Introduction. In total hip arthroplasty, correct sizing is critical for fixation and longevity of cementless components. Previously, three-dimensional CT templating has been shown to be more accurate than using 2D radiographs. The accuracy of the Optimized Positioning System (OPS. TM. ) planning software has not been reported. The aim of this study was to measure the accuracy of the OPS planning software in predicting the implanted acetabular cup and femoral stem size when used with the direct anterior approach. Method. Between October 2018 and March 2019, 95 patients received a bone preserving cementless MiniHip stem (Corin, UK). Sixty-three of these patients also received a cementless Trinity cup (Corin, UK). All patients were sent for OPS. TM. pre-operative planning, a patient-specific dynamic modelling software used to determine the optimal acetabular and femoral component size and positions. Average age was 57 (28 to 78) and 44% were female. All cases were performed using the direct anterior approach. The sizes of implants used were retrospectively compared to the planned OPS. TM. sizes. Results. Of the 95 cases, 98% (n=93) of MiniHip stems were within one size of that predicted, and 66% (n=63) matched exactly the predicted size. Of the 63 Trinity cups, 98% (n=62) were within one size of that predicted and 48% (n=30) matched exactly the predicted size. All stems and cups were within 2 sizes of plan [Fig. 1]. Conclusion. The OPS. TM. planning software successfully predicted more than 95% of implanted cup and stems within one size, with 100% implants being within 2 sizes. There is significant value in accurately predicting implant sizes preoperatively, both as an indicator to the surgeon as to the size expected, and for reducing the inventory supplied to the hospitals. For any figures or tables, please contact the authors directly

The excitement and enthusiasm that accompanies the introduction of many new technologies and techniques can be self-sustaining, meaning that the appeal of doing something new or different (not necessarily doing something better) becomes the prime driver. Such is likely the case today with the direct anterior approach to total hip arthroplasty. Can THA be done successfully through a direct anterior approach? Certainly the answer is yes; and with experience it can be done in relatively broad groups of patients with an acceptable risk of complications. Is it a better way to do THA than other approaches? Well probably not in 2012. Contemporary THA done with a variety of approaches and coupled with advanced anesthetic, pain management and rapid rehabilitation protocols has been shown to be safe and effective with both short hospital stays (48 hours) and even outpatient surgery in selected patients. No substantial clinical advantage has been shown to date with a direct anterior approach. The sometimes extraordinary claims associated with the direct anterior approach are accompanied by relatively ordinary data. The purported benefits of direct anterior related to more rapid recovery, better function, or a lower dislocation risk just have not proved to be demonstrable in broad groups of patients. In regard to recovery there are now several studies suggesting no difference at 2 hours; 2 days; 2 weeks or 2 years after surgery; and likely no difference at 2 months either. In regard to function there are now multiple gait analysis studies with no demonstrable benefit at 2 weeks or 6 weeks. In regard to lower risk of dislocation if we pool the data from big published studies Sariali (1.5%) Matta (0.6%) Jewett (1%) and Woolson (0%) the mean is 0.88%. Interestingly, contemporary posterior approach THA with formal capsular repair also has <1% dislocation rate when we look at published data from White (0.5%) Pagnano (0.3%) and Dorr (0%). The direct anterior does come at a cost including: longer operative times; additional equipment and/or personnel; unique complications; and in some techniques the need for intra-operative fluoroscopy with attendant exposure to radiation for the surgeon and staff. It is clear in 2012 that the direct anterior approach is just another technique for performing a very successful procedure, namely total hip arthroplasty. With advanced anesthetic, pain management, and rapid rehabilitation protocols it will be extremely difficult to prove any marginal benefit associated with THA surgical technique. To summarize the available data on direct anterior THA it is not unreasonable to conclude that “the extraordinary claims are accompanied by very ordinary data.”

Psoas tendinopathy is a potential cause of groin pain after primary total hip arthroplasty (THA). The direct anterior approach (DAA) is becoming increasingly popular as the standard approach for primary THA due to being a muscle preserving technique. It is unclear what the prevalence is for the development of psoas-related pain after DAA THA, how this can influence patient reported outcome, and which risk factors can be identified. This retrospective case control study of prospectively recorded data evaluated 1784 patients who underwent 2087 primary DAA THA procedures between January 2017 and September 2019. Psoas tendinopathy was defined as (1) persistence of groin pain after DAA THA and was triggered by active hip flexion, (2) exclusion of other causes such as dislocation, infection, implant loosening or (occult) fractures, and (3) a positive response to an image-guided injection with xylocaine and steroid into the psoas tendon sheath. Complication-, re-operation rates, and patient-reported outcome measures (PROMs) were measured. Forty-three patients (45 hips; 2.2%) were diagnosed with psoas tendinopathy according to the above-described criteria. The mean age of patients who developed psoas tendinopathy was 50.8±11.7 years, which was significantly lower than the mean age of patients without psoas pain (62.4±12.7y; p<0.001). Patients with primary hip osteoarthritis were significantly less likely to develop psoas tendinopathy (14/1207; 1.2%) in comparison to patients with secondary hip osteoarthritis to dysplasia (18/501; 3.6%) (p<0.001) or FAI (12/305; 3.9%) (p<0.001). Patients with psoas tendinopathy had significantly lower PROM scores at 6 weeks and 1 year follow-up. Psoas tendinopathy was present in 2.2% after DAA THA. Younger age and secondary osteoarthritis due to dysplasia or FAI were risk factors for the development of psoas tendinopathy. Post-operatively, patients with psoas tendinopathy often also presented with low back pain and lateral trochanteric pain. Psoas tendinopathy had an important influence on the evolution of PROM scores

The purpose of this study was to report all complications during the first consecutive 865 cases of bikini incision direct anterior approach (DAA) total hip arthroplasty (THA) performed by a single surgeon. The secondary aims of the study are to report our clinical outcomes and implant survivorship. We discuss our surgical technique to minimize complication rates during the procedure. We undertook a retrospective analysis of our complications, clinical outcomes and implant survivorship of 865 DAA THA's over a period of 6 years (mean = 5.1yrs from 2.9 to 9.4 years). The complication rates identified in this study were low. Medium term survival at minimum 2-year survival and revision as the end point, was 99.53% and 99.84% for the stem and acetabular components respectively. Womac score improved from 49 (range 40-58) preoperatively to 3.5(range 0-8.8) and similarly, HHS scores improved from 53(range 40-56) to 92.5(range 63-100) at final follow-up (mean = 5.1 yrs) when compared to preoperative scores. These results suggest that bikini incision DAA technique can be safely utilised to perform THA

Background. Pre-operative autologous blood donation is recommended as a means of reducing the need for allogeneic transfusion before simultaneous bilateral total hip arthroplasty (THA). However, there have been few reports on the optimal amount of autologous donation for this procedure. In this study we sought to determine the amount of autologous blood required for patient undergoing simultaneous bilateral THA using the direct anterior approach. Methods. We retrospectively enrolled 325 consecutive patients (650 hips) underwent simultaneous bilateral primary THA from January 2012 to June 2014. Thirty-three patients were men and 290 patients were women. The patients’ mean age at THA was 59.1 years. All THAs were performed using the direct anterior approach. Intraoperative blood salvage was applied for all patients and postoperative blood salvage was not applied for any patients. Results. The mean intraoperative blood loss and the mean operative time for the bilateral procedure were 413±165 g and 87.2±12.3 minutes, respectively. Two hundreds and forty-one of the 325 patients (74.2%) donated an average of 1.9 (range, 1–2) units of autologous blood before the operation. The mean hemoglobin levels on the preoperative day, postoperative day 1 and postoperative day 5 were 12.5g/dl, 10.5 g/dl and 9.5 g/dl, respectively. Only 1 patient (0.3%) required postoperative transfusions of allogeneic blood. All of the autologous units collected were transfused, and no units were wasted. Conclusion. Simultaneous bilateral THA can be performed without allogenic blood transfusion in 99.7% of patients. We could not find out significant effectiveness of an average of 1.9 units of autologous blood donation for this procedure in this study. We concluded that simultaneous bilateral THA can be performed without autologous blood donation in healthy patients without severe hip deformity. Whereas, preoperative donation of autologous blood might be suitable for patients with low body weight or patients with severe hip deformity. The minimally invasive aspect of the direct anterior approach seems to allow a low rate of allogeneic blood transfusion in the study

Introduction:. The incidence of heterotrophic ossification after primary total hip arthoplasty (THA) has been reported to be between 8 to 90%. The incidence is higher in lateral approach because of extensive muscular trauma associated with it. There exists limited data on the incidence of heterotrophic ossification after direct anterior approach (DAA) THA. The purpose of this study was to assess the incidence of heterotrophic ossification after THA via the direct anterior approach and the influence of surgical technique and chemoprophylaxis. Method:. A consecutive series of four hundred two primary uncemented direct anterior approach total hip arthoplasties in 378 patients were reviewed for incidence of heterotrophic ossification. In the first 200 total hip arthoplasties an anterior capsulectomy (Group 1) was done for exposure while in the subsequent 202 total hip arthoplasties a capsulotomy (Group 2) followed by complete release of supero-lateral flap of from its attachement to the gluteus minimus muscle and trochanter was performed (Figure 1). Group 1 received warfarin for thromboprophylaxis; while aspirin (thromboprophylaxis) and celecoxib (pain) was used in group 2. Heterotrophic ossification was classified according to Brooker's classification on plain radiographs. Results:. Heterotrophic ossification was significantly less in group 2 (4/202, 1.98%) as compared to group 1 (29/200, 14.5%). No severe heterotrophic ossification was found in group 2. Conclusion:. Release of the superior-lateral capsular flap from the gluteus minimus muscle allows the femoral mobilization required during the femoral preparation and exposes the trochanter for easier retractor placement and thereby minimizes the muscular traumatic insult. When combined with aspirin and celecoxib chemoprophylaxis, this technique may diminish heterotrophic ossification

Introduction. Prosthetic replacement remains the treatment of choice for displaced femoral neck fractures in the elderly population, with recent literature demonstrating significant functional benefits of total hip arthroplasty (THA) over hemiarthroplasty. Yet the fracture population also has historically high rates of early postoperative instability when treated with THA. The direct anterior approach (DAA) may offer the potential to decrease the risk of postoperative instability in this high-risk population by maintaining posterior anatomic structures. The addition of intraoperative fluoroscopy can improve precision in component placement and overcome limitations on preoperative planning due to poor preoperative radiographs performed in the emergency setting. Methods. We retrospectively reviewed clinical and radiographic outcomes of 113 consecutive patients with displaced femoral neck fractures treated by two surgeons over a five-year period. All underwent surgery via the DAA using fluoroscopic guidance, and were allowed immediate postoperative weight bearing without any hip precautions or restrictions. Charts were reviewed for relevant complications, while radiographs were reviewed for component positioning, sizing, and leg length discrepancy. Mean follow-up was 8.9 months. Results. Mean age was 79.3 years (range, 42 to 101), 73% of patients were women, and mean BMI was 22.6 kg/m. 2. Ninety patients (80%) received THA while 23 (20%) received unipolar or bipolar hemiarthroplasty. Mean acetabular anteversion was 15.0 degrees (range, 4 to 24) and mean abduction was 39.2 degrees (range, 27 to 51) with 95% of acetabular components in the combined safe zone as described by Lewinnek. Mean radiographic leg-length difference was +2.2 mm (range, −4.9 to +8.8mm). There was no femoral stem subsidence of more than 2mm. Only one patient (0.9%) dislocated postoperatively, who was eventually constrained for recurrent posterior instability 3 months following surgery. Delayed wound healing (6.1%) was the most common postoperative complication. Conclusions. The direct anterior approach allows a safe, effective, and reproducible approach for treatment of displaced femoral neck fractures, with very low rate of early postoperative instability compared to historical controls. The use of intraoperative fluoroscopy allows excellent component positioning, sizing, and restoration of leg length in spite of inconsistent preoperative radiographs

INTRODUCTION. The direct anterior approach (DAA) for total hip arthroplasty has become a popular technique. Proponents of the anterior approach cite advantages such as less muscle damage, lower dislocation risk, faster recovery, and more accurate implant placement for the approach. However, there is a steep, complex learning curve associated with the technique. The present study seeks to define the learning curve based on individual surgical and outcome variables for a high-volume surgeon. METHODS. 300 consecutive patients were retrospectively analyzed. Intraoperative outcomes measured include surgery time and estimated blood loss (EBL). Complications include intraoperative fracture, post-operative fracture, infection, dislocation, leg length discrepancy, loosening, and medical complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE). Segmented regression models were used to elucidate the presence of a learning curve and mastery of the procedure with regard to each individual variable. RESULTS. The mean operative time was 77.1 minutes (range 40–213). Operative time improved at a rate of 6.6 minutes per case for the first 15 cases then by an average of 5 seconds per subsequent case. The mean EBL for the series was 288.6 mL. Segmented regression shows EBL decreased at a rapid rate until case 52, followed by a more gradual decline. Complications were higher in the first 7 surgeries, with a 48% decrease in the likelihood of complication with each subsequent surgery. The improvement continued through the rest of the series with a 0.5% decrease in likelihood with each surgery. DISCUSSION. Our data contributes to the current body of literature by defining the learning curve with what we consider the most pertinent outcomes. First, we show that operative efficiency can be gained quite quickly (15 cases) while the slower improvement in EBL demonstrates continued learning about the anatomy. Our data is consistent with previous published reports regarding complication improvement. The present study will provide surgeons considering DAA useful information regarding what to expect during their learning curve. Furthermore, the data can be useful for surgeons charged with teaching the technique to critically evaluate what learning curve variables can be improved to hasten the learning curve

Introduction. The incorporation of computer navigation in total hip arthroplasty (THA) has been much slower then for total knee arthroplasty (TKA). Computer navigation has proven itself in the realm of TKA but still has yet to advance in THA. The reasons for this include the lack of ease of incorporation, accuracy and precision, and the addition of overall operative time. Another reason for this lack of progress is that a majority of THA's are done with the patient in the lateral position through a posterior or lateral approach making the tracker placement and the registration process somewhat cumbersome. In the direct anterior approach the patient is in the supine position, which accommodates pelvic tracker placement and significantly facilitates the registration process. At our institution we use the direct anterior approach and computer navigation on all of our primary THA's. We hypothesized that computer navigation facilitates cup placement and leg length determination with out significantly increasing our operative time. Materials and Methods. This was a prospective study comparing a consecutive series of 150 computer navigated total hips to a consecutive series of 150 none navigated total hips. The two groups were similar by age, sex, and BMI. Operative times were collected using our secure online database. The start and stop of operative time was incision to final reduction respectively. Post operative radiographs were analyzed using TraumaCad 2.0 (Voyant Health, Columbia, MD). Cup angle and leg length were measured on A/P pelvic views. Simple descriptive statistics and t-tests were used to analyze data. Results. There were a total of 134 men and 166 women with a pre operative diagnosis of osteoarthritis. The conventional cohort contained 64 men and 86 women with an average age of 65.6 (26.1-91.3) and BMI of 29.3(15.7-50.9). The computer navigation cohort contained 70 men and 80 women with an average age of 65.5 (44.8-90.2) and BMI of 28.6 (17.5-44.0). The average operative times of the conventional and computer navigation cohorts were 62.4 min (33-165) and 53.0 min (38-63) (p<0.0001) respectively. The average cup angle was 37.2 (25-52) for the conventional cohort and 41.0 (26-55) for the computer navigation cohort (p=0.0046). The leg length discrepancy average was 3.2 mm (-13.0mm to 13.0mm) for the conventional cohort and 2.1 mm (-6.0mm to 15.0mm) for the computer navigation cohort (p=0.0012). Conclusion. The results from our study suggest that computer navigation is easy to incorporate when utilizing a direct anterior approach and in fact shortens the operative time. The accuracy and precision of cup angle placement and leg length discrepancy are comparable to our conventional method but appears to be slightly improved with computer navigation. Although more work is needed to progress this promising technology, we feel that incorporating computer navigation for hip surgery in the supine position is simple and of great value

Aims. Accurate placement of acetabular and femoral stem components in total hip arthroplasty (THA) is an important factor in the success of the procedure. A variety of free hand or navigated techniques is reported. Survivorship and complications have been shown to be directly related to implant position during THA. The aim of this cadaver study was to assess the accuracy of the placement of the components in THA using patient specific instruments (PSI) in combination with a 3D planning software and the direct anterior approach. Method. Patient specific instruments (PSI) were developed to guide the surgeon during THA that were 3D printed with their bone models following a 3D software planning protocol (LPH software V2.5.1, Onefit-Medical, Eos Imaging Company, Besancon, France). Acetabular guides: cup, offset and straight reamer handle and impactor, femoral- and chisel guides were used in each THA (Fig. 1). To define anatomic bone landmarks and to generate a 3D model of each hip joint CT scans were performed preoperatively. The planning of component position was done by one surgeon (AZ) preop. Surgery was performed by two experienced surgeons (AZ, SD) on cadaver specimen with 4 hips in two separate series. A total of 8 hip replacements were evaluated pre- and postoperatively using CT-scans of each hip joint to compare planned to achieved results. Mechanical simulations of the guides were carried out to verify that there were no conflicts between the different instruments. To meet the ISO standard 16061: 2015 the compatibility of the instruments with the guides has been checked. Parameters were evaluated in 3D pelvic and femoral planes: center cup position, inclination angle, anteversion angle, cutting height and plan orientation, anteversion angle, flexion/extension angle, varus/valgus angle, anatomical and functional leg length, offset. Acceptance criteria: postop. parameters evaluated must not have a deviation of more than 5 degrees, 2,5 mm according to preop. planning. For every THA the test protocol has been completely realized. Results. The difference between the preop. and postop. measures in the first series of 4 hips revealed 2 outliers because of fractures of the acetabulum in 2 cases, related to bad cadaver quality. In the second series we found satisfactory results comparing the planned preop and postop component position (Fig. 2). For example difference of leg length showed a mean absolute of 1,58 mm, standard deviation 1,21 mm (min 0,62; max 3,34 mm). Offset revealed a mean absolute of 1,62 mm, standard deviation 0,57 mm (min 1,06; max 2,14 mm) concerning the difference between preop. planning and result postop. Conclusion. Accurate and safe placement of total hip components in THA, both acetabular cup and stem, performing the direct anterior approach can be achieved using a 3D preoperative planning along with patient specific instruments. The results of the cadaver study tests are promising and that is to be proven in the clinical setting and by application in the future

Increasing data is emerging, consistently demonstrating a more rapid recovery for patients undergoing direct anterior approach (DAA) surgery. In one study, objective findings of early recovery including timed up and go tests, Functional Independence Measures are significantly faster in the first 2 weeks, and normalise by 6 weeks. A more recent randomised study shows a quicker achievement of the functional milestones of discontinuing walking aids, discontinuing opioids, stair ascent, and walking 6 blocks, as well as accelerometer measures of activity in the first 2 weeks after surgery. In both of these studies, seasoned surgeons well beyond their learning curves performed the surgeries. A prospective MRI study of volume before and after surgery has shown full recovery or mild hypertrophy of most muscles at an average of 24 weeks from surgery, but a sustained loss of muscle volume for the obturator internus muscle in the DAA, and sustained loss of muscle volume for obturator internus, obturator externus, piriformis, and quadratus femoris in the posterior approach patients. The muscles that are released in the surgeries recover incompletely. Prospective assessment of muscle strength demonstrated loss of flexion strength in the DAA group and loss of external rotation strength in the posterior group at 6 weeks. By 3 months, the DAA group had returned to normal in their strength, while the posterior group had persistent external rotation weakness. Prospective assessment of gait, pre-operatively and at 6 months showed similar improvements in frontal and sagittal plane range of movement in gait, with a similar improvement in transverse plane movement (internal and external rotation) in the DAA group, but no change in the posterior cohort. The precision of socket placement, after undergoing a learning curve, was greater with the use of fluoroscopy in the DAA. Cutting and subsequently repairing a muscle can have a clinically insignificant, but nonetheless objectively measurable effect on the function of that muscle. Observed downsides of DAA include a higher prevalence of wound complications in obese patients, and possibly a higher risk of periprosthetic fractures in elderly, thin women. Recent larger registry data would also suggest that there is no difference in dislocation rate between the 2 referenced approaches, and possibly a higher femoral revision rate for the DAA. These may be honest and real depictions of a large learning curve as we further understand and disseminate the subtleties of proper execution of DAA surgery

Introduction. Dislocation is one of severe complications after total hip arthroplasty (THA). Direct anterior approach (DAA) is useful for muscle preservation. Therefore, it might be also effective to reduce dislocation. The purpose of this study is to investigate the ratio and factors of dislocations after THA with DAA. Materials & methods. Nine hundred fifity two primary THAs with DAA are examined. Mean age at operation was 64.9 yrs. 838 joints are in women and 114 (joints) in men. All THAs were performed under general anesthesia in supine position. We reviewed the ratio, onset and frequency of dislocations, build of the patients, preoperative Japanese Orthopaedic Association (JOA) Hip scores, implant setting angles, pelvic tilt angles and diameter of inner heads. Results. The ratio of dislocation was 14 joints (1.47%). All patients were women and mean age was 67.1 yrs. Anterior dislocation was in 9 joints and posterior was in 5 joints. Primary diagnosis for THA was the following: osteoarthritis in 9 hips and rheumatoid arthritis in 5 (hips). About primary onset, 7 joints were within 3 weeks, 5 joints from 3 weeks to 3 months and 2 joints after 3 months. About frequency, 9 joins were simple and 5 joints were multiple. Revision surgery was done in 2 joints due to ceramic fracture and cup migration. About build of the patients, mean body height was 153.1cm, mean body weight (was) 55.6 kg and mean BMI (was) 23.6. Mean preoperative JOA score was 40.0 points. Implant setting angles were the following: mean cup inclination was 42.4 degree, mean cup anteversion (was) 24.8 degree and mean stem anteversion (was) 18.7 degree. Cup inclination and anteversion in the anterior dislocation group were bigger than that in no dislocation group. Stem anteversion in the posterior dislocation group was smaller than that in no dislocation group. The difference of pelvic tilt angle between supine and standing position was 6.4 degree. It was significant bigger in the posterior dislocation group. The most of used Inner head was 28mm in 375 joints. There was no significant difference of the dislocation rate among inner head size. Discussion and conclusion. DAA-THA can expect the reduction of dislocation rate due to intermusclar approach; however there are some reports of high dislocation rate because of difficult technique. In our study, dislocation ratio was 1.47%. Risk factors of dislocation after THA was rheumatoid arthritis, large cup inclination and anteversion for anterior dislocation, small stem anteversion and large difference of pelvic tilt angle between supine and standing position for posterior dislocation

We investigated whether a novel, real-time fluoroscopy based navigation system optimized component positioning and leg length in fluoroscopically aided Direct Anterior Approach Total Hip Arthroplasty (DAA-THA). We retrospectively reviewed 75 fluoroscopically assisted DAA-THA performed by a single surgeon: 37 procedures used the software intraoperatively to overlay anteversion, inclination, and leg length information over the existing fluoroscopic radiograph with the aim of enhancing component positioning. The control group consisted of 38 procedures from the single surgeon's patient pool who had undergone non-navigated fluoroscopic assisted DAA-THA one month prior to the system's trial. We used the software to compute each data point on an immediate post operative AP radiograph to replicate the intra operative measurement process. Our results demonstrate that the navigation group measurements were significantly closer to the target numbers with less variation. The mean values were significantly closer to target values anteversion (control: 14°, navigated: 19.1°), inclination (control: 37.7°, navigated: 40.8°) and leg length discrepancy (control: 4.7mm, navigated: 0.1mm). The mean difference from target value were also statistically significant: for anteversion (control: −6.0°, navigated: −0.9°), inclination (control: −2.3°, navigated: 0.8°) and leg length discrepancy (control: 2.7°, navigated: −1.9°). In addition, surgical time was shorter in the navigation group (75.7 vs. 74 minutes; p=0.001). The p values were all statistically significant (anteversion 0.0001, inclination 0.0019, LLD < 0.001 and surgical time 0.001). The real-time feedback and calculations provided by the navigation software provided a reproducible precision for component positioning and leg length measurement during DAA-THA. For any figures or tables, please contact authors directly

Background. Minimally invasive surgery is being widely used in the field of total hip arthroplasty (THA). The advantages of the direct anterior approach (DAA), which is used in minimally invasive surgery, include low dislocation rate, quick recovery with less pain, and accuracy of prosthesis placement. However, minimally invasive surgery can result in more complications related to the learning curve. The aim of this study was to evaluate the learning curve of DAA-THA performed by a senior resident. Methods. Thirty-three consecutive patients (33 hips) who underwent primary THA were enrolled in this study. All operations were performed by a senior resident using DAA in the supine position without the traction table. The surgeon started using DAA exclusively for all cases of primary THA after being trained in this approach for 6 months. Operative time, intraoperative blood loss, complications, and accuracy of prosthesis placement were investigated. Results. The mean intraoperative blood loss was 524 mL (range, 130–1650 m L). The mean operative time was 60 min (range, 41–80 min). Radiographic analysis showed an average acetabular anteversion angle of 17.0±3.3°, abduction angle of 37.8±4.3°, and stem alignment of 0±0.8°. Thirty-two (97%) of 33 cups were placed within the Lewinnek's safe zone. The overall complication rate was 12% (4 of 33 hips), including 1 proximal femoral fracture (salvaged with circumferential wiring), 1 temporary femoral nerve palsy (completely recovered in 2 weeks), 1 stem subsidence (5 mm), and 1 cup migration. Three of these complications were occurred in the first 10 cases. No revision surgery was required, No postoperative dislocation occurred. Conclusion. We investigated the learning curve of DAA-THA performed by a senior resident. We considered the first 10 cases as the learning curve, but concluded that with adequate training this procedure can be performed safely and effectively without increasing the risk of complications

Direct anterior approach (DAA) is one of the best way to the hip joint for prevention of post-operative dislocation. We have applied this method as minimum invasive surgery (MIS) to more than two hundred developmental dysplastic hip of Japanese patients in total hip arthroplasty (THA) and there is no post-operative dislocation within three years of last observation carried forward (LOCF). The reason of this benefit is derived from the accuracy of cup positioning and keeping good muscle balance. But the learning curve is very important and some technical pitfalls are there in this approach. We have chosen thirty four patients that the duration of operating time more than one and half hours and loss of blood more than five hundred gram in hour series. The most important factors of the difficulties are the combinations of shortening of femoral neck, especially Perthes like deformity of developmental deformities of the hip joint (DDH) and widening of pelvic bone for the reason of insufficiency working spaces and the difficulties of broaching insertion (8/34). The second factor is the contracture of hip and knee joints combinations for the difficulties of lift up the proximal femur as broaching stem (3/34). The obesity, Body Mass Index (BMI) above thirty is not the reason of difficulties of women in our series. DAA can be extended to Smith-Petersen approach and very useful technique for primary THA in Japanese dysplastic hip patients

Direct anterior approach (DAA) using the Hueter interval for total hip replacement (THA) provides an inter-nervous and inter-muscular access to the hip joint. Although it is technically demanding, the learning curve has been shown to be around 40 cases and 6 months in a high-volume joint surgeon's practice. A level-one study has demonstrated that DAA provides equal or better results and an equivalent rate of complications when compared to the highly utilized direct lateral approach. Using the available evidence to perform a multi-criteria decision analysis we demonstrated that DAA can be the most efficient approach to perform THA. From our standpoint, there is no reason to speculate a surgical approach with such advantages will be abandoned in the future. The DAA is here to stay, and may become the gold standard for THA

Background. Acromegaly, which stems from high level of serum growth hormone secreted by a benign tumour in the anterior pituitary gland, is likely to cause severe peripheral joint pains due to hypertrophic changes in such joints. Recently, the life expectancy of such patients has been improved and more patients with acromegaly have undergone joint surgeries to mitigate joint pain and malfunctions. However, little is known about to what extent surgical procedures can improve the joint functions of acromegalic patients compared to non-acromegalic cases. Methods. First, we qualitatively analysed prognosis of total hip arthroplasty (THA) of acromegalic patients by investigating 11 cases in which direct anterior approach (DAA) THAs were performed to 8 acromegalic patients in our hospital between 2012 and 2015. Second, we quantitatively compared the functional prognosis of the 11 cases with that of 107 non-acromegalic cases. Technically, to control the difference in age, sex, height, and weight between the two patient groups, we first identified a model that could predict 3month-/6month-/12month-functional prognosis in the control cases. We estimated differences in functional outcomes between the two groups by calculating how accurately the control-case-based model could predict the prognosis of the acromegalic cases. Results. In the qualitative analysis, we found that compared to the control, the most acromegalic cases had atypically advanced degenerative arthritides with osteophytes and enthesophytes proliferations. In addition, some cases showed other signs, such as flattering of femoral head and arthritis with slight osteophytes. Regarding surgical procedures, acromegalic cases were likely to require longer operation time and larger amounts of blood loss compared to the control. In the quantitative analysis, we first identified a model in which age and body height could predict the functional prognosis of DAA THA in the non-acromegalic cases (F[2,104] = 6.7, P = 0.0017). We then found that the actual functional outcomes of the acromegalic cases were not significantly different from those predicted by this control-case-based model (P = 0.18). Conclusions. The qualitative analysis shows the atypical joint structures and resultant prolonged operation time and blood loss in the acromegalic cases. However, the quantitative analysis could not find significant differences in prognosis between the acromegalic and non-acromegalic cases. Although these observations and analyses need to be examined in studies with large sample sizes, this work suggests that functional outcomes of DAA THA to acromegalic patients can be comparable to that to non-acromegalic patients

Background. The direct anterior approach (DAA) for total hip arthroplasty (THA) is marketed with claims of superiority over other approaches. Femoral exposure can be technically challenging and potentially lead to early failure. We examined whether surgical approach is associated with early THA failure. Methods. A retrospective review of 478 consecutive early revision THAs within five years of primary THA at three academic centers from 2011 through 2014 was performed. Exclusion criteria resulted in a final analysis sample of 341 early failure THAs. Primary surgical approach was documented for each revision, along with time to revision, and failure etiology. Results. Early femoral component failure was more common with the DAA (49.6%) than the direct lateral (36.6%) and posterior (13.8%) approaches (p = 0.001). In multivariate regression controlling for age, sex, laterality, Dorr bone type, BMI at revision, bilateral procedure (yes/no), and femoral stem type, the DAA remained a significant predictor of early femoral failure (p = 0.001). The majority of early revisions for instability were associated with the posterior approach (47.5%) and the DAA (37.5%) compared to the direct lateral approach (15.9%, p = 0.0002). Conclusions. Despite claims of early recovery and improved outcomes with the DAA, our findings indicate the DAA likely confers greater risk for early femoral failure and, along with the posterior approach, a greater risk of early instability compared to the direct lateral approach following THA

INTRODUCTION. Traditionally, acetabular component insertion in direct anterior approach (DAA) total hip arthroplasty (THA) has been performed using fluoroscopic guidance. Handheld navigation systems can be used to address issues of alignment, cup placement and accuracy of measurements. Previous navigation systems have been used successfully in total knee arthroplasty (TKA) and has now been introduced in THA. We investigated the use of a new accelerometer-based, handheld navigation system during DAA THA to compare it to traditional means. This study aims to determine accuracy of acetabular cup placement as well as fluoroscopy times between two groups of patients. METHODS. Data was prospectively collected for a group of consecutive DAA THA procedures using a handheld navigation system (n=45) by a single surgeon. This was compared to data retrospectively collected for a group that underwent the same procedure without use of the navigation system(n=50). The time for use of the navigation system, including insertion of pins/registration, guiding cup position, and removal of pins, was recorded intraoperatively. Postoperative anteroposterior and cross-table lateral radiographs were used to measure acetabular inclination and anteversion angles. Targeted angles for all cases were 40° ±5 for inclination and 20° ±5 for anteversion. Intraoperative fluoroscopy exposure times were obtained from post-anesthesia care unit radiographs. RESULTS. Mean time of pin insertion/registration, cup positioning and removal was 180.5 seconds, 127.7 seconds and 26 seconds, giving a mean total time of 5.6 minutes. There were no significant differences in mean postoperative acetabular inclination angles between the navigation group as compared to the non-navigation group (39.8° vs 40.6°) (p = .2). There were no significant differences in mean postoperative acetabular anteversion angles between the navigation group as compared to the non-navigation group (24.3° vs 23.7°) (p=.5). Mean intraoperative fluoroscopy exposure times were significantly lower in the navigation group as compared to the non-navigation group (12.6 vs 22.2 seconds) (p<.0001). CONCLUSION. The findings demonstrated that a new handheld navigation system required minimal increase in operative time and was as accurate for cup positioning as fluoroscopically assisted DAA THA. Furthermore, there was a 45% reduction in fluoroscopy exposure time. Reduction in fluoroscopy time will lower radiation exposure for the surgeon and patients

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