title: Anterior and Anterolateral Approaches for THA Are Associated With Lower Dislocation Risk Without Higher Revision Risk.
abstract: BACKGROUND
  Lack of consensus continues regarding the benefit of anteriorly based surgical approaches for primary total hip arthroplasty (THA). The purpose of this study was to evaluate the risk of aseptic revision, septic revision, and dislocations for various approaches used in primary THAs from a community-based healthcare organization.
  
  
  OBJECTIVE
  (1) What is the incidence of aseptic revision, septic revision, and dislocation for primary THA in a large community-based healthcare organization? (2) Does the risk of aseptic revision, septic revision, and dislocation vary by THA surgical approach?
  
  
  METHODS
  The Kaiser Permanente Total Joint Replacement Registry was used to identify primary THAs performed between April 1, 2001 and December 31, 2011. Endpoints were septic revisions, aseptic revisions, and dislocations. The exposure of interest was surgical approach (posterior, anterolateral, direct lateral, direct anterior). Patient, implant, surgeon, and hospital factors were evaluated as possible confounders. Survival analysis was performed with marginal multivariate Cox models. Hazard ratios (HRs) and 95% confidence intervals (CIs) are reported. A total of 42,438 primary THAs were available for analysis of revision outcomes and 22,237 for dislocation. Median followup was 3 years (interquartile range, 1-5 years). The registry's voluntary participation is 95%. The most commonly used approach was posterior (75%, N = 31,747) followed by anterolateral (10%, N = 4226), direct anterior (4%, N = 1851), and direct lateral (2%, N = 667).
  
  
  RESULTS
  During the study period 785 hips (2%) were revised for aseptic reasons, 213 (0.5%) for septic reasons, and 276 (1%) experienced a dislocation. The revision rate per 100 years of observation was 0.54 for aseptic revisions, 0.15 for septic revisions, and 0.58 for dislocations. There were no differences in adjusted risk of revision (either septic or aseptic) across the different THA approaches. However, the anterolateral approach (adjusted HR, 0.29; 95% CI, 0.13-0.63, p = 0.002) and direct anterior approach (adjusted HR, 0.44; 95% CI, 0.22-0.87, p = 0.017) had a lower risk of dislocation relative to the posterior approach. There were no differences in any of the outcomes when comparing the direct anterior approach with the anterolateral approach.
  
  
  CONCLUSIONS
  Anterior and anterolateral surgical approaches had the advantage of a lower risk of dislocation without increasing the risk of early revision.
  
  
  METHODS
  Level III, therapeutic study.
authors.affiliation: Department of Orthopaedic Surgery, Orange County, Southern California Permanente Medical Group, Irvine, CA, USA.
authors.forename: Dhiren
authors.initials: D
authors.lastname: Sheth
authors.affiliation: Surgical Outcomes and Analysis, Kaiser Permanente, 8954 Rio San Diego Drive, Suite 406, San Diego, CA, 92108, USA.
authors.forename: Guy
authors.initials: G
authors.lastname: Cafri
authors.affiliation: Surgical Outcomes and Analysis, Kaiser Permanente, 8954 Rio San Diego Drive, Suite 406, San Diego, CA, 92108, USA. Maria.cs.inacio@kp.org.
authors.forename: Maria C S
authors.initials: MC
authors.lastname: Inacio
authors.affiliation: Surgical Outcomes and Analysis, Kaiser Permanente, 8954 Rio San Diego Drive, Suite 406, San Diego, CA, 92108, USA.
authors.forename: Elizabeth W
authors.initials: EW
authors.lastname: Paxton
authors.affiliation: Department of Orthopaedic Surgery, Orange County, Southern California Permanente Medical Group, Irvine, CA, USA.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Namba
mesh_terms: D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects / Q000379:methods*; D002140:California / Q000453:epidemiology; D005260:Female; D006254:Hawaii / Q000453:epidemiology; D006279:Health Maintenance Organizations; D006617:Hip Dislocation / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control*; D006621:Hip Joint / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D012042:Registries; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome