Direct Anterior Approaches in Hip Arthroplasty. An Ephemeral Trend or the Forthcoming ‘Gold Standard’?

The incidence of osteoarthritis and subsequent number of total hip arthroplasties rises each year, corresponding to the aging but yet more active population. Patients request minimal scars and improved early results accompanied by long procedure survivability. Orthopaedic surgeons have utilised minimal invasive procedures in order to achieve these goals and Direct Anterior Approaches (DAA) fit as such techniques. Modified by the traditional Smith Petersen approach, DAA such as the Anterior Minimally Invasive Surgery (AMIS) and Anterior Supine Intermuscular (ASI) exploit the same internervous plane between the sartorius, rectus femoris (femoral nerve) and tensor fascia lata (superior gluteal nerve). Instrumentation plays a major role in establishing good exposure to acetabulum and femur and differences exist between ASI and AMIS for the use of a special orthopaedic table (ASI uses a standard table). Clinical outcomes and survivability are analysed by several studies. Early results indicate faster recovery and shorter hospital stays and comparable medium and long term outcomes/survivability. However, most authors agree on DAA’s lengthy learning curve and suggest that a surgeon may accomplish optimal results after 30-50 procedures approximately. Intraoperative complications, such as injury to lateral femoral cutaneous nerve and femur fractures, are specifically seen with use of DAA. Surgeons should be well educated and trained in anterior hip approaches before applying the latter. Quicker rehabilitation and comparable arthroplasty survival may be achieved but few studies exist and more are needed to be set, before DAA becomes the new ‘gold standard’ in hip arthroplasty