, passing between the Rectusfemoris and Sartorius, innervated by the Femoral nerve, and the TFL and Glutealemuscles, innervated by the Gluteal nerves.
This approach provides a direct visualization of the acetabulum
and the anterioriliac spine landmarks to allow reference for appropriatecup positioning as Itutilizes anterior internervous and intermuscularplane.I have tried to get accustomed to this DAA by
initially as I was accustommedtothe Modified Posterior Aproach
to the Hip Joint andby doing a few cases of Hemiarthroplasty by
the DAA as shown in figure 3,and am fully convinced ofthe usefulness of this Approach tothe Hip Joint for the younger generation ofOrthopaedic Surgeonsin the world,because of multiple advantages.Dr.John O D’onnell,Associate Professor, Hip Arthroscopy
Australiais also theConvener and Host, Melbourne ISHA ASM
2018,andwould encourage allOrthopaedic Surgeons worldwide to
- Moore A.T.(1957) The self locking metal Hip Prosthesis.JBoneJt.Surg.39A,811.
- Figure reproduced with the kind permission of HiranAmarasekera,OrthopaedicResearch Fellow / PhD Student, WarwickMedicalSchool, University of Warwick, UK, UK from the book Arthroplasty - Update”,, ISBN 978-953-51-0995-
- Hueter C. Funfte abtheilung: die verletzung und krankheiten
des huftgelenkesneunundzwnzigtes capitel. In Hueter C, eGrundriss
derchirurgie. 2ndedition. Leipzig: FCW Vogel; 1883 pp129-
- Dr. med. Manfred Krieger and and Dr. med. Ilan Elias, Total
hip in a day,setup and early experiences in outpatient hip surgery, Hip Joint inAdults: Advances and Developments;Pan Stanford Publishing,Singapore,(Inpressworldwiderelease
on 30th April 2018)
- Direct Anterior Approach to the Hip Joint,by John O’Donnell,
Hip Joint inAdults: Advances and Developments;Pan Stanford
Publishing,Singapore,(Inpress-release worldwide on 30th April