First 100 Total Hip Arthroplasties Performed by a Young Surgeon Using the Direct Anterior Approach: Learning Curve and Complications

Overview

Journal Arch Orthop Trauma Surg

Specialties Emergency Medicine
General Surgery
Orthopedics

Date 2023 Oct 6

PMID 37803086

Authors

Yen-Wei Li

Shang-Won Yu

Jih-Hsi Yeh

Ching-Hou Ma

Cheng-Yo Yen

Yuan-Kun Tu

Affiliations

Soon will be listed here.

Abstract

Introduction: Most of the reported discussions about the learning curve for the direct anterior approach (DAA) in total hip arthroplasty (THA) have been by experienced surgeons. The study's aim was to describe the learning curve, short-term outcomes, complications, and adaptations to the DAA used in the first 100 THA cases experienced by a young surgeon who had received DAA training for trauma surgeries.

Materials And Methods: This retrospective study summarizes the first 100 consecutive cases experienced by a young surgeon who performed the unilateral DAA for THA between 2019 and 2021. Cumulative sum (CUSUM) analysis was performed to evaluate the learning curve on the basis of operative time and overall complications. The demographics data, short-term outcomes, and complications of the first 50 and second 50 cases were compared.

Results: The CUSUM curve declined after 49 and 55 cases, measured by operative time and overall complications, respectively. The median operative time (104 vs. 80 min) and intraoperative fluoroscopic time (38 vs. 12 s) increased significantly in the first 50 cases compared with the times in the second 50 cases. Complications tended to occur in the first 50 cases (12% vs. 6%), and the overall rate was 9%. Major complications all occurred in the first 50 cases, with a rate of 4%. Only one case, which involved a complicated periprosthetic fracture around the stem that extended to the tip, required the intervention of a senior surgeon.

Conclusions: Even after receiving training on the DAA for trauma surgeries, the young surgeon experienced a steep learning curve and more complications in the first 50 cases. The DAA for THA is a technically demanding procedure and may require guidance from an experienced surgeon to manage unexpected complications.

Citing Articles

Learning curve comparison between switching approach and switching implant in cementless short stem total hip arthroplasty.

Stadler C, Bolm J, Schopper C, Schauer B, Holzbauer M, Gotterbarm T Arch Orthop Trauma Surg. 2024; 144(9):4259-4265.

PMID: 39249133 PMC: 11564367. DOI: 10.1007/s00402-024-05518-9.

A neck-sparing short stem shows significantly lower blood loss in total hip arthroplasty compared to a neck-resecting short stem.

Stadler C, Schauer B, Brabec K, Schopper C, Gotterbarm T, Luger M Sci Rep. 2023; 13(1):19695.

PMID: 37951980 PMC: 10640618. DOI: 10.1038/s41598-023-47008-9.

References

Fehring T, Odum S, Troyer J, Iorio R, Kurtz S, Lau E . Joint replacement access in 2016: a supply side crisis. J Arthroplasty. 2010; 25(8):1175-81. DOI: 10.1016/j.arth.2010.07.025. View

Mjaaland K, Kivle K, Svenningsen S, Pripp A, Nordsletten L . Comparison of markers for muscle damage, inflammation, and pain using minimally invasive direct anterior versus direct lateral approach in total hip arthroplasty: A prospective, randomized, controlled trial. J Orthop Res. 2015; 33(9):1305-10. DOI: 10.1002/jor.22911. View

Restrepo C, Parvizi J, Eslam Pour A, Hozack W . Prospective randomized study of two surgical approaches for total hip arthroplasty. J Arthroplasty. 2010; 25(5):671-9.e1. DOI: 10.1016/j.arth.2010.02.002. View

Zhou Z, Li Y, Peng Y, Jiang J, Zuo J . Clinical efficacy of direct anterior approach vs. other surgical approaches for total hip arthroplasty: A systematic review and meta-analysis based on RCTs. Front Surg. 2022; 9:1022937. PMC: 9574056. DOI: 10.3389/fsurg.2022.1022937. View

Wang Z, Bao H, Hou J . Direct anterior versus lateral approaches for clinical outcomes after total hip arthroplasty: a meta-analysis. J Orthop Surg Res. 2019; 14(1):63. PMC: 6390312. DOI: 10.1186/s13018-019-1095-z. View

Hartford J, Bellino M . The learning curve for the direct anterior approach for total hip arthroplasty: a single surgeon's first 500 cases. Hip Int. 2017; 27(5):483-488. DOI: 10.5301/hipint.5000488. View

Nairn L, Gyemi L, Gouveia K, Ekhtiari S, Khanna V . The learning curve for the direct anterior total hip arthroplasty: a systematic review. Int Orthop. 2021; 45(8):1971-1982. DOI: 10.1007/s00264-021-04986-7. View

Kong X, Grau L, Ong A, Yang C, Chai W . Adopting the direct anterior approach: experience and learning curve in a Chinese patient population. J Orthop Surg Res. 2019; 14(1):218. PMC: 6636028. DOI: 10.1186/s13018-019-1272-0. View

de Steiger R, Lorimer M, Solomon M . What is the learning curve for the anterior approach for total hip arthroplasty?. Clin Orthop Relat Res. 2015; 473(12):3860-6. PMC: 4626490. DOI: 10.1007/s11999-015-4565-6. View

10.

Peters R, Ten Have B, Rykov K, van Steenbergen L, Putter H, Rutgers M . The learning curve of the direct anterior approach is 100 cases: an analysis based on 15,875 total hip arthroplasties in the Dutch Arthroplasty Register. Acta Orthop. 2022; 93:775-782. PMC: 9521054. DOI: 10.2340/17453674.2022.4802. View

11.

Foissey C, Fauvernier M, Fary C, Servien E, Lustig S, Batailler C . Total hip arthroplasty performed by direct anterior approach - Does experience influence the learning curve?. SICOT J. 2020; 6:15. PMC: 7273835. DOI: 10.1051/sicotj/2020015. View

12.

Woolson S, Pouliot M, Huddleston J . Primary total hip arthroplasty using an anterior approach and a fracture table: short-term results from a community hospital. J Arthroplasty. 2009; 24(7):999-1005. DOI: 10.1016/j.arth.2009.04.001. View

13.

Post Z, Orozco F, Diaz-Ledezma C, Hozack W, Ong A . Direct anterior approach for total hip arthroplasty: indications, technique, and results. J Am Acad Orthop Surg. 2014; 22(9):595-603. DOI: 10.5435/JAAOS-22-09-595. View

14.

Wernly D, Wegrzyn J, Lallemand G, Mahlouly J, Tissot C, Antoniadis A . Total hip arthroplasty through the direct anterior approach with and without the use of a traction table: a matched-control, retrospective, single-surgeon study. J Orthop Surg Res. 2021; 16(1):45. PMC: 7802295. DOI: 10.1186/s13018-020-02184-6. View

15.

Zhao G, Zhu R, Jiang S, Xu C, Xu N, Wang Y . Soft tissue restrictors of femoral elevation in direct anterior approach-an anatomic study. J Orthop Surg Res. 2018; 13(1):308. PMC: 6280390. DOI: 10.1186/s13018-018-1012-x. View

16.

Khan N, Abboudi H, Khan M, Dasgupta P, Ahmed K . Measuring the surgical 'learning curve': methods, variables and competency. BJU Int. 2013; 113(3):504-8. DOI: 10.1111/bju.12197. View

17.

Burnham Jr R, Kiernan H, Ortega L, Wesolowski M, Tauchen A, Russo M . Defining the Learning Curve of Anterior Total Hip Arthroplasty After Fellowship-specific Training. J Am Acad Orthop Surg. 2021; 30(1):e131-e138. DOI: 10.5435/JAAOS-D-21-00232. View

18.

Garbarino L, Gold P, Sodhi N, Iturriaga C, Mont M, Boraiah S . Does Structured Postgraduate Training Affect the Learning Curve in Direct Anterior Total Hip Arthroplasty? A Single Surgeon's First 200 Cases. Arthroplast Today. 2021; 7:98-104. PMC: 7818600. DOI: 10.1016/j.artd.2020.11.019. View

19.

Hallert O, Li Y, Brismar H, Lindgren U . The direct anterior approach: initial experience of a minimally invasive technique for total hip arthroplasty. J Orthop Surg Res. 2012; 7:17. PMC: 3419665. DOI: 10.1186/1749-799X-7-17. View

20.

Kawarai Y, Iida S, Nakamura J, Shinada Y, Suzuki C, Ohtori S . Does the surgical approach influence the implant alignment in total hip arthroplasty? Comparative study between the direct anterior and the anterolateral approaches in the supine position. Int Orthop. 2017; 41(12):2487-2493. DOI: 10.1007/s00264-017-3521-3. View