Does the surgical approach in one stage bilateral total hip arthroplasty affect blood loss?

Direct anterior approach with conventional instruments versus robotic posterolateral approach in elective total hip replacement for primary osteoarthritis: a case-control study

BACKGROUND

The purpose of this study is to compare peri-operative and short-term outcomes in patients who underwent elective total hip replacement (THA) for primary osteoarthritis (OA) with direct anterior approach (DAA) versus a pair-matched cohort of patients who underwent robotic-assisted THA with posterolateral approach.

MATERIALS AND METHODS

Data from consecutive patients who underwent elective hip replacement from 2021 to 2023 for primary OA were retrospectively retrieved and divided into two groups: the DAA group, who underwent THA with the DAA approach using conventional instruments, and the robotic posterolateral (R-PL group), who underwent robot arm-assisted THA with the posterolateral approach. Comparative assessed outcomes were: operative time, radiographical implant positioning, intake of rescue analgesics, blood loss, transfusion rate, leg length discrepancy and functional outcomes (Harris hip score and forgotten joint score).

RESULTS

A total of 100 pair-matched patients were retrieved with a mean age of 66.7 ± 10.7 (range: 32-85) years and a mean follow-up of 12.8 ± 3.6 (range: 7-24) months. No differences in patients' characteristics were detected. Patients in the R-PL group required less rescue tramadol (p > 0.001), ketorolac (p = 0.028) and acetaminophen (p < 0.001). There was no significant difference in the operative time between (MD = 5.0 min; p = 0.071). Patients in the DAA group had significantly lower Hb levels at day 1 (p = 0.002) without significant differences in transfusion rate (p = 0.283). Patients in the R-PL group had shorter length of stay (LOS) with a mean difference of 1.8 days [p < 0.001; 95% confidence interval (CI) 1.4-2.3]. No difference in clinical outcomes was found [leg length discrepancy (LLD), p = 0.572; HHS, p = 0.558; forgotten joint score (FJS), p = 0.629]. No radiographical differences were measured in cup inclination (MD = 2.0°, p = 0.069), malpositioning [odd ratio (OR) = 0.2; p = 0.141], stem alignment (OR = 0.3; p = 0.485) and stem sizing (OR = 1.5; p = 1.000). There was no difference in complication rate except for lateral femoral cutaneous nerve damage, which was higher in DAA group (p < 0.001).

CONCLUSIONS

R-PL and DAA THA had comparable short-term clinical and radiological outcomes along with similar complication rates. The R-PL group showed significantly lower Hb drop, rescue analgesic consumption and shorter LOS. This is a preliminary study and no strong recommendation can be provided. Further prospective randomized trials are requested to further investigate the cost-effectiveness of robotic surgery in THA.

LEVEL OF EVIDENCE

Level IV, case-control study.

The Efficacy of Bone Wax in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

Objectives

This meta-analysis was conducted to study the hemostatic efficacy of bone wax in total joint arthroplasty (TJA) defined in this manuscript as total knee arthroplasty and total hip arthroplasty.

Methods

PubMed, Embase, Google Scholar (page 1-20), and Scopus were searched updated to November 2023. Only comparative studies were included. The clinical outcomes evaluated were the transfusion rate, total blood loss, and the loss of hemoglobin on day 1, 3, and 5 post-operatively.

Results

Only 3 studies met the inclusion criteria and were included in this meta-analysis. Bone wax was associated with a reduced transfusion rate (p=0.01), reduced total blood loss (p=0.001), and a decrease in hemoglobin loss on day 1 (p<0.00001), day 3 (p<0.0001), and day 5 (p<0.00001) after the surgery.

Conclusion

Bone wax reduced the rate of transfusion, total blood loss, and hemoglobin loss after the surgery. This may induce a reduction the cost of correcting post-operative anemia as well as decrease hospital stay and improving functional outcomes in patients undergoing TJA. Better-conducted randomized controlled studies and cost-effectivity studies could strengthen these findings.

Which patient benefit most from minimally invasive direct anterior approach total hip arthroplasty in terms of perioperative blood loss? A retrospective comparative study from a cohort of patients with primary degenerative hips

INTRODUCTION

Total hip arthroplasty (THA) is a successful surgery, but despite the advancements in anesthesiology and orthopedics, sometimes blood transfusions are required to manage the anemia due to the blood loss, involving a substantial number of patients. The aim of this retrospective comparative study is to define how the choice of the surgical approach, either direct anterior (DA) or posterolateral (PL), may influence the postoperative blood loss and the need for transfusion in THA.

MATERIALS AND METHODS

Data collection was carried out retrospectively of THAs performed between 2016 and 2021 on primary hip osteoarthritis treated by DA or with PL approach. Clinical and perioperative anesthetic data were collected. Preoperative hemoglobin levels were compared with the lowest detected level by calculating ΔHb (hemoglobin decrease). Then, data from the two groups were cross-checked: duration of surgery, whether premedication with tranexamic acid, duration of the hospitalization, rate of need for hemotransfusions, and amount of blood transfused. The two samples were subdivided into subgroups according to age, BMI, tranexamic acid prophylaxis, and chronic treatment with drugs that alter coagulative properties.

RESULTS

Time of surgery was longer for patients treated with DA access (mean DA: 78.8 min; mean PL: 74.8 min; p: 0.05; 95% CI), but the length of hospitalization was shorter for patients treated with DA group with a mean time of 6.23 days versus 7.12 days for the PL group (p < 0.01). DA THA resulted advantageous mainly in patients between 66 and 75 years, showing a reduced postoperative transfusion requirement in the postoperative period (DA: 13.43%-mean: 1.33 units; PL: 26.82%-mean: 1.18 units; p: 0.044, 95% CI). Patients that assume blood-altering drugs showed a higher transfusion rate (p < 0.01), but comparison of the two subgroups showed that the choice of the surgical approach did not significantly affect the transfusion rate in these patients (p: 0.512). Prophylaxis with tranexamic acid reduced the transfusion rate (p < 0.01).

CONCLUSION

Patients treated by minimally invasive direct anterior approach undergo a significantly shorter hospitalization. From the analysis of patient's subgroups those aged between 66- and 75-years benefit from the DA approach mainly for the minor blood loss with less frequent transfusion requirement.

Pain and rehabilitation after total hip arthroplasty are approach dependent: results 6 weeks and 2 years after surgery in a multisurgeon, single-center, and prospective cohort study

PURPOSE

The aim of this study was the evaluation of pain, function, and overall satisfaction after total hip arthroplasty (THA) using three different standard surgical approaches (DAA (direct anterior approach), lateral, and posterior approach) 2 years postoperatively. Additionally, we compared the results with recently published results of the same study population 6 weeks postoperatively.

METHODS

In a multisurgeon, prospective, single-center cohort study, a total of initial 188 patients who underwent total hip arthroplasty (THA) between February 2019 and April 2019 were analyzed on pain, function, and satisfaction within the first days, 6 weeks, and 2 years postoperatively according to three different approaches (DAA, lateral, and posterior approach). Our research group recently published results directly and 6 weeks postoperatively. We evaluated the same study collectively 2 years postoperatively and compared the results with the data 6 weeks postoperatively. One hundred twenty-five patients could be included. Outcome parameters for the present study were the pain level according to the visual analogue scale (VAS), the modified Harris hip score (mHHS), and an overall satisfaction scale 2 years postoperatively.

RESULTS

Mean overall satisfaction 2 years postoperatively was 9.7 ± 1 (3-10). Satisfaction was significantly better for the DAA than for the lateral approach (p = 0.005). There were no significant differences between the lateral and posterior approaches (p = 0.06) and between the DAA and the posterior approaches (p = 0.11). In total, the mean pain level was 0.4 ± 0.9 (0-5) at 6 weeks and 0.5 ± 1.1 (0-7) at 2 years postoperatively (p = 0.3). Regarding the different approach groups, pain levels 6 weeks and 2 years postoperatively were significantly lower for the DAA than for the lateral approach (p = 0.02). There were no significant differences between DAA and posterior approach (p = 0.05) and the lateral and posterior approach (p = 0.26). The mean mHHS significantly increased from 84.7 + 14.5 (37.4-100) 6 weeks to 95 + 12.5 (23.1-100.1) 2 years postoperatively (p < 0.0001). Regarding the different approaches, mHHS was significantly higher for the DAA than for the lateral approach (p = 0.03). Differences between the DAA and the posterior approach (p = 0.11) and between the lateral and posterior approaches (p = 0.24) were insignificant.

CONCLUSION

At 2 years postoperative, DAA showed significantly better overall satisfaction, pain level, and mHHS than the lateral approach. The differences between DAA and the posterior approach and lateral and posterior approaches were insignificant. Whether the superior results of the DAA to the lateral approach persist over a longer period must be clarified by further studies.

STUDY DESIGN

Prospective cohort study, level of evidence 2.

Surgical load in major fractures - results of a survey on the optimal quantification and timing of surgery in polytraumatized patients

PURPOSE

It is known that the magnitude of surgery and timing of surgical procedures represents a crucial step of care in polytraumatized patients. In contrast, it is not clear which specific factors are most critical when evaluating the surgical load (physiologic burden to the patient incurred by surgical procedures). Additionally, there is a dearth of evidence for which body region and surgical procedures are associated with high surgical burden. The aim of this study was to identify key factors and quantify the surgical load for different types of fracture fixation in multiple anatomic regions.

METHODS

A standardized questionnaire was developed by experts from Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT)-Trauma committee. Questions included relevance and composition of the surgical load, operational staging criteria, and stratification of operation procedures in different anatomic regions. Quantitative values according to a five-point Likert scale were chosen by the correspondents to determine the surgical load value based on their expertise. The surgical load for different surgical procedures in different body regions could be chosen in a range between "1," defined as the surgical load equivalent to external (monolateral) fixator application, and "5," defined as the maximal surgical load possible in that specific anatomic region.

RESULTS

This questionnaire was completed online by 196 trauma surgeons from 61 countries in between Jun 26, 2022, and July 16, 2022 that are members of SICOT. The surgical load (SL) overall was considered very important by 77.0% of correspondents and important by 20.9% correspondents. Intraoperative blood loss (43.2%) and soft tissue damage (29.6%) were chosen as the most significant factors by participating surgeons. The decision for staged procedures was dictated by involved body region (56.1%), followed by bleeding risk (18.9%) and fracture complexity (9.2%). Percutaneous or intramedullary procedures as well as fractures in distal anatomic regions, such as hands, ankles, and feet, were consistently ranked lower in their surgical load.

CONCLUSION

This study demonstrates a consensus in the trauma community about the crucial relevance of the surgical load in polytrauma care. The surgical load is ranked higher with increased intraoperative bleeding and greater soft tissue damage/extent of surgical approach and depends relevantly on the anatomic region and kind of operative procedure. The experts especially consider anatomic regions and the risk of intraoperative bleeding as well as fracture complexity to guide staging protocols. Specialized guidance and teaching is required to assess both the patient's physiological status and the estimated surgical load reliably in the preoperative decision-making and operative staging.

Pain and rehabilitation after total hip arthroplasty are approach dependent: a multisurgeon, single-center, prospective cohort study

PURPOSE

The aim of this study was to assess perioperative pain and mobilization after total hip arthroplasty (THA) using three different surgical approaches.

METHODS

This was a multisurgeon, prospective, single-center cohort study. A total of 188 patients who underwent hip arthroplasty (THA) between February 2019 and April 2019 were analyzed according to the surgical approach used (direct anterior, lateral, and posterior approach). Outcome parameters were the daily walking distance during the inpatient stay, the pain level according to the visual analog scale (VAS) at rest and motion during the inpatient stay and at 6-week follow-up and the modified Harris Hips Score (mHHS) preoperatively and at 6 weeks.

RESULTS

The walking distance within the groups increased significantly during the inpatient stay (p < 0.001). The DAA and posterior approach patients had a significantly longer walking distance than the lateral approach patients on the third postoperative day (DAA vs. lateral, p = 0.02; posterior vs. lateral 3, p = 0.03). DAA and posterior approach patients reported significantly less pain during motion on the third postoperative day and at 6-week follow-up than the lateral approach patients (3 postoperative day: DAA vs. lateral, p = 0.011; posterior vs. lateral, p = 0.04; 6 weeks control: DAA vs. lateral, p = 0.001; Posterior vs. lateral 3, p = 0.005). The mHHS demonstrated significant improvement within each group. However, lateral approach patients reported significantly less improvement than the DAA and posterior approach patients (DAA vs. lateral, p = 0.007; posterior vs. lateral, p = 0.021).

CONCLUSION

This study analyzed perioperative pain progression and short-term rehabilitation after THA according to the different surgical approaches. Direct anterior and posterior approaches have shown comparable improvements in pain, walking distance, and mHHS. Whether this effect persists over a longer period of time must be clarified in future studies.

STUDY DESIGN

Prospective cohort study, level of evidence, 2.

The Efficacy of Bone Wax in Reduction of Perioperative Blood Loss in Total Hip Arthroplasty via Direct Anterior Approach: A Prospective Randomized Clinical Trial

BACKGROUND

Perioperative blood management in total hip arthroplasty (THA) has become a prime focus of research. Given the morbidity, delayed recovery, and prolonged hospital stay associated with postoperative anemia, various measures have been proposed to reduce perioperative blood loss (PBL). In this trial, we studied the efficacy of bone wax application on the distal cut surface of the femoral neck in reducing PBL during THA through the direct anterior approach.

METHODS

In a randomized controlled clinical trial, 152 patients underwent THA through the direct anterior approach with use of bone wax (n = 75) or without bone wax (control) (n = 77). The study was triple-blinded. The primary outcomes were apparent PBL (blood in sponges and suction canister) and total PBL on postoperative days (PODs) 3 and 5 (as calculated with the Good and Nadler methods). Transfusion and complications were the secondary outcomes.

RESULTS

No significant difference was found between the 2 groups in terms of age, sex, body mass index, American Society of Anesthesiologists score, etiology, preoperative hematologic/coagulation profile, anesthesia, intraoperative mean arterial pressure, or operative time. Apparent PBL, total PBL on POD3, and total PBL, in milliliters, on POD5 were significantly lower in the wax group, with median values of 200 (interquartile range [IQR]: 115 to 310) versus 370 (IQR: 195 to 513.7), 505.2 (IQR: 409.2 to 637.6) versus 747 (IQR: 494.6 to 955.4), and 536.7 (IQR: 430.9 to 689.3) versus 767.8 (IQR: 537.8 to 1,021.9) in the wax and control groups, respectively (p < 0.001). No significant differences in the rates of transfusion and complications were found.

CONCLUSIONS

Bone wax on the cut surface of femoral neck can significantly reduce PBL during THA through the direct anterior approach. Bone wax is accessible and inexpensive and can be considered a routine part of the surgical technique in THA through the direct anterior approach. This intervention has no impact on complication or transfusion rates.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Comparative study of bilateral total hip arthroplasty in one or two stages

INTRODUCTION

Bilateral total hip arthroplasty (Bi THA) for disabling bilateral hip osteoarthritis can be performed in one or two operative sessions. The objective of this study was to compare the complication rates of a group of patients who had bilateral THA in one operating session (Bi-1S THA) to a matched group of patients who had bilateral THA in two separate operating sessions (Bi-2S THA).

MATERIALS AND METHODS

This retrospective case-control study compared 84 Bi-1S THA matched to 84 Bi-2S THA by age, gender, diagnosis, ASA score (1-2) and surgical approach. The minimum follow-up was 12 months. Complication rates, total blood loss, number of blood transfusion units, and functional outcomes were assessed.

RESULTS

Twelve patients (14.3%) in the Bi-1S THA group had minor or major complications, compared to twenty-one (25%) in the Bi-2S THA group (p=0.08): there were fewer minor complications in the Bi-1S THA group and a similar rate of major complications amongst the two groups. Total blood loss estimated using the OSTHEO formula was significantly lower in patients operated on by Bi-1S THA (1853±753mL versus 2804±1012mL, p <0.0001). The number of blood transfusion units was similar between the groups (0.5±0.8 versus 0.3±1.4 respectively, p=0.55). No significant difference was found regarding the functional results.

CONCLUSION

Under the conditions of this study, bilateral total hip arthroplasty in one operative session leads to fewer minor complications, and a similar rate of major complications, when compared to bilateral total hip arthroplasty in two separate sessions. This strategy can therefore be recommended for ASA 1 and 2 patients, under the age of 80 with disabling bilateral osteoarthritis.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Direct Anterior versus Lateral Approach for Femoral Neck Fracture: Role in COVID-19 Disease

Background: During the COVID-19 emergency, the incidence of fragility fractures in elderly patients remained unchanged. The management of these patients requires a multidisciplinary approach. The study aimed to assess the best surgical approach to treat COVID-19 patients with femoral neck fracture undergoing hemiarthroplasty (HA), comparing direct lateral (DL) versus direct anterior approach (DAA). Methods: A single-center, observational retrospective study including 50 patients affected by COVID-19 infection (30 males, 20 females) who underwent HA between April 2020 to April 2021 was performed. The patients were allocated into two groups according to the surgical approach used: lateral approach and anterior approach. For each patient, the data were recorded: age, sex, BMI, comorbidity, oxygen saturation (SpO2), fraction of the inspired oxygen (FiO2), type of ventilation invasive or non-invasive, HHb, P/F ratio (PaO2/FiO2), hemoglobin level the day of surgery and 1 day post operative, surgical time, Nottingham Hip Fractures Score (NHFS) and American Society of Anesthesiologists Score (ASA). The patients were observed from one hour before surgery until 48 h post-surgery of follow-up. The patients were stratified into five groups according to Alhazzani scores. A non-COVID-19 group of patients, as the control, was finally introduced. Results: A lateral position led to a better level of oxygenation (p < 0.01), compared to the supine anterior approach. We observed a better post-operative P/F ratio and a reduced need for invasive ventilation in patients lying in the lateral position. A statistically significant reduction in the surgical time emerged in patients treated with DAA (p < 0.01). Patients within the DAA group had a significantly lower blood loss compared to direct lateral approach. Conclusions: DL approach with lateral decubitus seems to preserved respiratory function in HA surgery. Thus, the lateral position may be associated with beneficial effects on gas exchange.

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

BACKGROUND

Blood conservation and reduction in the need for allogeneic blood transfusion (ABT) has been a subject of importance in total hip arthroplasty. There are a number of well-recognized parameters that influence blood loss during total hip arthroplasty (THA). The role of surgical approach on blood loss and the rate of ABT during THA is not well studied. The hypothesis of this study was that blood loss and the need for ABT is lower with direct anterior (DA) approach.

METHODS

In a case-control retrospective cohort study, we analyzed 1,524 primary THAs performed at a single institution by seven fellowship-trained surgeons between January 2015 to March 2017. All patients received THA using either the modified direct lateral (DL) or direct anterior (DA) approach using a standard operating table. The overall ABT rate was 10.2% (155/1,524) in the cohort. Demographic, surgical, and postoperative data were extracted and analyzed. Logistic regression was used to identify independent risk factors for transfusion.

RESULTS

Higher preoperative hemoglobin (p<0.001), use of DA approach (p<0.016) and administration of tranexamic acid TXA, (p=0.024) were identified as independent factors which reduced the odds of ABT. Operative time (p<0.001) was associated with an increased odd of ABT, while age, BMI and type of anesthesia were not statistically significant.

CONCLUSION

Based on the findings of this study, direct anterior approach for THA appears to be protective against blood loss and reduced ABT rate, when controlling for confounding variables.

Tranexamic acid use in high-risk blood transfusion patients undergoing total hip replacement: a randomised controlled trial

INTRODUCTION

We hypothesised that a single preoperative intravenous dose of tranexamic acid (TXA) is effective in patients who undergo total hip arthroplasty (THA) and are at high risk of blood transfusion (preoperative haemoglobin level <13.0 g/dL).

METHODS

A prospective, randomised controlled study of 308 patients who underwent primary THA was conducted. 256 participants remained in the study and were divided into 2 major groups: high-risk group comprising 116 patients with preoperative Hb < 13.0 g/dL (57 of whom were treated with a 15 mg/kg intravenous bolus of TXA, and 59 of whom did not receive the medication) and low-risk group comprising 140 patients with Hb ⩾ 13.0 g/dL (71 of whom received the same dose of TXA, and 69 of whom did not). Participants were followed up at 3 weeks, 3 months, 6 months, and 1 year after surgery.

RESULTS

The use of TXA in both groups of patients significantly increased the levels of postoperative Hb and Ht. TXA protected high-risk patients from blood loss and from transfusion. In low-risk patients the use of TXA reduced blood loss but did not protect from blood transfusion. The median length of stay was significantly affected for high-risk patients. No thromboembolic event was recorded in either group.

CONCLUSIONS

TXA reduces intra- and postoperative bleeding, transfusion rates, and the length of hospital stays in patients with low preoperative Hb. The use of TXA in patients with normal preoperative Hb reduces blood loss but does not affect the transfusion rate.ClinicalTrials.gov Identifier: NCT03019198.

Direct anterior approach versus direct lateral approach in total hip arthroplasty and bipolar hemiarthroplasty for femoral neck fractures: a retrospective comparative study

BACKGROUND

In the current literature, there is no consensus on the best surgical approach in hip replacement for femoral neck fractures (FNFs).

AIM

The aim of this study is to compare the direct anterior approach (DAA) and the direct lateral approach (DLA) in patients treated with bipolar hemiarthroplasty (BHA) and total hip arthroplasty (THA) for FNFs.

MATERIALS AND METHODS

Patients with displaced FNFs (Garden type III and IV) treated operatively using BHA and THA were enrolled. The surgical approach techniques DAA and DLA are compared. The analysed variables are: mean surgery time, number of blood units transfused perioperatively, percentage of patients transfused, perioperative complications, pain and functional outcomes at 1 and 6 months and mortality at 1, 3 and 12 months.

RESULTS

Between 2015 and 2017, 37 patients underwent BHA by the DAA and 38 patients underwent BHA by the DLA, 69 patients underwent THA by the DAA and 60 patients underwent THA by the DLA. For THA, the DAA compared to the DLA had a higher mean surgery time (100.8 min vs. 97.7 min), a lower mean number of blood units transfused perioperatively (1.4 U vs. 1.9 U), a significantly lower percentage of patients transfused (53.6% vs. 71.7%), a higher rate of perioperative complications (10.1% vs. 1.6%), a lower pain referred and better functional outcomes in the first 6 postoperative months and a significantly lower mortality rate at 12 months (2.9% vs. 16.7%). For BHA, the advantages of the DAA over DLA are not as significant.

CONCLUSIONS

The direct anterior approach in THA for FNFs provides significant benefits in the early post-operative period compared to the direct lateral approach in terms of functional recovery, residual pain, blood loss and mortality rate in the elderly active population.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Comparison of short-term outcomes between direct anterior approach (DAA) and SuperPATH in total hip replacement: a systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Two minimally invasive approaches showed some advantages in outcomes compared to conventional approaches (CAs)-the direct anterior approach (DAA) and the supercapsular percutaneously assisted approach in THA (SuperPATH). To the best of our knowledge, DAA and SuperPATH have never been compared, neither in clinical studies, nor in a meta-analysis. To conduct a systematic review and network meta-analysis of randomized controlled trials comparing short-term outcomes of DAA and SuperPATH in total hip joint arthroplasty (THA).

METHODS

A systematic literature search up to May 2020 was performed to identify randomized controlled trials (RCTs) comparing SuperPATH with CAs and DAA with CAs in THA. We measured surgical, functional, and radiological outcomes. A network meta-analysis, using frequentist methods, was performed to assess treatment effects between DAA and SuperPATH. Information was borrowed from the above-mentioned RCTs, using the CA group as a common comparator.

RESULTS

A total of 16 RCTs involving 1392 patients met the inclusion criteria, three trials with a level I evidence, 13 trials with a level II evidence. The overall network meta-analysis showed that SuperPATH reduced operation time (fixed effect model: MD = 12.8, 95% CI 9.9 to 15.7), incision length (fixed effect model: MD = 4.3, 95% CI 4.0 to 4.5; random effect model: MD = 4.3, 95% CI 0.2 to 8.4), intraoperative blood loss (fixed effect model: MD = 58.6, 95% CI 40.4 to 76.8), and early pain intensity (VAS 1 day postoperatively with a fixed effect model: MD = 0.8, 95% CI 0.4 to 1.2). The two approaches did not differ in acetabular cup positioning angles and in functional outcome.

CONCLUSIONS

Our overall findings suggested that the short-term outcomes of THA through SuperPATH were superior to DAA. SuperPATH showed better results in decreasing operation time, incision length, intraoperative blood loss, and early pain intensity. DAA and SuperPATH were equal in functional outcome and acetabular cup positioning.

Single-Stage Bilateral Total Hip Arthroplasty in an Ambulatory Surgical Center: A Report of Three Cases

In recent years, there has been increased interest in transitioning total joint arthroplasty procedures from inpatient settings to ambulatory surgical centers to decrease costs and eliminate the need for hospital stays. In addition, simultaneous bilateral total hip arthroplasty (THA) has been found to be favorable in certain patient populations when compared with staged bilateral THA. In this study, we report the results of a series of three patients who underwent single-stage bilateral THA in a free-standing ambulatory surgical center with excellent short-term outcomes and no 90-day complications.

Perioperative strategies to reduce transfusion rates in one-stage bilateral total hip arthroplasty via direct anterior approach

Despite several blood management strategies available, blood transfusion rates following total hip arthroplasty remain high. Therefore, this study evaluated transfusion rates following bilateral hip arthroplasty via direct anterior approach using a multimodal blood loss management approach for 213 consecutive patients. All patients received standard surgical and post-operative procedures, with allogenic transfusion performed if hemoglobin was less than 8.0 g/dL with persistent clinical symptoms. Thirty-two patients (15%) required transfusion, with those patients significantly older and had lower pre-operative hemoglobin compared to non-transfusion patients. This transfusion rate was much lower than previous literature and could be an appropriate, multimodal blood loss management strategy.

Direct anterior approach for femoral component revision: Surgical technique for extended trochanteric osteotomy and anterior cortical window

Objective

Direct anterior approach (DAA) is becoming a popular option for both primary and revision total hip arthroplasty (THA). Adequate exposure is crucial in the setting of revision THA. The purpose of this article is to describe two different techniques for expanded femoral exposure through the DAA, the anterior extended trochanteric osteotomy and anterior cortical window.

Methods

Extensile exposure were carried out in cadavers, using the contralateral hip as a control. The exposure and technical viability were assessed.

Results

It was demonstrated that both extensile techniques can be carried out safely.

Conclusions

Extensile exposures including femoral osteotomies can be safely carried out for revision THA via DAA.

The direct anterior approach for simultaneous bilateral total hip arthroplasty: a short-term efficacy analysis

Purpose

Compared to the posterior approach (PA), the direct anterior approach (DAA) can achieve better clinical outcomes for total hip arthroplasty (THA). The purpose of this study was to investigate whether the same advantages associated with the DAA could be attained in patients undergoing simultaneous bilateral THA.

Method

We retrospectively reviewed 89 patients who underwent one-stage bilateral THA through the DAA (group A, n = 46) and through the PA (group B, n = 43) between June 2015 and November 2017 at our institution. The patients were followed up for a minimum of 1 year. There were no significant differences in gender, age, body mass index (BMI), preoperative hemoglobin level, preoperative Harris hip score (HHS), and preoperative visual analogue scale (VAS) score between the two groups (P > 0.05 for all).

Results

The incision length, operation time, intraoperative blood loss, blood transfusion volume, and the length of stay (LOS) were significantly less in group A than in group B (p < 0.05). The surgery-related complications were not significantly lower in group A (5.43%) than in group B (10.47%) (χ² = 2.209, p = 0.112). In 46 cases in group A, one hip had an acetabular anteversion higher than normal value. In both groups, one hip developed aseptic loosening. The HHS was significantly higher in group A than in group B 1, 3, 12 month(s) after operation (p < 0.05). The VAS was significantly lower in group A than in group B 1, 3, 12 month(s) after operation. Against the simple Likert scale, comprehensive satisfaction was significantly higher in group A (97.8%, 45/46) than in group B (76.7%, 33/43) (χ² = 9.119, p = 0.003).

Conclusion

In patients who underwent simultaneous bilateral THA, DAA could significantly relieve pain, accelerate the functional recovery of hip joint and improve the satisfaction more than PA. In clinical practice, however, more attention should be paid to strict compliance to operative indications and the prevention of early complications. The long-term effectiveness warrants further observation.

Safety of Single-Stage Bilateral Direct Anterior Approach Total Hip Arthroplasty Performed in All Eligible Patients at a Honolulu Hospital

Total hip arthroplasty (THA) is a commonly performed surgery, with candidates often requiring bilateral replacement. Simultaneous, single-stage bilateral THA offers several advantages and the direct anterior approach (DAA) for THA is well-suited for this procedure. In Hawai'i, single-stage bilateral DAA THA has yet to be adopted as a primary practice, and currently, there is limited research on patient outcomes following single-stage bilateral DAA THA in heterogeneous patient populations. In this study, we present our experience regarding intraoperative and 90-day complication rates encountered in a consecutive, all-inclusive cohort of single-stage bilateral DAA THA performed at the Straub Medical Center in Honolulu, Hawai'i, from January 2016 to May 2018. A total of 99 patients were included with a mean age of 64.7 ± 10.1 (mean ± standard deviation) years. The sample consisted of 43 (43.4%) males. Mean BMI was 27.0 ± 5.3 kg/m². The racial composition consisted of 50 (50.5%) Asian, 37 (37.4%) Caucasian, 8 (8.1%) Hawaiian/Pacific Islander, 1 (1.0%) African-American, 3 (3.0%) undisclosed. Mean operating time was 180 ± 23 minutes. Mean intraoperative blood loss was 386 ± 75 mL, and 11 (11.1%) patients received a postoperative allogenic blood transfusion. There were no major intraoperative complications. The only major local complication observed was one patient who developed high-grade heterotopic ossification requiring surgery. No major systemic complications occurred. The overall complication rate was 0.5%. In conclusion, we demonstrate that single-stage bilateral DAA THA is a safe option for the treatment of bilateral hip pathology in a wide spectrum of patients.

Direct Anterior Approach for One-Stage Bilateral Total Hip Arthroplasty in an ASA 3 Wheelchair-Dependent Woman

This case report involves a 79-year-old wheelchair-dependent woman with bilateral destructive coxarthrosis, requiring total hip arthroplasty (THA). Mobilization and transfers were unbearable due to the bilateral involvement of her hips. Performing unilateral THA would not be sufficient due to the coexisting pain from the contralateral side. Therefore, the decision was made to perform bilateral THA in one stage using the direct anterior approach (DAA). One-stage bilateral THA (1-SBTHA) using the DAA in ASA 3 patients is not previously described in the literature. The procedure was completed as planned, without any major perioperative complications. Eight weeks postoperatively, the patient was able to mobilize unaccompanied using a walker. She regained her mobility and independence. This outcome suggests that 1-SBTHA using DAA can be considered for disabling coxarthrosis in carefully selected ASA 3 patients. DAA is the superior approach for 1-SBTHA, due to decreased muscle damage leading to early mobilization with improved gait. Another benefit of DAA is that both hips can be draped simultaneously without repositioning the patient during the procedure.

Early morbidity and mortality after one-stage bilateral THA: Anterior versus posterior approach

BACKGROUND

Advantages of performing bilateral total hip arthroplasty (THA) in one stage include a single hospital stay, a single exposure to anaesthesia risks, and expedited rehabilitation. Controversy persists however, regarding safety, notably morbidity and mortality rates. Importantly, few studies have compared the anterior to the posterior approach for single-stage bilateral THA (1B-THA). The objective of this retrospective study in a uniform patient population was to compare the anterior and posterior approaches for 1B-THA in terms of: 1) early mortality rates, 2) early complications, 3) and 90-day re-admission rates, hospital stay lengths, and blood loss.

HYPOTHESIS

1B-THA in patients younger than 80 years who have an ASA score of 1 or 2 is associated with no early mortality and with low early morbidity rates regardless of whether the anterior or posterior approach is used.

MATERIAL AND METHODS

A single-centre retrospective comparative design was used to assess 90-day mortality and morbidity rates in consecutive patients who underwent 1B-THA between 2004 and 2018. The groups managed with the anterior approach (AA) without traction table and posterior approach (PA) were compared. The ASA score was ≤2 and age ≤80 years in all patients. The groups were comparable for age, sex distribution, ASA score, pre-operative haemoglobin level, and reason for THA.

RESULTS

We included 55 patients managed via the AA and 82 managed via the PA. No patients died in either group. Early complications occurred in 3 patients in the AA group and 6 in the AP group (p=0.74). No differences were noted between the two groups for each type of complication. In the AA group, 3 patients experienced major complications (p=0.06) (2 cerebrovascular events and 1 peri-prosthetic fracture). In the PA group, 6 patients experienced minor complications (1 case each of dislocation, piriformis syndrome, sacral pressure sore, and deep vein thrombosis and 2 cases of ilio-psoas irritation; p=0.08). Operative time was 144minutes (range, 110-195minutes) in the AA group and 171minutes (range, 108-255minutes) in the PA group (p<0.001). Mean hospital stay length was 7.6 days (range, 3-13 days) overall, 6.7 days (range, 5-11 days) in the AA group, and 8.2 days (range, 3-13 days) in the PA group (p<0.001). The early re-admission rate was 2.9% overall, with no difference between the AA group (3.6% [2/55]) and the PA group (2.4% [2/82]) A post-operative blood transfusion was required by 34/137 (24.8%) patients overall, 15/55(27.3%) patients in the AA group and 19/82 (23.2%) patients in the PA group (p=0.58).

DISCUSSION

In selected patients (ASA score 1 or 2 and age ≤80 years), 1B-THA was not followed by any early deaths in the patients managed using the anterior or posterior approach. Total early morbidity rates were low. Neither the types of complications nor the early re-admission rates differed between the AA and PA groups. The shorter operative time in the AA group is ascribable to change in patient installation between the two arthroplasties when the PA is used.

LEVEL OF EVIDENCE

III, comparative study of consecutive patients.

Is single-anaesthetic bilateral total hip replacement using cemented stems safe and appropriate? A review of four decades of practice

BACKGROUND

Symptomatic bilateral hip osteoarthritis can be treated surgically with either staged or single-anaesthetic bilateral total hip replacement (BTHR). Today the typical candidate for BTHR is more likely to receive cementless implants. We present the experience of BTHR at our institution using cemented stems combined with cemented and uncemented sockets and, to our knowledge, the largest prospective single-centre series.

PATIENTS AND METHODS

This cohort study reviews all patients (319 patients: 638 hips) having BTHR at our institution between December 1977 and December 2015. No case was lost to follow-up. Data were collected prospectively but reviewed retrospectively. Length of stay and complication rates were included, and data were compared with Hospital Episode Statistics figures for operations carried out between March 2005 and June 2014 to confirm local database validity. Patient experience and Oxford Hip Scores were obtained for a subgroup of this cohort, comparing them with patients who underwent bilateral staged operations performed within 1 year.

RESULTS

The rates for mortality, deep vein thrombosis, non-fatal myocardial infarction within 6 months were each 0.3% (1 episode) and non-fatal pulmonary embolism 0.6% (2 episodes). There were no intraoperative periprosthetic fractures or readmissions within 30 days.

CONCLUSIONS

Our study shows a low risk of complications when using cemented and hybrid BTHRs for selected patients and the risk of complications compares favourably with published results. Available functional scores compared favourably to a comparison group of patients undergoing bilateral staged procedures, and a positive impression on treatment experience from a subgroup of interviewed BTHR patients was noticeable.

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.

Biomarkers of muscle damage increased in anterolateral compared to direct lateral approach to the hip in hemiarthroplasty: no correlation with clinical outcome : Short-term analysis of secondary outcomes from a randomized clinical trial in patients with a displaced femoral neck fracture

In this study, we found elevated levels of serum CK in the anterolateral approach to the hip compared to the direct lateral approach in patients with a displaced femoral neck fracture. No correlation was found between levels of CK and functional outcomes.

INTRODUCTION

To compare increase in serum creatine kinase (CK) and its association with functional outcome between the muscle-sparing anterolateral approach and the direct lateral approach to the hip in patients with displaced femoral neck fracture (FNF).

METHODS

In this randomized trial, we enrolled eligible patients between 70 and 90 years of age with FNF. Patients were allocated to an uncemented hemiarthroplasty inserted through a direct lateral or an anterolateral approach. The primary endpoints were pain and patient satisfaction assessed by the Visual Analogue Scale (VAS). Among secondary endpoints was increase in CK at 24 and 48 h compared to baseline and its association with surgical parameters, Timed up and Go Test (TUG), Harris Hip Score (HHS), and the presence of a Trendelenburg sign using correlation analysis. This paper reports on increase in serum CK and its association with functional outcome.

RESULTS

At 24 h, there was a mean increase from baseline in total CK of 228 U/L (95% CI 187 to 269; P < 0.001). There was a difference between groups at 24 h in CK increase with higher levels in the anterolateral group (mean difference 80 U/L; 95% CI - 0.5 to 162; P = 0.05). Likewise, at 48 h, there was a mean difference of 117 U/L (95% CI 22 to 212; P = 0.01). No correlation was found between CK values and functional assessments.

CONCLUSIONS

Compared with the direct lateral approach, the anterolateral approach yielded higher levels of postoperative CK. However, there was no correlation between levels of CK and functional outcome.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02028468.

Bilateral Hip Arthroplasty: When Is It Safe to Operate the Second Hip? A Systematic Review

Introduction

Patients with degenerative hip disease frequently present with bilateral involvement that requires surgical management. The main goal when treating these patients is to achieve the maximum efficiency without increasing risk of perioperative complications; therefore, the decision regarding the best moment to operate the second hip becomes relevant. Although studies have addressed this topic, whether a simultaneous or staged surgery should be performed remains controversial. The purpose of this study was to determine, based on available evidence, the optimum strategy in terms of safety to operate the second hip in patients with bilateral involvement.

Materials and Methods

A meta-analysis was planned. A systematic review of the literature was performed including clinical trials or observational analytical studies comparing the safety of bilateral arthroplasty performed simultaneously or staged by measuring major and minor complications. The appropriateness of a meta-analysis was evaluated through the detailed analysis of the risk of bias and clinical heterogeneity of the included studies.

Results

Thirteen studies were selected after the systematic review. A wide variability in the methodological designs was found with a critical risk of bias in most of them. Considerable heterogeneity was detected in defining staged surgery in the cointerventions and how the outcomes were defined and measured. In response to these findings, a meta-analysis was considered not appropriate. The results showed no differences in the risk of mortality or systemic complications in young and healthy patients between simultaneous or staged surgeries. However, increased risk of complications for staged surgeries performed during the same hospitalization was observed.

Conclusions

Available evidence is very heterogeneous and the quality of evidence is low. The available evidence supports the performance of simultaneous hip arthroplasty in selected patients (not older than 65 years, ASA 1-2, without cardiovascular comorbidities) and suggests the avoidance of staged surgeries within the same hospitalization.

Perioperative Morbidity of Same-Day and Staged Bilateral Total Hip Arthroplasty

BACKGROUND

Management strategies for bilateral hip degenerative disease include same-day or staged bilateral total hip arthroplasty (THA), but information on outcomes remains sparse. We sought to describe in-hospital complications and blood transfusion rates after same-day and staged bilateral THAs at different time intervals and to assess risk factors for these events.

METHODS

We retrospectively reviewed administrative data for 3785 patients treated with same-day bilateral (n = 1946; group A) and staged bilateral THA within (1) 0-3 months apart (n = 328; group B); (2) 3-6 months apart (n = 703; group C); and (3) 6-12 months apart (n = 808; group D), between 1999 and 2014. We recorded demographics, the Charlson-Deyo comorbidity index and in-hospital local and systemic (minor and major) complications. Complication and blood transfusion rates among groups were compared. A logistic regression model was developed to identify risk factors for major complications.

RESULTS

Local complications were rare. Minor complications were less frequent in group A (P < .001). Major complications were more frequent in group D (P = .012). Group A had higher overall (P < .001) and allogeneic blood transfusion rates (P < .001) compared with the staged groups. Staged procedures within 6-12 months apart vs same-day bilateral THA, older age, Charlson-Deyo index ≥2 vs 0, and earlier vs recent admission year were associated with higher adjusted odds for major complications.

CONCLUSION

Same-day bilateral THA in a high-volume joint replacement center may be a safe option for younger and healthier patients, given the relatively low incidence of adverse events reported in this study.

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.

Patient Perceptions of the Direct Anterior Hip Arthroplasty

BACKGROUND

The quest for less invasive surgical approaches for total hip arthroplasty (THA) has garnered much attention recently in the community, as well as media outlets. There are very little data demonstrating the actual differences in these approaches. We are unaware of any information documenting patients' perceptions of the direct anterior approach (DAA) for THA. The purpose of this study was to collect information regarding patients' perceptions of the DAA THA.

METHODS

We surveyed 166 consecutive new patients being evaluated for hip osteoarthritis in our outpatient clinic. Demographic data and their knowledge of the DAA were collected, as well as a number of questions on a 5-item Likert scale.

RESULTS

Forty-six (28%) responded that they were aware of the DAA. Respondents primarily learned about the DAA from friends and family (58%), and healthcare professionals (38%). Respondents agreed or strongly agreed that the DAA is less painful (70%), reduces the amount of time spent on a cane after surgery (70%), damages tissues less (68%), allows patients to more quickly return to work (64%), and allows for shorter hospital stays (62%), compared to other procedures. In addition, 30% felt there is a consensus among surgeons that the DAA is the safest and most effective procedure for THA.

CONCLUSION

Many people are unaware of the DAA, with a majority of healthcare information being transmitted by friends and family members. The patients' perceptions are inconsistent with published data about the DAA and are likely influenced by marketing and individuals surrounding them.

One-stage bilateral implantation of a calcar-guided short-stem in total hip arthroplasty : Minimally invasive modified anterolateral approach in supine position

Objective

One-stage bilateral, muscle-preserving, calcar-guided implantation technique through the modified minimally invasive anterolateral approach in supine position.

Indications

Bilateral primary/secondary osteoarthritis of the hip; bilateral femoral head necrosis; ASA I–III.

Contraindications

ASA IV; severe osteoporosis, other factors jeopardizing stable anchorage of cementless, calcar-guided short-stem; infection.

Surgical technique

Supine position. Skin incision. Opening of fascia; blunt dissection, pushing gluteal muscles dorsally with the index finger. Capsulectomy. Individual osteotomy according to preoperative plan to determine short-stem position. Remove femoral head. Prepare acetabulum. Position cup. Femoral preparation with the curved opening awl. Spare greater trochanter and gluteal muscles. Insert trial rasps in ascending sizes with “round-the-corner” technique. Select offset version, then trial reposition with intraoperative radiograph and implantation of the definitive implant. Wound closure. Consultation with the anesthesiologist to confirm a stable patient. Same procedure on contralateral hip.

Postoperative management

Mobilization on day 1 with immediate full weight bearing. Remove wound drains and urinary catheter (only female patients) on day 2. Intensive protocol of physiotherapy and rehabilitation. Thrombosis prophylaxis. Rehabilitation from day 7.

Results

Almost 500 patients have undergone surgery since 2010. First consecutive 54 patients (108 hips) prospectively evaluated. After 2 years, Harris Hip Score was 98.8; satisfaction on visual analogue scale was 9.9. Low peri- and postoperative complication rates; no implant revisions.

Conclusion

The muscle-sparing approach and the special “round-the-corner” technique in one-stage bilateral procedure leads to rapid mobilization and rehabilitation with excellent early clinical results and high satisfaction rates.

The less invasive anterior approach for total hip arthroplasty: a comparison to other approaches and an evaluation of the learning curve - a systematic review

There is still discussion about possible advantages and disadvantages of the less invasive anterior approach for total hip arthroplasty (THA). The purpose of our systematic review was to evaluate literature regarding the anterior approach in comparison to other approaches. Furthermore, we investigated if there is a description of a learning curve for the anterior approach.Data were obtained from EMBASE, Cochrane, PsycINFO, CINAHL, Web-of-Science, Scopus, Google scholar, and PubMed since their inception up to June 2015. 2 reviewers independently selected the studies and independently conducted the quality assessment. Because studies were considered heterogeneous regarding outcome measures, determinants studied, and methodological quality, we decided to perform a "best evidence synthesis". A total of 64 studies met the inclusion criteria.Strong evidence for no difference in component placement between the anterior approach and other approaches was found. Also, strong evidence for faster postoperative recovery and less need for assistive devices after the anterior approach were found. All other studied parameters only demonstrated conflicting evidence. Although the learning curve for the anterior approach is not yet clear, this learning curve should not to be neglected.In conclusion, the less invasive anterior approach provides benefits in the early postoperative period only, when compared to other approaches.

Comparison of patient satisfaction after unilateral or simultaneous bilateral total hip arthroplasty through a direct anterior approach: Evaluation using the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire

BACKGROUND

The aim of this study was to compare patients' perception of treatment outcome after unilateral or simultaneous total hip arthroplasty (THA) using the newly developed Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ).

METHODS

This study included 429 patients treated with primary THA using a direct anterior approach, namely 304 cases of in the unilateral THA (58 males and 246 females; mean age, 62.3 years) and 125 cases of in the simultaneous bilateral THA (24 males and 101 females; mean age, 58.3 years). Items for evaluation included clinical outcomes and all four aspects of the JHEQ score, namely visual analog scale (VAS), pain, movement, and mental status.

RESULTS

The mean operative time per hip was 51.3 ± 19.4 min (range, 22-180 min) in unilateral group and 46.2 ± 15.1 min (range, 26-106 min) in simultaneous bilateral group. The mean operative blood loss per hip was 421.2 ml ± 232.1 ml (range, 70-1300 ml) in unilateral group and 200.8 ± 149.8 ml (range, 30-1040 ml) in simultaneous bilateral group. The total JHEQ score (pain/motion/mental status) improved from 26.5 ± 13.6 (preoperative, 10.1/6.8/9.6) to 69.4 ± 14.8 (1 year postoperatively, 25.1/20.5/23.8) in unilateral group and from 21.0 ± 8.2 (preoperative, 11.9/2.3/6.9) to 74.9 ± 9.5 (1 year postoperatively, 27.2/22.6/25.0) in simultaneous bilateral group. These results demonstrated a significant improvement before and after surgery for patients in both groups. There were not major complications such as dislocation, bone fracture, nerve palsy or symptomatic pulmonary embolism were observed.

CONCLUSION

In this study, we observed greater improvement in JHEQ in patients treated with bilateral simultaneous THA than in those treated with unilateral THA. These findings demonstrated that bilateral simultaneous THA was related to high patient satisfaction as well as high safety.

Total hip arthroplasty via the anterior approach: tips and tricks for primary and revision surgery

PURPOSE

Described for the first time in the 1950s, the direct anterior approach to the hip has been gaining in popularity over the last decade following the trend of minimally invasive surgery. This paper provides an overview of the approach and its indications and various uses and focuses on its utility in the revision setting. A detailed overview of the technique including tips and tricks as well as an explanation of common errors are included.

METHOD

Graphic and clinical study of the approach, indications and feasibility.

RESULTS

The reported benefits of the direct anterior technique include enhanced post-operative recovery and respect for all the innervation and vascularization territories. It has been shown to be safe and effective in revision settings, to decrease the occurrence of heterotopic ossification, to enhance the accuracy of acetabular cup positioning, and to improve post-operative rehabilitation while having comparable outcomes in terms of loosening or component failure. Additionally, thromboembolic events have been shown to be decreased compared to other approaches. The most common reported complications in the revision setting is intra-operative fracture. The decision of a surgeon to transition to this approach, however, comes with a learning curve and potentially detrimental complications if done improperly.

DISCUSSION

In addition to its appeal in the primary setting, the approach could possibly be a solution to decrease the morbidity associated with revision surgery through its use of a fresh tissue plane not previously traumatized with the primary approach.