Direct Anterior Approach Total Hip Arthroplasty Research Articles

Muscle recovery after total hip arthroplasty: prospective MRI comparison of anterior and posterior approaches.

The direct anterior approach (DAA) and the posterior approach (PA) are 2 common total hip arthroplasty (THA) exposures. This prospective study quantitatively compared changes in periarticular muscle volume after DAA and PA THA. 19 patients undergoing THA were recruited prospectively from the practices of 3 fellowship-trained hip surgeons. Each surgeon performed a single approach, DAA or PA. Enrolled patients underwent a preoperative MRI of the affected hip and two subsequent postoperative MRIs at around 6 weeks and 6 months after surgery. Clinical evaluations were done by Harris Hip Score at each follow-up interval. MRIs or 10 DAA and 9 PA patients were analysed. Groups did not differ significantly with regard to BMI, age, or preoperative muscle volume. 1 DAA patient suffered a periprosthetic fracture and was excluded from the study. DAA hips showed significant atrophy in the obturator internus (-37.3%) muscle at early follow-up, with persistent atrophy of this muscle at the final follow-up. PA hips showed significant atrophy in the obturator internus (-46.8%) and externus (-16.0%), piriformis (-8.12%), and quadratus femoris muscles (-13.1%) at early follow-up, with persistent atrophy of these muscles at final follow-up. Loss of anterior capsular integrity was present at final follow-up in 2/10 DAA hips while loss of posterior capsular integrity was present in 5/9 PA hips. There was no difference in clinical outcomes. This study demonstrates that DAA showed less persistent muscular atrophy than PA. Regardless of surgical approach, a muscle whose tendon is detached from its insertion is likely to demonstrate persistent atrophy 6 months following THA. Although the study was not powered to compare clinical outcomes, it should be noted that no significant difference in patient outcomes was observed.

Activities and participation after primary total hip arthroplasty; posterolateral versus direct anterior approach in 860 patients.

Background and purposeIn the past decade, a shift occurred in surgical total hip arthroplasty (THA) approaches to the posterolateral (PLA) and direct anterior approach (DAA). Comparisons of postoperative activities and participation between surgical approaches for THA are sparse. We therefore investigated the association between PLA and DAA for THA regarding the construct “activity and participation” (ICF model) during the first postoperative year.Patients and methodsThis was an observational cohort study on osteoarthritis patients scheduled for primary THA in 2 hospitals. Questionnaires to assess the ICF domain “activity and participation” were completed preoperatively, and 3, 6, and 12 months postoperatively (HOOS Activities of daily living (ADL) and Sport and Recreation Function (SR), Hospital for Special Surgery Hip Replacement Expectations Survey, and questions regarding return to work). Each hospital exclusively performed one approach (PLA [Alloclassic-Zweymüller stem] or DAA [Taperloc Complete stem]) for uncemented THA. Hospital was included as instrumental variable, thereby addressing bias by (un)measured confounders. Adjusted mixed-effect models were used, stratified by employment.ResultsTotal population: 238 PLA (24% employed) and 622 DAA (26% employed) patients. At 12 months, the PLA group had a lower ADL score (–7, 95% CI –12 to –2 points). At 6 months, significantly fewer PLA patients had fulfillment of the expectation sports-performance (OR = 0.3, CI 0.2–0.7]. Other outcomes were comparable.Employed population: At 6 and 12 months, PLA patients scored clinically lower on ADL (respectively –10, CI –19 to 0 and –9, CI –19 to 0 points) and SR (respectively –13, CI –21 to –4 and –9, CI –18 to –1 points). At 6 months, fewer PLA patients fulfilled the expectation joining recreational activities (OR = 0.2, CI 0.1–0.7]. Fulfillment of other expectations was comparable between groups. PLA patients less often returned to work within 3 months (31% vs. 45%), but rates were comparable at 12 months (86% vs. 87%).InterpretationOverall, functional recovery regarding “activity and participation” was comparable for PLA and DAA. Among employed patients, DAA resulted in better functional recovery and more fulfillment of expectations compared with PLA patients. DAA might also facilitate faster return to work.

Use of a novel imageless navigation system reduced fluoroscopy exposure and improved acetabular positioning in anterior approach total hip arthroplasty: a case-control study.

Direct anterior approach (DAA) for total hip arthroplasty (THA) frequently utilizes fluoroscopy. The purpose of this study is to assess the impact of using a novel, imageless THA navigation system on radiation exposure and acetabular cup placement consistency. This was a retrospective, single-surgeon cohort study of a consecutive group of patients who underwent DAA THA for osteoarthritis. An optic-based imageless navigation system was used to determine intraoperative acetabular inclination and anteversion angles referenced off of a generic coronal and sagittal plane in 71 cases (study group). These were compared with 71 manual cases (control group) for fluoroscopy exposure, operative duration, and acetabular placement variation. Cohorts were similar in their distributions of sex, race, ethnicity, and body mass index. Comparisons between groups were made using independent samples t tests. Alpha error was 0.05. Study patients experienced significantly less fluoroscopy exposure time {3.59 [Standard Deviation (SD) 1.95] vs. 9.15 (SD 5.98) seconds; p < 0.001} and dosage (0.30 [SD 0.23] vs. 0.78 [SD 0.63] mGy; p < 0.001). Study and control patients had similar operative times [82.69 (SD 11.70) vs. 89.54 (SD 14.60) minutes; p = 0.09]. The study group had a significantly lower radiographic variation for inclination and anteversion, based on mean proximity to the centroid of each cohort [3.55 (SD 1.88) vs. 5.39 (SD 3.51); p < 0.001] and also a greater proportion of cases that fell within 1 SD of the mean cohort inclination and anteversion (40.8% vs. 21.1%; p = 0.009). Use of a novel imageless navigation system for DAA THA significantly reduced fluoroscopic radiation exposure and improved consistency in acetabular cup placement.

The short external rotators in the anterior approach hip arthroplasty: do the tendons heal or not? A prospective MRI study.

Release of some of the short external rotator tendons may be needed in the direct anterior approach (DAA) for Total Hip Arthroplasty (THA). It is unknown if these tendons heal. The purpose of this prospective study is to examine short external rotator tendon healing after release and the associated effect on muscle volume. In addition, we examined the relation with external rotation force and patient reported outcome measures (PROMs). In 21 DAA THA patients, preoperative MRI was compared with postoperative MRI at 6 weeks and 12 months. PROMs and rotation force of both hips were assessed. Tendon integrity and muscle volume of the obturator internus and piriformis were assessed on MRI using dedicated software. In 5 patients all tendons remained intact, in 4 patients only the conjoined tendon was released and in 12 patients both the conjoined and piriformis were released. Obturator externus remained intact in all patients. In patients with tendon release, mean volume of obturator internus and piriformis muscle decreased 27% (SD 11) and 23% (SD 16) 6 weeks after surgery, respectively. Released tendons and muscle volume loss did not recover 12 months after surgery. We found no relation between tendon release and hip rotation force or PROMs. We found absent tendon healing and muscle volume loss when the conjoined or piriformis tendons were released. Although we found no relation between tendon detachment and hip force or PROMs, we have adapted our operative technique to make it more preserving for the piriformis.

A Consistent Anatomic Landmark for Identifying the Lateral Femoral Circumflex Artery in a Direct Anterior Hip Approach.

A direct anterior approach (DAA) is a technique practiced by arthroplasty surgeons that can be technically challenging, most notably for inexperienced surgeons. The lateral femoral circumflex artery (LFCA) is a branch of the femoral artery that crosses the surgical field during DAA and is an important landmark for superficial surgical dissection. If the vessel is not identified, significant bleeding may occur, and visualization may be impaired. This study aimed to develop a reliable method to identify and ligate the LFCA with minimal bleeding. First, a retrospective review was performed on a series of patients who underwent primary DAA total hip arthroplasty. Epidemiologic and intraoperative radiologic information was collected to determine the 2-dimensional location of the LFCA as it coursed through the surgical interval. Second, a series of computed tomography (CT) angiograms were compared to validate the intraoperative anatomic findings. In this study, 108 patients were evaluated fluoroscopically and 100 CT angiograms were obtained, for 208 total patients. The distance of the LFCA from the lesser trochanter with standard fluoroscopy (LT/TD) was 0.600 vs 0.438 on CT angiogram. Mean offset from midline (offset/femur diameter) was 0.166 lateral to midline vs 0.36 medial to midline. Median value of offset was 0 vs 0.411-representing a position on the anatomic axis of the femur. This study confirmed that the LFCA is found approximately one-third to two-thirds of the way between the lesser and greater trochanters along the anatomic axis of the femur for most patients. Surgeons who are new to DAA can use the LFCA as a reliable landmark to confirm the correct interval. [Orthopedics. 2022;45(5):262-268.].

Cemented Femoral Fixation in a High-Risk Cohort Diminishes Risk of Early Postoperative Periprosthetic Fracture

BackgroundEarly periprosthetic fractures (PPFx) following primary total hip arthroplasty (THA) create significant morbidity. Established risk factors for early PPFx include age, gender, body mass index, surgical approach, and implant fixation. We investigated the role of femoral fixation on early PPFx (<90 days postoperatively) in a high-risk cohort undergoing direct anterior approach (DAA) THA. MethodsThe final cohort comprised 344 consecutive patients (390 hips) with risk factors for PPFx (age >68 years and body mass index <25 kg/m2) who underwent primary DAA THA between May 4, 2009 and December 31, 2019 and had 90-day follow-up. Noncemented fixation was used in 229-hips, while cemented fixation was used in 161 hips. The primary outcome was early PPFx. Fisher’s exact test was used for categorical variables, while t-tests were used to compare continuous variables. ResultsWe observed 8 early PPFx (2.1%), all fractures occurring in the noncemented group. Baseline demographics were similar but not equal, with the cemented group being older (78.0 versus 76.3 years; P = .004) with a greater proportion of females (91.9% versus 69.4%; P < .001). The rate of early PPFx was significantly higher with noncemented fixation compared to cemented fixation (3.5% versus 0.0%; P = .023). A post hoc power analysis confirmed sufficient power (1−β = 0.81). ConclusionAlthough baseline risk factors for early PPFx are not easily modifiable, surgical factors can be modified. Cemented fixation has the potential to markedly reduce the risk of early PPFx in high-risk patients undergoing DAA THA.

Direct anterior approach hip arthroplasty: How to reduce complications - A 10-years single center experience and literature review.

BACKGROUNDThe direct anterior approach for total hip arthroplasty (DAA-THA) is increasing in popularity due to some advantages such as less surgical trauma, minimal dissection of soft tissues, shorter rehabilitation times, faster return to daily activities, lower incidence of dislocation. On the other hand, the literature reports a high rate of intraoperative complications, with many different rates and complication types in the published papers. AIMTo analyze our complications comparing results with the literature; to report measures that we have taken to reduce complications rate.METHODSAll DAA-THA patients with one year minimum follow up who were operated at a single high-volume centre, between January 2010 and December 2019 were included in this retrospective study. All surgeries were performed using cementless short anatomical or straight stems and press fit cups. Patients’ follow-up was performed, at 6 wk, 3 mo, then annually post-surgery with clinical and radiological evaluation. Primary outcomes were stem revision for aseptic loosening and all-cause stem revision. Second outcome was intra-operative and post-operative complications identification.RESULTSA total of 394 patients underwent DDA-THA from January 2010 and December 2019, for a total of 412 hips; twelve patients lost to follow-up and one patient who died from causes not related to surgery were excluded from the study. The average age at the time of surgery was 61 years (range from 28 to 78 years). Mean follow-up time was 64.8 mo (range 12-120 mo). Seven stems were revised. One cortical perforation, one trochanteric and lateral cortical wall intraoperative fracture, one diaphyseal fracture, three clinically symptomatic early subsidence and one late aseptic loosening. We also observed 3 periprosthetic fractures B1 according to the Vancouver Classification. Other minor complications not requiring stem revision were 5 un-displaced fractures of the calcar region treated with preventive cerclage, one early infection, one case of late posterior dislocation, 18 case of asymptomatic stem subsidence, 6 cases of lateral cutaneous femoral nerve dysesthesia.CONCLUSIONDAA is associated to good outcomes and lower incidence of dislocation. Complication rate can be reduced by mindful patient selection, thorough preoperative planning, sufficient learning curve and use of intraoperative imaging.

AAHKS Best Podium Presentation Research Award: Femoral Perforation During Direct Anterior Approach Total Hip Arthroplasty: Incidence, Cohort Characteristics, and Management

BackgroundCortical perforation during femoral preparation is a recognized complication of total hip arthroplasty (THA) but the incidence, patient characteristics, management, and outcome have not been described for the direct anterior approach (DAA). MethodsA database query of all primary and conversion DAA THAs performed by a single surgeon from 2009 to 2021 was used to identify hips that sustained a recognized intraoperative femoral perforation. Radiographs were used to assess stem subsidence, Dorr femur type, and Canal Flare Index. ResultsAmong 3,973 THAs, 16 patients (0.4%) sustained perforations during broaching including 8 males and 8 females with a mean age at surgery of 65.6 (range 41-81) years and a mean body mass index of 31.0 (range 19.0-44.4). Two hips were converted to longer primary cementless stems to bypass the perforation. For the remaining 14, the broach was redirected and the same primary stem was implanted. Limited weight-bearing (6 patients) or protected weight-bearing as tolerated with a walker/cane (10 patients) was advised postoperatively. At a mean follow-up of 18.7 (range 4-105) months, all stems were stable with no fractures, subsidence, or revisions. Factors associated with perforation included difficulty with exposure (body mass index >40 or a contracture), measurable osteoporosis (Canal Flare Index <3.0), and abnormal proximal femoral anatomy due to prior trauma, retained hardware, or Perthes disease. ConclusionIn this case series, isolated perforation of an otherwise intact femur during DAA was successfully managed with redirection of the broach, implantation of a primary stem that achieved axial/rotational stability, and protected weight-bearing. Level of EvidenceIV, Case Series.

Incidence of and Risk Factors for Lateral Trochanteric Pain After Direct Anterior Approach Total Hip Arthroplasty.

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

Does Surgical Approach for Total Hip Arthroplasty Impact Infection Risk in the Obese Patient? A Systematic Review.

This systematic review evaluated the combined effects of obesity and surgical approach on periprosthetic joint infection (PJI) rates after total hip arthroplasty (THA). Wound complication and PJI rates were elevated among patients with body mass index (BMI) of 30 kg/m2 or greater and 35 kg/m2 or greater, respectively, with the direct anterior approach (DAA). A BMI of 30 kg/m2 or greater also increased the risk of PJI with the posterior approach. Patients with BMI of 30 kg/m2 or greater undergoing anterolateral approach THA did not have increased risk of PJI. Patients with elevated BMI (≥30 kg/m2) are at risk for PJI, regardless of approach. Patients undergoing DAA THA who have BMI of 35 kg/m2 or greater may have an increased risk of PJI compared with those undergoing THA with other approaches. [Orthopedics. 2022;45(2):e67-e72.].

Direct Anterior Approach for Total Hip Arthroplasty in the Elderly with Femoral Neck Fractures: Comparison with Conventional Posterolateral Approach.

BackgroundThe aim of this study was to determine if it was feasible and safe to perform total hip arthroplasty (THA) using the direct anterior approach (DAA) when compared with the conventional posterolateral approach (PA) in patients with femoral neck fractures. The time required to start walking was investigated to identify advantages of the muscle-sparing approach. Safety of the approach was judged based on the incidence and nature of all complications.MethodsWe retrospectively reviewed 67 THA cases due to femoral neck fractures from October 2015 to January 2019. The PA was used in 31 cases, and the DAA was used in 36 cases. The average operative time and amount of bleeding were evaluated. Cup inclination, anteversion, and leg length discrepancy (LLD) were also measured on radiographs. The time to start walking and complications (e.g., intraoperative fracture, infection, and dislocation) were recorded.ResultsThe mean operative time was 84.35 ± 13.95 minutes in PA group and 99.22 ± 20.33 minutes in DAA group (p = 0.010). But after experiencing 20 cases using the DAA, there was no statistically significant difference in the operative time between the groups. The mean volume of bleeding was 428.73 ± 207.26 mL in the PA group and 482.47 ± 150.14 mL in the DAA group. There was no difference in the acetabular cup position between two groups. Ambulation was started at 3.94 days after surgery on average in the PA group and 3.14 days in the DAA group, showing a statistically significant difference. Intraoperative fracture and infection were not observed in either group. The incidence of LLD was 1 in each group. The dislocation rate was 3.2% (1 case) in the PA group and 5.5% (2 cases) in the DAA group.ConclusionsAlthough the DAA for THA was similar to the PA in terms of operative time, volume of bleeding, and complications, the DAA showed a great advantage in early rehabilitation as a muscle-sparing procedure in the elderly with femoral neck fractures.

Total hip arthroplasty through the direct anterior approach in morbidly obese patients.

AimsThere is evidence that morbidly obese patients have more intra- and postoperative complications and poorer outcomes when undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA). The aim of this study was to determine the efficacy of DAA for THA, and compare the complications and outcomes of morbidly obese patients with nonobese patients.MethodsMorbidly obese patients (n = 86), with BMI ≥ 40 kg/m2 who underwent DAA THA at our institution between September 2010 and December 2017, were matched to 172 patients with BMI < 30 kg/m2. Data regarding demographics, set-up and operating time, blood loss, radiological assessment, Harris Hip Score (HHS), International Hip Outcome Tool (12-items), reoperation rate, and complications at two years postoperatively were retrospectively analyzed.ResultsNo significant differences in blood loss, intra- and postoperative complications, or implant position were observed between the two groups. Superficial wound infection rate was higher in the obese group (8.1%) compared to the nonobese group (1.2%) (p = 0.007) and relative risk of reoperation was 2.59 (95% confidence interval 0.68 to 9.91). One periprosthetic joint infection was reported in the obese group. Set-up time in the operating table and mean operating time were higher in morbidly obese patients. Functional outcomes and patient-related outcome measurements were superior in the obese group (mean increase of HHS was 52.19 (SD 5.95) vs 45.1 (SD 4.42); p < 0.001), and mean increase of International Hip Outcome Tool (12-items) was 56.8 (SD 8.88) versus 55.2 (SD 5.85); p = 0.041).ConclusionOur results suggest that THA in morbidly obese patients can be safely and effectively performed via the DAA by experienced surgeons.Cite this article: Bone Jt Open 2022;3(1):4–11.

Application Value of Musculoskeletal Ultrasound in DAA-THA with Conjoined Tendon Repair

Objective: To observe the ultrasonographic characteristics of conjoined tendon repair in direct anterior approach for total hip arthroplasty (DAA-THA), and to evaluate the efficacy of musculoskeletal ultrasound in determining the healing after joint tendon repair. Methods: A total of 60 patients who required primary total hip arthroplasty in Yulin Orthopedic Hospital of Chinese and Western Medicine from July 2020 to July 2021 were selected; the patients were divided into two groups, an observation group, group A (n = 30), and a control group, group B (n = 30), according to different intraoperative methods. There was no significant difference in gender, age, and diagnosis between the two groups. Direct anterior approach was used for both the groups. For group A, the joint capsule and conjoined tendon (superior gemellus, obturator internus, and inferior gemellus) were repaired in situ, whereas for group B, only the joint capsule was repaired in situ, while the conjoined tendon was not repaired. The healing of the tendon was observed. Results: (1) in terms of diagnosis, after conjoined tendon repair, 26 cases in group A showed good tendon continuity, good tension, and a small amount of effusion echo around, three cases showed partial interruption of tendon echo, low echo, or no echo inside with insufficient structural clarity, and a case showed complete interruption; in group B, all 30 cases had continuous interruption, poor tension, tendon retraction, and thickening; the healing rate of group A’s conjoined tendon repair was 96.67%; (2) in terms of prognostic assessment, one month after the surgery, the Harris score of group A was significantly higher than that of group B (P &lt; 0.05); however, there was no significant difference in the terms of the Harris score between the two groups 3-6 months after surgery (P &gt; 0.05); the effective tension of conjoined tendon and the effective muscle strength of group A were significantly higher than those of group B (P &lt; 0.05). Conclusion: Musculoskeletal ultrasound has high diagnostic value in the healing of conjoined tendon and provides dynamic clinical observation after conjoined tendon repair in DAA-THA; it is proven that DAA-THA with conjoined tendon repair on the premise of reconstructing the joint capsule can well restore its tension, enhance its muscle strength, significantly improve early joint stability and joint function, as well as facilitate the rapid recovery of patients.

Reliability of a simple fluoroscopic image to assess leg length discrepancy during direct anterior approach total hip arthroplasty.

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

Transfusion Rates in Total Hip Arthroplasty Are lower in Patients with Direct Anterior Approach.

Blood conservation and reduction in the need for allogeneic blood transfusion (ABT) has been a subject of importance in total hip arthroplasty. There are a number of well-recognized parameters that influence blood loss during total hip arthroplasty (THA). The role of surgical approach on blood loss and the rate of ABT during THA is not well studied. The hypothesis of this study was that blood loss and the need for ABT is lower with direct anterior (DA) approach. In a case-control retrospective cohort study, we analyzed 1,524 primary THAs performed at a single institution by seven fellowship-trained surgeons between January 2015 to March 2017. All patients received THA using either the modified direct lateral (DL) or direct anterior (DA) approach using a standard operating table. The overall ABT rate was 10.2% (155/1,524) in the cohort. Demographic, surgical, and postoperative data were extracted and analyzed. Logistic regression was used to identify independent risk factors for transfusion. Higher preoperative hemoglobin (p<0.001), use of DA approach (p<0.016) and administration of tranexamic acid TXA, (p=0.024) were identified as independent factors which reduced the odds of ABT. Operative time (p<0.001) was associated with an increased odd of ABT, while age, BMI and type of anesthesia were not statistically significant. Based on the findings of this study, direct anterior approach for THA appears to be protective against blood loss and reduced ABT rate, when controlling for confounding variables.

Risk Factors for Periprosthetic Femoral Fracture in Non-cemented Total Hip Arthroplasty Through the Direct Anterior Approach.

Background: Although total hip arthroplasty (THA) performed through the direct anterior (DA) approach is frequently marketed as superior to other approaches, there are concerns about increased risks of intraoperative and early postoperative femoral fracture. Purpose: We sought to assess patient-specific and radiographic risk factors for intraoperative and early postoperative (90-day) periprosthetic femoral fracture (PPFx) following DA approach THA. Methods: We retrospectively reviewed 1107 consecutive, primary, non-cemented DA THAs, performed between April 2009 and January 2015, for intraoperative and early postoperative PPFx. Patients lost to follow-up before 90 days (63), cemented or hybrid THA (52), or early femoral failure for another indication (3) were excluded, yielding 989 hips for analysis. Demographic variables and patient comorbidities were analyzed as risk factors for PPFx. Continuous variables were initially compared with 1-way analysis of variance (ANOVA) and categorical variables with chi-square test. A demographic matched-paired radiographic analysis was performed for femoral stem canal fill and compared using univariate logistic regression. Results: The incidence of perioperative PPFx was 2.02%, including 10 intraoperative and 10 early postoperative fractures. Sustaining a postoperative PPFx was associated with being 70 years old or older with a body mass index (BMI) of less than 25, or with having either osteoporosis or Parkinson disease. Radiographs demonstrated that intraoperative PPFx was associated with stems that filled greater proximally rather than distally. Conclusion: Our cohort study found older age, age over 70 with BMI of less than 25, osteoporosis, and Parkinson disease were associated with increased risk for early postoperative PPFx following DA approach THA. Intraoperative fractures may occur with disproportionate proximal femoral canal fill. Further study can evaluate whether cemented femoral components may mitigate risk in these patient populations.

Bikini anterior hip replacements in obese patients are not associated with an increased risk of complication.

Direct anterior approach (DAA) arthroplasty has generated great interest because of its minimally invasive and muscle sparing nature. Obese patients are reported to be associated with greater incidence of complications in primary joint replacement. The purpose of this study was to compare patient outcomes and complication rates between obese and non-obese patients undergoing primary total hip arthroplasty (THA) through a Bikini direct anterior incision. This retrospective, single surgeon study compared the outcome of 258 obese patients and 200 non-obese patients undergoing DAA THA using a Bikini incision, over a 5-year period. The average follow-up was 3.2years (range 1.1-5.6years). There was no statistically significant differences in the complication rate between the two groups. The obese group recorded 2 major (venous thromboembolism and peri-prosthetic fracture) and 2 minor complications (superficial wound infection), compared with the non-obese group, which recorded 2 major (deep-wound infection and peri-prosthetic fracture) and 1 minor complication (superficial wound infection). Patient-reported outcomes (WOMAC and Harris Hip Scores) showed significant post-operative improvements (p < 0.001) and did not differ between the two groups. Bikini DDA THA does not increase the complication rate in obese patients and offers similar clinical improvements compared to non-obese patients.

Preoperative radiographs to predict component malposition in direct anterior approach total hip arthroplasty.

There is conflicting evidence as to whether or not patients undergoing total hip arthroplasty (THA) via the direct anterior approach (DAA) have increased risk of component malposition. The aim of this study was to investigate whether specific preoperative radiographic features were predictive of postoperative component malposition in DAA THA. We examined 204 THA operations performed for osteoarthritis via the DAA at a single institution. Preoperative radiographs were analysed with numerous pre-specified measurements and classifications being recorded. Postoperative radiographs were analysed to determine if any of these preoperative radiographic factors correlated with component malposition in regard to cup inclination, cup version, femoral stem coronal alignment, leg-length discrepancy (LLD) and femoral offset discrepancy. Numerous preoperative factors were associated with component malposition. Coxa profunda was found to be a significant predictor of cup anteversion being outside of the target range (p = 0.0089) and an increased centre-edge angle was a significant predictor for a postoperative LLD (p = 0.0134). A decreased neck-shaft angle (p = 0.0007) and a lower preoperative LLD (p = 0.0019) were both predictive of femoral stem coronal malalignment. Preoperative radiographs can be a valuable tool for surgeons in predicting patients at risk of component malposition in DAA THA.

Primary total hip arthroplasty via the direct anterior approach in the lateral decubitus position : surgical technique, learning curve, complications, and early results.

The direct anterior approach (DAA) for total hip arthroplasty (THA) has potential advantages over other approaches and is most commonly performed with the patient in the supine position. We describe a technique for DAA THA with the patient in the lateral decubitus position and report the early clinical and radiological outcomes, the characteristics of the learning curve, and perioperative complications. All primary DAA THAs performed in the lateral position by a single surgeon over a four-year period from the surgeon's first case using the technique were identified from a prospectively collected database. Modified Harris Hip Scores (mHHS) were collected to assess clinical outcome, and routine radiological analysis was performed. Retrospective review of the medical records identified perioperative complications, the characteristics of the learning curve, and revisions. A total of 257 patients were included in the study. Their mean age was 60 years (SD 9.0). A total of 164 (64%) were female. The mean mHHS improved significantly from 52.1 (SD 16.2) preoperatively to 94.4 (SD 11) at a follow-up of one year (p < 0.001), with 212 of 225 patients (94%) achieving a minimal clinically important difference (MCID) (> 8 points). Radiological evaluation showed a mean leg length discrepancy of 2.6 mm (SD 5.9) and a mean difference in femoral offset of 0.2 mm (SD 4.9). A total of 234/243 acetabular components (96.3%) were positioned within Lewinnek's safe zone. Analysis of operating time, blood loss, the position of the components, and complications did not identify a learning curve. A total of 14 patients (5.4%) had a major perioperative complication and three (1.2%) required revision THA. There were no major neurovascular complications and no dislocations. We have described and analyzed a surgical technique for undertaking DAA THA in the familiar lateral decubitus position using a routine operating table, positioning devices, and instrumentation, and shown that it can be performed safely and effectively under these circumstances. Cite this article: Bone Joint J2021;103-B(7 Supple B):53-58.

Heterotopic Ossification Following Direct Anterior Total Hip Arthroplasty With and Without Postoperative Analgesic Nonsteroidal Anti-inflammatories

BackgroundHeterotopic ossification (HO) can result in poorer clinical outcomes following total hip arthroplasty (THA). Multiple modes of intervention have been evaluated for HO prevention, including the use of nonsteroidal anti-inflammatories. Additionally, multimodal pain management strategies including celecoxib have become more prominent. Therefore, this study aims to evaluate the influence of celecoxib as part of postoperative analgesia on the risk of developing HO following the direct anterior approach (DA) for THA. MethodsA retrospective query identified primary DA THAs performed by a single surgeon between 2013 and 2020. Patients were grouped according to those who received 3 weeks celecoxib upon discharge, and those who did not. Radiographs were used to categorize patients according to the Brooker classification system for HO. Preoperative and 2-week, 6-week, 3-month, and 1-year postoperative X-rays were evaluated. ResultsA total of 688 DA THAs were included, demonstrating a 9.6% (n = 66) incidence of HO with Brooker classification: 1: 5.7% (n = 39); 2: 2.6% (n = 18); 3: 1.2% (n = 8); and 4: 0.1% (n = 1). Patients who did not receive celecoxib had a 14.3% (52/364) rate of HO following THA (odds ratio 4.53, P < .001) vs only 4.3% (14/324) in the celecoxib group (odds ratio 0.22, P < .001). Overall, 9 patients (1.3%) went on to develop significant HO (Booker 3 or greater): 8 (2.2%) in the control group and 1 (0.3%) in the celecoxib group (P < .001). ConclusionOur findings suggest a significant reduction in the formation of HO following DA THA when using postoperative analgesic celecoxib as part of a multimodal pain protocol. Future prospective randomized studies are needed to identify ideal dosage, duration, and formulation to reduce the risk of HO while optimizing multimodal pain management.