The direct anterior approach for total hip arthroplasty is gaining popularity, with some surgeons finding it decreases postoperative pain and quickens recovery due to muscle sparing and fewer dislocations.
While the approach may soon become the technique of choice for most orthopedic hip surgeons, Kristaps Keggi, MD, emeritus professor and senior research scientist of orthopedics and rehabilitation at New Haven, Conn.-based Yale University School of Medicine, began performing the approach back in 1972.
"From 1973 on, all of my primary replacements, complex revisions of the acetabulum and femur have been through the anterior approach," Dr. Keggi says. To date, he has completed between 10,000 and 11,000 direct anterior approach hip surgeries.
"It is also of interest that from the earliest days of this method I have been an advocate of same-day bilateral replacements as indicated in our 1980 publication, where 85 of the 104 replacements were bilateral," he notes.
Dr. Keggi and Terry Light, MD, now the Dr. William M. Scholl Professor of Orthopaedic Surgery at Maywood, Ill.-based Loyola Medicine, presented the direct anterior approach for total hip arthroplasty at the American Academy of Orthopaedic Surgeons 1997 annual meeting. At that time, Dr. Light served as a Yale orthopedic resident on Dr. Keggi's service.
In 1980, Clinical Orthopaedics and Related Research published their article, titled "Anterior approach to hip arthroplasty." The article explores the use of a slightly curved incision to make the femoral exposure, preparation and insertion easier. Dr. Keggi notes they tried various modifications of the incision, eventually settling on an oblique one, directly over the femoral neck.
"When exposing the anterior hip capsule we made a point of preserving a thin strip of the tensor fascia lata medially and still believe it is a good way to protect the lateral femoral cutaneous nerve," explains Dr. Keggi. Although he has not recently used the "fold back" greater trochanteric osteotomy as presented in 1977 and 1980, Dr. Keggi says the technique should still be remembered as another way to avoid major problems with the femoral shaft.
"It's been amusing over the years, when I see more people start doing it; that the procedure is sort of catching on," Dr. Keggi says. His insights proved instrumental in training the next generation of surgeons in the approach.
"My practice grew very quickly because I started the anterior approach," remembers Dr. Keggi. "In a matter of a few months, I had people coming from all over the state and beyond. At the time, advertising or any kind of publicity was totally forbidden, but by word of mouth the anterior approach as we performed it was catching on." At this time, Dr. Keggi operated and taught within the Yale University orthopedic residency program at Waterbury (Conn.) Hospital. Many surgeons made the trip to observe and learn from Dr. Keggi as he performed the approach.
Dr. Keggi praises the direct anterior approach for its faster recovery and lower pain levels: "Once you've mastered it, in my mind, there is no comparison between anterior and posterior."
He recently co-authored a book on the topic titled, The Direct Anterior Approach to Hip Reconstruction, along with B. Sonny Bal, MD, JD, MBA, and Lee E. Rubin, MD, in 2016.
"I want to repeat what Terry Light and I said in 1977: the direct anterior approach is a great way to reconstruct, replace and revise hips," concludes Dr. Keggi. "Forty years later the echo sounds good."