Approaches for Total Hip Arthroplasty: A Systematic Review

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.

A Modified Transgluteal Approach Sparing Abductor Function in Total Hip Arthroplasty Results in a Low Postoperative Dislocation Rate: A Retrospective Study of Short- and Long-Term Outcomes

Background A modified transgluteal approach in total hip arthroplasty (THA) can be utilized to preserve abductor muscle function and reduce dislocation rate. We present a study evaluating outcomes for a modified transgluteal approach using a validated patient-reported outcome measure (PROM) tool, the Oxford Hip Score (OHS). Methods This was a retrospective single-centre study over a four-year period. Short-term data was collected including intraoperative and postoperative complications, length of stay (LOS) in the hospital, and time from operation to mobilising independently. One year of data was collected, including plain radiograph findings and the incidence of Trendelenburg gait. Patients were contacted at a mean time of 2.7 years post-operatively so that OHS could be conducted. Results A total of 100 patients were identified within the inclusion criteria. The mean LOS for all patients was 2.8 days. The mean time from operation to mobilising independently without walking aids was 4.9 weeks. At the one-year follow-up, there was satisfactory radiographic assessment in 100% of patients. The mean OHS was 45.5 at 2.7 years, indicating satisfactory joint function in all patients. Conclusion This study supports the use of the modified transgluteal approach in THA, showing favourable outcomes in the time from operation to cessation in the use of walking aids, LOS and OHS. We report zero cases of Trendelenburg gait at the one-year follow-up and no dislocations at the three-year follow-up. Further studies are required to compare the outcomes of TGA to other approaches in THA.

Comparison of postoperative outcomes between endoscopy assisted minimal invasive direct anterior approach and bikini direct anterior approach in total hip arthroplasty

BACKGROUND

We have innovatively developed a modified bikini direct anterior approach total hip arthroplasty (THA), endoscopy assisted minimal invasive direct anterior approach (Endo-DAA). The study compared aesthetic appearance of the scar, postoperative radiographic and functional outcomes, and complications of Endo-DAA with Bikini-DAA.

METHODS

Patients who underwent primary THA using Endo-DAA or Bikini-DAA were included. The main innovation of Endo-DAA is the use of minimally invasive 5-7 cm proximal transverse incision and distal puncture with an endoscopy assisted split-type tool to complete the acetabular preparation and prosthesis implantation. Outcomes evaluated included evaluation of scar satisfaction, hip reconstruction including inclination, anteversion and leg-length discrepancy (LLD) and patient-reported outcomes including Harris Hip Scores (HHS) and Forgotten Joint Score (FJS). Follow-up time points included preoperative, 6 weeks, 6 months and 12 months.

RESULTS

Finally, 195 hips in Endo-DAA and 207 hips in Bikini DAA completed the follow-up. The Endo-DAA group was superior to the Bikini-DAA group in the cosmetic aspects of scars. the cup anteversion angle of Endo-DAA group was significantly better than that in the Bikini-DAA group. The early HHS and FJS of the Endo-DAA group were superior to those of the Bikini-group. Operation time, blood loss, incision length, length of stay and duration to start no-assistive-device walking were also significantly better in the Endo-DAA group. Furthermore, the Bikini-DAA group had a higher incidence of complication.

CONCLUSION

Compared with Bikini-incision, Endo-DAA improves patients' subjective satisfaction with scar aesthetics, accelerates rapid recovery of postoperative function, and reduces postoperative complications.

Combined Anterolateral and Posterior Approach in Total Hip Arthroplasty for Chronic Post-traumatic Hip Dislocation: A Case Report

Hip dislocation is rare, and it typically results from high-energy trauma such as traffic accidents. Its management involves prompt reduction of the dislocated hip to minimize the risk of subsequent femoral head necrosis. Consequently, cases of chronic hip dislocation are extremely rare. This report presents a case of a 33-year-old male with chronic posterior hip dislocation due to a traffic accident 13 years ago. The left femoral head was completely dislocated posteriorly from the acetabulum, forming a false acetabulum with an arthritic change. The patient experienced difficulty walking and performing daily activities due to pain. We performed a total hip arthroplasty (THA) using a combined anterolateral and posterior approach. The outcome was favorable, with no complications during the two-year follow-up period. THA using a combined anterolateral and posterior approach is a valuable option for patients with chronic post-traumatic hip dislocation because it offers the advantages of optical visibility and the management of the adhered soft tissues.

Postoperative lymphedema after primary total hip arthroplasty: prospective analysis of bikini incision-type direct anterior approach versus established standard approaches

BACKGROUND

Minimally invasive approaches to the hip joint for total hip arthroplasty such as the DAA ("Direct Anterior Approach with bikini incision") are increasingly utilized. According to the literature, this approach is more muscle-sparing, results in less postoperative pain, and achieves higher patient satisfaction. The existence of postoperative lymphedema after hip arthroplasty is hardly considered. The aim of this paper is to contribute to the evaluation of the different access methods related to postoperative lymphedema and their functional outcomes.

METHODS

This is a prospective non-randomized study at an orthopedic specialist clinic in Northern Europe. The surgeons that performed the arthroplasties are high-volume surgeons in private practice affiliated to the clinic. The study included 188 patients with primary hip arthroplasty in a 1:1 ratio (DAA: standard accesses (posterior, transgluteal, and anterolateral access)). Epidemiologic data, Harris Hip Score, Oxford Hip Score, European Quality of Life 5, and Visual Analog Scale were collected preoperatively on admission day, 3rd and 5th postoperative day, and follow-up after 1 year. Furthermore, the range of motion, gait, and ability to climb stairs, as well as the presence of hypesthesia were assessed. To evaluate the edema situation, both legs were measured on the 3rd and 5th postoperative day. The prescription of manual lymphatic drainage and remaining swelling conditions 1 year postoperatively were recorded.

RESULTS

For each group, 94 patients with a mean age of 61.7 years (DAA 60.7 and standard access 62.6) were included. All but one patient in the DAA group showed postoperative lymphedema (n: 93/94; 98.9%). In the standard surgery group, only n: 37/94 (39.4%) showed swelling symptoms requiring treatment. After 1 year, lymphedema persisted in 20 patients in the DAA group and 0 patients in the standard-OR group. Hypesthesia at the ventral thigh persisted in 16/94 (= 17%) patients of the DAA group versus 0/94 patients of the standard group after 12 months. Of these 16 cases, 10 had concomitant edema (62.5%). The DAA showed better results than the standard accesses in terms of Oxford Hip Score (p < 0.05) and ability to climb stairs (p < 0.05). In contrast, the Visual Analog Scale and patient quality of life results showed no significant difference (p > 0.05).

CONCLUSION

The present study demonstrated the increased incidence of postoperative lymphedema in patients operated on via DAA access using a Bikini-type skin incision. In the follow-up, significantly more hypesthesia of the ventral thigh occurred in the DAA group. Otherwise, the DAA proved to be superior to the standard approaches from a functional point of view at short-term follow-up. Future research is needed to compare the horizontally oblique to the longitudinal oblique skin incision technique in direct anterior hip surgery regarding the above-mentioned adverse effects found in this study.

Does intraoperative fluoroscopy improve acetabular component positioning and limb-length discrepancy during direct anterior total hip arthroplasty? A meta-analysis

BACKGROUND

The positioning of implant components for total hip arthroplasty (THA) is essential for joint stability, polyethylene liner wear, and range of motion. One potential benefit of the direct anterior approach (DAA) for THA is the ability to use intraoperative fluoroscopy for acetabular cup positioning and limb-length evaluation. Previous studies comparing intraoperative fluoroscopy with no fluoroscopy during DAA have reported conflicting results. This meta-analysis aimed to evaluate whether intraoperative fluoroscopy improves component positioning compared to no fluoroscopy during direct anterior total hip arthroplasty.

METHODS

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. We searched Web of Science, EMBASE, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, CNKI, VIP, and Wanfang database in May 2023 to identify studies involving intraoperative fluoroscopy versus no fluoroscopy during direct anterior total hip arthroplasty. Finally, we identified 1262 hips assessed in seven studies.

RESULTS

There were no significant differences in terms of acetabular cup inclination angle (ACIA, P = 0.21), ACIA within safe zone rate (P = 0.97), acetabular cup anteversion angle (ACAA, P = 0.26); ACAA within safe zone rate (P = 0.07), combined safe zone rate (P = 0.33), and limb-length discrepancy (LLD, P = 0.21) between two groups.

CONCLUSION

Even though intraoperative fluoroscopy was not related to an improvement in cup location or LDD. With fewer experienced surgeons, the benefit of intraoperative fluoroscopy might become more evident. More adequately powered and well-designed long-term follow-up studies were required to determine whether the application of the intraoperative fluoroscopy for direct anterior total hip arthroplasty will have clinical benefits and improve the survival of prostheses.