title: Prospective randomized study of direct anterior vs postero-lateral approach for total hip arthroplasty. Enhanced early outcomes with the anterior supine intermuscular approach in primary total hip arthroplasty. Prospective randomized study of two surgical approaches for total hip arthroplasty. Learning curve in tissue sparing total hip replacement: comparison between different approaches Does the Direct Anterior Approach in THA Offer Faster Rehabilitation and Comparable Safety to the Posterior Approach? Minimally invasive intermuscular approach does not improve outcomes in bipolar hemiarthroplasty for femoral neck fracture Early complications of anterior supine intermuscular total hip arthroplasty. Tackling the learning curve: comparison between the anterior, minimally invasive (Micro-hip®) and the lateral, transgluteal (Bauer) approach for primary total hip replacement Modified direct anterior approach in minimally invasive hip hemiarthroplasty in a geriatric population: a feasibility study and description of the technique Dislocation after total hip arthroplasty using Hueter anterior approach. Does the choice of approach for hip hemiarthroplasty in geriatric patients significantly influence early postoperative outcomes? A randomized-controlled trial comparing the modified Smith-Petersen and Hardinge approaches.
abstract: Benefits of a direct anterior approach ( DAA ) versus a posterior-lateral ( PA ) approach to THA were assessed in a single-surgeon , IRB-approved , prospect i ve , r and omized clinical study . Subjects ( 43 DAA and 44 PA ) were evaluated at 6 weeks , and 3 , 6 and 12 months . The primary end point was ability to climb stairs normally and walk unlimited at each time point . Secondary end points included assessment by several outcome instruments . DAA subjects performed better during the immediate post-operative period ; they had lower VAS pain scores on the first post-operative day , more subjects climbing stairs normally and walking unlimited at 6 weeks , and higher HOOS Symptoms scores at 3 months . There were no significant differences between groups at later time points . Findings confirm previous reports of benefits of DAA versus PA in early post-operative phases The advantages of minimally invasive surgical approaches for total hip arthroplasty are reported to include reduced blood loss , less pain , and shorter hospital stays , which combine to afford a faster recovery1 - 4 . However , other studies have failed to show any significant advantage over the use of st and ard surgical approaches ( Fig. 1)5 - 8 . Reported disadvantages of minimally invasive techniques are the substantial learning curve required and an increased risk of early complications3,9 - 12 . In addition , the long-term outcomes of minimally invasive procedures in terms of implant fixation and longevity remain unproven . Fig. 1 The st and ard direct lateral approach to the hip previously described by Frndak et al.21 is performed with the patient in the lateral decubitus position . ( Printed with permission of Joint Implant Surgeons , Inc. ) There are three basic categories of so-called minimally invasive total hip arthroplasty approaches : an abbreviated incision ( small incision ) , modifications of st and ard approaches with smaller incisions and less soft-tissue dissection ( less invasive ) , and novel approaches that reportedly do not cut muscle ( minimally invasive ) . We have had a broad experience , over the past seven years , with a less invasive modification of the direct lateral approach ( a modified Hardinge approach ) ( Fig. 2 ) . We previously reported less blood loss and a shorter hospital stay in association with this approach13 . Others have argued that the less invasive direct lateral approach does not provide an advantage over the traditional approach5 . Importantly , the soft-tissue dissection still requires removing and repairing the abductor musculature . Fig. 2 The less invasive direct lateral approach is performed with the patient in the lateral decubitus position . This approach employs an abbreviated skin and fascial incision with a limited abductor muscle dissection13 . ( Printed with permission of Joint Implant Surgeons , Inc. ) Several recent reports have The benefits of different surgical approaches for total hip arthroplasty continue to be debated . One hundred patients were prospect ively enrolled and r and omized into 2 groups . One group underwent total hip arthroplasty through a single-incision modified Smith-Peterson approach , whereas the other group  underwent total hip arthroplasty through a direct lateral approach . All patients received the same postoperative protocol . Evaluation included operative time , estimated blood loss , analgesia requirement , transfusions , and length of stay . Functional outcome was assessed preoperatively and postoperatively . Up to 1-year follow-up , the direct anterior group demonstrated significantly better improvement in both the mental and physical health dimensions of Short Form-36 and Western Ontario McMaster Osteoarthritis Index compared with direct lateral approach group . At 2 years , the results in both groups were the same Background The tissue sparing surgery ( TSS ) concept means not only smaller incisions but also less tissue disruption , allowing decreased blood loss and improved function . However , TSS techniques can result in more complications related to the learning curve . The aim of this study was to compare the learning curve of an experienced surgeon with different TSS approaches for total hip replacement ( THR ) from a clinical and surgical point of view , focussing especially on complications related to the use of different geometric stems . Material s and methods Sixty patients scheduled to be operated for a primary THR were enrolled in the study and were r and omly assigned to surgery by one of three different TSS approaches : lateral with mini incision ( group A ) , minimally invasive anterior ( group B ) and minimally invasive antero-lateral ( group C ) . Results from the three TSS groups were compared with a control group of 149 patients ( group D ) . Results Our results reveal significantly reduced blood loss in the TSS groups compared with the control group , with no differences between the TSS groups . We found better early functional scores in the two minimally invasive groups ( anterior and anterolateral ) , and a lower rate of complications with the antero-lateral TSS approach . Conclusion The antero-lateral TSS approach seems to be safer and less dem and ing than st and ard THR surgery , and is suitable for use with different stems Background Newer surgical approaches to THA , such as the direct anterior approach , may influence a patient ’s time to recovery , but it is important to make sure that these approaches do not compromise reconstructive safety or accuracy . Questions / purpose sWe compared the direct anterior approach and conventional posterior approach in terms of ( 1 ) recovery of hip function after primary THA  , ( 2 ) general health outcomes , ( 3 ) operative time and surgical complications , and ( 4 ) accuracy of component placement . Methods In this prospect i ve , comparative , nonr and omized study of 120 patients ( 60 direct anterior THA , 60 posterior THAs )  , we assessed functional recovery using the VAS pain score , timed up and go ( TUG ) test , motor component of the Functional Independence Measure ™ ( M-FIM ™ ) , UCLA activity score , Harris hip score , and patient-maintained subjective milestone diary and general health outcome using SF-12 scores . Operative time , complications , and component placement were also compared . Results Functional recovery was faster in patients with the direct anterior approach on the basis of TUG and M-FIM ™ up to 2 weeks ; no differences were found in terms of the other metrics we used , and no differences were observed between groups beyond 6 weeks . General health outcomes , operative time , and complications were similar between groups . No clinical ly important differences were observed in terms of implant alignment . Conclusions We observed very modest functional advantages early in recovery after direct anterior THA compared to posterior-approach THA . R and omized trials are needed to vali date these findings , and these findings may not generalize well to lower-volume practice setting s or to surgeons earlier in the learning curve of direct anterior THA.Level of Evidence Level II , therapeutic study . See Instructions for Authors for a complete description of levels of evidence Background Minimally invasive surgery ( MIS ) can lead to early recovery , but its postoperative effect is short after total hip arthroplasty for osteoarthritis . Because bipolar hemiarthroplasty ( BHA ) for femoral neck fractures is preferred for elderly patients , early functional recovery may prevent the rapid progression of disuse atrophy , and an MIS surgical approach may improve subsequent hip joint function . Methods MIS-BHA was performed using the direct anterior approach , without muscle or tendon detachment . A total of 83 patients who underwent BHA from April 2007 to February 2009 were assigned to MIS-BHA or conventional BHA . Selection of patients for MIS-BHA was not r and omized . Hip joint function was evaluated with the Hospital for Special Surgery ( HSS ) system at 1 month and 1 year after surgery . Results There were no significant differences in age , sex , height , weight , body mass index , time from admission to surgery , or preinjury HSS scores between two groups . HSS scores were higher with MIS-BHA ( 24.2 vs. 20.2 ; P = 0.01 ) at 1 month but were similar 1 year after surgery ( 29.9 vs. 27.2 ; P = 0.10 ) . Conclusions The effectiveness of MIS-BHA for femoral neck fracture is limited to the early postoperative period . Therefore , MIS-BHA does not appear to be appropriate for treatment of femoral neck fractures Anterior supine intermuscular total hip arthroplasty ( THA ) performed on a fracture table has been increasingly used for primary THA . Accurate cup placement , low incidence of dislocation , shorter hospital stay , and faster return of function are potential benefits of the technique . However , a high complication rate , particularly during a surgeon 's learning curve , has been reported . A retrospective analysis of 61 consecutive anterior supine intermuscular primary THAs with at least 6-month follow-up was performed . All procedures were performed using the anterior supine intermuscular approach with cementless implants under fluoroscopic guidance on a fracture table . Prospect ively collected data were retrospectively review ed to evaluate the early complication rate and radiographic accuracy of implant placement . Five ( 8.2 % ) intraoperative complications were observed : including 3 trochanteric fractures and 2 calcar fractures , 4 of which required cable fixation during the index procedure . One nondisplaced trochanteric fracture was treated conservatively . One patient sustained an injury of the lateral femoral cutaneous nerve . Postoperative complications included 1 anterior dislocation , 1 infected superficial hematoma , 1 stem subsidence , and 1 loose stem , with the latter 2 presenting as increasing thigh pain postoperatively and requiring stem revision . The overall complication rate was 16.4 % ( 10/61 ) . Overall , 3 patients ( 4 hips ; 6.5 % ) required reoperation . No femoral or sciatic nerve injuries occurred , and no patient was diagnosed with venous thromboembolism . All intraoperative fractures occurred during the first 32 cases , and none during the last 29 cases . A potentially high incidence of complications with the anterior supine intermuscular THA exists during a surgeon 's learning curve in an academic setting Background and purpose There is still conflicting evidence about the true benefit of minimally invasive ( MI ) techniques in total hip replacement ( THR ) . The aim of this prospect i ve study was to evaluate the safeness of a MI approach during the learning curve of a single surgeon . Second , clinical and radiographic results among the  MI THR group were compared with the results using a st and ard transgluteal ( Bauer ) approach . Methods 86 primary unilateral total hip arthroplasties ( THAs ) through a MI , anterior ( Micro-hip ® ) approach were performed by a single senior surgeon ( ES ) , representing a consecutive series of patients after beginning with the MI technique . Cases were compared to a matched cohort of patients who were treated with a st and ard transgluteal ( Bauer ) approach .  Operation time , incision length , perioperative blood loss , haemoglobin level and blood transfusions were monitored . Complications were documented and followed up 1 year postoperatively . The Harris Hip Score ( HHS ) , range of motion , use of analgetics , the Trendelenburg sign , sensibility of the lateral femoral cutaneous nerve and the acetabular/femoral component placement as well as potential heterotopic ossifications were analysed in both the groups after 12 months postoperatively . Results 74 MI THR patients and 60 st and ard THR patients were available for the one year follow-up . Operative time was significantly longer in the MI group , reduction in the haemoglobin level during the first 24 h was significant and the length of skin incision was significantly shorter . No significant differences were found for HHS , range of motion , use of analgetics , the Trendelenburg sign , and the acetabular/femoral component placement , heterotopic ossifications and intra- and postoperative complications . Sensibility of the lateral femoral cutaneous nerve was affected in three patients in the MI group . Radiographic evaluation revealed no component migration , implant subsidence or radiolucency signs in both the groups . DicussionConsistent with recent meta- analysis we found reduced blood loss , similar clinical /radiographic outcome and similar complication rates compared to st and ard THA . Our study shows , that MI THR is a safe procedure during the learning curve of an experienced surgeon Introduction The direct anterior approach ( DAA ) is generally accepted method for minimal invasive arthroplasty of the hip . As good results for total hip arthroplasty are already published , there is a lack of evidence for the implantation of bipolar hip hemiarthroplasty ( BHH ) in elderly patients with osteoporosis after femoral neck fracture . Material s and methods For hip arthroplasty using a direct anterior approach ( DAA ) in elderly patients with femoral neck fractures , a number of modifications of the original technique are being described . The modified DAA considers in particular the co-morbidity and the bone quality of the geriatric patient population . A consecutive series of 16 hemiarthroplasties using this technique is presented . In all 16 cases , the BHH was implanted in modified DAA technique . Mobility measured by 4-item Barthel Index , pain via visual analogue scale ( VAS ) , duration of surgery , external length of incision and blood loss were evaluated . Results There was no major operative complication during the procedures . The pain level decreased from 7 ( preoperatively ) to 0 at postoperative day 40 . The Barthel Index increased from 5 at first postoperative day to 40 at day 40 . Early postoperative mobilisation is efficiently accelerated . Mean operating time was 71 min ; the medium skin incision length was 8 cm . The mean haemoglobin level decreased from 118 g/dl preoperatively to 101 g/dl at first postoperative day . Conclusion The described modifications of the DAA help to implant a BHH gently in elderly patients with increasing risk of complications like iatrogenic fractures , wound or prosthesis infections and haematoma . This will hopefully lead to a faster rehabilitation and lower mortality rate for patients with femoral neck fractures in the future A prospect i ve study including 1764 hips has been carried out to evaluate the frequency of dislocation while using the Hueter anterior approach and the correlated factors . The dislocation group was compared with the patients without dislocation . We observed 27 dislocations ( 1.5 % ) . The dislocation rate when using 28 mm head diameter was 0.5 % . Two patients underwent a revision for recurrent dislocations . Correlated factors for dislocation were male sex , high body mass index , etiology of osteonecrosis , low head diameter , high bleeding , and low postoperative ROM . Dislocation risk while using Hueter approach is one of the lowest in the literature . The main disadvantages are the necessity for a specific orthopedic table and a more difficult exposure of the femur BACKGROUND Minimally invasive surgical approaches for total hip replacement , such as the modified Smith-Petersen approach , have been reported to be advantageous over alternative techniques because of reduced soft tissue damage and improved immediate postoperative rehabilitation . This study compares the advantages of the Smith-Petersen approach against the lateral Hardinge approach for femoral neck fractures in geriatric patients . METHODS In a r and omized-controlled trial , 48 patients were treated by a hemiarthroplasty of the hip using either a modified Smith-Petersen or a Hardinge approach .  Age , American Society of Anesthesiologists score , body mass index , blood loss , pain , and postoperative mobilization were compared between groups to detect statistically significant differences . The same outcome measures were analyzed for significant differences between patients with or without complications in each group . RESULTS The Smith-Petersen approach yielded a statistically significant increase in postoperative pain within the first 4 days and an increase in operation time . Complications were also associated with a significantly higher intraoperative time in the same group . However , 6 months postoperatively , there were no significant differences in the Harris Hip score between groups . CONCLUSIONS Despite early postoperative differences , postoperative mobility does not seem to be greatly influenced by the choice of either an anterior modified Smith-Petersen or a lateral Hardinge approach for hip hemiarthroplasty .  Operative time was significantly linked to postoperative complications . In this respect , it can be concluded that it is not be the approach itself that determines the early postoperative result , but the routine the individual surgeon has with it
target: Thus , while DAA hip arthroplasty can be successfully performed , it is not without complications .
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