Anterior Total Hip Arthroplasty Research Articles

Vertical or Horizontal (Bikini) Incision for Direct Anterior Total Hip Arthroplasty: Outcomes of Early (< 90 day) Revision

BackgroundThe horizontal ‘bikini’ incision for direct anterior approach (DAA) total hip arthroplasty (THA) has gained popularity due to its early wound healing characteristics, however, the non-extensile 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 THA 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. ConclusionOur 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.

The Learning Curve From Converting From Fluoroscopic to Robotic-Assisted Direct Anterior Total Hip Arthroplasty.

Robotic-assisted total hip arthroplasty (RA-THA) provides an alternative to fluoroscopic guidance, thus reducing radiation exposure for orthopaedic surgeons. This study was performed to assess the learning curve associated with the adoption of RA-THA using the direct anterior approach (DAA) with regard to surgical time, use of fluoroscopy, and implant placement. In addition, we compared complication rates and patient-reported outcome scores between both cohorts. A case report of an RA-THA is also presented. This was a retrospective, non-randomized evaluation of the learning curve by assessing surgical time on a consecutive series of 89 DAA cases performed by a single surgeon. There were 53 cases that had manual THA with fluoroscopy and 36 cases with RA-THA. All cases had an acetabular component placement target of 40° inclination and 20° anteversion. An independent reviewer blinded to surgical technique used the Widmer method to measure acetabular inclination and version. Patient demographics were similar for both groups. The mean surgical time for the manual fluoroscopic group was 88 ± 21 minutes and 101 ± 14 minutes for the RA-THA group. After 15 RA-THA cases, surgical time reached time neutral compared to the manual fluoroscopic group. The first 17 RA-THA cases utilized fluoroscopy to verify implant position until the surgeon became comfortable with the accuracy of the RA-THA system. After case 17, fluoroscopy was abandoned in all subsequent RA-THA cases. The mean radiation dose delivered to the surgical field was 5.61 ± 5.71 mGy. Manual THA with fluoroscopy resulted in a mean acetabular inclination of 41.3 ± 4.4° and a mean anteversion of 22.4 ± 3.0°. The RA-THA resulted in a mean acetabular inclination of 42.0 ± 4.2° and a mean anteversion of 22.3 ± 3.9°. There was no noted change in RA-THA placement accuracy after case 17, when fluoroscopy was eliminated from the surgical workflow. There were no statistical differences between the manual fluoroscopic and robotic-assisted groups with respect to complications and clinical PROM outcomes. The DAA THA can be performed with RA-THA and achieve comparable acetabular placement without fluoroscopy. Surgical time was higher for the RA-THA group during the learning curve, but then decreased and was consistent with the manual fluoroscopic group after 15 cases.

Low Rate of Early Periprosthetic Fractures in Direct Anterior Total Hip Arthroplasty with a Triple-Tapered Wedge Stem.

Utilization of the direct anterior approach (DAA) for total hip arthroplasty (THA) has been steadily increasing in recent years. While the DAA may offer some benefits compared to other approaches, there are still risks involved including relatively higher rates of periprosthetic femur fractures, especially when combined with cementless femoral stem use. The purpose of this study is to evaluate the early postoperative femoral complications with a short triple-wedge tapered stem used in primary THA via a DAA. A retrospective review was conducted of the arthroplasty registry of our institution from April 2022 to August 2023 to identify patients who underwent a primary THA via a DAA with the Short Medacta Stem (SMS) (Medacta International, Castel San Pietro, Switzerland). Patients were excluded if the stem was used for a revision surgery, they were within 90 days of surgery, or they refused research consent. Inclusion criteria was met in 262 patients (302 hips). Data was collected after reviewing the chart, and reports and radiographic measurements, including Dorr type and canal fit ratios, were obtained from preoperative and postoperative radiographs, respectively. A total of 302 total hips were included, 161 patients were male (53.3%) and 141 were female (46.7%), with an average age of 66.5 years (27-88, +/- 10.7 years). Average follow up was 0.3 years (range, 0.05-1.71 years). The majority of patients had a Dorr B femur (81.7%). The Median stem size used was an 8 (range, 2-15), and 89.4% of those had a collar. Average canal fill ratio was 0.83 (range, 0.43-0.98, +/- 0.07). Overall, there were two Vancouver B2a periprosthetic femoral shaft fractures (0.66%) that required revision surgery to a modular stem. In addition, there were two Vancouver Ag greater trochanteric fractures (0.66%) with acceptable alignment that did not require revision surgery. Demographic information about the patients with femoral complications is summarized in Table I. Average age of patients with femoral complications was 69.5 years, with an average canal fit ratio of 0.88. We found that the triple-wedge implant had a low rate of early femoral complication in primary THA from an anterior approach and is safe for use in THA from a DAA. More follow up is needed to evaluate continuing implant survivorship and patient outcomes.

Can Robotic-Arm Assistance Decrease Iatrogenic Soft-Tissue Damage During Direct Anterior Total Hip Arthroplasty?

Manual techniques for total hip arthroplasty (THA) have been widely utilized and proven to be clinically successful. However, the use of advanced computed tomography (CT) scan-based planning and haptically-bounded reamers in robotic-arm assisted total hip arthroplasty (RTHA) holds promise for potentially limiting surrounding soft-tissue damage. This cadaver-based study aimed to compare the extent of soft-tissue damage between a robotic-arm assisted, haptically-guided THA (RTHA) and a manual, fluoroscopic-guided THA (MTHA) direct anterior approach. There were six fresh-frozen torso-to-toe cadaver specimens included, with two surgeons each performing three RTHA and three MTHA procedures. One hip underwent an RTHA and the other hip received an MTHA in each cadaver. Postoperatively, one additional surgeon, blinded to the procedures, assessed and graded damage to nine key anatomical structures using a 1 to 4 grading scale: (1) complete soft-tissue preservation to <5% of damage; (2) 6 to 25% of damage; (3) 26 to 75% of damage; and (4) 76 to 100% of damage. Kruskal-Wallis hypothesis tests were used to compare soft-tissue damage between RTHA and MTHA cases and adjusted for ties. Pooled analysis of the gluteus minimus, sartorius, tensor fascia lata, and vastus lateralis muscle grades demonstrated that cadaver specimens who underwent RTHA underwent less damage to these structures than following MTHA (median, IQR: 1.0, 1.0 to 2.0 vs. 3.0, 2.0 to 3.0; p=0.003). Pooled analysis of the calculated volumetric damage (mm3) for the gluteus minimus, sartorius, tensor fascia lata, and vastus lateralis muscles demonstrated that the cadaver specimens that underwent RTHA underwent less damage to these structures than those that followed MTHA (median, IQR: 23, 2 to 586 vs. 216, 58 to 3,050; p=0.037). This cadaver-based study suggests that utilizing RTHA may lead to reduced soft-tissue damage compared with MTHA, likely due to enhanced preoperative planning with robotic-arm assisted software, real-time intraoperative feedback, haptically-bounded reamer usage, reduced surgical steps, as well as ease of use with reaming. These findings should be carefully considered when evaluating the utilization of robotic-arm assisted THA in practice.

Fluoroscopy-Assisted Computer Navigation Accurately Determines Cup Position and Leg Length for Anterior Hip Arthroplasty.

Recently, fluoroscopy-assisted computer navigation has been developed to assess intraoperative cup inclination/anteversion and leg-length discrepancy (LLD) in the operating room. However, there is a relative dearth of studies investigating the accuracy of this software compared with postoperative radiographs. We prospectively enrolled 211 navigated anterior total hip arthroplasties using fluoroscopy-assisted computer navigation software. Intraoperative navigated measurements were compared with postoperative anteroposterior radiographs to assess accuracy of cup inclination/anteversion and LLD. Continuous variables were analyzed using the Student's t test, and categorical variables were analyzed using Fisher's exact test. On postoperative radiographs, 94.3% of cups (199 of 211) were positioned within the Lewinnek "safe zone," compared with 99.1% navigated intraoperatively (P=.01). Eighty-two percent of hips (174 of 211) were navigated intraoperatively to LLDs within ±2 mm; on postoperative radiographs, 65% of hips (138 of 211) had LLDs within ±2 mm (P=.0001). Intraoperatively, 100% of hips (211 of 211) were navigated to LLDs within ±5 mm; similarly, on postoperative radiographs, 98% of hips (207 of 211) had LLDs within ±5 mm (P=.12). A novel fluoroscopy-assisted computer navigation platform accurately assessed intraoperative cup position and LLD during anterior total hip arthroplasty. Careful attention to fluoroscopic technique, positioning of radiographic landmarks, and knowledge of the limitations of fluoroscopy, including parallax effect, are important concepts that surgeons should incorporate into their decision algorithm. [Orthopedics. 202x;4x(x):xx-xx.].

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.

Virtual range of motion is a safe and acceptable alternative to intra-operative manual range of motion testing in direct anterior robotic total hip arthroplasty

IntroductionIn robotic total hip arthroplasty (THA), virtual range of motion (VROM) modeling allows the surgeon to account for spinopelvic motion and create an impingement-free range of motion that is patient-specific. The primary purpose of this study was to evaluate the risk of dislocation in patients undergoing direct anterior THA using VROM rather than manual ROM trialing. MethodsProspectively collected data was reviewed retrospectively of all consecutive anterior THAs performed by a single fellowship-trained surgeon. No patients were excluded from the study. VROM identified bone and implant impingement, which was recorded in degrees of hip external rotation(ER) at 0° of hip extension (standing), and in degrees of hip internal rotation(IR) at 90° of hip flexion (sitting). No patients had manual ROM trialing performed. Dislocation events were recorded during the first 3 months of follow-up. 362 patients, with a mean age of 67 and mean BMI of 28.8, were included. ResultsThis cohort, including 154 patients (42.5%) with abnormal spinopelvic motion, demonstrated zero dislocations using VROM. The average ER impingement occurred at 60.9° ER (range 20-90°), and 50.8° IR (range 25-90°). Patients with ER impingement <55° had significantly less acetabular anteversion (16.4° ±3.3°, p < 0.001). Compared to the entire cohort, anteversion of the acetabulum was also decreased in the stuck-sitting subgroup (17.4° ±3.3°, p < 0.001) and increased in the stuck standing subgroup (20.5° ±3.6°, p < 0.001). ER impingement was a stronger predictor of acetabular anteversion than spinopelvic motion category (r = 0.458). Patients with ER impingement <45° (6.4%) or IR impingement <35° (6.6%) were “early impingers”. ConclusionIn this cohort of anterior THA patients with a high proportion of abnormal spinopelvic motion, a technique utilizing only VROM produced no dislocations. An impingement-free zone of 45° ER standing and 35° IR sitting is recommended.

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.

Polyester Mesh with Liquid Adhesive Compared to Incisional Negative Pressure 2 Therapy for Direct Anterior Total Hip Arthroplasty in the 90-day Postoperative Period

Background Some data suggest higher rates of superficial wound complications following direct anterior approach to total hip arthroplasty (DAA-THA) compared to other approaches, likely owing to proximity of the incision to the groin crease. Increased body mass index (BMI) has also been associated with increased superficial wound complications regardless of approach. We investigated superficial wound complications following DAA-THA comparing two different dressing types, polyester mesh (PM) with liquid adhesive and incisional negative pressure therapy (iNPT), with additional analysis of the association of BMI and medical comorbidities with wound complications in each dressing type cohort. Methods Consecutive DAA-THAs were assessed (n = 711 total, 213 iNPT, 498 PM). Superficial or deep wound complications within 3 months of surgery were recorded. Demographics were compared using student’s t-test with Welch’s correction and Chi-square tests, where appropriate. Logistic regression on wound complication included the following variables: patient BMI, dressing type, active tobacco smoking, diabetes mellitus, liver disease, chronic kidney disease, and anemia. A p-value of &lt; 0.05 was considered statistically significant. Results The overall rate of wound complication was 9.00%. Wound dehiscence was the most frequent complication, affecting 26 patients (3.66%) overall. Multiple logistic regression showed that BMI and tobacco smoking were associated with increased wound complications (aOR=1.072, p=0.007; aOR=3.258, p=0.009) and that PM use was associated with fewer wound complications when compared to iNPT (aOR=0.555, p=0.047). Conclusions In this investigation, PM dressings after DAA-THA were associated with decreased risk of wound complication compared to iNPT. Secondarily, smoking and increased BMI were risk factors for postoperative wound complications.

Energy expenditure of femoral broaching in direct anterior total hip replacements-Comparison between manual and automated techniques.

Little information is known regarding the energy expenditure of the surgeon during total hip arthroplasty (THA). We sought to compare the energy expenditure associated with femoral broaching using two techniques: manual and automated. We recorded energy expenditure, minute ventilation, heart rate, and total broaching time of a single surgeon while broaching the femoral canal during direct anterior THA using two different techniques: Manual broaching (n=26) and automated broaching (n=20). Manual broaching required a longer time than automated broaching (6.1±1.1 vs. 3.7±0.9min; p<0.001) with an increase in energy expenditure (32.6±7.0 vs. 16.0±7.1 Calories; p<0.001). Heart rate was higher with manual broaching (99.4±9.8 vs. 90.1±9.8 beats per min; p=0.003), along with minute ventilation (36.5±7.0 vs. 30.3±5.8L/min; p=0.003). There were no intraoperative complications. Automated femoral broaching during THA can decrease the energy expenditure of broaching by 50% and time of broaching by 40%, when compared to manual technique. This research was not a clinical trial.

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.

Effectiveness of Flat-Panel Fluoroscopy in Direct Anterior Total Hip Arthroplasty: A Comparison to Image Intensifier Fluoroscopy With Radiopaque Grid

IntroductionThe use of traditional, image intensifier fluoroscopy with a radiopaque grid during direct anterior total hip arthroplasty (DA THA) has demonstrated reduced variability in component positioning and operative time compared to fluoroscopy without a grid. A disadvantage of image intensifier fluoroscopy is spatial distortion, particularly compared to flat-panel fluoroscopy systems. The purpose of this study is to determine whether flat-panel fluoroscopy decreases variability in component positioning during DA THA compared to the use of traditional grid fluoroscopy. MethodsWe retrospectively reviewed 70 consecutive DA THAs between February 2020 and February 2021: 36 using flat-panel fluoroscopy, and 34 using traditional fluoroscopy with a grid. Radiographs were independently reviewed by 2 authors to identify components exceeding goal parameters: cup abduction of 40 ± 10 degrees, as well as offset and limb lengths within 10 mm of the contralateral side. Binary values for goal parameter achievement were assigned for each THA. ResultsNo significant difference was observed in the number of hips that met goals for cup abduction (100% vs 97%, P = 1.00), hip offset (88% vs 88%, P = 1.00), limb length (91% vs 94% [ ±10 mm], P = .669, 65% vs 72% [±5 mm], P = .498), or for the number of hips that met all 3 component goals (79% vs 80%, P = 1.00). No significant difference in operative time was noted between the 2 groups (110.2 minutes vs 100.9, P = .76). ConclusionsWe demonstrated no significant difference in component positioning in DA THAs utilizing flat-panel fluoroscopy as compared to using traditional fluoroscopy with a grid.

Dislocation Following Anterior and Posterior Total Hip Arthroplasty in the Setting of Spinal Deformity and Stiffness: Evolving Trends Using a High-Risk Protocol at a Single Tertiary Center

BackgroundPatients who have spinal stiffness and deformity are at the highest risk for dislocation after total hip arthroplasty (THA). Previous reports of this cohort are limited to antero-lateral and postero-lateral (PL) approaches. We investigated the dislocation rate after direct anterior (DA) and PL approach THA with a contemporary high-risk protocol to optimize stability. MethodsWe investigated patients undergoing THA who had preoperative biplanar imaging from January-December 2019. Patients were identified using radiographic criteria of spinal-stiffness (<10-degree change in sacral slope from standing to seated) and deformity (flatback deformity with >10-degree difference in pelvic incidence and lumbar lordosis). There were 367 patients identified (181 DA, 186 PL). The primary outcome was dislocation rate at 2-years postoperatively. Risk-factors for dislocation were evaluated using logistic regressions (significance level of 0.05). ResultsThere were 6 (1.6%) dislocations in the entire cohort, with low dislocation rates for both DA (0.6%) and PL-THA (2.7%). We observed increased utilization of dual mobility with larger outer head bearings (>38 mm) with PL-THA (34.4 versus 5.0%, P < .01) and conversely increased utilization of 32-mm femoral-heads with DA-THA (39.4 versus 7.0%, P < .001). Surgical approach (PL) was not a significant risk-factor for dislocation (odds ratio: 5.03, P = .15). Patients who had a history of lumbar-fusion had 8-times higher odds for dislocation (OR: 8.20, P = .020). ConclusionsTo the best of our knowledge, this is the largest series to date evaluating DA and PL-THA in the hip-spine 2B-group. Our results demonstrate lower dislocation rate than expected with either surgical approach using a high-risk protocol.

Does Powered Femoral Broaching Compromise Patient Safety in Total Hip Arthroplasty?

During manual broaching (MB) in total hip arthroplasty (THA), off-axis forces delivered to the proximal femur and broach malalignment can lead to fractures and cortical perforations. Powered broaching (PB) is a novel alternative that delivers consistent impaction forces and reduces workload. This is the first large-scale study to compare intraoperative and 90-day rates of periprosthetic femur fractures (PFFs) and perforations in THA performed using MB vs PB. Our institutional database was reviewed for all patients undergoing primary cementless direct anterior THA from 2016 to 2021. Three surgeons performing 2048 THAs (MB= 800; PB= 1248) using the same stem design were included. PFFs and perforations within 90 days of the index procedure were compared. Differences in length of surgery and demographics were assessed. Calcar fractures occurred in <1% of patients (PB [0.96%, 12/1248] vs MB [0.25%, 2/800]; P= .06). Rates of trochanteric fractures did not differ (PB= 0.32% [4/1248] vs MB= 0.38% [3/800]; P= .84). Cortical perforations occurred in 0.24% (3/1248) of the PB cohort and in 0.75% (6/800) of the MB cohort (P= .09). No revisions due to aseptic loosening or PFF occurred within 120 days of surgery. Our single-center experience with powered femoral broaching in THA demonstrates PB is a safe and efficient means of performing direct anterior THA. Low rates (<1%) of PFF, perforation, and revision can be achieved. Given our positive experience with PB, all surgeon authors utilize PB nearly exclusively for elective primary direct anterior THA.

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.

Does intraoperative fluoroscopy improve acetabular component positioning and limb-length discrepancy during direct anterior total hip arthroplasty? A meta-analysis

BackgroundThe positioning of implant components for total hip arthroplasty (THA) is essential for joint stability, polyethylene liner wear, and range of motion. One potential benefit of the direct anterior approach (DAA) for THA is the ability to use intraoperative fluoroscopy for acetabular cup positioning and limb-length evaluation. Previous studies comparing intraoperative fluoroscopy with no fluoroscopy during DAA have reported conflicting results. This meta-analysis aimed to evaluate whether intraoperative fluoroscopy improves component positioning compared to no fluoroscopy during direct anterior total hip arthroplasty.MethodsA systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. We searched Web of Science, EMBASE, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, CNKI, VIP, and Wanfang database in May 2023 to identify studies involving intraoperative fluoroscopy versus no fluoroscopy during direct anterior total hip arthroplasty. Finally, we identified 1262 hips assessed in seven studies.ResultsThere were no significant differences in terms of acetabular cup inclination angle (ACIA, P = 0.21), ACIA within safe zone rate (P = 0.97), acetabular cup anteversion angle (ACAA, P = 0.26); ACAA within safe zone rate (P = 0.07), combined safe zone rate (P = 0.33), and limb-length discrepancy (LLD, P = 0.21) between two groups.ConclusionEven though intraoperative fluoroscopy was not related to an improvement in cup location or LDD. With fewer experienced surgeons, the benefit of intraoperative fluoroscopy might become more evident. More adequately powered and well-designed long-term follow-up studies were required to determine whether the application of the intraoperative fluoroscopy for direct anterior total hip arthroplasty will have clinical benefits and improve the survival of prostheses.

Comparative study of carbazochrome sodium sulfonate and tranexamic acid in reducing blood loss and inflammatory response following direct anterior total hip arthroplasty: a prospective randomized controlled trial.

Carbazochrome sodium sulfonate (CSS) is a haemostatic agent. However, its hemostatic and anti-inflammatory effects in patients undergoing total hip arthroplasty (THA) via a direct anterior approach (DAA) are unknown. We investigated the efficacy and safety of CSS combined with tranexamic acid (TXA) in THA using DAA. This study enrolled 100 patients who underwent primary, unilateral THA through a direct anterior approach. Patients were randomly divided into two groups: Group A used a combination of TXA and CSS, while Group B used TXA only. The primary outcome was total perioperative blood loss. The secondary outcomes were hidden blood loss, postoperative blood transfusion rate, inflammatory reactant levels, hip function, pain score, venous thromboembolism (VTE), and incidence of associated adverse reactions. The total blood loss (TBL) in group A was significantly lower than in group B. The levels of inflammatory reactants and the rate of blood transfusion were also significantly lower. However, the two groups had no significant differences in intraoperative blood loss, postoperative pain score, or joint function. There were no significant differences in VTE or postoperative complications between the groups. As a haemostatic agent, CSS combined with TXA can reduce postoperative blood loss in patients undergoing THA via DAA and seems to have an anti-inflammatory effect. Moreover, it did not increase the incidence of VTE or its related complications.

Influence of obesity and intra-operative imaging guidance technology on acetabular cup positioning in total hip arthroplasty.

Accuracy of acetabular cup positioning during total hip arthroplasty (THA) can be improved with intra-operative imaging but may be influenced by body mass index (BMI). This study assessed the influence of BMI (kg/m2) on cup accuracy when using intra-operative fluoroscopy (IF) alone or supplemented with a commercial product. This retrospective review included four consecutive cohorts of patients having undergone anterior approach THA with IF alone (2011-2015), IF and Overlay (2015-2016) (Radlink Inc., Los Angeles, CA), IF and Grid (2017-2018) (HipGrid Drone™, OrthoGrid Systems Inc., Salt Lake City, UT) and IF and Digital (2018-2020) (OrthoGrid Phantom®, OrthoGrid Systems, Inc., Salt Lake City, UT). Component placement accuracy was measured on 6-week post-operative weight bearing radiographs and compared between four BMI patient groups (BMI ≤ 25, 25 < BMI ≤ 30, 30 < BMI ≤ 35, and 35 < BMI). Total fluoroscopy times were also recorded directly from the fluoroscopy unit. Abduction angle significantly increased as BMI increased (p = 0.003) with IF alone but no difference was present in groups with guidance technology. Anteversion was significantly different between BMI groups for IF alone (p = 0.028) and Grid (p = 0.027) but was not different in Overlay (p = 0.107) or Digital (p = 0.210). Fluoroscopy time was significantly different between BMI categories for IF alone (p = 0.005) and Grid (p = 0.018) but was not different in Overlay (p = 0.444) or Digital (p = 0.170). Morbid obesity (BMI > 35) increases risk for malpositioning of acetabular cups and increases surgical time with IF alone or the Grid. Additional IF guidance technology (Overlay or Digital) increased cup positioning accuracy without decreasing surgical efficiency.

Collared fully hydroxyapatite-coated stem decreases the risk of early postoperative periprosthetic femoral fracture after direct anterior total hip arthroplasty

PurposePostoperative periprosthetic femoral fracture (PPFF) is one of the major complications following total hip arthroplasty (THA). The purpose of this study was to investigate the epidemiology of early PPFF (within 90 days) after THA. MethodsPrimary THA was performed for hip osteoarthritis through a direct anterior approach in 6769 cases. Among these, we retrospectively investigated the occurrence of postoperative PPFF that required surgical intervention. ResultsPostoperative PPFF was seen in 29 hips (29/6769; 0.43%), and the mean period from primary THA to fracture occurrence was 9.2 ​± ​8.5 days. Of these, 13 (13/2170; 0.60%) fractures were observed in prosthesis with flat tapered-wedge stems, 7 (7/1652; 0.42%) in straight tapered stems, 4 (4/1082; 0.37%) in cemented stems, and 1 (1/1.060; 0.09%) in collared fully hydroxyapatite-coated stem. The prevalence of PPFF in collared fully hydroxyapatite-coated stems was significantly lower than that of flat tapered-wedge stems. Five hips (5/29; 17.2%) required re-surgical intervention. ConclusionOur results indicate that, compared to the flat tapered-wedge stem, use of the collared fully hydroxyapatite-coated stem decreases the risk of early postoperative PPFF following direct anterior THA.

The Bikini Approach is Safe and Effective for Direct Anterior Approach THA

AbstractConventional incision orientation for direct anterior approach (DAA) total hip arthroplasty (THA) is longitudinal, paralleling fibers of the tensor fascia latae. Alternatively, a “bikini” incision can be oriented along Langer's lines. We sought to determine if there were any differences in surgical site complications (SSCs), mechanical complications, or reoperation between longitudinal and bikini DAA. We retrospectively reviewed 420 consecutive primary DAA THA by a single surgeon over a 2-year period. The surgeon was experienced with both incision orientations. Complications were recorded by chart review. Chi-square tests were used to examine for differences between categorical variables and t-tests for continuous variables. Longitudinal incisions were used in 320 patients (76.2%) while bikini incisions were used in 100 patients (23.8%). Women were significantly more likely to have a bikini incision (39.1% vs. 5.8%; p &lt; 0.00001). Across the entire cohort, patients undergoing THA through either longitudinal or bikini incision had comparable rates of SSCs (4.7% vs. 5.0%; p = 0.90). With longitudinal incisions, SSCs were more likely to occur in obese patients compared with nonobese patients (8.3% vs. 3.1%; p = 0.04). With bikini incisions, there was no difference in the rate of SSCs between obese and nonobese patients (4.0% vs. 5.3%; p = 0.79). There were no differences in mechanical complications or rates of reoperation (0.3% vs. 0.0%; p = 0.58). Both longitudinal and bikini incisions are safe and effective ways to perform the DAA for primary THA, with no differences in rates of SSCs, mechanical complications, or reoperation. For obese patients in this series, the bikini incision was associated with a lower rate of SSCs but requires future study due to dissimilar study groups.