Frame-based Draping Technique for Standard Table Direct Anterior Approach THA: Efficient and Safe?

Performing a direct anterior approach (DAA) for THA without the use of a traction table requires precise leg manipulation and exposure. We developed a novel frame-based horizontal one-piece drape with an impermeable cover enabling repeated leg hyperextension while maintaining sterility. However, the efficiency and revision risks of this frame-based DAA for THA on a standard table remain unevaluated, which may concern surgeons who are considering the technique.

(1) Does the frame-based DAA for THA technique require less time for setup and surgery than the traditional stockinette-based technique with its multipiece cover? (2) Is the frame-based DAA for THA technique associated with a higher infection revision rate or overall revision rate compared with other institutions as measured in the national joint registry?

This retrospective, comparative cohort study described the frame-based DAA for THA technique and evaluated its efficiency and safety. Efficiency was assessed as operative setup time and surgery duration using hospital data from consecutive unilateral DAA THAs performed by a single surgeon between January 2008 and December 2013. The control group included 387 patients (43% [167] male; mean ± SD age 73 ± 10 years; 64% [246] uncemented) using the traditional stockinette-based technique, while the intervention group comprised 385 patients (49% [188] male; age 70 ± 10 years; 89% [342] uncemented) using the frame-based technique. Safety was evaluated as 5-year revision rates and reason for revision from the mandatory Swiss National Joint Registry (SIRIS, covering 98% of all THAs in Switzerland), which also included patients who underwent revision at a different hospital than where the primary THA was performed. We compared 9973 DAA THAs performed at our institution (frame-based technique 46% [4612] male; age 67 ± 11 years; BMI 26 kg/m 2 ± 5; 98% [9799] cementless) with 88,443 DAA THAs performed nationwide (any other technique 48% [42,607] male; age 69 ± 11 years; BMI 27 ± 5 kg/m 2 ; 86% [75,649] cementless) between January 2014 and December 2024. The groups were comparable in terms of ASA classification and indication.

The frame-based DAA for THA technique had a shorter median (IQR) setup time (37 minutes [30 to 47] versus 47 minutes [39 to 57]; p < 0.001) and a shorter median (IQR) surgery duration (63 minutes [56 to 75] versus 72 minutes [63.0 to 81.5]; p < 0.001) compared with the stockinette-based DAA for THA technique. When compared with the national benchmark for DAA THAs performed using other techniques, the frame-based technique demonstrated a lower 5-year revision rate for periprosthetic joint infection (PJI) (0.43% [16 of 3651] [95% confidence interval (CI) 0.31% to 0.60%] versus 0.94% [292 of 31,070] [95% CI 0.88% to 1.02%]) and a lower overall 5-year revision rate (1.34% [49 of 3651] [95% CI 1.10% to 1.62%] versus 3.52% [1094 of 31,070] [95% CI 3.39% to 3.67%]; p < 0.001 for both comparisons).

The frame-based draping technique for DAA THAs on a standard table is simple, efficient, and safe. Compared with the traditional stockinette-based method, the frame-based technique with its one-piece drape shortens setup time and eliminates the risk of contamination when lowering the legs into hyperextension. Compared with other DAA for THA techniques, it is not associated with higher revision rates, particularly regarding PJI.

Level III, therapeutic study.