Direct Anterior Approach for Total Hip Arthroplasty in the Elderly with Femoral Neck Fractures: Comparison with Conventional Posterolateral Approach

BackgroundThe aim of this study was to determine if it was feasible and safe to perform total hip arthroplasty (THA) using the direct anterior approach (DAA) when compared with the conventional posterolateral approach (PA) in patients with femoral neck fractures. The time required to start walking was investigated to identify advantages of the muscle-sparing approach. Safety of the approach was judged based on the incidence and nature of all complications.MethodsWe retrospectively reviewed 67 THA cases due to femoral neck fractures from October 2015 to January 2019. The PA was used in 31 cases, and the DAA was used in 36 cases. The average operative time and amount of bleeding were evaluated. Cup inclination, anteversion, and leg length discrepancy (LLD) were also measured on radiographs. The time to start walking and complications (e.g., intraoperative fracture, infection, and dislocation) were recorded.ResultsThe mean operative time was 84.35 ± 13.95 minutes in PA group and 99.22 ± 20.33 minutes in DAA group (p = 0.010). But after experiencing 20 cases using the DAA, there was no statistically significant difference in the operative time between the groups. The mean volume of bleeding was 428.73 ± 207.26 mL in the PA group and 482.47 ± 150.14 mL in the DAA group. There was no difference in the acetabular cup position between two groups. Ambulation was started at 3.94 days after surgery on average in the PA group and 3.14 days in the DAA group, showing a statistically significant difference. Intraoperative fracture and infection were not observed in either group. The incidence of LLD was 1 in each group. The dislocation rate was 3.2% (1 case) in the PA group and 5.5% (2 cases) in the DAA group.ConclusionsAlthough the DAA for THA was similar to the PA in terms of operative time, volume of bleeding, and complications, the DAA showed a great advantage in early rehabilitation as a muscle-sparing procedure in the elderly with femoral neck fractures.     

Intraoperative Complications and Early Return to the Operating Room in Total Hip Arthroplasty Performed Through the Direct Anterior and Posterior Approaches. An Institutional Experience of Surgeons After Their Learning Curve

BackgroundProponents of the direct anterior approach (DAA) for total hip arthroplasty (THA) claim a faster recovery, whereas critics claim an increased risk of early femoral complications. This study analyzed intraoperative and postoperative complications requiring reoperation within one year after THA through the DAA and posterior approach (PA).MethodsA total of 2348 elective, unilateral DAA THAs in patients with osteoarthritis performed between 2016 and 2019 were matched 1:1 for age (±5 years), gender, body mass index (±5), and femoral fixation with 2348 patients who underwent PA THA during the same period. Mixed-effects logistic regression was used. Odds ratios were reported for the occurrence of intraoperative femoral fracture, postoperative femoral fracture, infection, dislocation, and other etiologies requiring reoperation within one year.ResultsIntraoperative femoral fracture occurred in 12 DAA (0.5%) and 14 PA (0.6%) patients. Twenty-five patients (1.06%) in the DAA and 28 (1.19%) in the PA group underwent reoperation within the first year. Reoperations were due to periprosthetic fracture (40%), infection (28%), dislocation (23%), and other (9%). Regression analysis revealed no difference in intraoperative femoral fracture (odds ratio (OR): 0.86, 95% confidence interval (CI): 0.40-1.86, P = .69), postoperative femoral fracture (OR: 1.10, 95% CI: 0.47-2.60, P = .83), infection (OR: 1.50, 95% CI: 0.53-5.23, P = .44), or reoperation within one year for other reasons (OR: 1.50, 95% CI: 0.25-9.00, P = .65). DAA had fewer dislocations requiring reoperation (OR: 0.20, 95% CI: 0.04-0.91, P = .02).ConclusionThis comparative study did not find differences in intraoperative or postoperative fracture or infection between DAA and PA. DAA was associated with a lower likelihood of reoperation for dislocation within one year of surgery.     

Use of Dual Mobility Acetabular Component and Anterior Approach in Patients With Displaced Femoral Neck Fracture

BackgroundAlthough the antidislocation effect of total hip arthroplasty (THA) via the direct anterior approach (DAA) with dual mobility cup (DMC) for displaced femoral neck fracture (FNF) has already been reported, the clinical result of DMC-DAA-THA for displaced FNF in terms of mortality, complications, and walking ability are still unclear.Methods106 cases with DMC-DAA-THA for displaced FNF were investigated of dislocation; perioperative complications; 3-, 6-, and12-month mortality rate; and pre/early postoperative walking ability. The walking ability was stratified into the following four categories: (1) use of a wheelchair (no walking), (2) walking alongside a support (including walkers designed for the elderly), (3) walking using one stick, and (4) unaided walking.ResultsThere was no dislocation withing one-year postoperative. The 3-, 6-, and 12-month mortality rate was 2.8%, 4.7%, and 5.7%. Total complications occurred in 14 cases (14.7%). Although there was no revision surgery, two cases (1.9%) of intraoperative fracture treated without additional fixation, and one case of postoperative fracture was occurred. Among patients with preinjury walking category 2, 3, and 4 (total 94 cases), the number of patients who recovered same walking category at two-week postoperation was 56 cases (59.6%).ConclusionsOur study demonstrated that DMC-DAA-THA for displaced FNF offered quick recovery of walking ability with no dislocation and low one-year mortality rate. We believe that the combination of early postoperative recovery due to the minimal invasiveness of the DAA and decreased dislocation rate due to increased range of motion by DMC and adequate soft tissue tension by DAA contributed to null dislocation.     

Acetabular and Femoral Component Positioning Using Direct Anterior Approach Versus Posterior Approach in Total Hip Arthroplasty

PurposeDirect anterior approach (DAA) has recently become popular in total hip arthroplasty (THA). However, irrespective of the surgical approach used, component malposition is an important factor affecting function and complications after THA. This study aims to compare component positioning on the femoral and acetabular side between DAA and posterior approach (PA) to the hip joint. We hypothesized that the two approaches are similar in terms of component positioning.MethodsWe prospectively studied 50 patients, matched according to age, sex, and body mass index, undergoing THA, divided non-randomly into 2 groups. Group 1 comprised 25 patients (35 hips) undergoing THA using DAA and group 2 comprised 25 patients (25 hips) undergoing THA using PA. Ten patients from group 1 had simultaneous bilateral THA. Radiological parameters studied were acetabular inclination (AI), coronal femoral stem alignment (CFA), leg length difference (LLD), acetabular cup version (AV), and femoral stem version (FV).ResultsThere was no significant difference in AI, CFA, LLD, AV, and FV between the two groups. Excellent to good inter and intra-observer reliability expressed in terms of intraclass correlation coefficient (ICC) was noted for all the radiographic measurements.ConclusionBoth DAA and PA for THA achieve comparable radiological component positioning. DAA may not provide any advantage over PA in terms of positioning of the prosthesis.Level of EvidenceLevel II, non-randomized comparative study.     

直接前侧入路与后外侧入路全髋关节置换术的疗效比较

目的 比较直接前侧入路(DAA)与后外侧入路(PA)行全髋关节置换术(THA)的疗效.方法 将60例行THA患者按随机数字表法分为PA组和DAA组,每组30例.比较两组切口长度、术中出血量、手术时间、住院时间、下床时间、部分负重锻炼时间和术后并发症情况.术后6、12个月采用髋关节Harris评分标准评价髋关节功能.结果...     

Outpatient Hip Safety in an Ambulatory Surgery Center Is Independent of Approach

BackgroundThere are few data comparing the direct anterior approach (DAA) and posterior approach (PA) for total hip arthroplasty (THA) in the outpatient setting. The purpose of this study is to compare 90-day complications between the 2 approaches. We hypothesized that they would be equally safe and effective.MethodsRetrospective review identified 432 THAs (346 DAA, 86 PA) performed at a single ambulatory surgery center (ASC). Outcomes compared included demographics, comorbidities, preoperative and discharge pain scores (visual analog scale [VAS]), overall time spent in the ASC, overnight stay, emergency room visits, admission, reoperation, and complications within a 90-day period.ResultsThere were no differences in mean preoperative VAS (DAA 4.7, PA 4.5), mean discharge VAS (DAA 0.8, PA 0.7), overall time spent in the ASC (DAA 9.0 hours, PA 9.3 hours), total number of overnight stays (DAA 0.9%, PA 1.2%), emergency room visits (DAA 1.7%, PA 1.2%), admissions (DAA 1.4%, PA 1.2%), reoperations (DAA 1.4%, PA 1.2%), or complications (DAA 3.5%, PA 2.3%).ConclusionThere were no differences in the safety outcomes, and overall there were few complications in the 90-day period, regardless of the surgeon’s preferred approach. This study indicates both DAA and PA are equally safe for THA in the outpatient setting, and the choice of surgical approach should be based on patient and surgeon preference.     

老年患者不同部位的髋部骨折对预后的影响

目的:研究骨折部位对老年髋部骨折预后的影响。方法:自2012年1月至2014年12月,共收治髋部骨折患者667例,根据骨折部位将髋部骨折分为股骨转子间骨折组和股骨颈骨折组,其中股骨转子间骨折组304例,男96例,女208例,平均年龄(80.33±7.94)岁;股骨颈骨折组217例,男74例,女143例,平均年龄(79.82±9.33)岁。比较两组患者入院资料、术后死亡率及独立生活能力的差异。结果:两组年龄、性别、合并症、ASA分级、麻醉方式差异不明显,但入院至手术等待时间、手术时间、术中出血量、术后引流量以及输血量差异有统计学意义。股骨转子间骨折术前、术后1、3、5 d白细胞计数较高,血红蛋白、白蛋白较低。股骨转子间骨折住院期间、术后1、3、6、12个月内死亡率较股骨颈骨折高,但差异无统计学意义。在存活患者中,出院时、术后1、3个月股骨颈骨折患者日常生活能力较股骨转子间骨折患者恢复更为满意,术后6、12个月,两组患者相比,日常独立生活能力差异无统计学意义。结论:尽管股骨转子间骨折对机体应激较大,但排除年龄、性别、合并症等因素的影响后,股骨转子间骨折和股骨颈骨折术后1年内死亡率差异不明显。和股骨转子间骨折患者相比,股骨颈骨折关节置换后早期功能恢复良好,但手术后1年,两者功能恢复差异不明显。     

微创直接前入路与后外侧入路全髋关节置换术早期疗效的比较

目的探讨微创直接前入路(direct anterior approach,DAA)全髋关节置换术治疗老年股骨颈骨折的价值。方法回顾性比较2016年9月~2017年12月微创DAA人工全髋关节置换术(DAA组)与后外侧入路同时重建外旋肌群(对照组)治疗股骨颈骨折的疗效,观察指标包括手术时间、手术切口长度、术中出血量、术后引流量、下地时间、髋臼外展角、柄假体颈干角、髋臼前倾角、髋臼假体直径、术后72 h疼痛视觉模拟评分(Visual Analogue Score,VAS)以及术后1、6个月Harris髋关节评分(Harris Hip Score,HSS)。结果DDA组手术切口长度(9.5±1.2)mm,明显短于对照组(15.1±1.1)mm(t=-21.920,P=0.00);术后引流量(263.7±115.1)ml,明显少于对照组(428.0±165.8)ml(t=-4.996,P=0.00);术后下地时间(1.9±0.9)d,明显短于对照组(4.6±0.6)d(t=-16.769,P=0.00);术后72 h内VAS评分(2.3±0.5)分,明显小于对照组评分(2.6±0.5)分(t=-2.552,P=0.013);术后1个月HHS评分(75.7±5.9)分,明显高于对照组(70.2±7.1)分(t=3.703,P=0.000);术后6个月2组HHS评分分别为(94.4±2.1)、(93.4±2.3)分,差异无统计学意义(t=1.947,P=0.055)。DAA组1例发生无移位大转子骨折,2个月后恢复,对照组发生1例脱位,并发症发生率分别为2.9%(1/35)、2.2%(1/45),差异无统计学意义(Fisher精确检验,P=1.000)。结论DAA全髋关节置换术治疗股骨颈骨折,手术切口较小,术后疼痛轻,术后首次下地时间早,早期髋关节功能好,早期的临床疗效好。     

Minimally invasive direct anterior approach versus standard lateral approach in the management of tumors of the femoral neck

BackgroundTo compare the clinical outcomes of patients with benign or aggressive tumors of the femoral neck who underwent surgical curettage with the use of the direct anterior approach (DAA) and a standard lateral approach.MethodsThose patients from 2010 to 2017 were retrospectively enrolled. The patients were divided into two groups: group A, consisting of patients who had undergone surgery via the lateral approach; and group B, consisting of patients who had undergone the same procedure via the DAA.ResultsFifty-eight patients were divided into group A (n = 46) and group B (n = 12). The median follow-up was 43 months (15–97 months). There was no significant difference in the 1-year and 3-year recurrence rates (p = 0.74). Group B had comparable operation time and a significantly shorter incision length, less intraoperative blood loss, less postoperative drainage, a shorter hospital stay and less pain on the first postoperative day. Group B also had better hip function as assessed by the Harris Hip Score one month and one year postoperatively. One patient in group B experienced intraoperative incomplete fracture of the femoral neck, which was treated conservatively.ConclusionsSurgical curettage for patients with benign or aggressive tumors of the femoral neck via the DAA had a comparable local control rate and a better perioperative and functional outcome than via the lateral approach. Certain quality of the femoral neck should be required to avoid pathological fracture, which is difficult to treat by internal fixation in the DAA.     

Prognosis of proximal femoral fracture in patients aged 90 years and older

PURPOSE: To examine the walking ability and survival outcome of patients aged 90 years and older who sustained proximal femoral fractures, and to compare the findings with those of younger patients reported in previous studies. METHODS: Between January 1997 and June 2004 inclusive, 56 patients (11 men and 45 women) aged 90 years and older (range, 90-103 years; mean, 93 years) with hip fracture were reviewed. Their walking ability and survival outcome at discharge was investigated. Comparison was made between patients aged 60 to 89 years and those aged 90 years and older with respect to sex, fracture type, and other characteristics. RESULTS: Of 56 patients, 26 injured the right side and 30 the left side. Before injury, 33 (59%) were living at home and 23 (41%) were institutionalised in long-term care facilities or other hospitals. Fracture occurred at the femoral neck in 14 patients and at the trochanter in 42. Ten patients were treated conservatively because of severe dementia, co-morbidity, or refusal of surgery by the patients or their families, whereas 46 underwent surgery. Of the 45 who were previously ambulatory, 22 regained walking ability on discharge from hospital. None of the 10 patients treated conservatively were ambulatory on discharge. During hospitalisation, 4 became bedridden and 5 died (mainly due to pneumonia); among these 9 patients, 5 were deemed physically unfit for surgery. CONCLUSION: Surgery is the treatment of choice for patients aged 90 years and older with proximal femoral fracture. However, they have a lower rate of regaining pre-injury walking ability and a higher in-hospital death rate than younger patients.     

Risk factors for prolonged operative time in femoral neck fracture patients undergoing hemiarthroplasty through direct anterior approach

Background

The use of direct anterior approach (DAA) for hemiarthroplasty in femoral neck fracture patients has recently increased worldwide. However, no previous studies have elucidated or validated risk factors for prolonged operative time in hemiarthroplasty through DAA. Accurately predicting operative time would contribute to and the selection of the most appropriate surgical approach for each patient and the effective use of operating room.

空心钉与髓内钉治疗青壮年股骨颈不稳定骨折的疗效观察

目的分析在直接前侧入路(DAA)辅助下空心螺钉与Intertan髓内固定治疗青壮年移位不稳型股骨颈骨折的临床疗效。 方法回顾分析浙江新安国际医院骨科2014年1月至2016年12月采用DAA入路切开复位治疗青壮年移位不稳定型(Garden Ⅲ、Ⅳ型)股骨颈骨折患者,资料均为GardenⅢ、Ⅳ不稳定型股骨颈骨折,24 h之内完成手术,年龄<60岁且随访资料完整;排除同侧转子间骨折、转子下骨折、股骨干骨折,长期使用大剂量激素或酗酒患者。DAA辅助空心钉螺钉内固定组(空心钉组)90例,DAA辅助Intertan髓内钉固定组(髓内钉组)89例,采用SPSS 21.0统计学软件对数据进行统计学分析。采取t检验和χ²检验比较手术时间、透视次数、出血量、住院日、骨折愈合时间、骨折不愈合及股骨头缺血性坏死率、Harris评分。 结果两组在年龄、性别、Garden分型比较上,差异无统计学意义(均P>0.05),有可比性。空心钉组在手术时间(45.4±15.6)min、透视次数(6.5±3.4)次、出血量(90.5±24.5)ml方面优于髓内钉组[分别为(75.2±12.4)min,(9.3±4.6)次,(159.7±40.2)ml](均为P<0.01);空心钉组在住院日(7.2±2.1)d方面与髓内钉组(8.2±1.3)d没有差异(t＝－1.567,P>0.05)。髓内钉组愈合时间(2.8±0.8)月,短于空心钉组[(3.8±0.7)月,(t＝5.375,P<0.01)]。髓内钉组骨折不愈合、股骨头缺血性坏死4例明显少于空心钉组15例(χ²＝6.005,P<0.05);Harris评分优良率空心钉组低于髓内钉组(χ²＝7.338,P<0.01)。 结论青壮年移位不稳定型股骨颈骨折早期采用DAA辅助入路Intertan髓内固定方法治疗可在直视下完成骨折复位,术后恢复快,骨折愈合率高,股骨头坏死发生率低,疗效满意。     

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.     

直接前入路与其他入路行人工股骨头置换治疗老年股骨颈骨折患者疗效的Meta分析

目的:用Meta分析的方法对国内外已发表较高质量的有关直接前入路(DAA)与其他入路行人工股骨头置换治疗老年股骨颈骨折患者的临床疗效进行系统评价。方法:计算机检索Cochrane Library、PubMed、EMBASE、Web of science、万方、中国知网数据库。检索中英文公开发表的文献。检索时间为建库至2019年5月20日,由2位作者严格按照纳入和排除标准独立筛选文献,提取资料和评价纳入研究质量。应用Cochrane关于RCT偏倚风险评估工具评价纳入的RCT文献质量。non-RCT采用NOS量表评价文献质量。采用Cochrane协作网提供的RevMan 5.3软件对纳入研究结果进行Meta分析,并对数据进行异质性检验。结果:最终纳入文献9篇,总样本量901例。其中DAA组429例,对照组472例。DAA组与对后侧、后外侧入路亚组比较,在脱位率上差异有统计学意义[OR=0.19,95%CI(0.06,0.61),P=0.005],DAA组脱位率更低。与外侧、前外侧入路亚组比较,脱位率无明显差异[OR=1.08,95%CI(0.20,5.76),P=0.93]。在感染率[OR=1.07,95%CI(0.47,2.43),P=0.88]、围手术期骨折率[OR=0.95,95%CI(0.36,2.50),P=0.92]、再手术率[OR=0.76,95%CI(0.30,1.89),P=0.55]、总并发症发生率[OR=0.88,95%CI(0.63,1.22),P=0.44]、死亡率[OR=1.33,95%CI (0.84,2.11),P=0.23]、手术时间[MD=1.43,95%CI (-5.85,8.71),P=0.70]上比较差异无统计学意义(P0.05)。结论:基于有限的资料,直接前入路较后侧、后外侧入路行人工股骨头置换治疗老年股骨颈骨折,术后脱位率显著性降低,与外侧、前外侧入路脱位率无显著性差异。     

Anterior Revision Hip Arthroplasty is Associated With Higher Wound Complications but Fewer Dislocations Compared to Posterior Revision Hip Surgery

BackgroundWound complication after primary direct anterior (DAA) hip arthroplasty has been reported in the literature but there has been no comparison regarding revision anterior vs revision posterior (PA) hip arthroplasty. The authors hypothesize that anterior approach revision surgery may have increased wound complications compared with posterior hip revisions and also report on secondary outcome metrics.MethodsNinety-nine DAA and 191 PA revisions were included for analysis. Preoperative demographic characteristics, indication for revision, operative details, type of revision performed, components utilized, and postoperative complications were compared between DAA and PA groups including multivariate analysis.ResultsThe DAA cohort demonstrated an increased risk of superficial wound complications (7.1% vs 0.5%, P = .003) and a decreased dislocation rate (2.0% vs 13.1%, P = .002). There was a trend toward increased overall complications in the PA group (OR 1.71, P = .078).ConclusionRevision DAA THA is associated with an increased risk of superficial wound complications, but may impart a decreased dislocation rate.     

Does serum calcium relate to different types of hip fracture? A retrospective study

Purpose: To investigate the potential correlation between two different types of hip fractures and serum calcium levels. Methods: We consecutively studied 101 cases of femoral neck fracture and 95 cases of femoral intertrochanteric fracture between January 2011 and December 2013. Fasting blood samples were taken and serum calcium measurements were performed respectively in three periods: the time of admission, postoperation, and discharge. Creatinine, alkaline phosphatase and albumin were also analyzed. Results: Considering the levels of serum calcium between two groups at the time of admission, postoperation and discharge, there was significant difference at admission and discharge (p < 0.05), while there was no significant difference at the time of postoperation (p > 0.05). The magnitude of serum calcium fluctuation was larger in femoral neck group than femoral intertrochanteric group. Concerning alkaline phosphatase and albumin levels at admission, there was no significant difference between two groups (p > 0.05). Conclusion: The capability of reservation and restoration of serum calcium in patients with femoral neck fracture is better than that in patients with femoral intertrochanteric fracture. A low serum calcium level may be susceptible to femoral intertrochanteric fracture.     

The Accuracy of Digital Templating for Primary Total Hip Arthroplasty: Is There a Difference Between Direct Anterior and Posterior Approaches?

Background

The direct anterior approach (DAA) has gained recent popularity for total hip arthroplasty (THA), as it provides immediate feedback on cup position and limb length using fluoroscopy. The purpose of this study is to evaluate any differences in the accuracy of digital templating for preoperative planning of THA, performed with 2 different surgical approaches: DAA using a radiolucent table with intraoperative fluoroscopy and the posterior approach (PA).

Predictors of Perioperative Vancouver B Periprosthetic Femoral Fractures Associated With the Direct Anterior Approach to Total Hip Arthroplasty

BackgroundThere is an association between intraoperative and postoperative femoral fractures and the direct anterior approach (DAA) to total hip arthroplasty (THA). The purpose of our study is to identify risk factors for Vancouver B fractures and to establish a predictable timeline for when these occur.MethodsWe retrospectively identified patients with Vancouver B periprosthetic femoral fractures (n = 49) after 11,509 elective primary cementless THA procedures through the DAA between 2012 and 2018 at a single institution. Fracture patients were matched to nonfracture patients (n = 267) by date of surgery and surgeon. Clinical and radiographic factors were collected for multivariable analysis to identify predictors of fracture.ResultsPeriprosthetic Vancouver B femoral fracture incidence was 0.4%. 48 (98%) fractures were postoperative. Fractures occurred at an average of 44 days after surgery (range: 1 to 653 days) with >85% of fractures occurring in the first 6 weeks postoperatively. Significant variables predictive of fracture included >3 degrees valgus and >5 degrees varus coronal stem malalignment, Dorr B and C femoral geometry, lower canal flare index (2.75 vs 3.20), advanced age, increased comorbidities, greater stem canal fill, and right-sided procedures.ConclusionDespite an overall low rate of Vancouver B perioperative periprosthetic femoral fractures, it is a devastating complication that typically presents within the first 6 weeks after DAA THA surgery. The risk is increased in patients with unfavorable proximal femoral geometry, coronal stem malalignment, advanced age, increased comorbidities, and right-sided procedures.     

Comparison of Wound Complications and Deep Infections With Direct Anterior and Posterior Approaches in Obese Hip Arthroplasty Patients

Background

The purpose of this study was to compare the posterior approach (PA) with the direct anterior approach (DAA) among obese and nonobese total hip arthroplasty patients to determine if obese DAA patients have a higher risk of infection or wound complications compared with obese PA patients.