CAN ANTERIOR APPROACH TOTAL HIP ARTHROPLASTY BE SAFELY INTRODUCED INTO CONTEMPORARY ARTHROPLASTY PRACTICE?

Anterior approach (AA) total hip arthroplasty (THA) is deemed to promote early postoperative mobilization and functional recovery by reducing postoperative pain. However, some studies have reported higher rates of adverse events when introducing AA into practice. The purpose of this study was to investigate the safety of introducing the AA-THA into practice by assessing short-term complications and length of hospital stay (LOS) between patients who received a primary, elective AA-THA compared to the lateral approach (LA) and the posterior approach (PA) in Alberta, Canada, from 2015 onward. Using a retrospective population-based cohort study design of prospectively collected patient-level data, 5,817 total patients were included in this study. Of these, 1939 were AA-THA and matched 1:1:1 to 1939 PA-THA and 1939 LA-THA. The Alberta Bone and Joint Health Institute (ABJHI) provincial administrative data repository was searched to identify patients who underwent an elective, primary, unilateral AA-THA between January 2015 and July 2022. The primary objective of this study was to compare adverse events between AA-THA and LA-THA as well as AA-THA and PA-THA. Secondary objectives were to compare need for blood transfusion, 30-day readmission rates, deep surgical site infections (SSI), length of hospital stay (LOS) and 30-day mortality. When matched for age and gender, 1939 patients were included in each group. No statistically significant difference was noted in AA-THA compared to LA-THA in transfusion rates (p=0.13), readmission within 30 days (p=0.259), 30-Day mortality (p=0.215), myocardial infarction (p=0.469), pneumonia (p=0.615), gastrointestinal bleeding (p=0.657), ileus (p=0.570), bleeding (p=0.083), delirium (p=0.483), intra-operative fractures (p=0.706), post-operative fractures (p=0.228), and dislocation (p=0.999). LOS was significantly reduced in the AA-THA group (p < 0.001). Similarly, there was no statistically significant difference in AA-THA to PA-THA in readmission within 30 days (p=0.361), 30-day mortality (p=0.141), myocardial infarction (p=0.227), pneumonia (p=0.999), gastrointestinal bleeding (p=0.257), ileus (p=0.139), intra-operative fracture (p=0.741) and dislocation (p=0.228). There were statistically significant increases in post-operative fracture (p=0.027), delirium (p=0.020), bleeding (p=0.013) and need for transfusion (p < 0.001) in the PA-THA group compared to AA-THA. There was a reduction in LOS in the AA-THA group (p < 0.001). When subgroup analysis matching included BMI, 1205 patients were analyzed per group, and this identified statistically significant increases in transfusion in both the LA-THA (p=0.007) and PA-THA (p=0.001) groups and bleeding in the PA-THA (p=0.026) group. By matching BMI, there was no statistical difference in post-operative fractures (p=0.108) and delirium (p=0.144) in PA-THA compared to AA-THA. Subgroup analysis for deep infection included 1158 patients per group. Compared to AA-THA, analysis showed a higher risk of deep infection in the LA-THA group (p=0.010) and no difference compared to the PA-THA group (0.114). With careful introduction, our Alberta experience demonstrates that AA-THA can be safely introduced into contemporary arthroplasty practice with comparable outcomes to LA and PA-THA. Careful introduction included participation in industry sponsored courses, cadaver labs, operating room visitations, reverse visitations, and scrubbing two surgeons for the first number of cases.