Anterior vs. posterior approach for total hip arthroplasty, a systematic review and meta-analysis

Current Trends in Clinical Practice for the Direct Anterior Approach Total Hip Arthroplasty

BACKGROUND

Despite increased popularity of the direct anterior approach (DAA) for total hip arthroplasty (THA), current practice trends and specific driving factors leading to adoption are not well established.

METHODS

We conducted an electronic e-mail survey of members of the American Association of Hip and Knee Surgeons inquiring into the choice of THA surgical approach, perceptions of clinical outcomes, and economic implications associated with the DAA.

RESULTS

Of 996 total respondents (44.3% American Association of Hip and Knee Surgeons member response rate), 56.2% currently perform the DAA. DAA performers have been in practice for statistically less time than non-performers (17.0 years vs 20.9 years, P < .001). Similarly, high-volume DAA surgeons have been in practice for less time than low-volume surgeons. DAA performers felt that revision case status (79.3%), complex anatomy (65.0%), and body habitus (53.0%) were factors leading to preferential use of the posterior approach. We also provide comprehensive data for perceived outcomes comparing the DAA and posterior approach. For current non-performers, the top reasons for not utilizing the DAA were feelings of worse outcomes, no clinical benefit, and concern for the learning curve. Economically, 76.1% of DAA performers reported increased patient market share by performing the DAA while 65.8% of non-performers endorsed lost patient market share. Only 3.0% of current non-performers plan to adopt the DAA in the future.

CONCLUSION

This is the first study of its kind to highlight current trends and clinical practices from a surgeon perspective regarding the DAA. Specifically, it provides comprehensive data regarding perceptions of clinical outcomes, practice economics, and driving factors for choice of surgical approach for surgeons who do and do not perform the DAA.

Total hip arthroplasty with accolade/trident through the direct minimally invasive anterior approach without traction table: Learning curve and results after a minimum of 5 years

BACKGROUND

The direct minimally invasive anterior approach (DMIAA) in total hip arthroplasty (THA) is widely accepted. In our department the DMIAA according to Rachbauer together with the Trident cup and Accolade stem was introduced in 2004. The purpose of the study was to demonstrate the five-year results and to analyze the learning curve of a new introduced approach.

PATIENTS AND METHODS

Between July 2004 and May 2006, a consecutive series of 151 THA in 147 patients was retrospectively analyzed. All patients were planned to received a THA with the Accolade/Trident implant system using the DMIAA without traction table. Clinical and radiographic data, complications and survivorship were documented with a follow-up of at least 5 years.

RESULTS

Regarding cup implantation, there were 11 (7.3%) failed intentions to treat due to missing pressfit (8 cases) and acetabular floor perforation (3 cases). No failed intentions to treat occurred during stem implantation. Total implant survival after 5 years follow-up after exclusion of 11 cases with failed intention to treat (N=140) was 96.9% (SD 1.4; CI 94.3-99.6). After exclusion of the failed intentions to treat (N=140, N=4 in the first 20 cases), there was significant (p<0.001) difference between the first 16 implants with a 5 year-survival of 83.2% (SD 8.6; CI 66.4-100) and 95.7% (SD 0.9; CI 93.9-97.5) for the following 124 implants. Radiolucent lines were observed in Gruen zone 1 in 3.3% and in Gruen zone 1 and 2 in 1.1%.

DISCUSSION

THA with Accolade/Trident using the DMIAA without traction table according to Rachbauer temporary exposed patients to a higher risk of implant revisions, which was normalized after the first 20 cases. Results of the learning curve are comparable to other techniques using an orthopaedic traction table. After the typical learning curve, the rate of 5 years implant failure is in accordance with the registry data for non-cemented implants. The Accolade stem showed minimal radiographic signs of radiolucency.

LEVEL OF EVIDENCE

IV, retrospective, consecutive case series.

The risk of revision after total hip arthroplasty in young patients depends on surgical approach, femoral head size and bearing type; an analysis of 19,682 operations in the Dutch arthroplasty register

Background

Total hip arthroplasty (THA) is used increasingly in younger patients. There is little knowledge about the effect of THA characteristics on risk of revision, especially in young patients. Therefore, we studied the influence of both patient-related and surgical factors on the risk of revision using data from the Dutch Arthroplasty Registry (LROI).

Methods

All patients younger than 55 years with a primary THA implanted in the Netherlands between 2007 and 2017 were selected (n = 19,682). The covariates age, sex, primary diagnosis, ASA-classification, surgical approach, fixation method, bearing type, head size and year of surgery were entered into Cox proportional hazards models to calculate hazard ratios for the risk of revision.

Results

The overall 5-year survival of primary THA was 95.3% (95% CI, 94.9–95.6). Use of the anterior approach resulted in a lower risk of revision than the use of the posterolateral approach (HR: 0.66, 95% CI: 0.47–0.92). THAs with a head diameter ≥ 38 mm had a higher risk of revision (HR: 1.90, 95% CI: 1.33–2.72) than THAs with 32 mm heads. Use of MoM bearings resulted in an increased risk when compared to C-PE (HR: 1.76, 95% CI: 1.27–2.43).

Conclusion

The risk of revision in patients younger than 55 years depends on surgical approach, head size and bearing type. The anterior approach resulted in a decreased risk of revision, whereas use of ≥38 mm heads and MoM bearings resulted in an increased risk of revision for any reason.

Relationship Between Functional Anatomy of the Hip and Surgical Approaches in Total Hip Arthroplasty

Multiple surgical approaches have been used successfully for total hip arthroplasty. Minimally invasive surgery, defined by the length of the incision, has been associated with less blood loss and shorter length of stay compared with conventional total hip arthroplasty. Differences in early functional outcomes, as well as the risk of early and long-term complications, have been observed between different anatomic surgical approaches. However, no single surgical approach has been established that achieves both the shortest functional recovery and the lowest rate of complications after total hip arthroplasty. [Orthopedics. 2019; 42(4):e356-e363.].

Prospective, Randomized Study of Direct Anterior Approach vs Posterolateral Approach Total Hip Arthroplasty: A Concise 5-Year Follow-Up Evaluation

BACKGROUND

Interest in direct anterior approach (DAA) has increased over the last decade. In our previously published study comparing DAA to posterolateral approach (PA), early 3-month benefits were noted in terms of pain and function. There was no difference noted at 6 or 12 months. This study reports average 5-year follow-up of our original study.

METHODS

Originally there were 43 DAA patients and 44 PA patients. At an average 5-year follow-up, patients were evaluated clinically with a University of California at Los Angeles activity score, Harris hip score, and Hip Disability and Osteoarthritis Outcome Score Jr Survivorship analysis was calculated. Radiographs were evaluated for loosening and evidence of radiolucent lines.

RESULTS

There were 2 deaths 1 in each group, neither was related to the implant or procedure. Four patients were lost to follow-up: 2 in the DAA group and 2 in the PA group. There was no statistical difference between surgical approaches in terms of Harris hip score, University of California at Los Angeles activity score, and Hip Disability and Osteoarthritis Outcome Score Jr. The 7-year survivorship was not significantly different. There were no loose implants at average 5-year follow-up.

CONCLUSION

Both DAA and PA yield good results at an average 5-year follow-up in terms of survivorship, function, rate of complications, and radiographic analysis.

Does the direct anterior approach allow earlier recovery of walking following total hip arthroplasty? A randomized prospective trial using accelerometry

INTRODUCTION

In total hip arthroplasty (THA), the anterior approach is attractive, being intermuscular, with theoretic functional benefit. Such benefit has been frequently claimed, but there are few data from randomized comparative studies using more precise metrics than patient satisfaction. We therefore conducted a randomized trial comparing early functional results between anterior and posterior approaches on gait analysis and functional scores.

HYPOTHESIS

The study hypothesis was that there is no difference between the two approaches in terms of early recovery of walking.

MATERIALS AND METHOD

A single-center single-surgeon prospective randomized study was conducted between February 2017 and April 2018. Inclusion criteria comprised: age<85 years, body-mass index (BMI)<32, and hip osteoarthritis with indication for THA. Preoperatively, the 2 groups were comparable for age, gender, BMI, Charnley, Harris, Postel-Merle-d'Aubigné and Oxford-12 scores and locomotor parameters (triaxial acceleration, step regularity and walking power). Preoperative and 3-, 6- and 12-week assessment comprised triaxial acceleration in walking and Postel-Merle-d'Aubigné, Harris and Oxford SF-12 scores.

RESULTS

One hundred patients were randomized to the anterior approach (AA: n=50) and posterior approach (PA: n=50) groups. Hospital stay was comparable between groups: PA, 2.8±1.78 days [range, 2.29-3.31 days]; AA, 2.84±1.25 days [range, 2.48-3.2 days] (p=0.8). Operative time was significantly longer in AA: 70.1±11 minutes vs. 56.7±11.79 (p<0.0001). There were no significant differences in locomotor parameters (p 0.122 to 0.987) or functional scores (p 0.052 to 0.968) over the 3-month follow-up. There was no difference in cup inclination: PA, 39.6±6.87° [range, 37.65-41.55°] vs. AA, 37.74±4.2° [range, 36.55-38.93°] (p=0.09). There were 8/50 cases (16%) of neurapraxia of the lateral cutaneous nerve of the thigh in the AA group; rates for other complications did not differ between groups.

CONCLUSION

Early functional results and especially objective locomotor parameters following THA were comparable between anterior and posterior approaches at 3 to 12 weeks. The approach should be chosen according to the surgeon's experience.

LEVEL OF EVIDENCE

II, low-power prospective randomized study.

An international comparison of THA patients, implants, techniques, and survivorship in Sweden, Australia, and the United States

Background and purpose - International comparisons of total hip arthroplasty (THA) practices and outcomes provide an opportunity to enhance the quality of care worldwide. We compared THA patients, implants, techniques, and survivorship in Sweden, Australia, and the United States. Patients and methods - Primary THAs due to osteoarthritis were identified using Swedish (n = 159,695), Australian (n = 279,693), and US registries (n = 69,641) (2003-2015). We compared patients, practices, and implant usage across the countries using descriptive statistics. We evaluated time to all-cause revision using Kaplan-Meier survival curves. We assessed differences in countries' THA survival using chi-square tests of survival probabilities. Results - Sweden had fewer comorbidities than the United States and Australia. Cement fixation was used predominantly in Sweden and cementless in the United States and Australia. The direct anterior approach was used more frequently in the United States and Australia. Smaller head sizes (≤ 32 mm vs. ≥ 36 mm) were used more often in Sweden than the United States and Australia. Metal-on-highly cross-linked polyethylene was used more frequently in the United States and Australia than in Sweden. Sweden's 5- (97.8%) and 10-year THA survival (95.8%) was higher than the United States' (5-year: 97.0%; 10-year: 95.2%) and Australia (5-year: 96.3%; 10-year: 93.5%). Interpretation - Patient characteristics, surgical techniques, and implants differed across the 3 countries, emphasizing the need to adjust for demographics, surgical techniques, and implants and the need for global standardized definitions to compare THA survivorship internationally.

Risk factors associated with cardiac complication after total joint arthroplasty of the hip and knee: a systematic review

Background

Cardiac complication represents a major cause of morbidity and mortality after total joint arthroplasty, thus necessitating investigation into the associated risks in total hip arthroplasty and total knee arthroplasty. There remains a lack of clarity for many risk factors in the current literature. The aim of this systematic review is to assess the most recent published literature and identify the risk factors associated with cardiac complication in total hip arthroplasty and total knee arthroplasty.

Methods

Scopus, PubMed, CINHAL, and Cochrane were searched to identify studies published since 2008 reporting on risk factors associated with cardiac complication in elective primary in total hip arthroplasty and total knee arthroplasty in patients ≥18 years old with osteoarthritis. Reported odds ratios, hazard ratios, and relative risk were the principal summary measures collected. The included studies were too heterogeneous to enable meta-analysis.

Results

Fifteen studies were included in this systematic review. Increasing age and history of cardiac disease were found by most studies to be positively associated with risk of cardiac complication. There was no strong association found between obesity and cardiac complication. The evidence for other risk factors was less clear in the examined literature, although there is suggestive evidence for male gender and cerebrovascular disease increasing risk.

Conclusions

Increasing age and history of cardiac disease increases the risk of cardiac complication after total hip arthroplasty and total knee arthroplasty. Other risk factors commonly attributed to increased risk in non-cardiac surgery including hypertension and obesity require further evaluation in arthroplasty.

Systematic review registration

A detailed protocol was published in the PROSPERO database (registration number CRD42018095887) for this systematic review.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-1058-9) contains supplementary material, which is available to authorized users.

Internal Validation of a Predictive Model for Complications After Total Hip Arthroplasty

BACKGROUND

Total hip arthroplasty (THA) is projected to increase in prevalence and associated complications will impose significant cost on the US healthcare system. The purpose of this study is to validate a predictive model for postoperative complications utilizing a novel 11-component hip-specific questionnaire encompassing preoperatively available clinical and radiographic data.

METHODS

Consecutive primary THA patients between January 2014 and January 2016 were included. Exclusion criteria included patients without questionnaire scoring variables and less than 1-year follow-up. Patients were stratified into 4 tiers based on their questionnaire score: low risk (>74), mild risk (57-73), moderate risk (41-56), and high risk (<40). A binary logistic regression was performed to determine if the questionnaire predicted complications. Receiver-operator curves were constructed to determine the threshold score below which there was a high likelihood of experiencing a complication.

RESULTS

Four hundred fifty patients were included in the final analysis with a mean (range) follow-up of 2.1 years (1.0-5.9), age of 63.1 years (25.7-9.17), and body mass index of 31.7 kg/m² (17.8-64.5). The complication rate was 13.6%. A hip questionnaire score of 73.8 conferred a 98.5% sensitivity and 98.5% negative predictive value for complications. The questionnaire score was the strongest predictor of a decreased complication likelihood (odds ratio 0.94, 95% confidence interval 0.90-0.97, P < .001). Risk tier was significantly associated with complications (low risk: 0; mild risk: 12; moderate risk: 25; and high risk: 24; P < .001).

CONCLUSION

This novel hip questionnaire demonstrated a high sensitivity and negative predictive value to identify patients at risk for postoperative complications. Future studies should attempt to prospectively validate the use of this questionnaire.

Total Hip Arthroplasty in Young Patients in The Netherlands: Trend Analysis of >19,000 Primary Hip Replacements in the Dutch Arthroplasty Register

BACKGROUND

Total hip arthroplasty (THA) is one of the most successful interventions in medical care. Because of shifting trends in THA and failure rates being higher in younger patients, we aimed to assess trends in implant fixation, bearing type, head diameter, and surgical approach in patients younger than 55 years in the Netherlands using data from the Dutch Arthroplasty Register.

METHODS

Trends in the method of implant fixation, bearing type, head diameter, and surgical approach were analyzed over year of surgery (2007-2016) and over age groups (<25, 25-29, 30-34, 35-39, 40-44, 45-49, and 50-54 years).

RESULTS

Between 2007 and 2016, a total of 19,915 primary THAs were performed in patients <55 years. Osteoarthritis was the most prevalent diagnosis (66.1%). Uncemented fixation was used in 79.5% of all performed THAs. The use of 32-mm head diameters increased (from 32.6% in 2007 to 50.1% in 2016), where an increasing trend toward the use of ceramic-on-polyethylene as most frequently used bearing type was present (from 37.5% in 2007 to 53.8% in 2016). The posterolateral surgical approach was the most frequently used approach; however, the anterior approach is used increasingly (0.1% in 2007 to 21.1% in 2016). Ceramic-on-polyethylene bearing surfaces, 32-mm head diameters, and the anterior approach were most commonly used in patients between 50 and 54 years.

CONCLUSION

There was a clear preference for uncemented fixation in young patients. In head diameter, bearing type, and surgical approach, clear trends were visible. Characteristics of THA in young patients were subject to changing perspectives.

Reattachment of an osteotomized greater trochanter in total hip arthroplasty using an ultra-high molecular weight polyethylene fiber cable

BACKGROUND

The optimum approach in total hip arthroplasty (THA) should reduce the risk of postoperative dislocation or limping, be applicable in every case, and be reusable in the future. The purpose of this study was to introduce our transgluteal approach for THA and to evaluate the type and frequency of complications around the greater trochanter.

METHODS

This study retrospectively evaluated 892 THA cases between January 2010 and March 2015 performed using our transgluteal approach that osteotomized only the lateral anteroinferior greater trochanter. The trochanteric fragment was reattached using one of three different protocols: Group A, three non-absorbable polyester sutures; Group B, two non-absorbable polyester sutures and one ultra-high molecular weight polyethylene (UHMWPE) fiber cable; or Group C, two UHMWPE fiber cables. Postoperative complications were assessed and recorded, and univariate logistic regression analyses were performed to determine whether risk factors and radiological complications around the greater trochanter were correlated.

RESULTS

None of the hips required revision for infection, dislocation, or limping. The rate of radiological complications around the greater trochanter at 1 year was 19.2% in Group A, 16.3% in Group B, and 7.9% in Group C (p < 0.001). Risk factors for radiological complications included the patient's disease or the surgeon's experience in Group A and the patient's age or the surgeon's experience in Group C. In the relationship between postoperative pain around the greater trochanter and radiological complications, there were no significant differences in all groups; no group interaction was observed (p= 0.3875).

CONCLUSION

The UHMWPE fiber cable was effective to reduce complications of the reattached osteotomized greater trochanter in THA.

Total hip arthroplasty through an anterior approach: The pros and cons

Total hip arthroplasty through an anterior approach has been increasing in popularity amongst surgeons and patients.

Anterior approach hip arthroplasty seems to offer improved early outcomes in terms of pain, rehabilitation and length of stay.

No difference in long-term outcomes has been shown between anterior and posterior or lateral approaches.

Proper formal training, utilization of fluoroscopy and adequate experience can mitigate risks of complications and improve early and medium-term outcomes.

Cite this article: EFORT Open Rev 2018;3:574-583. DOI: 10.1302/2058-5241.3.180023.

A Longitudinal Supra-Inguinal Fascia Iliaca Compartment Block Reduces Morphine Consumption After Total Hip Arthroplasty

BACKGROUND AND OBJECTIVES

The role of a fascia iliaca compartment block (FICB) for postoperative analgesia after total hip arthroplasty (THA) remains questionable. High-dose local anesthetics and a proximal injection site may be essential for successful analgesia. High-dose local anesthetics may pose a risk for local anesthetic systemic toxicity. We hypothesized that a high-dose longitudinal supra-inguinal FICB is safe and decreases postoperative morphine consumption after anterior approach THA.

METHODS

We conducted a prospective, double blind, randomized controlled trial. Patients scheduled for THA were randomized to group FICB (longitudinal supra-inguinal FICB with 40-mL ropivacaine 0.5%) or group C (control, no block). Standard hypothesis tests (t test or Mann-Whitney U test, χ test) were performed to analyze baseline characteristics and outcome parameters. The primary end point of the study was total morphine (mg) consumption at 24 hours postoperatively. Serial total and free ropivacaine serum levels were determined in 10 patients.

RESULTS

After obtaining ethical committee approval and written informed consent, 88 patients were included. Mean (SD) morphine consumption at 24 hours postoperatively was reduced in group FICB compared to group C: 10.25 (1.64) mg versus 19.0 (2.4) mg (P = 0.004). Using a mean dose of 2.6-mg/kg ropivacaine (range, 2-3.4 mg/kg), none of the patients had total or free ropivacaine levels above the maximum tolerated serum concentration.

CONCLUSIONS

We conclude that a high-dose longitudinal supra-inguinal FICB reduces postoperative morphine requirements after anterior approach THA.Clinical Trials Registry: EU Clinical Trials Register. www.clinicaltrialsregister.eu #2014-002122-12.

A systematic review and meta-analysis of direct anterior approach versus posterior approach in total hip arthroplasty

BACKGROUND

This meta-analysis aimed to evaluate the postoperative clinical outcomes and safety of the direct anterior approach (DAA) versus posterior approach (PA) in total hip arthroplasty (THA).

METHODS

We searched PubMed, Embase, Web of Science, the Cochrane Library, and Google databases from inception to June 2018 to select studies that compared the DAA and PA for THA. Only randomized controlled trials (RCTs) were included. Outcomes included Harris hip score at 2 weeks, 6 weeks, 12 weeks, and 1 year; VAS at 24 h, 48 h, and 72 h; incision length, operation time, postoperative blood loss, length of hospital stay, and complications (intraoperative fracture, postoperative dislocation, heterotopic ossification (HO), and groin pain).

RESULTS

Nine RCTs totaling 754 THAs (DAA group = 377, PA group = 377) met the criteria to be included in this meta-analysis. The present meta-analysis indicated that, compared with PA group, DAA group was associated with an increase of the Harris hip score at the 2-week and 4-week time points. No significant difference was found between DAA and PA groups of the Harris hip scores at 12 weeks, 1 year length of hospital stay (p > 0.05). DAA group was associated with a reduction of the VAS at 24 h, 48 h, and 72 h with statistical significance (p < 0.05). What is more, DAA was associated with a reduction of the incision length and postoperative blood loss (p < 0.05). There was no significant difference between the operation time and complications (intraoperative fracture, postoperative dislocation, HO, and groin pain).

CONCLUSION

In THA patients, compared with PA, DAA was associated with an early functional recovery and less pain scores. What is more, DAA was associated with shorter incision length and blood loss.

Simultaneous bilateral minimally invasive total hip arthroplasty: A comprehensive review of the literature

Several studies have reported that minimally- invasive total hip arthroplasty (MISTHA) may significantly reduce postoperative pain and results in faster postoperative rehabilitation when compared with the traditional lateral or posterior approach. Regarding bilateral hip osteoarthritis, there is still no consensus whether simultaneous bilateral MIS-THA can be established as the treatment of choice. Therefore, we searched the international databases of Pubmed, Medline, and Cochrane Database of Systematic Reviews using the key words minimally invasive bilateral total hip arthroplasty. From the initial 23 articles we found five clinical studies which met our inclusion criteria. From the perspective of possible intra- and postoperative complications, one-stage bilateral MIS THA was equally safe or safer than two-stage interventions. In addition, from a clinical outcome perspective, the one-stage procedure can be considered to be preferable. Higher blood transfusion requirements, which were expected following the standard bilateral simultaneous THA, seemed to be minimized with the simultaneous bilateral MIS THA. The supine position of the patient minimized the mean operation time. Approaches using the lateral decubitus position of the patient should be avoided in simultaneous bilateral THA due to the increased operation time. There is a lack of randomized, controlled clinical trials, comparing simultaneous bilateral MIS THA with staged bilateral MIS THA. Although simultaneous bilateral MIS THA seems to be efficacious, cost-effective and safe, more clinical trials are required to establish its superiority over the sequential MIS THA.

Evaluation of the Learning Curve When Transitioning From Posterolateral to Direct Anterior Hip Arthroplasty: A Consecutive Series of 1000 Cases

BACKGROUND

The direct anterior approach (DAA) for primary hip replacement has been gaining more attention and widespread use in recent years. There are a number of published studies evaluating the learning curve when a surgeon changes technique; these studies typically look at complications during the initial cases. This study examines procedure and total operating room (OR) time along with all complications for a surgeon transitioning from the posterolateral approach (PA) to DAA.

METHODS

A retrospective review of a single surgeon series of 1000 initial DAA procedures. Total OR time, procedure time, and complications were collected and analyzed. One-way analysis of variance and post hoc least significant difference tests were used for statistical analysis.

RESULTS

There was an initial increase in both procedure and OR times compared with the mature PA, by 34% and 30%, respectively. The procedure time became statistically equivalent to the mature PA time after the 400th DAA case, and significantly shorter after the 850th case. The total OR time became statistically equivalent after the 900th DAA case. There were 18 early (<90 days) and 18 late reoperations performed in this series with a nonsignificant trend toward femoral complications occurring early in the series. Minimum follow-up time was 2 years.

CONCLUSION

There was an initial increase in both total OR time and procedure time when an experienced surgeon introduced the DAA. By the end of the series, procedure time was significantly shorter and total OR time was equivalent. Complications overall were low and femoral complications decreased with time.

Capsular Ligament Function After Total Hip Arthroplasty

BACKGROUND

The hip joint capsule passively restrains extreme range of motion, protecting the native hip against impingement, dislocation, and edge-loading. We hypothesized that following total hip arthroplasty (THA), the reduced femoral head size impairs this protective biomechanical function.

METHODS

In cadavers, THA was performed through the acetabular medial wall, preserving the entire capsule, and avoiding the targeting of a particular surgical approach. Eight hips were examined. Capsular function was measured by rotating the hip in 5 positions. Three head sizes (28, 32, and 36 mm) with 3 neck lengths (anatomical 0, +5, and +10 mm) were compared.

RESULTS

Internal and external rotation range of motion increased following THA, indicating late engagement of the capsule and reduced biomechanical function (p < 0.05). Internal rotation was affected more than external. Increasing neck length reduced this hypermobility, while too much lengthening caused nonphysiological restriction of external rotation. Larger head sizes only slightly reduced hypermobility.

CONCLUSIONS

Following THA, the capsular ligaments were unable to wrap around the reduced-diameter femoral head to restrain extreme range of motion. The posterior capsule was the most affected, indicating that native posterior capsule preservation is not advantageous, at least in the short term. Insufficient neck length could cause capsular dysfunction even if native ligament anatomy is preserved, while increased neck length could overtighten the anterior capsule.

CLINICAL RELEVANCE

Increased understanding of soft-tissue balancing following THA could help to prevent instability and improve early function. This study illustrates how head size and neck length influence the biomechanical function of the hip capsule in the early postoperative period.

Hip muscle power recovery after hip replacement using anterior-based muscle-sparing approach in elderly femoral neck fracture: a prospective study in 40 patients

Introduction

The early rehabilitation and mobilization after hip arthroplasty (HA) in elderly femoral neck fracture (FNF) patients significantly reduces the postoperative morbidity and mortality. The direct anterior approach (DAA) without the muscle detachment has been shown to improve the early postoperative functional outcomes in coxarthrosis patients. However, the application of DAA on elderly FNF and the most suitable surgical technique have rarely been investigated. This study aimed to report the short-term outcome after our anterior-based muscle-sparing approach (ABMS) in elderly FNF.

Materials and methods

A prospective study, in 40 elderly unilateral FNF patients who underwent HA with ABMS, was conducted. The primary outcomes were hip flexion and abduction power at each follow-up period. The contralateral muscle power, measured at 3 and 6 months, was used as the control value. The perioperative data and complications were recorded.

Results

Thirty-two patients underwent bipolar hemiarthroplasty (BHA), while eight other patients received total hip arthroplasty (THA). The hip abduction power returned to control value at 6 weeks (99.0%±6.1%; 95% CI: 86.1–111.8). The hip flexion power returned to control at 3 months (108.5%±5.6%, 95% CI: 96.8–120.2). No iatrogenic nerve injury was found. The intraoperative femoral fracture (IFF) was found in 7 patients (17.5%), and was significantly related to the early period of learning skill (first 11 cases; p<0.01). BHA had nonsignificant higher IFF than THA (8 vs. 0; p=0.31).

Conclusion

After ABMS, the hip muscle could recover to the baseline value within 3 months without iatrogenic nerve injury. The ABMS-related complication, which was IFF, could be significantly improved with the learning skill. The adequate posterior soft tissue release and gentle manipulation of the hip joint might play important roles for IFF prevention. BHA might relate to higher risk of IFF because of difficult reduction from large femoral head diameter.

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

PURPOSE

The purpose of this study was to determine whether in-hospital outcomes are different with anterior approach (AA) or posterior approach (PA) in primary total hip arthroplasty (THA).

METHODS

We performed a systematic review with random-effects meta-analysis of random-ized controlled trials (RCTs) comparing AA with PA in primary THA. Hospital outcomes were reported as odds ratio (OR), weight mean difference, or standardized mean difference (SMD).

RESULTS

A total of seven RCTs with 609 patients were included. Outcomes favoring AA included 1.4 cm shorter incision (p=0.045), 0.5 days shorter hospital stay (p=0.01), 0.5 points less pain on a 0-10 scale (p=0.007), and less opioid use (SMD=-0.39 corresponding to 12 fewer morphine equivalents per day, p=0.01). The procedure time was 16 minutes longer with AA vs. PA (p=0.002). There were no statistical differences between AA and PA in operative blood loss (mean difference =19 mL, p=0.71), transfusions (9.7% vs. 16.2%, OR=0.45, p=0.39), or complications (5.5% vs. 4.1%, OR=1.42, p=0.62).

CONCLUSION

While the AA to primary THA may take longer time compared with the PA, the incision is shorter, and patients report slightly less pain, require less opioid medication, and leave the hospital earlier. The clinical relevance of these differences during longer-term follow-up is uncertain. The choice of surgical approach in primary THA should also consider factors such as experience of the surgeon and preferences of the surgeon and patient.

The effect of c-arm tilt on accuracy of intraoperative fluoroscopy in assessing acetabular component position during direct anterior approach for hip arthroplasty

Intraoperative fluoroscopy can improve the precision of acetabular component positioning during direct anterior hip arthroplasty. However, changes in pelvic tilt with c-arm positioning may compromise accuracy. A geometric model of an acetabular component's projection onto fluoroscopy images was created and manipulated to simulate c-arm tilt. An apparently ideally-placed cup will have its effective anteversion changed by 7.5° with just 10° of caudal/cephalad tilt of the c-arm. This effect is greater in cups that are more horizontally placed or less anteverted. Accurate c-arm positioning is crucial, as small errors in tilt can have considerable effects on final cup position.

Acetabular cup orientation and postoperative leg length discrepancy in patients undergoing elective total hip arthroplasty via a direct anterior and anterolateral approaches

Background

Total hip arthroplasty (THA) is considered a successful surgical procedure. It can be performed by several surgical approaches. Although the posterior and anterolateral approaches are the most common, there has been increased interest in the direct anterior approach. The goal of the present study is to compare postoperative leg length discrepancy and acetabular cup orientation among patients who underwent total hip arthroplasty through a direct anterior (DAA) and anterolateral (ALA) approaches.

Methods

The study included 172 patients undergoing an elective THA by a single surgeon at our institution within the study period. Ninety-eight arthroplasties were performed through the ALA and 74 arthroplasties through the DAA. Preoperative planning was performed for all patients. Assessment of the two groups included the following postoperative parameters: abduction angle, cup anteversion angle and leg length discrepancy (LLD). Additional analysis was done to evaluate component positioning by comparing deviation from the Lewinnek zone of safety in both approaches.

Results

For the DAA the absolute LLD was 11 mm, ranging from -6 mm to 5 mm. For the ALA, the absolute LLD was 36 mm, ranging from -22 mm to 14 mm. None of the DAA patients had an absolute LLD greater than 6 mm. Comparatively, 7.4% of the ALA group exceeded 6 mm of LLD in addition to 2.1% with LLD greater than 10 mm. 15% of the ALA group resided out of the Lewinnek abduction zone compared to 3% of the DAA group (P = 0.016). 17% of the ALA group were out of the Lewinnek anteversion zone as opposed to 8% of the DAA group (P = 0.094).

Conclusion

Our study demonstrates good component positioning outcomes and LLD values in patients following THA through the DAA compared to the ALA.

Similar Superior Patient-Reported Outcome Measures for Anterior and Posterolateral Approaches After Total Hip Arthroplasty: Postoperative Patient-Reported Outcome Measure Improvement After 3 months in 12,774 Primary Total Hip Arthroplasties Using the Anterior, Anterolateral, Straight Lateral, or Posterolateral Approach

BACKGROUND

Patient-reported outcome measures (PROMs) are used to evaluate the outcome of total hip arthroplasty (THA). We determined the effect of surgical approach on PROMs after primary THA.

METHODS

All primary THAs, with registered preoperative and 3 months postoperative PROMs were selected from the Dutch Arthroplasty Register. Based on surgical approach, 4 groups were discerned: (direct) anterior, anterolateral, direct lateral, and posterolateral approaches. The following PROMs were recorded: Hip disability and Osteoarthritis Outcome Score Physical function Short form (HOOS-PS); Oxford Hip Score; EQ-5D index score; EQ-5D thermometer; and Numeric Rating Scale measuring pain, both active and in rest. The difference between preoperative and postoperative scores was calculated (delta-PROM) and used as primary outcome measure. Multivariable linear regression analysis was performed for comparisons. Cohen's d was calculated as measure of effect size.

RESULTS

All examined 4 approaches resulted in a significant increase of PROMs after primary THA in the Netherlands (n = 12,274). The anterior and posterolateral approaches were associated with significantly more improvement in HOOS-PS scores compared with the anterolateral and direct lateral approaches. Furthermore, the posterolateral and anterior approaches showed greater improvement on Numeric Rating Scale pain scores compared with the anterolateral approach. No relevant differences in delta-PROM were seen between the anterior and posterolateral surgical approaches.

CONCLUSION

Anterior and posterolateral surgical approaches showed more improvement in self-reported physical functioning (HOOS-PS) compared with anterolateral and direct lateral approaches in patients receiving a primary THA. However, clinical differences were only small.

Influence of surgical approach on complication risk in primary total hip arthroplasty

Background and purpose - Systematic comparisons of anterior approach (A) versus posterior approach (P) in primary total hip arthroplasty (THA) have largely focused on perioperative outcomes. In this systematic review with meta-analysis, we compared complication risk of A versus P in studies of primary THA with at least 1-year mean follow-up. Patients and methods - We performed a systematic review of prospective and retrospective studies with at least 1-year mean follow-up that reported complications of A and P primary THA. Complications included infection, dislocation, reoperation, thromboembolic event, heterotopic ossification, wound complication, fracture, and nerve injury. Random effects meta-analysis was used for all outcomes. Complication risk was reported as rate ratio (RR) to account for differential follow-up durations; values >1 indicated higher complication risk with A and values <1 indicated lower risk with A. Results - 19 studies were included; 15 single-center comparative studies with 6,620 patients (2,278 A; 4,342 P) and 4 multicenter registries with 157,687 patients (18,735 A; 138,952 P). Median follow-up was 16 (12-64) months) with A and 18 (12-110) months with P. Anterior approach was associated with lower rate of infection (RR =0.55, p = 0.002), dislocation (RR =0.65, p = 0.03), and reoperation (RR =0.84, p < 0.001). No statistically significant differences were observed in rate of thromboembolic event (RR =0.59, p = 0.5), heterotopic ossification (RR =0.63, p = 0.1), wound complication (RR =0.93, p = 0.8), or fracture (RR =1.0, p = 0.9). There was a higher rate of patient-reported nerve injury with A (RR =2.3, p = 0.01). Interpretation - Comparing A with P in primary THA, A was associated with lower risk of reoperation, dislocation, and infection, but higher risk of patient-reported nerve injury.

Surgical Approaches and Hemiarthroplasty Outcomes for Femoral Neck Fractures: A Meta-Analysis

BACKGROUND

The lateral approach (LA), posterior approach (PA), and anterior approach (AA) are conventional surgical access routes for hemiarthroplasty in proximal femoral fractures. This meta-analysis assesses and compares the outcomes and attempts to identify the best approach for hemiarthroplasty in the treatment of proximal femoral fractures.

METHODS

An electronic search was performed from inception to October 25, 2017, for comparative studies including at least 2 of the conventional approaches. Outcomes including operation time, surgical blood loss, perioperative fractures, wound infections, dislocations, and hospital length of stay were plotted in forest plots.

RESULTS

Twenty-one eligible studies were selected including 3 randomized, controlled trials, 7 prospective and 11 retrospective cohort studies. The odds ratio (OR) for dislocations was significantly higher for the PA compared with the AA (OR, 2.61; 95% confidence interval [CI], 1.26 to 5.43; P = .01) and the LA (OR, 2.90; 95% CI, 1.63 to 5.14; P = .0003). The PA had a higher risk of reoperation compared to the AA (OR, 1.25; 95% CI, 1.12 to 1.41; P < .0001). No significant differences were found concerning perioperative fractures, wound infections, and hospital length of stay. Some studies suggest a better short-term functional outcome using the AA compared to the PA.

CONCLUSION

The PA for hemiarthroplasty in proximal femoral fractures poses an increased risk of dislocation and reoperation compared to the LA and AA. There are no evident advantages of the PA and its routine use for fracture-related hemiarthroplasty should be questioned.

A new mini-navigation tool allows accurate component placement during anterior total hip arthroplasty

Introduction

Computer-assisted navigation systems have been explored in total hip arthroplasty (THA) to improve component positioning. While these systems traditionally rely on anterior pelvic plane registration, variances in soft tissue thickness overlying anatomical landmarks can lead to registration error, and the supine coronal plane has instead been proposed. The purpose of this study was to evaluate the accuracy of a novel navigation tool, using registration of the anterior pelvic plane or supine coronal plane during simulated anterior THA.

Methods

Measurements regarding the acetabular component position, and changes in leg length and offset were recorded. Benchtop phantoms and target measurement values commonly seen in surgery were used for analysis. Measurements for anteversion and inclination, and changes in leg length and offset were recorded by the navigation tool and compared with the known target value of the simulation. Pearson's r assessed the relationship between the measurements of the device and the known target values.

Results

The device accurately measured cup position and leg length measurements to within 1° and 1 mm of the known target values, respectively. Across all simulations, there was a strong, positive relationship between values obtained by the device and the known target values (r=0.99).

Conclusion

The preliminary findings of this study suggest that the novel navigation tool tested is a potentially viable tool to improve the accuracy of component placement during THA using the anterior approach.

Does Surgical Approach Affect Outcomes in Total Hip Arthroplasty Through 90 Days of Follow-Up? A Systematic Review With Meta-Analysis

BACKGROUND

The choice between anterior approach (AA) and posterior approach (PA) in primary total hip arthroplasty (THA) is controversial. Previous reviews have predominantly relied on data from retrospective studies.

METHODS

This systematic review included prospective studies comparing postoperative outcomes through 90 days of AA vs PA in primary THA. Outcomes were pain severity, narcotic usage, hip function using Harris Hip Score, and complications. Random effects meta-analysis was performed for all outcomes. Efficacy data were reported as standardized mean difference (SMD) where values of 0.2, 0.5, 0.8, and 1.0 were defined as small, medium, large, and very large effect sizes, respectively. Complications were reported as the absolute risk difference (RD) where a positive value implied higher risk with AA and a lower value implied lower risk with AA.

RESULTS

A total of 13 prospective comparative studies (7 randomized) with patients treated with AA (n = 524) or PA (n = 520) were included. The AA was associated with lower pain severity (SMD = -0.37, P < .001), lower narcotic usage (SMD = -0.36, P = .002), and improved hip function (SMD = 0.31, P = .002) compared to PA. No differences between surgical approaches were observed for dislocation (RD = 0.2%, P = .87), fracture (RD = 0.2%, P = .87), hematoma (RD = 0%, P = .99), infection (RD = 0.2%, P = .85), thromboembolic event (RD = -0.9%, P = .42), or reoperation (RD = 1.3%, P = .26). Conclusions of this study were unchanged when subjected to sensitivity analyses.

CONCLUSION

In this systematic review and meta-analysis of prospective studies comparing postoperative outcomes through 90 days of AA vs PA in primary THA, patients treated with AA reported less pain, consumed fewer narcotics, and reported better hip function. No statistical differences in complication rates were detected between AA and PA. Ultimately, the choice of surgical approach in primary THA should consider preference and experience of the surgeon as well as preference and anatomy of the patient.

Quality assessment of systematic reviews on total hip or knee arthroplasty using mod-AMSTAR

Background

Increasing numbers of systematic reviews (SRs) on total knee arthroplasty (TKA) and total hip arthroplasty (THA) have been published in recent years, but their quality has been unclear. The purpose of this study is to evaluate the methodological quality of SRs on TKA and THA.

Methods

We searched Ovid-Medline, Ovid-Embase, Cochrane Databases (including HTA, DARE, and CDSR), CBM, CNKI, Wang Fang, and VIP, from January 2014 to December 2015 for THA and TKA. The quality of SRs was assessed using the modified 25-item “Assessment of Multiple Systematic Reviews” (mod-AMSTAR) tool, which was based on the AMSTAR scale. A T-test, nonparametric test, and linear regression were conducted to assess the relationship between bibliographical characteristics and methodological quality.

Results

Sixty-three SRs were included, from which the majority of SRs (50, 79.4%) were conducted in Asia. Only 4 reviews were rated as high quality, and most were weak in providing a priori design (6, 9.5%), not limiting the publication type (8, 13%), providing an excluded primary studies list (4, 6.3%) and reporting support for the included primary studies (1, 1.6%). Reviews published in English journals performed better than did Chinese journals in duplicate data extraction (81.3% vs 46.7%, p = 0.017; 70.8% vs 33.3%, p = 0.009) and providing source of support for the SR (87.5% vs 33.3%, P < 0.001). Reviews published in journals with a higher impact factor were associated with a higher mod-AMSTAR score (regression coefficient: 0.38, 95%CI: 0.11–0.65; P = 0.006).

Conclusion

The methodological quality of the included SRs is far from satisfactory. Authors of SRs should conform to the recommendations outlined in the mod-AMSTAR items. Areas needing improvement were providing a priori design, not limiting the publication type, providing an excluded primary studies list, and reporting conflicts of interest.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0488-8) contains supplementary material, which is available to authorized users.

Cementless Tapered-Wedge Stem Length Affects the Risk of Periprosthetic Femoral Fractures in Direct Anterior Total Hip Arthroplasty

BACKGROUND

Although the popularity of the direct anterior approach for total hip arthroplasty has increased, the femoral procedure in this approach is considered technically challenging, and one of the most frequent complications reported was periprosthetic femoral fractures. The present study aimed to identify factors for predicting the risk of periprosthetic femoral fractures after using stems with a cementless tapered-wedge design through the direct anterior approach.

METHODS

We retrospectively assessed the medical records of 686 patients (851 hips) who underwent primary total hip arthroplasty using a single stem with a cementless tapered-wedge design having a short or standard length option. The direct anterior approach on a standard operating table was used for all hips. Multivariate logistic regression analysis was performed to identify the independent predictors of intraoperative and early postoperative periprosthetic fractures.

RESULTS

Seventeen periprosthetic femoral fractures (2.0%) were observed, including 10 intraoperative (1.2%) and 7 postoperative (0.8%) fractures. The occurrence rate of fractures using short stems was significantly higher compared with that using standard stems. The multivariate logistic regression analysis revealed that only stem length was significantly associated with periprosthetic fractures.

CONCLUSION

Our results indicate that the stem design affects the risk of periprosthetic femoral fractures.

Medical resource utilization and costs for total hip arthroplasty: benchmarking an anterior approach technique in the Medicare population

AIMS

The anterior approach (AA) for total hip arthroplasty (THA) is associated with more rapid recovery when compared to traditional approaches. The purpose of this study was to benchmark healthcare resource utilization and costs for patients with THA via AA relative to matched patients.

MATERIALS AND METHODS

This study queried Medicare claims data (2012-2014) to identify patients who received THA via an AA from experienced surgeons, and matched these patients to a control cohort (all THA approaches). Direct and propensity-score matching were employed to maximize similarity between patients and hospitals in the two cohorts. Hospital length of stay (LOS), the proportion of patients discharged to home or home health, and post-acute claim payments during the 90-day episode were assessed. Generalized estimating equations were applied to control for imbalances between the cohorts and clustering of outcomes within hospitals.

RESULTS

A total of 1,794 patients were included after patient matching. Patients who received AA had significantly lower mean hospital LOS vs patients in the control group (2.06 ± 1.36 vs 2.98 ± 1.58 days, p < .0001). The adjusted proportion of patients discharged to home was nearly 20 percentage points higher in the AA cohort vs the control cohort (87.3% vs 68.7%, p < .0001). Post-acute claim payments for AA patients were nearly 50% lower than those for control patients ($4,139 vs $7,465, p < .0001).

CONCLUSION

AA patients had significantly lower post-acute care resource use when compared to control patients. Further research is warranted to evaluate the cost effectiveness of AA among surgeons of varying experience levels.

Antibiotic Prophylaxis and DAIR Treatment in Primary Total Hip and Knee Arthroplasty, A National Survey in The Netherlands

BACKGROUND

To prevent postoperative infection the use of systemic antibiotic prophylaxis is common ground. Type of antibiotic used and duration of prophylaxis are subject to debate. In case of suspected early periprosthetic infection a debridement, antibiotics and implant retention (DAIR) procedure is treatment of first choice. This study evaluated the antibiotic prophylaxis and DAIR treatment protocols nationwide as well as reporting of these DAIR procedures to the national joint registry.

METHODS

All institutions that performed total hip or knee arthroplasty were contacted to complete a 16-question online survey. Questions included availability of a protocol, type and duration of antibiotic prophylaxis used and tendency to register infectious complications in the Dutch Arthroplasty Register.

RESULTS

All ninety-nine consulted institutions responded to this survey. All but one institutions have a standardized hospital based protocol for antibiotic prophylaxis in primary total hip or knee arthroplasty. Cefazolin was antibiotic prophylaxis of choice in ninety-four institutions for both primary hip and knee arthroplasty. In ten institutions one preoperative gift of antibiotic prophylaxis was administered. A protocol describing treatment when suspecting early periprosthetic joint infection was present in seventy-one institutions. When performing a DAIR procedure modular parts were exchanged in seventy institutions in case of a hip prosthesis and in eighty-one institutions in case of a knee prosthesis. Sixty-three institutions register DAIR procedures in the Dutch Arthroplasty Register.

INTERPRETATION

In contradiction to the results of a recent study in Great Britain, we have found only little variety in availability of protocols and in the type of antibiotic used as prophylaxis in primary total hip and knee arthroplasty in The Netherlands. Not every institution has a protocol for treatment in suspicion of early infection. Although mobile parts are exchanged in the majority of cases, there appears to be an underreporting of DAIR procedures in the Dutch Arthroplasty Register.

Does hydroxyapatite coating of uncemented cups improve long-term survival? An analysis of 28,605 primary total hip arthroplasty procedures from the Nordic Arthroplasty Register Association (NARA)

OBJECTIVE

It is unclear whether hydroxyapatite (HA) coating of uncemented cups used in primary total hip arthroplasty (THA) improves bone ingrowth and reduces the risk of aseptic loosening. We therefore investigated survival of different uncemented cups that were available with or without HA coating.

METHOD

We investigated three different cup types used with or without HA coating registered in the Nordic Arthroplasty Register Association (NARA) database that were inserted due to osteoarthritis (n = 28,605). Cumulative survival rates and adjusted hazard ratios (HRs) for the risk of revision were calculated.

RESULTS

Unadjusted 13-year survival for cup revision due to aseptic loosening was 97.9% (CI: 96.5-99.4) for uncoated and 97.8% (CI: 96.3-99.4) for HA-coated cups. Adjusted HRs were 0.66 (CI 0.42-1.04) for the presence of HA coating during the first 10 years and 0.87 (CI 0.14-5.38) from year 10-13, compared with uncoated cups. When considering the endpoint cup revision for any reason, unadjusted 13-year survival was similar for uncoated (92.5% [CI: 90.1-94.9]) and HA-coated (94.7% [CI: 93.2-96.3]) cups. The risk of revision of any component due to infection was higher in THA with HA-coated cups than in THA with uncoated cups (adjusted HR 1.4 [CI 1.1-1.9]).

CONCLUSIONS

HA-coated cups have a similar risk of aseptic loosening as uncoated cups, thus the use of HA coating seems to not confer any added value in terms of implant stability. The risk of infection seemed higher in THA with use of HA-coated cups, an observation that must be investigated further.

Perioperative Comparison of Hip Arthroplasty Using the Direct Anterior Approach with the Posterolateral Approach

Purpose

The aim of the current study is to report the advantage and disadvantage of total hip arthroplasty performed in direct anterior approach (DAA) by comparing it to the posterolateral approach (PLA).

Materials and Methods

Twenty-five hip arthroplasty done in DAA (12 total hip arthroplasty [THA] and 13 bipolar hemiarthroplasty [BHA]) were compared with the same number done in PLA (13 THA and 12 BHA). Intraoperative assessments including operation time, anesthetic time, bleeding amount were recorded with intraoperative complications. Immediate postoperatively, position of the prosthesis and leg length discrepancy were measured and were compared between the two approaches.

Results

The operation time was 22 minutes and 19 minutes longer in DAA for THA and BHA respectively while the anesthetic time difference was 26 and 10 respectively. However, these parameters showed no statistical difference. No significance was found when bleeding amount was compared. For DAA, cup alignment was within safe zone in 100% both for inclination and for anteversion while this was 83.3% and 75.0% respectively in PLA. Leg length difference was 3 mm in DAA and 5 mm in PLA but had no significant difference. Tensor fascia lata tear was the most common complication occurring in 9 patients.

Conclusion

Although significant was not reached there was trend toward more operation time and anesthetic time when DAA was used. However, the trend also showed that cup and stem were likely to be in more accurate position and in adequate size which is likely due to the accurate use of fluoroscopy.

The effect of surgical approach on gait mechanics after total hip arthroplasty

BACKGROUND

Few studies have compared the biomechanical outcomes of different surgical approaches for hip arthroplasty. The purpose of this study was to compare hip, pelvic, and trunk kinematics and kinetics between individuals who underwent a posterior or anterolateral approach.

METHODS

Forty-five individuals between 40 and 80 years old underwent motion analysis during overground gait prior to hip arthroplasty and 3 months after surgery. Walking speed, hip flexion angle, hip extension angle, adduction angle and moment, trunk angle, trunk lean, and pelvis drop were compared between approaches.

FINDINGS

There were 30 subjects in the posterior group and 15 subjects in the anterolateral group. The groups did not change differently over time as there were no significant interaction effects. However, there were main effects for time; walking speed increased 19.9% (p < .001), hip flexion angle increased 3.3 degrees (p = 0.014) and peak hip extension increased 4.5 degrees (p = .001), and peak hip adduction significantly increased 1.9 degrees (p = .004) for the sample as a whole. Trunk angle (p = .283) and trunk lean (p = .401) did not significantly change between time points, but there was a significant increase in pelvic drop (p = .003).

INTERPRETATION

Surgical approach did not affect biomechanical outcomes 3 months after arthroplasty. Both groups showed improvement in sagittal plane hip kinetics and kinematics. However, increased pelvic drop may be indicative of residual hip weakness in both groups.

Comparison of Early Functional Recovery After Total Hip Arthroplasty Using a Direct Anterior or Posterolateral Approach: A Randomized Controlled Trial

BACKGROUND

Controversy exists as to whether early functional outcomes differ after total hip arthroplasty performed using the direct anterior approach (DAA) or the posterolateral approach (PLA).

METHODS

One hundred twenty patients were enrolled in this study and were divided into 2 groups based on surgical approach. Group A included patients who had a total hip arthroplasty with a DAA, whereas group B included those with a PLA. Patients were randomized into the DAA or PLA groups (n = 60), and perioperative and postoperative outcomes were recorded.

RESULTS

When compared with the PLA, the DAA had a shorter incision length (9.1 vs 13.1 cm; P < .01), shorter hospital stay (2.8 vs 3.3 days, P = .04), and lower self-reported pain. Both serum inflammatory and muscle damage markers were lower in the DAA group. However, the PLA had shorter operative times (65.5 vs 83.3 min, P = .03) and less intraoperative blood loss (123.8 vs 165.9 mL, P = .04). The DAA had significantly lower variance in cup inclination and anteversion. Similar rates of intraoperative complications were identified in the 2 groups. The DAA was associated with better functional recovery at 3 months based on the Harris hip score, University of California Los Angeles activity score, and gait analysis; however, functional recovery at 6 months was similar between the 2 groups.

CONCLUSION

We found functional advantages in early recovery after the DAA compared with the PLA. The DAA can offer rapid functional recovery with less muscle damage, greater pain relief, and lower variance in cup inclination and anteversion. However, no functional difference was found at 6 months follow-up.

Clinical Considerations for the Use Lower Extremity Arthroplasty in the Elderly

There is an increase in the aging population that has led to a surge of reported cases of osteoarthritis and a greater demand for lower extremity arthroplasty. This article aims to review the current treatment options and expectations when considering lower extremity arthroplasty in the elderly patient with an emphasis on the following subjects: (1) updated clinical guidelines for the management of osteoarthritis in the lower extremity, (2) comorbidities and risk factors in the surgical patient, (3) preoperative evaluation and optimization of the surgical patient, (4) surgical approach and implant selection, and (5) rehabilitation and life after lower extremity arthroplasty.

Interventions for treating displaced intracapsular femoral neck fractures in the elderly: a Bayesian network meta-analysis of randomized controlled trials

Displaced intracapsular femoral neck (AO type 31 B2/3) fractures have various treatments, including internal fixation (IF), unipolar uncemented hemiarthroplasty (HA), bipolar uncemented HA, unipolar cemented HA, bipolar cemented HA, uncemented total hip replacement (THR), and cemented THR. Systematic literature retrieval was performed from the databases to compare them in a network meta-analysis. Forty studies (85 arms) containing 6141 patients were included. Overall, our network meta-analysis rank the orders of 7 procedures in reoperation, mortality, dislocation and infection, which indicates that IF may provide the highest reoperation incidence, unipolar cemented HA may provide the lowest reoperation incidence; uncemented THR contributes the highest dislocation incidence; and bipolar uncemented HA provides the lowest infection incidence. No differences in mortality were observed among the treatments. This conclusion is indirect; higher-quality direct comparisons are required.

The direct anterior approach in total hip arthroplasty: a systematic review of the literature

AIMS

The most effective surgical approach for total hip arthroplasty (THA) remains controversial. The direct anterior approach may be associated with a reduced risk of dislocation, faster recovery, reduced pain and fewer surgical complications. This systematic review aims to evaluate the current evidence for the use of this approach in THA.

MATERIALS AND METHODS

Following the Cochrane collaboration, an extensive literature search of PubMed, Medline, Embase and OvidSP was conducted. Randomised controlled trials, comparative studies, and cohort studies were included. Outcomes included the length of the incision, blood loss, operating time, length of stay, complications, and gait analysis.

RESULTS

A total of 42 studies met the inclusion criteria. Most were of medium to low quality. There was no difference between the direct anterior, anterolateral or posterior approaches with regards to length of stay and gait analysis. Papers comparing the length of the incision found similar lengths compared with the lateral approach, and conflicting results when comparing the direct anterior and posterior approaches. Most studies found the mean operating time to be significantly longer when the direct anterior approach was used, with a steep learning curve reported by many. Many authors used validated scores including the Harris hip score, and the Western Ontario and McMaster Universities Arthritis Index. These mean scores were better following the use of the direct anterior approach for the first six weeks post-operatively. Subsequently there was no difference between these scores and those for the posterior approach.

CONCLUSION

There is little evidence for improved kinematics or better long-term outcomes following the use of the direct anterior approach for THA. There is a steep learning curve with similar rates of complications, length of stay and outcomes. Well-designed, multi-centre, prospective randomised controlled trials are required to provide evidence as to whether the direct anterior approach is better than the lateral or posterior approaches when undertaking THA. Cite this article: Bone JointJ 2017;99-B:732-40.

A Prospective Randomized Trial of Mini-Incision Posterior and 2-Incision Total Hip Arthroplasty: Minimum 5-Year Follow-Up

BACKGROUND

We previously described the results of a randomized controlled trial of mini-posterior vs 2-incision total hip arthroplasty and were unable to demonstrate significant differences in early outcomes. As less-invasive anterior approaches remain popular, the purpose of this report was to re-examine the outcomes at a minimum 5-year follow-up.

METHODS

Seventy-two patients undergoing primary total hip arthroplasty were randomized to a mini-posterior or 2-incision approach. Complications, revisions, and clinical outcome measures were compared. Radiographs were reviewed for implant loosening. A power analysis using a minimal clinically important difference value of 6 points for the Harris hip score revealed 28 patients required per group.

RESULTS

At a mean of 8.2 years (range, 5-10 years), 6 patients died without revision surgery and 63 of 66 living patients were reviewed. There were 6 total failures, 3 in each group. For unrevised patients, there were no significant differences between groups (posterior vs 2-incision) in the Harris hip score (95.5 ± 3.5 vs 95.7 ± 6.3; P = .88), 12-item Short Form Survey physical composite score (50.5 ± 8.5 vs 49.0 ± 9.1; P = .53), 12-item Short Form Survey mental composite score (57.3 ± 4.1 vs 55.4 ± 8.0; P = .25), or single assessment numeric evaluation score (97.1 ± 3.7 vs 97.8 ± 5.2; P = .55).

CONCLUSION

We found no differences in midterm outcomes between the 2 approaches. Given the increased complexity, operative time, and need for fluoroscopy with the 2-incision approach combined with equivalent early and midterm outcomes, the 2-incision approach has been abandoned in the senior author's practice.

Effect of femoral head size and surgical approach on risk of revision for dislocation after total hip arthroplasty

Background and purpose - Recurrent dislocation is the commonest cause of early revision of a total hip arthropasty (THA). We examined the effect of femoral head size and surgical approach on revision rate for dislocation, and for other reasons, after total hip arthroplasty (THA). Patients and methods - We analyzed data on 166,231 primary THAs and 3,754 subsequent revision THAs performed between 2007 and 2015, registered in the Dutch Arthroplasty Register (LROI). Revision rate for dislocation, and for all other causes, were calculated by competing-risk analysis at 6-year follow-up. Multivariable Cox proportional hazard regression ratios (HRs) were used for comparisons. Results - Posterolateral approach was associated with higher dislocation revision risk (HR =1) than straight lateral, anterolateral, and anterior approaches (HR =0.5-0.6). However, the risk of revision for all other reasons (especially stem loosening) was higher with anterior and anterolateral approaches (HR =1.2) and lowest with posterolateral approach (HR =1). For all approaches, 32-mm heads reduced the risk of revision for dislocation compared to 22- to 28-mm heads (HR =1 and 1.6, respectively), while the risk of revision for other causes remained unchanged. 36-mm heads increasingly reduced the risk of revision for dislocation but only with the posterolateral approach (HR =0.6), while the risk of revision for other reasons was unchanged. With the anterior approach, 36-mm heads increased the risk of revision for other reasons (HR =1.5). Interpretation - Compared to the posterolateral approach, direct anterior and anterolateral approaches reduce the risk of revision for dislocation, but at the cost of more stem revisions and other revisions. For all approaches, there is benefit in using 32-mm heads instead of 22- to 28-mm heads. For the posterolateral approach, 36-mm heads can safely further reduce the risk of revision for dislocation.

The Influence of Muscle Weakness on the Association Between Obesity and Inpatient Recovery From Total Hip Arthroplasty

BACKGROUND

There is ongoing discussion about whether preoperative obesity is negatively associated with inpatient outcomes of total hip arthroplasty (THA). The aim was to investigate the interaction between obesity and muscle strength and the association with postoperative inpatient recovery after THA.

METHODS

Preoperative obesity (body mass index [BMI] >30 kg/m²) and muscle weakness (hand grip strength <20 kg for woman and <30 kg for men) were measured about 6 weeks before THA. Patients with a BMI <18.5 kg/m² were excluded. Outcomes were delayed inpatient recovery of activities (>2 days to reach independence of walking) and prolonged length of hospital stay (LOS, >4 days and/or discharge to extended rehabilitation). Univariate and multivariable regression analyses with the independent variables muscle weakness and obesity, and the interaction between obesity and muscle weakness, were performed and corrected for possible confounders.

RESULTS

Two hundred and ninety-seven patients were included, 54 (18%) of whom were obese and 21 (7%) who also had muscle weakness. Obesity was not significantly associated with prolonged LOS (odds ratio [OR] 1.36, 95% confidence interval [CI] 0.75-2.47) or prolonged recovery of activities (OR 1.77, 95% CI 0.98-3.22), but the combination of obesity and weakness was significantly associated with prolonged LOS (OR 3.59, 95% CI 1.09-11.89) and prolonged recovery of activities (OR 6.21, 95% CI 1.64-23.65).

CONCLUSION

Obesity is associated with inpatient recovery after THA only in patients with muscle weakness. The results of this study suggest that we should measure muscle strength in addition to BMI (or body composition) to identify patients at risk of prolonged LOS.

Selection of a surgical approach for total hip arthroplasty according to the depth to the surgical site

BACKGROUND

The surgical depths of approaches for total hip arthroplasty (THA) have not been reported previously. In this study, we investigate the relationships between the distances to the centre of the femoral head in different approaches and body mass index (BMI).

METHODS

The study included patients with normal hip joints who presented to our hospital. We used the pelvic coordinate system relative to the anterior pelvic plane and the femur coordinate system relative to the posterior condylar plane. We assessed the anterior, anterolateral, lateral and posterior approaches, and defined each approach line. We evaluated each distance in terms of BMI and gender.

RESULTS

164 hips were assessed. The distance to the centre of the femoral head was the longest in the posterior approach, followed by the lateral, anterolateral, and anterior approaches (p<0.05). Additionally, the distance in each approach increased as patients' BMI increased. The approximated line tilts were almost the same. The correlation coefficients between BMI and the distance to the centre of the femoral head were high in all approaches. In the anterior and anterolateral approaches, men with low BMI had a short distance to the femoral head. The distance for each approach was measured according to the pelvic coordinate system and the femur coordinate system. The results showed no significant differences between them.

CONCLUSIONS

The distance to the centre of the femoral head is the shortest in the anterior approach, regardless of BMI and gender. The distance in each approach might increase with an increase in BMI. BMI has similar effects in all approaches.

Advances in hip arthroplasty surgery: what is justified?

Total hip arthroplasty (THA) surgery has shown dramatic changes in terms of increased number of procedures and of technical development in recent years. It has been described as “the operation of the 20^th century” for the excellent results, the high satisfaction of the patients and the improvement of the quality of life.

A lot of variations have been introduced over the last few decades in THA especially in terms of indications (both in younger and older patients), techniques and devices (approaches, tissue preservation, biomaterials and industrial finishing), per-operative management (blood loss and pain control) and post-operative protocols (the so called “fast track” surgery). Looking at all these advances the emerging question is: have all of them been justified both in terms of improvement of the results for the patients and of the cost/benefit ratio from an economical point of view?

The purpose of this paper is to critically analyse the advantages and the disadvantages of the theoretically proposed “advances in hip arthroplasty” and attempt to understand which are justified of such “advances” nowadays, based on the international and the European perspective with a focus on the author’s personal clinical experience.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.170008. Originally published online at www.efortopenreviews.org

[Comparison of early effectiveness between different approaches in primary total hip arthroplasty]

Objective

To compare the early effectiveness between by anterior approach via Bikini incision and by OCM approach in the primary total hip arthroplasty (THA).

Methods

Between June 2015 and March 2016, 60 patients with ischemic necrosis of the femoral head who accorded with the inclusion criteria were chosen in the study, who were divided into 2 groups according to different surgical approaches. THA was performed on 30 patients by anterior approach via Bikini incision (group A), and on 30 patients by OCM approach (group B). There was no significant difference in age, gender, body mass index, side of affected hip, Steinberg stage of ischemic necrosis of femoral head, preoperative hemoglobin, preoperative Harris score, and preoperative visual analogue scale (VAS) between 2 groups ( P>0.05). The operation time, length of incision, intraoperative blood loss, transfusion rate, starting time of straight leg raising exercise, starting time of active abduction of hip, hospitalization time, the incidence of limb length discrepancy, postoperative Harris score and VAS score were recorded and compared between 2 groups. Anteroposterior pelvic X-ray films were taken to measure acetabular abduction and acetabular anteversion.

Results

Primary healing of incision was obtained in all patients of 2 groups, and there was no significant difference in complication between 2 groups ( χ2=0.144， P=0.704). All the patients of 2 groups were followed up 3 to 12 months, averaged 6 months. There was no significant difference in operation time, length of incision, intraoperative blood loss, transfusion rate, hospitalization time, and starting time of straight leg raising exercise between 2 groups ( P>0.05). Group A was significantly shorter than group B in starting time of active abduction of hip ( t=-4.591, P=0.000), and was significantly lower than group B in the incidence of limb length discrepancy ( χ2=5.455, P=0.020). After operation, neither Harris score at 2 weeks, 6 weeks, 3 months, and 6 months nor VSA score at 24 hours and 6 weeks showed significant difference between 2 groups ( P>0.05). The anteroposterior pelvic X-ray films showed that all the prostheses were in good position, and there was no femoral prosthesis subsidence, acetabular cup displacement or dislocation. No significant difference was found in acetabular abduction and acetabular anteversion at 2 days after operation between 2 groups ( t=0.887, P=0.379; t=0.652, P=0.517).

Conclusion

Both of two approaches in THA can avoid muscle damage and achieve favorable short-term effectiveness. But, anterior approach via Bikini incision is superior to OCM approach in starting time of active abduction of hip and the incidence of limb length discrepancy.

The Impact of Surgical Technique on Patient Reported Outcome Measures and Early Complications After Total Hip Arthroplasty

BACKGROUND

This study examines patient and surgeon reported outcome measures, complications during index admission, length of stay (LOS), and discharge disposition in a series of total hip replacements (THR) performed via the direct anterior (DA) or posterolateral (PL) approach.

METHODS

Five surgeons performed 2698 total hip replacements (1457 DA vs 1241 PL) between January 2010 and June 2015. Complications during index admission were recorded using billing and claims data. Harris Hip Scores (HHS) and Hip disability and Osteoarthritis Outcome Scores (HOOS) were collected in a subset of patients.

RESULTS

Patients in the DA group had shorter LOS (2.3 DA vs 2.7 PL days, P < .001) and a larger proportion of patient discharges to home (79.0% DA vs 68.7% PL, P < .001). Surgical (0.75% DA vs 0.73% PL, P = .961) and medical (8.4% DA vs 8.1% PL, P = .766) complications during index admission were equivalent between groups. HHS (n = 462) favored the DA group at an early follow-up (P < .001), but did not differ at 1 year (P = .478). Logistic regression revealed that patients in the DA group were more likely to report no pain, no limp, walk unlimited distances, and climb stairs without the use of the railing at 3- to 6-month follow-up (P < .001). HOOSs were equivalent at all follow-ups regardless of approach.

CONCLUSION

Patients in the DA group had shorter LOS and were more likely to be discharged home. The DA group had better HHS at 3- to 6-month follow-up than patients in the PL group, with no difference in medical or surgical complications during index admission.