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

Motion acquisition of gait characteristics one week after total hip arthroplasty: a factor analysis

INTRODUCTION

Clinical gait analysis can be used to evaluate the recovery process of patients undergoing total hip arthroplasty (THA). The postoperative walking patterns of these patients can be significantly influenced by the choice of surgical approach, as each procedure alters distinct anatomical structures. The aim of this study is twofold. The first objective is to develop a gait model to describe the change in ambulation one week after THA. The secondary goal is to describe the differences associated with the surgical approach.

MATERIALS AND METHODS

Thirty-six patients undergoing THA with lateral (n = 9), anterior (n = 15), and posterior (n = 12) approaches were included in the study. Walking before and 7 days after surgery was recorded using a markerless motion capture system. Exploratory Factor Analysis (EFA), a data reduction technique, condensed 21 spatiotemporal gait parameters to a smaller set of dominant variables. The EFA-derived gait domains were utilized to study post-surgical gait variations and to compare the post-surgical gait among the three groups.

RESULTS

Four distinct gait domains were identified. The most pronounced variation one week after surgery is in the Rhythm (gait cycle time: + 32.9 % ), followed by Postural control (step width: + 27.0 % ), Phases (stance time: + 11.0 % ), and Pace (stride length: -  9.3 % ). In postsurgical walking, Phases is statistically significantly different in patients operated with the posterior approach compared to lateral (p-value = 0.017) and anterior (p-value = 0.002) approaches. Furthermore, stance time in the posterior approach group is significantly lower than in healthy individuals (p-value < 0.001).

CONCLUSIONS

This study identified a four-component gait model specific to THA patients. The results showed that patients after THA have longer stride time but shorter stride length, wider base of support, and longer stance time, although the posterior group had a statistically significant shorter stance time than the others. The findings of this research have the potential to simplify the reporting of gait outcomes, reduce redundancy, and inform targeted interventions in regards to specific gait domains.

Evaluation of Outcome after Total Hip Arthroplasty for Femoral Neck Fracture: Which Factors Are Relevant for Better Results?

Background: Femoral neck fractures (FNFs) are frequent orthopedic injuries in elderly patients. Despite improvements in clinical monitoring and advances in surgical procedures, 1-year mortality remains between 15% and 30%. The aim of this study is to identify variables that lead to better outcomes in patients treated with total hip arthroplasty (THA) for FNFs. Methods: All patients who underwent cementless THA for FNF from January 2018 to December 2022 were identified. Patients aged more than 80 years old and with other post-traumatic lesions were excluded. Patient data and demographic characteristics were collected. The following data were also registered: time trauma/surgery, surgical approach, operative time, intraoperative complications, surgeon arthroplasty-trained or not, and anesthesia type. In order to search for any predictive factors of better short- and long-term outcomes, we performed different logistic regression analyses. Results: A total of 92 patients were included. From multivariable logistic regression models, we derived that a direct anterior surgical approach and an American Society of Anesthesiologists (ASA) classification < 3 can predict improved short-term outcomes. Moreover, THAs performed by surgeons with specific training in arthroplasty have a lower probability of revision at 1 year. Mortality at 1 year was ultimately influenced by the ASA classification. Conclusions: A direct anterior approach and specific arthroplasty training of the surgeon appear to be able to improve the short- and long-term follow-up of THA after FNF.

The effect of 3 commonly used surgical approaches for total hip arthroplasty on mid- to long-term patient-reported outcome measures

INTRODUCTION

The most effective surgical approach for total hip arthroplasty (THA) remains controversial. Comparisons of surgical approach based on patient-reported outcome measures (PROMs) have been limited to short- to mid-term outcomes or the comparison of only 2 approaches. The aim of this study was to compare PROMs for the 3 main approaches for THA with up to 10 years follow-up.

METHODS

A total of 906 patients who underwent primary THA at a single hospital between 2009 and 2020 through an anterior (312), lateral (211) or posterior (383) approach were evaluated using the Oxford Hip Score (OHS), EuroQoL-5-Dimension (EQ-5D-5L) and visual analogue scale/verbal rating scale for pain (VAS/VRS). PROMs were prospectively collected before surgery and routinely at 6 weeks, 6 months and 1, 2, 5 and 10 years after surgery.

RESULTS

There was no significant difference in demographics or comorbidities between the 3 groups. All 3 approaches resulted in a significant improvement in overall PROMs after THA, and plateaued after 6 months postoperatively, with no difference between the approaches (OHS, p < 0.01;EQ-5D-5L Index, p < 0.01;VAS/VRS, p < 0.01). The EQ-5D-5L mobility dimension showed that the lateral approach resulted in 20% more patients reporting problems with mobility than the posterior and anterior approaches at the 6-week, 6-month, 2-year and 10-year follow-up.

CONCLUSIONS

This study shows that all 3 common THA approaches substantially and similarly improve the OHS, EQ-5D-5L Index and VRS between 6 months and 10 years postoperatively. However, patient-reported mobility was poorer after a lateral approach and continued to be so at long-term follow-up.

Periprosthetic fracture following anterior approach or dislocation after posterior approach: which one is the lesser evil?

INTRODUCTION

The most common approaches in total hip arthroplasty (THA) have different complication profiles; anterior-approach (AA-THA) has an increased risk of periprosthetic fractures (PPF); posterior-approach (PA-THA) is associated with higher dislocation risk. However, the relative severity of one versus the other is unknown. This study aims to compare outcome of patients who suffered PPF after AA-THA with those that sustained dislocation after PA-THA.

METHODS

This is a retrospective, single-center, multi-surgeon, consecutive case-series of primary THA patients. In a cohort of 9867 patients who underwent THA, 79 fulfilled the approach-specific, post-operative complication criteria, of which 44 were PPF after AA-THA and 35 with dislocation after PA-THA (age 67.9 years (range: 38.0-88.1), 58.2% women). Outcome included complication- and revision- rates, and patient-reported outcomes including Oxford Hip Score (OHS).

RESULTS

At 5.8 years follow-up (range: 2.0-18.5), reoperation was more common in the dislocation after PA-THA group (23/35 vs. 20/44; p = 0.072). Change of surgical approach occurred in 15/20 of patients with PPF after AA-THA, but none in those with dislocation after PA-THA. Following re-operation, complication rate was greater in the PPF group (9/20 vs. 4/23; p = 0.049). At latest follow-up, OHS were superior in the PPF after AA-THA group [42.6 (range: 25.0-48.0) vs. 36.6 (range: 21.0-47.0); p = 0.006].

CONCLUSION

Dislocation following PA-THA is more likely to require revision. However, PPF following AA-THA requires more often a different surgical approach and is at higher risk of complications. Despite the increased surgical burden post-operative PROMs are better in the peri-prosthetic fracture group, especially in cases not requiring reoperation.

LEVEL OF EVIDENCE

III, case-control study.

No clinically significant differences in patient-reported outcome measures across total hip arthroplasty approaches

INTRODUCTION

As recent studies demonstrate an ongoing debate surrounding outcomes and complications with respect to different total hip arthroplasty (THA) approaches, patient-reported outcome measures (PROMs) may provide valuable information for clinician and patient decision-making. Therefore, our systematic review aimed to assess how surgical approach influences patient-reported outcomes.

METHODS

5 online databases were queried for all studies published between January 1, 1997 and March 4, 2022 that reported on PROMs across various surgical approaches to THA. Studies reporting on PROMs in primary THA patients segregated by surgical approach were included. Articles reporting on revision THA, hip resurfacing, and arthroscopy were excluded. Mantel-Haenszel (M-H) models were utilised to calculate the pooled mean difference (MDs) and 95% confidence interval (CIs).

RESULTS

No differences between the DAA and other approaches were observed when evaluating HOOS (MD -0.28; 95% CI, -1.98-1.41; p = 0.74), HHS (MD 2.38; 95% CI, -0.27-5.03; p = 0.08), OHS (MD 1.35; 95% CI, -2.00-4.71; p = 0.43), FJS-12 (MD 5.88; 95% CI, -0.36-12.12; p = 0.06), VAS-pain (MD -0.32; 95% CI, -0.68-0.04; p = 0.08), and WOMAC-pain (MD -0.73; 95% CI, -3.85-2.39; p = 0.65) scores. WOMAC (MD 2.47; 95% CI, 0.54-4.40; p = 0.01) and EQ-5D Index (MD 0.03; 95% CI, 0.01-0.06; p = 0.002) scores were found to significantly favour the DAA cohort over the other approaches. Only the EQ-5D index score remained significant following sensitivity analysis.

CONCLUSIONS

Superiority of any 1 approach could not be concluded based on the mixed findings of the present analysis. Although our pooled analysis found no significant differences in outcomes except for those measured by the EQ-5D index, a few additional metrics, notably the WOMAC, HHS, FJS-12, and VAS-pain scores, leaned in favour of the DAA.

A Comparative Study of Bipolar Hemiarthroplasty for Intertrochanteric Fracture: Direct Anterior Approach versus Conventional Posterolateral Approach

Purpose

The aim of this study was to compare short-term results from use of the direct anterior approach (DAA) and the conventional posterolateral approach (PLA) in performance of bipolar hemiarthroplasty for treatment of femoral intertrochanteric fractures in elderly patients.

Materials and Methods

A retrospective review of 100 patients with intertrochanteric fractures who underwent bipolar hemiarthroplasty was conducted. The PLA was used in 50 cases from 2016 to 2019; since that time we have used the DAA in 50 cases from 2019 to 2021. Measurements of mean operative time, blood loss, hospitalization period, and ambulation status, greater trochanter (GT) migration and stem subsidence were performed. And the incidence of complications was examined.

Results

Operative time was 73.60±14.56 minutes in the PLA group and 79.80±8.89 minutes in the DAA group (P<0.05). However, after experiencing 20 cases using DAA, there was no statistically difference in operative time between two groups (P=0.331). Blood loss was 380.76±180.67 mL in the PLA group and 318.14±138.51 mL in the DAA group (P<0.05). The hospitalization was 23.76±11.89 days in the PLA group and 21.45±4.18 days in the DAA group (P=0.207). In both groups, there were no progressive GT migration, intraoperative fractures or dislocations, although there was one case of infection in the PLA group.

Conclusion

Although use of the DAA in performance of bipolar hemiarthroplasty required slightly more time in the beginning compared with the PLA, the DAA may well be an alternative, safe surgical technique as a muscle preserving procedure in elderly patients with intertrochanteric fractures.

Direct Anterior Approach Total Hip Arthroplasty Is Associated With Reduced 1-Year Mortality and Surgical Complications After Femoral Neck Fracture

BACKGROUND

In some studies, the direct anterior approach (DAA) for elective total hip arthroplasty (THA) is associated with decreased dislocation and greater functional gains compared to the posterior approach (PA), as well as higher functional outcomes compared to the direct lateral approach (LA) at 2 weeks postoperatively. Given the paucity of literature on femoral neck fracture (FNF), we aspired to determine the association between the surgical approach used in THA and outcomes.

METHODS

We conducted a retrospective review of patients undergoing THA for FNF at 9 institutions from 2010 to 2019. Patients who had high-energy injury mechanisms, were nonambulatory prior to injury, had concomitant femoral head or acetabular fractures, or did not reach minimum 1-year follow-up were excluded. The study included 622 THAs, of which 348 (56%) were performed through a DAA, 197 (32%) through a PA, and 77 (12%) through an LA. Postoperative complications and mortalities at 90 days and 1 year were compared between groups. Multivariable logistic regression models were constructed for each outcome of interest.

RESULTS

The DAA was associated with a decreased risk of 90-day dislocation (odds ratio [OR] 0.25; 95% confidence interval [CI] 0.10 to 0.62; P = .01), mechanical revision (OR 0.12; 95% CI 0.02 to 0.56; P = .01), and mortality (OR 0.38; 95% CI 0.16 to 0.91; P = .03) compared to the PA. The DAA was also associated with decreased risk of dislocation (OR 0.32; 95% CI 0.14 to 0.74; P = .01), mechanical revision (OR 0.22; 95% CI 0.08 to 0.65; P = .01), and mortality at 1 year compared to PA (OR 0.43; 95% CI 0.21 to 0.85; P = .02).

CONCLUSION

The DAA for THA after FNF is associated with higher in-hospital medical complications but lower risks of postoperative reoperation and mortality. Postdischarge care may impact this association and needs to be addressed in future studies. The DAA should be used among surgeons experienced with the approach for FNF to minimize complications.

LEVEL OF EVIDENCE

Retrospective cohort, Level III.

Early Practice All-Cause Complications for Fellowship-Trained Anterior Hip Surgeons Are Not Increased When Compared to "Gold Standard" Experienced Posterior Approach Surgeons

BACKGROUND

Increased complication rates have been reported during the learning curve for direct anterior approach (DAA) total hip arthroplasty (THA). However, emerging literature suggests that complications associated with the learning curve may be substantially reduced with fellowship training.

METHODS

Our institutional database was queried to identify 2 groups: (1) 600 THAs comprised of the first 300 consecutive cases performed by 2 DAA fellowship-trained surgeons; and (2) 600 posterolateral approach (PA) THAs, including the most recent 300 primary cases performed by 2 experienced PA surgeons. All-cause complications, revision rates, reoperations, operative times, and transfusion rates were evaluated.

RESULTS

Comparing DAA and PA cases, there were no significant differences in rates of all-cause complications (DAA = 18, 3.0% versus PA = 23, 3.8%; P = .43), periprosthetic fractures (DAA = 5, 0.8% versus PA = 10, 1.7%; P = .19), wound complications (DAA = 7, 1.2% versus PA = 2, 0.3%; P = .09), dislocations (DAA = 2, 0.3% versus PA = 8, 1.3%, P = .06), or revisions (DAA = 2, 0.3% versus PL = 5, 0.8%; P = .45) at 120 days postoperatively. There were 4 patients who required reoperation for wound complications, all within the DAA group (DAA = 4, 0.67% versus PA = 0; P = .045). Operative times were shorter in the DAA group (DAA <1.5 hours = 93% versus PA <1.5 hours = 86%; P < .01). No blood transfusions were given in either group.

CONCLUSION

In this retrospective study, DAA THAs performed by fellowship-trained surgeons early in practice were not associated with higher complication rates compared to THAs performed by experienced PA surgeons. These results suggest that fellowship training may allow DAA surgeons to complete their learning curve period with complication rates similar to experienced PA surgeons.

Selective THA-approach use amongst junior surgeons improves safety of introducing the anterior approach: a prospective, multi-surgeon, comparative, study

BACKGROUND

Learning curves associated with independent practice and anterior approach total hip arthroplasty (AA-THA) has been associated with inferior outcome. This study compared outcome of junior, fellowship-trained, surgeons who perform THA through both anterior and posterior (PA) approach, with senior surgeons who perform either AA or PA, to determine whether: 1. Fellowship training and selective practice allows for safe introduction of AA into practice; and 2. Whether selective approach-use influences outcome.

METHODS

This is a prospective, consecutive study comparing the first 800 THAs of two junior, dual-approach, surgeons (AA/PA: 455/345), with 400 THAs cases of two senior, single-approach, surgeons (AA/PA: 200/200), between 2018 and 2020. Most patients were female (54.4%), mean age was 65 years-old (range 19-96) and mean BMI was 29 kg/m2 (range 16-66). Outcome included radiologic measurements (inclination/anteversion and leg-length), complication- and revision rates, and patient-reported outcomes including Oxford Hip Score (OHS).

RESULTS

At 3.1 years (range 2.0-6.8) follow-up, there were 43 complications (3.6%), including 27 re-operations (2.3%); with no difference between junior and senior surgeons for AA-THA (Junior: 8/455 vs. Senior: 3/200; p = 0.355) or PA-THA (Junior: 11/345 vs. Senior: 5/200; p = 0.400). Amongst juniors, there was no difference in complications (AA:8/455 vs. PA:11/345; p = 0.140) and in ΔOHS (AA:20.5 ± 7.7 vs. PA:20.5 ± 8.0; p = 0.581) between approaches.

CONCLUSION

Contemporary training and selective approach-use minimizes the learning curve, allowing junior staff to have equivalent outcome to established, senior surgeons in both AA and PA. We would advocate for selective approach use amongst junior arthroplasty surgeons when introducing the AA into independent practice.

Comparing the Anterior-Based Muscle-Sparing Approach with the Direct Anterior Approach in Hip Arthroplasty: A Systematic Review and Pairwise Meta-Analysis

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.

The ABLE Anterior-Based Muscle-Sparing Approach: A Safe and Effective Option for Total Hip Arthroplasty

Background

The direct anterior and posterior approaches are well-researched options in total hip arthroplasty (THA). The less-studied anterior-based muscle-sparing approach, also known as the ABLE advanced anterior approach, centers on minimizing surgical trauma and medical costs while maintaining or improving patient outcomes.

Material and methods

THAs performed using the ABLE approach by 3 surgeons at a single institution between January 2013 and August 2020 were retrospectively assessed for outcomes pertaining to safety and performance intraoperatively, perioperatively, and postoperatively. Additionally, intraoperative and postoperative complications were evaluated, and patient-reported outcome measures and radiographic outcomes out to 1-year follow-up.

Results

There were 6251 THAs (5433 patients) eligible for inclusion. The mean surgical time was 65 minutes, mean intraoperative blood loss was 204 mL, and the transfusion rate was 0.5%. Patients had a mean length of stay of 1.4 days. Overall, 93.4% of patients were discharged home, 1.9% visited the emergency department within 30 days, and 2.9% had an unplanned readmission to the hospital within 90 days. The overall major surgical complication rate was 1.18%, with a dislocation rate of 0.13%, a deep infection rate of 0.19%, and a postoperative periprosthetic fracture rate of 0.37%.

Conclusions

The minimally invasive ABLE approach is a safe and effective surgical approach for patients undergoing THA. It can be performed efficiently and with limited complications, making it an appealing option for surgeons to utilize during this era of value-based care.

Failure to Meet Same-Day Discharge is Not a Predictor of Adverse Outcomes

INTRODUCTION

As more centers introduce same-day discharge (SDD) total joint arthroplasty (TJA) programs, it is vital to understand the factors associated with successful outpatient TJA and whether outcomes vary for those that failed SDD. The purpose of this study is to compare outcomes of patients that are successfully discharged home the day of surgery to those that fail-to-launch (FTL) and require a longer in-hospital stay.

MATERIALS AND METHODS

We retrospectively reviewed all patients who enrolled in our institution's SDD TJA program from 2015 to 2020. Patients were stratified into two cohorts based on whether they were successfully SDD or FTL. Outcomes of interest included discharge disposition, 90-day readmissions, 90-day revisions, surgical time, and patient-reported outcome measures (PROMs) as assessed by the FJS-12 (3 months, 1 year, and 2 years), HOOS, JR, and KOOS, JR (preoperatively, 3 months, and 1 year). Demographic differences were assessed with chi-square and Mann-Whitney U tests. Outcomes were compared using multilinear regressions, controlling for demographic differences.

RESULTS

A total of 1491 patients were included. Of these, 1384 (93%) were successfully SDD while 107 (7%) FTL and required a longer length-of-stay. Patients who FTL were more likely to be non-married (p = 0.007) and ASA class III (p = 0.017) compared to those who were successfully SDD. Surgical time was significantly longer for those who FTL compared to those who were successfully SDD (100.86 vs. 83.42 min; p < 0.001). Discharge disposition (p = 0.100), 90-day readmissions (p = 0.897), 90-day revisions (p = 0.997), and all PROM scores both preoperatively and postoperatively did not significantly differ between the two cohorts.

CONCLUSION

Our results support the notion that FTL is not a predictor of adverse outcomes as patients who FTL achieved similar outcomes as those who were successfully SDD. The findings of this study can aid orthopedic surgeons to educate their patients who wish to participate in a similar program, as well as patients that have concerns after they failed to go home on the day of surgery.

LEVEL III EVIDENCE

Retrospective Cohort Study.

Direct Anterior Approach for Total Hip Arthroplasty in the Elderly with Femoral Neck Fractures: Comparison with Conventional Posterolateral Approach

BACKGROUND

The aim of this study was to determine if it was feasible and safe to perform total hip arthroplasty (THA) using the direct anterior approach (DAA) when compared with the conventional posterolateral approach (PA) in patients with femoral neck fractures. The time required to start walking was investigated to identify advantages of the muscle-sparing approach. Safety of the approach was judged based on the incidence and nature of all complications.

METHODS

We retrospectively reviewed 67 THA cases due to femoral neck fractures from October 2015 to January 2019. The PA was used in 31 cases, and the DAA was used in 36 cases. The average operative time and amount of bleeding were evaluated. Cup inclination, anteversion, and leg length discrepancy (LLD) were also measured on radiographs. The time to start walking and complications (e.g., intraoperative fracture, infection, and dislocation) were recorded.

RESULTS

The mean operative time was 84.35 ± 13.95 minutes in PA group and 99.22 ± 20.33 minutes in DAA group (p = 0.010). But after experiencing 20 cases using the DAA, there was no statistically significant difference in the operative time between the groups. The mean volume of bleeding was 428.73 ± 207.26 mL in the PA group and 482.47 ± 150.14 mL in the DAA group. There was no difference in the acetabular cup position between two groups. Ambulation was started at 3.94 days after surgery on average in the PA group and 3.14 days in the DAA group, showing a statistically significant difference. Intraoperative fracture and infection were not observed in either group. The incidence of LLD was 1 in each group. The dislocation rate was 3.2% (1 case) in the PA group and 5.5% (2 cases) in the DAA group.

CONCLUSIONS

Although the DAA for THA was similar to the PA in terms of operative time, volume of bleeding, and complications, the DAA showed a great advantage in early rehabilitation as a muscle-sparing procedure in the elderly with femoral neck fractures.

Patient-reported results of simultaneous direct anterior approach and posterolateral approach total hip arthroplasties performed in the same patients

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.

Preoperative and Perioperative Predictors of Length of Hospital Stay after Primary Total Hip Arthroplasty-Our Experience on 743 Cases

The aim of this retrospective investigation is to evaluate the correlation between several preoperative and perioperative factors and the length of hospital stay in patients that underwent elective total hip arthroplasty with overnight admission. Medical records of patients that underwent THA from the beginning of 2016 to the end of 2018 were retrospectively screened. Demographics, comorbidities, whole blood count, intraoperative details, and length of postoperative stay were retrieved. The association between clinical, laboratory and surgical factors and the length of hospital stay was explored by means of negative binomial and logistic regression models. The median length of postoperative hospital stay was four days (Inter Quartile Range, IQR 3, 5). After univariate regression a stepwise multivariate regression showed that operative time (p = 0.001), the preoperative serum creatinine (p < 0.001), the intraoperative blood loss (p = 0.04) and the use of an anterolateral approach (p < 0.001) were found to correlate significantly with the increase of the hospitalization length, while no significant correlation was found for all the other features. Multivariable model fitted through logistic regression (LOS below or over the median value of four days) had an Area Under the Curve (AUC) of 0.748. Our analysis suggests a significant role played by different preoperative and perioperative variables in influencing the length of hospital stay.

Fibromyalgia syndrome - a risk factor for poor outcomes following orthopaedic surgery: A systematic review

BACKGROUND

Fibromyalgia (FM) is a complex syndrome incorporating many features associated with poor outcome in orthopaedic surgery. Aim of the present review was to comprehensively characterize the available evidence on the consequences of pre-existent FM on the outcomes of orthopaedic surgery.

METHODS

We performed a systematic search in MedLine and Web of Science (WOS) to identify studies evaluating the effect of FM on patient-centred outcomes, opioids consumption and postoperative complications.

RESULTS

The search strategy identified 519 records in PubMed and 507 in WOS. A total of 27 articles were deemed eligible for inclusion in qualitative synthesis. Based on quality assessment, 10 studies were rated as good quality, 10 as fair quality and 7 as poor quality. Studies reporting the prevalence of FM in consecutive patients undergoing orthopaedic surgery (n = 19) were included in quantitative synthesis. The pooled prevalence of FM in patients undergoing orthopaedic surgery was 4.1% (95% CI: 2.4-6.8) in those receiving hip or knee surgery, 10.1% (95% CI: 5.7-17.2) in those receiving shoulder or elbow surgery and 21.0% (95% CI: 18.5-23.7) in those receiving spinal surgery. The results of our systematic review consistently report FM as a significant risk factor for less satisfaction, higher pain, worse functional outcome, increased risk for postoperative opioids prescription and higher rate of medical and surgical complications following orthopaedic surgery.

CONCLUSION

Identifying pre-existing FM in patients scheduled for elective orthopaedic surgery may help to better assess the benefit/risk ratio, improve patients' awareness and minimize any discrepancy between expectancy and results.

Direct anterior approach versus posterolateral approach in total hip arthroplasty: a meta-analysis of results on early post-operative period

Background

This study was performed to compare the advantage and disadvantage of posterolateral approach (PLA) and direct anterior approach (DAA) in total hip arthroplasty (THA).

Methods

Relevant trials were identified via a search of the Cochrane Central Register of Controlled Trials and PubMed from inception to 1 June 2019. A meta-analysis was performed to compare postoperative perioperative and radiographic outcomes between DAA and PLA in THA with respect to the hospital stay, blood loss, incision length, operative time, complications, and femoral and cup component position. The Harris Hip Score (HHS) was also assessed before and after 6 months postoperatively.

Results

Nine eligible studies involving 22698 adult patients (DAA group, n = 2947; PLA group, n = 19751) were identified for analysis. Compared with the PLA group, the DAA group had shorter hospital stay and achieved better HHS within 6 months after operation (P < 0.05), but the HHS was no significant differences between the two groups over 6 months (P > 0.05). The DAA group had significantly longer operative time, more blood loss, and complications than the PLA group (P < 0.05). In addition, the femoral component positioned in neutral and cup component inclination angle was comparable between both groups (P > 0.05); however, cup component anteversion angle was significantly larger in the PLA group (P < 0.05).

Conclusion

Patients in the DAA group had higher HHS within 6 months and shorter hospital stay. The DAA could offer rapid early functional recovery after THA compared with the PLA. However, the DAA group often required longer operative time and had more blood loss. Furthermore, there was a higher early complication rate. Therefore, we believe that the direct anterior approach was a more difficult technique. The surgeon should be a well-trained joint surgeon with extensive prior hip replacement experience before performing THA through a DAA, and DAA was not suitable for beginners performing THA. In addition, we did not observe the difference with regard to the femoral component position and cup component inclination angle except for the smaller cup component anteversion angle in DAA group.

Comparison Between the Direct Anterior and Posterior Approaches for Total Hip Arthroplasty Performed for Femoral Neck Fracture

OBJECTIVES

To compare 90-day and 1-year outcomes, including mortality, of femoral neck fracture patients undergoing total hip arthroplasty (THA) by direct anterior approach (DAA) versus posterior approach (PA).

DESIGN

Retrospective cohort.

SETTING

Level I Trauma Center.

PATIENTS

One hundred forty-three consecutive intracapsular femoral neck fractures treated with THA from 2010 to 2018. The minimum follow-up was 12 months, and the average follow-up was 14.6 months (12-72 months).

MAIN OUTCOME MEASURES

Postoperative outcomes, including discharge ambulation, dislocation, periprosthetic joint infection, revision THA, and mortality at 90 days and 1 year after THA.

RESULTS

Of the 143 THA included, 44 (30.7%) were performed by DAA while 99 (69.3%) were performed by PA. In-hospital outcomes were similar between the cohorts. Compared with DAA patients, PA patients were more likely to ambulate without assistance preinjury (88.9% vs. 72.7%, P = 0.025) and be nonambulatory at the time of discharge (27.3% vs. 11.4%, P = 0.049). There were no significant differences in 90-day and 1-year postoperative outcomes between the DAA and PA groups, including dislocation, periprosthetic joint infection, periprosthetic fracture, mechanical complications, and revision surgery. Although there was no difference in mortality rate at 90 days, at 1-year follow-up the mortality rate was lower in the DAA group (0% vs. 11.1%, P = 0.018).

CONCLUSIONS

Performing THA by DAA provides similar benefits in regards to medical and surgical outcomes compared with the PA for displaced femoral neck fracture. However, the DAA may lead to decreased 1-year mortality rates, possibly, because of improved early ambulation capacity that is an important predictor of long-term mortality.

LEVEL OF EVIDENCE

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

Traction table versus standard table total hip arthroplasty through the direct anterior approach: a systematic review

BACKGROUND

The direct anterior approach (DAA) for total hip arthroplasty (THA) was originally performed with a supine patient on a specialised traction table, but the approach can also be performed on a standard operating table. Despite cost and safety implications, there are few studies directly comparing these techniques and table choice remains largely surgeon preference. The purpose of this review was to compare the clinical outcomes and complication profiles of traction and standard table DAA for primary THA.

METHODS

The authors searched databases for relevant studies, screening in duplicate. Study quality was assessed using MINORS criteria or Cochrane Risk of Bias Tool. Data pertaining to patient demographics, clinical outcomes, and complications were abstracted.

RESULTS

Of 3085 initial titles, 44 studies containing a total 26,353 patients were included and analysed. Mean operative time was 70.9 ± 21.2 minutes for standard table (n = 4402) and 100.1 ± 32.6 minutes for traction table (n = 3518). Mean estimated blood loss was 382.3 ± 246.4 mL for standard (n = 2992) and 531.7 ± 364.3 mL for traction table (n = 2675). Intra-operative fracture rate was 1.3% for standard table (n = 3940) and 1.7% for traction table (n = 8386). Complication rates including revisions, dislocations and peri-prosthetic fractures were qualitatively similar between traction and standard table studies.

CONCLUSION

Standard table and traction table DAA have similar outcomes and complications. Both techniques offer the short-term advantages of DAA when compared to other THA approaches. However, the standard table technique may offer perioperative advantages including decreased blood loss, shorter operative time, and fewer intraoperative fractures. In the context of rising global healthcare costs and lack of access to specialised orthopaedic traction tables, this review at minimum confirms the short-term safety of standard table DAA THA and prompts the need for future studies to directly compare these techniques.

Early Experience of Direct Anterior Approach Total Hip Arthroplasty: Analysis of the First 53 Cases

Purpose

To determine if it is feasible and safe for a surgeon to transition from using the posterolateral approach to direct anterior approach (DAA) by evaluating the first 53 cases of total hip arthroplasty using a DAA.

Materials and Methods

A retrospective review of 52 patients who underwent THA using a DAA between July 2017 and December 2018. Reasons for THA were: femoral neck fracture (n=34), avascular necrosis (n=13), and arthritis (n=6). The mean age was 70 years old. An assessment of feasibility was made by analyzing mean operative time and blood loss. Cup inclination, anteversion, and leg length discrepancy (LLD) were measured using postoperative radiology. Safety of the DAA was judged using the incidence and nature of all complications.

Results

The mean operative time was 112 minutes. 135 minutes for the 1st 10 cases, 100 minutes for 2nd 10 cases, 113 minutes for 3rd 10 cases, 119 minutes for 4th 10 cases, and 91 minutes for the final 13 cases. The mean blood loss was 724 mL. Average cup inclination was 40.27°; 2 cases were out of safety angle. Mean anteversion was 16.18°. No intraoperative fractures or infections were observed. LLD was detected in 3 cases, one of which underwent revision due to walking difficulty. Dislocation occurred in 3 cases, all within the first 20 cases, however, there was no recurrent dislocation.

Conclusion

DAA for THA was deemed to be feasible and safe based on an assessment of operative time, blood loss and complications.

A Comparison of Risk of Dislocation and Cause-Specific Revision Between Direct Anterior and Posterior Approach Following Elective Cementless Total Hip Arthroplasty

BACKGROUND

Use of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased over the last decade. We sought to investigate whether (1) a difference exists in dislocation risk for DAA compared with posterior THA, (2) a difference exists in risk for specific revision reasons, and (3) the likelihood of adverse 90-day postoperative events differs.

METHODS

We conducted a cohort study using data from Kaiser Permanente's Total Joint Replacement Registry. Patients aged ≥18 years who underwent primary cementless THA for osteoarthritis with a highly cross-linked polyethylene liner were included (2009-2017). Multivariable Cox proportional hazards regression was used to evaluate dislocation and cause-specific revision risks, and multivariable logistic regression was used to evaluate 90-day emergency department visits, 90-day unplanned readmissions, and 90-day complications (including deep infection, deep vein thrombosis, and pulmonary embolism).

RESULTS

Of 38,399 primary THA, 6428 (16.7%) were DAA. All-cause revision at 2-years follow-up was 1.78% (95% confidence interval [CI] = 1.46-2.17) for DAA and 2.28% (95% CI = 2.11-2.45) for posterior. After adjusting for covariates, DAA had a lower risk of dislocation (hazard ratio [HR] = 0.39, 95% CI = 0.29-0.53), revision for instability (HR = 0.33, 95% CI = 0.18-0.58), revision for periprosthetic fracture (HR = 0.57, 95% CI = 0.34-0.96), and readmission (odds ratio = 0.82, 95% CI = 0.67-0.99) compared with posterior approach but a higher risk of revision for aseptic loosening (HR = 2.26, 95% CI = 1.35-3.79).

CONCLUSION

While the DAA associated with lower risks of dislocation and revision for instability and periprosthetic fracture, it is associated with a higher revision risk for aseptic loosening. Surgeons should discuss these risks with their patients.

Patient-Reported Outcomes Following Total Hip Arthroplasty: A Multicenter Comparison Based on Surgical Approaches

BACKGROUND

Comparisons of patient-reported outcomes (PROs) based on surgical approach for total hip arthroplasty (THA) in the United States are limited to series from single surgeons or institutions. Using prospective data from a large, multicenter study, we compare preoperative to postoperative changes in PROs between posterior, transgluteal, and anterior surgical approaches to THA.

METHODS

Patient-reported function, global health, and pain were systematically collected preoperatively and at 1, 3, and 6 months postoperatively from patients undergoing primary THA at 26 sites participating in the Comparative Effectiveness of Pulmonary Embolism Prevention After Hip and Knee Replacement (ClinicalTrials.gov: NCT02810704). Outcomes consisted of the brief Hip disability and Osteoarthritis Outcome Score, the Patient-Reported Outcomes Measurement Information System Physical Health score, and the Numeric Pain Rating Scale. Operative approaches were grouped by surgical plane relative to the abductor musculature as being either anterior, transgluteal, or posterior.

RESULTS

Between 12/12/2016 and 08/31/2019, outcomes from 3018 eligible participants were examined. At 1 month, the transgluteal cohort had a 2.2-point lower improvement in Hip disability and Osteoarthritis Outcomes Score (95% confidence interval, 0.40-4.06; P = .017) and a 1.3-point lower improvement in Patient-Reported Outcomes Measurement Information System Physical Health score (95% confidence interval, 0.48-2.04; P = .002) compared to posterior approaches. There was no significant difference in improvement between anterior and posterior approaches. At 3 and 6 months, no clinically significant differences in PRO improvement were observed between groups.

CONCLUSION

PROs 6 months following THA dramatically improved regardless of the plane of surgical approach, suggesting that choice of surgical approach can be left to the discretion of surgeons and patients without fear of differential early outcomes.

Lower limb joint repair and replacement: an overview

In the last few years, much has been published concerning total joint arthroplasty, and debates and discussions to new questions and points of view started many years ago. In this commentary, we report the latest evidence of best practice in the field of lower limb arthroplasty; this evidence is based on a literature search conducted by using PubMed and Scopus databases with a time limit of five years. We found novel evidence regarding cemented and not cemented implant, implant design, anticoagulant use, tourniquets, and other aspects of joints replacement surgery that we consider a common part of modern orthopedic practice. We specifically focus on lower limb joint replacement.

Operative Times Have Remained Stable for Total Hip Arthroplasty for >15 Years: Systematic Review of 630,675 Procedures

Understanding trends in operative times has become increasingly important in light of total hip arthroplasty (THA) being added to the Centers for Medicare & Medicaid Services (CMS) 2019 Potentially Misvalued Codes List. The purpose of this review was to explore the mean THA operative times reported in the literature in order (1) to determine if they have increased, decreased, or remained the same for patients reported on between 2000 and 2019 and (2) to determine what factors might have contributed to the difference (or lack thereof) in THA operative time over a contemporary study period.

METHODS

The PubMed and EBSCOhost databases were queried to identify all articles, published between 2000 and 2019, that reported on THA operative times. The keywords used were "operative," "time," and "total hip arthroplasty." An article was included if the full text was available, it was written in English, and it reported operative times of THAs. An article was excluded if it did not discuss operative time; it reported only comparative, rather than absolute, operative times; or the cohort consisted of total knee arthroplasties (TKAs) and THAs, exclusively of revision THAs, or exclusively of robotic THAs. Data on manual or primary THAs were extracted from studies including robotic or revision THAs. Thirty-five articles reporting on 630,675 hips that underwent THA between 1996 and 2016 met our criteria.

RESULTS

The overall weighted average operative time was 93.20 minutes (range, 55.65 to 149.00 minutes). When the study cohorts were stratified according to average operative time, the highest number fell into the 90 to 99-minute range. Operative time was stable throughout the years reported. Factors that led to increased operative times included increased body mass index (BMI), less surgical experience, and the presence of a trainee.

CONCLUSIONS

The average operative time across the included articles was approximately 95 minutes and has been relatively stable over the past 2 decades. On the basis of our findings, we cannot support CMS lowering the procedural valuation of THA given the stability of its operative times and the relationship between operative time and cost.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Natural history of lateral femoral cutaneous nerve neuropraxia after anterior approach total hip arthroplasty

AIM:

The aim of this study was to examine the natural history of lateral femoral cutaneous nerve (LFCN) neuropraxia in a previously reported cohort of individuals after direct anterior approach (DAA).

METHODS:

99 patients (107 hips) with LFCN neuropraxia were identified, out of which 82 patients (87 hips) (83.1%) completed functional outcomes questionnaires at mean follow-up of 5.5 years (4.4-6.9 years). 5 patients were excluded from the study due to intra-articular source of pain and/or revision surgery. The total sample was composed of 77 patients (31 total hip replacements and 51 hip resurfacings) and functional outcomes scores were obtained for all patients.

RESULTS:

At average 5.46-year follow-up, 55 patients (60 hips 73%) still reported symptoms of LFCN neuropraxia but their Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were not inferior to those who had resolution for pain, function and stiffness: p values of 0.716, 0.171, and 0.238, respectively. The mean score on visual analogue scale decreased from 2.32 (SD 2.11) to 1.76 (SD 1.99). 1 patient (1.2%) reported his activities were limited by his symptoms.

CONCLUSION:

Although the majority of patients still report symptoms related to LFCN neuropraxia, symptoms do improve over time and there are no functional limitations. Even if LFCN neuropraxia following DAA does not lead to functional limitations, all patients should be made aware in order to alleviate any long-term functional concerns.

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

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

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

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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