What are the benefits and recommendations for an anterior hip replacement approach in patients with severe hip osteoarthritis?

Anterior Hip Replacement Approach

The anterior approach to total hip arthroplasty provides faster early recovery with less postoperative pain and better function in the first 8 weeks compared to other approaches, but shows no long-term outcome differences and carries higher complication risks during the learning curve.

Key Differences from Other Approaches

Surgical Technique

• The anterior approach utilizes the internervous plane between the tensor fasciae latae (laterally, superior gluteal nerve) and sartorius (medially, femoral nerve), preserving muscle integrity without cutting through muscle bellies 1, 2
• Patient positioning is supine, allowing intraoperative fluoroscopic assessment of leg lengths and component positioning, unlike lateral approaches 3
• The posterior approach requires cutting through the short external rotators and posterior capsule, while the lateral (Hardinge) approach splits the gluteus medius muscle 4

Early Postoperative Outcomes (First 8 Weeks)

• Pain reduction: VAS scores are 13 points lower on postoperative day 2 (42 vs 55) compared to lateral approach 5
• Functional recovery: Timed Up and Go test is 6 seconds faster on postoperative day 3 5
• Hip function: Harris Hip Score is 8 points higher at 8 weeks 5
• Quality of life: EQ-5D index is significantly higher (0.86 vs 0.78) at 8 weeks 5

Long-Term Outcomes (1-5 Years)

• No clinically relevant differences in pain, hip function, or quality of life exist between anterior and other approaches at 1 year or beyond 5
• Network meta-analysis shows anterior approach has higher postoperative Harris Hip Score within 1 month (mean difference 2.56-10.80 points vs other approaches), but this advantage disappears at final follow-up 4

Complications Profile

Approach-Specific Risks

• Higher early complication rate: 7 surgical approach-related complications occurred in the anterior group versus 0 in the lateral approach group in one randomized trial 5
• Femoral fractures: Increased risk with inadequate exposure during minimally invasive technique, particularly during the learning curve 1, 3
• Lateral femoral cutaneous nerve injury: Unique to anterior approach due to proximity of incision 1
• Femoral nerve palsy: Possible with excessive medial retraction during acetabular exposure 3

Comparative Complication Rates

• Posterior approach has the lowest overall complication risk (RR 0.39 compared to anterior approach) 4
• The steep learning curve for anterior approach means complication rates decrease significantly with surgeon experience 1

Clinical Recommendations

When to Choose Anterior Approach

• Patients prioritizing rapid early recovery (return to work within 6-8 weeks) benefit most from the 8-week functional advantage 5
• Younger, active patients who can tolerate the supine positioning and have normal anatomy 1
• Surgeons with completed learning curve (typically >100 cases) to minimize fracture and nerve injury risks 1

When to Avoid Anterior Approach

• Obese patients with large pannus that overlies the surgical field 3
• Patients with severe hip deformity requiring extensive exposure 3
• Surgeons early in their learning curve should consider lateral approach which has second-best outcomes for pain, function, and complications 4

Evidence Quality Considerations

The 2023 ACR/AAHKS guidelines on timing of arthroplasty do not specify surgical approach, focusing instead on when to proceed with surgery regardless of technique 6. The EULAR 2005 guidelines strongly recommend total hip replacement for refractory hip OA (86% strength of recommendation) but do not differentiate by surgical approach 6.

The lateral (Watson-Jones/Hardinge) approach represents the optimal balance, ranking second for all outcomes (pain, function, complications) and avoiding the anterior approach's higher complication rate while still providing acceptable early recovery 4. This makes it the safest choice for most surgeons and patients when considering the risk-benefit profile across the entire perioperative period.

Critical Pitfall

Do not delay hip arthroplasty to pursue additional nonoperative treatments once moderate-to-severe symptomatic OA is present and nonoperative therapy has failed—the 2023 ACR guidelines conditionally recommend proceeding directly to surgery without delay 6.