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).

Hip Abductor Strengths After Total Hip Arthroplasty Via the Lateral and Posterolateral Approaches

A retrospective control study was carried out to compare the postoperative hip abductor strengths after primary total hip arthroplasties via the lateral (lateral group; 38 hips) and posterolateral (posterior group; 40 hips) approaches. At a minimum of 2 years after total hip arthroplasty, abductor muscle strength was evaluated qualitatively by the Trendelenburg test and quantitatively using a dynamometer. The ratio of normalized strength of the reconstructed side to that of the nonoperated side was calculated (strength ratio). The Trendelenburg test was positive in 10 of 38 patients in the lateral group and in 11 of 40 patients in the posterior group. The average strength ratios of the lateral and posterior groups were 86.1% and 87.3%, respectively (P = .67). Strength ratio was positively correlated to femoral offset within both groups.     

No Differences in Midterm Sports Participation or Functional Scores After Total Hip Arthroplasty by Posterolateral Vs Anterolateral Approach

BackgroundPatients undergoing total hip arthroplasty (THA) frequently question surgeons on return to sports. We compared midterm sports participation and functional scores after THA by posterolateral approach (PLA) vs anterolateral approach (ALA).MethodsOf 1381 patients who underwent uncemented ceramic-on-ceramic THA for primary osteoarthritis, 503 were excluded because of preoperative or postoperative lower limb surgery, leaving 594 operated by PLA and 284 by ALA. Forgotten Joint Score (FJS), Oxford Hip Score (OHS), satisfaction, as well as motivation, participation, and discomfort regarding 22 sports were collected. A 1:1 matching was performed to obtain 2 groups of PLA and ALA patients with similar age, gender, body mass index, and sports motivation.ResultsMatching yielded 2 equal groups of 259 patients. There were no significant differences in FJS (P = .057), OHS (P = .685), satisfaction (P = .369), or rates of participation in light (P = .999), moderate (P = .632), or strenuous sports (P = .284). Participation in strenuous sports was reported by 50 PLA (19%) and 61 ALA (24%) patients, with differences for downhill skiing (22 vs 39), running (10 vs 19), and cross-country skiing (18 vs 10). More than 50% of motivated patients practiced most of their sports. Severe discomfort was reported similarly in PLA and ALA patients, mainly during running (13 vs 11), team ball games (9 vs 7), and downhill skiing (7 vs 8).ConclusionThere were no significant differences between PLA and ALA patients in terms of OHS, FJS, satisfaction, or sports participation rates. There is little or no evidence to promote an approach based on sports participation or functional improvement.Level of EvidenceLevel III, comparative study.     

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.     

Length of Stay,Discharge Disposition,and 90-Day Complications and Revisions Following Primary Total Hip Arthroplasty: A Comparison of the Direct Anterior,Posterolateral, and Direct Superior Approaches

BackgroundThe direct anterior (DA) approach is becoming increasingly popular for primary total hip arthroplasty (THA). The aim of this study is to evaluate early postoperative complication and revision rates based on surgical approach, comparing DA, posterolateral (PL), and direct superior (DS) approaches.MethodsAfter institutional review board approval, a total joint arthroplasty database from a single institution was used to identify all patients who underwent elective primary THA between July 2013 and November 2017 with a DA, PL, or DS hip approach. Patients were followed for complications out to 90 days postsurgery. Patients were divided into groups based on surgical approach and compared on length of stay, discharge disposition, and 90-day complication and revision rates.ResultsThere were 5341 THA procedures performed, with 3162 PL, 1846 DA, and 333 DS approaches. Length of stay was shorter for DS (1.7 ± 0.9 days) and DA (1.8 ± 0.9 days) than for PL approaches (2.3 ± 1.4 days, P < .001) The DS approach had the highest rate of home discharges (93.1%), but the highest short-term revision rate (1.5%, P = .011). The DA approach had the lowest intraoperative fracture rate (0.1%, P = .019) but the highest incidence of postoperative fractures (1.3%, P = .021). There were no differences in readmission (P = .056), 90-day events (P = .062), emergency department visits (P = .210), dislocations (P = .090), combined perioperative fractures (P = .289), venous thromboembolic events (P = .059), or acute infection rates (P = .287).ConclusionIn the era of bundled payments, the DA, PL, and DS approaches can all be effectively used.Level of EvidenceLevel III; retrospective comparative study.     

Similar Improvement in Gait Parameters Following Direct Anterior & Posterior Approach Total Hip Arthroplasty

We compared gait parameters prior to, at 6 months and 1 year following total hip arthroplasty (THA) performed via direct anterior approach (DAA) and posterior approach (PA) by a single surgeon in 22 patients. A gait analysis system involving reflective markers, infrared cameras and a multicomponent force plate was utilized. Postoperatively, the study cohort demonstrated improvement in flexion/extension range of motion (ROM) (P = 0.001), peak flexion (P = 0.005) and extension (P = 0.002) moments with no differences between groups. Internal/external ROM improved significantly in the DAA group (P = 0.04) with no change in the PA group. THA performed via DAA and PA offers similar improvement in gait parameters with the exception of internal/external ROM which might be related to the release and repair of external rotators during PA THA.     

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.

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.

Driving Simulator Brake Reaction Parameters After Total Hip Arthroplasty According to Different Surgical Approaches

BackgroundThe aim of this study is to validate the point of normalization of braking following total hip arthroplasty (THA) and to determine the relevance of the surgical approach.MethodsBrake reaction parameters (BRPs), including brake reaction time, total brake time, and brake pedal depression force were measured in 90 patients who underwent primary arthroplasty of the right hip (42 with direct anterior approach and 48 with posterolateral approach) using a modern driving simulator. The driving parameters were measured preoperatively and every 2 weeks postoperatively until the eighth week. BRPs were measured in 40 subjects without hip problems, and the results were used as a control. Statistical assessment was performed to analyze when the patients’ reaction to braking recovered to that of the control group with respect to different surgical approaches and also according to the pain.ResultsPreoperative BRPs of the patients undergoing THA were prolonged compared to the control group and were normalized at the sixth week following the operation. Although BRPs of the direct anterior approach group showed significantly better improvement compared to the posterolateral approach group (total brake time at week 2, brake reaction time and brake pedal depression at week 4), both groups reached baseline value at week 6. In addition, we found no correlation between the pain score and BRPs.ConclusionThe results of the current study indicate that the response to braking events normalizes at 6 weeks following THA in young active patients and is irrelevant to the surgical approach.     

A Comparison of Radiographic Outcomes After Total Hip Arthroplasty Between the Posterior Approach and Direct Anterior Approach With Intraoperative Fluoroscopy

Background

Radiographic outcomes after total hip arthroplasty (THA) have been linked to clinical outcomes. The direct anterior approach (DAA) for THA has been criticized by some for providing limited exposure and compromised implant position but allows for routine use of intraoperative fluoroscopy. We sought to determine whether radiographic measurements differed by THA approach using prospective cohorts.

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.     

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.     

Direct Anterior Approach for Primary Total Hip Arthroplasty Lowers the Risk of Dislocation Compared to the Posterior Approach: A Single Institution Experience

BackgroundOne purported benefit of the direct anterior approach (DAA) for total hip arthroplasty (THA) is a lower rate of postoperative dislocation.MethodsAn institutional database was used to identify 8840 primary THAs performed from 2003 to 2020 including 5065 (57%) performed using the DAA and 3775 (43%) performed via the posterior approach (PA). Direction and mechanism of dislocation were determined from chart review. Outcomes were compared using Kaplan-Meier survivorship with dislocation as the endpoint and a Cox multivariate regression was used to investigate factors associated with dislocation. The mean follow-up was 1.7 ± 2.0 years for the DAA and 3.1 ± 3.3 years for the PA.ResultsThe 0.5% (26/5065) incidence of dislocation among DAA hips was significantly less than the 3.3% (126/3775) among PA cases (P < .001). The majority of dislocations were posterior (DAA 57%, PA 79%) and occurred during activities of daily living (DAA 82%, PA 77%). Five-year survivorship was significantly higher for the DAA group compared to the PA group (99.1% vs 95.4%, P < .001). Dislocation risk was 4.9 times higher for the PA compared to the DAA (hazard ratio = 4.9, 95% confidence interval = 3.2-7.5, P < .001). Increasing head diameter reduced the risk (hazard ratio = 0.70, 95% confidence interval = 0.57-0.86, P < .001). The 0.2% incidence (10/5065) of revision for instability among the DAA group was significantly lower than the 1.1% (43/3775) rate for the PA group (P < .001).ConclusionCompared to primary THAs performed with the PA, DAA cases had a lower risk of dislocation, higher survivorship with dislocation as an endpoint, and a lower risk of revision for instability in this single institution cohort.     

Heterotopic Ossification in Primary Total Hip Arthroplasty Using the Direct Anterior vs Direct Lateral Approach

Background

The formation and severity of heterotopic ossification (HO) may be influenced by type of surgical approach. Our hypothesis was that because of differences in soft tissue dissection, differences exist in HO formation in primary total hip arthroplasty using direct anterior (DA) vs direct lateral (DL) approach.

Risk Factors for Iliopsoas Tendinopathy After Anterior Approach Total Hip Arthroplasty

BackgroundIliopsoas tendinopathy is a cause of groin pain following total hip arthroplasty (THA). With the anterior approach becoming increasingly popular, our aim was to determine the prevalence of iliopsoas tendinopathy following anterior approach THA, to identify risk factors and to determine an influence on patient-reported outcomes.MethodsThis is a retrospective case-control study of prospectively recorded data on 2,120 primary anterior approach THA (1,815 patients). The diagnosis of iliopsoas tendinopathy was based on (1) persistent postoperative groin pain, triggered by hip flexion; (2) absence of dislocation, infection, loosening, or fracture; and (3) decrease of pain after fluoroscopy-guided iliopsoas tendon sheet injection with xylocaine and corticosteroid. Outcomes included hip reconstruction (inclination/anteversion and leg-length), complication rates, reoperation rates, and patient-reported outcomes including Hip disability and Osteoarthritis Outcome Score.ResultsForty four patients (46 THAs) (2.2%) were diagnosed with iliopsoas tendinopathy. They were younger than patients who did not have iliopsoas tendinopathy (51 years [range, 27-76] versus 62 years [range, 20-90]; P < .001). Logistic regression analyses demonstrated that younger age (P < .001) and presence of a spine fusion (P = .008) (odds ratio 4.6) were the significant predictors of iliopsoas tendinopathy. These patients had lower Hip disability and Osteoarthritis Outcome scores, reported more often low back pain (odds ratio 4.8), and greater trochanter pain (odds ratio 5.4).ConclusionWe found an incidence of 2.2% of iliopsoas tendinopathy patients after anterior approach THA that compromised outcomes. Younger age and previous spine fusion were identified as most important risk factors. These patients were 5 times more likely to report low back pain and greater trochanter pain post-THA.     

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.

Procedure Duration,Time Under Anesthesia,and Readmissions in Direct Anterior and Posterior Approach Total Hip Arthroplasty

BackgroundOperative time is related to complications in primary total hip arthroplasty (THA). This study compared operative time in direct anterior (DA) and posterior approach THA and whether differences were related to increased hospital readmissions within 90 days of discharge.MethodsProspectively documented data on 3,152 consecutively performed THAs by 16 surgeons at a large Midwestern United States academic healthcare system were retrospectively reviewed. All surgeons were beyond their learning curve. Cases characterized by factors extending operative time were excluded. A total of 1,235 analysis cases were performed with the DA approach and 1,608 with the posterior approach. DA patients had lower mean body mass index (P < .001), were more likely to be classified as American Society of Anesthesiologists Physical Status 1 or 2 (P < .001), and more likely to have surgery in an ambulatory setting (P < .001).ResultsTime under anesthesia was significantly longer for DA procedures by 19 to 27 minutes in hospital and ambulatory settings, respectively (P < .001). Increasing body mass index had a greater impact on anesthesia time for DA patients (P = .020). There were no differences in nontraumatic readmissions within 90 days of surgery based on surgical approach (P ≥ .480); however, significantly more DA patients classified as ASA-PS 3 or 4 were readmitted compared to those classified as ASA-PS 1 or 2 (P < .001), a difference not observed for posterior approach patients.ConclusionAnesthesia time is a modifiable risk factor for patient safety and an important factor in healthcare resource utilization. Consideration of ways to reduce DA operative times is encouraged.     

The Anatomical Course of the Superior Gluteal Nerve With Regard to the Direct Anterior Approach for Primary and Revision Total Hip Arthroplasty

BackgroundDuring primary and revision total hip arthroplasty (THA) lesions of the superior gluteal nerve (SGN) can substantially compromise patient outcome. For the primary direct anterior approach (DAA) and its proximal approach extensions, especially the muscular branch entering the tensor fasciae latae (TFL) muscle is at risk. SGN lesions can result in fatty atrophy and functional loss of the TFL. Therefore, the course and branching pattern of the SGN were examined and related to the DAA and its proximal approach extension. The aim of the study is to describe safe and danger zones for the SGN with regard to the DAA and its proximal extensions.MethodsTwenty-five formalin-fixed cadavers with 48 hemipelves were dissected. The course, distribution, and branching pattern of the SGN and its muscular branch inserting into the TFL muscle were investigated with regard to the DAA with the help of anatomical landmarks like the greater trochanter and the iliac tubercle.ResultsIn 72.9% of the specimens the SGN passed the greater sciatic foramen superior to the piriformis muscle with one main trunk. The muscular branch of the SGN supplying the TFL divided from the main branch in 89.6% of the specimens at the level of the greater sciatic foramen. Before entering the TFL muscle the muscular branch showed a variable branching pattern in the interval between the gluteus medius and minimus. A danger zone for the SGN with regard to the DAA was found in the proximal fourth of the skin incision.ConclusionSpecial care in proximal instrument placement should be taken during the DAA. When extending the DAA proximally manipulations in the proximal, caudal surgical window should be performed with the utmost care.