The direct anterior approach for total hip replacement can be performed using a specialised traction table or a standard operating table. Dr Liew explores the differences, benefits, and his own preference.
The Direct Anterior Approach Overview
The direct anterior approach is a technique involving a significantly reduced damage profile when it comes to muscle and soft tissue. The approach uses muscular intervals rather than detaching muscle, as is the case with posterior or lateral approaches. Potential benefits include small amount of muscle damage, minimal post-operative restrictions, minimal blood loss, rapid recovery, quick mobilisation, and a good post-operative pain profile.
The Specialised Traction Table
A specialised traction table holds the foot in a boot and has the ability to position the leg precisely in space at the surgeon's desire. During the operation, several specific and measured movements are made to position the leg exactly correctly during the various parts of hip preparation. The table allows the use of specialised instruments in ways that are difficult without it.
Initial table designs had concerns regarding the femoral nerve, however these have been alleviated with the design developed by Dr Frederic Laude. This table uses a tension-releasing mechanism to take all traction off the leg during extension and adduction movements (the risk movements), almost obliterating any risk to the femoral nerve.
Benefits of the Traction Table
The traction table allows treatment of all cases of hip arthritis via the direct anterior approach, regardless of body habitus or hip anatomy. An additional benefit is the sterile surgical field — both legs do not need to be involved in the operation, potentially minimising cross-contamination.
Without the Traction Table
When the traction table is not used, the leg must be positioned under the other leg to achieve the same extended and adducted position. This requires a skilled assistant to hold the leg with the correct amount of tension throughout the operation.
Dr Liew's Approach
Dr Chien-Wen Liew uses a specialised traction table for all total hip replacements. He was selected as an Efort Fellow trained by world-recognised surgeon Dr Frederic Laude — the designer of the traction table used by Dr Liew and the pioneer of the approach as it is known today using the AMIS technique.
Dr Liew has trained in both traction and no-traction approaches to the hip and is proficient in both. He prefers the traction table as it facilitates a more ergonomic environment during surgery and maximises precision for every case.
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