Intraoperative Fluoroscopy with a Direct Anterior Approach Reduces Variation in Acetabular cup Abduction Angle

Introduction The purpose of this study was to compare acetabular cup position for 2 cohorts of total hip arthroplasty (THA) patients who had a direct anterior approach. Methods 100 THA cases were performed with an anterior approach using intraoperative fluoroscopy (IF) to aid in cup positioning. Another group of 100 cases underwent THA with an anterior approach without the use of any fluoroscopy. Postoperative abduction and anteversion angles were measured using Martell's hip analysis software. Results Mean abduction angle was 43.2° (standard deviation (SD) = 4.5°) for the IF group versus 37.5°(SD = 7.4°) for cases without IF (p<0.001). 18% more cases with IF fell within the Lewinnek safe zone (p<0.001); however, a similar number of cases had over 50° of abduction. The mean anteversion angles of the two groups were also significantly different (IF 21.8° vs. 24.9°) (p<0.01). Conclusions There was significantly less variation in cup position among the cases using IF with regards to abduction.

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Fluoroscopic Imaging of Acetabular Cup Position During THA Through a Direct Anterior Approach

Orthopedics ◽

10.3928/01477447-20140101-12 ◽

2014 ◽

Vol 37 (1) ◽

pp. 12-12 ◽

Cited By ~ 1

Author(s):

Ajit J. Deshmukh ◽

Parthiv A. Rathod ◽

Jose A. Rodriguez ◽

Andres M. Alvarez

Keyword(s):

Anterior Approach ◽

Direct Anterior Approach ◽

Acetabular Cup ◽

Fluoroscopic Imaging ◽

Cup Position ◽

Acetabular Cup Position

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Does a fluoro-assisted direct anterior approach for total hip arthroplasty pose an excessive risk of radiation exposure to the surgeon?

SICOT-J ◽

10.1051/sicotj/2020004 ◽

2020 ◽

Vol 6 ◽

pp. 6

Author(s):

Yuta Jinnai ◽

Tomonori Baba ◽

Xu Zhuang ◽

Hiroki Tanabe ◽

Sammy Banno ◽

...

Keyword(s):

Total Hip Arthroplasty ◽

Radiation Exposure ◽

Anterior Approach ◽

Direct Anterior Approach ◽

Proximal Femoral Fracture ◽

Fluoroscopy Time ◽

Exposure Level ◽

Intraoperative Fluoroscopy ◽

Significant Difference ◽

The Mean

Introduction: Intraoperative fluoroscopy can be easily used because patients are placed in the supine position during total hip arthroplasty via direct anterior approach (DAA-THA) to reduce complications. However, the cumulative level of radiation exposure by intraoperative fluoroscopy increases as the annual number of cases increases, increasing the risk of influencing the health of both the patients and medical workers. The objective of the study was to compare the radiation exposure time of DAA-THA with osteosynthesis and to determine if the level of radiation exposure exceeded safety limits. Material and methods: DAA-THA was performed in 313 patients between January 2016 and July 2018 and 60 patients with proximal femoral fracture were treated with osteosynthesis. The intraoperative fluoroscopy time was retrospectively surveyed and compared between these two groups. A total of eight surgeons operated DAA-THA employing the same procedure using a traction table. A total of nine surgeons operated osteosynthesis and fluoroscopy was appropriately used during reduction and implant insertion. Results: The mean operative time of DAA-THA was 103.3 min and that of osteosynthesis was 83.3 min, showing a significant difference (p < 0.05). The mean intraoperative fluoroscopy time was 0.83 min (SD ± 0.68) in DAA-THA and 8.91 min (SD ± 8.34) in osteosynthesis showing a significant difference (p < 0.05). Conclusions: The intraoperative exposure level was significantly lower and the fluoroscopy time was significantly shorter in DAA-THA than in osteosynthesis for proximal femoral fracture. It was clarified that the annual cumulative radiation exposure level in DAA-THA does not exceed the tissue dose limit.

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Fluoroscopic Imaging of Acetabular Cup Position During THA Through a Direct Anterior Approach

Orthopedics ◽

10.3928/01477447-20130920-06 ◽

2013 ◽

Vol 36 (10) ◽

pp. 776-777 ◽

Cited By ~ 10

Author(s):

Andres M. Alvarez ◽

Juan C. Suarez ◽

Preetesh Patel ◽

Edward G. Benton

Keyword(s):

Anterior Approach ◽

Direct Anterior Approach ◽

Acetabular Cup ◽

Fluoroscopic Imaging ◽

Cup Position ◽

Acetabular Cup Position

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Skin crease ‘bikini’ incision for the direct anterior approach in total hip arthroplasty

The Bone & Joint Journal ◽

10.1302/0301-620x.100b7.bjj-2017-1200.r2 ◽

2018 ◽

Vol 100-B (7) ◽

pp. 853-861 ◽

Cited By ~ 10

Author(s):

M. Leunig ◽

J. E. Hutmacher ◽

B. F. Ricciardi ◽

F. M. Impellizzeri ◽

H. A. Rüdiger ◽

...

Keyword(s):

Total Hip Arthroplasty ◽

Hip Arthroplasty ◽

Anterior Approach ◽

Direct Anterior Approach ◽

Abduction Angle ◽

Impaired Wound Healing ◽

Longitudinal Incision ◽

Total Hip ◽

Aesthetic Appearance ◽

The Mean

Aims The classical longitudinal incision used for the direct anterior approach (DAA) to the hip does not follow the tension lines of the skin and can lead to impaired wound healing and poor cosmesis. The purpose of this retrospective study was to determine the satisfaction with the scar, and functional and radiographic outcomes comparing the classic longitudinal incision with a modified skin crease ‘bikini’ when the DAA is used for total hip arthroplasty (THA). Patients and Methods A total of 964 patients (51% female; 59% longitudinal, 41% ‘bikini’) completed a follow-up questionnaire between two and four years postoperatively, including the Oxford Hip Score (OHS), the University of North Carolina ‘4P’ scar scale (UNC4P) and two items for assessing the aesthetic appearance of the scar and symptoms of numbness. The positioning of the components, rates of heterotopic ossification (HO) and rates of revision were assessed. Results The mean OHS was similar in both groups (p = 0.41). The mean UNC4P total score was slightly better (p = 0.01) and the proportion of patients who were very satisfied with the cosmetic aspects of the scar was higher in the ‘bikini’ group (p < 0.001). The proportion of patients reporting numbness in the scar was higher in the longitudinal group (14.5% vs 7.5%, respectively, p < 0.001). The abduction angle of the acetabular component, the position of the stem and rates of HO did not differ between the groups. There were no differences in the revision rates of both groups, being 2.3% in the longitudinal and 1.5% in the ‘bikini’ group (p = 0.911). Conclusion We found that a short oblique ‘bikini’ skin crease incision is safe when used for the DAA at THA, without compromising the positioning of the components or increasing the rate of lateral femoral cutaneous nerve dysaesthesia. Although it leads to a superior scar satisfaction, as it is less extensile, it should be used after having gained experience with the classic longitudinal incision. Cite this article: Bone Joint J 2018;100-B:853–61.

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Dislocation Rates following Anterior Approach THA: The Role of Functional Pelvic Tilt

The Journal of Hip Surgery ◽

10.1055/s-0038-1635101 ◽

2017 ◽

Vol 01 (04) ◽

pp. 194-199

Author(s):

Colin McNamara ◽

Eric Slotkin ◽

Amar Mutnal ◽

Wael Barsoum ◽

Juan Suarez ◽

...

Keyword(s):

Anterior Approach ◽

Pelvic Tilt ◽

Reference Frames ◽

Safe Zone ◽

Dislocation Rate ◽

Abduction Angle ◽

Acetabular Cup ◽

Level Of Evidence ◽

Zone Parameters ◽

The Mean

AbstractVarious target zones for acetabular cup placement have been suggested to minimize dislocation following total hip arthroplasty (THA), though dislocations occur despite proper positioning. The authors have reported accuracy of fluoroscopic guidance in cup positioning during direct anterior approach (DAA) THA when using a standardized fluoroscopic technique functional pelvic tilt. They believe that cup placement with regard to functional pelvic tilt, rather than static reference frames, will offer improved stability. A cohort of 1,597 fluoroscopy-assisted DAA primary unilateral THA patients was prospectively followed for a minimum of 1 year and component position measured radiographically. Target cup position was based off the standing anteroposterior pelvis while using conventional safe zone parameters. Dislocation rate was assessed. Average follow-up was 13.1 months (range 1–6 years). The mean abduction angle was 37.7° and the mean anteversion angle was 16.2°. Overall, 1,517 (95.0%) fell within the targeted abduction range, 1,528 (95.7%) fell within the targeted anteversion range, and 1,456 (91.2%) simultaneously met both criteria. There were nine dislocations, eight within the combined safe zone, for a dislocation rate of 0.56%. Fluoroscopy can improve accuracy and precision of cup placement in DAA THA. Conventional safe zone parameters applied using functional pelvic tilt resulted in a low dislocation rate, with most dislocations occurring within the safe zone. Using a dynamic functional safe zone may further reduce dislocation rates after DAA THA, though other factors that contribute to instability must be accounted for in future studies. This study had a III level of evidence.

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Promising medium-term results of anterior approach with an anatomical short stem in primary hip arthroplasty

Journal of Orthopaedics and Traumatology ◽

10.1186/s10195-021-00567-x ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Fabrizio Rivera ◽

Alessandro Bardelli ◽

Andrea Giolitti

Keyword(s):

Operating Room ◽

Anterior Approach ◽

Direct Anterior Approach ◽

Short Stem ◽

Medium Term ◽

Operating Room Table ◽

Sf 36 ◽

Standard Operating ◽

The Mean

Abstract Background In the last decade, the increase in the use of the direct anterior approach to the hip has contributed to the diffusion of the use of short stems in orthopedic surgery. The aim of the study is to verify the medium-term clinical and radiographic results of a cementless anatomic short stem in the anterior approach to the hip. We also want to verify whether the use of the standard operating room table or the leg positioner can affect the incidence of pre- and postoperative complications. Materials and methods All total hip arthroplasty patients with a 1-year minimum follow-up who were operated using the MiniMAX stem between January 2010 and December 2019 were included in this study. Clinical evaluation included the Harris Hip Score (HHS), Western Ontario and McMaster Universities Hip Outcome Assessment (WOMAC) Score, and Short Form-36 (SF-36) questionnaires. Bone resorption and remodeling, radiolucency, osteolysis, and cortical hypertrophy were analyzed in the postoperative radiograph and were related to the final follow-up radiographic results. Complications due to the use of the standard operating room table or the leg positioner were evaluated. Results A total of 227 patients (238 hips) were included in the study. Average age at time of surgery was 62 years (range 38–77 years). Mean follow-up time was 67.7 months (range 12–120 months). Kaplan–Meier survivorship analysis after 10 years revealed 98.2% survival rate with revision for loosening as endpoint. The mean preoperative and postoperative HHS were 38.35 and 94.2, respectively. The mean preoperative and postoperative WOMAC Scores were 82.4 and 16.8, respectively. SF-36 physical and mental scores averaged 36.8 and 42.4, respectively, before surgery and 72.4 and 76.2, respectively, at final follow-up. The radiographic change around the stem showed bone hypertrophy in 55 cases (23%) at zone 3. In total, 183 surgeries were performed via the direct anterior approach (DAA) on a standard operating room table, and 44 surgeries were performed on the AMIS mobile leg positioner. Comparison between the two patient groups did not reveal significant differences. Conclusion In conclusion, a short, anatomic, cementless femoral stem provided stable metaphyseal fixation in younger patients. Our clinical and radiographic results support the use of this short stem in the direct anterior approach. Level of evidence IV.

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5-Year Clinical and Radiographic Results of the Direct Anterior Approach for Total Hip Arthroplasty Using a Collared Cementless Femoral Short-Stem Prosthesis

Journal of Clinical Medicine ◽

10.3390/jcm11020346 ◽

2022 ◽

Vol 11 (2) ◽

pp. 346

Author(s):

Ali Darwich ◽

Kim Pankert ◽

Andreas Ottersbach ◽

Marcel Betsch ◽

Sascha Gravius ◽

...

Keyword(s):

Total Hip Arthroplasty ◽

Clinical Outcome ◽

Hip Arthroplasty ◽

Anterior Approach ◽

Hip Osteoarthritis ◽

Direct Anterior Approach ◽

Short Stem ◽

Total Hip ◽

The Mean

The aim of this study was to investigate the radiological and clinical outcome of the direct anterior approach (DAA) in total hip arthroplasty (THA) using a collared cementless femoral short-stem. This retrospective study included 124 patients with 135 THAs operated from 2014 to 2016 using a collared cementless triple tapered hydroxyapatite-coated femoral short-stem (AMIStem H Collared®, Medacta International, Castel San Pietro, Switzerland) implanted with a DAA. Follow-up was performed at three months, 12 months, and five years. Clinical outcome was assessed using the hip osteoarthritis outcome score (HOOS) and radiological analysis was done using conventional radiographs, which included evaluation of the femur morphology based on Dorr classification, of radiolucencies based on the Gruen zone classification and of stem subsidence. The mean age was 67.7 ± 11.3 years and the mean body mass index (BMI) was 27.4 ± 4.4 kg/m2. The stem survival rate at five years was 99.1% with one revision due to recurrent dislocations. Mean HOOS score improved from 40.9 ± 18.3 preoperatively to 81.5 ± 19.7 at three months, 89.3 ± 10.9 at 12 months, and 89.0 ± 14.0 at five years (all with p < 0.001). No significant correlations were found between age, femoral bone morphology, BMI and HOOS, and the appearance of relevant radiolucencies.

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Randomised Controlled Trial Comparing two Methods of Acetabular Cup Positioning during Total Hip Arthroplasty

Hip International ◽

10.1177/112070000701700303 ◽

2007 ◽

Vol 17 (3) ◽

pp. 137-142 ◽

Cited By ~ 5

Author(s):

P.-A. Vendittoli ◽

M. Ganapathi ◽

N. Duval ◽

P. Lavoie ◽

A. Roy ◽

...

Keyword(s):

Total Hip Arthroplasty ◽

Hip Arthroplasty ◽

Reference Points ◽

Abduction Angle ◽

Anatomical Landmarks ◽

Acetabular Cup ◽

Total Hip ◽

Increased Risk ◽

Visuospatial Perception ◽

Cup Positioning

Background Acetabular cup positioning is an important technical aspect in total hip arthroplasty. Most surgeons estimate cup abduction angle during surgery with the insertion rod position according to the patient's body anatomical landmarks or other reference points in the operating room. High acetabular component abduction angle is associated with an increased risk of dislocation, premature polyethylene wear and osteolysis. Method To evaluate the potential benefits of a new technique for vertical acetabular cup positioning, 100 acetabular cups were randomised to be inserted with or without an inclinometer. Abduction angles were measured on postoperative radiographs by 2 evaluators blind to the treatment group. Results Of the cups, 57% (27/47) were positioned within the desirable abduction angle range of 40°–49° with the inclinometer, compared with 50% (27/53) by visuospatial perception (p=0.454). The proportion of cups positioned outside a safe angle range of 30°–55° was low in both groups: 6% (3/47) for the inclinometer group versus 4% (2/53) for the visuospatial perception group (p=0.536). Conclusion The use of an inclinometer did not significantly improve the acetabular cup abduction angle obtained by our group of surgeons when compared with visuospatial perception. Newer techniques such as navigation may be useful in further optimising cup positioning and reducing the outliers.

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