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Aug 31, 2015

Does Surgical Approach Matter in Total Hip Replacement?

Traditionally total hip replacements were performed either via direct lateral (including Hardinge) or posterior approaches, but in more recent years the Direct Anterior Approach (DAA) has gained popularity in Australia. In this article, the features of the three most popular approaches are summarised with a review of the current literature on the effect of approach on patient outcomes. 

Direct lateral approach (Hardinge)

Initially published in 1982 by Kevin Hardinge in Wrightington, UK (1) the hip joint is accessed by detaching  the abductors (gluteus minimum and medius) off the front of the femur. Exposure is excellent and fully extensile both above and below and thus suitable for both primary and most revision situations, including periprosthetic fracture. Many variations of this initial technique have since been described, including trochanteric osteotomy as preferred by Sir John Charnley. There is an incidence of trochanteric pain syndrome and persistent limp due to impaired healing of the abductors back to the femur in some cases.


Posterior approach

This approach to the hip joint preserves the hip abductors and accesses the hip from below. Release of some or all of the short external rotators is required to access the hip joint in this approach. Like the direct lateral approach, the posterior approach is extensile in both directions and suitable for most revision situations. Traditional descriptions of the posterior approach often cite large curved incisions, release of all the short external rotators (from piriformis to quadratus femoris) and the gluteus maximus attachment. As experience with this approach has improved over the years, the same complete  exposure for primary hip replacement can be achieved with much smaller incisions, with complete sparing of piriformis, quadratus femoris, ITB and gluteus maximus insertion, improving early mobility and comfort.

Direct anterior approach (DAA)

The first written description of the direct anterior approach was cited in 1881, by a german physician, Carl Heuter. In 1917, Marius N. Smith-Petersen popularised this approach and thus became the eponymous term for DAA. It utilises the deep interval between rectus femoris and gluteus medius which lies directly over the front of the hip joint. The Smith-Petersen approach has commonly been used in orthopaedics, ranging from developmental hip dysplasia to adult reconstruction, surgical management of femoroacetabular impingement (FAI) and treatment of hip fractures. For the purposes of total hip arthroplasty, exposure in DAA can be challenging. To achieve adequate exposure judicious release of joint capsule, reflected head of rectus tendon and short external rotators tendons such as quadratus femoris, obturator externus or the gamelli are variably required. Specialised traction tables have been developed to aid in improving femoral exposure (2).

Each approach has inherent advantages and disadvantages. Historically the lateral approach has been associated with a lower dislocation rate but a higher rate of abductor dysfunction and potential for  a Trendelenberg positive gait and limp. However, more recent data using contemporary techniques such as improved soft tissue repair, modular implants to best restore patient anatomy and larger bearing surfaces show that there are few differences in complication rate, revision for all causes, and revision for dislocation (4). When taking into account patient reported outcome measures (PROM) to best gauge patient satisfaction, the posterior approach is superior (4 - 6).

More recently the DAA has gained popularity in primary hip replacement. Medical device companies have proposed components specifically intended for use with the DAA. Advocates of the DAA generally claim quicker recovery due to the muscle sparing nature of the approach as well as the small size of the incision. It is widely quoted that the learning curve quoted to be anywhere from 20 to 100 cases (7 - 8). A recent comparison of the DAA to contemporary posterior approach showed that the DAA was associated with higher visual pain analogue scores, longer operative times and increased use of walking aids at two weeks. There was no difference in hospital length of stay. By 8 weeks the DAA cohort had a lower rate of return to work and driving (9). Amlie et al similarly demonstrated no differences in PROM between either approach (10) whilst Christensen at al (11) has demonstrated more wound issues requiring return to theatre in the DAA cohort compared to posterior. The evidence remains unclear if any true benefit exists for the direct anterior approach. Nevertheless, whilst debate on this topic will no doubt continue it is important to recognise there are many factors that improves patient experiences. Few surgeons are performing hip arthroplasty with the same size incision and with the same extent of soft tissue release or exposure commonplace even 5 years ago. Similarly, advances in patient education, improved anaesthetic techniques including multimodal periarticular injections and a focus on multidisciplinary post-operative rehabilitation has an influence of potentially greater significance than surgical exposure alone.



  1. Hardinge, K. The direct lateral approach to the hip.  J Bone Joint Surg Br 64.1 (1982): 17-19.
  2. Bender, B, et al. Direct anterior approach for total hip arthroplasty. Orthopedic Clinics of North America 40.3 (2009): 321-328.
  3. Manktelow, A. et al. Hip Arthroplasty: Back to the Future?. Bone & Joint 360 4 (February 2015): 6-11
  4. Jameson, S. et al. A Comparison of Surgical Approaches for Primary Hip Arthroplasty: A Cohort Study of Patient Reported Outcome Measures (PROMs) and Early Revision Using Linked National Databases. The Journal of arthroplasty 29.6 (2014): 1248-1255.
  5. Lindgren, J. et al. Patient-reported outcome is influenced by surgical approach in total hip replacement a study of the Swedish Hip Arthroplasty Register including 42 233 patients. Bone & Joint Journal 96.5 (2014): 590-596.
  6. Amlie, E. et al. Worse patient-reported outcome after lateral approach than after anterior and posterolateral approach in primary hip arthroplasty: A cross-sectional questionnaire study of 1,476 patients 1-3 years after surgery. Acta orthopaedica 85.5 (2014): 463-469.
  7. Hunt, L. et al. 90-day mortality after 409 096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis. The Lancet 382.9898 (2013): 1097-1104.
  8. Müller, D. et al. Anterior minimally invasive approach for total hip replacement: five-year survivorship and learning curve. Hip international: the journal of clinical and experimental research on hip pathology and therapy 24.3 (2014): 277-283.
  9. Masonis, J. et al. Safe and accurate: learning the direct anterior total hip arthroplasty. Orthopedics 31.12 Suppl 2 (2008): 1417-1426.
  10. Poehling-Monaghan, K. et al. Direct Anterior versus Miniposterior THA With the Same Advanced Perioperative Protocols: Surprising Early Clinical Results. Clinical Orthopaedics and Related Research 473.2 (2015): 623-631.
  11. Christensen, C. et al. Greater Prevalence of Wound Complications Requiring Reoperation With Direct Anterior Approach Total Hip Arthroplasty. The Journal of arthroplasty 29.9 (2014): 1839-1841.

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