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
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
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.
M.M. Nogler, M.R. Thaler / The Journal of Arthroplasty xxx (2016) 1e5
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.
M.M. Nogler, M.R. Thaler / The Journal of Arthroplasty xxx (2016) 1e5
Fig. 7. Cutting the medial wall and lifting the bone fragment.
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.
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