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Direct Anterior Approach Is Associated with Superior Postoperative Sexual Function Compared with Anterolateral Approach in Men Undergoing Total Hip Arthroplasty: A Prospective Cohort Study

In a prospective cohort study of men undergoing total hip arthroplasty, the direct anterior approach was associated with superior postoperative erectile function and greater pain reduction compared to the anterolateral approach, although the latter group reported greater improvements in overall physical and psychological well-being.

Original authors: Miklós Szabó, Jozef Almási, Igor Bartl, Boris Šteno

Published 2026-07-01

📖 4 min read☕ Coffee break read

CC BY 4.0

Original authors: Miklós Szabó, Jozef Almási, Igor Bartl, Boris Šteno

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

Imagine your hip joint is like the hinge on a heavy, rusty garden gate. For years, the rust (arthritis) has made it creak, groan, and stick, making it hard to swing open. Eventually, you decide to replace the hinge with a brand-new, smooth one (Total Hip Arthroplasty, or THA).

This study is like a head-to-head race between two different mechanics (surgeons) trying to fix that gate. They both use the same high-quality new hinge, but they take different paths to get there:

The "Direct Anterior" Mechanic (DAA): This mechanic walks up to the gate from the front, slipping between the muscles without cutting them. It's like sneaking through a narrow gap in a fence to get to the gate.
The "Anterolateral" Mechanic (ALA): This mechanic approaches from the side. To get a good look, they have to temporarily pull back and untie a strong rope (the gluteus muscle) that holds the gate up, then tie it back up afterward.

The researchers wanted to see which mechanic not only fixed the gate better but also helped the homeowner (the patient) get back to their full life, including their private, intimate moments.

The Race Results

1. The Pain and Stiffness Scorecard
Both mechanics did a great job. After six months, the gate swung smoothly for everyone. However, the Direct Anterior (DAA) group had a slight edge here.

The Analogy: Think of the DAA patients as people who had a smoother, less bruised journey to the finish line. They reported less pain and less "stiffness" (like a gate that doesn't stick at all) compared to the side-approach group. The side-approach group felt better too, but they still felt a bit more "tightness" in their joints.

2. The "Well-Being" Scorecard
Here, the results got interesting.

The Analogy: Imagine two runners. Runner A (DAA) started the race feeling pretty good and stayed consistent. Runner B (ALA) started the race feeling terrible, so when they finished, they felt like they had made a huge leap forward.
Because the side-approach (ALA) patients started with lower scores for their physical and mental happiness, they felt like they gained more ground by the end. They felt a bigger boost in their overall mood and physical confidence, even though the DAA group still had slightly higher absolute scores overall.

3. The "Intimate Life" Scorecard (The Big Discovery)
This is the most unique part of the study. The researchers asked the men about their sexual health using a standard checklist (IIEF-5).

The Analogy: Think of sexual function as a battery.
- The DAA Group: Their battery started at 70% charge and went up to 85% after the surgery. The "front-door" approach seemed to help recharge the battery.
- The ALA Group: Their battery started at 70% and stayed exactly at 70%. It didn't get worse, but it didn't get better either.
The Claim: The study found that men who had the "front-door" (Direct Anterior) surgery saw a real improvement in their erectile function. The men who had the "side-door" (Anterolateral) surgery saw no change. The authors suggest that because the front-door approach avoids cutting or pulling on certain muscles and nerves, it might protect the "wiring" needed for intimate function better than the side approach.

The Catch (Limitations)

The authors are careful to point out that this isn't a perfectly fair race yet.

The Starting Line: The two groups of men weren't identical at the start. The DAA group was already feeling slightly better (less pain, happier) before the surgery even began. This might have made it easier for them to keep improving, while the other group had more "room to grow."
The Size: The group was small (87 men total), and it wasn't a random coin-flip assignment; the surgeons chose the approach.
The Time: They only watched the race for six months. We don't know if the differences will last for years.

The Bottom Line

Both ways of fixing the hip work well to stop pain and help you walk better. However, this study suggests that if you are a man looking to get back to a healthy, active sex life, the Direct Anterior approach (the front-door method) might give you a little extra boost in that specific area, likely because it's gentler on the surrounding tissues.

The authors conclude that while both methods are good, the "front-door" route might offer a special bonus for sexual health, a topic that doctors often forget to talk about with their patients.

Technical Summary: Direct Anterior Approach vs. Anterolateral Approach in Total Hip Arthroplasty and Postoperative Sexual Function

Problem Statement
Total hip arthroplasty (THA) is increasingly performed on younger, sexually active men for whom sexual function is a critical component of quality of life. While hip osteoarthritis (OA) significantly impairs sexual activity in up to 70% of patients, the impact of specific surgical approaches on postoperative sexual health remains under-investigated. Current literature focuses primarily on implant survivorship, revision rates, and general pain relief, often neglecting patient-centered outcomes such as erectile function. Furthermore, orthopedic practice frequently lacks structured communication regarding sexual health, with studies indicating that the majority of surgeons rarely discuss this topic with patients. This study addresses the gap in knowledge regarding whether the Direct Anterior Approach (DAA), known for muscle-sparing techniques and faster recovery, offers superior outcomes in erectile function compared to the Anterolateral Approach (ALA) in men undergoing primary THA.

Methodology
This was a prospective, multicenter cohort study conducted between May 2024 and April 2025 at two hospitals in Slovakia (Hospital Bory and Hospital Dunajská Streda). The study population consisted of 87 sexually active men aged 18–65 years diagnosed with symptomatic hip OA, rheumatoid arthritis, or osteonecrosis. Patients were divided into two groups based on the surgical approach:

Direct Anterior Approach (DAA) Group: $n = 49$
Anterolateral Approach (ALA) Group: $n = 38$

Surgical and Perioperative Protocols:

All procedures were performed by four orthopedic surgeons using cementless implants.
DAA: Performed on a standard operating table without traction, involving capsulectomy and releases as described by Chughtai, with optional conjoined tendon release.
ALA: Performed in the supine position with gluteus medius detachment and subsequent repair, along with capsulectomy.
Standardization: Fluoroscopy was used in both groups to standardize stem placement. All patients received a standardized perioperative analgesia protocol (including tranexamic acid, dexamethasone, and local infiltration) without routine opiate use.

Data Collection and Analysis:
Outcomes were assessed preoperatively and at six months postoperatively using three validated instruments:

WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index): Assessed pain, stiffness, and physical function.
WHOQOL-BREF (World Health Organization Quality of Life-BREF): Assessed physical and psychological well-being domains.
IIEF-5 (International Index of Erectile Function-5): Specifically measured erectile function.

Statistical analysis utilized two-way mixed-design ANOVAs with Time (pre- vs. post-surgery) as the within-subjects factor and Group (DAA vs. ALA) as the between-subjects factor. Effect sizes were reported as partial eta squared ( $\eta^2$ ).

Key Results
Both groups demonstrated significant improvements in pain, stiffness, physical function, and quality of life six months post-surgery. However, distinct differences emerged between the approaches:

Erectile Function (IIEF-5): A significant Time $\times$ Group interaction was observed ( $p = .047$ ). The DAA group showed a statistically significant improvement in erectile function (mean score increased from 19.53 to 21.04, $p < .001$ ). In contrast, the ALA group showed no significant change in erectile function (mean score changed from 19.71 to 19.97, $p = .572$ ).
Pain and Stiffness (WOMAC): Both groups experienced significant pain reduction. The DAA group reported consistently lower pain scores than the ALA group both pre- and post-operatively. Regarding stiffness, the DAA group demonstrated a significantly greater reduction over time compared to the ALA group (Time $\times$ Group interaction, $p < .001$ ), with DAA patients reporting significantly lower stiffness scores at the six-month follow-up.
Physical Function (WOMAC): Both groups achieved comparable, substantial improvements in physical function, with no significant difference in the magnitude of improvement between the two approaches.
Quality of Life (WHOQOL-BREF):
- Physical Well-being: The ALA group exhibited a greater relative improvement in physical well-being scores compared to the DAA group, despite starting from a lower baseline.
- Psychological Well-being: The ALA group showed a greater magnitude of improvement in psychological scores, largely attributed to lower preoperative baseline scores. Post-surgery, there was no significant difference in psychological well-being between the two groups.

Significance and Claims
The authors conclude that while both surgical approaches are effective in restoring hip function and improving general quality of life, the Direct Anterior Approach may confer a specific advantage regarding erectile function. The study suggests that the muscle-sparing nature of the DAA, which avoids abductor violation and potentially preserves neurovascular structures, could be associated with better sexual health outcomes in men.

The paper emphasizes that sexual health is a legitimate and important dimension of postoperative recovery that is currently under-addressed in clinical practice and research. By demonstrating a potential link between surgical approach and erectile function, the study advocates for the inclusion of sexual health metrics in future comparative studies and the integration of structured counseling regarding sexual activity into routine perioperative care.

Limitations
The authors note several limitations, including baseline differences between groups (the DAA group had higher preoperative scores in pain, physical health, and psychological well-being), a relatively small sample size, and the non-randomized design which introduces the risk of selection bias. Additionally, the study relied on self-reported data and had a follow-up period limited to six months, restricting conclusions about long-term effects. The authors call for larger, randomized, or carefully matched studies with longer follow-up periods to confirm these findings.

The Race Results

The Catch (Limitations)

The Bottom Line

Technical Summary: Direct Anterior Approach vs. Anterolateral Approach in Total Hip Arthroplasty and Postoperative Sexual Function

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