Teaching the direct anterior approach in Melbourne

A weekend in Melbourne

Over the weekend I was in Melbourne as faculty on a course teaching the direct anterior approach to hip replacement. Surgeons travelled in from Sydney, Melbourne, Adelaide and New Zealand for a day of classroom teaching and cadaveric surgery. I taught alongside Prof Ton Tran from Melbourne and Dr Jono De Hoog from Townsville. The course was run by Stryker.

I also spent a day filming a demonstration video with Stryker, working through the instrumentation used in anterior hip replacement in a cadaveric session. That video has not been released yet.

Patients never see this side of surgery. It happens on weekends, in laboratories, and it is rarely written about. That seemed like a reason to write about it.

What the direct anterior approach is

The direct anterior approach reaches the hip joint from the front of the body rather than from the side or the back. The surgeon works between the muscle planes rather than cutting through them, and the tissue at the back of the hip is left intact.

The practical result for most patients is that there are no posterior hip precautions after surgery. No rule about bending past ninety degrees, no rule about crossing your legs, no rule about how you sleep. I have written about what that means for recovery in how the direct anterior approach changed the way I do hip replacements.

It is my standard hip replacement. Every case is planned from a CT scan taken beforehand, which is used to work out the size and position of the implant for that individual hip. Where the hospital has the MAKO robotic system available, that plan is delivered robotically. Where it is not, the same plan is delivered using patient specific instruments manufactured from the same scan. Two technologies, the same objective.

Why the approach has to be taught properly

The direct anterior approach is harder to learn than the approaches most surgeons trained on. The anatomy looks different from the front and the exposure is less forgiving. A surgeon who has performed a thousand posterior hip replacements cannot simply turn the patient over and begin.

The published evidence is fairly blunt about this. A 2021 systematic review in International Orthopaedics pooled twenty-one studies covering 9,738 patients and found that operating times did not settle until roughly the hundredth case.¹ More importantly, the complication rate averaged 20.8 per cent in the early part of surgeons' experience and 7.6 per cent later on.

That difference belongs to the surgeon's learning, not to the operation itself. Which is the entire argument for structured teaching. A surgeon who learns the approach in a laboratory, with experienced faculty at the table and a cadaveric specimen rather than a patient in front of them, reaches competence sooner and with fewer people paying for the learning along the way. What that means for the person having the operation is covered in more detail in my guide to hip replacement recovery.

What a course like this involves

A good chunk of it is classroom work. Anatomy, patient selection, implant positioning, and a lot of time on what can go wrong and how you pick it up early. What I care most about teaching is meticulous technique. Respect the anatomy. Work with the tissue planes instead of forcing them. Take the time to expose the acetabulum and the femur properly. Performed with care, the approach delivers the exposure required to execute implant positioning accurately, which we know to be an essential component of hip replacement surgery.

Then into the lab, which is why everyone gets on a plane. Delegates do the approach themselves on anatomical specimens, faculty at the table with plenty of repetitions to help make it reproducible. Nothing substitutes for it. Ensuring familiarity with the anatomy and how the soft tissues behave is important for the success of the operation.

Plenty also happens away from the formal teaching. Over dinner, delegates raise questions they would not put to a full room. Faculty readily discuss the surgical challenges they have faced, and how they went on to get a good outcome for their patients.

Why this matters if you are the patient

You will never attend one of these courses, so it is fair to ask what it has to do with you.

Surgical technique is not fixed. The way I perform a hip replacement in 2026 is not identical to the way I performed one in 2018, and it should not be. Courses, cadaveric work and teaching other surgeons are the mechanisms by which technique gets refined and mistakes stop being repeated.

It is also entirely reasonable to ask your surgeon about their training and experience with the specific operation being proposed to you. How many do you perform? How did you learn it? Do you still teach or attend courses? These are fair questions, and any surgeon worth seeing will answer them without becoming defensive.

One honest caveat. The direct anterior approach is not the right answer for every hip. Complex anatomy, previous surgery and certain body shapes can make another approach the safer choice. The approach should be chosen for the patient in front of you, not chosen in advance and applied to everyone.

Common questions

How many hip replacements should my surgeon have performed?

There is no official minimum, and any single number would be misleading. What the evidence shows is that outcomes improve as a surgeon's experience with a particular approach grows. A 2021 systematic review found complication rates fell from 20.8 per cent in surgeons' early cases to 7.6 per cent later in their experience. It is reasonable to ask how many of your specific operation your surgeon performs each year, and reasonable to expect a straight answer.

What questions should I ask before hip replacement surgery?

Useful questions include which approach is recommended for you and why, how many of these operations your surgeon performs each year, how they trained in the technique, the risks in your particular case, and what recovery realistically looks like week by week. A surgeon comfortable with their practice will not mind any of these.

Is the direct anterior approach better than other approaches?

Not universally. The approach avoids posterior hip precautions and tends to give a quicker early recovery, but complex anatomy, previous surgery and certain body shapes can make another approach the safer choice. The right approach is the one that suits the individual hip.

Will my hip replacement be planned with a CT scan?

Every hip replacement Dr Mooney performs is planned from a CT scan taken beforehand, which is used to work out implant size and position for that individual hip. Where the hospital has the MAKO robotic system available, that plan is delivered robotically. Where it is not, the same plan is delivered using patient specific instruments made from the same scan.

Do surgeons practise on cadavers?

Yes. Cadaveric laboratories are a standard part of surgical training in Australia, both during training and later in a surgeon's career when learning a new technique. Specimens are donated for this purpose and treated with considerable respect. It is how a surgeon learns a new approach without a patient being part of the learning.