Approach For Primary Total Hip Arthroplasty Research Articles

Instability in Patients with Lumbar Spine Disease or Fusion Undergoing Posterior Approach vs. Lateral Approach Primary Total Hip Arthroplasty

Background and Hypothesis: 
 Dislocation rates after total hip arthroplasty (THA) in patients with fixed spinopelvic motion due to lumbar spine disease or fusion have been reported as high as 20%. Few studies exist that compare dislocation rates in patients with spine pathology undergoing THA via different surgical approaches. The purpose of this study was to compare postoperative dislocation rates in patients with lumbar spine disease or fusion between those undergoing a primary THA using a posterior versus direct lateral surgical approach. 
 
 Experimental Design or Project Methods: 
 With IRB approval, 1,205 primary THAs performed by two surgeons were retrospectively reviewed. One surgeon routinely performs THAs with a posterior approach while the other surgeon routinely uses a direct lateral approach. Chart review from the electronic medical record was conducted to identify patients who have lumbar spine disease or a lumbar spine fusion. Dislocations for patients with and without lumbar spine disease were compared by posterior approach and direct lateral approach. 
 
 Results: 
 767 posterior approach and 431 direct lateral approach THAs were available for analysis. 43.6% of all THAs had lumbar spine pathology (337/767 posterior and 185/431 direct lateral). The overall dislocation rate was 1.26% (15/1195). The main predictors of dislocation in binary logistic regression were the presence of lumbar spine pathology (OR 5.24, 95% CI: 1.47–18.69, p=0.018) and posterior surgical approach (OR 7.93, 95% CI: 1.04–60.6, p=0.046). The dislocation rate for direct lateral approach THAs with lumbar spine pathology was significantly lower compared to posterior approach THAs with lumbar spine pathology (0.0% vs 3.6%, p=0.011). 
 
 Conclusion and Potential Impact: 
 Although there were few dislocations, the study results suggest a direct lateral approach for primary THA may be beneficial to reduce postoperative dislocation for patients with limited spinopelvic motion due to lumbar spine pathology.

Periprosthetic Femur Fracture Risk: Influenced by Stem Choice, Not Surgical Approach

BackgroundPeriprosthetic femur fracture (PFF) remains a common reason for failure after total hip arthroplasty (THA). For over 10 years, our institution has performed both anterior approach (AA) and posterolateral (PL) approaches for primary THA with multiple stem designs. The aim of this study is to determine the 90-day relative risk of PFF with regard to approach and stem design. MethodsA retrospective review of our institutional database was performed on all patients undergoing primary THA from 2007 to 2018 using AA or PL approaches. Five surgeons performing 6309 THAs (AA = 4510; PL = 1799) using single-wedge taper (n = 2417) or fit-and-fill (n = 3892) stems were included. PFF occurring within 90 days of the index procedure were analyzed. Differences in PFF rates, fracture location, stem type, and treatment method were assessed. Comparisons were made using a Cox regression analysis. ResultsThe 90-day revision rate for fracture was 0.3%. Clinically significant fractures requiring cerclage cabling, stem change, revision, or open reduction internal fixation occurred in 0.9% of patients (intraoperative = 37, 0.6%; postoperative = 17, 0.3%). Cox regression found PFF risk was significant for female patients (P = .008), patients older than age 65 (P < .01), single-wedge taper stems (P = .05), and for cases with collarless stems (P = .04). Among PFF cases that required surgical intervention, risk factors were female sex, age older than 65, and body mass index under 25 (P < .05). Collarless stems were 2.6 times more likely to result in PFF than collared stems (P = .04). Single-wedge taper stems were 2.3 times more likely to result in PFF than fit-and-fill stems (P = .05). Approach was not found to be an independent risk factor for PFF (P = .85). ConclusionOur single-center experience demonstrates the risk of periprosthetic fracture within 90 days of surgery is significantly lower with collared stems and fit-and-fill stem designs. Female sex, age over 65, and body mass index below 25 nearly double the PFF risk. Surgical approach did not influence fracture rates.

Outcomes of combined hip procedure with dual mobility cup versus osteosynthesis for acetabular fractures in elderly patients: a retrospective observational cohort study of fifty one patients

PurposesAcetabular fractures are more and more common in the elderly. Open reduction and internal fixation (ORIF) may lead to poor outcomes and high revision rates. Primary total hip arthroplasty (THA) combined with internal fixation, also known as the combined hip procedure (CHP), associated with dual mobility cup (DM-CHP) could be an efficient procedure in selected elderly patients. The aim of this study is to compare functional and radiological outcomes between ORIF and DM-CHP.MethodsBetween 2007 and 2018, 51 patients older than 65 years were surgically treated for acetabular fractures. Twenty-six patients were treated by DM-CHP and 25 by ORIF. Each group was divided into two subgroups regarding a single or combined approach. Hospital stay, surgical time, intraoperative blood loss, and complications were documented. The Harris Hip Score (HHS) was used for measuring the functional outcome. Radiological analysis was used to assess the centre of rotation in the DM-CHP group.ResultsMedian surgery time and intra-operative blood loss were higher in DM-CHP than those in ORIF. Early medical complication rate was higher for a combined approach as compared with a single posterior approach in DM-CHP (p = 0.003). Dislocation rate was 7.7% in DM-CHP. Revision rate was higher in ORIF (20% versus 7.7%). HHS was similar in both groups.ConclusionsDM-CHP leads to similar functional outcomes and less revision than ORIF. This study strengthens the practice of using only the posterior approach for primary THA in the elderly. Dual mobility is a valid therapeutic option for acetabular fractures in elderly patients.

Early Outcome Comparison of the Posterior Approach and the Superior Approach for Primary Total Hip Arthroplasty.

BackgroundThe superior approach for total hip arthroplasty (THA) is a minimally invasive, tissue-sparing technique that may have clinical and economic benefits. The purpose of this study was to compare early outcomes between the posterior approach and the superior approach in primary THA. Our hypothesis was that the superior approach would have a noninferior length of stay (LOS), discharge destination, and blood loss compared with the posterior approach.MethodsAll primary THAs performed by a single surgeon at one institution were retrospectively reviewed over a 2-year period (2015-2017). There were 676 patients, 40.4% of whom underwent a posterior approach and 59.6% underwent a superior approach. LOS, discharge destination, blood loss, and operating room time were analyzed. Gender, body mass index, and American Society of Anesthesiologists status were recorded and controlled.ResultsThe posterior approach was independently associated with an almost threefold higher risk of prolonged LOS (>2 days, P < .001) (odds ratio: 2.90, 95% confidence interval: 1.87-4.49; P < .001). The mean LOS for the superior approach was 1.71 days vs 2.17 days for the posterior group (P < .001). Fewer patients in the superior approach cohort were discharged to a rehabilitation facility (8.9% vs 17.9%, P < .001). The mean operative time was shorter in the superior group (91.8 vs 95.8, P = .001). There was no statistically significant difference in acute postoperative blood loss. There were no dislocations or reoperations in either group.ConclusionsThe superior approach to THA was associated with a significantly shorter length of hospital stay and lower rate of discharge to rehab than the posterior approach. This approach can be used as a safe, minimally invasive, and tissue-sparing variation of a standard posterior approach for THA and has promising early outcomes.

Hospitalization length, surgical duration, and blood lost among the approaches for total hip arthroplasty: a Bayesian network meta-analysis.

Despite the numerous studies, there is no consensus concerning the best approach for total hip arthroplasty (THA), and debates are ongoing. The purpose of this study was to perform a Bayesian network meta-analysis (NMA) comparing several approaches for primary THA. The focus was on peri-operative outcomes: surgical duration, total estimated blood loss, and length of the hospitalization. This Bayesian network meta-analysis was conducted according to the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of health care interventions. In October 2019, the main databases were accessed. All the clinical trials comparing two or more different approaches for primary THA were assessed. For the methodology quality assessment, the PEDro score was performed. The Software STATA MP was used for the statistical analyses. The NMA was performed through the routine for Bayesian hierarchical random-effects analysis with the inverse variance statistic method for continuous variables. Data from 4843 procedures was analysed. Between patient's demographic, good baseline comparability was found. The comparison total estimated blood loss detected statistically significant inconsistency (P = 0.01). The posterolateral approach reported the lowest value for the surgical duration. The test for overall inconsistency was statistically significant (P = 0.4). The posterolateral approach reported the shortest hospitalization length. The test for overall inconsistency was statistically significant (P = 0.9). The posterolateral approach reported shorter surgical duration and hospitalization length. Concerning the analysis of total estimated blood loss, no significant result was obtained. Data must be considered in the light of the limitations of the present study.

In-hospital outcomes with anterior versus posterior approaches in total hip arthroplasty: meta-analysis of randomized controlled trials.

PurposeThe purpose of this study was to determine whether in-hospital outcomes are different with anterior approach (AA) or posterior approach (PA) in primary total hip arthroplasty (THA).MethodsWe performed a systematic review with random-effects meta-analysis of random-ized controlled trials (RCTs) comparing AA with PA in primary THA. Hospital outcomes were reported as odds ratio (OR), weight mean difference, or standardized mean difference (SMD).ResultsA total of seven RCTs with 609 patients were included. Outcomes favoring AA included 1.4 cm shorter incision (p=0.045), 0.5 days shorter hospital stay (p=0.01), 0.5 points less pain on a 0–10 scale (p=0.007), and less opioid use (SMD=−0.39 corresponding to 12 fewer morphine equivalents per day, p=0.01). The procedure time was 16 minutes longer with AA vs. PA (p=0.002). There were no statistical differences between AA and PA in operative blood loss (mean difference =19 mL, p=0.71), transfusions (9.7% vs. 16.2%, OR=0.45, p=0.39), or complications (5.5% vs. 4.1%, OR=1.42, p=0.62).ConclusionWhile the AA to primary THA may take longer time compared with the PA, the incision is shorter, and patients report slightly less pain, require less opioid medication, and leave the hospital earlier. The clinical relevance of these differences during longer-term follow-up is uncertain. The choice of surgical approach in primary THA should also consider factors such as experience of the surgeon and preferences of the surgeon and patient.

A Comparative Evaluation of Primary Total Hip Arthroplasty via Lateral and Posterolateral Approaches

Background: Total hip arthroplasty (THA) is regarded as the most successful and common surgical approach in orthopedic surgeries. Several surgical approaches have been described for THA to introduce minimally invasive surgical exposures. Posterolateral and lateral approaches are traditional and still most commonly used approaches for primary THA. In deciding which approach to use, consideration of complications, and clinical and radiological outcomes, using one approach or another should be evaluated. Objectives: The purpose of this study was to compare the early postoperative outcomes of posterolateral and lateral surgical approaches. Patients and Methods: The current study was conducted on a group of 134 primary hip arthroplasty of 120 patients who had undergone THA surgery at Shafa Orthopedic Hospital in Tehran, Iran, from March 2011 to October 2014. The lateral approach was used in 79 hips and, posterolateral approach was used in 55 hip based on surgeon’s preference. Two groups were assessed considering the following outcomes: clinical evaluation including Harris hip score (HHS), blood loss, blood transfusion, hemoglobin level, infections, deep vein thrombosis (DVT) and dislocation, as well as radiological evaluation including the proximal femur fracture, limb length discrepancy and cup inclination angle. The follow-up for both groups was at 6, 12, 24, 36 and 48 weeks after the surgery. Results: There was no significant difference between the two approaches regarding demographic characteristics, HHS, blood loss, transfusion, hemoglobin level, dislocation and cup inclination angle. However, there was a significant difference in the incidences of infections, DVT, proximal femur fracture and discrepancy of limb length between the two approaches. Conclusions: The results of this study indicate that both lateral and posterolateral approaches offer similar early clinical outcomes and some different radiological outcomes.

Comparison of Complications in Transtrochanteric and Anterolateral Approaches in Primary Total Hip Arthroplasty

Three surgical approaches to primary total hip arthroplasty (THA) have been in use since Charnley popularized the transtrochanteric approach. This study was designed to examine the difference in morbidity between the transtrochanteric approach and the anterolateral approach in primary THA. Information on 891 patients who underwent primary THA performed by a single surgeon was collected prospectively between 1998 and 2003 using a modified SF-36 form, preoperatively, intraoperatively, and at 3 months postoperatively. The transtrochanteric group had higher morbidity and more patients who were dissatisfied with their THA. There was a greater range of motion in the anterolateral group.

Review: Posterior Soft Tissue Repair in Primary Total Hip Arthroplasty

IntroductionThe posterior approach is the most common approach usedin the United States. Its main advantages include (1) lessextensive tissue dissection, (2) better visualization of theacetabulum, (3) lower incidence of heterotopic boneformation, and (4) preservation of the abductor mechanism.Historically, the posterior approach in primary total hiparthroplasty (THA) was associated with an increased riskof postoperative dislocation compared to the anterolateralor the transtrochanteric approach [1–3]. The senior author(P.M.P.) has described a posterior soft tissue repairreattaching the short external rotators and the posteriorcapsule to the greater trochanter. This repair has subse-quently resulted in a significant reduction of the risk ofpostoperative dislocation [4]. The current review describesthe surgical technique used by the senior author anddiscusses alternative techniques, biomechanical founda-tions, and the clinical outcome of patients undergoingprimary THA thorough a posterior approach with softtissue repair.Surgical techniqueThe patient is positioned in the lateral decubitus positionfor a standard posterior approach. Through a straightposterior incision, the fascia lata and the gluteus maximusmuscle are identified. It is the philosophy of the seniorauthor (P.M.P.) to use an adequate incision length becausea meticulous repair will require good exposure. Currentlythe average incision length is about 6 in.The fascia lata is incised and the gluteus maximus isfinger-split along its fibers. A Charnley retractor is insertedto improve visualization of the posterior capsule and shortexternal rotators. Using electrocautery, the posterior fattissue and remnants of the bursa are divided, therebypreserving a layer of tissue that later can be closed over theshort external rotators. Proximally, the posterior boarder ofthe gluteus medius, and, distally, the proximal boarder ofthe quadratus femoris muscle are identified. The piriformistendon is palpated and a thin, bent Hohmann retractor isinserted over the tendon between the gluteus medius andminimus to expose the short external rotators (Fig. 1).Distally, an Aufranc retractor is inserted between thequadratus femoris muscle and the distal part of theposterior capsule. Successively the hip is positioned ininternal rotation to improve the access to the insertion ofthe piriformis and conjoined tendon. Considering that bothtendons are inserted in the piriformis fossa further anteriorthan is generally expected, it is important to release thetendon as close to its anatomic position as possible. Thiswill preserve maximum tendon length for a later tension-free repair. At its anatomic insertion the piriformis andconjoined tendon (common insertion of inferior gemellus,superior gemellus, and obturator internus muscle) willmerge to form a single wide tendon belly. As long as twoseparate tendons are released, it is likely that the tendonwas cut far away from its insertion site in the piriformisfossa. As soon as the tendon is released, two no. 2Ethibond sutures are looped through the short externalrotator tendons twice, and the tendons are pulled posteriorto expose the posterior capsule (Fig. 2). Then, the posteriorboarder of the gluteus minimus muscle is identified and aperiosteal elevator is slit between the muscle and theposterior capsule. As soon as the gluteus minimus iselevated off the posterior capsule, the thin bent Hohmannretractor is repositioned underneath it, and the posteriorcapsule is incised. Using an electrocautery, the capsuleincision is started at the 1o’clock position and descendsanteriorly toward the greater troachanter. It is important tostart the incision proximally because this part of the