Three-Dimensional Pelvic Kinematics During Direct Anterior Approach Total Hip Arthroplasty on an Orthopaedic Table.

BACKGROUND: Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is a pertinent and preventable complication following total hip arthroplasty (THA). Direct anterior approach (DAA) THA has gained global popularity for its potential benefits; however, the optimal duration of postoperative venous VTE prophylaxis remains controversial. This study aimed to compare the efficacy of two weeks versus four weeks of rivaroxaban as postoperative VTE prophylaxis in patients undergoing minimally invasive DAA THA. METHODS: We conducted a retrospective analysis of the medical records of 526 consecutive patients who underwent elective primary THA via the DAA between 1 January 2017 and 31 December 2022. We compared the incidence of symptomatic and asymptomatic VTE, and the rate of complications associated with VTE prophylaxis within six months postoperatively in patients who received either a two- or four-week course of rivaroxaban as VTE prophylaxis following DAA THA. Duplex venous ultrasound was routinely performed at three weeks for all patients to evaluate for the presence of lower limb DVT. RESULTS: The study included 356 patients who received four weeks of treatment and 170 patients who received two weeks of rivaroxaban for postoperative VTE prophylaxis. The two groups were equally matched for age, sex, comorbidities, and preoperative vTe risk, according to the Caprini score. The overall incidence of VTE was 1% (n = 6) and included three DVTs and three pulmonary emboli (PEs). Of the DVTs detected via duplex venous ultrasound, two were diagnosed as symptomatic DVTs, and one was diagnosed as an asymptomatic DVT. The incidence of VTE was significantly greater in the two-week group than in the four-week group (p = 0.043), and all patients in whom a VTE occurred had a body mass index (BMI) of > 30 kg/m2 and a preoperative Caprini score indicating moderate or high risk. No statistically significant difference was noted in the rate of wound complications (p = 0.40) or the incidence of periprosthetic joint infections between the two cohorts (p = 0.56). CONCLUSION: A four-week course of rivaroxaban demonstrated superior efficacy in reducing the incidence of VTE compared to a two-week regimen in patients undergoing DAA THA. Importantly, the extended duration of rivaroxaban prophylaxis did not result in a significant increase in the rate of complications associated with VTE prophylaxis. These findings underscore the potential benefits of a prolonged rivaroxaban regimen for optimising postoperative VTE prevention, particularly in obese patients and high-risk patients undergoing minimally invasive DAA THA.

Lateral trochanteric pain (LTP) is a common complication after total hip arthroplasty (THA). The goals of this study were to report the incidence of LTP after direct anterior approach (DAA) THA, describe the treatment course and outcomes, and examine patient-specific and implant-related potential risk factors. A retrospective review identified patients who underwent primary DAA THA with at least 1-year follow-up. Postoperative functional outcome scores and LTP occurrence were recorded. Patient demographics, surgical indications, implant characteristics, medical comorbidities, and radiographic parameters were obtained. Logistic regression analysis was used to identify risk factors. A total of 610 THA procedures were performed for 563 patients (mean follow-up, 30.9±15.2 months). The overall incidence of LTP was 11.6%. All cases of LTP were successfully treated conservatively, although these patients, compared with patients who did not have postoperative LTP, experienced significantly lower functional outcome scores (Harris Hip Score, 96.6±4.7 [range, 55-100] vs 89.9±8.5 [range, 42-100], respectively; P<.001). Logistic regression analysis identified female sex (odds ratio, 2.30; 95% CI, 1.32-4.02), diabetes mellitus (odds ratio, 2.32; 95% CI, 1.11-4.88), hypertension (odds ratio, 1.94; 95% CI, 1.15-3.28), and the use of an offset acetabular liner (odds ratio, 2.50; 95% CI, 1.06-5.91) as independent risk factors for LTP. There was no correlation between LTP and radiographic parameters. The incidence of LTP after DAA THA is similar to reported rates for other THA surgical approaches. Female sex, medical comorbidities, and the use of offset acetabular liners are likely associated, and patients should be counseled appropriately. Postoperative LTP results in worse functional outcomes, although all cases can be treated conservatively. [Orthopedics. 2022;45(2):e79-e85.].

BackgroundAchieving correct leg and femoral neck lengths remains a challenge during total hip arthroplasty (THA). Several methods for intraoperative evaluation and restoration of leg length have been proposed, and each has inaccuracies and shortcomings. Both the supine positioning of a patient on the operating table during the direct anterior approach (DAA) THA and the preservation of the anterior capsule tissue are simple, readily available, and cost-effective strategies that can lend themselves well as potential solutions to this problem.TechniqueThe joint replacement is performed through a longitudinal incision (capsulotomy) of the anterior hip joint capsule, and release of the capsular insertion from the femoral intertrochanteric line. As trial components of the prosthesis are placed, the position of the released distal capsule in relationship to its original insertion line is an excellent guide to leg length gained, lost, or left unchanged.MethodsThe radiographs of 80 consecutive primary THAs were reviewed which utilized anterior capsule preservation and direct capsular measurement as a means of assessing change in leg/femoral neck length. Preoperatively, the operative legs were 2.81 +/- 8.5 mm (SD) shorter than the nonoperative leg (range: 17.7 mm longer to 34.1 mm shorter). Postoperatively, the operative legs were 1.05 +/- 5.64 mm (SD) longer than the nonoperative leg (range: 14.9 mm longer to 13.7 mm shorter).ConclusionThe preservation and re-assessment of the native anterior hip capsule in relationship to its point of release on the femur is a simple and effective means of determining leg/femoral neck length during DAA THA.

There is a paucity of literature analyzing data for return to sport (RTS) and return to work (RTW) in the setting of direct anterior approach (DAA) total hip arthroplasty (THA). The aims of this systematic review are to identify existing literature and to aggregate rates of RTS/RTW following DAA THA in a meta-analysis. A query of major databases yielded 1819 initial studies. A random-effects model approach was implemented for meta-analysis. Moderator effects were assessed with respect to patient demographics and functional outcomes. Five studies reporting RTS after DAA THA were identified, representing a total of 204 patients with a mean age of 60.2±7.5 years and mean follow up of 31.8±9.5 months. Pooled rate of RTS was 76%(95% confidence interval [CI], 63%-86%;range 58%-100%). Pooled rate of return to the same sport was 77%(95%CI, 64%-86%;range of 62%-100%). Pooled rate of RTS to the same intensity was 58%(95%CI, 48%-68%;range of 41%-68%). Meta-regression demonstrated no significant correlations between independent variables and RTS characteristics. Three studies reported RTW rates. Rates of RTW within 3-months were 30%, 45%, and 60%. One study reported rate of RTW of 79% at 6-months and 87% at 12-months. One study demonstrated a mean time to RTW of 38±24.8 days. Pooled rate of RTS is satisfactory following DAA THA and are comparable to rates of RTS aggregated without delineating surgical approach. Data supporting RTW rates following DAA THA limited, and thus more primary studies are needed to establish if this approach confers an advantage of faster RTS/RTW.

Acetabular Abduction and Dislocations in Direct Anterior vs Posterior Total Hip Arthroplasty: A Retrospective, Matched Cohort Study

A Novel Classification System to Predict Case Difficulty in Direct Anterior Approach Total Hip Arthroplasty.

PurposeTo evaluate the rates of lateral femoral cutaneous nerve (LFCN) injury in patients who underwent a direct anterior approach (DAA) total hip arthroplasty (THA) with and without previous hip arthroscopy.MethodsWe retrospectively investigated consecutive DAA THAs performed by a single surgeon. These cases were grouped into patients with and without a history of previous ipsilateral hip arthroscopy. LFCN sensation was assessed during the initial follow-up (6 weeks) and 1-year (or most recent) follow-up visits. The incidence and character of LFCN injury was compared between the 2 groups.ResultsIn total, 166 patients underwent a DAA THA with no previous hip arthroscopy, and 13 had a history of previous arthroscopy. Of the 179 total patients who underwent THA, 77 experienced some form of LFCN injury at initial follow-up (43%). The rate of injury for the cohort with no previous arthroscopy was 39% (n = 65/166) on initial follow-up, whereas the rate of injury for the cohort with a history of previous ipsilateral arthroscopy was 92% (n =12/13) on initial follow-up (P < .001). In addition, although the difference was not significant, 28% (n = 46/166) of the group without history of previous arthroscopy and 69% (n = 9/13) of the group with a history of previous arthroscopy had continued symptoms of LFCN injury at most recent follow-up.ConclusionsIn this study, patients who underwent hip arthroscopy before an ipsilateral DAA THA were at increased risk of LFCN injury compared with patients who underwent a DAA THA without a previous hip arthroscopy. At final follow-up of patients with initial LFCN injury, symptoms resolved in 29% (n = 19/65) of patients with no previous hip arthroscopy and 25% (n = 3/12) of patients with previous hip arthroscopy.Level of EvidenceLevel III, case–control study.

BACKGROUNDDirect anterior approach (DAA) total hip arthroplasty (THA) in a supine position provides a unique opportunity to assess leg length discrepancy (LLD) intra-operatively with fluoroscopy. Reported fluoroscopic techniques are useful but are generally complicated or costly. Despite the use of multiple techniques for leg length assessment, LLD continues to be a major post-operative source of patient dissatisfaction further emphasizing the importance of near-anatomic restoration. The utility of an alternative direct measurement of LLD on an intra-operative fluoroscopic pelvic image during DAA THA has not been reported. AIMTo determine the reliability of a novel simple intra-operative measurement of LLD using a parallel line technique on a single fluoroscopic digital image of the pelvis.METHODSOne hundred and seventy-one patients who underwent DAA THA were included for analysis. Intra-operative fluoroscopic and post-operative anterior-posterior radiographs were imported to TraumaCad and calibrated for LLD measurement. LLD was measured on each image using the right-left hip differences in lesser trochanter to pelvic reference line distances. Pelvic reference points included the teardrops and ischia. Fluoroscopic LLD was compared to the gold-standard measurement of LLD measured on a post-operative radiograph. RESULTSMean absolute difference in teardrop referenced LLD between fluoroscopic and post-operative radiographs was 2.17 mm and based on the ischia mean absolute difference was 2.63 mm. Linear regression of fluoroscopic and post-operative radiograph LLD based on teardrop and ischia LLD found r2 values of 0.57 and 0.84, respectively. Mean absolute difference between fluoroscopic and post-operative x-ray LLD was within 5 mm in 95% of cases regardless of pelvic reference.CONCLUSIONThis study demonstrates that a single fluoroscopic view obtained during DAA THA for leg length assessment is clinically useful.

Patient Radiation Exposure During Fluoro-Assisted Direct Anterior Approach Total Hip Arthroplasty

Preoperative 2D digital templating aids surgical planning in total hip arthroplasty (THA). We evaluated template accuracy by comparing preoperative templated measurements with postoperative findings and final implant sizes. We retrospectively reviewed a consecutive series of 100 patients who underwent fluoroscopy-guided direct anterior approach (DAA) THA by a single surgeon from November 2022 to September 2024. All patients received an Emphasys femoral stem with a Pinnacle acetabular cup. A single arthroplasty surgeon used Traumacad™ software for preoperative templating, which was compared to postoperative measurements and implants. Preoperative template averages were: cup size (55.1mm), femur size (5.8), head size (36mm), and inclination (41.0°). Delta values (difference between postoperative and templated measurements) were: neck cut length (5.6mm), neck cut angle (2.8°), LLD (0.1mm), cup size (1.3mm), femur size (0.7), head size (0mm), and inclination (2.9°). Cup size was perfectly predicted in 56% of cases, 95% within two sizes; femur size was perfect in 52% of cases, 88% within one size, and 95% within two sizes. Stem offset was 94% accurate. Regression analysis found that higher BMI and male gender were associated with less accurate predictions for neck angle and cup size, respectively. While variables such as higher BMI and male gender may influence the accuracy of templating, our findings suggest that 2D templating for DAA THA offers reliable predictions within a narrow range for final implant sizes, neck cut, and planned leg length changes.

Background Direct anterior approach(DAA) for total hip arthroplasty (THA), which has the characteristics of less trauma, quick recovery and low risk of early dislocation, is a popular surgical procedure for osteonecrosis of the femoral head. Common early complications of DAA total hip arthroplasty include the injury of lateral femoral cutaneous nerve, deep vein thrombosis, poor incision healing and unequal length of legs, etc. Emphysema of scrotum and thigh is very rare and there is no report about it occurred after DAA total hip arthroplasty.Case presentation: This is the first report about emphysema of scrotum and thigh after DAA total hip arthroplasty. A 55-year-old man with osteonecrosis of the left femoral head suffered unexplained emphysema of scrotum and the left thigh after DAA total hip arthroplasty. On the second day after operation, the patient complained of swelling and pain in his left thigh and swelling in the scrotum. The ultrasound examination of the scrotum indicated subcutaneous emphysema of the scrotum. The computed tomography scan and the ultrasound examination of the left thigh revealed pneumoderm and air in the intramuscular spaces. we gave the patient symptomatic treatment to ease pain and improve blood circulation, but we did not obtain a obvious curative effect. On the ninth postoperative day, the swelling of the patient’s left thigh and the scrotum partially relieved and he was discharged. The patient recovered well at one month and one year follow-up.Conclusion We firstly report a rare complication of emphysema of scrotum and thigh after direct anterior approach total hip arthroplasty in order to recommend it to orthopedists and attach their attention. We did not find the exact cause of this rare complication and hope to discuss the potential causes with all colleagues at the same time.

The direct anterior approach (DAA) is a popular approach for primary total hip arthroplasty (THA). However, the contemporary outcomes for DAA THA need further elucidation. Therefore, we aimed to describe implant survivorship, complications, and clinical outcomes after DAA THA. From our multi-institutional total joint registry, 3,184 patients who had undergone 3,698 primary DAA THA between 2010 and 2019 were identified. The identified patients had a mean age of 65 years and a mean body mass index (BMI) of 29 kg/m 2 , and 53% of patients were female. The indications for revision and reoperation and the incidence of complications were collected and analyzed. Potential risk factors, including age, sex, BMI, and high-volume compared with low-volume operating surgeons, were examined. Descriptive statistics and Kaplan-Meier survivorship with Cox regression analyses were performed. At 10 years following primary DAA THA, the cohort had 96% (95% confidence interval [CI], 95% to 98%) survivorship free of any revision and 94% (95% CI, 92% to 96%) survivorship free of any reoperation. The leading indications for revision were periprosthetic joint infection (PJI) (n = 24; 5-year cumulative incidence, 0.93% [95% CI, 0.6% to 1.5%]), periprosthetic fracture (n = 20; 5-year cumulative incidence, 0.62% [95% CI, 0.4% to 1.0%]), and aseptic loosening (n = 14; 11 femoral, 3 acetabular; 5-year cumulative incidence, 0.84% [95% CI, 0.5% to 1.5%]). A BMI of ≥40 kg/m 2 was found to be significantly associated with PJI (hazard ratio [HR], 6.4; p < 0.001), reoperation (HR, 3.5; p < 0.001), and nonoperative complications (HR, 2.3; p = 0.018). Survivorship free of recurrent instability was 99.6% (95% CI, 99.4% to 99.8%) at 5 and 10 years, and the cumulative incidence of revision for instability was 0.14% at 5 years. In one of the largest published series to date, survivorship following DAA THA was satisfactory at early to intermediate follow-up. The leading indications for revision were PJI, periprosthetic fracture, and aseptic loosening. Instability after DAA THA was uncommon and infrequently led to revision. As a note of caution, a BMI of ≥40 kg/m 2 was identified as a risk factor for adverse outcome after DAA THA. Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

It is challenging to treat developmental dysplasia of the hip (DDH) classified Crowe III-IV using direct anterior approach (DAA) total hip arthroplasty (THA), and very little is known on its outcome. This study aimed to investigate the clinical result in this defined disorder with DAA versus posterolateral approach. Twenty-three consecutive hips with Crowe III-IV DDH who underwent DAA were retrospectively evaluated from 2016 through 2018. Outcomes were primarily assessed by HHS, WOMAC, and SF-12 physical scales. The second evaluations included leg length discrepancy, hip muscle strength, radiographic review, complications, and limp recovery. Results were compared to a control cohort of 50 hips underwent posterolateral THA concurrently within the observational period. At last follow-up (DAA 28.5 months; PLA 39.0 months), the mean increase of the HHS for DAA was 48.2 and 30.3 for PLA (p = 0.003). The improvement in WOMAC score in DAA cohort was 15.89 higher that of the PLA cohort after adjusting preoperative difference [R2 = 0.532, P = 0.000, 95% CI (10.037, 21.735)]. DAA had more rapid recovery of hip abductor strength at 1-month (p = 0.03) and hip flexor strength at 3 months (p = 0.007) compared to PLA. No significant differences were found in the radiographic analysis with the exception of increased acetabular anteversion in the DAA cohort (p = 0.036). Satisfactory improvement in limp, indicated by the percentage of limp graded as none and mild to the total, was much higher in DAA cohort (97.6%), compared to that of PLA cohort (90.0%, p = 0.032). DAA for high-dislocated dysplasia demonstrate a significant improvement in clinical result comparable to posterolateral approach. Improved clinical outcome in terms of increased HHS and WOMAC scores, rapid recovery of hip abductor and flexor strength, and enhanced limp recovery without an increased risk in complications, could be acquired when the surgeons were specialized in this approach.

Satisfaction in Patients Requesting Contralateral Direct Anterior Approach After Ipsilateral Posterior Total Hip Arthroplasty: A Crossover Study.

PurposeThe purpose of this study was to report all complications during the first consecutive 865 cases of bikini incision direct anterior approach (DAA) total hip arthroplasty (THA) performed by a single surgeon. The secondary aims of the study are to report our clinical outcomes and implant survivorship. We discuss our surgical technique to minimize complication rates during the procedure.MethodsWe undertook a retrospective analysis of our complications, clinical outcomes and implant survivorship of 865 DAA THA’s over a period of 6 years (mean = 3.9yrs from 0.9 to 6.8 years).ResultsThe complication rates identified in this study were low. Medium term survival at minimum 2-year survival and revision as the end point, was 99.53% and 99.84% for the stem and acetabular components respectively. Womac score improved from 49 (range 40–58) preoperatively to 3.5(range 0–8.8) and similarly, HHS scores improved from 53(range 40–56) to 92.5(range 63–100) at final follow-up (mean = 3.9 yrs) when compared to preoperative scores.ConclusionsThese results suggest that bikini incision DAA technique can be safely utilised to perform THA.