The anterior approach for total hip arthroplasty (THA) carries a higher risk of wound complications, which can significantly affect patient outcomes and increase healthcare costs. There is limited research comparing infection rates based on closure techniques in patients who undergo THA. Therefore, this study aims to compare wound complications based on interrupted or continuous sutures for skin closure after anterior approach THA.

This single-surgeon retrospective study extracted data from 388 patients who had undergone a primary THA using the anterior approach. Patient demographics, comorbidities, perioperative factors, and infection-related complications were recorded. All variables associated with a given infection complication were controlled for in a binary logistic regression model.

After controlling for confounding variables, wound closure type was not associated with any infectious complications. BMI was a strongly associated factor in PJI (p = 0.028; 95 % CI = 1.02-1.34), prolonged drainage (p < 0.001; 95 % CI = 1.08-1.28), readmission (p = 0.023; 95 % CI = 1.01-1.20), and I&D and revision surgery (p = 0.021; 95 % CI = 1.02-1.31).

Body mass index was the sole factor associated with a higher risk of wound complications postoperatively. These findings suggest a non-inferiority between continuous and interrupted suture closure techniques regarding wound-related infectious complications in anterior total hip arthroplasty.

No studies have compared two portable navigation systems, including augmented reality (AR) hip navigation and the Naviswiss system, to improve the accuracy of acetabular component alignment during total hip arthroplasty (THA) in the posterolateral approach. We investigated the difference in cup placement accuracy between the two systems.

We retrospectively compared THAs performed using the AR hip navigation (n = 32) and those performed using Naviswiss (n = 41) from June 2021 to April 2023. All patients underwent THA in the posterolateral approach. The primary endpoint includes radiological inclination (RI) and radiological anteversion (RA) measured on postoperative radiographs, and the absolute value error of radiological inclination (δRI) and radiological anteversion (δRA) between the final cup alignment displayed on the navigation screen at final cup fixation and cup alignment measured on postoperative radiographs.

No significant differences in the mean RI and mean rRA and δRI and δRA were found between the two groups. The percentage of cases with both δRI and δRA of < 3° were 31% and 24% in the AR hip and Naviswiss groups, respectively, with no significant difference. The percentage of cases in both δRI and δRA of < 5° was 66% and 90% in the AR hip and Naviswiss groups, respectively (p = 0.009). No cases demonstrated both δRI and δRA of > 5°.

No significant differences were found between the two systems. The Naviswiss system demonstrated a higher percentage of errors within 5° than the AR navigation system, indicating that Naviswiss reproduced functional pelvic plane more accurately.

Increased perioperative complications in obese patients undergoing total hip arthroplasty (THA) have previously been reported. There is a relative paucity of data evaluating these complications strictly in the context of anterior-based THA. In this study, we compare the outcomes following anterior-based THA as a function of body mass index (BMI).

A 1:1 matched retrospective cohort study was conducted. Patients undergoing anterior-based THA from January 2022 to June 2024 with a BMI >35 kg/m2 were matched 1:1 based on age and sex to patients with a BMI <35 kg/m2 from our division registry. Demographic data, surgical details, complications (intraoperative and postoperative), and patient-reported outcome measures (PROMs: 12-Item Short Form P/M, Western Ontario and McMaster Universities Osteoarthritis Index-P/S/F) were collected and analyzed.

There were 280 patients included (140 per group). There were 27 postoperative complications in the BMI >35 kg/m2 group and 10 in the BMI <35 kg/m2 group (P < .01). There were 10 major complications (4 dislocations, 2 periprosthetic fractures, and 4 deep infections requiring incision and drainage) in the BMI over 35 kg/m2 group, with no major complications occurring in the lower BMI group. There were 3 intraoperative complications (periprosthetic fracture), all in patients with BMI >35 kg/m2. There was significant improvement in Western Ontario and McMaster Universities Osteoarthritis Index P/S/F scores and 12-Item Short Form pain in both groups at 3 months postoperatively, with greater improvements seen in the BMI >35 kg/m2 group.

The present study found that despite significant differences in postoperative complications, there were significant improvements in PROMs in patients with a BMI above and below 35 kg/m2 who underwent anterior THA.

Corticosteroid injections following total hip arthroplasty (THA) are commonly utilized to address soft-tissue pathology such as bursitis and tendinitis. The THA surgical approaches differ in the extent of muscle and soft-tissue dissection. The aim of this study was to compare the impact of surgical approach on postoperative corticosteroid injection requirements when controlling for multiple covariates. A secondary aim was to identify risk factors associated with the various injection types.

This was a propensity-matched retrospective study of 10,907 THA patients from June 2016 to December 2022 at a single, urban, academic health center. Patients were stratified into cohorts based on surgical approach: anterior (n = 4,287) and posterior (n = 6,620), then propensity-matched 1:1 with nearest-neighbor matching to form two cohorts of 4,287 patients. Baseline characteristics and corticosteroid injection data for soft-tissue pathology were obtained and analyzed. Chi-square and multivariate logistic regression analyses were used to assess the impact of patient and surgical factors on receiving postoperative steroid injections.

A posterior approach conferred increased risk of postoperative injections (aOR [adjusted odds ratio] 1.242, P = 0.001) after controlling for multiple covariates. The posterior approach also had higher total rates of greater trochanter (GT) bursitis injections postoperatively compared to the anterior group (11.5 versus 7.3%, P < 0.001). Both surgical approaches demonstrated comparable rates of iliopsoas bursitis injections (P = 0.39), gluteus medius tendinosis injections (P = 0.09), and lateral femoral cutaneous nerve injections (P = 0.27). The strongest predictor of postoperative injections was a history of preoperative injection (aOR 3.772, P < 0.001).

Posterior approach, women, and history of preoperative corticosteroid injection were identified as the strongest risk factors for postoperative GT bursitis injection or postoperative soft-tissue injection. These factors should be considered when counseling patients on expected postoperative outcomes and the likelihood of corticosteroid injections following THA.

To our knowledge, outcomes of patients undergoing staged, bilateral total hip arthroplasty (THA) via dissimilar surgical approaches have not yet been investigated. This study examined demographics, implant selection, technology utilization, and component positioning between hips in patients who underwent one THA via posterior and one via direct anterior approach and secondarily evaluated patient-reported outcomes.

There were 36 patients (72 hips) who underwent staged, bilateral, primary, elective THAs via different approaches from January 2012 to December 2023. Patient demographics, intraoperative technology utilization, implants used, and pre- and postoperative Hip Dysfunction and Osteoarthritis Outcome Scores for Joint Replacement (HOOS-JR) scores were recorded. The hip center of rotation, acetabular height and anteversion, and metaphyseal canal fill were measured on postoperative radiographs. Femoral stem coronal and sagittal plane angulation following both approaches were also compared on postoperative radiographs.

There were 15 (41.7%) patients who underwent posterior THA first. The mean time between operations was five years (range, 0.93 to 10.2). Intraoperative technology utilization was more common for the anterior THA (P = 0.002). There were no significant differences in hip center of rotation (P = 0.292), acetabular anteversion (P = 0.428), or acetabular height (P = 0.935) between patients' anterior and posterior approach THAs. The proportion of patients who had posterior stem angulation was significantly greater following anterior THA; neutral stem angulation was seen more frequently following posterior THA (P = 0.005). Lipped liners (P < 0.001), high offset femoral stems (P = 0.007), and dual or triple-taper stems (P < 0.001) were more commonly utilized in posterior THAs. For patients who had pre- and postoperative HOOS-JR for each hip, there was no significant difference in postoperative score improvement between anterior and posterior THAs (P = 0.697), with a mean follow-up time of 2.4 years (range, 0.3 to 9.28) for posterior and 6.1 years (range, 2.8 to 10.3) for anterior THAs (P = 0.249).

Patients undergoing staged, bilateral THAs via different surgical approaches exhibit radiographic characteristics likely attributable to technical challenges for each approach. However, these differences related to approach do not seem to impact short-term clinical and patient-reported outcomes.

Background: It is unclear what influence patient sex and body mass index (BMI) have on perioperative outcomes following total hip arthroplasty (THA), especially regarding anterior versus posterolateral approaches. Purpose/Study Questions: We sought to compare perioperative outcomes of primary THA via direct anterior (DAA) versus posterolateral (PLA) approaches, stratified by patient sex and BMI. Methods: A retrospective review at a single institution identified 8258 patients 18 to 80 years old who underwent primary THA via DAA or PLA for osteoarthritis between February 2019 and April 2022. Patients were stratified by sex and BMI (<30 or 30-40). We compared operative times, lengths of stay (LOS), opioid consumption and prescribing patterns, and achievement of Hip Injury and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) across the cohorts. Results: Median operative time was 6 to 11 minutes longer for DAA than for PLA. Median LOS was shorter for DAA, with the largest difference observed in women with BMI <30 (19-hour difference) and BMI 30 to 40 (20-hour difference). In-hospital milligram morphine equivalents consumed were lower for DAA in men with BMI <30 (45 vs 53), women with BMI <30 (45 vs 53), and women with BMI 30-40 (60 vs 75). There was no difference observed in HOOS JR MCID, SCB, or PASS achievement scores at 1 year for any cohort. Conclusion: This retrospective study found longer operative times for DAA than PLA and shorter LOS in women undergoing DAA than those undergoing PLA. There were minimal clinical differences in in-hospital opioid consumption, 90-day opioid prescription patterns, and patient-reported outcome measures. These findings suggest that patient sex and BMI may have implications on case scheduling and discharge planning for primary THA. Further study is warranted.

Background/Objectives: Reported patient results after total hip arthroplasty (THA) have been described as a function of surgical approach. Such results have commonly been subjective. Though self-reported outcomes are of value and often utilized, inclusion of functional performance measures represents an objective measure to compare THA techniques. Methods: Patients that underwent primary THA surgery at our institution were grouped by surgical approach (Direct Anterior vs Posterior). Patient data were collected pre-operatively, as well as post-operatively at three and twelve months. Hip Dysfunction and Osteoarthritis Outcome Score (HOOS JR) was utilized, and function was assessed with the timed up and go test (TUGT), 4-m walk test (4MWT), and 30 s sit-to-stand (30STS) test. Unpaired T tests were used to compare mean results and differences between the groups. Results: Functional outcome scores were improved to a similar degree for both surgical approach groups at all the time points post-operatively. At 3 months, the TUGT was improved by 2.33 s for the posterior group, the 30STS was increased by 2.71 repetitions, and the 4MWT was increased by 1.23 s; the anterior group had 2.66 s, 2.49 repetition, and 1.18 s improvements in the three functional tests, respectively. At 12 months, the posterior group had improvements of 2.86 s, 3.99 repetition, and 1.19 s, while the anterior group had improvements of 3.15 s, 3.83 repetition, and 1.23 s, respectively. No clinical and statistical significant differences in surgical approach were noted in these measures. In contrast, the anterior group showed a statistically significant but not clinically significant improvement in self-reported HOOS JR scores compared to the posterior group at the 3-month post-operative mark (p = 0.045). Conclusions: This study suggests both anterior and posterior surgical approaches to total hip arthroplasty yield equivalent functional results at 3 months and one year post-operatively, while the anterior approach demonstrates more improved patient satisfaction than the posterior approach at the 3-month post-operative assessment.

Background: Adequate implantation is important to avoid complications following total hip arthroplasty (THA). This study aimed to evaluate the accuracy and precision of implant placement in the direct anterior approach (DAA) using fluoroscopy in comparison with the anterolateral approach in lateral decubitus position (OCM) using a single implant. Methods: We retrospectively compared propensity score-matched THAs in DAA with fluoroscopy and in OCM. The achievement ratio of the Lewinnek cup safe zone, absolute difference in alignment, and positioning from preoperative planning was evaluated and compared between each approach. Results: 33 patients in both groups were eligible for this study. Significantly more cups were inside the safe zone in the DAA group than in the OCM group (33/33 vs. 25/33, p=0.0048). No significant differences were found between the DAA group and OCM group regarding the discrepancy from the target cup inclination, anteversion, and three-dimensional positioning. No significant difference was noted in stem alignment; however, the equality of coronal alignment variances was smaller in the DAA group (p=0.0047). No significant differences were found in the clinical score and complication rate. Conclusion: The DAA using fluoroscopy may provide more accuracy for cup placement and precision for stem placement than OCM.

While some literature suggests that wound complications are increased for primary total hip arthroplasty (THA) procedures utilizing the direct anterior (DA) approach, the impact of the surgical approach on wound complications after revision THA cases remains unknown. This study aimed to compare wound complications between different surgical approaches in revision THA.

The retrospective study identified 1,749 consecutive patients who underwent revision THA at a single institution between 2017 and 2023. Patients were categorized based on components revised (acetabular only, femur only, both-component, head-liner exchange) during revision THA and by surgical approach (DA, direct lateral (DL), postero-lateral (PL)) for each category. The primary outcome of the study was wound complications within 90 days of surgery.

The wound complication rates for acetabular-only revisions were 0.83 for DA approach, 4.64 for DL approach, and 3.9% for PL approach (P = 0.149). Femoral component revisions had wound complication rates of 9.68 for DA approach, 5.06 for DL approach, and 13.2% for PL approach (P = 0.065). For both component revisions, the wound complication rates were 5.83 for DA approach, 4.49 for DL approach, and 8.47% for PL approach (P = 0.28). Also, head and liner exchange wound complication rates were 6.94 for DA approach, 6.21 for DL approach, and 11.3% for PL approach (P = 0.301). Readmission rates and reoperation rates were similar for all approaches in all revisions except for femoral component revisions performed through the PL approach, which had an increased risk of readmission (12.3%, P = 0.008) and reoperation (10.4%, P = 0.012) compared to DA approach (8.6 and 6.45%, respectively) and DL approach (2.53 and 1.9%, respectively).

The surgical approach appears to have minimal impact on the likelihood of developing wound complications in revision THAs. The need for readmission and reoperation was also similar across surgical approaches for various revision THA procedures.

The use of technology in direct anterior approach (DAA) total hip arthroplasty (THA) is expanding. Although the use of computer-navigation (CN-THA) and robotics (RA-THA) has previously demonstrated improved component positioning, it is important to understand whether its use is associated with differences in intraoperative complications or early return to the operating room when compared to fluoroscopy-only (manual-THA) DAA THA.

3433 DAA THAs (226 RA-THA, 1007 CN-THA, 2200 manual-THA) performed at a single institution were retrospectively reviewed. Cohorts were adjusted for age, sex, BMI, femoral fixation, history of spine fusion, and Charlson Co-morbidity Index (CCI) using Inverse Probability of Treatment Weight (IPTW). Operative times were identified. Intraoperative fractures and re-operations within 1 year were identified via chart review.

There were no statistically significant differences in intraoperative fracture among the cohorts (0.4% RA-THA, 0.4% CN-THA, 0.4% manual-THA; p > 0.529). There were also no statistically significant differences (p > 0.589) among the cohorts in rates of return to the operating room within 1 year for postoperative fracture (0.0% RA-THA, 0.4% CN-THA, 0.4% manual-THA), dislocation (0.0% RA-THA, 0.0% CN-THA, 0.1% manual-THA), infection (0.4% RA-THA, 0.7% CN-THA, 0.5% manual-THA), or other aetiologies (0.0% RA-THA, 0.2% CN-THA, 0.1% manual-THA).

This study did not find a statistically significant difference in intraoperative fracture or re-operations within 1 year between DAA THA performed with RA, CN, or manual techniques. The introduction of technology to THA is not associated with increase in reoperations within one-year.

Total hip arthroplasty (THA), a commonly performed surgical procedure for management of end-stage osteoarthritis, is considered minimally invasive and the popularity of the direct anterior approach (DAA) is increasing. The objective of this study is to analyze the current literature on DAA THA through conduct of a comprehensive bibliometric analysis.

A comprehensive search of the Web of Science Core Collection was conducted for identification of articles published between 1993 and 2022. Specific keywords associated with hip replacement and the anterior approach were used as an attempt to identify articles published in scientific journals.

As a result of the analysis, 743 articles were linked to DAA THA. The highest number of annual publications was reported for 2021, with 120 articles, followed by 2022 with 113 articles, 2020 with 104 articles, and 2018 with 69 articles. The United States led in contributions with 34.1% in production. The Medical University of Innsbruck contributed the highest number of studies with 263 articles, followed by the University of Ottawa with 229. The Journal of Arthroplasty emerged as the most influential journal with 903 articles and 4,571 citations. Keywords including "dislocation," "posterior approach," and "revision" were used frequently in 2015-2020, along with the increasing emphasis on perioperative complications and comparing different approaches.

The findings of this analysis provide helpful insights into the current attitude regarding DAA THA research, highlighting emerging trends and guiding the direction of future research. The increasing scientific production reflects growing interest in DAA THA.

The direct anterior approach (DAA) is a popular approach for primary total hip arthroplasty (THA). However, the contemporary outcomes for DAA THA need further elucidation. Therefore, we aimed to describe implant survivorship, complications, and clinical outcomes after DAA THA.

From our multi-institutional total joint registry, 3,184 patients who had undergone 3,698 primary DAA THA between 2010 and 2019 were identified. The identified patients had a mean age of 65 years and a mean body mass index (BMI) of 29 kg/m 2 , and 53% of patients were female. The indications for revision and reoperation and the incidence of complications were collected and analyzed. Potential risk factors, including age, sex, BMI, and high-volume compared with low-volume operating surgeons, were examined. Descriptive statistics and Kaplan-Meier survivorship with Cox regression analyses were performed.

At 10 years following primary DAA THA, the cohort had 96% (95% confidence interval [CI], 95% to 98%) survivorship free of any revision and 94% (95% CI, 92% to 96%) survivorship free of any reoperation. The leading indications for revision were periprosthetic joint infection (PJI) (n = 24; 5-year cumulative incidence, 0.93% [95% CI, 0.6% to 1.5%]), periprosthetic fracture (n = 20; 5-year cumulative incidence, 0.62% [95% CI, 0.4% to 1.0%]), and aseptic loosening (n = 14; 11 femoral, 3 acetabular; 5-year cumulative incidence, 0.84% [95% CI, 0.5% to 1.5%]). A BMI of ≥40 kg/m 2 was found to be significantly associated with PJI (hazard ratio [HR], 6.4; p < 0.001), reoperation (HR, 3.5; p < 0.001), and nonoperative complications (HR, 2.3; p = 0.018). Survivorship free of recurrent instability was 99.6% (95% CI, 99.4% to 99.8%) at 5 and 10 years, and the cumulative incidence of revision for instability was 0.14% at 5 years.

In one of the largest published series to date, survivorship following DAA THA was satisfactory at early to intermediate follow-up. The leading indications for revision were PJI, periprosthetic fracture, and aseptic loosening. Instability after DAA THA was uncommon and infrequently led to revision. As a note of caution, a BMI of ≥40 kg/m 2 was identified as a risk factor for adverse outcome after DAA THA.

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Total hip arthroplasty (THA) has significantly improved the lives of patients with degenerative hip disorders. The direct anterior approach (DAA) is favored for its minimally invasive nature, leading to less postoperative pain and a faster recovery. The bikini incision (BI) approach was developed to enhance aesthetic outcomes while maintaining the clinical and functional benefits of the DAA. Despite its advantages, the BI technique presents challenges, controversies persist regarding its efficacy and safety, and there is no consensus within the medical community about its overall benefits. Incisions aligned with Langer's lines, like the BI, promote better healing and minimal scarring. Studies indicate that BI patients report higher satisfaction with scar appearance and texture compared to traditional DAA patients. However, the BI carries a higher risk of lateral femoral cutaneous nerve (LFCN) injury, although most symptoms resolve within 6 months. For obese patients, the BI is associated with fewer complications, such as infections and delayed healing, compared to the conventional DAA, making it a safe and effective option. BI patients also experience better aesthetic outcomes and functional recovery, with reduced pain and itching. The BI technique in THA represents a significant advancement, offering improved aesthetic and wound-healing outcomes. The shift from the traditional DAA to the BI aligns with patient preferences for scars that are less visible and conspicuous. Despite the steep learning curve and risks, careful patient selection and refined surgical techniques can enhance the BI's benefits. Future research should focus on long-term outcomes and comparative studies to further establish the BI's efficacy and safety. As patient demand for aesthetically favorable surgeries grows, the BI is likely to become a preferred approach in THA.

Rising demand for total hip arthroplasty (THA) in ambulatory surgery centers (ASCs) requires improved efficiency, considering varying surgical approach time requirements, to manage caseloads and ensure safe same-day discharge (SDD). This study examines care phase durations, SDD success and delays, and outcomes, including 90-day complication rates and 1-year patient-reported outcomes (PROs).

A retrospective review of primary THA patients at a single ASC (January 2019 to January 2021) was conducted. Data on demographics, phase-of-care times, perioperative outcomes, 90-day complications, and PROs were stratified by surgical approach. Comparison was done using 2-tailed t-test and Fisher exact test. Stepwise regression controlled for age, gender, body mass index, assistive device use, class attendance, American Society of Anesthesia score, Charlson comorbidity index, and diagnosis.

Groups differed in age, BMI, assistive device use, class attendance, and preoperative Veterans Rand 12-Item Health Survey physical component scores. The direct anterior approach (DAA) and posterior approach (PA) cohorts showed significant differences in phase-of-care times, except for spinal-time, and total-physical therapy (PT)-time-in-postanesthesia care unit (PACU). DAA was faster in spinal-start-to-incision-time (26.8 versus 35.0; P < 0.001), set-up/take-down-time (20.5 versus 30.2; P < 0.001), operative time (OR; 37.5 versus 50.4; P < 0.001), total operating room time (57.8 versus 80.5; P < 0.001), and arrival-to-discharge-time (383.8 versus 418.4; P < 0.001). PA was faster in time-to-initiation-of-PT (46.3 versus 71.4; P < 0.001), PACU-arrival-to-PT-cleared-time (124.9 versus 144.3; P < 0.001), and total-PACU-time (127.8 versus 143.4; P < 0.001). Surgical approach, age, BMI, and preoperative assistive device use predicted time differences. Excessive spinal was the main cause of PT delays. No differences in 90-day complications or PROs were observed.

DAA showed shorter total OR and arrival-to-discharge-times compared to PA, with similar complications and PROs. Both approaches effectively achieved SDD. Operative and set-up/take-down-time drove DAA efficiency, but PT initiation was delayed due to standard spinal blocks with shorter OR times.

Dislocation is a major complication of total hip arthroplasty (THA). This study aimed to assess the dislocation rate after THA using the combined strategy of using CT-based navigation, large diameter heads, and posterior soft tissue repair in a large cohort.

We included 1410 patients who had undergone primary cementless THA using the CT-based navigation system. The posterior approach was used by a single surgeon for all patients. The participants included 143 (10.1 %) men and 1267 (89.9 %) women, with a mean age of 65 years. The mean body mass index was 24 kg/m2. Additionally, the incidence rate of postoperative dislocation per year was calculated. The dislocation onset was classified as early when the dislocation occurred within 2 years of the primary THA and late when it occurred more than 2 years after the primary THA. Recurrence and revision rates in patients with dislocations were investigated.

The postoperative dislocation rate was 0.56 % (8 patients). The mean time to dislocation onset was 11.2 (0.5-20.0) months postoperatively. All postoperative dislocations occurred in the early phase whereas none in the late phase, showing a significant difference (p < 0.01). Six (0.43 %) patients experienced recurrent dislocations or required revision.

THA using the combined strategy resulted in low dislocation rates, especially without late dislocation.

Concerns remain with regards to safety of fast-track (FT) and especially outpatient procedures. The purpose of this study was to compare complication rates and clinical outcomes of propensity-matched patients who received FT total hip arthroplasty (THA) in outpatient versus inpatient settings. The hypothesis was that 90-day postoperative complication rates of outpatient FT THA would not be higher than after inpatient FT THA.

This is a prospective study of consecutive patients who received FT THA at various rates of outpatient and inpatient surgery by 10 senior surgeons (10 centres). The decision between outpatient and inpatient surgery was made on a case-by-case basis depending on the surgeon and patient. All patients were followed until 90 days after surgery. Complications, readmissions and reoperations were collected, and their severity was assessed according to Clavien-Dindo. Patients completed Oxford Hip Score (OHS) at the latest follow-up.

Compared to inpatient FT THA, patients scheduled for outpatient FT THA had no significant differences in 90-day postoperative complication rates (10.7% vs. 12.9%, p = 0.129). There were no significant differences between the 2 groups in 90-day readmission rates and reoperation rates, in severity of postoperative complications, and in time of occurrence of postoperative complications.

There were no differences in rates of intraoperative complications, 90-day postoperative complications, readmissions, or reoperations between outpatient and inpatient FT THA. These findings may help hesitant surgeons to move towards outpatient THA pathways as there is no greater risk of early postoperative complications that could be more difficult to manage after discharge.

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.

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.

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).

In the current study, no significant differences in postoperative functional outcome were found between DAA and PA in all follow-up moments.

The purpose of this study was to evaluate the impact of direct anterior approach (DAA) or posterior approach (PA) on step and stair counts after total hip arthroplasty using a remotely monitored mobile application with a smartwatch while controlling for baseline characteristics.

This is a secondary data analysis from a prospective cohort study of patients utilizing a smartphone-based care management platform. The primary outcomes were step and stair counts and changes from baseline through one year. Step and stair counts were available for 1,501 and 847 patients, respectively. Longitudinal regression models were created to control for baseline characteristics.

Patients in the DAA group had significantly lower body mass index (P = .049) and comorbidities (P = .028), but there were no significant differences in age (P = .225) or sex (P = .315). The DAA patients had a higher average and improvement from baseline in step count at 2 and 3 weeks postoperatively after controlling for patient characteristics (P = .028 and P = .044, respectively). The average stair counts were higher for DAA patients at one month postoperatively (P = .035), but this difference was not significant after controlling for patient demographics. Average stair ascending speeds and changes from baseline were not different between DAA and PA patients. Descending stair speed was higher at 2 weeks postoperatively for DAA patients, but was no longer higher after controlling for baseline demographics.

After controlling for baseline characteristics, DAA patients demonstrate earlier improvement in step count than PA patients after total hip arthroplasty. However, patient selection and surgeon training may continue to influence outcomes through a surgical approach.

Background A modified transgluteal approach in total hip arthroplasty (THA) can be utilized to preserve abductor muscle function and reduce dislocation rate. We present a study evaluating outcomes for a modified transgluteal approach using a validated patient-reported outcome measure (PROM) tool, the Oxford Hip Score (OHS). Methods This was a retrospective single-centre study over a four-year period. Short-term data was collected including intraoperative and postoperative complications, length of stay (LOS) in the hospital, and time from operation to mobilising independently. One year of data was collected, including plain radiograph findings and the incidence of Trendelenburg gait. Patients were contacted at a mean time of 2.7 years post-operatively so that OHS could be conducted. Results A total of 100 patients were identified within the inclusion criteria. The mean LOS for all patients was 2.8 days. The mean time from operation to mobilising independently without walking aids was 4.9 weeks. At the one-year follow-up, there was satisfactory radiographic assessment in 100% of patients. The mean OHS was 45.5 at 2.7 years, indicating satisfactory joint function in all patients. Conclusion This study supports the use of the modified transgluteal approach in THA, showing favourable outcomes in the time from operation to cessation in the use of walking aids, LOS and OHS. We report zero cases of Trendelenburg gait at the one-year follow-up and no dislocations at the three-year follow-up. Further studies are required to compare the outcomes of TGA to other approaches in THA.

There is a paucity of literature analyzing data for return to sport (RTS) and return to work (RTW) in the setting of direct anterior approach (DAA) total hip arthroplasty (THA).

The aims of this systematic review are to identify existing literature and to aggregate rates of RTS/RTW following DAA THA in a meta-analysis.

A query of major databases yielded 1819 initial studies. A random-effects model approach was implemented for meta-analysis. Moderator effects were assessed with respect to patient demographics and functional outcomes.

Five studies reporting RTS after DAA THA were identified, representing a total of 204 patients with a mean age of 60.2±7.5 years and mean follow up of 31.8±9.5 months. Pooled rate of RTS was 76%(95% confidence interval [CI], 63%-86%;range 58%-100%). Pooled rate of return to the same sport was 77%(95%CI, 64%-86%;range of 62%-100%). Pooled rate of RTS to the same intensity was 58%(95%CI, 48%-68%;range of 41%-68%). Meta-regression demonstrated no significant correlations between independent variables and RTS characteristics. Three studies reported RTW rates. Rates of RTW within 3-months were 30%, 45%, and 60%. One study reported rate of RTW of 79% at 6-months and 87% at 12-months. One study demonstrated a mean time to RTW of 38±24.8 days.

Pooled rate of RTS is satisfactory following DAA THA and are comparable to rates of RTS aggregated without delineating surgical approach. Data supporting RTW rates following DAA THA limited, and thus more primary studies are needed to establish if this approach confers an advantage of faster RTS/RTW.

Online resources are important for patient self-education and reflect public interest. We described commonly asked questions regarding the direct anterior versus posterior approach (DAA, PA) to total hip arthroplasty (THA) and the quality of associated websites.

We extracted the top 200 questions and websites in Google's "People Also Ask" section for 8 queries on January 8, 2023, and grouped websites and questions into DAA, PA, or comparison. Questions were categorized using Rothwell's classification (fact, policy, value) and THA-relevant subtopics. Websites were evaluated by information source, Journal of the American Medical Association Benchmark Criteria (credibility), DISCERN survey (information quality), and readability.

We included 429 question/website combinations (questions: 52.2% DAA, 21.2% PA, 26.6% comparison; websites: 39.0% DAA, 11.0% PA, 9.6% comparison). Per Rothwell's classification, 56.2% of questions were fact, 31.7% value, 10.0% policy, and 2.1% unrelated. The THA-specific question subtopics differed between DAA and PA (P < .001), specifically for recovery timeline (DAA 20.5%, PA 37.4%), indications/management (DAA 13.4%, PA 1.1%), and technical details (DAA 13.8%, PA 5.5%). Information sources differed between DAA (61.7% medical practice/surgeon) and PA websites (44.7% government; P < .001). The median Journal of the American Medical Association Benchmark score was 1 (limited credibility, interquartile range 1 to 2), with the lowest scores for DAA websites (P < .001). The median DISCERN score was 55 ("good" quality, interquartile range 43 to 65), with the highest scores for comparison websites (P < .001). Median Flesch-Kincaid Grade Level scores were 12th grade level for both DAA and PA (P = .94).

Patients' informational interests can guide counseling. Internet searches that explicitly compare THA approaches yielded websites that provide higher-quality information. Providers may also advise patients that physician websites and websites only describing the DAA may have less balanced perspectives, and limited information regarding surgical approaches is available from social media resources.

Lumbar spinal fusion (LSF) is a risk factor for dislocation following total hip arthroplasty (THA). The effect of the surgical approach on this association has not been investigated. This study examined the association between the surgical approach and dislocation following THA in patients who had prior LSF.

We retrospectively reviewed 16,223 primary elective THAs at our institution from June 2011 to September 2022. Patients who had LSF prior to THA were identified using International Classification of Diseases (ICD) codes. Patients were stratified by LSF history, surgical approach, and intraoperative robot or navigation use to compare dislocation rates. There were 8,962 (55.2%) posterior, 5,971 (36.8%) anterior, and 1,290 (8.0%) laterally based THAs. Prior LSF was identified in 323 patients (2.0%). Binary logistic regressions were used to assess the association of patient factors with dislocation risk.

There were 177 dislocations identified in total (1.1%). In nonadjusted analyses, the dislocation rate was significantly higher following the posterior approach among all patients (P = .003). Prior LSF was associated with a significantly higher dislocation rate in all patients (P < .001) and within the posterior (P < .001), but not the anterior approach (P = .514) subgroups. Multivariate regressions demonstrated anterior (OR [odds ratio] = 0.64, 95% CI [confidence interval] 0.45 to 0.91, P = .013), and laterally based (OR = 0.42, 95% CI 0.18 to 0.96, P = .039) approaches were associated with decreased dislocation risk, whereas prior LSF (OR = 4.28, 95% CI 2.38 to 7.69, P < .001) was associated with increased dislocation risk. Intraoperative technology utilization was not significantly associated with dislocation in the multivariate regressions (OR = 0.72, 95% CI 0.49 to 1.06, P = .095).

The current study confirmed that LSF is a significant risk factor for dislocation following THA; however, anterior and laterally based approaches may mitigate dislocation risk in this population. In multivariate analyses, including surgical approach, LSF, and several perioperative variables, intraoperative technology utilization was not found to be significantly associated with dislocation risk.

Recently, surgeons introduced a minimally invasive modification on the classic posterolateral approach (PLA) in total hip arthroplasty (THA): the direct superior approach (DSA). We investigated the association between surgeon's experience and the risk of early revision of the DSA in primary THA, using data from the Dutch Arthroplasty Register (LROI).

We retrieved all primary THAs performed using the DSA in 4 hospitals between 2016 and 2022 (n = 1551). Procedures were sorted in 5 groups using the date of operation and number of previous procedures per surgeon: 1-25; 26-50; 51-75; 76-100; >100. Subsequently, data from different surgeons were pooled together and the risk of revision was calculated via a multilevel time-to-event analysis.

The overall revision rate was 1.5% after a mean follow-up of 2 years. Patients from the 1-25 group had comparable risks of revision compared to patients in the >100 group (hazard ratio [HR] 1.0 [CI, 0.3-3.2]). The risk for patients in groups 26-50, 51-75 and 75-100 was also not statistically different from the >100 group (resp. HR 1.5 [CI, 0.5-5.0], 1.8 [CI, 0.5-6.4] and 0.5 [CI, 0.1-4.0]). Main reasons of revision were dislocation (0.5%) and infection (0.4%).

We did not identify an association between the surgeon's experience and the early risk of revision for the DSA in primary THA in the Netherlands. The DSA seems safe in the early adoption phases with a low risk of revision due to dislocation and revision for all other causes.

The direct anterior approach (DAA) and posterior approach (PA) for total hip arthroplasty (THA) have advantages and disadvantages, but their physiologic burden to the surgeon has not been quantified. This study was conducted to determine whether differences exist in surgeon physiological stress and strain during DAA in comparison to PA.

We evaluated a prospective cohort of 144 consecutive cases (67 DAA and 77 PA). There were 5, high-volume, fellowship-trained arthroplasty surgeons who wore a smart-vest that recorded cardiorespiratory data while performing primary THA DAA or PA. Heart rate (beats/minute), stress index (correlates with sympathetic activations), respiratory rate (respirations/minute), minute ventilation (L/min), and energy expenditure (calories) were recorded, along with patient body mass index and operative time. Continuous data was compared using t-tests or Mann Whitney U tests, and categorical data was compared with Chi-square or Fischer's exact tests.

There were no differences in patient characteristics. Compared to PA, performing THA via DAA had a significantly higher surgeon stress index (17.4 versus 12.4; P < .001), heart rate (101 versus 98.3; P = .007), minute ventilation (21.7 versus 18.7; P < .001), and energy expenditure per hour (349 versus 295; P < .001). However, DAA had a significantly shorter operative time (71.4 versus 82.1; P = .001).

Surgeons experience significantly higher physiological stress and strain when performing DAA compared to PA for primary THA. This study provides objective data on energy expenditure that can be factored into choice of approach, case order, and scheduling preferences, and provides insight into the work done by the surgeon.

Concurrent use of minus heads with tapered stems in total hip arthroplasty (THA) decreases the prosthetic range of motion (pROM). Three-dimensional preoperative templating can simulate the location of the impingement by taking the hip through a virtual pROM. This enables surgeons to simulate how modifying the type of implant, orientation, and position influences impingement. We hypothesized that CT-based modeling would result in a decrease in the pROM, thereby increasing the risk of impingement when minus heads are used.

Forty-three patients who underwent robotic-assisted primary THAs were included. Prosthetic head diameter (32/36-mm) and head length (minus/zero/plus) were the predictors. Maximum external rotation at full hip extension and internal rotation at 90° and 100° of flexion prior to prosthetic impingement were the outcome variables. A CT-based preoperative planning software was used for pROM estimation and impingement detection.

Significant decreases in pROM were found for both head diameters as the head length decreased and was more pronounced in external rotation during full hip extension (changes of 2.8-3.4° for the 32-mm head and 1.6-2.8° for the 36-mm head (p = 0.00011)). The magnitude of loss in pROM when using a minus head was larger than the gain provided by a plus head in tapered stems (p < 0.0001).

Head length affects the offset and pROM. When the use of minus heads or smaller heads is indicated, 3D preoperative templating for assessing postoperative pROM and impingement provides surgeons with options to consider alternate surgical plans offering additional assurance and protection from dislocation.

Controversy remains over outcomes between total hip arthroplasty approaches. This study aimed to compare the time to achieve the minimal clinically important difference (MCID) for the Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form (HOOS-PS) and the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-Physical for patients who underwent anterior and posterior surgical approaches in primary total hip arthroplasty.

Patients from 2018 to 2021 with preoperative and postoperative HOOS-PS or PROMIS Global-Physical questionnaires were grouped by approach. Demographic and MCID achievement rates were compared, and survival curves with and without interval-censoring were used to assess the time to achieve the MCID by approach. Log-rank and weighted log-rank tests were used to compare groups, and Weibull regression analyses were performed to assess potential covariates.

A total of 2,725 patients (1,054 anterior and 1,671 posterior) were analyzed. There were no significant differences in median MCID achievement times for either the HOOS-PS (anterior: 5.9 months, 95% confidence interval [CI]: 4.6 to 6.4; posterior: 4.4 months, 95% CI: 4.1 to 5.1, P = .65) or the PROMIS Global-Physical (anterior: 4.2 months, 95% CI: 3.5 to 5.3; posterior: 3.5 months, 95% CI: 3.4 to 3.8, P = .08) between approaches. Interval-censoring revealed earlier times of achieving the MCID for both the HOOS-PS (anterior: 1.509 to 1.511 months; posterior: 1.7 to 2.3 months, P = .87) and the PROMIS Global-Physical (anterior: 3.0 to 3.1 weeks; posterior: 2.7 to 3.3 weeks, P = .18) for both surgical approaches.

The time to achieve the MCID did not differ by surgical approach. Most patients will achieve clinically meaningful improvements in physical function much earlier than previously believed.

Level III, Retrospective Comparative Study.

The surgical approach of hemiarthroplasty for displaced femoral neck fractures remains debated. The study objective was to compare in-hospital outcomes for geriatric displaced femoral neck fractures treated with hemiarthroplasty based on surgical approach (direct lateral vs. posterior approach).

This retrospective cohort study included geriatric patients (≥60 y/o) admitted 7/1/2016-3/31/2020 treated with hemiarthroplasty. Outcomes included: operative time (incision to closure), length of stay (HLOS), and blood loss volume (mL). The Harding direct lateral approach was compared to the posterior approach; P < .05.

There were 164 patients (59% direct lateral, 41% posterior). Patients treated with the direct lateral approach had an advanced directive (P = .03), dementia, (P = .03), or were functionally dependent (P = .03) more often than patients treated with the posterior approach. Time to surgery was comparable between groups (P = .52). The direct lateral approach was associated with a shorter operative time (2.3 vs. 2.8 h, P = .03), a longer HLOS (5.0 vs. 4.0 days, P < .01), and a lower median volume of blood loss (50 vs. 100 mL, P = .01), than the posterior approach, respectively. In a stratified analysis, for those who were not functionally dependent, did not have dementia or an advanced directive, the direct lateral approach led to a longer HLOS (P = .03) and shorter operative time (P = .04) than the posterior approach. Whereas among those who were functionally dependent, had dementia or had an advanced directive, the direct lateral approach led to less blood loss (P = .02) than the posterior approach.

While those treated with the direct lateral approach lost significantly less blood, they had a significantly longer HLOS than those treated with the posterior approach. Comorbidities significantly modified outcomes, which may suggest their presence could assist with treatment decisions.

This study found neither approach, the direct lateral nor posterior, to be superior. Surgical approach could remain physician preference.

Following removal of total hip arthroplasty (THA) from the inpatient only (IPO) list by the Center for Medicare Services (CMS), arthroplasty surgeons face increased pressure to perform procedures on an outpatient (OP) basis. The purposes of the present study were to compare patients booked for THA as OP who required conversion to IP status postoperatively, to patients who were booked as, and remained OP, and to identify factors predictive of conversion from OP to IP status.

We retrospectively reviewed all patients who underwent a primary THA at our institution between January 1, 2020 and April 26, 2022. All patients included were originally scheduled for OP surgery and were separated based on conversion to IP status postoperatively. Multiple regression analyses were used to determine the significance of all perioperative variables. Modeling via binary logistic regressions were used to determine factors predictive of status conversion.

Of 1,937 patients, 372 (19.2%) designated as OP preoperatively required conversion to IP status postoperatively. These patients had significantly higher facility discharge rates (P < 0.001) and 90-day readmission rates (P = 0.024). Patients aged 65 and older (P < 0.001), females (P < 0.001), patients with Black/African American race (P = 0.027), with a recovery room arrival time after 12 pm (P < 0.001), with a BMI > 30 kg/m2 (P = 0.001), and with a Charlson Comorbidity Index (CCI) ≥ 4 (P = 0.013) were Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation more likely to require conversion to IP designation. Marital status and time of procedure were also significant factors, as patients who were married (P < 0.001) and who were the first case of the day (P < 0.001) were less likely to be converted to IP.

Several factors were identified which could help determine appropriate hospital designation status at the time of surgical booking to ultimately avoid insurance claim denials. These included BMI, certain demographic factors, CCI ≥ 4, and patients 65 or older.

Retrospective Cohort Study.

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.

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.

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.

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 I evidence, because this is a systematic review and meta-analysis of randomized controlled trials.

The Hueter-Anterior Approach (HAA) with its limited soft tissue and internervous dissection has been shown to be an effective approach for primary total hip and hip resurfacing arthroplasty (HRA). The purpose of this study is to evaluate the clinical outcome of patients requiring revision of HRA to total hip replacement using the HAA, assessing function and complications.

We performed a retrospective review of a prospectively maintained research database. Between 2006 and 2015, 555 primary metal-on-metal (MoM) HRAs were performed via the HAA; we identified 33 hips in 30 patients that required revisions for aseptic causes to THA: aseptic loosening of acetabulum in 12 and femoral in 7, 10 for pseudotumour/ALTR, 4 for femoral neck fracture. All revision surgeries were performed through a HAA by a single surgeon who had also performed the index operation. PROMs were collected preoperatively and yearly at various timepoints postoperatively.

The mean age at time of revision was 48.9 years (±5.3 SD) for 22 males (67%) and 11 females (33%). The mean time to revision surgery/failure of hip resurfacing was 3.3 years (±2.4 SD). There were 5 major reoperations with 3 infections, 1 acetabular loosening and 1 trunnionosis. There were significant improvements in multiple PROMs.

The HAA is a viable surgical approach for revision of HRA with smaller initial HRA acetabular components generally requiring a relatively larger acetabular compoent at time of revision. Patients reported improvement in symptoms and function and a lower risk of subsequent reoperation than what has previously been reported for failed MoM bearings.

Background: Little is known about patients' postoperative week-by-week progress after undergoing posterior approach total hip arthroplasty (THA) with regard to pain, function, return to work, and driving. Purpose: We sought to evaluate a large cohort of patients undergoing posterior approach THA with modified posterior hip precautions to better understand the trajectory of recovery. Methods: Patients at a single institution undergoing primary posterior approach THA by fellowship-trained arthroplasty surgeons were prospectively enrolled. Patient functional status and early rehabilitation recovery milestones were evaluated preoperatively and each week postoperatively for 6 weeks. Results: Of 312 patients who responded to weekly questionnaires, there were varying response rates per question. At 1 week after surgery, 15% (39/256) of respondents had returned to work, increasing to 57% (129/225) at week 6. At 6 weeks, 77% of patients (174/225) had returned to driving; 25% (56/225) were taking pain medication (including prescription opioids or nonsteroidal anti-inflammatory drugs); and 15% (34/225) were using assistive devices (down from 91%, 78%, 56%, 35%, and 27% at weeks 1, 2, 3, 4, and 5, respectively). Average postoperative Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement and Lower Extremity Functional Scale scores were significantly higher than preoperative scores. Respondents reported significantly less pain at each week postoperatively than the previous week. Conclusion: These findings suggest that there may be an expected pathway for recovery after posterior THA using perioperative pain protocols, modified postoperative precautions, and physical therapy protocols to improve patient outcomes after THA, with most patients returning to normal at 4 weeks. Defining the expected recovery timeline may help surgeons in counseling patients preoperatively and guiding their recovery.

Patients undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA) may experience faster recovery but may also have better baseline health than those who undergo THA with the posterior approach (PA). This study aimed to compare patient-reported outcome measures (PROMs) between the DAA and PA while controlling for baseline factors.

This is a secondary data analysis from a prospective cohort study of patients utilizing a smartphone-based care management platform following THA. The primary outcomes were HOOS JR and EQ-5D-5L through 1 year and change from baseline. Longitudinal regression models were created to control for baseline characteristics and investigate the impact of surgical approach on PROMs.

Of 1364 THAs evaluated, 731 (53.6%) were female, and 840 (61.6%) used the PA. Patients in the PA group were of similar age but had higher body mass index and comorbidity scores. Pre-operative HOOS JR and EQ-5D-5L were comparable, but higher post-operatively in the DAA group through 6 months (p = 0.03 and p = 0.005). At 1 year post-operatively, HOOS JR and EQ-5D-5L did not vary between groups (p = 0.48 and p = 0.56), nor did changes from baseline (p = 0.47 and p = 0.11). After controlling baseline characteristics, DAA was significantly associated with higher average HOOS JR through 6 months (p = 0.03) and EQ-5D-5L through 3 months (p  = 0.005), but not at 12 months (p = 0.89 and p = 0.56).

THA patients undergoing DAA demonstrate earlier improvements in HOOS JR and EQ-5D-5L. However, these differences may not be clinically significant and are not evident at 1-year post-operative. Patient selection and surgeon training may continue to affect outcomes by surgical approach.

This study sought to evaluate the safety, efficacy, and resource utilization of a pilot outpatient surgery program for total hip arthroplasty compared to traditional inpatient total hip arthroplasty performed via the posterolateral approach.

A cohort of 68 patients from two sites were enrolled in a regional pilot project for outpatient total hip arthroplasty (THA) and matched 1:1 against a cohort of patients undergoing routine inpatient THA. Data was extracted retrospectively from patient and hospital charts including adverse events (AE), readmission within 90 days, emergency room (ER) visits, patient calls, patient-reported outcome measures, length of stay, and multiple surgical variables.

The outpatient group had a mean hospital stay of 13 hours, whereas the inpatient group had a mean of 58 hours (p<0.001). Three outpatients and four inpatients experienced post-op complications. Three inpatients and one outpatient visited the ER within 8 weeks of surgery. No difference in pre-operative hemoglobin (p = 0.210), or surgical blood loss (p = 0.550) was found between study groups. There was no difference found between groups regarding Oxford-12 Hip Score improvement, nor satisfaction at six months, one and two years (p>0.125).

This study demonstrates that outpatient THA using the posterolateral approach is as safe and effective as inpatient THA for overall healthy and carefully screened patients, based on the low rate of AEs observed and similar patient outcomes reported. Significantly reduced time in hospital demonstrates the reduced healthcare resources associated with outpatient THA.

Fascia iliaca compartment block (FICB) is one of the regional nerve blocks used to reduce pain after total hip arthroplasty (THA). We aim to assess the efficacy of FICB in reducing post-operative pain and opioid consumption.

We searched PubMed, Web of Science, Cochrane Library, Embase, and Scopus on February 19, 2023, and we updated our search in august 2023 using relevant search strategy. Studies were extensively screened for eligibility by title and abstract screening, followed by full-text screening. We extracted the data from the included studies, and then pooled the data as mean difference (MD) or odds ratio (OR) with a 95% confidence interval (CI), using Review Manager Software (ver. 3.5).

FIBC significantly reduced analgesic consumption at 24 h (MD = -8.75, 95% CI [-9.62, -7.88] P < 0.00001), and at 48 h post-operatively. (MD = -15.51, 95% CI [-26.45, -4.57], P = 0.005), with a significant sensory block of the femoral nerve (P = 0.0004), obturator nerve (P = 0.0009), and lateral femoral cutaneous nerve (P = 0.002). However, FICB was not associated with a significant pain relief at 6, 24, and 48 h postoperatively, except at 12 h where it significantly reduced pain intensity (MD = -0.49, 95% CI [-0.85, -0.12], P = 0.008). FICB was also not effective in reducing post-operative nausea and vomiting (MD = 0.55, 95% CI [0.21, 1.45], P = 0.23), and was associated with high rates of quadriceps muscle weakness (OR = 9.09, % CI [3.70, 22.30], P = < 0.00001).

FICB significantly reduces the total analgesic consumption up to 48 h; however, it is not effective in reducing post-operative pain, nausea and vomiting and it induced postoperative muscle weakness.

Hip OA is becoming more common, with a greater number of younger individuals undergoing total hip arthroplasty (THA). These individuals have the desire to return to considerable loading and in some instances return to sport. The purpose of this review was to investigate the current guidelines and/or protocols for hypertrophy or strengthening in individuals who have undergone total hip arthroplasty. A total of 16 papers were identified, some of which also addressed total knee arthroplasty. There is no consensus for the best practice for a hypertrophy program following THA especially regarding when a direct anterior approach was used during hip arthroplasty. Further research is needed as this is a growing area in rehabilitation. This review aims to bridge the gap by offering a comprehensive synthesis of the available literature on postoperative rehabilitation after THA, with a specific emphasis on identifying the most effective muscular strengthening and hypertrophy training programs for patients undergoing anterior approach hip surgery.

Patients with a high comorbidity burden (HCB) can achieve similar improvements in quality of life compared with low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences total hip arthroplasty (THA) outcomes in HCB patients has not been investigated. This study aimed to compare complication rates and implant survivorship in HCB patients operated on by high-volume (HV) and non-HV THA surgeons.

Patients with Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiologists grade of III or IV, undergoing primary elective THA between January 2013 and December 2021, were retrospectively reviewed. Patients were separated into groups based on whether they were operated on by a HV surgeon (defined as the top 25% of surgeons at our institution by number of primary THAs per year) or a non-HV surgeon. Groups were propensity-matched 1:1 to control for demographic variables. A total of 1,134 patients were included in the matched analysis. Between groups, 90-day readmissions and revisions were compared, and Kaplan-Meier analysis was used to evaluate implant survivorship within the follow-up period.

Years of experience were comparable between non-HV and HV surgeons (p = 0.733). The HV group had significantly shorter surgical times (p < 0.001) and shorter length of stay (p = 0.009) than the non-HV group. The HV group also had significantly fewer 90-day readmissions (p = 0.030), all-cause revisions (p = 0.023), and septic revisions (p = 0.020) compared with the non-HV group at latest follow-up. The HV group had significantly greater freedom from all-cause (p = 0.023) and septic revision (p = 0.020) than the non-HV group.

The HCB THA patients have fewer 90-day readmissions, all-cause revisions, and septic revisions, as well as shorter length of stay when treated by HV surgeons. THA candidates with a HCB may benefit from referral to HV surgeons to reduce procedural risk and improve postoperative outcomes.

For Crowe IV dysplasia, the clinical efficacy and surgical technique of subtrochanteric osteotomy (SO) within the direct anterior approach total hip arthroplasty (DAA-THA) was a subject of debate. This study aimed to describe the surgical technique and clinical outcomes in 11 cases of SO in DAA-THA and to summarize the relevant literature on this topic. Between June 2016 and June 2023, we retrospectively evaluated patients diagnosed with Crowe IV hip dysplasia at our institution. Criteria identified 11 patients who underwent SO during DAA-THA. Comprehensive data encompassing demographic information, radiological data, prosthetic implant type, and surgical intricacies were collected. In addition, an exhaustive review of existing case series literature was undertaken utilizing the PubMed databases. There were no revisions, deaths, dislocations, or infections. One hip (9.09%) had an intraoperative proximal split fracture, two hips (18.2%) had lower limb deep vein thrombosis, and one hip (9.09%) had symptoms of femoral nerve injury. Radiological data showed improved bilateral femoral offset, leg length discrepancy, and anatomical acetabular. During the mean follow-up of 2.18(1.06-2.46) years, patients demonstrated enhanced functional outcomes, with average changes of 25.2 in the Harris hip score and 47 in the WOMAC score. Reviewing the literature, most studies have favored S-ROM prostheses and transverse osteotomy techniques. Intraoperative fractures were notably frequent, with rates peaking at 25%. Nonunion and nerve injury were secondary common complications. SO via DAA-THA may offer satisfactory clinical and radiographic outcomes, but the literature review underscores the need for heightened awareness of intraoperative fracture risk. Proximal detachment of the vastus intermedius plays a pivotal role in SO exposure through the DAA.

Excessive posterior pelvic tilt (PT) may increase the risk of anterior instability after total hip arthroplasty (THA). The aim of this study was to investigate the changes in PT occurring from the preoperative supine to postoperative standing position following THA, and identify factors associated with significant changes in PT.

Supine PT was measured on preoperative CT scans and standing PT was measured on preoperative and one-year postoperative standing lateral radiographs in 933 patients who underwent primary THA. Negative values indicate posterior PT. Patients with > 13° of posterior PT from preoperative supine to postoperative standing (ΔPT ≤ -13°) radiographs, which corresponds to approximately a 10° increase in functional anteversion of the acetabular component, were compared with patients with less change (ΔPT > -13°). Logistic regression analysis was used to assess preoperative demographic and spinopelvic parameters predictive of PT changes of ≤ -13°. The area under receiver operating characteristic curve (AUC) determined the diagnostic accuracy of the predictive factors.

PT changed from a mean of 3.8° (SD 6.0°)) preoperatively to -3.5° (SD 6.9°) postoperatively, a mean change of -7.4 (SD 4.5°; p < 0.001). A total of 95 patients (10.2%) had ≤ -13° change in PT from preoperative supine to postoperative standing. The strongest predictive preoperative factors of large changes in PT (≤ -13°) from preoperative supine to postoperative standing were a large posterior change in PT from supine to standing, increased supine PT, and decreased standing PT (p < 0.001). Flexed-seated PT (p = 0.006) and female sex (p = 0.045) were weaker significant predictive factors. When including all predictive factors, the accuracy of the AUC prediction was 84.9%, with 83.5% sensitivity and 71.2% specificity.

A total of 10% of patients had > 13° of posterior PT postoperatively compared with their supine pelvic position, resulting in an increased functional anteversion of > 10°. The strongest predictive factors of changes in postoperative PT were the preoperative supine-to-standing differences, the anterior supine PT, and the posterior standing PT. Surgeons who introduce the acetabular component with the patient supine using an anterior approach should be aware of the potentially large increase in functional anteversion occurring in these patients.

Previous data suggest that obesity does not impact surgical outcomes following total knee arthroplasty performed by high-volume (HV) surgeons. However, this effect has yet to be studied in total hip arthroplasty (THA) patients. This study aimed to evaluate the impact of patient obesity on THA outcomes when surgery is performed by HV surgeons.

A retrospective analysis of patients who underwent primary, elective THA between January 2012 and December 2022 with a HV surgeon (top 25% of surgeons by number of annual primary THA) was performed. Patients were stratified by their body mass index (BMI) into 3 cohorts: BMI ≥ 40 (morbidly obese [MO]), 30 ≤ BMI < 40 (obese), and BMI < 30 (nonobese); and 1:1:1 propensity matched based on baseline characteristics. A total of 13,223 patients were evaluated, of which 669 patients were included in the final matched analysis (223 patients per group). The average number of annual THAs performed for HV surgeons was 171 cases.

The MO patients had significantly longer surgical times (P < .001) and hospital lengths of stay (P < .001). Rates of 90-day readmissions (P = .211) and all-cause, septic, and aseptic revisions at the latest follow-up (P = .268, P = .903, and P = .168, respectively) were comparable between groups. In a subanalysis for non-HV surgeons, MO patients had a significantly greater risk of revision (P = .021) and trended toward significantly greater readmissions (P = .056).

Clinical outcomes and complication rates after THA performed by a HV surgeon are similar regardless of patient obesity status. Patients who have MO may experience improved outcomes and reduced procedural risks if they are referred to HV surgeons.

III.

Backgroumd: There have been few reports on the long-term survival of computed tomography (CT)-navigated total hip arthroplasty (THA), which should lead to a lower incidence of dislocation and loosening. In this study, we examined survivorship, dislocation, and loosening incidence using plain radiographs over a minimum 15-year follow-up after CT-navigated THA.

We retrospectively reviewed 145 consecutive CT-navigated THAs for >15 years. We surveyed the angles placed in both the acetabular and femoral components, survivorship, the occurrence of dislocation, the revision rate, and the fixation grade of the acetabular component.

The mean follow-up duration was 18.4 years. Overall, 73.8% of THAs were within the safe zone of Lewinnek. There were four dislocations (2.8%), with three occurring within 1 month after surgery and the other within 7 years after surgery. Revision THA was performed in one case (0.69%); consequently, the survival rate was 99.3%. The fixation grade was evaluated in 144 hips, and those were evaluated as having "no loosening".

CT-navigated THA was speculated to contribute to long-term survivorship, with a low rate of loosening, even after 18 years of follow-up. It was speculated that the acetabular component was placed at an acceptable insertion angle and a suitable position for stable initial fixation.

Primary total hip arthroplasty (THA) is increasingly being performed in the outpatient setting. However, there is little known regarding the differences in same-day discharge (SDD) rates and complications of operative approach in same-day total hip arthroplasty in the ambulatory surgery center (ASC) setting.

A retrospective chart review was performed between July 2019 and October 2021 for all patients who underwent primary THA in a single freestanding ASC. Successful SDDs, surgical approaches, lengths of surgery, estimated blood losses (EBL), complications, and readmission events were recorded for each patient. Complications were compared using Pearson Chi-Squares, while EBL and surgery lengths were compared with 1-way analysis of variances (ANOVA) (alpha = 0.5). There were 17 total complications in 326 total hip arthroplasties (5.2%), including direct admissions to the emergency department, 30-day and 90-day readmissions, wound complications, instability, infection, and revision surgery. Among all complications, there were 5 direct admissions, making the successful SDD rate 98.5%.

Complications and direct admissions were not associated with approach. The 30-day readmission rates were associated with approach, with no readmissions in the direct anterior approach (DAA) or the antero-lateral approach (AL) cohorts and 3 (4.3%) in the posterior approach (PA) cohort.

In the ASC setting, patients undergoing THA regardless of approach showed no difference in successful SDDs or complications aside from 30-day readmissions. Same-day THA can be safely performed in the DAA, AL, and PA to the hip.

Total hip arthroplasty is as an effective intervention to relieve pain and improve hip function. Approaches of the hip have been exhaustively explored about pros and cons. The efficacy and the complications of hip approaches remains inconclusive. This study conducted an umbrella review to systematically appraise previous meta-analysis (MAs) including conventional posterior approach (PA), and minimally invasive surgeries as the lateral approach (LA), direct anterior approach (DAA), 2-incisions method, mini-lateral approach and the newest technique direct superior approach (DSA) or supercapsular percutaneously-assisted total hip (SuperPath).

To compare the efficacy and complications of hip approaches that have been published in all MAs and randomized controlled trials (RCTs).

MAs were identified from MEDLINE and Scopus from inception until 2023. RCTs were then updated from the latest MA to September 2023. This study included studies which compared hip approaches and reported at least one outcome such as Harris Hip Score (HHS), dislocation, intra-operative fracture, wound complication, nerve injury, operative time, operative blood loss, length of hospital stay, incision length and VAS pain. Data were independently selected, extracted and assessed by two reviewers. Network MA and cluster rank and surface under the cumulative ranking curve (SUCRA) were estimated for treatment efficacy and safety.

Finally, twenty-eight MAs (40 RCTs), and 13 RCTs were retrieved. In total 47 RCTs were included for reanalysis. The results of corrected covered area showed high degree (13.80%). Among 47 RCTs, most of the studies were low risk of bias in part of random process and outcome reporting, while other domains were medium to high risk of bias. DAA significantly provided higher HHS at three months than PA [pooled unstandardized mean difference (USMD): 3.49, 95% confidence interval (CI): 0.98, 6.00 with SUCRA: 85.9], followed by DSA/SuperPath (USMD: 1.57, 95%CI: -1.55, 4.69 with SUCRA: 57.6). All approaches had indifferent dislocation and intraoperative fracture rates. SUCRA comparing early functional outcome and composite complications (dislocation, intra-operative fracture, wound complication, and nerve injury) found DAA was the best approach followed by DSA/SuperPath.

DSA/SuperPath had better earlier functional outcome than PA, but still could not overcome the result of DAA. This technique might be the other preferred option with acceptable complications.

To establish a multivariate linear equation to predict the diameter (outer diameter) of the acetabular prosthesis used in total hip arthroplasty.

A cohort of 258 individuals who underwent THA at our medical facility were included in this study. The independent variables encompassed the patients' height, weight, foot length, gender, age, and surgical access. The dependent variable in this study was the diameter of the acetabular prosthesis utilized during the surgical procedure. The entire cohort dataset was randomly partitioned into a training cohort and a validation cohort, with a ratio of 7:3, employing the SPSS 26.0 software. Pearson correlation analysis was conducted to examine the relationships between the patients' height, weight, foot length, gender, age, surgical access, and the diameter of the acetabular prosthesis in the training cohort. Additionally, a multiple linear regression equation was developed using the independent variables from the training cohort and the diameter of the acetabular prosthesis as the dependent variable. This equation aimed to predict the diameter of the acetabular prosthesis based on the patients' characteristics. The accuracy of the equation was evaluated by substituting the data of the validation cohort into the multiple linear equation. The predicted acetabular prosthesis diameters were then compared with the actual diameters used in the operation.

The correlation analysis conducted on the training cohort revealed that surgical access (r = 0.054) and age (r = -0.120) exhibited no significant correlation with the diameter of the acetabular prosthesis utilized during the intraoperative procedure. Conversely, height (r = 0.687), weight (r = 0.654), foot length (r = 0.687), and sex (r = 0.354) demonstrated a significant correlation with the diameter of the acetabular prosthesis used intraoperatively. Furthermore, a predictive equation, denoted as Y (acetabular prosthesis diameter in mm) = 20.592 + 0.548 × foot length (cm) + 0.083 × height (cm) + 0.077 × weight (kg), was derived. This equation accurately predicted the diameter within one size with an accuracy rate of 64.94% and within two sizes with an accuracy rate of 94.81%.

Anthropometric data can accurately predict the diameter of acetabular prosthesis during total hip arthroplasty.

A comparative study of joint amnesia in patients undergoing total hip arthroplasty with the direct anterior approach and posterior approach was conducted through a comprehensive evaluation.

The literature on joint amnesia in postoperative patients who underwent total hip arthroplasty by the direct anterior approach and the posterior approach was systematically searched in PubMed, Embase, Web of Science, Cochrane Library, CNKI, CBM, Wanfang, and VIP databases from the time of library construction until February 13, 2023. Meta-analysis was performed using RevMan 5.3 software after independent searching, screening of the literature, data extraction, and quality assessment of the included studies by two investigators in strict accordance with the guidelines for conducting meta-analyses.

A total of one RCT and six cohort studies were included in this meta-analysis. Meta-analysis results indicated that at 1 month postoperatively (MD = 2.08, 95% CI (0.20, 3.96), P = 0.03), 3 months (MD = 10.08, 95% CI (1.20, 18.96), P = 0.03), and 1 year (MD = 6.74, 95% CI (1.30, 12.19), P = 0.02), DAA total hip arthroplasty was associated with better FJS compared to PA at 1 year postoperatively. However, there was no statistical significance in FJS between the two groups at 5 years postoperatively (MD = 1.35, 95% CI (- 0.58, 3.28), P = 0.17).

Current evidence suggests that the degree of joint amnesia after THA for DAA was not found to be superior to that of PA. Further, these findings require confirmation by including a larger number of high-quality randomized controlled studies.

Systematic review; Level of evidence, 3.