Total hip arthroplasty performed by direct anterior approach – Does experience influence the learning curve?

Introduction: Proficiency in the direct anterior approach (DAA) as with many surgical techniques is considered to be challenging. Added to this is the controversy of the benefits of DAA compared to other total hip arthroplasty (THA) approaches. Our study aims to assess the influence of experience on learning curve and clinical results when transitioning from THA via posterior approach in a lateral position to DAA in a supine position. Methods: A consecutive retrospective series of 525 total hip arthroplasty of one senior and six junior surgeons was retrospectively analysed from May 2013 to December 2017. Clinical results were analysed and compared between the two groups and represented as a learning curve. Mean follow up was 36.2 months ± 11.8. Results: This study found a significant difference in complications between the senior and junior surgeons for operating time, infection rate, and lateral femoral cutaneous nerve (LFCN) neuropraxia. A trainee’s learning curve was an average of 10 DAA procedures before matching the senior surgeon. Of note, the early complications correlated with intraoperative fractures increased with experience in both groups. Operating time for the senior equalised after 70 cases. Dislocation rate and limb length discrepancy were excellent and did not show a learning curve between the two groups. Conclusion: DAA is a safe approach to implant a THA. There is a learning curve and initial supervision is recommended for both seniors and trainees. Level of evidence: Retrospective, consecutive case series; level IV.

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Fully hydroxyapatite-coated collared femoral stems in direct anterior versus direct lateral hip arthroplastyFully hydroxyapatite-coated collared femoral stems in direct anterior versus direct lateral hip arthroplasty

Canadian Journal of Surgery ◽

10.1503/cjs.000920 ◽

2021 ◽

Vol 64 (2) ◽

pp. E205-E210

Author(s):

Sebastian Heaven ◽

Maxwell Perelgut ◽

Edward Vasarhelyi ◽

James Howard ◽

Matthew Teeter ◽

...

Keyword(s):

Total Hip Arthroplasty ◽

Hip Arthroplasty ◽

Anterior Approach ◽

Direct Anterior Approach ◽

Lateral Approach ◽

Early Recovery ◽

Total Hip ◽

Significant Difference ◽

Femoral Stems ◽

Direct Lateral Approach

Background: Total hip arthroplasty (THA) via the direct anterior approach has increased in popularity in the last decade, with research supporting enhanced early recovery; however, some investigators have reported increased early revision rates in direct anterior THA. We examined outcomes from a single institution’s experience with a fully hydroxyapatite-coated collared femoral stem implanted via the anterior or the lateral approach. Methods: Patients who had received fully hydroxyapatite-coated collared femoral stems as part of THA surgery performed by 1 of 3 surgeons between January 2012 and September 2017 were identified from our institutional database. We examined revision rates for the 2 approaches and compared them between the 2 groups. We also analyzed outcomes on plain film radiographs obtained immediately postoperatively and at 1 and 2 years. Results: A total of 695 patients received a fully hydroxyapatite-coated collared stem during the study period. Total hip arthroplasty was performed via the direct anterior approach in 281/778 hips (36.1%) and via the direct lateral approach in 497 (63.9%). Nineteen patients (2.5%) underwent subsequent revision surgery; there was no statistically significant difference in the revision rate between the anterior and lateral approaches (2.5% v. 2.4%, p = 0.95). The mean subsidence of the stem at 1 year was 1.68 mm (standard deviation 11.7 mm). No statistically significant differences were observed between the cohorts for any of the radiographic measurements at either follow-up time. Conclusion: We found no significant difference in revision rates between the direct anterior and direct lateral approach. Stem subsidence levels were in keeping with expected values, and no major changes in stem position occurred during the first postoperative year. Surgical approach did not appear to substantially affect biomechanical stem behaviour.

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Does total hip arthroplasty via the direct anterior approach using dual mobility increase leg length discrepancy compared with single mobility?

Arthroplasty ◽

10.1186/s42836-020-00060-6 ◽

2021 ◽

Vol 3 (1) ◽

Author(s):

Seiya Ishii ◽

Yasuhiro Homma ◽

Tomonori Baba ◽

Yuta Jinnai ◽

Xu Zhuang ◽

...

Keyword(s):

Total Hip Arthroplasty ◽

Hip Arthroplasty ◽

Anterior Approach ◽

Direct Anterior Approach ◽

Leg Length Discrepancy ◽

Leg Length ◽

Dual Mobility ◽

Total Hip ◽

Length Discrepancy ◽

Significant Difference

Abstract Background Total hip arthroplasty (THA) via the direct anterior approach (DAA) using dual mobility cup (DMC) is considered to effectively prevent postoperative dislocation. However, the dislocation and reduction procedure using a trial implant during the surgery is difficult because of high soft tissue tension. Thereby, leg length discrepancy (LLD) is difficult to assess when using DM via the DAA. Purpose To compare the LLD between cases using conventional SM and those using DMC in THA via the DAA with fluoroscopy. Patients and methods We retrospectively investigated 34 hips treated with DMC (DMC-DAA group) and 31 hips treated with SM (SM-DAA group). The LLD was defined as the difference in the distance from the teardrop to the medial-most point of the lesser trochanter between the operative and nonoperative sides at immediate postoperative X-ray. Results The mean LLD in the DMC-DAA group and SM-DAA group was 0.68 ± 7.7 mm and 0.80 ± 5.5, respectively, with no significant difference. The absolute value of the LLD in the DMC-DAA group and SM-DAA group was 6.3 ± 4.4 mm and 5.9 ± 5.5, respectively, with no significant difference. Conclusion Despite the difficulty in assessment of the LLD during THA via the DAA using DMC, this technique does not increase the LLD compared with the use of SM. Level of evidence III, matched case-control study.

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The Learning Curve for the Direct Anterior Approach for Total Hip Arthroplasty: A Single Surgeon's First 500 Cases

Hip International ◽

10.5301/hipint.5000488 ◽

2017 ◽

Vol 27 (5) ◽

pp. 483-488 ◽

Cited By ~ 26

Author(s):

James M. Hartford ◽

Michael J. Bellino

Keyword(s):

Total Hip Arthroplasty ◽

Learning Curve ◽

Heterotopic Ossification ◽

Hip Arthroplasty ◽

Anterior Approach ◽

Direct Anterior Approach ◽

Fracture Rate ◽

Leg Length ◽

Total Hip ◽

Major Complications

Background Concerns arise over the early complications encountered during the learning curve for the direct anterior approach for total hip arthroplasty. The purpose of this study is to examine the learning experience of a single surgeon in adapting this approach. Methods The 1st 500 primary total hip arthroplasties are reviewed. The patients were evaluated out to 3 months. Rates of major complications, reoperations, periprosthetic fractures, heterotopic ossification, leg length discrepancies and lateral femoral cutaneous nerve deficits were identified for each of 100 patients. Results The major complication rate decreased from 5% to 2% throughout the series. Reoperation rates fluctuated from 2% in the 1st 100 cases to 3% in the 4th 100 cases to 1% in the 5th 100 cases. The periprosthetic fracture rate decreased from 9% to 2%. Conclusions The incidence of heterotopic ossification declines throughout the series and is attributed to changes in irrigation technique and quantity. The incidence of major complications decreases with increasing experience. The most dramatic improvements occur after the 1st group of 100 cases.

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Transitioning the total hip arthroplasty technique from posterior approach in lateral position to direct anterior approach in supine position—risk factors for acetabular malpositioning and the learning curve

International Orthopaedics ◽

10.1007/s00264-020-04583-0 ◽

2020 ◽

Vol 44 (9) ◽

pp. 1669-1676 ◽

Cited By ~ 1

Author(s):

Constant Foissey ◽

Cécile Batailler ◽

Cam Fary ◽

Francesco Luceri ◽

Elvire Servien ◽

...

Keyword(s):

Risk Factors ◽

Total Hip Arthroplasty ◽

Learning Curve ◽

Hip Arthroplasty ◽

Supine Position ◽

Anterior Approach ◽

Posterior Approach ◽

Direct Anterior Approach ◽

Lateral Position ◽

Total Hip

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The Surgeon Mentor Program: Outcomes of Total Hip Arthroplasty via the Direct Anterior Approach

The Journal of Hip Surgery ◽

10.1055/s-0041-1736158 ◽

2021 ◽

Author(s):

Melinda Jiang ◽

Mark Inglis ◽

David Morris ◽

Nathan Eardley-Harris ◽

Christopher J. Wilson

Keyword(s):

Total Hip Arthroplasty ◽

Length Of Stay ◽

Learning Curve ◽

Hip Arthroplasty ◽

Complication Rate ◽

Anterior Approach ◽

Direct Anterior Approach ◽

Initial Increase ◽

Mentoring Program ◽

Total Hip

AbstractThe direct anterior approach (DAA) for total hip arthroplasty has been increasing in popularity due to potential benefits including less pain, faster recovery, decreased risk of dislocation, and a reduced length of stay. The DAA has been described by many to have a steep learning curve owing to its greater risk of complications when first using the approach. The primary aim of this study was to design and implement a specific surgeon mentor program in an attempt to reduce the learning curve of the DAA. Surgeons completed the surgical education and mentoring program designed to reduce the initial increase in complication rate when first learning the DAA in a public hospital setting. A retrospective review of clinical and radiological outcomes on the first 67 cases was then conducted. Of these, 43 cases were eligible for inclusion. The 43 patients in this study had a mean age of 66.7, BMI of 26.7, and 57% of them were female. Follow-up was between 39 and 49 months, with a mean of 46 months. There were no fractures, dislocations, or blood transfusions. One patient required revision for deep infection. The mean length of stay was 2.81 days. At 6 weeks postoperative, 86% were independently mobile, 9.3% were using a cane, and 4.7% were being weaned off a walker. The radiological assessments found a mean cup abduction of 39.9 ± 5.1 degrees, mean femoral offset of 1.6 ± 5.5 mm, and a total hip offset of 1.3 ± 7 mm greater than the contralateral hip. Patients had a mean leg length discrepancy of −0.9 ± 5.9 mm. In conclusion, a surgeon mentoring program was designed and implemented to reduce the learning curve of the DAA in our center, with satisfactory 3-year clinical and radiological outcomes achieved. This study provides preliminary support for the potential utility of the mentoring program in facilitating other centers in safely introducing the DAA into their practice without an initial increase in complication rate.

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The external obturator footprint as a landmark in total hip arthroplasty through a direct anterior approach: a CT-based analysis

Hip International ◽

10.1177/1120700018761320 ◽

2018 ◽

Vol 29 (1) ◽

pp. 96-101 ◽

Cited By ~ 1

Author(s):

Hannes A Rüdiger ◽

Benjamin Fritz ◽

Franco M Impellizzeri ◽

Michael Leunig ◽

Christian W Pfirrmann ◽

...

Keyword(s):

Total Hip Arthroplasty ◽

Hip Arthroplasty ◽

Anterior Approach ◽

Direct Anterior Approach ◽

Ct Scans ◽

Anatomical Landmarks ◽

Greater Trochanter ◽

Total Hip ◽

Significant Difference ◽

Anatomical Axis

Background: Anatomical landmarks for templating of total hip arthroplasty (THA) that are visible both during surgery and on radiographs are rare. If surgery is performed through a direct anterior approach the external obturator tendon (EO) is consistently visible. To use this point as a reference the exact position and dimensions of the footprint need to be known. Aim: To determine the location and dimension of the EO footprint on pelvic radiographs by correlating the EO anatomy in CT scans with conventional radiographs. Methods: CT scans and radiographs of 200 patients were analysed. The EO tendon was identified on CT scans; the height of its footprint, and its distance to the tip of the greater trochanter and to the anatomical axis of the femur was measured. The accuracy and inter-rater reliability in the identification of the EO footprint was determined. Results: The EO tendon was visible on all CT scans and it’s footprint was identifiable on all corresponding radiographs. It’s cranio-caudal dimension was 6.4 ± 1.4 mm. It’s distance to the tip of the greater trochanter was 16.0 ± 3.1 mm. The EO footprint was located 5.2 ± 3.7 mm lateral to the femoral anatomical axis. There was no significant difference regarding the accuracy of EO footprint localisation on radiographs among the 2 readers. Conclusion: The EO footprint on the greater trochanter is consistently visible on CT scans and radiographs. As the variability of the footprint dimension is small, this structure may serve as a useful landmark in THA, particularly when performed through a direct anterior approach.

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Posterior versus direct anterior approach in total hip arthroplasty: difference in patient-reported outcomes measured with the Forgotten Joint Score-12

SICOT-J ◽

10.1051/sicotj/2018051 ◽

2018 ◽

Vol 4 ◽

pp. 54 ◽

Cited By ~ 9

Author(s):

Yu Ozaki ◽

Tomonori Baba ◽

Yasuhiro Homma ◽

Hironori Ochi ◽

Taiji Watari ◽

...

Keyword(s):

Total Hip Arthroplasty ◽

Hip Arthroplasty ◽

Anterior Approach ◽

Patient Reported Outcomes ◽

Direct Anterior Approach ◽

Harris Hip Score ◽

Total Hip ◽

Forgotten Joint Score ◽

Significant Difference ◽

Patient Reported

Introduction: When the postoperative outcome of primary total hip arthroplasty (THA) was compared with the direct anterior approach (DAA) and the posterior approach (PA), there was no significant difference of the clinical outcome at 6 months to 1 year after surgery in many studies. This study was performed to compare the medium-term outcome of THA via the DAA or PA and clarify which approach achieves better quality of life (QOL). Methods: We investigated 61 hips receiving primary THA (30 via DAA and 31 via PA), using hip function scores such as the Harris Hip Score (HHS) and patient-reported outcomes such as the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ), and the Forgotten Joint Score-12 (FJS). Results: The mean duration of postoperative follow-up was 36.8 months in the DAA group and 40.5 months in the PA group. There was no difference in preoperative or postoperative HHS between the two groups. Although there was no difference of postoperative WOMAC and JHEQ, the postoperative FJS-12 score was significantly higher in the DAA group than in the PA group (75.2 ± 15.9 versus 60.1 ± 24.4, p = 0.01). Conclusion: When forgetting the artificial joint in daily life is the target, better QOL can be achieved by performing THA via the DAA.

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