title: A comparison between the direct anterior and posterior approaches for total hip arthroplasty: the role of an 'Enhanced Recovery' pathway.
abstract: OBJECTIVE
  We assessed the difference in hospital based and early clinical outcomes between the direct anterior approach and the posterior approach in patients who undergo total hip arthroplasty (THA).
  
  
  METHODS
  The outcome was assessed in 448 (203 males, 245 females) consecutive patients undergoing unilateral primary THA after the implementation of an 'Enhanced Recovery' pathway. In all, 265 patients (mean age: 71 years (49 to 89); 117 males and 148 females) had surgery using the direct anterior approach (DAA) and 183 patients (mean age: 70 years (26 to 100); 86 males and 97 females) using a posterior approach. The groups were compared for age, gender, American Society of Anesthesiologists grade, body mass index, the side of the operation, pre-operative Oxford Hip Score (OHS) and attendance at 'Joint school'. Mean follow-up was 18.1 months (one to 50).
  
  
  RESULTS
  There was no significant difference in mean length of stay (p = 0.07), pain scores on the day of surgery, the first, second and third post-operative days (p = 0.36, 0.23, 0.25 and 0.59, respectively), the day of mobilisation (p = 0.12), the mean OHS at six and 24 months (p = 0.08, and 0.29, respectively), the incidence of infection (p = 1.0), dislocation (p = 1.0), re-operation (p = 0.21) or 28 days' re-admission (p = 0.06). Significantly more patients in the DAA group achieved a planned discharge target of three days post-operatively (68% vs 56%, p = 0.007). The rate of periprosthetic femoral fractures was significantly higher in the DAA group (p = 0.04).
  
  
  CONCLUSIONS
  We conclude that there is no difference in clinical outcomes between the DAA and the posterior approach in patients undergoing THA when an 'Enhanced Recovery' pathway is used. However, a significantly higher rate of periprosthetic femoral fractures remains a concern with the DAA, even in experienced hands.
  
  
  CONCLUSIONS
  Our results show that the DAA for THA is not superior to posterior approach when 'Enhanced Recovery' pathway is used. Cite this article: Bone Joint J 2016;98-B:754-60.
authors.affiliation: Wrexham Maelor Hospital, Croesnewydd Road Wrexham, LL13 7TD, UK.
authors.forename: I A
authors.initials: IA
authors.lastname: Malek
authors.affiliation: Wrexham Maelor Hospital, Croesnewydd Road Wrexham, LL13 7TD, UK.
authors.forename: G
authors.initials: G
authors.lastname: Royce
authors.affiliation: Wrexham Maelor Hospital, Croesnewydd Road Wrexham, LL13 7TD, UK.
authors.forename: S U
authors.initials: SU
authors.lastname: Bhatti
authors.affiliation: Wrexham Maelor Hospital, Croesnewydd Road Wrexham, LL13 7TD, UK.
authors.forename: J P
authors.initials: JP
authors.lastname: Whittaker
authors.affiliation: Wrexham Maelor Hospital, Croesnewydd Road Wrexham, LL13 7TD, UK.
authors.forename: S P
authors.initials: SP
authors.lastname: Phillips
authors.affiliation: Wrexham Maelor Hospital, Croesnewydd Road Wrexham, LL13 7TD, UK.
authors.forename: I R B
authors.initials: IR
authors.lastname: Wilson
authors.affiliation: Wrexham Maelor Hospital, Croesnewydd Road Wrexham, LL13 7TD, UK.
authors.forename: J R
authors.initials: JR
authors.lastname: Wootton
authors.affiliation: Wrexham Maelor Hospital, Croesnewydd Road Wrexham, LL13 7TD, UK.
authors.forename: I
authors.initials: I
authors.lastname: Starks
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019644:Arthroplasty, Replacement, Hip / Q000379:methods*; D019091:Critical Pathways; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D010359:Patient Readmission; D019990:Perioperative Care / Q000379:methods*; D057068:Periprosthetic Fractures / Q000453:epidemiology; D011183:Postoperative Complications / Q000453:epidemiology; D011300:Preoperative Care / Q000379:methods*; D012086:Reoperation; D012189:Retrospective Studies; D006113:United Kingdom / Q000453:epidemiology
keywords: Direct Anterior approach; ERAS; Enhanced Recovery; Outcome; Posterior approach; Total hip replacement