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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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McCormick KL, Mastroianni MA, Kolodychuk NL, Herndon CL, Shah RP, Cooper HJ, Sarpong NO. Complications and Survivorship After Aseptic Revision Total Hip Arthroplasty: Is There a Difference by Surgical Approach? J Arthroplasty 2024:S0883-5403(24)00651-X. [PMID: 38936438 DOI: 10.1016/j.arth.2024.06.050] [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: 01/23/2024] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Revision total hip arthroplasty (rTHA) has traditionally been performed through the posterolateral approach (PA). Anterior approaches (AA) for rTHA are increasingly being utilized. The purpose of this study was to compare complications and survivorship from re-revision and reoperation after aseptic rTHA performed using an AA versus a PA. METHODS We retrospectively reviewed patients who underwent aseptic rTHA either through an AA (direct anterior approach [DAA], anterior-based muscle sparing [ABMS]) or PA from January 2017 to December 2021. There were 116 patients who underwent AA-rTHA (DAA 50, ABMS 66) or PA-rTHA (n = 105). Patient demographics, complications, and postoperative outcomes were collected. RESULTS The most common indication in both groups was aseptic loosening (n = 26, 22.4% AA, n = 28, 26.7% PA). Acetabular revision alone was most common in the AA group (n = 33, 28.4%), while both components were most commonly revised in the PA groups (n = 47, 44.8%). In all the AA-rTHA group, the index total hip arthroplasty was performed through a PA in 51% of patients, while the PA-rTHA group had the index procedure performed via AA in 4.8%. There was no statistically significant difference in re-revision rate between the DAA, ABMS, or PA groups (9.55 versus 5.3% versus 11.4%, respectively, P = .11). The most common overall reason for re-revision was persistent instability, with no difference in incidence of postoperative hip dislocation (n = 4, 6.8% DAA, n = 3, 5.3%, n = 10, 9.5% PA; P = .31). CONCLUSIONS This study demonstrates no difference in complication or re-revision survivorship after aseptic rTHA performed through a DAA, ABMS approach, or PA, nor between anterior or posterior-based approaches. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Kyle L McCormick
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Michael A Mastroianni
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Nicholas L Kolodychuk
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Carl L Herndon
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Roshan P Shah
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - H John Cooper
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Nana O Sarpong
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
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Coxe FR, Kahlenberg CA, Garvey M, Cororaton A, Jerabek SA, Mayman DJ, Figgie MP, Sculco PK. Early Recovery Outcomes in Patients Undergoing Contemporary Posterior Approach Total Hip Arthroplasty: Each Week Shows Progress. HSS J 2024; 20:245-253. [PMID: 39281992 PMCID: PMC11393627 DOI: 10.1177/15563316231158615] [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: 10/28/2022] [Accepted: 12/19/2022] [Indexed: 09/18/2024]
Abstract
Background: Little is known about patients' postoperative week-by-week progress after undergoing posterior approach total hip arthroplasty (THA) with regard to pain, function, return to work, and driving. Purpose: We sought to evaluate a large cohort of patients undergoing posterior approach THA with modified posterior hip precautions to better understand the trajectory of recovery. Methods: Patients at a single institution undergoing primary posterior approach THA by fellowship-trained arthroplasty surgeons were prospectively enrolled. Patient functional status and early rehabilitation recovery milestones were evaluated preoperatively and each week postoperatively for 6 weeks. Results: Of 312 patients who responded to weekly questionnaires, there were varying response rates per question. At 1 week after surgery, 15% (39/256) of respondents had returned to work, increasing to 57% (129/225) at week 6. At 6 weeks, 77% of patients (174/225) had returned to driving; 25% (56/225) were taking pain medication (including prescription opioids or nonsteroidal anti-inflammatory drugs); and 15% (34/225) were using assistive devices (down from 91%, 78%, 56%, 35%, and 27% at weeks 1, 2, 3, 4, and 5, respectively). Average postoperative Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement and Lower Extremity Functional Scale scores were significantly higher than preoperative scores. Respondents reported significantly less pain at each week postoperatively than the previous week. Conclusion: These findings suggest that there may be an expected pathway for recovery after posterior THA using perioperative pain protocols, modified postoperative precautions, and physical therapy protocols to improve patient outcomes after THA, with most patients returning to normal at 4 weeks. Defining the expected recovery timeline may help surgeons in counseling patients preoperatively and guiding their recovery.
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Affiliation(s)
- Francesca R Coxe
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA
| | - Cynthia A Kahlenberg
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA
| | - Matthew Garvey
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA
| | - Agnes Cororaton
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA
| | - Seth A Jerabek
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA
| | - David J Mayman
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA
| | - Mark P Figgie
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA
| | - Peter K Sculco
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA
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Choudhary A, Pisulkar G, Taywade S, Awasthi AA, Salwan A. A Comprehensive Review of Total Hip Arthroplasty Outcomes in Post-traumatic Hip Arthritis: Insights and Perspectives. Cureus 2024; 16:e56350. [PMID: 38633974 PMCID: PMC11021999 DOI: 10.7759/cureus.56350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 03/17/2024] [Indexed: 04/19/2024] Open
Abstract
Post-traumatic hip arthritis presents a challenging condition characterized by degenerative changes in the hip joint following traumatic injury. Total hip arthroplasty (THA) is a cornerstone in managing this condition, offering significant pain relief, functional improvement, and enhanced quality of life. This comprehensive review aims to synthesize existing literature to elucidate the outcomes of THA in post-traumatic hip arthritis, exploring factors influencing surgical success and identifying areas for further research. Key findings reveal favourable clinical outcomes associated with THA, though considerations such as patient characteristics, surgical techniques, and implant selection impact outcomes. Implications for clinical practice underscore the importance of tailored preoperative assessment and ongoing advancements in surgical approaches and implant technology. Furthermore, opportunities for future research lie in long-term durability studies, patient-reported outcomes assessment, and exploration of innovative surgical techniques. Overall, THA emerges as a promising intervention for post-traumatic hip arthritis, yet continual refinement through research and innovation remains imperative to optimize patient care in this population.
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Affiliation(s)
- Abhishek Choudhary
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Gajanan Pisulkar
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Shounak Taywade
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Abhiram A Awasthi
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Ankur Salwan
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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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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Chang JS, Kang MW, Lee DH, Kim JW, Kim CH. Comparing the Anterior-Based Muscle-Sparing Approach with the Direct Anterior Approach in Hip Arthroplasty: A Systematic Review and Pairwise Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1390. [PMID: 37629680 PMCID: PMC10456498 DOI: 10.3390/medicina59081390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/23/2023] [Accepted: 07/27/2023] [Indexed: 08/27/2023]
Abstract
Background and Objectives: The anterior-based muscle-sparing (ABMS) approach, which utilizes the interval between the tensor fasciae latae posteriorly, offers several advantages, such as the reduced risk of nerve injury and the freedom to choose various implants. Herein, we aimed to compare the outcome of ABMS to the direct anterior (DA) approach using pairwise meta-analysis techniques. Materials and Methods: A systematic search of the MEDLINE (PUBMED), Embase, and Cochrane Library databases was performed for studies published up to 7 June 2023, which compared the ABMS approach with the DA approach for hip arthroplasty. We compared (1) perioperative outcomes (operation time, visual analog scale (VAS) score, total opioid consumption, length of hospital stay (LOS), and the number of patients discharged to their homes); (2) postoperative complications (neuropraxia/nerve injury, dislocation, surgical site infection, intraoperative fracture, and reoperation rate); and (3) implant position (cup inclination, cup anteversion, and stem alignment). Results: Ten studies were eligible for meta-analysis, including 1737 patients who underwent hip arthroplasty with the ABMS approach and 1979 with the DA approach. The pooled analysis showed no differences in all outcome variables, including perioperative outcomes, postoperative complications, and the implant position between the two surgical approaches. Conclusions: In current meta-analysis, the ABMS approach demonstrated comparable results to the conventional DA approach in terms of both clinical and radiologic outcomes as well as postoperative complications. Furthermore, the ABMS approach has the advantage of a broader indication and fewer limitations in terms of the surgical position compared to the DA approach. Therefore, the ABMS approach can be even more beneficial as an option within MSA, surpassing the utility of the DA approach.
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Affiliation(s)
- Jae Suk Chang
- Department of Orthopedic Surgery, National Police Hospital, Seoul 05715, Republic of Korea; (J.S.C.); (M.W.K.); (D.H.L.)
| | - Min Wook Kang
- Department of Orthopedic Surgery, National Police Hospital, Seoul 05715, Republic of Korea; (J.S.C.); (M.W.K.); (D.H.L.)
| | - Dong Hwan Lee
- Department of Orthopedic Surgery, National Police Hospital, Seoul 05715, Republic of Korea; (J.S.C.); (M.W.K.); (D.H.L.)
| | - Ji Wan Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea;
| | - Chul-Ho Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea;
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Passano B, Simcox T, Singh V, Anil U, Schwarzkopf R, Davidovitch RI. Does Surgical Approach to the Hip Play a Role in Same-Day Discharge Outcomes? J Arthroplasty 2023:S0883-5403(22)01132-9. [PMID: 36608836 DOI: 10.1016/j.arth.2022.12.042] [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: 09/08/2022] [Revised: 12/19/2022] [Accepted: 12/27/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Different approaches for total hip arthroplasty (THA) may offer advantages in regard to achieving same-day-discharge (SDD) success. METHODS We retrospectively identified patients aged ≥ 18 years who underwent elective primary THA from 2015 to 2020 who were formally enrolled in a single institution's SDD program. A total of 1,127 and 207 patients underwent THA via direct anterior approach and posterior approach, respectively, were included. Cohorts were assigned based on approach. The primary outcome was failure-to-launch, defined as hospital stay extending past 1 midnight. Secondary outcomes included Forgotten Joint Score-12, Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, 90-day readmission and revision rate, and surgical time. Patient-reported outcomes were collected at 3 and 12 months. RESULTS After controlling for demographic differences, posterior approach patients had higher rates of failure-to-launch (12.1% versus 5.9%, P = .002) and longer surgical times (99 versus 80 minutes; P < .001) compared to direct anterior approach patients. The cohorts had similar readmission (1.7% versus 1.4%; P = .64) and revision rates (1% versus 1%; P = .88). The magnitude of improvement in Hip Disability and Osteoarthritis Outcome Score for Joint Replacement scores from preoperative to 12 months was similar between cohorts (35.3 versus 34.5; P = .42). The differences in outcome scores between cohorts at each time point were not considered clinically significant. CONCLUSION Our analysis suggests that patient selection and surgical approach may be important for achieving SDD. Surgical approach did not significantly impact readmission or revision rates nor did it have a meaningful impact on patient-reported outcomes in the first year after surgery.
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Affiliation(s)
- Brandon Passano
- Department of Orthopedic Surgery, NYU Long Island, Mineola, New York
| | - Trevor Simcox
- Department of Orthopedic Surgery, NYU Long Island, Mineola, New York
| | - Vivek Singh
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York; Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Utkarsh Anil
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Roy I Davidovitch
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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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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Armbruster M, Paulus A. [Postoperative imaging of the hip]. RADIOLOGIE (HEIDELBERG, GERMANY) 2022; 62:862-869. [PMID: 35904572 DOI: 10.1007/s00117-022-01050-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 06/15/2023]
Abstract
CLINICAL ISSUE To assess postoperative imaging of the hip joint regarding possible complications, it is indispensable to have in-depth knowledge of commonly used surgical techniques, access routes, and the implanted materials. STANDARD RADIOLOGICAL METHODS While radiography is used to evaluate the position of foreign material and to rule out periprosthetic fractures that have occurred intraoperatively, follow-up examinations might show signs of material failure, aseptic loosening, prosthesis infections, or the occurrence of heterotopic ossifications. If radiographic findings are ambiguous, computed tomography (CT) may be used to clarify findings, whereas magnetic resonance imaging (MRI) is helpful to identify intra- and periarticular soft tissue pathologies such as surgery-associated cartilage and ligament damage, muscle insufficiency, or metallosis. METHODOLOGICAL INNOVATION AND EVALUATION To guide clinical decision making in common postoperative complications, various classification systems are available, e.g., for periprosthetic fractures, aseptic loosening, or heterotopic ossification. However, the differentiation between aseptic material loosening and septic endoprosthesis infection remains challenging if based on imaging alone. PRACTICAL RECOMMENDATIONS The assessment of postoperative hip imaging should be closely linked to the respective surgical technique and the implanted foreign material, whereby different probabilities of specific complications can be derived.
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Affiliation(s)
- Marco Armbruster
- Klinik und Poliklinik für Radiologie, LMU Klinikum München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland.
| | - Alexander Paulus
- Klinik und Poliklinik für Orthopädie, Physikalische Medizin und Rehabilitation, LMU Klinikum, Campus Großhadern, München, Deutschland
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Soza D, Pujol O, Lara Y, Castellanos S, Hernández A, Barro V. A comparative of a single novice surgeon's direct anterior approach and posterior approach learning curves in total hip arthroplasty: a retrospective cohort study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022; 32:767-774. [PMID: 34129119 DOI: 10.1007/s00590-021-03039-4] [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: 03/07/2021] [Accepted: 04/09/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The purpose of the present study was to compare a novice surgeon's learning curves with the direct anterior approach and posterior approach in total hip arthroplasty. METHODS A consecutive series of 376 total hip arthroplasties performed from November 2014 to September 2019 in a level-one healthcare center by a single surgeon (V.B) were retrospectively studied. Demographic data, functional outcomes, and complications were collected and compared. RESULTS Within the ranks of the patients studied, we found differences between groups with respect to dislocation rate and length of stay; these were lower in the direct anterior approach (DAA) group. The approach was not associated with an increase in complications, but rather with a decrease in the rate of dislocations and better functional outcomes at 1-year follow-up. Operative time was initially higher with this approach, but equalized during the learning curve. CONCLUSION The DAA can be safe even in the early stages of a novice surgeon's learning curve. It does not present a higher complication rate than the posterior approach, either in infection rate or in periprosthetic fractures. However, the DAA may provide greater functionality, lower dislocation rate and a shorter hospital stay. It can also be concluded that after having performed a certain number of interventions, operative time for the DAA can be comparable to that of other approaches.
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Affiliation(s)
- Diego Soza
- Hip Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona Departament de Cirurgia, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Oriol Pujol
- Hip Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona Departament de Cirurgia, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Yuri Lara
- Hip Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona Departament de Cirurgia, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Sara Castellanos
- Hip Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona Departament de Cirurgia, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Alejandro Hernández
- Hip Surgery Unit, Orthopedic Surgery Department, Josep Trueta University Hospital, Av. França s/n, 17007, Girona, Spain
| | - Víctor Barro
- Hip Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona Departament de Cirurgia, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain
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Postoperative Patient-reported Pain and Opioid Consumption After Total Hip Arthroplasty: A Comparison of the Direct Anterior and Posterior Approaches. J Am Acad Orthop Surg 2022; 30:e108-e117. [PMID: 34406982 DOI: 10.5435/jaaos-d-21-00082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 07/19/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Although one of the touted benefits of the direct anterior approach (DAA) includes decreased postoperative pain, there is no consensus on the effect of surgical approach on postoperative pain and subsequent analgesic consumption. METHODS Consecutive patients undergoing total hip arthroplasty by a single surgeon from May 2016 to March 2020 were identified. Procedures were categorized as DAA or posterior approach. Patient demographics and surgical details were assessed. Patient-reported maximum pain by postoperative day (POD), total opioid consumption during hospitalization, and whether the patient required a refill of opioid prescription within 3 months after discharge were compared between the two surgical approaches through multivariate analyses. RESULTS A total of 611 patients were included in this study (447 DAA and 164 posterior approaches). On multivariate analyses that controlled for preoperative/intraoperative differences, patients in the DAA group had lower average maximum reported pain (0 to 10 scale) on POD #0 (6.5 versus 6.8, P = 0.034) and POD #1 (5.4 versus 6.1, P = 0.018). However, the DAA was not associated with a statistically significant reduction in total inpatient oral morphine equivalents consumed (79.8 versus 100.1, P = 0.486). Furthermore, there was no association between surgical approach and opioid prescription refill within 3 months after discharge (P = 0.864). DISCUSSION The DAA was associated with slightly lower patient-reported pain. Furthermore, statistical analysis did not provide the necessary evidence to reject the null hypothesis, which was that there would be no difference in opioid utilization between the two approaches. Other perioperative factors may be more important to opioid use reduction than the surgical approach alone.
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Nambiar M, Cheng TE, Onggo JR, Maingard J, Troupis J, Pope A, Armstrong MS, Singh PJ. No Difference in Functional, Radiographic, and Survivorship Outcomes Between Direct Anterior or Posterior Approach THA: 5-Year Results of a Randomized Trial. Clin Orthop Relat Res 2021; 479:2621-2629. [PMID: 34237041 PMCID: PMC8726547 DOI: 10.1097/corr.0000000000001855] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/13/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Both the direct anterior approach (DAA) and posterior approach (PA) to THA have known advantages and disadvantages. The comparison between DAA and PA THA has been widely explored during the early postoperative period. However, few randomized trials have compared these approaches at a minimum follow-up of 5 years; doing so would be important to establish any differences in mid-term outcomes or complications. QUESTIONS/PURPOSES We performed a randomized trial comparing DAA and PA in THA in terms of (1) patient-reported outcome scores, (2) quality of life and functional outcomes assessed by the EQ-5D and 10-meter walk test results, (3) radiographic analysis, and (4) survivorship and surgical complications at a minimum of 5 years follow-up. METHODS Two hip specialist surgeons performed both DAA and PA THA using the same THA components at two hospital sites. One hundred twelve patients on the elective THA surgical waitlist were invited to participate in the study. Thirty-four patients did not meet the study's inclusion criteria and were excluded, and three patients declined to participate in the study. The remaining 75 patients who were eligible were randomized into DAA and PA groups. Thirty-seven patients were initially randomized to receive DAA THA, but two did not and were excluded, resulting in 48% (35 of 73) of patients who received DAA THA; 52% (38 of 73) of patients were randomized into and received PA THA. Over a minimum 5 years of follow-up, 3% (1 of 35) of DAA patients were lost to follow-up, and none of the patients undergoing PA THA were lost. A per-protocol analysis was adopted, resulting in further patients being excluded from analysis. Of the 73 study patients, 99% (72; DAA: 35, PA: 37) were analyzed at 1 year, 95% (69; DAA: 34, PA: 35) were analyzed at 2 years, and 72% (52; DAA: 23, PA: 29) were analyzed at 5 years. The primary outcome was the Oxford Hip Score (OHS) and WOMAC score. Secondary outcomes included the EQ-5D and EQ-5D VAS scores, 10-meter walk test results, radiographic evidence of loosening (femoral: lucency > 2 mm at the implant-bone interface, subsidence > 2 mm; acetabular: migration or change in inclination), 5-year survivorship analysis from all-cause revisions, and surgical complications. The study was powered to detect a 10-point difference in the WOMAC score, which is equivalent to the minimum clinically important difference (MCID). RESULTS There were no differences in primary outcomes (OHS and WOMAC scores) or secondary outcomes (EQ-5D scores, EQ-5D VAS scores, and 10-meter walk test result) between the DAA and PA groups at the 5-year follow-up interval. The median (range) OHS at 5 years was 46 (16 to 48) for DAA and 47 (18 to 48) for PA groups (p = 0.93), and the median WOMAC score was 6 (0 to 81) for DAA and 7 (0 to 59) for PA groups (p = 0.96). The median EQ-5D score was 1 (0.1 to 1) for DAA and 1 (0.5 to 1) for PA groups (p = 0.45), and the median EQ-5D VAS score was 85 (60 to 100) for DAA and 95 (70 to 100) for PA groups (p = 0.29). There were no cases of component loosening on radiographs. There was no difference in component survival between the two approaches at 5 years (DAA: 97% [95% CI 85% to 100%] versus PA: 97% [95% CI 87% to 100%]). Eight of 23 patients in the DAA group reported decreased sensation in the lateral femoral cutaneous nerve distribution. CONCLUSION DAA and PA are both effective approaches in performing primary THA. Each approach has its associated risks and complications. The choice of THA should be based on individual patient factors, surgeon experience, and shared decision-making. Early registry data indicate DAA and PA THA are comparable, but longer-term data with larger numbers of patients will be required before one can safely conclude equal survivorship between both approaches. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Mithun Nambiar
- Department of Orthopaedic Surgery, Box Hill Hospital, Box Hill, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Tze E. Cheng
- Department of Orthopaedic Surgery, Box Hill Hospital, Box Hill, Victoria, Australia
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - James R. Onggo
- Department of Orthopaedic Surgery, Box Hill Hospital, Box Hill, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Julian Maingard
- Monash Imaging, Monash Medical Centre, Clayton, Victoria, Australia
| | - John Troupis
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
- Monash Imaging, Monash Medical Centre, Clayton, Victoria, Australia
| | - Alun Pope
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Michael S. Armstrong
- Department of Orthopaedic Surgery, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Parminder J. Singh
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
- Department of Orthopaedic Surgery, Maroondah Hospital, Ringwood, Victoria, Australia
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Yang Z, Feng S, Guo KJ, Zha GC. Patient-reported results of simultaneous direct anterior approach and posterolateral approach total hip arthroplasties performed in the same patients. J Orthop Traumatol 2021; 22:46. [PMID: 34773489 PMCID: PMC8590638 DOI: 10.1186/s10195-021-00611-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 10/31/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Several studies have compared clinical results of the direct anterior approach (DAA) and the posterolateral approach (PLA) in total hip arthroplasty (THA); however, the effect of the surgical approach on outcome of THA remains controversial. Most of these studies used two distinct groups of patients, and THAs were performed by different surgeons, using different designs of prosthesis. These confounding factors may limit the strength of the conclusions. The purpose of this prospective, simultaneous bilateral randomized study was to investigate whether patients would perceive the difference between the direct anterior approach (DAA) and the posterolateral approach (PLA) after THA. MATERIALS AND METHODS Among 20 patients scheduled to undergo same-day bilateral THA between October 2017 and August 2019, one hip was randomly assigned to DAA and the other to PLA. Patient-reported outcome measures [Hip disability and Osteoarthritis Outcome Score (HOOS), patients' hip pain on mobilization] and physician-assessed measures [Harris Hip Score (HHS), operative time, intraoperative blood loss, cup abduction, cup anteversion, stem orientation, and incidence of complications (intraoperative fracture, nerve damage, incisional problem, or postoperative dislocation)] were compared. RESULTS All patients were followed up for 12 months. Hip pain was significantly less with DAA-THA compared with PLA-THA at postoperative 1, 3, and 7 days (p < 0.05). There was no clinical difference between DAA-THA and PLA-THA in terms of the VAS, HOOS, or HSS at 6 weeks and 3, 6, and 12 months postoperatively (p > 0.05). DAA-THA had a longer operative time and shorter length of incision compared with PLA-THA. There was no statistical difference between DAA-THA and PLA-THA in terms of intraoperative blood loss, cup abduction, cup anteversion, stem orientation, and perioperative complications (p > 0.05). CONCLUSIONS This study demonstrates that DAA-THA and PLA-THA could provide comparable HHS and HOOS at all follow-ups. Compared with PLA-THA, DAA-THA is associated with less hip pain within postoperative 7 days and shorter incision length, but longer operative time. LEVEL OF EVIDENCE Level I, therapeutic study. Trial registration Chinese Clinical Trail Registry, ChiCTR1800019816. Registered 30 November 2018-retrospectively registered, http://www.chictr.org.cn/showproj.aspx?proj=30863.
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Affiliation(s)
- Zhi Yang
- Department of Orthopedic Surgery, The Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Xuzhou, 221002, Jiangsu, People's Republic of China
| | - Shuo Feng
- Department of Orthopedic Surgery, The Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Xuzhou, 221002, Jiangsu, People's Republic of China
| | - Kai-Jin Guo
- Department of Orthopedic Surgery, The Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Xuzhou, 221002, Jiangsu, People's Republic of China
| | - Guo-Chun Zha
- Department of Orthopedic Surgery, The Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Xuzhou, 221002, Jiangsu, People's Republic of China.
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Zhang Y, Yao Y, Wang Y, Zhuang Z, Shen Y, Jiang Q, Chen D. Preoperative ultrasound to map the three-dimensional anatomical distribution of the lateral femoral cutaneous nerve in direct anterior approach for total hip arthroplasty. J Orthop Surg Res 2021; 16:623. [PMID: 34663391 PMCID: PMC8522191 DOI: 10.1186/s13018-021-02763-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 09/30/2021] [Indexed: 12/02/2022] Open
Abstract
Background The postoperative complaints of hypoesthesia or a burning sensation due to lateral femoral cutaneous nerve (LFCN) injury in patients are not yet solved. The present study aimed to identify the three-dimensional (3D) distribution of LFCN using preoperative ultrasound and evaluate the rate of injury in direct anterior approach for total hip arthroplasty. Methods A total of 59 patients (28 males and 31 females, age 69.0 ± 4.6 years, BMI 24.7 ± 3.0 kg/m2) were randomly allocated to the ultrasound group and 58 patients (28 males and 30 females, age 68.5 ± 4.5 years, BMI 24.8 ± 2.8 kg/m2) were in the control group. Surgeons received the data of 3D distribution of LFCN only in the ultrasound group before surgery with respect to the direction, the depth on the skin, and the length to tensor fasciae latae (TFL). The anatomical characteristics of LFCN in the surgical region were summarized. At 1 and 3 months of post surgery, the rate of LFCN injury and abnormal sensitive area was evaluated in both groups. Results There was a significant consistency in gender, age and BMI of these two groups (P > 0.05). Based on the data from the ultrasound group, over 90% of patients had one or two branches of LFCN. LFCN always courses in the fascia layer, the depth ranged from 6.8 ± 2.6 (3.0–12.0) mm to 11.1 ± 3.4 (4.0–17.0) mm and depended on the thickness of the subcutaneous fat, and length was 3.3 ± 4.6 (− 5.0–10.0) mm at proximal part and − 2.7 ± 4.7 (− 10.0–8.0) at distal end to the medial edge of TFL. Both the rate of LFCN injury and abnormal sensory area in the ultrasound group was significantly lower than those in the control group (3.4% vs. 25.9%, P = 0.001, at 1 month; 3.4% vs. 22.4%, P = 0.005, at 3 months). Conclusions LFCN mostly courses along the medial border of TFL in the fascia layer. The 3D distribution of LFCN using preoperative ultrasound mapping could help the surgeons to evaluate the risk of injury preoperatively and decrease the rate of injury during the operation. However, some branch injuries, especially for the fan type LFCN, could not be avoided.
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Affiliation(s)
- Yu Zhang
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Branch of National Clinical Research Center for Orthopedics, Sports Medicine Rehabilitation, Nanjing, People's Republic of China
| | - Yao Yao
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Branch of National Clinical Research Center for Orthopedics, Sports Medicine Rehabilitation, Nanjing, People's Republic of China
| | - Yexian Wang
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Branch of National Clinical Research Center for Orthopedics, Sports Medicine Rehabilitation, Nanjing, People's Republic of China
| | - Zaikai Zhuang
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Branch of National Clinical Research Center for Orthopedics, Sports Medicine Rehabilitation, Nanjing, People's Republic of China
| | - Ying Shen
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Branch of National Clinical Research Center for Orthopedics, Sports Medicine Rehabilitation, Nanjing, People's Republic of China
| | - Qing Jiang
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China. .,Branch of National Clinical Research Center for Orthopedics, Sports Medicine Rehabilitation, Nanjing, People's Republic of China.
| | - Dongyang Chen
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China. .,Branch of National Clinical Research Center for Orthopedics, Sports Medicine Rehabilitation, Nanjing, People's Republic of China.
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Sershon RA, McDonald JF, Nagda S, Hamilton WG, Engh CA. Custom Triflange Cups: 20-Year Experience. J Arthroplasty 2021; 36:3264-3268. [PMID: 34074542 DOI: 10.1016/j.arth.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/19/2021] [Accepted: 05/05/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The custom triflange acetabular component is used during revision THA to address severe acetabular bone loss. Midterm results are promising, with low rates of loosening and triflange revision reported. However, reoperation and overall complication rates remain high. We aim to investigate our institution's custom triflange experience over 20 years by evaluating implant survivorship, reoperations, complications, and clinical outcomes. METHODS Prospectively collected data were reviewed for 50 patients undergoing revision THA with the use of a triflanged component from January 2000 to December 2018. 94% among these cases had a known outcome or minimum two year follow-up. Outcomes related to the triflange component were recorded, including revisions, reoperations, surgical complications, medical complications, Harris hip scores, and patient satisfaction. Phone interviews were conducted with patients whose recent follow-up exceeded 2 years. Radiographic review was performed to define implants as either stable or unstable. RESULTS The average Harris hip scores improved 24 points (49 to 73; P < .001). 91% of eligible patients were satisfied at follow-up. One patient was scheduled for revision at an outside institution during the study period. There were 2 reoperations (1 acute infection and 1 screw removal). One patient died due to pulmonary thromboembolism. A Trendelenberg gait was present in 46% (23/50) of patients. There were 14 major complications (28%). Dislocation (12%) was the most common complication. CONCLUSION Custom triflange components provide a reliable solution for managing complex acetabular defects in revision THA. Patients should be counseled on magnitude of surgery and the high incidence of complications, specifically infection and dislocation.
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Affiliation(s)
- Robert A Sershon
- Inova Mount Vernon Hospital Joint Replacement Center, Alexandria, VA; Anderson Orthopaedic Research Institute, Alexandria, VA
| | | | - Saira Nagda
- Anderson Orthopaedic Research Institute, Alexandria, VA
| | - William G Hamilton
- Inova Mount Vernon Hospital Joint Replacement Center, Alexandria, VA; Anderson Orthopaedic Research Institute, Alexandria, VA
| | - C Anderson Engh
- Inova Mount Vernon Hospital Joint Replacement Center, Alexandria, VA; Anderson Orthopaedic Research Institute, Alexandria, VA
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16
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Rykov K, Meys TWGM, Knobben BAS, Sietsma MS, Reininga IHF, Ten Have BLEF. MRI Assessment of Muscle Damage After the Posterolateral Versus Direct Anterior Approach for THA (Polada Trial). A Randomized Controlled Trial. J Arthroplasty 2021; 36:3248-3258.e1. [PMID: 34116911 DOI: 10.1016/j.arth.2021.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/26/2021] [Accepted: 05/07/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There is controversy in literature whether the direct anterior approach (DAA) results in less muscle damage compared with the posterolateral approach (PLA) for total hip arthroplasty. The aim of this randomized controlled trial was to assess muscle damage between these two approaches. METHODS Forty-six patients were included. Muscle atrophy, determined with the Goutallier classification, and muscle surface of twelve muscles were analyzed on magnetic resonance imaging images made preoperatively and one year postoperatively. Differences in component placement after DAA or PLA were assessed on radiographs. Harris hip scores and Hip disability and Osteoarthritis and Outcome Score were used as functional outcomes. RESULTS External rotator musculature was damaged in both approaches. After PLA, the obturator muscles showed significantly more atrophy and a decrease in muscle surface. After DAA, the tensor fascia latae showed an increased muscle atrophy and the psoas muscle showed a decreased muscle surface. An increase in muscle surface was seen for the rectus femoris, sartorius, and quadratus femoris after both approaches. The muscle surface of the gluteus medius and iliacus was also increased after PLA. No difference in muscle atrophy was found between the approaches for these muscles. The inclination angle of the cup in PLA was significantly higher. No differences were found in functional outcomes. CONCLUSION Different muscle groups were affected in the two approaches. After PLA, the external rotators were more affected, whereas the tensor fascia latae and psoas muscles were more affected after DAA.
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Affiliation(s)
- Kyrill Rykov
- Department of Orthopaedic Surgery, Martini Hospital Groningen, the Netherlands
| | - Tim W G M Meys
- Department of Radiology, Martini Hospital Groningen, the Netherlands
| | - Bas A S Knobben
- Department of Orthopaedic Surgery, Martini Hospital Groningen, the Netherlands
| | - Maurits S Sietsma
- Department of Orthopaedic Surgery, Martini Hospital Groningen, the Netherlands
| | - Inge H F Reininga
- Department of Trauma Surgery, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Bas L E F Ten Have
- Department of Orthopaedic Surgery, Martini Hospital Groningen, the Netherlands
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17
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Pujol O, Soza D, Lara Y, Castellanos S, Hernández A, Barro V. Restoring hip biomechanics during the learning curve of a novice surgeon: Direct anterior approach vs posterior approach. J Orthop 2021; 26:72-78. [PMID: 34349397 DOI: 10.1016/j.jor.2021.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/11/2021] [Indexed: 02/06/2023] Open
Abstract
Introduction It remains controversial whether the direct anterior approach (DAA) or the posterior approach (PA) allows better restoration of hip biomechanics after total hip arthroplasty (THA). Besides, it is not certain which approach is best for a novice surgeon to avoid implant malposition, neither during the learning curve nor once the curve plateau has been reached. Methods We performed a retrospective cohort study of THAs operated on between 2014 and 2019 by a single novice surgeon (DAA, n = 187; PA, n = 184). The surgeon used both approaches, and thus went through parallel learning curves. Results While the DAA presented a greater number of acetabular cup implantations within Lewinnek's "safe zone" for inclination (84.5% vs. 79.3%; p = 0.003), the PA returned superior results for anteversion (77.7% vs. 68.4%; p = 0.000). The PA showed a tendency to verticalize acetabular cups, while the DAA tended to antevert them. The DAA resulted in fewer patients with leg length discrepancy (3.2% vs. 8.2%, p = 0.041). No differences were found in stem coronal alignment or femoral offset. Conclusion Both approaches are safe and reliable for restoring hip biomechanics through THA surgery during the learning curve of a novice hip surgeon. Similar radiological outcomes are also seen once the surgeon has reached the learning curve plateau.
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Affiliation(s)
- Oriol Pujol
- Hip Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona Departament de Cirurgia, Barcelona, Spain
| | - Diego Soza
- Hip Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona Departament de Cirurgia, Barcelona, Spain
| | - Yuri Lara
- Hip Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona Departament de Cirurgia, Barcelona, Spain
| | - Sara Castellanos
- Hip Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona Departament de Cirurgia, Barcelona, Spain
| | - Alejandro Hernández
- Hip Surgery Unit, Orthopedic Surgery Department, Josep Trueta University Hospital, Girona, Spain
| | - Víctor Barro
- Hip Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona Departament de Cirurgia, Barcelona, Spain
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Meneghini RM. Techniques and Strategies to Optimize Efficiencies in the Office and Operating Room: Getting Through the Patient Backlog and Preserving Hospital Resources. J Arthroplasty 2021; 36:S49-S51. [PMID: 33785228 PMCID: PMC9758392 DOI: 10.1016/j.arth.2021.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 02/02/2023] Open
Abstract
The effects of the coronavirus disease 2019 pandemic are pervasive and have decreased the volume of hip and knee arthroplasty procedures since the mandated cessation of elective surgical procedures at the height of the pandemic in early 2020. Therefore, a backlog of patients in need of these elective procedures is a probable consequence and increased productivity and efficiency in patient care delivery is essential now and into the future. This article outlines multiple strategies and techniques to develop and optimize efficiency in the hip and knee arthroplasty practice. Techniques for increasing surgical efficiency are detailed, along with perioperative strategies in the hospital, ambulatory surgery center, and office settings are outlined and discussed.
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Affiliation(s)
- R. Michael Meneghini
- Address correspondence to: R. Michael Meneghini, MD, Department of Orthopaedic Surgery, Indiana University Health Hip & Knee Center, Indiana University School of Medicine, 13100 East 136th Street, Suite 2000, Fishers, IN 46037
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Zhao W, Li S, Yin Y, Wang Z, Sun G, Peng X, Lan J, Ye Y. Direct Anterior Approach in Lateral Decubitus Position Versus Supine Position for Unilateral Total Hip Arthroplasty: A Comparative Study. Orthop Surg 2021; 13:786-790. [PMID: 33709496 PMCID: PMC8126895 DOI: 10.1111/os.12881] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 10/08/2020] [Accepted: 10/26/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To compare the clinical efficacy of the direct anterior approach in lateral decubitus position (L-DAA) and supine position (S-DAA) for unilateral total hip arthroplasty. METHODS A retrospective study was conducted on 89 patients who underwent primary unilateral total hip arthroplasty in our department between August 2016 and December 2017. There were 46 patients who underwent L-DAA and 43 patients who underwent S-DAA. The body mass index (BMI), operation time, blood loss, preoperative Hb, first day and third day postoperative Hb, incision length, hospital stay, preoperative and postoperative Harris score, preoperative and postoperative visual analogue scale (VAS) score, radiological evaluation, intraoperative and postoperative complication, postoperative absolute length difference of lower extremity were recorded and analyzed. P < 0.05 was set as the significant difference. RESULTS All patients were followed up for 8-23 months, with an average of 15.6 months. No significant differences were found in preoperative and postoperative Harris scores, preoperative Hb, incision lengths, radiological evaluations, preoperative and postoperative VAS scores, and hospital stay (P > 0.05). However, significant differences were detected in BMI, blood loss, first day and third day postoperative Hb, and operation time (P < 0.05). There were no postoperative complications in the L-DAA and S-DAA groups. During the operation, two cases of proximal femoral fracture occurred in the L-DAA group, four in the S-DAA group, and the difference was statistically significant. There were significant differences found in the postoperative absolute length difference of lower extremity between the two groups. CONCLUSION Compared with the S-DAA approach, the L-DAA approach had the advantages of shorter operation time and less blood loss. Compared with S-DAA, it was easier to expose the proximal femur, and lower BMI was required in L-DAA. However, it was more difficult to compare the length of both lower extremities in the L-DAA approach than in the S-DAA approach.
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Affiliation(s)
- Wenbo Zhao
- Department of Joint Surgery, Suining Central Hospital, Suining, China
| | - Shanwu Li
- Department of Joint Surgery, Suining Central Hospital, Suining, China
| | - Yi Yin
- Department of Joint Surgery, Suining Central Hospital, Suining, China
| | - Zhiqiang Wang
- Department of Joint Surgery, Suining Central Hospital, Suining, China
| | - Guanjun Sun
- Department of Joint Surgery, Suining Central Hospital, Suining, China
| | - Xu Peng
- Department of Joint Surgery, Suining Central Hospital, Suining, China
| | - Jiaping Lan
- Department of Joint Surgery, Suining Central Hospital, Suining, China
| | - Yongjie Ye
- Department of Joint Surgery, Suining Central Hospital, Suining, China
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Goyal T, Choudhury AK, Paul S, Gupta T, Das L. Acetabular and Femoral Component Positioning Using Direct Anterior Approach Versus Posterior Approach in Total Hip Arthroplasty. Indian J Orthop 2021; 55:1215-1224. [PMID: 34824723 PMCID: PMC8586307 DOI: 10.1007/s43465-020-00343-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/30/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Direct anterior approach (DAA) has recently become popular in total hip arthroplasty (THA). However, irrespective of the surgical approach used, component malposition is an important factor affecting function and complications after THA. This study aims to compare component positioning on the femoral and acetabular side between DAA and posterior approach (PA) to the hip joint. We hypothesized that the two approaches are similar in terms of component positioning. METHODS We prospectively studied 50 patients, matched according to age, sex, and body mass index, undergoing THA, divided non-randomly into 2 groups. Group 1 comprised 25 patients (35 hips) undergoing THA using DAA and group 2 comprised 25 patients (25 hips) undergoing THA using PA. Ten patients from group 1 had simultaneous bilateral THA. Radiological parameters studied were acetabular inclination (AI), coronal femoral stem alignment (CFA), leg length difference (LLD), acetabular cup version (AV), and femoral stem version (FV). RESULTS There was no significant difference in AI, CFA, LLD, AV, and FV between the two groups. Excellent to good inter and intra-observer reliability expressed in terms of intraclass correlation coefficient (ICC) was noted for all the radiographic measurements. CONCLUSION Both DAA and PA for THA achieve comparable radiological component positioning. DAA may not provide any advantage over PA in terms of positioning of the prosthesis. LEVEL OF EVIDENCE Level II, non-randomized comparative study.
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Affiliation(s)
- Tarun Goyal
- Department of Orthopaedics, All India Institute of Medical Sciences, Bathinda, 151001 Punjab India
| | | | - Souvik Paul
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Tushar Gupta
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Lakshmana Das
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
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Zhang WC, Xiao D. Efficacy of proprioceptive training on the recovery of total joint arthroplasty patients: a meta-analysis. J Orthop Surg Res 2020; 15:505. [PMID: 33143719 PMCID: PMC7640714 DOI: 10.1186/s13018-020-01970-6] [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: 06/20/2020] [Accepted: 09/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Optimal balance control is of paramount importance for function recovery after total joint arthroplasty (TJA). The study objective of this meta-analysis was to assess the short- and mid-term effects of proprioceptive and balance training for patients undergoing TJA. METHODS Electronic searches were conducted from PubMed, Cochrane library, and Embase databases to identify eligible RCTs through May 2020. Standard mean difference (SMD) with 95% confidence interval (95%CI) was applied to calculate pooled effect estimates between proprioceptive and balance training and control group. Main outcomes were self-reported functionality, balance, pain, quality of life, and function (range of motion). RESULTS Seven randomized controlled trials were finally included in this meta-analysis. Pooled results found that balance and proprioceptive trainings have a positive role in improving self-reported functionality at short-term after TJA. Moreover, balance and proprioceptive trainings were associated with an increase of the balance at short- and mid-term after TJA. These results were further confirmed by subgroup analysis between preoperative and postoperative administration of balance and proprioceptive trainings. CONCLUSION Our meta-analysis suggests that balance and proprioceptive trainings after TJA improved self-reported functionality and balance. These improvements were maintained at mid-terms. More research is needed to confirm balance and proprioceptive trainings for pain and quality of life for TJA.
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Affiliation(s)
- Wen-Chao Zhang
- Department of Neurorehabilitation, The Affiliated Rehabilitation Hospital of Chongqing Medical University, No. 50, Wenhuaqicun, Chongqing, Jiulongpo district, China
| | - Deng Xiao
- Department of Neurorehabilitation, The Affiliated Rehabilitation Hospital of Chongqing Medical University, No. 50, Wenhuaqicun, Chongqing, Jiulongpo district, China.
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