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

2017 ◽  
Vol 27 (5) ◽  
pp. 483-488 ◽  
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.

Heterotopic Ossification after Direct Anterior Approach Total Hip Arthroplasty

2019 ◽  
Vol 03 (04) ◽  
pp. 186-190
Author(s):  
Eric M. Cohen ◽  
Jacob M. Babu ◽  
Scott Ritterman ◽  
John Tuttle ◽  
Daniel Eisenson ◽  
...  
Keyword(s):  
Total Hip Arthroplasty ◽  
Heterotopic Ossification ◽  
Hip Arthroplasty ◽  
Anterior Approach ◽  
Surgical Excision ◽  
Direct Anterior Approach ◽  
Thrombosis Prophylaxis ◽  
Baseline Characteristic ◽  
Total Hip ◽  
Tissue Handling

AbstractPrevious studies have demonstrated varying rates of heterotopic ossification (HO) after total hip arthroplasty (THA) depending on which anatomical approach is utilized. The direct anterior approach (DAA) is considered to be a muscle-sparing approach to the hip, which may lead to decreased rates of HO formation. This study evaluated the incidence of HO formation after DAA THA. The current work is a retrospective review of patients who underwent DAA THA. Six-month postoperative radiographs were evaluated and HO grade was classified using the Brooker classification system. Baseline characteristic differences between the Brooker classification groups were analyzed, specifically looking at: age, sex, type of deep venous thrombosis prophylaxis utilized, and preoperative Bombelli arthritis type. The overall incidence of HO in this DAA group was 179/485 patients (36.9%). There were 14 patients (2.9%) with Brooker Type 3 HO and 1 patient (0.21%) with Brooker Type 4 HO. No surgical excision of HO was performed. Patients were significantly more likely to develop HO if they had Bombelli hypertrophic arthritis (p < 0.00003). Preoperative radiographic imaging suggesting Bombelli hypertrophic arthritis is predictive of HO formation, warranting consideration for HO prophylactic treatment. The radiographic incidence of HO in DAA THA was 36.9%, which is within the previously reported range of HO seen for lateral and posterior approaches to the hip. HO after total hip arthroplasty is likely due to soft tissue handling, hemostasis, and patient factors, rather than type of surgical approach.

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

SICOT-J ◽  
2020 ◽  
Vol 6 ◽  
pp. 15 ◽  
Author(s):  
Constant Foissey ◽  
Mathieu Fauvernier ◽  
Cam Fary ◽  
Elvire Servien ◽  
Sébastien Lustig ◽  
...  
Keyword(s):  
Total Hip Arthroplasty ◽  
Learning Curve ◽  
Hip Arthroplasty ◽  
Anterior Approach ◽  
Operating Time ◽  
Surgical Techniques ◽  
Direct Anterior Approach ◽  
Clinical Results ◽  
Total Hip ◽  
Significant Difference

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.

scholarly journals Leg and Femoral Neck Length Evaluation Using an Anterior Capsule Preservation Technique in Primary Direct Anterior Approach Total Hip Arthroplasty

2017 ◽  
Vol 7 (1) ◽  
Author(s):  
Stephen J Nelson ◽  
Murillo Adrados ◽  
Raj J Gala ◽  
Erik J Geiger ◽  
Matthew L Webb ◽  
...  
Keyword(s):  
Total Hip Arthroplasty ◽  
Femoral Neck ◽  
Hip Arthroplasty ◽  
Anterior Approach ◽  
Direct Anterior Approach ◽  
Operating Table ◽  
Leg Length ◽  
Neck Length ◽  
Anterior Capsule ◽  
Total Hip

BackgroundAchieving correct leg and femoral neck lengths remains a challenge during total hip arthroplasty (THA).  Several methods for intraoperative evaluation and restoration of leg length have been proposed, and each has inaccuracies and shortcomings.  Both the supine positioning of a patient on the operating table during the direct anterior approach (DAA) THA and the preservation of the anterior capsule tissue  are simple, readily available, and cost-effective strategies that can lend themselves well as potential solutions to this problem.TechniqueThe joint replacement is performed through a longitudinal incision (capsulotomy) of the anterior hip joint capsule, and release of the capsular insertion from the femoral intertrochanteric line. As trial components of the prosthesis are placed, the position of the released distal capsule in relationship to its original insertion line is an excellent guide to leg length gained, lost, or left unchanged.MethodsThe radiographs of 80 consecutive primary THAs were reviewed which utilized anterior capsule preservation and direct capsular measurement as a means of assessing change in leg/femoral neck length. Preoperatively, the operative legs were 2.81 +/- 8.5 mm (SD) shorter than the nonoperative leg (range: 17.7 mm longer to 34.1 mm shorter).  Postoperatively, the operative legs were 1.05 +/- 5.64 mm (SD) longer than the nonoperative leg (range: 14.9 mm longer to 13.7 mm shorter).ConclusionThe preservation and re-assessment of the native anterior hip capsule in relationship to its point of release on the femur is a simple and effective means of determining leg/femoral neck length during DAA THA.

scholarly journals Reliability of a simple fluoroscopic image to assess leg length discrepancy during direct anterior approach total hip arthroplasty

2021 ◽  
Vol 12 (11) ◽  
pp. 850-858
Author(s):  
Sandi Caus ◽  
Hailee Reist ◽  
Christopher Bernard ◽  
Michael Blankstein ◽  
Nathaniel J Nelms
Keyword(s):  
Total Hip Arthroplasty ◽  
Hip Arthroplasty ◽  
Anterior Approach ◽  
Direct Anterior Approach ◽  
Leg Length Discrepancy ◽  
Leg Length ◽  
Total Hip ◽  
Fluoroscopic Image ◽  
Length Discrepancy

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

Arthroplasty ◽  
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.

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

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.

Does the thigh circumference affect the positioning of the acetabular component when using the direct anterior approach in total hip arthroplasty?

2019 ◽  
Vol 101-B (5) ◽  
pp. 529-535 ◽  
Author(s):  
C. A. Jacobs ◽  
E. T. Kusema ◽  
B. J. Keeney ◽  
W. E. Moschetti
Keyword(s):  
Total Hip Arthroplasty ◽  
Acetabular Component ◽  
Hip Arthroplasty ◽  
Anterior Approach ◽  
Direct Anterior Approach ◽  
Leg Length Discrepancy ◽  
Leg Length ◽  
Thigh Circumference ◽  
Total Hip ◽  
Length Discrepancy

Aims The hypothesis of this study was that thigh circumference, distinct from body mass index (BMI), may be associated with the positioning of components when undertaking total hip arthroplasty (THA) using the direct anterior approach (DAA), and that an increased circumference might increase the technical difficulty. Patients and Methods We performed a retrospective review of prospectively collected data involving 155 consecutive THAs among 148 patients undertaken using the DAA at an academic medical centre by a single fellowship-trained surgeon. Preoperatively, thigh circumference was measured at 10 cm, 20 cm, and 30 cm distal to the anterior superior iliac spine, in quartiles. Two blinded reviewers assessed the inclination and anteversion of the acetabular component, radiological leg-length discrepancy, and femoral offset. The radiological outcomes were considered as continuous and binary outcome variables based on Lewinnek’s ‘safe zone’. Results Similar trends were seen in all three thigh circumference groups. In multivariable analyses, patients in the largest 20 cm thigh circumference quartile (59 cm to 78 cm) had inclination angles that were a mean of 5.96° larger (95% confidence interval (CI) 2.99° to 8.93°; p < 0.001) and anteversion angles that were a mean of 2.92° larger (95% CI 0.47° to 5.37°; p = 0.020) than the smallest quartile. No significant differences were noted in leg-length discrepancy or offset. Conclusion There was an associated increase in inclination and anteversion as thigh circumference increased, with no change in the risk of malpositioning the components. THA can be performed using the DAA in patients with large thigh circumference without the risk of malpositioning the acetabular component. Cite this article: Bone Joint J 2019;101-B:529–535.

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