 HIP
The direct anterior approach in total hip
arthroplasty
A SYSTEMATIC REVIEW OF THE LITERATURE
G. Meermans,
S. Konan,
R. Das,
A. Volpin,
F. S. Haddad
From University
College London
Hospitals, London,
United Kingdom
Aims
The most effective surgical approach for total hip arthroplasty (THA) remains controversial.
The direct anterior approach may be associated with a reduced risk of dislocation, faster
recovery, reduced pain and fewer surgical complications. This systematic review aims to
evaluate the current evidence for the use of this approach in THA.
Materials and Methods
Following the Cochrane collaboration, an extensive literature search of PubMed, Medline,
Embase and OvidSP was conducted. Randomised controlled trials, comparative studies, and
cohort studies were included. Outcomes included the length of the incision, blood loss,
operating time, length of stay, complications, and gait analysis.
Results
 G. Meermans, MD,
Orthopaedic Surgeon
Bravis Hospital,
Boerhaaveplein 1, 4624VT
Bergen op Zoom, The
Netherlands.
 S. Konan, MBBS, MD(res),
FRCS(Tr&Orth), Orthopadic
Consultant
 R. Das, MBBS, MRCS,
Orthopaedic SpR
 A. Volpin, MD, Clinical Fellow
University College London
Hospitals, 235 Euston Road,
London, NW1 2BU, UK.
 F. S. Haddad, BSc MD (Res),
FRCS (Tr&Orth), Professor of
Orthopaedic Surgery,
University College London
Hospitals, 235 Euston Road,
London, NW1 2BU, UK and
NIHR University College
London Hospitals Biomedical
Research Centre, UK.
Correspondence should be sent
to A. Volpin; e-mail:
volpinandrea@hotmail.com
©2017 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.99B6.
38053 $2.00
Bone Joint J
2017;99-B:732–40.
Received 13 February 2016;
Accepted after revision 12
December 2016
732
A total of 42 studies met the inclusion criteria. Most were of medium to low quality. There
was no difference between the direct anterior, anterolateral or posterior approaches with
regards to length of stay and gait analysis.
Papers comparing the length of the incision found similar lengths compared with the
lateral approach, and conflicting results when comparing the direct anterior and posterior
approaches.
Most studies found the mean operating time to be significantly longer when the direct
anterior approach was used, with a steep learning curve reported by many.
Many authors used validated scores including the Harris hip score, and the Western
Ontario and McMaster Universities Arthritis Index. These mean scores were better following
the use of the direct anterior approach for the first six weeks post-operatively. Subsequently
there was no difference between these scores and those for the posterior approach.
Conclusion
There is little evidence for improved kinematics or better long-term outcomes following the
use of the direct anterior approach for THA. There is a steep learning curve with similar rates
of complications, length of stay and outcomes.
Well-designed, multi-centre, prospective randomised controlled trials are required to
provide evidence as to whether the direct anterior approach is better than the lateral or
posterior approaches when undertaking THA.
Cite this article: Bone Joint J 2017;99-B:732–40.
There is much debate about the most effective
surgical approach for total hip arthroplasty
(THA). Various approaches have been used
over the years. Analysis of current practices
from reviews of national joint registries show
that most surgeons use the posterior approach,
followed by the lateral, and < 5% of surgeons
in United Kingdom, Sweden and New Zealand
practice the anterior approach.1
In the National Joint Registry of England,
Wales and Northern Ireland ninth annual
report2 the approach used is reported to be
posterior in 59% of cases, lateral and
Hardinge in 35%, anterior/anterolateral in
< 1% and other in 5%.
Our aim in this systematic review was to
analyse and evaluate the current evidence
regarding the outcome of the anterior
approach in contrast with the posterior, lateral
and anterolateral approach in THA.
Posterior approach
The posterior approach, described separately
by Moore,3 Kocher4 and von Langenbeck5 is
the most commonly used approach for resurfacing as well as for THA. The patient is placed
THE BONE & JOINT JOURNAL
THE DIRECT ANTERIOR APPROACH IN TOTAL HIP ARTHROPLASTY
2654 potentially relevant studies
identified and screened on title
2201 studies excluded after
screening on title
453 potentially relevant
studies screened on abstract
380 studies excluded after
screening on abstract
76 studies screened on full text
42 studies included:
- 3 with anterolateral approach as study contrast
- 19 with lateral approach as study contrast
- 20 with posterior approach as study contrast
Fig. 1
Flowchart showing the selection of articles.
in the lateral position and the incision is made over the posterior aspect of the greater trochanter. It has the benefit of
not interfering with the abductor mechanism, however,
there is a risk of damage to the sciatic nerve during dissection or compression under retractors, as it lies over the
external rotator muscles. The inferior gluteal artery may be
damaged as it leaves the pelvis beneath the piriformis and
supplies the gluteus maximus muscle. The main disadvantage of this approach, reported in a meta-analysis of > 13
000 THAs is a rate of dislocation of about 3.23% for the
posterior approach (3.95% without posterior repair and
2.03% with posterior repair), 2.18% for the anterolateral
approach, and 0.55% for the direct lateral approach.6
Anterolateral and lateral approaches
The anterolateral approach was described separately by
Watson-Jones in 1936.7 The patient is placed in either the
supine or lateral position and the plane between tensor fascia lata and gluteus medius is developed. The abductor
mechanism must be released to allow adequate view of the
anterior capsule of the hip. This release can be done either
VOL. 99-B, No. 6, JUNE 2017
733
by a trochanteric osteotomy or a release of the gluteus
medius.
The direct lateral approach which was described by
Hardinge in 19828 and also subsequently by Bauer et al,9
avoids the need for trochanteric osteotomy and the gluteus
medius muscle is preserved. The risks associated with lateral approaches include injury to the superior gluteal nerve
and heterotopic ossification.10
Direct anterior approach
The direct anterior approach which was initially described
by Hueter11 in 1870 and subsequently by Smith-Petersen et
al12 and Judet and Judet,13 is associated with a reduced risk
of dislocation, faster recovery, less pain and fewer surgical
complications.14
With the patient in the supine position the interval
between tensor fascia lata and sartorius is developed to
access the hip. This avoids detachment of muscle from
bone.
The anterior approach is used commonly in paediatric
surgery for developmental dysplasia of the hip. It is also
being used increasingly for femoroacetabular impingement,
hip resurfacing and to access the anterior aspect of the acetabulum.14,15 The disadvantages of the anterior approach
are thought to include a steep learning curve and the need
for further release of tendon and capsule,14,16 and the difficulty of using it in obese patients.15
Materials and Methods
An extensive computerised literature search of EMBASE,
MEDLINE OvidSP, Web of Science, Cochrane Central,
PubMed Publisher and Google Scholar was conducted. The
following combined key words were used: hip arthroplasty(ies)/replacement(s), minimally invasive/MIS/miniincision, and/or approach/anterior approach/direct anterior/Smith-Petersen/Hueter.
The bibliographies of retrieved studies and other relevant
publications, including reviews, were cross-referenced for
additional potential articles.
Inclusion criteria were: randomised controlled trials published in English; studies which included the anterior
approach for THA and at least one of the following was
assessed: surgical details including blood loss and operating
time; length of in hospital stay; adverse events including
complications; and radiographic outcomes including the
number of acetabular components outside the desired
alignment range. We excluded in vitro studies and cadaver
studies.
The selection was performed in two stages. The first,
based on the title and abstract and taking into consideration the inclusion criteria, was independently performed by
two reviewers (GM, RD). Disagreements were resolved by
consensus (Fig. 1).
Secondly, the quality of each study which was included
was assessed by two independent reviewers (AV and SK).
The risk of bias was investigated using a standardised set of
734
G. MEERMANS, S. KONAN, R. DAS, A. VOLPIN, F. S. HADDAD
Table I. Quality assessment
Question
Response
Is there a clearly stated aim?
Did they have a “study question” or “main aim” or “objective”?
The question addressed should be precise and relevant in light of available
literature.
To be scored adequate the aim of the study should be coherent with the
“Introduction” of the paper.
Did the authors say: “consecutive patients” or “all patients during period from …
to….” or “all patients fulfilling the inclusion criteria”?
Did the authors report the inclusion and exclusion criteria?
Did they say “prospective”, “retrospective” or “follow-up”?
Inclusion of consecutive patients
A description of inclusion and exclusion criteria
Prospective collection of data. Data were collected according
to a protocol established before the beginning of the study
The study is NOT PROSPECTIVE when: chart review, database review, clinical
guideline, practical summaries.
Surgical technique description
Did they report the surgical technique description?
Outcome measures
Did they report outcome measures to evaluate patients after the operation?
Unbiased assessment of the study outcome and determinants To be judged as adequate the following 2 aspects had to be positive:
- Outcome and determinants had to be measured independently
- Both for cases and controls the outcome and determinants had to be assessed in
the same way
Were the determinant measures used accurate (valid and
For studies where the determinant measures are shown to be valid and reliable, the
reliable)?
question should be answered adequate. For studies, which refer to other work that
demonstrates the determinant measures are accurate, the question should be
answered as adequate.
Loss to follow-up
Did they report the losses to follow-up?
Adequate statistical analysis
Was an adequate statistical analysis performed?
criteria based on modified questions of existing quality
assessment tools (Table I). When the criterion was met in
the study, one point was given, otherwise zero points. Zero
points were also given when information concerning the
specific criterion was not mentioned.
A maximum score of ten points could be obtained; studies were considered of high methodological quality if a total
score of more than six points was obtained.
Each study was independently assessed for its design and
methodology and level of evidence, assessed by two authors
(AV and SK) (Supplementary Table i).
The following data were extracted from each study: the
authors, the journal and year of publication, the surgical
approaches, use of traction table, intra-operative fluoroscopy, patient selection and the number of patients. Intraoperative details of length of incision, operating time, blood
loss, post-operative details included pain, recovery from
surgery, post-operative rehabilitation, length of stay, gait
analysis, follow-up and complications were all analysed.
There were significant differences in study design and outcome measures. We analysed each outcome measure separately.
In order to compare studies, a review was undertaken in
accordance with Preferred Reporting Items for Systematic
Reviews and Meta-Analyses guidelines.16 A total of 42
studies were used for this systematic review, however several studies did not report all descriptive statistics for all
outcomes, or did not include that particular outcome measure in the study. Case series studies were excluded. The
studies which were included in the review are shown in
Supplementary Table ii.
Statistical analysis. In order to compare studies, effect sizes
were, derived from means and standard deviations (SD),
and Cohen’s kappa was calculated when all information
was available. The latter were plotted as charts and tables.
Results
The assessment of the risk of bias. One study had a high
risk of bias; the remaining had a low risk of bias
(Table II).17-55
Incision. A number of authors compared the length of incision of the direct anterior and the lateral approaches.
Hozak and Klatt17 found similar mean lengths of 10 cm.
However, Sebečić et al18 and Sendtner et al19 noted shorter
mean lengths of 7.5 cm and 8.5 cm, respectively in the
direct anterior approach (p < 0.01). In the first retrospective
non-randomised study20 there were 35 patients in each
arm, while the second19 had 74 patients treated with the
direct anterior approach and 60 patients treated with a lateral approach. We did not find any data comparing the
lengths of the incisions in the anterolateral and direct anterior approaches.
Studies comparing the direct anterior approach with the
posterior approach have usually found the incision to be
shorter in the direct anterior approach. Pilot et al20 compared ten patients in each arm of a prospective study and
found that the mean length of the incision for the posterior
approach was 17.5 cm versus 8.6 cm for the direct anterior
approach (p < 0.001). Martin et al21 concurred, with a
mean length of 19.2 cm for the posterior approach versus
11 cm for the direct anterior approach (p < 0.0001). There
was evidence of selection bias in this study as patients with
THE BONE & JOINT JOURNAL
THE DIRECT ANTERIOR APPROACH IN TOTAL HIP ARTHROPLASTY
735
Table II. The assessment of the risk of bias
Study
Criteria
Hananouchi et al10
Barrett et al14
Nam et al15
Hozack and Klatt17
Sebečić et al18
Sendtner et al19
Pilot et al20
Martin et al21
Rodriguez et al22
Bergin et al23
Berend et al24
D'Arrigo et al25
Alecci et al26
Nakata et al27
Ilchmann et al28
Mayr et al29
Seng et al30
Wayne and Stoewe31
Rathod et al32
Schweppe et al33
Spaans et al34
Zawadsky et al35
Restrepo et al36
Pogliacomi et al37
Pogliacomi et al38
Taunton et al39
Amlie et al40
Maffiuletti et al41
Klausmeier et al42
Lamontagne et al43
Varin et al44
Ward et al45
Rathod et al46
Reininga et al47
Parvizi et al48
Baba et al49
Bremer et al50
Christensen et al51
Goebel et al52
Lugade et al53
Sugano et al54
Yi et al55
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
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1
1
1
1
1
1
1
1
1
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1
1
2
1
1
1
1
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1
higher body mass index (BMI) were selected to have surgery using a posterior approach due to the difficulty of
using direct anterior approach in the obese patient. The
mean BMI was 34.1 in those in whom a posterior approach
was used and 28.5 in those in whom a direct anterior
approach was used (p < 0.0001). The studies comparing the
direct anterior and the posterior approaches did not distinguish between an extended posterior approach and a modified minimally invasive posterior approach.22 The latter is
more commonly used today.22 The length of the incision
does not reflect the underlying soft-tissue trauma and
caution should be exercised in its use as a marker for
invasiveness.
VOL. 99-B, No. 6, JUNE 2017
Total
3
0
1
1
1
0
0
0
1
1
1
0
1
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1
1
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5
1
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6
1
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1
1
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1
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1
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1
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1
7
0
1
1
0
0
1
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1
1
1
0
0
1
1
0
1
0
0
1
0
1
0
1
0
0
1
1
0
1
1
1
1
1
1
0
0
0
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1
1
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0
8
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
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1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
9
0
1
0
0
0
0
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1
0
1
1
1
0
0
0
0
0
0
0
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10
1
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6
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7
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9
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7
7
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6
6
8
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9
7
9
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6
9
8
7
9
9
7
6
8
9
7
6
7
6
8
8
6
6
Other studies comparing the direct anterior and posterior approaches had smaller margins of difference between
the lengths of incision lengths. Barrett et al14 found that
incisions were a mean of 1 cm shorter when the posterior
approach was used. In a study of 57 patients, Bergin et al23
reported that the mean length of incision was 15.4 cm in
the posterior approach and 12.1 cm in the direct anterior
approach (p < 0.001).
Operating time. The operating time was recorded in 25
studies10,14,18-38,48 and the consensus was that the direct
anterior approach took longer than either the lateral, anterolateral or posterior approaches (Tables III and IV). Berend et al24 found that the operating times were initially
736
G. MEERMANS, S. KONAN, R. DAS, A. VOLPIN, F. S. HADDAD
Table III. Mean operating time in minutes, direct anterior approach (DAA)
versus anterolateral and lateral approaches (AL/L) (standard deviation if
included)
180
160
Study
DAA
AL/L
Hozack and Klatt17
Sebečić et al18
Sendtner et al19
Berend et al24
D’Arrigo et al25
Alecci et al26
Ilchmann et al28
Mayr et al29
Seng et al30
Wayne and Stoewe31
Restrepo et al36
Pogliacomi et al37
Pogliacomi et al38
Parvizi et al48
57
85
77 (16)
69
121 (23.6)
89 (19)
119
70
73
115
56
93
111
140 (27.38)
55
78
69 (25)
68
77 (15.1)
81 (15)
07
70
56
98
54
90
85
130 (24.68)
DAA
Lat
AL
Mean operative time (mins)
140
120
100
80
60
40
20
0
Hozack17
Mayr29
Seng30
Berend24
Pogliacomi37 Sebeèiæ18
Alecci26
D’Arrigo25 IIchmann28
Restrepo36 Sendtner19 Wayne31
Parvizi48
Fig. 2
Graph showing mean operating times for the direct anterior approach (DAA) versus lateral (Lat) and anterolateral (AL) (standard deviation bars).
longer but this difference disappeared during the study
period and represented the learning curve of the technique.
Their anterior supine intermuscular approach took a mean
of 69 minutes versus 68 minutes for the less invasive direct
lateral approach (p = 0.7).
One study showed a high effect size for the difference in
operating times between the direct anterior and posterior
approaches. D'Arrigo et al25 reported a significantly
increased operating time, again thought to be due to the
learning curve associated with the direct anterior approach.
They found a significantly longer operating time in the first
ten cases than in the second ten cases (p = 0.013) (Figs 2
and 3).56
Blood loss. Blood loss was recorded in various ways,
including change in serum haemoglobin level, intraoperative measurement of blood loss and the number of
units of post-operative transfusion.
Alecci et al26 recorded a difference between the mean levels of haemoglobin pre-operatively and on the first postoperative day of 3.5 g/dL (SD 1) in the lateral approach
group versus 3.1 g/dL (SD 0.9) in the anterior approach
group (p < 0.0005). They also recorded that 7.5% of
patients in the lateral group had an intra-operative blood
transfusion compared with 1.8% in the anterior group
(p = 0.008). A total of 85 patients (40%) in the lateral
groups had a post-operative blood transfusion and 44
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180
Mean operative time (mins)
160
737
DAA
Post
140
120
100
80
60
40
20
0
Bergin23
Pilot20
Martin21
Ratho46 Schweppe35 Zawadsky35
14
10
27
Barrett Hananouchi Nakata
Poehling- Rodriguez36 Spaans34
Monaghan56
Fig. 3
Graph showing mean operating times for the direct anterior approach (DAA) versus posterior
(Post) (standard deviation bars).
(19%) in the direct anterior group. There was a statistically
significant difference between the two groups in the
volumes of intra-operative colloid and crystalloid infusion
(p < 0.0005). The use of intravenous fluids may clearly
confound the reported blood loss.
D'Arrigo et al25 recorded a mean blood loss of 1219 ml
(SD 786.5) in the lateral minimally invasive (MIS) group,
1344 ml (SD 710.0) in the anterior MIS group, 1279 ml
(SD 694.9) in the anterolateral MIS group and 1644 ml
(SD 757.7) in standard lateral group for a total of 60
patients enrolled in the study. In the comparison of the first
three groups, no statistically significant difference was found
(p > 0.05), however they were all significantly less than the
blood loss in the standard lateral group. The technique used
to measure blood loss was from Rosencher et al.57
Nakata et al27 found a statistically significant increase in
blood loss in the direct anterior group (99 hips). The mean
intra-operative blood loss was 526.1 ml in the direct anterior group and 426.9 ml in the mini-posterior group
(p= 0.46). This was thought to be due either to technical
difficulties in femoral preparation or a steep learning curve.
When compared with the posterior approach, Bergin et
al,23 Hananouchi et al10 and Martin et al21 did not find a
statistically significant difference in blood loss.
No study considered the confounding factors that should
be allowed for or kept consistent in both arms of the study.
The pre-operative level of haemoglobin and medical
comorbidities play a role in the loss of blood. It is not possible from these studies to draw conclusions about which of
the surgical approaches is associated with the least blood
loss (Table V).
Length of stay. A total of 12 studies.17,18,22,24-28,30,32,34,36
looked into the effect of the surgical approach on the length of
stay as a measure of recovery. Most concluded that the length of
VOL. 99-B, No. 6, JUNE 2017
stay is not significantly related to the approach. Many authors
reported a difference in length of stay of < 24 hours between
various surgical approaches.17,22,24,26,28,30,33,34,36 The mean
length of stay was between two and five days in most studies. The length of stay was significantly longer in the studies
which reported a difference between approaches. Alecci et
al26 reported a mean length of stay of ten days (SD 3.5) for
THAs undertaken through a lateral approach and seven
days (SD 2) for those undertaken through direct anterior
approaches, which was statistically significant (p < 0.05).
Nakata et al27 recorded a mean length of stay of 30.4 days
(SD 1.2) for those undertaken using a posterior approach
and 22.2 days (SD 1.4) for those using a direct anterior
approach (p = 0.003).
Sebečič et al18 reported that patients whose THA was
undertaken through an anterior approach were discharged
from hospital a mean of two days earlier than those undertaken through a lateral approach.
Post-operative recovery. The most common measures of outcome which were used were the Harris hip score (HHS)17 and
the Western Ontario and McMaster Universities Arthritis
Index (WOMAC).37,59 These were used in 13 studies.14,18,19,22,25,28,30,34,36,37-40 Higher WOMAC scores indicate
worse pain, stiffness and functional limitations. Amlie et al40
compared various indicators of outcome and found that the
WOMAC score was comparable in patients whose THA had
been undertaken using the direct anterior and posterior
approaches and better than those using the anterolateral
approach.
The mean HHSs were better for the direct anterior
approach in some studies.32,37,41 Seng et al30 reported a
mean HHS of 81 in those with a direct anterior approach
and 75 in those with a lateral approach. (p < 0.0001).
Sebečič et al18 found similar mean HHSs in those
738
G. MEERMANS, S. KONAN, R. DAS, A. VOLPIN, F. S. HADDAD
Table IV. Mean operating time in minutes, direct anterior
approach (DAA) versus posterior (standard deviation if included)
Study
DAA
Posterior
Hananouchi et al10
Barrett et al14
Pilot et al20
Martin et al21
Rodriguez et al22
Bergin et al23
Nakata et al27
Rathod et al32
Schweppe et al33
Spaans et al34
Zawadsky et al35
129
84 (12.4)
99.5
141 (22)
90(15)
78 (17.9)
104.7
90
109
84
102.7 (20.9)
115
60 (12.4)
81
114 (22)
85 (14)
118 (19.4)
100.4
84
102
46 (9)
87.8 (20)
Table V. Blood loss
Barrett et al14
Bergin et al23
Nakata et al27
Spaans et al34
Pogliacomi et al37
Pogliacomi et al38
Effect size
Cohen d
0.52
0.142
0.724
0.463
-0.105
-0.461
1.21
0.288
2.1
1.044
-0.211
-1.03
undertaken with a direct anterior approach and those with
lateral approach (80 versus 69), two months postoperatively (p < 0.01). Four months post-operatively, this
difference had narrowed to 92 versus 88 without statistical
significance. Other authors concurred with the conclusion
that the HHS improves initially, but these benefits are not
continued into the longer term.8,24,39 Pogliacomi et al37
found a mean HHS of 91 in the direct anterior group versus
89 in the lateral group at one-year follow-up.
Barrett et al14 compared the direct anterior and posterior
approaches and also found initial improvements in the
mean HHS, six weeks post-operatively (89.5 versus 81.4)
(p < 0.0001). They suggested that the benefits of DAA
might be seen only in the period immediately following surgery, in fact the mean scores were comparable at three
months, six months and one year post-operatively. Taunton
et al39 again found similar mean HHSs up to a year postoperatively in the direct anterior and posterior groups. The
mean WOMAC scores were inferior in the posterior group
(87.2 versus 91.5) (p = 0.043).
Four other studies23,29,34,43 recorded similar functional
scores between the direct anterior and posterior
approaches.
Gait analysis. Few authors recorded gait analysis.43-48
Klausmeier et al42 undertook a small non-randomised
study with 12 patients having a THA using a direct anterior
approach, 11 using an anterolateral approach and a control
group of ten patients. Pre-operatively the patients in both
the direct anterior and anterolateral groups had reduced
strength of the hip and gait when compared with controls.
There were no statistically significant differences between
the two approaches for most of the measurements of
isometric strength and dynamic measurements of gait at six
or 16 weeks, post-operatively. The measurements of
strength and gait in both groups were reduced when compared with the controls. There was no direct measurement
of flexion of the hip which would be the most affected
activity by the direct anterior approach and the follow-up
was too short to draw conclusions.
Two studies18,40reported that patients who have undergone THA have abnormal kinematics on climbing stairs,
regardless of surgical approach. The group having a THA
using a direct anterior approach, however, had fewer differences compared with a normal control group, and their
magnitude was usually less than in those who had a THA
using a direct lateral approach. Patients in the direct anterior group were slightly better at climbing stairs. This study
was not randomised and there was a mean age difference of
about six years between the two groups (60.5 in the direct
anterior group and 66 in the lateral group) and different
uncemented components were used in the two groups. Both
are confounding variables.
Four studies21,45-47 reported similar post-operative gait
analyses between THAs undertaken using the direct anterior and posterior approaches. Various authors21,45-47 agree
that prior to THA, patients change their pattern of gait to
reduce the pain and this pre-operative adjustment and alteration of muscle mass will contribute to the post-operative
function.
Discussion
In this study, we analysed studies from the literature dealing
with the anterior, anterolateral and posterior approaches to
the hip joint. Several criteria were analysed and we were
not able to identify any superiority for the use of the direct
anterior approach in THA. A previous review60 has compared the direct anterior and lateral and posterior
approaches. A comparison with the anterolateral approach
has been included in this review article.
Many outcome measures were investigated. The length
of the incision was used as a surrogate for an assessment of
invasiveness. Soft-tissue dissection, release and inadvertent
injury play an important role in the outcome following
THA.42 Operating times varied and there was a statistically
significant increase in operating time for the direct anterior
approach. A steep learning curve for this approach has been
described,40 leading to complications that were rarely seen
in other approaches such as breaching the femoral canal.31
This may be related to a learning curve or simply to an
inadequate exposure. The reporting of blood loss in nonrandomised studies showed no evidence of accounting for
confounding variables. However, as reported by Parvizi et
al,48 less blood loss is associated with an anterior approach
compared with a direct lateral approach, in which the incision is longer with more soft-tissue dissection, and the
abductor muscles are violated.
With the use of modern anaesthetic techniques and the
routine use of tranexamic acid there should be minimal
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THE DIRECT ANTERIOR APPROACH IN TOTAL HIP ARTHROPLASTY
blood loss irrespective of the surgical approach. The nature
of the rehabilitation protocol required for discharge varied
throughout the studies. Length of stay is affected by many
issues including local protocols, the decisions of the surgeon, enhanced recovery pathways, society’s culture and
expectations, the requirements of insurance companies, the
pressures on beds and the destination at discharge.61
Most studies concluded that the short-term results
favoured the direct anterior approach. Amlie et al40
reported that 107 patients (25%) who underwent THA
using a lateral approach described developing a limp postoperatively. This was more than twice as many as in those
who underwent THA using the direct anterior or posterior
approaches. Limping had a serious effect on the patients’
ability to return to recreation and sports. Moreover, as
reported by Sebeči et al,18 patients whose THA was undertaken using an anterior approach could walk without
crutches eight days after surgery. However, in the mid- and
long-term this benefit was negligible. Most studies did not
assess outcome more than one year post-operatively.
The studies of gait analysis did not include pre-operative
assessment or the analysis of patterns of muscle activation
using electromyography.
Lamontagne et al43 showed that patients whose THA
was undertaken using a direct anterior approach had kinematics which were slightly closer to normal those whose
operation was undertaken using a lateral approach. However, no comparison was made with the posterolateral
approach.
This review has several limitations. Our findings were
similar to those of previous reviews,1,60 however, we
included more studies and we attempted to compare the
surgical approaches in this review article. The main limitation of this review is that the papers which were
included were single centre studies with heterogeneity of
surgical technique, length of follow-up and outcomes
scores. More randomised large multi-centre controlled trials, comparing the three surgical approaches, might provide an answer to which is the best approach when
performing a THA.
In conclusion, the current evidence does not support the
recent enthusiasm for the use of the direct anterior
approach. It offers an intermuscular plane, but has a considerable learning curve. However, it seems that the anterolateral approach which compromises the abductor
mechanism does not offer any particular advantage. The
question that still remains unanswered is which of the
abductor sparing direct anterior and posterior approaches
offers a significant advantage to the patient.
Take home message:
- To date, there is no real evidence that the direct anterior
approach of the hip represents a better approach compared
with the lateral or posterior approaches for performing a THA.
VOL. 99-B, No. 6, JUNE 2017
739
Supplementary material
Tables showing levels of evidence and randomisation
of direct anterior approach versus lateral and versus
posterior approachs are available alongside the online version of this article at www.bjj.boneandjoint.org.uk
Author contributions:
G. Meermans: Participated in the conception and design of the study, Acquisition of data, Analysed and interpreted the data, Drafted the manuscript.
S. Konan: Drafted and revised the manuscript critically for important intellectual
content.
R. Das: Involved in the acquisition of data, Interpretation of the data, Drafted the
manuscript.
A. Volpin: Drafted and revised the manuscript.
F. S. Haddad: Jointly conceived the study, Participated in its design, Interpreted
the data, Drafted and revised the manuscript critically for important intellectual
content.
This research/study/project was supported by the National Institute for Health
Research University College London Hospitals Biomedical Research Centre.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
This article was primary edited by J. Scott.
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