Do Postoperative Results Differ in a Randomized Trial Between a Direct Anterior and a Direct Lateral Approach in THA?

Mjaaland, Knut Erik; Kivle, Kjetil; Svenningsen, Svein; Nordsletten, Lars

doi:10.1097/corr.0000000000000439

Cited by 55 publications

(93 citation statements)

References 58 publications

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“…Two trials comparing the lateral with the posterior approach showed the posterior approach had greater improvement in muscle strength at 1 year (n = 47) [20], and fewer dislocations at an average 3-year follow-up (n = 196) [21]. A recent RCT (n = 164) found the lateral approach was associated with more abductor muscle weakness and worse PROMs, but the anterior approach had more nerve injuries [22]. A systematic review, including 12 RCTs, reported similar risks of dislocation, nerve injury, infection and venous thromboembolism between the posterior approach and the minimally invasive posterior approach [10].…”

Section: Discussionmentioning

confidence: 99%

The effect of surgical approach in total hip replacement on outcomes: an analysis of 723,904 elective operations from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

Blom

Hunt

Matharu

et al. 2020

BMC Med

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Background: Total hip replacement (THR) is clinically and cost-effective. The surgical approach employed influences the outcome; however, there is little generalisable and robust evidence to guide practice. Methods: A total of 723,904 primary THRs captured in the National Joint Registry, linked to hospital inpatient, mortality and patient-reported outcome measures (PROMs) data with up to 13.75 years follow-up, were analysed. There were seven surgical approach groups: conventional posterior, lateral, anterior and trans-trochanteric groups and minimally invasive posterior, lateral and anterior. Survival methods were used to compare revision rates and 90-day mortality. Groups were compared using Cox proportional hazards and Flexible Parametric Survival Modelling (FPM). Confounders included age at surgery, sex, risk group (indications additional to osteoarthritis), American Society of Anesthesiologists grade, THR fixation, thromboprophylaxis, anaesthetic, body mass index (BMI) and deprivation. PROMs were analysed with regression modelling or non-parametric methods. Results: Unadjusted analysis showed a higher revision risk than the referent conventional posterior for the conventional lateral, minimally invasive lateral, minimally invasive anterior and trans-trochanteric groups. This persisted with all adjusted FPM and adjusted Cox models, except in the Cox model including BMI where the higher revision rate only persisted for the conventional lateral approach (hazard rate ratio (HRR) 1.12 [95% CI 1.06,1.17] P < 0•001) and trans-trochanteric approaches (HRR 1.48 [95% CI 1.14,1.91] P = 0.003). PROMs demonstrated statistically, but not clinically, significant differences. Self-reported complications were more frequent with the conventional lateral approach, and the risk of 90-day mortality was higher (HRR 1.15 [95%CI 1.01-1.30] P = 0.029).

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Section: Discussionmentioning

confidence: 99%

The effect of surgical approach in total hip replacement on outcomes: an analysis of 723,904 elective operations from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

Blom

Hunt

Matharu

et al. 2020

BMC Med

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“…Multiple clinical studies have shown that the DAA is able to provide an excellent overview about the acetabulum and the surrounding osseous pelvic structures, which explains the high accuracy of acetabular component placement that can be achieved when using this approach [35]. The pearls and pitfalls of the DAA have been discussed previously at large and it seems that the DAA is associated with lower dislocation rates when compared to posterior approaches and a reduced rate of Trendelenburg positive patients when compared to lateral approaches [2,3,36]. As we know from the literature, revision hip arthroplasty can result in soft tissue defects and particularly lesions of the abductor apparatus, increasing the risk for dislocation and insufficient muscular stabilization of the pelvis during standing.…”

Section: Discussionmentioning

confidence: 98%

“…In 70% (n = 43) of the hips, this was the first revision, whereas 30% (n = 18) of the hips underwent at least one previous revision (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11). In 14 hips, the index procedure was performed in the authors' department, while all others were referrals.…”

Section: Methodsmentioning

confidence: 99%

“…In the direct anterior approach (DAA), the surgeon enters the hip joint through the intermuscular and interneural plane between the tensor fasciae latae (TFL) and the sartorius muscle [1]. In comparison to lateral approaches, the DAA is supposed to be associated with an accelerated early functional recovery and a reduced rate of postoperative Trendelenburg-positive patients [2]. Recent analyses of arthroplasty registries demonstrated that the DAA is further associated with a lower risk of revision for dislocation when compared to posterior approaches [3][4][5].…”

Section: Introductionmentioning

confidence: 99%

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Revision Arthroplasty Through the Direct Anterior Approach Using an Asymmetric Acetabular Component

Prodinger

Lazic

Horas³

et al. 2020

JCM

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Despite increasing numbers of primary hip arthroplasties performed through the direct anterior approach (DAA), there is a lack of literature on DAA revision arthroplasty. The present study was performed in order to evaluate outcomes and revision rates after revision through the DAA using an asymmetric acetabular component with optional intra- and extramedullary fixation. In a retrospective cohort study, we analyzed prospectively collected data of 57 patients (61 hips, 43 female, 18 male) who underwent aseptic acetabular component revision through the DAA with the abovementioned implant system between January 2015 and December 2017. The mean follow-up was 40 months (12–56). Survival rates were estimated using the Kaplan–Meier method. All complications were documented and functional outcomes were assessed pre- and postoperatively. Kaplan–Meier analysis revealed an estimated five-year implant survival of 97% (confidence interval CI 87–99%). The estimated five-year survival with revision for any cause was 93% (CI 83–98%). The overall revision rate was 6.6% (n = 4). Two patients had to undergo revision due to periprosthetic infection (3.3%). In one patient, the acetabular component was revised due to aseptic loosening four months postoperatively. Another patient suffered from postoperative iliopsoas impingement and was treated successfully by arthroscopic iliopsoas tenotomy. Two (3.3%) of the revised hips dislocated postoperatively. The mean Harris Hip Score improved from 35 (2–66) preoperatively to 86 (38–100) postoperatively (p < 0.001). The hip joint’s anatomical center of rotation was restored at a high degree of accuracy. Our findings demonstrate that acetabular revision arthroplasty through the DAA using an asymmetric acetabular component with optional intra- and extramedullary fixation is safe and practicable, resulting in good radiographic and clinical midterm results.

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“…The use of the direct lateral approach in THA is associated with a limp postoperatively 35,36 and limping is associated with lower PROM scores after THA. 7,36 These findings are similar to ours. The abductor mechanism of the hip was investigated by an experienced physiotherapist performing the Trendelenburg test as described by Hardcastle and Nade.…”

Section: Discussionmentioning

confidence: 99%

High risk of positive Trendelenburg test after using the direct lateral approach to the hip compared with the anterolateral approach

Ugland

Haugeberg

Svenningsen

et al. 2019

The Bone & Joint Journal

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Aims The aim of this randomized trial was to compare the functional outcome of two different surgical approaches to the hip in patients with a femoral neck fracture treated with a hemiarthroplasty. Patients and Methods A total of 150 patients who were treated between February 2014 and July 2017 were included. Patients were allocated to undergo hemiarthroplasty using either an anterolateral or a direct lateral approach, and were followed for 12 months. The mean age of the patients was 81 years (69 to 90), and 109 were women (73%). Functional outcome measures, assessed by a physiotherapist blinded to allocation, and patient-reported outcome measures (PROMs) were collected postoperatively at three and 12 months. Results A total of 11 patients in the direct lateral group had a positive Trendelenburg test at one year compared with one patient in the anterolateral group (11/55 (20%) vs 1/55 (1.8%), relative risk (RR) 11.1; p = 0.004). Patients with a positive Trendelenburg test reported significantly worse Hip Disability Osteoarthritis Outcome Scores (HOOS) compared with patients with a negative Trendelenburg test. Further outcome measures showed few statistically significant differences between the groups. Conclusion The direct lateral approach in patients with a femoral neck fracture appears to be associated with more positive Trendelenburg tests than the anterolateral approach, indicating a poor clinical outcome. Cite this article: Bone Joint J 2019;101-B:793–799.

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Do Postoperative Results Differ in a Randomized Trial Between a Direct Anterior and a Direct Lateral Approach in THA?

Abstract: Level I, therapeutic study.

Cited by 55 publications

References 58 publications

The effect of surgical approach in total hip replacement on outcomes: an analysis of 723,904 elective operations from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

The effect of surgical approach in total hip replacement on outcomes: an analysis of 723,904 elective operations from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

Revision Arthroplasty Through the Direct Anterior Approach Using an Asymmetric Acetabular Component

High risk of positive Trendelenburg test after using the direct lateral approach to the hip compared with the anterolateral approach

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