The increased demand for total hip arthroplasty (THA) is having a significant impact on healthcare resources, resulting in increased interest in outpatient care pathways to reduce resource consumption. This study compared costs between patients who underwent outpatient THA using a Direct Anterior (DA) approach compared to a Direct Lateral (DL) approach to understand the effect of surgical approach on resource use. We conducted a prospective randomized controlled trial for DA patients undergoing primary THA. We compared patients in the outpatient arm of the trial to a prospective cohort of outpatient DL approach THAs. We recorded all costs including: equipment, length of stay in hospital, and laboratory or other medical tests. Following discharge, participants also completed a self-reported cost diary recording resource utilization such as emergency department visits or subsequent hospitalizations, tests and procedures, consultations or follow-up, healthcare professional services, rehabilitation, use of pain medications, informal care, productivity losses and out of pocket expenditures. We report costs from both Canadian public health care payer (HCP) and a societal perspective. The HCP perspective includes any direct health costs covered by the publicly funded system. In addition to the health care system costs, the societal perspective also includes additional costs to the patient (e.g. physiotherapy, medication, or assistive devices), as well as any indirect costs such as time off paid employment for patients or caregivers. We included 127 patients in the DA group (66.6 years old) and 51 patients in the DL group (59.4 years old) (p<0.01). There were no statistically significant differences in costs between groups from both the healthcare payer (DA= 7910.19, DL= 7847.17, p=0.80) and societal perspectives (DA= 14657.21, DL= 14581.21, p=0.96). In patients undergoing a successful outpatient hip replacement, surgical approach does not have an effect on cost from in hospital or societal perspectives

Introduction. While additional resources associated with direct anterior (DA) approach total hip arthroplasty (THA) such as fluoroscopy, staff, and special tables are well recognized, time consumption is not well studied. The purpose of this study was to analyze anesthesia and surgical time in DA and posterior approach THA in a large healthcare system across multiple facilities and surgeons. Methods. 3,155 unilateral primary THAs performed via DA or posterior approaches between 1/1/2017 and 06/30/2019 at nine hospitals and ambulatory surgery centers (ASC) in a large metropolitan healthcare system were retrospectively reviewed. All surgeons were experienced and beyond learning curves. 247 cases were excluded to eliminate confounds. Operating room (OR) in and out times and surgical times were collected via EMR electronic and manual data extraction with verification. Multivariate statistical analyses were utilized with p<0.05 significant. Results. 1261 DA approach (43%) and 1647 posterior approach (57%) THAs were analyzed. Mean total OR time, including anesthesia and positioning, was greatest for hospital-based DA THAs (146 mins), followed by hospital posterior approach THAs (126.4 mins), ASC-based DA THAs (118.1 mins) and ASC posterior THAs (90.1 mins) (p<0.001). In multivariate analysis, compared to the optimal ASC posterior approach group, the total OR time predictive model added 31 minutes per ASC DA THA, 33 minutes per hospital posterior THA, and 56 minutes for hospital DA THA (p<0.001). Similar predictive effect was observed for surgical time, which added 18 minutes per ASC-based DA THA, 22 minutes for hospital posterior THA and 29 minutes for hospital DA THA (p<0.001). Conclusion. In the COVID era, efficiency should be enhanced to maximize patient access for elective procedures and facilitate the healthcare system financial recovery. Despite equivocal clinical results, DA approach THA consumes substantially more OR time when compared to the posterior approach in both the hospital and ASC setting

The purpose of our study was to prospectively examine early functional differences in gait between the direct anterior and direct lateral surgical approaches for total hip arthroplasty over the first three months postoperatively. Forty participants were prospectively enrolled to either the direct anterior (20 patients) or direct lateral group (20 patients) based on their surgeon's expertise. Outcome measures were collected preoperatively at their preadmission appointment and postoperatively at discharge from the hospital, two weeks, six weeks and three months. We used the GAITRite® system to measure gait velocity, stride length, single-limb support and single-limb support symmetry. We also had participants complete the Timed Up and Go test and a series of questionnaires at each visit: WOMAC, SF-12, Harris Hip Score, and pain VAS. Our primary outcome, gait velocity, was significantly greater in the direct anterior group at discharge and six weeks postoperatively with adjusted mean differences of 0.12m/s and 0.17m/s respectively. Single-limb support symmetry was also significantly better in the direct anterior group at two weeks, six weeks and three months with adjusted mean differences of 0.10, 0.09 and 0.04 respectively. The direct anterior group also had significantly shorter times to complete the Timed Up and Go test at two and six weeks with adjusted mean differences of −9.02s and −2.64s. There were no differences between the groups at any time point for the WOMAC, SF-12, Harris Hip Score, or pain VAS. Preliminary results of our expertise-based study have found the direct anterior approach to total hip arthroplasty offers better early functional outcomes than the direct lateral approach

The trend towards more minimal access has led to a series of instruments being developed to enable adequate access for Direct Anterior Approach (DAA) for hip arthroplasty. These include longer levers, hooks attached to the operating table and a series of special attachments to the operating table to position the leg and apply traction where necessary. The forces applied in this way may be transmitted locally, damaging muscle used as a fulcrum, or the knee and ankle joints when torque has to be applied to the femur through a boot. The arthroplasty surgeon's aim is to minimise the forces applied to both bone and soft tissue during surgery.

We surmised that the forces needed for adequate access were related to the extent of the capsular and soft tissue releases, and that they could be measured and optimised. with the aim of minimising the forces applied to the tissues around the hip.

Eight fresh frozen specimens from pelvis to mid tibia from four cadavers were approached using the DAA. A 6-axis force/torque sensor and 6-axis motion tracking sensor were attached to a threaded rod securely fastened to the tibial and femoral diaphysis. The torque needed to provide first extension, then external rotation, adequate for hip arthroplasty were measured as the capsular structures were divided sequentially.

The Zona Orbicularis (ZO) and Ischiofemoral Ligament(IFL) contributed most of the resistance to both extension (4.0 and 3.1Nm) and external rotation torque (5.8 and 3.9Nm). The contributions of the conjoint tendon (1.5 and 2.4Nm) and piriformis (1.2 and 2.3Nm) were substantially smaller.

By releasing the Zona Orbicularis and Ischiofemoral Ligament, the torque needed to deliver the femur for hip arthroplasty could be reduced to less than the torque needed to open a jar (2.9–5.5Nm).

Introduction. The influence of surgical approach for total hip arthroplasty (THA) on scar healing and scar perception is unknown. The purpose of this study was to evaluate patients’ perception of their scar following direct anterior (DA) or posterior approach (PA) for THA utilizing validated scar assessment scales. Methods. Fifty DA and 58 PA THA patients underwent scar assessment using the Patient Observer Scar Assessment Scale (POSAS) and Stony Brook Scar Evaluation Scales (SBSES). Patients were included if they had at least 1-year follow-up, and had no previous surgery or intervention (i.e. radiation) around the assessed hip. The mean age was different between the cohorts (DA 67 vs PA 62 years, p=0.03). Other variables including gender, BMI, Charlson Comorbidity Index, steroid use, diabetes, and smoking were similar (p>0.05 for all comparisons). All patients had subcuticular running closure, secured with skin adhesive glue. Mean time from THA to scar assessment was 3.1 and 3.6 years for the DA and PA groups, respectively (p=0.18). Results. The overall opinion of the scar on the POSAS observer scale was graded as closer to normal skin more often for the PA than DA cohort (p=0.04). Age was not predictive of overall scar opinion on this scale (p=0.60). Scar vascularity, pigmentation, thickness, relief, pliability, and surface area were graded similarly (p>0.05 for all comparisons). For the POSAS patient scale, scar pain, itchiness, color, stiffness, thickness, or irregularities were graded similarly (p>0.05 for all comparisons). On the SBSES, there was no difference for scar width, height, color, and presence of hatch marks (p>0.05 for all comparisons). Overall scar appearance was rated as “good” in 94% of the DA and 91% of the PA patients (p=0.72). Discussion/Conclusion. Scar healing is reported to resemble normal skin more often following a PA approach on a validated scar assessment scale. There were no other significant differences for other scar attributes. Summary Statement. When comparing scar healing and perception after total hip arthroplasty, the posterior approach heals with more normal looking skin as assessed on a validated scare assessment scale

Aims. We studied the impact of direct anterior (DA) versus non-anterior (NA) surgical approaches on prosthetic joint infection (PJI), and examined the impact of new perioperative protocols on PJI rates following all surgical approaches at a single institution. Patients and Methods. A total of 6086 consecutive patients undergoing primary total hip arthroplasty (THA) at a single institution between 2013 and 2016 were retrospectively evaluated. Data obtained from electronic patient medical records included age, sex, body mass index (BMI), medical comorbidities, surgical approach, and presence of deep PJI. There were 3053 male patients (50.1%) and 3033 female patients (49.9%). The mean age and BMI of the entire cohort was 62.7 years (18 to 102, . sd. 12.3) and 28.8 kg/m. 2. (13.3 to 57.6, . sd. 6.1), respectively. Infection rates were calculated yearly for the DA and NA approach groups. Covariates were assessed and used in multivariate analysis to calculate adjusted odds ratios (ORs) for risk of development of PJI with DA compared with NA approaches. In order to determine the effect of adopting a set of infection prevention protocols on PJI, we calculated ORs for PJI comparing patients undergoing THA for two distinct time periods: 2013 to 2014 and 2015 to 2016. These periods corresponded to before and after we implemented a set of perioperative infection protocols. Results. There were 1985 patients in the DA group and 4101 patients in the NA group. The overall rate of PJI at our institution during the study period was 0.82% (50/6086) and decreased from 0.96% (12/1245) in 2013 to 0.53% (10/1870) in 2016. There were 24 deep PJIs in the DA group (1.22%) and 26 deep PJIs in the NA group (0.63%; p = 0.023). After multivariate analysis, the DA approach was 2.2 times more likely to result in PJI than the NA approach (OR 2.2 (95% confidence interval 1.1 to 3.9); p = 0.006) for the overall study period. Conclusion. We found a higher rate of PJI in DA versus NA approaches. Infection prevention protocols such as use of aspirin, dilute povidone-iodine lavage, vancomycin powder, and Gram-negative coverage may have been positively associated with diminished PJI rates observed for all approaches over time. Cite this article: Bone Joint J 2019;101-B(6 Supple B):2–8

Introduction. The direct anterior (DA) approach for total hip arthroplasty has demonstrated successful short term outcomes. However, debate remains about which patients are candidates fo this approach. To our knowledge, there are no studies which specifically investigate short-term outcomes in obese versus non-obese patients undergoing THA through a DA approach. The purpose of this study was to evaluate complication rates and short term outcomes of obese, pre-obese, and normal BMI patients undergoing THA through DA approach. Methods. A retrospective review of 151 consecutive patients who underwent unilateral THA through a DA approach for osteoarthritis or avascular necrosis was performed after IRB approval. Forty patients had a normal BMI, 54 were pre-obese, and 57 were obese by WHO classification (37 class I obese, 12 class II obese, and 8 class III obese). Electronic and paper charts were reviewed to determine differences in surgical time, length of stay, disposition, wound and major complications, and short term outcome measures. Results. When comparing normal and pre-obese patients to a combined group of WHO class I, II, and III obese patients, surgical time was increased by 15.8 minutes (P <0.0001), narcotic use was increased at two weeks (P=0.0242), and assistive device use was increased at 2 weeks (P=0.0079) in the obese patient group. There were trends toward increased wound complications in obese patients, 14.3% vs 4.2% (P=0.0569), increased major complications, 7.1% vs 1.1% (P=0.0633), and a higher use of rehabilitation facilities, 20.0% vs 9.5% (p=0.0676). Conclusions. This study demonstrated significantly increased surgical time and higher use of narcotics and assistive devices in obese patients. Trends toward increased wound and major complications, and a higher likelihood of rehabilitation placement were found. This study helps determine appropriate candidates for THA through a DA approach as obese patients may have more complicated postoperative courses

Purpose: Femoroacetabular impingement (FAI) is recognized as an etiological risk factor for hip arthritis. The potential for joint preserving surgical techniques that may delay the progression to early arthritis and retard the possibility of arthroplasty at a young age is promising. This study presents the outcome of surgical treatment of FAI through a less invasive technique performed through a modified Smith-Peterson approach without hip dislocation, or arthroscopy. Method: Using an institutional database, a total of 72 patients (80 hips) with radiographic and clinical diagnosis of FAI who underwent direct anterior femoroacetabular osteoplasty (FAO) were identified. Preoperative and postoperative functional evaluation was performed on these patients. The operative findings were recorded in detail and evaluated with regard to outcome. Results: Intraoperative diagnosis of labral tear and osteochondral lesions in the anterosuperior acetabulum was confirmed in all cases. The surgical approach provided adequate access to allow labral repair and osteoplasty of the femoral neck and the acetabulum, whenever needed. There were no intraoperative complications. All patients experienced a significant improvement in function as measured by modified Harris hip and SUSHI scores. Majority (85%) of the patients were satisfied with the outcome of the surgery. In addition, Health Survey SF-36 showed most patients felt their health had improved significantly. The predictors of poor outcome were previous hip scope, lack of labrum for repair, large chondral lesions, and workman’s compensation status. Conclusion: This study presents the early results of a less invasive surgical treatment for femoroacetabular impingement. This ongoing study shows that the described technique seems to be a viable approach for treatment of this painful condition in the young

INTRODUCTION. Cadaveric studies have reported damage to the direct head of rectus femoris and tensor fascia lata muscles with direct anterior approach(DAA) and to the abductors, external rotators with posterior approach(PA). The aim of this prospective study was to evaluate differences in hip muscle strength recovery between DAA and posterior approach (PA) THA. METHODS. Patients with unilateral hip osteoarthritis undergoing THA at a single institution from January 2011 to October 2011 were enrolled. All DAA THA's were performed by one surgeon, and all PA THA's were performed by another surgeon with similar design of components, pain management and rehabilitation protocols. Hip muscle strength was measured with a handheld dynamometer in all planes by a single observer preoperatively, at 6 weeks, 3 months and 6 months. Functional recovery was assessed with the motor component of Functional Independence Measure, UCLA activity score, Harris hip score, SF-12 score. RESULTS. There were 30 patients (15 per group) with similar age, sex, BMI and preoperative functional scores. There was a significant difference between groups in ER strength recovery pattern(p=0.04) with greater mean deficit in PA group from preoperative to 6 weeks(37%), 3 months (28%) and 6 months (25%); whereas DAA group demonstrated 3% mean deficit at 6 weeks, 2% mean improvement at 3 months and 10% mean improvement at 6 months from preoperative values. Flexion strength decreased in DAA group by a mean of 10% at 6 weeks(p=0.07) but improved at 3 months by a mean of 12% as compared to preoperative values. There were no differences in recovery pattern of other hip movements between groups. Functional recovery scores between groups were similar. DISCUSSION. Both DAA and PA THA offer similar recovery in hip muscle strength up to 6 months with exceptions of ER strength deficit in PA group and a trend to flexion strength deficit at 6 weeks in DAA group

Aims

Dual-mobility acetabular components (DMCs) have improved total hip arthroplasty (THA) stability in femoral neck fractures (FNFs). In osteoarthritis, the direct anterior approach (DAA) has been promoted for improving early functional results compared with the posterolateral approach (PLA). The aim of this study was to compare these two approaches in FNF using DMC-THA.

Background. Between 1999 and August 2005, we performed Direct Lateral Approach (DLA) in lateral decubitus position as the main approach for primary total hip arthroplasty (THA). After August 2005, we introduced Direct Anterior Approach(DAA) in supine position. Intraoperative target orientation in primary THA was planned in 40–45°cup abduction, 10–20°cup anteversion, and 10–20° stem anteversion. Precice implant positioning has been considered to be very important for postoperative function and stability. The purpose of this study was to compare the DLA and DAA for implant positioning accuracy. Methods. From 1999 to July 2009, we performed 566 primary THAs(78 male, 488 female). The subjects were divided into two groups of 224 DLA and 342 DAA (72 in early stage and 270 in late stage) The difference of the mean age at surgery and preoperative diagnosis among the groups were not significant. We planned to set the cup anteversion at 20°in DAA early stage and 12.5°in late stage DAA due to the development of postoperative dislocation in several cases with early stage DAA. We measured the cup and stem alignment postoperatively using radiography and computed tomography, and measured the combined anteversion angle by Widmer. Statistical analysis was done using the Bartlett Statistical Test and F-test. The results were expressed as median and interquartile range, with an alpha level set at less than 0.05. Results. Cup abduction angle with DLA was 42.7±6.25 °(average±standard deviation), 42.1±4.1°with early stage DAA and 41.9±5.3°with late stage DAA. There was no significant difference between the approaches with average and standard deviation (SD) of cup abduction. The mean cup anteversion with DLA (17.3±10.0°) was significantly smaller than that with early stage DAA(26.6±8.1°) and late stage DAA(21.0±8.0°). SD of cup anteversion with DLA was significantly larger than that with both DAA groups. The mean stem anteversion was significantly smaller with DLA (18.9±14.3) and late stage DAA (16.7±11.1°) than that with early stage DAA (23.5±11.9°). SD of stem anteversion with DLA was significantly larger than that with both DAA groups. There were 9 hips of dislocation: 5 hips in DLA, 3 in early DAA and one in late DAA. SD of combined anteversion Value with DLA(30.5±13.7) was significantly larger than that with early DAA (40.3±12.2) and late DAA (32.7±11.1.∗∗∗∗∗. Conclusion. Significantly less SD for anteversion of stem and cup was demonstrated with DAA compared with DLA. Stable operative positioning with DAA could yield a more accurate and reliable implantation compared with DLA in lateral position. DAA in supine position was a superior approach for primary THA

Aims

We assessed the difference in hospital based and early clinical outcomes between the direct anterior approach and the posterior approach in patients who undergo total hip arthroplasty (THA).

Background. The anterior approach for total hip arthroplasty has recently been hypothesized to result in less muscle damage. While clinical outcome studies are essential, they are subject to patient and surgeon bias. We prospectively analyzed biochemical markers of muscle damage and inflammation in patients receiving anterior and posterior minimally-invasive total hip arthroplasty to provide objective evidence of the surgical insult. Methods. 29 patients receiving an anterior and 28 patients receiving a posterior total hip arthroplasty were analyzed. Peri-operative and radiographic data were collected to ensure similar cohorts. Creatine kinase, C-reactive protein, Interleukin-6, Interleukin-1beta, and Tumor necrosis factor-alpha were collected pre-operatively, post-operatively, and on post-operative days 1 and 2. Comparisons between the groups were made using the Student's t-test and Fisher's Exact test. Independent predictors of elevation in markers of inflammation and muscle damage were determined using multivariate logistic regression analysis. Results. Markers of inflammation were slightly decreased in direct anterior group (mean differences in C-reactive protein 27.5 [95% confidence interval −24.7–79.6] mg/dL, Interleukin-6 13.5 [95% confidence interval −11.5–38.4] pg/ml, Interleukin-1beta 42.6 [95% confidence interval −10.4–95.6], and Tumor necrosis factor-alpha 148.6 [95% confidence interval −69.3–366.6] pg/ml). The rise in creatine kinase was 5.5 times higher in the post anesthesia care unit (mean difference 150.3 [95% confidence interval 70.4–230.2] units/L, p < 0.05) and nearly twice as high cumulatively in the miniposterior approach group (305.0 [95% confidence interval −46.7–656.8] units/L, p < 0.05). Conclusion. Anterior total hip arthroplasty caused significantly less muscle damage compared to traditional posterior surgery as indicated by creatine kinase levels. The clinical importance of this rise needs to be delineated by further clinical studies. The overall physiologic burden as measured by markers of inflammation, however, appears to be similar. Objective measurement of muscle damage and inflammation provides an unbiased way of determining the immediate effects of surgical intervention in total hip arthroplasty patients

We perform the direct approach using a standard radiolucent operative table with extender at the foot, and the assistance of fluoroscopy. The patient is positioned supine with the pubic symphysis aligned at the table break. The anterior superior iliac spine (ASIS) and center of the knee are marked, and a line drawn between. The incision commences proximally from two finger breadths distal and two finger breadths lateral to the ASIS, and extends distally 8–10 cm. Using fluoroscopy, the anterior aspect femoral neck is located. The incision is placed over the lateral aspect of the greater trochanter, which avoids the lateral femoral cutaneous nerve. The tensor fascia lata is identified, which has a distinctive purple hue, and dissected free from the intermuscular septum lateral to the sartorius and the rectus muscles. The deep, investing aponeurosis of the tensor fascia lata is split using a tonsil. Just below lie the lateral circumflex vessels, two veins and one artery, which must be either ligated or cauterised. A retractor is placed superior to the femoral neck over top of the superior hip capsule. A blunt, cobra-type retractor is then placed along the inferior femoral neck, deep to the rectus muscle and the rectus tendon. A sharp retractor is then used to peel the rectus off from the anterior capsule and placed over the anterior rim of the acetabulum. An anterior capsulectomy is performed. A saw blade is positioned for femoral neck resection and confirmed with fluoroscopy. After resection, acetabular retractors are placed, the socket is reamed, the cup is placed, and position confirmed with fluoroscopy. Turning to the femoral side, the surgeon palpates underneath and around the tensor, around the lateral aspect of the femur, proximal to the gluteus maximus tendon, and places a bone hook around the proximal femur. Femoral preparation and stem insertion require maneuvering the table and adjusting the patient position. The table is “jack-knifed” by lowering the foot of the table to approximately 45 degrees and placing the bed into approximately 15 degrees of Trendelenburg. The contralateral well leg is placed on the padded Mayo stand. A table-mounted femur elevator is attached to the bed, requiring a change in surgical gloves, and attached to the traction hook around the proximal femur. Gentle retraction is placed on the femur to tension the capsule. As the capsule is released the femur will begin to come up/out of the wound and into view. With increasing gentle retraction via the table-mounted hook, the femur is elevated. Simultaneously, the operative limb is externally rotated and adducted underneath the non-operative leg in a lazy “figure of 4” position by the assistant. The use of a “broach-only” stem design is preferred as direct straight reaming of the femur is difficult in most cases. Fluoroscopic images are obtained to confirm femoral implant positioning, offset, neck and leg length. A standardised rapid recovery hospitalization and rehabilitation protocol is used in all cases.

Introduction

Dissemination of Total hip Arthroplasty through the direct anterior approach has, depending upon one's experience and perspective, benefitted from or been plagued by aggressive marketing. Although first developed over 60 years ago it was all but unknown until the past decade. This study exams one community surgeon's experience and thus sheds light on whether the ATHA is a viable operation for all orthopaedic surgeons.

Background

Direct anterior approach (DAA), total hip arthroplasty (THA, performed with the patient in the supine position, creates a unique opportunity to do bilateral THA under one anesthesia. Previous studies evaluating this option are limited by small sample size or lack of control group. The purpose of this study is to compare early clinical outcomes of simultaneous bilateral, unilateral and staged bilateral DAA-THA.

Introduction:

Direct anterior approach (DAA) total hip arthroplasty (THA) has been reported to be a muscle sparing approach. The purpose of this study was to compare gait patterns over time between patients undergoing THA via DAA and posterior approach (PA).

Introduction

The Direct Anterior Approach (DAA) offers potential advantages of quicker rehabilitation compared to posterior approach THR. The aim of this study was to compare hospital based and early clinical outcomes between these two groups with utilisation of Enhanced Recovery After Surgery (ERAS) protocol.

Aims

It has been suggested that the direct anterior approach (DAA) should be used for total hip arthroplasty (THA) instead of the posterior approach (PA) for better early functional outcomes. We conducted a value-based analysis of the functional outcome and associated perioperative costs, to determine which surgical approach gives the better short-term outcomes and lower costs.

Aims

Use of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased in recent years due to proposed benefits, including a lower risk of dislocation and improved early functional recovery. This study investigates the dislocation rate in a non-selective, consecutive cohort undergoing THA via the DAA without any exclusion or bias in patient selection based on habitus, deformity, age, sex, or fixation method.