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General Orthopaedics


Current Concepts in Joint Replacement (CCJR) – Spring 2015


Outcome in total hip replacement is influenced by a variety of factors including patient selection, implant technology, surgical expertise and peri-operative management. As it relates to the direct anterior approach, there has been extensive marketing in order to drive patients to specific surgeons who use specific implants. Associated with this marketing, claims about superiority of this approach have been made with very little evidence to support these claims.

In a study comparing the direct anterior (DA) to the miniposterior approach, Pagnano et al showed no difference in length of stay, operative complications, IV breakthrough analgesia, stairs, maximum feet walked in hospital or percent discharged to home. The DA approach had longer operative times, higher maximum visual analog pain score and at two weeks more of the DA group required gait aids. At eight weeks the DA group had a higher Harris Hip Score but lower return to work and driving. They concluded no advantage of the DA approach. Even when comparing the DA approach to the conventional posterior approach Ranawat et al were only able to identify some benefit at 2 weeks which had disappeared by 6 weeks. Finally in a randomised prospective trial Taunton et al demonstrated very little differences between the DA and miniposterior approaches. The DA group time to ambulation without aids was slightly better in the DA group (22 vs. 28 days) and the three week SF mental scores were slightly better in the miniposterior group. They concluded little clinical or radiographic benefit was seen between the cohorts.

The evidence suggests if done well both approaches work well. The key to long term success is to get the parts in write regardless of approach.