Is the Direct Anterior Approach for Total Hip Arthroplasty Effective in Obese Patients? Early Clinical and Radiographic Results from a Retrospective Comparative Study

Body Mass Index as a Risk Factor for Readmission Rates in Direct Anterior Approach Total Hip Arthroplasty

Background

Multiple studies have examined the relationship between obesity and increased risk of perioperative complications in patients undergoing total hip arthroplasty (THA). The purpose of this study was to compare the rate of perioperative complications stratified by body mass index (BMI) in patients undergoing THA through a direct anterior (DA) approach.

Methods

A retrospective review at a single high-volume orthopaedic specialty hospital identified all DA THAs performed between January 2019 and August 2022. Patients were stratified by BMI into the following cohorts: underweight (BMI<18.5), normal (BMI = 18.5-25), overweight (BMI = 25-30), obese class I (BMI = 30-35), obese class II (BMI = 35-39.9), and obese class III (BMI ≥ 40). Primary outcomes collected included 30-day and 90-day readmissions, emergency department visits, intraoperative fracture, and 90-day infection requiring return to the operating room. There were 4767 patients with a mean BMI of 28 kg/m2 (15.5-54.5) and a mean age of 67 years (18-100 years).

Results

Thirty-day readmission rates in the obese class III (6.2%) were significantly higher when compared individually to all other cohorts (P < .001). Additionally, logistic regression found that underweight patients had an increased likelihood of an intraoperative fracture (odds ratio [OR]: 13.120, 95% confidence interval [CI]: 1.172-146.930, P < .001), and both obese classes I and III were more likely to have a 90-day infection that required a return to the operating room (OR: 8.508, 95% CI: 1.023-70.779, P < .001 and OR: 29.853, 95% CI: 2.683-332.187, P < .001, respectively).

Conclusions

Obese class III patients have a higher rate of 30-day readmission following DA THA than all other BMI cohorts and are at increased risk of infection requiring return to the operating room when compared to patients with normal BMI. Surgeons should counsel patients regarding the increased potential complication risks related to BMI.

Abdominal Pannus Should Not Dictate Surgical Approach in Primary Total Hip Arthroplasty

Background

Increased pannus size is a risk factor for complications with anterior approach total hip arthroplasty (THA). However, it is unclear if changing to a posterior approach mitigates this risk. The purpose of this study was to evaluate whether abdominal pannus size had a differential effect on complication rate comparing anterior vs posterior THA.

Methods

One thousand consecutive primary THA patients-478 anterior and 522 posterior-were retrospectively reviewed for complications and their abdominal pannus was radiographically measured on an anteroposterior pelvis image and placed into 1 of 4 categories based on its vertical size (no pannus [G0], above symphysis [G1], below symphysis [G2], or below ischial tuberosities [G3]). Chi-squared tests for univariate and logistic regression models controlled for age, race, gender, body mass index, Charlson comorbidity index, and smoking.

Results

Comparing wound complications at increasing pannus size, anterior vs posterior (G0 1.9% vs 3.9%, P = .21; G1 7.2% vs 6.7%, P = .08; G2 17.9% vs 11.6%, P = .27; G3 16.7% vs 15.5%, P = .84), similar results were found with reoperations (G0 0.9% vs 1.1%, P = .080; G1 1.4% vs 2%, P = .72; G2 3.0% vs 5.8%, P = .41; G3 1.7% vs 4.5%, P = .33). Additionally, logistic regression models demonstrated no statistically significant difference in the odds of wound complications or reoperations between the approaches at each pannus size.

Conclusions

In patients with an abdominal pannus, there is no difference in the risk of delayed wound healing or reoperation within 90 postoperative days comparing anterior to posterior approach.

What Is the Most Optimal Bearing Surface for Minimizing Instability After Revision Total Hip Arthroplasty?

Based on the results of our meta-analysis, dual mobility implants appear to have the most efficacy in preventing instability following revision total hip arthroplasty. Notwithstanding, given the relatively small sample sizes of the included studies, in conjunction with heterogeneity in study design, it is important to recognize that further large randomized controlled trials are necessary to determine the optimal bearing surface to reduce the risk of instability after revision total hip arthroplasty.

Enhancing recovery: surgical techniques and rehabilitation strategies after direct anterior hip arthroplasty

Total hip arthroplasty (THA) is a common surgical procedure for hip joint pathologies, with the direct anterior approach (DAA) gaining popularity due to potential benefits in postoperative recovery. This review aims to provide a comprehensive analysis of rehabilitation strategies following DAA THA, focusing on surgical techniques, postoperative care, and outcomes. The evolution of the DAA to THA is discussed, highlighting historical advancements and comparisons with other surgical approaches. Surgical techniques and considerations specific to the DAA are detailed, including outcomes and complications compared to alternative approaches. The role of the surgical technique in influencing postoperative rehabilitation is explored, emphasizing the importance of optimizing surgical procedures for enhanced recovery. Postoperative care and rehabilitation models following DAA THA are examined, with a focus on the impacts of different rehabilitation protocols on patient outcomes. The review underscores the significance of tailored rehabilitation programs in promoting optimal recovery and patient satisfaction. Current evidence from recent studies, meta-analyses, and clinical trials is critically analyzed to provide insights into the effectiveness of postoperative rehabilitation strategies. The review identifies gaps in the existing literature and proposes recommendations for future research to improve rehabilitation protocols and enhance outcomes. In conclusion, this review highlights the importance of postoperative rehabilitation in the context of DAA THA. By synthesizing historical perspectives, current evidence, and future directions, the review offers a comprehensive understanding of rehabilitation strategies following DAA THA. The findings underscore the need for personalized rehabilitation programs and ongoing research to optimize postoperative recovery and improve outcomes in the field of THA.

Anterior Minimally Invasive Approach (AMIS) for Total Hip Arthroplasty: Analysis of the First 1000 Consecutive Patients Operated at a High Volume Center

(1) Background: Direct anterior approach (DAA) has recently acquired popularity through improvements such as the anterior minimally invasive surgical technique (AMIS). This retrospective study examines the first 1000 consecutive THAs performed utilizing the AMIS approach in a high-volume center between 2012 and 2017. (2) Methods: 1000 consecutive THAs performed at a single institution utilizing the AMIS approach were retrospectively analyzed with a minimum five-year follow-up. Full evaluation of demographic information, clinical parameters, intraoperative complications, and radiological examinations are reported. (3) Results: Overall complication rate was 9.4% (94/1000), including 8 dislocations, 57 femoral-cutaneous nerve injuries, 12 intraoperative femoral fractures, 9 infections and 8 leg length discrepancy. Implant survival rates were 98.5% at 1 year, 97.5% at 3 years, 97% at 5 years, and 95.3% at 7 years. Causes of failure included periprosthetic fractures (0.8%), implant dislocations (0.6%), septic loosening (0.5%), aseptic mobilizations (0.2%), and symptomatic limb length discrepancies (0.2%). (4) Conclusions: Controversies persist around the direct anterior approach (DAA) for THA, primarily regarding the increased complications rate during the learning curve. However, this study advocates for widespread adoption of the DAA approach. The results demonstrate acceptable complication rates and remarkable functional outcomes, affirming its viability in the broader orthopedic patient population.

Endoscopic Arthroplasty via Mini-open Direct Anterior Approach Improves Postoperative Complications and Acetabular Components of Total Hip Arthroplasty in Obese Patients

To overcome the high-risk complications and poor alignment of acetabular components in obese patients associated with direct anterior approach (DAA) for total hip arthroplasty (THA), we innovated an endoscopic arthroplasty via mini-open direct anterior approach technique (Endo-DAA). The purpose of this study was to compare the clinical and radiographic outcomes in obese patients subjected to THA between Endo-DAA, Bikini DAA, and conventional DAA. In this retrospective controlled study, a total of 360 consecutive primary THA on obese patients (body mass index greater than 28 kg/m2) via Endo-DAA, Bikini DAA, and conventional DAA performed from October 2017 to October 2022 by different surgeons and in a single center were included. Assessments including perioperative parameters, clinical outcomes, complications, and radiologic measurements were retrieved from patients before the surgery, perioperative period and the latest follow-up. A total of 360 consecutive THA (Endo-DAA = 108, Bikini DAA = 116, Conventional DAA = 136) with complete follow-up data were analyzed. Compared to Bikini DAA or conventional DAA, Endo-DAA significantly shortened the length of incision (5.46 ± 0.53), the duration of operation (64.47 ± 12.38), and postoperative hospital stay (2.15 ± 0.89). Endo-DAA significantly reduces wound related complications compared with conventional DAA. Besides, Endo-DAA achieved a significantly better alignment of acetabular components compared to Bikini DAA or conventional DAA. Furthermore, Endo-DAA improved postoperative pain at the activity at 24 h postoperatively and early functional scores. The Endo-DAA THA technique provides better short-term clinical and radiographic results in obese patients with a low rate of postoperative complications compared to Bikini DAA or conventional DAA.

The Medium- to Long-Term Results of Vascular-Sparing Subcapital Osteotomy (VASSCO) for Pediatric Patients with Chronic Slipped Capital Femoral Epiphysis

Background: In patients affected by chronic slipped capital femoral epiphysis (C-SCFE), the performance of a subcapital osteotomy is an effective procedure to correct the deformity at the proximal femur. However, the rate of postoperative complications is very high, with iatrogenic avascular necrosis of the femoral head (AVN) being the most bothersome. To overcome the risk of AVN, the modified Dunn procedure according to Ganz and, more recently, the Vascular Sparing Subcapital Osteotomy (VASSCO) technique have been proposed; however, only short-term follow-up studies are available on the latter technique being used. The aim of this study is therefore to show our mid-term clinical and radiological results with the VASSCO technique. Materials and Methods: A total of 26 patients underwent VASSCO for moderate or severe stable C-SCFE between 2012 and April 2016 with an average 10-year follow-up (range 8-12 years). The outcomes was evaluated using the HHS and pre- and postoperative ROM. The radiological outcomes and complications were collected. Results: No major intraoperative complications occurred; three patients reported postoperative transient apraxia of the lateral femoral cutaneous nerve, which completely recovered in six months. All the radiological outcomes showed substantial improvement postoperatively. One case patient developed AVN of the femoral head and required a total hip arthroplasty after 12 years. Conclusions: The current data suggest that VASSCO osteotomy is a reliable technique with very good clinical results at mid-term follow-up; it could be considered a valuable alternative to using more complex techniques to restore the proximal femoral anatomy in moderate to severe C-SCFE.