The direct anterior approach to the hip: a useful tool in experienced hands or just another approach?

The direct anterior approach (DAA) to the hip was initially described in the nineteenth century and has been used sporadically for total hip arthroplasty (THA). However, recent increased interest in tissue-sparing and small incision arthroplasty has given rise to a sharp increase in the utilization of the DAA. Although some previous studies claimed that this approach results in less muscle damage and pain as well as rapid recovery, a paucity in the literature exists to conclusively support these claims. While the DAA may be comparable to other THA approaches, no evidence to date shows improved long-term outcomes for patients compared to other surgical approaches for THA. However, the advent of new surgical instruments and tables designed specifically for use with the DAA has made the approach more feasible for surgeons. In addition, the capacity to utilize fluoroscopy intraoperatively for component positioning is a valuable asset to the approach and can be of particular benefit for surgeons during their learning curve. An understanding of its limitations and challenges is vital for the safe employment of this technique. This review summarizes the pearls and pitfalls of the DAA for THA in order to improve the understanding of this surgical technique for hip replacement surgeons.

A Formal Same-Day Discharge Total Joint Arthroplasty Program May Not Be Necessary: A Propensity-Matched Cohort Study.

BACKGROUND: Same-day discharge (SDD) total joint arthroplasty (TJA) programs often have stringent selection criteria. Some patients deemed ineligible may nonetheless be discharged on the day of surgery. This study compares the outcomes between patients enrolled in our SDD TJA program who were SDD to those who did not participate in the program but were also SDD. METHODS: We retrospectively reviewed all patients who were SDD following TJA from 2015 to 2020. Patients were stratified into two cohorts based on whether they were formally enrolled in our institution's SDD TJA program. Propensity-score matching was performed to limit confounding and independent sample t-tests or Pearson's chi-squared tests were used to compare outcomes of interest between the matched groups. RESULTS: Of the 1778 patients included, 1384 (78%) completed the SDD TJA program and 394 (22%) were SDD but did not participate in the SDD TJA program. Upon 1:1 propensity-score matching, a total of 550 patients were matched for comparison. The surgical time was significantly longer for patients who did not participate in the SDD TJA program compared to those who participated in the program (109.39 vs 87.29 minutes; P < .001). Discharge disposition (P = .999), 90-day emergency department visits (P = .476), 90-day all-cause readmissions (P = .999), 90-day all-cause revisions (P = .563), and Hip disability and Osteoarthritis Outcome Scores for Joint Replacement (HOOS, JR) and Knee Injury and Osteoarthritis Outcome Scores for Joint Replacement at all time points did not significantly differ. CONCLUSION: Enrollment in a formal SDD TJA program may not be a necessary precursor to achieving similar outcomes following TJA for patients who are SDD without formally enrolling. Therefore, a formal program may no longer be needed at an institution with well-established evidence-based protocols with strong success and an experience with value-based care. LEVEL III EVIDENCE: Retrospective Cohort Study.

Does racial background influence outcomes following total joint arthroplasty?

BACKGROUND: The purpose of this study is to assess whether racial differences influence patient-reported outcome measures (PROMs) following primary total hip (THA) and knee (TKA) arthroplasty. METHODS: We retrospectively reviewed patients who underwent primary THA or TKA from 2016 to 2020 with available PROMs. Both THA and TKA patients were separated into three groups based on their ethnicity: Caucasian, African-American, and other races. Patient demographics, clinical data, and PROMs at various time-periods were collected and compared. Demographic differences were assessed using chi-square and ANOVA. Univariate ANCOVA was utilized to compare outcomes and PROMs while accounting for demographic differences. RESULTS: This study included 1999 THA patients and 1375 TKA patients. In the THA cohort, 1636 (82%) were Caucasian, 177 (9%) were African-American, and 186 (9%) were of other races. In the TKA cohort, 864 (63%) were Caucasian, 236 (17%) were African-American, and 275 (20%) were of other races. Surgical-time significantly differed between the groups that underwent THA (88.4vs.100.5vs.96.1; p < 0.001) with African-Americans requiring the longest operative time. Length-of-stay significantly differed in both THA (1.5vs.1.9vs.1.8; p < 0.001) and TKA (2.1vs.2.5vs.2.3; p < 0.001) cohorts, with African-Americans having the longest stay. Caucasians reported significantly higher PROM scores compared to non-Caucasians in both cohorts. All-cause emergency-department (ED) visits, 90-day postoperative events (readmissions&revisions), and discharge-disposition did not statistically differ in both cohorts. CONCLUSION: Non-Caucasian patients demonstrated lower PROM scores when compared to Caucasian patients following TJA although the differences may not be clinically relevant. LOS was significantly longer for African-Americans in both THA and TKA cohorts. Further investigation identifying racial disparity interventions is warranted. LEVEL OF EVIDENCE: Prognostic Level III.

Robotics Versus Navigation Versus Conventional Total Hip Arthroplasty: Does the Use of Technology Yield Superior Outcomes?

BACKGROUND: The use of technology such as navigation and robotic systems may improve the accuracy of component positioning in total hip arthroplasty (THA), but its impact on patient-reported outcome measures (PROMs) remains unclear. This study aims to elucidate the association between the use of intraoperative technology and PROMs in patients who underwent primary THA. METHODS: We retrospectively reviewed a consecutive series of patients who underwent primary THA between 2016 and 2020 and answered PROM questionnaires. Patients were separated into 3 groups depending on intraoperative technology utilization: computer-assisted navigation, robotic-assisted, or no technology (conventional) THA. Forgotten Joint Score-12 and Hip disability and Osteoarthritis Outcome Score, Joint Replacemen scores were collected at various time points. Demographic differences were assessed with chi-square and analysis of variance. Mean scores between groups were compared using univariate analysis of covariance, controlling for all significant demographic differences. RESULTS: Of the 1960 cases identified, 896 used navigation, 135 used robotics, and 929 used no technology. There were significant statistical differences in one-year Hip disability and Osteoarthritis Outcome Score, Joint Replacement scores (85.23 vs 85.95 vs 86.76, respectively; P = .014) and two-year Forgotten Joint Score-12 scores (64.72 vs 73.35 vs 74.63, respectively; P = .004) between the 3 groups. However, these differences did not exceed the mean clinically important differences. Length of stay was statistically longest for patients who underwent conventionally performed THA versus navigation and robotics (2.22 vs 1.46 vs 1.91, respectively; P < .001). Surgical time was significantly longer for cases performed using robotics versus navigation and conventionally (119.61 vs 90.35 vs 95.35, respectively; P < .001). CONCLUSION: Statistical differences observed between all modalities are not likely to be clinically meaningful with regard to early patient-reported outcomes. Although intraoperative use of technology may improve the accuracy of implant placement, these modalities have not yet translated into improved early reported functional outcomes. LEVEL III EVIDENCE: Retrospective cohort.