Orthopedics

Feature Article 

Complication Rates for the Anterior Approach to Total Hip Arthroplasty

Konstantin J. Gruenwald, BA; Michael A. Arata, MD; Steven E. Fisher, MD

Abstract

Total hip arthroplasty (THA) is one of the most successful orthopedic surgeries performed in the United States. Orthopedic surgeons have looked to minimally invasive approaches for THA to reduce peri- and postoperative complications, and to improve patients' quality of life; the anterior approach THA has been advocated as such a minimally invasive surgery. This study involved a retrospective chart review of 2647 consecutive unilateral THAs using the anterior approach. The following parameters and complications were examined: patient demographics, surgery duration (open to close), postoperative length of stay, intraoperative fractures requiring internal fixation, femoral or sciatic nerve injuries with or without motor loss, deep infections managed with operative irrigation and debridement, deep venous thromboses (DVTs), and dislocations. Mean patient age and body mass index were 65 years and 29.78 kg/m2, respectively. Mean length of surgery was 69.1 minutes, and mean length of stay was 1.6 days postoperatively. The complication rates were as follows: dislocations, 19 (0.72%); DVT, 12 (0.45%); fractures, 13 (0.49%); infections, 49 (1.85%); and nerve injuries, 11 (0.42%). These findings demonstrate the anterior approach to THA has very low complication rates and acceptably low rates of infection. In addition, the minimally invasive THA has an acceptably low duration and a substantially reduced length of stay compared with more traditional THA approaches. [Orthopedics. 2020;43(3):e147–e150.]

Abstract

Total hip arthroplasty (THA) is one of the most successful orthopedic surgeries performed in the United States. Orthopedic surgeons have looked to minimally invasive approaches for THA to reduce peri- and postoperative complications, and to improve patients' quality of life; the anterior approach THA has been advocated as such a minimally invasive surgery. This study involved a retrospective chart review of 2647 consecutive unilateral THAs using the anterior approach. The following parameters and complications were examined: patient demographics, surgery duration (open to close), postoperative length of stay, intraoperative fractures requiring internal fixation, femoral or sciatic nerve injuries with or without motor loss, deep infections managed with operative irrigation and debridement, deep venous thromboses (DVTs), and dislocations. Mean patient age and body mass index were 65 years and 29.78 kg/m2, respectively. Mean length of surgery was 69.1 minutes, and mean length of stay was 1.6 days postoperatively. The complication rates were as follows: dislocations, 19 (0.72%); DVT, 12 (0.45%); fractures, 13 (0.49%); infections, 49 (1.85%); and nerve injuries, 11 (0.42%). These findings demonstrate the anterior approach to THA has very low complication rates and acceptably low rates of infection. In addition, the minimally invasive THA has an acceptably low duration and a substantially reduced length of stay compared with more traditional THA approaches. [Orthopedics. 2020;43(3):e147–e150.]

Total hip arthroplasty (THA) is one of the most successful orthopedic surgeries performed in the United States.1,2 Currently, more than 300,000 THAs are performed in the United States annually. As the population ages, Kurtz et al3 estimate the number of patients requiring THA is expected to increase to more than 572,000 by 2030. The original surgical technique has evolved greatly since the first successful THAs were performed by Sir John Charnley in England during the 1960s.

The anterior surgical approach was commonly performed by Judet in France in the 1940s, a modification of the Heuter approach developed in Germany in the 1930s. In the United States, this approach is referred to as the Smith-Peterson approach. This approach was popularized more recently in the United States by Matta4 after studying acetabular and pelvic fracture surgery with Judet's student, Letournel, in France in 1981. This approach uses an anterior incision in the inter-nervous plane between the femoral and superior gluteal nerves, as well as the intermuscular intervals superficially between the sartorius and tensor fasciae latae muscle, and deeply between the rectus femoris and gluteus medius. The procedure avoids the transection of muscles and tendons.

It has been suggested the anterior approach results in reduced complication rates and shorter postoperative hospital stays.5,6 The purpose of this study was to examine patient demographics as well as surgical statistics and peri- and postoperative complications for a large cohort of patients who underwent THA using the anterior approach within a 6-year period from 2010 through 2015.

Materials and Methods

Surgeons at Fort Wayne Orthopedics began using the anterior approach to THA in 2008. This study presents a retrospective chart review of 2647 patients who underwent a unilateral THA using the anterior approach performed by 9 surgeons from August 2010 through December 2015. The surgeries were performed using either a standard operating table or a specialized Hana table (Mizuho OSI, Union City, California), with varying use of intraoperative radiographic assistance. A Smith-Peterson anterior surgical approach as described by Matta4 was used.

The preference of 8 of the surgeons included in this study was to use the specialized Hana table. This table allows for intraoperative imaging, resulting in improved accuracy with placement of hip components. One surgeon included in this study preferred to use a standard table exclusively.

Surgery was performed with patients under either spinal or general anesthesia. Patients were mobilized within a few hours after surgery and ambulated with a physical therapist. Most of the patients subsequently were discharged home. The authors' postoperative protocol encouraged full weight bearing on the operative leg initially with the assistance of crutches or a walker. In most cases, patients were promoted to using a cane 2 weeks postoperatively. Patients were encouraged to work on hip flexor and abductor strengthening exercises at home. Physical therapy post-discharge was unnecessary in most cases.

Patient restrictions after surgery such as avoiding sitting in a low chair or crossing one's legs were not routinely imposed, and postoperative hip precautions were not required. It was not unusual for patients to present to the office for their first postoperative office visit at 2 weeks ambulating without any external aids and without a limp. This was not encouraged but occasionally was observed. Most patients recovered rapidly after surgery and ambulated normally without pain or a limp within a few weeks.

This study was limited to THAs performed on patients aged 18 years or older by surgeons of Fort Wayne Orthopedics. Each patient's sex and preoperative diagnosis were recorded, and total values were calculated. Mean patient age, height, and weight were determined, as well as minimum and maximum values for these demographics. In addition, mean, minimum, and maximum body mass index (BMI) were calculated for each patient.

Length of hospital stay and duration of surgery were recorded from patients' medical records, and mean values were calculated. In addition, data were recorded for the following complications: deep wound infections requiring operative irrigation and debridement, deep venous thromboses (DVTs), dislocations, intraoperative fractures requiring internal fixation, and femoral or sciatic nerve injuries with or without motor loss. Although transient anterolateral thigh paresthesias due to irritation of the lateral femoral cutaneous nerve are common with the anterior approach to the hip, these complications were excluded as there is no resultant functional loss, and most symptoms resolve spontaneously within a short period following surgery. Minor incidental, nondisplaced fractures that did not alter the surgical procedure or require treatment were excluded. The number of each of these complications was determined and reported, as well as the percentage of patients who experienced each complication.

Results

Demographics

The number of surgeries performed each year was as follows: 80 in 2010; 313 in 2011; 492 in 2012; 552 in 2013; 567 in 2014; and 643 in 2015. Patient demographics are presented in Table 1. More women (1397 [52.8%]) underwent the procedure than men (1250 [47.2%]). Mean BMI was 29.78 kg/m2, and mean age was 65.17 years. Generally, during the length of the study, mean patient age decreased each year (Figure 1), and mean patient BMI increased each year (Figure 2). Preoperative diagnoses were osteoarthritis (2403 [90.78%]), avascular necrosis (142 [5.36%]), fractures (90 [3.40%]), and rheumatoid arthritis (12 [.45%]).

Patient Demographics

Table 1:

Patient Demographics

Mean age of patients by year.

Figure 1:

Mean age of patients by year.

Mean body mass index of patients by year. In 2014, mean body mass index surpassed 30 kg/m2, that of obesity.

Figure 2:

Mean body mass index of patients by year. In 2014, mean body mass index surpassed 30 kg/m2, that of obesity.

Surgical Statistics and Complications

Mean length of hospital stay was 1.6 days, and mean duration of surgery was 69.1 minutes. Data on peri- and postoperative complications are presented in Table 2.

Surgical Statistics and Complication Rates

Table 2:

Surgical Statistics and Complication Rates

Discussion

Mean patient age decreased and mean patient BMI increased (Figure 2) during the length of the study. This change may be attributed to several factors. As surgeons become more experienced with the anterior approach, they may become more comfortable performing the procedure on patients with increasing BMI. However, this alone could not account for the decreasing age of patients seen during this study. Another possibility is the growing prevalence of obesity in Indiana, the state in which this study was conducted.7 Obesity increases the risk for hip osteoarthritis, which therefore may reduce the age of onset of osteoarthritis requiring joint replacement.8 Another study examining the relationship between age and BMI for THA might determine the nature of the trends in the current study.

Table 3 compares the complication rates and surgical statistics of the current study that used an anterior approach with 2 other studies that used an anterolateral Watson-Jones approach and a posterior modified Southern approach.9,10 The anterior approach resulted in equal or fewer complications in all categories analyzed except for nerve injuries and wound infections requiring irrigation and debridement. However, the difference in the sample size of the studies may be a confounding factor. At the least, the complication rates for the anterior approach are comparable to those for more traditional approaches.

Comparison of Surgical Data and Complication Rates for Anterior, Anterolateral, and Posterior Total Hip Arthroplasty

Table 3:

Comparison of Surgical Data and Complication Rates for Anterior, Anterolateral, and Posterior Total Hip Arthroplasty

Jahng et al11 determined obesity and diabetes mellitus are positively correlated to rates of infection requiring surgical intervention when using the direct anterior approach. Their study included 651 consecutive patients and reported a 1.9% (n=12) incidence of infection requiring surgery. The current study had a 1.85% incidence of deep infection requiring surgical intervention, which is comparable to the incidence reported by Jahng et al.

A total of 19 (0.72%) dislocations occurred in the current study. Tamaki et al12 reported a similarly low dislocation rate of 0.92% after mean follow-up of 7.8 years. This low rate is attributed to the retention of all tendon and muscle attachments to the proximal femur that occurs with the anterior approach. In addition, the use of intraoperative radiographs assists in accurate hardware placement and is believed to be a factor in decreasing the risk of dislocation.

Eleven nerve injuries (0.42%) to either the sciatic or femoral nerve occurred in the current study. It is noteworthy that 8 of the 11 nerve injuries were associated with 1 surgeon. This surgeon was the sole surgeon in the study who performed the anterior hip surgery on a standard operating table. The nerve injury rate excluding this surgeon was 0.11%. The dislocation, infection, and nerve injury rates for the current study were comparable to those of the more traditional lateral Hardinge and posterolateral surgical approaches.1,5

Table 4 compares the results of the current study with those of Bhandari et al13 using the anterior approach to THA. Mean surgical duration in the current study was significantly lower than in the comparison study. With the exception of intraoperative fractures, Bhandari et al reported lower complication rates.

Comparison of Results Between Studies

Table 4:

Comparison of Results Between Studies

Of particular interest is the substantially reduced hospital length of stay with the anterior approach than with more traditional approaches. The shorter postoperative hospital stay is consistent with the results of other studies that have analyzed hospital length of stay.2,5,13–15 The shorter length of stay could substantially decrease costs incurred by the hospital and patients with the use of fewer resources.

With retention of the short external rotator muscles and the posterior hip capsule, the joint retains stability when using the anterior approach. The greater stability may reduce dislocation rates postoperatively, which is suggested by the results of this study (Table 2). Despite the substantially reduced operative time of the current study compared with that reported by Bhandari et al,13 the current study demonstrated a comparable low dislocation rate. In summary, the authors' experience with the anterior approach for THA has resulted in rapid mobilization and recovery of patients, a shorter hospital stay, and high patient satisfaction.

Conclusion

This study performed a retrospective chart review of a large cohort of patients from a uniform population who underwent surgery by the same group of surgeons, making for a relatively homogeneous background. The advantage to the anterior approach for THA is reduced peri- and postoperative complications. Complication rates, surgery duration, and length of hospital stay were presented to help orthopedic surgeons more accurately compare the complication profile of the anterior approach with other approaches. In this study, the rates of complication for THA using the anterior approach were relatively lower with a substantially reduced length of hospital stay, thereby potentially improving the postoperative short-term outcomes and quality of life for THA patients.

References

  1. Barrett WP, Turner SE, Leopold JP. Prospective randomized study of direct anterior vs postero-lateral approach for total hip arthroplasty. J Arthroplasty. 2013;28(9):1634–1638. doi:1.1016/j.arth.2013.01.034 [CrossRef] PMID:23523485
  2. Higgins BT, Barlow DR, Heagerty NE, Lin TJ. Anterior vs. posterior approach for total hip arthroplasty, a systematic review and meta-analysis. J Arthroplasty. 2015;30(3):419–434. doi:1.1016/j.arth.2014.1.020 [CrossRef] PMID:25453632
  3. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780–785. PMID: 17403800
  4. Matta JM. Anterior approach for total hip replacement: background and operative technique. In: Scuderi GR, Tria AJ, Berger RA, eds. MIS Techniques in Orthopedics. New York, NY: Springer Science+Business Media; 2006:121–140.
  5. Wayne N, Stoewe R. Primary total hip arthroplasty: a comparison of the lateral Hardinge approach to an anterior mini-invasive approach. Orthop Rev (Pavia). 2009;1(2):e27. doi:1.4081/or.2009.e27 [CrossRef] PMID:21808689
  6. Goebel S, Steinert AF, Schillinger J, et al. Reduced postoperative pain in total hip arthroplasty after minimal-invasive anterior approach. Int Orthop. 2012;36(3):491–498. doi:1.1007/s00264-011-1280-0 [CrossRef] PMID:21611823
  7. Jackson JE, Doescher MP, Jerant AF, Hart LG. A national study of obesity prevalence and trends by type of rural county. J Rural Health. 2005;21(2):140–148. doi:1.1111/j.1748-0361.2005.tb00074.x [CrossRef] PMID:15859051
  8. Cooper C, Inskip H, Croft P, et al. Individual risk factors for hip osteoarthritis: obesity, hip injury, and physical activity. Am J Epidemiol. 1998;147(6):516–522. doi:1.1093/oxfordjournals.aje.a009482 [CrossRef] PMID:9521177
  9. Maratt JD, Gagnier JJ, Butler PD, Hallstrom BR, Urquhart AG, Roberts KC. No difference in dislocation seen in anterior vs posterior approach total hip arthroplasty. J Arthroplasty. 2016;31(9)(suppl):127–130. doi:1.1016/j.arth.2016.02.071 [CrossRef] PMID:27067754
  10. Sawaia RN, Galvão AF, Oliveira FM, Secunho GR, Filho GV. Minimally invasive antero-lateral access route for total hip arthroplasty. Rev Bras Ortop. 2015;46(2):183–188. doi:1.1016/S2255-4971(15)30237-8 [CrossRef] PMID:27027008
  11. Jahng KH, Bas MA, Rodriguez JA, Cooper HJ. Risk factors for wound complications after direct anterior approach hip arthroplasty. J Arthroplasty. 2016;31(11):2583–2587. doi:1.1016/j.arth.2016.04.030 [CrossRef] PMID:27267230
  12. Tamaki T, Oinuma K, Miura Y, Higashi H, Kaneyama R, Shiratsuchi H. Epidemiology of dislocation following direct anterior total hip arthroplasty: a minimum 5-year follow-up study. J Arthroplasty. 2016;31(12):2886–2888. doi:1.1016/j.arth.2016.05.042 [CrossRef] PMID:27378635
  13. Bhandari M, Kreuzer S, Dodgin D, et al. Anterior Total Hip Arthroplasty Collaborative (ATHAC) Investigators. Outcomes following the single-incision anterior approach to total hip arthroplasty: a multi-center observational study. Orthop Clin North Am. 2009;40:329–342. doi:1.1016/j.ocl.2009.03.001 [CrossRef];
  14. Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res. 2005;441(441):115–124. doi:1.1097/01.blo.0000194309.70518.cb [CrossRef] PMID:16330993
  15. Sibia US, Turner TR, MacDonald JH, King PJ. The impact of surgical technique on patient reported outcome measures and early complications after total hip arthroplasty. J Arthroplasty. 2017;32(4):1171–1175. doi:1.1016/j.arth.2016.1.031 [CrossRef] PMID:27876253

Patient Demographics

CharacteristicValue
Sex, No.
  Male1250 (47.2%)
  Female1397 (52.8%)
Age, y
  Minimum22
  Mean65.17
  Maximum96
Height, in
  Minimum54
  Mean67.06
  Maximum82.5
Weight, lb
  Minimum78
  Mean191.18
  Maximum385
Body mass index, kg/m2
  Minimum14.74
  Mean29.78
  Maximum56.68

Surgical Statistics and Complication Rates

ComplicationValue
Dislocation, No.19 (0.72%)
Deep venous thrombosis, No.12 (0.45%)
Fracture (intraoperative), No.13 (0.49%)
Infection (deep), No.49 (1.85%)
Nerve injury, No.11 (0.42%)
Duration of surgery, mean (range), min69.1 (28–225)
Length of stay, mean (range), d1.6 (0–14)

Comparison of Surgical Data and Complication Rates for Anterior, Anterolateral, and Posterior Total Hip Arthroplasty

ComplicationAnterior Approacha (n=2647)Anterolateral Approachb (n=278)Posterior Approachc (n=2147)
Dislocation, No.19 (0.72%)2 (0.72%)17 (0.79%)
Deep venous thrombosis, No.12 (0.45%)3 (1.1%)
Fracture (intraoperative), No.13 (0.49%)26 (1.21%)
Infection (deep), No.49 (1.85%)2 (0.72%)6 (0.28%)
Nerve injury, No.11 (0.42%)1 (0.36%)
Duration of surgery, mean (range), min69.1 (28–225)6376.35
Length of stay, mean (range), d1.6 (0–14)2.54

Comparison of Results Between Studies

ComplicationCurrent Study (n=2647)Bhandari et al13 (n=1152)
Dislocation, No.19 (0.72%)0.63%
Deep venous thrombosis, No.12 (0.45%)
Fracture (intraoperative), No.13 (0.49%)0.7%
Infection (deep), No.49 (1.85%)0.78%
Nerve injury, No.11 (0.42%)0.2%
Duration of surgery, mean, min69.195.3
Length of stay, mean, d1.63.6
Authors

The authors are from the Indiana University School of Medicine (KJG), Indianapolis, and Fort Wayne Orthopedics (MAA, SEF), Fort Wayne, Indiana.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Konstantin J. Gruenwald, BA, 18 Hickory Hills Circle, Little Rock, AR 72212 ( kgruenwa@iu.edu).

Received: November 08, 2018
Accepted: March 04, 2019
Posted Online: February 20, 2020

10.3928/01477447-20200213-07

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