Adopting the direct anterior approach: experience and learning curve in a Chinese patient population

Abstract

Background There are concerns regarding the complications encountered during the learning curve when switching to a direct anterior approach (DAA) for total hip arthroplasty (THA). The purpose of our study is to report our outcomes and complications after adopting a new approach in a Chinese patient population. Methods From 2016 to 2018, a single surgeon’s first 100 cases with unilateral DAA for THA were reviewed. The patients were divided into 2 groups, the first 50 cases were designated as group A and the second 50 cases were designated as group B. The preoperative, intraoperative, and postoperative clinical data were analyzed. The cumulative summation method (CUSUM) was used to determine the learning curve. Results There was a significant decrease in the complication rate from 44% in the first 50 cases to 16% in the second 50. The first 50 cases showed a significant increase in operating time, length of hospitalization, fluoroscopy, and complications. There was no significant difference in implant position, postoperative leg length discrepancy (LLD), Harris score, or creatine kinase. CUSUM analysis showed that complication rates and operating time reached acceptable and steady state after 88 cases and 72 cases respectively. Conclusions Adopting DAA in a Chinese patient population has its own unique considerations and challenges. Even in the hands of an experienced surgeon, DAA is still a technically demanding procedure.

Total hip arthroplasty performed by direct anterior approach – Does experience influence the learning curve?

“…A steady state of operating time was reached at around 70 cases for the senior which is similar to literature [17]. This improvement of the operating time is attributed to a reduction in fluoroscopy time and a more efficient exposure.…”

“…Woolson et al reported a 9% incidence of major complications in a group of community orthopaedic surgeons in their learning curve with the DAA [15]. Kong et al reported an initial higher rate of complications of 44% in the first 50 cases of the learning curve which decreased to 16% in the second 50 cases [17].…”

“…As Zawadsky et al [14] reported, we do believe that these complications were captured during the learning curve (LC) of the DAA or as Woolson et al [15] described among inexperienced surgeons without support. Studies have reported the LC of the DAA as 16-88 for the number of DAA to have an acceptable risk of revision [16][17][18][19].…”

Dimensional Changes of Lumbar Intervertebral Foramen in Direct Anterior Approach‐Specific Hyperextension Supine Position

“…In some patients, the nerve root impingement caused by foraminal stenosis occurs in extension but is relieved in flexion 22,23 . Hyperextending the hip joint is recommended to attain appropriate exposure of the proximal femur during the femoral preparation in patients undergoing DAA THA 3,5,6 ; therefore, a special position might change the morphology of the LIVF and lead to more pressure on and potential injury of the spinal nerve root. This study first investigated the changes in LIVF dimensions when subjects were placed in DAA-specific hyperextension supine position.…”

“…The posterolateral approach, the lateral approach, and the direct anterior approach (DAA) are the most commonly used approaches during the operation 3,4 . DAA is a muscle-sparing method that provides a truly intranervous and intermuscular approach 5,6 . It has gained increasing popularity due to less soft tissue damage and shorter recovery time 3,4,7 .…”