Anterior Approach for Primary Total Hip Arthroplasty is Worthwhile

Brent Lanting, M.D., FRCSC
London, ON

Over the years, there has been a significant evolution of Total Hip Arthroplasty (THA), with changes to peri-operative medical management, implant design and bearing surfaces. However, surgical approach has evolved at a much slower rate, with the progression from the transtrochanteric approach to the posterior or direct lateral approach occurring in the 1970's1. Although the posterior and direct lateral approaches are still more common, improved education, modern instrumentation and appropriate implants have led to the increased popularity of direct anterior approach (DAA). From a review of literature, the advantages of a DAA can be seen to outweigh the disadvantages for both the patient and the surgeon.


The DAA utilizes the intermuscular plane originally described by Hueter, and further developed by Smith-Peterson2. This approach has been termed a minimally invasive approach, but is more correctly called a muscle sparing approach as the skin incision is not necessarily shorter than other approaches. The approach is designed to spare the musculature of the abductors, which has been demonstrated in cadaver studies3. The DAA for THA is done with the patient in a supine position, and can be conducted on a standard operative table or on a specialized table; with or without the use of fluoroscopy.

The surgical approach has an impact on the patient during the peri-operative time period. The muscle sparing nature of the DAA has been demonstrated to reduce systemic inflammation, with the posterior approach having 5.5 times greater cumulative serum CK than the DAA4. Immediate peri-operative pain levels are also diminished, as compared to the direct lateral approach5. Return to function is more rapid compared to the direct lateral6,7,8, and the minimally invasive posterior approaches9. Longer term functional differences are less well defined10. Decreased length of stay has also been demonstrated6, and no hip precautions or weight-bearing restrictions are required in the postoperative period12. Cohort studies examining outcomes of DAA THA have demonstrated low dislocation rates of 0.64% in one study of 494 patients11 and 0.01% in a study of over 2000 patients12, without hip precautions. It has been shown that patients are more satisfied and their recovery is faster with fewer hip precautions13.

The surgical approach selected by surgeons for THA in their practice must allow sufficient exposure. It should facilitate the insertion of THA components in the appropriate position, so that the patient is given a stable, painless hip with good functional longevity14. The factors influencing the choice of surgical approaches include dislocation rates, wear rates, leg lengths and patient functionality. The most immediate advantage of the direct anterior approach is that a stable hip can be achieved under fluoroscopic control while optimizing leg lengths (Figure 1) and component position intra-operatively (Figure 2). Leg length discrepancies are known to impact patient reported scores15, and intra-operative X-ray has been shown to improve leg length accuracy16. Cup position is known to be impacted by approach17, and improved position has been demonstrated when using the DAA9. As placement of the acetabluar component is an important predictor of wear18, it can be hypothesized that improved cup position may result in increased longevity of the implant. Dislocation rates are reported to be low in cohort studies11,12.


Figure 1: Assessment of leg lengths using fluoroscopy intra-operatively.
Figure 2: During insertion of the acetabular component, fluoroscopy can be used to optimize anteversion and inclination.

However, the approach does possess some complications and challenges unique to it. The most common unique complication is sensory deficit to the lateral femoral cutaneous nerve19. Intraoperative fractures are reported and are commonly referred to as an inherent complication of the DAA11. A group of low volume orthopaedic surgeons reported an intraoperative fracture rate of 6.5%, with no dislocations20. However, this group changed surgical approaches after a single visit to a DAA expert; or after no specific training at all. There is a learning curve associated with beginning a new approach, with a reduction in fracture rates over time21. Also, specific instruments are required, and their use needs to be understood11,12. Careful wound care is also required, as the incision site complication rate may be elevated due to the location of the incision. Increased blood loss has been reported7. Appropriate surgical mentorship, cadaver training, and surgical team exposure to the approach with careful patient selection is advised before beginning this approach.

The muscle sparing DAA has significant short-term benefits of decreased peri-operative pain, early function, and potential for improved implant longevity, long-term function, and low dislocation rates. It is important for the surgical team to have appropriate exposure to the approach, as the learning curve is significant, with increased risk of intra-operative complications if the nuances of the approach are not understood. This approach is worthwhile, and has a role for successful THA.


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