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Direct Anterior Approach – Traction table or No Traction Table

Dr Chien-Wen Liew – Orthopaedic Surgeon – Adelaide, South Australia.

The following article is intended for medical students, registrars and surgeons. It is aimed at an audience with medical knowledge.

The direct anterior approach is a technique involving a significantly reduced damage profile when it comes to muscle and soft tissue damage. The approach uses muscular intervals rather than detaching muscle as is the case with Posterior or Lateral approaches to the hip. Using a direct anterior approach for total hip replacement, a patient can potentially benefit in many ways, including:

  • Small amount of muscle damage during surgery
  • Minimal post operative restrictions
  • Minimal blood loss
  • Generally a rapid recovery
  • Quick mobilisation after surgery
  • Good post operative pain profile

The direct anterior approach for total hip replacements can be performed using a specialised table or a normal operating table. There are benefits of both, however in many cases, a specialised table provides an easier operation, with further minimised tissue damage.

A specialised traction table holds the foot in a boot and has the ability to position the leg in space, at the surgeons desire. During the operation, several specific and measured movements are made to the leg to position the leg in exactly the correct position during the various parts of preparation to the hip joint. The table allows the use of specialised instruments in ways that are difficult without the table. Initial designs of the table had problems with risk to the femoral nerve, however these have now been alleviated with the design from Dr Frederic Laude. This table specifically uses a tension releasing mechanism to take all traction off the leg during extension and adduction movements (risk movements) of the leg, therefore almost obliterating the risk to the femoral nerve.

There have been reports of lower limb injury from using the traction table in the past. This was due to the traction not being released during extension and adduction, causing an issue with torque forces on the lower leg. This is almost non existent with current methods using the method that was developed by Dr Laude. In other approaches, such as the Posterior and Lateral approaches, the leg is similarly positioned with a torsion force to the leg, however it is not rigidly bound in the boot.

The traction table allows for all cases of hip arthritis to be treated via the direct anterior approach. Another benefit of the traction table is that it is thought to be a very sterile environment for the surgical field. This means that both legs do not need to be involved in the operation, potentially minimising cross contamination from the other leg during the procedure.

When the traction table is not used, the leg must be positioned under the other leg, thus achieving the same extended and adducted position. This requires a skilled assistant to hold the leg with the correct amount of tension on the opposite side of the body.

Dr Chien-Wen Liew uses a specialised traction table for all total hip replacements. He was selected to be an Efort Fellow trained by world recognised surgeon, Dr Frederic Laude. Dr Laude is the designer of the traction table used by Dr Liew and the approach as it is known today. The table is one of the most widely used traction tables for the direct anterior approach in the world. Dr Liew has trained in both traction and no traction approaches to the hip, and is proficient in the use of either. He prefers to use a traction table as it facilitates a more ergonomic environment during surgery.


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