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Introduction: Orthopaedic surgeons often cite concern for a learning curve as a barrier to adopting the direct anterior approach (DAA) for total hip arthroplasty (THA) while transitioning from other approaches. Studies both assessing and describing a practical approach and strategy to safely accomplish this transition, as well as the effect on clinical outcomes, are not well described. Methods: This prospective study compares a single surgeon's operative results and complications for the first consecutive 100 direct anterior THA to the last 100 consecutive posterior THA after 7 years in practice. The regimented and disciplined learning strategy used to implement the DAA is detailed in this study. The data were analyzed using univariate and multivariate regression models. Results: Univariate analyses identified significant differences in sex, age, Asian race, and diagnostic cause for THA between the two cohorts. Multivariate analyses controlled for these differences and showed that relative to posterior THA, direct anterior THA cases were associated with 7-minute longer procedures (P = 0.002) and lengths of stay that were 0.7 days fewer (P = 0.013). No significant differences were present in the estimated blood loss, and importantly, no significant differences in death or surgical complication rates between cohorts. Discussion: This study suggests that the DAA for THA can be safely implemented without the increased and adverse risk to the patient when a structured learning process is maintained and meticulously performed.

Total hip arthroplasty (THA) after acetabular fracture presents unique challenges, including acetabular fixation. Twelve patients with a history of acetabular fracture underwent THA with porous metal cups. The average age was 57 years (range 24-88). THA was performed at an average 20 months from initial fracture. Average follow-up was 39 months (range 24-49). Average WOMAC scores improved from 32 to 79; UCLA scores improved from 1.75 to 5.25. There was one case of acetabular loosening in a renal transplant patient with rheumatoid arthritis. No other patients showed progressive radiolucent lines. At average three-year follow-up, porous metal components afforded improved clinical and radiographic outcomes in the majority of patients. Longer follow-up will determine whether porous metal is a durable option in the management of prior acetabular fracture.

Dislocation is among the most commonly reported complications following revision total hip arthroplasty. Dual-mobility bearings may lower the risk of dislocation. The authors report the results of a multicenter study evaluating the use of a dual-mobility acetabular cup design that was cemented into a metal shell as part of complex acetabular reconstructions or in cases where the risk of dislocation was felt to be high, such as isolated bearing exchanges. Eighteen patients were identified for being at high risk of dislocation who underwent cementation of a dual-mobility shell that is specifically made for cementation, into a fully porous metal revision acetabular cup (10 patients) or into a well-fixed cup at the time of revision without removal of the existing acetabular component (eight patients). Patients were assessed clinically and radiographically at a minimum of 2 years for the evidence of dislocation, revision surgery, and implant loosening. At a mean of 36 months (range, 25–56 months), one patient died and one was lost to follow-up. There were no known cases of hip dislocation. There was one repeat revision, for a deep infection treated with irrigation and debridement. The mean preoperative Harris Hip Score of 46 (range, 40–79) improved to a mean of 65 points (range, 41–97) at the most recent evaluation. Acetabular components were retained in 8 out of 18 cases and the dual-mobility shell was cemented into it. Cementation of a dual-mobility cup into a shell at the time of a revision surgery is a safe and reliable construct at minimum of 2 years for patients at high risk of dislocation. There were no complications related to the cementation of the cup into the metal shell. Longer follow-up is required to further assess the durability of this construct.

The long-term survival of ceramic-on-ceramic bearings in young, active patients with osteonecrosis undergoing total hip arthroplasty (THA) is unknown. A previously published study demonstrated a high activity level in these young patients at 5-year follow-up, and this is a second follow-up report on this previously reported series. The purpose of this study is to determine whether high activity level is associated with ceramic-on-ceramic THA failure at long-term follow-up. This is a retrospective review of a single-surgeon consecutive series of index cases performed between 2003 and 2010. Inclusion criteria were ceramic-on-ceramic THA articulations in patients younger than 50 with a diagnosis of osteonecrosis. Mean follow-up was 12.5 years (range 9–17). Data were collected by survey via mail, telephone, e-mail, and social media. Preoperative and postoperative Western Ontario and McMaster University (WOMAC) Arthritis Index and University of California at Los Angeles (UCLA) activity scores were collected. Student t-tests were used as appropriate. There were 97 patients in this series. Mean age at THA was 36 (range 14–50). Since the prior report, four more patients have been confirmed deceased, and four more have been lost to follow-up. We confirmed that six patients were deceased and 42 were otherwise lost to follow-up. The response rate was 54%. The vast majority of patients were highly active at latest follow-up (73% with UCLA scores between 7 and 10). UCLA scores (1–10 scale) improved from a preoperative mean of 3.4 to postoperative 7.1 (p < 0.001). WOMAC scores (1–100 scale) increased from preoperative mean of 38.7 to postoperative 86.1 (p < 0.001). At latest follow-up, four patients had undergone revision surgery. There were no ceramic component failures. One patient underwent early revision for femoral component loosening, one was revised for chronic pain at another institution. Since the prior report there have been two additional revisions; one patient was revised for instability at 5-year postop, and one patient was revised for periprosthetic fracture at 10 years. Despite additional loss to follow-up and lack of clinical and radiographic measures, this survey study suggests that at long-term follow-up ceramic bearings accommodate high activity level with excellent component survivorship (93%) in young patients undergoing THA.