title: Direct Anterior Approach: Risk Factor for Early Femoral Failure of Cementless Total Hip Arthroplasty: A Multicenter Study.
abstract: BACKGROUND
  The direct anterior approach for total hip arthroplasty (THA) is marketed with claims of superiority over other approaches. Femoral exposure can be technically challenging and potentially lead to early failure. We examined whether surgical approach is associated with early THA failure.
  
  
  METHODS
  A retrospective review of 478 consecutive early revision THAs performed within 5 years after the primary THAs at 3 academic centers from 2011 through 2014 was carried out. Exclusion criteria resulted in a final analysis sample of 342 early-failure THAs. The surgical approach of the primary operation that was revised, the time to the revision, and the etiology of the failure leading to the revision were documented.
  
  
  RESULTS
  Analysis of the revisions due to early femoral failure showed them to be more common in patients who had undergone the direct anterior approach (57/112; 50.9%) than in those treated with the direct lateral (39/112; 34.8%) or the posterior (16/112; 14.3%) approach (p = 0.001). In multivariate regression analysis controlling for age, sex, laterality, Dorr bone type, body mass index (BMI) at revision, bilateral procedure (yes/no), and femoral stem type, the direct anterior approach remained a significant predictor of early femoral failure (p = 0.007). The majority of early revisions due to instability were associated with the posterior (19/40; 47.5%) or direct anterior (15/40; 37.5%) approach (p = 0.001 for the comparison with the direct lateral approach [6/40; 15.0%]).
  
  
  CONCLUSIONS
  Despite claims of earlier recovery and improved outcomes with the direct anterior approach for THA, our findings indicate that that approach may confer a greater risk of early femoral failure and, along with the posterior approach, confer a greater risk of early instability compared with the direct lateral approach.
  
  
  METHODS
  Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: 1Department of Orthopaedic Surgery, Indiana University School of Medicine, Fishers, Indiana 2School of Medicine, Indiana University-Purdue University at Indianapolis, Indianapolis, Indiana 3The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania 4OrthoCarolina Hip and Knee Center, Charlotte, North Carolina.
authors.forename: R Michael
authors.initials: RM
authors.lastname: Meneghini
authors.forename: Addison S
authors.initials: AS
authors.lastname: Elston
authors.forename: Antonia F
authors.initials: AF
authors.lastname: Chen
authors.forename: Michael M
authors.initials: MM
authors.lastname: Kheir
authors.forename: Thomas K
authors.initials: TK
authors.lastname: Fehring
authors.forename: Bryan D
authors.initials: BD
authors.lastname: Springer
mesh_terms: D000077:Acetabulum / Q000293:injuries; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects / Q000379:methods*; D001843:Bone Cements; D005260:Female; D005264:Femoral Fractures / Q000209:etiology / Q000601:surgery; D050723:Fractures, Bone / Q000209:etiology / Q000601:surgery; D006622:Hip Prosthesis; D006801:Humans; D008297:Male; D008875:Middle Aged; D057068:Periprosthetic Fractures / Q000209:etiology; D011183:Postoperative Complications / Q000209:etiology; D011475:Prosthesis Failure / Q000209:etiology*; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012307:Risk Factors
chemical_list: D001843:Bone Cements