Revision risk by using the direct superior approach (DSA) for total hip arthroplasty compared with postero-lateral approach: early nationwide results from the Dutch Arthroplasty Register (LROI)




Arthroplasty, Direct superior approach, Dislocation, Hip, Surgical approach


Background and purpose: The direct superior approach (DSA) is a modification of the classic posterolateral approach (PLA) for total hip arthroplasty (THA), in which the iliotibial band and short external rotators are spared. The revision rate of the DSA has not been investigated previously using arthroplasty registry data. We examined the reasons and risk of revision of the DSA, compared with the direct anterior approach (DAA) and PLA.
Patients and methods: In this population-based cohort study we included 175,543 primary THAs performed between 2014 and 2020 (PLA, n = 117,576; DAA, n = 56,626; DSA, n = 1,341). Competing risk survival analysis and multivariable Cox proportional hazard analyses, adjusted for potential confounders, were performed.
Results: After 3 years, crude revision rates due to any reason were 2.1% (95% confidence interval [CI] 1.3–3.3) for DSA, and 2.9% (CI 2.8–3.0) for PLA. Crude dislocation revision rates were 0.3% (CI 0.1–0.8) for DSA, versus 1.0% (CI 0.9–1.0) for PLA. Dislocation revision rate for DSA did not differ from DAA (0.3% [CI 0.2–0.3]). Multivariable Cox regression analysis demonstrated no overall difference in revision rates for the DSA (HR 0.6 [CI 0.4–1.09) compared with the PLA. Lower risk of revision due to dislocation was found in patients operated on through the DSA (HR 0.3 [0.1–0.9]) compared with the PLA.
Conclusion: Early nationwide results suggest that the DSA for total hip arthroplasty seems to show a tendency towards a lower risk of revision for dislocation but no overall reduced revision risk compared with the PLA.


Download data is not yet available.


Zijlstra W P, De Hartog B, Van Steenbergen L N, Scheurs B W, Nelissen R G H H. Effect of femoral head size and surgical approach on risk of revision for dislocation after total hip arthroplasty. Acta Orthop 2017; 88(4): 395-401. doi: 10.1080/17453674.2017.1317515 DOI:

Dutch Arthroplasty Register (LROI). Annual report. LROI report, 2021. Numbers – LROI Report - Information on orthopaedic prosthesis procedures in the Netherlands ( Last accessed: March, 2022.

Charney M, Paxton E W, Stradiotto R, Lee J J, Hinman A D, et al. A comparison of risk of dislocation and cause-specific revision between direct anterior and posterior approach following elective cementless total hip arthroplasty. J Arthroplasty 2020; 35(6): 1651-7. doi: 10.1016/j.arth.2020.01.033. DOI:

Meermans G, Konan S, Das R, Volpin A, Haddad F S. The direct anterior approach in total hip arthroplasty: a systematic review of the literature. Bone Joint J 2017; 99-B(6): 732-40. doi: 10.1302/0301620X.99B6.38053. DOI:

Kuijpers M F L, Hannink G, Vehmeijer S B W, van Steenbergen L N, Schreurs B W. The risk of revision after total hip arthroplasty in young patients depends on surgical approach, femoral head size and bearing type; an analysis of 19,682 operations in the Dutch arthroplasty register. BMC Musculoskelet Disord 2019; 20(1): 385. doi: 10.1186/s12891-0192765-z. DOI:

Hoskins W, Bingham R, Lorimer M, de Steiger R N. Early rate of revision of total hip arthroplasty related to surgical approach. J Bone Joint Surg 2020; 102(21): 1874-82 doi: 10.2106/JBJS.19.01289 DOI:

Docter S, Philpot H T, Godkin L, Bryant D, Somerville L, et al. Comparison of intra and post-operative complication rates among surgical approaches in Total Hip Arthroplasty: a systematic review and meta-analysis. J Orthop 2020; (20): 310-25. doi: 10.1016/j.jor.2020.05.008 DOI:

Nam D, Meyer Z, Rames RD, Nunley R M, Barrack R L, et al. Is the direct superior, iliotibial band-sparing approach associated with decreased pain after total hip arthroplasty? J Arthroplasty 2017; 32(2): 453-7. doi: 10.1016/j.arth.2016.07.045. DOI:

Barrett A A, Ezzibdeh R M, Horst P K, Roger D J, Amanatullah D F. Direct superior approach to the hip for total hip arthroplasty. JBJS Essent Surg Tech 2019; 9(2):e17. doi: 10.2106/JBJS.ST.18.00078. DOI:

Kayani B, Konan S, Chandramohan R, Haddad F S. The direct superior approach in total hip arthroplasty. Br J Hosp Med 2019; 80(6): 320-4. doi: 10.12968/hmed.2019.80.6.320. DOI:

Duijnisveld B J, van den Hout J A A M, Wagenmakers R, Koenraadt K L M, Bolder S B T. No learning curve of the direct superior approach in total hip arthroplasty. Orthop Surg 2020; 12(3): 852-60. doi:10.1111/os.12689. DOI:

Korth M J S, Ezzibdeh R, Arora P, Amanatullah D F. Excellent clinical and radiographic outcomes with direct superior total hip arthroplasty with a minimum of two-year follow up. Surg Technol Int 2021; 37: 342-6.

Tsiridis E, Kenanidis E, Potoupnis M, Sayegh F E. Direct superior approach with standard instrumentation for total hip arthroplasty: safety and efficacy in a prospective 200-case series. Hip Int 2020; 30(5): 552-8. doi: 10.1177/1120700019843120. DOI:

Ezzibdeh R, Korth M J S, Arora P, Amanatullah D F. Case-controlled analysis of the direct superior and mini-posterior approach for total hip arthroplasty at a minimum of two years of follow up. Surg Technol Int 2021; 37: 353-9. DOI:

LeRoy T E, Hayden B L, Desmarais J, Menendez M E, Ward D. Early outcome comparison of the posterior approach and the superior approach for primary total hip arthroplasty. Arthroplast Today 2020; 6(3): 508-12. doi: 10.1016/j.artd.2020.05.005. DOI:

Kenanidis E, Paparoidamis G, Pegios VF, Anagnostis P, Potoupnis M, et al. Earlier functional recovery and discharge from hospital for THA patients operated on via direct superior compared to standard posterior approach: a retrospective frequency-matched case-control study. Hip Int 2022:11207000221086506. doi: 10.1177/11207000221086506. DOI:

Leonard H J, Ohly N E. Direct superior approach for total hip arthroplasty. Bone Joint J 2021;103-B(3):500-6. doi: 10.1302/0301620X.103B3.BJJ-2020-0916.R1. DOI:

Roger D J, Hill D. Minimally invasive total hip arthroplasty using a transpiriformis approach: a preliminary report. Clin Orthop Relat Res 2012; 470(8): 2227-34. doi: 10.1007/s11999-011-2225-z. DOI:

Ulivi M, Orlandini L, Vitale JA, Meroni V, Prandoni L, et al. Direct superior approach versus posterolateral approach in total hip arthroplasty: a randomized controlled trial on early outcomes on gait, risk of fall, clinical and self-reported measurements, Acta Orthop 2021; 92(3): 274-9. doi: 10.1080/17453674.2020.1865633. DOI:

de Steiger R N, Lorimer M, Solomon M. What is the learning curve for the anterior approach for total hip arthroplasty? Clin Orthop Relat Res 2015; 473(12): 3860-6. doi: 10.1007/s11999-015-4565-6. DOI:

van Steenbergen L N, Denissen G A W, Spooren A, van Rooden S M, van Oosterhout F J, et al. More than 95% completeness of reported procedures in the population-based Dutch Arthroplasty Register. Acta Orthop 2015; 86(4): 498-505. doi: 10.3109/17453674.2015.1028307 DOI:

Dutch Arthroplasty Register (LROI).– LROI Report - Information on data quality and validity. ( Last accessed: March, 2023.

Thabane L, Mbuagbaw L, Zhang S, Samaan Z, Marcucci M, et al. A tutorial on sensitivity analyses in clinical trials: the what, why, when and how. BMC Med Res Methodol 2013; 13: 92. doi: 10.1186/1471-2288-13-92. DOI:

Enocson A, Hedbeck C J, Tidermark J, Pettersson H, Ponzer S, Lapidus L J. Dislocation of total hip replacement in patients with fractures of the femoral neck. Acta Orthop 2009; 80(2): 184-9. doi: 10.3109/17453670902930024. DOI:

Peters R M, van Steenbergen L N, Stewart R E, Stevens M, Rijk P C, et al. Patient characteristics influence revision rate of total hip arthroplasty: American Society of Anesthesiologists score and body mass index were the strongest predictors for short-term revision after primary total hip arthroplasty. J Arthroplasty 2020; 35(1): 188-92.e2. doi: 10.1016/j.arth.2019.08.024. DOI:

Wagner E R, Kamath A F, Fruth K M, Harmsen W S, Berry D J. Effect of body mass index on complications and reoperations after total hip arthroplasty. J Bone Joint Surg 2016; 98(3): 169-79. doi: 10.2106/JBJS.O.00430. DOI:



How to Cite

van Dooren , B., Peters, R. M., Ettema, H. B., Schreurs, B. W., van Steenbergen, L. N., Bolder, S. B. T., & Zijlstra, W. P. (2023). Revision risk by using the direct superior approach (DSA) for total hip arthroplasty compared with postero-lateral approach: early nationwide results from the Dutch Arthroplasty Register (LROI). Acta Orthopaedica, 94, 158–164.





Most read articles by the same author(s)

1 2 3 > >>