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Periprosthetic fracture following anterior approach or dislocation after posterior approach: which one is the lesser evil?

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

Abstract

Introduction

The most common approaches in total hip arthroplasty (THA) have different complication profiles; anterior-approach (AA-THA) has an increased risk of periprosthetic fractures (PPF); posterior-approach (PA-THA) is associated with higher dislocation risk. However, the relative severity of one versus the other is unknown. This study aims to compare outcome of patients who suffered PPF after AA-THA with those that sustained dislocation after PA-THA.

Methods

This is a retrospective, single-center, multi-surgeon, consecutive case-series of primary THA patients. In a cohort of 9867 patients who underwent THA, 79 fulfilled the approach-specific, post-operative complication criteria, of which 44 were PPF after AA-THA and 35 with dislocation after PA-THA (age 67.9 years (range: 38.0–88.1), 58.2% women). Outcome included complication- and revision- rates, and patient-reported outcomes including Oxford Hip Score (OHS).

Results

At 5.8 years follow-up (range: 2.0–18.5), reoperation was more common in the dislocation after PA-THA group (23/35 vs. 20/44; p = 0.072). Change of surgical approach occurred in 15/20 of patients with PPF after AA-THA, but none in those with dislocation after PA-THA. Following re-operation, complication rate was greater in the PPF group (9/20 vs. 4/23; p = 0.049). At latest follow-up, OHS were superior in the PPF after AA-THA group [42.6 (range: 25.0–48.0) vs. 36.6 (range: 21.0–47.0); p = 0.006].

Conclusion

Dislocation following PA-THA is more likely to require revision. However, PPF following AA-THA requires more often a different surgical approach and is at higher risk of complications. Despite the increased surgical burden post-operative PROMs are better in the peri-prosthetic fracture group, especially in cases not requiring reoperation.

Level of evidence

III, case–control study

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References

  1. Higgins BT, Barlow DR, Heagerty NE, Lin TJ (2015) Anterior vs. posterior approach for total hip arthroplasty, a systematic review and meta-analysis. J Arthroplast 30(3):419–434

    Google Scholar 

  2. 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

    PubMed  Google Scholar 

  3. Yue C, Kang P, Pei F (2015) Comparison of direct anterior and lateral approaches in total hip arthroplasty: a systematic review and meta-analysis (PRISMA). Medicine (Baltimore) 94(50):e2126

    PubMed  Google Scholar 

  4. Jameson SS, Mason J, Baker P, Gregg PJ, McMurtry IA, Deehan DJ et al (2014) A comparison of surgical approaches for primary hip arthroplasty: a cohort study of patient reported outcome measures (PROMs) and early revision using linked national databases. J Arthroplast 29(6):1248–55.e1

    Google Scholar 

  5. Chechik O, Khashan M, Lador R, Salai M, Amar E (2013) Surgical approach and prosthesis fixation in hip arthroplasty world wide. Arch Orthop Trauma Surg 133(11):1595–1600

    PubMed  Google Scholar 

  6. Kennon RE, Keggi JM, Wetmore RS, Zatorski LE, Huo MH, Keggi KJ (2003) Total hip arthroplasty through a minimally invasive anterior surgical approach. J Bone Joint Surg Am 85-A(Suppl 4):39–48

    Google Scholar 

  7. Corten K, Holzapfel BM (2021) Direct anterior approach for total hip arthroplasty using the “bikini incision.” Oper Orthop Traumatol 33(4):318–330

    PubMed  Google Scholar 

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

    Google Scholar 

  9. Sibia US, Turner TR, MacDonald JH, King PJ (2017) The impact of surgical technique on patient reported outcome measures and early complications after total hip arthroplasty. J Arthroplast 32(4):1171–1175

    Google Scholar 

  10. Lee GC, Marconi D (2015) Complications following direct anterior hip procedures: costs to both patients and surgeons. J Arthroplast 30(9 Suppl):98–101

    Google Scholar 

  11. Taunton MJ, Trousdale RT, Sierra RJ, Kaufman K, Pagnano MW (2018) John charnley award: randomized clinical trial of direct anterior and miniposterior approach THA: which provides better functional recovery? Clin Orthop Relat Res 476(2):216–229

    PubMed  PubMed Central  Google Scholar 

  12. Angerame MR, Fehring TK, Masonis JL, Mason JB, Odum SM, Springer BD (2018) Early failure of primary total hip arthroplasty: is surgical approach a risk factor? J Arthroplast 33(6):1780–1785

    Google Scholar 

  13. 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

    PubMed  PubMed Central  Google Scholar 

  14. Müller 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

    PubMed  Google Scholar 

  15. Christensen CP, Karthikeyan T, Jacobs CA (2014) Greater prevalence of wound complications requiring reoperation with direct anterior approach total hip arthroplasty. J Arthroplast 29(9):1839–1841

    Google Scholar 

  16. Hartford J, Knowles S (2016) Risk factors for perioperative femoral fractures: cementless femoral implants and the direct anterior approach using a fracture table. J Arthroplast 31(9):2013–2018

    Google Scholar 

  17. 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

    PubMed  Google Scholar 

  18. Van de Meulebroucke C, Beckers J, Corten K (2019) What can we expect following anterior total hip arthroplasty on a regular operating table? A validation study of an artificial intelligence algorithm to monitor adverse events in a high-volume. Nonacademic Setting J Arthroplast 34(10):2260–2266

    Google Scholar 

  19. Hamilton W, Parks N, Huynh C (2015) Comparison of cup alignment, jump distance, and complications in consecutive series of anterior approach and posterior approach total hip arthroplasty. J Arthroplast 30(11):1959–1962

    Google Scholar 

  20. McGoldrick N, Antoniades S, El Meniawy S, Kreviazuk C, Beaulé P, Grammatopoulos G (2021) Supine versus lateral position for total hip replacement: accuracy of biomechanical reconstruction. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-021-04179-2

    Article  PubMed  Google Scholar 

  21. van Erp JHJ, Hüsken MFT, Filipe MD, Snijders TE, Kruyt MC, de Gast A et al (2022) Did the dislocation risk after primary total hip arthroplasty decrease over time? A meta-analysis across six decades. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-022-04678-w

    Article  PubMed  PubMed Central  Google Scholar 

  22. Berry DJ, von Knoch M, Schleck CD, Harmsen WS (2005) Effect of femoral head diameter and operative approach on risk of dislocation after primary total hip arthroplasty. J Bone Joint Surg Am 87(11):2456–2463

    PubMed  Google Scholar 

  23. Dimentberg E, Barimani B, Alqahtani M, Tayara B, Belzile E, Albers A (2022) The incidence of hip dislocation after posterior approach primary total hip arthroplasty: comparison of two different posterior repair techniques. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-022-04609-9

    Article  PubMed  Google Scholar 

  24. Kobayashi N, Kamono E, Kameda K, Yukizawa Y, Takagawa S, Honda H et al (2022) Is there any clinical advantage of capsular repair over capsular resection for total hip arthroplasty? An updated systematic review and meta-analysis. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-022-04444-y

    Article  PubMed  Google Scholar 

  25. Haynes JA, Hopper RH Jr, Ho H, McDonald JF 3rd, Parks NL, Hamilton WG (2022) Direct anterior approach for primary total hip arthroplasty lowers the risk of dislocation compared to the posterior approach: a single institution experience. J Arthroplast 37(3):495–500

    Google Scholar 

  26. Bendich I, Landy DC, Do H, Krell E, Diane A, Boettner F et al (2021) Intraoperative complications and early return to the operating room in total hip arthroplasty performed through the direct anterior and posterior approaches. An institutional experience of surgeons after their learning curve. J Arthroplast 36(8):2829–2835

    Google Scholar 

  27. Charney M, Paxton EW, Stradiotto R, Lee JJ, Hinman AD, Sheth DS et al (2020) A comparison of risk of dislocation and cause-specific revision between direct anterior and posterior approach following elective cementless total hip arthroplasty. J Arthroplast 35(6):1651–1657

    Google Scholar 

  28. Kurkis GM, Chihab S, Farley KX, Anastasio AT, Bradbury TL, Guild GN (2021) Anterior revision hip arthroplasty is associated with higher wound complications but fewer dislocations compared to posterior revision hip surgery. J Arthroplast 36(1):250–254

    Google Scholar 

  29. Dion CA, Schmidt-Braekling T, Falsetto A, Kreviazuk C, Beaulé PE, Grammatopoulos G (2022) Does surgical approach influence the natural history of the unstable total hip arthroplasty? J Arthroplast 37(4):787–794

    Google Scholar 

  30. Holder N, Papp S, Gofton W, Beaulé PE (2014) Outcomes following surgical treatment of periprosthetic femur fractures: a single centre series. Can J Surg 57(3):209–213

    PubMed Central  Google Scholar 

  31. Schöfl T, Calek AK, Zdravkovic V, Zurmühle P, Ladurner A (2022) Mid-term outcomes following transfemoral revision of total hip arthroplasty for vancouver B2/B3 periprosthetic fractures. Injury 53(2):653–660

    PubMed  Google Scholar 

  32. Barrack RL (2003) Dislocation after total hip arthroplasty: implant design and orientation. J Am Acad Orthop Surg 11(2):89–99

    PubMed  Google Scholar 

  33. Kotwal RS, Ganapathi M, John A, Maheson M, Jones SA (2009) Outcome of treatment for dislocation after primary total hip replacement. J Bone Joint Surg Br 91(3):321–326

    CAS  PubMed  Google Scholar 

  34. Barlow BT, McLawhorn AS, Westrich GH (2017) The cost-effectiveness of dual mobility implants for primary total hip arthroplasty: a computer-based cost-utility model. J Bone Joint Surg Am 99(9):768–777

    PubMed  Google Scholar 

  35. Young SW, Walker CG, Pitto RP (2008) Functional outcome of femoral peri prosthetic fracture and revision hip arthroplasty: a matched-pair study from the New Zealand registry. Acta Orthop 79(4):483–488

    PubMed  Google Scholar 

  36. Duncan CP, Masri BA (1995) Fractures of the femur after hip replacement. Instr Course Lect 44:293–304

    CAS  Google Scholar 

  37. Murray DW, Carr AJ, Bulstrode C (1993) Survival analysis of joint replacements. J Bone Joint Surg Br 75(5):697–704

    CAS  PubMed  Google Scholar 

  38. Gofton WT, Ibrahim MM, Kreviazuk CJ, Kim PR, Feibel RJ, Beaulé PE (2020) Ten-year experience with the anterior approach to total hip arthroplasty at a tertiary care center. J Arthroplast 35(5):1281–9.e1

    Google Scholar 

  39. McGoldrick NP, Cochran MJ, Biniam B, Bhullar RS, Beaulé PE, Kim PR et al (2022) Can we predict fracture when using a short cementless femoral stem in the anterior approach? J Arthroplast 37(8s):S901–S907

    Google Scholar 

  40. Kocher T (1911) Textbook of operative surgery. Macmillan, New York

    Google Scholar 

  41. von Langenbeck B (1874) Chirurgische Beobachtungen aus dem Kriege. Hirschwald, Berlin

    Google Scholar 

  42. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213

    PubMed  PubMed Central  Google Scholar 

  43. Wylde V, Learmonth ID, Cavendish VJ (2005) The Oxford hip score: the patient’s perspective. Health Qual Life Outcomes 3:66

    PubMed  PubMed Central  Google Scholar 

  44. EuroQol group (1990) EuroQol–a new facility for the measurement of health-related quality of life. Health Policy 16(3):199–208

    Google Scholar 

  45. Kaplan E, Meier P (1958) Nonparametric estimation from incomplete observations. J Am Stat Assoc 53:457–481

    Google Scholar 

  46. Molenaers B, Driesen R, Molenaers G, Corten K (2017) The direct anterior approach for complex primary total hip arthroplasty: the extensile acetabular approach on a regular operating room table. J Arthroplast 32(5):1553–1559

    Google Scholar 

  47. Singh G, Khurana A, Gupta S (2021) Evaluation of direct anterior approach for revision total hip arthroplasty: a systematic review. Hip Pelvis 33(3):109–119

    PubMed  PubMed Central  Google Scholar 

  48. Thaler M, Corten K, Nogler M, Holzapfel BM, Moskal J (2022) Femoral revision with the direct anterior approach. Oper Orthop Traumatol 34(3):189–202

    PubMed  PubMed Central  Google Scholar 

  49. Ghijselings SG, Driesen R, Simon JP, Corten K (2017) Distal extension of the direct anterior approach to the hip: a cadaveric feasibility study. J Arthroplast 32(1):300–303

    Google Scholar 

  50. Grob K, Monahan R, Gilbey H, Yap F, Filgueira L, Kuster M (2015) Distal extension of the direct anterior approach to the hip poses risk to neurovascular structures: an anatomical study. J Bone Joint Surg Am 97(2):126–132

    Google Scholar 

  51. Hartford JM, Bellino MJ (2017) The learning curve for the direct anterior approach for total hip arthroplasty: a single surgeon’s first 500 cases. Hip Int 27(5):483–488

    PubMed  Google Scholar 

  52. Tande AJ, Patel R (2014) Prosthetic joint infection. Clin Microbiol Rev 27(2):302–345

    PubMed  PubMed Central  Google Scholar 

  53. Peersman G, Laskin R, Davis J, Peterson M (2001) Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res 392:15–23

    Google Scholar 

  54. Werner BC, Brown TE (2012) Instability after total hip arthroplasty. World J Orthop 3(8):122–130

    PubMed  PubMed Central  Google Scholar 

  55. McGrory BJ, McGrory CP, Barbour L, Barbour B (2010) Transient subluxation of the femoral head after total hip replacement. J Bone Joint Surg Br 92(11):1522–1526

    CAS  PubMed  Google Scholar 

  56. Philpott A, Weston-Simons JS, Grammatopoulos G, Bejon P, Gill HS, McLardy-Smith P et al (2014) Predictive outcomes of revision total hip replacement–a consecutive series of 1176 patients with a minimum 10-year follow-up. Maturitas 77(2):185–190

    CAS  PubMed  Google Scholar 

  57. Foissey C, Kenney R, Luceri F, Servien E, Lustig S, Batailler C (2021) Greater trochanter fractures in the direct anterior approach: evolution during learning curve, risk factors and consequences. Arch Orthop Trauma Surg 141(4):675–681

    PubMed  Google Scholar 

  58. Ramkumar PN, Navarro SM, Haeberle HS, Ng M, Piuzzi NS, Spindler KP (2018) No difference in outcomes 12 and 24 months after lower extremity total joint arthroplasty: a systematic review and meta-analysis. J Arthroplast 33(7):2322–2329

    Google Scholar 

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Funding

No funding was received for this study.

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Authors and Affiliations

  1. Division of Orthopaedic Surgery, Critical Care Wing, The Ottawa Hospital, 501 Smyth RoadSuite CCW 1638, Ottawa, ON, K1H 8L6, Canada

    Jeroen C. F. Verhaegen, Tom Schmidt-Braekling, Roger Wei, Paul E. Beaulé & George Grammatopoulos

  2. University Hospital Antwerp, Edegem, Belgium

    Jeroen C. F. Verhaegen

  3. Orthopaedic Centre Antwerp, Antwerp, Belgium

    Jeroen C. F. Verhaegen

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  1. Jeroen C. F. Verhaegen
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Ottawa Arthroplasty Group

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Correspondence to George Grammatopoulos.

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Verhaegen, J.C.F., Schmidt-Braekling, T., Wei, R. et al. Periprosthetic fracture following anterior approach or dislocation after posterior approach: which one is the lesser evil?. Arch Orthop Trauma Surg 144, 465–473 (2024). https://doi.org/10.1007/s00402-023-05034-2

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