Total hip arthroplasty has steadily evolved to improve patient outcomes and safety.  One innovation has been to incorporate less invasive surgical methods, such as the direct anterior surgical approach.
 
The Direct Anterior Approach to Hip Reconstruction is a comprehensive reference text that addresses contemporary surgeon interest in innovation and less invasive surgery.  This resource will help with introductory learning, intermediate technical development, and advanced revision total hip skills using the direct anterior technique. Accordingly, the text is structured into three sections as follows:
 

• Basic concepts: Surgical hip anatomy, patient selection, and placement of single, multiple, and extensile incisions for primary total hip arthroplasty

 

• Intermediate concepts: Adoption of imaging and navigation technologies, use of traction tables to enhance positioning, and presentation of unique instruments and custom devices that have evolved specifically for the direct anterior approach

 

• Advanced concepts: Using the direct anterior approach for bearing and liner exchanges, acetabular revisions, femoral component revisions, and both component revisions.

 
 
Drs. B. Sonny Bal, Lee E. Rubin, and Kristaps J. Keggi have combined their unique perspectives, along with those of a renowned group of North American and European experts in the anterior hip reconstruction surgery to create this reference.  Dr. Keggi was among the first to recognize the benefits of the direct anterior approach in hip reconstruction; this text is based on his 50-plus years of experience as a clinician and pioneer surgeon.  
 
The Direct Anterior Approach to Hip Reconstruction provides a stepwise learning process for surgeons interested in mastering total hip arthroplasty using the direct anterior approach, with detailed chapters and video instruction, contributed by a distinguished group of international experts in the field.
 
The chapters focus on using the direct anterior approach to address a variety of hip problems well beyond performing total hip arthroplasty for osteoarthritis. The unique applications of the direct anterior approach within the orthopedic sub-specialties are addressed in chapters covering the fields of pediatrics, sports medicine, trauma, and tumor surgery.  Other chapters address subjects like femoroacetabular impingement, hip preservation surgery, and postoperative rehabilitation protocols designed to improve patient outcomes.
 
The final section of the text reviews the evidence-based outcomes related to direct anterior total hip arthroplasty, addressing evolving implant design concepts specific to this approach, and outlining directions for educating the next generation of surgeons who will continue to develop and refine these techniques. Complementing the written text is a website with educational videos to further enhance the learning experience.
 
To date, no other reference has addressed the need for comprehensive education for the orthopedic resident, fellow, or surgeon seeking to learn about the direct anterior approach for hip reconstruction.  This resource should be invaluable to orthopedic surgeons worldwide and will contribute to improving patient safety, reducing complications, and better surgical outcomes. Indeed, this landmark publication is truly the world’s first comprehensive text on anterior hip surgery.
 

B. Sonny Bal, MD, JD, MBA is an arthroplasty surgeon, who was one of the early adopters of anterior total hip arthroplasty. Dr. Bal has an academic appointment at the University of Missouri in Columbia, Missouri. In addition to clinical work, he is active in materials science research at the Missouri University of Science & Technology at Rolla, Missouri, and heads a silicon nitride ceramic manufacturer located in Salt Lake City, Utah. Dr. Bal is also an attorney and active in medico-legal education and consulting work.
 
Originally from New Jersey, Lee E. Rubin, MD matriculated as an undergraduate Presidential Scholar at Brandeis University, Waltham, Massachusetts and graduated Cum Laude in 2000. He then graduated with Alpha Omega Alpha distinction from the Tufts University School of Medicine, Boston, Massachusetts in 2004. Dr. Rubin completed his orthopedic training at Yale University, New Haven, Connecticut in 2009, followed by an Adult Reconstruction Fellowship focused on the Direct Anterior Approach with Dr. Kristaps J. Keggi and the Keggi Orthopedic Foundation in Connecticut in 2010.
Dr. Rubin is presently affiliated with University Orthopedics, Inc and is an Assistant Professor of Orthopedic Surgery on the faculty of the Warren Alpert Medical School of Brown University in Providence, Rhode Island. He is actively engaged in numerous clinical research projects through The Miriam Hospital’s Total Joint Center, Providence, Rhode Island, and has published over 50 scientific posters, papers, and book chapters. He is a Fellow of the American Academy of Orthopaedic Surgery (AAOS), a Fellow of the American Association of Hip and Knee Surgeons (AAHKS) an active member of the Orthopaedic Research Society (ORS), and is a Faculty Member of the International Congress for Joint Reconstruction (ICJR).

In 2013, Dr. Rubin was selected and awarded as one of the Forty Under 40 in Rhode Island by the Providence Business News. In 2013, he was elected to serve on the Executive Committee of the Rhode Island Orthopedic Society (RIOS), and was invited to serve on the Board of the Yale Orthopaedic Association in 2016. He is an editorial board member and reviewer for a number of prestigious orthopedic journals, is actively involved with the Rhode Island Chapter of the Arthritis Foundation, and was the Chapter’s Medical Honoree at the Providence Walk to Cure Arthritis event in 2015. He lives outside of Providence, Rhode Island with his wife and 2 children.
 
Kristaps J. Keggi, MD, Dr Med (hc) is the Elihu Professor of Orthopaedics and Rehabilitation at the Yale University School of Medicine in New Haven, Connecticut. Dr. Keggi was born in Latvia and arrived in America as a World War II refugee at the age of 15 years. With the exception of 2 years of general surgical training at the “Old” Roosevelt Hospital in New York City and 2 years of military service with the United States Army in Texas and Vietnam (3rd Surgical Hospital, Army, Mobile), Dr. Keggi has been associated with Yale College and Yale University since 1951. First, he attended Yale as an undergraduate and medical student, later trained as a Yale orthopedic resident, and ultimately joined the teaching faculty of the university, a post he holds to the present day.

Dr. Keggi completed his orthopedic training in 1964 and was practicing and teaching orthopedic surgery for more than 5 years when the Charnley Low Friction Arthroplasty was brought to the United States. He was among the first in Connecticut to perform this procedure in its classical transtrochanteric manner. Based on his training with Wayne O. Southwick, MD, who encouraged innovative thinking, he rapidly moved to utilize the less traumatic Direct Anterior Approach. With the help of Terry Light, MD, his resident at the time, he presented the DAA technique for total hip arthroplasty (THA) and published his early results as a Scientific Exhibit at the 1977 Meeting of the AAOS in Las Vegas. Subsequently, in October of 1980, he published the results in Clinical Orthopaedics and Related Research, thereby becoming one of the first American surgeons to publish on the DAA for THA. Continuously since that era, the DAA has been his primary approach for all simple and complex hip arthroplasty procedures.

Over the course of a career spanning over 50 years, Dr. Keggi has improved the lives of thousands of patients, has taught over 150 Yale residents, and has hosted more than 250 international fellows brought to Yale and The Waterbury Hospital from Latvia, Estonia, Lithuania, Russia, Ukraine, Georgia, Belarus, Kazakhstan, Uzbekistan, Tajikistan, Sweden, Germany, and Vietnam. He is the author of numerous publications on total hip surgery, has lectured at multiple meetings and locations, and has visited sites around the world to teach and perform DAA hip replacements.

During his career, Dr. Keggi has received numerous Yale teaching awards, honorary degrees from Universities around the world, and has been honored with the Latvian Order of the Three Stars in 1993, the V Class Order of the Estonian Red Cross in 1999, the Distinguished Service Medal of the Latvian Physicians Association (the second ever awarded) in 2009, and the Silver Medal of Medical Dignity and Service to Russian Medicine in 2012. He was granted honorary memberships in both the Latvian Academy of Science in 1990 and the Russian Academy of Science in 1993. One of his greatest honors was to have received the George H.W. Bush Lifetime of Leadership Award from his alma mater, Yale University, in 2005.
 

Dedication

Acknowledgments

About the Editors

Contributing Authors

Foreword by Larry Dorr, MD 

Introduction

Section I Basic Direct Anterior Approach Surgical Technique

Chapter 1 Applied Anatomy of the Anterior Hip and Thigh

Blake E. Peterson, MD and Brett D. Crist, MD

Chapter 2 Indications for the Direct Anterior Approach

R. Presley Swann, MD, MS and Christopher E. Pelt, MD

Chapter 3 Managing Single and Multiple Incisions in Direct Anterior Hip Surgery

Scott A. Ritterman, MD; Kristaps J. Keggi, MD, Dr Med (hc); and Lee E. Rubin, MD

Chapter 4 Primary Total Hip Arthroplasty Using the Hana Table

Navid M. Ziran, MD and Joel M. Matta, MD

Chapter 5 Extensile Approach to Anterior Hip Surgery

Blake E. Peterson, MD and Brett D. Crist, MD

Chapter 6 Anterior Supine Intermuscular Total Hip Replacement

Keith R. Berend, MD; Nathan J. Turnbull, MD; Robert E. Howell, MD; and Adolph V. Lombardi Jr, MD, FACS

Chapter 7 Tips and Tricks for Overcoming the Direct Anterior Approach Learning Curve

Benjamin Domb, MD and Timothy Jackson, MD

Section II Intermediate Direct Anterior Approach Techniques

Chapter 8 Understanding the Risks in New Technologies

B. Sonny Bal, MD, JD, MBA and Lawrence Brenner, JD

Chapter 9 Direct Anterior Total Hip Arthroplasty in the Lateral Decubitus Position

Wietse P.R. Melman, MD; Markus C. Michel, MD; and Cees C.P.M. Verheyen, MD, PhD

Chapter 10 Direct Anterior Total Hip Replacement With Leg Positioning

System and Fluoroscopy

Adam M. Freedhand, MD; Preetesh D. Patel, MD; and Eric M. Slotkin, DO

Chapter 11 Computer Navigation and Robotics in Anterior Hip Reconstruction

David Dodgin, MD; E. Matthew Heinrich, MD; and Joseph T. Moskal, MD, FACS

Chapter 12 Transitioning to Direct Anterior Total Hip Replacement

Blake E. Peterson, MD; Joseph Morgan, MD; and B. Sonny Bal, MD, JD, MBA

Chapter 13 Specialized Instruments for the Direct Anterior Approach

Dan Gerscovich, MD; Anthony S. Unger, MD; Evan Smith, MD; Kristaps J. Keggi, MD, Dr Med (hc); and Lee E. Rubin, MD

Chapter 14 Specialized Retraction for Direct Anterior Total Hip Arthroplasty

Daniel C. Allison, MD, MBA and Timothy McTighe, Dr HS (hc)

Section III Advanced Adult Reconstructive Techniques

Chapter 15 Avoiding, Recognizing, and Treating Complications of the Direct Anterior Hip Approach

Mohan S. Tripathi, MD and Stephen Kayiaros, MD

Chapter 16 How to Identify and Correct Technical Errors With the Direct Anterior Approach

Michael P. Ast, MD and Hari P. Bezwada, MD

Chapter 17 Head and Liner Revision Surgery via the Direct Anterior Approach

Scott A. Ritterman, MD; Matthew E. Deren, MD; and Lee E. Rubin, MD

Chapter 18 Simultaneous Bilateral Direct Anterior ApproachTotal Hip Arthroplasty

Stefan Kreuzer, MD, MSc and Amir Pourmoghaddam, PhD

Chapter 19 Acetabular Direct Anterior Approach Revision Surgery

Jonathan Yerasimides, MD

Chapter 20 Anterior Approach Femoral Revision Surgery

Michael Nogler, MD, MA, MSc

Section IV Direct Anterior Approach Across Orthopedic Specialties: Pediatrics

Chapter 21 Direct Anterior Hip Surgery in Pediatric Patients

Jonathan R. Schiller, MD; Philip McClure, MD; and Lee E. Rubin, MD

Chapter 22 Management of Developmental Dysplasia of the Hip With the Bernese Periacetabular Osteotomy

Atul F. Kamath, MD; Reinhold Ganz, MD; and Michael Leunig, MD

Section V Direct Anterior Approach Across Orthopedic Specialties: Sports/Hip Preservation

Chapter 23 Limited Exposure Direct Anterior Approach for Treatment of Femoroacetabular Impingement

Lee E. Rubin, MD; Joseph A. Gil, MD; and Scott A. Ritterman, MD

Chapter 24 Addressing Acetabular and Femoral Lesions in Hip Impingement With the Direct Anterior Approach

Garrett Davis, MD, MBA, MS and Javad Parvizi, MD, FRCS

Section VI Direct Anterior Approach Across Orthopedic Specialties: Trauma

Chapter 25 Management of Acetabular Fractures in the Elderly WithDirect Anterior Hip Surgery

Steve Papp, MD; Wade Gofton, MD; Derek Butterwick, MD; Allan Liew, MD; and Paul E. Beaulé, MD

Section VII Direct Anterior Approach Across Orthopedic Specialties: Adult Reconstruction/Hip Preservation

Chapter 26 Proximal Femur-Preserving Hip Reconstruction With the Direct Anterior Approach

Stefan Kreuzer, MD, MSc and Amir Pourmoghaddam, PhD

Section VIII Direct Anterior Approach Across Orthopedic Specialties: Oncology

Chapter 27 Tumor Reconstruction of Hip and Proximal Femur With the Anterior Approach

Herrick J. Siegel, MD and Daniel C. Allison, MD, MBA

Section IX Direct Anterior Approach Across Orthopedic Specialties: Rehabilitation

Chapter 28 Patient Rehabilitation After Direct Anterior Hip Surgery

Sarvang Dalal, PT, DPT, MSPT, MTC, FAAOMPT and Amir Pourmoghaddam, PhD

Section X Direct Anterior Approach Across Orthopedic Specialties: Anesthesia

Chapter 29 Anesthesia for the Direct Anterior Approach to Total Hip Arthroplasty

Anjali O. Rozario, MD and Stavros G. Memtsoudis, MD, PhD

Section XI Outcomes

Chapter 30 Multi-Center Outcomes

Harman Chaudhry, MD and Mohit Bhandari, MD, PhD, FRCSC

Chapter 31 Current Direct Anterior Approach Outcomes Literature Review

Tim P. Lovell, MD

Chapter 32 Training and Educating Others About Direct Anterior Hip Surgery

John A. Scanelli, MD and Joseph T. Moskal, MD, FACS

Chapter 33 Understanding Short Femoral Stem Design and Application in Direct Anterior

Approach Total Hip Arthroplasty

Timothy McTighe, Dr HS (hc) and Daniel C. Allison, MD, MBA

Section XII Conclusion

Chapter 34 In Closing: The Futureof Direct Anterior Hip Surgery

Lee E. Rubin, MD; B. Sonny Bal, MD, JD, MBA;and Kristaps J. Keggi, MD, Dr Med (hc)

Financial Disclosures

Index