Anterior Approach History
The Anterior Approach for Total Hip Replacement: History
Joel M. Matta, M.D.
Director, Hip and Pelvis Institute
St. John’s Health Center
Santa Monica, CA 90404
Today’s Anterior Approach technique follows the Heuter approach which was first described in the German orthopedic literature in the 1930’s. The approach can also be called the “Short Smith-Pete” because it follows the interval of the Smith-Petersen distal to the anterior superior iliac spine.
The first hip Arthroplasty performed through this approach was by Robert Judet in 1947 at Garches Hospital in Paris and a Judet acrylic prosthesis was implanted. The surgery was facilitated by operating on the Judet Table with the patient in the supine position. The Judet Table was originally designed by Henri Judet, an orthopedic surgeon and Robert Judet’s father. The reasons for Judet’s choice of this approach for hip Arthroplasty are several: 1) The hip is an anterior joint, closer to the skin anterior than posterior 2) The approach follows the anatomic interval between the zones of enervation of the superior and inferior gluteal nerves lateral and the femoral nerve medial 3) The approach exposes the hip without detachment of muscle from the bone.
Today Thierry Judet, the son of Robert Judet continues to use this approach as well as the Judet table for hip Arthroplasty. Prof. Thierry Judet, Chief of Orthopedics at Garches, has used this approach and table for over 20 years and more than 2000 cases. It has been the preferred technique for primary and revision hip Arthroplasty at Garches since 1947. It has been used for a great variety of prosthesis including the Judet acrylic, the Judet uncemented, conventional cemented, partial femoral head resurfacing and total hip surface replacement. The original approach was slightly longer and extended onto the iliac crest and also more distally. The tensor fascia lata muscle was partly detached from the crest. Over time the incision has to a degree shrunk but the interval remains the same.
While this history of the Anterior Approach for THA has been little known in the orthopedic world, the history of Charnley’s experience is widely known. Charnley implanted the first consistently successful THA in the 1960’s. He also positioned the patient supine though used a more standard flat topped operating table with the leg draped free and manipulated by a scrubbed assistant. This approach necessitated a trochanteric osteotomy. Because of recognized complications of this osteotomy, the posterior approach was later adopted by many surgeons with the patient necessarily positioned in the lateral position. Because of problems with hip dislocation however following the posterior approach some surgeons later adopted the anterolateral Harding approach. The down side of the Harding approach however, has been the necessity of detachment of the gluteus minimus and a portion of the gluteus medius from the greater trochanter which can lead to a delay in functional recovery.
The anterior approach however, preserves posterior structures that are important for preventing dislocation while preserving important muscle attachments to the greater trochanter. It is obvious that lack of disturbance of the minimus and medius insertions facilitates recovery of a normal gait. The surgeon should also consider the role of the gluteus maximus and tensor fascia lata muscles as abductors and pelvic stabilizers. These two muscles insert on the fascia lata/iliotibial band which joins them and together form a “deltoid of the hip”. Lack of disturbance of this “hip deltoid” is a further benefit of the anterior approach.
I first saw this THA technique in 1981 when I visited Emile Letournel in Paris to study acetabular and pelvic fracture surgery. Letournel had been Robert Judet’s resident. I observed the patient placed supine on the Judet Table. The leg was not draped free but the foot placed in a boot and manipulated by a mobile spar that was operated by an unscrubbed assistant. I recall being quite impressed but a little confused and I did not pursue this technique. My main interest at the time was pelvic and acetabular fracture treatment and when I performed THA I continued to use the posterior approach. In 1996 I was approached by a patient who had had one hip replaced by this technique in France but now lived in the US and required replacement of the other hip. He was very enthusiastic about the anterior approach because of the lack of muscle disturbance and the rapid recovery he had experienced and requested that I replace his other hip by the same technique. This led me to reconsider the value of this technique and its potential benefits of reduced dislocation risk and enhanced recovery rate. At the time I frequently used the Judet table for acetabular fracture surgery. I replaced this man’s hip using the anterior approach on the Judet table and began my own series of patients. I proceeded slowly at first with only 20 to 30 cases per year but I now use this approach frequently and for all primary hip arthroplasties.
My own concept of minimally invasive is that it is more important what we do under the skin than the specific length of the incision. Stretching, contusing and abrading tissue is not what I consider minimally invasive. The main advantage of this approach is that it is not necessary to detach or split any muscle from the pelvis or the femur and the “hip deltoid” is not disturbed. The result is that there is an immediate stability of the hip that obviates the need for dislocation precautions. Also, there is a rapid recovery of function. I believe another advantage of the technique as I apply it is use of the image intensifier for immediate information regarding acetabular position and femoral length and offset. Accuracy of component position and leg length is thereby enhanced. The supine position that is preferred for this approach facilitates the accuracy of acetabular position as well as assessment of leg length.
For surgeons not familiar with THR through the anterior approach it is easy to appreciate the straightforward acetabular access. The femoral access however is less easy to conceptualize. The femoral access is greatly enhanced by a special orthopedic table. The original table designed and used in France was the Judet/Tasserit table. Today the Mizuho OSI PROfx® or hana® table is the new and improved surgical tool. With the patient positioned supine the leg is not draped free but is attached to a mobile strut that can apply traction, rotate the leg, and angulate the leg in all directions. External rotation of the leg to 90 degrees and hyperextension of the hip to 30 degrees allows femoral preparation and prosthesis insertion in a somewhat anterior to posterior direction. The table also elevates the proximal femur to enhance access. The anterior approach is the approach used for acetabular component insertion with the minimally invasive 2 incision technique. With use of the table however, a second posterior incision becomes unnecessary.
Either cemented or uncemented components can be implanted through this approach. Femoral components that require straight reamers however are more difficult to place and not as applicable to this approach.
I have used this approach for primary THR for the past 7 years and now use it for all primary cases unless there is an acetabular posterior defect that requires posterior graft and plate fixation.
The following images (case 1 and case 2) depict typical operative steps for the anterior approach for hip replacement. I consider the Mizuho OSI PROfx® or hana® table and femoral broaches with an offset handle to be essential instruments for minimizing soft tissue trauma.
The question is often asked: Is the Judet/Tasserit or PROfx® or hana® table necessary for use of this approach. Kristaps Keggi of Waterbury, Connecticut has used the Anterior (Heuter) Approach for over 3000 hip replacements while operating on a standard table. It is Dr Keggi’s practice however to frequently utilize secondary incisions for acetabular and/or femoral preparation. Though I have seen that is possible to use the anterior approach without the table, the table obviates the need for secondary incisions. Additionally it is my impression that femoral access is significantly more difficult without the PROfx® or hana® table. Improving the femoral access not only eliminates secondary incisions but also reduces muscle trauma that can result from forceful retraction.
I prefer use of the image intensifier to improve the accuracy of acetabular position as well as leg length and offset. Image time averages 50 seconds. The surgeon experiences negligible x-ray exposure if he stands one meter away while imaging. If the surgeon prefers, the operation can be performed without the image intensifier utilizing the normal measures for assessing leg length (pre-op templates, prosthesis relation to femoral landmarks, soft tissue tension, and patella palpation).
Most small incision surgery techniques advocated are only for selected patients. The most common criterion is a body mass index (weight in kg / height in meters) of less than 35. I use the anterior approach for all patients, certainly high BMI patients are more difficult but incisions over 10 cm are infrequent and 12 cm is almost always the maximum necessary. Small incision surgery of obese patients through the anterior approach is possible partly because the subcutaneous fat over the anterolateral proximal thigh does not increase in thickness as dramatically as it does posteriorly or laterally.
As we endeavor to minimize the soft tissue invasion, I think it is useful to consider: Which patients need the most help in dislocation prevention and functional rehab, the thin and fit patient or the obese and deconditioned patient?.