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Transitioning the total hip arthroplasty technique from posterior approach in lateral position to direct anterior approach in supine position—risk factors for acetabular malpositioning and the learning curve

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Cup positioning is important for optimum hip stability, avoiding component impingement and decreasing both bearing surface wear and revision rate. Transitioning from posterior approach in a lateral position to direct anterior approach (DAA) in a supine presents unique challenges for surgeons. The aim of this study was to examine the learning curve when using standard instrumentation that was not specific to DAA.


A consecutive retrospective series of 537 total hip arthroplasty by DAA from May 2013 to December 2017. Cup positioning was analysed on radiographs and classified whether inside or outside two safe zones (inclination 30–50° and anteversion 10–30°). The demographic data (age, BMI, gender, neck shaft angle (NSA)), surgeon’s dominant side and experience were assessed as risk factors.


Eighty per cent of cups (n = 426) were in the combined safe zones. Eighty-eight per cent (n = 470) were in appropriate anteversion and 87% (n = 463) abduction. Two factors that were significant were identified: Cups of left hips operated by right-handed surgeons were more anteverted (OR = 4.06) and more vertical (OR = 2.23); females had a higher anteversion of the cup (OR = 2.42). Obesity, age and NSA were not risk factors for cup malposition. There was a spike of cups too horizontal at the beginning of the experience (OR = 3.86), and no learning curve was observed in the other orientations.


With our DAA technique using standard instrumentation, there were no risk factors linked to the patient identified for cup malposition. DAA-specific instrumentation is not required to achieve optimum positioning of the cup. Surgeon has to be aware of an excess of abduction at the beginning of his experience and an excess of anteversion and adduction when performing THA on the opposite side of his dominant hand.

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Authors and Affiliations



Constant Foissey: study design, data collection, statistical analysis, literature review and manuscript writing

Cécile Batailler: study design, manuscript editing

Cam Fary: literature review, manuscript editing

Francesco Luceri: data collection, literature review

Elvire Servien: study design, manuscript editing.

Sébastien Lustig: study design, supervision, literature review and manuscript editing.

All authors read and approved the final manuscript

Corresponding author

Correspondence to Constant Foissey.

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Conflict of interest

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. CoFo, CB and CaFa declare that they have no conflict of interest. SL: consultant for Stryker; institutional research support from Corin and Amplitude. ES: institutional research support from Corin.

Ethics approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The Advisory Committee on Research Information Processing in the Field of Health (CCTIRS) approved this study on June 4, 2015 under number 15-430. For this type of study, formal consent is not required.

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Level of evidence: IV retrospective, consecutive case series

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Foissey, C., Batailler, C., Fary, C. et al. Transitioning the total hip arthroplasty technique from posterior approach in lateral position to direct anterior approach in supine position—risk factors for acetabular malpositioning and the learning curve. International Orthopaedics (SICOT) 44, 1669–1676 (2020).

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