title: Safety in early experience with a direct anterior approach using fluoroscopic guidance with manual leg control for primary total hip arthroplasty: a consecutive one hundred and twenty case series.
abstract: An encouraging result with direct anterior approach (DAA) is attractive for both patients and surgeons. However, the risks associated with beginning to use DAA require further analysis of the learning curve and better countermeasures to ensure safety. We ask whether the complication rate in the DAA by the inexperienced surgeon could be decreased with specific countermeasures. Our hypothesis was that the complication rate would be low even in early phase of the learning curve using the DAA with these particular countermeasures.
  
  
  
  We investigated a consecutive series of 120 primary THA using the DAA with four specific countermeasures; 1) defined exclusion criteria for DAA; 2) no positioning table; 3) use of fluoroscopy as much as required; and 4) having an experienced assistant for DAA (one who has performed the procedure in more than 100 cases). The operative time, the time of fluoroscopic use during the operation, intra and post-operative complications, re-operation for any reason, and cup and stem alignment were investigated.
  
  
  
  Although the operation times were similar, the duration of fluoroscopy decreased with surgeons' experience. There were no intra-operative complications and no re-operations for any reason. One anterior dislocation was observed in one patient. The mean cup inclination and anteversion angle was 39.7° ± 7.6° and 30.3° ± 7.6°; 43.3 % of stems were positioned in flexion, 55.8 % in the neutral position on the lateral view.
  
  
  
  We demonstrated a lower complication rate during our early experience with the DAA using four countermeasures. Using these countermeasures for the first 40 cases may be useful for surgeons who are considering DAA.
authors.affiliation: Department of Orthopaedic Surgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan, 113-0033. yhomma@juntendo.ac.jp.
authors.forename: Yasuhiro
authors.identifier: 0000-0002-7891-3024
authors.initials: Y
authors.lastname: Homma
authors.affiliation: Department of Orthopaedic Surgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan, 113-0033.
authors.forename: Tomonori
authors.initials: T
authors.lastname: Baba
authors.affiliation: Department of Orthopaedic Surgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan, 113-0033.
authors.forename: Hideo
authors.initials: H
authors.lastname: Kobayashi
authors.affiliation: Department of Orthopaedic Surgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan, 113-0033.|Department of Orthopaedic Surgery, Hôpital Henri Mondor, Créteil, France, 94010.
authors.forename: Asuka
authors.initials: A
authors.lastname: Desroches
authors.affiliation: Department of Orthopaedic Surgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan, 113-0033.
authors.forename: Yu
authors.initials: Y
authors.lastname: Ozaki
authors.affiliation: Department of Orthopaedic Surgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan, 113-0033.
authors.forename: Hironori
authors.initials: H
authors.lastname: Ochi
authors.affiliation: Department of Orthopaedic Surgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan, 113-0033.
authors.forename: Mikio
authors.initials: M
authors.lastname: Matsumoto
authors.affiliation: Department of Orthopaedic Surgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan, 113-0033.
authors.forename: Takahito
authors.initials: T
authors.lastname: Yuasa
authors.affiliation: Department of Orthopaedic Surgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, Japan, 113-0033.
authors.forename: Kazuo
authors.initials: K
authors.lastname: Kaneko
mesh_terms: D000328:Adult; D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000379:methods*; D005260:Female; D005471:Fluoroscopy; D006621:Hip Joint / Q000000981:diagnostic imaging* / Q000601:surgery; D006622:Hip Prosthesis; D006801:Humans; D007592:Joint Diseases / Q000601:surgery*; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D056888:Patient Positioning; D061214:Patient Safety; D012086:Reoperation; D012189:Retrospective Studies
keywords: Complication; Direct anterior approach; Fluoroscopy; Learning curve