Total Hip Replacement:

Recent publications in the orthopaedic literature on the evidence for the direct anterior approach for total hip replacement include the following:

(1) Early outcome comparison between the direct anterior approach and the mini-incision posterior approach for primary total hip arthroplasty: 150 consecutive cases.  

J Arthroplasty. 2014 Jun;29(6):1256-60. Epub 2013 Dec 1. Zawadsky MW1, Paulus MC1, Murray PJ2, Johansen MA1.

Abstract:  This study evaluated early postoperative results of 150 consecutive primary total hip arthroplasties performed by a single hip replacement surgeon; 50 from mini-incision posterior approach, 50 during the learning curve for the direct anterior approach, and 50 subsequent cases when the approach was routine. The anterior approach groups had significantly reduced hospital length of stays (2.9 and 2.7 days versus 3.9 days for the posterior group; P < 0.0001) and discharge to home versus rehab was more likely (80% and 84% in anterior groups, 56% in posterior group; P = 0.0028). In the anterior groups, there was significantly less use of assistive devices and narcotics at 6 weeks, and pain was significantly lower. Primary total hip arthroplasty using the anterior approach allows for superior recovery in a matched cohort of patients.


(2) Direct Anterior Total Hip Arthroplasty Yields More Rapid Voluntary Cessation of All Walking Aids: A Prospective, Randomized Clinical Trial.

J Arthroplasty. 2014 May 25.  Taunton MJ1, Mason JB2, Odum SM2, Springer BD2.

Abstract:  This study sought to prospectively examine the clinical and radiographic differences between direct anterior (DA-THA) and mini-posterior approach total hip arthroplasty (MPA-THA). Fifty-four patients were prospectively randomized to either MPA or DA-THA. Patient recorded diaries were collected. Radiographs were reviewed. SF-36, WOMAC and HHS scores were tabulated. Time to ambulation without any assistive device favored DA-THA (22 vs. 28days, P=0.04). Three week SF mental scores favored MPA-THA (60.66 vs. 58.43, P=0.01). In a randomized prospective trial, patients undergoing DA-THA voluntarily quit use of all walking aids on average 6days earlier than patients with a MPA-THA. Little additional clinical or radiographic benefit was seen between the cohorts.

(3) Standard Transgluteal versus Minimal Invasive Anterior Approach in hip Arthroplasty: A Prospective, Consecutive Cohort Study.

Orthop Rev (Pavia). 2013 Nov 6;5(4):e31. Ilchmann T, Gersbach S, Zwicky L, Clauss M.

Abstract: A minimally invasive anterior approach (MIS) was compared to a standard lateral approach in primary total hip arthroplasty. Clinical and radiological outcomes were analyzed 6 weeks, 12 weeks, one year and two years after hip replacement surgery. The duration of surgery was longer, mobility one week after hip replacement surgery was better and time of hospitalisation was shorter for minimally invasive-treated patients. They had less pain during movement, limping, better Harris Hip Score and satisfaction after 6 weeks, which remained after 12 weeks and 1 year, but not after two years. There were two deep infections in the MIS group. Radiological results were not affected. The infections might be a point of concern, but there were no other disadvantages of the MIS approach. In fact, early rehabilitation was facilitated and clinical results were improved. Our results encourage the continuous use of the MIS anterior approach instead of the lateral approach.

(4) Worse patient-reported outcome after lateral approach than after anterior and posterolateral approach in primary hip arthroplasty.

Acta Orthop. 2014 Jun 23:1-7. Amlie E1, Havelin LI, Furnes O, Baste V, Nordsletten L, Hovik O, Dimmen S.

Abstract: Background – The surgical approach in total hip arthroplasty (THA) is often based on surgeon preference and local traditions. The anterior muscle-sparing approach has recently gained popularity in Europe. We tested the hypothesis that patient satisfaction, pain, function, and health-related quality of life (HRQoL) after THA is not related to the surgical approach. Patients – 1,476 patients identified through the Norwegian Arthroplasty Register were sent questionnaires 1-3 years after undergoing THA in the period from January 2008 to June 2010. Patient-reported outcome measures (PROMs) included the hip disability osteoarthritis outcome score (HOOS), the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), health-related quality of life (EQ-5D-3L), visual analog scales (VAS) addressing pain and satisfaction, and questions about complications. 1,273 patients completed the questionnaires and were included in the analysis. Results – Adjusted HOOS scores for pain, other symptoms, activities of daily living (ADL), sport/recreation, and quality of life were significantly worse (p < 0.001 to p = 0.03) for the lateral approach than for the anterior approach and the posterolateral approach (mean differences: 3.2-5.0). These results were related to more patient-reported limping with the lateral approach than with the anterior and posterolateral approaches (25% vs. 12% and 13%, respectively; p < 0.001). Interpretation – Patients operated with the lateral approach reported worse outcomes 1-3 years after THA surgery. Self-reported limping occurred twice as often in patients who underwent THA with a lateral approach than in those who underwent THA with an anterior or posterolateral approach. There were no significant differences in patient-reported outcomes after THA between those who underwent THA with a posterolateral approach and those who underwent THA with an anterior approach.

(5) Does surgical approach in total hip arthroplasty affect rehabilitation, discharge disposition, and readmission rate?
Surg Technol Int. 2013 Sep;23:219-27.

Abstract: There is a substantial preoccupation with different surgical approaches and minimally invasive techniques that may improve clinical outcomes for patients who undergo total hip arthroplasty. This study assessed the impact on hospital-related outcomes of the direct anterior approach (DAA) compared with the posterior approach (PA) performed by a single josurgeon in 100 consecutive patients in each cohort. Patient age was similar in the DAA (61 ± 1.1 years) compared with the PA (62 ± 1.3, p = 0.733); however, BMI tended to be lower in DAA patients (29.1 ± 0.8) compared with PA patients (31.3 ± 0.7, p = 0.057). The DAA compared with the PA was associated with significantly less blood loss (285 ± 15 vs. 367 ± 21ml, p = 0.002) and transfusions (18 vs. 39 units, p = 0.009), less narcotic usage on postoperative days 1-3 (101 ± 12 vs. 146 ± 12 morphine equivalent dose, p = 0.010), a quicker hospital discharge (70 ± 3.3 vs. 97 ± 5.5 hours, p < 0.001), and a more favorable disposition (97% vs. 84% discharged home, p = 0.003). Thirty-day readmission rate was significantly higher with the PA (9%) compared with the DAA (1%, p = 0.030). The number of cups in the safe zone (5° to 25° anteversion and 30° to 50° inclination) was significantly higher with the DAA (92%) compared with the PA (75%, p = 0.002), possibly attributed to fluoroscopy used with the DAA. The DAA muscle-preservation technique may have led to the benefits observed in this study compared with the muscle-splitting technique associated with the PA.

(6) Prospective randomized study of direct anterior vs postero-lateral approach for total hip arthroplasty. 
J Arthroplasty. 2013 Oct;28(9):1634-8. 2013 Mar 19.Barrett WP1, Turner SE, Leopold JP.

Abstract: Benefits of a direct anterior approach (DAA) versus a posterior-lateral (PA) approach to THA were assessed in a single-surgeon, IRB-approved, prospective, randomized clinical study. Subjects (43 DAA and 44 PA) were evaluated at 6 weeks, and 3, 6 and 12 months. The primary end point was ability to climb stairs normally and walk unlimited at each time point. Secondary end points included assessment by several outcome instruments. DAA subjects performed better during the immediate post-operative period; they had lower VAS pain scores on the first post-operative day, more subjects climbing stairs normally and walking unlimited at 6 weeks, and higher HOOS Symptoms scores at 3 months. There were no significant differences between groups at later time points. Findings confirm previous reports of benefits of DAA versus PA in early post-operative phases.