Total Hip Replacement Using the Direct Anterior Approach : Review

Worldwide, the Direct Anterior Approach (DA) for Total Hip Arthroplasty (THA) has been gaining popularity. In the past years, there has been increasing interest in this approach given its early recovery rates. Advocates for this technique claim that its intermuscular and internervous nature offer patients a better and more anatomical management of soft tissues leading to better functional results and less pain. This review exhibits the anatomic and surgical considerations of the procedures as well as its main advantages and potential complications.https://orcid.org/0000-0001-6852-0350https://orcid.org/0000-0003-0157-3639https://orcid.org/0000-0003-0895-2586Revista Internacional - No indexadaN

Optimum anatomic socket position and sizing for the direct anterior approach: impingement and instability

© 2019 A comprehensive strategy is important for ensuring reproducible and safe acetabular component sizing and positioning. Presented here is our approach for anatomic acetabular component positioning in direct anterior total hip arthroplasty. This strategy has evolved with our understanding of the ramifications of socket sizing and positioning on instability and impingement. Data collected by a single surgeon (J.A.R.) between 2009 and 2011 influenced our current paradigm. We compare the sizing and positioning parameters of the anterior and posterior approach, thus demonstrating how the 2 are different. By highlighting these differences, we hope to provide a clear, defined approach to acetabular placement and sizing for direct anterior-approach total hip arthroplasty

Direct anterior approach in total hip arthroplasty: a narrative review

Objective: Worldwide, a growing number of Total Hip Arthroplasty (THA) procedures are being performed each year. However, despite this significant global demand, the ideal surgical approach remains controversial. Globally there has been a significant increase in the use of direct anterior approach THA. Therefore, the objective of this paper was to synthesise the vast body of new, evolving information into one non-biased narrative review, to provide an overarching review of various aspects of this approach, including controversial issues such as, benefits, functional outcomes, complications, costs, and surgical technique. Data source: The following keywords were entered into various scientific databases including, Mbase, Google scholar and PubMed. Only articles published in journals between 2017 and 2021 were extracted and included in this review. We found 148 articles published during this period and we used the 82 most relevant articles to collate this narrative review. Data selection/ extraction: Three fellowship trained arthroplasty orthopaedic surgeons, (JRTP, LM and JC) went through all the papers and selected the 82 most relevant papers for inclusion in this review. Conclusion: There has been significant interest and renewed vaguer in publication rates by authors worldwide evaluating the use of the DAA in THA. Most recent studies show that there is increasing evidence that the DAA is a safe, reliable, and reproducible surgical approach to THA. Direct anterior approach provides, in the most part, superior early short term functional outcomes in comparison with other THA approaches. It has however also been shown that a steep learning curve exists when using this approach. While complication rates are similar to those seen in other approaches, the types of complications however remain slightly different with an increase incidence of intraoperative peri-prosthetic femoral fractures, wound complications and femoral stem aseptic loosening being significantly greater in the direct anterior approach

Bipolar hemiarthroplasty of hip joint: prospective randomised comparative study of direct anterior approach versus posterior approach

Background: The dilemma while treating cases with hemiarthroplasty is the surgical approach to be employed. The aim of present study is comparison of posterior approach and direct anterior approach with regards to various relevant outcomes and evaluate early surgical complications.Methods: In this randomized observational study conducted over 2 years, 20 patients each with intra-capsular neck femur fracture were enrolled as per predefined selection criteria and treated with hemiarthroplasty (bipolar) either by posterior approach or by direct anterior approach. Follow up was done for all the patients at regular intervals with standard post-operative protocol, including evaluation for surgical complications, active range of motion and assessment of Harris hip score.Results: Overall infection rate was 5% (two patients in posterior approach, no patient in direct anterior approach, the difference being statistically insignificant). No incidences of dislocation were reported in either group. Two patients of posterior approach had abductor weakness. Periprosthetic fracture and deep vein thrombosis were observed in one case each in posterior approach group. In posterior surgical group, excellent Harris hip score in 25% patients, good in 57.5% patients and fair in 17.5% patients were observed; while in direct anterior surgical group, excellent score was observed in 12.5% patients, good in 55% patients and fair in 32.5% patients.Conclusions: No major clinically or statistically significant differences were observed between for outcomes and complications between the two approaches. Larger randomized trials with bigger samples are recommended

Surgical technique: Tscherne-Johnson extensile approach for tibial plateau fractures.

BackgroundThe standard approach to lateral tibial plateau fractures involves elevation of the iliotibial band (IT) and anterior tibialis origin in continuity from Gerdy's tubercle and metaphyseal flare. We describe an alternative approach to increase lateral plateau joint exposure and maintain iliotibial band insertion to Gerdy's tubercle.Description of techniqueThe approach entails a partial tenotomy of the anterior half of the IT band leaving the posterior IT band insertion attached to Gerdy's tubercle. Fracture lines around Gerdy's tubercle are completed or the tubercle was osteotomized and externally rotated and the joint overdistracted, allowing direct visualization of the joint depression. Joint elevation, grafting, and internal fixation are performed through this window.MethodsWe retrospectively reviewed 76 patients (two groups), Schatzker Types I to II and IV to VI fractures (66 patients), between 1989 and 2005, and 10 patients, with 10 bicondylar posterior plateau fractures, from 2002 to 2010. All patients were followed a minimum of 12 months (average, 3.9 years; range, 12 months to 10 years). Ten patients, with posterior plateau fractures, received anterolateral plateau intraarticular osteotomy for exposure of centroposterior and posterolateral articular depression.ResultsAverage knee ROM was 2° of flexion (range, -3° to 5°) to greater than 120° of flexion (range, 100°-145°). In 66 patients, average articular depression improved from 7.4 mm to 1 mm (range, 0-5 mm) and, in 10 posterior fractures, from 18 mm to 1 mm (range, 0-4.5 mm). Infection occurred in one of the 76 patients; acute débridement and intravenous antibiotics resulted in control of the infection.ConclusionsThis approach reliably increases direct visualization of the lateral plateau articular fractures and maintains IT band insertion. Articular osteotomy of the anterolateral plateau provides access to extensive posterior plateau fractures

Surgical approach in primary total hip arthroplasty: Anatomy, technique and clinical outcomes

©2015 8872147 Canada Inc. Total hip arthroplasty (THA) has revolutionized the treatment of hip arthritis. A number of surgical approaches to the hip joint exist, each with unique advantages and disadvantages. The most commonly used approaches include the direct anterior, direct lateral and posterior approaches. A number of technical intricacies allow safe and efficient femoral and acetabular reconstruction when using each approach. Hip dislocation, abductor insufficiency, fracture and nerve injury are complications of THA, although their relative risk varies by approach. Numerous clinical trials have sought to elicit differences in patient-reported outcomes, complication rates and return to function among the surgical approaches. This review outlines some of the technical pearls of performing a THA through either a direct anterior, direct lateral or posterior approach. A literature review outlines the impact of surgical approach on clinical outcomes and clinically relevant complication rates

The “Pre-Finishing” Approach in Direct Anterior Restorations. A Case Series

n esthetic restorations of anterior teeth the clinician has to manage several aspects in order to have a predictable outcome. A deep knowledge of the anatomy as well as the adhesive procedures and the optical properties of resin-based composites are mandatory to achieve esthetic results. Contemporary restorative materials present either several shades and different translucency properties and therefore they are able to mimic teeth’s optical behavior thus providing a natural aspect to anterior restorations. The wrong thickness of different composite layers may provide unpleasant results such as low value (grayish) restorations that often requires reintervention. A precise step-by-step procedure is therefore mandatory to provide the proper shade at the correct place. There is therefore the need of some corrections and adjustments during the layer procedure in order to avoid errors in shade positioning that could affect final result. The authors present a case series (six clinical cases) treated with the proposed technique with up to five years follow-up

Facing complications of direct anterior approach in total hip arthroplasty during the learning curve

This study aims to evaluate complications and early postoperative clinical outcomes of direct anterior approach (DAA) in total hip arthroplasty (THA)

Soft tissue damage after minimally invasive THA: A comparison of 5 approaches

Methods 5 surgeons each performed a total hip arthroplasty on 5 fresh frozen cadaver hips, using either a MIS anterior, MIS anterolateral, MIS 2-incision, MIS posterior, or lateral transgluteal approach. Postoperatively, the hips were dissected and muscle damage color-stained. We measured proportional muscle damage relative to the midsubstance cross-sectional surface area (MCSA) using computerized color detection. The integrity of external rotator muscles, nerves, and ligaments was assessed by direct observation. Results None of the other MIS approaches resulted in less gluteus medius muscle damage than the lateral transgluteal approach. However, the MIS anterior approach completely preserved the gluteus medius muscle in 4 cases while partial damage occurred in 1 case. Furthermore, the superior gluteal nerve was transected in 4 cases after a MIS anterolateral approach and in 1 after the lateral transgluteal approach. The lateral femoral cutaneous nerve was transected once after both the MIS anterior approach and the MIS 2-incision approach. Interpretation The MIS anterior approach may preserve the gluteus medius muscle during total hip arthroplasty, but with a risk of damaging the lateral femoral cutaneous nerv

The design of a randomised controlled trial to evaluate the (cost-) effectiveness of the posterolateral versus the direct anterior approach for THA (POLADA - trial)

Background: Total hip arthroplasty (THA) is one of the most successful orthopaedic procedures. Because of the increasing number of THAs, a growing demand for faster recovery and a greater emphasis on cost-effectiveness, minimally invasive THAs have been introduced in the last decades. The direct anterior approach is a minimally invasive, tissue-sparing approach in which intermuscular planes are used. Theoretically, this approach should result in a faster recovery of physical functioning and higher health-related quality of life. Methods/design: A randomised controlled trial will be performed. Patients will be randomly allocated to undergo THA by means of the anterior or posterolateral approach. Both the intervention and control group will consist of two subgroups: 1) patients with a good bone stock who will receive an uncemented femoral stem, and 2) patients with a poor bone stock who will receive a cemented femoral stem. Patients between 18 and 90 years with primary or secondary osteoarthritis will be included. Physical functioning and health-related quality of life will be assessed by means of questionnaires. Additionally, performance based tests will be performed to objectively assess the physical functioning. Cost-effectiveness will be assessed by obtaining data on medical costs in and outside the hospital and other nonmedical costs. Measurements will take place preoperatively, two and six weeks, three months and one year postoperatively. Discussion: There is some evidence that the anterior approach results in reduced tissue damage and faster recovery in the direct postoperative period, compared to the posterolateral approach. However, there is still a lack of well-designed studies that have confirmed the better outcomes and cost-effectiveness of the anterior approach. Therefore, the purpose of this study is to assess the physical functioning, health related quality of life and the cost-effectiveness of the anterior approach, compared to the conventional posterolateral approach