Why I Do the Direct Anterior Approach

    At ICJR’s Pan Pacific Orthopaedic Congress, Dr. William Hozack discussed his rationale for adopting the direct anterior approach for total hip arthroplasty. Following is the abstract of his presentation.

    By William J. Hozack, MD

    Total hip athroplasty (THA) is about functionality, and soft tissue damage affects functionality. Consequences of soft tissue damage include:

    • Weakness
    • Limp
    • Soreness
    • Heterotopic ossification
    • Stiffness
    • General disappointment with the result

    RELATED: Register to attend the 7th Annual Direct Anterior Approach Hip Course

    Because the direct anterior approach (DAA) to THA is an approach between nerves (superior gluteal and femoral) and between muscles (TFL and sartorius/rectus femoris), it has the potential to maximize patient functionality. The DAA approach does not violate the gluteus maximus muscle or the iliotibial band. It also spares the gluteus medius and minimus muscles.

    Bergin et al [1] evaluated inflammatory markers after THA procedures performed with the DAA and posterolateral approach and found these markers to be significantly lower with the DAA. In theory, this suggests less overall soft tissue trauma with the DAA.

    The DAA preserves the posterior capsule, which minimizes the risk of dislocation and eliminates the need for hip precautions. This serves to enhance patient confidence and speed of recovery. While speed of recovery is not the most important factor surrounding THA, patients like the ability to return to work and other activities quickly after the surgery. The ability of patients undergoing DAA THA to achieve a faster recovery has been documented in several studies.

    The DAA is associated with a learning curve, especially for surgeons who adopt the approach after finishing their training programs. A higher rate of complications is likely during the learning curve, as documented by Woolson (JOA, 2009). Patients should be informed of the possibility of lateral femoral cutaneous nerve neuropraxia, which is common after DAA – up to to 80% in a study by Goulding (CORR 2010). No functional limitations seem to be incurred, however.

    In summary, let’s look at what is good, neutral, and bad about the DAA versus other approaches to THA.

    What is good about the DAA?

    • Minimally invasive surgery, done properly
    • Anatomic dissection between nerves and muscles
    • No hip precautions
    • Faster early recovery
    • Earlier return to work

    What is neutral about the DAA?

    • Long-term clinical results no different
    • Surgical pain equivalent
    • Complications equally frequent
    • Not safer
    • Implants do not last longer

    What is bad about the DAA?

    • Thigh numbness
    • Learning curve increases complications

    Author Information

    William J. Hozack, MD, is the Walter Annenberg Professor of Orthopedic Surgery, Rothman Institute Orthopedics, Thomas Jefferson University, Philadelphia, Pennsylvania.


    1. Bergin PF, Doppelt JD, Kephart CJ, et al. Comparison of minimally invasive direct anterior versus posterior total hip arthroplasty based on inflammation and muscle damage markers. J Bone Joint Surg Am. 2011 Aug 3;93(15):1392-8. doi: 10.2106/JBJS.J.00557.