Perspective

Direct anterior, mini-posterior approaches for THA associated with few complications

Activity monitoring showed there was faster overall recovery in the direct anterior approach group vs the mini-posterior approach group.

SAN DIEGO — Patients who underwent total hip arthroplasty through either the direct anterior or mini-posterior approach experienced excellent early postoperative recovery with low complication rates, according to results presented at the American Academy of Orthopaedic Surgeons Annual Meeting, here.

“The anterior and posterior approach provided excellent early postoperative recovery with a low complication rate,” Michael J. Taunton, MD, of the Mayo Clinic in Rochester, Minn., said. “The anterior patients had a faster overall recovery rate with shorter times to achieve functional milestones and also as measured by quantitative activity monitoring at 2 weeks.”

Regardless of the total hip arthroplasty (THA) approach used, all patients received standardized multi-modal perioperative pain and physical therapy protocols, according to Taunton.

Michael J. Taunton, MD
Michael J. Taunton

Taunton and his colleagues randomly assigned 115 patients undergoing THA to treatment through a direct anterior approach (DAA) or mini-posterior approach based on operating surgeon, patient age, gender and BMI. Patients recorded their daily functional milestones using a diary the hospital provided to them.

Researchers collected clinical data preoperatively and at 2 weeks, 8 weeks and 1 year postoperatively. They also used the SF-12 and Hip disability and Osteoarthritis Outcome Score (HOOS) preoperatively and at 8 weeks and 1 year postoperatively.

“Additionally, this study employed a unique technology utilizing proprietary ambulatory activity monitors that allow us to objectively evaluate physical activity in the daily living environment,” Taunton said.

THA done with DAA
The anterolateral (a) and lateral radiographs (b) of the right hip demonstrate the acetabular component, femoral head and femoral stem in appropriate position after THA done with DAA.

Images: Taunton MJ

Patients who underwent the DAA received less morphine, had lower overall pain scores and could walk further in their first physical therapy session than the mini-posterior group.

The DAA group discontinued the use of gait aids and narcotics and could ascend stairs and walk 6 blocks about 5 days earlier than the mini-posterior approach group.

“Looking at activity, we see a drop in both groups at 2 weeks — 4,000 steps for the anterior approach and 2,200 steps for the posterior approach — which was statistically significant,” Taunton said.

Although the gait monitors showed entropy measurements dropped in both groups at 2 weeks, patients in the DAA group had a trend toward a more normal gait, Taunton noted.

Taunton said there were statistically significant differences in SF-12 physical component change between the groups at 2 months postoperatively. However, that difference was gone by 1 year and he noted no differences between the groups’ SF-12 mental component scores at 2 months or 1 year.

Results showed an overall complication rate of 8% with the DAA and 10% with the mini-posterior approach.

“Looking at the radiographic outcomes, there were no differences among the two groups. Additionally, there were no signs of failures of any implants or subsidence,” Taunton said.

Complications included one dislocation, two wound problems and one fall in the DAA group and one dislocation, one wound dehiscence, two intraoperative calcar fractures and one deep vein thrombosis in the mini-posterior approach group, he said.

“Looking at the HOOS, there was no difference in the absolute or delta changes at 2 months or 1 year,” Taunton said. – by Casey Tingle

Disclosure: Taunton reports he receives research support from DePuy Synthes and Stryker, and receives IP royalties from and is a paid consultant for DJO Global.

SAN DIEGO — Patients who underwent total hip arthroplasty through either the direct anterior or mini-posterior approach experienced excellent early postoperative recovery with low complication rates, according to results presented at the American Academy of Orthopaedic Surgeons Annual Meeting, here.

“The anterior and posterior approach provided excellent early postoperative recovery with a low complication rate,” Michael J. Taunton, MD, of the Mayo Clinic in Rochester, Minn., said. “The anterior patients had a faster overall recovery rate with shorter times to achieve functional milestones and also as measured by quantitative activity monitoring at 2 weeks.”

Regardless of the total hip arthroplasty (THA) approach used, all patients received standardized multi-modal perioperative pain and physical therapy protocols, according to Taunton.

Michael J. Taunton, MD
Michael J. Taunton

Taunton and his colleagues randomly assigned 115 patients undergoing THA to treatment through a direct anterior approach (DAA) or mini-posterior approach based on operating surgeon, patient age, gender and BMI. Patients recorded their daily functional milestones using a diary the hospital provided to them.

Researchers collected clinical data preoperatively and at 2 weeks, 8 weeks and 1 year postoperatively. They also used the SF-12 and Hip disability and Osteoarthritis Outcome Score (HOOS) preoperatively and at 8 weeks and 1 year postoperatively.

“Additionally, this study employed a unique technology utilizing proprietary ambulatory activity monitors that allow us to objectively evaluate physical activity in the daily living environment,” Taunton said.

THA done with DAA
The anterolateral (a) and lateral radiographs (b) of the right hip demonstrate the acetabular component, femoral head and femoral stem in appropriate position after THA done with DAA.

Images: Taunton MJ

Patients who underwent the DAA received less morphine, had lower overall pain scores and could walk further in their first physical therapy session than the mini-posterior group.

The DAA group discontinued the use of gait aids and narcotics and could ascend stairs and walk 6 blocks about 5 days earlier than the mini-posterior approach group.

“Looking at activity, we see a drop in both groups at 2 weeks — 4,000 steps for the anterior approach and 2,200 steps for the posterior approach — which was statistically significant,” Taunton said.

Although the gait monitors showed entropy measurements dropped in both groups at 2 weeks, patients in the DAA group had a trend toward a more normal gait, Taunton noted.

Taunton said there were statistically significant differences in SF-12 physical component change between the groups at 2 months postoperatively. However, that difference was gone by 1 year and he noted no differences between the groups’ SF-12 mental component scores at 2 months or 1 year.

Results showed an overall complication rate of 8% with the DAA and 10% with the mini-posterior approach.

“Looking at the radiographic outcomes, there were no differences among the two groups. Additionally, there were no signs of failures of any implants or subsidence,” Taunton said.

Complications included one dislocation, two wound problems and one fall in the DAA group and one dislocation, one wound dehiscence, two intraoperative calcar fractures and one deep vein thrombosis in the mini-posterior approach group, he said.

“Looking at the HOOS, there was no difference in the absolute or delta changes at 2 months or 1 year,” Taunton said. – by Casey Tingle

Disclosure: Taunton reports he receives research support from DePuy Synthes and Stryker, and receives IP royalties from and is a paid consultant for DJO Global.

    Perspective

    Bryan D. Springer

    • Taunton and colleagues should be applauded for a well-done prospective, randomized study comparing the DAA vs. mini-posterior approach. In this study, the DAA provided a modest (approximately 5 day) benefit in discontinuation of gait aids and opioids, ascending stairs and walking 6 blocks. There was no difference in VAS pain scores and opioid consumption in the hospital. At the 2-month evaluation, there was no difference in parameters between the two groups. The authors conclude both approaches provide excellent early results with low complication rates.

      These modest early gains should be tempered by numerous studies showing concerns for increased complications with the DAA approach. Many factors lead to success in THA. While surgical approach may play a small role in some patients, the long-term goals of THA, namely durable fixation and low wear, should not be trumped by minimal short-term benefits.

      • Bryan D. Springer, MD
      • OrthoCarolina Hip and Knee Center
        Charlotte, N.C.
    • Disclosures: Springer reports he is a consultant for Stryker Orthopedics and ConvaTec and is on the speakers bureau for CeramTec.