Skip to main content
SpringerLink
Log in

Does the Direct Anterior Approach in THA Offer Faster Rehabilitation and Comparable Safety to the Posterior Approach?

  • Symposium: 2013 Hip Society Proceedings
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Newer surgical approaches to THA, such as the direct anterior approach, may influence a patient’s time to recovery, but it is important to make sure that these approaches do not compromise reconstructive safety or accuracy.

Questions/purposes

We compared the direct anterior approach and conventional posterior approach in terms of (1) recovery of hip function after primary THA, (2) general health outcomes, (3) operative time and surgical complications, and (4) accuracy of component placement.

Methods

In this prospective, comparative, nonrandomized study of 120 patients (60 direct anterior THA, 60 posterior THAs), we assessed functional recovery using the VAS pain score, timed up and go (TUG) test, motor component of the Functional Independence Measure™ (M-FIM™), UCLA activity score, Harris hip score, and patient-maintained subjective milestone diary and general health outcome using SF-12 scores. Operative time, complications, and component placement were also compared.

Results

Functional recovery was faster in patients with the direct anterior approach on the basis of TUG and M-FIM™ up to 2 weeks; no differences were found in terms of the other metrics we used, and no differences were observed between groups beyond 6 weeks. General health outcomes, operative time, and complications were similar between groups. No clinically important differences were observed in terms of implant alignment.

Conclusions

We observed very modest functional advantages early in recovery after direct anterior THA compared to posterior-approach THA. Randomized trials are needed to validate these findings, and these findings may not generalize well to lower-volume practice settings or to surgeons earlier in the learning curve of direct anterior THA.

Level of Evidence

Level II, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3A–B

Similar content being viewed by others

References

  1. Alecci V, Valente M, Crucil M, Minerva M, Pellegrino CM, Sabbadini DD. Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: perioperative findings. J Orthop Traumatol. 2011;12:123–129.

    Article  PubMed Central  PubMed  Google Scholar 

  2. Amstutz HC, Thomas BJ, Jinnah R, Kim W, Grogan T, Yale C. Treatment of primary osteoarthritis of the hip: a comparison of total joint and surface replacement arthroplasty. J Bone Joint Surg Am. 1984;66:228–241.

    CAS  PubMed  Google Scholar 

  3. Bal BS, Haltom D, Aleto T, Barrett M. Early complications of primary total hip replacement performed with a two-incision minimally invasive technique. J Bone Joint Surg Am. 2005;87:2432–2438.

    Article  PubMed  Google Scholar 

  4. Berend KR, Lombardi AV Jr, Seng BE, Adams JB. Enhanced early outcomes with the anterior supine intermuscular approach in primary total hip arthroplasty. J Bone Joint Surg Am. 2009;91(suppl 6):107–120.

    Article  PubMed  Google Scholar 

  5. Berger RA, Jacobs JJ, Meneghini RM, Della Valle C, Paprosky W, Rosenberg AG. Rapid rehabilitation and recovery with minimally invasive total hip arthroplasty. Clin Orthop Relat Res. 2004;429:239–247.

    Article  PubMed  Google Scholar 

  6. Bergin PF, Doppelt JD, Kephart CJ, Benke MT, Graeter JH, Holmes AS, Haleem-Smith H, Tuan RS, Unger AS. Comparison of minimally invasive direct anterior versus posterior total hip arthroplasty based on inflammation and muscle damage markers. J Bone Joint Surg Am. 2011;93:1392–1398.

    Article  PubMed  Google Scholar 

  7. Chimento GF, Pavone V, Sharrock N, Kahn B, Cahill J, Sculco TP. Minimally invasive total hip arthroplasty: a prospective randomized study. J Arthroplasty. 2005;20:139–144.

    Article  PubMed  Google Scholar 

  8. Dastane M, Dorr LD, Tarwala R, Wan Z. Hip offset in total hip arthroplasty: quantitative measurement with navigation. Clin Orthop Relat Res. 2011;469:429–436.

    Article  PubMed  Google Scholar 

  9. Dorr LD, Maheshwari AV, Long WT, Wan Z, Sirianni L. Early pain relief and function after posterior minimally invasive and conventional total hip arthroplasty: a prospective, randomized, blinded study. J Bone Joint Surg Am. 2007;89:1153–1160.

    PubMed  Google Scholar 

  10. Dorr LD, Thomas D, Long WT, Polatin PB, Sirianni LE. Psychologic reasons for patients preferring minimally invasive total hip arthroplasty. Clin Orthop Relat Res. 2007;458:94–100.

    PubMed  Google Scholar 

  11. Ellison B, Cheney NA, Berend KR, Lombardi AV Jr, Mallory TH. Minimal stress shielding with a Mallory-Head titanium femoral stem with proximal porous coating in total hip arthroplasty. J Orthop Surg Res. 2009;4:42.

    Article  PubMed Central  PubMed  Google Scholar 

  12. Guide to the Uniform Data Set for Medical Rehabilitation (Adult FIM), Version 4.0. Buffalo, NY: State University of New York at Buffalo; 1993.

  13. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty: an end result study using a new method of result evaluation. J Bone Joint Surg Am. 1969:51:737–755.

    CAS  PubMed  Google Scholar 

  14. Hershkovitz K, Brill S. Get up and go—home. Aging Clin Exp Res. 2006;18:301–306.

    Article  PubMed  Google Scholar 

  15. Kosinski M. Scoring the SF-12 physical and mental summary measures. Medical Outcomes Trust Bulletin. 1997;5:3–4.

    Google Scholar 

  16. Liaw CK, Yang RS, Hou SM, Wu TY, Fuh CS. Measurement of acetabular cup anteversion on simulated radiographs. J Arthroplasty. 2009;24:468–474.

    Article  PubMed  Google Scholar 

  17. Lovell TP. Single-incision direct anterior approach for total hip arthroplasty using a standard operating table. J Arthroplasty. 2008;23:64–68.

    Article  PubMed  Google Scholar 

  18. Maffiuletti NA, Impellizzeri FM, Widler K, Bizzini M, Kain MS, Munzinger U, Leunig M. Spatiotemporal parameters of gait after total hip replacement: anterior versus posterior approach. Orthop Clin North Am. 2009;40:407–415.

    Article  PubMed  Google Scholar 

  19. Maheshwari AV, Blum YC, Shekhar L, Ranawat AS, Ranawat CS. Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center. Clin Orthop Relat Res. 2009;467:1418–1423.

    Article  PubMed  Google Scholar 

  20. Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res. 2005;441:115–124.

    Article  PubMed  Google Scholar 

  21. Mayr E, Nogler M, Benedetti MG, Kessler O, Reinthaler A, Krismer M, Leardini A. A prospective randomized assessment of earlier functional recovery in THA patients treated by minimally invasive direct anterior approach: a gait analysis study. Clin Biomech (Bristol, Avon). 2009;24:812–818.

    Article  PubMed  Google Scholar 

  22. Nakata K, Nishikawa M, Yamamoto K, Hirota S, Yoshikawa H. A clinical comparative study of the direct anterior with mini-posterior approach: two consecutive series. J Arthroplasty. 2009;24:698–704.

    Article  PubMed  Google Scholar 

  23. Ogonda L, Wilson R, Archbold P, Lawlor M, Humphreys P, O’Brien S, Beverland D, A minimal-incision technique in total hip arthroplasty does not improve early postoperative outcomes: a prospective, randomized, controlled trial. J Bone Joint Surg Am. 2005;87:701–710.

    Article  PubMed  Google Scholar 

  24. Ostendorf M, van Stel HF, Buskens E, Schrijvers AJ, Marting LN, Verbout AJ, Dhert WJ. Patient-reported outcome in total hip replacement: a comparison of five instruments of health status. J Bone Joint Surg Br. 2004;86:801–808.

    Article  CAS  PubMed  Google Scholar 

  25. Ottenbacher KJ, Hsu Y, Granger CV, Fiedler RC. The reliability of the functional independence measure: a quantitative review. Arch Phys Med Rehabil. 1996;77:1226–1232.

    Article  CAS  PubMed  Google Scholar 

  26. Pagnano MW, Trousdale RT, Meneghini RM, Hanssen AD. Slower recovery after two-incision than mini-posterior-incision total hip arthroplasty: a randomized clinical trial. J Bone Joint Surg Am. 2008;90:1000–1006.

    Article  PubMed  Google Scholar 

  27. Podsiadlo D, Richardson S. The timed “up & go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142–148.

    CAS  PubMed  Google Scholar 

  28. Ranawat CS, Ranawat AS, Rasquinha VJ. Mastering the art of cemented femoral stem fixation. J Arthroplasty. 2004;19:85–91.

    Article  PubMed  Google Scholar 

  29. Ranawat CS, Rao RR, Rodriguez JA, Bhende HS. Correction of limb-length inequality during total hip arthroplasty. J Arthroplasty. 2001;16:715–720.

    Article  CAS  PubMed  Google Scholar 

  30. Restrepo C, Parvizi J, Pour AE, Hozack WJ. Prospective randomized study of two surgical approaches for total hip arthroplasty. J Arthroplasty. 2010;25:671–679.

    Article  PubMed  Google Scholar 

  31. Spaans AJ, van den Hout JA, Bolder SB. High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach. Acta Orthop. 2012;83:342–346.

    Article  PubMed  Google Scholar 

  32. Woolson ST, Mow CS, Syquia JF, Lannin JV, Schurman DJ. Comparison of primary total hip replacements performed with a standard incision or a mini-incision. J Bone Joint Surg Am. 2004;86:1353–1358.

    PubMed  Google Scholar 

  33. Woolson ST, Pouliot MA, Huddleston JI. Primary total hip arthroplasty using an anterior approach and a fracture table: short-term results from a community hospital. J Arthroplasty. 2009;24:999–1005.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We thank Kelly Stets MD, Raman Thakur MD, Anitha Jacob PA-C, Julie Pate PA-C, Leah Verebes PA, Neil Moskowitz PT, Daniel Gross DPT, PT, and Kshitij Agrawal MD for their help with this study.

Author information

Authors and Affiliations

  1. The Center for Joint Preservation and Reconstruction, North Shore LIJ/Lenox Hill Hospital, 130 E 77th Street, 11th Floor, New York, NY, 10075, USA

    José A. Rodriguez MD, Ajit J. Deshmukh MD, Parthiv A. Rathod MD, Michelle L. Greiz PT, Prashant P. Deshmane MD, Matthew S. Hepinstall MD & Amar S. Ranawat MD

Authors
  1. José A. Rodriguez MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ajit J. Deshmukh MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Parthiv A. Rathod MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Michelle L. Greiz PT
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Prashant P. Deshmane MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Matthew S. Hepinstall MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Amar S. Ranawat MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ajit J. Deshmukh MD.

Additional information

Each author certifies that he or she, or a member of his or her immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

About this article

Cite this article

Rodriguez, J.A., Deshmukh, A.J., Rathod, P.A. et al. Does the Direct Anterior Approach in THA Offer Faster Rehabilitation and Comparable Safety to the Posterior Approach?. Clin Orthop Relat Res 472, 455–463 (2014). https://doi.org/10.1007/s11999-013-3231-0

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-013-3231-0

Keywords

Search

Navigation