A retrospective cohort was performed to compare systemic and local in-hospital complications associated with a direct anterior approach (DAA) vs. posterior approach total hip arthroplasty (THA) for surgeons who are transitioning from posterior to DAA – i.e. during the learning curve when complications have been shown to be highest. The posterior approach is the most commonly used approach for THA in the US, however in recent years the DAA has been gaining popularity as a true internevrous and intermuscular approach because of its potential for less soft tissue insult, faster functional recovery, and reduced dislocation. Concerns with the DAA include increased operating time, greater blood loss, and a technical learning curve with a difficult exposure accompanied by potential complications such as femoral fracture, femoral loosening and wound healing issues. Two groups of patients undergoing primary unilateral DAA (n=289) vs posterior (n=4249) based on the operating surgeon who used a single approach in a non-selective manner.

• The primary outcomes were in-hospital complications, identified using ICD-9-CM codes classified as local, minor systemic or major systemic
• The secondary outcome was the need for revision surgeries which was captured after a 4 year follow up period
• The DAA group demonstrated shorter length of hospital stay, procedure time, lower blood transfusion rate and increased discharge to home rate
• Local and major systemic in-hospital complications were rare and the rate was comparable between the two groups. The minor systemic complication rate was significantly greater for the posterior group (10.9% vs 6.2% DAA)
• Revision rate was significantly greater for the posterior group (2.7% posterior vs 0.7% DAA). The incidence of revision for dislocation was 1.5% for the posterior approach vs 0.4% for the DAA

In a large volume arthroplasty center with similar demographics, health status, and perioperative protocols, there was a higher rate of minor systemic in-hospital morbidities and overall revisions after THA by the posterior approach in comparison with the direct anterior approach.

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