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Anterior-Based Muscle-Sparing Approach for Total Hip Arthroplasty and Transitioning From a Posterior Approach for Total Hip Arthroplasty: Minimizing the Learning Curve

March 01, 2019

Contributors: Mike Anderson, MS, ATC; Jill Erickson, PA; Scott Lindsley; Christopher L Peters, MD; Ryland Kagan, MD; Ryland Kagan, MD

Minimally invasive approaches for total hip arthroplasty (THA) are increasing in popularity as surgeons attempt to decrease the postoperative recovery period after this successful and functionally restorative procedure. The anterior-based muscle-sparing (ABMS) approach for THA is associated with rapid functional recovery, resulting in outcomes and complication rates similar to those of other THA approaches. However, concern exists with regard to surgeons who are considering changing their THA approach because of the potential for increased complications during the learning curve period associated with other anterior-based THA approaches. This video reports on the early transition period of an experienced orthopaedic surgeon from a traditional posterior THA approach to an ABMS approach, demonstrates the ABMS approach for THA in a patient and a cadaver model, and presents the preoperative and postoperative imaging studies of a patient who underwent THA via the ABMS approach. The video uses live surgical footage supplemented with cadaver model dissection to introduce and detail the steps of the ABMS approach for THA. The video also presents data from a retrospective cohort study on the first 100 primary THA procedures (96 patients) performed by the senior author between August 2016 and August 2017 using the ABMS approach. These procedures were compared with 91 primary THA procedures (89 patients) performed between July 2015 and July 2016 using a mini-posterior approach. Gamma regression with robust standard errors was used to compare the length of stay between the cohorts. Estimated blood loss was evaluated using mediation analysis. Surgical time, radiographic measures, and patient-reported outcomes were assessed using generalized estimating equation regression. We found no difference in the estimated blood loss (P = 0.452) and surgical time (P = 0.564) between the cohorts. The ABMS cohort had a slightly shorter length of stay (P = 0.001), with an adjusted mean length of stay of 1.53 days (95% confidence interval, 1.4 to 1.6 days) compared with 1.85 days (95% confidence interval, 1.8 to 1.9 days) in the mini-posterior cohort. One intraoperative medial calcar fracture occurred in the ABMS cohort. No additional intraoperative complications were reported. No difference was reported in the proportion of patients within the Lewinnek safe zone for abduction (P = 0.347). No difference was reported in the adjusted mean change in patient-reported outcomes using the Patient-Reported Outcomes Measurement Information System Physical Function Computer Adaptive Test and Global Health outcome measures at a follow up of 6 weeks (all P > 0.05). Our data demonstrated a small learning curve period (if any) for an experienced senior surgeon transitioning from a mini-posterior THA approach to an ABMS approach. The main advantages of the ABMS approach for THA are lateral patient positioning, direct visualization of the acetabulum and femur, more lateral incision placement, and ease of conversion to an extensile approach.

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