Total Hip ArthroplastyPosterior Approach (PA) vs. Direct
Anterior Approach (DAA)Aaron Tang, SPT
Total Hip ArthroplastyReconstructive procedure to replace the
acetabulofemoral joint with prosthesis in order to regain normal,
pain-free hip motion to perform ADLsGoal of the procedure is to
mitigate hip pain, restore function, and improve quality of
life208,600 THA procedures performed in 2005, projected to increase
to 572,000 THA procedures to be performed in 2030. 3
Posterior Approach (PA)
Patient positioned on their sideIncision (4 inches to up to 12
inches) from just below the iliac crest to medial to the greater
trochanterGluteus maximus is cut and pulled back revealing the hip
external rotators
https://www2.aofoundation.org/wps/portal/!ut/p/a0/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_A0M3D2DDbz9_UMMDRyDXQ3dw9wMDAzMjfULsh0VAbWjLW0!/?approach=Posterolateral%20approach&bone=Femur&classification=31-B3&implantstype=&method=Arthroplasty&redfix_url=1284974569031&segment=Proximal&showPage=approach&treatment=&contentUrl=/srg/31/04-Approaches/2008/31_Posterolateral_2010.jsp
Posterior Approach (PA)
TenotomyGluteus Medius/Minimus may be detached off the greater
trochanterPiriformis and the Superior Gemelli are detached and
pulled back with the other ERSciatic Nerve is close to the this
region and the surgeons have to be careful about injuring
itCapsulectomy is performedFemur head is dislocated from the
acetabulumFemur Head is cut and Acetabulum is cleaned out
Direct Anterior Approach (DAA) 7
ASIS is identified and an incision is made 3cm x 3cm from it
over the Hueter interval between the TFL and sartoriusThe lateral
cutaneous femoral nerve and femoral bundle (femoral artery, vein,
and nerve) are in close approximation and are retractedTFL and
Sartorius are retractedRectus Femoris and Gluteus Medius are
retractedRectus femoris lies deep to the sartorius and TFLGluteus
medius/minimus inserts into the greater trochanterIliopsoas tendon
may be in the way
Direct Anterior Approach (DAA) 7
Fluoroscopy can be used for better view of the jointCapsulectomy
is performedFemoral Neck osteotomy performedLeg placed in
extension, adduction, and external rotation
IndicationsDiagnosis of primary OA (PA 82.3%, DAA 87.2%),
secondary OA (PA 5.6%, DAA 4.4%), inflammatory OA (PA 6.2%, DAA
4.9%), fracture (1.3% PA, DAA 1.4%), osteonecrosis (PA 4.4%, DAA
1.7%), or metabolic (PA 0.3%, DAA 0.3%) 5Debilitating hip pain and
stiffnesspain does not disappear even at reststiffness causing
severe functional limitationsAll conservative treatments were
ineffectivemedication, physical therapy, steroid injection, weight
loss, activity modification
seconday OA: trauma, injury, sedentary, developmental dysplasia,
legg calve perthesinflammatory OA: rheumatoid arthritis, juvenile
rheumatoid arthritisfracture: femoral headosteonecrosismetabolic:
metabolic bone disease
Additional Considerations for PA vs. DAA THABMIIn a study by
Slaven et al., 4 of 6 patients with a BMI of > 34 kg/m2 had
unsuccessful outcomes and all patients with a BMI of 40.0 kg/m2 is
a contraindication to DAA due to a greater risk of wound
complications. DAA patients typically have a lower BMI6, 7AgeIn a
study by Slaven, et al., all patients under the age of 68.5 with a
BMI 40.0 kg/m2Limited exposure to the proximal femurSteep learning
curve/ Surgeons familiarity and comfort with the procedure 11
Increased rate of nerve complications
