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Adverse effects associated with the direct anterior approach for total hip arthroplasty: a Bayesian meta-analysis

  • Hip Arthroplasty
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Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Introduction

The direct anterior approach (DAA) is an increasingly popular technique for performing total hip arthroplasty (THA). This muscle-sparing approach may yield functional benefits. However, DAA has been associated with an increased risk incidence (RI) of intra- and postoperative complications.

Materials and methods

A systematic review of the published literature was conducted to document the cumulative RI of intra- and postoperative complications, as well as the presence of a learning curve in subjects undergoing THA with a DAA. Study selection and data extraction were carried out independently in duplicate. A Bayesian zero-inflated random-effect model was used to calculate pooled estimates for the different endpoints.

Results

Thirty-eight studies (6485 patients) were analysed. RIs of 0.8 % [95 % confidence interval (CI): 0.4–1.6 %] and 0.5 % (95 % CI: 0.3–0.9 %) were found for intra-operative trochanter and femoral fractures, respectively, and of 0.9 % (95 CI: 0.3–2.6 %) for postoperative transient lateral cutaneous femoral nerve (LCFN) impairment. A clear RI for early revisions (2.1 %; 95 % CI: 1.4–2.8 %) and other surgical re-interventions (1.3 %; 95 % CI: 0.7–1.9 %) was present, but these values do not differ from reported RIs for THA overall. The RI for dislocation was low (0.6 %; 95 % CI: 0.4–0.9 %) compared with the reported literature.

Conclusions

DAA is a technically demanding procedure, with outcomes possibly indicative of surgeon learning curve. A risk for intra-operative fractures and LCFN is evident, although the risk for other adverse effects is comparable to those with other approaches.

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References

  1. Horne PH, Olson SA (2011) Direct anterior approach for total hip arthroplasty using the fracture table. Curr Rev Musculoskelet Med 4(3):139–145

    Article  PubMed Central  PubMed  Google Scholar 

  2. Barton C, Kim PR (2009) Complications of the direct anterior approach for total hip arthroplasty. Orthop Clin North Am 40(3):371–375

    Article  PubMed  Google Scholar 

  3. Judet J, Judet R (1950) The use of an artificial femoral head for arthroplasty of the hip joint. J Bone Joint Surg Br 32-B(2):166–173

    CAS  PubMed  Google Scholar 

  4. Matta JM, Ferguson TA (2005) The anterior approach for hip replacement. Orthopedics 28(9):927–928

    PubMed  Google Scholar 

  5. Matta JM, Shahrdar C, Ferguson T (2005) Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res 441:115–124

    Article  PubMed  Google Scholar 

  6. Alecci V, Valente M, Crucil M, Minerva M, Pellegrino CM, Sabbadini DD (2011) Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: perioperative findings. J Orthop Traumatol 12(3):123–129

    Article  PubMed Central  PubMed  Google Scholar 

  7. Berend KR, Lombardi AV Jr, Seng BE, Adams JB (2009) Enhanced early outcomes with the anterior supine intermuscular approach in primary total hip arthroplasty. J Bone Joint Surg Am 91(Suppl 6):107–120

    Article  PubMed  Google Scholar 

  8. Anterior Total Hip Arthroplasty Collaborative I, Bhandari M, Matta JM, Dodgin D, Clark C, Kregor P, Bradley G, Little L (2009) Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observational study. Orthop Clin North Am 40(3):329–342

    Article  Google Scholar 

  9. Moskal JT (2011) Anterior approach in THA improves outcomes: affirms. Orthopedics 34(9):e456–e458

    PubMed  Google Scholar 

  10. Moskal JT, Capps SG, Scanelli JA (2013) Anterior muscle sparing approach for total hip arthroplasty. World J Orthop 4(1):12–18

    Article  PubMed Central  PubMed  Google Scholar 

  11. Jewett BA, Collis DK (2011) High complication rate with anterior total hip arthroplasties on a fracture table. Clin Orthop Relat Res 469(2):503–507

    Article  PubMed Central  PubMed  Google Scholar 

  12. Spaans AJ, van den Hout JA, Bolder SB (2012) High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach. Acta Orthop 83(4):342–346

    Article  PubMed Central  PubMed  Google Scholar 

  13. Woolson ST (2006) In the absence of evidence–why bother? A literature review of minimally invasive total hip replacement surgery. Instr Course Lect 55:189–193

    PubMed  Google Scholar 

  14. Yi C, Agudelo JF, Dayton MR, Morgan SJ (2013) Early complications of anterior supine intermuscular total hip arthroplasty. Orthopedics 36(3):e276–e281

    Article  PubMed  Google Scholar 

  15. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b2535

    Article  PubMed Central  PubMed  Google Scholar 

  16. Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR (1978) Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg 60A(2):217–220

    Google Scholar 

  17. Rometsch E, Bos PK, Koes BW (2012) Survival of short hip stems with a “modern”, trochanter-sparing design—a systematic literature review. Hip Int J Clin Exp Res Hip Pathol Ther 22(4):344–354

    Google Scholar 

  18. Huisstede B, Miedema HS, van Opstal T, de Ronde MT, Verhaar JA, Koes BW (2008) Interventions for treating the radial tunnel syndrome: a systematic review of observational studies. J Hand Surg 33(1):72–78

    Article  Google Scholar 

  19. Wu HY, Huang JW, Lin HJ, Liao WC, Peng YS, Hung KY, Wu KD, Tu YK, Chien KL (2013) Comparative effectiveness of renin-angiotensin system blockers and other antihypertensive drugs in patients with diabetes: systematic review and bayesian network meta-analysis. BMJ 347:f6008

    Article  PubMed Central  PubMed  Google Scholar 

  20. Lunn DJ, Thomas A, Best N, Spiegelhalter D (2000) WinBUGS – a Bayesian modelling framework: concepts, structure, and extensibility. Stat Comput 10:325–337

    Article  Google Scholar 

  21. Goytia RN, Jones LC, Hungerford MW (2012) Learning curve for the anterior approach total hip arthroplasty. J Surg Orthop Adv 21(2):78–83

    Article  PubMed  Google Scholar 

  22. Seng BE, Berend KR, Ajluni AF, Lombardi AV Jr (2009) Anterior-supine minimally invasive total hip arthroplasty: defining the learning curve. Orthop Clin North Am 40(3):343–350

    Article  PubMed  Google Scholar 

  23. Alexandrov T, Ahlmann ER, Menendez LR (2014) Early clinical and radiographic results of minimally invasive anterior approach hip arthroplasty. Adv Orthop 2014:954208

    PubMed Central  PubMed  Google Scholar 

  24. Benoit B, Gofton W, Beaule PE (2009) Hueter anterior approach for hip resurfacing: assessment of the learning curve. Orthop Clin North Am 40(3):357–363

    Article  PubMed  Google Scholar 

  25. Bhargava T, Goytia RN, Jones LC, Hungerford MW (2010) Lateral femoral cutaneous nerve impairment after direct anterior approach for total hip arthroplasty. Orthopedics 33(7):472

    PubMed  Google Scholar 

  26. De Geest T, Vansintjan P, De Loore G (2013) Direct anterior total hip arthroplasty: complications and early outcome in a series of 300 cases. Acta Orthop Belg 79(2):166–173

    PubMed  Google Scholar 

  27. Gebel P, Oszwald M, Ishaque B, Ahmed G, Blessing R, Thorey F, Ottersbach A (2012) Process optimized minimally invasive total hip replacement. Orthop Rev (Pavia) 4(1):e3

    Article  Google Scholar 

  28. Kreuzer S, Leffers K, Kumar S (2011) Direct anterior approach for hip resurfacing: surgical technique and complications. Clin Orthop Relat Res 469(6):1574–1581

    Article  PubMed Central  PubMed  Google Scholar 

  29. Masonis J, Thompson C, Odum S (2008) Safe and accurate: learning the direct anterior total hip arthroplasty. Orthopedics 31(12 Suppl 2)

  30. Muller DA, Zingg PO, Dora C (2014) Anterior minimally invasive approach for total hip replacement: five-year survivorship and learning curve. Hip Int 24(3):277–283

    Article  PubMed  Google Scholar 

  31. Oinuma K, Eingartner C, Saito Y, Shiratsuchi H (2007) Total hip arthroplasty by a minimally invasive, direct anterior approach. Oper Orthop Traumatol 19(3):310–326

    Article  PubMed  Google Scholar 

  32. Pogliacomi F, Paraskevopoulos A, Costantino C, Marenghi P, Ceccarelli F (2012) Influence of surgical experience in the learning curve of a new approach in hip replacement: anterior mini-invasive vs. standard lateral. Hip Int 22(5):555–561

    Article  PubMed  Google Scholar 

  33. Rachbauer F (2005) Minimally invasive total hip arthroplasty via direct anterior approach. Orthopade 34 (11):1103–1104, 6–8, 10

  34. Woolson ST, Pouliot MA, Huddleston JI (2009) Primary total hip arthroplasty using an anterior approach and a fracture table: short-term results from a community hospital. J Arthroplasty 24(7):999–1005

    Article  PubMed  Google Scholar 

  35. Zawadsky MW, Paulus MC, Murray PJ, Johansen MA (2013) Early outcome comparison between the direct anterior approach and the mini-incision posterior approach for primary total hip arthroplasty: 150 consecutive cases. J Arthroplasty 29(6):1256–1260

    Article  PubMed  Google Scholar 

  36. Marshall DP, Pykerman K, Werle J, Lorenzetti D, Wasylak T, Nosewothy T, Dick DA, O`Connor G, Sundaram A, Sundaram A, Heintzbergen S, Frank C (2014) Hip resurfacing versus total hip arthroplasty: a systematic review comparing standardized outcomes. Clin Orthop Relat Res 472:2217–2230

    Article  PubMed Central  PubMed  Google Scholar 

  37. Katz JN, Wright EA, Wright J, Malchau H, Mahomed NN, Stedman M, Baron JA, Losina E (2012) Twelve-year risk of revision after primary total hip replacement in the U.S. Medicare population. J Bone Joint Surg Am 94(20):1825–1832

    Article  PubMed Central  PubMed  Google Scholar 

  38. Australian Orthopedic Assocation National Joint Replacement Registry (2014) Annual Report 2014

  39. Masonis JL, Bourne RB (2002) Surgical approach, abductor function, and total hip arthroplasty dislocation. Clin Orthop Relat Res 405:46–53

    Article  PubMed  Google Scholar 

  40. Kwon MS, Kuskowski M, Mulhall KJ, Macaulay W, Brown TE, Saleh KJ (2006) Does surgical approach affect total hip arthroplasty dislocation rates? Clin Orthop Relat Res 447:34–38

    Article  PubMed  Google Scholar 

  41. Smith TO, Blake V, Hing CB (2011) Minimally invasive versus conventional exposure for total hip arthroplasty: a systematic review and meta-analysis of clinical and radiological outcomes. Int Orthop 35(2):173–184

    Article  PubMed Central  PubMed  Google Scholar 

  42. Roth A (2012) The minimally invasive anterolateral approach. A review of the literature. Orthopade 41(5):377–381

    Article  CAS  PubMed  Google Scholar 

  43. Woolson ST, Mow CS, Syquia JF, Lannin JV, Schurman DJ (2004) Comparison of primary total hip replacements performed with a standard incision or a mini-incision. J Bone Joint Surg Am 86-A (7):1353–1358

    PubMed  Google Scholar 

  44. Nakata K, Nishikawa M, Yamamoto K, Hirota S, Yoshikawa H (2009) A clinical comparative study of the direct anterior with mini-posterior approach: two consecutive series. J Arthroplasty 24(5):698–704

    Article  PubMed  Google Scholar 

  45. Siguier T, Siguier M, Brumpt B (2004) Mini-incision anterior approach does not increase dislocation rate: a study of 1037 total hip replacements. Clin Orthop Relat Res 426:164–173

    Article  PubMed  Google Scholar 

  46. Crist BD, Ivie CB, Bal BS (2014) Total hip replacement with use of a direct anterior approach. A critical analysis review. JBJS Rev 2(6):e4

    Article  Google Scholar 

  47. Unger AS, Stronach BM, Bergin PF, Nogler M (2014) Direct anterior total hip arthroplasty. Instr Course Lect 63:227–238

    PubMed  Google Scholar 

  48. Roue J, de Thomasson E, Carlier AM, Mazel C (2007) Influence of body mass index on outcome of total hip arthroplasty via a minimally invasive anterior approach. Rev Chir Orthop Reparatrice Appar Mot 93(2):165–170

    Article  CAS  PubMed  Google Scholar 

  49. Bal BS, Vallurupalli S (2008) Minimally invasive total hip arthroplasty with the anterior approach. Indian J Orthop 42(3):301–308

    Article  PubMed Central  PubMed  Google Scholar 

  50. Barrett WP, Turner SE, Leopold JP (2013) Prospective randomized study of direct anterior vs postero-lateral approach for total hip arthroplasty. J Arthroplasty 28(9):1634–1638

    Article  PubMed  Google Scholar 

  51. Bergin PF, Doppelt JD, Kephart CJ, Benke MT, Graeter JH, Holmes AS, Haleem-Smith H, Tuan RS, Unger AS (2011) Comparison of minimally invasive direct anterior versus posterior total hip arthroplasty based on inflammation and muscle damage markers. J Bone Joint Surg Am 93(15):1392–1398

    Article  PubMed Central  PubMed  Google Scholar 

  52. Hallert O, Li Y, Brismar H, Lindgren U (2012) The direct anterior approach: initial experience of a minimally invasive technique for total hip arthroplasty. J Orthop Surg Res 7:17

    Article  PubMed Central  PubMed  Google Scholar 

  53. Hoell S, Sander M, Gosheger G, Ahrens H, Dieckmann R, Hauschild G (2014) The minimal invasive direct anterior approach in combination with large heads in total hip arthroplasty—is dislocation still a major issue? a case control study. BMC Musculoskelet Disord 15:80

    Article  PubMed Central  PubMed  Google Scholar 

  54. Ilchmann T, Gersbach S, Zwicky L, Clauss M (2013) Standard transgluteal versus minimal invasive anterior approach in hip arthroplasty: a prospective, consecutive cohort study. Orthop Rev (Pavia) 5(4):e31

    Article  Google Scholar 

  55. Kleindert K, Werner C, Mamisch-Saupe N, Kalberer F, Dora C (2012) Closed suction drainage with or without re-transfusion of flitered shed blood does not offer advantages in primary non-cemented total hip replacement using a direct anterior approach. Arch Orthop Traum Surg 132:131–136

    Article  Google Scholar 

  56. Martin CT, Pugely AJ, Gao Y, Clark CR (2013) A comparison of hospital length of stay and short-term morbidity between the anterior and the posterior approaches to total hip arthroplasty. J Arthroplasty 28(5):849–854

    Article  PubMed  Google Scholar 

  57. Noth U, Nedopil A, Holzapfel BM, Koppmair M, Rolf O, Goebel S, Eulert J, Rudert M (2012) Minimally invasive anterior approach. Orthopade 41(5):390–398

    Article  CAS  PubMed  Google Scholar 

  58. Pogliacomi F, De Filippo M, Paraskevopoulos A, Alesci M, Marenghi P, Ceccarelli F (2012) Mini-incision direct lateral approach versus anterior mini-invasive approach in total hip replacement: results 1 year after surgery. Acta Biomed 83(2):114–121

    PubMed  Google Scholar 

  59. Restrepo C, Parvizi J, Pour AE, Hozack WJ (2010) Prospective randomized study of two surgical approaches for total hip arthroplasty. J Arthroplasty 25(5):671–679 e1

    Article  PubMed  Google Scholar 

  60. Rodriguez JA, Deshmukh AJ, Rathod PA, Greiz ML, Deshmane PP, Hepinstall MS, Ranawat AS (2014) Does the direct anterior approach in THA offer faster rehabilitation and comparable safety to the posterior approach? Clin Orthop Relat Res 472(2):455–463

    Article  PubMed Central  PubMed  Google Scholar 

  61. Schweppe ML, Seyler TM, Plate JF, Swenson RD, Lang JE (2013) Does surgical approach in total hip arthroplasty affect rehabilitation, discharge disposition, and readmission rate? Surg Technol Int 23:219–227

    PubMed  Google Scholar 

  62. Sendtner E, Borowiak K, Schuster T, Woerner M, Grifka J, Renkawitz T (2011) Tackling the learning curve: comparison between the anterior, minimally invasive (Micro-hip) and the lateral, transgluteal (Bauer) approach for primary total hip replacement. Arch Orthop Traum Surg 131:597–602

    Article  Google Scholar 

  63. Sugano N, Takao M, Sakai T, Nishii T, Miki H, Nakamura N (2009) Comparison of mini-incision total hip arthroplasty through an anterior approach and a posterior approach using navigation. Orthop Clin North Am 40(3):365–370

    Article  PubMed  Google Scholar 

  64. Wayne N, Stoewe R (2009) Primary total hip arthroplasty: a comparison of the lateral Hardinge approach to an anterior mini-invasive approach. Orthop Rev (Pavia) 1(2):e27

    Article  Google Scholar 

  65. Yerasimides JG (2010) Use of the Fitmore(R) hip stem bone-preserving system for the minimally invasive anterior-supine approach in hip replacement. Am J Orthop (Belle Mead NJ) 39(10 Suppl):13–16

    Google Scholar 

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Acknowledgments

This study was funded by Biomet Europe BV, Dordrecht, The Netherlands. The sponsor had no involvement in the writing of the report or in the decision to submit the results for publication.

Conflict of interest

GDL and PF are consultants for Biomet Europe BV, Dordrecht, The Netherlands. The other authors have no conflict of interest.

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Authors and Affiliations

  1. Orthopedics AZ Damiaan, Gouwelozestraat 100, 8400, Ostend, Belgium

    Thomas De Geest & Geert De Loore

  2. AMR Advanced Medical Research, Männedorf, Switzerland

    Peter Fennema & Gerlinde Lenaerts

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  1. Thomas De Geest
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Correspondence to Thomas De Geest.

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De Geest, T., Fennema, P., Lenaerts, G. et al. Adverse effects associated with the direct anterior approach for total hip arthroplasty: a Bayesian meta-analysis. Arch Orthop Trauma Surg 135, 1183–1192 (2015). https://doi.org/10.1007/s00402-015-2258-y

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