Comparison of Perioperative Outcomes and Early Complications Between a Direct Anterior Approach or Posterolateral Approach in Simultaneous Bilateral Total Hip Arthroplasty: A Retrospective Study

Abstract

Background: Controversies remain on the best surgical approaches for unilateral total hip arthroplasty (THA). There are little data on simultaneous bilateral THA via direct anterior approach (SimBDAA-THA) or posterolateral approach (SimBPA-THA). Purpose: We sought to assess differences in perioperative outcomes and early medical and surgical complications between SimBDAA-THA and SimBPA-THA. Methods: This retrospective study involved patients who underwent either SimBDAA-THA in a supine position (n = 73) or SimBPA-THA in a lateral position (n = 162) at our institution from January 2015 to November 2021. The 2 groups were compared in terms of clinical and demographic characteristics, surgical parameters, and complications during 6-months of follow-up. Results: There were no differences in clinical and demographic characteristics between the 2 groups prior to surgery. Simultaneous bilateral THA via direct anterior approach significantly shortened the length of both the operation (117.50 ±19.42 vs 143.97 ± 32.20 min) and the hospitalization (140.64 ± 43.22 vs 156.24 ± 56.64 h) but increased perioperative loss of hemoglobin (3.28 ± 1.01 vs 3.21 ± 2.26 g/dL). There were no significant differences between the two groups in transfusion rate; levels of interleukin-6, C-reactive protein or creatine kinase; or complications. Conclusion: This retrospective study of patients at a single institution found minimal differences in perioperative outcomes or early medical and surgical complications between SimBDAA-THA and SimBPA-THA except operative time and length of hospitalization. Larger studies with longer follow-up should be conducted to identify whether a direct anterior approach is superior to a posterolateral one.

Keywords

direct anterior approach simultaneous bilateral total hip arthroplasty posterolateral approach surgical approach

Introduction

Simultaneous bilateral total hip arthroplasty (SimBTHA) is used for the treatment of bilateral hip diseases [22]. Two common approaches used during simultaneous bilateral total hip arthroplasty (THA) include a direct anterior approach (SimBDAA-THA) and a posterolateral approach (SimBPA-THA). In contrast to the more common posterolateral approach, the direct anterior approach is considered minimally invasive and does not involve muscle detachment [35]. No consensus exists on which approach is superior in terms of clinical benefit and safety.

In comparison to the posterolateral approach, the direct anterior approach has been associated with milder inflammatory response, shorter hospital stays, and lower risk of dislocation [19,25,43]. On the contrary, it has also been associated with longer operative time, greater blood loss, and higher rate of complications. In addition, surgeons face a steep learning curve when practicing the direct anterior approach, which increases the risk of complications [1,3,8,10,40,46]. Since DAA-THA is performed in the supine position, it may permit a simultaneous bilateral procedure without repositioning of the patient [20,21].

While numerous studies have compared outcomes between unilateral DAA-THA and PA-THA [2,28,36], we are aware of only one study comparing the approaches when both hips were replaced simultaneously [9]. According to that study, SimBDAA-THA was associated with better outcomes, particularly in accordance with the “enhanced recovery after surgery” protocol. However, that study involved a small sample and did not report perioperative outcomes or postdischarge complications.

We performed this retrospective study to compare perioperative blood loss and acute phase responses between SimBDAA-THA and simultaneous bilateral THA via posterolateral approach (SimBPA-THA). A 30-day re-admission, early medical and surgical complications are also traced and included for comparison. Our hypothesis is that SimBDA-THA would share similar perioperative outcome with SimBPA-THA without the increased risk of complications.

Methods

We conducted a retrospective cohort study of adults (≥18 years old) with confirmed bilateral hip disease who underwent SimBDAA-THA or SimBPA-THA at our institution. Ethical approval was obtained from the Clinical Trials and Biomedical Ethics Committee of our institution, which waived the requirement for informed consent because patients, at the time of treatment, consented for their anonymized medical data to be analyzed and published for research purposes.

Eligible patients were identified from electronic medical records as well as ancillary clinical and administrative data systems at our institution. All patients who underwent SimBDAA-THA in a supine position or SimBPA-THA in a lateral position from January 2015 to November 2021 were considered, as long as they were followed up for at least 6 months after discharge. Cases were excluded if patient data were incomplete or if surgery was performed to treat hemophilic arthropathy.

A total of 243 patients were retrospectively identified, and from that group, 8 were excluded due to missing data (n = 3) or hemophilic arthropathy (n = 5). Finally, 235 patients were enrolled in the study, with 73 in the SimBDAA-THA group and 162 in the SimBPA-THA group. There were no significant clinicodemographic differences between groups (Table 1).

Table 1.

Clinicodemographic characteristics of patients and surgical parameters.

Characteristic or parameter	SimBDAA-THA group (n = 73)	SimBPA-THA group (n = 162)	P
Age (years)	42.82 ± 8.65	43.32 ± 9.68	.706^a
Sex (male)	7 (9.59)	14 (8.64)	.814^b
Height (m)	1.68 ± 0.06	1.67 ± 0.07	.267^a
Weight (kg)	69.02 ± 10.64	67.91 ± 9.90	.443^a
Body mass index (kg/m²)	24.38 ± 3.42	24.36 ± 3.45	.967^a
ASA classification			.484^b
1	6 (8.22)	7 (4.32)
2	62 (84.93)	143 (88.27)
3	5 (6.85)	12 (7.40)
Femoral stem length			<.001^b
Short	33 (45.20)	29 (17.90)
Standard	40 (54.79)	133 (82.10)
Operative time (min)	117.50 ± 19.42	143.97 ± 32.20	<.001^c
Length of hospitalization (hour)	140.64 ± 43.22	156.24 ± 56.64	.036^a

Values are n (%) or mean ± SD, unless otherwise noted.

SimB simultaneous bilateral; DAA direct anterior approach; THA total hip arthroplasty; PA posterolateral approach; ASA American Society of Anesthesiologists.

Independent-samples t test.

c2 test.

Mann-Whitney U test.

All SimBDAA-THA surgeries were performed by the same senior surgeon who had completed at least 100 unilateral DAA-THA cases prior to this study and was therefore considered to have passed the “learning curve” [3]. Simultaneous bilateral THA via posterolateral approach surgeries were performed by 5 senior surgeons, 4 of whom performed THA exclusively via the posterolateral approach and one of whom used the direct anterior approach in more than 50% of cases.

All surgical procedures were performed under general anesthesia based on our previously reported protocol for unilateral THA [46]. Fluoroscopy was used to check the prosthesis size, hip offset and limb length in SimBDAA-THA. Preoperative planning was useful to provide the size, position of prosthesis in SimBPA-THA procedures. Patients positioned in lateral decubitus using standard positioners also assisted the implantation of prosthesis. All patients received the same multimodal analgesia in perioperative period. After admission, celecoxib was administered unless sulfa allergy necessitated using loxoprofen. Before the wound was sutured, local infiltration analgesia (20 mL of 0.33% ropivacaine) was injected into tissues. Press-fit acetabular components (Pinnacle Cup, DePuy) were used along with cement-free, hydroxyapatite-coated standard-length femoral stems (Corail, DePuy) or short-length femoral stems (Trilock, DePuy). The same femoral stem prosthesis was used for both hips in the same patient.

All patients were treated in a standardized manner in terms of intraoperative use of tranexamic acid, prophylaxis antibiotics, thromboprophylaxis with low-molecular-weight heparin, and postoperative rehabilitation. Briefly, cefazolin 1500 mg was given intravenously 30 minutes before surgery. Tranexamic acid (20 mg/kg) was intravenously injected 5 to 10 minutes before skin incision. Two senior surgeons performing SimBPA-THA would apply one intravenous injection of 10 mg dexamethasone before incision to control inflammation. If patients experienced postoperative nausea or vomiting, another intravenous injection of 5 mg dexamethasone was applied. For thromboprophylaxis, a half-dose of low-molecular-weight heparin (2000 IU) was subcutaneously administered at 6 hours postoperatively and repeated at 24-hour intervals. Ankle dorsal and plantar flexion, quadriceps muscle strength exercises began immediately after fully awake from anesthesia. The rehabilitation nurse guided patients to perform active range of motion, strength training, and ambulation with the walker.

Data on clinicodemographics, surgical parameters, and outcomes were obtained from our institution’s electronic registry system. Demographic data included age, height, weight, body mass index, and American Society of Anesthesia score. Surgical data included femoral stem type (standard- or short-length), operative time, and length of hospitalization. Data were also extracted on the following perioperative outcomes: volume of intraoperative blood loss; concentrations of preoperative hemoglobin (HgB), HgB on postoperative day 1 (POD1), and the mean difference between preoperative HgB and POD1 HgB; and rates of autologous or allogeneic blood transfusion. The calculation of intraoperative blood loss was determined by measuring the volume of suction drain contents and the weight of sponges used during the surgery.

All autologous blood transfusions in our study were performed during surgery. Surgeons would consider autologous blood transfusion if predicted intraoperative blood loss exceed 300 ml. Shed blood was isolated from the wound, anticoagulated, filtered, centrifuged, washed, and concentrated, then transfused back into the patient before the end of surgery. Allogeneic blood transfusion was performed when the patient’s POD1 HgB level was below 7 g/dL or between 7 and 10 g/dL with clinical signs of hypovolemia (systolic blood pressure <100 mmHg, heart rate >100 beats/min, urine output <30 mL/h). Complete blood counts were performed on POD2 in patients who received either type of blood transfusion.

On POD1, blood was collected to assay muscle damage by measuring serum creatine kinase by enzymatic method (Cobas, Roche) and the acute phase reactants C-reactive protein by immunoturbidimetry (Cobas, Roche), and interleukin-6 by electro-chemiluminescent immunoassays (Cobas, Roche).

The discharge criteria were as follows: (1) the patient is stable and tolerating a normal diet; (2) the wound is dry without bleeding and exudation; (3) hip flexion ≥100° hip extension between −5° and 0°; (4) patients exhibit independent bed mobility and safe ambulation with a walker. In general, patients were encouraged to discharge home, unless the occurrence of in-hospital complications. The follow-up was at 2 weeks (by outpatient clinical visit), 3 months (by telephone), 6 months (by outpatient clinical visit) postoperatively.

We extracted data on 30-day hospital readmission for any cause and medical and surgical complications within 6 months after discharge. Medical complications assessed were myocardial infarction, pulmonary infection, sepsis, acute kidney injury, urinary tract infection, and symptomatic deep vein thrombosis. Surgical complications assessed were dislocation, periprosthetic fracture, and infection (periprosthetic or at the surgical site).

Statistical Analysis

All statistical analyses were performed using SPSS 26 (IBM). Frequencies and percentages were reported for categorical variables, while means and standard differences were reported for continuous variables. Intergroup differences in continuous variables were assessed using the independent-samples t test if data were normally distributed, or the Mann-Whitney U test if data were skewed. Categorical variables were analyzed by χ² or Fisher’s exact test as appropriate. Statistical significance was defined as P < .05. Since no sample size calculation was undertaken a priori, a post hoc power analysis was performed using G* power 3.1 (University Düsseldorf, Germany) [12].

Results

The proportion of short-stem prosthesis was significantly higher in the SimBDAA-THA group than in the SimBPA-THA group (45.20% vs 17.90%; P < .001). In addition, SimBDAA-THA was associated with significantly shorter operative time (117.50 ± 19.42 vs 143.97 ± 32.20 min;P < .001) and shorter overall length of hospital stay (140.64 ± 43.22 vs 156.24 ± 56.64 h; P = .036; power = 81.37%).

The two surgical approaches did not differ significantly in intraoperative blood loss (245.28 ± 106.41 vs 225.10 ± 91.79 ml; P = .146) or preoperative HgB (15.09 ± 1.03 vs 14.91 ± 1.44 g/dl; P = .441; Table 2). However, SimBDAA-THA was associated with a larger decrease in HgB levels between the preoperative period and POD1 (3.28 ± 1.01 vs 3.21 ± 2.26 g/dl; P = .009). Five patients undergoing SimBDAA-THA (6.85%) received autologous blood transfusions. Around 17 patients undergoing SimBPA-THA (10.49%) received blood transfusions, of which 15 (9.26%) were autologous and 2 (1.23%) allogeneic. The total rate of blood transfusions was similar between the groups (P = .734). The length of stay for transfused patients was 158.16 ± 62.88 hours.

Table 2.

Perioperative outcomes.

Outcome	SimBDAA-THA group (n = 73)	SimBPA-THA group (n = 162)	P
Intraoperative blood loss (ml)	245.28 ± 106.41	225.10 ± 91.79	.146^a
Preoperative HgB (g/dl)	15.09 ± 1.03	14.91 ± 1.44	.441^a
Mean difference between preoperative and POD1 HgB (g/dL)	3.28 ± 1.01	3.21 ± 2.26	.009*^b
Blood transfusion, any type	5 (6.85)	17 (10.49)	.734^c
Transfusion type
Autologous	5 (6.85)	15 (9.26)
Allogeneic	0	2 (1.23)
Rate of dexamethasone	13 (17.80)	78 (48.15)	<.001*^d
Postoperative indicators
C-reactive protein (mg/l)	59.04 ± 27.03	58.34 ± 34.45	.922^a
Interleukin-6 (mg/l)	154.72 ± 118.43	133.32 ± 141.36	.485^a
Creatine kinase* (U/l)	963.85 ± 668.27	893.15 ± 532.95	.225^a

Values are shown as n (%) or mean ± SD, unless otherwise noted.

SimB simultaneous bilateral; DAA direct anterior approach; THA total hip arthroplasty; PA posterolateral approach; HgB hemoglobin; OD1 postoperative day 1.

Independent-samples t test.

Mann-Whitney U test.

Fisher’s exact test.

c2 test.

Statistically significant.

Furthermore, the 2 surgical approaches did not lead to significantly different postoperative levels of the muscular damage marker creatine kinase (963.85 ± 668.27 vs 893.15 ± 532.95 U/l; P = .225) or the inflammatory markers C-reactive protein (59.04 ± 27.03 vs 58.34 ± 34.45 mg/l;P = .922) or interleukin-6 (154.72 ± 118.43 vs 133.32 ± 141.36 mg/l; P = .485) (Table 2). About 78 (48.15%) patients in SimBPA-THA received the intravenous injection of dexamethasone, while 13 (17.80%) patients in SimBDAA-THA received dexamethasone (P < .001).

During 6-month follow-up, there was no difference in an overall rate of complications (P = 1.000) between the SimBDAA-THA and SimBPA-THA groups. One pulmonary infection occurred in SimBDAA-THA at postoperative day 1, while 1 pulmonary infection occurred in the SimBPA-THA group at postoperative day 2. No other medical complication occurred during follow-up. No surgical complication occurred in SimBDAA-THA. The SimBPA-THA group had 1 surgical-site infection and 1 periprosthetic infection within 1 month after the procedure, and both patients were hospitalized. A third patient experienced dislocation at 5 months after the procedure.

Discussion

The rising demand for primary THA in patients with bilateral hip diseases has refocused attention on simultaneous bilateral replacement surgery as a way to accelerate recovery [24,30]. The best surgical approach for simultaneous bilateral hip arthroplasty remains controversial [29]. We compared perioperative outcomes, early medical and surgical complications between SimBDAA-THA and SimBPA-THA (Table 3). We found that the direct anterior approach shortened procedure time and length of stay but did not improve perioperative outcomes or lessen early complications.

Table 3.

Hospital readmission and early complications.

Outcome	SimBDAA-THA group (n = 73)	SimBPA-THA group (n = 162)	P ^a
Hospital readmission within 30 days	0	2 (1.23)	.341
Total complications within 6 months	1 (1.36)	4 (2.47)	1
Medical complications
Pulmonary infection	1 (1.36)	1 (0.61)	.526
Surgical complications
Dislocation	0	1 (0.61)	.501
Periprosthetic fracture	0	0	NA
Infection	0	2 (1.23)	.341
At surgical site	0	1 (0.61)	.501
Periprosthetic	0	1 (0.61)	.501

Values indicated as n (%), unless otherwise noted.

SimB simultaneous bilateral; DAA direct anterior approach; THA total hip arthroplasty; PA posterolateral approach.

Fisher’s exact test.

This study has several limitations. Our sample was retrospective and came from a single center. The small sample size might lead to type II error. A post-hoc power analysis was performed and determined that power was more than 80%. Second, we did not analyze patient-reported outcomes. Patients’ perception of their abilities and quality of life can influence recovery [17] and should be considered in future studies. Based on the current anesthetic record, we were not able to record repositioning time during SimBPA-THA, which was a potential factor influencing operative time. Third, because 1 surgeon performed all SimBDAA-THA surgeries. Finally, we followed patients for only 6 months postprocedure; future work should compare the benefits and safety of the two surgical approaches over longer periods.

Our results confirm that SimBDAA-THA can shorten operative time, reflecting the fact that no repositioning or secondary disinfection of the patient are needed because the patient is already in the supine position. In contrast to our findings, some studies have associated unilateral DAA-THA with longer operative time [29,46]. A longer operative time might increase the exposed time of wound and instruments, which was associated with the seeding of wound with bacteria [6]. The prolonged anesthetic time contributed to immunodeficiency through hypothermia [13,16]. Therefore, longer operative time increases the potential risk of adverse events and early complications [6,41]. The shorter operative time with SimBDAA-THA in our study translated to shorter length of hospitalization.

During the direct approach, a challenging stage is the preparation of the femoral canals due to the difficulty of elevation of femur [11,29]. Compared to a standard-length femoral stem, a short-length femoral stem reduces the need for elevation of femur and is therefore favored by surgeons [18]. This explains why 45.20% of SimBDAA-THA procedures in our study involved a short-stem prosthesis, compared to only 17.90% of SimBPA-THA procedures (P < .001). No surgical complication occurred within 6 months in patients who underwent SimBDAA-THA involving either standard- or short-length stems, consistent with previous reports of similar clinical outcomes and survival between the two types of stems [42,45].

Simultaneous bilateral arthroplasty can lead to greater blood loss than unilateral arthroplasty, which may necessitate blood transfusion [24] as well as increase health care costs and the risk of infection, morbidity, and mortality [4,33]. The rate of transfusions has decreased as a result of the routine use of tranexamic acid and restrictive transfusion guidelines [21,38]. In fact, DAA-THA has been associated with greater blood loss than PA-THA, without a change in the transfusion rate [46]. In this study, the two surgical approaches were associated with similar intraoperative blood loss, but SimBDAA-THA was associated with greater reduction in Hgb level from the preoperative period to POD1 than SimBPA-THA. Nevertheless, the greater HgB loss did not translate to an increased rate of transfusion. This is consistent with previous work that transfusion rate among patients undergoing unilateral THA did not depend on whether a direct anterior or posterolateral approach was used [38].

In our study, all transfusions in the SimBDAA-THA group and nearly all transfusions in the SimBPA-THA group were autologous, which may be associated with lower risk of infections and reoperation than allogeneic blood transfusion [15,31]. In fact, autologous blood transfusion has been shown to reduce the need for allogeneic blood transfusion in total knee arthroplasty [33]. The literature and this study support autologous transfusion as an alternative to allogeneic transfusion in simultaneous bilateral total hip arthroplasties.

Our study found no significant difference in the level of muscular damage or acute inflammation between SimBDAA-THA and SimBPA-THA, which is inconsistent with previous work [5,46] and with the view of DAA-THA as a minimally invasive approach that minimizes these problems [37]. We speculate that the discrepancy between our study and previous ones is due to the routine application of dexamethasone in SimBPA-THA by 2 senior surgeons, which exerts anti-inflammatory effects and prevention of nausea and vomiting in total joint arthroplasty [26,44]. Previous randomized controlled trials from our center showed dexamethasone to be effective in unilateral THA [26,27]. Dexamethasone is a highly effective anti-inflammatory and immunosuppressant, which might increase the risk of infections. However, the majority of studies do not support this hypothesis [14]. The application of dexamethasone in diabetes mellitus has transient effects in elevating glucose, which may require changes in administration of diabetic medication [32]. Further study should compare whether extent of muscle damage or acute inflammation depends on details of perioperative management or patient characteristics.

Despite previous studies linking the direct anterior approach to higher risk of femoral fractures and prosthetic joint infection [29,34], no difference in femoral fractures or prosthetic joint infections were found in this study. Studies with longer follow-up have reported complication rates up to 2% for hip arthroplasties involving the direct anterior approach [21,34]. Risk of complications likely depends on the surgeon’s proficiency and operating time [39], as well as patient age [7,23]. The overall rate of complications (2.13%) in our sample of patients, most of whom were younger than 50 years, was similar to the range of 2% to 6.6% reported several studies involving patients underwent simultaneous bilateral THA [21,30,33]. Future work should clarify how surgical skill and patient characteristics influence risk of early complications.

In conclusion, our retrospective review suggests that using direct anterior or posterolateral approach in simultaneous bilateral THA may lead to comparable outcomes, including short-term medical and surgical complication rates. Future studies with larger cohorts and longer follow-up should verify and extend our findings.

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Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the 1.3.5 project for disciplines of excellence–Clinical Research Incubation Project, West China Hospital, Sichuan University (grant no. ZYJC18040).

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.

Informed Consent

Informed consent was waived from all patients included in this study.

Level of Evidence

Level III: Therapeutic Study

Required Author Forms

Disclosure forms provided by the authors are available with the online version of this article as supplemental material.

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