The Problem State

Specialty OR tables may not be the most efficient approach for doing direct anterior hip arthroplasty.

With the number of total hip arthroplasty’s set to grow to over 600,000 by 20251, and with more than half of hip arthroplasty surgeons performing direct anterior hip arthroplasty (DAA), the demand for DAA continues to rise.

Though DAA is commonly performed on a traction table or with an adjustable traction attachment, there is growing interest in the perioperative and economic advantages of DAA technique on a standard OR table2.

Dr. Andrew Battenberg has found that the off-table approach can be more efficient and less costly than traction tables. Using a standard OR table with a foam-based, pre-contoured tabletop positioner, enables a surgeon to establish a reproducible pelvic position, stabilize the pelvis for dislocation and relocation, ensure femoral exposure on the operative side, and use intra-op fluoroscopy as needed.

A Cost Effective and Efficient Approach to Off-Table DA Hip Surgery

Considering healthcare’s chronic staffing shortages and pressure to control costs, efficient, cost-effective solutions are needed. Transitioning from an “on-table” to an “off-table” technique for THA via the DAA is associated with substantial improvements in operative and perioperative efficiency. After adjusting for a learning curve, the mean surgical time improved by 28 minutes (23.11%) and total room time by 43 minutes (23.37%), which allowed for an additional case per room per day2.

Andrew Battenberg, MD

Dr. Battenberg is Chief of Orthopedics at Kaiser Vacaville Medical Center. He specializes in direct anterior hip arthroplasty using minimally invasive techniques; most of his cases are primary DAA.  He received his medical degree from UCLA, completed his orthopedic surgical residency at Harbor-UCLA Medical Center, and followed with an Adult Reconstruction fellowship at the Rothman Institute in Philadelphia, Pennsylvania.
Andrew Battenberg, MD

Download the technique guide:

A Step-by-Step Guide to the DAA technique using the BoneFoam DAA Positioner

Using this approach has streamlined and standardized my patient positioning for direct anterior hip replacement, and it helps to maximize our OR efficiency. The reproducible pelvic position allows me to achieve ideal implant position and hip reconstruction without the need for fluoroscopy.

Direct Anterior Hip Positioning System

Reproducibly achieve adduction to optimize femoral exposure and maximize OR throughput

In the following educational videos, Dr. Battenberg demonstrates off-table positioning techniques and the use and benefits of the Direct Anterior Hip Positioning System compared to a Traction Table.

Positioning the pelvis is critical to success in using the Direct Anterior Positioning System.

See how OR workflow is simplified, and learn key features of the system that help to improve femoral exposure.

The surgeon has complete control of the operative extremity.

See how using a slight Trendelenberg position increases femoral extension and exposure.

Adduction is the key to optimizing femoral exposure, not extension.

1. J. A. Singh, S. Yu, L. Chen and J. D. Cleveland, "Rates of Total Joint Replacement in the United States Using the National Inpatient Sample," Journal of Rheumatology, 2019.

2. Owen TM, Horberg JV, Corten K, Moskal JT. “The Off-Table Technique Increases Operating Room Efficiency in Direct Anterior Hip Replacement,” Arthroplast Today, vol. 15, pp. 167-173, 2022.

3. R. Rathi, I. Tourabaly and A. Nogier, "Two-incisions direct anterior approach for THR: Surgical technique and early outcome," Journal of Orthopaedics, vol. 14, no. 3, pp. 398-402, 2017.

4. R. Coelho, C. Gomes, M. Sakaki and E. Montag, "Genitoperineal Injuries Associated with the Use of an Orthopedic Table With a Perineal Posttraction," The Journal of Trauma, vol. 65, no. 4, pp. 820-823, 2008.