Compared learning curves of the direct anterior and anterolateral approach for minimally invasive hip replacement

Abstract

Minimally invasive hip arthroplasty becomes increasingly popular. It is technically challenging and the approaches used are associated with a considerable learning curve. This nurtures concerns regarding patient safety, surgical training, and cost effectiveness. Consequently, we initiated a study comparing the learning curves of a supervised trainee surgeon utilizing both the anterolateral and direct anterior approach (DAA) when introduced to minimally invasive hip replacement surgery. Outcome measurements included the Harris hip score (HHS), cup inclination and anteversion, offset and leg length, stem placement, surgical time and complications. Time from incision to suture decreased significantly over time but did not differ between both groups. The functional outcomes (HHS) after six weeks and three months were comparable (p=0.069 and 0.557) and within the expected range equalling 90.3 (anterior) and 89.2 (anterolateral) points. With both approaches safe component placement was readily achieved. Both offset and leg length, however, were reconstructed more reliably with the DAA (p=0.02 and 0.001). A higher rate of dislocations was seen with the anterior, more perioperative infections with the anterolateral approach. We suggest that supervision by an experienced surgeon favourably influences the learning curves for both the minimally invasive DAA and anterolateral approach and conclude that the greatest improvement is seen within the first 60 cases.

Surgical Technique of Direct Anterior Approach for Primary Total Hip Arthroplasty Using a Leg Positioning Traction System

“…However, DAA for THA is a technically challenging operation with a well-defined learning curve [ 11 , 12 , 13 ] and several potential complications, including femur fractures [ 14 ], perforations [ 15 ], and lateral femoral cutaneous nerve (LFCN) injury [ 16 ]. Furthermore, it can be difficult to sufficiently expose the acetabulum and femur without causing excessive tension on surrounding tissues [ 17 ]. Compounding these known challenges with our patients’ delayed presentation and aversion to surgery, DAA is a surgical technique that should be approached with caution to maintain its predictable outcomes in Indian population.…”