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Di Martino A, Keating C, Butsick MJ, Platano D, Berti L, Hunter LN, Faldini C. Enhancing recovery: surgical techniques and rehabilitation strategies after direct anterior hip arthroplasty. J Orthop Traumatol 2024; 25:45. [PMID: 39349698 PMCID: PMC11442739 DOI: 10.1186/s10195-024-00786-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 08/15/2024] [Indexed: 10/04/2024] Open
Abstract
Total hip arthroplasty (THA) is a common surgical procedure for hip joint pathologies, with the direct anterior approach (DAA) gaining popularity due to potential benefits in postoperative recovery. This review aims to provide a comprehensive analysis of rehabilitation strategies following DAA THA, focusing on surgical techniques, postoperative care, and outcomes. The evolution of the DAA to THA is discussed, highlighting historical advancements and comparisons with other surgical approaches. Surgical techniques and considerations specific to the DAA are detailed, including outcomes and complications compared to alternative approaches. The role of the surgical technique in influencing postoperative rehabilitation is explored, emphasizing the importance of optimizing surgical procedures for enhanced recovery. Postoperative care and rehabilitation models following DAA THA are examined, with a focus on the impacts of different rehabilitation protocols on patient outcomes. The review underscores the significance of tailored rehabilitation programs in promoting optimal recovery and patient satisfaction. Current evidence from recent studies, meta-analyses, and clinical trials is critically analyzed to provide insights into the effectiveness of postoperative rehabilitation strategies. The review identifies gaps in the existing literature and proposes recommendations for future research to improve rehabilitation protocols and enhance outcomes. In conclusion, this review highlights the importance of postoperative rehabilitation in the context of DAA THA. By synthesizing historical perspectives, current evidence, and future directions, the review offers a comprehensive understanding of rehabilitation strategies following DAA THA. The findings underscore the need for personalized rehabilitation programs and ongoing research to optimize postoperative recovery and improve outcomes in the field of THA.
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Affiliation(s)
- Alberto Di Martino
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy.
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136, Bologna, Italy.
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States.
| | - Christopher Keating
- Department of Physical Therapy, Jefferson College of Rehabilitation Sciences, Thomas Jefferson University, Philadelphia, PA, United States
| | - Michael J Butsick
- Department of Physical Therapy, Jefferson College of Rehabilitation Sciences, Thomas Jefferson University, Philadelphia, PA, United States
| | - Daniela Platano
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136, Bologna, Italy
- Physical Medicine and Rehabilitation Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Lisa Berti
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136, Bologna, Italy
- Physical Medicine and Rehabilitation Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Louis N Hunter
- Department of Physical Therapy, Jefferson College of Rehabilitation Sciences, Thomas Jefferson University, Philadelphia, PA, United States
- Jefferson College of Health Professions, Thomas Jefferson University, Philadelphia, PA, United States
| | - Cesare Faldini
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136, Bologna, Italy
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
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Chen M, Kayani B, Masri BA. CORR® Synthesis: To What Degree Does the Direct Anterior Approach Improve Outcomes in THA? A Systematic Evaluation of Meta-analyses. Clin Orthop Relat Res 2024:00003086-990000000-01749. [PMID: 39330942 DOI: 10.1097/corr.0000000000003195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 06/28/2024] [Indexed: 09/28/2024]
Affiliation(s)
- Maio Chen
- AO Foundation Innovation Translation Center, Davos, Switzerland
| | - Babar Kayani
- University College Hospital, London, England, UK
- University of British Columbia, Vancouver, BC, Canada
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Wang K, Zhang T, Xia R, Wang J, Yu J, Wang W. Efficacy of direct anterior approach versus posterolateral approach in total hip arthroplasty: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05547-4. [PMID: 39287787 DOI: 10.1007/s00402-024-05547-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 09/03/2024] [Indexed: 09/19/2024]
Abstract
BACKGROUND To compare the efficacy of the direct anterior approach (DAA) versus the posterolateral approach (PLA) in total hip arthroplasty (THA) in terms of operation time, incision length, intraoperative blood loss, postoperative pain, and incision infection rate. METHODS We systematically searched databases including China National Knowledge Infrastructure (CNKI), Wanfang Data, VIP Chinese sci-tech journals, Chinese Biomedical Literature Database (CBM), PubMed, and Cochrane Library up to December 2023. We included randomized controlled trials (RCTs) that compared DAA with PLA in THA, with a minimum sample size of 80 and a follow-up of at least 6 months. Studies were screened by two independent researchers, following PRISMA guidelines. Data were extracted using a pre-established feature table, capturing study design, sample size, patient demographics, and outcomes of interest. Meta-analysis was performed using RevMan 5.4.1 software. Heterogeneity was assessed using the Q-value statistical test and I² test. The fixed-effects model was used when heterogeneity was low; otherwise, the random-effects model was applied. RESULTS A total of 19 RCTs met the inclusion criteria. The Meta-analysis revealed that DAA was associated with a longer operation time [MD = 5.89, 95%CI(2.26 to 9.51), P = 0.001] but resulted in a smaller incision length [MD = -2.99, 95%CI(-3.76 to -2.22), P < 0.00001], less intraoperative blood loss [MD=-108.36, 95%CI(-131.10 to -85.62), P < 0.00001], lower incidence of postoperative incision infection [OR = 0.39, 95%CI(0.19 to 0.83), P = 0.01], and reduced hip Visual Analog Scale (VAS) scores on the 1st and 3rd days postoperatively [MD=-0.85, 95%CI(-0.96 to -0.74), P < 0.00001; MD=-0.60, 95%CI(-1.13 to -0.07), P = 0.03]. No significant difference was observed in VAS scores on the 7th postoperative day. CONCLUSION The DAA for THA offers advantages over PLA, including reduced incision size, blood loss, and postoperative pain, albeit with a longer operation time. These findings should guide clinical decision-making, considering the benefits and potential increased complexity of the DAA.
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Affiliation(s)
- Kunhao Wang
- Department of Orthopedics I, Qunli Branch of the First Affiliated Hospital of Harbin Medical University, No. 2075, Qunli 7th Avenue, Daoli District, Harbin City, Heilongjiang Province, 150077, China
| | - Tao Zhang
- Department of Orthopedics I, Qunli Branch of the First Affiliated Hospital of Harbin Medical University, No. 2075, Qunli 7th Avenue, Daoli District, Harbin City, Heilongjiang Province, 150077, China
| | - Ruiyang Xia
- Department of Orthopedics I, Qunli Branch of the First Affiliated Hospital of Harbin Medical University, No. 2075, Qunli 7th Avenue, Daoli District, Harbin City, Heilongjiang Province, 150077, China
| | - Jiankai Wang
- Department of Orthopedics I, Qunli Branch of the First Affiliated Hospital of Harbin Medical University, No. 2075, Qunli 7th Avenue, Daoli District, Harbin City, Heilongjiang Province, 150077, China
| | - Jinliang Yu
- Department of Orthopedics I, Qunli Branch of the First Affiliated Hospital of Harbin Medical University, No. 2075, Qunli 7th Avenue, Daoli District, Harbin City, Heilongjiang Province, 150077, China
| | - Wenbo Wang
- Department of Orthopedics I, Qunli Branch of the First Affiliated Hospital of Harbin Medical University, No. 2075, Qunli 7th Avenue, Daoli District, Harbin City, Heilongjiang Province, 150077, China.
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Huebschmann NA, Lawrence KW, Robin JX, Rozell JC, Hepinstall MS, Schwarzkopf R, Aggarwal VK. Does Surgical Approach Affect Dislocation Rate After Total Hip Arthroplasty in Patients Who Have Prior Lumbar Spinal Fusion? A Retrospective Analysis of 16,223 Cases. J Arthroplasty 2024; 39:S306-S313. [PMID: 38604275 DOI: 10.1016/j.arth.2024.03.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Lumbar spinal fusion (LSF) is a risk factor for dislocation following total hip arthroplasty (THA). The effect of the surgical approach on this association has not been investigated. This study examined the association between the surgical approach and dislocation following THA in patients who had prior LSF. METHODS We retrospectively reviewed 16,223 primary elective THAs at our institution from June 2011 to September 2022. Patients who had LSF prior to THA were identified using International Classification of Diseases (ICD) codes. Patients were stratified by LSF history, surgical approach, and intraoperative robot or navigation use to compare dislocation rates. There were 8,962 (55.2%) posterior, 5,971 (36.8%) anterior, and 1,290 (8.0%) laterally based THAs. Prior LSF was identified in 323 patients (2.0%). Binary logistic regressions were used to assess the association of patient factors with dislocation risk. RESULTS There were 177 dislocations identified in total (1.1%). In nonadjusted analyses, the dislocation rate was significantly higher following the posterior approach among all patients (P = .003). Prior LSF was associated with a significantly higher dislocation rate in all patients (P < .001) and within the posterior (P < .001), but not the anterior approach (P = .514) subgroups. Multivariate regressions demonstrated anterior (OR [odds ratio] = 0.64, 95% CI [confidence interval] 0.45 to 0.91, P = .013), and laterally based (OR = 0.42, 95% CI 0.18 to 0.96, P = .039) approaches were associated with decreased dislocation risk, whereas prior LSF (OR = 4.28, 95% CI 2.38 to 7.69, P < .001) was associated with increased dislocation risk. Intraoperative technology utilization was not significantly associated with dislocation in the multivariate regressions (OR = 0.72, 95% CI 0.49 to 1.06, P = .095). CONCLUSIONS The current study confirmed that LSF is a significant risk factor for dislocation following THA; however, anterior and laterally based approaches may mitigate dislocation risk in this population. In multivariate analyses, including surgical approach, LSF, and several perioperative variables, intraoperative technology utilization was not found to be significantly associated with dislocation risk.
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Affiliation(s)
- Nathan A Huebschmann
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, 301 East 17th Street, 15th Fl Suite 1518, New York, New York 10003
| | - Kyle W Lawrence
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, 301 East 17th Street, 15th Fl Suite 1518, New York, New York 10003
| | - Joseph X Robin
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, 301 East 17th Street, 15th Fl Suite 1518, New York, New York 10003
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, 301 East 17th Street, 15th Fl Suite 1518, New York, New York 10003
| | - Matthew S Hepinstall
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, 301 East 17th Street, 15th Fl Suite 1518, New York, New York 10003
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, 301 East 17th Street, 15th Fl Suite 1518, New York, New York 10003
| | - Vinay K Aggarwal
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, 301 East 17th Street, 15th Fl Suite 1518, New York, New York 10003
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Morgan S, Jarvis S, Conti A, Staudinger K, Reynolds C, Greenseid S, Bar-Or D. No Differences in Major In-Hospital Outcome Metrics When Comparing the Direct Lateral Approach to the Posterior Approach for Hemiarthroplasties After Traumatic Displaced Femoral Neck Fractures. Geriatr Orthop Surg Rehabil 2024; 15:21514593241278390. [PMID: 39161684 PMCID: PMC11331455 DOI: 10.1177/21514593241278390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 07/23/2024] [Accepted: 08/04/2024] [Indexed: 08/21/2024] Open
Abstract
Introduction The surgical approach of hemiarthroplasty for displaced femoral neck fractures remains debated. The study objective was to compare in-hospital outcomes for geriatric displaced femoral neck fractures treated with hemiarthroplasty based on surgical approach (direct lateral vs. posterior approach). Materials and Methods This retrospective cohort study included geriatric patients (≥60 y/o) admitted 7/1/2016-3/31/2020 treated with hemiarthroplasty. Outcomes included: operative time (incision to closure), length of stay (HLOS), and blood loss volume (mL). The Harding direct lateral approach was compared to the posterior approach; P < .05. Results There were 164 patients (59% direct lateral, 41% posterior). Patients treated with the direct lateral approach had an advanced directive (P = .03), dementia, (P = .03), or were functionally dependent (P = .03) more often than patients treated with the posterior approach. Time to surgery was comparable between groups (P = .52). The direct lateral approach was associated with a shorter operative time (2.3 vs. 2.8 h, P = .03), a longer HLOS (5.0 vs. 4.0 days, P < .01), and a lower median volume of blood loss (50 vs. 100 mL, P = .01), than the posterior approach, respectively. In a stratified analysis, for those who were not functionally dependent, did not have dementia or an advanced directive, the direct lateral approach led to a longer HLOS (P = .03) and shorter operative time (P = .04) than the posterior approach. Whereas among those who were functionally dependent, had dementia or had an advanced directive, the direct lateral approach led to less blood loss (P = .02) than the posterior approach. Discussion While those treated with the direct lateral approach lost significantly less blood, they had a significantly longer HLOS than those treated with the posterior approach. Comorbidities significantly modified outcomes, which may suggest their presence could assist with treatment decisions. Conclusions This study found neither approach, the direct lateral nor posterior, to be superior. Surgical approach could remain physician preference.
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Affiliation(s)
- Steven Morgan
- Department of Orthopedic Trauma, Swedish Medical Center, Englewood, CO, USA
| | - Stephanie Jarvis
- Department of Statistical, Injury Outcomes Network (ION) Research, Englewood, CO, USA
| | - Alexander Conti
- Department of Orthopedic Trauma, Swedish Medical Center, Englewood, CO, USA
| | - Kelsey Staudinger
- Department of Orthopedic Trauma, Swedish Medical Center, Englewood, CO, USA
| | - Cassandra Reynolds
- Department of Orthopedic Trauma, Swedish Medical Center, Englewood, CO, USA
| | - Samantha Greenseid
- Department of Orthopedic Trauma, Swedish Medical Center, Englewood, CO, USA
| | - David Bar-Or
- Department of Orthopedic Trauma, Swedish Medical Center, Englewood, CO, USA
- Department of Statistical, Injury Outcomes Network (ION) Research, Englewood, CO, USA
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Douven DPM, van Kampen PM, Werner PH, Schrier JC. No difference in early functional outcome between the direct anterior approach and posterior approach in patients following total hip arthroplasty. Hip Int 2024:11207000241269285. [PMID: 39129272 DOI: 10.1177/11207000241269285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
BACKGROUND Objective and subjective outcomes in the direct anterior approach (DAA) and posterior approach (PA) in total hip arthroplasty (THA) were assessed in this study, using the Oxford Hip Score (OHS) as primary outcome. Pain, 3 objective performance-based tests, surgical time, blood loss and length of stay were assessed as secondary outcomes. METHODS Patients with primary end-stage osteoarthritis were prospectively enrolled by shared decision making for the DAA (32 patients) or PA (26 patients). Baseline data were collected preoperatively and outcomes postoperatively at 2-, 6-, 9- and 12-month follow-up. RESULTS There is no significant difference (p < 0.05) between the DAA and PA on primary outcome (OHS). There was a main effect of time which indicated an increase of OHS over time independent of group (p < 0.01). CONCLUSIONS In the current study, no significant differences in postoperative functional outcome were found between DAA and PA in all follow-up moments.
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Affiliation(s)
- Dirk P M Douven
- Department of Research and Innovation, Bergman Clinics, Naarden, the Netherlands
| | - Paulien M van Kampen
- Department of Research and Innovation, Bergman Clinics, Naarden, the Netherlands
| | - Paul H Werner
- Department of Orthopaedic Surgery, Bergman Clinics, Breda, the Netherlands
| | - Joost C Schrier
- Department of Orthopaedic Surgery, Bergman Clinics, Breda, the Netherlands
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Wang H, Liu JF, Wang F, Yuan T, Jiang H, Wei Z, Zhang Y, Meng J. A comparison of the clinical efficacy of total hip arthroplasty via direct anterior approach and posterior approach: A meta-analysis. Medicine (Baltimore) 2024; 103:e39237. [PMID: 39121305 PMCID: PMC11315513 DOI: 10.1097/md.0000000000039237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 07/18/2024] [Indexed: 08/11/2024] Open
Abstract
BACKGROUND The approach of total hip arthroplasty (THA) has long been controversial, and many studies have compared different approaches. However, there is still a lack of consistent conclusions and comprehensive, systematic comparisons and evaluations. METHODS This study retrieved 7 databases: PubMed, Web of Science, Embase, Cochrane Library, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, and Wanfang Database. The search time ranged from the establishment of each database to November 1, 2023. Data analysis was performed using Review Manager 5.4, and outcome was presented as the weighed mean difference for continuous data and risk/odds ratio for dichotomous data. We used the Mantel-Haneszel method and random effects model to obtain the overall effects of the differences in the impact of 2 surgical methods on clinical outcomes in all included studies. RESULTS A total of 33 articles were included in this study, including 14478 participants, 4911 participants in DAA group and 9567 participants in PA group. The visual analogue scale scores of the DAA group at 1 day and 2 days after THA were significantly lower than those of the PA group (mean difference [MD] = -0.56, 95% confidence interval [CI]: -0.83 to -0.30, P < .01) at 1 day and (MD = -0.67, 95% CI: -1.16 to -0.17, P = .01) at 2 days. The risk of intraoperative fracture (odds ratio = 2.18, 95% CI: 1.11-4.29, P = .05) and lateral femoral nerve injury (risk ratio = 7.84, 95% CI: 1.69-36.42, P < .01) in the DAA group was significantly higher than that of the PA group. The number of prostheses in the Lewinnek safe zone of the DAA group was significantly higher than that of the PA group (risk ratio = 1.13, 95% CI: 1.00-1.27, P = .05). The results showed no significant difference between the DAA group and the PA group in the time to stop using walking aids, dislocation rate, groin pain, incision complications, heterotopic ossification, intraoperative blood loss, and acetabular anterior (P > .05). CONCLUSION Compared with the PA group, patients in the DAA group showed more ideal anatomical and imaging results, shorter hospital stay, and showing advantages in postoperative pain, but with a higher incidence of intraoperative complications.
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Affiliation(s)
- Hao Wang
- Xiangya School of Medicine, Central South University, Changsha, China
| | - Jin-Feng Liu
- Department of Oncology, Rizhao Hospital of Traditional Chinese Medicine, Rizhao, China
| | | | - Tiange Yuan
- Xiangya School of Medicine, Central South University, Changsha, China
| | - Hengduo Jiang
- Xiangya School of Medicine, Central South University, Changsha, China
| | - Zhuoqi Wei
- Xiangya School of Medicine, Central South University, Changsha, China
| | - Yang Zhang
- Xinjiang Medical University, Urumqi, China
| | - Jiahao Meng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
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Hoskins W, Corfield S, Peng Y, Graves SE, Bingham R. A comparison of cemented femoral fixation via anterior versus posterior approach total hip arthroplasty: an analysis of 60,739 total hip arthroplasties. Hip Int 2024; 34:442-451. [PMID: 38529902 PMCID: PMC11264548 DOI: 10.1177/11207000241239914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 11/04/2023] [Indexed: 03/27/2024]
Abstract
BACKGROUND Anterior approach total hip arthroplasty (THA) decreases the rate of dislocation but increases femoral-sided complications in the way of periprosthetic fractures and component loosening. A cemented prosthesis may reduce femoral-sided complications and improve the risk:benefit profile of anterior approach THA. METHODS Data from the Australian National Joint Replacement Registry were analysed for patients undergoing primary THA via the anterior or posterior approach using a cemented polished femoral stem from January 2015 to December 2021. The primary outcome measure was the cumulative percent revision (CPR) for all causes and CPR for femoral component loosening and fracture. The CPR for the primary outcome measures were compared between the anterior and posterior approach and adjusted for age, sex, ASA score, BMI and femoral head size. RESULTS The study included 60,739 THAs with cemented stems (10,742 anterior, 49,997 posterior). The rate of revision of the anterior versus the posterior approach did not significantly differ (HR 0.87 (95% CI, 0.74-1.03), p = 0.100). Anterior approach THA had a significantly higher rate of revision for femoral component loosening (HR 5.06 [95% CI, 3.08-8.30], p < 0.001); and a decreased rate of revision for infection (HR 0.59 [95% CI, 0.43-0.81], p = 0.001) and dislocation/instability (HR 0-3 months 0.48 [95% CI, 0.27-0.83], p = 0.008; HR >3 months 0.30 [95% CI, 0.15-0.61], p < 0.001). There was no difference in the rate of revision surgery for fracture between the 2 approaches (HR 1.01 [95% CI, 0.71-1.43]), p = 0.975). CONCLUSIONS There is no significant difference in overall revision rates with cemented femoral fixation performed with an anterior or posterior approach. Cemented fixation performed with the anterior approach partly mitigates femoral complications with no difference in the revision rate for fracture but an increased rate of femoral component loosening.
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Affiliation(s)
- Wayne Hoskins
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
- Traumaplasty. Melbourne, East Melbourne, VIC, Australia
| | - Sophie Corfield
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
| | - Yi Peng
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
| | - Stephen E Graves
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
| | - Roger Bingham
- Traumaplasty. Melbourne, East Melbourne, VIC, Australia
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Ramadanov N, Voss M, Hable R, Prill R, Hakam HT, Salzmann M, Dimitrov D, Diquattro E, Ostojic M, Królikowska A, Becker R. Indirect comparisons of traction table versus standard table in total hip arthroplasty through direct anterior approach: a systematic review and frequentist network meta-analysis. J Orthop Surg Res 2024; 19:384. [PMID: 38951886 PMCID: PMC11218227 DOI: 10.1186/s13018-024-04852-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/13/2024] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND It remains unclear whether the use of an orthopaedic traction table (TT) in direct anterior approach (DAA) total hip arthroplasty (THA) results in better outcomes. The aim of this systematic review and network meta-analysis was to compare the THA outcomes through DAA on a standard operating table and the THA outcomes through DAA on a TT. METHODS PubMed, Epistemonikos, and Google Scholar were searched for relevant randomized controlled trials (RCTs) up to 01 January 2024. An indirect comparison in network meta-analysis was performed to assess treatment effects between DAA on a TT and DAA on a standard table, using fixed-effects and random-effects models estimated with frequentist approach and consistency assumption. Standardized mean differences (SMDs) with 95% confidence intervals (CIs) were estimated for continuous variables and odds ratios (ORs) with 95% CIs were estimated for binary variables. RESULTS The systematic review of the literature identified 43 RCTs with a total of 2,258 patients. DAA with TT had a 102.3 mL higher intraoperative blood loss and a 0.6 mmol/L lower Hb 3 days postoperatively compared with DAA without TT (SMD = 102.33, 95% CI 47.62 to 157.04; SMD = - 0.60, 95% CI - 1.19 to - 0.00). DAA with TT had a 0.15 lower periprosthetic fracture OR compared with DAA without TT (OR 0.15, 95% CI 0.03 to 0.86). There were no further significant differences in surgical, radiological, functional outcomes and in complication rates. CONCLUSION Based on our findings and taking into account the limitations, we recommend that particular attention be paid to the risk of periprosthetic fracture in DAA on a standard operating table and blood loss in DAA with TT. Since numerous other surgical, radiological, functional outcome parameters and other complication rates studied showed no significant difference between DAA on a standard operating table and DAA with TT, no recommendation for a change in surgical technique seems justified. LEVEL OF EVIDENCE Level I evidence, because this is a systematic review and meta-analysis of randomized controlled trials.
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Affiliation(s)
- Nikolai Ramadanov
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg/Havel, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany.
- Faculty of Health Science Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany.
| | - Maximilian Voss
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg/Havel, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
| | - Robert Hable
- Faculty of Applied Computer Science, Deggendorf Institute of Technology, Deggendorf, Germany
| | - Robert Prill
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg/Havel, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
- Faculty of Health Science Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
| | - Hassan Tarek Hakam
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg/Havel, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
- Faculty of Health Science Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
| | - Mikhail Salzmann
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg/Havel, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
| | - Dobromir Dimitrov
- Department of Surgical Diseases, Faculty of Medicine, Medical University of Pleven, Pleven, Bulgaria
| | - Emanuele Diquattro
- Orthopaedics,Traumatology and Prosthetic Surgery and Revisions of Hip and Knee Implants, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Marko Ostojic
- Department of Orthopaedics and Traumatology, University Hospital Mostar, Mostar, Bosnia and Herzegovina
| | - Aleksandra Królikowska
- Ergonomics and Biomedical Monitoring Laboratory, Wroclaw Medical University, Wrocław, Poland
| | - Roland Becker
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg/Havel, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
- Faculty of Health Science Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
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Sarhan O, Megalla M, Imam N, Ren AN, Redfern RE, Klein GR. Improved patient reported outcomes with the direct anterior approach versus the posterior approach for total hip arthroplasty in the early post-operative period. Arch Orthop Trauma Surg 2024; 144:2373-2380. [PMID: 38520548 DOI: 10.1007/s00402-024-05271-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 03/05/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Patients undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA) may experience faster recovery but may also have better baseline health than those who undergo THA with the posterior approach (PA). This study aimed to compare patient-reported outcome measures (PROMs) between the DAA and PA while controlling for baseline factors. METHODS This is a secondary data analysis from a prospective cohort study of patients utilizing a smartphone-based care management platform following THA. The primary outcomes were HOOS JR and EQ-5D-5L through 1 year and change from baseline. Longitudinal regression models were created to control for baseline characteristics and investigate the impact of surgical approach on PROMs. RESULTS Of 1364 THAs evaluated, 731 (53.6%) were female, and 840 (61.6%) used the PA. Patients in the PA group were of similar age but had higher body mass index and comorbidity scores. Pre-operative HOOS JR and EQ-5D-5L were comparable, but higher post-operatively in the DAA group through 6 months (p = 0.03 and p = 0.005). At 1 year post-operatively, HOOS JR and EQ-5D-5L did not vary between groups (p = 0.48 and p = 0.56), nor did changes from baseline (p = 0.47 and p = 0.11). After controlling baseline characteristics, DAA was significantly associated with higher average HOOS JR through 6 months (p = 0.03) and EQ-5D-5L through 3 months (p = 0.005), but not at 12 months (p = 0.89 and p = 0.56). CONCLUSION THA patients undergoing DAA demonstrate earlier improvements in HOOS JR and EQ-5D-5L. However, these differences may not be clinically significant and are not evident at 1-year post-operative. Patient selection and surgeon training may continue to affect outcomes by surgical approach.
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Affiliation(s)
- Omar Sarhan
- Rothman Orthopedic Institute, Hackensack, NJ, USA
| | | | - Nareena Imam
- Rothman Orthopedic Institute, Hackensack, NJ, USA
| | - Anna N Ren
- Zimmer Biomet, 345 E Main St, Warsaw, IN, 46580, USA
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11
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Parihar A, Deckard ER, Buller LT, Meneghini RM. Instability in Patients With Lumbar Spine Disease Undergoing Posterior Approach and Lateral Approach Primary Total Hip Arthroplasty. J Am Acad Orthop Surg 2024; 32:e396-e404. [PMID: 38175997 DOI: 10.5435/jaaos-d-23-00885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/18/2023] [Indexed: 01/06/2024] Open
Abstract
INTRODUCTION Dislocation rates in patients who have fixed spinopelvic motion have been reported up to 20%. Few studies have directly compared dislocation rates in patients who have spine pathology undergoing total hip arthroplasty (THA) through different surgical approaches. This study compared postoperative dislocation rates in patients who had lumbar spine disease and underwent primary THA using a posterior or direct lateral approach. METHODS Between 2011 and 2017, consecutive cohorts of primary THAs were retrospectively reviewed. One surgeon routinely used a posterior approach, while the other used a direct lateral approach. Chart and radiographic review were conducted to identify patients who had lumbar spine disease. Dislocations among cohorts with and without lumbar spine disease were compared by posterior and direct lateral approaches. RESULTS The overall dislocation rate was 1.3% (15/1,198). The top four predictors of dislocation were presence of lumbar spine disease (odds ratio [OR] 5.0; P = 0.014), posterior surgical approach (OR, 6.5; P = 0.074), cases performed for fracture (OR, 4.4; P = 0.035), and women (OR, 4.6; P = 0.050). Dislocation rates among direct lateral approach patients who had lumbar spine pathology were significantly lower than posterior approach patients who had lumbar spine pathology (0.0% versus 3.6%; P = 0.011). DISCUSSION Although dislocation rates were low in both groups, study results suggest that a direct lateral approach for primary THA may reduce postoperative dislocations for patients who have limited spinopelvic motion due to lumbar spine pathology. Furthermore, surgeons using the posterior approach might consider optimizing the femoral head to acetabular cup ratio in patients who have lumbar spine disease.
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Affiliation(s)
- Amrit Parihar
- From the Department of Orthopaedic Surgery, Indiana University School of Medicine (Parihar, Buller, and Meneghini), and the Indiana Joint Replacement Institute, Indianapolis, Indiana (Deckard, and Meneghini)
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12
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Richards JT, Slaven SE, Yow BG, Tracey RW, Mack AW, Cody JP. Rapid Return to Braking After Anterior and Posterior Approach Total Hip Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202404000-00008. [PMID: 38569087 PMCID: PMC10994538 DOI: 10.5435/jaaosglobal-d-23-00093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 02/07/2024] [Accepted: 02/19/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Little is known about the effect of surgical approach on return to braking after total hip arthroplasty (THA), and few studies have investigated braking after THA with modern surgical techniques and rehabilitation protocols. METHODS In a prospective comparative design, we enrolled 65 patients who received right-sided primary THA at our institution from April 2018 through March 2020, 34 with a direct anterior approach (DAA) and 31 with a posterior approach (PA). Braking tests measuring brake reaction time (BRT) and brake pedal depression (BPD) were administered to patients preoperatively and at 1, 2, and 4 weeks postoperatively using a realistic driving simulator. BRT and BPD were compared between groups and preoperatively versus postoperatively using mixed-effects models. RESULTS Preoperative BRT averaged 638 msec in the DAA group and 604 msec in the PA group (P = 0.31). At 1 week postoperatively, the DAA group had significantly prolonged BRT compared with preoperatively (694 msec, P = 0.02). No significant difference was observed in the PA group (633 msec, P = 0.31). Both groups had returned to baseline by 2 weeks, and both had significantly faster BRT at 4 weeks compared with preoperatively (583 msec for DAA, P = 0.01; 537 msec for PA, P < 0.001). BPD was similar between groups, and there were no significant differences between preoperative and postoperative BPD at any time point. CONCLUSIONS With modern surgical techniques, BRT after right-sided THA returns to baseline levels approximately 2 weeks after surgery. There seems to be a quicker return to preoperative BRT observed in patients with a PA.
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Affiliation(s)
- John T. Richards
- From the Department of Orthopaedic Surgery, Uniformed Services University-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Sean E. Slaven
- From the Department of Orthopaedic Surgery, Uniformed Services University-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Bobby G. Yow
- From the Department of Orthopaedic Surgery, Uniformed Services University-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Robert W. Tracey
- From the Department of Orthopaedic Surgery, Uniformed Services University-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Andrew W. Mack
- From the Department of Orthopaedic Surgery, Uniformed Services University-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - John P. Cody
- From the Department of Orthopaedic Surgery, Uniformed Services University-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD
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13
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Xianzuo Z, Xianyue S, Maimaitiabula A, Zian Z, Haining Z, Bo Y, Chen Z. Which way forward? Comparing radiological outcomes using three different surgical approaches in robotic assisted total hip arthroplasty. Expert Rev Med Devices 2024; 21:325-334. [PMID: 38551127 DOI: 10.1080/17434440.2024.2334932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 03/11/2024] [Indexed: 04/23/2024]
Abstract
OBJECTIVES To assess the accuracy and precision of acetabular component placement in robot-assisted surgery total hip arthroplasty (RAS-THA) using three different approaches. METHODS This study is a secondary analysis from a multicenter, randomized controlled trial comparing the Trex RS Hip 1.0 robot navigation system across different surgical approaches. It involved 145 patients treated at three Chinese medical centers from June 2021 to July 2022. Patients with end-stage joint disease were randomly assigned to either the RAS or control group. Acetabular component positioning was evaluated radiographically, and registration accuracy was measured using Root Mean Square Error (RMSE). RESULTS The overall RMSE was 0.72 mm (SD = 0.24 mm), indicating consistent accuracy regardless of surgical approach. Significant variations in anteversion were noted across groups (p = 0.001). Lateral RAS-THA showed enhanced precision. The RAS Direct Anterior Approach (DAA) group had the least deviation in the rotation center's horizontal distance (0.89 ± 1.14 mm, p = 0.0014) and minimal leg length discrepancy (2.41 ± 1.17 mm). The RAS DAA approach also produced more consistent results. CONCLUSION Robotic assistance in THA, especially via the DAA approach, enhances the accuracy and precision of acetabular component positioning. Consistent registration accuracy across various surgical approaches confirms the reliability of these methods for THA. CLINICAL TRIAL REGISTRATION www.clinicaltrials.gov identifier is ChiCTR2100044124.
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Affiliation(s)
- Zhang Xianzuo
- Department of Orthopedics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Shen Xianyue
- Department of Orthopedics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Abasi Maimaitiabula
- Department of Orthopedics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Zhang Zian
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Zhang Haining
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Yang Bo
- Department of Joint Surgery, Weifang People's Hospital, Weifang, Shandong, P.R. China
| | - Zhu Chen
- Department of Orthopedics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
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14
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Streck LE, Chiu YF, Haralambiev L, Boettner F. The Surgical Approach Impacts Component Selection in Total Hip Arthroplasty: A Matched Cohort Study of 7,460 Hips. J Arthroplasty 2024; 39:739-743. [PMID: 37633508 DOI: 10.1016/j.arth.2023.08.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/17/2023] [Accepted: 08/19/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND A higher risk of dislocation following total hip arthroplasty (THA) has been reported for the posterior approach (PA) compared to the anterior approach (AA). Dual mobility implants, larger head sizes, and elevated or face-changing liners can reduce the risk for dislocation. It remains unclear whether the component selection is influenced by the surgical approach. METHODS This is a retrospective study of 7,048 patients who underwent 7,460 primary THA with either AA or PA for primary hip osteoarthritis or osteonecrosis of the femoral head between 2019 and 2021. A propensity score model based on age, body mass index, height, and American Association of Anesthesiologists Score was applied. There were 2,502 AA-THA matched with 4,958 PA-THA (2,456 1:2, and 46 1:1). Groups were compared with multiple linear regression analyses/multivariate logistic regressions after controlling for American Association of Anesthesiologists Score and body mass index. In a second step, only hips operated by surgeons using both approaches were matched 1:1 (1,204 PA and AA, respectively). The same statistics were performed after controlling for "surgeon". RESULTS The PA was associated with a more frequent use of dual mobility implants, elevated liners, face-changing liners, as well as heads with 36 mm or larger diameters, and the implanted cups were significantly larger (P < .001, respectively). These findings were consistent for both matched cohorts. CONCLUSION The surgical approach impacts the component selection in THA. Patients undergoing PA-THA are more likely to receive implants with larger head size or stabilizing features compared to AA-THA.
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Affiliation(s)
- Laura E Streck
- Adult Reconstruction and Joint Replacement Department, Hospital for Special Surgery, New York, New York
| | - Yu-Fen Chiu
- Hospital for Special Surgery, Biostats Core, Research Administration, New York, New York
| | - Lyubomir Haralambiev
- Adult Reconstruction and Joint Replacement Department, Hospital for Special Surgery, New York, New York
| | - Friedrich Boettner
- Adult Reconstruction and Joint Replacement Department, Hospital for Special Surgery, New York, New York
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Washburn F, Mushaben J, Eichenseer C, Sanderson B, Tran B, Golden T. Perioperative periprosthetic femur fracture associated with direct anterior total hip arthroplasty using metaphyseal fit and fill stem. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:869-877. [PMID: 37750976 PMCID: PMC10858129 DOI: 10.1007/s00590-023-03682-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/13/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION This study aims to identify radiographic and clinical risk factors of perioperative periprosthetic femur fracture associated with the direct anterior approach (DAA) using a metaphyseal fit and fill stem. We hypothesize stem malalignment with this femoral implant places increased stress on the medial calcar region, which leads to an increased risk of periprosthetic fracture. METHODS We compared patients with periprosthetic femur fractures following DAA total hip arthroplasty (THA) utilizing the Echo Bi-Metric Microplasty Stem (Zimmer Biomet, Warsaw, IN) to a cohort of patients who did not sustain a periprosthetic fracture from five orthopedic surgeons over four years. Postoperative radiographs were evaluated for stem alignment, neck cut level, Dorr classification, and the presence of radiographic pannus. Univariate and logistic regression analyses were performed. Demographic and categorical variables were also analyzed. RESULTS Fourteen hips sustained femur fractures, including nine Vancouver B2 and five AG fractures. Valgus stem malalignment, proud stems, extended offset, and patients with enlarged radiographic pannus reached statistical significance for increased fracture risk. Low femoral neck cut showed a trend toward statistical significance. CONCLUSION Patients undergoing DAA THA using a metaphyseal fit and fill stem may be at increased risk of perioperative periprosthetic fracture when the femoral stem sits proudly in valgus malalignment with extended offset and when an enlarged pannus is seen radiographically. This study identifies a specific pattern in the Vancouver B2 fracture cohort with regard to injury mechanism, time of injury, and fracture pattern, which may be attributed to coronal malalignment of the implant.
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Affiliation(s)
- Frederic Washburn
- Department of Orthopedics, Community Memorial Hospital, 147 Brent St., Ventura, CA, 93003, USA.
| | - Jacob Mushaben
- Department of Orthopedics, Community Memorial Hospital, 147 Brent St., Ventura, CA, 93003, USA
| | - Clayton Eichenseer
- Department of Orthopedics, Community Memorial Hospital, 147 Brent St., Ventura, CA, 93003, USA
| | - Brent Sanderson
- Department of Orthopedics, Community Memorial Hospital, 147 Brent St., Ventura, CA, 93003, USA
| | - Britni Tran
- Graduate Medical Education, Community Memorial Hospital, 147 Brent St., Ventura, CA, 93003, USA
| | - Thomas Golden
- Department of Orthopedics, Community Memorial Hospital, 147 Brent St., Ventura, CA, 93003, USA
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Thompson Z, Khoshbin A, Ward S, Brillantes J, Melo L, Waddell JP, Atrey A. The impact of operative approach and intraoperative imaging on leg length discrepancy and acetabular component angle in total hip arthroplasty: a retrospective cohort study. INTERNATIONAL ORTHOPAEDICS 2024; 48:473-479. [PMID: 37715062 DOI: 10.1007/s00264-023-05962-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 08/27/2023] [Indexed: 09/17/2023]
Abstract
PURPOSE Operative approach in total hip arthroplasty (THA) has long been a topic of debate with each approach having unique benefits and disadvantages. One purported benefit of an anterior approach to THA is that it allows for intraoperative positioning using fluoroscopy rather than manual positioning. Proper positioning allows for improved outcomes including leg length discrepancy and acetabular component angle. This study aims to examine if operative approach and use of imaging in intraoperative positioning impact LLD and cup angle post-operatively. METHODS A total of 300 hips were enrolled in the study with 100 hips per approach (anterior with fluoroscopy, lateral, and posterior). Retrospective chart review was conducted to assess patient demographics and radiographic analysis used to determine LLD and acetabular cup angle. RESULTS Of the three groups, those receiving anterior approach THAs were on average older than those in the posterior group. Analysis comparing the LLD and acetabular angle across the three groups showed no statistically significant difference in LLD (p=0.091); this was also reflected when comparing hips that received fluoroscopy with those that did not (p=0.91). For acetabular angle, while no difference existed when comparing hips that received imaging versus those that did not, statistically significant differences were observed when comparing the three intraoperative approaches (p<0.0001). CONCLUSIONS Neither intraoperative approach nor the use of intraoperative imaging in THA has a statistically significant effect on LLD post-operatively. However, approach did impact the acetabular cup angle across all three distinct approaches.
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Affiliation(s)
- Zoe Thompson
- University of Toronto, 27 King's College Cir, Toronto, ON M5S, Canada.
| | - Amir Khoshbin
- University of Toronto, 27 King's College Cir, Toronto, ON M5S, Canada
- St. Michael's Hospital, University of Toronto, 30 Bond St., Toronto, ON, M5B 1W8, Canada
| | - Sarah Ward
- University of Toronto, 27 King's College Cir, Toronto, ON M5S, Canada
- St. Michael's Hospital, University of Toronto, 30 Bond St., Toronto, ON, M5B 1W8, Canada
| | - Jacqueline Brillantes
- University of Toronto, 27 King's College Cir, Toronto, ON M5S, Canada
- St. Michael's Hospital, University of Toronto, 30 Bond St., Toronto, ON, M5B 1W8, Canada
| | - Luana Melo
- St. Michael's Hospital, University of Toronto, 30 Bond St., Toronto, ON, M5B 1W8, Canada
| | - James P Waddell
- St. Michael's Hospital, University of Toronto, 30 Bond St., Toronto, ON, M5B 1W8, Canada
| | - Amit Atrey
- University of Toronto, 27 King's College Cir, Toronto, ON M5S, Canada
- St. Michael's Hospital, University of Toronto, 30 Bond St., Toronto, ON, M5B 1W8, Canada
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17
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Nitiwarangkul L, Hongku N, Pattanaprateep O, Rattanasiri S, Woratanarat P, Thakkinstian A. Which approach of total hip arthroplasty is the best efficacy and least complication? World J Orthop 2024; 15:73-93. [PMID: 38293261 PMCID: PMC10824060 DOI: 10.5312/wjo.v15.i1.73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/20/2023] [Accepted: 12/29/2023] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND Total hip arthroplasty is as an effective intervention to relieve pain and improve hip function. Approaches of the hip have been exhaustively explored about pros and cons. The efficacy and the complications of hip approaches remains inconclusive. This study conducted an umbrella review to systematically appraise previous meta-analysis (MAs) including conventional posterior approach (PA), and minimally invasive surgeries as the lateral approach (LA), direct anterior approach (DAA), 2-incisions method, mini-lateral approach and the newest technique direct superior approach (DSA) or supercapsular percutaneously-assisted total hip (SuperPath). AIM To compare the efficacy and complications of hip approaches that have been published in all MAs and randomized controlled trials (RCTs). METHODS MAs were identified from MEDLINE and Scopus from inception until 2023. RCTs were then updated from the latest MA to September 2023. This study included studies which compared hip approaches and reported at least one outcome such as Harris Hip Score (HHS), dislocation, intra-operative fracture, wound complication, nerve injury, operative time, operative blood loss, length of hospital stay, incision length and VAS pain. Data were independently selected, extracted and assessed by two reviewers. Network MA and cluster rank and surface under the cumulative ranking curve (SUCRA) were estimated for treatment efficacy and safety. RESULTS Finally, twenty-eight MAs (40 RCTs), and 13 RCTs were retrieved. In total 47 RCTs were included for reanalysis. The results of corrected covered area showed high degree (13.80%). Among 47 RCTs, most of the studies were low risk of bias in part of random process and outcome reporting, while other domains were medium to high risk of bias. DAA significantly provided higher HHS at three months than PA [pooled unstandardized mean difference (USMD): 3.49, 95% confidence interval (CI): 0.98, 6.00 with SUCRA: 85.9], followed by DSA/SuperPath (USMD: 1.57, 95%CI: -1.55, 4.69 with SUCRA: 57.6). All approaches had indifferent dislocation and intraoperative fracture rates. SUCRA comparing early functional outcome and composite complications (dislocation, intra-operative fracture, wound complication, and nerve injury) found DAA was the best approach followed by DSA/SuperPath. CONCLUSION DSA/SuperPath had better earlier functional outcome than PA, but still could not overcome the result of DAA. This technique might be the other preferred option with acceptable complications.
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Affiliation(s)
- Lertkong Nitiwarangkul
- Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
- Orthopaedics Surgery, Police General Hospital, Bangkok 10330, Thailand
| | - Natthapong Hongku
- Department of Orthopaedics, Faculty of Medicine Vajira Hospital, Navamindrahiraj University, Bangkok 10300, Thailand
| | - Oraluck Pattanaprateep
- Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Sasivimol Rattanasiri
- Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Patarawan Woratanarat
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Ammarin Thakkinstian
- Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
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Zou ZH, Liu XQ, Li WH, Zhou XT, Li XF. Development and validation of multiple linear regression models for predicting total hip arthroplasty acetabular prosthesis. J Orthop Surg Res 2024; 19:73. [PMID: 38233875 DOI: 10.1186/s13018-024-04526-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/01/2024] [Indexed: 01/19/2024] Open
Abstract
PURPOSE To establish a multivariate linear equation to predict the diameter (outer diameter) of the acetabular prosthesis used in total hip arthroplasty. METHODS A cohort of 258 individuals who underwent THA at our medical facility were included in this study. The independent variables encompassed the patients' height, weight, foot length, gender, age, and surgical access. The dependent variable in this study was the diameter of the acetabular prosthesis utilized during the surgical procedure. The entire cohort dataset was randomly partitioned into a training cohort and a validation cohort, with a ratio of 7:3, employing the SPSS 26.0 software. Pearson correlation analysis was conducted to examine the relationships between the patients' height, weight, foot length, gender, age, surgical access, and the diameter of the acetabular prosthesis in the training cohort. Additionally, a multiple linear regression equation was developed using the independent variables from the training cohort and the diameter of the acetabular prosthesis as the dependent variable. This equation aimed to predict the diameter of the acetabular prosthesis based on the patients' characteristics. The accuracy of the equation was evaluated by substituting the data of the validation cohort into the multiple linear equation. The predicted acetabular prosthesis diameters were then compared with the actual diameters used in the operation. RESULTS The correlation analysis conducted on the training cohort revealed that surgical access (r = 0.054) and age (r = -0.120) exhibited no significant correlation with the diameter of the acetabular prosthesis utilized during the intraoperative procedure. Conversely, height (r = 0.687), weight (r = 0.654), foot length (r = 0.687), and sex (r = 0.354) demonstrated a significant correlation with the diameter of the acetabular prosthesis used intraoperatively. Furthermore, a predictive equation, denoted as Y (acetabular prosthesis diameter in mm) = 20.592 + 0.548 × foot length (cm) + 0.083 × height (cm) + 0.077 × weight (kg), was derived. This equation accurately predicted the diameter within one size with an accuracy rate of 64.94% and within two sizes with an accuracy rate of 94.81%. CONCLUSION Anthropometric data can accurately predict the diameter of acetabular prosthesis during total hip arthroplasty.
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Affiliation(s)
- Ze-Hui Zou
- Department of Sports Medicine, Orthopedic Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Xu-Qiang Liu
- Department of Sports Medicine, Orthopedic Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Wei-Hua Li
- Department of Sports Medicine, Orthopedic Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Xin-Tao Zhou
- Department of Sports Medicine, Orthopedic Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Xiao-Feng Li
- Department of Sports Medicine, Orthopedic Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China.
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19
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Wu N, Ma J, Xiong X, Luo X, Ma X, Yang X, Wang W, Wang Y, Wang Z, Ma F. The influence of direct anterior approach and postero-lateral approach on wound complications after total hip arthroplasty: A meta-analysis. Int Wound J 2024; 21:e14395. [PMID: 37699722 PMCID: PMC10784622 DOI: 10.1111/iwj.14395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/26/2023] [Accepted: 08/31/2023] [Indexed: 09/14/2023] Open
Abstract
To date, we have reviewed the synthesis literature critically through four databases: PubMed, Embase, Cochrane Library and Web of Science. Eight relevant studies were examined after compliance with the criteria for inclusion and exclusion, as well as documentation quality evaluation. This report covered all randomised, controlled studies of total hip arthroplasty (THA) comparing the direct anterior approach (DAA) with the postero-lateral approach (PLA). The main result was surgical site infection rate. The secondary results were duration of the operation, length of the incision and VAS score after surgery. The results of the meta-analyses of wound infections in the present trial did not show any statistically significant difference in DAA versus PLA (between DAA and PLA) (OR = 1.42, 95%CI: 0.5 to 4.04, p = 0.51). Compared with PLA, DAA had shorter surgical incision (WMD = -3.2, 95%CI: -4.00 to -2.41; p < 0.001) and longer operative times(WMD = 14. 67, 95%CI: 9.24 to 20.09; p < 0.001). Postoperative VAS scores were markedly lower in DAA compared with PLA within 6 weeks of surgery (p < 0.05), with low heterogeneities(I2 = 0). We found that DAA did not differ significantly from PLA in terms of the risk of wound infection for THA and that the surgical incisions was shorter and less postoperative pain after surgery, even though DAA surgery takes longer.
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Affiliation(s)
- Ning Wu
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
- The Third Clinical Medical CollegeNingxia Medical UniversityYinchuanChina
| | - Jingzu Ma
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
| | - Xianghua Xiong
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
- The Third Clinical Medical CollegeNingxia Medical UniversityYinchuanChina
| | - Xiaohai Luo
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
| | - Xiaolin Ma
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
- The Third Clinical Medical CollegeNingxia Medical UniversityYinchuanChina
| | - Xiao Yang
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
- The Third Clinical Medical CollegeNingxia Medical UniversityYinchuanChina
| | - Wei Wang
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
- The Third Clinical Medical CollegeNingxia Medical UniversityYinchuanChina
| | - Yuhai Wang
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
| | - Zhaofu Wang
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
- The First Clinical Medical CollegeLanzhou UniversityLanzhouChina
| | - Feng Ma
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
- The Third Clinical Medical CollegeNingxia Medical UniversityYinchuanChina
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Tanabe H, Baba T, Ozaki Y, Yanagisawa N, Homma Y, Nagao M, Kaneko K, Ishijima M. Conventional versus lateral fasciotomy for prevention of lateral femoral cutaneous nerve injury in the non-fan-type nerve in total hip arthroplasty with direct anterior approach. Bone Joint J 2023; 105-B:1252-1258. [PMID: 38035608 DOI: 10.1302/0301-620x.105b12.bjj-2023-0375.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Aims Lateral femoral cutaneous nerve (LFCN) injury is a potential complication after the direct anterior approach for total hip arthroplasty (DAA-THA). The aim of this study was to determine how the location of the fasciotomy in DAA-THA affects LFCN injury. Methods In this trial, 134 patients were randomized into a lateral fasciotomy (n = 67) or a conventional fasciotomy (n = 67) group. This study was a dual-centre, double-blind, prospective randomized controlled two-arm trial with parallel group design and a 1:1 allocation ratio. The primary endpoint was the presence of LFCN injury, which was determined by the presence of numbness, decreased sensation, tingling, jolt-like sensation, or pain over the lateral aspect of the thigh, excluding the surgical scar, using a patient-based questionnaire. The secondary endpoints were patient-reported outcome measures (PROMs) using the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ), and the Forgotten Joint Score-12 (FJS-12). Assessments were obtained three months after surgery. Results The incidence of LFCN injury tended to be lower in the lateral fasciotomy group (p = 0.089). In the lateral fasciotomy group, there were no significant differences in the mean PROM scores between patients with and without LFCN injury (FJS-12: 54.42 (SD 15.77) vs 65.06 (SD 26.14); p = 0.074; JHEQ: 55.21 (SD 12.10) vs 59.72 (SD 16.50); p = 0.288; WOMAC: 82.45 (SD 6.84) vs 84.40 (SD 17.91); p = 0.728). In the conventional fasciotomy group, there were significant differences in FJS-12 and JHEQ between patients with and without LFCN injury (FJS-12: 43.21 (SD 23.08) vs 67.28 (SD 20.47); p < 0.001; JHEQ: 49.52 (SD 13.97) vs 59.59 (SD 15.18); p = 0.012); however, there was no significant difference in WOMAC (76.63 (SD 16.81) vs 84.16 (SD 15.94); p = 0.107). Conclusion The incidence of LFCN injury at three months after THA was comparable between the lateral and conventional fasciotomy groups. Further studies are needed to assess the long-term effects of these approaches.
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Affiliation(s)
- Hiroki Tanabe
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan
| | - Tomonori Baba
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan
| | - Yu Ozaki
- Department of Orthopedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | | | - Yasuhiro Homma
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan
| | - Masashi Nagao
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan
- Medical Technology Innovation Center, Juntendo University, Tokyo, Japan
| | - Kazuo Kaneko
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan
| | - Muneaki Ishijima
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan
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21
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Brunello M, Di Martino A, Ruta F, Ferri R, Rossomando V, D'Agostino C, Pederiva D, Schilardi F, Faldini C. 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. Musculoskelet Surg 2023; 107:431-437. [PMID: 37314642 PMCID: PMC10709233 DOI: 10.1007/s12306-023-00792-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/05/2023] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- M Brunello
- 1St Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| | - A Di Martino
- 1St Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy.
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy.
| | - F Ruta
- 1St Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| | - R Ferri
- 1St Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| | - V Rossomando
- 1St Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| | - C D'Agostino
- 1St Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| | - D Pederiva
- 1St Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| | - F Schilardi
- 1St Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| | - C Faldini
- 1St Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
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22
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Wilson EJ, Fricka KB, Ho H, Hamilton WG, Sershon RA. Early Practice All-Cause Complications for Fellowship-Trained Anterior Hip Surgeons Are Not Increased When Compared to "Gold Standard" Experienced Posterior Approach Surgeons. J Arthroplasty 2023; 38:2355-2360. [PMID: 37179026 DOI: 10.1016/j.arth.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 05/02/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Increased complication rates have been reported during the learning curve for direct anterior approach (DAA) total hip arthroplasty (THA). However, emerging literature suggests that complications associated with the learning curve may be substantially reduced with fellowship training. METHODS Our institutional database was queried to identify 2 groups: (1) 600 THAs comprised of the first 300 consecutive cases performed by 2 DAA fellowship-trained surgeons; and (2) 600 posterolateral approach (PA) THAs, including the most recent 300 primary cases performed by 2 experienced PA surgeons. All-cause complications, revision rates, reoperations, operative times, and transfusion rates were evaluated. RESULTS Comparing DAA and PA cases, there were no significant differences in rates of all-cause complications (DAA = 18, 3.0% versus PA = 23, 3.8%; P = .43), periprosthetic fractures (DAA = 5, 0.8% versus PA = 10, 1.7%; P = .19), wound complications (DAA = 7, 1.2% versus PA = 2, 0.3%; P = .09), dislocations (DAA = 2, 0.3% versus PA = 8, 1.3%, P = .06), or revisions (DAA = 2, 0.3% versus PL = 5, 0.8%; P = .45) at 120 days postoperatively. There were 4 patients who required reoperation for wound complications, all within the DAA group (DAA = 4, 0.67% versus PA = 0; P = .045). Operative times were shorter in the DAA group (DAA <1.5 hours = 93% versus PA <1.5 hours = 86%; P < .01). No blood transfusions were given in either group. CONCLUSION In this retrospective study, DAA THAs performed by fellowship-trained surgeons early in practice were not associated with higher complication rates compared to THAs performed by experienced PA surgeons. These results suggest that fellowship training may allow DAA surgeons to complete their learning curve period with complication rates similar to experienced PA surgeons.
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Affiliation(s)
- Eric J Wilson
- Anderson Orthopaedic Research Institute, Alexandria, Virginia
| | - Kevin B Fricka
- Anderson Orthopaedic Research Institute, Alexandria, Virginia
| | - Henry Ho
- Anderson Orthopaedic Research Institute, Alexandria, Virginia
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23
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Shah ID, Piple AS, Schlauch AM, Crawford BD, Tamer P, Prentice HA, Grimsrud CD. Direct Anterior Versus Posterior Approach for Total Hip Arthroplasty Performed for Displaced Femoral Neck Fractures. J Orthop Trauma 2023; 37:539-546. [PMID: 37348042 DOI: 10.1097/bot.0000000000002650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVES To compare perioperative, 90-day, and 1-year postoperative complications and outcomes between the direct anterior approach (DAA) and the posterior approach for total hip arthroplasty in geriatric patients with displaced femoral neck fractures (FNFs). DESIGN Retrospective cohort study. SETTING Multicenter Health care Consortium. PATIENTS Seven-hundred and nine patients 60 years or older with acute displaced FNFs between 2009 and 2021. INTERVENTION Total hip arthroplasty using either DAA or posterior approach. MAIN OUTCOME MEASUREMENTS Rates of postoperative complications including dislocations, reoperations, and mortality at 90 days and 1 year postoperatively. Secondary outcome measures included ambulation capacity at discharge, ambulation distance with inpatient physical therapy, discharge disposition, and narcotic prescription quantities (morphine milligram equivalents). RESULTS Through a multivariable regression analysis, DAA was associated with significantly shorter operative time ( B = -6.89 minutes; 95% confidence interval [CI] -12.84 to -0.93; P = 0.024), lower likelihood of blood transfusion during the index hospital stay (adjusted odds ratios = 0.54; 95% CI 0.27 to 0.96; P = 0.045), and decreased average narcotic prescription amounts at 90 days (B = -230.45 morphine milligram equivalents; 95% CI -440.24 to -78.66; P = 0.035) postoperatively. There were no significant differences in medical complications, dislocations, reoperations, and mortality at 90 days and 1 year postoperatively. CONCLUSION When comparing the DAA versus posterior approach for total hip arthroplasty performed for displaced FNF, DAA was associated with shorter operative time, lower likelihood of blood transfusion, and lower 90-day postoperative narcotic prescription amounts. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ishan D Shah
- Department of Orthopaedic Surgery, St. Mary's Medical Center, San Francisco, CA
| | - Amit S Piple
- The Taylor Collaboration, St. Mary's Medical Center, San Francisco, CA
| | - Adam M Schlauch
- Department of Orthopaedic Surgery, St. Mary's Medical Center, San Francisco, CA
| | - Benjamin D Crawford
- Department of Orthopaedic Surgery, St. Mary's Medical Center, San Francisco, CA
| | - Pierre Tamer
- Department of Orthopaedic Surgery, St. Mary's Medical Center, San Francisco, CA
| | - Heather A Prentice
- Medical Device and Surveillance Department, Kaiser Permanente, San Diego, CA; and
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24
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Borsinger TM, Chandi SK, Puri S, Debbi EM, Blevins JL, Chalmers BP. Total Hip Arthroplasty: An Update on Navigation, Robotics, and Contemporary Advancements. HSS J 2023; 19:478-485. [PMID: 37937097 PMCID: PMC10626925 DOI: 10.1177/15563316231193704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/05/2023] [Indexed: 11/09/2023]
Abstract
While total hip arthroplasty (THA) remains effective for improvement of pain and function in patients with osteoarthritis and avascular necrosis, there remain areas of continued pursuit of excellence, including decreasing rates of dislocation, leg length discrepancy, implant loosening, and infection. This review article covers several bearing surfaces and articulations, computer-assisted navigation and robotic technology, and minimally invasive surgical approaches that have sought to improve such outcomes. Perhaps the most significant improvement to THA implant longevity has been the broad adoption of highly cross-linked polyethylene, with low wear rates. Similarly, navigation and robotic technology has proven to more reproducibly achieve intraoperative component positioning, which has demonstrated clinical benefit with decreased risk of dislocation in a number of studies. Given the projected increase in THA over the coming decades, continued investigation of effective incorporation of technology, soft tissue-sparing approaches, and durable implants is imperative to continued pursuit of improved outcomes in THA.
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Affiliation(s)
- Tracy M Borsinger
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Sonia K Chandi
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Simarjeet Puri
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Eytan M Debbi
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Jason L Blevins
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Brian P Chalmers
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
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25
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Obando DV, Gallego KJ, Gonzalez S, Álvarez AG, Bautista M, Sánchez-Vergel A. Results of the transition from posterolateral to anterior minimally invasive approach for total hip arthroplasty. J Orthop Surg Res 2023; 18:816. [PMID: 37907985 PMCID: PMC10619261 DOI: 10.1186/s13018-023-04291-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/15/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND The anterior minimally invasive (AMI) approach reduces soft tissue damage, risk of dislocation and enhances recovery, but it is associated with certain complications. The aim of this study is to compare the outcomes of patients who underwent total hip arthroplasty (THA) through posterolateral (PL) and AMI approaches performed by the same surgeon, in order to determine the learning curve associated with this new approach. METHODS This retrospective cohort study included patients who underwent THA via PL and AMI approach between 2017 and 2022, with a minimum follow-up of 1 year. Hip fracture and oncologic patients were excluded. Demographic variables, functional scores and perioperative complications were assessed. A bivariate analysis was performed to identify differences between groups. RESULTS Data of 124 AMI and 120 PL patients were analyzed. Demographic characteristics among groups were homogeneous. Functional outcomes at 3 months were superior for AMI (Oxford: 43 vs. 38; p < 0.05), no dislocations were identified (0% vs. 4.2%; p < 0.05) and no differences in the transfusion rate were found (6.5% AMI vs. 6.7% PL; p = 0.996). Infection rate was 4% for AMI and 3.4% for PL (p = 0.572). Surgical time was shorter for the PL approach, but the median surgical time of the last 25 AMI cases was shorter. CONCLUSIONS The AMI approach is an excellent alternative for patients requiring THA. Although surgical time and perioperative bleeding were greater during the learning curve, this approach offers improved functional outcomes and a lower dislocation rate, without significant differences in transfusion and infection outcomes, demonstrating that responsible innovation and safe implementation of new techniques is possible.
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Affiliation(s)
| | | | | | | | - María Bautista
- Servicio de Ortopedia y Traumatología, Hospital Universitario Fundación Valle del Lili, Carrera 98 # 18-49, Cali, 760032, Colombia
| | - Alfredo Sánchez-Vergel
- Facultad de Medicina, Universidad Icesi, Cali, Colombia.
- Servicio de Ortopedia y Traumatología, Hospital Universitario Fundación Valle del Lili, Carrera 98 # 18-49, Cali, 760032, Colombia.
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Ang JJM, Onggo JR, Stokes CM, Ambikaipalan A. Comparing direct anterior approach versus posterior approach or lateral approach in total hip arthroplasty: a systematic review and meta-analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2773-2792. [PMID: 37010580 PMCID: PMC10504117 DOI: 10.1007/s00590-023-03528-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/13/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND There are several approaches to THA, and each has their respective advantages and disadvantages. Previous meta-analysis included non-randomised studies that introduce further heterogeneity and bias to the evidence presented. This meta-analysis aims to present level I evidence by comparing functional outcomes, peri-operative parameters and complications of direct anterior approach (DAA) versus posterior approach (PA) or lateral approach (LA) in THA. PATIENTS AND METHODS A comprehensive multi-database search (PubMed, OVID Medline, EMBASE) was conducted from date of database inception to 1st December 2020. Data from randomised controlled trials comparing outcomes of DAA versus PA or LA in THA were extracted and analysed. RESULTS Twenty-four studies comprising 2010 patients were included in this meta-analysis. DAA has a longer operative time (MD = 17.38 min, 95%CI: 12.28, 22.47 min, P < 0.001) but a shorter length of stay compared to PA (MD = - 0.33 days, 95%CI: - 0.55, - 0.11 days, P = 0.003). There was no difference in operative time or length of stay when comparing DAA versus LA. DAA also had significantly better HHS than PA at 6 weeks (MD = 8.00, 95%CI: 5.85, 10.15, P < 0.001) and LA at 12 weeks (MD = 2.23, 95%CI: 0.31, 4.15, P = 0.02). There was no significant difference in risk of neurapraxia for DAA versus LA or in risk of dislocations, periprosthetic fractures or VTE between DAA and PA or DAA and LA. CONCLUSION The DAA has better early functional outcomes with shorter mean length of stay but was associated with a longer operative time than PA. There was no difference in risk of dislocations, neurapraxias, periprosthetic fractures or VTE between approaches. Based on our results, choice of THA approach should ultimately be guided by surgeon experience, surgeon preference and patient factors. LEVEL OF EVIDENCE I Meta-analysis of randomised controlled trials.
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Affiliation(s)
- James Jia Ming Ang
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800 Australia
| | - James Randolph Onggo
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800 Australia
- Department of Orthopaedic Surgery, Box Hill Hospital, Victoria, Australia
| | - Christopher Michael Stokes
- Department of Orthopaedic Surgery, Box Hill Hospital, Victoria, Australia
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Victoria, Australia
| | - Anuruban Ambikaipalan
- Department of Orthopaedic Surgery, Box Hill Hospital, Victoria, Australia
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Victoria, Australia
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Rizk PA, Silverberg A, Deen J, Pulido L, Horodyski M, Gray C. Radiographic parameters of pelvic and proximal femoral morphology do not predict outcomes for direct anterior total hip arthroplasty. Injury 2023; 54:110968. [PMID: 37679210 DOI: 10.1016/j.injury.2023.110968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/24/2023] [Accepted: 07/30/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Radiographic predictors of outcomes associated with direct anterior approach (DAA) total hip arthroplasty (THA) are largely unknown. Anecdotally, some surgeons limit surgery to patients with low body mass index (BMI) or "favorable" bony morphology. Objective data on the impact of these factors is limited. We sought to determine radiographic and demographic predictors of outcomes after DAA arthroplasty. METHODS A consecutive series of patients undergoing unilateral, elective DAA THA, who had linked pre- and post-operative patient reported outcome scores, from January 1, 2017 to March 30, 2019 were included. Radiographic measurements, including proxies for pelvic overhang, femoral canal access, acetabular morphologic changes, and markers of disease severity, were performed on calibrated radiographs. Intra-observer consistency was also evaluated. Outcome measures included disease specific and general health patient-reported outcomes scores, while surgical difficulty was approximated by estimated blood loss and surgical time. Multivariate analyses were performed to determine statistically significant correlations. RESULTS 168 patients were included. Overall, patients experienced significant improvement in outcome scores (mean ∆ HOOS-JR 39.4, PROMIS-physical 12.3). There were two reoperations (1.2%), for recurrent dislocation. Female sex (p = 0.015) and increasing age (p == 0.019) were associated with shorter surgical times. No statistically significant correlations were found between the radiographic parameters and outcome measures. Intraclass correlation coefficients of the radiographic measurements were overall strong (0.73-1.0). CONCLUSION We demonstrated consistent results in this series of patients despite variation in bony morphology. Our findings suggest that DAA THA can be safely performed on a broader patient population.
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Affiliation(s)
- Paul A Rizk
- Department of Orthopaedics, University of Florida College of Medicine, 3450 Hull Road, PO Box 112727, Gainesville, FL 32611, United States.
| | - Arnold Silverberg
- Haywood Regional Medical Center, 262 Leroy George Drive, Clyde, NC 28721, United States
| | - Justin Deen
- Department of Orthopaedics, University of Florida College of Medicine, 3450 Hull Road, PO Box 112727, Gainesville, FL 32611, United States
| | - Luis Pulido
- Department of Orthopaedics, University of Florida College of Medicine, 3450 Hull Road, PO Box 112727, Gainesville, FL 32611, United States
| | - Marybeth Horodyski
- Department of Orthopaedics, University of Florida College of Medicine, 3450 Hull Road, PO Box 112727, Gainesville, FL 32611, United States
| | - Chancellor Gray
- Department of Orthopaedics, University of Florida College of Medicine, 3450 Hull Road, PO Box 112727, Gainesville, FL 32611, United States
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Ramadanov N, Ostojic M, Lazaru P, Liu K, Hable R, Marinova-Kichikova P, Dimitrov D, Becker R. Risk Factors and Predictors for Functional Outcome and Complication Rate in Total Hip Arthroplasty through Minimally Invasive and Conventional Approaches: A Systematic Review and Meta-Regression Analysis of 41 Randomized Controlled Trials. J Clin Med 2023; 12:5895. [PMID: 37762836 PMCID: PMC10531834 DOI: 10.3390/jcm12185895] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 08/27/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVE To investigate and identify risk factors and predictors for the difference in functional outcome and complications between total hip arthroplasty (THA) through minimally invasive and conventional approaches, using a meta-regression analysis of randomized controlled trials (RCTs). METHODS A systematic review of the literature up to 31 July 2022 was performed. A meta-regression was conducted based on a random effects meta-analysis using the Hartung-Knapp-Sidik-Jonkman method. RESULTS A total of 41 RCTs with 3607 patients were found. The following predictors of HHS ≥ 6 months postoperatively were identified: patient age (predictor estimate = 0.14; p < 0.01), avascular necrosis of the femoral head (predictor estimate = -0.03; p = 0.04); incision length (predictor estimate = -0.82; p < 0.01). The following predictors of complication rate were identified: osteoarthritis (predictor estimate = 0.02; p = 0.02); femoral neck fracture (predictor estimate = -0.02; p = 0.02); SuperPATH (predictor estimate = -1.72; p < 0.01). CONCLUSIONS Patient age, avascular necrosis of the femoral head, and incision length were identified as predictors of the effect size of the HHS ≥ 6 months postoperatively; and osteoarthritis, femoral neck fracture, and SuperPATH as predictors of the effect size of the complication rate. Based on these findings, we recommend that more frequent use of minimally invasive THA in elderly patients should be considered. LEVEL OF EVIDENCE I a systematic review of all relevant randomized controlled trials. Registered in PROSPERO on 10 August 2022 (CRD42022350287).
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Affiliation(s)
- Nikolai Ramadanov
- Center of Orthopaedics and Traumatology, Brandenburg Medical School, University Hospital Brandenburg an der Havel, 14770 Brandenburg an der Havel, Germany;
| | - Marko Ostojic
- Department of Orthopedics, University Hospital Mostar, 88000 Mostar, Bosnia and Herzegovina;
| | - Philip Lazaru
- Department of General and Visceral Surgery, Minimally Invasive Surgery and Coloproctology, St. Marien Hospital, 12249 Berlin, Germany;
| | - Kuiliang Liu
- Department for Orthopaedics and Trauma Surgery, Siloah St. Trudpert Hospital, 75179 Pforzheim, Germany;
| | - Robert Hable
- Faculty of Applied Computer Science, Deggendorf Institute of Technology, 94469 Deggendorf, Germany;
| | - Polina Marinova-Kichikova
- Department of Surgical Propaedeutics, Faculty of Medicine, Medical University of Pleven, 5800 Pleven, Bulgaria;
| | - Dobromir Dimitrov
- Department of Surgical Diseases, Faculty of Medicine, Medical University of Pleven, 5800 Pleven, Bulgaria;
| | - Roland Becker
- Center of Orthopaedics and Traumatology, Brandenburg Medical School, University Hospital Brandenburg an der Havel, 14770 Brandenburg an der Havel, Germany;
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Ben Elyahu R, Ohana N, Agabaria E, Biadsi A, Segal D, Yaacobi E, Palmanovich E, Markushevich M, Brin YS. Direct Anterior vs. Direct Lateral Approach Total Hip Arthroplasty for Displaced Femoral Neck Fracture. J Clin Med 2023; 12:5019. [PMID: 37568421 PMCID: PMC10420011 DOI: 10.3390/jcm12155019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/22/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND This study compared outcomes of the direct anterior approach (DAA) and direct lateral approach (DLA) for treating displaced femoral neck fractures in active elderly patients. METHODS This retrospective study included active elderly patients who sustained a displaced femoral neck fracture and underwent a cementless total hip arthroplasty either with a supine DAA or a decubitus DLA. Patients were assessed using the Harris hip score at discharge and at a 6-week follow-up. RESULTS A total of 41 women and 18 men were included in the study. Of those, 22 underwent DLA and 37 received DAA, all performed by the same team. In both groups, 69% were women, mean age was 70 years, and mean BMI was 25.2. Mean hemoglobin loss was 2.3 g/dl between admission and the first post-operative day in both groups. Similar numbers in each cohort were discharged home rather than to a rehabilitation center. The patients who underwent the DAA experienced a 2-day reduction in their hospital stay compared to the DLA group (4.2 ± 1.9 vs. 6.8 ± 3.7, respectively; p < 0.001). The Harris hip score in the DAA group was significantly higher at the 6-week follow-up than in the DLA group (87.23 ± 7.75 vs. 81.23 ± 7.67, respectively; p < 0.031). CONCLUSIONS The patients who underwent THA with the DAA demonstrated better short term outcomes compared to the alternative approach for displaced femoral neck fractures in active elderly patients. DAA helped patients regain independence faster and might decrease hospitalization and rehabilitation costs. Based on these results, we recommend using the DAA for active elderly patients with a displaced femoral neck fracture.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Yaron Shraga Brin
- Department of Orthopedic Surgery, Meir Medical Center, Tel-Aviv University, Kfar-Saba 4428164, Israel; (R.B.E.); (N.O.); (E.A.); (A.B.); (D.S.); (E.Y.); (E.P.); (M.M.)
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Chen L, Sun S, Wang Q, Bahete A, Cai L, Kang P. Comparison of Perioperative Outcomes and Early Complications Between a Direct Anterior Approach or Posterolateral Approach in Simultaneous Bilateral Total Hip Arthroplasty: A Retrospective Study. HSS J 2023; 19:172-179. [PMID: 37065100 PMCID: PMC10090840 DOI: 10.1177/15563316221145688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 11/11/2022] [Indexed: 01/15/2023]
Abstract
Background: Controversies remain on the best surgical approaches for unilateral total hip arthroplasty (THA). There are little data on simultaneous bilateral THA via direct anterior approach (SimBDAA-THA) or posterolateral approach (SimBPA-THA). Purpose: We sought to assess differences in perioperative outcomes and early medical and surgical complications between SimBDAA-THA and SimBPA-THA. Methods: This retrospective study involved patients who underwent either SimBDAA-THA in a supine position (n = 73) or SimBPA-THA in a lateral position (n = 162) at our institution from January 2015 to November 2021. The 2 groups were compared in terms of clinical and demographic characteristics, surgical parameters, and complications during 6-months of follow-up. Results: There were no differences in clinical and demographic characteristics between the 2 groups prior to surgery. Simultaneous bilateral THA via direct anterior approach significantly shortened the length of both the operation (117.50 ±19.42 vs 143.97 ± 32.20 min) and the hospitalization (140.64 ± 43.22 vs 156.24 ± 56.64 h) but increased perioperative loss of hemoglobin (3.28 ± 1.01 vs 3.21 ± 2.26 g/dL). There were no significant differences between the two groups in transfusion rate; levels of interleukin-6, C-reactive protein or creatine kinase; or complications. Conclusion: This retrospective study of patients at a single institution found minimal differences in perioperative outcomes or early medical and surgical complications between SimBDAA-THA and SimBPA-THA except operative time and length of hospitalization. Larger studies with longer follow-up should be conducted to identify whether a direct anterior approach is superior to a posterolateral one.
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Affiliation(s)
- Liyile Chen
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Shuo Sun
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Qiuru Wang
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Aergen Bahete
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Lijun Cai
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Pengde Kang
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
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Awad ME, Farley BJ, Mostafa G, Darwiche HF, Saleh KJ. The risk of hospital readmission, revision, and intra- and postoperative complications between direct anterior versus posterior approaches in primary total hip arthroplasty: a stratified meta-analysis and a probability based cost projection. Hip Int 2023; 33:442-462. [PMID: 35437055 DOI: 10.1177/11207000211066454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION This study presents stratified meta-analysis and projected cost per case analysis of direct anterior approach (DAA) versus posterior approach (PA) in total hip arthroplasty (THA) to determine the best surgical approach and guarantee hip joint longevity. METHODS Several online databases were searched for clinical trials comparing DAA and PA in primary THA. The stratified analysis was conducted to test for confounding and biases across the different types of included trials. The average cost and probability were used to determine projected added costs of medical and surgical management for complications. RESULTS 30 clinical trials included 11,562 patients who underwent THA. Almost 50% of these patients performed DAA. As compared to PA, both non-stratified and stratified analyses demonstrated that DAA has a significant higher incidence of the overall intra- and postoperative complications (non-stratified, OR 1.64; p = 0.003) (stratified, OR 4.12; p = 0.005), nerve injury (non-stratified, OR 22.0; p < 0.00001) (stratified, OR 0.28; p < 0.00001), higher rate of revision surgery (non-stratified; OR 1.54; p = 0.01) (stratified, OR 7.37; p = 0.006), and higher incidence of surgical wound complications (non-stratified; OR 1.67; p = 0.002) as compared to PA following primary THA. In addition, DAA demonstrated higher trends of incidence (non-statistically significant) of femur fracture (Non-stratified, OR 1.32, p = 0.10) and thrombo-embolic complications (Retrospective studies, OR 1.39, p = 0.69). However, PA demonstrated higher trends of incidence (non-statistically significant) of hip joint dislocation, as compared to DAA. (Stratified RCTs, OR 0.63, p = 0.65]. Collectively, this amounts a $421,068.68 surplus in DAA complication costs. CONCLUSIONS PA may provide a more lucrative, safer approach to those undergoing THA given its comparable postoperative outcomes, reduced complication rates, and lower overall cost relative to DAA.
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Affiliation(s)
- Mohamed E Awad
- Resident Research Partnership, Detroit, MI, USA
- Michigan State University, College of Osteopathic Medicine, Detroit, MI, USA
- FAJR Scientific, Northville, MI, USA
| | - Brendan J Farley
- Resident Research Partnership, Detroit, MI, USA
- FAJR Scientific, Northville, MI, USA
- Central Michigan University, College of Medicine, Mount Pleasant, MI, USA
| | - Gamal Mostafa
- Wayne State University, School of Medicine, Detroit, MI, USA
| | - Hussein F Darwiche
- Department of Orthopedic Surgery, Detroit Medical Center, Detroit, MI, USA
| | - Khaled J Saleh
- Resident Research Partnership, Detroit, MI, USA
- Michigan State University, College of Osteopathic Medicine, Detroit, MI, USA
- FAJR Scientific, Northville, MI, USA
- Central Michigan University, College of Medicine, Mount Pleasant, MI, USA
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Kunze KN, McLawhorn AS, Jules-Elysee KM, Alexiades MM, Desai NA, Lin Y, Beathe JC, Ma Y, Zhang W, Sculco TP. Effect of anterior approach compared to posterolateral approach on readiness for discharge and thrombogenic markers in patients undergoing unilateral total hip arthroplasty: a prospective cohort study. Arch Orthop Trauma Surg 2023; 143:2217-2226. [PMID: 35652949 DOI: 10.1007/s00402-022-04484-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 05/15/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION The direct anterior approach (DAA) for total hip arthroplasty (THA) is considered less invasive than the posterolateral approach (PLA), possibly leading to earlier mobilization, faster recovery, and lower levels of thrombogenic markers. The purpose of the current study was to prospectively compare readiness for discharge, rehabilitation milestones, markers of thrombosis and inflammation at 6 weeks postoperatively between DAA and PLA. METHODS A total of 40 patients (20 anterior and 20 posterolateral) were prospectively enrolled. Readiness for discharge, length of stay (LOS), and related outcomes were additionally documented. Blood was drawn at baseline, wound closure, 5-h post-closure, and 24-h post-closure for assays of interleukin-6 (IL-6), PAP (plasmin anti-plasmin), a marker of fibrinolysis, and PF1.2 (Prothrombin fragment 1.2), a marker of thrombin generation. RESULTS Compared to the PLA group, the DAA group was ready for discharge a mean 13 h earlier (p = 0.03), while rehabilitation milestones were met a mean 10 h earlier (p = 0.04), and LOS was 13 h shorter (p = 0.02) on average. Pain scores at all study timepoints and patient satisfaction at 6 weeks were similar (p > 0.05). At 24 h postoperatively, PAP levels were 537.53 ± 94.1 µg/L vs. 464.39 ± 114.6 µg/L (p = 0.05), and Il-6 levels were 40.94 ± 26.1 pg/mL vs. 60.51 ± 33.0 pg/mL (p = 0.03), in DAA vs. PLA, respectively. CONCLUSIONS In the immediate postoperative period, DAA patients were ready for discharge before PLA patients. DAA patients had shorter LOS, a lower inflammatory response, and higher systemic markers of fibrinolysis. However, these differences may not be clinically significant. Future studies with larger study populations are warranted to confirm the validity and significance of these findings. LEVEL OF EVIDENCE Level II, Therapeutic Study.
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Affiliation(s)
- Kyle N Kunze
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 E. 70th Street, New York, NY, 10021, USA.
| | - Alexander S McLawhorn
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 E. 70th Street, New York, NY, 10021, USA
| | | | - Michael M Alexiades
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 E. 70th Street, New York, NY, 10021, USA
| | - Natasha A Desai
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 E. 70th Street, New York, NY, 10021, USA
| | - Yi Lin
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA
| | - Jonathan C Beathe
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA
| | - Yan Ma
- Department of Epidemiology and Biostatistics, George Washington University, Washington, DC, USA
| | - Wei Zhang
- Department of Epidemiology and Biostatistics, George Washington University, Washington, DC, USA
| | - Thomas P Sculco
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 E. 70th Street, New York, NY, 10021, USA
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Butler JT, Stegelmann SD, Butler JL, Bullock M, M Miller R. Comparing dislocation rates by approach following elective primary dual mobility total hip arthroplasty: a systematic review. J Orthop Surg Res 2023; 18:226. [PMID: 36945061 PMCID: PMC10032016 DOI: 10.1186/s13018-023-03724-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/16/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Dual mobility components can be implanted during total hip arthroplasty (THA) for primary osteoarthritis via a direct anterior approach (DAA), anterolateral approach (ALA), direct lateral approach (DLA), or posterior/posterolateral approach (PLA). This review compares dual mobility hip dislocation rates using these approaches for elective primary THA. METHODS PubMed, Embase, and Cochrane databases were systematically searched for articles published after January 1, 2006 that reported dislocation rates for adult patients after primary THA with dual mobility implants. Articles were excluded if they reported revision procedures, nonelective THA for femoral neck fractures, acetabular defects requiring supplemental implants, prior surgery, or ≤ 5 patients. The primary outcome was hip dislocation rate. Secondary outcomes included infection, Harris Hip Score (HHS), and Postel-Merle d'Aubigné (PMA) score. RESULTS After screening 542 articles, 63 met inclusion criteria. Due to study heterogeneity, we did not perform a meta-analysis. Eight studies reported DAA, 5 reported ALA, 6 reported the DLA, and 56 reported PLA. Study size ranged from 41 to 2,601 patients. Mean follow-up time ranged from 6 months to 25 years. Rates of infection and dislocation were low; 80% of ALA, 87.5% of DAA, 100% of DLA, and 82.1% of PLA studies reported zero postoperative dislocations. Studies reporting postoperative HHS and PMA scores showed considerable improvement for all approaches. CONCLUSIONS Patients undergoing primary THA with dual mobility implants rarely experience postoperative dislocation, regardless of surgical approach. Additional studies directly comparing DAA, ALA, DLA, and PLA are needed to confirm these findings.
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Affiliation(s)
- Justin T Butler
- Department of Orthopedic Surgery, Mercy Health St. Vincent Medical Center, 2409 Cherry St, Suite #10, Toledo, OH, 43608, USA.
| | - Samuel D Stegelmann
- Department of Orthopedic Surgery, Mercy Health St. Vincent Medical Center, 2409 Cherry St, Suite #10, Toledo, OH, 43608, USA
| | - Johnathon L Butler
- Department of Orthopedic Surgery, Mercy Health St. Vincent Medical Center, 2409 Cherry St, Suite #10, Toledo, OH, 43608, USA
| | - Matthew Bullock
- Department of Orthopedic Surgery, Marshall University Joan C. Edwards School of Medicine, Huntington, WV, USA
| | - Richard M Miller
- Department of Orthopedic Surgery, Mercy Health St. Vincent Medical Center, 2409 Cherry St, Suite #10, Toledo, OH, 43608, USA
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Is outcome of total hip arthroplasty for hip fracture inferior to that of arthritis in a contemporary arthroplasty practice? J Arthroplasty 2023:S0883-5403(23)00201-2. [PMID: 36889530 DOI: 10.1016/j.arth.2023.02.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/22/2023] [Accepted: 02/25/2023] [Indexed: 03/10/2023] Open
Abstract
INTRODUCTION Outcome of total hip arthroplasty (THA) for femoral neck fractures (FNF) has been associated with higher complication rates. However, THA for FNF is not always performed by arthroplasty-surgeons. This study aimed to compare THA outcomes for FNF to osteoarthritis (OA). In doing so, we described contemporary THA failure modes for FNF performed by arthroplasty surgeons. METHODS This was a retrospective, multi-surgeon study from an academic center. Of FNF treated between 2010 and 2020, 177 received THA by an arthroplasty-surgeon [mean age 67 years (range, 42 to 97), sex: 64.4% women]. These were matched (1:2) for age and sex with 354 THAs performed for hip OA, by the same surgeons. No dual-mobilities were used. Outcomes included radiologic measurements (inclination/anteversion and leg-length), mortality, complications, reoperation rates and patient-reported outcomes including Oxford Hip Score (OHS). RESULTS Post-operative mean leg-length difference was 0 millimeters (mm) (range, -10 to -10 mm), with a mean cup inclination and anteversion of 41 and 26° respectively. There was no difference in radiological measurements between FNF and OA patients (p=0.3). At 5 years follow-up, mortality rate was significantly higher in the FNF-THA compared to the OA-THA group (15.3 vs. 1.1%; p<0.001). There was no difference in complications (7.3 vs. 4.2%; p=0.098) or reoperation rates (5.1 vs. 2.9%; p=0.142) between groups. Dislocation rate was 1.7%. OHS at final follow-up was similar [43.7 points (range, 10 to 48) vs. 43.6 points (range, 10 to 48); p=0.030]. CONCLUSION Total hip arthroplasty for the treatment of FNF is a reliable option and is associated with satisfactory outcomes. Instability was not a common reason of failure, despite not using dual-mobility articulations in this at-risk population. This is likely due to THAs being performed by the arthroplasty staff. When patients live beyond 2-years, similar clinical and radiographic outcomes with low rates of revision can be expected, comparable to elective THA for OA.
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Shen J, Ji R, Yao S, Ruan P, Zhu Z, Wang X, Sun H, Chen J, Ruan H, Ji W. Direct Anterior Approach Provides Superior Prosthesis Adaptability in the Early Postoperative Period of Total Hip Arthroplasty. Orthop Surg 2023; 15:679-686. [PMID: 36513388 PMCID: PMC9977592 DOI: 10.1111/os.13640] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 11/26/2022] [Accepted: 11/27/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Prosthesis awareness is the perception of foreign bodies, which has a critical effect on the function of the prosthetic joint. In total hip arthroplasty (THA), the direct anterior approach (DAA) has more advantages than the posterior approach (PA), including superior rehabilitation outcomes. This study was to evaluate the recovery of "prosthesis awareness" through these two approaches. METHODS Three hundred and seventy-six patients who received THA with either DAA (n = 41) or PA (n = 335) from January 2016 to December 2017 were retrospectively analyzed. The Forgotten Joint Score-12 (FJS-12), Harris hip score (HHS), and visual analog scale (VAS) analyses were used to evaluate the recovery of "prosthesis awareness" in these patients 2 weeks, 1, 3, 6, and 12 months after surgery. The student t-test, Wilcoxon rank sum test, chi-square test, and MANOVA were used to compare the differences among groups. RESULTS We found that DAA patients had higher FJS-12 scores than PA patients at 2 weeks (42.15 ± 3.36 vs. 38.09 ± 3.28, p = 0.042), 1 month (49.06 ± 5.14 vs. 41.11 ± 5.21, p = 0.038), and 3 months (53.23 ± 4.07 vs. 48.09 ± 3.71, t = 3.152, p = 0.045). And the recovery rates of FJS-12 scores in DAA and PA groups at 2 weeks, 1 month, and 3 months after surgery were 75.46% ± 6.04%, 84.05% ± 6.57%, 91.37% ± 7.13%, and 74.14% ± 5.54%, 78.16% ± 6.01%, 88.23% ± 6.42%, respectively. To compare the recovery effects of the two procedures in more detail, we classified the 12 items in FJS-12 that evaluate different types of gravity center motions into three categories: low-movement group (LG), middle-movement group (MG), and high-movement group (HG). Interestingly, DAA patients had significantly higher HG than PA patients at 2 weeks, 1 month, and 3 months after operation (t = 3.225, p = 0.022 at 2 weeks, t = 3.081, p = 0.041 at 1 month and t = 2.783, p = 0.046 at 3 months), whereas no significant differences were observed in LG- and MG-related items. In addition, there were no significant differences in HHS and VAS scores between DAA and PA patients at 2 weeks (p = 0.102, p = 0.093), or from 1 month to 12 months (each p > 0.05). CONCLUSIONS DAA-mediated THA is superior to PA in terms of prosthesis adaptability and recovery of hip joint motion in the first 3 months after surgery, especially concerning high-movement gravity center motions.
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Affiliation(s)
- Jing Shen
- Orthopaedics DepartmentThe First Affiliated Hospital of Zhejiang Chinese Medical UniversityHangzhouChina
| | - Ruiqing Ji
- Department of AnaesthesiaThe Second Clinical Medical College of Wenzhou Medical UniversityWenzhouChina
| | - Sai Yao
- Institute of Orthopaedics and TraumatologyThe First Affiliated Hospital of Zhejiang Chinese Medical UniversityHangzhouChina
| | - Pengfei Ruan
- Orthopaedics DepartmentThe First Affiliated Hospital of Zhejiang Chinese Medical UniversityHangzhouChina
| | - Zhouwei Zhu
- Orthopaedics DepartmentThe First Affiliated Hospital of Zhejiang Chinese Medical UniversityHangzhouChina
| | - Xiang Wang
- Orthopaedics DepartmentThe First Affiliated Hospital of Zhejiang Chinese Medical UniversityHangzhouChina
| | - Huihui Sun
- Orthopaedics DepartmentLanxi People's HospitalLanxiChina
| | - Jie Chen
- Orthopaedics DepartmentThe First Affiliated Hospital of Zhejiang Chinese Medical UniversityHangzhouChina
| | - Hongfeng Ruan
- Institute of Orthopaedics and TraumatologyThe First Affiliated Hospital of Zhejiang Chinese Medical UniversityHangzhouChina
| | - Weifeng Ji
- Orthopaedics DepartmentThe First Affiliated Hospital of Zhejiang Chinese Medical UniversityHangzhouChina
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Lin DY, Samson AJ, Cehic MG, Brown B, Kaambwa B, Wilson C, Kroon HM, Jaarsma RL. Short-term difference only in reported outcomes (PROMs) after anterior or posterior approach to total hip arthroplasty: a 4-year prospective multi-centre observational study. J Orthop Surg Res 2023; 18:119. [PMID: 36803363 PMCID: PMC9936928 DOI: 10.1186/s13018-023-03603-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/10/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND The direct anterior approach (DAA) in total hip arthroplasty (THA) may demonstrate better functional recovery compared to the posterior approach (PA). METHODS In this prospective multi-centre study, patient-related outcome measures (PROMs) and length of stay (LOS) were compared between DAA and PA THA patients. The Oxford Hip Score (OHS), EQ-5D-5L, pain and satisfaction scores were collected at four perioperative stages. RESULTS 337 DAA and 187 PA THAs were included. The OHS PROM was significantly better in the DAA group at 6 weeks post-operatively (OHS: 33 vs. 30, p = 0.02, EQ-5D-5L: 80 vs. 75, p = 0.03), but there were no differences at 6 months and at 1 year. EQ-5D-5L scores were similar between both groups at all time points. LOS as inpatient was significantly different, in favour of DAA [median 2 days (IQR 2-3) vs. PA 3 (IQR 2-4), p ≤ 0.0001]. CONCLUSIONS Patients undergoing DAA THA have shorter LOS and report better short-term Oxford Hip Score PROMs at 6 weeks, but DAA did not convey long-term benefits over PA THA.
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Affiliation(s)
- D-Yin Lin
- Department of Anesthesiology, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia.
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.
| | - Anthony J Samson
- Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Adelaide, SA, Australia
| | - Matthew G Cehic
- Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Adelaide, SA, Australia
| | - Brigid Brown
- Department of Anesthesiology, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia
| | - Billingsley Kaambwa
- Health Economics, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Christopher Wilson
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Adelaide, SA, Australia
| | - Hidde M Kroon
- Department of Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Surgery, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Ruurd L Jaarsma
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Adelaide, SA, Australia
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Pitz-Gonçalves LI, Deckard ER, Meneghini RM. Large Femoral Heads and Select Dual-Mobility Bearings Are Associated With Reduced Instability in Contemporary Posterior Approach Total Hip Arthroplasty. J Arthroplasty 2023:S0883-5403(23)00119-5. [PMID: 36791889 DOI: 10.1016/j.arth.2023.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/31/2023] [Accepted: 02/04/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Postoperative dislocation is considered the main drawback of posterior approach total hip arthroplasty (THA). Thinner highly cross-linked polyethylene and dual-mobility bearings allow maximizing femoral head diameter per a given cup size. This study evaluated dislocation rates as large femoral head bearings were introduced into a practice over an 11-year period. METHODS A total of 1,511 consecutive primary THAs were retrospectively reviewed. Demographics, implant sizes, femoral head-acetabular cup ratio, and dislocation status were collected from the electronic medical record. Data were evaluated using time series analysis techniques as larger femoral heads, thinner polyethylene liners, and dual-mobility bearings were introduced. The cohort was 57% women with mean age and body mass index of 62 years (range, 13 to 93) and 31 kg/m2 (range, 13 to 54), respectively. RESULTS The overall dislocation rate was 0.98%. Use of femoral head sizes ≥ 40 millimeters increased from 4% in the years 2010 to 2016 to 51% in the years 2017 to 2021, correlating with a 50% reduction in dislocation rate from 1.4% to 0.7% (P = .279). Also, no dislocations occurred in patients who had dual-mobility bearings or ≥ 40-millimeter femoral heads (P = .007). Twelve of 14 dislocations occurred in cases with head-cup ratio < 0.7 (P = .013). Thirteen of 14 dislocations were in women (P = .005). CONCLUSION Maximizing the femoral head diameter per given cup size correlated with a decrease in dislocation rate in modern posterior approach THA. Furthermore, these results suggest that dual-mobility articulations should be reserved for high-risk patients or patients in whom a 40-millimeter femoral head is not possible. LEVEL OF EVIDENCE IV-consecutive case series; no control group.
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Affiliation(s)
- Lauren I Pitz-Gonçalves
- Department of Orthopaedic Surgery and Rehabilitation Services, The University of Chicago, Chicago, Illinois
| | - Evan R Deckard
- Indiana Joint Replacement Institute, Indianapolis, Indiana
| | - R Michael Meneghini
- Indiana Joint Replacement Institute, Indianapolis, Indiana; Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Patel N, Golwala P. Approaches for Total Hip Arthroplasty: A Systematic Review. Cureus 2023; 15:e34829. [PMID: 36919077 PMCID: PMC10008322 DOI: 10.7759/cureus.34829] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2023] [Indexed: 02/12/2023] Open
Abstract
These surgical procedures have their own challenges, limitations, and success rate. The choice of surgical approach will depend on many factors including the surgeon's choice, type of pathology, bone stock, age of the patient, and experience of the surgeon. Whichever approach is used for total hip arthroplasty (THA), the primary goals of the surgery would be pain relief and enhancement in the quality of the patient's life suffering from hip pathologies. To further understand the advantages and potential pitfalls associated with different surgical approaches, we conducted a review study comparing different surgical approaches for THA in terms of their clinical and functional outcomes. All the studies done on surgical approaches used in THA published articles in the English language and from 2015 onward were included in the review. The databases searched were COCHRANE, MEDLINE, PEDRO, CINHAL, etc. Search engines that were searched were Google Scholar, Pub Med, and Science Direct. As per the inclusion criteria, out of 50 studies, 26 studies were included in the study which underwent critical analysis. Considering all the factors reviewed from the literature, the posterior approach or posterolateral approach is optimally beneficial.
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Affiliation(s)
- Niketa Patel
- Department of Physiotherapy, Sumandeep Vidyapeeth Deemed to be University, Vadodara, IND
| | - Paresh Golwala
- Department of Orthopedics, Sumandeep Vidyapeeth Deemed to be University, Vadodara, IND
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Koster M, Luzier AD, Temmerman OPP, Vos SJ(CJ, Benner JL. How do dislocation rates differ between different approaches to total hip arthroplasty? A systematic review and meta-analysis. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2023. [DOI: 10.1177/22104917221147688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Different surgical approaches for total hip arthroplasty (THA) exist, without predisposition when it comes to dislocation risk. The direct anterior approach (DAA) is thought to have reduced risk since soft tissue trauma is minimalized. Therefore, we assessed the dislocation risk for different surgical approaches, and the relative dislocation risk of DAA compared to other approaches. Methods: Six electronic databases were systematically searched for prospective studies reporting dislocation following THA. Proportion meta-analyses were performed to assess the dislocation rate for subgroups of the surgical approach. Meta-analysis for binary outcomes was performed to determine the relative risk of dislocation for the DAA compared to other approaches. Results: Eleven studies with 2025 patients were included (mean age 64.6 years, 44% male, mean follow-up 10.5 months), of which four studies were also used in the risk ratio meta-analysis. Overall dislocation rate was 0.79% (95% CI 0.37–1.69). Subgroup analyses showed that most dislocations occurred in the posterior approaches group (1.38%), however non-significant. Furthermore, the DAA emerged with a non-significant lower risk of dislocation (RR 0.37, 95% CI 0.05–2.46) compared to other surgical approaches. Conclusion: Current literature shows non-significant predisposition for a surgical approach to THA regarding dislocation risk. To what extent patient characteristics influence the risk of dislocation could not be determined. Future research should focus on this, as well as on the influence of a surgeon's experience with a specific approach.
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Affiliation(s)
- Marc Koster
- Department of Orthopedic Surgery, CORAL Centre for Orthopedic Research Alkmaar, Northwest Clinics, Alkmaar, The Netherlands
| | - Anton D Luzier
- Faculty of Health, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Olivier PP Temmerman
- Department of Orthopedic Surgery, CORAL Centre for Orthopedic Research Alkmaar, Northwest Clinics, Alkmaar, The Netherlands
| | - Stan J (CJ) Vos
- Department of Orthopedic Surgery, CORAL Centre for Orthopedic Research Alkmaar, Northwest Clinics, Alkmaar, The Netherlands
| | - Joyce L Benner
- Department of Orthopedic Surgery, CORAL Centre for Orthopedic Research Alkmaar, Northwest Clinics, Alkmaar, The Netherlands
- Department of Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
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Assessing Leg Length and Offset in Anterior Total Hip Arthroplasty: Overlay Versus AP Pelvis Intraoperative Radiographic Techniques: A Retrospective Cohort Study. J Am Acad Orthop Surg 2023; 31:106-113. [PMID: 36580052 DOI: 10.5435/jaaos-d-22-00142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 08/06/2022] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Two intraoperative radiographic techniques to determine leg length and offset during anterior total hip arthroplasty (THA) are the AP pelvis and overlay techniques. The AP pelvis method measures LLDs and offset using AP fluoroscopic images, whereas the overlay method uses printed images of the native and replaced hips. The purpose of this study was to compare these techniques regarding clinical and radiographic LLD and offset discrepancies. METHODS Patients of a single surgeon at two hospitals from September 2017 to January 2021 were retrospectively reviewed. Clinically detectable LLD was recorded. Radiographic measurements were obtained from preoperative and postoperative radiographs. LLD was determined based on the vertical distance between the lesser trochanters and the ischial tuberosities. Total offset was measured using a combination of femoral and medial offset. The Student t-test, Fisher exact test, and Wilcoxon rank sum tests were used for statistical analysis. RESULTS Seventy-one procedures were done using the overlay technique and 61 used for the AP pelvis technique. No significant differences were observed in mean postoperative LLD (2.66 versus 2.88 mm, P = 0.66) and mean postoperative offset discrepancy (5.37 versus 4.21 mm, P = 0.143) between the overlay versus AP pelvis groups. The mean preoperative to postoperative absolute difference in offset was less than 5 mm in both groups. Clinically detectable LLD was noted in six of 71 patients in the overlay group and one of 61 in the AP pelvis group (P = 0.123). CONCLUSION No notable differences were observed in intraoperative leg length and offset discrepancies during direct anterior THA between the AP pelvis and overlay techniques, suggesting they are equally effective in determining LLD and offset intraoperatively. The choice of technique to use anterior THA should be based primarily on the surgeon's preference, comfort, and available resources.
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Yan L, Ge L, Dong S, Saluja K, Li D, Reddy KS, Wang Q, Yao L, Li JJ, Roza da Costa B, Xing D, Wang B. Evaluation of Comparative Efficacy and Safety of Surgical Approaches for Total Hip Arthroplasty: A Systematic Review and Network Meta-analysis. JAMA Netw Open 2023; 6:e2253942. [PMID: 36719679 PMCID: PMC9890287 DOI: 10.1001/jamanetworkopen.2022.53942] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/12/2022] [Indexed: 02/01/2023] Open
Abstract
Importance Each approach for primary total hip arthroplasty (THA) has a long learning curve, so a surgeon's choice to change their preferred approach needs to be guided by clear justifications. However, current evidence does not suggest that any of the THA approaches are more beneficial than others, and the choice of approach is mainly based on the knowledge and experience of the surgeon and individual patient characteristics. Objective To assess the efficacy and safety associated with different surgical approaches for THA. Data Sources A comprehensive search of PubMed, EMBASE, and Cochrane databases from inception to March 26, 2022; reference lists of eligible trials; and related reviews. Study Selection Randomized clinical trials (RCTs) comparing different surgical approaches, including the 2-incision approach, direct anterior approach (DAA), direct lateral approach (DLA), minimally invasive direct lateral approach (MIS-DLA), minimally invasive anterolateral approach (MIS-ALA), posterior approach (PA), minimally invasive posterior approach (MIS-PA), and supercapsular percutaneously assisted total hip arthroplasty (SuperPath), for primary THA. Data Extraction and Synthesis Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, 2 reviewers independently extracted data on study participants, interventions, and outcomes as well as assessed the risk of bias using the Cochrane risk of bias tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation framework. A frequentist framework was used to inform a series of random-effects network meta-analyses. Main Outcomes and Measures The outcomes were hip score (range, 0-100, with higher scores indicating better overall hip condition), pain score (range, 0-100, with higher scores indicating more pain), hospitalization time, operation time, quality of life score, blood loss, cup abduction angle, and cup anteversion angle. Results Of 2130 retrieved studies, 63 RCTs including 4859 participants (median [IQR] age, 64.0 [60.3-66.5] years; median [IQR] percentage male, 46.74% [38.64%-54.74%]) were eligible for analysis. Eight surgical approaches were evaluated. For hip score, DAA (mean difference [MD], 4.04; 95% CI, 1.92 to 6.16; moderate certainty), MIS-ALA (MD, 3.00; 95% CI, 0.43 to 5.59; moderate certainty), MIS-DLA (MD, 3.37; 95% CI, 1.05 to 5.68; moderate certainty), MIS-PA (MD, 4.46; 95% CI, 1.60 to 7.31; moderate certainty), PA (MD, 4.37; 95% CI, 1.87 to 6.88; high certainty), and SuperPath (MD, 5.00; 95% CI, 0.58 to 9.42; high certainty) were associated with greater improvement in hip score compared with DLA. DLA was associated with lower decrease in pain score than SuperPath (MD, 1.16; 95% CI, 0.13 to 2.20; high certainty) and MIS-DLA (MD, 0.90; 95% CI, 0.04 to 1.76; moderate certainty). PA was associated with shorter operation times compared with 2-incision (MD, -23.85 minutes; 95% CI, -36.60 to -11.10 minutes; high certainty), DAA (MD, -13.94 minutes; 95% CI, -18.79 to -9.08 minutes; moderate certainty), DLA (MD, -10.50 minutes; 95% CI, -16.07 to -4.94 minutes; high certainty), MIS-ALA (MD, -6.76 minutes; 95% CI, -12.86 to -0.65 minutes; moderate certainty), and SuperPath (MD, -13.91 minutes; 95% CI, -21.87 to -5.95 minutes; moderate certainty). The incidence of 6 types of complications did not differ significantly between the approaches. Conclusions and Relevance In this study, moderate to high certainty evidence indicated that compared with PA, all surgical approaches except DLA were associated with similar improvements of hip score but longer operation time. DLA was associated with smaller improvement of hip score. The safety of the different approaches did not show significant differences. These findings will help health professionals and patients with better clinical decision-making and also provide references for policy makers.
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Affiliation(s)
- Lei Yan
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Second Clinical Medical College, Shanxi Medical University, Taiyuan, China
- Department of Orthopedics, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Long Ge
- Evidence Based Social Science Research Centre, School of Public Health, Lanzhou University, Lanzhou, China
- Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shengjie Dong
- Orthopedic Department, Yantaishan Hospital, Yantai, China
| | - Kiran Saluja
- Bruyere Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Dijun Li
- Second Clinical Medical College, Shanxi Medical University, Taiyuan, China
- Department of Orthopedics, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - K. Srikanth Reddy
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- World Health Organization, Geneva, Switzerland
| | - Qi Wang
- Health Policy PhD Program and McMaster Health Forum, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jiao Jiao Li
- School of Biomedical Engineering, Faculty of Engineering and IT, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Bruno Roza da Costa
- Institute of Health Policy, Management, and Evaluation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Dan Xing
- Arthritis Clinic & Research Center, Peking University People’s Hospital, Peking University, Beijing, China
| | - Bin Wang
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Jungwirth-Weinberger A, Do HT, Krell EC, Valle AGD, Chalmers BP, Boettner F. Blood management in direct anterior versus posterior primary total hip arthroplasty using tranexamic acid: a matched cohort study. Arch Orthop Trauma Surg 2023; 143:91-95. [PMID: 34152489 DOI: 10.1007/s00402-021-03965-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 05/18/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Proponents of the direct anterior approach (DAA) for THA claim patients recover faster compared to primary THA through the posterior approach (PA). Blood loss and transfusion have substantially declined with the use of tranexamic acid (TXA). However, it is still controversial if hemoglobin drops and transfusion rates are affected by the surgical approach when TXA is routinely used. MATERIALS AND METHODS 2418 patients undergoing DAA THA were matched 1:1 with patients undergoing PA THA according to preoperative hemoglobin (± 1 g/dl), age (± 5 years), sex, BMI (± 5 kg/m2) and year of surgery (± 2 years). All patients received perioperative TXA. None of the patients donated autologous blood. Hemoglobin levels, drain placement and output, blood transfusion rates and volume as well as length of stay were recorded. RESULTS A closed suction drain was used in 121 (5.0%) DAA and in 135 (5.6%) PA THAs (p = 0.369). Mean drain output was higher in the DAA compared to the PA group (134 ml (0-520 ml) versus 92.3 ml (0-600 ml), p = 0.004). There was no difference in hemoglobin drop [2.6 g/dl versus 2.6 g/dl (p = 0.143)] and transfusion rate [n = 31 (1.3%) versus n = 29 (1.2%), p = 0.793)] between DAA and PA THA. Mean transfusion amounts were 421.8 ml (250-1120.8 ml) in the DAA and 353.9 ml (250-560 ml) in the PA group (p = 0.801). The length of stay was shorter in the DAA group with a mean 1.6 days versus 2.1 days in the PA group (p ≤ 0.001). CONCLUSION In this large matched cohort study, there was no difference in the perioperative hemoglobin drop, the transfusion rate and the transfusion amount between DAA and PA THA.
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Affiliation(s)
- Anna Jungwirth-Weinberger
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedics and Traumatology, Cantonal Hospital Baden, Im Ergel 1, 5404, Baden, Switzerland
| | - Huong T Do
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Ethan C Krell
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | | | - Brian P Chalmers
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Friedrich Boettner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
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Kraus KR, Dilley JE, Ziemba-Davis M, Meneghini RM. Procedure Duration, Time Under Anesthesia, and Readmissions in Direct Anterior and Posterior Approach Total Hip Arthroplasty. J Arthroplasty 2022; 37:2387-2393. [PMID: 35798136 DOI: 10.1016/j.arth.2022.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 06/27/2022] [Accepted: 06/29/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Operative time is related to complications in primary total hip arthroplasty (THA). This study compared operative time in direct anterior (DA) and posterior approach THA and whether differences were related to increased hospital readmissions within 90 days of discharge. METHODS Prospectively documented data on 3,152 consecutively performed THAs by 16 surgeons at a large Midwestern United States academic healthcare system were retrospectively reviewed. All surgeons were beyond their learning curve. Cases characterized by factors extending operative time were excluded. A total of 1,235 analysis cases were performed with the DA approach and 1,608 with the posterior approach. DA patients had lower mean body mass index (P < .001), were more likely to be classified as American Society of Anesthesiologists Physical Status 1 or 2 (P < .001), and more likely to have surgery in an ambulatory setting (P < .001). RESULTS Time under anesthesia was significantly longer for DA procedures by 19 to 27 minutes in hospital and ambulatory settings, respectively (P < .001). Increasing body mass index had a greater impact on anesthesia time for DA patients (P = .020). There were no differences in nontraumatic readmissions within 90 days of surgery based on surgical approach (P ≥ .480); however, significantly more DA patients classified as ASA-PS 3 or 4 were readmitted compared to those classified as ASA-PS 1 or 2 (P < .001), a difference not observed for posterior approach patients. CONCLUSION Anesthesia time is a modifiable risk factor for patient safety and an important factor in healthcare resource utilization. Consideration of ways to reduce DA operative times is encouraged.
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Affiliation(s)
- Kent R Kraus
- Medical Resident, Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Julian E Dilley
- Medical Resident, Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mary Ziemba-Davis
- Orthopedic Research Director, Indiana University Health Hip & Knee Center, Saxony Hospital, Fishers, Indiana
| | - R Michael Meneghini
- Professor of Clinical Orthopaedic Surgery, Indiana University School of Medicine, Department of Orthopaedic Surgery, Indianapolis, Indiana
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Kunze KN, Huddleston HP, Romero J, Chiu YF, Jerabek SA, McLawhorn AS. Accuracy and Precision of Acetabular Component Position Does Not Differ Between the Anterior and Posterior Approaches to Total Hip Arthroplasty With Robotic Assistance: A Matched-Pair Analysis. Arthroplast Today 2022; 18:68-75. [PMID: 36275492 PMCID: PMC9583454 DOI: 10.1016/j.artd.2022.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/22/2022] [Accepted: 08/09/2022] [Indexed: 11/24/2022] Open
Abstract
Background Deviation from planned component placement with robot-assisted total hip arthroplasty (RA-THA) may differ based on surgical approach. The purpose of this study was to compare radiographic accuracy and precision of acetabular component position using RA-THA with the direct anterior approach (DAA) or posterior approach (PA). Methods Between 2016 and 2019, 134 PA RA-THA patients were matched to 134 DAA RA-THA patients based on age (±10 years), body mass index (±5 kg/m2), and sex (exact). Acetabular component position was assessed using (1) planned position on preoperative computed tomography, (2) intraoperative position, and (3) position on 6-week postoperative radiographs using the digital Ein Bild Röntgen Analyse system. Results Accuracy of acetabular component inclination in the PA cohort was lower than that in the DAA cohort (PA: 4.3° ± 2.8° vs DAA: 3.1° ± 2.4°, P = .001). Inclination precision was not statistically different (PA: 3° ± 2.4° vs DAA: 2.5° ± 1.8°, P = .071). Anteversion accuracy was not statistically different (PA: 4.1° ± 3.7° vs DAA: 3.5° ± 2.5°, P = .091). Acetabular component anteversion was more precise with DAA (PA: 4.1° ± 3.7° vs DAA: 2.9° ± 2.0°, P = .001). Radiographic outliers (anteversion or inclination was >10° or <-10° from the planned target) were significantly more prevalent in the PA cohort than in the DAA cohort (12 vs 3, P = .016). Conclusions The acetabular component can be positioned with excellent precision and accuracy when using RA-THA regardless of approach. Although the DAA resulted in a slight increase in precise placement of cup anteversion and more accurate placement of cup abduction with fewer outliers, these small differences may not be clinically meaningful.
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Affiliation(s)
- Kyle N. Kunze
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA,Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, New York, NY, USA,Corresponding author. Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East. 70th Street, New York, NY, USA 10021. Tel.: +1 609 214 9245.
| | - Hailey P. Huddleston
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA,Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, New York, NY, USA
| | - Joey Romero
- Center for Hip and Knee Replacement, St. David’s Medical Center, Austin, TX, USA
| | - Yu-Fen Chiu
- Biostatistics Core, Research Administration, Hospital for Special Surgery, New York, NY, USA
| | - Seth A. Jerabek
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA,Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, New York, NY, USA
| | - Alexander S. McLawhorn
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA,Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, New York, NY, USA
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Ramadanov N, Bueschges S, Liu K, Lazaru P, Marintschev I. Direct and indirect comparisons in network meta-analysis of SuperPATH, direct anterior and posterior approaches in total hip arthroplasty. Sci Rep 2022; 12:16778. [PMID: 36202828 PMCID: PMC9537282 DOI: 10.1038/s41598-022-20242-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 09/12/2022] [Indexed: 12/05/2022] Open
Abstract
SuperPATH is a novel approach to the hip joint that needs to be compared to other known surgical approaches. To conduct a network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing short-term outcomes of SuperPATH, direct anterior (DAA), and posterior/ posterolateral approaches (PA) in total hip joint arthroplasty (THA). We performed a systematic review on PubMed, CNKI, Embase, The Cochrane Library, Clinical trials, and Google Scholar up to November 30th, 2021. We assessed treatment effects between SuperPATH, DAA, and PA by performing a frequentist NMA, including a total of 20 RCTs involving 1501 patients. SuperPATH showed a longer operation time (MD = 16.99, 95% CI 4.92 to 29.07), a shorter incision length (MD = −4.71, 95% CI −6.21 to −3.22), a lower intraoperative blood loss (MD = −81.75, 95% CI −114.78 to −48.72), a higher HHS 3, 6 and 12 months postoperatively (MD = 2.59, 95% CI 0.59–4.6; MD = 2.14, 95% CI 0.5–3.77; MD = 0.6, 95% CI 0.03–1.17, respectively) than PA. DAA showed a higher intraoperative blood loss than PA and SuperPATH (MD = 91.87, 95% CI 27.99–155.74; MD = 173.62, 95% CI 101.71–245.53, respectively). No other relevant differences were found. In conclusion, the overall findings suggested that the short-term outcomes of THA through SuperPATH were statistically superior to PA. DAA and PA as well as SuperPATH and DAA showed indifferent results.
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Affiliation(s)
- Nikolai Ramadanov
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg an der Havel, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany.
| | - Simon Bueschges
- Faculty of Medicine, Department of Statistics, University of Salamanca, Salamanca, Spain
| | - Kuiliang Liu
- Department for Orthopaedics and Trauma Surgery, Siloah St. Trudpert Hospital, Pforzheim, Germany
| | - Philip Lazaru
- Center for Surgery, Evangelical Hospital Ludwigsfelde-Teltow, Ludwigsfelde, Germany
| | - Ivan Marintschev
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Friedrich Schiller University, Jena, Germany
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Zhou Z, Li Y, Peng Y, Jiang J, Zuo J. Clinical efficacy of direct anterior approach vs. other surgical approaches for total hip arthroplasty: A systematic review and meta-analysis based on RCTs. Front Surg 2022; 9:1022937. [PMID: 36263087 PMCID: PMC9574056 DOI: 10.3389/fsurg.2022.1022937] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/16/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Direct anterior approach (DAA) is an accurate technique for total hip arthroplasty (THA) through the muscle gap. Physicians who apply DAA believe that it accelerates patient recovery and results in lower rates of postoperative dislocation. However, the traditional surgical approach adherents believe that it is shorter and has fewer complications than DAA. METHODS We use the method of META analysis to organize and analyze the data of the randomized controlled studies (RCT) obtained after our screening. To compare the clinical efficacy of DAA approach and other surgical approaches for THA. RESULTS After rigorous screening, 15 RCT studies were included in our study, and data were extracted. The study included 1,450 patients from 15 RCTs, with a mean age of 63 years and a distribution of 52-67 years. Six weeks after the operation, the Harris hip score of the DAA approach improved by an average of 4.06 points (95% confidence interval (CI) 2.54 -5.59, P < 0.01, I 2 = 45%, which can significantly improve the clinical efficacy of patients. However, the 0.61 points [95% confidence interval (CI) -1.13 -2.34, P > 0.01, I 2 = 0%] at 3 months and 1.49 points [95% confidence interval (CI) -1.65 -2.25, P > 0.01, I 2 = 0%] at 12 months postoperatively. In terms of dislocation rate, results show that the use of DAAs does not reduce Dislocation Rate with significant statistical heterogeneity among study groups (95% CI 0.18-2.94 P > 0.001, I 2 = 0%). CONCLUSION The hip function of DAA was superior to posterolateral approach (PLA) and latera approach (LA) in the early days after hip replacement, especially within six weeks. However, at six months or more after surgery, the difference was not significant. The DAA did not show a lower rate of dislocation than other surgical approaches. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/PROSPERO.
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Affiliation(s)
- Zhongsheng Zhou
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China,Scientific Research Center, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Yang Li
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Yachen Peng
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jinlan Jiang
- Scientific Research Center, China-Japan Union Hospital of Jilin University, Changchun, China,Correspondence: Jinlan Jiang, Jianlin Zuo
| | - Jianlin Zuo
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China,Correspondence: Jinlan Jiang, Jianlin Zuo
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Gazendam A, Bozzo A, Ekhtiari S, Kruse C, Hiasat N, Tushinski D, Bhandari M. Short-term outcomes vary by surgical approach in total hip arthroplasty: a network meta-analysis. Arch Orthop Trauma Surg 2022; 142:2893-2902. [PMID: 34410479 DOI: 10.1007/s00402-021-04131-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 08/15/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The direct anterior approach (DAA) has increased in popularity in recent years. Proponents cite its muscle-sparing approach and purported reduction in pain and improvement in function when compared to the traditional surgical approaches. There remains controversy surrounding the validity of these claims. The objective of this study was to compare the common total hip surgical approaches in terms of pain scores, functional outcomes, opioid use and complications within the first 12 weeks postoperatively. METHODS A network meta-analysis of randomized controlled trials (RCT) comparing postoperative outcomes of different surgical approaches in primary THA up to 12 weeks was performed. PubMed, MEDLINE, Embase, Web of Science and SCOPUS were systematically searched from inception to May 2020. Outcomes included pain scores, functional outcome scores, length of stay (LOS), complications and opioid consumption. RESULTS Twenty-five RCTs (n = 2339) were included. The DAA demonstrated statistically significant improvement in Harris Hip Scores at 6 weeks when compared to the posterior and direct lateral approaches. The DAA reduced pain scores on postoperative day 2 and at 2 weeks compared to the direct lateral approach. The anterolateral approach was found to have a significantly shorter LOS compared to the other major surgical approaches. The differences in functional outcomes or pain scores did not surpass conventional cutoffs for a minimal clinically important difference. CONCLUSION The DAA led to functional improvements at 6 weeks compared to the posterior and direct lateral approaches and reduced postoperative pain compared to the direct lateral approach. However, these improvements failed to reach clinical significance. All major surgical approaches led to large improvements in function by 12 weeks with relatively low complication rates. Whether a short-term statistically significant improvement in function is sufficiently patient important to recommend DAA as a standard remains uncertain.
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Affiliation(s)
- Aaron Gazendam
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, St. Joseph's Hospital, Room G522, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada.
| | - Anthony Bozzo
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, St. Joseph's Hospital, Room G522, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
| | - Seper Ekhtiari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, St. Joseph's Hospital, Room G522, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
| | - Colin Kruse
- McMaster Medical School, McMaster University, Hamilton, ON, Canada
| | - Nancy Hiasat
- Near East University Hospital, North Nicosia, Turkey
| | - Daniel Tushinski
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, St. Joseph's Hospital, Room G522, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, St. Joseph's Hospital, Room G522, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
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Maezawa K, Nozawa M, Gomi M, Sugimoto M, Maruyama Y. Changes in serum creatine kinase and C-reactive protein after posterior and direct anterior approaches in total hip arthroplasty. Hip Int 2022; 32:591-595. [PMID: 33290100 DOI: 10.1177/1120700020978643] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Some studies reported that measuring serum creatine kinase (CK) level is an objective method with which to determine the relative invasiveness of surgery. The purpose of this study was to evaluate the change in postoperative serum CK levels as a measure of whether the direct anterior approach (DAA) is less invasive than the posterior approach (PA) regarding postoperative rehabilitation. MATERIALS AND METHODS We prospectively recruited 71 women who were undergoing total hip arthroplasty, 47 were treated by the PA and 24 by the DAA. Serum CK and C-reactive protein (CRP) levels were measured preoperatively and 3 hours and 1, 4, 7, 10, and 14 days after the operation. RESULTS The serum CK levels were significantly higher in the DAA group than in the PA group on postoperative days 1, 4, 7, 10, and 14. On postoperative day 4 and 7, the percentage of patients whose serum CK levels were above the normal range was 46.8% and 8.5% in the PA group and 95.2% and 45.5% in the DAA group. CONCLUSIONS CK levels were significantly higher in the 2 weeks after THA by a DAA than after the same procedure by a PA indicating that DAA causes prolonged muscle damage. Although the DAA is considered to be a muscle-sparing approach this may not be the case and DAA may not actually be a minimally-invasive approach.
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Affiliation(s)
- Katsuhiko Maezawa
- Orthopaedic Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Masahiko Nozawa
- Orthopaedic Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Motoshi Gomi
- Orthopaedic Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Munehiko Sugimoto
- Orthopaedic Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Yuichiro Maruyama
- Orthopaedic Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
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49
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Combs DB, Hummel A, Nishioka ST, Andrews SN, Nakasone CK. Reducing transfusion in hip arthroplasty: tranexemic acid diminishes influence of anesthesia administered. Arch Orthop Trauma Surg 2022; 143:3535-3540. [PMID: 35996031 DOI: 10.1007/s00402-022-04591-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 08/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The risk of transfusion following total hip arthroplasty (THA) continues to be problematic. The best choice of anesthesia (spinal vs general) and impact of tranexamic acid (TXA) use in reducing transfusions following surgery remain unclear. Therefore, the purpose of this study was to compare rates of blood transfusion following THA via the anterior approach using three different anesthesia protocols with and without TXA. MATERIALS AND METHODS This retrospective review included 1399 patients (1659 hips), receiving spinal anesthesia (SA) without (248 patients) and with TXA (77 patients), general anesthesia (GA) without (151 patients) and with TXA (171) and general anesthesia with paravertebral block (GA-PVB) and TXA (748 patients). All procedures were performed by a single surgeon. Chi-Squared tests and logistic regression were performed to evaluate the rate and risks of transfusion between groups. RESULTS Without TXA, transfusion rate with GA (24.5%) was higher than SA (13.4%) (p = 0.004). With TXA, there was no difference in transfusion rates between GA (4.6%), SA (3.9%) or GA-PVB (4.0%). The multivariable regression revealed bilateral (Odds Ratio (OR): 6.473; p < 0.001), female (OR: 2.046; p = 0.004), age (OR: 1.028; p = 0.012) and pre-operative anemia (OR: 2.604; p < 0.001) as increasing the risk of transfusion while use of TXA (OR: 0.168; p < 0.001) significantly reduced transfusion risk. CONCLUSION The use of TXA during THA via the anterior approach removed the influence of anesthesia type regarding risk of transfusion. The use of TXA may reverse presumed disadvantages of GA alone, potentially facilitating rapid discharge following surgery.
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Affiliation(s)
- Dylan B Combs
- John A Burns School of Medicine, 651 Ilalo Street, Honolulu, HI, 96813, USA
| | - Amelia Hummel
- John A Burns School of Medicine, 651 Ilalo Street, Honolulu, HI, 96813, USA
| | - Scott T Nishioka
- John A Burns School of Medicine, 651 Ilalo Street, Honolulu, HI, 96813, USA.,Straub Medical Center, Bone and Joint Center, 888 South King Street, Honolulu, HI, 96818, USA
| | - Samantha N Andrews
- Straub Medical Center, Bone and Joint Center, 888 South King Street, Honolulu, HI, 96818, USA. .,Department of Surgery, University of Hawai'I, 1356 Lusitana Street, Honolulu, HI, 96813, USA.
| | - Cass K Nakasone
- Straub Medical Center, Bone and Joint Center, 888 South King Street, Honolulu, HI, 96818, USA.,Department of Surgery, University of Hawai'I, 1356 Lusitana Street, Honolulu, HI, 96813, USA
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50
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Goyal T, Choudhury AK, Paul S, Das L, Gupta T. The direct anterior approach without traction table: How does it compare with the posterior approach? - A prospective non-randomised trial. J Clin Orthop Trauma 2022; 31:101924. [PMID: 35941870 PMCID: PMC9356358 DOI: 10.1016/j.jcot.2022.101924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/09/2022] [Accepted: 06/17/2022] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The direct anterior approach (DAA) for total hip replacement (THR) is relatively new. It has been proved superior to other techniques concerning early functional outcomes, stability, and earlier recovery. But DAA-THR has a steeper surgical learning curve and, in its original description, needs special operating room equipment. This study aims to present clinical, functional, and radiological outcomes of DAA compared to the posterior approach (PA), performed using a routine operating table and instrumentation sets. METHODS Eighty patients undergoing THR were non-randomly allocated prospectively into Group 1 DAA and Group 2 PA. Visual analog scale (VAS) for pain was recorded preoperatively and at 6, 12, 24, 48, and 72 h after the surgery and at 1st and 2nd year postoperatively. Both groups' functional outcomes were evaluated pre-and postoperatively at 1st and 2nd-year follow-up with Harris hip score (HHS) and SF-12. Perioperative parameters like blood loss, length of hospital stay, duration of surgery, postoperative complications, and radiological prosthesis positioning were also compared between the two groups. RESULTS All patients were comparable according to their baseline demographic characteristics. DAA was found to have significantly better early HHS at one year (p = 0.001) and VAS for hip pain (p < 0.05) at 12, 24, 48, and 72 hrs postoperative period only. Clinical outcomes were comparable at the final follow-up of 2 years. Perioperative variables were also similar except the incision length, length of stay in the hospital, and average time to weight bear without walking aids which were statistically better in DAA than PA group. There was no difference in radiological prosthesis positioning. Postoperative complication rates were also comparable in the two groups. CONCLUSION Though technically demanding, DAA provides better early functional outcomes with comparable radiological outcomes and complication rates than the PA.Level of evidence: Non-randomized comparative trial, Level II.
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Affiliation(s)
- Tarun Goyal
- Department of Orthopaedics, All India Institute of Medical Sciences, Bathinda, Punjab, 151001, India,Corresponding author.
| | | | - Souvik Paul
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Lakshmana Das
- Department of Orthopaedics, All India Institute of Medical Sciences, Bathinda, Punjab, 151001, India
| | - Tushar Gupta
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
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