The Direct Anterior Approach in Complex Primary and Revision Total Hip Arthroplasty

In total hip arthroplasty (THA), the direct anterior approach (DAA) is advertised to result in faster postoperative recovery and has gained enormous popularity over the past decade. However, in complex primary and revision THA, the DAA can be challenging. The objective is to provide evidence of the benefits of the DAA and its feasibility in complex primary and revision THA. Methods. A review of the literature was performed to provide evidence of the benefits of the DAA in THA, including results of our own RCT comparing DAA vs posterolateral approach (PLA) with wearables. Furthermore, the feasibilitly of the DAA in complex primary and revision THA is discussed and personal experiences are shared. True benefits of the DAA include: less pain, faster recovery, shorter length of stay, better intra-operative leg length asessment, possibity to use a C-arm, succesful single day surgery, succesful bilateral THA, less dislocations and less overall revisions. In complex primary THA, such as morbid obesity, DDH, failed hip fracture surgery with hardware removal, the DAA can be challenging and its benefits may not outweigh the disadvantages of its minimally-invasive character. In revision THA, the DAA may be favorable in isolated cup revisions as it allows better ischiopubic screw placement under fluroscopy, shorter length of stay and provides less instability postoperatively. The DAA for THA seems to result in faster recovery, with less dislocations and less overall revisions. However, in complex primary THA, the advantages of the DAA may not always outweigh its disadvantages. In revision THA, there seems to be a benefit of the DAA for isolated acetabular revision surgery.