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Primary THA Through the Anterior-Based Muscle-Sparing Approach on a Standard Surgical Table
Numerous anterior approaches have been described for total hip arthroplasty (THA), including the direct anterior (Smith-Petersen), Hueter, Watson-Jones, Rottinger, Bauer, Dall, Hardinge, Ganz, and Levine approaches. To further complicate terminology, many of these approaches have descriptors such as modified, mini, minimally invasive, or muscle-sparing. In comparing surgical approaches to the hip, the role of muscle detachment is more important than that of the muscle interval used for dissection. The surgical approach is defined by its relationship to the greater trochanter (posterior, posterior-superior, anterior, or transtrochanteric) and the specific muscles detached. Other considerations include body or leg position (supine versus lateral, flexion versus extension), the type of surgical table required, and the need for fluoroscopy or computer-assisted navigation. This chapter reviews the surgical steps for primary total hip arthroplasty using an anterior-based muscle-sparing (ABMS) approach. Although multiple terms have been used to describe the ABMS approach, it is inaccurate to characterize it as either an anterolateral or a modified Watson-Jones approach because both of those approaches involve detachment of the abductor muscles. The ABMS approach uses the Watson-Jones interval for exposure of fractures of the femoral neck, but does not include detachment of the abductors. The ABMS approach is similar to the direct anterior approach but uses a standard surgical table. To facilitate leg position during the approach, a split lower extremity table drop or a split leg pegboard attachment (an inexpensive attachment for a standard surgical table) can be used. The extremity is prepped free, allowing intraoperative assessment of range of motion and stability. Because the patient is positioned laterally, dissection can be done through an extensile or a so-called minimally invasive approach, resulting in the versatility of this approach for both primary and revision scenarios. The ABMS approach does not put the femoral cutaneous nerve at risk, and it facilitates faster recovery because it does not violate the abductor muscles.