MRI Assessment of Muscle Damage After the Posterolateral Versus Direct Anterior Approach for THA (Polada Trial). A Randomized Controlled Trial

BACKGROUND: There is controversy in literature whether the direct anterior approach (DAA) results in less muscle damage compared with the posterolateral approach (PLA) for total hip arthroplasty. The aim of this randomized controlled trial was to assess muscle damage between these two approaches. METHODS: Forty-six patients were included. Muscle atrophy, determined with the Goutallier classification, and muscle surface of twelve muscles were analyzed on magnetic resonance imaging images made preoperatively and one year postoperatively. Differences in component placement after DAA or PLA were assessed on radiographs. Harris hip scores and Hip disability and Osteoarthritis and Outcome Score were used as functional outcomes. RESULTS: External rotator musculature was damaged in both approaches. After PLA, the obturator muscles showed significantly more atrophy and a decrease in muscle surface. After DAA, the tensor fascia latae showed an increased muscle atrophy and the psoas muscle showed a decreased muscle surface. An increase in muscle surface was seen for the rectus femoris, sartorius, and quadratus femoris after both approaches. The muscle surface of the gluteus medius and iliacus was also increased after PLA. No difference in muscle atrophy was found between the approaches for these muscles. The inclination angle of the cup in PLA was significantly higher. No differences were found in functional outcomes. CONCLUSION: Different muscle groups were affected in the two approaches. After PLA, the external rotators were more affected, whereas the tensor fascia latae and psoas muscles were more affected after DAA

The learning curve of the direct anterior approach is 100 cases: an analysis based on 15,875 total hip arthroplasties in the Dutch Arthroplasty Register

Background and purpose — In the last decade, the direct anterior approach (DAA) for total hip arthroplasty (THA) has become more popular in the Netherlands. Therefore, we investigated the learning curve and survival rate of the DAA in primary THA, using data from the Dutch Arthroplasty Register (LROI). Patients and methods — We identified all patients who received a primary THA using the DAA in several highvolume centers in the Netherlands between 2007 and 2019 (n = 15,903). Procedures were ordered per surgeon, using date of operation. Using the procedure number, operations were divided into 6 groups based on the number of previous procedures per surgeon (first 25, 26–50, 51–100, 101–150, 151–200, > 200). Data from different surgeons in different hospitals was pooled together. Revision rates were calculated using a multilevel time-to-event analysis. Results — Patients operated on in group 1–25 (hazard ratio [HR] 1.6; 95% CI 1.1–2.4) and 26–50 (HR 1.6; CI 1.1–2.5) had a higher risk for revision compared with patients operated on in group > 200 THAs. Between 50 and 100 procedures the revision risk was increased (HR 1.3; CI 0.9–1.9), albeit not statistically significant. From 100 procedures onwards the HR for revision was respectively 1.0 (CI 0.6–1.6) and 0.8 (CI 0.5–1.4) for patients in operation groups 101–150 and 151–200. Main reasons for revision were loosening of the stem (29%), periprosthetic infection (19%), and dislocation (16%). Interpretation — We found a 64% increased risk of revision for patients undergoing THA using the DAA for the first 50 cases per surgeon. Between 50 and 100 cases, this risk was 30% increased, but not statistically significant. From 100 cases onwards, a steady state had been reached in revision rate. The learning curve for DAA therefore is around 100 cases