Direct Anterior Approach

Can you please give me your opinion on the new Direct Anterior approach, not the anterolateral approach but the DIRECT anterior approach. A couple of doctors have started using this and I want to get some feedback from the top doctors on it. Maybe you can touch on the differences between this and the posterior approach that many of you use? Pros and cons?

Thanks so much, Vicky

Dr. De Smet:
Dear Vicky,

Very simple explanation. It is not a new technique used already for more then 40 or 50 years. There is only one centre well known for this Technique in Paris, namely group of Prof. Judet. It should not touch any muscle. For total hip OK, but new technique for a lot of people and again a learning curve. Other downside is need of a traction table (possible other problems, some people had even ankle fractures!) and problems is heavy and muscular people! The exposure is just less as with posterior approach!! The problem with anterior is just like mini invasive it is FASHION, try to make a new publicity stunt.  One thing is sure to do RESURFACING with a direct anterior approach it is asking for problems (70% male, muscular patients!!). You will have again probably to opposite parties in this technique to make the other one feeling or showing badly and nobody telling the true story in between.

Greetz, KOEN

Dr. Rogerson:
I'm familiar with Joel Matta's and the French anterior approach using the special table but have only seen it utilized for THA and not Resurfacing yet.  In the posterior approach you worry about traction on the sciatic nerve but in the direct anterior approach you are pushing the head posteriorly and doing some posterior capsular release (by necessity for a resurfacing) so one would still be potentially compromising circulation and risking direct pressure on the sciatic.  That being said, I would still like to see an actual video of the direct anterior for resurfacing and am attending the L.A. course Oct 24-25 where all the approaches will be examined.  More later.


Dr. Schmazlried:
Like any surgical procedure, it is more about who does it than what is done.  I think that a good, experienced surgeon will get good results – after some learning curve.  There is no comparative data.

Thomas P. Schmalzried, M.D.

Dr. Ure:
Hi Vicki,

Pretty soon you are going to know more about hip resurfacing than the hip resurfacing specialists (if you don't already)!

The "new Direct Anterior approach", in fact isn't new. It was the approach used by Dr. Wagner in Germany when he was doing the old polyethylene hip resurfacings in the 70's. Doctors who are unfamiliar with orthopedic history may think they are onto something new, but they aren't.

What is different is that Dr. Wagner made no attempt at limiting incision size. The phrase "minimally invasive" hadn't been coined yet. Today, surgeons are trying to do the surgery through a much smaller incision, with less soft tissue releases, etc. The surgery is touted by some as being the only true intermuscular approach to the hip, where no tendons need to be cut.

Unfortunately, that isn't quite the true scenario, at least with hip resurfacing. Whether you perform the surgery through the postero-lateral (my preferred approach) or the direct anterior (an approach I have used but abandoned), tendons have to be cut. In both cases you have to release hip capsule, and in approximately the same amount. Recovery time is about the same for both approaches, in my experience. There was a paper presented at EFORT in Nice, France this year which also showed no advantage of the direct anterior to the posterolateral approach, in terms of function or recovery time. Given this, and given that the posterolateral approach is simpler, it is not surprising the about 98% of the surgeons around the world use it instead of the direct anterior.

Hope all is going well with you!

Regards, Dr Ure

Dr. Clarke:

I hope all is well. This approach has theoretical advantages, but I will stay on the sidelines for now.  I am personally concerned by the potential for inadequate acetabular fixation or component mal-alignment as a result of inadequate exposure.  This is an exacting operation and the published results when done through the posterior approach are a compelling reason to stay with that approach.

Best Regards, Michael

Dr. Su:
Hi Vicky,

I think the direct anterior approach is intriguing in that it is an intermuscular approach, without cutting or detaching any muscles. However, I have witnessed it before and found it to be a struggle with a limited exposure. The potential advantage is a preservation of the blood supply to the femoral head, but as we have discussed before, the NCP approach to the hip via the posterior may be able to do the same thing.

I think the posterior approach is more suitable for the majority of patients because it gives the best visualization for component positioning, can be easily extended, and offers just as quick a recovery.

Regards, Ed