Abstract
Purpose
In this study we compare the surgical outcome of DAA and PA more than 5-year follow-up evaluation.
Materials and methods
This is a retrospective cohort single-surgeon study of consecutive primary THAs using the DAA or PA.
Results
There was no significant difference in HHS and JHEQ score. Posterior dislocation occurred in 4 cases in PA group (9.5%, p = 0.038) while there was no dislocation in DAA group.
Conclusion
Both DAA and PA yield good results at the final follow-up in terms of function, quality of life, and survivorship. However dislocation was significantly higher in PA group.
Keywords: Total hip arhtoplasty, Direct anterior approach, Posterior approach, Surgical outcome
1. Introduction
Interest in direct anterior approach (DAA) has gained in recent years for total hip arhtroplasty (THA). DAA has become an increasingly popular THA technique due in large part to the potentially faster functional recovery, decreased visual analogue scale pain scores, decreased length of stay, increased rate of discharge to home, and reduced use of assistive devices.1,2 There are a number of prospective clinical studies comparing the DAA to other approaches. When DAA is compared to a posterior approach (PA), some reported a more rapid recovery for hip function and gait ability using DAA.3,4 One study reported no difference in gait characteristics, pain or function after six months but greater stiffness in patients undergoing the PA.5 Lower dislocation rates have been reported with the DAA, attributed to the use of supine positioning, possible intraoperative fluoroscopy, and more accurate implant positioning.6, 7, 8
However, other reports have noted that there was no systematic advantage of DAA versus PA THA.9,10 Recent systematic review of the literature also found little evidence for improved kinematics or long-term outcomes following the DAA for THA.11 In addition, a recent meta-analysis showed that current evidence comparing outcomes following DAA versus PA THA does not demonstrate clear superiority of either approach, and there was a risk of intra-operative fractures and lateral femoral cutaneous nerve impairment in DAA group.12
Because the DAA is the less studied approach, controversy exists regarding long-term benefits of the DAA. There is little evidence for long-term outcome and complications. The purpose of this study is to report the clinical outcome (subjective and objective) and complications for more than 5-year follow-up, and to address whether there is a difference between DAA and PA groups in long-term follow-up.
2. Materials and methods
Institutional review board approval was obtained before review of any records. This is a retrospective cohort single-surgeon study of consecutive primary THAs using the DAA or PA from February 2012 to July 2015. We excluded Crowe group IV developmental dysplasia of the hip (DDH) requiring acetabular reconstruction in both group. One patient died in both group and a total of 86 consecutive THAs (DAA 44, PA 42) were prospectively collected and retrospectively reviewed. All subjects enrolled in this study received the Trident cup-Accolade stem system (Stryker Orthopaedics, Mahwah, NJ, USA). DAA-THA was performed in the supine position on a normal table with fluoroscopy and subsequent repair of the anterior capsule. PA-THA was performed in the lateral decubitus position with division and subsequent repair of the hip external rotators and capsule. In both group, the cup was set up, aiming for an inclination angle of 40° and an anteversion angle of 15°. Regardless of approach, all patients were subjected to the same preoperative, perioperative, anesthetic, rehabilitation, and pain protocols, except for the requirement for hip precautions in the PA group which do not apply to the DAA group. For the post-operative pain management, we used patient controlled epidural analgesia (PCEA). All patients discharge from hospital after they were able to go up and down the stairs with cane, as we do not have rehabilitation facility outside the hospital.
As a subjective measurement, surgeon reported outcome measurement (Harris Hip Score; HHS)13 was used. As an objective measurement, the self-administered Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ)14 was used for assessment preoperatively and postoperatively following THA. The JHEQ takes into account facets of the Asian life-style, it may help improve the assessment of QOL for Asian patients. At the same time, the JHEQ can also be useful in Western populations for evaluating patients who frequently engage in deep flexion of the hip joint. The patients filled it out by themselves. We also recorded post-operative complications including dislocation, deep vein thrombosis, intraoperative fracture, deep infection, and re-operation for any reason.
2.1. Statistical analysis
Statistical analysis of differences between the two groups was performed using GraphPad Prism 5 version 5.0. Chi-square test was used for qualitative variables, and Student's t-test was used for quantitative variables. Levels of significance reaching 95% or more were accepted.
3. Results
Patient characteristics such as gender, diagnosis, age at operation, BMI, ASA, and follow-up period were not significant different between two groups (Table 1). There was a significant improvement in function as measured by the HHS, and JHEQ score after THA in both groups (Table 2). However, at the final follow-up, there was no significant difference in HHS and JHEQ score (92.1 vs 93.1 p = 0.239, 71.3 vs 72.3 p = 0.581, respectively) (Table 2).
Table 1.
Characteristics of the patients.
| DAA (SD) | PA (SD) | P-value | |
|---|---|---|---|
| No. of hips | 44 | 42 | |
| Gender F/M | 41/3 | 37/5 | 0.417 |
| Diagnosis OA/ANF | 40/4 | 35/7 | 0.293 |
| Age at operation | 63.3 (13.3) | 60.9 (11.7) | 0.592 |
| BMI (kg/m2) | 24.0 (3.75) | 23.5 (3.55) | 0.572 |
| ASA | 2.0 (0.39) | 2.06 (0.34) | 0.498 |
| Follow-up period | 74.2 (7.63) | 77.7 (12.3) | 0.213 |
OA; osteoarthritis, ANF; aseptic necrosis of femoral head.
Table 2.
Outcome by surgical approach.
| DAA (SD) | PA (SD) | p-value | |
|---|---|---|---|
| Harris Hip Score | |||
| Pre-ope | 47.7 (7.94) | 49.8 (5.41) | 0.317 |
| Final follow-up |
92.1 (4.39) |
93.1 (3.83) |
0.239 |
| JHEQ Score | |||
| Pre-ope | 18.0 (10.8) | 22.2 (11.8) | 0.112 |
| Final follow-up | 71.3 (7.39) | 72.3 (6.35) | 0.581 |
Postoperative complications in the DAA and PA groups are listed in Table 3. Posterior dislocation occurred in 4 cases in PA group (9.5%, p = 0.038) while there was no dislocation in DAA group. In these cases, acetabular component was implanted in the safe zone and femoral component was implanted in neutral. None of the patients with dislocation developed re-dislocation who requires revision surgery. In the DAA group, stem subsidence occurred in one case. At the final follow-up, there was no revision case in both groups.
Table 3.
Complications.
| DAA | PA | p-value | |
|---|---|---|---|
| Dislocation | 0 | 4 (9.5%) | 0.038 |
| Stem subsidence | 1 (2/2%) | 0 | 0.326 |
| Revision | 0 | 0 |
4. Discussion
Interest in muscle-sparing less invasive procedures in THA have gained popularity. However, superiority of surgical approach is still controversial. Several articles reported a benefit in early phase (3–6 months) in DAA vs PA group but no difference at 1 year in functional outcome.1, 2, 3, 4 Maldonado et al.15 at minimum 2-year follow-up noted superior quality of life outcomes for DAA group when compared with a propensity score matched group of PA surgeries. Barret et al.16 at an average 5-year follow-up noted no significant difference between surgical approaches (DAA and PA) in terms of HSS and quality of life outcomes. These results are consistent with our study.
Regarding the postoperative complications, Mjaaland et al.17 who used Norwegian registry data at 5-year follow-up and noted no significant difference in survivorship between DAA and PA. Barret et al.16 also found no loose implant at average 5-yerar follow-up and the 7-year survivorship was not significantly different. However, Ponzio et al.18 at minimum 4-year follow-up reported significantly higher revision rate for the PA group (2.7%) compared with DAA group (0.7%) due mainly to a higher dislocation rate in PA group. Sheth et al.19 who used The Kaiser Permanente Total Joint Registry at median 3-year follow-up noted anterolateral approach and DAA had a lower risk of dislocation relative to PA and concluded DAA had the advantage of dislocation without increasing the risk of revision. Concerning the stem stability, Eto et al.20 noted revision of the femoral component for aseptic loosening is more commonly associated with the DAA in their referral practice.
In our series, we found stem subsidence in DAA group but no revision was necessary.
We also found significantly higher dislocation rate in PA group. As acetabular component was implanted in the safe zone and femoral component was implanted in neutral in all dislocation cases, surgical approach, especially muscle-sparing technique is important to avoid dislocation after THA.
There are several limitations to this study. First, this is a retrospective study, and the patients in this study were not randomized. Second, it is a single-surgeon, single-center study. So it is not clear that our results may be generalized. Longer follow-up is needed to examine survivorship.
5. Conclusion
Both DAA and PA yield good results at the final follow-up in terms of function, quality of life, and survivorship. However dislocation was significantly higher in PA group. Surgical approach plays an important role to avoid dislocation after THA.
Although there is a learning curve for DAA,21 based on our results, we continue to use the DAA to reduce dislocation for primary THA.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the medical research ethics committee at our institute.
Declaration of competing interest
The authors declare that they have no conflict of interest.
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