Direct Anterior Approach for Hip Arthroplasty

Direct Anterior Approach for Hip Arthroplasty

Gregory K. Deirmengian, MD

William J. Hozack, MD

Dr. Deirmengian or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Angiotech; serves as a paid consultant to or is an employee of Synthes, Angiotech, Zimmer, and Biomet; and has stock or stock options held in CD Diagnostics. Dr. Hozack or an immediate family member has received royalties from Stryker; serves as a paid consultant to or is an employee of Stryker; has received research or institutional support from Stryker; and serves as a board member, owner, officer, or committee member of The Hip Society.


Total hip arthroplasty (THA) is one of the most successful surgical procedures in modern medicine. The procedure reliably relieves pain, restores function, and improves quality of life for most patients with debilitating hip arthritis. Successful achievement of the technical goals of THA requires surgical exposure of the acetabulum and proximal femur. This may be achieved through one of many well-described and commonly used approaches, each with its own advantages and disadvantages.

The long-term success of THA has been well established. Recent attention has been placed on early outcomes and the achievement of a rapid recovery. It appears that this goal may be attained through the integration of a combination of tactics, including patient education and preconditioning, anesthesia, surgical technique, aggressive postoperative physical therapy, and modern approaches to pain management.1,2,3 The literature has placed considerable focus on elements of surgical technique that may influence the speed of recovery.

The most common approaches for THA include the posterior approach and the modified Hardinge (also called direct lateral) approaches. Attempts to minimize the invasiveness of these approaches have involved limiting the size of the skin incision and the extent of the corresponding deep dissection. Several studies have shown, however, that the size of the skin incision does not influence the speed of recovery.4 Furthermore, in inexperienced hands, small-incision surgery may lead to inadequate exposure, resulting in technical errors that may compromise the long-term outcome of the procedure.5

The direct anterior approach is a modification of the classic Smith Petersen approach and was first described for use in THA by Judet in 1947.6 Recently, the direct anterior approach has become popular for THA because of its unique potential for achieving the goals of the procedure while minimizing the splitting or detaching of muscles or tendons. Careful technique leads to minimization of soft-tissue trauma, which is known to affect rapid recovery. As with any approach to the hip, proper exposure is the most important factor in achieving proper component sizing and positioning. This chapter describes our method of achieving appropriate exposure and minimizing soft-tissue trauma with the direct anterior approach.



Radiographic evaluation is standard for all hip approaches. AP radiographs of the pelvis and hip and a lateral radiograph of the hip are obtained and reviewed.
The radiographs also are used for templating with standard overlay templates or with a digital templating system. Preoperative prediction of the appropriate component sizes may provide important clues in the intraoperative setting. For example, if the femoral trial broach is several sizes smaller than the size predicted with templating, then the surgeon may have inadequately lateralized the broach in preparing the femur.

FIGURE 1 AP radiograph of the hip demonstrates a short, varus femoral neck. This anatomic pattern is associated with a difficult reconstruction.

FIGURE 2 Photograph shows the room setup using a standard operating table for the direct anterior approach for total hip arthroplasty. The gel bump, 30° of table flexion, and the distal arm board on the nonsurgical side of the table facilitate the extension and adduction of the surgical lower extremity necessary for femoral exposure.

image VIDEO 57.1 Direct Anterior Approach for Total Hip Arthroplasty. Gregory K. Deirmengian, MD; William J. Hozack, MD (23 min)

Feb 2, 2020 | Posted by in ORTHOPEDIC | Comments Off on Direct Anterior Approach for Hip Arthroplasty

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