Patients to Avoid Until You’ve Done 100 Direct Anterior Approach THAs

    Over the past decade, orthopaedic surgeons have become more and more interested in the direct anterior approach for total hip arthroplasty (THA) due to the reported benefits of shorter length of stay, greater likelihood of discharge home, and faster functional recovery, [1,2] as well as 30-day major and minor complications similar to those of THA through the lateral and posterior approaches. [3]

    Proficiency in the direct anterior approach takes time due to the nuances of acetabular and femoral exposure and component positioning, the different implants and instruments, and the need to train the OR staff. That’s why experts in the direct anterior approach generally recommend starting with “easier” patients and working up to more challenging cases as the surgeon and the OR team become more comfortable with the approach.

    RELATED: Safely Transitioning from the Posterior to the Direct Anterior Approach

    So, who are the so-called “easier” patients? At ICJR’s 7th Annual Direct Anterior Approach Hip Course, Martin Thaler, MD, MSc, from the Medical University Innsbruck in Austria, recommended starting with these patients:

    • Average weight or thin
    • Average muscle mass or lean
    • Decent bone quality
    • Active
    • Osteoarthritis
    • Older but not too old

    RELATED: Register for ICJR’s 8th Annual Direct Anterior Approach Hip Course

    Which patients should be avoided during the 100-patient learning curve? The list is fairly long, according to Dr. Thaler. The reason? The surgeon will want to build confidence and comfort with the new approach early in the learning process. These challenging patients could derail that process – and put the patient at risk for complications:

    • Short femoral neck or small femoral canal
    • High valgus angle
    • Prominent anterior inferior iliac spine
    • Short distance from the anterior superior iliac spine to the trochanter
    • Large osteophytes
    • Acetabular deformities such as protrusio acetabuli, coxa profunda, or hip dysplasia
    • Severe osteoporosis
    • Severe leg length discrepancies
    • Any indication for THA other than osteoarthritis, such as femoral neck fracture or conversion to THA
    • Previous hip arthroscopy, which indicates a tight, strong capsule with little room for maneuvering

    RELATED: Dr. Frederic Laude on the Direct Anterior Approach Learning Curve

    In addition, Dr. Thaler recommends using shorter stems and instruments specifically designed for direct anterior approach THA. But don’t change implants/instruments and the approach at the same time: Switch to the shorter stems and direct anterior approach instruments first, become familiar and comfortable with using them, and then begin the transition to the direct anterior approach.

    Click the image above to watch Dr. Thaler’s presentation and learn more about considerations for the first 100 direct anterior approach THAs.

    Disclosures: Dr. Thaler has disclosed that he is a consultant for DJO.


    1. Connolly KP, Kamath AF. Direct anterior total hip arthroplasty: Comparative outcomes and contemporary results. World J Orthop. 2016 Feb 18; 7(2): 94–101.
    2. Taunton MJ, Trousdale RT, Sierra RJ, Kaufman K, Pagnano MW. John Charnley Award: Randomized clinical trial of direct anterior and miniposterior approach tha: which provides better functional recovery? Clin Orthop Relat Res. 2018 Feb;476(2):216-229. doi: 10.1007/s11999.0000000000000112.
    3. Hart A, Wyles CC, Abdel MP, Perry KI, Pagnano MW, Taunton MJ. Thirty-day major and minor complications following total hip arthroplasty-a comparison of the direct anterior, lateral, and posterior approaches. J Arthroplasty. 2019 Jun 27. pii: S0883-5403(19)30637-0. doi: 10.1016/j.arth.2019.06.046. [Epub ahead of print]