Direct Anterior Approach for Hip Fractures

I’m pleased to be one of the first surgeons in Australia to adapt the Direct Anterior Approach for arthroplasty for hip fractures.

While the Posterior approach is currently still the most widely known approach used in Australia, many surgeons who routinely utilise the posterior approach for their elective total hip replacement cases still use a lateral approach for fracture surgery as arthroplasty cases done for fractures are known to carry a higher rate of dislocation. This risk of dislocation is considered highest for these cases done via the posterior approach.

The Lateral approach has a lower risk of dislocation but involves incising the part of abductor muscle tendons (the gluteus medius, gluteus minimus and vastus lateralis tendons) off the femur bone. These are repaired at the end of the procedure but it takes months for them to to heal securely and so patients may limp or need to use a walking frame or crutches for several months.

The Direct Anterior approach offers the advantage that the hip is accessed from the front, between muscles at the front of the hip. Therefore the posterior capsule and posterior muscles are not disturbed, and the lateral abductor muscles are also not disrupted.

The Direct Anterior Approach has been my preferred approach for elective hip surgery for a few years now but I’ve been cautious to apply it to fracture surgery as exposure of the femur can be more difficult and it gives one less of a straight-line shot down the femoral canal, which can be more difficult if needing to cement the prosthesis.

However, as my experience with the DAA approach has grown I’ve felt increasingly comfortable to perform more challenging cases via this approach. I think the tissue-sparing features of the approach provide advantages for the patient.

The Anterior approach hip replacement which I performed on Sunday for a displaced femoral neck fracture was walking laps of the ward was able to be discharged 3 days post op. Previously such patients would be barely taking a few steps with the physio that early and would be discharged to an inpatient rehab facility.
I don’t think that surgeons starting out with DAA should be doing difficult cases or using this technique on osteoporotic patients as there can be technical challenges and one needs to be slow and careful and have a good feel for the procedure but for the experienced surgeon, fracture cases via DAA is viable.