Do the Early Advantages of the DAA Continue in Follow-up?
At ICJR’s Pan Pacific Orthopaedic Congress, Dr. Adoph Lombardi examined data from his practice comparing patients who underwent a THA through the direct lateral approach with those who underwent a direct anterior approach THA.
By Adolph V. Lombardi Jr., MD, FACS
Numerous variations of the direct lateral, or anterolateral abductor splitting approach, for total hip arthroplasty (THA) have been described, with the essence of all being a partial release of the confluence of the vastus lateralis and gluteus medius and minimus from the anterolateral attachment to the femur.
For more than a decade, the author’s practice has utilized a less-invasive modification to the direct lateral approach (LIDL). Essentials to this approach include:
- Avoidance of dissection into the vastus lateralis insertion
- A limit of 1-2 cm proximal dissection into the gluteus medius
- An effort to spare the majority of the gluteus minimus insertion
Virtues of the direct lateral approach are excellent visualization of the acetabulum and proximal femur for appropriate component alignment and orientation. We previously reported less blood loss and a shorter hospital stay with the LIDL approach compared with the standard direct lateral approach. 
While touted as safer with respect to minimizing dislocation, the LIDL approach has been reported to require a slightly prolonged rehabilitation to eliminate postoperative limp. The soft-tissue dissection still requires removing and repairing the abductor musculature.
Direct anterior approaches have gained popularity as minimally invasive methods for performing primary total hip arthroplasty. Because the anterior interval is intermuscular and internervous, the anterior approach has the potential advantage of requiring little or no muscle dissection and is a true minimally invasive alternative.
Some studies have reported high intraoperative and postoperative complication rates, increased transfusion risk, and questionable clinical benefits with direct anterior approaches. However, in an earlier study from our center, we found significantly improved early recovery of patients who underwent THA via the anterior supine intermuscular (ASI) approach versus LIDL, with a higher rate of hospital discharge directly to home as well as improved Harris hip scores and lower-extremity activity scale scores at 6 weeks. 
While there were complications associated with this approach, the rate was not significantly higher (with the number of patients studied) than the rate with the LIDL approach.
We wanted to determine if the early clinical benefits of the ASI approach remained with longer follow-up. Therefore, we reviewed our primary THA experience with a single short, tapered titanium femoral component, comparing outcomes between THA performed with an LIDL versus the ASI approach.
A query of our practice registry revealed 240 patients (281 hips) who underwent primary cementless THA with a short, tapered femoral component between January 2006 and February 2008. A high offset option was utilized in 54% of patients. Age averaged 62.7 years, and BMI averaged 29.4 kg/m2.
The ASI approach was utilized in 143 THA procedures, and the LIDL approach was used in 138 THA procedures. Disease profiles, gender, age, BMI, and preoperative clinical scores were similar between approach groups.
Follow-up averaged 4.6 years. Stem length averaged 107.2 mm (95-120). Harris hip scores improved by an average 33.7 points, from 50.3 preoperatively to 84.0 at most recent follow-up, with no differences between approach groups.
Six stems (2.1%) have been revised: 2 in the LIDL group (both for infection) and 4 in the ASI group (1 for infection, 2 for periprosthetic femoral fracture, and 1 well-fixed stem with a loose cup revised for the inability to dissociate the femoral head from the trunion [p=NS]).
Operative times were longer for with ASI than with LIDL (72.4 versus 65.5 minutes, [p=0.0001]), likely a reflection of our more established experience with the LIDL at the time of the study. While length of stay, estimated blood loss and transfusion needs were similar, mean hemoglobin level at discharge was lower in ASI patients than LIDL patients (10.2 versus 10.9 g/dL; p=0.0003). Mean length of stay was similar between approach groups, at 1.9 days for the ASI group and 2.0 days for the LIDL.
In this series, good results with a low rate of stem revision were achieved with a short, tapered titanium femoral component with proximal, porous plasma-sprayed coating, using either a less-invasive direct lateral or direct anterior approach. Patients treated with the LIDL approach had equivalent clinical and functional results compared with patients treated with the ASI approach.
Dr. Lombardi’s presentation can be found here.
Adolph V. Lombardi Jr., MD, FACS, is from Joint Implant Surgeons, Inc.; The Ohio State University Wexner Medical Center; and Mount Carmel Health Systems, New Albany, Ohio.
- Berend KR, Lombardi AV Jr. Total hip arthroplasty via the less invasive anterolateral abductor splitting approach. Seminars in Arthroplasty. 15(2):87-93, April 2004.
- Berend KR, Lombardi AV Jr, Seng BE, Adams JB. Enhanced early outcomes with the anterior supine intermuscular approach in primary total hip arthroplasty. J Bone Joint Surg Am. 2009 Nov;91 Suppl 6:107-20.