Anterior Approach in Total Hip Replacement

Anterior Approach in Total Hip Replacement:

Contrary Articles and Literature Review

John G. Mayer M.D.

2014

http://www.ncbi.nlm.nih.gov/pubmed/24698816

J Arthroplasty. 2014 Jul;29(7):1507. doi: 10.1016/j.arth.2014.01.028. Epub 2014 Mar 5.

A tale of two approaches.

Comment in

“Dr Barret fails to discuss that the LFCN is often traumatized during the muscle splitting and often vigorous retraction needed to expose the anterior hip capsule. Reports of LFCN injury range from15% to 67% for THA with Anterior Approach in two recent studies by highly experienced hip surgeons (see 2010 section).....

...My opinion is that there is inherent expectation or interview bias (where the patient gives favorable information or pushes further to validate the expected outcome) also may have played a role in the collection of the study data...Each approach has its drawbacks...Dr Barret did not have any inquiry as to the common post op problem of quad pain and hip flexor soreness....So far, I am not convinced that the anterior approach is all that its advocates wish it to be."

http://www.ncbi.nlm.nih.gov/pubmed/24549773

Clin Orthop Relat Res. 2014 Jun;472(6):1877-85. doi: 10.1007/s11999-014-3512-2. Epub 2014 Feb 19.

Does fluoroscopy with anterior hip arthoplasty decrease acetabular cup variability compared with a nonguided posterior approach?

1Center for Joint Preservation & Reconstruction, NorthshoreLIJ/Lenoxhill Hospital, 130 E 77th Street, 11th Floor, New York, NY, 10075, USA, drparthivrathod@gmail.com.

Abstract

Background

The direct anterior approach for THA offers some advantages, but is associated with a significant learning curve. Some of the technical difficulties can be addressed by the use of intraoperative fluoroscopy which may improve the accuracy of acetabular component placement.

Questions/purposes:

The purposes of this study were to determine if (1) there is decreased variability of acetabular cup inclination and anteversion with the direct anterior approach using fluoroscopic guidance as compared with the posterior approach THA without radiographic guidance; (2) if there is a learning curve associated with achieving accuracy with the direct anterior approach THA. We also wanted (3) to assess the frequency of complications including dislocation with the anterior approach, which initially had a learning curve, and the posterior approach.

Methods:

This retrospective, comparative study of 825 THAs (372 posterior THAs without fluoroscopic guidance and 453 direct anterior THAs, performed by one surgeon, focused on a radiographic analysis to determine cup inclination and anteversion on standardized pelvic radiographs using specialized software. The first 100 direct anterior THAs performed while transitioning from the posterior approach to the direct anterior approach were included in the learning curve group. During this learning curve period, the direct anterior approach was used for all patients except those with conversion of previously fixed intertrochanteric or femoral neck fractures to THAs, gluteus medius tears, and obese patients with an immobile abdominal pannus (100 of 127 THAs). Variability of the acetabular component was compared among the posterior group, learning curve group, and direct anterior group.

Results:

Variances for cup inclination and anteversion were significantly lower in the direct anterior group (19 and 16 respectively, p < 0.01) as compared with the posterior group (50 and 79 respectively).Target inclination and anteversion were achieved better in the direct anterior group (98% and 97% respectively) as compared with the posterior group (86% and 77% respectively) (p < 0.01, OR for inclination = 9.1, 95% CI, 3.5 to 23.4; OR for anteversion = 8, 95% CI, 4 to 16). In the learning curve group, target anteversion achieved (91% of cases) was marginally lower than that of the direct anterior group (p = 0.03; OR = 2.9, 95% CI, 1.1 to 7.3) and target inclination (95%) was similar (p = 0.13). There was one posterior dislocation in the posterior group, two anterior dislocations in the learning curve group, and none in the direct anterior group.

Conclusions:

Use of fluoroscopy with the patient in the supine position during direct anterior THA enables intraoperative assessment of cup orientation resulting in decreased variability of acetabular cup anteversion. However, there is a learning curve associated with achieving this accuracy. We could not discern whether this difference was the result of the approach or the use of fluoroscopy in the direct anterior group.

Level Of Evidence:

PMID:24549773 [PubMed - in process] PMCID: PMC4016457 [Available on 2015/6/1]

http://www.ncbi.nlm.nih.gov/pubmed/23963704

Clin Orthop Relat Res. 2014 Feb;472(2):455-63. doi: 10.1007/s11999-013-3231-0..

Does the direct anterior approach in THA offer faster rehabilitation and comparable safety to the posterior approach?

1The Center for Joint Preservation and Reconstruction, North Shore LIJ/Lenox Hill Hospital, 130 E 77th Street, 11th Floor, New York, NY, 10075, USA.

Abstract

BACKGROUND:

Newer surgical approaches to THA, such as the direct anterior approach, may influence a patient's time to recovery, but it is important to make sure that these approaches do not compromise reconstructive safety or accuracy.

QUESTIONS/PURPOSES:

We compared the direct anterior approach and conventional posterior approach in terms of (1) recovery of hip function after primary THA, (2) general health outcomes, (3) operative time and surgical complications, and (4) accuracy of component placement.

METHODS:

In this prospective, comparative, nonrandomized study of 120 patients (60 direct anterior THA, 60 posterior THAs), we assessed functional recovery using the VAS pain score, timed up and go (TUG) test, motor component of the Functional Independence Measure™ (M-FIM™), UCLA activity score, Harris hip score, and patient-maintained subjective milestone diary and general health outcome using SF-12 scores. Operative time, complications, and component placement were also compared.

RESULTS:

Functional recovery was faster in patients with the direct anterior approach on the basis of TUG and M-FIM™ up to 2 weeks; no differences were found in terms of the other metrics we used, and no differences were observed between groups beyond 6 weeks. General health outcomes, operative time, and complications were similar between groups. No clinically important differences were observed in terms of implant alignment.

CONCLUSIONS:

We observed very modest functional advantages early in recovery after direct anterior THA compared to posterior-approach THA. Randomized trials are needed to validate these findings, and these findings may not generalize well to lower-volume practice settings or to surgeons earlier in the learning curve of direct anterior THA. PMID:23963704 [PubMed - indexed for MEDLINE] PMCID: PMC3890195 [Available on 2015/2/1]

http://www.ncbi.nlm.nih.gov/pubmed/24267204

Orthop Clin North Am. 2014 Jan;45(1):19-31. doi: 10.1016/j.ocl.2013.08.007. Epub 2013 Oct 10.

The rationale for short uncemented stems in total hip arthroplasty.

Patel RM1, Stulberg SD.

Author information 1Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, 676 N. St. Clair, Suite #1350, Chicago, IL 60611, USA.

Abstract

Uncemented femoral implants of various designs have proved to provide stable initial and long-term fixation in patients who undergo total hip arthroplasty. Challenges in primary total hip arthroplasty have led to the evolution of short stem designs. These challenges include proximal/metaphyseal and distal/diaphyseal mismatch; facilitation of less-invasive surgical exposures, especially the direct anterior approach; and bone preservation for potential revision surgery. 

Copyright © 2014 Elsevier Inc. All rights reserved.

PMID:24267204  [PubMed - indexed for MEDLINE] 

2013

Clin Orth and Rel Res 468(9): 2397-404:  9/1/10

J Arthroplasty. 2013 Sep;28(8):1401-7. doi: 10.1016/j.arth.2012.11.018. Epub 2013 Mar 16.

Does the anterior approach for THA provide closer-to-normal lower-limb motion?

Varin D1Lamontagne MBeaulé PE.

Author information

Abstract

The purpose of this study was to compare the muscle-sparing anterior approach for total hip arthroplasty to a traditional lateral approach using 3D motion analysis. Kinematics and kinetics of walking were obtained for 40 patients (20 anterior and 20 lateral) and 20 control participants. Participants were assessed six to twelve months postoperatively. It was hypothesized that the anterior group would have closer-to-normal range of motion, moments, and powers than the lateral group. Both surgical groups had gait anomalies, such as significantly lower peak hip abduction moments. It is therefore thought that other variables such as preoperative gait adaptations, trauma from the surgery, or postoperative protection mechanisms for avoiding loading the prosthesis might be more influential factors than surgical approach when determining function after surgery.

Copyright © 2013 Elsevier Inc. All rights reserved.

KEYWORDS:

THA; anterior approach; gait; kinematics; kinetics

PMID:23507070

http://www.ncbi.nlm.nih.gov/pubmed/citmatch/

Direct Anterior versus Mini-Posterior Total Hip Arthroplasty with the Same Advanced Pain Management and Rapid Rehabilitation Protocol: Some Surprises in Early Outcome



Monaghan
etal. American Association of Hip and Knee Surgeons(AAHKS) 
November 9, 2013

Program Description:

Purpose:


Determining the effect of surgical technique on early outcome is confounded when advances in pain management, rapid rehabilitation, or patient education are introduced or applied asynchronously. We sought to determine the influence of surgical technique alone in contemporary cohorts of total hip arthroplasties done by 2 fellowship trained surgeons each performing their technique of choice with the same advanced pain and rapid rehabilitation protocol.

Methods:

126 consecutive direct anterior (DA) procedures were compared with 96 consecutive mini-posterior (MP) procedures done from July 2011 - February 2012. Groups did not differ (p>0.2 for all) in age (64+/-12 years), sex (50% female), body mass index (30 +/-5.7), or preoperative Harris Hip Score (HHS) (55+/-12). Operative details, in-hospital complications, visual analog scale (VAS) pain scores, and functional milestones at two- and eight-weeks were reviewed.

Results:

No differences in length of stay (2.2 days), operative or in-hospital complications, intravenous breakthrough analgesia, stairs, maximum feet walked in-hospital, or discharge disposition (80% home) all p>0.2. The DA group had a higher VAS max pain (5.3 DA; +/- 2, vs 3.8 MP; +/-2 p=<0.0001). At two weeks, more DA patients required gait aids (92% vs 68% of MP; p=<0.0001). At eight weeks, DA had higher HHS (95 versus 89) but a lower return to work and driving; no difference: gait aids, narcotics, ADLs, or walking 0.5 mile. More wound problems occurred in the mini-posterior (p=<0.01).

Conclusion:

With the same advanced pain and rehabilitation protocol it was somewhat surprising to find that the direct anterior had more early pain and more often used gait aids at 2 weeks. The DA group had fewer early wound problems contrasting with the belief that anteriorly based incisions would be more problematic.


Significance:

Advanced pain and rehabilitation protocols may trump surgical approach in determining most early outcomes after contemporary hip arthroplasty

http://www.ncbi.nlm.nih.gov/pubmed/23821968

Acta Orthop Belg. 2013 Apr;79(2):166-73.

Direct anterior total hip arthroplasty: complications and early outcome in a series of 300 cases.

De Geest T1, Vansintjan P, De Loore G.

Author information 1AZ Damiaan Hospital, Ostend, Belgium. degeestthomas@yahoo.com

Abstract

The direct anterior approach for total hip arthroplasty has gained popularity throughout the last decade. Early reports showed successful results with rapid functional recovery and low dislocation rates. However there is some concern about the high number of complications induced by the technique. The aim of this study was to examine the early radiological outcome and perioperative complications in a consecutive series of 300 total hip arthroplasties performed through a minimal invasive anterior approach with the aid of a positioning table. We observed 9(3%) intra-operative complications : two femoral perforations, 4 calcar fractures and 3 greater trochanter fractures. There were 42 (14%) postoperative complications and 20 (6.7%) patients required a surgical re-intervention. Our major finding was early peri-prosthetic femoral fracture in 5 patients, not noticed during surgery. The dislocation ratio (2 cases, 0.66%) was low. The complication ratio decreased throughout our series, but statistical significance could not be shown (p = 0.26). Surgeons should be aware of the high risk of occult intra-operative fractures when starting with this technique.

PMID:23821968 [PubMed - indexed for MEDLINE

Orthopedics 36(3): 276-81:  3/1/13

Article Source

Early Complications of Anterior Supine Intermuscular Total Hip Arthroplasty

Chengla Yi, MD, PhD; Juan F. Agudelo, MD; Michael R. Dayton, MD; Steven J. Morgan, MD

Orthopedics  March 2013 - Volume 36 · Issue 3: e276-e281

DOI: 10.3928/01477447-20130222-14

Abstract

Anterior supine intermuscular total hip arthroplasty (THA) performed on a fracture table has been increasingly used for primary THA. Accurate cup placement, low incidence of dislocation, shorter hospital stay, and faster return of function are potential benefits of the technique. However, a high complication rate, particularly during a surgeon’s learning curve, has been reported. A retrospective analysis of 61 consecutive anterior supine intermuscular primary THAs with at least 6-month follow-up was performed. All procedures were performed using the anterior supine intermuscular approach with cementless implants under fluoroscopic guidance on a fracture table. Prospectively collected data were retrospectively reviewed to evaluate the early complication rate and radiographic accuracy of implant placement. Five (8.2%) intraoperative complications were observed: including 3 trochanteric fractures and 2 calcar fractures, 4 of which required cable fixation during the index procedure. One nondisplaced trochanteric fracture was treated conservatively. One patient sustained an injury of the lateral femoral cutaneous nerve. Postoperative complications included 1 anterior dislocation, 1 infected superficial hematoma, 1 stem subsidence, and 1 loose stem, with the latter 2 presenting as increasing thigh pain postoperatively and requiring stem revision. The overall complication rate was 16.4% (10/61). Overall, 3 patients (4 hips; 6.5%) required reoperation. No femoral or sciatic nerve injuries occurred, and no patient was diagnosed with venous thromboembolism. All intraoperative fractures occurred during the first 32 cases, and none during the last 29 cases. A potentially high incidence of complications with the anterior supine intermuscular THA exists during a surgeon’s learning curve in an academic setting.

“Is there faster Recovery after Direct Anterior Approach (DAA) than Posterior Approach Total Hip Arthroplasty?”  Author: Deshmukh M.D. et al

American Academy of Orthopedic Surgeons (AAOS) Annual Meeting 2013

 

Conclusion: “Functional recovery was faster in patients with DAA on the basis of TUG and M- FIM scores up to 2 wks. No differences were observed between groups at 6 wks, 12 wks, and one year. Complications of DAA included one fracture and 4 pts with groin pain due to psoas tendon impingement. In PA groups, one patient had a dislocation and 2 had groin pain.”

“Similar Improvement in Gait Parameters with Direct Anterior and Posterior Approach Total Hip Arthroplasty”.

Author: Orishimo MS and Kremenic M.D. et al  American Academy of Orthopedic Surgeons (AAOS) Annual Meeting 2013

 

Conclusion: “THA performed via DAA and PA offer similar improvement in gait parameters up to one year follow up with the exception of internal/ external ROM.”

“Which Muscle Sparing Approach is Better- Direct Anterior or Antero-lateral in total hip Arthroplasty?”. Author: Iwaki M.D. et al

American Academy of Orthopedic Surgeons (AAOS) Annual Meeting 2013

 

“No significant difference with respect to strength up to 3 wks… or in clinical scores.”

Conclusion: We found no differences between DAA and MIS-AL approach clinically except for cup anteversion which is more accurate in the DAA group compared to the MIS-AL group.

Differences in Hip Strength Recovery with Direct Anterior and Posterior Approach Total Hip Arthroplasty”.  Author: Rathop M.D. et al.

American Academy of Orthopedic Surgeons (AAOS) Annual Meeting 2013

 

Conclusion: “Both DAA and PA THA offer similar recovery in hip muscle strength up to one year with the exceptions of persistent ER strength deficit in PA group, and flexion strength deficit in the DAA group at 6 wks. This may be related to the release of the external rotators in PA group and hip flexor irritation in the DAA groups.”

The Anterior Approach Is the Answer ?: AGAINST   Symposium

Author: Haddad, BSc, MCh, FRCS, FFSEM; London  al  American Academy of Orthopedic Surgeons (AAOS) Annual Meeting 2013

Excerpts….

“The perceived benefits are minimal soft tissue damage, avoidance of the abductors, optimal visualization of the acetabulum, and preservation of the posterior capsule and external rotators. There is however very little evidence that it reduces dislocation.

“Pellici et al described an “enhanced posterior repair” which drastically reduces the number of dislocations following THR through a posterior approach. The authors found their dislocations fell from 4% to 0% in one study of 395 cases, and from 6.2% to 0.8% in 124 cases.”

“This enhanced repair is described by Suh et al. The dislocation rate without repair was 6.4% in 250 primary THR’s, but was maintained at 1% in 96 augmented with the posterior repair.” Clin Orthop Relat Res 2004; 162

Siguier et al reviewed 1037 primary THR’s carried out through a minimally invasive anterior approach and reported a dislocation rate of 0.96%

“The anterior approach has a learning curve and is found difficult by many, and hence may sacrifice component orientation and soft tissue balance if undertaken inexpertly.”

A specialized fracture table is often required and intra operative XR fluoroscopy, due to more difficult access to the femur…”fractures may occur” and “must be performed carefully”.

“The anterior approach is considered a difficult procedure to adopt when compared to posterior or trans gluteal exposures.” Spaans et al described their learning curve through their first 46 cases. They found the operative times nearly doubled, increased blood loss and greater complication rates…” Even as they gained experience their results did not improve significantly. Masonis et al demonstrated the use of fluoroscopy and operative time was shown to have a learning curve in the first 100 cases. Lateral Cutaneous Femoral Nerve injury (LFCN) is at risk from the retraction of the tissue required. Patients may complain of “parasthesias” in the lateral thigh or a burning pain or dysesthesia. Bhargava et al found in his series of 81 THR’s,..the incidence of LFCN neuropraxia was 14.8 %.

Conclusion: The disadvantages of the anterior approach are its labor intensiveness, learning curve, a specialized operating table and intra-operative fluoroscopy. “Further analysis is required so that we can understand the risk-benefit ratio of the anterior approach. At present the evidence that this is the answer to the dislocation risk that we run for every THR is lacking. The Anterior Approach should stay in the hands of enthusiasts while we continue to optimize existing approaches to improve patient outcomes.”

http://www.ncbi.nlm.nih.gov/pubmed/23409847

Acta Orthop. 2013 Feb;84(1):116-7. doi: 10.3109/17453674.2013.773412.

High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach.

Hartog YM, Vehmeijer SB.

Comment in Author's reply to den Hartog. [Acta Orthop. 2013]

Comment on High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach. [Acta Orthop. 2012]

PMID:23409847 [PubMed - indexed for MEDLINE] PMCID: PMC3584595 Free PMC Article Publication Types, MeSH Terms

Acta Orthop. Feb 2013; 84(1): 116–11     Published online Feb 26, 2013. doi:  10.3109/17453674.2013.773412 PMCID: PMC3584595

High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach

 Y.M. den Hartog and S.B.W. Vehmeijer      Author information ► Copyright and License information ►

Sir–There are several advantages with the direct anterior approach for total hip arthroplasty. However, it is technically demanding with its own unique set of complications which implies a substantial learning period (Masonis et al. 2008Barton and Kim 2009Bhandari et al. 2009Goytia et al. 2012).

A recent report in the Acta Orthopaedica, titled “High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach” (Spaans et al. 2012) presents the early results of the direct anterior approach, which showed no improvement in functional outcome and a higher early complication rate compared with the posterolateral approach. The authors found no learning effect regarding operating time, blood loss and hospital stay after 46 cases.

Several studies have shown that the learning curve of the anterior approach requires more than 46 patients. During this learning curve, the complication rate is higher because of the technical difficulties. The complication rate, operating time and blood loss diminish after the surgeon has gained more experience (Masonis et al. 2008Berend et al. 2009Bhandari et al. 2009Seng et al. 2009Goytia et al. 2012).

Spaans et al. report the use of a minimal invasive technique. In fact the anterior approach itself is not a minimal invasive technique and the incision sometimes needs to be enlarged to obtain a good view of the operative field. When a surgeon starts with the direct anterior approach, we would always advice to not to use the minimal invasive technique.

Readers may interpret the Spaans et al. article as showing the direct anterior approach for total hip arthroplasty gives a higher complication rate than the posterolateral approach. However the high complication rate in their study seems to be due to the effect of the learning curve and the use of a minimal invasive approach, instead of the use of the direct anterior approach. The learning curve is not unique for the direct anterior approach (Salai et al. 1997). Also the posterior approach is a technical demanding procedure with its own set of complications and indeed its own learning curve. Moreover, the learning curve is longer when using a minimal invasive technique (Swanson 2007).

Feb 2013; 84(1): 116–117.

Published online Feb 26, 2013. doi:  10.3109/17453674.2013.773412

High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach

A.J. Spaans, J.A.A.M. van den Hout, and S.B.T. Bolder

Author information ► Copyright and License information ►

Sir–As Hartog and Vehmeijer write, the direct anterior approach for total hip arthroplasty has a major disadvantage; it is technically demanding. As we tried to explain in our article (Spaans et al. 2012), the learning curve of the direct anterior approach is long. Every new operation technique is associated with a learning curve. The question raises how many patients a surgeon would like to expose to this learning curve. Especially when he masters another surgical approach, with good results and a low complication rate.

How long is the learning curve for performing the direct anterior approach for total hip arthroplasty? According to Woolson et al. (2009) and D’Arrigo et al. (2009) the learning curve comprises 20–30 patients, but it in our hands it apparently exceeded 46 patients with still long operation time and increased blood loss. This has also been reported by other authors: Goytia et al. (2012) found their learning curve to be around 60 patients, Bhandari et al. (2009) described a decreased complication rate first after more than 100 cases.

Even when an experienced orthopedic surgeon changes an approach, a learning curve is present. We found it unacceptable to subject more than our 46 patients to a new technique with more complications than we observed in patients operated through our regular posterolateral approach. That was the reason we finished the direct anterior approach. Any surgeon who considers to change the approach for hip arthroplasty should be aware that this very likely will result in a longer operation time and higher complication rate in not a small number of patients. The message of our study was that surgeons, even with a lot of experience and good results with one approach for total hip arthroplasty, should really consider the value of changing their standard approach to a new and technically difficult operation, especially when the potential advantage of the new technique has not yet been proven which is the case with the direct anterior approach. It may be unethical to subject patients to a long learning curve when there is a good alternative operation available. Further studies should reveal the true value of direct anterior approach for hip arthroplasty and we would encourage all orthopedic surgeons to share their clinical results with this technique, especially in comparison to a posterior approach.

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References

Barton C, Kim PR. Complications of the direct anterior approach for total hip arthroplasty. Orthop Clin North Am. 2009;40(3):371–5. [PubMed]

Berend KR, Lombardi AV, Seng BE, Adams JB. Enhanced early outcomes with the anterior supine intermuscular approach in primary total hip arthroplasty. J Bone Joint Surg (Am) (Suppl 6) 2009;91:107–20. [PubMed]

Bhandari M, Matta JM, Dodgin D, Clark C, Kregor P, Bradley G, Little L. Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observational study. Orthop Clin North Am. 2009;40(3):329–42. [PubMed]

D’Arrigo C, Speranza A, Monaco E, Carcangiu A, Ferretti A. Learning curve in tissue sparing total hip replacement: comparison between different approaches. J Orthop Traumatol. 2009;10:47–54. [PMC free article] [PubMed]

Goytia RN, Jones LC, Hungerford MW. Learning curve for the anterior approach total hip arthroplasty. J Surg Orthop Adv. 2012;21(2):78–83. [PubMed]

Masonis J, Thompson C, Odum S. Safe and accurate: learning the direct anterior total hip arthroplasty. Orthopedics (Suppl 2) 2008;31(12) [PubMed]

Salai M, Mintz Y, Giveon U, Chechik A, Horoszowski H. The learning curve of total hip arthroplasty. Arch Orthop Trauma Surg. 1997;116:420–2. [PubMed]

Seng BE, Berend KR, Ajluni AF, Lombardi AV. Anterior-supine minimally invasive total hip arthroplasty: defining the learning curve. Orthop Clin N Am. 2009;40:343–50.[PubMed]

Spaans AJ, Hout vd J A AM, Bolder S BT. High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach.Acta Orthop. 2012;83(4):342–6. [PMC free article] [PubMed]

Swanson TV. Posterior single-incision approach to minimally invasive total hip arthroplasty. Int Orthop (Suppl 1) 2007;31:S1–5. [PMC free article] [PubMed]

Woolson ST, Puoliot MA, Huddleston JI. Primary total hip arthroplasty using an anterior approach and a fracture table. Short term results from a community hospital. J Arthroplasty. 2009;24(7):999–1004. [PubMed]

http://www.ncbi.nlm.nih.gov/pubmed/23395031

Instr Course Lect. 2013;62:251-63.

Primary and revision anterior supine total hip arthroplasty: an analysis of complications and reoperations.

Berend KR1, Kavolus JJ, Morris MJ, Lombardi AV Jr.

Author information 1Department of Orthopaedics, The Ohio State University, Mount Carmel Health System, New Albany, OH, USA.

Abstract

Anterior total hip arthroplasty (THA) has been touted by some as a muscle-sparing, less invasive procedure. Reports have focused on the high intraoperative and postoperative complication rates, the increased transfusion risk, and its questionable clinical benefits. The senior author's experience regarding complications and reoperations that occurred after primary and revision THA using an anterior supine intermuscular approach has been generally favorable. An electronic database was used to identify 906 patients treated with 1,035 consecutive anterior supine intermuscular THAs performed by a single surgeon between January 2007 and December 2010, which included 986 primary THAs, 2 resurfacings, 2 conversions of failed open reduction and internal fixation for fracture, and 45 revision THAs. The surgical technique used an anterior approach with a modified Smith-Petersen interval and was performed with the patient supine on a standard operating table without traction. The transfusion rate was 5%. There were three intraoperative calcar cracks and one canal perforation, which was treated with cerclage cables. Four wound complications required débridement, four hips had substantial lateral femoral cutaneous nerve paresthesias that had not resolved by the 12-month follow-up, and one femoral nerve palsy was reported. At up to 40 month's follow-up, there have been 25 revisions (2.4%), including 9 periprosthetic femoral fractures; 1 stem subsidence; 4 hips with aseptic loosening; 5 metal-on-metal bearing complications; 1 cup malpositioning, which was corrected the same day; 4 dislocations; and 1 infection. This 4-year experience with primary and revision anterior THAs has showed acceptable rates of perioperative transfusion, complications, and revisions.

PMID:23395031 [PubMed - indexed for MEDLINE] 

J of Ortho Research 31(2): 288-94:  2/1/13

J Orthop Res. 2013 Feb;31(2):288-94. doi: 10.1002/jor.22210. Epub 2012 Aug 8.

Comparison of gait in patients following a computer-navigated minimally invasive anterior approach and a conventional posterolateral approach for total hip arthroplasty: a randomized controlled trial.

Reininga IH1Stevens MWagenmakers RBoerboom ALGroothoff JWBulstra SKZijlstra W.

Author information

Abstract

Minimally invasive total hip arthroplasty (MIS THA) aims at minimizing damage to muscles and tendons to accelerate postoperative recovery. Computer navigation allows a precise prosthesis alignment without complete visualization of the bony landmarks during MIS THA. A randomized controlled trial (RCT) was conducted to determine the effectiveness of a computer-navigated MIS anterior approach for THA compared to a conventional posterolateral THA technique on the restoration of physical functioning during recovery following surgery. Thirty-five patients underwent computer-navigated MIS THA via the anterior approach, and 40 patients underwent conventional THA using the conventional posterolateral approach. Gait analysis was performed preoperatively, 6 weeks, and 3 and 6 months postoperatively using a body-fixed-sensor based gait analysis system. Walking speed, step length, cadence, and frontal plane angular movements of the pelvis and thorax were assessed. The same data were obtained from 30 healthy subjects. No differences were found in the recovery of spatiotemporal parameters or in angular movements of the pelvis and thorax following the computer-navigated MIS anterior approach or the conventional posterolateral approach. Although gait improved after surgery, small differences in several spatiotemporal parameters and angular movements of the trunk remained at 6 months postoperatively between both patient groups and healthy subjects.

Copyright © 2012 Orthopaedic Research Society.

PMID:22886805

 [PubMed - indexed for MEDLINE]

2013

Acta Orthop. Aug 2012; 83(4): 342–346. 

Published online Aug 25, 2012. doi: 10.3109/17453674.2012.711701 

PMCID: PMC3427623 

High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach

Anne J Spaans, Joost A A M van Hout, and Stefan B T Bolder 

Department of Orthopaedic Surgery, Amphia Hospital, Breda, the Netherlands 

Correspondence: Email: ln.aihpma@1redlobS, Email: moc.liamg@snaapsenna 

Author information ►Article notes ►Copyright and License information ► 

Received December 30, 2011; Accepted May 6, 2012. 

Copyright : © Nordic Orthopaedic Federation 

This is an open-access article distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the source is credited. 

This article has been cited by other articles in PMC. 

Abstract

Background and purpose

There is growing interest in minimally invasive surgery techniques in total hip arthroplasty (THA). In this study, we investigated the learning curve and the early complications of the direct anterior approach in hip replacement.

Methods

In the period January through December 2010, THA was performed in 46 patients for primary osteoarthritis, using the direct anterior approach. These cases were compared to a matched cohort of 46 patients who were operated on with a conventional posterolateral approach. All patients were followed for at least 1 year.

Results

Operating time was almost twice as long and mean blood loss was almost twice as much in the group with anterior approach. No learning effect was observed in this group regarding operating time or blood loss. Radiographic evaluation showed adequate placement of the implants in both groups. The early complication rate was higher in the anterior approach group. Mean time of hospital stay and functional outcome (with Harris hip score and Oxford hip score) were similar in both groups at the 1-year follow-up.

Interpretation

The direct anterior approach is a difficult technique, but adequate hip placement was achieved radiographically. Early results showed no improvement in functional outcome compared to the posterolateral approach, but there was a higher early complication rate. We did not observe any learning effect after 46 patients.

In recent years, there has been growing interest in minimally invasive surgery (MIS) techniques for total hip arthroplasy (THA). A number of articles have described the operation using smaller incisions and different approaches. The advantages of these MIS techniques are considered to be reduced soft tissue trauma, reduced blood loss, less postoperative pain, shorter hospital stay, a better cosmetic appearance, and faster recovery time (Howell et al. 2004, Siddiqui et al. 2005, Sendtner et al. 2010, Bergin et al. 2011). However, some studies have also shown a worse outcome using these approaches (Pagnano et al. 2005, D’Arrigo et al. 2009, Woolson et al. 2009). Furthermore, tissue-sparing surgery may result in a higher complication rate, particularly in the so-called “learning curve” period—the first 20 cases for a single surgeon (D’Arrigo et al. 2009).

The soft-tissue-preserving nature of the direct anterior approach (DAA) combined with the relatively low risk of dislocation has generated interest in this approach for hip replacement over the last decade (Siguier et al. 2004, Rachbauer and Krismer 2008). Safe and reliable placement of the implants can be obtained, and muscle strength was found to be improved up to 2 years after THA using an anterior approach rather than an anterolateral approach (Mayr et al. 2009). Light and Keggi (1980) described the technique of using the anterior approach with a curved transverse skin incision. It was basically a modified Smith-Peterson approach to the hip joint (Light and Keggi 1980, Oinuma et al. 2007). This approach is muscle-splitting, because it uses the intermuscular plane between the gluteus medius and the tensor muscles laterally, and the sartorius and rectus muscles medially. Additionally, the DAA is the only true internerve approach between the zones of innervation of the superior and inferior gluteal nerves laterally and the femoral nerve medially. As a result, the risk of limping as with the anterior and lateral approaches can be reduced and the higher risk of dislocation associated with posterior approaches is avoided (Lowell and Aufranc 1968, Siguier et al. 2004, Lovell 2008, Bender et al. 2009).

Acetabular exposure is relatively easy, with excellent visualization. There is a very small danger of injuring the sciatic or femoral nerve. Disadvantages include the difficulty in doing straight reaming, the femoral exposure, and possible damage to the lateral femoral cutaneous nerve (Lowell and Aufranc 1968, Light and Keggi 1980, Siguier et al. 2004, Oinuma et al. 2007, Bender et al. 2009, Goulding et al. 2010).

Regarding early complications, the hypothesis to be tested was that patients operated for a THA through a DAA would have a more rapid early recovery and better postoperative results than patients operated through our regular posterolateral approach (PLA). We also examined our learning curve with this new technique.

Patients and methods

In the period January through December 2010, 46 patients were operated with THA using the DAA. All patients were followed after surgery. Inclusion criteria were primary osteoarthritis in patients with a BMI of < 35, for adequate visibility with an MIS approach. Exclusion criteria were secondary osteoarthritis, tumors, hip deformities, and previous surgery to the affected hip. All the operations were performed by 2 surgeons (JH and SB), who operated together on all patients. Before starting this operation technique, the surgeons had an internal education and training on cadavers that was supervised by an experienced orthopedic surgeon who had used the DAA for 5 years. This surgeon also assisted at and supervised the first 4 operations performed by JH and SB in our own hospital. All DAA patients were included in the study, including the first 4 supervised cases.

The DAA patients were compared to a matched cohort of 46 patients who were treated with THA by a posterolateral approach (PLA) because of primary osteoarthritis. The patients were matched by age and co-morbidities. The distribution of sexes in the DAA group was almost equal, whereas there were more female patients in the PLA group. The BMI was statistically significant higher in the PLA group (Table 1).

Operation technique

We operated the patients strictly according to the operation technique described by Rachbauer and Krismer (2008). Uncemented femoral and acetabular components were used in all patients. This included a Trident cup, an Accolade TMZF stem, a highly crosslinked polyethylene X3 liner, and a cobalt chrome 36-mm head (all Stryker Orthopaedics, Mahwah, NJ). The implant size used was chosen by the surgeon as the most appropriate for each patient after preoperative digital templating had been performed.

Postoperative care

All patients received the same standardized postoperative rehabilitation protocol, which included antibiotics for 24 h, antithrombotic prophylaxis for 6 weeks postoperatively, and physiotherapy from the first day after surgery with full weight bearing. Patients were either discharged home or transferred to a rehabilitation facility based on their medical condition, progress in therapy, and home support system.

Evaluation

We evaluated the short-term results in the DAA and PLA groups. Operative, clinical, and radiographic outcomes and early complications were analyzed.

In the DAA group, we evaluated the learning effect of the operative outcome by dividing the group into 3 subgroups. The first hip placement with DAA at our center was included. The 3 subgroups were: hips 1–15 (subgroup 1), hips 16–30 (subgroup 2), and hips 31–46 (subgroup 3). We compared operation time (skin incision to skin closure), intraoperative blood loss, time of hospital stay, clinical outcome, and complications in the 3 subgroups.

Clinical outcome was measured with the Harris hip score and the Oxford hip score questionnaires. All patients were scored preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively. Radiographic analysis was done with standard anteroposterior pelvic and lateral views directly after surgery and at 6 weeks and 12 months, or if indicated for complications. These radiographs were evaluated independently by the same 2 senior orthopedic surgeons (JH and SB) for component position measured by leg-length difference, cup inclination angle, and stem alignment. Determination of leg length was done by measuring the vertical height from the teardrop line (a horizontal line drawn along the lower edge of the right and left acetabular teardrops, assuming pelvic symmetry) to a point chosen on the lesser trochanter. The vertical height to the same landmark was measured on the contralateral hip, and the difference was considered to be the postoperative leg-length discrepancy, with a maximum of 10 mm (Matta et al. 2005). Cup inclination was assessed by goniometric measurement of the angle between the teardrop line and the major diameter of the ellipse represented by the rim of the acetabular cup, with a target range of 35° to 55° (Matta et al. 2005). Stem position was evaluated by goniometric measurement of the angle subtended by the femoral shaft axis and the long axis of the femoral component on AP radiographs. Femoral component angulation between 3° varus and 3° valgus relative to the femoral shaft axis was considered “well-aligned” (Lewinnek et al. 1978, Dorr and Wan 1998, Sendtner et al. 2010).

Statistics

Baseline information and information collected at each study visit was compared between each intervention group using the Student t-test. All p-values were 2-tailed, and the significance level was set at 0.05. The analyses were performed using SPSS software version 18.0.

Results

Operation time

The mean duration of the procedure was 84 min in the DAA group and 46 min in the PLA group (p < 0.001) (Table 2). The mean surgical time decreased with increasing experience, although not statistically significantly (Table 3).

Blood loss

Mean intraoperative blood loss was 704 mL in the DAA group and 364 mL in the PLA group (p < 0.001) (Table 2). There was no reduction in the learning curve (Table 3). There were 7 patients in the PLA group and 27 patients in the DAA group who had blood loss of more than 500 mL.

Hospitalization

The mean length of hospital stay was 4.8 days in the DAA group and 4.7 days in the PLA group, without any reduction in the learning curve (Tables 2 and and33).

Clinical outcome

Harris hip scores and Oxford hip scores were similar between the groups. In both groups, there was a statistically significant difference between pre- and postoperative measurements. There was no statistically significant difference in clinical outcome between the DAA group and the PLA group (data not shown).

Complications

No superficial or deep wound infections and no deep venous thrombosis or nerve palsies (including the sciatic, femoral, or lateral cutaneous nerve of the thigh) occurred. The overall rate of other complications was higher in the DAA group (Table 4).

In the DAA group, 4 patients required an intraoperative conversion from a DAA to a PLA. After exposure of the hip using a DAA, the anterior wound was closed before THA was completed and the operation had to be finished by performing a PLA. The results of these 4 patients were included in the DAA group. In 2 of these patients there was technical error—inadequate visibility in one case and the need for cementing in the other. In 2 cases, the reason for conversion was a fracture and the need for a more extensile approach: in 1 case there was an acetabular fissure with the need for grafting and a cemented cup, and in 1 case there was a trochanteric fracture in femoral preparation with the need for placement of a hook plate. 1 patient had continuous weakness in the quadriceps muscle, even after more than a year of follow-up. We saw 2 early failures with the need for revision within 1 year for cup loosening and 1 early revision for femoral failure.

In the PLA group also, 1 patient had an intraoperative acetabular fissure that required a restrictive postoperative regime without acetabular grafting. 1 patient had a postoperative periprosthetic fracture within a year, after trauma.

1 patient in each group had a postoperative dislocation. In the DAA group, this happened in a patient who also had had an intraoperative conversion to a PLA.

Radiographic evaluation

The prostheses in both groups had adequate placement without significant differences in cup inclination, leg-length difference, or femoral stem alignment (Table 5).

Radiographic outcomes. Numbers are mean (SD) 

Discussion

The strengths of our study include the consecutive series of patients, who were all subjected to the same preoperative and postoperative care protocols (regarding rehabilitation and pain). We included all patients operated with a DAA, including the very first one. We found that there was twice as much intraoperative blood loss, an almost doubled operation time, and more complications in the DAA group without any improvement in hospital stay or early functional outcome. There was only a decreasing trend in the learning curve associated with the operating time, but there was no effect regarding the amount of blood loss intraoperatively or the length of hospital stay, even after 46 cases.

There are many different approaches for THA, all with advantages and disadvantages. According to the recent literature, MIS techniques could—at least in theory—improve the results of conventional THA approaches, especially in the early postoperative period with reduced blood loss, tissue disruption, and hospital stay; they could give similar clinical outcomes and complication rates to those of conventional THA (Matta et al. 2005, Oinuma et al. 2007, Cheng et al. 2009, Mayr et al. 2009, Sendtner et al. 2010, Alecci et al. 2011).

The main advantage of the DAA would be that it follows a well-delineated intermuscular and internervous plane. It leaves the hip abductors and the posterior soft tissue envelope intact, potentially reducing the instability and dislocations associated with the release of these structures that is required in the posterior approach (Lowell and Aufranc 1968, Siguier et al. 2004, Lovell 2008, Bender et al. 2009). Also, the insertions of the gluteus minimus and gluteus medius remain intact, to reduce the postoperative limb and abductor dysfunction reported with the lateral and anterolateral approaches (Siguier et al. 2004, Rachbauer and Krismer 2008).

Good results have been achieved in some studies with the DAA for THA (Matta et al. 2005, Oinuma et al. 2007, Alecci et al. 2011). They found similar operating times to those in the present study (75–89 min), but less blood loss (350–393 mL) and fewer complications (in only 1.8–3.4% of their patients). Unfortunately, not all authors described (the effects of) their learning curve. Also, it is unclear whether their first patients were included in these studies.

Other studies have reported worse results of DAA (D’Arrigo et al. 2009, Woolson et al. 2009). They found a longer operating time (121–168 min) and more blood loss (858–1,344 mL). A high rate of complications (13–25%) was reported in their DAA groups. In the study by Woolson et al., the number of complications appeared to decrease after 30–50 operations. Also, we found a longer operation time in the DAA group, more blood loss, and no difference in length of hospital stay. Additionally, there were more complications in the DAA group.

Intraoperative complications and component misalignment could be more prevalent in MIS- THA due to the constrained surgical field, which makes visualization of anatomical landmarks and alignment of the components more challenging (D’Arrigo et al. 2009, Woolson et al. 2009). Intraoperative fracture of the proximal femur is the most frequent complication associated with minimally invasive techniques (D’Arrigo et al. 2009). We had 1 trochanteric fracture in the DAA group. We found an adequate positioning of the prosthesis with no differences between the PLA and DAA groups by measurement on conventional radiographs. Every new operation technique is associated with effort and often with a (temporary) increase in adverse events, the so-called learning curve (D’Arrigo et al. 2009, Krismer 2009). The learning curve is commonly thought to be on 20 cases for a single surgeon, but from our results, we believe that the learning curve for the DAA is at least more than 46 cases.

Based on our experience, we recommend that hip surgeons should be very careful in changing their daily routine and performing THA through a technique whose benefit has not been proven in the long term and which could cause an increase in complications, especially during the learning-curve phase. After 46 patients, we still did not see any evidence of further improvement with the DAA for THA. The complication rate after DAA may therefore be unacceptably high for some surgeons who already have a low complication rate with the conventional approach for hip replacement.

Acknowledgments

JH and SB planned and designed the study. They also operated all the patients and provided the radiographic measurements. AS wrote the manuscript. All authors participated in the interpretation of the results and in improvement of the manuscript. Statistical analysis was done by AS.

No competing interests declared.

References

Alecci V, Valente M, Crucil M, Minerva M, Pellegrino CM, Sabbadini DD. Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: perioperative findings. J Orthop Traumatol. 2011;12(3):123–9. [PMC free article] [PubMed

Bender B, Nogler M, Hozack WJ. Direct anterior approach for total hip arthroplasty. Orthop Clin N Am. 2009;40:321–8. [PubMed

Bergin PF, Doppelt JD, Kephart CJ, Benke MT, Graeter JH, Holmes AS, Haleen-Smith H, Tuan RS, Unger AS. Comparison of minimally invasive direct anterior versus posterior total hip arthroplasty based on inflammation and muscle damage markers. J Bone Joint Surg (Am) 2011;93(15):1392–8. (3) [PMC free article] [PubMed

Cheng T, Feng JG, Liu T, Zhang XL. Minimally invasive total hip arthroplasty: a systematic review. Int Orthop. 2009;33:1473–81. [PMC free article] [PubMed

D’Arrigo C, Speranza A, Monaco E, Carcangiu A, Ferretti A. Learning curve in tissue sparing total hip replacement: comparison between different approaches. J Orthop Traumatol. 2009;10:47–54. [PMC free article] [PubMed

Dorr LD, Wan Z. Causes of and treatment protocol for instability of total hip replacement. Clin Orthop. 1998;(355):144–51. [PubMed

Goulding K, Beaulé PE, Kim PR, Fazekas A. Incidence of lateral femoral cutaneous nerve neuropraxia after anterior approach hip arthroplasty. Clin Orthop. 2010;(468):2397–404. [PMC free article] [PubMed

Howell JR, Garbuz DS, Duncan CP. Minimally invasive hip replacement: rationale, applied anatomy, and instrumentation. Orthop Clin North Am. 2004;35:107–18. [PubMed

Krismer M. Eur Intern Lectures. 2009. Total hip arthroplasty: a comparison of current approaches; pp. 163–74. 

Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR. Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg (Am) 1978;60:217–20. [PubMed

Light TR, Keggi KJ. Anterior approach to hip arthroplasty. Clin Orthop. 1980;(152):255–60. [PubMed

Lovell T. Single-incision direct anterior approach for total hip arthroplasty using a standard operating table. J Arthroplasty. 2008;23(7):64–8. [PubMed

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Matta JM, Shahrdar C, Ferguson T. Clin Orthop. 441. 2005. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table; pp. 115–24. [PubMed

Mayr E, Nogler M, Benedetti MG, Kessler O, Reinthaler A, Krismer M, Leardini A. A prospective randomized assessment of earlier functional recovery in THA patients treated by minimally invasive direct anterior approach: a gait analysis study. Clin Biomech. 2009;24:812–8. [PubMed

Oinuma K. Eingartner Ch, Saito Y, Shiratsuchi H. Total hip arthroplasty by a minimally invasive, direct anterior approach. Oper Orthop Traumatol. 2007;19:310–26. [PubMed

Pagnano MW, Leone J, Lewallen DG, Hanssen AD. Two-incision THA had modest outcomes and some substantial complications. Clin Orthop. 2005;(441):86–90. [PubMed

Rachbauer F, Krismer M. Minimal invasive Hüftendoprothetik über den anterioren Zugang. Oper Orthop Traumatol. 2008;20:239–51. [PubMed

Sendtner E, Borowiak K, Schuster T, Woerner M, Grifka J, Renkawitz T. Tackling the learning curve: comparison between the anterior, minimally invasive (micro-hip) and the lateral, transgluteal (Bauer) approach for primary total hip replacement. Arch Orthop Trauma Surg. 2010;131(5):597–602. [PubMed

Siddiqui NA, Mohandas P, Muirhead-Allwood S, Nuthall T. A review of minimally invasive hip replacement surgery – current practice and the way forward. Curr Orthop. 2005;19:247–54. 

Siguier T, Siguier M, Brumpt B. Mini-incision anterior approach does not increase dislocation rate. A study of 1037 total hip replacements. Clin Orthop. 2004;(426):164–73. [PubMed

Woolson ST, Puoliot MA, Huddleston JI. Primary total hip arthroplasty using an anterior approach and a fracture table. Short term results from a community hospital. J Arthroplasty. 2009;24(7):999–1004. [PubMed]

Short version of above

http://www.ncbi.nlm.nih.gov/pubmed/22880711

Acta Orthop. 2012 Aug;83(4):342-6. doi: 10.3109/17453674.2012.711701. Epub 2012 Aug 10.

High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach.

Spaans AJ1, van den Hout JA, Bolder SB.

Author information 1Department of Orthopaedic Surgery, Amphia Hospital, Breda, the Netherlands. annespaans@gmail.com

Abstract

BACKGROUND AND PURPOSE: 

There is growing interest in minimally invasive surgery techniques in total hip arthroplasty (THA). In this study, we investigated the learning curve and the early complications of the direct anterior approach in hip replacement.

METHODS: 

In the period January through December 2010, THA was performed in 46 patients for primary osteoarthritis, using the direct anterior approach. These cases were compared to a matched cohort of 46 patients who were operated on with a conventional posterolateral approach. All patients were followed for at least 1 year.

RESULTS: 

Operating time was almost twice as long and mean blood loss was almost twice as much in the group with anterior approach. No learning effect was observed in this group regarding operating time or blood loss. Radiographic evaluation showed adequate placement of the implants in both groups. The early complication rate was higher in the anterior approach group. Mean time of hospital stay and functional outcome (with Harris hip score and Oxford hip score) were similar in both groups at the 1-year follow-up.

INTERPRETATION: 

The direct anterior approach is a difficult technique, but adequate hip placement was achieved radiographically. Early results showed no improvement in functional outcome compared to the posterolateral approach, but there was a higher early complication rate. We did not observe any learning effect after 46 patients.

Comment in High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach. [Acta Orthop. 201

Author's reply to den Hartog. [Acta Orthop. 2013]

PMID: 22880711 [PubMed - indexed for MEDLINE]  PMCID: PMC3427623

http://www.ncbi.nlm.nih.gov/pubmed/22476355

J Orthop Traumatol. 2012 Jun;13(2):115; author reply 117. doi: 10.1007/s10195-012-0190-2. Epub 2012 Apr 5.

Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: perioperative findings.

Meena S.

Comment on

Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: perioperative findings. [J Orthop Traumatol. 2011]

Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: perioperative findings.Alecci V, Valente M, Crucil M, Minerva M, Pellegrino CM, Sabbadini DD. J Orthop Traumatol. 2011 Sep; 12(3):123-9. Epub 2011 Jul 12.

PMID:22476355 [PubMed - indexed for MEDLINE]  PMCID: PMC3349027

Primary Total Hip Arthroplasty using a Direct Anterior vs. Posterolateral Approach; a Comparative Study.

Author: Bhadra et al. American Academy of Orthopedic Surgeons (AAOS)  Annual Meeting 2012

 

Direct anterior (DA) group had a better postoperative day 2 walking distance and better pain scores. Direct anterior group had complications in 11 patients (27.5%) Thigh lateral femoral cutaneous nerve pain in seven.. ... Direct anterior approach is more effective than posterolateral approach for every early functional recovery and pain control but at a higher complication rate. 

Prospective Randomized Multicenter Study of a "New" Approach to MIS THA; Stem Subsidence an Issue.

Author: Greidanus et al. American Academy of Orthopedic Surgeons (AAOS)  Annual Meeting 2012

... Five sub-specialized hip surgeons at three academic centers participated in the study of a "new" anterolateral minimally invasive (MIS) approach to THR. It was a multicenter prospective randomized trial comparing it to the "standard" limited incision approaches already in use. Cup and stem alignment were satisfactory with no difference between the group but there was a highly significant difference in stem subsidence, with a mean migration of 4.23 mm in the "new" group. Also there were four trochanteric fractures in this group. Furthermore, the risk of painful stem subsidence and fracture was increased. The authors have returned to the standard surgical approaches in use before the trial. 

Gait Analysis after Total Hip Arthroplasty – Minimally Invasive Anterolateral vs. Conventional Lateral Approach.

Author: Landgraeber et al. American Academy of Orthopedic Surgeons (AAOS)  Annual Meeting 2012

Minimally invasive (MIS) total hip arthroplasty is claimed to be superior to the standard technique because it reduces operative trauma but there is still controversy as to whether minimally invasive total hip arthroplasty enhances the postoperative outcome. 

... the mean difference was not significantly better in MIS than the conventional group. Physical examination also revealed no differences between the two groups. Both physical examination and gait analysis showed that the conventional approach and the minimally invasive approach led to equally good operative results.

Early Complications of Total Hip Arthroplasty using the Anterior Supine Approach on the orthopedic table.

Author: Yi et al. American Academy of Orthopedic Surgeons (AAOS)  Annual Meeting 2012

Anterior supine intermuscular (ASI) total hip arthroplasty performed on a fracture table has been increasingly used for primary total hip arthroplasty (THA); however, a high complication rate, particularly during a surgeons early learning curve has been reported. 

Intraoperative complications included three trochanteric fractures and two calcar fractures, four of which required cable fixation during the original operation. One patient sustained an injury of the lateral femoral cutaneous nerve. There is a high incidence of complications during the early learning curve of the anterior supine THA using the fracture table in an academic setting. 

Posterior Approach.

Author: Dorr . American Academy of Orthopedic Surgeons (AAOS)  Annual Meeting 2012

Approach is not important for outcome of THR operation. 

Technique of surgeon is more important for soft tissue result. 

Component positions and biomechanical reconstruction determine the longevity of the operation and quality of the outcome. 

Soft tissue injury is surgeon-dependent, not approach-dependent. 

Component positioning. 

Dependent on three-dimensional conceptualization of the surgeon. 

Posterior approach is superior because;
*Manual component precision is the same with all techniques:  *Dislocation (published results) is currently the same with all techniques: *Gait analysis shows recovery is the same with all techniques:*Pain for the patient is better:*Blood loss is less:*Fractures are less: *Marketing budget is less. 

2011

http://www.ncbi.nlm.nih.gov/pubmed/21902130

Orthopedics. 2011 Sep 9;34(9):e459-61. doi: 10.3928/01477447-20110714-29.

Anterior approach in THA improves outcomes: opposes.

Sculco TP.

Author information Hospital for Special Surgery, New York, New York, USA. sculcot@hss.edu

Abstract

Total hip arthroplasty (THA) can be performed through multiple surgical approaches, including anterior, anterolateral, lateral, transtrochanteric, posterolateral, posterior, and the 2-incision technique. The overwhelming majority of THAs today are performed through a posterolateral approach, which has many advantages: it can be extended without difficulty, it is expeditious, it results in reduced blood loss and little muscle damage, and recovery is rapid. The major disadvantage of the approach is its increased dislocation rate, which has become less of a problem with the advent of larger femoral heads and dual-mobility acetabular components. The anterior approach is another hip approach with advantages and disadvantages. One disadvantage is the need for a special table on which to perform the procedure, which can cost ≥$100,000. Many surgeons also recommend the use of intraoperative fluoroscopy with this approach, which prolongs surgery and adds possible draping contamination during the fluoroscopy. Exposure of the femur may be difficult with this approach, especially in patients with increased body mass index. The operative time also tends to be longer with this approach, as exposure may be more tedious. The published data report significant complications with this procedure.

Copyright 2011, SLACK Incorporated.

Anterior approach in THA improves outcomes: affirms. [Orthopedics. 2011]

PMID:21902130 [PubMed - indexed for MEDLINE] 

http://www.ncbi.nlm.nih.gov/pubmed/22458062

Rev Med Brux. 2011;32(6 Suppl):S76-83.

Total hip arthroplasty by mini-approach: review of literature and experience of direct anterior approach on orthopaedic table

[Article in French]

Jayankura M1, Potaznik A.

Author information 1Service d'Orthopédie-Traumatologie, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Bruxelles. mjayanku@ulb.ac.be

Abstract

In addition to the choice of the surgical approach, the respective place of the mini-incisions and mini-invasive surgery for total hip arthroplasty (THA) remains a controversial topic. The purpose of this study was to specify the advantages and disadvantages of these different approaches by a systematic review of the orthopedic literature and by our experience of the first 100 THA implanted by mini-invasive direct anterior approach (DAA) on orthopedic table. Selecting 15 orthopedic journals, we found 252 articles among which 65 are particularly relevant; 25 correspond to randomized studies. Mini-invasive approaches permit to obtain results at least equivalent to standard approaches with regard to operative time, general complications and adequate component positioning. Contrarily to posterior approach, DAA is associated to a low dislocation rate, even in so-called "at risks patients". Recent randomized studies highlight an earlier functional recovery in patients treated by mini-invasive approaches and particularly by DAA. This advantage seems to persist only the first six weeks but it could be interesting to patients avid to resume quickly their activities. Nevertheless, further studies are mandatory to confirm the observed results and to specify the place of the mini-invasive approaches with regard to early recovery as long-term results.

PMID:22458062  [PubMed - indexed for MEDLINE

http://www.ncbi.nlm.nih.gov/pubmed/20886324

Clin Orthop Relat Res. 2011 Feb;469(2):503-7. doi: 10.1007/s11999-010-1568-1.

High complication rate with anterior total hip arthroplasties on a fracture table.

Jewett BA1, Collis DK.

Author information 1Slocum Orthopedic Center, 55 Coburg Road, Eugene, OR 97401, USA. BAJewett@mac.com

Abstract

BACKGROUND: 

Recent attention in THA has focused on minimally invasive techniques and their short-term outcomes. Despite much debate over the outcomes and complications of the two-incision and the mini-lateral and mini-posterior approaches, complications arising from use of the anterior THA on a fracture table are not well documented.

QUESTIONS/PURPOSES: 

We determined the intraoperative and postoperative complications with the anterior approach to THA through an extended single-surgeon patient series.

METHODS: 

We reviewed 800 primary THAs performed anteriorly with the aid of a fracture table over 5 years and recorded all intraoperative and postoperative complications up to latest followup (average, 1.8 years; range, 0-5 years). Patients with severe acetabular deformity or severe flexion contractures were excluded and those surgeries were performed with a lateral approach during the time period of this study.

RESULTS: 

Intraoperative complications included 19 trochanteric fractures, three femoral perforations, one femoral fracture, one acetabular fracture, one bleeding complication, and one case of cardiovascular collapse. There were no ankle fractures. Postoperative complications included seven patients with dislocations; seven with deep infections; one with delayed femur fracture; 37 with wound complications, among which 13 had reoperation for local débridement; 14 with deep venous thrombosis; and two with pulmonary embolism; and 31 other nonfatal medical complications.

CONCLUSIONS: 

The main intraoperative complications of trochanteric fractures and perforations occurred mostly early in the series, while the main postoperative complications related to wound healing were prevalent throughout the entire series. Despite potential advantages of use of a fracture table, surgeons should be aware of the potential complications of trochanteric fractures, perforations, and wound-healing problems associated with this technique.

PMID:20886324 [PubMed - indexed for MEDLINE]  PMCID: PMC3018203

2010

http://www.ncbi.nlm.nih.gov/pubmed/20810235    

J Arthroplasty. 2010 Oct;25(7):1171-2; author reply 1172-3. doi: 10.1016/j.arth.2010.06.010.

Minimally invasive anterior approach with a fracture table for total hip arthroplasty. Letter to the editor.

Moskal JT, Capps SG.

Comment on Primary total hip arthroplasty using an anterior approach and a fracture table: short-term results from a community hospital. [J Arthroplasty. 2009

Letter to the Editor

Received 7 May 2010; accepted 18 June 2010. published online 01 September 2010.

 To the Editor:

The literature, in general, makes numerous positive claims regarding minimally invasive anterior approach with a fracturetable for total hip arthroplasty (THA) including less soft tissue damage, shorter surgery time, less pain, quicker recovery and return to unassisted ambulation, and reduced risk of dislocation with early elimination of hip precautions 123.

In contrast to most published reports produced by orthopedic innovators who specialize in joint arthroplasty, a recent report in the Journal of Arthroplasty, titled “Primary Total Hip Arthroplasty Using an Anterior Approach and a Fracture Table: Short-term Results From a Community Hospital” by Woolson et al [1], presents the short-term results from a group of 5 community-practice orthopedists using this surgical approach for THA. Four of the 5 surgeons trained by visiting one innovator surgeon and observing the procedure. The fifth surgeon did not observe the procedure with an innovator surgeon. None of the surgeons received formal cadaver or laboratory training before performing the anterior approach on patients. The community-practice orthopedists' main goal in changing from a conventional posterior approach to the minimally invasive anterior approach was to reduce the number of postoperative dislocations after THA. A serious flaw in this report, given that dislocation rates before implementing this surgical approach were not reported, is the difficultly in making any quantitative conclusions regarding the stated goal of reducing postoperative dislocations (Table 1).

Table 1. Complications Using the Mini-incision Anterior Approach with Fracture Table (MIAAFT) for THA

MIAAFT THAComplications (rate, %)Dislocations (rate, %)
Berend et al [2]2588 (3.10%)0
Siguier et al [3]103721 (2.03%)10 (0.96%)
Bradley [4]1026 (5.88%)4 (3.92%)
Matta et al [5]49420 (4.05%)3 (0.62%)
Mast et al [6]2944 (1.36%)1 (0.34%)
Memminger and Bombelli [7]344 (11.76%)0
Sariali et al. [8]176427 (1.53%)27 (1.53%)
Yerasimides and Matta [9]65719 (2.9%)3 (4.57%)
Summary4640109 (2.35%)48 (1.03%)
Woolson et al [1]24739 (15.79%)0

In a retrospective review of 231 patients (247 hip replacements) compared with innovator results, surgery time was twice as long, blood loss was twice as large, and major complication rate was 6 times as great. From a direct quote, “The serious nature of the complications brings into question whether the procedure is actually minimally invasive for community-practice surgeons. It was clear that extensive training in the minimally invasive anterior approach with a fracture table was necessary before performing the procedure on patients.”

It is clear from the bulk of published studies that any surgeon using this technique benefits from extensive training. The need for extensive training in new surgical techniques is not unique to the anterior approach. Public desire for minimally invasive surgery certainly drives the change over to such procedures, but they should be approached with great caution. The advantages to the anterior approach are attainable in experienced hands: less soft tissue damage, reduced surgery time, fewer dislocations, early elimination of hip precautions, and faster return to function are desirable to all.

The early experience, “learning curve,” and technical complications of the minimally invasive anterior approach are emphasized [4]. Given the consistently reported 95% to 98% success rate of conventional hip arthroplasty, it is imperative to make any change with foresight and then to document the consequence of that change [4]. This report sheds light on the very early result of a change only to the surgical approach to THA 345. Woolson et al [1] state that “training and experience are crucial to successfully performing this minimally invasive surgical technique, so there is a learning curve for the surgeon and the team. But one can always start with a regular incision length and decrease it when getting familiar with the approach.”

Why was minimally invasive anterior approach with fracture table THA instituted at this community-hospital without proper surgeon training? If the driving factor was reducing dislocation rates, what was the dislocation rate before using the anterior approach? An additional concern that led to the change to the minimally invasive anterior approach THA was a desire to reduce complication rates, yet despite the resulting high complication rate, this procedure is still in use by the 5 community-practice orthopedists; does this imply that there are unnamed benefits that outweigh the complication risks that the surgeons reported?

Many orthopedists are using procedures and technologies not available during their formal residency training. American Academy of Orthopaedic Surgeons requires practicing orthopedic surgeons to obtain certain continuing medical education credits annually and encourages attendance at cadaver and bioskills laboratory centers such as that established in Chicago and other locations, as well as encouraging communications between peers and visits to innovators to learn new concepts and learn how to safely use new techniques and technologies.

The recent article concerning community-hospital orthopedists using minimally invasive anterior approach THA does not answer the question “should community-hospital orthopaedists use this technique,” although some may interpret their article as an example or reason why community-hospital orthopedists should not use it. The question is not “should this technique be used”; the question is “how should this technique be introduced and implemented?”

Clin Orth and Rel Res 468(9): 2397-404:  9/1/10

Clin Orthop Relat Res. 2010 Sep;468(9):2397-404. doi: 10.1007/s11999-010-1406-5.

Incidence of lateral femoral cutaneous nerve neuropraxia after anterior approach hip arthroplasty.

Goulding K1Beaulé PEKim PRFazekas A.

Author information

Abstract

BACKGROUND:

Although injury to the lateral femoral cutaneous nerve (LFCN) is a known complication of anterior approaches to the hip and pelvis, no study has quantified its' incidence in anterior arthroplasty procedures.

QUESTIONS/PURPOSES:

We therefore defined the incidence, functional impact, and natural history of LFCN neuropraxia after an anterior approach for both hip resurfacing (HR) and primary total hip arthroplasty (THA).

METHODS:

We followed 132 patients who underwent an anterior hip approach (55 THA; 77 HR). We administered self-reported questionnaires for sensory deficits of LFCN, neuropathic pain score (DN4), visual analog scale, as well as SF-12, UCLA, and WOMAC scores at one year postoperatively. A subset of 60 patients (30 THA; 30 HR) was evaluated at two time intervals.

RESULTS:

One hundred seven patients (81%) reported LFCN neuropraxia with a mean severity score of 2.32/10 and a mean DN4 score of 2.42/10. Hip resurfacing had a higher incidence of neuropraxia as compared with THA: 91% versus 67%, respectively. No functional limitations were reported on SF-12, WOMAC, or UCLA scores. Of the subset of 60 patients followed over an average of 12 months, 53 (88%) reported neuropraxia at the first followup interval with only three (6%) having complete resolution at second followup. Improvement in DN4 scores was observed over time: 3.6 versus 2.5, respectively.

CONCLUSIONS:

Although LFCN neuropraxia was a frequent complication after anterior approach THA, it did not lead to functional limitations in our patients. A decrease in symptoms occurred over time but only a small number of patients reported complete resolution.

LEVEL OF EVIDENCE:

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

PMID:20532717 [PubMed - indexed for MEDLINE]  PMCID: PMC2919880

Orthopedics 33(7): 472  7/1/10

Orthopedics. 2010 Jul 13;33(7):472. doi: 10.3928/01477447-20100526-05. 

Lateral femoral cutaneous nerve impairment after direct anterior approach for total hip arthroplasty.

Bhargava T1, Goytia RN, Jones LC, Hungerford MW

Author information 

1Department of Orthopedic Surgery, The Johns Hopkins University at Good Samaritan Hospital, Baltimore, Maryland, USA.

Abstract

The anterior supine approach for total hip arthroplasty (THA) offers the advantage of operating through a true intravascular and intranervous plane, but it places the lateral femoral cutaneous nerve at risk. The purpose of this study was to identify the incidence of and impairment relating to injury of the lateral femoral cutaneous nerve. We performed a retrospective chart review of 81 hips undergoing anterior supine THA from November 2005 through May 2007 to determine operative time, estimated blood loss, fluoroscopic time, type of anesthesia used, intraoperative complications, and postoperative systemic and wound complications. Postoperative radiographs were evaluated for leg-length discrepancy, acetabular inclination and anteversion, and femoral stem position. Patients were reassessed at 6 weeks, 3 months, 6 months, 1 year, and 2 years. At each visit, patients were questioned about numbness or paresthesias in the distribution of the lateral femoral cutaneous nerve; if present, the patient outlined the area with a marking pen. This area was photographed, and data were collected. No hip had frank numbness; 12 hips (14.8%) had paresthesias. For those 12, symptoms resolved in 4 by 6 months, in 6 by 1 year, and in 10 (83.3%) by 2 years; 2 remained unresolved. No significant difference was found between patients with and without paresthesias or between patients with resolved or unresolved paresthesias. Impaired sensation did not appear to affect functional outcome or Harris Hip Score. Incision position, dissection plane, retractor placement, tension and soft tissue handling, and surgeon experience may affect incidence of injury to the lateral femoral cutaneous nerve.

Copyright 2010, SLACK Incorporated.

PMID:20608633 [PubMed - indexed for MEDLINE

2009

http://www.ncbi.nlm.nih.gov/pubmed/19493651

J Arthroplasty. 2009 Oct;24(7):999-1005. doi: 10.1016/j.arth.2009.04.001. Epub 2009 Jun 2.

Primary total hip arthroplasty using an anterior approach and a fracture table: short-term results from a community hospital.

Woolson ST1, Pouliot MA, Huddleston JI.

Author information 

1Department of Orthopedic Surgery, Stanford University Medical Center, Stanford, California 94305, USA.

Abstract

There are no data regarding the efficacy and safety of minimally invasive hip arthroplasty technique performed by community practice orthopedists. The early clinical and radiographic results of primary total hip arthroplasty using a minimally invasive anterior approach to the hip performed on a fracture table were studied. Two hundred thirty-one consecutive patients (247 hips) of 5 community practice surgeons were studied. The average surgical time (164 minutes) and estimated blood loss (858 mL) were more than double, and the major complication rate (9%) was 6 times that reported by an innovator of the procedure. However, no postoperative dislocations occurred. Adequate training is critical to reduce the risk of complications during the learning experience of minimally invasive hip arthroplasty procedures by community practice surgeons.

Comment in Minimally invasive anterior approach with a fracture table for total hip arthroplasty. Letter to the editor. [J Arthroplasty. 2010]

PMID:19493651 [PubMed - indexed for MEDLINE] 

http://www.ncbi.nlm.nih.gov/pubmed/21808689

Orthop Rev (Pavia). 2009 Oct 10;1(2):e27. doi: 10.4081/or.2009.e27.

Primary total hip arthroplasty: a comparison of the lateral Hardinge approach to an anterior mini-invasive approach.

Wayne N1, Stoewe R.

Author information 1Sykehuset Buskerud Vestre Viken, Drammen, Norway;

Abstract

The anterior mini-invasive (MI) approach to performing total hip arthroplasty (THA) is associated with less soft tissue damage and shorter postoperative recovery than other methods. Our hospital recently abandoned the traditional lateral Hardinge (LH) approach in favour of this new method. We compared the first 100 patients operated after the changeover to the new method (MI group) to the last 100 patients operated using the traditional method (LH group). Clinical and radiological parameters and complications were recorded pre- and postoperatively and the collected data of the two groups were statistically compared. There were no statistically significant differences between either group with regard to patient demographics or procedural data, placement of the femur component, postoperative leg discrepancy, prosthesis dislocation, blood transfusion, or postoperative dislocation of the components. The MI group had a significantly longer operating time, more bleeding, higher rate of nerve damage, and a higher percentage of acetabular component malposition whilst having a significantly shorter hospital stay and significantly fewer infections of the operative site in comparison to the LH group. Additionally, and perhaps most worrying was the clinically significant increase in intraoperative femur fractures in the MI group. The changeover to the anterior mini-invasive approach, which was the surgeons' initial experience with the MI technique, resulted in a drastic increase in the number of overall complications accompanied by less soft tissue damage and a shorter period of rehabilitation. Our results suggest that further analysis of this surgical MI technique will be needed before it can be recommended for widespread adoption.

KEYWORDS: 

Hardinge; anterior approach; hip surgery; joint surgery; mini-invasive surgery; orthopedics; total hip arthroplasty.

PMID:21808689 [PubMed]  PMCID: PMC3143982

 

Orthopedic Clinics of North America 40(3) 407-15:  7/1/09

Spatiotemporal parameters of gait after total hip replacement: anterior versus posterior approach.

Orthopedic Clinics of North America - Volume 40, Issue 3 (July 2009) About This Journal
DOI: 10.1016/j.ocl.2009.02.004

abstract

The objective of this preliminary study was to examine possible differences in gait characteristics between subjects operated by way of a direct anterior approach and a posterior approach for primary total-hip arthroplasty, and age-matched healthy controls. Fifty-one subjects walked over an instrumented mat at two different speeds (self-selected comfortable and faster than normal) and spatiotemporal gait parameters were calculated using a validated methodology. Despite excellent clinical and radiographic scores, and irrespective of surgical approach, patients demonstrated an impaired walking performance (lower velocity and shorter step lengths) during fast walking, but not at the self-selected comfortable speed compared with healthy controls. Subjects operated with the posterior approach reported significantly higher stiffness than anterior subjects, but similar pain and function. Six months after total arthroplasty for primary osteoarthritis of the hip, gait characteristics were comparable between subjects having received the direct anterior approach and the posterior approach.

Citation:
Spatiotemporal parameters of gait after total hip replacement: anterior versus posterior approach.
Maffiuletti NA - Orthop Clin North Am - 01-JUL-2009; 40(3): 407-15
MEDLINE® is the source for the citation and abstract of this record 

NLM Citation ID:
19576409 (PubMed ID)

Orthopedic Clinics of North America 40(3) 365-70:  7/1/09

Comparison of mini-incision total hip arthroplasty through an anterior approach and a posterior approach using navigation.

Abstract

This study reports on differences in the use of minimally invasive surgery for total hip arthroplasty related to the direction of cup insertion against the operating table, intraoperative hip range of motion, stability, and a choice of cup liners for both a mini-incision posterior approach (MPA) and a mini-incision anterior approach (MAA) using Stryker Navigation's CT-Hip system. The MPA group consisted of 39 consecutive patients and the MAA group consisted of 33 consecutive patients. Clinically, there was no significant difference in the average Japanese Orthopedic Association hip score or the Oxford hip score preoperatively and at 6 months and 2 years follow-up. The intraoperative joint stability measurements showed no large difference between the two groups when malpositioning of the cup was eliminated.

Authors Sugano NTakao MSakai TNishii TMiki HNakamura N

Source The Orthopedic clinics of North America 40:3 2009 Jul pg 365-70

PubMed ID19576404

Orthopedic Clinics of North America 40(3) 371-5:  7/1/09

Complications of the direct anterior approach for total hip arthroplasty.

Abstract

With the direct anterior approach gaining in popularity, it is important to appreciate the complications that are specific to it. The authors outline these potential complications and offer advice on the ways and the techniques to avoid them. This information is especially useful to the surgeon considering using this approach for the first time or to the surgeon who may already have encountered some of these complications as a result of using this approach.

Authors Barton CKim PR

Source

The Orthopedic clinics of North America 40:3 2009 Jul pg 371-5

 

PubMed ID19576405

http://www.ncbi.nlm.nih.gov/pubmed/19576400

Orthop Clin North Am. 2009 Jul;40(3):329-42. doi: 10.1016/j.ocl.2009.03.001.

Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observational study.

Anterior Total Hip Arthroplasty Collaborative Investigators, Bhandari M, Matta JM, Dodgin D, Clark C, Kregor P, Bradley G, Little L.

Collaborators (14)

Matta JM, Bhandari M, Dodgin D, Kreuzer S, Bradley G, Sprague S, Sidorkiewicz N, Mignot T, Grimes J, Masonis J, Yun A, Matthys G, Jewett B, Bellino M.

Abstract

The authors conducted a retrospective, multicenter cohort study of 1,152 patients across nine clinical sites across the United States, evaluating complications and function associated with the anterior approach to total hip arthroplasty using an orthopedic table. Eligible patients included those with primary diagnosis of hip arthritis. Outcomes included hospital stay, use of assistive devices, complications, and function. In the cohort of 1,152 patients treated with the anterior approach to total hip arthroplasty, the authors found (i) an acceptable complication profile with a very low dislocation rate, (ii) an early return to function, and (iii) a decline in complications in surgeons with greater than 100 case experiences.

PMID:19576400 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/19576405

Orthop Clin North Am. 2009 Jul;40(3):371-5. doi: 10.1016/j.ocl.2009.04.004.

Complications of the direct anterior approach for total hip arthroplasty.

Barton C1, Kim PR.

Author information 1The Ottawa Hospital-General Campus, University of Ottawa, 501 Smyth Road, CCW 1650, Ottawa, Ontario, Canada.

Abstract

With the direct anterior approach gaining in popularity, it is important to appreciate the complications that are specific to it. The authors outline these potential complications and offer advice on the ways and the techniques to avoid them. This information is especially useful to the surgeon considering using this approach for the first time or to the surgeon who may already have encountered some of these complications as a result of using this approach.

PMID:19576405 [PubMed - indexed for MEDLINE

http://www.ncbi.nlm.nih.gov/pubmed/19384637

J Orthop Traumatol. 2009 Mar;10(1):47-54. doi: 10.1007/s10195-008-0043-1. Epub 2009 Jan 31.

Learning curve in tissue sparing total hip replacement: comparison between different approaches.

D'Arrigo C1, Speranza A, Monaco E, Carcangiu A, Ferretti A.

Author information 

1II School of Medicine, Orthopaedic Unit, S. Andrea Hospital, "Sapienza" University of Rome, Rome, Italy.

Abstract

BACKGROUND: 

The tissue sparing surgery (TSS) concept means not only smaller incisions but also less tissue disruption, allowing decreased blood loss and improved function. However, TSS techniques can result in more complications related to the learning curve. The aim of this study was to compare the learning curve of an experienced surgeon with different TSS approaches for total hip replacement (THR) from a clinical and surgical point of view, focussing especially on complications related to the use of different geometric stems.

MATERIALS AND METHODS: 

Sixty patients scheduled to be operated for a primary THR were enrolled in the study and were randomly assigned to surgery by one of three different TSS approaches: lateral with mini incision (group A), minimally invasive anterior (group B) and minimally invasive antero-lateral (group C). Results from the three TSS groups were compared with a control group of 149 patients (group D).

RESULTS: 

Our results reveal significantly reduced blood loss in the TSS groups compared with the control group, with no differences between the TSS groups. We found better early functional scores in the two minimally invasive groups (anterior and anterolateral), and a lower rate of complications with the antero-lateral TSS approach.

CONCLUSION: 

The antero-lateral TSS approach seems to be safer and less demanding than standard THR surgery, and is suitable for use with different stems.

PMID:19384637 [PubMed]  PMCID: PMC2657353

2008

http://www.ncbi.nlm.nih.gov/pubmed/19298019

Orthopedics. 2008 Dec;31(12 Suppl 2). pii: orthosupersite.com/view.asp?rID=37187.

Safe and accurate: learning the direct anterior total hip arthroplasty.

Masonis J1, Thompson C, Odum S.

Author information 

1OrthoCarolina Hip & Knee Center, 1025 Morehad Medical Drive, Charlotte, NC 28204, USA.

Abstract

Wear, instability, leg length, and muscle recovery are the major obstacles in total hip arthroplasty (THA). The direct anterior approach with fluoroscopic assistance has been proposed to address all four of these issues. The goal of this study was to assess the learning curve, safety, and accuracy of direct anterior THA. A retrospective review was completed on a single surgeon's initial consecutive series of 300 THAs performed via a direct anterior approach. Cases were grouped based on chronologic order (1-100, 101-200, 201-300). Operative time, fluoroscopy time, estimated blood loss, radiographic leg length discrepancy (LLD), radiographic cup abduction angle, and complications were recorded. Data were analyzed using an analysis of variance. Postoperatively, all patients were managed without dislocation precautions. The average age for the cohort was 58.9 years, and the average BMI was 29. All groups were similar with respect to age and BMI. Direct anterior THA demonstrated significant reductions inoperative and fluoroscopy after the first 100 cases. Mean surgery time was 132.8 minutes for group 1, 109.9 for group 2, and 106.1 for group 3 (P<.001). Mean fluoroscopy time was 32.1 seconds for group 1, 14.5 for group 2, and 14.5 for group 3 (P<.001). There was one dislocation in group 3 and three intraoperative calcar fractures in the first 100 cases. There were no infections. Direct anterior THA demonstrated a reduction in operative time and fluoroscopy time after the initial 100 cases. Calcar fracture did not occur after the first 62 cases. Cup abduction angle, dislocation rate, and LLD were excellent in all groups.

PMID:19298019 [PubMed - indexed for MEDLINE] 

 

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