Achieving Swift Recovery: Enhanced Recovery (ERAS) Direct Anterior Approach Total Hip Replacement

_{Hip arthroplasty is a surgical procedure centred around a hip implant made of durable materials.}

Total hip replacement, also called total hip arthroplasty, is a procedure where orthopaedic surgeons replace a damaged or worn-out joint with an artificial joint. Usually, doctors would recommend patients who are suffering from degenerative diseases such as osteoarthritis and osteonecrosis to undergo this surgical procedure. The goal of total hip replacement is to alleviate pain, improve joint function, and enhance the quality of life of patients who have not found relief from non-surgical treatment methods such as painkillers or physical therapy.

Total hip replacement surgeries can be scary to some patients and it is completely normal to feel a mix of emotions about the procedure. However, the good news is that hip replacement surgeries are known for their high success rates and the direct anterior approach is recognised as the least invasive approach to total joint arthroplasty. 

What is Direct Anterior Approach (DAA) in Total Hip Replacement (THR)?

The Direct Anterior Approach (DAA) to Total Hip Replacement (THR) is a surgical technique used to replace a dysfunctional hip joint with an artificial implant. Unlike traditional hip replacement approaches that involve accessing the hip joint from the side (lateral) or back (posterior) of the body, the DAA involves accessing the hip joint from the front (anterior) of the body, avoiding major muscles and tendons.

This minimally invasive surgical technique reduces tissue damage, typically resulting in pain relief and faster recovery times compared to traditional approaches. Patients undergoing DAA THR often experience shorter hospital stays and quicker return to daily activities, improving their overall quality of life.

What is Enhanced Recovery After Surgery (ERAS) Direct Anterior Approach in Total Hip Replacement

At Alps Orthopaedic Centre, we utilise Enhanced Recovery After Surgery (ERAS) protocols to prioritise the wellbeing of our patients. ERAS is a holistic approach that aims to improve clinical outcomes and most importantly, to expedite the recovery process of patients. ERAS typically involves medical professionals to be involved in all three phases of a patient’s journey, mainly, before, during and after surgery.

Furthermore, the ERAS protocol complements the DAA THR approach by optimising preoperative preparation, intraoperative techniques, and postoperative care. This comprehensive approach includes personalised pain management strategies, early mobilisation, and nutritional support, all aimed at enhancing recovery outcomes. This approach not only improves patient outcomes but also contributes to a more efficient healthcare system by reducing hospital stays and enhancing overall patient satisfaction.

What to expect before the surgery?

Preoperative optimisation is key to a successful surgery and speedy recovery. Under the ERAS protocol, patients undergo thorough assessments and receive personalised care plans, including nutrition counselling and exercise regimes. These measures enhance overall health, reduce surgical risks, and pave the way for a smoother recovery.

During the preoperative stage, patients can expect comprehensive and proactive steps to optimise their physical and psychological well-being before the surgery. For instance, patients would:

• Receive information and knowledge of the surgical process. This helps to facilitate a smoother transition from pre to postoperative. 
• Restrict consumption of alcohol and smoking for at least 4 weeks.
• Avoid eating solid foods for at least 6 hours before the surgery. 

What to expect during the surgery?

The Direct Anterior Approach offers distinct advantages. By accessing the hip joint from the front, surgeons can preserve crucial muscles and tissues, leading to less trauma and postoperative pain. This minimally invasive approach also promotes faster healing and reduced scarring, contributing to improved cosmetic outcomes.

During the intraoperative stage, patients may experience:

• Skin preparation to prevent surgical site infections
• Local anaesthetics to ensure that patients feel minimal pain during the operation process
• Blood loss management tools such as tranexamic acid which helps to prevent or reduce excessive bleeding

What to expect after the surgery?

Light stretching is generally beneficial shortly after ERAS Direct Anterior Approach (DAA) surgery, but it's crucial to seek the guidance of your orthopaedic surgeon because every patient’s condition is unique.

Image by Vlada Karpovich on Pexels

After undergoing the ERAS Direct Anterior Approach (DAA) day surgery, your orthopaedic surgeon will recommend physiotherapy and wound care options to regain strength, flexibility, and stability in the operated hip and aid in a swift return to normal activity. Attending a structured rehabilitation programme supervised by healthcare professionals is recommended.

Postoperative care under the ERAS protocol focuses on early mobilisation. Patients are encouraged to engage in gentle exercises soon after surgery, walking with assistance, and physiotherapy interventions, promoting joint flexibility and muscle strength. 

Advanced pain management techniques, such as multimodal analgesia, help alleviate discomfort while minimising opioid use and its associated side effects. After the surgery, patients can expect a comprehensive plan to facilitate their recovery process, some of which would include:

• Physiotherapy sessions to restore movement and strength on the operated hip
• Information on activities to refrain from, such as lifting heavy objects or doing any form of intense physical activity
• Follow-up appointments with your orthopaedic surgeon to minimise post-surgery complications

How is Direct Anterior Approach in Total Hip Replacement Performed?

Compared to traditional hip replacement surgeries, the direct anterior approach is a minimally invasive surgical procedure where orthopaedic surgeons access the hip by making a small frontal incision up to 3-4 inches from the front of the thigh (anterior). This approach allows surgeons to navigate through the space between key thigh muscles such as the sartorius, rectus femoris and tensor fasciae latae, without the need to cut or detach these muscle tissues. It helps to minimise tissue trauma and facilitate a rapid and less painful recovery process for patients. 

What are the Benefits of the Direct Anterior Surgical Approach?

The Direct Anterior Approach has several benefits such as: 

• Earlier Postoperative Recovery
  
  

As this procedure does not require the removal or detachment of any muscle tissues, it significantly reduces the risk of muscle atrophy and strength loss, which are common concerns for patients undergoing surgery. This helps patients maintain a healthy baseline of muscle function post-surgery, which often translates to a reduced hospital stay and an expedited timeline for patients to resume their normal routines.

• Lower Hip Dislocation Rate Post-operation

With the preservation of soft tissue tension, the direct anterior approach promotes the preservation of the hip's soft tissue tensions, minimising undue stress on the joint. This ensures that the hip joint remains stable post-surgery which significantly lowers the risk of dislocation. 

• Accuracy in Prosthesis Placement
  

The intraoperative imaging used during the direct anterior approach process allows surgeons to evaluate a patient’s leg length, enabling them to place the hip prosthesis with precision. Precise placement is critical for patients as it influences their hip’s joint range of motion, implant longevity and, most importantly, reduces the likelihood of revision surgeries. 

What are the Risks of the Direct Anterior Surgical Approach?

While there are benefits with the direct anterior approach, as with any other surgery, it  still comes with risks, this approach has several risks such as:

1.  Nerve Injury

There is a small risk of damaging nerves at the surgical site or around it. This can come in the form of numbness around the thigh area.

2. Wound Complications and Infection

Although the direct anterior approach is minimally invasive, the small incision made still has a small risk of wound or deep infection. 

3. Intraoperative Fractures

When handled with inexperienced hands, there’s a possibility that fractures may occur during the surgery, which may lead to the extended duration of the surgery or even longer hospital stays. 

Rest assured, at Alps Orthopaedic Centre, our experienced orthopaedic surgeon, Dr Jerry Chen, will discuss these potential risks with you to help you make an informed decision.

When should you consider the Direct Anterior Approach?

If you are experiencing hip arthritis and chronic hip pain, it is recommended to consult with an orthopaedic surgeon to explore whether the ERAS Direct Anterior Approach Surgery is suitable for you.

Patients with hip arthritis and osteonecrosis are common candidates for hip replacement surgery. If you experience chronic pain in your hips and find that physical activities such as prolonged walking, working out, bending down to pick something up or climbing the stairs are painful, you may want to consult an orthopaedic surgeon.

Recognising the potential risks associated with this procedure underscores the importance of an ERAS approach and the necessity for specialised guidance from an orthopaedic surgeon throughout the preparation, the procedure, and recovery. In general, most complications can be effectively managed. Even if complications arise post-surgery, success can still usually be achieved if pain relief and improved function are attained in the long term.

Visit Alps Orthopaedic Centre

To determine a suitable treatment option for your knee pain, schedule an appointment with our experienced Consultant Orthopaedic Surgeon, Dr Jerry Chen, for a thorough assessment and treatment plan.

^{Why Alps Orthopaedic Centre?}

At Alps Orthopaedic Centre, we specialise in Enhanced Recovery After Surgery (ERAS). Performed as a Day Surgery, the ERAS Direct Anterior Approach in Total Hip Replacement (THR) technique as well as ERAS Total Knee Replacement (TKR), reduces the average hospitalisation stay, utilising techniques which enable the patient to suffer from less pain and recover faster. We are an Orthopaedic clinic in Singapore, which specialises in ERAS and do our utmost to enable patients to return to everyday activities as early as possible. 

Our Orthopaedic clinic provides specialised diagnosis and effective treatment of musculoskeletal problems, especially Day Surgery / Enhanced Recovery After Surgery (ERAS) For Hip and Knee Surgery, Sports Injuries and Trauma Fractures. If you are considering hip or knee surgery or minimally invasive treatments, book an appointment with our experienced Consultant Orthopaedic Surgeon, Dr Jerry Chen, for a thorough assessment and treatment plan. 

Our aim is to boost patient well-being, optimising every aspect of the surgical journey. By minimising the recovery period, patients are able to go back to activities that they love. The Alps team offers comprehensive financial counselling sessions to ensure our patients understand their options and make informed decisions regarding their treatment plans.

Consultant Orthopaedic Surgeon Dr Jerry Chen and his Team at Alps are committed to supporting you on your journey to understanding, managing, and thriving despite hip pains. Alps is part of the Beyond Medical Group, a collective of medical specialists that has also been ranked as one of Singapore’s Top 100 Fastest-Growing Companies for 2024. For more in-depth information, feel free to book a consultation with Dr Jerry to explore Alp’s comprehensive services and stay informed on the latest developments in hip care.

^{Dr Jerry Chen}

MBBS (S’pore), MRCSEd, MMed (Ortho), FRCSEd (Ortho)

Fellowship-trained Consultant Orthopaedic Surgeon & Medical Director

• ✅Before starting Alps Orthopaedic Centre, Dr Jerry Chen was a Consultant at Singapore General Hospital (SGH), where he accumulated over 13 years of experience in Orthopaedic Surgery. 
• ✅Dr Chen spearheaded the workgroup for Enhanced Recovery After Surgery (ERAS) for hip and knee replacement surgeries at SGH, where he successfully employed ERAS, benefiting more than 2,000 patients thus far.  
• ✅Having performed over 500 surgeries in a year, he has been instrumental in helping numerous patients recover from injuries and diseases and return to their active lifestyles.
• ✅His clinical interests include Enhanced Recovery After Surgery (ERAS) for Hip and Knee, Sports Injuries, Minimally Invasive Surgery and Robotic Surgery.

Alps Orthopaedic Centre Website: https://www.alpsortho.sg/

Dr Jerry Chen Profile: https://www.alpsortho.sg/about-dr-jerry-chen/

Appointment Line: +(65) 9088 4555

Email: info@alpsortho.sg

References:

Dall'Oca, C., Ceccato, A., Cresceri, M., Scaglia, M., Guglielmini, M., Pelizzari, G., Valentini, R., & Magnan, B. (2020). Facing complications of direct anterior approach in total hip arthroplasty during the learning curve. Acta bio-medica : Atenei Parmensis, 91(4-S), 103–109. https://doi.org/10.23750/abm.v91i4-S.9728

Galakatos G. R. (2018). Direct Anterior Total Hip Arthroplasty. Missouri medicine, 115(6), 537–541.

Mayr, E., Nogler, M., Benedetti, M. G., Kessler, O., Reinthaler, A., Krismer, M., & Leardini, A. (2009). A prospective randomized assessment of earlier functional recovery in THA patients treated by minimally invasive direct anterior approach: a gait analysis study. Clinical biomechanics (Bristol, Avon), 24(10), 812–818. https://doi.org/10.1016/j.clinbiomech.2009.07.010

Realyvasquez, J., Singh, V., Shah, A. K., Ortiz, D., 3rd, Robin, J. X., Brash, A., Kurapatti, M., Davidovitch, R. I., & Schwarzkopf, R. (2022). The direct anterior approach to the hip: a useful tool in experienced hands or just another approach?. Arthroplasty (London, England), 4(1), 1. https://doi.org/10.1186/s42836-021-00104-5

Riga, M., Altsitzioglou, P., Saranteas, T., & Mavrogenis, A. F. (2023). Enhanced recovery after surgery (ERAS) protocols for total joint replacement surgery. SICOT-J, 9, E1. https://doi.org/10.1051/sicotj/2023030

Zhou, Z., Li, Y., Peng, Y., Jiang, J., & Zuo, J. (2022). Clinical efficacy of direct anterior approach vs. other surgical approaches for total hip arthroplasty: A systematic review and meta-analysis based on RCTs. Frontiers in surgery, 9, 1022937. https://doi.org/10.3389/fsurg.2022.1022937