How the direct anterior approach changed the way I do hip replacements

Introduction

When I trained in orthopaedic surgery, the posterior approach to hip replacement was the standard. It was — and still is — an excellent technique. The vast majority of hip replacements performed in Australia use it. It works, it is reproducible, and it has decades of evidence behind it.

But it comes with one feature that has always sat uneasily with me: the posterior hip precautions. After a posterior approach hip replacement, patients are told not to bend the hip past 90 degrees, not to cross their legs, and not to rotate the foot inwards. These restrictions last six to twelve weeks. For a patient who has been struggling to put on their shoes for a year, being told they cannot cross their legs or bend forward after surgery adds a layer of complexity and anxiety to an already difficult recovery. I kept thinking: what if you did not cut the posterior capsule at all?

Finding the anterior approach

The direct anterior approach (DAA) enters the hip joint from the front, working between the muscle planes rather than cutting through them. Crucially, it leaves the posterior capsule — the main structure preventing dislocation from behind — completely intact. No posterior restrictions needed.

I was introduced to the DAA during my orthopaedic training, but it was during my fellowship in Perth in 2016 — where I also trained in robotic-assisted joint replacement — that I committed to learning it properly. The DAA has a steeper learning curve than the posterior approach. The anatomy looks different from the front. I chose to invest that time. I believed then — and the evidence has since reinforced — that a well-performed DAA hip replacement gives patients a better early experience of recovery.

The most common thing patients say to me at their six-week review is that they had forgotten the operation had happened. That never gets old.

What it means for my patients

The practical difference for patients is significant. In the first weeks after a DAA hip replacement, patients can move freely. They can bend to tie their shoes, sit in a low chair, get in and out of a car without a careful set of rules to follow. There are no restrictions on how they sleep.

This matters more than it might sound. For older patients managing hip replacement recovery alongside other health conditions, simplifying the post-operative period reduces stress and allows physiotherapy to focus on building strength and confidence rather than managing precaution compliance.

I have found the recovery is also, on average, faster. Because no muscle is cut or detached — only gently separated along natural tissue planes — the hip recovers its normal muscle function more quickly. Most of my DAA patients are walking without a stick by two to three weeks. This is not universal — every patient’s recovery is their own — but it is the pattern I see consistently.

Combining DAA with robotic assistance

One development I find particularly valuable is the combination of the DAA with MAKO robotic planning and assistance. The anterior approach gives access to the hip in a way that is highly compatible with CT-based pre-operative planning. This combination — a muscle-sparing approach with robotic-assisted placement precision — represents, in my view, the current best practice for hip replacement in appropriately selected patients.

An honest caveat

The DAA is not universally appropriate. In patients with very complex anatomy, a high BMI, or prior surgery that has altered the normal tissue planes, other approaches may be technically safer. I make this assessment at consultation for every patient and will always recommend the approach that is right for that individual — not the approach I prefer in the abstract.

What I will say is that for patients who are suitable candidates, the DAA has genuinely changed the experience of hip replacement — for them and for me. The six-week review conversation is different. The questions are about what they can do now, not what they are still not allowed to do. That shift matters.