The direct anterior approach is a minimally invasive technique for total hip replacement that preserves muscles, reduces post-operative restrictions, and allows rapid recovery. Dr Liew is the first official Australian Efort Fellow of Dr Frederic Laude, the pioneer of this approach.
About the Direct Anterior Approach
The direct anterior approach for total hip replacements is fast becoming one of the more popular approaches for the insertion of a hip prosthesis. The approach was developed over 50 years ago and popularised in the early 1980s by French Surgeon Dr Frederic Laude, who trained under the renowned pelvic surgeon Dr Judet. It is a minimally invasive approach in its true sense — achieving the desired operation safely with a small incision and minimal muscle and soft tissue damage under the skin.
Whilst the DAA is not the most common approach in Adelaide, it has been the standard of care in France and Switzerland for over 25 years. Throughout this time it has been refined into a safe and effective procedure.
Potential Benefits of the Direct Anterior Approach
- Dislocation risk: As the approach does not require releasing posterior muscles, the dislocation profile differs from a posterior approach. After a DAA hip replacement, the rate of posterior dislocation is quite rare, and post-operative restrictions are minimal.
- No post-operative restrictions: Patients can sit in a normal chair, use a normal toilet, and get in and out of a car early in their recovery. No pillows are used between legs after surgery.
- Blood loss: The DAA encounters only one main vessel — the ascending branch of the lateral femoral circumflex artery, which is specifically tied off during surgery. As minimal muscles are cut, bleeding from muscle is minimised.
- Pain relief: Patients are given a nerve block combined with local anaesthetic infiltration. Most wake up with very little pain and require only tablet analgesics post-operatively.
- Truly inter-nervous and inter-muscular: Access to the hip is between muscles and the nerves that supply them, without cutting through any muscle to obtain access.
Potential Risks of the Direct Anterior Approach
- Anterior scar: Unlike posterior approach scars hidden on the back of the upper leg, there is a visible scar on the front of the leg. However, the wound length is generally shorter than other approaches.
- Lateral cutaneous nerve of the thigh: A purely sensory nerve, this can be affected in some patients resulting in altered sensation on the side of the thigh. This does not affect any muscle function, and in approximately 80% of cases the sensation returns by 3–4 weeks.
- Learning curve: The DAA is more technically demanding and requires dedicated training. Dr Liew has trained with Dr Laude, Dr Dora, and Dr Field in over 150 total hip replacements and has performed the approach exclusively for over 10 years.
The Arthroplasty Society Recommendation
The current arthroplasty society recommendation (2011) for hip approaches states:
- There are multiple ways to approach a hip joint — none are “new”
- Surgical approach has little influence on results
- There is no scientific evidence that endorses one surgical approach over the other
- Surgeons should tell patients which works best in their hands but should not claim an advantage over approaches used by other surgeons
Whilst Dr Liew performs the DAA for almost all total hip replacements, all patients are encouraged to seek a second opinion to decide what approach is best for them.
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