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

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Carlo Dall'Oca
Alberto Ceccato
Matteo Cresceri
Marco Scaglia
Matteo Guglielmini
Gianmarco Pelizzari
Roberto Valentini
Bruno Magnan


DAA (Direct anterior approach), THA


Background: This study aims to evaluate complications and early postoperative clinical outcomes of direct anterior approach (DAA) in total hip arthroplasty (THA). Methods: Ninety-one consecutive patients who underwent primary elective unilateral THA between January 2013 and December 2019 were identified. Collected data included age of patient, BMI, ASA score, EBL (estimated blood loss), LOS (length of stay), operating time, and intra/postoperative complications. The recorded complications included prolonged wound drainage without infection, superficial and deep infection, dislocation, periprosthetic fracture, aseptic loosening or failure of osteointegration and nervous damage. Any reoperation, with or without prosthetic component revision, was recorded. Results: Fourteen complications (15,4%) and 12 (13,18%) postoperative anemizations were observed in this series. No deep infection was reported. Most common complications were nerve damage (3/91;3,29%), greater trochanter fracture (3/91; 3,29%), and wound trouble (3/91; 3,29%). Two (2,19%) dislocations were reported. One (1,09%) intraoperative periprosthetic fracture was treated with cerclage wiring. One (1,09%) revision was needed for an acetabular mobilization. One patient (1,09%) had severe periprosthetic ectopic ossifications (Brooker 4), needing reintervention because of severe limitations of the range of motion (ROM). Conclusions: Complications rate in this study with THA by DAA is comparable to those reported in literature. DAA is a safe, efficient procedure but it needs a steep learning curve. (www.actabiomedica.it)


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1: Berry DJ, Bozic KJ. Current practice patterns in primary hip and knee arthroplasty among members of the American Association of Hip and Knee Surgeons. J Arthroplasty 2010; 25(6 Suppl.):2.

2: Post ZD, Orozco F, Diaz-Ledezma C, Hozack WJ, Ong A. Direct anterior approach for total hip arthroplasty: indications, technique, and results. J Am Acad Orthop Surg 2014; 22(9):595.

3: Malik AK, Chou DT, Witt JD. Anterior approaches to the hip for the treatment of femoro-acetabular impingement: a cadaveric approach. Hip Int 2010;20(4):482.

4: Moskal JT. Anterior approach in THA improves outcomes: affirms. Orthopedics 2011; 34(9):e456.

5: Pogliacomi F, De Filippo M, Paraskevopoulos A, Alesci M, Marenghi P, Ceccarelli F. Mini-incision direct lateral approach versus anterior mini-invasive approach in total hip replacement: results 1 year after surgery. Acta Biomedica 2012; 83(2): 114-21.

6: Saklad M. Grading of patients for surgical procedures. Anestesiol 1941;2:281-4

7: Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, Garvin KL, Mont MA, Wongworawat MD, Zalavras CG. New definition for periprosthetic joint infection: from the workgroup of the musculoskeletal infection society. Clin Orthop Relat Res. 2011;469(11):2992–4.

8: Purcell RL, Parks NL, Gargiulo JM, Hamilton WG. Severely Obese Patients Have a Higher Risk of Infection After Direct Anterior Approach Total Hip Arthroplasty. J Arthroplasty 2016; 31:162-5

9: Brooker AF, Bowerman JW, Robinson RA, Riley RH Jr. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg Am 1973;55(8):1629-1632.

10: Rachbauer F, Kain MS, Leunig M. The history of the anterior approach to the hip. Orthop Clin North Am 2009;40:311-20.)

11: Restrepo C, Parvizi J, Pour AE, Hozack WJ. Prospective randomized study of two surgical approaches for total hip arthroplasty. J Arthroplasty 2010;25:671-9.e1.

12: Homma Y, Baba T, Sano K, Ochi H, Matsumoto M, Kobayashi H, Yuasa T, Maruyama Y, Kaneko K. Lateral femoral cutaneous nerve injury with the direct anterior approach for total hip arthroplasty. Int Orthop 2016;40:1587-93.

13: Rudin D, Manestar M, Ullrich O, Erhardt J, Grob K. The Anatomical Course of the Lateral Femoral Cutaneous Nerve with Special Attention to the Anterior Approach to the Hip Joint. J Bone Joint Surg Am 2016;98:561-7.

14: Goulding K, Beaulé PE, Kim PR, Fazekas A. Incidence of lateral femoral cutaneous nerve neuropraxia after anterior approach hip arthroplasty. Clin Orthop Relat Res 2010;468:2397-404

15: Eksioglu F, Uslu M, Gudemez E, Atik OS, Tekdemir I. Reliability of the safe area for the superior gluteal nerve. Clin Orthop Relat Res 2003:111-6.

16: Grob K, Manestar M, Ackland T, Filgueira L, Kuster MS. Potential Risk to the Superior Gluteal Nerve During the Anterior Approach to the Hip Joint: An Anatomical Study. J Bone Joint Surg Am 2015;97:1426-31.

17: Meneghini RM, Pagnano MW, Trousdale RT, Hozack WJ. Muscle damage during MIS total hip arthroplasty: Smith- Petersen versus posterior approach. Clin Orthop Relat Res 2006;453:293-8.

18: Pfirrmann CWA, Notzli HP, Dora C, Hodler J, Zanetti M. Abductor tendons and muscles assessed at MR imaging after total hip arthroplasty in asymptomatic and symptomatic patients. Radiology 2005;235:969-76.

19: Woolson ST, Pouliot MA, Huddleston JI. Primary total hip arthroplasty using an anterior approach and a fracture table: short-term results from a community hospital. J Arthroplasty 2009;24:999-1005.

20: Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res 2005;441:115-24.

21: De Geest T, Vansintjan P, De Loore G. Direct anterior total hip arthroplasty: complications and early outcome in a series of 300 cases. Acta Orthop Belg 2013;79:166-73.

22: Sidler-Maier CC, Waddell JP. Incidence and predisposing factors of periprosthetic proximal femoral fractures: a literature review. Int Orthop 2015;39:1673-82.

23: Berend KR, Mirza AJ, Morris MJ, Lombardi AV Jr. Risk of Periprosthetic Fractures With Direct Anterior Primary Total Hip Arthroplasty. J Arthroplasty 2016;31:2295-8.

24: Franklin J, Malchau H. Risk factors for periprosthetic femoral fracture. Injury 2007;38:655-60.

25: Ulrich SD, Seyler TM, Bennett D, Delanois RE, Saleh KJ, Thongtrangan I, Kuskowski M, Cheng EY, Sharkey PF, Parvizi J, Stiehl JB, Mont MA. Total hip arthroplasties: what are the reasons for revision? Int Orthop 2008;32:597-604.

26: Dall'Oca C, Trivellin G, D'Orazio L, Sambugaro E, Mezzari S, Zanetti G, Corbo VR, Magnan B. Hip arthroscopy in osteoarthritis consequent to FAI Acta Biomed. 2016 Apr 15;87 Suppl 1:46-52.

27: Meneghini RM, Elston AS, Chen AF, Kheir MM, Fehring TK, Springer BD. Direct Anterior Approach: Risk Factor for Early Femoral Failure of Cementless Total Hip Arthroplasty: A Multicenter Study. J Bone Joint Surg Am 2017;99:99-105.

28: Eto S, Hwang K, Huddleston JI, Amanatullah DF, Maloney WJ, Goodman SB. The Direct Anterior Approach is Associated With Early Revision Total Hip Arthroplasty. J Arthroplasty 2017;32:1001-5.

29: Sheth D, Cafri G, Inacio MCS, Paxton EW, Namba RS. Anterior and Anterolateral Approaches for THA Are Associated With Lower Dislocation Risk Without Higher Revision Risk. Clin Orthop Relat Res 2015;473:3401-8.

30: Bergin PF, Doppelt JD, Kephart CJ, Benke MT, Graeter JH, Holmes AS, Haleem-Smith H, Tuan RS, Unger AS. Comparison of minimally invasive direct anterior versus posterior total hip arthroplasty based on inflammation and muscle damage markers. J Bone Joint Surg Am 2011;93:1392-8.

31: Martin CT, Pugely AJ, Gao Y, Clark CR. A comparison of hospital length of stay and short-term morbidity between the anterior and the posterior approaches to total hip arthroplasty. J Arthroplasty 2013;28:849-54.

32: Scaglia M, Ditta A, Magnan B, Navarro U, Cassini M Late bleeding during anterior approach to the hip: case report. Acta Biomed. 2019 Dec 5;90(12-S):184-186

33: Jewett BA, Collis DK. High complication rate with anterior total hip arthroplasties on a fracture table. Clin Orthop Relat Res 2011;469:503-7.

34: Christensen CP, Karthikeyan T, Jacobs CA. Greater prevalence of wound complications requiring reoperation with direct anterior approach total hip arthroplasty. J Arthroplasty 2014;29:1839-41.

35: Watts CD, Houdek MT, Wagner ER, Sculco PK, Chalmers BP, Taunton MJ. High Risk of Wound Complications Following Direct Anterior Total Hip Arthroplasty in Obese Patients. J Arthroplasty 2015;30:2296-8.

36: Pugely AJ, Martin CT, Gao Y, Schweizer ML, Callaghan JJ. The Incidence of and Risk Factors for 30-Day Surgical Site Infections Following Primary and Revision Total Joint Arthroplasty. J Arthroplasty 2015;30:47-50.

37: Patel VP, Walsh M, Sehgal B, Preston C, DeWal H, Di Cesare PE. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg Am 2007;89:33-8.

38: Jahng KH, Bas MA, Rodriguez JA, Cooper HJ. Risk Factors for Wound Complications After Direct Anterior Approach Hip Arthroplasty. J Arthroplasty 2016;31:2583-7.

39: Purcell RL, Parks NL, Gargiulo JM, Hamilton WG. Severely Obese Patients Have a Higher Risk of Infection After Direct Anterior Approach Total Hip Arthroplasty. J Arthroplasty 2016;31:162-5

40: Łęgosz P, Otworowski M, Sibilska A, Starszak K, Kotrych D, Kwapisz A, Synder M. “Heterotopic Ossification: A Challenging Complication of Total Hip Arthroplasty: Risk Factors, Diagnosis, Prophylaxis, and Treatment.” BioMed research international vol. 2019 3860142.

41: Zhu Y, Zhang F, Chen W, Zhang Q, Liu S, Zhang Y. Incidence and risk factors for heterotopic ossification after total hip arthroplasty: a meta-analysis. Arch Orthop Trauma Surg 135, 1307–1314 (2015).

42: Pogliacomi F, Paraskevopoulos A, Costantino C, Marenghi P, Ceccarelli F. Influence of surgical experience in the learning curve of a new approach in hip replacement: anterior mini-invasive vs standard lateral. Hip International 2012; 22(5): 555-61.