Anterior Approach Total Hip Arthroplasty Research Articles

Orthostatic retractor placement reduces operating time and post-operative inflammatory response during the learning curve of anterior approach THA

IntroductionHandheld retractor placement (HHRP) is prone to repetitive repositioning. This could lead to muscle damage especially during a procedure with a steep learning curve. In an attempt to minimize retractor repositioning during the learning curve of direct anterior approach (DAA) total hip arthroplasty (THA), we used a table mounted orthostatic retractor placement (ORP) device. PurposeTo investigate whether ORP would reduce the extent of muscle damage, OR-time and post-operative inflammatory response. Materials and methods29 Patients were operated by 2 surgeons who randomly used HHRP or ORP during their learning curve of DAA THA. There were 14 patients in a control group who were operated by an experienced surgeon. Blood levels of Creatine Kinase (CK), C-Reactive Protein (CRP), Hemoglobin (Hb), Lactate Dehydrogenase (LDH) and Erythrocyte Sedimentation Rate (ESR) were measured at 1 h pre- and 24 and 48 h post-operatively. ResultsThe mean OR-time was 67 and 50 min in the HHRP and ORP cohort, respectively (p < 0,001). Post-operative CRP levels were significantly higher in the HHRP cohort at 24 h (HHRP 60.64 mg/L (25.20–143.20); ORP 34.67 mg/L (9.30–71.20)) (p = 0.003) and 48 h post-operatively (HHRP 154.54 mg/L (65.90–369.00); ORP 81.60 mg/L (21.30–219.40) (p = 0.004). The post-operative Hb-levels were significantly lower in the HHRP cohort at 24 h (HHRP 11.11 g/dL (9.10–12.30); ORP 11.37 g/dL (8.80–14.00)) (p = 0.0008) and 48 h (HHRP 10.86 g/dL (9.50–12.00); ORP 11.25 g/dL (8.60–14.10)) (p = 0.03). Post-operative ESR levels were significantly higher in the HHRP cohort 48 h post-op (HHRP 45.21 mm/h (14.00–83.00); ORP 23.73 mm/h (2.00–73.00)) (p = 0.004). No significant differences were found for the CK and LDH levels at any time postoperatively. There were no complications in any group. ConclusionThe use of an orthostatic retractor placement device allows for reducing the OR-time, post-operative blood loss and post-operative inflammatory response during the learning curve of DAA THA.

General vs Neuraxial Anesthesia in Direct Anterior Approach Total Hip Arthroplasty: Effect on Length of Stay and Early Pain Control

BackgroundRecent literature has suggested some benefits for neuraxial anesthesia (NA) as an alternative for general anesthesia (GA) for primary total hip arthroplasty patients. We examined the impact of NA vs GA on outcomes for patients undergoing direct anterior (DA) approach total hip arthroplasty (THA) in an institution with established rapid recovery protocols. MethodsA retrospective review was conducted for 500 consecutive THA patients from a single institution. Univariate analysis and multivariate linear regression were used to compare outcomes for THA patients receiving NA and GA. ResultsThere was a significant difference in length of stay with NA patients having a shorter length of stay (NA 32.7 hours vs GA 38.1 hours, P = .003). Patients receiving NA had significantly lower PACU morphine milligram equivalents (MME) (NA 10.2 MME vs GA 15.6 MME, P < .001) and reported a lower score on the PACU pain numeric rating scale (NA 2.1 vs GA 3.7, P < .001). ConclusionNeuraxial anesthesia is associated with decreased LOS, decreased PACU MME, and a lower PACU pain score for patients undergoing primary DA THA. These trends remained consistent when controlling for age, gender, BMI, and ASA.

Impact of Dexamethasone on Length of Stay and Early Pain Control in Direct Anterior Approach Total Hip Arthroplasty With Neuraxial Anesthesia

BackgroundDexamethasone has been shown to reduce postoperative pain and opioid consumption for total joint arthroplasty patients; however, its impact on patients who received neuraxial anesthesia (NA) is not well described. We examined the impact of perioperative dexamethasone on outcomes for patients undergoing direct anterior approach total hip arthroplasty (THA) under NA. MethodsA retrospective review was conducted for 376 THA patients from a single institution. Univariate analysis was used to compare postoperative outcomes for 164 THA patients receiving dexamethasone compared to 212 who did not receive dexamethasone. ResultsNo differences in age, gender, body mass index, or American Society of Anesthesiologists (ASA) Score were observed between the groups. Patients receiving perioperative dexamethasone reported statistically significantly lower postanesthesia care unit (PACU) pain numeric rating scale (Dexamethasone 1.6 vs No dexamethasone 2.3, P = .014) and received lower PACU morphine milligram equivalents (MME) (Dexamethasone 8.57 vs No dexamethasone 11.44, P < .001). Patients receiving dexamethasone had significantly shorter LOS (Dexamethasone 29.40 vs No dexamethasone 35.26 hrs., P < .001). ConclusionPerioperative dexamethasone is associated with decreased postoperative pain and narcotic consumption, and shorter length of stay for patients undergoing primary direct anterior approach THA with NA.

Direct anterior approach versus direct lateral approach in total hip arthroplasty and bipolar hemiarthroplasty for femoral neck fractures: a retrospective comparative study.

In thecurrent literature, there is no consensus on the best surgical approach in hip replacement for femoral neck fractures (FNFs). The aim of this study is to compare the direct anterior approach (DAA) and the direct lateral approach (DLA) in patients treated with bipolar hemiarthroplasty (BHA) and total hip arthroplasty (THA) for FNFs. Patients with displaced FNFs (Garden type III and IV) treated operatively using BHA and THA were enrolled. The surgical approach techniques DAA and DLA are compared. The analysed variables are: mean surgery time, number of blood units transfused perioperatively, percentage of patients transfused, perioperative complications, pain and functional outcomes at 1 and 6months and mortality at 1, 3 and 12months. Between 2015 and 2017, 37 patients underwent BHA by the DAA and 38 patients underwent BHA by the DLA, 69 patients underwent THA by the DAA and 60 patients underwent THA by the DLA. For THA, the DAA compared to the DLA had a higher mean surgery time (100.8min vs. 97.7min), a lower mean number of blood units transfused perioperatively (1.4U vs. 1.9U), a significantly lower percentage of patients transfused (53.6% vs. 71.7%), a higher rate of perioperative complications (10.1% vs. 1.6%), a lower pain referred and better functional outcomes in the first 6 postoperative months and a significantly lower mortality rate at 12months (2.9% vs. 16.7%). For BHA, the advantages of the DAA over DLA are not as significant. The direct anterior approach in THA for FNFs provides significant benefits in the early post-operative period compared to the direct lateral approach in terms of functional recovery, residual pain, blood loss and mortality rate in the elderly active population. Level IV, retrospective cohort study.

The Actis and Corail Femoral Stems Provide for Similar Clinical and Radiographic Outcomes in Total Hip Arthroplasty.

The introduction of new devices for total hip arthroplasty (THA) offers surgeons the ability to address deficits in the portfolio. However, once introduced, data regarding the performance of devices is not publicly available until their use is widespread. The objective of this study was to compare the clinical and radiographic performance, including patient reported outcomes and radiographic evidence of osseointegration, subsidence, and stress shielding, of the newer Actis femoral component to the Corail stem (DePuy Synthes, Warsaw, IN, USA), which has an extensive clinical history. This short-term, retrospective cohort study was a single surgeon series of 330 anterior approach THAs, consisting of 165 cases using the Actis stem and 165 cases using the Corail stem. Both devices were cementless, titanium, tapered, hydroxyapatite-coated stems. They differed in geometry, neck choices, broach philosophy, and collar availability. Data was obtained for 1year following THA. Functional outcomes were measured with the Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR.) survey. Complications were recorded from patient charts, and radiographic analysis was performed for signs of osseointegration, subsidence, and stress shielding. The groups shared similar demographic characteristics except the Actis population was younger with fewer women. The complication rate did not significantly vary, and no patient required revision within the first year. Radiographically, one patient in each group demonstrated subsidence. No cases exhibited radiolucent lines, and the prevalence of stress shielding at 1year was comparable. HOOS, JR. scores did not significantly vary at 8weeks or 1year. The Actis stem does not carry an increased risk of device-related complications compared with the Corail implant. Although aspects of bone remodeling differed between groups, Actis achieved radiographic signs of bone ingrowth at the 1-year mark and performed well clinically, with equivalent patient reported outcome scores to the Corail stem.

Good long-term outcomes for Direct Anterior Approach Total Hip Arthroplasty in South Africa

This study aims to assess long-term outcomes of Total Hip Arthroplasty (THA) through Direct Anterior Approach (DAA) in a developing country using traditional and novel Patient-Reported Outcomes. There were 522 patients (mean age, 56.5 years; 66.3% female) after mean follow-up 7.35 years. There were 13 revisions. Overall 5-year implant survival rate was 97.5%. Patient Joint Perception scores of 65.5% perceived a completely natural joint. Mean Hip Disability and Osteoarthritis Score was 89.1. Median Forgotten Joint Score-12 was 90 and modified Harris Hip Score was 88. Primary DAA THA in sub-Saharan Africa allows good clinical outcomes at minimum 5 years follow-up.

The Direct Anterior Approach Total Hip Arthroplasty Reliably Achieves "Safe Zones" for Combined Anteversion.

BackgroundIn total hip arthroplasty (THA), component position is critical to avoid instability and improve longevity. Appropriate combined femoral and acetabular component anteversion is important for improved THA stability and increased impingement-free range of motion. In direct anterior THA (DA-THA), concern has been expressed regarding the accuracy of femoral component positioning. This study seeks to quantify acetabular, femoral, and combined component orientation relative to the accepted “safe zones” in patients who have undergone DA-THA.MethodsTwenty-nine patients who had THA performed via direct anterior approach had postoperative computerized tomography scans done to assess femoral anteversion. Stem rotational alignment was measured relative to the transepicondylar axis (TEA) and the posterior condylar axis (PCA) of the femur at the knee. Acetabular abduction and version were recorded on anteroposterior pelvis radiographs.ResultsThe mean stem anteversion was 17.5° (standard deviation = 10.8°) from the TEA and 21.7° (standard deviation = 11.3°) from the PCA. Ten of 30 cups were appropriately anteverted; however, all the cups had appropriate abduction. Combined version when using the TEA resulted in 79% (23/29) of patients within the “safe zone” of 25°-50°. Pearson correlation coefficients were high for both stem anteversion from the TEA (R = 0.96) and PCA (R = 0.98); however, interobserver reliability for combined component anteversion was greater for the TEA (kappa, 0.83 vs 0.65).ConclusionsCombined anteversion within the “safe zone” was achieved 79% of the time with DA-THA. Interestingly, most of the “excessive” combined anteversion appears to be related to increased anteversion of the acetabular component with only 10 patients within the acetabular cup “safe zone” of 5°-25°.

Correction to: Biomechanical reconstruction parameters obtained after direct anterior approach total hip arthroplasty do not compromise clinical outcome

The original version of this article unfortunately contained a mistake. Figures3 and 4 captions were interchanged.

23-hour Total Hip Replacement Requiring Only 3.5 Opioid Pills Through 6 Weeks: A Non-selected Prospective Consecutive One Year Cohort

Background Many treatment protocols surrounding post-surgical pain management following total hip arthroplasty (THA) rely heavily on opioid medications and conventional formal physical therapy. We hypothesized that an expanded 90-day multimodal protocol could lead to a postoperative opioid-free or significantly reduced-opioid THA recovery with little or no need for formal physical therapy. Methods Prospective consecutive patients undergoing THA were enrolled in a 3 month long (6 weeks preoperatively and 6 weeks postoperatively) multimodal protocol including a robust education and optimization program with home-based physical therapy. All patients received a direct anterior approach THA on a Hana table by a single, fellowship-trained surgeon in a community practice. Opioid consumption was recorded at preoperative, postoperative, 3 week and 6 week timepoints. Results A total of 207 consecutive patients underwent THA and completed their 6-week follow-up evaluations. Seventy-nine patients (38%) required no opioid pills, 75 (36%) used 1-5 pills, 47 (23%) used 6-10 pills and 6 (3%) used more than ten pills. Overall 97% of patients undergoing DAA THA required 10 pills or less. Of those patients who reported taking at least one opioid pill, 92/128 (72%) took tramadol rather than stronger opioids. Average number of opioids was 3.5 pills per patient. Additionally, at 6 weeks, 95% of patients required no formal physical therapy. The percentage of patients discharged home the same day was 64% with 94% home by POD #1. Average length of stay was .42 days. Conclusion This study confirms that an expanded length multimodal protocol can significantly reduce or eliminate opioid consumption following outpatient DAA THA. It additionally confirms that the majority of patients may do well with a simple home exercise program.

Clinical and Radiographic Outcomes after Direct Anterior Approach Total Hip Arthroplasty Using Two Specialized Surgical Tables.

BackgroundSpecialized tables for direct anterior (DA) approach total hip arthroplasty (THA) have required an unscrubbed assistant for manipulation of the operative limb. A novel surgical table attachment designed for the DA approach is fully surgeon controlled and partially automated. The purpose of this study is to compare the clinical outcomes in patients who underwent THA through a DA approach with an assistant-controlled vs the surgeon-controlled (SC) table.MethodsThis is a retrospective study of 343 patients who underwent primary THA between January 2017 and October 2017. Two cohorts were established based on the surgical table used. Surgical and clinical data included the surgical time, length of stay, presence of pain (groin, hip, or thigh pain) at latest follow-up, and revision for any reason. Immediate postoperative radiographs were compared with latest follow-up radiographs to assess for leg length discrepancy, stem alignment, and stem subsidence.ResultsOne hundred sixty-seven (48.7%) cases were performed using the assistant-controlled table, and 176 (51.3%) cases were performed using the SC table. The surgical time was significantly greater for surgeries using the SC table (70.2 minutes vs 66.1 minutes, P < .001). Neither group experienced any intraoperative fractures or postoperative dislocations. There were no significant differences in any other clinical or radiographic outcomes.ConclusionsAlthough the surgical time with the self-controlled table was longer by approximately 4 minutes, this discrepancy disappeared with progression through the learning curve. In our experience, the SC table allows for greater autonomy for the operating surgeon and eliminates the need for a full-time employee in the operating room workflow.

A survey of Hip Society surgeons concerning the direct anterior approach total hip arthroplasty.

To establish whether there was a consensus among the members of the Hip Society (HS) on the role of direct anterior approach (DAA) contemporary primary total hip arthroplasty (THA). An online survey was sent to all 112 active and senior members of the HS, to which 71 members responded. The survey was constructed to determine whether they believed that evidence-based medicine proves, in modern clinical practice, that the DAA has significant benefits compared to risks when contrasted with other approaches. In addition, they were asked if they currently used the DAA. While only 16.9% (12/71) of respondents had been trained in a generic anterior approach during residency, 49.3% (35/71) had used the DAA in their clinical practice in the past or were using it at the present time. Unexpectedly, 42.9% (15/35) of respondents who had used the DAA in the past had abandoned it by the time of this survey. Only 22.5% (16/71) of all respondents believed that evidence-based medicine proves that the DAA has significant benefits compared to risks in contrast to other approaches. A comprehensive literature review found only three prospective randomized clinical trials (RCT) comparing the DAA with another approach with greater than one-year follow-up. Two showed minor benefits within the early postoperative period only, and one of those showed poorer mid-term results. Most of the published comparison studies with short follow-up show longer surgical times and greater blood loss for the DAA, and many three-month comparison studies show higher complication rates for the DAA using a proprietary traction table. The complications included problems with wound healing, lateral femoral cutaneous nerve injury, femoral component loosening, and femoral fractures. Because of the lack of evidence from RCTs showing superiority of the DAA over other approaches and reports of higher complications, the opinion of a large majority (77.5%; 55/71) of HS surgeons was that the DAA lacks sufficient evidence to warrant its use. Cite this article: Bone Joint J 2020;102-B(7 Supple B):57-61.

Comparison of Component Placement Accuracy Using Two Intraoperative Fluoroscopic Grid Technologies During Direct Anterior Total Hip Arthroplasty

BackgroundIntraoperative fluoroscopy is beneficial when performing total hip arthroplasty (THA) via the direct anterior approach; however, image distortion may influence component placement. A manual gridding system (MGS) and a digital gridding system (DGS) are commercially available, aimed at visually representing or correcting image distortion. Therefore, the purpose of this study is to compare component placement accuracy following direct anterior approach THA when intraoperative fluoroscopy was supplemented with MGS or DGS. MethodsA retrospective evaluation of acetabular cup abduction (ABD), leg length discrepancy (LLD) and global hip offset difference (GHO) was completed for consecutive patients from 6 week post-THA weight-bearing radiographs. The predefined target LLD and GHO was <10 mm and ABD target was 45° ± 10°. Differences between MGS and DGS were determined by independent t-tests. ResultsThe MGS (250 patients, 315 hips) and DGS (183 patients, 218 hips) achieved targeted ABD in 98.7% and 96.8% of cases, respectively, and ABD was significantly lower in the MGS group (45.14 ± 4.03° and 47.01 ± 4.39°, respectively) (P < .001). Compared to MGS, the DGS group averaged significantly higher GHO (3.64 ± 2.44 and 4.45 ± 2.73 mm, respectively, P = .002) but was not significantly different regarding LLD (2.92 ± 2.55 and 3.19 ± 2.46 mm, respectively, P = .275). No significant group difference was noted for percentage within the targeted LLD and GHO; however, 93.5% of DGS and 97.6% of MGS achieved all three (P = .031). ConclusionThe use of both the MGS and DGS resulted in consistent component placement within the predefined target zone. Although the MGS appeared to be slightly more consistent, these differences are unlikely to be clinically significant.

Early Experience of Direct Anterior Approach Total Hip Arthroplasty: Analysis of the First 53 Cases.

PurposeTo determine if it is feasible and safe for a surgeon to transition from using the posterolateral approach to direct anterior approach (DAA) by evaluating the first 53 cases of total hip arthroplasty using a DAA.Materials and MethodsA retrospective review of 52 patients who underwent THA using a DAA between July 2017 and December 2018. Reasons for THA were: femoral neck fracture (n=34), avascular necrosis (n=13), and arthritis (n=6). The mean age was 70 years old. An assessment of feasibility was made by analyzing mean operative time and blood loss. Cup inclination, anteversion, and leg length discrepancy (LLD) were measured using postoperative radiology. Safety of the DAA was judged using the incidence and nature of all complications.ResultsThe mean operative time was 112 minutes. 135 minutes for the 1st 10 cases, 100 minutes for 2nd 10 cases, 113 minutes for 3rd 10 cases, 119 minutes for 4th 10 cases, and 91 minutes for the final 13 cases. The mean blood loss was 724 mL. Average cup inclination was 40.27°; 2 cases were out of safety angle. Mean anteversion was 16.18°. No intraoperative fractures or infections were observed. LLD was detected in 3 cases, one of which underwent revision due to walking difficulty. Dislocation occurred in 3 cases, all within the first 20 cases, however, there was no recurrent dislocation.ConclusionDAA for THA was deemed to be feasible and safe based on an assessment of operative time, blood loss and complications.

Direct Anterior Approach in Crowe Type III-IV Developmental Dysplasia of the Hip: Surgical Technique and 2 years Follow-up from Southwest China.

ObjectivesTo summarize our pioneering surgical practice and clinical outcome of Crowe type III‐IV developmental dysplasia of the hip (DDH) with a direct anterior approach total hip arthroplasty in a single teaching hospital in Southwest China.MethodsFourteen patients (15 hips) diagnosed with Crowe type III‐IV developmental dysplasia of the hip were involved in this single‐center retrospective study between 2016 and 2018. A comprehensive surgical procedure, including preoperative planning and algorithms for leg length equalization, intraoperative stepwise soft tissue release, bone defect reconstruction, and an innovative subtrochanteric osteotomy, was described. Furthermore, advancements in intraoperative CT guidance, computer navigation, and nerve monitoring were available for specific demands. The short‐term clinical outcome was evaluated at the endpoint of follow‐up by three patient‐reported functional scales (Harris, WOMAC, and SF‐12 scores), and objective data collected at the clinic, including functional recovery (muscle strength of hip flexor and abductor, correction of the pelvic tilt, leg length discrepancy, and limp), radiographic analysis, and complication occurrence.ResultsThe intraoperative variables were carefully recorded. The mean operating times in Crowe type III and IV groups were 115.8 min and 156.2 min, and the median blood loss volumes were 520.5 mL and 810.2 mL, respectively. The general changes in the Harris, SF‐12, and WOMAC scores of the two groups were 46.2, 8.7 and 134.3, respectively, at a mean follow‐up of 25.4 months. Enhanced recovery of hip abductor muscle strength was identified in 85.7% of the population at the third postoperative month. The equalization of leg length and correction of the pelvic tile were observed at the sixth postoperative month, with a 36‐mm decrease in leg length discrepancy. No radiographic evidence of the loosening or migration of the components was observed. A self‐innovated subtrochanteric shortening osteotomy was performed in five patients, and they healed after 6 months. Specific complications included two cases of distal femoral cracks and one case of a periprosthetic fracture needing internal fixation. Two patients received a late iliotibial band release at the 3rd month postoperatively due to progressive genu valgum. No records of infection, dislocation, nerve palsy, bone non‐union, or revision surgery were identified.DiscussionThe direct anterior approach total hip arthroplasty showed potential advantages, including optimum component positioning, improved hip stability, steerable complication rate, and enhanced functional recovery with Crowe type III‐IV DDH. The short‐term outcome is comparable to that of the traditional posterolateral approach.

Short-Term Radiographic Evaluation of a Tri-Tapered Femoral Stem in Direct Anterior Total Hip Arthroplasty

Direct anterior approach (DAA) total hip arthroplasty (THA) has become increasingly popular, largely due to utilization of a true internervous and intermuscular plane. However, recent literature has demonstrated an increased rate of femoral implant subsidence with this approach. Hence, different femoral implants, such as the tri-tapered femoral stem, have been developed to facilitate proper component insertion and positioning to prevent this femoral subsidence. The purpose of this study was to evaluate the subsidence rate of a tri-tapered femoral stem implanted utilizing a DAA, and to determine if the proximal femoral bone quality affects the rate of subsidence. A retrospective analysis of 155 consecutive primary THAs performed by a single surgeon was conducted. Age, gender, primary diagnosis, and radiographic measurements of each subject were recorded. Radiological evaluations, such as bone quality, femoral canal fill, and implant subsidence, were measured on standardized anteroposterior (AP) and frog-leg lateral radiographs of the hip at 6-week and 6-month postoperative follow-up evaluations. The average subsidence of femoral stems was 1.18 ± 0.8 mm. There was no statistical difference in the amount of subsidence based on diagnosis or proximal femora quality. The tri-tapered stem design consistently filled the proximal canal with an average of 91.9 ± 4.9% fill. Subsidence was not significantly associated with age, canal flare index (CFI), or experience of the surgeon. THA utilizing the DAA with a tri-tapered femoral stem can achieve consistent and reliable fit regardless of proximal femoral bone quality.

Perioperative Fracture Risk and Two-Year Survivorship of a Short Tapered Femoral Stem following Direct Anterior Approach Cementless Total Hip Arthroplasty with a Fracture Table

AbstractThe cementless, tapered wedge, short femoral stem implant is commonly used in direct anterior approach (DAA) total hip arthroplasty (THA). The lack of access and visualization, however, may increase the risk of perioperative fracture and early failure. Therefore, the current study examined perioperative complications and 2-year implant survivorship following DAA THA performed using a fracture table and short, tapered wedge femoral stem. A retrospective analysis was conducted on patients having undergone DAA THA with a cementless, tapered wedge, short femoral stem. Perioperative fractures were noted and survivorship was determined by the incidence of revision surgery within a minimum 2-year follow-up period. A total 366 consecutive patients (441 hips) were identified in the cohort. Four patients (6 hips; 1.4%) were lost to follow-up and three patients died from unrelated causes. Average follow-up time for the remaining 359 patients (435 hips) was 32.9 ± 10.2 months. There were no intraoperative factures but three perioperative fractures within two weeks. Aseptic loosening occurred in one stem at 13 months, resulting in a 99.1% survival rate with a mean survival time of 23.8 ± 0.1 months (95% confidence interval: 23.6–24.0 months). The use of a short, tapered wedge femoral stem and a fracture table for DAA THA resulted in 0.7% periprosthetic fractures and only one aseptic loosening within 2 years. These results suggest that proper femoral exposure with the use of a fracture table and a short, tapered wedge femoral stem does not appear to increase the risk of periprosthetic femoral fracture.

Simultaneous Bilateral Minimally Invasive Direct Anterior Approach Total Hip Arthroplasty with fast track Protocol.

Advanced degenerative hip joint disease is bilateral in approximately 20% of cases, prompting questions of whether it is necessary to perform two separate surgical procedures, whether simultaneous bilateral hip replacement makes the surgical treatment too extensive, and whether it significantly affects the postoperative course. The study analysed the duration of hospitalisation, perioperative complications, and the need for blood transfusion in 30 patients (27 men and 3 women) with bilateral hip osteoarthritis who underwent simultaneous bilateral total hip replacement from a minimally invasive direct anterior approach followed by a fast track protocol for optimisation of perioperative management between 2014 and 2017. The mean age of patients was 60.2 years (range 43 to 77 years) and the mean follow-up period was 28 months (range 18 to 48 months). Mean duration of hospitalisation was 4.5 days (range 3 to 9 days). A total of 4 patients (13%) required allogeneic blood transfusion. No patient developed thromboembolic or infectious complications or implant dislocation after surgery. Apart from one case where the acetabulum was not selected correctly, which resulted in postoperative loosening, there were no other significant medical events potentially related to the surgical treatment. Simultaneous bilateral total hip arthroplasty using a minimally invasive direct approach and a fast track protocol for optimisation of perioperative management does not increase the need for perioperative blood transfusion or the number of surgical complications and constitutes a safe, effective, and recommendable method of treatment in patients with advanced bilateral degenerative disease of the hip joints.

Complication Rates for the Anterior Approach to Total Hip Arthroplasty.

Total hip arthroplasty (THA) is one of the most successful orthopedic surgeries performed in the United States. Orthopedic surgeons have looked to minimally invasive approaches for THA to reduce peri- and postoperative complications, and to improve patients' quality of life; the anterior approach THA has been advocated as such a minimally invasive surgery. This study involved a retrospective chart review of 2647 consecutive unilateral THAs using the anterior approach. The following parameters and complications were examined: patient demographics, surgery duration (open to close), postoperative length of stay, intraoperative fractures requiring internal fixation, femoral or sciatic nerve injuries with or without motor loss, deep infections managed with operative irrigation and debridement, deep venous thromboses (DVTs), and dislocations. Mean patient age and body mass index were 65 years and 29.78 kg/m2, respectively. Mean length of surgery was 69.1 minutes, and mean length of stay was 1.6 days postoperatively. The complication rates were as follows: dislocations, 19 (0.72%); DVT, 12 (0.45%); fractures, 13 (0.49%); infections, 49 (1.85%); and nerve injuries, 11 (0.42%). These findings demonstrate the anterior approach to THA has very low complication rates and acceptably low rates of infection. In addition, the minimally invasive THA has an acceptably low duration and a substantially reduced length of stay compared with more traditional THA approaches. [Orthopedics. 2020;43(3):e147-e150.].

Direct Anterior Approach Total Hip Arthroplasty Revisited.

In total hip arthroplasty, the advantages of the direct anterior approach (DAA) compared with the direct lateral and posterior approaches include a true intermuscular approach that spares the abductor musculature, protects the soft tissues surrounding the hip, and thus maintains hip joint stability. The disadvantages of the DAA compared with the direct lateral and posterior approaches include a steep learning curve; intraoperative radiation exposure; injury to the nerves, vessels, and muscles; and intraoperative and early postoperative complications including blood loss, wound-healing problems, increased time under anesthesia, proximal femoral fractures and dislocations, complex femoral exposure and bone preparation, and sagittal malalignment of the stem leading to loosening and an increased revision rate. Stem implantation in flexed sagittal position and early femoral-stem failures are more common with the DAA compared with the direct lateral and posterior approaches.

Anterior acetabular retractors and the femoral neurovascular bundle in anterior total hip arthroplasty: a cadaveric study.

The direct anterior approach for primary total hip arthroplasty (THA) has become increasingly popular in recent years. Nerve compression or traction with a retractor is a common cause of nerve injury in this approach. The purpose of this cadaveric study was to evaluate the anatomic relationship of the femoral neurovascular bundle to the anterior acetabular retractor during direct anterior approach THA. Eleven fresh-frozen cadavers underwent a standard direct anterior THA, with placement of an anterior acetabular retractor in the usual fashion between the iliopsoas and acetabulum for visualization during acetabular preparation. Careful dissection of the femoral triangle was performed, and the distances from the anterior retractor tip to the femoral nerve, artery, and vein were recorded and analyzed as mean distance ± standard deviation. In all 11 cadavers, the retractor tip was medial to the femoral nerve. The mean distance from retractor tip to femoral artery and vein was 5.9mm (SD = 5.5, range 0-20) and 12.6mm (SD 0.7, range 0-35), respectively. Surgeons should be aware of the proximity of the neurovascular structures in relation to the anterior acetabular retractor in the direct anterior approach, taking care to avoid perforating the iliopsoas muscle during retractor insertion and limit excessive traction to prevent nerve injury.