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 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

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

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

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.

Introduction. There is renewed interest in dislocation after surgical approach with popularization of the direct anterior approach. The purported advantage of both the lateral and direct anterior approaches is decreased risk of dislocation. The purpose of this study was to assess the risk of dislocation by approach following modern primary THA. Methods. All primary THAs at a single academic institution from 2010 to 2017 were analyzed through our institutional total joint registry. There were 7023 THAs including 3754 posterior, 1732 lateral, and 1537 direct anterior. Risk of dislocation was assessed against the competing risks of revision surgery and death as well as by individual patient and surgical factors including surgical approach. Risk of revision surgery was considered as a secondary outcome. Step-wise selection was utilized to develop multivariable models. Clinical outcomes were documented with the Harris Hip Score (HHS). Mean age was 63 years, 51% were female, and mean body mass index (BMI) was 30 kg/m. 2. Minimum follow-up was 2 years. Results. The cumulative incidence of dislocation at 1-year and 5-years by approach was as follows: posterior (2.1%; 3.0%), lateral (0.7%; 0.7%), direct anterior (0.4%; 0.4%) (p<0.001) (Figure 1). Compared to the posterior cohort, the adjusted risk of dislocation was decreased for the lateral (hazard ratio [HR]=0.28, p<0.001) and direct anterior cohorts (HR=0.18, p<0.001). The cumulative incidence of revision for instability at 1-year and 5-years by approach was as follows: posterior (0.8%; 1.0%), lateral (0.6%; 0.6%), direct anterior (0%; 0%) (p=0.09). The adjusted risk of all-cause revision surgery was increased among the lateral cohort compared to posterior (HR=1.75, p=0.003) and direct anterior (HR=2.44, p=0.002) and among patients with diagnoses other than osteoarthritis (HR=2.89, p<0.001). Among patients who dislocated, 69 (83%) had anteversion >25° (Figure 2). Mean increase in HHS from preoperative assessment to final follow-up was greatest among direct anterior patients (37 points), followed by posterior patients (33 points), followed by lateral patients (29 points) (p<0.05, all comparisons). Conclusions. This study documents the risk of dislocation by surgical approach among a large contemporary cohort undergoing primary THA. The risk of dislocation was higher following the posterior approach, whereas all-cause revision surgery was found to be higher following the lateral approach. For any tables or figures, please contact the authors directly

The purpose of this study was to investigate the influence of surgical approach on femoral stem version in THA. This was a retrospective database review of 830 THAs in 830 patients that had both preoperative and postoperative CT scans. All patients underwent staged bilateral THAs and received CT-based 3D planning on both sides. Stem version was measured in the second CT-scan and compared to the native neck axis measured in the first CT-scan, using the posterior condyles as the reference for both. Cases were performed by 104 surgeons using either a direct anterior (DAA, n=303) or posterior (PA, n=527) approach and one of four stem designs: quadrangular taper, calcar-guided short stem, flat taper and fit-and-fill. Sub-analyses investigated changes in version for low (≤5°), neutral (5–25°) and high (≥25°) native version subgroups and for the different implant types. Native version was not different between approaches (DAA = 12.6°, PA = 13.6°, p = 0.16). Overall, DAA stems were more anteverted relative to the native neck axis vs PA stems (5.9° vs 1.4°, p<0.001). This trend persisted in hips with high native version (3.2° vs -5.3°, p<0.01) and neutral native version (5.3° vs 1.3°, p<0.001), but did not reach significance in the low native version subgroup (8.9° vs 5.9°, p=0.13). Quadrangular taper, calcar-guided, and flat taper stem types had significantly more anteversion than native for DAA, while no differences were found for PA. Stems implanted with a direct anterior approach had more anteversion than those implanted with a posterior approach. The smaller surgical field, soft tissue tension and lack of a “tibial” vertical reference frame may contribute to this finding

Short stems have been developed to conserve bone stock, especially in younger populations undergoing a total hip arthroplasty (THA), and showed similar functional outcomes compared to conventional stems. Recent literature suggested that stem length might be an independent risk factor for acute periprosthetic femoral fracture in direct anterior THA (1) or with different short stem designs (2). The purpose of the present study was to compare the incidence of acute periprosthetic femoral fractures, between stems of the same manufacture (Taperloc microplasty vs Taperloc complete), which have the same stem characteristics, except for the stem length which is 35 mm shorter in Taperloc microplasty during posterior and lateral THA. Our institution's arthroplasty database was searched for all primary total hip arthroplasties utilizing short femoral stems performed between August 2016 and August 2023. Pre-operative X-rays for each case were analysed to characterize the proximal femoral geometry, specifically the canal bone ratio (CBR) and canal flare index (CFI). Data analysis was performed to identify risk factors for periprosthetic fractures. For the time period assessed, 2107 femoral stems (Taperloc Microplasty:1727, Taperloc complete: 380) were implanted. Females constituted 53% of the cohort. The average patient age was 70±11 years. The periprosthetic fracture rate was 0.94%, with 20 periprosthetic fractures (Taperloc Microplasty:17, Taperloc complete: 3) excluding 2 greater trochanteric fractures (1 at each group), identified at follow-up of three months. There was no significant difference between the periprosthetic fracture rates between the two stems (0.98% vs 0.79%, p>0.72) The multivariate regression analysis demonstrated that the stem length, CBR, CFI, age, and gender were not risk factors for periprosthetic fracture. The present study demonstrated that both Taperloc Microplasty and Taperloc complete stems had similar rates of periprosthetic fractures, and the stem length was not a risk factor for a periprosthetic fracture during uncemented THA. 1. Tamaki T, Cementless Tapered-Wedge Stem Length Affects the Risk of Periprosthetic Femoral Fractures in Direct Anterior Total Hip Arthroplasty. J Arthroplasty. 2018 Mar;33(3):805-809. 2. Staunton P. Acute Periprosthetic Hip Fracture with Short Uncemented Femoral Stems. J Arthroplasty 2024 accepted

Aims. Acetabular edge-loading was a cause of increased wear rates in metal-on-metal hip arthroplasties, ultimately contributing to their failure. Although such wear patterns have been regularly reported in retrieval analyses, this study aimed to determine their in vivo location and investigate their relationship with acetabular component positioning. Methods. 3D CT imaging was combined with a recently validated method of mapping bearing surface wear in retrieved hip implants. The asymmetrical stabilizing fins of Birmingham hip replacements (BHRs) allowed the co-registration of their acetabular wear maps and their computational models, segmented from CT scans. The in vivo location of edge-wear was measured within a standardized coordinate system, defined using the anterior pelvic plane. Results. Edge-wear was found predominantly along the superior acetabular edge in all cases, while its median location was 8° (interquartile range (IQR) -59° to 25°) within the anterosuperior quadrant. The deepest point of these scars had a median location of 16° (IQR -58° to 26°), which was statistically comparable to their centres (p = 0.496). Edge-wear was in closer proximity to the superior apex of the cups with greater angles of acetabular inclination, while a greater degree of anteversion influenced a more anteriorly centred scar. Conclusion. The anterosuperior location of edge-wear was comparable to the degradation patterns observed in acetabular cartilage, supporting previous findings that hip joint forces are directed anteriorly during a greater portion of walking gait. The further application of this novel method could improve the current definition of optimal and safe acetabular component positioning. Cite this article: Bone Joint Res 2021;10(10):639–649

Aims. To achieve the functional benefits of the direct anterior (DA) approach and the fixation benefits of cemented replacement, this study combined the two techniques posing the following questions: does the limited access of the DA approach adversely affect the cement technique?; and does such a cementing technique reduce the incidence of cementless complications?. Methods. A consecutive series of 341 patients (360 hips) receiving the DA approach between 2016 and 2018 were reviewed. There were 203 cementless stems and 157 cemented stems. Mean age was 75 years (70 to 86) in the cementless group and 76 years (52 to 94) in the cemented group, with 239 (70%) females in the whole series. Femoral complications were compared between the two groups. Mean follow-up was 1.5 years (0.1 to 4.4) for patients in the cementless group and 1.3 years (0.0 to 3.9) for patients in the cemented group. Results. The cementless group had a higher rate of femoral complications (8 vs 0; p = 0.011). There were two loose stems and six fractures, all requiring revision. Fractures occurred a mean 14.5 days (2 to 31) postoperatively and loosening at 189 days and 422 days postoperatively. Femoral cementing can be done using the DA approach safely and reduces the number of complications compared with a contemporary cementless series. Conclusion. A higher rate of early fractures and loosening occurred with cementless stems. This was not observed in our cemented stem cohort and cementing was safely accomplished through the DA approach. The modern femoral cementing process with the DA approach does not add to surgical complexity or time, has fewer early complications, and is a safer option for older patients compared to cementless femoral arthroplasties. Cite this article: Bone Joint J 2021;103-B(7 Supple B):33–37

Introduction. Cutibacterium acnes (C. acnes) is now recognized as a clinical entity in periprosthetic joint infections (PJI) of the shoulder and spine. However, the colonization rate of C. acnes in the adult hip is currently unknown. Therefore, the purpose of this study was to investigate the rate of C. acnes colonization from the skin of healthy subjects from various anatomic locations corresponding to direct anterior and lateral/posterolateral surgical approaches. Methods. 90 patients scheduled for hip or knee surgery were recruited for cultured biopsies. Four 3-mm dermal punch biopsies were collected after administration of anesthesia, but prior to delivery of perioperative antibiotics. Pre-biopsy skin prep consisted of a standardized pre-operative 2% chlorhexidine skin cleanse and an additional 70% isopropyl alcohol mechanical skin scrub immediately prior to biopsy collection. Two culture samples 10-cm apart were collected from a location approximating a standard direct anterior skin incision, and two samples 10-cm apart were collected from a location approximating a lateral skin incision (suitable for a posterior, direct-lateral or anterolateral surgical approach). Samples were cultured for two weeks. Results. 22 of the 90 (24%) patients had a positive culture biopsy, fourteen of which (16% of all patients) were positive for C. acnes. Ten (71%) of the culture positive biopsies for C. acnes were obtained from the anterior location with 50% of those obtained from the most proximal sample site. Conclusions. Approximately 16% of the patients in the study demonstrated positive C. acnes colonization about the hip, the majority of which occurred from an anterior location. C. acnes should be considered in the diagnosis of PJI after THA. Given the high rate of skin colonization, particularly as regards the direct anterior approach to the hip, these results have stimulated consideration for different skin preparations for the THA patient. For any tables or figures, please contact the authors directly

Aims. The direct anterior (DA) approach has been associated with rapid patient recovery after total hip arthroplasty (THA) but may be associated with more frequent femoral complications including implant loosening. The objective of this study was to determine whether the addition of a collar to the femoral stem affects implant migration, patient activity, and patient function following primary THA using the DA approach. Methods. Patients were randomized to either a collared (n = 23) or collarless (n = 26) cementless femoral stem implanted using the DA approach. Canal fill ratio (CFR) was measured on the first postoperative radiographs. Patients underwent a supine radiostereometric analysis (RSA) exam postoperatively on the day of surgery and at two, four, six, 12, 26, and 52 weeks postoperatively. Patient-reported outcome measures (Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index, the 12-item Short Form Health Survey Mental and Physical Score, and University of California, Los Angeles (UCLA) Activity Score) were measured preoperatively and at each post-surgery clinic visit. Activity and function were also measured as the weekly average step count recorded by an activity tracker, and an instrumented timed up-and-go (TUG) test in clinic, respectively. Results. Comparing the RSA between the day of surgery baseline exam to two weeks postoperatively, subsidence was significantly lower (mean difference 2.23 mm (SD 0.71), p = 0.023) with collared stems, though these patients had a greater CFR (p = 0.048). There was no difference (p = 0.426) in subsidence between stems from a two-week baseline through to one year postoperatively. There were no clinically relevant differences in PROMs; and there was no difference in the change in activity (p = 0.078) or the change in functional capacity (p = 0.664) between the collared stem group and the collarless stem group at any timepoint. Conclusion. Presence of a collar on the femoral stem resulted in reduced subsidence during the first two postoperative weeks following primary THA using the DA approach. However, the clinical implications are unclear, and larger studies examining patient activity and outcomes are required. Cite this article: Bone Joint J 2020;102-B(12):1654–1661

Aims. Of growing concern in arthroplasty is the emergence of atypical infections, particularly Cutibacterium (formerly Propionibacterium) sp. infections. Currently, the dermal colonization rate of Cutibacterium about the hip is unknown. Therefore, the aim of this study was to investigate colonization rates of Cutibacterium sp. at locations approximating anterior and posterolateral approaches to the hip joint. Methods. For this non-randomized non-blinded study, 101 adult patients scheduled for hip or knee surgery were recruited. For each, four 3 mm dermal punch biopsies were collected after administration of anaesthesia, but prior to antibiotics. Prebiopsy skin preparation consisted of a standardized preoperative 2% chlorhexidine skin cleansing protocol and an additional 70% isopropyl alcohol mechanical skin scrub immediately prior to biopsy collection. Two skin samples 10 cm apart were collected from a location approximating a standard direct anterior skin incision, and two samples 10 cm apart were collected from a lateral skin incision (suitable for posterior, direct-lateral, or anterolateral approaches). Samples were cultured for two weeks using a protocol optimized for Cutibacterium. Results. A total of 23 out of 404 cultures (collected from 101 patients) were positive for a microorganism, with a total of 22 patients having a positive culture (22%). Overall, 15 of the cultures in 14 patients were positive for Cutibacterium sp. (65%), of which Cutibacterium acnes comprised the majority (n = 13; 87%). Other isolated microorganisms include coagulase-negative Staphylococcus (n = 6), Clostridium (n = 1), and Corynebacterium (n = 1). Of all positive cultures, 15 were obtained from the anterior location (65%), of which seven (60%) were from the most proximal biopsy location. However, these findings were not statistically significant (anterior vs lateral, p = 0.076; proximal vs distal, p =0.238). Conclusion. Approximately 14% (14/101) of the patients demonstrated a positive Cutibacterium colonization about the hip, the majority anteriorly. Given the high colonization rate of Cutibacterium, alternative skin preparations for total hip arthroplasty should be considered. Cite this article: Bone Joint J 2020;102-B(7 Supple B):52–56

115 patients undergoing primary unilateral THA were randomized to either DAA or MPA. Groups did not differ in mean age, sex, or mean body mass index. Functional results included time to discontinue gait aids, discontinue all narcotics, and independence with various activities of daily living. Activity in study subjects was measured with 5 wearable activity monitoring sensors with tri-axial MEMS accelerometers and validated custom algorithms and conducted over three days at pre-op, 2 weeks, 8 weeks, and one year. SF-12, WOMAC, and HHS scores to one year were also tabulated. Early functional recovery slightly favoured DAA compared to MPA; time to discontinue walker (10 vs. 14.5 days), time to discontinue all gait aids (17.3 vs 23.6 days), ascend stairs with gait aid (5.4 vs. 10.3 days), and to walk 6 blocks (20.5 vs. 26.0 days). There were no other differences in early functional milestones. Activity monitoring at two weeks postoperatively slightly favoured DAA; mean steps per day were 3897 versus MPA 2,235, percent of day active, DAA 10.5% versus MPA 6.9%. There was no difference in activity monitoring pre-operatively, at two months, or at one year. There was no difference at one year with the SF-12. There was no difference in the SF-12 mental component or the HOOS at any time point. There was no loosening or subsidence of any of the components in any hip. Both the direct anterior and posterior approach provided excellent early postoperative recovery with a low complication rate. The direct anterior patients had slightly faster recovery than the mini-posterior approach patients, with slightly shorter times to achieve milestones of function and as measured by advanced, quantitative activity monitoring at 2 weeks postoperatively

Background. The acknowledged benefit of the direct anterior (DA) approach is early functional return. Most surgeons in the U.S. use cementless femoral replacement given the negative track record of some cemented designs. However, delayed osseointegration of a femoral stem typically seen in older patients with poor bone quality will delay recovery, diminishing the benefits of the DA approach. Registry studies have shown a higher revision rate and complications in this patient population leading to a renewed interest in cemented fixation. Questions posed. To achieve the functional benefits of the DA approach and the fixation benefits of cemented replacement, this study combined the 2 techniques posing the following questions:1) Does the limited access of the DA approach adversely affect the cement technique? 2) Does such a cementing technique reduce the incidence of cementless complications?. Methods. A consecutive series of 341 patients (360 hips) receiving the DA approach between 2016–2018 were reviewed. There were 203 cementless stems and 157 cemented stems. Mean age was 75 in the cementless group and 76 in the cemented group, 70% females. Femoral complications were compared between the 2 groups using the T-test. Results. The cementless group had a higher rate of femoral complications (8 versus 0, P=0.011). There were 2 loose stems and 6 fractures, all requiring revision. Fractures occurred about 14.5 days and loosening about 10 months postoperatively. Conclusion. A higher rate of complications occurred with cementless stems. Cemented stems are protective in patients above 70 and can be safely done through the DA approach