This presentation summarizes the latest evidence on surgical approaches for primary hip replacement in an PICO format.

1. Anterior vs Posterolateral
Surgical Approaches in
Primary Total Hip Arthroplasty
E.S. Veltman / R.W. Poolman
23 augustus 2016

2. Introduction
• THA very succesful procedure
• >90% patients satisfied
• Over 28.000 THA yearly in the Netherlands
• Most frequently used approaches posterolateral (62%),
straight lateral (20%) en anterior (12%)
• Optimal approach remains topic of discussion
• Most discussion concerning postoperative muscle strength

3. Comparing approaches
• Posterolateral
• Anterior

4. Anterior vs Posterior
Advantages
• Low dislocation risk
• Minimal muscle damage
• Less postoperative pain
• Swift rehabilitation
• Surgery in supine position
Disadvantages
• Long learning curve (100pt)
• Peroperative femur fractures
• More blood loss
• Longer duration of surgery
• Different approach for revision
Advantages
• Short learning curve (50pt)
• Proven excellent long term
outcome
• Little blood loss
Disadvantages
• More muscle damage
• Higher dislocation risk

5. PICO
• P: patients receiving THA
• I: anterior approach
• C: posterolateral approach
• O: outcome (surgery, function, patient satisfaction,
complications)

6. Search
• ("arthroplasty, replacement, hip"[MeSH Terms] OR
("arthroplasty"[All Fields] AND "replacement"[All
Fields] AND "hip"[All Fields]) OR "hip replacement
arthroplasty"[All Fields] OR ("total"[All Fields] AND
"hip"[All Fields] AND "arthroplasty"[All Fields]) OR
"total hip arthroplasty"[All Fields]) AND
((anterior[All Fields] AND approach[All Fields]) OR
(posterolateral[All Fields] AND approach[All
Fields]))

7. Results
• 598 studies
• Higgins et al: systematic review 2015 (2 RCT, 5
prospective comparative studies, 10 retrospective
comparative studies)
New in 2015/16:
• Malek et al
• Maratt et al
• Winther et al

8. Measured outcome HHS, VAS, SF36, walking distance

10. Anterior vs Posterior

11. • 448 patients undergoing unilateral primary THA
• 265 patients (age 71, 117 male) direct anterior
approach
• 183 patients (age 70, 86 male) posterior approach
• No difference in age, gender, ASA grade, BMI, the
side of the operation, pre-operative Oxford Hip
Score (OHS) and attendance at ‘Joint school’.

13. • 2147 DAA THA patients were matched with PA THA based
on age, gender, BMI and ASA using data from a state joint
replacement registry

15. In 60 patients leg press and abduction strength were
evaluated 2 weeks or less preoperatively, 2 and 8 days
postoperatively, and at 6-week and 3-month follow-up.

17. Discussion
• Learning curve anterior approach is longer
• Comparable risk of dislocation
• More peroperative blood loss and femoral fractures in
anterior approach
• Longer in-hospital stay with posterolateral approach (1
day, possibly due to placebo effect)
• Functional outcome (at mid- and longterm follow-up)
comparable
• Both approach are safe in experienced surgeons
• Placebo effect

18. References
• LROI anual report 2014
• Higgins BT, et al. Anterior vs. Posterior Approach for Total Hip Arthroplasty, a
Systematic Review and Meta-analysis. The Journal of Arthroplasty 30 (2015) 419–434
• Malek IA, et al. A comparison between the direct anterior and posterior approaches for
total hip arthroplasty. Bone Joint J 2016;98-B:754–60.
• Maratt JD, et al. No Difference in Dislocation Seen in Anterior Vs Posterior Approach
Total Hip Arthroplasty. The Journal of Arthroplasty. DOI 10.1016/j.arth.2016.02.071
• Winther SB, et al. Muscular strength after total hip arthroplasty. A prospective
comparison of 3 surgical approaches. Acta Orthopaedica 2016; 87 (1): 22–28
• De Anta-Díaz B, et al. No differences between direct anterior and lateral approach for
primary total hip arthroplasty related to muscle damage or functional outcome.
International Orthopaedics (SICOT). DOI 10.1007/s00264-015-3108-9