Direct anterior approach for femoral component revision: Surgical technique and pearls

The direct anterior approach (DAA) has gained widespread acceptance for primary total hip arthroplasty because it utilizes an intermuscular and internervous interval, minimizes soft tissue disruption, and facilitates rapid postoperative recovery. Although its application in primary arthroplasty is well established, femoral component revision through the DAA remains technically demanding and has been described less frequently because of concerns regarding femoral exposure and implant extraction. Nevertheless, recent advances in extensile modifications of the approach have expanded its role in complex revision procedures. This article describes a comprehensive stepwise surgical technique for femoral component revision through the extensile DAA. The surgical anatomy, patient positioning, sequential capsular releases, femoral elevation techniques, tensor fascia lata (TFL) snip, proximal and distal extensions, interbundle technique, extended trochanteric osteotomy, and anterior femoral corticotomy are presented in detail. Technical pearls that facilitate safe femoral exposure while preserving the abductor mechanism and minimizing neurovascular injury are highlighted. Practical strategies for avoiding intraoperative complications, including protection of the lateral femoral cutaneous nerve, preservation of vascular pedicles, and prevention of iatrogenic femoral fractures, are also discussed. When performed by surgeons experienced with the DAA, the extensile anterior approach provides reproducible exposure for complex femoral revision while maintaining the advantages of a muscle-preserving surgical interval. Familiarity with extensile techniques and meticulous soft tissue handling are essential for successful application. This technical guide aims to provide a practical framework for surgeons performing femoral revision arthroplasty through the direct anterior approach.