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When would the direct anterior approach for THA be contraindicated?

Issue: October 2019

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Click here to read the Cover Story, "Data, results spark debate about anterior THA approach."

Few reasons to avoid it

In reality, there is no absolute contraindication for the direct anterior approach. I use the direct anterior approach on more than 95% of my patients who undergo THA.

There are few instances where I might shy away from the direct anterior approach. The first would be the presence of compromised anterior soft tissue or skin, such as fungal infection in the crease area or perhaps skin atrophy due to prolonged exposure to steroids.

A second issue is the presence of posteriorly based hardware on the acetabulum from prior fracture fixation, which can be a challenge to reach and remove with an anterior approach. It is sometimes possible to use metal-cutting burrs to remove only the hardware that is in the way and still use the anterior THA approach.

It can also be difficult to work from the front when doing an extended trochanteric osteotomy to remove a well-fixed femoral stem in a revision setting.

While these issues may be considered contraindications during a surgeon’s early learning curve with the direct anterior approach, they may not pose as great a challenge once the surgeon is highly experienced in the approach. More residents and fellows are gaining good experience in their training, which is a significant help in bringing the direct anterior approach further into the mainstream.

• For more information:
• Juan Carlos Suarez, MD, specializes in reconstructive surgery at Miami Orthopedics & Sports Medicine Institute with Baptist Health South Florida in Miami.

Disclosure: Suarez reports he is a consultant for DePuy Synthes.

Direct anterior approach preferred

In 2019, we prefer the direct anterior approach for almost all primary and most revision THAs regardless of patient complexity, bony deformity or deficiency. This especially includes patients at higher risk for dislocation, such patients who are elderly or have dementia, decreased cognitive function, neuromuscular disorders (paralysis, spasticity, Parkinson’s disease), seizures, polio, femoral neck fractures, osteonecrosis, alcoholism, substance abuse, hypermobility or spinopelvic stiffness, where there is a tendency to avoid the posterior approach and/or use a dual mobility construct. In addition to a lower dislocation rate, other advantages of the direct anterior approach include a faster functional recovery with earlier discontinuation of all gait aids compared to other approaches.

Supine positioning of the patient with the direct anterior approach facilitates accurate acetabular component placement through standardized pelvic position during surgery with little movement of the pelvis through the course of the procedure. The supine position of the patient permits the facile intraoperative use of fluoroscopy for the assessment of component position, offset, center of rotation, limb length, and fit and fill of the acetabular and femoral components. This also allows the intraoperative confirmation of preoperative goals, as well as provides an opportunity to make modifications or adjustments before completion of the procedure and helps avoid outliers.

There are certainly patients for whom the direct anterior approach to the hip may be less indicated, such as those with retained posterior acetabular fracture implants that require removal. Additionally, depending on the surgeon’s experience, an alternate approach may be considered for patients with Crowe IV dysplasia requiring a femoral shortening osteotomy, or for a protuberant abdomen that may occlude access to the anterior aspect of the hip or raise concerns for the increased risk of infection with the procedure.

Surgical approach, implant choice and usage of advanced technologies are no substitute for the surgeon’s experience and empathy. We prefer the anterior approach in almost all patients due to improved hip stability and more accurate acetabular component placement in addition to the early recovery benefits.

• References:
• Angerame MR, et al. J Arthroplasty. 2018;doi:10.1016/j.arth.2018.01.014.
• Barrett WP, et al. J Arthroplasty. 2019;doi:10.1016/j.arth.2019.01.060.
• Cheng TE, et al. J Arthroplasty. 2017;doi:10.1016/j.arth.2016.08.027.
• Debi R, et al. BMC Musculoskelet Disord. 2018;doi:10.1186/s12891-018-2097-4.
• Fleischman AN, et al. J Arthroplasty. 2019;doi:10.1016/j.arth.2019.02.029.
• Goodman GP, et al. Hip Int. 2017;doi:10.5301/hipint.5000507.
• Hamilton WG, et al. J Arthroplasty. 2015;doi:10.1016/j.arth.2015.05.022.
• Jahng KH, et al. J Arthroplasty. 2016;doi:10.1016/j.arth.2016.04.030.
• James CR, et al. J Arthroplasty. 2018;doi:10.1016/j.arth.2018.01.040.
• Jang ES, et al. J Orthop. 2018;doi:10.1016/j.jor.2018.03.036.
• Jennings JD, et al. Orthopedics. 2015;doi:10.3928/01477447-20151020-04.
• Ji W, et al. Int Orthop. 2016;doi:10.1007/s00264-015-2803-x.
• Kucukdurmaz F, et al. Surgeon. 2018;doi:10.1016/j.surge.2018.09.001.
• Lin TJ, et al. J Arthroplasty. 2017;doi:10.1016/j.arth.2016.07.046.
• Matta JM, et al. Clin Orthop Relat Res. 2005;doi:10.1097/01.blo.0000194309.70518.cb.
• Moskal JT, et al. J Arthroplasty. 2011;doi:10.1016/j.arth.2010.11.011.
• Moskal JT, et al. World J Orthop. 2013;doi:10.5312/wjo.v4.i1.12.
• Ozaki Y, et al. SICOT J. 2018;doi:10.1051/sicotj/2018051.
• Ponzio DY, et al. J Arthroplasty. 2018;doi:10.1016/j.arth.2017.11.053.
• Purcell RL, et al. J Arthroplasty. 2018;doi:10.1016/j.arth.2017.07.047.
• Rathod PA, et al. Clin Orthop Relat Res. 2014;doi:10.1007/s11999-014-3512-2.
• Sheth D, et al. Clin Orthop Relat Res. 2015;doi:10.1007/s11999-015-4230-0.
• Soderquist MC, et al. J Arthroplasty. 2017;doi:10.1016/j.arth.2017.04.011.
• Takada R, et al. Orthop Traumatol Surg Res. 2019;doi:10.1016/j.otsr.2019.05.004.
• Watts CD, et al. J Arthroplasty. 2015;doi:10.1016/j.arth.2015.06.016.

• For more information:
• Joseph T. Moskal, MD, FACS, is chair of the department of orthopedic surgery, chief of adult reconstruction and senior vice president of Carilion Clinic in Roanoke, Virginia.
• Theodore T. Manson, MD, MS, is an associate professor in the department of orthopedic surgery at University of Maryland in Baltimore.

Disclosures: Moskal reports he receives IP royalties from Corin U.S.A. and DePuy Synthes; is a paid consultant for Corin U.S.A., Stryker and United Orthopaedic Company; receives stock or stock options from Invuity and Think Surgical; and is a paid presenter or speaker for Stryker. Manson reports he is a consultant for DePuy Synthes and Stryker and receives research support from DePuy Synthes.

Finding solutions for contraindications

Use of the direct anterior approach (Heuter) for hip replacement is increasing worldwide. Benefits of the technique include a rapid recovery, a low dislocation rate and reliability of implant placement. As the technique gains wider acceptance, similarly there has been an interest in expanding indications for its use. Obesity, dysplasia or revision surgery were considered contraindications to this approach, but as more surgeons become familiar with the technique, these are no longer seen as contraindications, but rather opportunities to improve outcomes for patients who would otherwise be considered “high risk.”

In the obese patient, meticulous incision placement, vacuum-assisted wound dressings or use of the “bikini” incision may be of value in reducing wound complications while, at the same time, use of fluoroscopy allows for excellent control of implant position, even when a large soft tissue envelope obscures landmarks required for standard techniques. In the dysplastic patient, we take advantage of the fact the hip is an anterior structure in the body. By approaching the dysplastic hip from anterior, there is ease of access while simultaneously providing excellent control of reaming and implant placement. This facilitates acetabular component positioning and stability in even the most dysplastic hips.

In “high risk” revision arthroplasty, the anterior approach offers even more advantages. In addition to providing unmatched control of implant placement, preservation of the often-damaged abductors can mitigate some of the postoperative dislocation risk, while enhancing recovery to the point where even revision arthroplasty can be performed in an outpatient environment.

So, when asked about the contraindications for anterior approach THA, I have pause about making any declarations. I know the anatomic limitations of the approach. Access to the posterior column or posterior wall of the acetabulum can be exceedingly difficult. Access to the posterior lateral femur for extraction of well-fixed implants or fixation of the trochanter can be challenging. However, as surgical techniques and strategies evolve, we may find suitable solutions for these problems. We may one day find solutions to these problems that allow the opportunities of the anterior approach and its facilitating technologies to be applied to many of today’s “contraindications.”

• For more information:
• Nicholas H. Mast, MD, is an orthopedic surgeon at the Hip and Pelvis Institute of San Francisco.

Disclosures: Mast reports he is a consultant and receives Honoraria for medical education from DePuy/Synthes and is a shareholder in Radlink.