Hip resurfacing through the direct anterior (Hueter) approach
Hip resurfacing (HR) is an attractive option for the young and active patient with hip osteoarthritis, offering preservation of femoral bone stock, a very low dislocation rate, near-physiological biomechanics and a favourable return to sport. It is, however, technically demanding and is conventionally performed through a posterior approach. The direct anterior (Hueter) approach (DAA) spares the peri-articular musculotendinous structures and the medial femoral circumflex artery, potentially adding more rapid recovery and a reduced risk of femoral head osteonecrosis to the recognised benefits of resurfacing. Combining the two procedures has, nonetheless, been described in only a handful of publications.
Surgical technique: We describe HR performed through the DAA with the patient supine on a traction table. The key steps are presented in sequence: pre-operative planning of implant size and cervical guide-wire trajectory; the Hueter approach and capsular release; anterior dislocation and exposure of the femoral head; guide-wire placement and femoral preparation; acetabular reaming and cup impaction; completion of the femoral component; and reduction, stability testing and femoral neck plasty. The specific pitfalls — femoral notching, restricted access to the superior neck and acetabular exposure — are highlighted, alongside the value of intra-operative fluoroscopy and the traction table.
Results: A continuous, prospective, single-surgeon series of 44 resurfacings in 41 patients (mean age 51.8 years), performed between 2024 and 2025 with a metal-on-metal implant, is presented. At a mean follow-up of 12.2 months, all clinical scores improved markedly (Harris Hip Score 49.7 to 94.7; Oxford Hip Score 19.9 to 44.8). The mean operating time was 67.9 minutes; the mean acetabular inclination was 34.9° and the mean femoral valgus 7.97°, with no component in varus or excessive inclination. No femoral neck fractures, early complications or revisions occurred; two cases of psoas tendinopathy were recorded during follow-up.
Conclusions: Performed meticulously and with optimal implant positioning, HR through the DAA combines the advantages of resurfacing with preservation of the soft tissues and of the femoral head blood supply, without an apparent increase in early complications.
