Extensile Direct Anterior Approach for Primary and Revision Total Hip Arthroplasty: Proximal and Distal Extension Techniques

Background:The direct anterior approach (DAA) for total hip arthroplasty (THA) has gained wide acceptance as a minimally invasive, musclesparing technique that facilitates accurate component positioning and faster postoperative recovery.However, its application in complex primary and revision cases remains limited due to perceived challenges in surgical exposure.Objective: This study aims to describe the surgical anatomy, indications, and technical nuances of proximal and distal extensions of the DAA that enable safe and effective management of complex primary and revision THA.Materials and methods: Anatomical dissections and clinical experience were used to delineate proximal and distal extensile modifications of the standard DAA.The proximal extension provides access to the iliac wing and anterior column for acetabular reconstruction, while the distal extension facilitates femoral stem removal, extended trochanteric osteotomy (ETO), and long-stem implantation.Both maintain intermuscular and internervous planes, preserving abductor integrity and minimizing soft-tissue trauma.Results: The proximal extension improved acetabular visualization and allowed management of superior and anterior column deficiencies without repositioning the patient.The distal extension provided direct access to the femoral diaphysis for complex revisions and periprosthetic fracture fixation.These modifications maintained neurovascular safety, optimized exposure, and preserved the inherent benefits of the anterior approach. Conclusion:The extensile DAA offers a comprehensive, single-incision strategy for complex primary and revision THA.Mastery of proximal and distal extensions enables advanced reconstructive procedures while maintaining soft-tissue preservation and functional anatomy.With experience and appropriate instrumentation, this approach may evolve into a standard option for revision hip arthroplasty.