The Direct Anterior Approach and Modern Implant Longevity

Beyond computer navigation, robotics and AI, there has also been advancement in surgical approach. Older approaches like the posterior and direct lateral approach cut through muscle to enter the hip. The direct anterior approach (also called direct superior approach) avoids any muscle cut or nerve violation, with very minimal blood loss and a minimally invasive incision - patients can often go home after one day, or even as daycare.

In our setup, infection risk is under 0.3%. The two main factors are patient factors (immunocompromise, uncontrolled diabetes, hepatitis B, HIV or other viral disease) and surgeon/facility factors (poor surgical technique, poor OT culture, inadequate medication availability, or poor post-operative care).

There is a gut-joint axis theory: poor absorption of micronutrients, from conditions like coeliac disease, gluten allergy, Crohn's disease, ulcerative colitis or chronic acid-peptic disease, is linked to an increased chance of arthritis, whether autoimmune or degenerative. Post-operatively, any surgery causes a drop in general immunity for 12 to 20 weeks, since the patient is in a hyper-catabolic state, so we need to give a good protein diet (milk and milk products, protein powder, vegetarian protein) and increase total calories so the patient regains immunity as soon as possible.

There are two types of surgery: arthroscopic and open. For most patients without too many dislocations, arthroscopic Bankart repair plus a Remplissage procedure is the gold standard. For patients with more than 10 dislocations, open surgery is usually better. Bone defects on the socket side get bony augmentation; larger defects on the humeral head side may need grafting, or the tissue can be managed by moving the teres minor muscle into the defect - the traditionally open Latarjet procedure for this is now increasingly done arthroscopically.

There is no strict age criterion. Implant durability was initially only around 10 years; we are now in the third generation of implants with a longevity of almost 30 years. Hip replacement can be done from age 18 once bone growth is complete, with no upper limit based on physiological rather than chronological age - we have done hip replacement at age 104. Younger patients, even under 20, may need replacement for traumatic arthritis, sickle cell disease or haemophilic arthropathy.

An approach that avoids cutting muscle or disturbing nerves, resulting in minimal blood loss, a smaller incision, and often same-day or next-day discharge.

No strict limit - implants now last 30+ years, hip replacement is done from age 18 with no upper age cap (performed even at age 104), based on physiological rather than chronological age.