From the Guidelines
The anterior approach for total hip replacement is associated with less postoperative pain compared to the posterolateral approach, as confirmed by a meta-analysis by Wang et al. 1. This approach involves accessing the hip joint from the front of the body, between muscle planes rather than cutting through muscles. The primary benefits include:
- Faster recovery time and reduced post-operative pain since the procedure spares key muscles by working between natural tissue planes
- Patients typically experience less post-operative pain medication requirements and can often begin walking the same day of surgery
- The anterior approach also provides better immediate stability with lower dislocation rates because the posterior capsule and external rotator muscles remain intact
- This approach allows for more accurate leg length restoration and component positioning since the patient is positioned supine, making intraoperative fluoroscopy easier to use
- Additionally, patients face fewer post-operative movement restrictions compared to posterior approaches, allowing them to resume normal activities sooner However, this technique requires specialized training and equipment, has a steeper learning curve for surgeons, and may not be suitable for all patients, particularly those with obesity or complex hip anatomy. The decision to use an anterior approach should be individualized based on patient factors and surgeon experience, considering the potential benefits and drawbacks, as well as the lack of strong evidence supporting one approach over another in terms of postoperative pain management, as noted in the prospect guideline for total hip arthroplasty 1.
From the Research
Advantages of Anterior Approach for Total Hip Replacement
- The anterior approach is intermuscular and internervous, allowing the surgeon to reach the capsule without muscle detachment 2
- Faster recovery and excellent functional outcome are reported with the anterior approach 2, 3
- Reduced postoperative pain and hospital stay are also advantages of the anterior approach 2, 4
- The direct anterior technique has been shown to be safe and effective in revision settings, decreasing the occurrence of heterotopic ossification and enhancing the accuracy of acetabular cup positioning 3
- Thromboembolic events have been shown to be decreased compared to other approaches 3
- Patients undergoing direct anterior approach total hip arthroplasty (DA THA) have improved physical function, shorter length of stay, improved mobilisation, decreased narcotic requirements, and improved inpatient pain scores compared to posterior approach THA 4
Comparison with Posterior Approach
- There is no significant difference in clinical outcomes between the direct anterior approach and the posterior approach in patients undergoing total hip arthroplasty when an 'Enhanced Recovery' pathway is used 5
- However, a significantly higher rate of periprosthetic femoral fractures remains a concern with the direct anterior approach 5
- DA THA patients discontinued their assistive device, left their home, and drove a car sooner than posterior approach patients 4