Abstract
INTRODUCTION:
The senior surgeon has performed THA in his practice for over 30 years, and, while performing THA and revision THA utilizing a variety of surgical approaches, has employed and taught the modified Gibson posterolateral approach to the hip joint as his “workhorse” surgical approach for the majority of his career. In following the development of the DAA, he felt that there were subgroups of patients in his practice for whom the DAA, and supine THA, might prove beneficial, and started to introduce this approach into his practice 2 years ago. This retrospective review describes the risks and benefits of choosing to introduce this approach, and outlines a rational way in which surgeons can decide if they should learn and then offer this approach to appropriate patients within their practice.
METHODS AND MATERIALS:
A retrospective study was performed comparing outcomes of patients who underwent THA with the standard posterolateral approach vs. those who underwent THA with the direct anterior approach. Demographics such as age, gender, BMI and medical history were obtained. In addition, operative information and pre- and post-operative Harris Hip Score (HHS) evaluations were collected. Radiographic information and details about complications were also acquired.
RESULTS:
Procedure time and operating room time were significantly different between groups (p < 0.0001), where procedure time averaged 23 minutes longer for the DAA and operating room time averaged 39 minutes longer for the DAA. Mean blood loss between groups was also significantly different (p = 0.0018), where the DAA averaged 244 cc more blood loss.
Mean abduction angle for the DAA was 42 degrees vs. 50 degrees for the posterolateral approach (p < 0.0001). Mean version for the DAA was 21 degrees vs. 18 for the posterolateral approach (p = 0.0233). There were no differences between the groups when comparing HHS except for post-op visit 2 pain (p = 0.0291) and post-op visit 2 adduction (p = 0.0248).
The type of stem used had a significant affect on the amount of complications that occurred (p = 0.0442) in the DAA only. The number of complications that occurred did not differ significantly between groups (p = 0.1737). However, the types of complications that occurred were different. The complication that occurred most often in the DAA was periprosthetic fracture, and the complications that occurred most often in the posterolateral group were wound issues and dislocations.
DISCUSSION:
A further look into the results indicates that there is a learning curve for an experienced surgeon who is beginning to use the direct anterior approach.
CONCLUSIONS:
For a senior surgeon, the DAA may offer some benefit to his patient population. These benefits are in terms of ease of recovery from surgery, choice and predictability of implants utilized, and absence of restrictions for patients and nursing staff during the recovery process. To minimize the risk of introduction of this procedure, the surgeon and his team need to plan the learning approach, structure the introduction using familiar and predictable implants, and adjust the indications for its application through careful patient selection. Careful discussions with the patients involved are an important part of a successful introduction.
