Management of Intraoperative Fractures During Primary Direct Anterior Total Hip Arthroplasty.

Abstract

Direct anterior approach (DAA) total hip arthroplasty has seen increased adoption in the United States, although utilization varies globally with posterior approaches remaining prevalent in many regions. The muscle-sparing interval and potential for early functional recovery have contributed to its use; however, DAA introduces distinct technical challenges, particularly with femoral exposure and implant positioning. Intraoperative fractures, although relatively uncommon, represent a clinically important complication affecting both the acetabulum and the femur. Effective management requires early recognition, careful assessment of implant stability, and a structured, approach-specific decision-making strategy. Stable constructs may be managed with observation or supplemental fixation, whereas unstable implants often require revision techniques, extensile exposure, or alternative surgical approaches. This review outlines DAA-specific risk factors, mechanisms of injury, and evidence-based management strategies for intraoperative acetabular and femoral fractures, with emphasis on practical intraoperative decision making to restore stability and optimize outcomes.