Orthopaedic trauma surgeons and direct anterior total hip arthroplasty: evaluation of learning curve at a level I academic institution

  • Philip J. York
  • Stephanie L. Logterman
  • David J. Hak
  • Andreas Mavrogenis
  • Cyril MauffreyEmail author
Original Article • HIP - TRAUMA



Interest in the direct anterior approach for total hip arthroplasty has increased over recent years; however, the potential for substantial complications exists, especially during the surgeon’s learning curve. We evaluated the change in various metrics to help identify a single surgeon’s learning curve. Additionally, we examined whether the learning curve was different for primarily arthroplasty versus trauma-trained surgeons.


We reported outcomes from the first 50 total hip arthroplasties performed through a direct anterior approach by a trauma fellowship-trained orthopaedic surgeon. Intraoperative and post-operative clinical outcomes were evaluated, including length of procedure, estimated blood loss, length of hospitalization, disposition to home versus care facility, need for blood transfusion, and complications. Previous reported learning curve outcomes were analysed with a comparison between those who are primarily arthroplasty specialists versus those who include hip arthroplasty as only a portion of their practice.


A significant difference in surgical time from 135 to 113 min was observed between the first 25 cases and the last 25. Estimated blood loss (EBL) and lateral femoral cutaneous nerve injury rates decreased but not to a significant degree. Among reported learning curves, surgical time was significantly lower among fellowship-trained arthroplasty specialists when compared with other surgeons.


Our data support that surgeons who perform primarily joint arthroplasty will likely have a decreased surgical time, but similar EBL compared to those who include arthroplasty as only a portion of their practice, however, a number of confounding variables do exist, and additional investigation is warranted.


Direct anterior approach Learning curve Total hip arthroplasty 


Compliance and ethical standards

Conflict of interest

The authors declare that they have no conflict of interest in relation to this manuscript.

Ethical approval

IRB ethical approval was obtained prior to the start of this study.


There was no funding received for this study.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Berend K, Lombardi AJ, Seng B, Al E (2009) Enhanced early outcomes with the anterior supine intermuscular approach in primary total hip arthroplasty. J Bone Jt Surg Am 91:107–120CrossRefGoogle Scholar
  2. 2.
    Paillard P (2007) Hip replacement by a minimal anterior approach. Int Orthop 31:13–15CrossRefPubMedCentralGoogle Scholar
  3. 3.
    Repantis T, Bouras T, Korovessis P (2015) Comparison of minimally invasive approach versus conventional anterolateral approach for total hip arthroplasty: a randomized controlled trial. Eur J Orthop Surg Traumatol Orthop Traumatol 25:111–116. doi: 10.1007/s00590-014-1428-x CrossRefGoogle Scholar
  4. 4.
    York P, Smarck C, Judet T (2016) Total hip arthroplasty via the anterior approach: tips and tricks for primary and revision surgery. Int Orthop. doi: 10.1007/s00264-016-3125-3 PubMedGoogle Scholar
  5. 5.
    Pala E, Trono M, Bitonti A, Lucidi G (2016) Hip hemiarthroplasty for femur neck fractures: minimally invasive direct anterior approach versus postero-lateral approach. Eur J Orthop Surg Traumatol 26:423–427. doi: 10.1007/s00590-016-1767-x CrossRefPubMedGoogle Scholar
  6. 6.
    Homma Y, Baba T, Kobayashi H et al (2016) Benefit and risk in short term after total hip arthroplasty by direct anterior approach combined with dual mobility cup. Eur J Orthop Surg Traumatol 26:619–624. doi: 10.1007/s00590-016-1808-5 CrossRefPubMedGoogle Scholar
  7. 7.
    Jewett B, Collis D (2007) High complication rate with anterior total hip arthroplasties on a fracture table. Clin Orthop Relat Res 469:503–507CrossRefGoogle Scholar
  8. 8.
    Pilot P, Kerens B, Draijer W, Al E (2006) Is minimally invasive surgery less invasive in total hip replacement? A pilot study. Injury 37S:S17–S23CrossRefGoogle Scholar
  9. 9.
    Homma Y, Baba T, Ochi H et al (2016) Greater trochanter chip fractures in the direct anterior approach for total hip arthroplasty. Eur J Orthop Surg Traumatol 26:605–611. doi: 10.1007/s00590-016-1798-3 CrossRefPubMedGoogle Scholar
  10. 10.
    Alecci V, Valente M, Crucil M, Al E (2011) Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: perioperative findings. J Orthop Traumatol 12:123–129CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    De Geest T, Vansintjan P, De Loore G (2013) Direct anterior total hip arthroplasty: complications and early outcome in a series of 300 cases. Acta Orthop 79:166–173Google Scholar
  12. 12.
    Post Z, Orozco F, Diaz-Ledezma C, Al E (2014) Direct anterior approach for total hip arthroplasty: indications, technique, and results. J Am Acad Orthop Surg 22:595–603CrossRefPubMedGoogle Scholar
  13. 13.
    Spaans A, van den Hout J, Bolder S (2012) High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach. Acta Orthop 83:342–346CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Woolson S, Pouliot M, Huddleston J (2009) Primary total hip arthroplasty using an anterior approach and a fracture table: short-term results from a community hospital. J Arthroplast 24:999–1005CrossRefGoogle Scholar
  15. 15.
    American Academy of Orthopaedic Surgeons (2004) Orthopaedic practice in the US. 2005–2006. Final reportGoogle Scholar
  16. 16.
    Seng B, Berend K, Ajluni A, Al E (2009) Anterior-supine minimally invasive total hip arthroplasty: defining the learning curve. Orthop Clin North Am 40:343–350CrossRefPubMedGoogle Scholar
  17. 17.
    De Geest T, Fennema P, Lenaerts G, Al E (2015) Adverse effects associated with the direct anterior approach for total hip arthroplasty: a Bayesian meta-analysis. Arch Orthop Trauma Surg 135:1183–1192. doi: 10.1007/s00402-015-2258-y CrossRefPubMedGoogle Scholar
  18. 18.
    Alexandrov T, Ahlmann E, Menendez L (2014) Early clinical and radiographic results of minimally invasive anterior approach hip arthroplasty. Adv Orthop. doi: 10.1155/2014/954208 PubMedPubMedCentralGoogle Scholar
  19. 19.
    Yi C, Agudelo J, Dayton M, Al E (2013) Early complications of anterior supine intermuscular total hip arthroplasty. Orthopedics 36:e276–e281CrossRefPubMedGoogle Scholar
  20. 20.
    Bhargava T, Goytia R, Jones L, Al E (2010) Lateral femoral cutaneous nerve impairment after direct anterior approach for total hip arthroplasty. Orthopedics 33:472PubMedGoogle Scholar
  21. 21.
    D’Arrigo C, Speranza A, Monaco E, Al E (2009) Learning curve in tissue sparing total hip replacement: comparison between different approaches. J Orthop Trauma 10:47–54CrossRefGoogle Scholar
  22. 22.
    Oinuma K, Eingartner C, Saito Y, Al E (2007) Total hip arthroplasty by a minimally invasive, direct anterior approach. Oper Orthop Traumatol 19:310–326CrossRefPubMedGoogle Scholar
  23. 23.
    Zawadsky M, Paulus M, Murray P, Al E (2013) Early outcome comparison between the direct anterior approach and the mini-incision posterior approach for primary total hip arthroplasty: 150 consecutive cases. J Arthroplast 29:1256–1260CrossRefGoogle Scholar

Copyright information

© Springer-Verlag France 2017

Authors and Affiliations

  1. 1.University of ColoradoAuroraUSA
  2. 2.Denver Health Medical CenterDenverUSA
  3. 3.First Department of OrthopaedicsAttikon University HospitalHaidari, AthensGreece

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