RESUMEN

PURPOSE: Achieving the initial stability of implants is necessary for hip hemiarthroplasty (HHA), especially in elderly patients, and this can be achieved with a cement mantle of quality. The direct anterior approach (DAA) for HHA lately has shown positive results. However, evidence is lacking of HHA in elderly patients with osteoporosis after femoral neck fracture (FNF). This study compares differences in cement mantle quality after HHA, its complications, radiological outcomes and functional status in elderly patients with FNF intervened through different approaches. METHODS: A non-interventional, retrospective case-control study was conducted. 150 cases were selected based on the surgical approach (DAA, DLA and PLA) in a 1:1:1 proportion between 2018 and 2019. Under 75 years old suspicion or confirmation of a pathological fracture were excluded. Antibiotic-loaded cement was utilized. Cement preparation involved vacuum centrifugation and standard instructions for preparation canal and filling, and prosthesis placement were followed. RESULTS: No statistically significant differences in cement mantle quality, radiological outcomes, and the majority of the postoperative complications and functional status considering the surgical approach (p > 0.05). However, the DAA was associated significantly with shorter hospital stays (8.3 days vs 11.3 and 13 days for DLA and PLA) a decrease in postoperative blood transfusion (22% vs 34% and 53%), and lower rate of loss of walking (8% vs 20% and 28.6%). CONCLUSION: The DAA for HHA in patients with FNF provides a high-quality cement mantle, similar to other approaches. Also, the DAA shows advantages like shorter hospital stays and lower transfusion rates in elderly patients.

RESUMEN

INTRODUCTION: Implementing new approaches or new implants is always related with a certain learning curve in total hip arthroplasty (THA). Currently, many surgeons are switching to minimally invasive approaches combined with short stems for performing THA. Therefore, we aimed to asses and compare the learning curve of switching from an anterolateral Watson Jones approach (ALA) to a direct anterior approach (DAA) with the learning curve of switching from a neck-resecting to a partially neck-sparing short stem in cementless THA. MATERIALS AND METHODS: The first 150 consecutive THA performed through a DAA (Group A) and the first 150 consecutive THA using a partially neck-sparing short stem (Group B) performed by a single surgeon were evaluated within this retrospective cohort study. All cases were screened for surgery related adverse events (AE). Furthermore, the operative time of each surgery was evaluated and the learning curve assessed performing a cumulative sum (CUSUM) analysis. RESULTS: Overall, significantly more AE occurred in Group A compared to Group B (18.0% vs. 10.0%; p = 0.046). The sub-analysis of the AE revealed higher rates of periprosthetic joint infections (2.7% vs. 0.7%; p = 0.176), periprosthetic fractures (4.0% vs. 2.0%; p = 0.310) and overall revisions (4.7% vs. 1.3% p = 0.091) within Group A without statistical significance. The CUSUM analysis revealed a consistent reduction of operative time after 97 cases in Group A and 79 cases in Group B. CONCLUSION: A significantly higher overall rate of AE was detected while switching approach compared to switching implant for performing THA. However, according to the results of this study, surgeons should be aware of the learning curve of the adoption to a new implant with different fixation philosophy as well.

RESUMEN

BACKGROUND: To compare the efficacy of the direct anterior approach (DAA) versus the posterolateral approach (PLA) in total hip arthroplasty (THA) in terms of operation time, incision length, intraoperative blood loss, postoperative pain, and incision infection rate. METHODS: We systematically searched databases including China National Knowledge Infrastructure (CNKI), Wanfang Data, VIP Chinese sci-tech journals, Chinese Biomedical Literature Database (CBM), PubMed, and Cochrane Library up to December 2023. We included randomized controlled trials (RCTs) that compared DAA with PLA in THA, with a minimum sample size of 80 and a follow-up of at least 6 months. Studies were screened by two independent researchers, following PRISMA guidelines. Data were extracted using a pre-established feature table, capturing study design, sample size, patient demographics, and outcomes of interest. Meta-analysis was performed using RevMan 5.4.1 software. Heterogeneity was assessed using the Q-value statistical test and I² test. The fixed-effects model was used when heterogeneity was low; otherwise, the random-effects model was applied. RESULTS: A total of 19 RCTs met the inclusion criteria. The Meta-analysis revealed that DAA was associated with a longer operation time [MD = 5.89, 95%CI(2.26 to 9.51), P = 0.001] but resulted in a smaller incision length [MD = -2.99, 95%CI(-3.76 to -2.22), P < 0.00001], less intraoperative blood loss [MD=-108.36, 95%CI(-131.10 to -85.62), P < 0.00001], lower incidence of postoperative incision infection [OR = 0.39, 95%CI(0.19 to 0.83), P = 0.01], and reduced hip Visual Analog Scale (VAS) scores on the 1st and 3rd days postoperatively [MD=-0.85, 95%CI(-0.96 to -0.74), P < 0.00001; MD=-0.60, 95%CI(-1.13 to -0.07), P = 0.03]. No significant difference was observed in VAS scores on the 7th postoperative day. CONCLUSION: The DAA for THA offers advantages over PLA, including reduced incision size, blood loss, and postoperative pain, albeit with a longer operation time. These findings should guide clinical decision-making, considering the benefits and potential increased complexity of the DAA.

RESUMEN

INTRODUCTION: Venous thromboembolism (VTE) remains a major complication after total hip arthroplasty (THA), irrespective of the surgical approach. This study investigated the incidence of VTE in patients undergoing THA through intermuscular minimally invasive surgical techniques, which included a direct anterior approach (DAA), an anterolateral approach (AL), and an anterolateral supine approach (ALS), at a single institution. METHODS: A hundred consecutive patients treated with each surgical approach were evaluated. Plasma D-dimer levels one month preoperatively and one day postoperatively, operative time, and intraoperative blood loss were recorded, and the presence of VTE was evaluated based on multidetector-row computed tomography performed the day after surgery. Student's t-test and Pearson's chi-square test or one-way analysis of variance were used in statistical analysis. RESULTS: No differences among the groups in terms of age, height, weight, operative time, intraoperative bleeding, and preoperative and postoperative D-dimer levels were observed. The overall incidence of VTE was 21%. The incidences of VTE were 30% in AL, 17% in ALS, and 16% in DAA, representing a significantly higher rate in AL than in ALS and DAA (P=0.025). The incidences of VTE on the operated side were 19% in AL, 13% in ALS, and 12% in DAA, with no statistically significant differences. The incidences of VTE on the non-operated side were 22% in AL, 9% in ALS, and 8% in DAA; these differences were statistically significant (P=0.0045). DISCUSSION: Results showed that the incidence of VTE was significantly higher in AL than in ALS and DAA, especially for the non-operated side.

RESUMEN

BACKGROUND: Stem anteversion (SA) in total hip arthroplasty (THA) is crucial for postoperative outcomes, affecting dislocation risk and hip function. Accurate SA placement is challenged by intraoperative estimation methods, with discrepancies reported between predicted and true SA. This study investigates the effect of conventional methods and intraoperative fluoroscopic confirmation on SA accuracy in THA performed with a direct anterior approach using a traction table. METHODS: This involves 200 patients undergoing primary THA from August 2019 to January 2023, divided into a conventional group (n = 100) and a fluoroscopic group (n = 100). Postoperative SA measurements were conducted using computed tomography scans. Statistical analysis focused on comparing the SA angles and the prevalence of excessive SA (≥>35° and ≥>40°) between the groups. RESULTS: The fluoroscopic group showed a lower average SA angle (24.3° ± 8.3°) compared to the conventional group (30.0° ± 11.3°), with a statistically significant difference (p < 0.01). Excessive SA (≥>40°) was found in 17% of the conventional group, significantly reduced to 5% in the fluoroscopic group (p < 0.01). Similarly, SA exceeding 35° was present in 39% of the conventional group, compared to only 11% in the fluoroscopic group (p < 0.01), indicating a substantial reduction in excessive SA placements with fluoroscopic guidance. DISCUSSION: The study demonstrates that intraoperative fluoroscopic guidance significantly enhances the accuracy of SA placement in THA, reducing the variability and proportion of excessive SA. This suggests a critical reevaluation of conventional estimation methods in favor of fluoroscopic confirmation to improve surgical outcomes. CONCLUSION: Intraoperative fluoroscopic confirmation of knee external rotation angle markedly decreases the proportion of excessive SA and enhances the precision of stem placement in THA with a direct anterior approach. This technique represents a significant advancement in surgical practice, offering a simple and effective method to achieve optimal postoperative results.

RESUMEN

Objective: The direct anterior approach (DAA) is a recognized technique for total hip arthroplasty (THA) that spares soft tissue. Functional and clinical outcomes following THA via the DAA in patients with complex acetabular deformities, specifically coxa profunda (CP) and protrusio acetabuli (PA), have yet to be determined. Methods: A retrospective analysis was conducted on 188 primary THA cases, including 100 CP hips and 88 PA hips, performed via the DAA. Functional and clinical outcomes were evaluated by means of the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Harris Hip Score (HHS) preoperatively and at a mean follow-up of 46 ± 14 months. Furthermore, potential complications were assessed. Results: From the preoperative to the latest postoperative visit, a significant improvement in the WOMAC total score was observed (CP: -34.89 ± 20.66; PA: -40.38 ± 21.11). The length of stay (LOS) was the only parameter predictive of the postoperative WOMAC total score, with each day of LOS increasing the postoperative WOMAC by a mean of 1.77 points (p < 0.01). The HHS improved by 38.37 ± 14.23 (PA-group) and 32.79 ± 14.89 points (CP-group). No significant difference in the patient-reported outcome measures (PROMs) between the CP- and PA-group was found. The survival rate for any revision was 97.70% (PA-group) and 92.80% (CP-group). Conclusion: The results of this study indicate that the minimally invasive DAA was not predictive of the functional and clinical outcome following DAA-THA in patients with CP and PA. Improvements in the mean WOMAC and HHS scores were above or within the reported MCID. Additionally, revision rates were well below those reported in the literature for short and intermediate follow-up periods.

RESUMEN

BACKGROUND: Objective and subjective outcomes in the direct anterior approach (DAA) and posterior approach (PA) in total hip arthroplasty (THA) were assessed in this study, using the Oxford Hip Score (OHS) as primary outcome. Pain, 3 objective performance-based tests, surgical time, blood loss and length of stay were assessed as secondary outcomes. METHODS: Patients with primary end-stage osteoarthritis were prospectively enrolled by shared decision making for the DAA (32 patients) or PA (26 patients). Baseline data were collected preoperatively and outcomes postoperatively at 2-, 6-, 9- and 12-month follow-up. RESULTS: There is no significant difference (p < 0.05) between the DAA and PA on primary outcome (OHS). There was a main effect of time which indicated an increase of OHS over time independent of group (p < 0.01). CONCLUSIONS: In the current study, no significant differences in postoperative functional outcome were found between DAA and PA in all follow-up moments.

RESUMEN

BACKGROUND: The direct anterior approach is increasingly used for primary total hip arthroplasty (THA) due to its minimally invasive nature and rapid recovery time. Difficulties in identifying the correct intermuscular interval can arise during the procedure, sometimes resulting in excessive medial exposure. This study aimed to evaluate demographics and risk factors, outcomes, and potential complications in those THA patients in which a medialized approach was performed. METHODS: We retrospectively reviewed cases of anterior THA to identify cases where the surgical approach to the hip was more medial than the standard interval. Demographic data, operative time, blood loss, intraoperative and postoperative complications, radiographic findings were collected and compared with a control group of 50 THA performed using the standard anterior intermuscular interval. RESULTS: In a series of 1,450 anterior total hip arthroplasty (THA) procedures performed between January 2018 and December 2021, with an average follow-up of 33 ± 22.3 months, six patients (0.4%) had a medialized surgical interval. In one case the superficial layer was medial to the sartorious muscle while in the other five cases, the interval was lateral to the sartorius superficially, and medial to the rectus femoris deeply. Four out of 6 patients (66.6%) showed neuropraxia affecting the femoral nerve, and 3 out of 6 (50%) had involvement of the lateral femoral cutaneous nerve. In 6 out of 6 patients (100%), surgery was performed during the learning curve of DAA. No patients in the control group developed femoral nerve neuropraxia, and 2 out of 50 patients (4%) showed involvement of the lateral femoral cutaneous nerve. DISCUSSION AND CONCLUSION: The anterior approach can rarely result in excessive medial exposure to the hip joint, especially during the learning curve. In our study cohort, an increased rate of neurological complications and reduced outcomes were observed, thereby rendering this event of particular clinical significance. To avoid unconventional intermuscular intervals, patient positioning and correct identification of the muscle bellies by recognizing the orientation of the muscle fibers are useful, together with the identification and ligation of the circumflex vessels, to ensure the identification of the correct intermuscular interval.

RESUMEN

Purpose: The direct anterior approach (DAA) for conducting total hip arthroplasty (THA) is gaining popularity worldwide. However, careful selection of patients and surgeon experience are important. Although promising outcomes have been reported in international studies, research on DAA in Southern and Southeast Asia has been limited. Materials and Methods: This prospective study included 157 patients who underwent THA using the DAA between January 2019 and June 2022. The patients were divided into three groups for the comparison. Data on preoperative, intraoperative, and postoperative variables were acquired. Improvement of the surgeon's performance to use of a DAA approach was examined using the CUSUM (cumulative summation method). Results: The mean age of the patients was 43.9 years. Differences in intraoperative variables and complications were observed among the three groups, and improved outcomes were reported in later cases. Functional outcomes showed significant improvement, and no differences were observed between groups. The results of learning curve analysis indicated a shift towards consistent success after the 82nd case, reaching an acceptable rate of failure by the 118th case. Conclusion: The findings of this study suggest that DAA can offer benefits but there is a learning curve. Complications were initially high but began decreasing after approximately 80 cases. Careful selection of patients is critical, particularly in the effort to minimize being presented with a challenging case. This study provides insights that may be helpful to surgeons when considering DAA; however, further study is warranted.

RESUMEN

Purpose: Leg length discrepancy (LLD) is a common complication following total hip arthroplasty (THA). The direct anterior approach (DAA) for THA is gaining popularity due to its advantages, but there is limited research on the incidence and size of LLD. This systematic review aims to explore the differences in LLD between DAA and other approaches, as well as the techniques to control LLD in DAA. Methods: A comprehensive literature search was conducted to identify relevant studies comparing THA by DAA with other surgical approaches and investigating methods to control LLD in DAA, following PRISMA guidelines and a priori registration on PROSPERO (CRD42023412644). The quality of the included studies was assessed. Data on preoperative and postoperative LLD and other relevant outcomes were extracted and analyzed descriptively. Results: In total, 29 studies were included in this systematic review. The majority (86%) were classified as level IV evidence. Comparisons between DAA and posterior approach (PA) or anterolateral approach (ALA) showed DAA had lower rates of LLD >10 mm compared to PA and ALA. Different pre- and intra-operative techniques were evaluated, but no consensus on the best method for preventing LLD in DAA was reached. Conclusion: DAA shows comparable or superior results in the prevention of LLD compared to other surgical approaches. Supine patient placement, direct leg measurement, and the use of IF contribute to these outcomes. Intraoperative fluoroscopy with a grid and preoperative planning offers a good option, especially for training purposes, but its role in preventing LLD by experienced DAA surgeons needs further investigation.

RESUMEN

INTRODUCTION: Simultaneous bilateral total hip arthroplasty (THA) has demonstrated similar clinical outcomes to staged bilateral THA. However, there is scarce data regarding the early postoperative complications. This study compares simultaneous to staged bilateral THA with the direct anterior approach (DAA) regarding early complications and revision surgeries. METHODS: This retrospective case-control study included all bilateral THAs, performed by DAA between 2013 and 2021 with a minimum follow-up of 6 months. A total of 264 THAs (132 patients) were identified [simultaneous group (1T): 58 patients; staged group (2T): 74] with a mean follow-up of 54 months. Complications and revisions, clinical outcomes, and days off work were assessed at the last follow-up. Moreover, blood loss was evaluated by the modified method of Mercuriali and Inghilleri. RESULTS: Blood loss was higher in the 1T group (1003 mL 1T vs. 740 mL 2T; p < 0.001) but there was no significant difference in transfusion rates (5% 1T vs. 3% 2T; p = 0.4). There were no complications in 1T, while the complication rate was 5.2% (n = 6) in 2T (p = 0.012). There were 5 revisions in the 2T group, including 2 debridements with polyethylene exchange and implant retention for early infections, 2 revisions for aseptic loosening in the same patient, and 1 revision due to fracture. Postoperative pain on D3 was equivalent in both groups (4.2 1T vs. 4.3 2T; p = 0.79). The improvement in function according to the HHS at 2 months was better in the 1T group, but not significant (36.8 1T vs. 32.9 2T; p = 0.05). The total number of days off work was significantly higher in the 2T group (82.6 days vs. 178.8; p = 0.025). DISCUSSION: Simultaneous bilateral THA with the DAA seems to be a safe procedure, with no risk of increased early postoperative complications when compared to the staged procedure with similar functional outcomes and significantly fewer complications and days off work.

RESUMEN

Total femur replacement is a well-recognized salvage procedure and an alternative to hip disarticulation in patients with massive femoral bone loss. Compared to conventional total femur replacement, intramedullary total femur (IMTF) requires less soft tissue dissection and preserves femoral bone stock and soft-tissue attachments. Despite these advantages, patients can still anticipate compromised functional outcomes and high complication rates following IMTF. Prior studies describe IMTF with the patient positioned laterally and utilizing posterior or anterolateral approaches to the hip. We describe our IMTF technique performed via the direct anterior approach in the supine position. In our experience, this is an effective method, with potential benefits including intraoperative limb length and rotational assessment, use of fluoroscopy, more convenient exposure of the knee, and potential lower rates of hip instability.

RESUMEN

Background: Impaction in total hip arthroplasty has typically been conducted using a mallet. A surgical automated impactor has been developed with the goal of reducing surgeon variability, fatigue, and injury. There is also potential to reduce the variability of each impaction step in which automated impaction is used, through reproducible and consistent application of force. Methods: Patients were randomized into either the mallet control group, or the automated impaction study group (1:1 randomization). The primary endpoint analysis was conducted to demonstrate that femoral broaching time (in minutes) with an automated impactor is noninferior to femoral broaching time with manual instruments (mallet) under a noninferiority (NI) margin of 1.25 minutes, with a subsequent test of superiority. A total of 218 patients were randomized and treated (109 in each group). Results: Mean femoral broaching time was 5.8 minutes in the automated impaction study group (automated), and 8.1 minutes in the mallet control group (mallet), a 28.4% reduction (P = .0005). However, there was not a difference in surgery duration between the groups. Three fractures were reported in the mallet group and 1 in the automated group. Conclusions: In this randomized multicenter study, an automated impactor was shown to reduce femoral broaching time in primary total hip arthroplasty, with no increase in fractures, but no decrease in operating room time was noted.

RESUMEN

BACKGROUND: The surgical approach impacts the outcomes and recovery after total hip arthroplasty (THA), and approaches may affect the stem positioning. Contrary to the general concept of minimally invasive surgery, the direct anterior approach (DAA) results in more intraoperative blood loss. Therefore, the objective of this study was to compare stem positioning and hidden blood loss (HBL) among three surgical approaches: the minimally invasive DAA, Orthopadische Chirurgie Munchen (OCM), and the traditional posterolateral approach (PLA). METHODS: A total of 201 patients undergoing their first non-cemented THA using the DAA, OCM, and PLA were included in the study. General demographic data, stem alignment, and blood loss were evaluated. Specific comparison measurements included femoral neck anteversion, femoral stem anteversion, alignment of the stem in coronal and sagittal planes, proximal and distal medullary ratios, and femoral offset. Blood loss was measured by calculating Intraoperative Blood Loss ( IBL), visible blood loss (VBL), and hidden blood loss (HBL). RESULTS: There were no significant differences in age, gender, body mass index, preoperative diagnosis, or femoral Dorr classification among the three groups. The mean surgical time was longer for the DAA and OCM compared to the PLA (P < 0.01). IBL was highest in the DAA group and lowest in the PLA (P < 0.05). Postoperative stem anteversion were significantly different among the groups, with the DAA showing the greatest anteversion difference (P < 0.05). There was no difference in the stem coronal alignment. However, there were more valgus and varus implants in the sagittal plane for the DAA and OCM. The femoral offset reduction was less optimal in the DAA and OCM groups (P < 0.05). The proximal and distal medullary ratios were lower in the DAA and OCM (P < 0.05). HBL was significantly lower in the DAA and OCM compared to the PLA (P < 0.05). CONCLUSION: Minimally invasive approaches such as DAA and OCM offer advantages in muscle and soft tissue preservation, leading to reduced HBL compared to the conventional PLA. However, these approaches present challenges in femoral stem positioning and longer surgical times.

Asunto(s)

RESUMEN

OBJECTIVE: Although the direct anterior approach can reduce muscle damage and ensure accurate prosthesis placement, the steep learning curve and increased risk of complications associated with DAA necessitate careful consideration. Therefore, we describe a technique for a novel percutaneously endoscopic-assisted total hip arthroplasty through mini bikini direct anterior approach (mDAA) and report the learning curve and initial outcomes. METHODS: The first 125 THA performed by a single surgeon between September 2020 and February 2022 using the anterior approach were included, comprising the initial 41 cases of bikini DAA (bDAA) and the subsequent 84 cases of mDAA. Outcome measures included perioperative outcomes and postoperative complications. The cumulative sum analysis (CUSUM) was used to determine the learning curve of anterior approach THA for each patient's ORT. Multivariable analysis was performed to determine risk correlation. RESULTS: A total of 125 anterior approach THA completed between 2020 and 2022 were identified. Among these, 41 were performed via bDAA and 84 via mDAA. No statistically significant differences were observed between the groups in terms of age, gender distribution, BMI or follow-up time. A significant reduction in ORT was noted, from 140 min for bDAA to 130 min for mDAA. Furthermore, there was a consistent decrease in LOI, LOS, and wound-healing problems. There was no statistically significant difference between groups with respect to Harris Hip Scores and other postoperative complications. The curve inflection points of the learning curve for the bDAA and mDAA group were located in the 22nd and 68th cases, respectively. The reduction of hemoglobin indicated a predicted increase in ORT. CONCLUSIONS: In this study, ORT, LOI, LOS, and wound-healing problems decreased overall in mDAA group. After mastering the bDAA technique, approximately 27 mDAA cases are needed to acquire proficiency in this technique. Hence, mDAA is a valuable alternative for those seeking smaller incisions, resolving wound healing problems, and aiming for enhanced recovery after surgery.

Asunto(s)

RESUMEN

BACKGROUND: In total hip arthroplasty via the direct anterior approach, appropriate exposure is critical to allow preparation of the femur. The objective of this study was to explore the optimal soft tissue releases needed to allow broaching of the femur through a combination of experimental tests and computer simulations. METHODS: Fourteen full-body cadaveric specimens were included in this study. Total hip arthroplasty was performed via the direct anterior approach with the femur at 20° adduction and 20°extension. Soft tissue releases were performed sequentially, namely, the transverse iliofemoral ligament, descending iliofemoral ligament, ischio-femoral ligament, conjoint tendon, and obturator externus. After each release, the femur mobility was assessed by applying a 6 Nm external rotation torque and a 120 N distraction force. Subsequently, using specimen-specific models and models of the broach and handle, the broach passage after each release was simulated, and the release that allowed broach passage was analyzed. FINDINGS: The average external rotation after releasing the transverse and descending iliofemoral ligaments increased by 14.1° ± 6.1° and 13.8° ± 5.3°. With subsequent soft tissue releases, the rotational mobility increased incrementally, though the impact decreased. Impingement between the broach passage and the pelvis was mainly at the anterior superior iliac spine and the anterior inferior iliac spine. The volume of impingement decreased from 4.8 ± 4.5 cm3 after resection of the femoral head to 1.8 ± 1.6 cm3 and 1.2 ± 1.9 cm3 after release of the transverse and descending iliofemoral ligament, respectively. INTERPRETATION: With sequential soft-tissue releases, the femur mobility increased incrementally. However, the number of releases needed for each femur varied extensively between specimens. Most (10/14) femurs became accessible after the release of the ilio-femoral or ischio-femoral ligament.

Asunto(s)

RESUMEN

BACKGROUND: It remains unclear whether the use of an orthopaedic traction table (TT) in direct anterior approach (DAA) total hip arthroplasty (THA) results in better outcomes. The aim of this systematic review and network meta-analysis was to compare the THA outcomes through DAA on a standard operating table and the THA outcomes through DAA on a TT. METHODS: PubMed, Epistemonikos, and Google Scholar were searched for relevant randomized controlled trials (RCTs) up to 01 January 2024. An indirect comparison in network meta-analysis was performed to assess treatment effects between DAA on a TT and DAA on a standard table, using fixed-effects and random-effects models estimated with frequentist approach and consistency assumption. Standardized mean differences (SMDs) with 95% confidence intervals (CIs) were estimated for continuous variables and odds ratios (ORs) with 95% CIs were estimated for binary variables. RESULTS: The systematic review of the literature identified 43 RCTs with a total of 2,258 patients. DAA with TT had a 102.3 mL higher intraoperative blood loss and a 0.6 mmol/L lower Hb 3 days postoperatively compared with DAA without TT (SMD = 102.33, 95% CI 47.62 to 157.04; SMD = - 0.60, 95% CI - 1.19 to - 0.00). DAA with TT had a 0.15 lower periprosthetic fracture OR compared with DAA without TT (OR 0.15, 95% CI 0.03 to 0.86). There were no further significant differences in surgical, radiological, functional outcomes and in complication rates. CONCLUSION: Based on our findings and taking into account the limitations, we recommend that particular attention be paid to the risk of periprosthetic fracture in DAA on a standard operating table and blood loss in DAA with TT. Since numerous other surgical, radiological, functional outcome parameters and other complication rates studied showed no significant difference between DAA on a standard operating table and DAA with TT, no recommendation for a change in surgical technique seems justified. LEVEL OF EVIDENCE: Level I evidence, because this is a systematic review and meta-analysis of randomized controlled trials.

Asunto(s)

RESUMEN

Background Direct anterior total hip arthroplasty (DA-THA) has increased in popularity over recent decades. However, DA-THA has been reported to have a higher incidence of superficial wound complications, including infection and incisional dehiscence, compared to other surgical approaches to hip arthroplasty. While this indicates a need for optimal wound closure, little research exists on the preferred method of skin closure following DA-THA. This study aimed to determine if there was any difference in rates of superficial infection, wound dehiscence, or overall wound complications with skin closure using a running subcuticular 3-0 Monocryl® suture compared to surgical staples following DA-THA.  Methods Records of patients who underwent DA-THA at our institution between July 2017 to July 2022 were retrospectively reviewed. Data were abstracted on patient demographics, comorbidities, skin closure method, and wound complications from the electronic medical record. Superficial infection and wound dehiscence were classified based on explicit diagnosis in post-operative records and incision photographs taken during follow-up visits. Overall wound complications were classified in patients who experienced either superficial infection, incisional dehiscence, or both complications following surgery. Descriptive statistics and chi-squared measures were obtained from post-operative patient data, and significance was set at p [Formula: see text] 0.05. Results A total of 365 DA-THAs were completed in 349 patients. A running subcuticular 3-0 Monocryl® suture closed 207 surgeries (56.7%), while surgical staples closed 158 surgeries (43.3%). There was no significant difference in independent rates of superficial infection (p = 0.076) or wound dehiscence (p = 0.118) between suture and staple cohorts; however, suture closure (10, 2.7%) was associated with a significantly higher rate of overall wound complications compared to staple closure (1, 0.3%) (p = 0.020). Conclusion DA-THA carries the risk of overall wound complications, including superficial infection and wound dehiscence. Our findings suggest superficial skin closure with staples may be preferred over sutures due to lower rates of overall wound complications. Further studies are needed to determine the optimal method of skin closure following DA-THA.

RESUMEN

The direct anterior approach (DAA) has been increasing in popularity for primary total hip arthroplasty (THA). Despite previously documented anatomic limitations to its direct distal extension, alternative exposure methods have been described to safely access the femoral diaphysis and facilitate increasingly complex primary and revision THA scenarios. The DAA has several purported advantages compared to alternative approaches (eg, posterior and lateral-based), including its muscle-sparing nature, use of an internervous plane, and preservation of posterior stabilizing structures. Proponents of the DAA cite decreased postoperative pain, quicker recovery times, potentially lower dislocation rates, ease of intraoperative fluoroscopy, and improved implant placement/restoration of leg lengths. The current literature, however, is sparse when considering the use of this approach in the setting of severely dysplastic hips necessitating a concurrent subtrochanteric shortening osteotomy. When utilizing a posterior approach in this population, previous work from Ollivier and colleagues demonstrated high rates of cementless implant osseointegration and significantly improved clinical outcomes at long-term follow-up. Although relatively few reports of addressing this pathology via the DAA currently exist, initial results are promising. This study seeks to provide a detailed description of a surgical technique for performing primary THA and ipsilateral subtrochanteric shortening osteotomy in this patient population utilizing an extensile DAA.

RESUMEN

The differences in complication rates between the direct anterior and posterior approaches for hemiarthroplasty in elderly patients with femoral neck fractures are not yet fully understood. Dislocation, a severe complication associated with increased mortality and often requiring additional surgery, may occur less frequently with the direct anterior approach compared to the posterior approach. Careful consideration of patient demographics is essential when planning the surgical approach. Future research in this area should focus on robust randomized controlled trials involving elderly patients recovering from femoral neck fractures.