Anatomic Total Hip Component Position Is More Reproducible With the Direct Anterior Approach Using Intraoperative Fluoroscopy

Abstract

Background: Total hip arthroplasty (THA) has demonstrated excellent results regardless of the surgical approach. However, the approach used may be a factor in final positioning of implants. We hypothesized that the direct anterior approach (DAA) with fluoroscopy would be associated with more anatomic implant positioning than the posterior approach (PA). Methods: A retrospective review of 200 patients was performed. One hundred patients underwent THA utilizing the PA, and 100 patients, with the DAA. All patients had an anterior-posterior pelvis radiograph preoperatively and postoperatively with a magnification marker present to standardize each radiograph. Exclusion criteria included contralateral THA or any pelvic or femoral deformity. Results: Preoperative radiographs demonstrated identical cohorts with respect to leg length, femoral offset, and total offset. Postoperatively, the DAA achieved more accurate anatomic restoration of leg length (1.6 mm vs 5.5 mm; P < .0001), femoral offset (4.8 mm vs 9.3 mm; P < .0001), and total offset (0.5 mm vs 4.7 mm; P < .0001) compared with the PA. Ideal cup abduction and anteversion were significantly superior to the DAA (96% vs 78%, P ¼ .0002, and 69% vs 24%, P < .0001, respectively). Conclusions: This study is the first to compare anatomic implant positioning between patients undergoing THA with these 2 approaches. All parameters were significantly closer to anatomic implant positioning with the DAA. There are at least 2 potential explanations for this: (1) The DAA implant positioning was performed under fluoroscopic guidance, whereas the PA was not. (2) The PA disrupts the posterior capsule and external rotators, and therefore, increased offset or leg length may be necessary to achieve comparable hip stability with the DAA.

Total Hip Arthroplasty through Direct Anterior Approach in a Patient with Ipsilateral Knee Arthrodesis: A Case Report

“…We believe that intraoperative fluoroscopy can be an excellent guide to restore the anatomy, especially when using a DAA. Martin et al concluded that the anatomy is better restored in a DAA when using fluoroscopy, compared to the posterior approach [ 23 ]. Moreover, Boe et al stated that using hip templating, restoring the anatomy and biomechanics can be achieved, and in combination with adequate soft-tissue balancing, a stable and ideal arthroplasty can be the result [ 24 ].…”

Direct Anterior Versus Posterior Approach for Total Hip Arthroplasty Performed for Displaced Femoral Neck Fractures

“…40 However, with DAA, intraoperative fluoroscopy allows for a more efficient evaluation of cup orientation, leg length, offset, and restoration of the center of rotation. 41 Furthermore, the hip joint capsule may be damaged in a fractured setting, which may require more time to repair with the PA. Repair of the anterior capsular layer is less emphasized for the DAA because of the infrequency of anterior dislocations because studies have demonstrated that capsulectomy does not increase dislocation rates in the elective population. 42,43 Although the DAA may be perceived as technically challenging for unfamiliar surgeons, this study demonstrates that it can be performed efficiently even in a fracture setting.…”

Digital Fluoroscopic Navigation for Limb Length Restoration During Anterior Total Hip Arthroplasty

“…The use of fluoroscopy has been largely favored in recent clinical studies when utilized during the anterior approach [ 14 , 16 ]. Leucht et al.…”