To the Editor: In their article on isolated acetabular liner exchange, Lombardi and Berend1 state that,
because extensile exposure is often required, the use of a minimally invasive approach (eg, direct anterior muscle-splitting approach) is discouraged except … when there is absolutely no concern that an acetabular revision will be required. The procedure may turn into a full acetabular revision, stem revision, or both. Appropriate exposure is required in these cases.
Our group performs all hip arthroplasty procedures, including primary hips, acetabular liner exchanges, complete revisions, and hip resurfacing,2 via the direct anterior approach. We have often heard and read statements regarding its particular impossibility or inapplicability with respect to revision surgery and have sought to educate our colleagues on its benefits. The direct anterior approach as it applies to modern hip arthroplasty was first presented at the AAOS Annual Meeting in 19773 and detailed further in 1980.4 The direct anterior approach is a subset of the classic Smith-Petersen approach,5 about which Campbell’s Surgical Orthopaedics still reports, 91 years later, that “nearly all surgery of the hip can be carried out through this approach, or separate parts can be used for separate purposes.”6 We described our experience with the anterior approach for revision surgery at a recent AAOS Annual Meeting in a scientific exhibit, which was later reproduced for publication in the Journal of Bone and Joint Surgery7 and elsewhere8 with extended descriptions and diagrams, specifically including 119 cases of acetabular cup exchange.
The direct anterior approach, in fact, has many benefits over other approaches for revision surgery. The patient is supine and more easily positioned, assessed, and monitored by the anesthesiologist. The patient’s pelvic position is anatomic, which allows for proper placement of components, especially in revision surgery, when bony landmarks may be compromised. The approach is the shortest route to the hip in patients of all sizes and entirely avoids the sciatic nerve, which may be matted in scar tissue from previous posterior hip surgery. The medial aspect of the ilium and intrapelvic structures is readily accessible for management in either planned or contingency circumstances. The approach is fully extensile laterally to the knee and is suitable for all manner of osteotomies, plating, cerclage, and total femoral replacement, all of which we have done.
We agree that the anterior approach should not be used for revision surgery, even liner exchange, unless the surgeon has good prior experience with primary anterior hip surgery. However, we strongly disagree with the authors’ broadly general statement and inference that the direct anterior approach cannot be used in revision surgery. Furthermore, we would invite any surgeon wishing to learn more about the direct anterior muscle-sparing approach for primary, revision, and resurfacing hip arthroplasty surgery to visit our orthopaedic centers to see the utility of the technique in action.
The Author Replies: We are certainly keenly aware of the significant contribution of Dr. Kristaps Keggi and his colleagues with respect to the anterior supine approach to the hip for arthroplasty. Indeed, we were personally impressed with their scientific exhibit and subsequent publication in the Journal of Bone and Joint Surgery.7 We congratulate their ongoing success with this specific approach and applaud their willingness to teach the orthopaedic community.
Since the inception of Joint Implant Surgeons in the early 1970s, its surgeons, who have dedicated their practice to adult reconstruction of the hip and knee, have used a variety of approaches to the hip. Our experience has therefore led us to tailor the approach to the specific needs and requirements of the particular arthroplasty. In primary total hip arthroplasties, we perform either a direct anterior supine intramuscular approach or a direct lateral approach. We would tend to avoid a direct anterior supine approach in obese patients with a large panniculus, which drapes over the incision. It has the potential to compromise wound healing. We would also personally tend to avoid using a direct anterior approach in extremely large, muscular males. In our less complicated, straightforward acetabular revisions, either liner exchange or cup exchange, we use a direct anterior approach or the direct lateral approach.
However, when extensive reconstruction is required, including the utilization of a protrusio cage or porous metal augments, we favor the utilization of a direct lateral approach. When posterior plating is contemplated, a posterior approach may be more amenable. Also, there are indications to perform an extended trochanteric osteotomy when anticipating complex femoral reconstruction. Additionally, we have on occasion used a transfemoral approach when there is concern that an extended trochanteric osteotomy is compromised by the quality of the bone laterally. Therefore, we do not believe that our opinion greatly differs from that of Dr. Keggi and his colleagues. Familiarity with all of the surgical approaches used is mandatory as the surgical exposure must be complementary and extensile to facilitate the appropriate reconstruction. We trust that you will find our response helpful.
1. Lombardi AV, Berend KR: Isolated acetabular liner exchange. J Am Acad Orthop Surg
2. Rubin LE, Keggi JM, Kennon RE, Keggi KJ: The direct anterior approach without traction table for hip resurfacing arthroplasty. Presented at the 2008 Annual Meeting of the Connecticut Orthopaedic Society, Farmington, Connecticut, May 16, 2008.
3. Keggi KJ, Light TR: Clinical exhibit: The anterior approach to total hip replacement. Presented at the 44th Annual Meeting of the American Academy of Orthopaedic Surgeons, Las Vegas, Nevada, February 1-3, 1977.
4. Light TR, Keggi KJ: Anterior approach to hip arthroplasty. Clin Orthop Relat Res
5. Smith-Petersen MN: A new supraarticular subperiosteal approach to the hip joint. Am J Orthop Surg
6. Crenshaw AH: Surgical techniques and approaches, in Canale TS (ed): Campbell’s Operative Orthopaedics
, ed 10. Philadelphia, PA: Mosby, 2003, pp 58-61.
7. Kennon R, Keggi J, Zatorski LE, Keggi KJ: Anterior approach for total hip arthroplasty: Beyond the minimally invasive technique. J Bone Joint Surg Am
8. Keggi KJ, Kennon RE: The direct anterior approach, in Hozak WJ, Krismer M, Nogler M, et al (eds): Minimally Invasive Total Joint Arthroplasty
. Heidelberg, Germany: Springer, 2004, pp 60-66.