Surgical Approaches for Primary Total Hip Arthroplasty from Charnley to Now

Fragility of Statistical Differences Between Surgical Approaches in Total Hip Arthroplasty

BACKGROUND

Total hip arthroplasty (THA) is a successful treatment for hip osteoarthritis, but the optimal surgical approach for this procedure is a topic of debate. This review uses fragility analysis to determine the statistical fragility of randomized controlled trials (RCTs) comparing the 3 most common surgical approaches for THA: direct anterior, direct lateral, and posterior.

MATERIALS AND METHODS

A systematic review was conducted to identify RCTs comparing 2 of the 3 surgical approaches for THA. Dichotomous outcomes and study characteristics were extracted from each study that met the inclusion criteria. Fragility index (FI) and fragility quotient (FQ) were calculated for each significant outcome (P≤.05), and reverse fragility index and quotient (rFI and FQ) were calculated for each nonsignificant outcome (P>.05).

RESULTS

Our search yielded 20 studies in total, with 146 identified dichotomous outcomes. In total, the outcomes had a median FI of 5 and a median rFI of 5. Significant outcomes that favored the anterior approach had a median FI of 6, and significant outcomes that favored the posterior or lateral approach both had a median FI of 1.

CONCLUSION

The RCTs comparing approaches to THA had a median FI of 5, signifying that the reversal of 5 events would be sufficient to change the significance of the entire outcome. This value is comparable to other FI values within the orthopedic literature, but subgroup analyses elucidated areas of greater statistical fragility, particularly in outcomes favoring either the lateral or posterior approach in THA. [Orthopedics. 2025;48(3):166-173.].

Radiographic and Clinical Outcomes After Direct Anterior Versus Mini Posterior Total Hip Arthroplasty

Background

Total hip arthroplasty (THA) is a successful surgical treatment for end-stage hip arthritis. There is controversy over whether the surgical approach leads to any differences in implant sizing, implant positioning, and clinical outcomes. This study sought to compare radiographic and clinical outcomes when performing primary THA through the direct anterior approach (DAA) and posterior approach (PA).

Methods

In this retrospective cohort study of patients undergoing primary THA, 198 DAA patients were matched to 198 PA patients. Surgeries were performed by 3 fellowship-trained surgeons. Radiographic parameters analyzed were acetabular cup anteversion and abduction angles, femoral stem coronal alignment, femoral offset, and leg-length discrepancy. Postoperative complications, including periprosthetic joint infection, wound complications, periprosthetic fracture, and dislocation, were extracted from the medical record. Statistical analysis was performed to compare radiographic and clinical outcomes between groups.

Results

There were no statistically significant differences for any postoperative complications between the 2 groups. One dislocation occurred in the PA group, and no dislocations occurred in the DAA group. DAA had a longer operative time (117 vs 79 minutes, P < .01). PA had a higher increase in femoral offset compared to the contralateral limb (2.76 mm vs 1.01 mm, P < .01), higher cup anteversion (26.17° vs 23.44°, P < .001), and higher use of dual mobility components (6.06% vs 1.01%, P = .007).

Conclusions

Both DAA and PA lead to acceptable clinical and radiographic outcomes for primary THA, with significant differences noted for cup position, femoral offset, and use of dual mobility components. These differences likely represent surgeon factors to help mitigate the risk for dislocation.

Body Mass Index Above 35 Has Increased Risk of Complications but Still Achieves Clinically Meaningful Improvement in Patient-Reported Outcomes After Anterior-Based Total Hip Arthroplasty

Background

Increased perioperative complications in obese patients undergoing total hip arthroplasty (THA) have previously been reported. There is a relative paucity of data evaluating these complications strictly in the context of anterior-based THA. In this study, we compare the outcomes following anterior-based THA as a function of body mass index (BMI).

Methods

A 1:1 matched retrospective cohort study was conducted. Patients undergoing anterior-based THA from January 2022 to June 2024 with a BMI >35 kg/m2 were matched 1:1 based on age and sex to patients with a BMI <35 kg/m2 from our division registry. Demographic data, surgical details, complications (intraoperative and postoperative), and patient-reported outcome measures (PROMs: 12-Item Short Form P/M, Western Ontario and McMaster Universities Osteoarthritis Index-P/S/F) were collected and analyzed.

Results

There were 280 patients included (140 per group). There were 27 postoperative complications in the BMI >35 kg/m2 group and 10 in the BMI <35 kg/m2 group (P < .01). There were 10 major complications (4 dislocations, 2 periprosthetic fractures, and 4 deep infections requiring incision and drainage) in the BMI over 35 kg/m2 group, with no major complications occurring in the lower BMI group. There were 3 intraoperative complications (periprosthetic fracture), all in patients with BMI >35 kg/m2. There was significant improvement in Western Ontario and McMaster Universities Osteoarthritis Index P/S/F scores and 12-Item Short Form pain in both groups at 3 months postoperatively, with greater improvements seen in the BMI >35 kg/m2 group.

Conclusions

The present study found that despite significant differences in postoperative complications, there were significant improvements in PROMs in patients with a BMI above and below 35 kg/m2 who underwent anterior THA.

Does Surgical Approach in Total Hip Arthroplasty Affect Postoperative Corticosteroid Injection Requirements?

BACKGROUND

Corticosteroid injections following total hip arthroplasty (THA) are commonly used to address soft tissue pathology such as bursitis and tendinitis. The THA surgical approaches differ in the extent of muscle and soft tissue dissection. The aim of this study was to compare the impact of surgical approach on postoperative corticosteroid injection requirements when controlling for multiple covariates. A secondary aim was to identify risk factors associated with the various injection types.

METHODS

This was a propensity-matched retrospective study of 10,907 THA patients from June 2016 to December 2022 at a single urban academic health center. Patients were stratified into cohorts based on the following surgical approaches: anterior (n = 4,287) and posterior (n = 6,620), then propensity-matched 1:1 with nearest neighbor matching to form two cohorts of 4,287 patients. Baseline characteristics and corticosteroid injection data for soft-tissue pathology were obtained and analyzed. Chi-square and multivariate logistic regression analyses were used to assess the impact of patient and surgical factors on receiving postoperative steroid injections.

RESULTS

A posterior approach conferred increased risk of postoperative injections (adjusted odds ratio 1.242, P = 0.001) after controlling for multiple covariates. The posterior approach also had higher total rates of greater trochanter bursitis injections postoperatively compared to the anterior group (11.5 versus 7.3%, P < 0.001). Both surgical approaches demonstrated comparable rates of iliopsoas bursitis injections (P = 0.39), gluteus medius tendinosis injections (P = 0.09), and lateral femoral cutaneous nerve injections (P = 0.27). The strongest predictor of postoperative injections was a history of preoperative injection (adjusted odds ratio 3.772, P < 0.001).

CONCLUSIONS

Posterior approach, women, and history of preoperative corticosteroid injection were identified as the strongest risk factors for postoperative greater trochanter bursitis injection or postoperative soft tissue injection. These factors should be considered when counseling patients on expected postoperative outcomes and the likelihood of corticosteroid injections following THA.

Recovery Time and Success: A Comparative Study of Robotic and Manual Total Hip Arthroplasty Outcomes

BACKGROUND

Despite the growing utilization of robotic-assisted total hip arthroplasty (rTHA), major debate remains regarding its comparative effectiveness in achieving optimal patient outcomes compared to manual total hip arthroplasty (mTHA). This study aimed to compare both the rate and time to achieve minimal clinically important difference (MCID) between rTHA and mTHA.

METHODS

We conducted a retrospective analysis comparing 341 rTHAs with a 1:3 propensity score-matched cohort of 1,023 mTHAs performed from 2016 to 2022. Propensity scores were generated based on age, sex, body mass index, and Charlson comorbidity index. Patient-reported outcomes were evaluated using preoperative and postoperative scores of Patient-Reported Outcomes Measurement Information System (PROMIS) Global Physical, PROMIS Physical Function-10a (PF-10a), and Hip disability and Osteoarthritis Outcome Score - Physical Function Shortform (HOOS-PS). The time to achieve MCID was assessed using survival curves with and without interval censoring, and statistical comparisons were performed using log-rank and weighted log-rank tests.

RESULTS

Manual total hip arthroplasty demonstrated a significantly higher rate of achieving MCID for PROMIS Global Physical (84.1 versus 79.8%, P = 0.003) and HOOS-PS (60.0 versus 44.9%, P < 0.001), while rates for PROMIS PF-10a were similar (58.6 versus 56.0%, P = 0.085). In the interval-censored analysis, rTHA achieved MCID for HOOS-PS significantly faster than mTHA (0.67 versus 1.0 months, P < 0.001). However, no significant differences were found for PROMIS Global Physical (0.24 versus 0.70 months, P = 0.18) and PROMIS PF-10a (1.60 versus 3.03 months, P = 0.73) when compared to mTHA.

CONCLUSIONS

We conducted a propensity score-matched analysis of rTHA and mTHA, accounting for baseline characteristics, but not factors such as case difficulty and anatomic complexity. We found that rTHA achieved MCID faster, while mTHA had a higher overall proportion of MCID achievement. Robotic-assisted surgery may expedite initial recovery, while manual techniques may lead to better long-term outcomes.

Transition from straight lateral to direct anterior approach in total hip arthroplasty: a retrospective single-centre study

INTRODUCTION

The muscle-sparing direct anterior approach (DAA) for total hip arthroplasty (THA) has gained popularity for reduced postoperative pain and faster rehabilitation. The aim of this study was to evaluate the potential benefits of transitioning from straight lateral approach (SLA) THA to DAA THA, and investigate whether these benefits outweigh potential disadvantages of the DAA learning curve.

METHOD

Patients undergoing surgery between 2015 and 2020 (n = 2275) were categorised into three periods: pre-transition period (2015-2016) utilizing SLA exclusively, transition period (2017-2018) incorporating both SLA and DAA, and post-transition period (2019-2020) employing only DAA. The Hip disability and Osteoarthritis Outcome Score - Physical function Short-form (HOOS-PS) was recorded pre-surgery and one-year post-surgery. Furthermore, complications, blood loss, duration of surgery and length of stay were compared between groups.

RESULTS

A larger improvement in HOOS-PS score was found for DAA in comparison with SLA (37.13 ± 18.62 vs. 32.55 ± 22.83; p < 0.001). Significant improvements were found for the DAA group regarding duration of surgery (70:02 ± 15:54 min vs. 79:47 ± 15:03 min; p < 0,001) and length of stay (1.68 ± 1.80 days vs. 3.39 ± 1.85 days; p < 0,001) compared to the SLA group. Total number of complications was higher for SLA (n = 87 (9.2%)) compared to DAA (n = 77 (6.5%); p = 0.018), with more femoral fractures for SLA (n = 35 (3.7%) vs. n = 6 (0.5%); p < 0.001) whereas more dislocations were found for DAA (n = 24 (2.0)% vs. n = 7 (0.7%); p = 0.017). More specifically, a higher number of dislocations occurred during the DAA transition period when compared to the SLA pre-transition period (n = 12 (2.7%) vs. n = 4 (0.6%); p = 0.008).

CONCLUSIONS

Transitioning from SLA to DAA for THA improves patient-reported outcomes but does not seem to result in a higher overall complication rate. Suggesting the advantages of the DAA outweigh the potential disadvantages of the learning curve.

Does Surgical Approach Affect Dislocation Rate After Total Hip Arthroplasty in Patients Who Have Prior Lumbar Spinal Fusion? A Retrospective Analysis of 16,223 Cases

BACKGROUND

Lumbar spinal fusion (LSF) is a risk factor for dislocation following total hip arthroplasty (THA). The effect of the surgical approach on this association has not been investigated. This study examined the association between the surgical approach and dislocation following THA in patients who had prior LSF.

METHODS

We retrospectively reviewed 16,223 primary elective THAs at our institution from June 2011 to September 2022. Patients who had LSF prior to THA were identified using International Classification of Diseases (ICD) codes. Patients were stratified by LSF history, surgical approach, and intraoperative robot or navigation use to compare dislocation rates. There were 8,962 (55.2%) posterior, 5,971 (36.8%) anterior, and 1,290 (8.0%) laterally based THAs. Prior LSF was identified in 323 patients (2.0%). Binary logistic regressions were used to assess the association of patient factors with dislocation risk.

RESULTS

There were 177 dislocations identified in total (1.1%). In nonadjusted analyses, the dislocation rate was significantly higher following the posterior approach among all patients (P = .003). Prior LSF was associated with a significantly higher dislocation rate in all patients (P < .001) and within the posterior (P < .001), but not the anterior approach (P = .514) subgroups. Multivariate regressions demonstrated anterior (OR [odds ratio] = 0.64, 95% CI [confidence interval] 0.45 to 0.91, P = .013), and laterally based (OR = 0.42, 95% CI 0.18 to 0.96, P = .039) approaches were associated with decreased dislocation risk, whereas prior LSF (OR = 4.28, 95% CI 2.38 to 7.69, P < .001) was associated with increased dislocation risk. Intraoperative technology utilization was not significantly associated with dislocation in the multivariate regressions (OR = 0.72, 95% CI 0.49 to 1.06, P = .095).

CONCLUSIONS

The current study confirmed that LSF is a significant risk factor for dislocation following THA; however, anterior and laterally based approaches may mitigate dislocation risk in this population. In multivariate analyses, including surgical approach, LSF, and several perioperative variables, intraoperative technology utilization was not found to be significantly associated with dislocation risk.

Incidence of heterotopic ossification following total hip arthroplasty by approach: a systematic review

BACKGROUND

Heterotopic ossification (HO) formation has been increasingly recognized as a complication of major orthopedic surgeries, particularly total hip arthroplasty (THA). Though, the overall incidence of HO following THA has been well-documented, it is often not reported by severity or by surgical approach.

QUESTIONS/PURPOSES

(1) What are the demographics of patients with HO? (2) What is the severity of HO following THA using the Brooker classification? (3) What is the incidence and class of HO following different THA approaches (anterior, posterior, posterolateral, anterolateral, superior, lateral, trans-gluteal)? (4) What are the number and training level of surgeons who performed each procedure?

METHODS

The PubMed, Embase, and Web of Science databases were queried, and PRISMA guidelines were followed. Qualitative and quantitative analyses were performed using Microsoft Excel.

RESULTS

We isolated 26 studies evaluating 6512 total hip arthroplasties (THA). The mean HO percentage overall was 28.8%, mostly Class I (54.2%) or Class II (29.6%). The highest percentage of HO was associated with the modified direct lateral (57.2%) and the traditional lateral (34.6%) approaches. The lowest HO percentages were identified following posterolateral (12.8%) and direct superior approaches (1%). Most studies reported a singular senior surgeon operating within the same approach for all patients.

CONCLUSIONS

The traditional lateral and modified direct lateral approaches to THA resulted in the highest percentage of HO postoperatively. However, most ossification cases were not clinically significant and did not strongly affect overall patient morbidity. Further studies are warranted to identify an association between severity of ossification and different arthroplasty approaches.

A Comprehensive Review of Total Hip Arthroplasty Outcomes in Post-traumatic Hip Arthritis: Insights and Perspectives

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.

Comparison of clinical outcomes of supercapsular percutaneously-assisted approach total hip arthroplasty versus conventional posterior approach for total hip arthroplasty in adults: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis was aimed to compare the postoperative clinical outcomes between the supercapsular percutaneously assisted total hip (SuperPATH, SP) and conventional posterior/posterolateral approach (PA) for total hip arthroplasty in patients who have failed conservative treatment for hip-related disorders.

METHODS

PRISMAP guidelines were followed in this systematic review. CNKI, Wanfang, PubMed, Embase, Cochrane, Web of Science databases and the reference list grey literature were searched for studies according to the search strategy. Endnote (version 20) was used to screen the searched studies according to the inclusion and exclusion criterias and extract the data from the eligible studied. RR and 95% CI were used for dichotomous variables and MD and 95% CI were used for continuous variables. All analyses and heterogeneity of outcomes were analysed by Review Manage (version 5.4). Publication bias of included studies was analysed by Stata (version 16.0).

RESULTS

Thirty-six randomized control studies were included. Compared to PA group, SP group had a shorter incision length, less intraoperative blood loss, a shorter length of hospital stay and do activities earlier. Hip function (HHS) was significantly improved within three months postoperatively. Pain of hip (VAS) was significantly reduced within one month postoperatively. The state of daily living (BI) was significantly improved within three months. Patients' overall health status (SF-36) improved significantly postoperatively. There was no difference in postoperative complications between the two approaches. PA had a shorter operative time and a higher accuracy of prosthesis placement.

CONCLUSION

The advantages of SuperPATH include accelerated functional recovery and less trauma associated with surgery. However, it required a longer operative time and implantation of the prosthesis was less accurate than that of PA.

Perioperative nursing care for hip arthroplasty patients with concomitant hypertension: A minireview

Hip replacement (HA) is mainly indicated for the elderly, who generally suffer from various underlying diseases such as hypertension. This article provides a review of the key points of perioperative nursing care for patients with hypertension undergoing HA. It analyzes the key points of care during the perioperative period (preoperative, intraoperative, and postoperative) and proposes directions for the development of perioperative nursing care for HA. The prognosis for patients can be improved through the modification of traditional medical approaches and the application of new technologies and concepts.

Subsidence of a Single-Taper Femoral Stem in Primary Total Hip Arthroplasty: Characterization, Associated Factors, and Sequelae

BACKGROUND

We characterized subsidence of an uncemented single-taper femoral stem in primary total hip arthroplasty (THA), determined factors associated with subsidence, and evaluated the impact of subsidence on outcome.

METHODS

This retrospective study included 502 primary THAs performed using a single-taper stem in Dorr type A and B femora between 2014 and 2018. Subsidence was measured based on distance from the greater trochanter to stem shoulder on calibrated X-rays. Demographics, case-specific data, and outcomes were collected. Changes in subsidence and variables associated with subsidence were determined.

RESULTS

Stem subsidence was 1.5 ± 2.3 mm, 1.6 ± 2.0 mm, 2.0 ± 2.6 mm, 2.3 ± 2.3 mm, 2.6 ± 2.5 mm, and 2.7 ± 3.0 mm at 6 weeks, 3 months, 6 months, 1 year, 2 years, and ≥3 years from THA, respectively. Subsidence across all patients at final mean follow-up of 24 months (range, 1 to 101 months) was 2.2 ± 2.6 mm. Pairwise comparison demonstrated that subsidence occurred predominantly within the first 6 months. Significant subsidence (≥5 mm) occurred in 17.3% and was associated with a body mass index (BMI) ≥25 (P=0.04). Dorr type, age, sex, and American Society of Anesthesiologists class were not associated with subsidence. There were two patients (0.4%) who underwent a revision that could be attributed to subsidence. There was no association between subsidence and pain, limp, need for ambulatory aid, or analgesic use.

CONCLUSION

In primary THAs performed using a single-taper prosthesis, average subsidence was 2.2 mm and significant subsidence occurred in 17.3%. Patient BMI was associated with subsidence. Revision surgery related to subsidence was infrequent (0.4%).

Modernizing Our Understanding of Total Hip Arthroplasty in the Pediatric and Young Adult Patient: A Single-center Experience

INTRODUCTION

Pediatric hip disorders represent a broad range of pathology and remain a significant source of morbidity for children and young adults. Surgical intervention is often required for joint preservation, but when salvage is not possible, joint replacement may be indicated to eliminate pain and preserve function. Although there have been significant updates in the management of both pediatric hip disease and the field of total hip arthroplasty (THA), there is a paucity of literature reflecting advancements in the area of pediatric and young adult (PYA) arthroplasty. No study has investigated the impact of approach on outcomes after PYA THA. The purpose of this study is to describe the indications, techniques, and early outcomes of THA in the PYA population in a modern practice setting.

METHODS

We performed a retrospective descriptive analysis of all patients undergoing primary THA performed at a tertiary care children's hospital from 2004 to 2019. Ninety-three hips in 76 patients were evaluated. Demographics, intraoperative variables, postoperative pain and function ratings, and complication and revision rates were collected.

RESULTS

Eighty-five hips in 69 patients were included. Patients were aged 12 to 23 years old, with males and females represented equally (33 vs. 36, respectively). The most common cause of hip pain was avascular necrosis (AVN, 56/85, 66%), most commonly due to slipped capital femoral epiphysis (13/56, 23%) idiopathic AVN (12/56, 21%), and chemotherapy (12/56, 21%). Half of all hips had been previously operated before THA (43/85). Thirty-six procedures were performed via the posterolateral approach (36/85, 42%), 33 were performed via direct anterior approach (33/85, 39%), and 16 were performed via the lateral approach (LAT, 16/85, 19%). At final follow-up, 98% (83/85) of patients had complete resolution of pain, 82% (70/85) had no notable limp, and 95% (81/85) had returned to all activities. There were 6 complications and 1 early revision. Average Hip disability and Osteoarthritis Outcomes Score for Joint Replacement scores increased by 37 points from 56 to 93. The overall revision-free survival rate for PYA THA was 98.8% (at average 19-mo follow-up).

CONCLUSIONS

Modern PYA THA is dissimilar in indications and surgical techniques to historic cohorts, and conclusions from prior studies should not be generalized to modern practice. In our practice, PYA patients most commonly carry a diagnosis of AVN, and THA can be performed with modern cementless fixation with large cup and head sizes and ceramic-on-cross-linked polyethylene bearings utilizing any approach. Further study is required to better characterize middle-term and long-term results and patient-reported outcomes.

LEVEL OF EVIDENCE

Therapeutic Level IV-retrospective case series.

Evaluating Outcomes of Spinopelvic Fixation for Patients Undergoing Long Segment Thoracolumbar Fusion with a Prior Total Hip Arthroplasty

INTRODUCTION

Understanding the relationship between spinal fusion and its effects on relative spinopelvic alignment in patients with prior total hip arthroplasty (THA) is critical. However, limited data exist on the effects of long spinal fusions on hip alignment in patients with a prior THA. Our objective was to compare clinical outcomes and changes in hip alignment between patients undergoing long fusion to the sacrum versus to the pelvis in the setting of prior THA.

METHODS

Patients with a prior THA who underwent elective thoracolumbar spinal fusion starting at L2 or above were retrospectively identified. Patients were placed into one of two groups: fusion to the sacrum or pelvis. Preoperative, six-month postoperative, one-year postoperative, and delta spinopelvic and acetabular measurements were measured from standing lumbar radiographs.

RESULTS

A total of 112 patients (55 sacral fusions, 57 pelvic fusions) were included. Patients who underwent fusion to the pelvis experienced longer length of stay (LOS) (8.31 vs. 4.21, P < 0.001) and less frequent home discharges (30.8% vs. 61.9%, P = 0.010), but fewer spinal revisions (12.3% vs. 30.9%, P = 0.030). No difference was observed in hip dislocation rates (3.51% vs. 1.82%, P = 1.000) or hip revisions (5.26% vs. 3.64%, P = 1.000) based on fusion construct. Fusion to the sacrum alone was an independent predictor of an increased spine revision rate (odds ratio: 3.56, P = 0.023). Patients in the pelvic fusion group had lower baseline lumbar lordosis (LL) (29.2 vs. 42.9, P < 0.001), six-month postoperative LL (38.7 vs. 47.3, P = 0.038), and greater 1-year ∆ pelvic incidence-lumbar lordosis (-7.98 vs. 0.21, P = 0.032).

CONCLUSION

Patients with prior THA undergoing long fusion to the pelvis experienced longer LOS, more surgical complications, and lower rate of spinal revisions. Patients with instrumentation to the pelvis had lower LL preoperatively with greater changes in LL and pelvic incidence-lumbar lordosis postoperatively. No differences were observed in acetabular positioning, hip dislocations, or THA revision rates between groups.

Does Surgical Approach to the Hip Play a Role in Same-Day Discharge Outcomes?

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.

A feasibility study to evaluate a purposeful walk intervention with a distance goal using a commercially available activity monitor in elderly people post total hip replacement surgery

Introduction

Total hip replacement (THR) is performed in an increasing number of individuals around the world and while improvements in pain reduction and long-term enhancement of muscle strength are well documented, the improvement in daily activity does not follow the same trend. This study aimed to determine the feasibility of a 5-week intervention where a personalised outdoor walking distance is monitored using a commercial activity monitor (Fitbit Charge 4).

Method

Data was collected on gait and activities of daily living using patient reported outcome measures. Following the completion of the intervention period, participants took part in a semi-structured interview to voice their opinion on the use of the activity monitor, their experiences, and any challenges in order to assess the feasibility of the intervention. All quantitative data were presented descriptively, using appropriate summary statistics. Interviews were analysed using thematic analysis.

Results

Five participants who had undergone total hip replacement surgery within the postoperative period of 3 to 6 months were recruited from the local community.

Conclusion

The findings suggest that the intervention was feasible and that it encouraged all participants to increase their daily activity. Therefore, it can be concluded that a follow-up effectiveness trial is warranted.

Abductor muscle function after anterolateral approach in patients with unilateral end-stage hip osteoarthritis undergoing total hip arthroplasty: A prospective study

Background

Total hip arthroplasty (THA) is a successful procedure for treating end-stage hip osteoarthritis (OA). Regarding the surgical approach for THA, the anterolateral (AL) approach, which requires anterior hemimyotomy of the gluteus medius muscle, has shown a long-term favorable outcome. However, to date, complete information related to hip abductor muscle outcomes after the AL approach is unavailable. This study therefore aimed to evaluate the postoperative outcome of patients who undergo THA using the AL approach in terms of hip abductor muscle recovery, pain, function, and muscle healing status.

Methods

Twenty patients diagnosed with unilateral end-stage hip OA underwent cementless THA with the AL approach. All patient procedures were performed by a single surgeon. Preoperative and postoperative data were collected at 2-week, 6-week, 3-month, and 6-month follow-up periods. Hip abductor muscle power was measured via handheld dynamometer. The healing of the musculotendinous repair was evaluated with magnetic resonance imaging at 9 months.

Results

After THA, hip abductor muscle power in the operated hip significantly increased as early as 3 months post-procedure when compared with the preoperative value (p < 0.05). The other parameters-including pain score, Harris hip score, and WOMAC score-significantly improved as early as 2 weeks post-operation (p < 0.05). In all patients, MRI scans showed good healing of the muscle repair site without a gap in the gluteus medius muscle. However, three patients (15%) had some fibrosis and tendon swelling at the repair site.

Conclusion

This study demonstrated that patients with end-stage hip OA could experience significantly improved hip abductor motor function as early as 3 months after undergoing THA with the AL approach. Moreover, despite patients experiencing anterior hemimyotomy of the gluteus medius muscle, no significant complications emerged at the muscle repair site in the AL approach.

Serum biomarkers for the assessment of muscle damage in various surgical approaches in primary total hip arthroplasty: a systematic review of comparative studies

PURPOSE

Using serum biomarkers, this systematic review assessed soft tissue injury following different total hip arthroplasty surgical approaches. The purposes were to determine if there is any advantage between the standard and minimal invasive approaches, and to compare tissue damage of the respective surgical approaches using biomarkers such as creatine kinase, myoglobin, c-reactive protein, erythrocyte sedimentation rate, skeletal troponin and interleukins.

METHOD

A search in Pubmed/MEDLINE, Scopus and Web of Science databases was conducted in October 2021 with the use of PRISMA guidelines. Search items were ("biomarkers" OR "markers" OR "tissue damage" OR "muscle damage") AND "approach" AND ("total hip arthroplasty" OR "total hip replacement"). Inclusion criteria were prospective, randomized, controlled trials or prospective, comparative studies, comparing serum markers for muscle damage in two or more surgical approaches for primary total hip arthroplasty. Exclusion criteria were study protocols, case reports, systematic reviews, meta-analyses, studies in non-English language or without available full text, and studies not recording biomarkers of muscle damage.

RESULTS

Initial search revealed 508 studies; after subtraction of duplicates, and exclusion criteria, 31 studies remained for analysis. No advantage between different approaches was found when evaluating biomarkers, and no specific biomarkers had a distinct role in tissue damage in total hip arthroplasty. Anterior and minimally invasive approaches were associated with lower values of soft tissue (creatine kinase) and inflammation (c-reactive protein) biomarkers compared to the standard approaches.

CONCLUSION

Measurement of serum biomarkers after primary total hip arthroplasty for the estimation of tissue damage has unclear or little clinical value.

TRIAL REGISTRATION

PROSPERO Registration: CRD42022303959.

The Impact of Surgeon Variability on Patient-Reported Outcomes in Total Hip Arthroplasty

BACKGROUND

Patient-related and surgery-related factors have been shown to be drivers of outcomes after total hip arthroplasty (THA); however, the impact of intersurgeon variability is poorly understood. The purpose of this study is to assess the following: (1) overall effect of surgeon on 1-year patient-reported outcome measures (PROMs), length of stay (LOS), discharge disposition, and 90-day readmission following THA; and (2) variability in 1-year PROMs among surgeons.

METHODS

A prospective cohort of 3,695 patients who underwent THA between 2016 and 2018 was included. Seventy-eight percent of patients completed 1-year follow-up. Thirty-one surgeons from a large healthcare system were included. Likelihood ratio tests analyzed the relationship among surgeon and 1-year Hip Disability and Osteoarthritis Outcome Score (HOOS)-Pain, HOOS-Physical Function Short-Form, HOOS-Joint Replacement, University of California, Los Angeles activity score, Patient Acceptable Symptom State, LOS, discharge disposition, and 90-day readmission. Mixed-effect proportional odds and logistic regression models were used to determine variable importance for each outcome.

RESULTS

In total, 90.5% of patients responded positively to 1-year Patient Acceptable Symptom State. There was a significant association among surgeon and 1-year PROMs, LOS, discharge disposition (P < .001), and readmission (P = .002). For HOOS-Pain, Physical Function Short-Form, and Joint Replacement, surgeon (Akaike information criterion increase: 34.6, 18.7, 17.1, respectively) was a greater contributor to outcome than patient-level factors, including age, gender, and comorbidity. Differences in the highest and lowest median probability of achieving any given score on 1-year PROMs ranged from 11% to 18.5%. Variability was not explained by approach (P = .431) or case volume (correlation coefficient, ρ = 0.19).

CONCLUSION

Surgeon-level variability appears to be a greater driver of 1-year PROMs than some patient-level characteristics. Incorporating surgeon as a variable is beneficial for model-fitting and important for increasing value in THA.

Minimally invasive anterolateral approach versus direct anterior approach total hip arthroplasty in the supine position: a prospective study based on early postoperative outcomes

BACKGROUND

Minimally anterolateral approach (MAA) and direct anterior approach (DAA) have been reported as beneficial for total hip arthroplasty (THA) due to their ability to reduce postoperative pain and lead to quicker rehabilitation by preserving muscle insertions. As there is an ongoing debate on the effect of these two approaches on early postoperative outcomes, this prospective study aimed to assess the difference in early clinical, radiological, and patient-reported outcomes between the two minimally invasive approaches.

METHODS

A total of 98 patients, 50 in the MAA group and 48 in the DAA group, were included in the study. Patients with complete data were evaluated preoperatively and postoperatively at 2, 6, and 12 weeks. Clinical measurements, including the ability to climb stairs and walk, 6-min walk test (6MWT), the Forgotten Joint Scale (FJS-12), Japanese Orthopedic Association (JOA) Hip scores, radiological evaluation, and complications were analyzed.

RESULTS

There were no significant differences in clinical outcomes and implant alignments between MAA and DAA groups. In regards to patient-reported outcomes, the FJS-12 was significantly higher in the MAA group compared to group DAA at 2 and 6 weeks postoperatively. However, there was no significant difference in the FJS-12 between the two groups 12 weeks after surgery. The differences also included shorter operative times (62.4 ± 9.05 min vs. 71 ± 8.01 min), less blood loss (132.6 ± 43.31 ml vs. 159.23 ± 37.25 ml), lower Hb drop (29.56 ± 8.02 g/L vs. 36.4 ± 7.12 g/L), and fewer blood transfusions in the MAA group (4.0% vs. 18.8%). The incidence of the lateral femoral cutaneous nerve (LFCN) neuropraxia after surgery was 7 (14.6%) in the DAA group and 0 in the MAA group. One fracture was found in each group and managed conservatively.

CONCLUSION

MAA and DAA approach yielded excellent and similar early clinical outcomes. However, better patient-reported outcomes could be achieved by MAA THA. The MAA resulted in a safer approach associated with shorter operative times, less blood loss, lower Hb drop, fewer blood transfusions, and LFCN neuropraxia than DAA. A longer follow-up is needed to further examine differences between these procedures.

Efficacy of Supercapsular Percutaneously-Assisted Total Hip Arthroplasty in the Elderly With Femoral Neck Fractures: A Meta-analysis

Introduction

Supercapsular Percutaneously-Assisted Total Hip (SuperPATH) approach is a novel minimally invasive surgical technique for total hip arthroplasty (THA). This meta-analysis was conducted to evaluate the outcomes following THA via the SuperPATH approach in elderly patients with femoral neck fractures (FNFs), compared with those via traditional surgical approaches.

Methods

Eligible studies were retrieved through searching 7 electronic databases and manually screening related references. Objectives were surgical-related parameters, functional outcomes, and incidence of postoperative complications.

Results

9 comparative studies were included. Pooled results suggested that at the cost of longer operative time (WMD: 14.25, 95% CI: 3.25 to 25.25), the SuperPATH technique was superior to traditional approaches regarding incision length (WMD: −4.51, 95% CI: −6.46 to −2.56), intraoperative blood loss (WMD: −80.47, 95% CI: −122.36 to −38.57), and hospital stays (WMD: −3.35, 95% CI: −5.05 to −1.65). SuperPATH groups exhibited significantly increased Harris Hip Scores within 1 month after surgery (7d, WMD: 9.85, 95% CI: 6.40 to 13.30; 14d, WMD: 10.68, 95% CI: 8.29 to 13.08; 1 month, WMD: 6.17, 95% CI: 3.56 to 8.78) and had a reduced incidence of overall complications (OR: .19, 95% CI: .09 to .41). No significant differences were found between the 2 groups regarding postoperative pain relief.

Conclusion

Elderly patients with FNFs are potential candidates for THA treatment via the SuperPATH technique, which is associated with improved surgical outcomes, better short-term functional recovery, and lower risk of total complications as compared to traditional approaches. Additional studies are needed to further confirm our conclusions and validate the long-term efficacy of SuperPATH.

The effect of gluteus maximus tenotomy in primary total hip arthroplasty with posterior approach: Kinematic analysis of hip extensor strength

BACKGROUND

The posterior approach (PA) is the most commonly used surgical approach for total hip arthroplasty (THA), but the proximity of the sciatic nerve may increase the likelihood of sciatic nerve injury (SNI). Gluteus maximus tenotomy can be performed to prevent SNI because tenotomy increases the distance between the femoral neck and sciatic nerve and prevents compression of the sciatic nerve by the gluteus maximus tendon (GMT) during hip movements. We aimed to kinematically compare the postoperative hip extensor forces of patients who have and have not undergone gluteus maximus tenotomy to determine whether there is a difference in hip extensor strength.

METHODS

Seventy-two patients who underwent gluteus maximus tenotomy during THA were included in the group 1, and 86 patients who did not undergo tenotomy were included in group 2. The Harris hip score, body mass index and hip extensor forces were measured both preoperatively, and 6 months after surgery with an isokinetic dynamometer and compared.

RESULTS

The mean age was 64.6 ± 2.3 years in group 1 and 63.8 ± 2.1 in group 2. Mean body mass index was 25.7 ± 1.1 in group 1, and 25.5 ± 1.3 in group 2. Baseline Harris hip score (HHS) was 42.36 ± 12 in group 1 and 44.07 ± 9.4 in group 2 (p = 0.31), whereas it was 89.1 ± 7.8 and 88.4 ± 8.1 at 6 months after surgery, respectively. Baseline hip extensor force (HEF) was 2 ± 0.4 Nm/kg in group 1, and 2.1 ± 0.7 Nm/kg in group 2 (p = 0.28), while it was 2.4 ± 0.6 Nm/kg, and 2.5 ± 0.5 Nm/kg, respectively at 6 month follow-up (p = 0.87). Both groups had significantly improved HHS and HEF when comparing baseline and postoperative measurements (p < 0.0001). No cases of sciatic nerve palsy were noted in group 1, whereas there were two (2.32%) cases in group 2, postoperatively.

CONCLUSION

The release of the GMT during primary hip arthroplasty performed with the PA did not lead to significant decrease in hip extension forces. Hip extensor strength improves after THA regardless of tenotomy. Gluteus maximus tenotomy with repair does not reduce muscle strength and may offer better visualization.

Dislocation rates following total hip arthroplasty via the direct anterior approach in a consecutive, non-selective cohort

AIMS

Use of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased in recent years due to proposed benefits, including a lower risk of dislocation and improved early functional recovery. This study investigates the dislocation rate in a non-selective, consecutive cohort undergoing THA via the DAA without any exclusion or bias in patient selection based on habitus, deformity, age, sex, or fixation method.

METHODS

We retrospectively reviewed all patients undergoing THA via the DAA between 2011 and 2017 at our institution. Primary outcome was dislocation at minimum two-year follow-up. Patients were stratified by demographic details and risk factors for dislocation, and an in-depth analysis of dislocations was performed.

RESULTS

A total of 2,831 hips in 2,205 patients were included. Mean age was 64.9 years (24 to 96), mean BMI was 29.2 kg/m² (15.1 to 53.8), and 1,595 patients (56.3%) were female. There were 11 dislocations within one year (0.38%) and 13 total dislocations at terminal follow-up (0.46%). Five dislocations required revision. The dislocation rate for surgeons who had completed their learning curve was 0.15% compared to 1.14% in those who had not. The cumulative periprosthetic infection and fracture rates were 0.53% and 0.67%, respectively.

CONCLUSION

In a non-selective, consecutive cohort of patients undergoing THA via the DAA, the risk of dislocation is low, even among patients with risk factors for instability. Our data further suggest that the DAA can be safely used in all hip arthroplasty patients without an increased risk of wound complications, fracture, infection, or revision. The inclusion of seven surgeons increases the generalizability of these results. Cite this article: Bone Joint J 2021;103-B(7 Supple B):38-45.

Direct Anterior Approach to the Hip Does Not Increase the Risk for Subsequent Periprosthetic Joint Infection

BACKGROUND

Recent studies suggest an increased risk for periprosthetic joint infection (PJI) utilizing the direct anterior (DA) approach to the hip. The purpose of this study was to investigate whether such an increased risk does indeed exist on a large cohort of patients, operated by experienced surgeons and taking into account various confounders.

METHODS

This was a single institutional study, including all patients who underwent primary total hip arthroplasty during the last decade, who were operated on by four high-volume arthroplasty surgeons utilizing a single surgical approach. Three of them utilized the direct lateral (DL) approach while one of them used the DA approach throughout the entire study. Patient characteristics, demographics, and comorbidities were assessed as well as operative and perioperative factors and their association with PJI. Association between surgical approach and PJI was evaluated in a univariate followed by a multivariate regression analysis.

RESULTS

A total of 10,201 patients were included in the study. Of those, 4390 (43.0%) underwent total hip arthroplasty through the DA approach and 5811 (57.0%) through the DL approach. PJI rates were 0.9% (38/4390) in the DA group compared with 1.3% (73/5811) in the DL group (P = .068). Results from a regression analysis showed no significant association between PJI and DA approach (adjusted odds ratio 0.760, 95% confidence interval 0.428-1.348, P = .348). The risk remained nonsignificant in patients with higher body mass index. There were also no significant differences in the infecting organisms between the two groups.

CONCLUSION

The DA approach to the hip does not increase the risk for subsequent PJI.

Surgical Approach to Total Hip Arthroplasty Affects the Organism Profile of Early Periprosthetic Joint Infections

The optimal approach for total hip arthroplasty (THA) remains hotly debated. While wound complications following the direct anterior approach are higher than with other approaches, the organism profile of periprosthetic joint infections (PJIs) by approach remains unknown. Our goal was to compare the organism profiles of PJIs following direct anterior and non-anterior THA.

METHODS

We retrospectively reviewed 12,549 primary THAs (4,515 direct anterior and 8,034 non-anterior) that had been performed between January 2012 and September 2019 at a university-affiliated single-specialty orthopaedic hospital to identify patients with an early postoperative PJI. Criteria used for the diagnosis of a PJI were the National Healthcare Safety Network, which screens for PJI that occurs within 90 days of index arthroplasty, and the Musculoskeletal Infection Society guidelines. Patient demographic information and organism characteristics were recorded for analysis.

RESULTS

We identified 84 patients (38 who underwent the direct anterior approach and 46 who underwent the non-anterior approach) with an early postoperative PJI following primary THA (0.67% total THA PJI rate, 0.84% direct anterior THA PJI rate, and 0.57% non-anterior THA PJI rate). The direct anterior THA cohort had a significantly lower body mass index and American Society of Anesthesiologists score than the non-anterior THA cohort (29.5 versus 35.2 kg/m2, p < 0.0001; 2.29 versus 2.63, p = 0.016, respectively). Regarding organism profile, patients in the direct anterior THA cohort had significantly more monomicrobial gram-negative infections than the non-anterior THA cohort (4 versus 0, p = 0.038). We did not identify any demographic risk factors other than approach for gram-negative PJI. There were no significant differences in methicillin-resistant Staphylococcus aureus, methicillin-sensitive Staphylococcus aureus, coagulase-negative Staphylococcus, obligate anaerobes, polymicrobial, or PJIs due to other organisms by approach.

CONCLUSIONS

Direct anterior THA approaches have a greater risk of monomicrobial gram-negative PJI, likely due to the unique microbiome of the inguinal region. While targeted infection prophylaxis may reduce these infections, it is not entirely effective on its own. Future studies with larger sample sizes are required to help us develop more targeted perioperative infection prophylaxis.

LEVEL OF EVIDENCE

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