Anterior Approach Total Hip Arthroplasty Research Articles

Vertical or Horizontal (Bikini) Incision for Direct Anterior Total Hip Arthroplasty: Outcomes of Early (

BackgroundThe horizontal ‘bikini’ incision for direct anterior approach (DAA) total hip arthroplasty has gained popularity due to its early wound healing characteristics; however, the nonextensile nature of this approach may pose problems in treating early complications. This study sought to characterize the outcomes of early revision (<90 days) in patients who underwent anterior hip arthroplasty utilizing either a traditional longitudinal incision or a horizontal (bikini) incision. MethodsThis retrospective study identified patients who underwent DAA primary total hip arthroplasty with a subsequent DAA revision within 90 days. Patients were divided into two cohorts based on the orientation of their incision: either ‘longitudinal incision’ (in accordance with the Smith Peterson interval) or ‘horizontal bikini incision’ (in accordance with the hip flexion crease). ResultsThere were 74 patients who underwent DAA revision arthroplasty within 90 days of primary arthroplasty; 65 had a longitudinal incision, and 9 had a horizontal (bikini) incision. In the longitudinal incision group, 2 patients (3.1%) required plastic surgery closure, and 11 patients (16.9%) required additional operations. Of the 9 bikini incision patients, 6 patients required the assistance of plastic surgery closure, and 7 patients required multiple orthopaedic operations. ConclusionsOur study suggests that a horizontal bikini incision is less forgiving in the early postoperative period if a more extensile exposure is needed for revision surgery, as measured by the need for plastic surgery and additional returns to the operating room. In our cohort, the longitudinal incision allowed for the management of early surgical complications with less morbidity.

Reliability and accuracy of intraoperative fluoroscopy assessment of acetabular cup anteversion in supine direct anterior approach total hip arthroplasty

Poor implantation positioning of hip prostheses is considered the primary factor affecting postoperative joint wear. Cup anteversion in direct anterior approach (DAA) total hip arthroplasty (THA) is often excessive. Intraoperative fluoroscopy (IF) are effective for improving implant placement accuracy. This study aimed to analyze IF’s reliability and accuracy in assessing intraoperative anteversion. Sixty-two consecutive hips underwent primary THA utilizing DAA alongside IF for cup placement. Intraoperative anteversion was measured using IF images, while postoperative CT and standard anteroposterior (AP) radiographs were used to calculate true anteversion component angles. Differences and correlations between intraoperative and true anteversions were analyzed, and intraclass correlation coefficients (ICC) determined the inter- and intra-observer reliabilities. Excellent intra- and inter-observer reliabilities were observed for all radiographic and CT methods (ICC > 0.9). Strong correlations (PCC > 0.6) existed between anteversion measured on IF image and postoperative CT and AP pelvic measurements. Intraoperative anteversion measured on IF images (16.8 ± 3.2°) was smaller than anteversion measured postoperatively on AP X-rays (21.3 ± 4.7°, P < 0.001) and CT (22.0 ± 4.9°, P < 0.001), with average differences of 4.5°and 5.3°, respectively. Under several influencing factors, the accuracy of IF in assessing cup anteversion in DAA-THA may be limited. However, this still requires large-sample experiments for verification.

Direct Anterior Approach Total Hip Arthroplasty for Femoral Neck Fractures in the Lateral Position.

To compare the clinical efficacy of artificial total hip arthroplasty(THA) for femoral neck fracture between direct anterior approach(DAA) in lateral position and posterior lateral approach(PLA). Comparison of 200 cases of patients who underwent THA collected between September 2019 and August 2021 was done. Incision length, intraoperative bleeding, operative time, difference in postoperative haemoglobin from preoperative levels, length of hospital stay, postoperative time to get off the floor, visual analogue score (VAS) for pain, preoperative and postoperative Harris scores for the hip, and measurements of the acetabular abduction angle and anterior acetabular tilt angle at 6 months postoperatively were collected, and all the cases were followed up for at least 2 years. Compared with the PLA group, the DAA group had a shorter incision length, less intraoperative blood loss, less postoperative haemoglobin reduction compared with the preoperative period, a shorter hospital stay and an earlier first time to get off the floor after surgery, however, the comparison of operative times was not statistically significant; Patients in the DAA group had a lower VAS in the early postoperative period compared to PLA; Patients in the DAA group had higher hip Harris scores at 6 weeks and 6 months postoperatively; There was no significant difference in acetabular abduction angle and acetabular anterior tilt angle between the two groups at 6 months postoperatively. Compared to PLA, DAA in THA is minimally invasive, has less pain, less bleeding, earlier time out of bed, shorter hospital stay, better early hip function, faster rehabilitation, and better joint stability.

Five-Year Survivorship of Total Hip Arthroplasty With a Proximally Coated, Medially Collared, Triple-Tapered Femoral Stem: A Retrospective, Multicenter Registry Review.

Background The anterior approach for total hip arthroplasty (THA) has gained popularity in recent years. Some surgeons have been hesitant to adopt the approach due to concerns over increased complications such as intraoperative fracture, stem loosening, and stem revision. This study aims to evaluate the all-cause revision rate and survivorship of a collared,triple-tapered stem that was designed specifically for use with the anterior approach in THA to enhance outcomes and reduce adverse events. Methodology A retrospective outcomes review was conducted to assess survivorship and clinical outcomes for a specific proximally coated, medially collared triple-tapered (MCTT) femoral stem. Results In a cohort of 5,264 hips, Kaplan-Meier survivorship estimates (95% confidence interval [CI]; N with further follow-up), with survivorship defined as no revision of any component for any reason at five years after the index procedure, were 98.9% (97.8%-99.4%; 43) under the clinical assumption and 99.6% (99.4%-99.7%; 894) under the registry assumption. With survivorship defined as stem revision for any reason, survivorship estimates at five years postoperatively were 99.6% (99.3%-99.8%; 43) under the clinical assumption and 99.8% (99.7%-99.9%; 894) under the registry assumption. The mean follow-up time was 94.52 days (standard deviation [SD] 2.24, range 90.03-96.02). At five years postoperatively, the mean Harris Hip Score was 95.19, and the mean Hip Disability and Osteoarthritis Outcome Score Junior (HOOS JR) score was 98.66. Conclusions Our evaluation demonstrates excellent construct and stem survivorshipand very low complication ratesat midterm postoperative follow-up.

Similar incidence of postoperative sciatic nerve palsy in direct anterior and posterior approach total hip arthroplasty.

Sciatic nerve palsy is a rare but devastating complication following total hip arthroplasty (THA). While the use of the direct anterior approach is increasing, limited data exist regarding sciatic nerve palsy and surgical approach. The purpose of this study was to determine the factors and outcomes associated with sciatic nerve palsy (SNP) after THA. A retrospective analysis was performed at a single institution of 7 SNP that occurred in 4045 THA via direct anterior approach and 10 SNP in 8854 THA via posterior approach, being operated between 01 January 2017 and 12 December 2021. SNP patients were matched 1:5 to patients without SNP. Medical records were reviewed for demographics including age, gender, body mass index (BMI), comorbidities, and preoperative indication. Additional workup of SNP patients including advanced imaging and reoperation were documented. Recovery grades were assigned to all SNP patients at most recent clinical follow-up. 5 of the SNP were complete and 12 partial. They occurred as frequently with the direct anterior (0.17%) and posterior approach (0.11%, p = 0.5). The presence of femur cables and reoperations were associated with SNP (p = 0.04 and p = 0.002, respecitvely). Age, gender, BMI, comorbidities, and surgical indication had no effect on SNP. 4 of the 17 affected patients had almost complete recovery at latest follow-up. The incidence of SNP was similar in direct anterior and posterior approach. Surgeons should counsel patients regarding the risks of SNP regardless of the used approach.

Rapid Return to Braking After Anterior and Posterior Approach Total Hip Arthroplasty.

Little is known about the effect of surgical approach on return to braking after total hip arthroplasty (THA), and few studies have investigated braking after THA with modern surgical techniques and rehabilitation protocols. In a prospective comparative design, we enrolled 65 patients who received right-sided primary THA at our institution from April 2018 through March 2020, 34 with a direct anterior approach (DAA) and 31 with a posterior approach (PA). Braking tests measuring brake reaction time (BRT) and brake pedal depression (BPD) were administered to patients preoperatively and at 1, 2, and 4 weeks postoperatively using a realistic driving simulator. BRT and BPD were compared between groups and preoperatively versus postoperatively using mixed-effects models. Preoperative BRT averaged 638 msec in the DAA group and 604 msec in the PA group (P = 0.31). At 1 week postoperatively, the DAA group had significantly prolonged BRT compared with preoperatively (694 msec, P = 0.02). No significant difference was observed in the PA group (633 msec, P = 0.31). Both groups had returned to baseline by 2 weeks, and both had significantly faster BRT at 4 weeks compared with preoperatively (583 msec for DAA, P = 0.01; 537 msec for PA, P < 0.001). BPD was similar between groups, and there were no significant differences between preoperative and postoperative BPD at any time point. With modern surgical techniques, BRT after right-sided THA returns to baseline levels approximately 2 weeks after surgery. There seems to be a quicker return to preoperative BRT observed in patients with a PA.

A comparison of cemented femoral fixation via anterior versus posterior approach total hip arthroplasty: an analysis of 60,739 total hip arthroplasties.

Anterior approach total hip arthroplasty (THA) decreases the rate of dislocation but increases femoral-sided complications in the way of periprosthetic fractures and component loosening. A cemented prosthesis may reduce femoral-sided complications and improve the risk:benefit profile of anterior approach THA. Data from the Australian National Joint Replacement Registry were analysed for patients undergoing primary THA via the anterior or posterior approach using a cemented polished femoral stem from January 2015 to December 2021. The primary outcome measure was the cumulative percent revision (CPR) for all causes and CPR for femoral component loosening and fracture. The CPR for the primary outcome measures were compared between the anterior and posterior approach and adjusted for age, sex, ASA score, BMI and femoral head size. The study included 60,739 THAs with cemented stems (10,742 anterior, 49,997 posterior). The rate of revision of the anterior versus the posterior approach did not significantly differ (HR 0.87 (95% CI, 0.74-1.03), p = 0.100). Anterior approach THA had a significantly higher rate of revision for femoral component loosening (HR 5.06 [95% CI, 3.08-8.30], p < 0.001); and a decreased rate of revision for infection (HR 0.59 [95% CI, 0.43-0.81], p = 0.001) and dislocation/instability (HR 0-3 months 0.48 [95% CI, 0.27-0.83], p = 0.008; HR >3 months 0.30 [95% CI, 0.15-0.61], p < 0.001). There was no difference in the rate of revision surgery for fracture between the 2 approaches (HR 1.01 [95% CI, 0.71-1.43]), p = 0.975). There is no significant difference in overall revision rates with cemented femoral fixation performed with an anterior or posterior approach. Cemented fixation performed with the anterior approach partly mitigates femoral complications with no difference in the revision rate for fracture but an increased rate of femoral component loosening.

Extended offset stems are infrequently required in anterior approach total hip arthroplasty and low usage does not compromise stability.

Extended offset (EO) stems are commonly used in posterior approach (PA) total hip arthroplasty (THA), but usage rates and complications are not well studied with anterior approach (AA) THA. This study evaluated usage rates, radiographic outcomes and complications following AA THA between patients receiving EO stems and a matched cohort receiving standard offset (SO) stems. This retrospective review evaluated 1515 consecutive AA THA performed between 2014 and 2021. The recent 100 EO were included in radiographic and complication analysis and were matched to 100 SO stems based on stem size, procedure (unilateral/bilateral), sex, body mass index (BMI), and age. Data collection included patient demographics; pre- and postoperative radiographic measurements of leg length difference (LLD) and global hip offset difference (GHOD); and complications within 1year. Independent t-tests and Chi-squared analyses compared EO and SO groups. EO was utilized in 8% of all AA THA. Despite matching procedures, the distribution of racial groups was different between EO and SO groups, respectively: Caucasian (75% vs. 43%), Asian (12% vs. 35%), Native Hawaiian/Pacific Islander (NHPI) (9% vs. 13%), and other (4% vs. 9%) (p < 0.001). No fractures, dislocations, or revisions occurred within 1year after surgery in either group. One deep infection was noted in the SO group. The proportions of patients following surgery who had a GHOD < 6mm (76% vs. 82%; p = 0.193) and LLD < 6mm (81% vs. 86%; p = 0.223) were not significantly different between EO and SO groups, respectively. Prioritizing hip symmetry over stability results in a high proportion of patients achieving hip symmetry without high usage of EO stems in AA THA. Furthermore, low use of EO stems did not result in increased dislocations. Due to racial anatomical differences, Caucasian patients required EO stems to achieve hip symmetry more frequently than Asian and NHPI patients.

Magnetic resonance imaging of femoral nerve injury in the setting of anterior approach total hip arthroplasty

PurposeTo illustrate MRI findings in patients with femoral neuropathy following anterior approach total hip arthroplasty (THA). MethodsThis was a retrospective review of patients who underwent MRI for femoral neuropathy following anterior approach THA between January 1, 2010, and July 1, 2022. Included patients had no preexisting neurologic condition. Clinical and diagnostic data were collected. MRIs were reviewed in consensus by 2 musculoskeletal radiologists. ResultsA total of 115 patient records were reviewed, 17 of which were included in the final analysis (mean age 64 years; 11 females). Study subjects presented with weakness with hip flexion and knee extension and pain and numbness in the femoral nerve distribution. In 7 subjects, the femoral nerve appeared normal. In 5 subjects, the femoral nerve was hyperintense on fluid-sensitive fat-suppressed imaging. In 4 patients, mass effect on the femoral nerve by either ill-defined soft tissue edema (n = 2), seroma (n = 1), or heterotopic ossification (n = 1) was detected. Only 1 patient had a nerve transection. Patients were imaged at a median time of 8 months (range: 1 day to 11 years) following arthroplasty placement. Clinical follow-up was available in 8 patients, of whom half had complete symptomatic resolution and half had partial improvement at a mean follow-up time of 39.3 months (SD 51.1). Of these 8, 1 underwent revision arthroplasty, 1 had removal of hardware, and another had excision of heterotopic ossification. ConclusionMRI provides a means to directly evaluate the femoral nerve following anterior approach THA in both the immediate and chronic postoperative periods.

MACHINE LEARNING CAN PREDICT DIFFICULTY IN ANTERIOR APPROACH TOTAL HIP ARTHROPLASTY TO IMPROVE PATIENT SAFETY AND SURGICAL TRAINING

Anterior approach total hip arthroplasty (AA-THA) has a steep learning curve, with higher complication rates in initial cases. Proper surgical case selection during the learning curve can reduce early risk. This study aims to identify patient and radiographic factors associated with AA-THA difficulty using Machine Learning (ML).Consecutive primary AA-THA patients from two centres, operated by two expert surgeons, were enrolled (excluding patients with prior hip surgery and first 100 cases per surgeon). K- means prototype clustering – an unsupervised ML algorithm – was used with two variables - operative duration and surgical complications within 6 weeks - to cluster operations into difficult or standard groups.Radiographic measurements (neck shaft angle, offset, LCEA, inter-teardrop distance, Tonnis grade) were measured by two independent observers. These factors, alongside patient factors (BMI, age, sex, laterality) were employed in a multivariate logistic regression analysis and used for k-means clustering. Significant continuous variables were investigated for predictive accuracy using Receiver Operator Characteristics (ROC).Out of 328 THAs analyzed, 130 (40%) were classified as difficult and 198 (60%) as standard. Difficult group had a mean operative time of 106mins (range 99–116) with 2 complications, while standard group had a mean operative time of 77mins (range 69–86) with 0 complications. Decreasing inter-teardrop distance (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.95–0.99, p = 0.03) and right-sided operations (OR 1.73, 95% CI 1.10–2.72, p = 0.02) were associated with operative difficulty. However, ROC analysis showed poor predictive accuracy for these factors alone, with area under the curve of 0.56. Inter-observer reliability was reported as excellent (ICC &gt;0.7).Right-sided hips (for right-hand dominant surgeons) and decreasing inter-teardrop distance were associated with case difficulty in AA-THA. These data could guide case selection during the learning phase. A larger dataset with more complications may reveal further factors.

Fluoroscopy Versus Imageless Optical Navigation in Direct Anterior Approach Total Hip Arthroplasty.

Utilization of the direct anterior approach (DAA) for total hip arthroplasty (THA) has risen in popularity. Accurate implant placement is a critical factor that influences patient outcomes. The goal of this study was to compare the accuracy and precision of fluoroscopy with imageless optical navigation in DAA THA. This was a cohort study of 640 consecutive primary DAA THAs performed with intraoperative fluoroscopy (n = 300 patients) or imageless optical navigation (n = 304 patients). Accuracy was compared by measuring acetabular cup inclination, anteversion, and leg-length discrepancy (LLD). The proportion of implants placed within the Lewinnek safe zone and those placed within a more precise target of 40 ± 5° inclination and 20 ± 5° anteversion was evaluated. According to the Lewinnek criteria, there was no difference in the percentage of implants placed within both inclination and anteversion targets (fluoroscopy: 90.3%; navigation: 88.8%, P = 0.519). Using the more precise targets, navigation increased the implants positioned correctly for both inclination and anteversion (fluoroscopy: 50.3%; navigation: 65.6%, P < 0.001). Navigation increased the proportion of implants positioned within the target anteversion zone (fluoroscopy: 71.3%; navigation: 83.8%, P < 0.001) but not inclination (fluoroscopy: 71.9%; navigation: 76.9%, P = 0.147). The mean LLD was higher with the use of fluoroscopy compared with navigation (5.5 mm, standard deviation: 4.1; 4.6 mm, SD: 3.4, P < 0.005). No difference in dislocation rate was observed ( P = 0.643). Both fluoroscopy and imageless optical navigation demonstrated accurate acetabular implant positioning during DAA THA. Navigation was more precise and associated with improved acetabular anteversion placement and restoration of LLD. Navigation is an accurate alternative to fluoroscopy with decreased radiation exposure.

Fluoroscopy-guided direct anterior approach total hip arthroplasty provides more accurate component positions in the supine position than in the lateral position

PurposeThe position of the acetabular and femoral components is critical for stability and wear resistance. The aim of this study is to investigate whether the fluoroscopy-guided direct anterior approach in the supine position (S-DAA) is more helpful in improving the position of acetabular and femoral components than the fluoroscopy-guided direct anterior approach in the lateral decubitus position (L-DAA).MethodsA retrospective analysis of 76 cases of fluoroscopy-guided direct anterior approach total hip arthroplasty (38 cases in the S-DAA and 38 cases in the L-DAA group) was performed in one hospital from 2019 to 2021. The differences in inclination, anteversion, femoral offset (FO), global offset (GO), and leg length discrepancy (LLD) measurements during and after surgery were analyzed. The postoperative femoral offset (FO), global offset (GO), leg length discrepancy (LLD), and preoperative and postoperative Harris hip score were compared between the two groups.ResultsIn the S-DAA group, there were no significant differences in the mean intraoperative inclination angle anteversion angle, FO, GO, and LLD compared to the postoperative values, whereas in the L-DAA group, there were significant differences between the intraoperative and postoperative measurements (P < 0.001, P = 0.009, P＜0.001, P＜0.001 and P = 0.008, respectively). Additionally, there were significant differences in the accuracy of LLD, FO, and GO between the two groups (P < 0.001). Compared with the L-DAA group, the average differences of inclination, anteversion, LLD, FO, and GO during and after operation in the S-DAA group were smaller, and the consistency was higher. There was a significant difference in Harris hip score between the two groups at 1 week after surgery (P = 0.033). There was no significant difference in Harris hip score between 1 month and 3 months after surgery (P = 0.482 and P = 0.797, respectively).ConclusionsIn the supine group, the direct anterior approach (DAA) provides more accurate positioning of the acetabular and femoral components. However, there was no significant difference in hip joint function and activity between the two groups at follow-up.

Fluoroscopy-based robotic assistance for total hip arthroplasty improves acetabular cup placement accuracy for obese patients compared to the manual, fluoroscopic- assisted technique.

Patient obesity is a risk factor for poor acetabular cup positioning in total hip arthroplasty (THA). To assess the impact of using a novel, fluoroscopy-based robotic THA system on acetabular cup placement in obese versus non-obese patients. A review of 105 consecutive manual unassisted (mTHA) (47 Obese/58 Non-obese) and 102 robotic-assisted (RA-THA) (50 Obese/52 Non-obese) primary, direct anterior approach THA procedures was conducted. All cases were performed by a single surgeon, for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Obesity was defined as a Body Mass Index (BMI) ⩾ 30 kg/m2. Outcomes included acetabular cup inclination and anteversion, and the proportion of cups within the Lewinnek safe-zone. Obese patients in the mTHA cohort had larger cup inclination angles on average compared to non-obese patients (44.82∘± 6.51 vs. 41.39∘± 6.75; p= 0.009). Obese mTHA patients were less likely to have cup placement within the Lewinnek zone compared to non-obese mTHA patients (0.48 vs. 0.67; p= 0.027). Obesity had no effect on the accuracy of RA-THA. Obesity affects the placement of the acetabular component in manual THA. The novel, fluoroscopy-based robotic THA system in this study demonstrated accurate cup placement regardless of obesity status.

Low Risk of Fracture Using a Cementless Triple-Tapered Collared Femoral Stem With Automated Impaction in Direct Anterior Approach Total Hip Arthroplasty

BackgroundDirect anterior approach (DAA) total hip arthroplasty (THA) has been associated with increased periprosthetic femoral fracture (PFF) risk. The aim of our study was to evaluate the fracture risk utilizing a triple-tapered, collared stem with automated impaction through the anterior approach. MethodsWe retrospectively reviewed consecutive DAA THA procedures at a single institution performed by 4 experienced DAA THA surgeons between 2019 and 2021. We collected data on age, sex, body mass index, preoperative diagnosis, and intraoperative and early postoperative PFF within 6 weeks postoperatively. Preoperative radiographs were evaluated to determine femoral neck-shaft angle and Dorr classification. We used Wilcoxon rank sum or Chi-square tests to assess differences between patients who did and did not have PFF. We also evaluated potential risk factors for PFF in unadjusted and adjusted regression analyses. In all, 24 PFFs (1.6%) occurred. There were 18 fractures (1.2%) recognized and managed intraoperatively (15 calcar, 2 greater trochanter, 1 posterior cortical). There were 6 PFFs (0.4%) identified postoperatively (5 greater trochanter, 1 diaphyseal), of which one required revision surgery. ResultsIdentified risk factors for fracture in adjusted regression models included women (odds ratio [OR] = 2.76, P = .047), preoperative coxa valga (OR = 4.54, P = .005), and coxa vara (OR = 2.85, P = .03). ConclusionsThe incidence of PFFs is low using a triple-tapered, collared cementless femoral stem with automated impaction through the DAA. Our findings agree with previous reports that have demonstrated women and preoperative valgus neck angle are risk factors for PFF.

Leg position effects on the femoral neurovascular bundle location during a direct anterior approach total hip arthroplasty: a radiographic study

BackgroundFemoral neurovascular injury is a serious complication in a direct anterior approach (DAA) total hip arthroplasty. However, dynamic neurovascular bundle location changes during the approach were not examined. Thus, this study aimed to analyze the effects of leg position on the femoral neurovascular bundle location using magnetic resonance imaging (MRI).MethodsThis study scanned 30 healthy volunteers (15 males and 15 females) with 3.0T MRI in a supine and 30-degree hip extension position with the left leg in a neutral rotation position and the right leg in a 45-degree external extension position. The minimum distance from the edge of the anterior acetabulum to the femoral nerve (dFN), artery, and vein were measured on axial T1-weighted images at the hip center level, as well as the angle to the horizontal line of the femoral nerve (aFN), artery (aFA), and vein from the anterior acetabulum.ResultsThe dFN in the supine position with external rotation was significantly larger than supine with neutral and extension with external rotation position (20.7, 19.5, and 19.0; p = 0.031 and 0.012, respectively). The aFA in supine with external rotation was significantly larger than in other postures (52.4°, 34.2°, and 36.2°, p < 0.001, respectively). The aFV in supine with external rotation was significantly larger than in supine with a neutral position (52.3° versus 47.7°, p = 0.037). The aFN in supine and external rotation was significantly larger than other postures (54.6, 38.2, and 33.0, p < 0.001, respectively).ConclusionsThis radiographic study revealed that the leg position affected the neurovascular bundle location. These movements can be the risk of direct neurovascular injury or traction.

The impact of operative approach and intraoperative imaging on leg length discrepancy and acetabular component angle in total hip arthroplasty: a retrospective cohort study.

Operative approach in total hip arthroplasty (THA) has long been a topic of debate with each approach having unique benefits and disadvantages. One purported benefit of an anterior approach to THA is that it allows for intraoperative positioning using fluoroscopy rather than manual positioning. Proper positioning allows for improved outcomes including leg length discrepancy and acetabular component angle. This study aims to examine if operative approach and use of imaging in intraoperative positioning impact LLD and cup angle post-operatively. A total of 300 hips were enrolled in the study with 100 hips per approach (anterior with fluoroscopy, lateral, and posterior). Retrospective chart review was conducted to assess patient demographics and radiographic analysis used to determine LLD and acetabular cup angle. Of the three groups, those receiving anterior approach THAs were on average older than those in the posterior group. Analysis comparing the LLD and acetabular angle across the three groups showed no statistically significant difference in LLD (p=0.091); this was also reflected when comparing hips that received fluoroscopy with those that did not (p=0.91). For acetabular angle, while no difference existed when comparing hips that received imaging versus those that did not, statistically significant differences were observed when comparing the three intraoperative approaches (p<0.0001). Neither intraoperative approach nor the use of intraoperative imaging in THA has a statistically significant effect on LLD post-operatively. However, approach did impact the acetabular cup angle across all three distinct approaches.

Radiographic parameters of pelvic and proximal femoral morphology do not predict outcomes for direct anterior total hip arthroplasty

BackgroundRadiographic predictors of outcomes associated with direct anterior approach (DAA) total hip arthroplasty (THA) are largely unknown. Anecdotally, some surgeons limit surgery to patients with low body mass index (BMI) or “favorable” bony morphology. Objective data on the impact of these factors is limited. We sought to determine radiographic and demographic predictors of outcomes after DAA arthroplasty. MethodsA consecutive series of patients undergoing unilateral, elective DAA THA, who had linked pre- and post-operative patient reported outcome scores, from January 1, 2017 to March 30, 2019 were included. Radiographic measurements, including proxies for pelvic overhang, femoral canal access, acetabular morphologic changes, and markers of disease severity, were performed on calibrated radiographs. Intra-observer consistency was also evaluated. Outcome measures included disease specific and general health patient-reported outcomes scores, while surgical difficulty was approximated by estimated blood loss and surgical time. Multivariate analyses were performed to determine statistically significant correlations. Results168 patients were included. Overall, patients experienced significant improvement in outcome scores (mean ∆ HOOS-JR 39.4, PROMIS-physical 12.3). There were two reoperations (1.2%), for recurrent dislocation. Female sex (p = 0.015) and increasing age (p == 0.019) were associated with shorter surgical times. No statistically significant correlations were found between the radiographic parameters and outcome measures. Intraclass correlation coefficients of the radiographic measurements were overall strong (0.73–1.0). ConclusionWe demonstrated consistent results in this series of patients despite variation in bony morphology. Our findings suggest that DAA THA can be safely performed on a broader patient population.

Accuracy of Leg Length and Hip Offset Measurements Using a Fluoroscopic Grid During Anterior Approach Total Hip Arthroplasty.

Minimizing leg length (LLD) and hip offset (OD) discrepancies is critical for tissue tension and implant longevity in total hip arthroplasty (THA). The direct anterior approach (DAA) helps surgeons recreate these values under fluoroscopy. Several methods to accomplish this have been described, with no consensus on which is superior. This study evaluated the ability to minimize LLD and OD using a surgeon-controlled, adjustable fluoroscopic grid. We hypothesized that this tool would recreate parameters to within 10 mm of the contralateral side. One hundred eleven primary THAs performed with an adjustable radiopaque grid to equalize leg length and hip offset were retrospectively reviewed. These values were measured on postoperative radiographs and compared to the contralateral hip. Patients were excluded if they had inadequate imaging, revision arthroplasty, preexisting deformities, or underwent approaches other than DAA. Mean age was 59.1±11.1 years, 63.1% of patients were female, and average body mass index was 27.8±7.0. Mean LLD was 3.7±3.0 mm, while mean OD was 4.6±3.6 mm. 95.5% of hips showed LLD < 10 mm, while 93.7% of hips had OD < 10 mm. Furthermore, 76.6% of hips had LLD < 5 mm, while 62.2% of hips had OD < 5 mm. The described technique restored limb length and hip offset during DAA THA. This technique yields consistent results and offers an inexpensive alternative to costly digital software and more cumbersome fixed grid systems.

Direct Anterior vs. Direct Lateral Approach Total Hip Arthroplasty for Displaced Femoral Neck Fracture.

This study compared outcomes of the direct anterior approach (DAA) and direct lateral approach (DLA) for treating displaced femoral neck fractures in active elderly patients. This retrospective study included active elderly patients who sustained a displaced femoral neck fracture and underwent a cementless total hip arthroplasty either with a supine DAA or a decubitus DLA. Patients were assessed using the Harris hip score at discharge and at a 6-week follow-up. A total of 41 women and 18 men were included in the study. Of those, 22 underwent DLA and 37 received DAA, all performed by the same team. In both groups, 69% were women, mean age was 70 years, and mean BMI was 25.2. Mean hemoglobin loss was 2.3 g/dl between admission and the first post-operative day in both groups. Similar numbers in each cohort were discharged home rather than to a rehabilitation center. The patients who underwent the DAA experienced a 2-day reduction in their hospital stay compared to the DLA group (4.2 ± 1.9 vs. 6.8 ± 3.7, respectively; p < 0.001). The Harris hip score in the DAA group was significantly higher at the 6-week follow-up than in the DLA group (87.23 ± 7.75 vs. 81.23 ± 7.67, respectively; p < 0.031). The patients who underwent THA with the DAA demonstrated better short term outcomes compared to the alternative approach for displaced femoral neck fractures in active elderly patients. DAA helped patients regain independence faster and might decrease hospitalization and rehabilitation costs. Based on these results, we recommend using the DAA for active elderly patients with a displaced femoral neck fracture.

Effect of posture on total hip arthroplasty through direct anterior approach

To investigate the effect of different postures on direct anterior approach(DAA) total hip arthroplasty. Total of 94 patients who underwent DAA total hip arthroplasty from July 2016 to June 2020 were retrospectively analyzed. They were divided into two groups according to different positions during the operation, including 45 cases in lateral position and 49 cases in supine position (with the aid of stent). The general data such as gender, affected limb, body mass index(BMI), incision length, operation time, intraoperative bleeding volume, drainage volume 24 hours after operation, hemoglobin difference before and after operation, first landing time after operation, postoperative hospitalization time, postoperative complications, visual analogue scale(VAS) at 1 day, 1, 2 weeks, 1, 3 and 6 months after operation, Harris score at 1, 2 weeks, 1, 3 and 6 months after operation were observed and compared between the two groups. Patients in both groups were followed up for 6 to 12 months with an average of (8.31±2.22) months. There was no significant difference between two groups in gender, affected limb, age, height, weight, body mass index(BMI), preoperative VAS score and preoperative Harris score(P>0.05). The incision length, operation time, intraoperative bleeding volume, 24-hour drainage volume, hemoglobin difference before and after operation, first time to the ground and postoperative hospitalization time of patients in supine position (assisted by stent) group were all better than those in lateral position group(P<0.05);There was no significant difference in the number of blood transfusions during and after operation(P=0.550). There was no significant difference in anteversion angle and abduction angle in the supine position(with the aid of stent) group during and after operation (P=0.825, P=0.066);There was significant difference in anteversion angle and abduction angle in the lateral position group during and after operation(P<0.05). VAS of patients in supine position (assisted by stent) group were lower than those in lateral position group at 1 day, 1, 2 weeks and 1 month after operation(P<0.05), and there was no statistical difference between two groups at 3 and 6 months after operation(P>0.05). Harris scores of patients in supine position(assisted by stent) group were higher than those in lateral position group at 1 week, 1 month and 3 months after operation(P<0.05), and there was no significant difference between two groups at 6 months after operation(P>0.05). Compared with the lateral position, the supine position DAA total hip arthroplasty has the advantages of small incision, short operation time, less bleeding, early landing time, short hospitalization time, and small intraoperative acetabular cup position judgment error. It has the advantage of fast postoperative recovery, but the recovery of hip joint function is the same after 6 months.