{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T01:20:43Z","timestamp":1790644843148,"version":"4.1.0"},"reference-count":42,"publisher":"MDPI AG","issue":"16","license":[{"start":{"date-parts":[[2024,8,6]],"date-time":"2024-08-06T00:00:00Z","timestamp":1722902400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Open Access Publication Fund of the University of Wuerzburg"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Objective: The direct anterior approach (DAA) is a recognized technique for total hip arthroplasty (THA) that spares soft tissue. Functional and clinical outcomes following THA via the DAA in patients with complex acetabular deformities, specifically coxa profunda (CP) and protrusio acetabuli (PA), have yet to be determined. Methods: A retrospective analysis was conducted on 188 primary THA cases, including 100 CP hips and 88 PA hips, performed via the DAA. Functional and clinical outcomes were evaluated by means of the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Harris Hip Score (HHS) preoperatively and at a mean follow-up of 46 \u00b1 14 months. Furthermore, potential complications were assessed. Results: From the preoperative to the latest postoperative visit, a significant improvement in the WOMAC total score was observed (CP: \u221234.89 \u00b1 20.66; PA: \u221240.38 \u00b1 21.11). The length of stay (LOS) was the only parameter predictive of the postoperative WOMAC total score, with each day of LOS increasing the postoperative WOMAC by a mean of 1.77 points (p &lt; 0.01). The HHS improved by 38.37 \u00b1 14.23 (PA-group) and 32.79 \u00b1 14.89 points (CP-group). No significant difference in the patient-reported outcome measures (PROMs) between the CP- and PA-group was found. The survival rate for any revision was 97.70% (PA-group) and 92.80% (CP-group). Conclusion: The results of this study indicate that the minimally invasive DAA was not predictive of the functional and clinical outcome following DAA-THA in patients with CP and PA. Improvements in the mean WOMAC and HHS scores were above or within the reported MCID. Additionally, revision rates were well below those reported in the literature for short and intermediate follow-up periods.<\/jats:p>","DOI":"10.3390\/jcm13164596","type":"journal-article","created":{"date-parts":[[2024,8,6]],"date-time":"2024-08-06T11:54:19Z","timestamp":1722945259000},"page":"4596","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Functional Outcome after Direct Anterior Approach Total Hip Arthroplasty (DAA-THA) for Coxa Profunda and Protrusio Acetabuli\u2014A Retrospective Study"],"prefix":"10.3390","volume":"13","author":[{"given":"Tizian","family":"Heinz","sequence":"first","affiliation":[{"name":"Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr 11, 97074 Wuerzburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hristo","family":"Vasilev","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr 11, 97074 Wuerzburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2356-547X","authenticated-orcid":false,"given":"Philip Mark","family":"Anderson","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr 11, 97074 Wuerzburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5522-0092","authenticated-orcid":false,"given":"Ioannis","family":"Stratos","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr 11, 97074 Wuerzburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9362-2914","authenticated-orcid":false,"given":"Axel","family":"Jakuscheit","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr 11, 97074 Wuerzburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9086-3541","authenticated-orcid":false,"given":"Konstantin","family":"Horas","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr 11, 97074 Wuerzburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Boris Michael","family":"Holzapfel","sequence":"additional","affiliation":[{"name":"Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center, Munich (MUM), University Hospital, LMU Munich, Marchioninistr 15, 81377 Munich, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4982-6594","authenticated-orcid":false,"given":"Maximilian","family":"Rudert","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr 11, 97074 Wuerzburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3551-3204","authenticated-orcid":false,"given":"Manuel","family":"Wei\u00dfenberger","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr 11, 97074 Wuerzburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,8,6]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1508","DOI":"10.1016\/S0140-6736(07)60457-7","article-title":"The operation of the century: Total hip replacement","volume":"370","author":"Learmonth","year":"2007","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"47","DOI":"10.2106\/JBJS.H.00756","article-title":"A systematic approach to the plain radiographic evaluation of the young adult hip","volume":"90","author":"Clohisy","year":"2008","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1148\/128.1.1","article-title":"The adult hip: An anatomic study. Part I: The bony landmarks","volume":"128","author":"Armbuster","year":"1978","journal-title":"Radiology"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1148\/128.1.11","article-title":"The adult hip: An anatomic study. Part II: The soft-tissue landmarks","volume":"128","author":"Guerra","year":"1978","journal-title":"Radiology"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"282","DOI":"10.1186\/s13018-023-03764-y","article-title":"Cementless total hip arthroplasty for treatment of acetabular protrusion secondary to rheumatoid arthritis","volume":"18","author":"Liu","year":"2023","journal-title":"J. Orthop. Surg. Res."},{"key":"ref_6","first-page":"160","article-title":"Health-type total hip arthroplasty combined with compression bone grafting for rheumatoid arthritis with acetabular retraction","volume":"29","author":"Lu","year":"2015","journal-title":"Chin. J. Reconstr. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1186\/s13018-018-0809-y","article-title":"Total hip arthroplasty to treat acetabular protrusions secondary to rheumatoid arthritis","volume":"13","author":"Zhen","year":"2018","journal-title":"J. Orthop. Surg. Res."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"839","DOI":"10.1007\/s00264-014-2580-y","article-title":"Long-term results of the uncemented acetabular component in a primary total hip arthroplasty performed for protrusio acetabuli: A fifteen year median follow-up","volume":"39","author":"Baghdadi","year":"2015","journal-title":"Int. Orthop."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"79","DOI":"10.5435\/00124635-200103000-00002","article-title":"Protrusio acetabuli: Diagnosis and treatment","volume":"9","author":"McBride","year":"2001","journal-title":"J. Am. Acad. Orthop. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"670","DOI":"10.1002\/bjs.18002610403","article-title":"Adolescent deformities of the acetabulum: An investigation into the nature of protrusio acetabuli","volume":"26","author":"Gilmour","year":"2005","journal-title":"Br. J. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"567","DOI":"10.1259\/0007-1285-38-452-567","article-title":"The Aetiology of Primary Protrusio Acetabuli","volume":"38","author":"Alexander","year":"1965","journal-title":"Br. J. Radiol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"229","DOI":"10.1302\/0301-620X.69B2.3546328","article-title":"Bone grafting for protrusio acetabuli during total hip replacement. A review of the Wrightington method in 61 hips","volume":"69","author":"Hirst","year":"1987","journal-title":"J. Bone Jt. Surg. Br."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"108","DOI":"10.1302\/0301-620X.82B1.0820108","article-title":"Loosening of the cup after low-friction arthroplasty in patients with acetabular protrusion. The importance of the position of the cup","volume":"82","author":"Madero","year":"2000","journal-title":"J. Bone Jt. Surg. Br."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"819","DOI":"10.1054\/arth.2000.7110","article-title":"Acetabular reconstruction with impacted morcellized cancellous bone autograft and cemented primary total hip arthroplasty: A 10- to 17-year follow-up study","volume":"15","author":"Welten","year":"2000","journal-title":"J. Arthroplast."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1302\/0301-620X.95B11.32900","article-title":"Acetabular protrusio: Surgical technique of dealing with a problem in depth","volume":"95-b","author":"Mullaji","year":"2013","journal-title":"Bone Jt. J."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1757","DOI":"10.1007\/s00264-015-2804-9","article-title":"Acetabuloplasty with bone grafting in uncemented hip replacement for protrusion","volume":"39","author":"Zuh","year":"2015","journal-title":"Int. Orthop."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1143","DOI":"10.1016\/j.arth.2006.11.005","article-title":"Primary total hip arthroplasty in protrusio acetabuli using impacted morsellized bone grafting and cementless cups: A medium-term radiographic review","volume":"22","author":"Mullaji","year":"2007","journal-title":"J. Arthroplast."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Heinz, T., Vasilev, H., Anderson, P.M., Stratos, I., Jakuscheit, A., Horas, K., Holzapfel, B.M., Rudert, M., and Wei\u00dfenberger, M. (2023). The Direct Anterior Approach (DAA) as a Standard Approach for Total Hip Arthroplasty (THA) in Coxa Profunda and Protrusio Acetabuli? A Radiographic Analysis of 188 Cases. J. Clin. Med., 12.","DOI":"10.3390\/jcm12123941"},{"key":"ref_19","first-page":"e14048","article-title":"Managing Protrusio Acetabuli With a Direct Anterior Approach Total Hip Replacement","volume":"13","author":"Yun","year":"2021","journal-title":"Cureus"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"S31","DOI":"10.4103\/sja.SJA_543_18","article-title":"The STROBE guidelines","volume":"13","author":"Cuschieri","year":"2019","journal-title":"Saudi J. Anaesth."},{"key":"ref_21","first-page":"730","article-title":"Total Hip Replacement for Osteoarthritis-Evidence-Based and Patient-Oriented Indications","volume":"118","author":"Deckert","year":"2021","journal-title":"Dtsch. Arztebl. Int."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"L\u00fctzner, C., Deckert, S., G\u00fcnther, K.-P., Postler, A.E., L\u00fctzner, J., Schmitt, J., Limb, D., and Lange, T. (2022). Indication Criteria for Total Hip Arthroplasty in Patients with Hip Osteoarthritis\u2014Recommendations from a German Consensus Initiative. Medicina, 58.","DOI":"10.3390\/medicina58050574"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"2191","DOI":"10.1001\/jama.2013.281053","article-title":"World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects","volume":"310","author":"Association","year":"2013","journal-title":"JAMA"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"287","DOI":"10.1007\/s00064-021-00725-8","article-title":"Primary hip arthroplasty via the direct anterior approach","volume":"33","author":"Rudert","year":"2021","journal-title":"Oper. Orthop. Traumatol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"175","DOI":"10.3758\/BF03193146","article-title":"G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences","volume":"39","author":"Faul","year":"2007","journal-title":"Behav. Res. Methods"},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Singh, J.A., Schleck, C., Harmsen, S., and Lewallen, D. (2016). Clinically important improvement thresholds for Harris Hip Score and its ability to predict revision risk after primary total hip arthroplasty. BMC Musculoskelet. Disord., 17.","DOI":"10.1186\/s12891-016-1106-8"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1408","DOI":"10.1016\/j.joca.2019.05.002","article-title":"A systematic review of estimates of the minimal clinically important difference and patient acceptable symptom state of the Western Ontario and McMaster Universities Osteoarthritis Index in patients who underwent total hip and total knee replacement","volume":"27","author":"MacKay","year":"2019","journal-title":"Osteoarthr. Cartil."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"76","DOI":"10.1097\/00003086-197505000-00012","article-title":"Protrusio acetabuli in rheumatoid arthritis","volume":"108","author":"Hastings","year":"1975","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"275","DOI":"10.1016\/S0883-5403(87)80059-1","article-title":"Long-term results of total hip arthroplasty in protrusio acetabuli","volume":"2","author":"Bayley","year":"1987","journal-title":"J. Arthroplast."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"212","DOI":"10.1097\/00003086-197509000-00029","article-title":"Intrapelvic Protrusion of the Acetabular Component Following Total Hip Replacement","volume":"111","author":"Salvati","year":"1975","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1177\/112070000801800105","article-title":"Results of acetabular wiremesh and autograft in protrusio acetabuli","volume":"18","year":"2008","journal-title":"Hip Int."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"3251","DOI":"10.1007\/s11999-013-3072-x","article-title":"Restoration of the hip center during THA performed for protrusio acetabuli is associated with better implant survival","volume":"471","author":"Baghdadi","year":"2013","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"12","DOI":"10.5371\/hp.2024.36.1.12","article-title":"Total Hip Arthroplasty in Protrusio Acetabuli: A Systematic Review","volume":"36","author":"Ansari","year":"2024","journal-title":"Hip Pelvis"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1080\/000164700317413102","article-title":"Impacted morsellized bone grafting and cemented primary total hip arthroplasty for acetabular protrusion in patients with rheumatoid arthritis: An 8- to 18-year follow-up study of 36 hips","volume":"71","author":"Rosenberg","year":"2000","journal-title":"Acta Orthop. Scand."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1007\/s00776-004-0845-9","article-title":"Results of total hip arthroplasty with bone graft and support ring for protrusio acetabuli in rheumatoid arthritis","volume":"10","author":"Mibe","year":"2005","journal-title":"J. Orthop. Sci."},{"key":"ref_36","first-page":"227","article-title":"Direct anterior total hip arthroplasty","volume":"63","author":"Unger","year":"2014","journal-title":"Instr. Course Lect."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1339","DOI":"10.1016\/j.arth.2020.01.004","article-title":"Mid-term Follow-up of the Direct Anterior Approach in Acetabular Revision Hip Arthroplasty Using a Reconstruction Cage With Impaction Grafting","volume":"35","author":"Thaler","year":"2020","journal-title":"J. Arthroplast."},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Prodinger, P.M., Lazic, I., Horas, K., Burgkart, R., von Eisenhart-Rothe, R., Weissenberger, M., Rudert, M., and Holzapfel, B.M. (2020). Revision Arthroplasty Through the Direct Anterior Approach Using an Asymmetric Acetabular Component. J. Clin. Med., 9.","DOI":"10.3390\/jcm9093031"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"S24","DOI":"10.1016\/j.arth.2019.02.006","article-title":"Current Practice Trends in Primary Hip and Knee Arthroplasties Among Members of the American Association of Hip and Knee Surgeons: A Long-Term Update","volume":"34","author":"Abdel","year":"2019","journal-title":"J. Arthroplast."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"732","DOI":"10.1302\/0301-620X.99B6.38053","article-title":"The direct anterior approach in total hip arthroplasty","volume":"99-B","author":"Meermans","year":"2017","journal-title":"Bone Jt. J."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"229","DOI":"10.1186\/s13018-018-0929-4","article-title":"A systematic review and meta-analysis of direct anterior approach versus posterior approach in total hip arthroplasty","volume":"13","author":"Wang","year":"2018","journal-title":"J. Orthop. Surg. Res."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1078","DOI":"10.1302\/0301-620X.103B6.BJJ-2020-1271.R1","article-title":"Direct anterior approach has short-term functional benefit and higher resource requirements compared with the posterior approach in primary total hip arthroplasty","volume":"103-B","author":"Awad","year":"2021","journal-title":"Bone Jt. J."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/16\/4596\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T15:30:44Z","timestamp":1760110244000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/16\/4596"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,8,6]]},"references-count":42,"journal-issue":{"issue":"16","published-online":{"date-parts":[[2024,8]]}},"alternative-id":["jcm13164596"],"URL":"https:\/\/doi.org\/10.3390\/jcm13164596","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,8,6]]}}}