No Difference in Functional, Radiographic, and Survivorship Outcomes Between Direct Anterior or Posterior Approach THA: 5-Year Results of a Randomized Trial.

BACKGROUND: Both the direct anterior approach (DAA) and posterior approach (PA) to THA have known advantages and disadvantages. The comparison between DAA and PA THA has been widely explored during the early postoperative period. However, few randomized trials have compared these approaches at a minimum follow-up of 5 years; doing so would be important to establish any differences in mid-term outcomes or complications. QUESTIONS/PURPOSES: We performed a randomized trial comparing DAA and PA in THA in terms of (1) patient-reported outcome scores, (2) quality of life and functional outcomes assessed by the EQ-5D and 10-meter walk test results, (3) radiographic analysis, and (4) survivorship and surgical complications at a minimum of 5 years follow-up. METHODS: Two hip specialist surgeons performed both DAA and PA THA using the same THA components at two hospital sites. One hundred twelve patients on the elective THA surgical waitlist were invited to participate in the study. Thirty-four patients did not meet the study's inclusion criteria and were excluded, and three patients declined to participate in the study. The remaining 75 patients who were eligible were randomized into DAA and PA groups. Thirty-seven patients were initially randomized to receive DAA THA, but two did not and were excluded, resulting in 48% (35 of 73) of patients who received DAA THA; 52% (38 of 73) of patients were randomized into and received PA THA. Over a minimum 5 years of follow-up, 3% (1 of 35) of DAA patients were lost to follow-up, and none of the patients undergoing PA THA were lost. A per-protocol analysis was adopted, resulting in further patients being excluded from analysis. Of the 73 study patients, 99% (72; DAA: 35, PA: 37) were analyzed at 1 year, 95% (69; DAA: 34, PA: 35) were analyzed at 2 years, and 72% (52; DAA: 23, PA: 29) were analyzed at 5 years. The primary outcome was the Oxford Hip Score (OHS) and WOMAC score. Secondary outcomes included the EQ-5D and EQ-5D VAS scores, 10-meter walk test results, radiographic evidence of loosening (femoral: lucency > 2 mm at the implant-bone interface, subsidence > 2 mm; acetabular: migration or change in inclination), 5-year survivorship analysis from all-cause revisions, and surgical complications. The study was powered to detect a 10-point difference in the WOMAC score, which is equivalent to the minimum clinically important difference (MCID). RESULTS: There were no differences in primary outcomes (OHS and WOMAC scores) or secondary outcomes (EQ-5D scores, EQ-5D VAS scores, and 10-meter walk test result) between the DAA and PA groups at the 5-year follow-up interval. The median (range) OHS at 5 years was 46 (16 to 48) for DAA and 47 (18 to 48) for PA groups (p = 0.93), and the median WOMAC score was 6 (0 to 81) for DAA and 7 (0 to 59) for PA groups (p = 0.96). The median EQ-5D score was 1 (0.1 to 1) for DAA and 1 (0.5 to 1) for PA groups (p = 0.45), and the median EQ-5D VAS score was 85 (60 to 100) for DAA and 95 (70 to 100) for PA groups (p = 0.29). There were no cases of component loosening on radiographs. There was no difference in component survival between the two approaches at 5 years (DAA: 97% [95% CI 85% to 100%] versus PA: 97% [95% CI 87% to 100%]). Eight of 23 patients in the DAA group reported decreased sensation in the lateral femoral cutaneous nerve distribution. CONCLUSION: DAA and PA are both effective approaches in performing primary THA. Each approach has its associated risks and complications. The choice of THA should be based on individual patient factors, surgeon experience, and shared decision-making. Early registry data indicate DAA and PA THA are comparable, but longer-term data with larger numbers of patients will be required before one can safely conclude equal survivorship between both approaches. LEVEL OF EVIDENCE: Level I, therapeutic study.

A Prospective Randomized Clinical Trial in Total Hip Arthroplasty-Comparing Early Results Between the Direct Anterior Approach and the Posterior Approach.

BACKGROUND: We report a prospective randomized study comparing early clinical results between the direct anterior approach (DAA) and posterior approach (PA) in primary hip arthroplasty. METHODS: Surgeries were performed by 2 senior hip arthroplasty surgeons. Seventy-two patients with complete data were assessed preoperatively 2, 6, and 12 weeks postoperatively. The primary outcomes were the Western Ontario McMasters Arthritis Index and Oxford Hip Scores. Secondary outcome measures included the EuroQoL, 10-meter walk test, and clinical and radiographic parameters. RESULTS: Data analyses showed no difference between DAA (n = 35) and PA (n = 37) groups when comparing total scores for primary outcomes. No significant differences were observed for 10-meter walk test, EuroQoL, and radiographic analyses. Subgroup analysis for surgeon 1 identified that the DAA group had shorter acute hospital stay, less postoperative opiate requirements, and smaller wounds. However, this was offset by increased operative time, higher intraoperative blood loss, and weaker hip flexion at 2 and 6 weeks. Subgroup analysis of items on the Western Ontario McMasters Arthritis Index and Oxford Hip Score identified that hip flexion activity favored the DAA group up to 6 weeks postoperatively. There was an 83% incidence of lateral cutaneous nerve of thigh neuropraxia at the 12-week mark in the DAA group. No neuropraxias occurred in the PA group. One dislocation occurred in each group. A single patient from the DAA group required reoperation for leg-length discrepancy. CONCLUSION: DAA total hip arthroplasty (THA) has comparable results with PA THA. Choice of surgical approach for THA should be based on patient factors, surgeon preference, and experience.

Vastus lateralis transfer for severe hip abductor deficiency: a salvage procedure.

INTRODUCTION: Abductor muscle deficiency can be a debilitating problem following hip arthroplasty surgery. We report outcomes of a novel method of abductor muscle function reconstruction surgery in patients with chronic, irreparable gluteus medius and minimus defects. PATIENTS AND METHODS: Four consecutive patients who underwent our method of abductor reconstruction surgery were retrospectively reviewed. All patients had severe pain and positive Trendelenberg gait before surgery. TECHNIQUE: the vastus lateralis (VL) muscle was raised on its neurovascular pedicle and transferred 12-14 centimetres by proximal translation. The proximal portion of VL was reattached via bony anchors to the external surface of the iliac wing just below the iliac crest. The distal portion of VL reattached to the lateral femoral shaft, lateral intermuscular septum, and the fascia of vastus intermedius. RESULTS: Average follow-up was 10 months (range 7-15 months). Three of the four patients report dramatic improvement in pain as measured by the visual analogue pain scale. The same three patients report being "extremely satisfied" with the pain relief achieved and "extremely satisfied" with the operation overall. Two patients reported being "extremely satisfied" with improvements in walking. Hip abduction power improved in all patients but to varying degrees. CONCLUSION: The results show that our method of VL transfer may be a viable option for patients with severe abductor deficiency. Modest but clinically relevant early results are seen.

Mechanical characteristics of antibiotic-laden bone cement.

We studied the mechanical characteristics of cement-antibiotic combinations in vitro. Palacos R was tested without antibiotics, with gentamicin alone and with gentamicin plus vancomycin or flucloxacillin. Palacos LV was studied only with gentamicin added. CMW 1 was studied with gentamicin added, with gentamicin plus vancomycin, and with gentamicin plus flucloxacillin. We performed four-point bending tests on beams of cement to establish bending strength and modulus, and compared the values to ISO standards. Density was also assessed. Palacos R was the strongest of the cements (bending strength 80 MPa). Palacos formulations (apart from Palacos LV) had a higher density and bending modulus than CMW 1. Statistical comparison of various cements with plain Palacos R showed lower density in 4 of the mixtures, and lower bending strength and modulus in 6 of the mixtures. Palacos R/gentamicin plus vancomycin and CMW 1/gentamicin plus vancomycin had bending strength slightly above minimum ISO standards, suggesting that the addition of vancomycin during cement mixing may compromise the outcome in revision surgery for sepsis.