Direct Anterior Approach for Total Hip Arthroplasty

Michael J Taunton
US Musculoskeletal Review, 2011;6(1):42-5
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Abstract

Choice of surgical approach for total hip arthroplasty has provided significant controversy in the orthopaedic literature. Less-invasive approaches, such as the direct anterior approach, have been devised to improve function outcomes compared with traditional approaches. Recent studies have sought to answer the question of which approach provides consistent and reproducible procedure for total hip arthroplasty. Prospectively, in comparison to the anterolateral approach, there is a statistically significant difference in post-operative patient reported outcomes. This is limited to only one single surgeon study. Retrospectively there is a significant difference in early post-operative milestones compared with the posterior approach. Gait study shows differences in post-operative function in a larger number of gait parameters. However, there are a limited number of studies, and more prospective analysis is required. The direct anterior approach for primary total hip arthroplasty is a safe, reliable, and reproducible approach. Further prospective research is required to determine which patients may best benefit by this approach.
Keywords
Total hip arthroplasty, direct anterior approach, less-invasive procedures, rehabilitation, complications
Disclosure The author has no conflicts of interest to declare.
Received: March 17, 2011 Accepted May 31, 2011
Correspondence: Michael J Taunton, MD, Clinical Instructor, 200 First Street SW, Rochester MN 55905. E: taunton.michael@mayo.edu

Standard primary total hip arthroplasty (THA) can reliably alleviate pain, improve function, and improve the quality of life in a broad section of patients with end-stage arthrosis of the hip. However, minimally invasive approaches have been devised with the goal of decreasing peri-operative pain, speed early post-operative function, and improve patient satisfaction with the procedure compared with standard THA. These patient-centered goals are combined with the surgeon’s desire of a safe, reproducible minimally invasive procedure that has durable, properly positioned components.

Many minimally invasive approaches have been introduced in the past decade, and each has its reported pros and cons.1–13 Clearly, there is a variation in the muscles that are disturbed, and potentially damaged, in the procedures. Meneghini and Pagnano performed an elegant study in 12 cadaveric hips, and found that less damage occurred in the gluteus minimus muscles and minimus tendon with the Direct Anterior Smith-Peterson approach compared with the posterolateral approach. However, the tensor fascia latae muscle was damaged (mean of 31%), as well as direct head of the rectus femoris (mean 12%) during the Smith-Peterson approach. The piriformis or conjoined tendon was transected in 50% of the anterior approaches to mobilize the femur.14 The direct anterior approach for primary THA was developed to try to address some of the complications of THA including dislocation, leg-length discrepancy, and abductor dysfunction. The purpose of this article is to evaluate the literature in terms of this approach and comment on the direction for further investigation.

History
The Heuter Approach to the hip was first reported for hip joint exposure by Judet and Judet in 1947.15 The direct anterior approach was first reported in the US by Keggi16 for primary THA. Matta began using the direct anterior approach in 1996, and now uses the approach for all primary THA unless there is a posterior acetabular defect that requires bone graft and plate fixation.5 The approach has evolved, and many surgeons now utilize a supine position on an orthopedic fracture table, with image intensification to ensure the accuracy of acetabular component positioning, leg length and offset.

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