{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T10:39:55Z","timestamp":1786703995065,"version":"build-2736575974"},"reference-count":42,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2023,4,16]],"date-time":"2023-04-16T00:00:00Z","timestamp":1681603200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and objectives: Total hip arthroplasty (THA) in obese patients (BMI &gt; 30) is considered technically demanding, and it is associated with higher rates of general and specific complications including infections, component malpositioning, dislocation, and periprosthetic fractures. Classically, the Direct Anterior Approach (DAA) has been considered less suitable for performing THA surgery in the obese patient, but recent evidence produced by high-volume DAA THA surgeons suggests that DAA is suitable and effective in obese patients. At the authors\u2019 institution, DAA is currently the preferred approach for primary and revision THA surgery, accounting for over 90% of hip surgeries without specific patient selection. Therefore, the aim of the current study is to evaluate any difference in early clinical outcomes, perioperative complications, and implant positioning after primary THAs performed via DAA in patients who were divided according to BMI. Material and methods: This study is a retrospective review of 293 THA implants in 277 patients that were performed via DAA from 1 January 2016 to 20 May 2020. Patients were further divided according to BMI: 96 patients were normal weight (NW), 115 were overweight (OW), and 82 were obese (OB). All the procedures were performed by three expert surgeons. The mean follow-up was 6 months. Patients\u2019 data, American Society of Anesthesiologists (ASA) score, surgical time, days in rehab unit, pain at the second post-operative day recorded by using a Numerical Rating Scale (NRS), and number of blood transfusions were recorded from clinical charts and compared. Radiological evaluation of cup inclination and stem alignment was conducted on post-operative radiographs; intra- and post-operative complications at latest follow-up were recorded. Results: The average age at surgery of OB patients was significantly lower compared to NW and OW patients. The ASA score was significantly higher in OB patients compared to NW patients. Surgical time was slightly but significantly higher in OB patients (85 \u00b1 21 min) compared to NW (79 \u00b1 20 min, p = 0.05) and OW patients (79 \u00b1 20 min, p = 0.029). Rehab unit discharge occurred significantly later for OB patients, averaging 8 \u00b1 2 days compared to NW patients (7 \u00b1 2 days, p = 0.012) and OW patients (7 \u00b1 2 days; p = 0.032). No differences in the rate of early infections, number of blood transfusions, NRS pain at the second post-operative day, and day of post-operative stair climbing were found among the three groups. Acetabular cup inclination and stem alignment were similar among the three groups. The perioperative complication rate was 2.3%; that is, perioperative complication occurred in 7 out of 293 patients, with a significantly higher incidence of surgical revisions required in obese patients compared to the others. In fact, OB patients showed a higher revision rate (4.87%) compared to other groups, with 1.04% for NW and 0% for OW (p = 0.028, Chi-square test). Causes for revision in obese patients were aseptic loosening (2), dislocation (1), and clinically significant post-operative leg length discrepancy (1), with a revision rate of 4\/82 (4.87%) during follow-up. Conclusions: THA performed via DAA in obese patients could be a solid choice of treatment, given the relatively low rate of complications and the satisfying clinical outcomes. However, surgical expertise on DAA and adequate instrumentation for this approach are required to optimise the outcomes.<\/jats:p>","DOI":"10.3390\/medicina59040769","type":"journal-article","created":{"date-parts":[[2023,4,17]],"date-time":"2023-04-17T03:14:09Z","timestamp":1681701249000},"page":"769","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":14,"title":["Is the Direct Anterior Approach for Total Hip Arthroplasty Effective in Obese Patients? Early Clinical and Radiographic Results from a Retrospective Comparative Study"],"prefix":"10.3390","volume":"59","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0716-4951","authenticated-orcid":false,"given":"Alberto","family":"Di Martino","sequence":"first","affiliation":[{"name":"I Orthopedic and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy"},{"name":"Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Niccol\u00f2","family":"Stefanini","sequence":"additional","affiliation":[{"name":"I Orthopedic and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy"},{"name":"Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9376-5480","authenticated-orcid":false,"given":"Matteo","family":"Brunello","sequence":"additional","affiliation":[{"name":"I Orthopedic and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy"},{"name":"Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6606-4950","authenticated-orcid":false,"given":"Barbara","family":"Bordini","sequence":"additional","affiliation":[{"name":"Medical Technology Laboratory, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Federico","family":"Pilla","sequence":"additional","affiliation":[{"name":"I Orthopedic and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy"},{"name":"Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9640-5031","authenticated-orcid":false,"given":"Giuseppe","family":"Geraci","sequence":"additional","affiliation":[{"name":"I Orthopedic and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy"},{"name":"Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2616-0662","authenticated-orcid":false,"given":"Claudio","family":"D\u2019Agostino","sequence":"additional","affiliation":[{"name":"I Orthopedic and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy"},{"name":"Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Federico","family":"Ruta","sequence":"additional","affiliation":[{"name":"I Orthopedic and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy"},{"name":"Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cesare","family":"Faldini","sequence":"additional","affiliation":[{"name":"I Orthopedic and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy"},{"name":"Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,4,16]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"402","DOI":"10.1159\/000442721","article-title":"European Guidelines for Obesity Management in Adults","volume":"8","author":"Yumuk","year":"2015","journal-title":"Obes. Facts"},{"key":"ref_2","first-page":"S176","article-title":"Obesity: Definition, Comorbidities, Causes, and Burden","volume":"22","author":"Caroline","year":"2016","journal-title":"Am. J. Manag. Care."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"919","DOI":"10.1089\/lap.2018.0380","article-title":"Epidemiology of Obesity and Associated Comorbidities","volume":"28","author":"Andolfi","year":"2018","journal-title":"J. Laparoendosc. Adv. Surg. Tech."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1016\/S1098-3597(99)90002-9","article-title":"Obesity and its comorbid conditions","volume":"2","author":"Khaodhiar","year":"1999","journal-title":"Clin. Cornerstone"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"(2013). Obesity and Total Joint Arthroplasty. J. Arthroplast., 28, 714\u2013721.","DOI":"10.1016\/j.arth.2013.02.011"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1071","DOI":"10.1111\/j.1467-789X.2011.00916.x","article-title":"A systematic review on changed biomechanics of lower extremities in obese individuals: A possible role in development of osteoarthritis","volume":"12","author":"Runhaar","year":"2011","journal-title":"Obes. Rev."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"36","DOI":"10.12927\/hcpol.2006.18121","article-title":"Obesity and joint replacement surgery in Canada: Findings from the Canadian Joint Replacement Registry (CJRR)","volume":"1","author":"Zhu","year":"2006","journal-title":"Healthc. PolicyPolit. De Sante"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"3281","DOI":"10.1016\/j.arth.2018.02.073","article-title":"Complications and Obesity in Arthroplasty\u2014A Hip is Not a Knee","volume":"33","author":"DeMik","year":"2018","journal-title":"J. Arthroplast."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1503\/cjs.007214","article-title":"Surgical approach in primary total hip arthroplasty: Anatomy, technique and clinical outcomes","volume":"58","author":"Petis","year":"2015","journal-title":"Can. J. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1070","DOI":"10.1001\/jama.2020.0785","article-title":"Association Between Surgical Approach and Major Surgical Complications in Patients Undergoing Total Hip Arthroplasty","volume":"323","author":"Pincus","year":"2020","journal-title":"JAMA"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"595","DOI":"10.5435\/JAAOS-22-09-595","article-title":"Direct anterior approach for total hip arthroplasty: Indications, technique, and results","volume":"22","author":"Post","year":"2014","journal-title":"J. Am. Acad. Orthop. Surg."},{"key":"ref_12","first-page":"75","article-title":"Direct anterior approach versus posterolateral approach in total hip arthroplasty: Effects on early post-operative rehabilitation period","volume":"31","author":"Faldini","year":"2017","journal-title":"J. Biol. Regul. Homeost. Agents"},{"key":"ref_13","first-page":"193","article-title":"Is a minimally invasive anterior approach effective in old patients? A pilot study","volume":"30","author":"Faldini","year":"2016","journal-title":"J. Biol. Regul. Homeost. Agents"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1384","DOI":"10.1016\/j.arth.2015.03.002","article-title":"Increased Complications in Obese Patients Undergoing Direct Anterior Total Hip Arthroplasty","volume":"30","author":"Russo","year":"2015","journal-title":"J. Arthroplast."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e67","DOI":"10.3928\/01477447-20211227-03","article-title":"Does Surgical Approach for Total Hip Arthroplasty Impact Infection Risk in the Obese Patient? A Systematic Review","volume":"45","author":"Shah","year":"2022","journal-title":"Orthopedics"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"2296","DOI":"10.1016\/j.arth.2015.06.016","article-title":"High Risk of Wound Complications Following Direct Anterior Total Hip Arthroplasty in Obese Patients","volume":"30","author":"Watts","year":"2015","journal-title":"J. Arthroplast."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"776","DOI":"10.1007\/s43465-020-00164-w","article-title":"Total Hip Arthroplasty in the Obese Patient: Tips and Tricks and Review of the Literature","volume":"54","author":"Rhind","year":"2020","journal-title":"Indian J. Orthop."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"2919","DOI":"10.1007\/s00402-021-04143-0","article-title":"Bikini anterior hip replacements in obese patients are not associated with an increased risk of complication","volume":"142","author":"Nizam","year":"2021","journal-title":"Arch. Orthop. Trauma Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1302\/2633-1462.31.BJO-2021-0166.R1","article-title":"Total hip arthroplasty through the direct anterior approach in morbidly obese patients","volume":"3","author":"Argyrou","year":"2022","journal-title":"Bone Jt. Open"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"877","DOI":"10.5312\/wjo.v12.i11.877","article-title":"Direct anterior approach vs Hardinge in obese and nonobese osteoarthritic patients: A randomized controlled trial","volume":"12","author":"Macheras","year":"2021","journal-title":"World J. Orthop."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1093\/ajcn\/47.2.225","article-title":"Body fat deposition in adult obese women. I Patterns of fat distribution","volume":"47","author":"Johnston","year":"1988","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"217","DOI":"10.2106\/00004623-197860020-00014","article-title":"Dislocations after total hip-replacement arthroplasties","volume":"60","author":"Lewinnek","year":"1978","journal-title":"J. Bone Joint. Surg. Am."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"463","DOI":"10.1054\/arth.2002.32171","article-title":"Results of a tapered cementless femoral stem implanted in varus","volume":"17","author":"Khalily","year":"2002","journal-title":"J. Arthroplast."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1302\/0301-620X.99B1.BJJ-2016-0346.R1","article-title":"Obesity in total hip arthroplasty: Does it make a difference?","volume":"99","author":"Haynes","year":"2017","journal-title":"Bone Jt. J."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1002\/jor.24460","article-title":"Overweight and Obese Patients Require Total Hip and Total Knee Arthroplasty at a Younger Age","volume":"38","author":"Clement","year":"2019","journal-title":"J. Orthop. Res."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"613","DOI":"10.1177\/1120700017754058","article-title":"Body mass index and in-hospital postoperative complications following primary total hip arthroplasty","volume":"28","author":"Gurunathan","year":"2018","journal-title":"HIP Int."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"2535","DOI":"10.1016\/j.arth.2018.03.071","article-title":"Is Direct Anterior Approach a Credible Option for Severely Obese Patients Undergoing Total Hip Arthroplasty? A Matched-Control, Retrospective, Clinical Study","volume":"33","author":"Antoniadis","year":"2018","journal-title":"J. Arthroplast."},{"key":"ref_28","first-page":"555","article-title":"The Influence of Body Mass Index and Hip Anatomy on Direct Anterior Approach Total Hip Replacement","volume":"25","author":"Sang","year":"2016","journal-title":"Med. Princ. Pract. Int. J. Kuwait. Univ. Health Sci. Cent."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"2652","DOI":"10.1016\/j.arth.2020.04.018","article-title":"Perioperative Complications Stratified by Body Mass Index for the Direct Anterior Approach to Total Hip Arthroplasty","volume":"35","author":"Hartford","year":"2020","journal-title":"J. Arthroplast."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"162","DOI":"10.1016\/j.arth.2016.03.037","article-title":"Severely Obese Patients Have a Higher Risk of Infection After Direct Anterior Approach Total Hip Arthroplasty","volume":"31","author":"Purcell","year":"2016","journal-title":"J. Arthroplast."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s10195-021-00583-x","article-title":"Low rate of early periprosthetic fractures in cementless short-stem total hip arthroplasty using a minimally invasive anterolateral approach","volume":"22","author":"Luger","year":"2021","journal-title":"J. Orthop. Traumatol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s40634-020-00318-7","article-title":"Minimizing complications in bikini incision direct anterior approach total hip arthroplasty: A single surgeon series of 865 cases","volume":"8","author":"Alva","year":"2021","journal-title":"J. Exp. Orthop."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"431","DOI":"10.1177\/1120700020977166","article-title":"Incision site fat thickness and 90-day complications for direct anterior and posterior approach total hip arthroplasty","volume":"32","author":"Sprowls","year":"2020","journal-title":"HIP Int."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"646","DOI":"10.1302\/0301-620X.101B6.BJJ-2018-1474.R1","article-title":"Surgical approach significantly affects the complication rates associated with total hip arthroplasty","volume":"101","author":"Aggarwal","year":"2019","journal-title":"Bone Jt. J."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1407","DOI":"10.1016\/j.arth.2019.12.009","article-title":"Predictors of Perioperative Vancouver B Periprosthetic Femoral Fractures Associated With the Direct Anterior Approach to Total Hip Arthroplasty","volume":"35","author":"Griffiths","year":"2019","journal-title":"J. Arthroplast."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"404","DOI":"10.1111\/ans.16611","article-title":"Periprosthetic fractures of the femur in primary total hip arthroplasty: A New Zealand Joint Registry analysis","volume":"91","author":"Stringer","year":"2021","journal-title":"ANZ J. Surg."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"987","DOI":"10.1016\/j.arth.2016.08.008","article-title":"Acetabular Component Position and the Risk of Dislocation Following Primary and Revision Total Hip Arthroplasty: A Matched Cohort Analysis","volume":"32","author":"Sadhu","year":"2017","journal-title":"J. Arthroplast."},{"key":"ref_38","first-page":"187","article-title":"The Effect of Obesity on Fluoroscopy-Assisted Direct Anterior Approach Total Hip Arthroplasty","volume":"78","author":"Davidovitch","year":"2020","journal-title":"Bull. NYU Hosp. Jt. Dis."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"891","DOI":"10.1007\/s00402-020-03457-9","article-title":"The direct anterior approach provokes varus stem alignment when using a collarless straight tapered stem","volume":"141","author":"Haversath","year":"2020","journal-title":"Arch. Orthop. Trauma Surg."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1047","DOI":"10.5435\/JAAOS-D-22-00150","article-title":"Incidence, Timing, and Predictors of Hip Dislocation After Primary Total Hip Arthroplasty for Osteoarthritis","volume":"30","author":"Gillinov","year":"2022","journal-title":"J. Am. Acad. Orthop. Surg."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1723","DOI":"10.1016\/j.arth.2019.03.060","article-title":"Total Hip Arthroplasty Through the Direct Anterior Approach Using a Bikini Incision Can Be Safely Performed in Obese Patients","volume":"34","author":"Manrique","year":"2019","journal-title":"J. Arthroplast."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1013","DOI":"10.1007\/s00264-013-1833-5","article-title":"A minimally invasive approach for total hip arthroplasty does not diminish early post-operative outcome in obese patients: A prospective, randomised trial","volume":"37","author":"Dienstknecht","year":"2013","journal-title":"Int. Orthop."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/59\/4\/769\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T19:16:42Z","timestamp":1760123802000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/59\/4\/769"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,4,16]]},"references-count":42,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2023,4]]}},"alternative-id":["medicina59040769"],"URL":"https:\/\/doi.org\/10.3390\/medicina59040769","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,4,16]]}}}