Patient’s perspective on direct anterior versus posterior approach total
Walaa Ikram Elassuity
Mostafa Abdelmaboud Azab
Received: 15 May 2018 / Accepted: 24 May 2018
SICOT aisbl 2018
Purpose Total hip arthroplasty approach comparison focused on patient’s perspective. The direct anterior approach (DAA) has
gained immense popularity in the last decade and is widely advocated as a superior approach in terms of quicker recovery and
better overall outcome. However, the question if the level of DAA promotion is justified seems to be rarely posed.
Methods A single-surgeon consecutive series of patients who underwent bilateral THA, one in DAA and the other in posterior
approach (PA). The same implant design and same component sizes were used for the both sides. All the operations were
performed by a single surgeon under the same pre- and post-operative care protocol.
Results Twenty-one patients underwent bilateral THA, mean age 60.09 years. Oxford Hip Score (OHS) was used for functional
outcome assessment. There were no statistically significant differences between two approaches in terms of functional outcome
(mean OHS for DAA series was 42.95 and that for the PA was 43.38, p 0.07 at an alpha level of 0.05). Fifteen patients gave the
advantage to PA, and six patients favoured DAA.
Conclusion By study design, we tried to reduce the biases and acquire approach appraisal from patient’s perspective. We
anticipated the outcome in favour of DAA, but the results favoring PA came as a surprise. Future prospective randomized studies
on evaluation of DAA and other approaches not only from surgeon’sorindustry’s point of view, performed on a larger and more
uniform groups, are warranted to further explore the subjective differences between DAA and PA.
Keywords Direct anterior approach
Total hip arthroplasty approach
Recent publications, industry seminars, professional meet-
ings, and online discussions among interested orthopaedic
surgeons have shown increased popularity and utilization of
DAA. The knowledge of DAA-related anatomy, technical tips
and tricks of the trade, and specialized instrumentation and
implants have advanced considerably, and there is no doubt
that DAA has passed a long way from hype to ripe and has
gained a foothold in the orthopaedic mainstream, in line with
PLA and other approaches [1–4].
Yet, there is little evidence for improved kinematics or bet-
ter long-term outcomes following the use of the DAA for
THA; additionally, many authors reported a steep learning
curve and mean operating times significantly longer with the
DAA . Proponents of DAA widely advocate it as a superior
approach in terms of quicker recovery, decrease of hospital
stay, and reduced dislocation risk [6–8]. Improved earlier
functional outcome during the first 6 weeks to 6 months with
DAATHAwhen compared to PATHA seems to be one of the
most exploited DAA features [9–11], even though there are
studies that are not so unanimous [12, 13].
The DAA is intensively being promoted, by surgeons, es-
pecially the podium regulars, or by industry, yet the question if
the level of DAA promotion is justified seems to be rarely
posed. Concerns regarding possible complications, particular-
ly wound complications, neural injury, periprosthetic/greater
trochanter fractures, and longer operative time, are somehow
readily neglected, mentioned as non-contributory, or assigned
to the steep part of the learning curve period [6, 14].
* Dragan Radoicic
Orthopedic Surgery and Traumatology Clinic, Military Medical
Academy, Belgrade, Serbia
Exeter Bone&Joint, Abu Dhabi, United Arab Emirates
Exeter Bone&Joint, Dubai, United Arab Emirates