My Reasoning for
Total Hip Replacements

0:00 · Start

Hi,, I'm Dr Chien-Wen Liew from Orthopaedics 360 in Adelaide, South Australia. I'm a hip and knee replacement surgeon. And today I'd like to talk a little bit about what the direct anterior approaches for total hip replacements.

0:24 · When did I change to DAA

It's something that I change to roughly nine or ten years ago. The direct anterior approach for total hip replacement has been around for a long time. When I trained in this in 2013, it was something that I went to France, Switzerland and the U.S. to learn. It is something that is very different to the standard approach that I learned during my orthopaedic training.

0:48 · Anatomy of the direct anterior appoach

The direct anterior approach utilises an interval between muscles, tendons and into nervous planes that sit right here at the front of the hip. For my male patients, there is an incision place just here on the front, and from my female, most of my female patients. An incision placed in this angle, called the bikini line incision underneath that skin incision, is really where the magic happens.

1:12 · Handling of muscles tendons and ligaments

We do not cut or detach any tendons or muscle to approach the hip, and this enables us to have very few restrictions on movement.

1:23 · Intra-operative imaging

After the surgery, the operation itself is enhanced with intraoperative imaging, something that I was not able to do beforehand. It allows me to image the hip to ensure that what I have achieved during surgery matches exactly to what we've planned.

1:38 · What is patient specific technology

And, as you know, if you're a patient of mine, we perform all of our total hip replacements using something called patient-specific technology. This means that we perform a three-dimensional scan on the hip many weeks before the surgery, so that I can perform the surgery on the hip. Before you even come into the operating theater. That enables me to identify any anatomical differences, any positioning changes, or any implant related changes that we may need to do to ensure that we're positioning and performing the surgery with as much accuracy as possible. We get important readouts about things like leg length and position of the implant, and we match those measurements during surgery without intraoperative scan.

2:21 · Lack of movement restrictions

Part of the benefits of the direct anterior approach for total hip replacements are the lack of movement restrictions immediately after the surgery. In general, we allow all of our patients to move as they please, which means that no pillows are strapped between the legs and there are no movement restrictions. You can sit up as high as you like, you can sit on any toilet seats or load chairs that you wish,

and you are allowed to cross your legs or lie on your side immediately after the surgery. This relates to the risk of dislocation, and whilst a dislocation is certainly possible with any approaches to the hip, the risk is low. And something that we do not really think about. If there are any limitations on the position of the leg, it would really just be going into very abnormal positions, such as yoga positions.

During that first six to eight weeks after surgery, after that, the risk of dislocation is low and is discussed with each patient unless there was major trauma involved. Hip replacement, by any approach, generally has good long-term results. We find that the direct anterior approach is something that, for my patients, with the technology that we use, allows our patients to return back to their normal function. A lot earlier than what our patients used to do.

3:34 · Is the DAA suitable for anyone?

With some of the more conventional approaches, some of our patients do ask us, is the direct anterior approach suitable for anyone? And certainly, we have found that over the last almost 10 years of performing this operation. There are very, very few patients who are not suitable for the direct anterior approach. One of that type of patient that may not be suitable for. This is if you have an extremely elevated body mass index,

where we cannot palpate the bony landmarks around the front of the hip. If that is the case, then potentially the risk profile is higher and we would opt to try to reduce that weight before performing the surgery.

4:11 · DAA for special anatomies

We have performed the direct anterior approach for complex hip replacements, such as developmental dysplasia, perthes disease, and anatomical abnormalities, where the hip is almost fused. However, they are certainly more complex and require additional planning.

4:27 · My aim for performing a DAA for THR

My aim of performing a total hip replacement is to restore my patient's function back to a point where they really do not think about the fact that they've got a hip replacement in there. We usually find that our patients achieve this somewhere between six to nine months after surgery. And the holy grail? And what we hope to achieve in every one of our patients is called the forgotten hip.

4:48 · Limitations after a THR

Whilst we don't let our patients run long distance, they are certainly very functional, and most of them really do not feel that the hip replacement they have leads to any limitations in quality of life.

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Transcript edited lightly for readability.