Direct anterior approach total hip arthroplasty with an orthopedic traction table.

OBJECTIVE: Direct anterior approach total hip arthroplasty (DAA THA) has gained significant popularity in the last decade as it is a muscle-sparing procedure. Modern techniques for DAA THA utilize both a standard operating table and an orthopedic traction table. As the use of an orthopedic traction table shows technical ease and predictability, this article will focus on the use of the orthopedic table or table extension to facilitate DAA THA.

INDICATIONS: Primary or secondary arthritis requiring THA; revision surgery-both acetabular and femoral.

CONTRAINDICATIONS: Posterior wall hardware requiring removal; posterior mass (tumor) to be removed at surgery: large, overhanging pannus; need for gluteal tendon reconstruction; anterior skin envelope not conducive to DAA.

SURGICAL TECHNIQUE: The incision is made over the tensor fascia latae. Capsulotomy is performed exposing the hip joint. After osteotomy of the femoral neck, traction is placed on the leg utilizing the orthopedic table and the head is removed. The acetabular cup is inserted. Traction, flexion, and internal reduction are used simultaneously while directing the femoral head into the acetabulum.

RESULTS: In a meta-analysis, operative time (100 vs. 71 min), blood loss (531 vs. 382 ml), and intraoperative fracture rate (1.7 vs. 1.3%) were increased in the traction table cohort. All other complications and outcome measurements were the same. Traction-table related complications such as pudendal nerve palsy and ankle fractures were not found. An assessment of the senior author's initial 855 DAA THAs (2008-2014) showed a mean operative time of 65 min with a mean blood loss of 238 ml. Operative times decreased to average 56 min. Intraoperative fracture rate was 0.8%. Infection rate was 2.1%. Finally, 1.5% femoral implants did not osseointegrate and required revision after an average of 3.0 years.