Clinical Orthopaedics and Related Research®

, Volume 473, Issue 2, pp 623–631 | Cite as

Direct Anterior versus Miniposterior THA With the Same Advanced Perioperative Protocols: Surprising Early Clinical Results

  • Kirsten L. Poehling-MonaghanEmail author
  • Atul F. Kamath
  • Michael J. Taunton
  • Mark W. Pagnano
Symposium: 2014 Hip Society Proceedings



Although some surgeons strongly advocate for one approach over the other, there are few data directly comparing the direct anterior approach with a miniposterior approach for total hip arthroplasty (THA).


Using the same advanced pain and rapid rehabilitation protocols for both groups, we compared the direct anterior and miniposterior approaches with respect to (1) return to activities of daily living at 2 days, 2 weeks, or 2 months; (2) risk of intraoperative or early postoperative complications; and (3) component position.


Over a 1-year period we identified all consecutive, primary direct anterior and miniposterior THAs performed by two surgeons at our institution, totaling 242 patients. Of those, 20 did not meet inclusion criteria as a result of prior trauma or surgery about the hip. A total of 222 patients, 126 direct anterior and 96 miniposterior, were retrospectively evaluated. All cases were done by one of two surgeons, one of whom performs THA exclusively through the direct anterior approach and the other who only uses the miniposterior approach. Groups did not differ demographically with mean ± SD age 64 ± 12 years, mean body mass index 30 ± 5.7 kg/m2, and 50% female. The same rapid rehabilitation protocols were used with no postoperative hip positioning precautions.


No differences were seen between the two groups in mean length of stay (2.2 days; range, 1–9 days), operative or in-hospital complications, intravenous breakthrough analgesia, stairs, maximum feet walked in-hospital, or percent discharged to home (80% [177 of 222]; all p > 0.2). The direct anterior patients had longer mean operative times (114 minutes; range, 60–251 minutes) than the miniposterior patients (mean, 60 minutes; range, 41–113 minutes; p < 0.001). The direct anterior group had a higher maximum visual analog scale pain score (5.3 direct anterior; ± 2, versus 3.8 MP; ± 2; p < 0.0001). At 2 weeks, more direct anterior patients required gait aids (92% [116 of 126]) than miniposterior (68% [62 of 96]; p < 0.0001). At 8 weeks, direct anterior patients had higher mean Harris hip scores (95 versus 89) but a lower return to work and driving with no difference in their use of gait aids, narcotics, activities of daily living, or walking 0.5 mile. More wound problems occurred in the miniposterior group (p < 0.01). With the numbers available, component alignment was not different between the study groups (p > 0.05 for all comparisons).


There was no systematic advantage of direct anterior THA versus miniposterior THA. Contrary to conventional belief and somewhat surprising were the fewer minor wound problems in the direct anterior group and the higher proportion of patients free of gait aids at 2 weeks and back to driving and working at 8 weeks in the miniposterior group. Factors other than surgical approach, perhaps including attentive pain management, patient selection, surgical volume and experience, careful preoperative templating, and rapid rehabilitation protocols, may be more important in terms of influencing early recovery after THA.

Level of Evidence

Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.


Visual Analog Scale Pain Score Early Postoperative Complication Direct Anterior Approach Midlevel Provider Advanced Pain 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Barrett WP, Turner SE, Leopold JP. Prospective randomized study of direct anterior vs postero-lateral approach for total hip arthroplasty. J Arthroplasty. 2013;28:1634–1638.PubMedCrossRefGoogle Scholar
  2. 2.
    Berger RA. The technique of minimally invasive total hip arthroplasty using the two-incision approach. Instr Course Lect. 2004;53:149–155.PubMedGoogle Scholar
  3. 3.
    Berger RL, Celli BR, Meneghetti AL, Bagley PH, Wright CD, Ingenito EP, Gray A, Snider GL. Limitations of randomized clinical trials for evaluating emerging operations: the case of lung volume reduction surgery. Ann Thorac Surg. 2001;72:649–657.PubMedCrossRefGoogle Scholar
  4. 4.
    Bertin KC, Rottinger H. Anterolateral mini-incision hip replacement surgery: a modified Watson-Jones approach. Clin Orthop Relat Res. 2004;429:248–255.PubMedCrossRefGoogle Scholar
  5. 5.
    Browne JA, Pagnano MW. Surgical technique: a simple soft-tissue-only repair of the capsule and external rotators in posterior-approach THA. Clin Orthop Relat Res. 2012;470:511–515.PubMedCentralPubMedCrossRefGoogle Scholar
  6. 6.
    Chimento, GF, Pavone V, Sharrock N, Kahn B, Cahill J, Sculco TP. Minimally invasive total hip arthroplasty: a prospective randomized study. J Arthroplasty. 2005;20:139–144.PubMedCrossRefGoogle Scholar
  7. 7.
    Dorr LD, Maheshwari AV, Long WT, Wan Z, Sirianni LE. Early pain relief and function after posterior minimally invasive and conventional total hip arthroplasty: a prospective, randomized, blinded study. J Bone Joint Surg Am. 2007;89:1153–1160.PubMedGoogle Scholar
  8. 8.
    Downing ND, Clark DI, Hutchinson JW, Colclough K, Howard PW. Hip abductor strength following total hip arthroplasty: a prospective comparison of the posterior and lateral approach in 100 patients. Acta Orthop Scand. 2001;72:215–220.PubMedCrossRefGoogle Scholar
  9. 9.
    Gore DR, Murray MP, Sepic SB, Gardner GM. Anterolateral compared to posterior approach in total hip arthroplasty: differences in component positioning, hip strength, and hip motion. Clin Orthop Relat Res. 1982;165:180–187.PubMedGoogle Scholar
  10. 10.
    Howell JR, Masri BA, Duncan CP. Minimally invasive versus standard incision anterolateral hip replacement: a comparative study. Orthop Clin North Am. 2004;35:153–162.PubMedCrossRefGoogle Scholar
  11. 11.
    Inaba Y, Wan Z, Sirianni L, Boutary M. Operative and patient care techniques for posterior mini incision total hip arthroplasty. Clin Orthop Relat Res. 2005;441:104–114.PubMedCrossRefGoogle Scholar
  12. 12.
    Ito Y, Matsushita I, Watanabe H, Kimura T. Anatomic mapping of short external rotators shows the limit of their preservation during total hip arthroplasty. Clin Orthop Relat Res. 2012;470:1690–1695.PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Jewett BA, Collis DK. High complication rate with anterior total hip arthroplasties on a fracture table. Clin Orthop Relat Res. 2011;469:503–507.PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Krych AJ, Pagnano MW, Coleman Wood K, Meneghini RM, Kaufman K. No strength or gait benefit of two-incision THA: a brief followup at 1 year. Clin Orthop Relat Res. 2011;469:1110–1118.PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Maheshwari AV, Blum YC, Shekhar L, Ranawat AS, Ranawat CS. Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center. Clin Orthop Relat Res. 2009;467:1418–1423.PubMedCentralPubMedCrossRefGoogle Scholar
  16. 16.
    Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res. 2005;441:115–124.PubMedCrossRefGoogle Scholar
  17. 17.
    Mayr E, Nogler M, Benedetti MG, Kessler O, Reinthaler A, Krismer M, Leardini A. A prospective randomized assessment of earlier functional recovery in THA patients treated by minimally invasive direct anterior approach: a gait analysis study. Clin Biomech (Bristol, Avon). 2009;24:812–818.PubMedCrossRefGoogle Scholar
  18. 18.
    Meneghini RM, Pagnano MW, Trousdale RT, Hozack WJ. Muscle damage during MIS total hip arthroplasty: Smith-Peterson versus posterior approach. Clin Orthop Relat Res. 2006;453:293–298.PubMedCrossRefGoogle Scholar
  19. 19.
    Meneghini RM, Smits SA. Early discharge and recovery with three minimally invasive total hip arthroplasty approaches: a preliminary study. Clin Orthop Relat Res. 2009;467:1431–1437.PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    Nakata K, Nishikawa M, Yamamoto K, Hirota S, Yoshikawa H. A clinical comparative study of the direct anterior with mini-posterior approach: two consecutive series. J Arthroplasty. 2009;24:698–704.PubMedCrossRefGoogle Scholar
  21. 21.
    O’Brien DA, Rorabeck CH. The mini-incision direct lateral approach in primary total hip arthroplasty. Clin Orthop Relat Res. 2005;441:99–103.PubMedCrossRefGoogle Scholar
  22. 22.
    Ogonda L, Wilson R, Archbold P, Lawlor M, Humphreys P, O’Brien S, Beverland D. A minimal-incision technique in total hip arthroplasty does not improve early postoperative outcomes: a prospective, randomized, controlled trial. J Bone Joint Surg Am. 2005;87:701–710.PubMedCrossRefGoogle Scholar
  23. 23.
    Pagnano MW, Trousdale RT, Meneghini RM, Hanssen AD. Slower recovery after two-incision than mini-posterior-incision total hip arthroplasty: a randomized clinical trial. J Bone Joint Surg Am. 2008;90:1000–1006.PubMedCrossRefGoogle Scholar
  24. 24.
    Restrepo C, Parvizi J, Pour AE, Hozack WJ. Prospective randomized study of two surgical approaches for total hip arthroplasty. J Arthroplasty. 2010;25:671–679.PubMedCrossRefGoogle Scholar
  25. 25.
    Sculco TP. Minimally invasive total hip arthroplasty: in the affirmative. J Arthroplasty. 2004;19(Suppl 1):78–80.PubMedCrossRefGoogle Scholar
  26. 26.
    Siguier T, Siguier M, Brumpt B. Mini-incision anterior approach does not increase dislocation rate: a study of 1037 total hip replacements. Clin Orthop Relat Res. 2004;426:164–173.PubMedCrossRefGoogle Scholar
  27. 27.
    Spaans AJ, van den Hout JA, Bolder SB. High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach. Acta Orthop. 2012;83:342–346.PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Tiberi JV, Pulos N, Kertzner M, Schmalzried TP. A more reliable method to assess acetabular component position. Clin Orthop Relat Res. 2012;470:471–476.PubMedCentralPubMedCrossRefGoogle Scholar
  29. 29.
    Vail TP, Callaghan JJ. Minimal incision total hip arthroplasty. J Am Acad Orthop Surg. 2007;15:707–715.PubMedGoogle Scholar
  30. 30.
    Watts CD, Pagnano MW. Minimising blood loss and transfusion in contemporary hip and knee arthroplasty. J Bone Joint Surg Br. 2012;94(Suppl A):8–10.PubMedCrossRefGoogle Scholar
  31. 31.
    Woolson ST, Mow CS, Syquia JF, Lannin JV, Schurman DJ. Comparison of primary total hip replacements performed with a standard incision or a mini-incision. J Bone Joint Surg Am. 2004;86:1353–1358.PubMedGoogle Scholar
  32. 32.
    Wright JM, Crockett HC, Delgado S, Lyman S, Madsen M, Sculco TP. Mini-incision for total hip arthroplasty: a prospective, controlled investigation with 5-year follow-up evaluation. J Arthroplasty. 2004;19:538–545.PubMedCrossRefGoogle Scholar
  33. 33.
    Wylde V, Maclean A, Blom AW. Post-operative radiographic factors and patient-reported outcome after total hip replacement. Hip Int. 2012;22:153–159.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2014

Authors and Affiliations

  • Kirsten L. Poehling-Monaghan
    • 1
    Email author
  • Atul F. Kamath
    • 1
  • Michael J. Taunton
    • 1
  • Mark W. Pagnano
    • 1
  1. 1.Department of Orthopedic SurgeryMayo ClinicRochesterUSA

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