Adolescent idiopathic scoliosis is a three-dimensional deformity of the spine, affecting 1–3% of the population. Most cases are treated conservatively. Curves exceeding 45° in the thoracic spine and 40° in the lumbar spine may require correction and fusion surgery, to limit the progression of the curve and prevent restrictive pulmonary insufficiency (curves above 70°). When fusion is required, it may be performed either by posterior or anterior approaches. Posterior is useful for thoracic (Lenke I) curves, notably to correct the thoracic hypokyphosis frequently observed in AIS. Anterior approaches by thoraco-lombotomies allow an effective correction of thoraco-lumbar and lumbar curves (Lenke V and VI), with fewer levels fused than with posterior approaches. However, the approach requires diaphragm splitting and one may be concerned about the long-term pulmonary consequences. The literature provides conflicting insight regarding the consequences of the approach in anterior scoliosis correction, the interpretation of the results being difficult knowing that the correction of the scoliosis itself may improve pulmonary function. This is a retrospective observational study done at a Tertiary Institution. The HRQOL scores have been collected as a prospective cohort. Clinical and radiographic data was collected from patients charts and analysed by two senior surgeons. A cohort of 64 patients were operated in the given time period. 50 patients met the inclusion criteria. No major complications were reported. The Union rate was 100% and no post operative complications were noted. Pre and post SRS scores improved in all patients. The Anterior approach for Lenke V AIS gives great surgical exposure and allows for excellent correction of Cobb angle with minimal risk to the patient

Background. Over 35% of surgeons in the United States, and 10% in Canada use the direct anterior approach for primary total hip arthroplasty (THA). Some of the key barriers in its wider adoption are the learning curve and associated increased risk of adverse events. The purpose of this study was to determine the adoption rate as well as 90-day re-admission and adverse event of the anterior approach in a community-based hospital. Methods. From December 2015 to August 2018, two laterally based approach senior orthopaedic surgeons with over 20 years of practice performed 319 primary total hip replacements, with 164 being done through the anterior approach and 155 through the lateral approach. All but 8 of the anterior approaches were done on a regular operating table. Results. The anterior and lateral approach groups were comparable in age with mean 69.1+/− 10.2 and 68.9+/−9.3, respectively (p= 0.886), however the anterior group had patients with a statistically significantly lower BMI than the lateral group with mean 28.2+/−5.4 and 31.0+/−6.3, respectively (p < 0.001). Furthermore, there was a much lower percentage of females in the anterior group than in the lateral group with 49.4% and 65.2%, respectively (p= 0.004). It took surgeon A and B 12 and 24 months for the anterior approach to represent over 50% of their monthly cases, respectively. The anterior approach now accounts for approximately 80% of surgeon A's practice and 100% in surgeon B's practice in the last 6 and 18 months, respectively. Intraoperative adverse events were comparable between anterior and lateral approaches, with one incidence in each group (p= 0.968), however post-operative adverse events were more prevalent in the lateral group (n= 24) when compared to anterior group (n= 11) (p= 0.012). Further details of both approaches are provided in figure 1. Conclusion. Within a well-structured environment, the anterior approach can be safely introduced into a community-based practice. The progressive adoption of a new surgical technique combined with more experienced surgeon as a resource is an effective way that requires further study. For any figures or tables, please contact the authors directly

Psoas tendinopathy is a potential cause of groin pain after primary total hip arthroplasty (THA). The direct anterior approach (DAA) is becoming increasingly popular as the standard approach for primary THA due to being a muscle preserving technique. It is unclear what the prevalence is for the development of psoas-related pain after DAA THA, how this can influence patient reported outcome, and which risk factors can be identified. This retrospective case control study of prospectively recorded data evaluated 1784 patients who underwent 2087 primary DAA THA procedures between January 2017 and September 2019. Psoas tendinopathy was defined as (1) persistence of groin pain after DAA THA and was triggered by active hip flexion, (2) exclusion of other causes such as dislocation, infection, implant loosening or (occult) fractures, and (3) a positive response to an image-guided injection with xylocaine and steroid into the psoas tendon sheath. Complication-, re-operation rates, and patient-reported outcome measures (PROMs) were measured. Forty-three patients (45 hips; 2.2%) were diagnosed with psoas tendinopathy according to the above-described criteria. The mean age of patients who developed psoas tendinopathy was 50.8±11.7 years, which was significantly lower than the mean age of patients without psoas pain (62.4±12.7y; p<0.001). Patients with primary hip osteoarthritis were significantly less likely to develop psoas tendinopathy (14/1207; 1.2%) in comparison to patients with secondary hip osteoarthritis to dysplasia (18/501; 3.6%) (p<0.001) or FAI (12/305; 3.9%) (p<0.001). Patients with psoas tendinopathy had significantly lower PROM scores at 6 weeks and 1 year follow-up. Psoas tendinopathy was present in 2.2% after DAA THA. Younger age and secondary osteoarthritis due to dysplasia or FAI were risk factors for the development of psoas tendinopathy. Post-operatively, patients with psoas tendinopathy often also presented with low back pain and lateral trochanteric pain. Psoas tendinopathy had an important influence on the evolution of PROM scores

Short cementless femoral stems are increasingly popular as they allow for less dissection for insertion. Use of such stems with the anterior approach (AA) may be associated with considerable per-operative fracture risk. This study's primary aim was to evaluate whether patient-specific femoral- and pelvic- morphology and surgical technique, influence per-operative fracture risk. In doing so, we aimed to describe important anatomical thresholds alerting surgeons. This is a single-center, multi-surgeon retrospective, case-control matched study. Of 1145 primary THAs with a short, cementless stem inserted via the AA, 39 periprosthetic fractures (3.4%) were identified. These were matched for factors known to increase fracture risk (age, gender, BMI, side, Dorr classification, stem offset and indication for surgery) with 78 THAs that did not sustain a fracture. Radiographic analysis was performed using validated software to measure femoral- (canal flare index [CFI], morphological cortical index [MCI], calcar-calcar ratio [CCR]) and pelvic- (Ilium-ischial ratio [IIR], ilium overhang, and ASIS to greater trochanter distance) morphologies and surgical technique (% canal fill). Multivariate and Receiver-Operator Curve (ROC) analysis was performed to identify predictors of fracture. Femoral factors that differed included CFI (3.7±0.6 vs 2.9±0.4, p3.17 and II ratio>3 (OR:29.2 95%CI: 9.5–89.9, p<0.001). Patient-specific anatomical parameters are important predictors of fracture-risk. When considering the use of short stems via the AA, careful radiographic analysis would help identify those at risk in order to consider alternative stem options

Introduction. The limited field of view with less-invasive hip approaches for total hip arthroplasty can make a reliable cup positioning more challenging. The aim of this study was to evaluate the accuracy of cup placement between the traditional transgluteal approach and the anterior approach in a routine setting. Objectives. We asked if the (1) accuracy, (2) precision, and (3) number of outliers of the prosthetic cup orientation differed between three study groups: the anterior approach in supine position, the anterior approach in lateral decubitus position, and the transgluteal approach in lateral decubitus position. Methods. In a retrospective comparative study we compared the inclination and anteversion of the cup after total hip arthroplasty (THA) in a consecutive series of 325 patients (350 hips). The transgluteal approach group consisted of 67 hips operated in lateral decubitus position; the anterior approach in supine position consisted of 127 operated and the anterior approach in lateral decubitus position consisted of 156 hips. The aim of the cup orientation was Lewinnek's safe zone defined by an inclination of 40±10° and an anteversion of 15°±10°. The postoperative cup orientation was determined using a validated computer-assisted method based on statistical shape modeling. This method allows the virtual creation of an accurate three-dimensional pelvic model for each individual patient based on the two-dimensional anteroposterior pelvic radiograph. The inclination and anteversion was then calculated relative to the anterior pelvic plane – a natural reference plane for the calculation of inclination and anteversion. Accuracy was defined as the difference from the cup orientation to Lewinnek's target value. Precision was defined as the standard deviation of the two angles. Outliers were characterized by an anteversion or inclination angle outside of Lewinnek's safe zone. Results. (1) The accuracy of the anterior approach in supine position did not differ compared to the transgluteal approach, but differed to the anterior approach in supine position for inclination (p=0.882; p<0.001) (Figure 1) and anteversion (p = 0.014; p<0.001) (Figure 2). (2) The precision of the anterior approach in supine position was significantly higher compared to the transgluteal approach (p<0.001) and the anterior approach in lateral decubitus position for anteversion (p<0.001 for both groups) and inclination (p<0.001 for both groups) (Figure 3). (3) There was a significantly reduced number of outliers for the anterior approach in supine position compared to the anterior approach in lateral position (p=0.001) but not in comparison to the transgluteal approach (p=0.999) (Figure 2). Conclusions. The anterior approach in supine position results in a more precise placement of the prosthetic cup both for inclination and anteversion. Cup placement with less-invasive approaches does not lead to a higher variability of cup placement despite the more limited surgical field of view. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

INTRODUCTION. Proponents of the THA anterior approach have advocated for the use of dedicated surgical tables similar to those used in lower extremity fracture care that allow for traction, rotation, and angulation of the limb during surgery. Some tables require a specially-trained assistant to manipulate the table, whereas some may be manipulated by the surgeon. The purpose of this study is to compare the clinical outcomes in patients who underwent THA through an anterior approach on an assistant-controlled (AC) versus a surgeon-controlled (SC) table. METHODS. This is a retrospective study of 343 consecutive THA patients from January 2017 – October 2017. Surgical and clinical data included surgical time, LOS, presence of pain (groin, hip, or thigh pain) at latest follow-up, and revision for any reason. Immediate postoperative radiographs were compared with latest follow-up radiographs to assess for LLD, stem alignment, and stem subsidence. RESULTS. 167 (48.7%) cases were performed using the AC table, and 176 (51.3%) were performed using the SC table. Overall, surgical time was significantly greater for surgeries which utilized the self-controlled table (70.2 minutes vs. 66.1 minutes, respectively). There was a statistically significant difference between the first and last third of cases performed on the SC table (73.6 minutes vs. 68.0 minutes, respectively). There were no significant differences in any clinical or radiographic outcomes. DISCUSSION. Surgeons who routinely perform an anterior approach for THA can expect similar outcomes using an SC table as opposed to an AC table. Although surgical time with the SC table was longer by approximately four minutes, this difference is not clinically significant. In addition, surgical time with the SC table may be decreased following an initial learning curve. The SC table allows for greater surgeon control during the procedure and a significantly smaller institutional financial investment due to the reduced manpower required

The purpose of this study was to report all complications during the first consecutive 865 cases of bikini incision direct anterior approach (DAA) total hip arthroplasty (THA) performed by a single surgeon. The secondary aims of the study are to report our clinical outcomes and implant survivorship. We discuss our surgical technique to minimize complication rates during the procedure. We undertook a retrospective analysis of our complications, clinical outcomes and implant survivorship of 865 DAA THA's over a period of 6 years (mean = 5.1yrs from 2.9 to 9.4 years). The complication rates identified in this study were low. Medium term survival at minimum 2-year survival and revision as the end point, was 99.53% and 99.84% for the stem and acetabular components respectively. Womac score improved from 49 (range 40-58) preoperatively to 3.5(range 0-8.8) and similarly, HHS scores improved from 53(range 40-56) to 92.5(range 63-100) at final follow-up (mean = 5.1 yrs) when compared to preoperative scores. These results suggest that bikini incision DAA technique can be safely utilised to perform THA

The approach to total hip arthroplasty (THA) should allow adequate visualization and access so as to implant in optimal position whilst minimizing muscle injury, maintaining or restoring normal soft tissue anatomy and biomechanics and encouraging a rapid recovery with minimal complications. Every surgeon who performs primary hip arthroplasties will expound the particular virtues of his or her particular routine surgical approach. Usually this approach will be the one to which the surgeon was most widely exposed to during residency training. There is a strong drive from patients, industry, surgeon marketing campaigns, and the media to perform THA through smaller incisions with quicker recoveries. The perceived advantage of the anterior approach is the lack of disturbance of the soft tissues surrounding the hip joint, less pain, faster recovery with the potential for earlier return to work, shorter hospital stay and improved cosmetic results. The potential disadvantages include less visibility, longer operation time, nerve injuries, femoral fractures, malposition and a long learning curve for the surgeon (and his / her patients). The anterior approach was first performed in Paris, by Robert Judet in 1947. The advantages of the anterior approach for THA are several. First, the hip is an anterior joint, closer to the skin anterior than posterior. Second, the approach follows the anatomic interval between the zones of innervation of the superior and inferior gluteal nerves lateral and the femoral nerve medial. Third, the approach exposes the hip without detachment of muscle from the bone. The mini-incision variation of this exposure was developed by Joel Matta in 1996. He rethought his approach to THA and his goals were: lower risk of dislocation, enhanced recovery, and increased accuracy of hip prosthesis placement and leg length equality. This approach preserves posterior structures that are important for preventing dislocation while preserving important muscle attachments to the greater trochanter. The lack of disturbance of the gluteus minimus and gluteus medius insertions facilitates gait recovery and rehabilitation, while the posterior rotators and capsule provide active and passive stability and account for immediate stability of the hip and a low risk of dislocation. A disadvantage of the approach is the fact that a special operating table with traction is required. Potential complications include intraoperative femoral and ankle fractures. These can be avoided through careful manipulation of the limb. If a femoral fracture occurs, the incision can be extended distally by lengthening the skin incision downward along the anterolateral aspect of the thigh, and splitting the interval between the rectus femoris and the vastus lateralis. The choice of approach used to perform a primary THA remains controversial. The primary goals are pain relief, functional recovery and implant longevity performed with a safe and reproducible approach without complications. The anterior approach is promising in terms of hospital stay and functional recovery. Although recent studies suggest that component placement in minimally invasive surgery is safe and reliable, no long-term results have been published. Further follow-up and development is necessary to compare the results with the posterior approach as most of the positive data is based on comparisons with the anterolateral approach. The proposed benefits of the anterior approach are not supported by the current available literature. The issues regarding the difficult learning curve, rate of complications, operative time, requirement for trauma tables and image intensifier should be taken into account by surgeons starting with the anterior approach in THA

The approach to total hip arthroplasty (THA) should allow adequate visualization and access so as to implant in optimal position whilst minimizing muscle injury, maintaining or restoring normal soft tissue anatomy and biomechanics and encouraging a rapid recovery with minimal complications. The direct anterior approach (DAA) for THA was first performed in Paris, by Robert Judet in 1947. This procedure has since been performed consistently by a small group of surgeons and has recently gained great popularity. Access to the hip can be safely performed with one or two assistants. The advantages of the anterior approach for hip arthroplasty are several. First, the hip is an anterior joint, closer to the skin anterior than posterior. Second, the approach follows the anatomic interval between the zones of innervation of the superior and inferior gluteal nerves lateral and the femoral nerve medial. Third, the approach exposes the hip without detachment of muscle from the bone. Care must be taken to avoid cutting the lateral femoral cutaneous nerve which runs over the fascia of the sartorius. The mini-incision variation of this exposure was developed by Joel Matta in 1996. He rethought his approach to hip arthroplasty and by abandoning the posterior approach and adopting the anterior approach his goals were: lower risk of dislocation, enhanced recovery, and increased accuracy of hip prosthesis placement and leg length equality. This approach preserves posterior structures that are important for preventing dislocation while preserving important muscle attachments to the greater trochanter. The lack of disturbance of the gluteus minimus and gluteus medius insertions facilitates gait recovery and rehabilitation while the posterior rotators and capsule provides active and passive stability and accounts for immediate stability of the hip and a low risk of dislocation. Using the anterior approach, patients are allowed to mobilise their hip freely. The gluteus maximus and tensor fascia latae muscles insert on the iliotibial band which joins them and form a ´hip deltoid´. Lack of disturbance of these abductors and pelvic stabilisers is another benefit of the anterior approach and accelerates gait recovery. The lateral femoral cutaneous nerve is at risk when the fascia is incised between the tensor fascia latae and the sartorius muscle. Damaging it may lead to a diminished sensation on the lateral aspect of the thigh and formation of a neuroma. A disadvantage of the approach is the fact that a special operating table with traction is required. Potential complications include intra-operative femoral and ankle fractures. These can be avoided through careful manipulation of the limb. If a femoral fracture occurs, the incision can be extended distally along the anterolateral aspect of the thigh, and splitting the interval between the rectus femoris and the vastus lateralis. In obese or muscular patients, where visibility is in doubt, an increase of the incision length will give the surgeon the required view. The choice of approach used to perform a primary THA remains controversial. The primary goal of a hip replacement is pain relief, functional recovery and implant longevity performed with a safe and reproducible approach without complications. The anterior approach is promising in terms of hospital stay and functional recovery. Although recent studies suggest that component placement in minimally invasive surgery is safe and reliable, no long-term results have been published. Further follow-up and development is necessary to compare the results with the posterior approach. The proposed benefits of with the DAA are not supported by the current available literature. The issues regarding the difficult learning curve, rate of complications, operative time, requirement for trauma tables and image intensifier should be taken into account by surgeons starting with the DAA in THA

Introduction. In total hip arthroplasty, correct sizing is critical for fixation and longevity of cementless components. Previously, three-dimensional CT templating has been shown to be more accurate than using 2D radiographs. The accuracy of the Optimized Positioning System (OPS. TM. ) planning software has not been reported. The aim of this study was to measure the accuracy of the OPS planning software in predicting the implanted acetabular cup and femoral stem size when used with the direct anterior approach. Method. Between October 2018 and March 2019, 95 patients received a bone preserving cementless MiniHip stem (Corin, UK). Sixty-three of these patients also received a cementless Trinity cup (Corin, UK). All patients were sent for OPS. TM. pre-operative planning, a patient-specific dynamic modelling software used to determine the optimal acetabular and femoral component size and positions. Average age was 57 (28 to 78) and 44% were female. All cases were performed using the direct anterior approach. The sizes of implants used were retrospectively compared to the planned OPS. TM. sizes. Results. Of the 95 cases, 98% (n=93) of MiniHip stems were within one size of that predicted, and 66% (n=63) matched exactly the predicted size. Of the 63 Trinity cups, 98% (n=62) were within one size of that predicted and 48% (n=30) matched exactly the predicted size. All stems and cups were within 2 sizes of plan [Fig. 1]. Conclusion. The OPS. TM. planning software successfully predicted more than 95% of implanted cup and stems within one size, with 100% implants being within 2 sizes. There is significant value in accurately predicting implant sizes preoperatively, both as an indicator to the surgeon as to the size expected, and for reducing the inventory supplied to the hospitals. For any figures or tables, please contact the authors directly

INTRODUCTION. The direct anterior approach (DAA) for total hip arthroplasty has become a popular technique. Proponents of the anterior approach cite advantages such as less muscle damage, lower dislocation risk, faster recovery, and more accurate implant placement for the approach. However, there is a steep, complex learning curve associated with the technique. The present study seeks to define the learning curve based on individual surgical and outcome variables for a high-volume surgeon. METHODS. 300 consecutive patients were retrospectively analyzed. Intraoperative outcomes measured include surgery time and estimated blood loss (EBL). Complications include intraoperative fracture, post-operative fracture, infection, dislocation, leg length discrepancy, loosening, and medical complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE). Segmented regression models were used to elucidate the presence of a learning curve and mastery of the procedure with regard to each individual variable. RESULTS. The mean operative time was 77.1 minutes (range 40–213). Operative time improved at a rate of 6.6 minutes per case for the first 15 cases then by an average of 5 seconds per subsequent case. The mean EBL for the series was 288.6 mL. Segmented regression shows EBL decreased at a rapid rate until case 52, followed by a more gradual decline. Complications were higher in the first 7 surgeries, with a 48% decrease in the likelihood of complication with each subsequent surgery. The improvement continued through the rest of the series with a 0.5% decrease in likelihood with each surgery. DISCUSSION. Our data contributes to the current body of literature by defining the learning curve with what we consider the most pertinent outcomes. First, we show that operative efficiency can be gained quite quickly (15 cases) while the slower improvement in EBL demonstrates continued learning about the anatomy. Our data is consistent with previous published reports regarding complication improvement. The present study will provide surgeons considering DAA useful information regarding what to expect during their learning curve. Furthermore, the data can be useful for surgeons charged with teaching the technique to critically evaluate what learning curve variables can be improved to hasten the learning curve

For learning any new technique the main principle to follow is: learn the technique thoroughly from start to finish and adopt it as taught, without attempting to modify it until you are very familiar with it. Orthopaedic table enhanced anterior approach THA (ATHA) is at this point a well-established teachable and repeatable technique though its safety and efficacy depends on adherence to details. These technical details have evolved to become part of the technique since I first taught it at a course in 2003. The technical details and innovations have utilised the invaluable input from high volume expert surgeons as well as from less experienced surgeons taking on the challenges of learning. Considering anterior approach (AA), three technical aspects can be a “mental block” for the uninitiated surgeon: 1) supine position, 2) the orthopaedic table, 3) checking cup position, leg length and offset with the image intensifier/C-arm. Keep in mind that though you may have been initially trained and experienced with lateral position, a flat table and no x-ray checks, these three technical aspects greatly facilitate Anterior Approach and enhance its repeatability, safety, accuracy and overall “ease of use”. Anterior approach technical instruction is available at a number of venues and the preceding is consistent with the surgeon developed technique taught at courses. Visiting a surgeon who is expert in AA can also provide an effective supplemental educational experience

BACKGROUND. Hip arthroplasty is an ultimate treatment for individuals with severe hip osteoarthritis. There are several available approaches when performing this type of surgery, however there is a growing interest in using the least invasive procedures. These less invasive procedures aid in healthy bone preservation which may be particularly important for younger populations undergoing hip arthoplasy (Rajakulendran & Field, 2012). Accurate and reliable measurement techniques are needed to better study and monitor the outcome of different implantation techniques during the postop recovery. OBJECTIVES. To develop a better understanding of spatiotemporal aspects of gait pre- and post- hip arthroplasty through the anterior approach. METHODS. Six subjects treated with an anterior approach hip-arthroplasty were instructed to walk over a 30 foot walkway while wearing a lumbar gait sensor that is equipped with an accelerometer and gyroscope used to track changes in body position and hip angles. Subjects were tested before surgery, 3 and 6 weeks post-surgery, and 3 and 6 months post-surgery. The subjects were compared to healthy, age-matched controls. RESULTS. The use of this device enabled the measurement of consistent gait temporal characteristics throughout the different time points. It was found that spatiotemporal parameters improved as time progressed post-surgery. Furthermore, it is noted that the most substantial improvements were observed after the six week mark with a possible plateauing observed after the three month mark. The following figures illustrate the changes over time experienced by a subject. Their data is also compared to that of a healthy control. Figure 1 summarizes the 6-month follow up results of a female subject with anterior approach THA. CONCLUSIONS. The greatest improvements in performance were observed as early as 6 weeks post-surgery in some of the subjects. The data also suggests that improvements may plateau after 3 months post-surgery. These biomechanical findings may help with post-surgical physical activity and therapeutic recommendations as well as providing clinicians with a better prognosis time frame for the anterior approach hip arthroplasty

The first rule in properly cementing a femoral component is obtaining adequate exposure of the proximal femur. This is achieved reproducibly in anterior approach surgery with anterior and superior capsulotomy, combined with release of the conjoined tendon from the inner trochanter and piriformis tendon retraction, or flip behind the trochanter. This will be demonstrated. The steps of cementation are well established, and not specific to one approach. They involve entry to the proximal femur in a lateral and posterior position, achieving central alignment within the proximal femur with the broach, application of a cement restrictor to a point 1.5 to 2cm distal to the proposed tip of the implant, appropriate preparation of the cancellous bone to receive the cement, applying cement in a sufficiently doughy state to be able to achieve penetration into the cancellous bone, and mechanical pressurization into that cancellous bone. We routinely apply cement directly to the proximal aspect of the femoral component as the cement sticks to the metal, preventing marrow contents generated during the insertion from contacting the metal. In discussing the factors contributing to a dry surgical field, the importance of relative hypotension achieved from regional anesthesia cannot be overstated

The anterior approach is now an accepted approach for total hip arthroplasty. First described over a century ago, its popularity has grown significantly in the last decade with the advent of a reproducible technique on an orthopaedic table. Potential advantages include quicker recovery times, less post-operative pain, improved hip biomechanics, and more accurate cup position. While both femoral exposure and learning curve are often cited as potential drawbacks, a large percentage of US surgeons now utilise this teachable approach. The adoption of this approach has facilitated the development of new tools to assist the arthroplasty surgeon in a more efficient and efficacious manner. The anterior approach is performed with the patient in a supine position on an orthopaedic table. The supine position provides improved visualization of the acetabulum, appreciation of pelvic position as well as the advantage of intra-operative fluoroscopy. While many technologies including navigation and first generation robotics exist to assist the surgeon with virtual information; only fluoroscopy provides the surgeon with real time actual information. The interpretation of fluoroscopic images carries a learning curve and potential for error. New technology now exists to assist the surgeon to better interpret fluoroscopic images including anteversion and abduction of cup, leg length and offset. Since the first hip surgery was performed by Sir John Charnley, hip surgeons have utilised specialised tools including reamers, drills, saws, and mallets during surgery to assist with cup insertion, femoral preparation, stem insertion, liner insertion and head impaction. Many tools in the operating room including drills, reamers, and saws have moved from hand powered operation to pneumatic and now battery powered operation to assist with efficiency, efficacy, and reduced surgeon fatigue. A new, battery powered impaction device provides a consistent and constant energy that does not rely on the surgeon's mallet speed, throw distance, or impact contact. This may represent the next generation of surgical tools available to the arthroplasty surgeon that has the potential to make the mallet obsolete

The excitement and enthusiasm that accompanies the introduction of many new technologies and techniques can be self-sustaining, meaning that the appeal of doing something new or different (not necessarily doing something better) becomes the prime driver. Such is likely the case today with the direct anterior approach to total hip arthroplasty. Can THA be done successfully through a direct anterior approach? Certainly the answer is yes; and with experience it can be done in relatively broad groups of patients with an acceptable risk of complications. Is it a better way to do THA than other approaches? Well probably not in 2012. Contemporary THA done with a variety of approaches and coupled with advanced anesthetic, pain management and rapid rehabilitation protocols has been shown to be safe and effective with both short hospital stays (48 hours) and even outpatient surgery in selected patients. No substantial clinical advantage has been shown to date with a direct anterior approach. The sometimes extraordinary claims associated with the direct anterior approach are accompanied by relatively ordinary data. The purported benefits of direct anterior related to more rapid recovery, better function, or a lower dislocation risk just have not proved to be demonstrable in broad groups of patients. In regard to recovery there are now several studies suggesting no difference at 2 hours; 2 days; 2 weeks or 2 years after surgery; and likely no difference at 2 months either. In regard to function there are now multiple gait analysis studies with no demonstrable benefit at 2 weeks or 6 weeks. In regard to lower risk of dislocation if we pool the data from big published studies Sariali (1.5%) Matta (0.6%) Jewett (1%) and Woolson (0%) the mean is 0.88%. Interestingly, contemporary posterior approach THA with formal capsular repair also has <1% dislocation rate when we look at published data from White (0.5%) Pagnano (0.3%) and Dorr (0%). The direct anterior does come at a cost including: longer operative times; additional equipment and/or personnel; unique complications; and in some techniques the need for intra-operative fluoroscopy with attendant exposure to radiation for the surgeon and staff. It is clear in 2012 that the direct anterior approach is just another technique for performing a very successful procedure, namely total hip arthroplasty. With advanced anesthetic, pain management, and rapid rehabilitation protocols it will be extremely difficult to prove any marginal benefit associated with THA surgical technique. To summarize the available data on direct anterior THA it is not unreasonable to conclude that “the extraordinary claims are accompanied by very ordinary data.”

The direct anterior approach to total hip arthroplasty (THA) is growing in popularity. This growth is fueled by interest from surgeons and patients alike, both of whom are in search of improved outcomes in THA. While the benefits of the approach are likely less pronounced than some marketing claims made, delivering a surgical recovery that has less pain and faster function is of significant value to today's patient. Published data has demonstrated subtle improvement in pain and function when compared with both the lateral and posterior approaches. Usually these clinical results are equivalent by 2 or 3 months post-operative. This can lead to accelerated recovery, a shorter length of stay, and a more cost-effective result. Some surgeons have utilised this approach as they implement outpatient THA as well. Another added benefit is that a supine patient positioning allows for easy implementation of intra-operative fluoroscopy, which has been shown to reduce outliers in component positioning. Improved component positioning has the potential to reduce dislocation rates, lower bearing wear, and improve longevity. While image guided implant positioning can be used with any approach or patient position, it is efficient, affordable, and available to implement with the anterior approach. Using intra-operative imaging requires learning how to use and interpret the image, because incorrect utilization of fluoroscopy can be as harmful as it can be helpful. Surgeons who are contemplating adapting the approach in practice must be aware of the potential pitfalls and learning curve, as studies have demonstrated increased operative time, blood loss, and peri-operative complications in the early cases. However, with appropriate training, patient selection, and implementation, the approach can be safely used in all THA patients

Over the past 15 years Anterior Approach (AA) THA has shown a dramatic increase in adoption by surgeons (over 30%) and choice by patients with a corresponding decrease in the percentage of hips performed with traditional posterior and lateral approaches. I began AA in 1996 in order to solve the classic problems of potential dislocation associated with posterior approach and potential abductor weakness associated with the lateral (Harding) approach. Surgeon education on AA began in 2013 and has accelerated since. AA is usually performed with the aid of an orthopaedic table which facilitates exposure though many cases are also performed on a standard operating table. Intraoperative image intensification has provided real-time feedback and accuracy for cup position leg length and offset and is facilitated by the supine position and a radiolucent orthopaedic table, however, AA can be performed without it. Earlier functional recovery with decreased post-operative pain is the best documented benefit of AA as well as decreased dislocation rate. My own point of view is to take advantage of a switch to AA to improve more than your surgical approach. Improve also hip biomechanics, cup position, ease of surgery, bone preparation, and soft tissue handling. A proven and repeatable technique and use of available technologies will facilitate this

There are numerous examples in medicine where “eminence trumps evidence.” The direct anterior approach (DA) is no exception. Its meteoric rise has largely been driven by industry and surgeon promotion. This surgical approach continues to garner interest, but this interest is largely for marketing purposes, as emerging data would suggest a high risk, low reward operation. In addition, factors such as selection bias and impact bias, have substantially swayed peoples interest into making an inferior operation look better. There are several factors related to the direct anterior approach that should give us pause. Those include the surgeon learning curve, limited functional benefit and increased complications. There is no question the DA approach for total hip arthroplasty (THA) has a long and steep learning curve. The majority of studies would suggest at minimum, 50–100 cases before a surgeon is comfortable with this approach and some studies would suggest the technical difficulties of this approach remain an issue even with increasing experience. This proves difficult with an attempted rapid adoption of this technique by a surgeon who may perform less than 50 THAs per year but feel the need to offer this approach to their patients for marketing purposes. One of the many touted benefits of the DA approach is the perception of improved functional outcomes. Many of the early studies showed early improvement in gait, pain and mobility. However, these studies compared the DA approach to an anterolateral approach. Even when compared to the anterolateral approach, considered the most invasive and least muscle sparing, the benefits of the DA approach were only short term (6 weeks). The majority of retrospective studies, prospective randomised studies and meta-analyses comparing DA to a posterior approach show little, if any, benefit of one approach over another with regards to functional benefit. Another touted benefit includes a low or no dislocation risk associated with the posterior approach. On the contrary many studies have failed to demonstrate lower dislocation rates with the DA approach compared to a contemporary posterior approach. A recent registry study from the Michigan Arthroplasty Registry Quality Initiative (MARQI) showed equal dislocation rates between the DA and posterior approach. Concerns have also been raised regarding unique and more frequent complications with the DA approach compared to other surgical approaches for total hip arthroplasty. Unique complications such as ankle fractures and a high incidence of nerve injury, especially damage to the lateral femoral cutaneous nerve, have been reported. In addition, the data now clearly show a higher incidence of complications on the femoral side, including early loosening and periprosthetic fracture. As responsible surgeons, if we want to say the DA approach is different, then fine, we can say it's different. Claims of superiority of one approach over another have not been born our in the literature and in fact much of the data would suggest a high risk no reward operation for the DA approach compared to other surgical approaches for total hip arthroplasty

Background. Pre-operative autologous blood donation is recommended as a means of reducing the need for allogeneic transfusion before simultaneous bilateral total hip arthroplasty (THA). However, there have been few reports on the optimal amount of autologous donation for this procedure. In this study we sought to determine the amount of autologous blood required for patient undergoing simultaneous bilateral THA using the direct anterior approach. Methods. We retrospectively enrolled 325 consecutive patients (650 hips) underwent simultaneous bilateral primary THA from January 2012 to June 2014. Thirty-three patients were men and 290 patients were women. The patients’ mean age at THA was 59.1 years. All THAs were performed using the direct anterior approach. Intraoperative blood salvage was applied for all patients and postoperative blood salvage was not applied for any patients. Results. The mean intraoperative blood loss and the mean operative time for the bilateral procedure were 413±165 g and 87.2±12.3 minutes, respectively. Two hundreds and forty-one of the 325 patients (74.2%) donated an average of 1.9 (range, 1–2) units of autologous blood before the operation. The mean hemoglobin levels on the preoperative day, postoperative day 1 and postoperative day 5 were 12.5g/dl, 10.5 g/dl and 9.5 g/dl, respectively. Only 1 patient (0.3%) required postoperative transfusions of allogeneic blood. All of the autologous units collected were transfused, and no units were wasted. Conclusion. Simultaneous bilateral THA can be performed without allogenic blood transfusion in 99.7% of patients. We could not find out significant effectiveness of an average of 1.9 units of autologous blood donation for this procedure in this study. We concluded that simultaneous bilateral THA can be performed without autologous blood donation in healthy patients without severe hip deformity. Whereas, preoperative donation of autologous blood might be suitable for patients with low body weight or patients with severe hip deformity. The minimally invasive aspect of the direct anterior approach seems to allow a low rate of allogeneic blood transfusion in the study