Recent advances in the direct anterior approach to total hip arthroplasty: a surgeon's perspective.

INTRODUCTION: The direct anterior approach (DAA) has its origins in the first and oldest approach for hip replacement in the literature, but at the same time it would not be fanciful to suggest its increasing popularity as the latest approach for hip replacement procedures, especially among younger surgeons. However, in a geographical context, the DAA is not considered the major approach in most countries. Moreover, the term DAA encompasses numerous variations in terms of technique. AREAS COVERED: In this narrative review, we describe our recent experience of advances in the DAA in terms of improved techniques and devices, along with some of its disadvantages. Also, we express our perspective on its future application. EXPERT OPINIONS: The DAA is established as one of exemplary approaches to THA. The use of fluoroscopy, the traction table, and appropriate soft tissue management has become essential in the DAA for a safe and trouble-free procedure with adequate patient comfort. With the combination of recent technologies such as robotics, three-dimensional preoperative planning, and artificial intelligence (AI)-based surgeon assist systems, we can look forward to the DAA being performed more efficiently in the future.

Lateral versus conventional fasciotomy for prevention of lateral femoral cutaneous nerve injury in total hip arthroplasty with direct anterior approach: a study protocol for a dual-center, double-blind, randomized controlled trial.

BACKGROUND: An incision for total hip arthroplasty (THA) via the direct anterior approach (DAA) is generally made outside of the space between the sartorius and tensor fasciae latae muscles to prevent lateral femoral cutaneous nerve (LFCN) injury. Anatomical studies have revealed that the LFCN courses between the sartorius and tensor fasciae latae muscles. When the LFCN branches radially while distributing in the transverse direction from the sartorius muscle to the tensor fasciae latae muscle, it is called the fan type. Studies suggest that damage to the fan type LFCN is unavoidable during conventional fasciotomy. We previously demonstrated that injury to non-fan variation LFCN occurred in 28.6% of patients who underwent THA by fasciotomy performed 2 cm away from the intermuscular space. This suggests that the conventional approach also poses a risk of LFCN injury to non-fan variation LFCN. LFCN injury is rarely reported in the anterolateral approach, which involves incision of fascia further away than the DAA. The purpose of this study is to investigate how the position of fasciotomy in DAA affects the risk of LFCN injury. METHODS: We will conduct a prospective, randomized, controlled study. All patients will be divided into a fan variation and a non-fan variation group using ultrasonography before surgery. Patients with non-fan variation LFCN will receive conventional fasciotomy and lateral fasciotomy in the order specified in the allocation table created in advance by our clinical trial center. The primary endpoint will be the presence of LFCN injury during an outpatient visit using a patient-based questionnaire. The secondary endpoints will be assessed based on patient-reported outcomes at 3 months after surgery in an outpatient setting using the Western Ontario and McMaster Universities Osteoarthritis Index, the Japanese Orthopaedic Association Hip-disease Evaluation Questionnaire, and the Forgotten-Joint Score-12. DISCUSSION: We hypothesize that the incidence of LFCN injury due to DAA-THA is reduced by making the incision further away from where it is typically made in conventional fasciotomy. If our hypothesis is confirmed, it will reduce the disadvantages of DAA and improve patient satisfaction. TRIAL REGISTRATION: UMIN Clinical Trials Registry, UMIN000035945 . Registered on 20 February, 2019.

Relationship between Charlson comorbidity index, early recovery and 2-year mortality in elderly patients undergoing surgical treatment of inter-trochanteric fractures: a retrospective analysis.

The aim of this study was to evaluate how the Charlson Comorbidity Index (CCI) scores contribute to early recovery and 2-year mortality in elderly patients undergoing surgical treatment of inter-trochanteric fractures. 60 cases with unilateral intertrochanteric fracture were retrospectively analyzed and divided into Low-CCI group (CCI: 1-4) or high-CCI groups (CCI: 5-6). All the patients' electronic hospital records were reviewed. The preoperative situations (demographic data, comorbidities and fracture conditions), perioperative situations (wait time, operation time, implant choice, blood loss, transfusion or not) and postoperative situations (complications, first time out of bed, function about 1-/2- week and 2-year mortality) were recorded. 51.67% were in low-CCI group and 48.33% in high-CCI group. The survival rates in low- and high-CCI group were 93.5% and 86.2% respectively. According to the functional results of 1- or 2- week after operation, no significant difference was found (P = 0.955, 0.140). Log-rank analysis showed that the main prognostic factors were blood loss, first time out of bed and complication (P < 0.05). Multivariate analysis confirmed that complication and first time out of bed were significant factor on survival rate (P = 0.029, 0.010). Charlson comorbidity index maybe not the indicator of 2-year mortality in older patients with intertrochanteric fractures. In order to improve the prognosis, more attentions should be paid to reduce the complications and encourage postoperative earlier excise out of bed.

Valgus osteotomy for atypical interprosthetic femoral fracture with lateral bowing of the femur.

INTRODUCTION: In recent years, it has been reported that periprosthetic femoral fractures in the form of atypical femoral fractures (AFFs) are found occasionally as difficult-to-treat conditions. To date, there have been no reports of interprosthetic femoral fractures (IPFFs) having the form of AFFs. We report a case of an atypical IPFF with breakage of the plate due to abnormal femoral alignment. CASE REPORT: A 70-year-old woman was admitted. She underwent left knee replacement and left hemi-arthroplasty at ages 61 and 60. And she had been taking bisphosphonate for 5 years. A plain X-ray revealed IPFF. The fracture was a complete transverse fracture with circumscribed thickening of the lateral cortical bone ("beak sign") at the fracture site. She underwent surgery. A reversed condylar locking compression plate (LCP) was used for internal fixation. Subsequently, she could walk without particular pain. Five months after the operation, she heard the snap of a bone breaking, and had difficulty walking. Plain X-ray revealed a re-fracture of the fracture site and breakage of the plate at the same high position. She underwent re-operation. A valgus osteotomy was performed at an angle of 15°. A reversed condylar LCP was used on the lateral side of the femur. A bone grafting was performed focusing on the fracture site. In addition, a short-LCP was fixed anteriorly to the femur. The bone union 1 year and 6 months postoperatively. She could walk, with no impairment being noted regarding ADL. CONCLUSIONS: We performed osteosynthesis for an IPFF having the characteristics of AFF, but the patient suffered breakage of the plate and re-fracture. Bone union was achieved as a result of re-operation that consisted of valgus osteotomy of the fracture site in combination with autologous bone grafting and double orthogonal plating.

Does total hip arthroplasty via the direct anterior approach using dual mobility increase leg length discrepancy compared with single mobility?

BACKGROUND: Total hip arthroplasty (THA) via the direct anterior approach (DAA) using dual mobility cup (DMC) is considered to effectively prevent postoperative dislocation. However, the dislocation and reduction procedure using a trial implant during the surgery is difficult because of high soft tissue tension. Thereby, leg length discrepancy (LLD) is difficult to assess when using DM via the DAA. PURPOSE: To compare the LLD between cases using conventional SM and those using DMC in THA via the DAA with fluoroscopy. PATIENTS AND METHODS: We retrospectively investigated 34 hips treated with DMC (DMC-DAA group) and 31 hips treated with SM (SM-DAA group). The LLD was defined as the difference in the distance from the teardrop to the medial-most point of the lesser trochanter between the operative and nonoperative sides at immediate postoperative X-ray. RESULTS: The mean LLD in the DMC-DAA group and SM-DAA group was 0.68 ± 7.7 mm and 0.80 ± 5.5, respectively, with no significant difference. The absolute value of the LLD in the DMC-DAA group and SM-DAA group was 6.3 ± 4.4 mm and 5.9 ± 5.5, respectively, with no significant difference. CONCLUSION: Despite the difficulty in assessment of the LLD during THA via the DAA using DMC, this technique does not increase the LLD compared with the use of SM. LEVEL OF EVIDENCE: III, matched case-control study.

Use of traction table did not increase complications in total hip arthroplasty through direct anterior approach performed by novice surgeon.

PURPOSE: The purpose of this study was to investigate the surgical outcomes of total hip arthroplasty (THA) through direct anterior approach (DAA) performed by beginners by comparing the outcomes after the introduction of DAA-THA between using a normal operating table and a traction table. METHODS: The total subjects were 200 patients, there were 120 cases from the introduction of three surgeons using a normal table and 80 cases from two surgeons using a traction table. The surgical procedure was standardized, and a surgeon skilled in DAA entered the operating room and instructed the novice surgeons of DAA in all cases. RESULTS: The mean operative time was no significant difference between the two groups (p = 0.093). The difference in slope of the operative time was no significant difference between the two groups (p value = 0.089). The mean fluoroscopy time and the mean blood loss were significant difference between the two groups (p < 0.05). The difference in slope of the fluoroscopy time and blood loss were significant difference between the two groups (p < 0.05). There were no intraoperative complications and no reoperations for any reason. CONCLUSIONS: At the facility with a surgeon skilled in DAA, the use of a traction table in DAA did not increase the complication rate compared with the use of a normal operating table when the exclusion criteria for DAA were set and surgery was performed using intraoperative fluoroscopy under supervision by a skilled surgeon.

Does a fluoro-assisted direct anterior approach for total hip arthroplasty pose an excessive risk of radiation exposure to the surgeon?

INTRODUCTION: Intraoperative fluoroscopy can be easily used because patients are placed in the supine position during total hip arthroplasty via direct anterior approach (DAA-THA) to reduce complications. However, the cumulative level of radiation exposure by intraoperative fluoroscopy increases as the annual number of cases increases, increasing the risk of influencing the health of both the patients and medical workers. The objective of the study was to compare the radiation exposure time of DAA-THA with osteosynthesis and to determine if the level of radiation exposure exceeded safety limits. MATERIAL AND METHODS: DAA-THA was performed in 313 patients between January 2016 and July 2018 and 60 patients with proximal femoral fracture were treated with osteosynthesis. The intraoperative fluoroscopy time was retrospectively surveyed and compared between these two groups. A total of eight surgeons operated DAA-THA employing the same procedure using a traction table. A total of nine surgeons operated osteosynthesis and fluoroscopy was appropriately used during reduction and implant insertion. RESULTS: The mean operative time of DAA-THA was 103.3 min and that of osteosynthesis was 83.3 min, showing a significant difference (p < 0.05). The mean intraoperative fluoroscopy time was 0.83 min (SD ± 0.68) in DAA-THA and 8.91 min (SD ± 8.34) in osteosynthesis showing a significant difference (p < 0.05). CONCLUSIONS: The intraoperative exposure level was significantly lower and the fluoroscopy time was significantly shorter in DAA-THA than in osteosynthesis for proximal femoral fracture. It was clarified that the annual cumulative radiation exposure level in DAA-THA does not exceed the tissue dose limit.

Posterior versus direct anterior approach in revision hip arthroplasty using Kerboull-type plate.

INTRODUCTION: The purpose of this study was to investigate revision with a Kerboull-type plate through the posterior approach (PA) and direct anterior approach (DAA) and compare the clinical outcome. SUBJECTS AND METHODS: Fifty-four patients (56 hip joints) underwent revision surgery in which acetabular reconstruction was performed concomitantly using the Kerboull-type plate and allogeneic bone. Revision surgery through DAA was performed in 21 hip joints and these were compared with 34 hip joints treated through PA. There was no significant difference in the patient demographics between the DAA and PA. RESULTS: There was no significant difference between the operative times in the DAA and PA groups (203.2 ± 43.5 and 211.7 ± 41.8 min). There was a significant difference between the intraoperative blood loss in the DAA and PA groups (503.9 ± 223.7 mL and 703.8 ± 329.6 mL, respectively, p < 0.05). There was no significant difference between the modified Harris Hip Score in the DAA and the PA groups. The loosening of the acetabular component was observed in four cases (11.8%) in the PA group. In the DAA and PA groups, the 5-year survival rates were 100 and 85.7%, respectively. Recurrent dislocation of the hip was observed in six cases (one case in the DAA group (4.8%) and five cases in the PA group (14.7%)). CONCLUSIONS: It was verified that the difference in the surgical approach of acetabular reconstruction concomitantly using the Kerboull-type plate and allogeneic bone graft influenced the postoperative outcome.

Objective evaluation for initial stability of highly porous cup without screws in total hip arthroplasty for femoral neck fracture.

BACKGROUND: The purpose of this study was to objectively investigate the initial fixation of highly porous cups in THA for femoral neck fractures. METHODS: THA for displaced femoral neck fractures was performed in 52 consecutive patients. We objectively measured the rotational torque for cup stability, and the primary endpoint was the success rate of press-fit fixation without screws. RESULTS: The success rate of press-fit fixation without screws was 96.1%. No specific complications were occurred. CONCLUSION: The initial stability of highly porous cups was excellent for femoral neck fractures with a high success rate of press-fit fixation without screws.

Posterior versus direct anterior approach in total hip arthroplasty: difference in patient-reported outcomes measured with the Forgotten Joint Score-12.

INTRODUCTION: When the postoperative outcome of primary total hip arthroplasty (THA) was compared with the direct anterior approach (DAA) and the posterior approach (PA), there was no significant difference of the clinical outcome at 6 months to 1 year after surgery in many studies. This study was performed to compare the medium-term outcome of THA via the DAA or PA and clarify which approach achieves better quality of life (QOL). METHODS: We investigated 61 hips receiving primary THA (30 via DAA and 31 via PA), using hip function scores such as the Harris Hip Score (HHS) and patient-reported outcomes such as the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ), and the Forgotten Joint Score-12 (FJS). RESULTS: The mean duration of postoperative follow-up was 36.8 months in the DAA group and 40.5 months in the PA group. There was no difference in preoperative or postoperative HHS between the two groups. Although there was no difference of postoperative WOMAC and JHEQ, the postoperative FJS-12 score was significantly higher in the DAA group than in the PA group (75.2 ± 15.9 versus 60.1 ± 24.4, p = 0.01). CONCLUSION: When forgetting the artificial joint in daily life is the target, better QOL can be achieved by performing THA via the DAA.

Superoxide dismutase activity is significantly lower in end-stage osteoarthritic cartilage than non-osteoarthritic cartilage.

Recent studies have shown that superoxide dismutase 1 (SOD1), SOD2, and SOD3 are significantly decreased in human osteoarthritic cartilage. SOD activity is a marker that can be used to comprehensively evaluate the enzymatic capacities of SOD1, SOD2, and SOD3; however, the trend of SOD activity in end-stage osteoarthritic tissues remains unknown. In the present study, we found that SOD activity in end-stage osteoarthritic synovium of the knee was significantly lower than that in control synovium without the influence of age. The SOD activity was significantly lower in the end-stage knee osteoarthritic cartilage than in the control, but a weak negative correlation was observed between aging and SOD activity. However, SOD activity in end-stage hip osteoarthritic cartilage was significantly lower than that in control cartilage without the influence of aging. The relationship between osteoarthritis and SOD activity was stronger than the relationship between aging and SOD activity. These results indicate that direct regulation of SOD activity in joint tissues may lead to suppression of osteoarthritis progression.

Lumbar artery branches coursing vertically over the intervertebral discs of the lower lumbar spine: an anatomic study.

PURPOSE: Bleeding from the lumbar artery is a potential complication during the transpsoas approach to the lower lumbar intervertebral discs. In this anatomic study, the morphological relationships between the branches of the lumbar artery and the lower intervertebral disc were investigated to assess the risk of injury to the branches of the lumbar segmental arteries. METHODS: We studied 88 sites (86 lumbar arteries) at the third and fourth lumbar vertebrae bilaterally in 22 formalin-fixed cadavers. The branches of the lumbar artery coursing along the lateral sides of the lower intervertebral disc [muscular branch, anastomotic branch, and branch supplying the spinal nerve and plexus (BSNP)] and the iliolumbar artery running upward over the L4-5 disc were identified. Branches crossing the intervertebral discs vertically were evaluated. RESULTS: Muscular branches with a lumen structure longer than 2 cm coursed vertically over the middle third of the intervertebral disc in 3 of 88 sites (3.4 %). Anastomotic branches ran downward in 13 of 88 (14.8 %), and iliolumbar arteries ran upward on the posterior third of the lateral sides of the disc in 2 of 88 (2.3 %). BSNPs ran downward through the posterior third of the disc at 18 of 88 sites (20.5 %). Overall, the arterial branches coursed vertically over the posterior third of the lateral sides of the intervertebral discs in approximately 30 % of subjects. CONCLUSIONS: Lumbar artery branches coursed vertically over the middle third and the posterior third of the lateral sides of the intervertebral discs in approximately 3 and 30 % of subjects, respectively.