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The Journal of Arthroplasty xxx (2016) 1e5

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The Journal of Arthroplasty


journal homepage: www.arthroplastyjournal.org

Original Article

The Direct Anterior Approach for Hip Revision: Accessing the Entire
Femoral Diaphysis Without Endangering the Nerve Supply
Michael M. Nogler, MD, MA, MSc a, *, Martin R. Thaler, MD b
a
b

Department of Orthopaedic SurgerydExperimental Orthopaedics, Innsbruck Medical University, Innsbruck, Austria


Department of Orthopaedic Surgery, Innsbruck Medical University, Innsbruck, Austria

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 2 May 2016
Received in revised form
17 July 2016
Accepted 21 July 2016
Available online xxx

Background: The direct anterior approach (DAA) to the hip has been criticized as an approach that is
limited to primary arthroplasty only. Our study objective was to demonstrate, in a cadaveric setting, that
an alternate extension of the DAA can be used to reach the femur at the posterior border of the lateral
vastus muscle without endangering the nerve supply.
Methods: The iliotibial tract is split anteriorly and pulled laterally, thereby opening the interval to the
lateral-posterior aspect of the vastus muscle. The muscle fascia is incised at the posterior border to access
the femoral diaphysis. The vastus mobilization is started distally and laterally to the greater trochanter,
leaving a muscular bridge between the vastus and the medial gluteal muscle intact. If it is necessary to
open the femoral cavity for implant retrieval, we perform an anterior wall osteotomy instead of an
extended trochanteric osteotomy.
Results: It was possible to split the iliotibial band and pull it laterally, thereby exposing the entire vastus
lateralis muscle. The junction of the vastus lateralis and vastus intermedius was not encountered in all
cases, nor was the nerve supply with all nerve bers in that interval.
Conclusion: The alternate technique described here for accessing the femoral diaphysis allows for easy
access to the lateral aspect of the vastus lateralis and the femoral diaphysis. Using this technique, it
should also be possible to access the femur and perform all necessary reconstructive procedures on it
without damaging the surrounding nerve structures.
2016 Elsevier Inc. All rights reserved.

Keywords:
direct anterior approach
revision
total hip arthroplasty
technique
nerve supply

The direct anterior approach (DAA) is a well-established surgical


approach to total hip arthroplasty (THA) [1-4]. Over the past
decade, there has been a focus on reducing the invasiveness of THA.
As a result, the minimally invasive technique of approaching the hip
through the anterior portal has been gaining popularity [5-7]. Instruments have been developed and improved upon to facilitate
muscle sparing introduction through a smaller intramuscular and
internerval interval [8-10]. Numerous publications have shown
that, with proper training on using the correct technique, this
approach is not only a safe, standard approach for primary THA, but

One or more of the authors of this paper have disclosed potential or pertinent
conicts of interest, which may include receipt of payment, either direct or indirect,
institutional support, or association with an entity in the biomedical eld which
may be perceived to have potential conict of interest with this work. For full
disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2016.07.044.
* Reprint requests: Michael M. Nogler, MD, MA, MSc, Department of Orthopaedic
SurgerydExperimental Orthopaedics, Innsbruck Medical University, Innrain 36,
6020 Innsbruck, Austria.
http://dx.doi.org/10.1016/j.arth.2016.07.044
0883-5403/ 2016 Elsevier Inc. All rights reserved.

it also has the potential to facilitate faster rehabilitation [11-15].


Therefore, the DAA can be considered as one of the standard
approaches to THA.
Standard approaches to the hip should be exible enough to
accommodate revision in addition to primary THA. A standard
surgical approach to THA used for primary cases should be easy to
extend when either intraoperative complications are encountered,
or when a failed implant needs to be revised. Therefore, a surgical
approach such as the DAA should be usable for revisions caused by
implant loosening, implant infection, and periprosthetic fractures.
Unlike the posterior approach, the standard anterolateral approach,
and their related versions, the DAA has been criticized as an
approach that is limited to primary arthroplasty only. This concern
is due to the location of the muscular conjunction of the rectus
femoris and vastus lateralis muscles at the level of the lesser
trochanter and the nerve branches of the femoral nerve, which
cross that area from the medial to the lateral side. Recently, Grob
et al [16] reported extensively on this anatomic aspect. It was
demonstrated clearly that the vastus lateralis muscle is innervated

M.M. Nogler, M.R. Thaler / The Journal of Arthroplasty xxx (2016) 1e5

In a standard DAA, we place the skin incision slightly lateral


posterior to the anterior border of the tensor fasciae latae (TFL). The

incision starts distally to the anterior superior iliac spine (ASIS) and
can be extended to the level of the ASIS in the case of revision. To
access the femoral diaphysis, the skin incision must be extended
distally at the length determined by the situation being treated,
such as implant retrieval or periprosthetic fracture. For cosmetic
reasons, we prefer to curve the incision laterally from the point
most distal to the original DAA approach, forming a lazy S shape
(Fig. 1).
A partial TFL release can be performed if straight access to the
femoral cavity is needed. The anterior border of the TFL is identied. At this level, the IT band typically connects into the much
thinner fascia of the quadriceps muscles. We split the fascia
longitudinally (IT band split) as far distally as needed. The fascia can
then be bluntly mobilized from the underlying vastus lateralis
muscle. The posterior border of the vastus can be exposed by
pulling the fascia laterally and internally rotating the leg (Fig. 2). We
incise the muscle fascia at the posterior border to access the
femoral diaphysis (Fig. 3). Muscle bers are dissected from the bony
surface with a Cobb instrument.
We start the medial mobilization of the vastus lateralis distally
and laterally to the greater trochanter, leaving a muscular bridge
between the vastus and the medial gluteal muscle intact.
The posterior blood supply of the lateral vastus muscle stems from
the rst, second, and third perforating arteries, which stem
from the lateral profunda. The dominant blood supply stems from
the descending branch of the lateral circumex vessel [17]. The
technique of lifting the lateral vastus and ligating the perforating
vessels is well described by Kerschbaumer et al [18]. To ensure a
bony blood supply, we always protect as much muscle attachment
as possible at the anterior aspect of the femur. Sharp Hohmann
retractors can be used to lift up the vastus anteriorly to expose the
lateral surface of the femur. Depending on the pathology, cables or
cerclage wires can now be guided around the femur, or plates can
be applied with screw xation.
The lateral perforating vessels must be carefully exposed and
ligated, as they are the major sources of bleeding. They will easily
retract medially behind the femur after being cut (Fig. 4).
If it is necessary to open up the femoral cavity for implant
retrieval, we perform an anterior wall osteotomy instead of an
extended trochanteric osteotomy. This allows us to leave the bony
continuity intact and does not require cutting of the muscular
chain of gluteal and vastus muscles. The anterior wall osteotomy
as described by Wagner and Wagner [19] is performed by dening
its distal border (Fig. 5). Drill holes are made to avoid stress
fractures during the osteotomy. It is also possible to place a protective cerclage wire distally to those holes if desired. Next, an
oscillating saw or wide, sharp osteotomes are used to make a

Fig. 2. The fascia is split longitudinally and as far distally as needed. The fascia can
then be bluntly mobilized from the underlying vastus lateralis muscle. IT, iliotibial; TFL,
tensor fasciae latae.

Fig. 3. The muscle fascia is incised at the dorsal border to access the femoral diaphysis,
and muscle bers are dissected from the bony surface using a Cobb instrument. VL,
vastus lateralis.

Fig. 1. The lazy S shape resulting from curving the incision laterally from the point
most distal to the original direct anterior approach (DAA) approach. ASIS, anterior
superior iliac spine.

by branches from the femoral nerve that cross the interval distally
and laterally to the lesser trochanter. Any attempt to extend the
surgical approach to the bone distally to the lesser trochanter by
splitting the conjunction between rectus and vastus lateralis would
destroy these nerve branches, and subsequent muscular degeneration must be expected. However, this action is necessary to reach
the femoral diaphysis to perform cerclage, wiring, plating, or even
implant retrieval. We propose an alternate extension of the DAA to
reach the femur at the posterior border of the lateral vastus muscle,
wherein the iliotibial (IT) band is split through its anterior border
and retracted laterally, thereby opening the interval to the
lateral-posterior aspect of the vastus muscle.
The goal of this study was to demonstrate and evaluate, in a
cadaveric setting, our technique to access the entire femoral
diaphysis without endangering the nerve supply. Using this
alternate method, which is based on thorough anatomic investigation, it should be possible to access the femur and perform all
necessary reconstructive procedures on it without encountering
the surrounding nerve structures and creating any visible
damage.
Materials and Methods
Surgical Technique

M.M. Nogler, M.R. Thaler / The Journal of Arthroplasty xxx (2016) 1e5

Fig. 4. The lateral perforating vessels must be carefully exposed and ligated, as they
are the major sources of bleeding. They will easily retract medially behind the femur
after being cut.

horizontal cut into the lateral femoral surface up to the level of the
vastus lateralis insertion into the gluteal medius muscle. We
prefer to cut the bone underneath the vastus origin using an
osteotomy (Fig. 6). The medial wall is cut anteriorly to the implant
surface by carefully advancing thin osteotomes medially in a
stepwise manner (Fig. 7). Eventually, an anterior bony fragment
will be mobilized, thus providing open access to the femoral
cavity. The blood supply of the bony fragment is usually uncompromised because it is still connected to the muscle. This fragment
can be reafxed easily at the end of the procedure by using
cerclage wires. The vastus lateralis is put back in place, and its
fasciae are sutured (Fig. 8).

Cadaveric Evaluation
Forty-three human cadavers (19 males, 24 females) with a mean
body mass index (BMI) of 26 (range 18-36) were acquired for this
study. All cadavers were alcoholeglycerol xated. The cadavers
were used after a standard DAA had been performed on them in
surgical training courses under the supervision of the authors. For
the anatomically focused study, we chose cadavers with intact
femoral bones only. The skin incision was extended distally by
following the standard DAA approach, starting at or slightly below
the level of the ASIS for an incision length of 10 cm. In all cases, the
extension of the approach to reach the lateral aspect of the femoral
diaphysis was performed as described previously to 2 cm below the
isthmus of the femur, which was determined by using a C-arm
image. The goal was to reach the full vastus lateralis muscle after
splitting the anterior IT band without any further releases and to
subsequently perform the procedure without needing to detach the

Fig. 5. The anterior wall osteotomy is performed by dening its distal border. Drill
holes are made to avoid stress fractures during the osteotomy.

Fig. 6. The bone underneath the vastus origin is cut using an anterior wall osteotomy.

vastus lateralis origin and without damaging the nerve branches


that cross vastus lateralis.
Results
All cadavers tested had a skin incision starting at or up to 2-cm
distal to the ASIS. The skin incision was placed 1.9-3.8 cm laterally
to the level of the ASIS. Skin incision length was at a mean of 9.4 cm.
In 17 cadavers, a TFL release had been performed. Regardless of
muscular conguration or BMI, it was possible to split the IT band
as described and pull the IT band laterally, thereby exposing the
whole of the vastus lateralis muscle. This was done by simply
pulling the band with a big rake; further releases were not required,
and excessive force was unnecessary. The junction of the vastus
lateralis and vastus intermedius was not encountered in all cases,
nor was the nerve supply with all nerve bers in that interval. Also
in all cases, it was possible to perform an anterior wall osteotomy
and create an unbroken anterior wall fragment that was covered by
vastus lateralis musculature. The muscular bridge between the
vastus lateralis and gluteus medius could be preserved in all cases,
as could the origin of the vastus lateralis.
Discussion
Grob et al [16] have clearly demonstrated the extent of damage
caused if the extension of the DAA is performed directly anterior by
splitting the conjunction of vastus lateralis and vastus intermedius
of the quadriceps muscle. We described a viable alternative
extension that avoids any damage to the nerve supply from the
femoral nerve. The lateral approach to the diaphysis is a
well-known access portal to the femur, and we proposed using this
access portal in an extended DAA. In the beginning, it was unclear if
it was possible to mobilize the IT band sufciently to access the
posterior border of the vastus lateralis. We suspected that
the tension of the IT band was too high and would impede a surgically sufcient space to reach down to the vastus lateralis, release
its posterior border, and access the lateral aspect of the femoral
diaphysis. In our cadavers, not only we found that this was indeed
possible in all cases independent from body congurations, but we
also found it very easy when compared to all the other approaches
with which we have experience (posterior, lateral, anterolateral,
transgluteal).
In our opinion, this alternate type of extension has several
advantages over a direct anterior extension. Our proposed technique allows the junction of the vastus lateralis and vastus
intermedius to be preserved. This area remains untouched;
therefore, all neurovascular structures in this area remain untouched as well. An approach to the lateral aspect of the diaphysis
by releasing the posterior border has been well described [19-24].

M.M. Nogler, M.R. Thaler / The Journal of Arthroplasty xxx (2016) 1e5

Fig. 7. Cutting the medial wall and lifting the bone fragment.

The reconstruction of the coverage through the vastus lateralis is


simply performed by a running suture of the vastus lateralis fascia
that has been split. The whole of the femur becomes accessible by
lifting up the vastus lateralis, and the possibility of extending this
access distally is unlimited, as one need only to release the vastus
lateralis.
Using this alternative approach to the diaphysis also has
advantages over approaching the diaphysis through the extension
of either the lateral or posterior approaches because with this
alternate extension technique, the IT band is split at the level of
the anterior border of the TFL. Anatomically, this is the junction of
the actual IT band, which is stronger, and the anterior fascia of the
quadriceps. This means, in essence, that the IT band remains
intact and needs only to be reconnected to the quadriceps fascia to
avoid muscular herniation. Its functional structure is uncompromised. Retraction forces remain minimal because the IT band does
not have to be split and retracted; it needs only to be pulled
laterally.
All standard techniques for implant removal (bone windows,
extended trochanteric osteotomies) [25] and all techniques for
osteosynthesis (cables, wires, plates, strut grafts) can be performed
using the alternate extension approach described here to easily
open and retract the soft tissue. We prefer to perform the anterior
wall osteotomy with subsequent cerclage wiring the fragment back
to the diaphysis. This allows us to keep the longitudinal structure of
the femur uncompromised, thereby avoiding the biomechanical
disadvantages of the popular extended trochanteric osteotomy [2628] described by Nobel et al [29]. Using this alternate technique, we
were still able to open the femur well enough to retrieve any
implant. We also preserved the muscular bridge between the
gluteus medius and vastus lateralis for the same reason. When
using this alternate technique, the attachment of the gluteus
medius on the greater trochanter is preserved.

Fig. 8. Closing the VL fascia.

Conclusion
The alternate technique described here for accessing the
femoral diaphysis allows for easy access to the lateral aspect of the
vastus lateralis and, posterior to that, the femoral diaphysis. This
lateral access can be connected to the anterior intermuscular portal
between the TFL and rectus femoris by sacricing the origin of
vastus lateralis at the greater trochanter area. For implant retrieval,
we propose doing an anterior wall osteotomy of the femur. Clinical
evaluation of this alternate extension of the DAA to access the
femoral diaphysis is currently underway and will be reported on
when completed.
Acknowledgments
The authors would like to thank Kate Matthews, MA, ELS, for her
editing assistance.
References
1. Hendrikson RP, Keggi KJ. Anterior approach to resurfacing arthroplasty of the
hip: a preliminary experience. Conn Med 1983;47(3):131.
2. Keggi KJ, Huo MH, Zatorski LE. Anterior approach to total hip replacement:
surgical technique and clinical results of our rst one thousand cases using
non-cemented prostheses. Yale J Biol Med 1993;66(3):243.
3. Light TR, Keggi KJ. Anterior approach to hip arthroplasty. Clin Orthop Relat Res
1980;(152):255.
4. Judet J, Judet H. Anterior approach in total hip arthroplasty. Presse Med
1985;14(18):1031.
5. Kreuzer S, Leffers K, Kumar S. Direct anterior approach for hip resurfacing:
surgical technique and complications. Clin Orthop Relat Res 2011;469(6):1574.
6. Unger AC, Schulz AP, Paech A, et al. Modied direct anterior approach in
minimally invasive hip hemiarthroplasty in a geriatric population: a feasibility
study and description of the technique. Arch Orthop Trauma Surg 2013;133(11):
1509.
7. Bender B, Nogler M, Hozack WJ. Direct anterior approach for total hip arthroplasty. Orthop Clin North Am 2009;40(3):321.
8. Nogler M, Krismer M, Hozack WJ, et al. A double offset broach handle for
preparation of the femoral cavity in minimally invasive direct anterior total hip
arthroplasty. J Arthroplasty 2006;21(8):1206.
9. Putzer D, Mayr E, Haid C, et al. Force transmission in offset broach handles used for
hip replacement: comparison of three different designs. Hip Int 2013;23(2):187.
10. Lovell TP. Single-incision direct anterior approach for total hip arthroplasty
using a standard operating table. J Arthroplasty 2008;23(7 Suppl):64.
11. Mayr E, Nogler M, Benedetti MG, et al. A prospective randomized assessment of
earlier functional recovery in THA patients treated by minimally invasive direct
anterior approach: a gait analysis study. Clin Biomech (Bristol, Avon)
2009;24(10):812.
12. Taunton MJ, Mason JB, Odum SM, et al. Direct anterior total hip arthroplasty
yields more rapid voluntary cessation of all walking aids: a prospective, randomized clinical trial. J Arthroplasty 2014;29(9 Suppl):169.
13. Hoell S, Sander M, Gosheger G, et al. The minimal invasive direct anterior
approach in combination with large heads in total hip arthroplastydis dislocation still a major issue? A case control study. BMC Musculoskelet Disord
2014;15:80.
14. Barrett WP, Turner SE, Leopold JP. Prospective randomized study of direct
anterior vs postero-lateral approach for total hip arthroplasty. J Arthroplasty
2013;28(9):1634.

M.M. Nogler, M.R. Thaler / The Journal of Arthroplasty xxx (2016) 1e5
15. Moskal JT. Anterior approach in THA improves outcomes: afrms. Orthopedics
2011;34(9):e456.
16. Grob K, Monahan R, Gilbey H, et al. Distal extension of the direct anterior
approach to the hip poses risk to neurovascular structures: an anatomical study.
J Bone Joint Surg Am 2015;97(2):126.
lzle F. Raising of microvascular aps: a systematic approach.
17. Wolff K, Ho
Heidelberg, Germany: Springer-Verlag; 2005. p. 41.
die
18. Kerschbaumer F, Weise K, Wirth CJ, et al. Operative Zugangswege in Orthopa
und Traumatologie: Begrndet von Rudolf Bauer, Fridun Kerschbaumer und Sepp
Poisel. Stuttgart, Germany: Georg Thieme Verlag KG; 2013. p. 170.
19. Wagner M, Wagner H. Der transfemorale Zugang zur Revision von Hftendoprothesen. Oper Orthop Traumatol 1999;(11):278.
20. Bauer R. Lateraler Zugang zum femur. In: Bauer R, Kerschbauerm F, editors.
Operative Zugangswege in Orthop
adie und Traumatologie. Stuttgart: Georg
Thieme Verlag; 1990. p. 122.
21. Maffulli N. Lateral approach to the thigh. In: Sivananthan S, Sherry E, Warnke P,
et al., editors. Mercer's textbook of orthopaedics and trauma. 10th ed. Boca
Raton: Taylor & Francis Group; 2012. p. 75.
22. Ramos RS. Posterior-lateral approach in surgery of the diaphysis of femur. An
Paul Med Cir 1951;62(6):407.

23. Giannoudis VP, Pape HC, Schtz M. Lateral approachdfemur shaft. In: Cholton C,
editor. Ao Surgery Reference. Davos, Switzerland: AO Foundation; 2007. https://
www2.aofoundation.org/wps/portal/surgery?showPage=approach&contentUrl=
srg/32/04-Approaches/32-A20_lat_appr.jsp&bone=Femur&segment=Shaft&
approach=Lateral [accessed xx.xx.xx].
24. Wagner H. A revision prosthesis for the hip joint. Orthopade 1989;18(5):
438.
25. Peters Jr PC, Head WC, Emerson Jr RH. An extended trochanteric osteotomy for
revision total hip replacement. J Bone Joint Surg Br 1993;75(1):158.
26. Charity J, Tsiridis E, Gusmao D, et al. Extended trochanteric osteotomy followed
by cemented impaction allografting in revision hip arthroplasty. J Arthroplasty
2013;28(1):154.
27. Chen WM, McAuley JP, Engh Jr CA, et al. Extended slide trochanteric
osteotomy for revision total hip arthroplasty. J Bone Joint Surg Am 2000;82(9):
1215.
28. Della Valle CJ, Berger RA, Rosenberg AG, et al. Extended trochanteric osteotomy
in complex primary total hip arthroplasty. A brief note. J Bone Joint Surg Am
2003;85-A(12):2385.
29. Noble AR, Branham DB, Willis MC, et al. Mechanical effects of the extended
trochanteric osteotomy. J Bone Joint Surg Am 2005;87(3):521.

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