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

An Intraoperative Method to Minimize Leg Length Discrepancy in Anterior Minimally Invasive Total Hip Arthroplasty-A Prospective Study

While several intraoperative devices have been described in the literature for assessing leg length discrepancy (LLD), none have been utilized during total hip arthroplasty (THA) performed via the Anterior Minimally Invasive Surgery (AMIS) approach. The aim of this prospective study was to evaluate the efficacy and accuracy of a compass device in assessing leg length during THA performed using the AMIS technique. A prospective study was conducted involving 35 patients who consecutively underwent unilateral primary THA using the AMIS technique at our department from September 2017 to December 2018. LLD was measured by comparing preoperative and postoperative anteroposterior radiographs of the pelvis, independently assessed by two observers. The mean preoperative LLD was 3.6 (SD 3.9, range, 0.2-19.3) mm. The mean postoperative LLD was 2.5 (SD 3.0, range, 0-12.2) mm. A postoperative LLD of less than 5 mm was observed in 88.2% of cases, with 94.1% having values less than 10 mm. In conclusion, the compass device emerged as a valuable tool for ensuring precise limb length control in THA with the AMIS approach, offering both efficiency and cost-effectiveness in clinical practice.

Is There a Learning Curve for the 5-Year Implant Survival Rate of Total Hip Arthroplasty Using the Direct Anterior Approach With a Traction Table? A Prospective Cohort Study

BACKGROUND

The direct anterior approach (DAA) for total hip arthroplasty (THA) is attracting attention as a minimally invasive surgery, but the learning curve to master this approach is a concern, and its effect on long-term results is unknown. The purpose of this prospective cohort study was to clarify how the learning curve affects the 5-year results of DAA THA with a traction table.

METHODS

Of 402 THA cases using DAA with a mobile traction table and fluoroscopy, 249 cases composed of the first 50 cases for each surgeon were assessed during a learning curve, and 153 cases were evaluated after more than 50 cases of experience.

RESULTS

The 5-year-implant survival rate was 99.2% both during and after the learning curve. The 2-year complication rate in the learning curve group was 8.9 versus 5.9%, which was not statistically significant. The 2-to-5-year complication rates also did not differ between the cohorts (0 versus 0.7%). Both groups demonstrated decreased complication rates when comparing 2-year complications to 2-to-5-year complications. Clinical scores significantly improved by 2 years and were maintained at 5 years in both groups. The cup safe-zone success rates were 96.4% during the learning curve and 98.7% after the learning curve. The stem safe-zone success rates were 97.2% during the learning curve and 96.1% after the learning curve. Surgical time was approximately 20 minutes shorter after the first 50 cases than during the learning curve (70.8 versus 90.6 minutes, P = .001). Intraoperative blood loss was significantly less after the learning curve than during the learning curve.

CONCLUSIONS

This study implies that the learning curve affects perioperative results such as surgical time and intraoperative blood loss, but has little effect on short-term results up to 2 years after surgery and no effect on mid-term results from 2 to 5 years after surgery.

Clinical outcomes following direct anterior approach during total hip arthroplasty without hip extension: a retrospective comparative study

BACKGROUND

Traditional total hip arthroplasty (THA) using the direct anterior approach (DAA) requires a hip extension. This study aimed to compare the clinical outcomes of patients undergoing THA with DAA using either the no hip extension (NHE) or the traditional hip extension (THE) strategy.

METHODS

A retrospective analysis of demographics, clinical and radiological outcomes, and occurrence of complications was performed using data from 123 patients treated between January 2020 and November 2021. The patients were categorised into two groups: NHE (84 patients) and THE (39 patients).

RESULTS

The NHE group exhibited shorter operative time and had more male participants with higher ages. Comparable outcomes were observed in the visual analogue scale, Harris Hip, and Oxford Hip scores at the final follow-up. Furthermore, complications were observed in the NHE and THE groups, including two and one greater trochanteric fractures and three and one transfusions, respectively.

CONCLUSIONS

Compared to the THE, employing the NHE strategy during THA with DAA in elderly and young female patients resulted in comparable clinical outcomes with several advantages, such as favourable surgical time. The NHE method also exhibited good safety and effectiveness. Therefore, the NHE strategy may be a favourable option for elderly and young female patients.

Polyethylene thickness does not influence aseptic revision rate with highly cross-linked liners in THA with 36-mm femoral heads

BACKGROUND

To reduce the risk of dislocation, larger head size can be used in total hip arthroplasty (THA). However, larger head size leads to thinner acetabular liners. With conventional polyethylene, thickness of >8 mm has been advocated to reduce stress and wear rate of the polyethylene. Modern polyethylene has become more wear-resistant. In this study, we investigated if the thickness of sequentially cross-linked polyethylene (XLPE) liners is associated with failure of THA in the medium term.

PATIENTS AND METHODS

3654 THAs were included (2009-2016), in which THA was performed with a XLPE liner in combination with a 36-mm femoral head. Patient and surgical characteristics were collected. We compared implant survival of THA with thin liners (<7.9 mm) and thick liners (⩾7.9 mm) with a Kaplan Meier survival analysis at 5 years, median follow-up and 10 years of follow-up with and point aseptic loosening and performed a multivariate analysis to estimate hazard ratios (HR).

RESULTS

Median follow-up was 7.7 years (IQR 5.6-9.8). In total, 179 revision procedures were performed, where 82 revisions (46%) were performed for aseptic loosening. The survival rate at 5 years, median and 10 years of follow-up showed no statistically significant difference in implant survival. The survival rate at 10 years follow-up was for thin liners 97.1% (95% CI, 96.3-97.9) and for thick liners 98.2% (95% CI, 97.4-99.0) in the aseptic loosening group (chi-square 2.55; p = 0.11).The adjusted HR for thick liners (⩾7.9 mm) was 0.65 (95% CI, 0.38-1.08) compared with the thin liners (<7.9 mm), which was not significantly different.

CONCLUSIONS

From this single-centre retrospective study it appears that thinner polyethylene liners are well tolerated when using second-generation highly cross-linked polyethylene. Thickness of the XLPE liners did not influence the risk of aseptic loosening of the implants in the medium term.

Taper-wedge stem suitable for anterior approach total hip arthroplasty: Adequate biomechanical reconstruction parameters and excellent clinical outcome at mid-term follow-up

BACKGROUND

The direct anterior approach (DAA) for total hip arthroplasty (THA) is a less invasive and muscle-sparing approach that seems to improve early function and patient satisfaction. Several studies, however, have reported high complication and revision rates due to the technical difficulties related to the femoral preparation.

AIM

To evaluate the usefulness and safety of a new stem equipped with a morphometric design and a size-specific medial curvature in DAA for THA.

METHODS

This retrospective study was based on 130 patients that underwent mini-invasive DAA procedures for THA using the Accolade II stem. A total of 144 procedures were included in the assessment, which was based on postoperative complications, survival rates, functional parameters, and patient related outcomes.

RESULTS

Overall complications were recorded in 6 procedures (4.2%). There were no complications related to the stem implantation and no intraoperative fractures. Only one patient was revised for deep infection. On radiographs, biomechanical hip reconstruction was satisfactory and no stem showed any subsidence greater than 2 mm. Full osseointegration based on Engh scores was seen in all of the implanted stems. Median Harris hip score at final follow-up was 99 points (range 44-100 points), which resulted excellent in 91.3% of patients. The median values of the osteaorthritis outcome score ranged from 87.5 to 95.

CONCLUSION

The mid-term positive outcomes and low complication rate in our consecutive series of patients support the safety and suitability of this new stem design in DAA for THA.

The percutaneous learning curve of 3rd generation minimally-invasive Chevron and Akin osteotomy (MICA)

BACKGROUND

Minimally-invasive Chevron and Akin osteotomy (MICA) represents the third-generation percutaneous hallux valgus surgery which is characterized by an extra-articular osteotomy, stable internal fixation and a high potential for correction. Compared to other percutaneous techniques of the foot, MICA is generally regarded as an advanced and demanding surgical procedure with a flat learning curve. The aim of this study is to analyze a single-surgeons experience with his first 50 consecutive MICA procedures.

METHODS

Between May 2018 and February 2021, 50 consecutive MICA procedures performed by the author with the "K-wires-First technique" were prospectively analyzed focusing on surgery duration, number of fluoroscopies, correction results and surgery-associated complications. A modification of the original MICA technique as described by its inaugurators Redfern and Vernois allows the use of a standard-sized C-arm and aims to reduce revison rates and conversion to open surgery by placing the guidewires prior to performing the osteotomy.

RESULTS

The average surgery time for all MICA procedures was 46.8 min (SD 12.1, range 31-90 min). The average amount of fluoro shots required to perform MICA was n = 126.6 (SD 40.8, range 65-231). Comparing the preoperative and 6-week postoperative radiographs, the IMA decreased after MICA by a mean of 10.8° from 16.2° to 5.4° and the HVA by a mean of 22.1° from 30.6° to 8.5°. One case required intraoperative conversion to open hallux correction. There were 4 feet in three patients with secondary screw removal of the Chevron fixation due to prominent proximal screw tips.

CONCLUSIONS

Although the learning curve of 3rd generation MICA is flat and requires specific training and intensive practice, the rate of complications is not elevated compared to other percutaneous hallux valgus techniques. Strict adherence to the principles of 3rd generation MICA with stable fixation and meticulous intraoperative control of each surgical step helps to reduce surgery-associated complications. The learning curve showed a continous improvement in regard to surgery time and use of fluoroscopy. After 40 procedures, the surgery time consistently dropped under 45 min and required less than 100 fluoro-shots. The modified surgical technique may help reduce Chevron screw mal-positioning when using large C-arm fluoroscopy for this procedure.

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

PURPOSE

Direct anterior approach (DAA) arthroplasty has generated great interest because of its minimally invasive and muscle sparing nature. Obese patients are reported to be associated with greater incidence of complications in primary joint replacement. The purpose of this study was to compare patient outcomes and complication rates between obese and non-obese patients undergoing primary total hip arthroplasty (THA) through a Bikini direct anterior incision.

METHODS

This retrospective, single surgeon study compared the outcome of 258 obese patients and 200 non-obese patients undergoing DAA THA using a Bikini incision, over a 5-year period. The average follow-up was 3.2 years (range 1.1-5.6 years).

RESULTS

There was no statistically significant differences in the complication rate between the two groups. The obese group recorded 2 major (venous thromboembolism and peri-prosthetic fracture) and 2 minor complications (superficial wound infection), compared with the non-obese group, which recorded 2 major (deep-wound infection and peri-prosthetic fracture) and 1 minor complication (superficial wound infection). Patient-reported outcomes (WOMAC and Harris Hip Scores) showed significant post-operative improvements (p < 0.001) and did not differ between the two groups.

CONCLUSIONS

Bikini DDA THA does not increase the complication rate in obese patients and offers similar clinical improvements compared to non-obese patients.

Learning curve for active robotic total knee arthroplasty

PURPOSE

Total Knee Arthroplasty (TKA) procedures incorporate technology in an attempt to improve outcomes. The Active Robot (ARo) performs a TKA with automated resections of the tibia and femur in efforts to optimize bone cuts. Evaluating the Learning Curve (LC) is essential with a novel tool. The purpose of this study was to assess the associated LC of ARo for TKA.

METHODS

A multi-center prospective FDA cohort study was conducted from 2017 to 2018 including 115 patients that underwent ARo. Surgical time of the ARo was defined as Operative time (OT), segmented as surgeon-dependent time (patient preparation and registration) and surgeon-independent time (autonomous bone resection by the ARo). An average LC for all surgeons was computed. Complication rates and patient-reported outcome (PRO) scores were recorded and examined to evaluate for any LC trends in these patient related factors.

RESULTS

The OT for the cases 10-12 were significantly quicker than the OT time of cases 1-3 (p < 0.028), at 36.5 ± 7.4 down from 49.1 ± 17 min. CUSUM and confidence interval analysis of the surgeon-dependent time showed different LCs for each surgeon, ranging from 12 to 19 cases. There was no difference in device related complications or PRO scores over the study timeframe.

CONCLUSION

Active Robotic total knee arthroplasty is associated with a short learning curve of 10-20 cases. The learning curve was associated with the surgical time dedicated to the robotic specific portion of the case. There was no learning curve-associated device-related complications, three-dimensional component position, or patient-reported outcome scores.

LEVEL OF EVIDENCE

Level II.

The learning curve for the direct anterior total hip arthroplasty: a systematic review

BACKGROUND

The direct anterior approach (DAA) for total hip arthroplasty (THA) is a muscle-sparing approach thought to have less post-operative pain and quicker recovery, with similar functional outcomes to other approaches. However, it is technically challenging and transitioning surgeons may experience increased complication rates. The purpose of this systematic review is to identify reported learning curves associated with the DAA.

METHODS

Three databases (MEDLINE, Embase, and Web of Science) were searched using terms including "total hip arthroplasty," "direct anterior approach," and "learning curve." Study characteristics, patient demographics, learning curve analyses, and complications were abstracted.

RESULTS

Twenty-one studies met inclusion criteria, with a total of 9738 patients (60% female), an average age of 63.7 years (range: 13-94), body mass index of 27.0 kg/m2 (range: 16.8-58.9), and follow-up of 19 months (range: 1.5-100). There were five retrospective cohort studies and 13 case series representing fair methodological quality. Six studies depicted a true learning curve, with mean operative time of 156.59 ± 41.71 minutes for the first case, 93.18 ± 14.68 minutes by case 30, and 80.45 ± 12.28 minutes by case 100. Mean complication rate was 20.8 ± 12.7% in early groups and decreased to 7.6 ± 7.1% in late groups.

CONCLUSION

This review demonstrated a substantial learning curve associated with the DAA to THA. Operative time plateaued after approximately 100 cases. Complication rates decreased substantially from early to late groups.

Does using the direct anterior approach with a standard table for total hip arthroplasty reduce leg length discrepancies? Comparative study of traction table versus standard table

INTRODUCTION

Primary total hip replacement (THR) comes with a risk of leg length discrepancy (LLD), which occurs in 25 % of cases, especially when the surgery is done using an anterior approach on a traction table, since it is not easy to verify the lengths of the legs. By doing the anterior approach on a standard table an intraoperative visual evaluation of leg lengths can be done after the trial implants are in place. As far as we know, the ability to set the leg length has not been compared between procedures done on a standard table or a traction table. This led us to carry out a retrospective comparative study to determine whether using a standard table for anterior THR will 1) allow better control over leg length, 2) increase the risk of incorrect implant positioning, 3) increase the surgical complication rate.

HYPOTHESIS

Anterior THR on a standard table will allow better control over leg length than anterior THR on a traction table.

MATERIAL AND METHODS

This single center retrospective study included 266 THRs done between January 1, 2018 and November 2, 2019 for primary (n=219) or secondary (n=47) hip osteoarthritis. The 137 cases done with a traction table were compared to the 129 cases with a standard table. The two groups were comparable in terms of age, sex, body mass index, indication and bilateral implants. They were not comparable in the surgeon experience (more junior surgeons in the standard table group [p<0.001]) and types of implants used (more cementless cups and stems in the standard table group [p=0.001]). Radiographs were used to measure the LLD, cup inclination, and femoral stem placement in the frontal plane. Any early complications were documented. The target was for the operated leg to be the same length as the contralateral leg, which was defined as within 10mm of each other.

RESULTS

The mean postoperative LLD was comparable between the traction table group 1.56±7.32 mm (min -15.6 max 17.2) and the standard table group 0.53±6.93 mm (min -16.4 max 13.7) (p=0.24). In the traction table group, 81 % (111/137) of patients had legs of the same length, versus 84 % (109/129) in the standard table group (p=0.7). Cup inclination was comparable with a mean of 40.4±7.1 degrees (min 23.4; max 58.5) in the traction table group versus 39.3±7.5 degrees (min 19.9; max 60.9) in the standard table group (p=0.21). The frontal position of the femoral stem was comparable between groups with a mean of 0.09±0.45 degrees (min -1; max 3.98) in the traction table group versus 0.08±0.59 degrees (min -4.97; max 1.93) in the standard table group (p=0.86). There were 5 complications (3.7 %) in the traction table group versus 11 (8.5 %) in the standard table group (p=0.16).

CONCLUSION

Use of a standard table to carry out THR by the direct anterior approach does not provide better control over leg length than using a traction table, subject to preoperative planning. When doing the procedure on a standard table, the implant placement is at least comparable, with a similar risk of complications.

LEVEL OF EVIDENCE

III; case matched study.

Fatty muscle infiltration of the hip lateral rotator muscles following direct anterior minimally invasive total hip arthroplasty

INTRODUCTION

There is no consensus as to the best surgical approach to use when doing total hip arthroplasty (THA). There has been renewed interest in recent years in so-called anatomic minimally invasive direct anterior approaches (DAA). However, their reduced impact has not been confirmed with imaging data. This led us to carry out a prospective study to 1) evaluate fatty infiltration (FI) of muscles around the hip joint and 2) analyze how this FI changes over time.

HYPOTHESIS

THA done by the DAA induces FI of the anterolateral muscles around the hip adjacent to the approach.

MATERIAL AND METHODS

A continuous case series of THA by DAA using a traction table was done by a single experienced surgeon. MRI images (GE Optima* MR360 1.5T) were taken preoperatively, then at 3 months and 1 year after the THA surgery. Muscle FI was classified as described by Goutallier by an independent radiologist on all the muscles around the hip joint. A Wilcoxon test was used to compare the preoperative MRI data to the data at 3 months and 1 year postoperative.

RESULTS

Sixty-nine MRI examinations were done in 23 patients. Two were not interpretable because the patient moved during the preoperative acquisition. No intraoperative or postoperative complications were reported. None of the patients had hip pain or limped at 1 year postoperative. The FI was significantly worse from the preoperative MRI to the 3-month postoperative MRI (p=0.02) and 1-year MRI (p=0.0007) in the internal obturator muscle and at 1 year in the piriformis muscle (p=0.04). There was no significant difference for the other muscles. The rectus femoris, superior and inferior gemellus muscles and the quadratus femoris could not be analyzed.

DISCUSSION

Our hypothesis was not confirmed, although we had a paradoxical finding of muscle FI in the posterior lateral rotator muscles not the anterolateral muscles after THA by DAA. These lesions may be secondary to detachment or denervation of these muscles when elevating the femur to prepare the femoral canal or insert the stem.

LEVEL OF EVIDENCE

IV; Prospective case series.

Total hip arthroplasty performed by direct anterior approach - Does experience influence the learning curve?

INTRODUCTION

Proficiency in the direct anterior approach (DAA) as with many surgical techniques is considered to be challenging. Added to this is the controversy of the benefits of DAA compared to other total hip arthroplasty (THA) approaches. Our study aims to assess the influence of experience on learning curve and clinical results when transitioning from THA via posterior approach in a lateral position to DAA in a supine position.

METHODS

A consecutive retrospective series of 525 total hip arthroplasty of one senior and six junior surgeons was retrospectively analysed from May 2013 to December 2017. Clinical results were analysed and compared between the two groups and represented as a learning curve. Mean follow up was 36.2 months ± 11.8.

RESULTS

This study found a significant difference in complications between the senior and junior surgeons for operating time, infection rate, and lateral femoral cutaneous nerve (LFCN) neuropraxia. A trainee's learning curve was an average of 10 DAA procedures before matching the senior surgeon. Of note, the early complications correlated with intraoperative fractures increased with experience in both groups. Operating time for the senior equalised after 70 cases. Dislocation rate and limb length discrepancy were excellent and did not show a learning curve between the two groups.

CONCLUSION

DAA is a safe approach to implant a THA. There is a learning curve and initial supervision is recommended for both seniors and trainees.

LEVEL OF EVIDENCE

Retrospective, consecutive case series; level IV.

Anterior approach without traction table: A means of saving time and money in hemiarthroplasty for femoral neck fracture? A case-matched study with and without traction table

BACKGROUND

The costs incurred by management of displaced femoral neck fracture are a public health issue. The anterior approach can be used for partial hip replacement, but costs in terms of equipment and time incurred by using a traction table have not to our knowledge been estimated in this indication. We therefore performed a case-control study, comparing (1) installation and deinstallation times (IT, DT) in partial hip replacement using a standard versus a traction table (ST, TT), and (2) operating times, limb-length radiography and intraoperative complications.

HYPOTHESIS

Performing the anterior approach on a standard table saves installation and deinstallation time and operating time, without leading to more intraoperative complications.

MATERIALS AND METHODS

A comparative retrospective study included 102 patients (mean age, 84.8±8 years; 46 ST, 56 TT). Installation time (IT) was calculated between entry in the operating room and performance of the incision; operating time (OT) between incision and closure; and deinstallation time (DT) between closure and leaving the operating room.

RESULTS

Mean IT in ST (25.5±6.2min) was significantly shorter than in TT (33.9±6.2min) (p=1.1*10^-9), as were DT (13±4.7 versus 17±3.4min) (p=4.1*10^-6) and OT (73.5±15.9 versus 82.6±21.3minutes) (p=0.01). There were 4 intraoperative complications: 1 greater trochanter fracture in ST and 2 greater trochanter fractures and 1 proximal femoral fracture in TT. Limb-length discrepancy was comparable between ST (3.7±3.2mm (range, 0-15mm)) and TT (5.3±4.6mm (range, 0-20mm)) (p=0.06).

DISCUSSION

Patient installation on a standard table reduced installation, deinstallation and operating time compared to use of a traction table, without increasing the complications rate.

LEVEL OF EVIDENCE

III, case-control study.