Anterior and Anterolateral Approaches for THA Are Associated With Lower Dislocation Risk Without Higher Revision Risk

Abstract

Background Lack of consensus continues regarding the benefit of anteriorly based surgical approaches for primary total hip arthroplasty (THA). The purpose of this study was to evaluate the risk of aseptic revision, septic revision, and dislocations for various approaches used in primary THAs from a community-based healthcare organization. Questions/purposes (1) What is the incidence of aseptic revision, septic revision, and dislocation for primary THA in a large community-based healthcare organization? (2) Does the risk of aseptic revision, septic revision, and dislocation vary by THA surgical approach? Methods The Kaiser Permanente Total Joint Replacement Registry was used to identify primary THAs performed between April 1, 2001 and December 31, 2011. Endpoints were septic revisions, aseptic revisions, and dislocations. The exposure of interest was surgical approach (posterior, anterolateral, direct lateral, direct anterior). Patient, implant, surgeon, and hospital factors were evaluated as possible confounders. Survival analysis was performed with marginal multivariate Cox models. Hazard ratios (HRs) and 95% confidence intervals (CIs) are reported. A total of 42,438 primary THAs were available for analysis of revision outcomes and 22,237 for dislocation. Median followup was 3 years (interquartile range, 1-5 years). The registry's voluntary participation is 95%. The most commonly used approach was posterior (75%, N = 31,747) followed by anterolateral (10%, N = 4226), direct anterior (4%, N = 1851), and direct lateral (2%, N = 667). Results During the study period 785 hips (2%) were revised for aseptic reasons, 213 (0.5%) for septic reasons, and 276 (1%) experienced a dislocation. The revision rate per 100 years of observation was 0.54 for aseptic revisions, 0.15 for septic revisions, and 0.58 for dislocations. There were no differences in adjusted risk of revision (either septic or aseptic) across the different THA approaches. However, the anterolateral approach (adjusted HR, 0.29; 95% CI, 0.13-0.63, p = 0.002) and direct anterior approach (adjusted HR, 0.44; 95% CI, 0.22-0.87, p = 0.017) had a lower risk of dislocation relative to the posterior approach. There were no differences in any of the outcomes when comparing the direct anterior approach with the anterolateral approach. Conclusions Anterior and anterolateral surgical approaches had the advantage of a lower risk of dislocation without increasing the risk of early revision. Level of Evidence Level III, therapeutic study.

Does Surgical Approach Affect Outcomes in Total Hip Arthroplasty Through 90 Days of Follow-Up? A Systematic Review With Meta-Analysis

“…We found no statistically significant differences in complication rates between surgical approaches. Prior studies reporting complication rates between the 2 approaches are conflicting [4,21,35,36]. Complications were uncommon and this meta-analysis may have been underpowered to detect clinically meaningful differences between surgical approaches.…”

Effect of femoral head size and surgical approach on risk of revision for dislocation after total hip arthroplasty

“…2015, Sheth et al. 2015). This has also been reported in studies comparing the (antero-) lateral approach and the posterolateral approach (Arthursson et al.…”

“…2014, Clyburn 2015, Sheth et al. 2015). Several studies have suggested that there is a more stable hip and faster recovery if the surgical dissection is done using the anterior approach (Matta and Ferguson 2005, Barrett et al.…”

Surgical Approaches for Total Hip Arthroplasty

“…Masonis and Bourne similarly reported dislocation rates of 0.55%, 2.18%, and 3.23% for DLA, anterolateral, and PA, respectively 49. Sheth et al ., in a large registry study on 42,438 primary THAs, also reported significantly lower dislocation rates with both DAA and anterolateral approach versus PA 34. However, other studies have reported equivalent rates of dislocation for all approaches, and hence, the data are not completely clear 32515253…”