Direct Anterior Approach Total Hip Arthroplasty



Let’s Talk about DAA THA


Direct Anterior Approach (DAA) Total Hip Arthroplasty (THA) is a relatively new surgical technique that is touted to have earlier return to activity and better outcomes due to its tissue sparing approach (1). Surgeons tend to perform it on younger, more active patients but as the technique becomes more widely available, more and more people with a varied health history will be offered this approach.

Why is a DAA THA appealing? Simply put, muscle and tendon are not cut.

In traditional posterior and lateral approaches, the hip external rotator group and abductors are cut and subsequently repaired (2).­­ Strengthening of the cut muscles is delayed for 6-8 weeks post-surgery to allow them to heal and during that waiting period, much of their strength is lost. It takes 3-6 months of specific strengthening to regain lost strength. Both the hip external rotators and the abductors are strong muscle groups that are important for hip stability. Losing strength in this area can affect your ability to stand on one leg (balance) and walk up and down stairs.

Is an anterior approach better than a lateral or posterior approach? In a word, ‘no.’ An anterior approach is just different.


Studies comparing anterior and lateral approaches show that a DAA may be associated with earlier return to function, but long term function is no different (2). Muscle specific strengthening needs to happen after surgery, regardless of the approach. Balance exercises complement this strengthening and both types are replaced by foundational movement such as a squat, step up and lunge. Most people undergo a hip replacement because they’re experiencing extreme pain that is limiting their quality of life. All three approaches to hip replacement eliminate the arthritis and by doing so hopefully eliminate the pain.

How much physiotherapy is recommended after a DAA THA?


The amount of physiotherapy after a DAA is typically less than a lateral or posterior approach. Because muscles are not cut, there is less need for muscle specific exercises. Depending on how independent a person is with exercises, physiotherapy is typically recommended at a frequency of 1-2x per week for 8 weeks. After that point, most people are independent with their exercises and are able to see physiotherapy every 2-4 weeks for new exercises until their goals are achieved.

Many people consent to total joint replacement without having an understanding of the recovery period. Muscle healing can take 6-8 weeks, with strengthening taking another 3-6 months. If your goal is to walk up and down the stairs proficiently and to balance on one leg, you’ll likely feel fully recovered at the 3-6 month mark. Like anterior cruciate ligament reconstruction, physiotherapy is recommended until 9 or 12 months post-op if you wish to be more active and walk on unstable surfaces, hike or participate in sport.

What activity is safe after a THA?


Surgeon recommendation on participation in sport varies widely with some recommending against any impact (no jumping or running) and others accepting doubles tennis, gentle skiing and other light impact activities (3). Logically, the concern with impact heavy sport is that repeated impact might result in early wear of the prosthetic components leading to a revision total hip arthroplasty when one might not be needed (3). Current evidence suggests that in the short to medium term, amateur sporting activity may not cause a prosthetic hip to wear out before its time (4). Unfortunately, studies reporting beyond 10 year follow up are few and the long term effects of sport are relatively unknown (4).

Stephen Baker graduated from Western University with a Masters of Physical Therapy. He has a passion for helping people who have sustained a fracture or had surgery regain full function and return to their daily adventures. Book with Stephen today.

References:

1. Galakatos GR. Direct Anterior Total Hip Arthroplasty. Mo Med. 2018;115(6):537-541.

2. Petis S, Howard JL, Lanting BL, Vasarhelyi EM. Surgical approach in primary total hip arthroplasty: anatomy, technique and clinical outcomes. Can J Surg. 2015;58(2):128-139. doi:10.1503/cjs.007214

3. Meira EP, Zeni J Jr. Sports participation following total hip arthroplasty. Int J Sports Phys Ther. 2014;9(6):839-850.

4. Meek RMD, Treacy R, Manktelow A, Timperley JA, Haddad FS. Sport after total hip arthroplasty: undoubted progress but still some unknowns. Bone Joint J. 2020;102-B(6):661-663. doi:10.1302/0301-620X.102B6.BJJ-2020-0208