Comparison of Early Functional Recovery After Total Hip Arthroplasty Using a Direct Anterior or Posterolateral Approach: A Randomized Controlled Trial

doi:10.1016/j.arth.2017.05.056

The Journal of Arthroplasty

Volume 32, Issue 11, November 2017, Pages 3421-3428

https://doi.org/10.1016/j.arth.2017.05.056 Get rights and content

Abstract

Background

Controversy exists as to whether early functional outcomes differ after total hip arthroplasty performed using the direct anterior approach (DAA) or the posterolateral approach (PLA).

Methods

One hundred twenty patients were enrolled in this study and were divided into 2 groups based on surgical approach. Group A included patients who had a total hip arthroplasty with a DAA, whereas group B included those with a PLA. Patients were randomized into the DAA or PLA groups (n = 60), and perioperative and postoperative outcomes were recorded.

Results

When compared with the PLA, the DAA had a shorter incision length (9.1 vs 13.1 cm; P < .01), shorter hospital stay (2.8 vs 3.3 days, P = .04), and lower self-reported pain. Both serum inflammatory and muscle damage markers were lower in the DAA group. However, the PLA had shorter operative times (65.5 vs 83.3 min, P = .03) and less intraoperative blood loss (123.8 vs 165.9 mL, P = .04). The DAA had significantly lower variance in cup inclination and anteversion. Similar rates of intraoperative complications were identified in the 2 groups. The DAA was associated with better functional recovery at 3 months based on the Harris hip score, University of California Los Angeles activity score, and gait analysis; however, functional recovery at 6 months was similar between the 2 groups.

Conclusion

We found functional advantages in early recovery after the DAA compared with the PLA. The DAA can offer rapid functional recovery with less muscle damage, greater pain relief, and lower variance in cup inclination and anteversion. However, no functional difference was found at 6 months follow-up.

Section snippets

Patients

The study protocol was approved by the Ethics Committee of West China Hospital of Sichuan University and this study was registered in the Chinese Clinical Trial Registry (CTR-INR-16010136). Written informed consent was obtained from all participants. All patients undergoing primary THA at our hospital between January 2015 and March 2016 who had been diagnosed with osteoarthritis of the hip (DDA group = 41; PLA group = 40), femoral head necrosis (Ficat III or IV) (DDA group = 13; PLA group =

Results

Between January 2015 and March 2016, 203 primary THAs were performed by the senior clinician. Of these, 40 patients declined to participate and 35 failed to qualify based on the inclusion and exclusion criteria. The remaining 128 were enrolled in the study and randomized evenly between the DAA and PLA groups. Sixty-four patients were allocated to the DAA or PLA group, 4 were lost to follow-up, and 60 were followed up at 6 months, respectively (Fig. 2). The 2 patient groups were similar across

Discussion

Some studies have demonstrated that the DAA was associated with faster recovery compared with the PLA [27], whereas other studies reported that the DAA led to similar early functional recovery and had a steeper learning curve when compared with the PLA [28]. Thus, whether the DAA exhibits better clinical outcomes with respect to ambulatory ability, pain control, and early functional recovery remains controversial. We therefore undertook this randomized controlled trial to evaluate whether the

Conclusions

Our results suggest that for THA, the DAA offers more rapid recovery with less muscle damage than the PLA. At the same time, the DAA is associated with longer operating time, greater intraoperative blood loss, and a potentially higher complication rate. These disadvantages may reflect the steep learning curve for the DAA, because they appear to improve as the surgeon becomes more experienced with the procedure. This highlights the need for adequate anatomical knowledge and skill development

Acknowledgments

This research did not receive financial support from funding agencies in the public, commercial, or not-for-profit sectors.

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Surgical Approach Does Not Affect Chronic Opioid Usage After Total Hip Arthroplasty
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Three different surgical approaches (the direct anterior, antero-lateral, and posterior) are commonly used for total hip arthroplasty (THA). Due to an internervous and intermuscular approach, the direct anterior approach may result in less postoperative pain and opioid use, although all 3 approaches have similar outcomes 5 years after surgery. Perioperative opioid medication consumption poses a dose-dependent risk of long-term opioid use. We hypothesized that the direct anterior approach is associated with less opioid usage over 180 days after surgery than the antero-lateral or posterior approaches.
A retrospective cohort study was performed including 508 patients (192 direct anterior, 207 antero-lateral, and 109 posterior approaches). Patient demographics and surgical characteristics were identified from the medical records. The state prescription database was used to determine opioid use 90 days before and 1 year after THA. Regression analyses controlling for sex, race, age, and body mass index were used to determine the effect of surgical approach on opioid use over 180 days after surgery.
No difference was seen in the proportion of long-term opioid users based on approach (P = .78). There was no significant difference in the distribution of opioid prescriptions filled between surgical approach groups in the year after surgery (P = .35). Not taking opioids 90 days prior to surgery, regardless of approach, was associated with a 78% decrease in the odds of becoming a chronic opioid user (P < .0001).
Opioid use prior to surgery, rather than THA surgical approach, was associated with chronic opioid consumption following THA.
Accuracy and Precision of Acetabular Component Position Does Not Differ Between the Anterior and Posterior Approaches to Total Hip Arthroplasty With Robotic Assistance: A Matched-Pair Analysis
2022, Arthroplasty Today
Deviation from planned component placement with robot-assisted total hip arthroplasty (RA-THA) may differ based on surgical approach. The purpose of this study was to compare radiographic accuracy and precision of acetabular component position using RA-THA with the direct anterior approach (DAA) or posterior approach (PA).
Between 2016 and 2019, 134 PA RA-THA patients were matched to 134 DAA RA-THA patients based on age (±10 years), body mass index (±5 kg/m²), and sex (exact). Acetabular component position was assessed using (1) planned position on preoperative computed tomography, (2) intraoperative position, and (3) position on 6-week postoperative radiographs using the digital Ein Bild Röntgen Analyse system.
Accuracy of acetabular component inclination in the PA cohort was lower than that in the DAA cohort (PA: 4.3° ± 2.8° vs DAA: 3.1° ± 2.4°, P = .001). Inclination precision was not statistically different (PA: 3° ± 2.4° vs DAA: 2.5° ± 1.8°, P = .071). Anteversion accuracy was not statistically different (PA: 4.1° ± 3.7° vs DAA: 3.5° ± 2.5°, P = .091). Acetabular component anteversion was more precise with DAA (PA: 4.1° ± 3.7° vs DAA: 2.9° ± 2.0°, P = .001). Radiographic outliers (anteversion or inclination was >10° or <−10° from the planned target) were significantly more prevalent in the PA cohort than in the DAA cohort (12 vs 3, P = .016).
The acetabular component can be positioned with excellent precision and accuracy when using RA-THA regardless of approach. Although the DAA resulted in a slight increase in precise placement of cup anteversion and more accurate placement of cup abduction with fewer outliers, these small differences may not be clinically meaningful.
Comparison of gait and hip ambulation ability after total hip arthroplasty through different approaches
2024, Chinese Journal of Tissue Engineering Research
Which way forward? Comparing radiological outcomes using three different surgical approaches in robotic assisted total hip arthroplasty
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Improved patient reported outcomes with the direct anterior approach versus the posterior approach for total hip arthroplasty in the early post-operative period
2024, Archives of Orthopaedic and Trauma Surgery
Which approach of total hip arthroplasty is the best efficacy and least complication?
2024, World Journal of Orthopedics

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: No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.05.056.

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Primary ArthroplastyComparison of Early Functional Recovery After Total Hip Arthroplasty Using a Direct Anterior or Posterolateral Approach: A Randomized Controlled Trial

Abstract

Background

Methods

Results

Conclusion

Section snippets

Patients

Results

Discussion

Conclusions

Acknowledgments

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

Clin Biomech (Bristol, Avon)

Hum Mov Sci

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

Clin Biomech (Bristol, Avon)

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

The effect of elective total hip replacement on health-related quality of life

J Bone Joint Surg Am

Reduced postoperative pain in total hip arthroplasty after minimal-invasive anterior approach

Int Orthop

Comparative retrospective study of the direct anterior and transgluteal approaches for primary total hip arthroplasty

Int Orthop

Primary Arthroplasty
Comparison of Early Functional Recovery After Total Hip Arthroplasty Using a Direct Anterior or Posterolateral Approach: A Randomized Controlled Trial