Comparison of Early Functional Recovery After Total Hip Arthroplasty Using a Direct Anterior or Posterolateral Approach: A Randomized Controlled Trial

Background

Controversy exists as to whether early functional outcomes differ after total hip arthroplasty performed using the direct anterior approach (DAA) or the posterolateral approach (PLA).

Component Placement in Direct Lateral vs Minimally Invasive Anterior Approach in Total Hip Arthroplasty: Radiographic Outcomes From a Prospective Randomized Controlled Trial

BackgroundEnd-stage coxarthrosis is increasingly common; however, limited evidence exists on the effect of direct lateral approach (DLA) and minimally invasive direct anterior approach (MIDA) on component placement in total hip arthroplasty (THA). We therefore conducted a prospective, randomized controlled trial to determine the component placement in DLA vs MIDA in THA.MethodsBetween January 2012 and June 2013, 164 patients with clinically and radiologically confirmed coxarthrosis aged 20-80 years were randomized to either DLA or MIDA (active comparator). Excluded were patients with previous ipsilateral hip surgery, a body mass index >35 kg/m², and/or mental disability. Primary clinical outcomes have been published elsewhere. Secondary outcomes included radiographic assessment of the acetabular component (cement-mantle thickness, inclination, and anteversion), femoral stem position (varus/valgus and THA index), offset restoration, and leg length discrepancy.ResultsThe mean cement-mantle was significantly thicker in zone 1 in the MIDA group (mean difference = 0.51 mm, 95% confidence interval [CI] 0.09-0.93, P = .018), and the mean degrees of inclination and anteversion were higher in the MIDA group (mean difference = 2.5°, 95% CI 0.3-4.6, P = .023 and mean difference = 3.6°, 95% CI 2.2-5.0, P < .0001, respectively). According to the defined reference range, cup inclination was more often adequate in the DLA group (67.9% (53/78) in the DLA group vs 52.4% (43/82) in the MIDA group, P = .045). There were no differences in frontal or lateral femoral stem position, global offset restoration, or leg length discrepancy.ConclusionIn this population of Norwegian patients with coxarthrosis, radiographic assessment showed limited differences in component placement between MIDA and DLA. The findings suggest that component placement is similar in the 2 surgical approaches.     

Comparison of Postoperative Outcomes Between Traditional Longitudinal Incision and Bikini Incision in Total Hip Arthroplasty via Direct Anterior Approach: A Randomized Controlled Trial

BackgroundThe purpose of this study is to compare a traditional longitudinal incision to an oblique “bikini” incision during total hip arthroplasty (THA) via direct anterior approach (DAA), in terms of the aesthetic appearance of the scar, postoperative functional recovery, and complications.MethodsThis study is a single-surgeon experience in the Chinese population. Patients who came to our institute needing a THA via DAA were enrolled in our randomized controlled trial and randomly allocated to undergo traditional longitudinal incision (control) or bikini incision. Primary outcomes were measured using the scar cosmesis assessment and rating scale, the visual analog scale for pain, Oxford hip score, and University of California Los Angeles activity-level rating. Secondary outcomes were postoperative serum markers of muscle damage, inflammation, hemoglobin drop, and implant stability. The occurrence of postoperative complications, such as nerve and wound healing, was also recorded.ResultsThere were no differences in demographic or clinical characteristics before surgery. A greater proportion of patients in the bikini group were satisfied with the appearance of their scar, giving significantly better scar cosmesis assessment and rating scores. There was no difference in postoperative functional recovery, levels of serum markers, or positioning of the implant components. Incision type had no effect on duration of hospitalization. The incidence of complications did not differ significantly between groups.ConclusionThe bikini incision can improve patients’ subjective satisfaction with scar aesthetics after THA via DAA and does not detract from a quick functional recovery. Studies with larger sample sizes should be conducted to further investigate associated complications.The Clinical Trial Registration NumberChiCTR1900022870.     

MAASH Technique for Total Hip Arthroplasty: A Capsular Work

Background

Dislocation and leg length discrepancy are major complications following total hip arthroplasty (THA). Many surgical approaches for THA have been described, but none suggest a capsular incision that assures good exposure while maintaining adequate capsule integrity in closure.

Purposes

Modified anterolateral approach for stable hip (MAASH) is a modification of the classical Hardinge approach, but specifically preserves the anterior iliofemoral lateral ligament and pubofemoral ligament excising the “weak area” of the capsule, in the so called “internervous safe zone” and introducing the “box concept” for the anterior approach to the hip. This is the main difference of the MAASH approach. This technique can be used as a standard for all THA standard models, but we introduce new devices to make it easier.

Methods

From November 2007 to May 2012, data were collected for this observational retrospective consecutive case study. We report the results of 100 THA cases corresponding to the development curve of this new concept in THA technique.

Results

MAASH technique offers to hip surgeons, a reliable and reproducible THA anterolateral technique assuring accurate reconstruction of leg length and a low rate of dislocation. Only one dislocation and six major complications are reported, but most of them occurred at the early stages of technique development.

Conclusion

MAASH technique proposes a novel concept on working with the anterior capsule of the hip for the anterolateral approach in total hip arthroplasty, as well as for hemiarthroplasty in the elderly population with high dislocation risk factors. MAASH offers maximal stability and the ability to restore leg length accurately.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-013-9332-1) contains supplementary material, which is available to authorized users.     

Intraoperative Psoas Compartment Block vs Preoperative Fascia Iliaca Block for Pain Control After Direct Anterior Total Hip Arthroplasty: A Randomized Controlled Trial

Background

Modern joint arthroplasty protocols place an emphasis on minimizing patient-reported postoperative pain while minimizing opioid consumption. The use of multimodal pain management protocols has been reported to improve patient outcomes and satisfaction after total hip arthroplasty.

Incidence of Heterotopic Ossification in Direct Anterior Total Hip Arthroplasty: A Retrospective Radiographic Review

Heterotopic ossification (HO) is a complication following total hip arthroplasty (THA) with traditional approaches. The direct anterior approach (DAA) has become a popular approach for THA; however, no study has evaluated HO formation following DAA THA. We examined the incidence of HO in a consecutive series of THA using the DAA in two separate hospitals. Standard preoperative radiographs were examined to determine the type of degenerative arthritis, and follow-up radiographs of at least 6 months after surgery were evaluated for the presence and classification of HO. The overall incidence of HO after DAA THA in this study was 98/236, or 41.5%, which falls within the reported range from recent studies involving more traditional approaches to the hip.     

Prospective Randomized Study of Two Surgical Approaches for Total Hip Arthroplasty

The benefits of different surgical approaches for total hip arthroplasty continue to be debated. One hundred patients were prospectively enrolled and randomized into 2 groups. One group underwent total hip arthroplasty through a single-incision modified Smith-Peterson approach, whereas the other group underwent total hip arthroplasty through a direct lateral approach. All patients received the same postoperative protocol. Evaluation included operative time, estimated blood loss, analgesia requirement, transfusions, and length of stay. Functional outcome was assessed preoperatively and postoperatively. Up to 1-year follow-up, the direct anterior group demonstrated significantly better improvement in both the mental and physical health dimensions of Short Form-36 and Western Ontario McMaster Osteoarthritis Index compared with direct lateral approach group. At 2 years, the results in both groups were the same.     

The Direct Anterior Approach is Associated With Early Revision Total Hip Arthroplasty

Background

The direct anterior approach for total hip arthroplasty (THA) has generated increased interest recently. The purpose of this study was to compare the duration to failure and reasons for revision of primary THA performed elsewhere and subsequently revised at our institution after the direct anterior vs other nonanterior surgical approaches to the hip.

Cementless Tapered-Wedge Stem Length Affects the Risk of Periprosthetic Femoral Fractures in Direct Anterior Total Hip Arthroplasty

Background

Although the popularity of the direct anterior approach for total hip arthroplasty has increased, the femoral procedure in this approach is considered technically challenging, and one of the most frequent complications reported was periprosthetic femoral fractures. The present study aimed to identify factors for predicting the risk of periprosthetic femoral fractures after using stems with a cementless tapered-wedge design through the direct anterior approach.

Muscle Damage After Total Hip Arthroplasty Through the Direct Anterior Approach for Developmental Dysplasia of the Hip

Background

Total hip arthroplasty (THA) through the direct anterior approach (DAA) is known to cause less muscle damage than other surgical approaches. However, more complex primary cases, such as developmental dysplasia of the hip (DDH), might often cause muscle damage. The objective of the present study was to clarify the muscle damage observed 1 year after THA through the DAA for DDH using magnetic resonance imaging.

Acetabular Total Hip Arthroplasty Revision: A Summary of Operative Factors,Outcomes, and Comparison of Approaches

BackgroundRevision total hip arthroplasty (THA) presents a greater risk to patients than primary THA, and surgical approach may impact outcomes. This study aimed to summarize acetabular revisions at our institution and to compare outcomes between direct anterior and posterior revision THA.MethodsA series of 379 acetabular revision THAs performed from January 2010 through August 2022 was retrospectively reviewed. Preoperative, perioperative, and postoperative factors were summarized for all revisions and compared between direct anterior and posterior revision THA.ResultsThe average time to acetabular revision THA was 10 years (range, 0.04 to 44.1), with mechanical failure (36.7%) and metallosis (25.6%) being the most prevalent reasons for revision. No differences in age, body mass index, or sex were noted between groups. Anterior revision patients had a significantly shorter length of stay (2.2 versus 3.2 days, P = .003) and rate of discharge to a skilled nursing facility (7.5 versus 25.2%, P = .008). In the 90-day postoperative period, 9.2% of patients returned to the emergency department (n = 35) and twelve patients (3.2%) experienced a dislocation. There were 13.2% (n = 50) of patients having a rerevision during the follow-up period with a significant difference between anterior and posterior approaches (3.8 versus 14.7%, respectively, P = .049).ConclusionThis study provides some evidence that the anterior approach may be protective against skilled nursing facility discharge and rerevision and contributes to decreased lengths of stay. We recommend surgeons select the surgical approach for revision THA based on clinical preferences and patient factors.     

Prospective Randomized Study of Direct Anterior vs Postero-Lateral Approach for Total Hip Arthroplasty

Benefits of a direct anterior approach (DAA) versus a posterior-lateral (PA) approach to THA were assessed in a single-surgeon, IRB-approved, prospective, randomized clinical study. Subjects (43 DAA and 44 PA) were evaluated at 6 weeks, and 3, 6 and 12 months. The primary end point was ability to climb stairs normally and walk unlimited at each time point. Secondary end points included assessment by several outcome instruments. DAA subjects performed better during the immediate post-operative period; they had lower VAS pain scores on the first post-operative day, more subjects climbing stairs normally and walking unlimited at 6 weeks, and higher HOOS Symptoms scores at 3 months. There were no significant differences between groups at later time points. Findings confirm previous reports of benefits of DAA versus PA in early post-operative phases.     

In-Hospital Morbidity and Postoperative Revisions After Direct Anterior vs Posterior Total Hip Arthroplasty

Background

The direct anterior approach (DAA) offers the potential for less soft tissue insult, improved early recovery, and reduced dislocation rates. However, complications are associated with the DAA, particularly during the learning curve. We compare the DAA learning curve experience with the posterior approach regarding in-hospital complications and revision rate.

Distal Extension of the Direct Anterior Approach to the Hip: A Cadaveric Feasibility Study

Background

The direct anterior approach (DAA) is becoming more popular as the standard surgical approach for primary total hip arthroplasty. However, femoral complications of up to 2.8% have been reported. Therefore, it is important for surgeons to understand the periarticular neurovascular anatomy in order to safely deal with intraoperative complications.

Early Outcome Comparison Between the Direct Anterior Approach and the Mini-Incision Posterior Approach for Primary Total Hip Arthroplasty: 150 Consecutive Cases

This study evaluated early postoperative results of 150 consecutive primary total hip arthroplasties performed by a single surgeon; 50 from mini-incision posterior approach, 50 during the learning curve for the direct anterior approach, and 50 subsequent cases when the approach was routine. The anterior approach groups had significantly reduced hospital length of stays (2.9 and 2.7 days versus 3.9 days for the posterior group; P < 0.0001) and discharge to home versus rehab was more likely (80% and 84% in anterior groups, 56% in posterior group; P = 0.0028). In the anterior groups, there was significantly less use of assistive devices and narcotics at 6 weeks, and pain was significantly lower. Primary total hip arthroplasty using the anterior approach allows for superior recovery in a matched cohort of patients.     

A Comparison of Risk of Dislocation and Cause-Specific Revision Between Direct Anterior and Posterior Approach Following Elective Cementless Total Hip Arthroplasty

BackgroundUse of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased over the last decade. We sought to investigate whether (1) a difference exists in dislocation risk for DAA compared with posterior THA, (2) a difference exists in risk for specific revision reasons, and (3) the likelihood of adverse 90-day postoperative events differs.MethodsWe conducted a cohort study using data from Kaiser Permanente’s Total Joint Replacement Registry. Patients aged ≥18 years who underwent primary cementless THA for osteoarthritis with a highly cross-linked polyethylene liner were included (2009-2017). Multivariable Cox proportional hazards regression was used to evaluate dislocation and cause-specific revision risks, and multivariable logistic regression was used to evaluate 90-day emergency department visits, 90-day unplanned readmissions, and 90-day complications (including deep infection, deep vein thrombosis, and pulmonary embolism).ResultsOf 38,399 primary THA, 6428 (16.7%) were DAA. All-cause revision at 2-years follow-up was 1.78% (95% confidence interval [CI] = 1.46-2.17) for DAA and 2.28% (95% CI = 2.11-2.45) for posterior. After adjusting for covariates, DAA had a lower risk of dislocation (hazard ratio [HR] = 0.39, 95% CI = 0.29-0.53), revision for instability (HR = 0.33, 95% CI = 0.18-0.58), revision for periprosthetic fracture (HR = 0.57, 95% CI = 0.34-0.96), and readmission (odds ratio = 0.82, 95% CI = 0.67-0.99) compared with posterior approach but a higher risk of revision for aseptic loosening (HR = 2.26, 95% CI = 1.35-3.79).ConclusionWhile the DAA associated with lower risks of dislocation and revision for instability and periprosthetic fracture, it is associated with a higher revision risk for aseptic loosening. Surgeons should discuss these risks with their patients.     

Hospital Adverse Events and Perioperative Outcomes in Bilateral Direct Anterior Approach Total Hip Arthroplasty

BackgroundPerioperative hospital adverse events represent a significant outcome that is often overlooked. Even “minor events” such as fever or tachycardia may lead to significant costs due to workup tests, interconsultations, and/or increased length of stay (LOS). The optimal timing of bilateral direct anterior approach total hip arthroplasty (DAA-THA) remains unsettled. Consequently, we wanted to compare hospital LOS, discharge disposition, hospital adverse events (major and minor), and transfusion rates between simultaneous and staged bilateral DAA-THA.MethodsA retrospective chart review was conducted on a consecutive series of 347 primary bilateral DAA-THAs (204 patients) performed by 2 surgeons in a single institution (2010-2016). The hips finally included were categorized as simultaneous (Sim-n = 61), staged 1 (Stg1-n = 143), or staged 2 (Stg2-n = 143). We also compared simultaneous with staged surgeries performed ≤1 and >1 year apart. Baseline demographics, LOS, discharge disposition, hospital adverse events, and transfusions were assessed.ResultsThe simultaneous group had significantly younger patients and a higher proportion of males when compared with the staged groups and showed significant longer LOS [2.61 (Sim) vs 2.06 (Stg1) vs 1.63 (Stg2) days, P < .001], lower proportion of home discharge [77% (Sim) vs 91.6% (Stg1) vs 96.5% (Stg2), P < .001], as well as higher (overall) rate of adverse events [31.1% (Sim) vs 28.7% (Stg1) vs 14.0% (Stg2), P = .003] and transfusions [45.9% (Sim) vs 6.3% (Stg1) vs 7.0% (Stg2), P < .001]. However, most transfusions were autologous [37.7% (Sim) vs 3.5% (Stg1) vs 0% (Stg2), P < .001].ConclusionOur data show that bilateral DAA-THAs performed in a staged fashion, rather than simultaneously, have a shorter hospital LOS and decreased rates of adverse events and overall transfusions. Notwithstanding, simultaneous surgery should still be considered an option in selected patients.Level of EvidenceLevel III.     

Psoas Compartment Block vs Periarticular Local Anesthetic Infiltration for Pain Management After Anterior Total Hip Arthroplasty: A Prospective,Randomized Study

Background

The psoas compartment block (PCB) or periarticular soft-tissue local anesthetic injection are forms of regional anesthesia often used as one of the components in multimodal anesthesia applied during total hip arthroplasty (THA). The most efficacious form of regional anesthesia for THA has yet to be determined.