Anterior fix-and-replace strategy using direct anterior and pararectus approaches for acetabular fractures in older patients

BACKGROUND: Most reported fix-and-replace procedures use a posterior or lateral approach for total hip arthroplasty (THA) and a Kocher-Langenbeck, anterior intrapelvic, or ilioinguinal approach for acetabular fixation, which may require separate anterior and posterior exposures. Evidence on fully anterior, single-position workflows combining anterior acetabular fixation with THA remains limited. AIM: The aim of this study was to assess the outcomes of acute THA through the direct anterior approach (DAA) combined with pararectus in patients considered suitable for a fix-and-replace strategy. METHODS: This retrospective single-centre case series included 20 patients aged ≥ 60 years (mean age: 82 ± 10 years) selected for a fix-and-replace strategy based on predefined indications - such as acetabular dome destruction, femoral head damage, pre-existing hip degeneration - between 2009 and 2023. All underwent single-stage pararectus fixation and DAA THA in the supine position without posterior exposure or repositioning. Acetabular reconstruction constructs were used in 19 patients and dual-mobility articulation in five patients. The primary outcome was revision surgery within two years. Secondary outcomes included surgical data, 30-day complications, mortality, postoperative weight bearing, radiographic findings, mobility, pain, and patient satisfaction. RESULTS: Revision surgery was required in 4 patients (20%) within two years: Two for infection, one for recurrent instability, and one for progressive mechanical failure with persistent non-union. Mean operative time was 216 ± 49 min, and estimated blood loss was 969 ± 537 mL. Four patients had Sink grade ≥ 3 complications within 30 days, including 1 death. Five deaths were counted for the 2-year mortality endpoint. Full weight bearing was prescribed in 6 patients. One additional asymptomatic construct subsidence was managed non-operatively. At latest follow-up, 12/16 patients were ambulatory, 12/14 were pain-free or had only mild pain, and 13/17 were satisfied or very satisfied. CONCLUSION: Acute total hip arthroplasty through the direct anterior approach combined with pararectus fixation is a feasible fully anterior, single-position strategy for selected older patients. The surgical strategy described herein achieved favorable outcomes in the present patient cohort, supporting its continued use as a rational treatment approach in appropriately selected patients.