What Are the Criteria for Patient Selection with the Direct Anterior Approach?

    Dr. Preetesh Patel answers questions from ICJR about how patient selection evolves as the surgeon becomes more familiar and comfortable with the direct anterior approach for total hip arthroplasty.

    ICJR: Which patients do you recommend that surgeons start with when they’re just learning the direct anterior approach, and why?

    Preetesh D. Patel, MD: The learning curve for the direct anterior approach can be steep, but it can be minimized by a combination of cadaveric training, educational tools/videos, and direct surgical observation through site visits. 

    Early in the learning curve, patient selection is of paramount importance to avoid complications. The 2 commonly important parameters are the patient’s body habitus and the patient’s radiographic anatomy. 

    • From a body habitus standpoint, start with taller, thinner, and less muscular patients.
    • From a radiographic standpoint, choose patients with a narrow ilium and longer distances from the anterior superior iliac spine to the tip of the greater trochanter. Exposure will be easier in these patients, especially when it comes to elevating the femur.

    Following these recommendations will increase working space at the hip joint during acetabular and femoral preparation. 

    Surgeons who are early in the learning curve should also carefully consider choosing patients with less acetabular and femoral preoperative deformity. 

    ICJR: As the surgeon becomes more proficient with this approach, how should his or her patient selection evolve?

    Dr. Patel: Patient selection can evolve to include previous limitations of body habitus and anatomic challenge as noted on radiographs. 

    For example, obese patients become easier in the direct anterior approach, as less adipose tissue is typically found on the anterior thigh than on the posterior thigh. Muscular patients, although more difficult in the beginning, can become routine as time goes on. 

    Becoming familiar with more extensile releases, such as the origin of the tensor fasciae latae or the dorsolateral capsule and external rotators, is important.

    Similarly, becoming more familiar with the acetabular and femoral prep/releases will allow a surgeon to take on patients with:

    • Wider ilia
    • Varus femoral neck/shaft angles
    • Narrow femoral canals
    • Femoral rotational deformities
    • Acetabular osteophytosis/deformities
    • Protrusio
    • Dysplasia 

    As with any other operation, surgeons should start cautiously when evolving their patient selection criteria and expand as their comfort level increases.  

    ICJR: Are there any patients for whom the direct anterior approach is not appropriate?

    Dr. Patel: In its truest form, the direct anterior approach can be utilized for any primary or revision operation, if the surgeon is familiar and comfortable with the goals of the particular surgery. For example:

    • In a primary setting, retained hardware and deformity can be addressed through this surgical approach, just as with other surgical approaches. 
    • In the revision setting, being familiar with extensile exposure options, such as anterior iliac crest osteotomies, femoral standard and extended trochanteric osteotomies, and femoral window osteotomies, will allow a surgeon to remove well-fixed implants and reconstruct significant bone loss.   

    About the Expert

    Preetesh D. Patel, MD, is Section Head, Adult Joint Reconstruction, and Fellowship Director, Adult Joint Reconstruction, at Cleveland Clinic Florida in Weston, Florida.


     Dr. Patel has no disclosures relevant to this article.