Abstract
Total hip arthroplasty (THA) has been cited as one of the most successful surgical procedures performed today. However, as hip surgeons, we desire constantly improving outcomes for THA patients with more favorable complication rates. At the same time, patients desire hip pain relief and return to function with as little interruption of life as possible. The expectation of patients has changed; they have more physical demands for strength and flexibility, and aspire to achieve more in their recreational pursuits. Additionally, health care system constraints require the THA episode of care to become more efficient as the number of procedures increases with time. These factors, over the past fifteen years, have led to a search for improved surgical approaches and peri-operative pain and rehabilitation protocols for primary THA. The orthopaedic community has seen improved pain control, length of stay, and reduction in complications with changes in practice and protocols. However, the choice of surgical approach has provided significant controversy in the orthopaedic literature. In the 2000s, the mini-posterior approach (MPA) was demonstrated as the superior tissue sparing approach. More recently, there has been a suggestion that the direct anterior approach (DAA) leads to less muscle damage, and improved functional outcomes.
A recent prospective randomised trial has shown a number of early deficits of the posterior approach when compared to the direct anterior approach. The posterior approach resulted in patients taking an additional 5 days to discontinue a walker, discontinue all gait aids, discontinue narcotics, ascend stairs with a gait aid, and to walk 6 blocks. Patients receiving the posterior approach required more morphine equivalents in the hospital, and had higher VAS pain scores in the hospital than the direct anterior approach. Interestingly, activity monitoring at two weeks post-operatively also favored DAA with posterior approach patients walking 1600 steps less per day than DAA patients. There has been little difference in the radiographic outcomes or complications between approaches in prospective randomised trials.
A number of randomised clinical trials have demonstrated that both the direct anterior and posterior approach provided excellent early post-operative recovery with a low complication rate. DAA patients have objectively faster recovery with slightly shorter times to achieve milestones of function, with similar radiographic and clinical outcomes at longer-term outcomes, with a similar complication rate.
