直接前侧入路全髋关节置换是否导致髋臼前壁偏心磨挫？

doi:10.3969/j.issn.2095-4344.1192

中国组织工程研究 ›› 2019, Vol. 23 ›› Issue (20): 3117-3123.doi: 10.3969/j.issn.2095-4344.1192

• 人工假体 artificial prosthesis • 下一篇

直接前侧入路全髋关节置换是否导致髋臼前壁偏心磨挫？

苏联彬^1，2，冯尔宥¹，张怡元^1，2，卓有光^1，2，肖莉莉¹，王武炼¹，林飞太¹

¹厦门大学附属福州第二医院关节外科，福建省福州市 350007；²厦门大学医学院，福建省厦门市 361005

出版日期:2019-07-18 发布日期:2019-07-18
通讯作者: 张怡元，主任医师，教授，硕士生导师，厦门大学附属福州第二医院关节外科，福建省福州市 350007；厦门大学医学院，福建省厦门市 361005
作者简介:苏联彬，男，1992年生，福建省人，汉族，厦门大学在读硕士。
基金资助:
福建省自然科学基金(2017J01333)，项目负责人：冯尔宥

Whether direct anterior approach for total hip arthroplasty is a risk factor of eccentric reaming to the anterior column of the acetabulum?

Su Lianbin^{1, 2}, Feng Eryou¹, Zhang Yiyuan^{1, 2}, Zhuo Youguang^{1, 2}, Xiao Lili¹, Wang Wulian¹, Lin Feitai¹

¹Department of Joint Surgery, FuZhou Second Hospital of Xiamen University, Fuzhou 350007, Fujian Province, China; ²Medical College of Xiamen University, Xiamen 361005, Fujian Province, China

Online:2019-07-18 Published:2019-07-18
Contact: Zhang Yiyuan, Chief physician, Professor, Master’s supervisor, Department of Joint Surgery, FuZhou Second Hospital of Xiamen University, Fuzhou 350007, Fujian Province, China; Medical College of Xiamen University, Xiamen 361005, Fujian Province, China
About author:Su Lianbin, Master candidate, Department of Joint Surgery, FuZhou Second Hospital of Xiamen University, Fuzhou 350007, Fujian Province, China; Medical College of Xiamen University, Xiamen 361005, Fujian Province, China
Supported by:
the Natural Science Foundation of Fujian Province, No. 2017J01333 (to FEY)

摘要/Abstract

摘要：

文题释义：

髋臼角：自髋臼髂部斜面所引的斜形线，与“Y”形软骨连线所形成的夹角。

髋臼角正常范围：骨盆平片显示，髋臼角正常值20°-30°，大于30°，提示有髋发育不良。

摘要

背景：目前有学者认为直接前侧入路行髋关节置换术会导致髋臼前壁的过度磨挫，但是缺少确切的临床证据来证实。

目的：试验拟通过髋臼CT影像测量，观察比较直接前侧入路与后外侧入路行全髋置换髋臼前后壁偏心磨挫情况的差异。

方法：纳入2015年10月至2017年12月在厦门大学附属福州第二医院由同一主刀医生行初次关节置换患者共60例，直接前侧入路组及后外侧入路组各30例(各占50%)。采用影像阅读系统收集并测量所有病例手术前后髋臼前壁、后壁横断面积，髋臼前后壁高、髋臼横径及髋臼前倾角的变化，以评价髋臼骨储量相关指标的变化。参加研究的人员均具有骨科手术5-10年的临床经验，手术医生职称为副主任医师以上。试验经厦门大学附属福州第二医院伦理委员会批准，批准时间2017-06-01。试验方案经患者和相关家属知情同意，并签署知情同意书。

结果与结论：术后髋臼骨储量相关指标变化：两组术后前后壁横断面积、髋臼前后壁高度均小于术前(P < 0.05)，髋臼横径大于术前(P < 0.01)，而前倾角差异无显著性意义(P > 0.05)。直接前侧入路组术后髋臼前壁面积高于后外侧入路组(P < 0.05)，两组髋臼后壁面积、髋臼前壁、后壁高度、髋臼横径及前倾角差异无显著性意义(P > 0.05)。结果证实：与后外侧入路行全髋置换相比，直接前侧入路术后髋臼前壁面积变大，其他髋臼前后壁骨储量参数指标变化不显著，试验推测直接前侧入路行全髋关节置换并不是导致髋臼前壁偏心磨挫的危险因素，未来还需多中心、前瞻性的随机对照研究来进一步验证。

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程
orcid: 0000-0001-5176-8384(Zhang Yiyuan)

关键词: 髋臼前柱, 前倾角, 全髋关节置换, 直接前侧入路, 后外侧入路, 股骨头坏死, 危险因素, 组织工程

Abstract:

BACKGROUND: Direct anterior approach has been reported to be associated with a risk of reaming the anterior column of the acetabulum, but there is little evidence supporting this opinion.

OBJECTIVE: To reveal differences in the bone stock of the anterior and posterior columns between the direct anterior approach and the posterolateral approach in total hip arthroplasty by CT measurement.

METHODS: Sixty cases of primary total hip arthroplasty through direct anterior approach (n=30) or posterolateral approach (n=30) at Fuzhou Second Hospital of Xiamen University from October 2015 to December 2017 were enrolled. The cross-sectional area of the anterior and posterior column of the acetabulum, the height of the anterior and posterior column, acetabular diameter, and anteversion were measured by CT. All researchers had 5-10 years of clinical experience, and the surgeons were associate chief physicians or above. The trial has been approved by the Ethics Committee of Fuzhou Second Hospital of Xiamen University on June 1, 2017. All patients signed the written informed consents.

RESULTS AND CONCLUSION: (1) The postoperative cross-sectional area of the anterior and posterior column of the acetabulum, and the height of the anterior and posterior column in the two groups were less than those at baseline (P < 0.05), the acetabular diameter was larger than that at baseline (P < 0.01), and the anteversion showed no significant difference (P > 0.05). The area of the anterior column in the direct anterior approach group was higher than that in the posterolateral approach group (P < 0.05), and other parameters were insignificantly different between two groups (P > 0.05). (2) In summary, compared with posterolateral approach in total hip arthroplasty, direct anterior approach leads to increased area of the anterior column, and made no effect on other parameters. Thereafter, direct anterior approach is not a risk factor for eccentric reaming the anterior column of acetabulum, and the conclusion needs to be confirmed by multicenter, prospective randomized controlled trials.

Key words: anterior column of the acetabulum, anteversion, total hip arthroplasty, direct anterior approach, posterolateral approach, femur head necrosis, risk factors, tissue engineering

中图分类号:

R459.9|R603

苏联彬，冯尔宥，张怡元，卓有光，肖莉莉，王武炼，林飞太. 直接前侧入路全髋关节置换是否导致髋臼前壁偏心磨挫？[J]. 中国组织工程研究, 2019, 23(20): 3117-3123.

Su Lianbin, Feng Eryou, Zhang Yiyuan, Zhuo Youguang, Xiao Lili, Wang Wulian, Lin Feitai. Whether direct anterior approach for total hip arthroplasty is a risk factor of eccentric reaming to the anterior column of the acetabulum?[J]. Chinese Journal of Tissue Engineering Research, 2019, 23(20): 3117-3123.

图/表（结果） 3

Quantitative analysis of participants

With parameters of 10 cases in preparatory work, and according to formula of estimation of sample size in group design

, the results showed that at least 26 cases would be needed to reach statistical significance. Therefore, we chose eligible 30 cases from October 2015 to December 2017, and 575 cases of THA were completed in our department.

Comparison of the measurement parameters between PLA and DAA groups

There was no significant difference in all preoperative parameters (P > 0.05) (Table 2). The postoperative CSA of the anterior column in the DAA group was larger than that in the PLA group (P=0.04). No significant differences were observed for the CSA of the anterior-posterior, posterior column, height of the anterior and posterior column, acetabular diameter and anteversion postoperation (P > 0.05) between two groups. Meanwhile, there was no significant difference in the bone loss perioperatively (Table 3).

Comparison of perioperative parameters between PLA or DAA groups

The postoperative cross-sectional area of the anterior and posterior column of the acetabulum, and the height of the anterior and posterior column in the two groups were less than those at baseline (P < 0.05), the acetabular diameter was larger than that at baseline (P < 0.01), and the anteversion showed no significant difference (P=0.89) (Table 3).

Multivariate linear regression analysis

The approach was a risk factor of the CSA loss of anterior column (β=0.36, 95%CI: 0.01-0.71, P < 0.05), and not significantly risk factor for CSA loss of posterior (β=0.22, 95%CI: -0.37-0.82, P=0.46), and anterior-posterior column (β=0.58, 95%CI: -0.23-1.40, P=0.16). The gender, laterality, body mass index, age, primary diagnosis were not associated with CSA loss of anterior, posterior and anterior-posterior column (P > 0.05) (Table 4).

Adverse reactions

Three patients in the DAA group suffered from lateral femoral cutaneous nerve injury and all recovered at postoperative 6 months. No adverse reactions such as infection, prosthesis loosening and rupture, venous thrombosis, heterotopic ossification or bone resorption occurred (Table 5).

参考文献

[1] Moretti V, Post Z. Surgical approaches for total hip arthroplasty Indian J Orthop. 2017;51(4):368-376.

[2] Jordan J, Helmick J, Renner B, et al. Prevalence of hip symptoms and radiographic and symptomatic hip osteoarthritis in African Americans and Caucasians: the Johnston County Osteoarthritis Project. J Rheumatol. 2009;36(4):809-815.

[3] Maradit Kremers H, Larson DR, Crowson CS, et al. Prevalence of total hip and knee replacement in the United States. J Bone Joint Surg Am. 2015;97(17):1386-1397.

[4] Singh JA. Epidemiology of knee and hip arthroplasty: a systematic review. Open Orthop J. 2011;16(5):80-85.

[5] Petis S, Howard JL, Lanting BL, et al. Surgical approach in primary total hip arthroplasty: anatomy, technique and clinical outcomes. Can J Surg. 2015;58(2):128-139.

[6] Connolly KP, Kamath AF. Direct anterior total hip arthroplasty: literature review of variations in surgical technique.World J Orthop. 2016;7(1):38-43.

[7] Ji W, Stewart N. Fluoroscopy assessment during anterior minimally invasive hip replacement is more accurate than with the posterior approach. Int Orthop. 2016;40(1):21-27.

[8] Zhang YJ, Li J, Qi K, et al. Comparison of efficacy and safety between the anterior and the posterior approaches to total hip arthroplasty. Beijing Da Xue Xue Bao. 2017;49(2):201-205.

[9] Lin TJ, Bendich I, Ha AS, et al. A comparison of radiographic outcomes after total hip arthroplasty between the posterior approach and direct anterior approach with intraoperative fluoroscopy. J Arthroplasty. 2017;32(2):616-623.

[10] Post ZD, Orozco F, Diaz-Ledezma C,et al. Direct anterior approach for total hip arthroplasty: indications, technique, and results. J Am Acad Orthop Surg. 2014;22(9):595-603.

[11] Radoicic D, Zec V, Elassuity WI, et al. Patient's perspective on direct anterior versus posterior approach total hip arthroplasty. Int Orthop. 2018;42(12):2771-2775.

[12] Nistor DV, Caterev S,. Bolboaca SD, et al. Transitioning to the direct anterior approach in total hip arthroplasty. Is it a true muscle sparing approach when performed by a low volume hip replacement surgeon? Int Orthop. 2017;41(11):2245-2252.

[13] Seng BE, Berend KR, Ajluni AF, et al. Anterior-supine minimally invasive total hip arthroplasty: defining the learning curve. Orthop Clin North Am. 2009;40(3):343-350.

[14] Kobayashi H, Homma Y. Surgeons changing the approach for total hip arthroplasty from posterior to direct anterior with fluoroscopy should consider potential excessive cup anteversion and flexion implantation of the stem in their early experience. Int Orthop.2016;40(9):1813-1819.

[15] Barton C, Kim PR. Complications of the direct anterior approach for total hip arthroplasty. Orthop Clin North Am. 2009;40(3):371-375.

[16] Chechik O, Khashan M, Lador R, et al. Surgical approach and prosthesis fixation in hip arthroplasty world wide. Arch Orthop Trauma Surg. 2013;133(11):1595-600.

[17] Holst DC, Yang CC. Surgical anatomy of the direct anterior approach for total hip arthroplasty. Ann Joint. 2018;3:23-23.

[18] Uemura K, Takao M. Sakai T, et al. Volume increases of the gluteus maximus, gluteus medius, and thigh muscles after hip arthroplasty. J Arthroplasty. 2016;31(4):906-912.

[19] Xu D, Koyama H, Furuhashi H, et al. Comparison of hip muscle volume between fit-and-fill stem and tapered-wedge stem after total hip arthroplasty using the anterolateral approach. J Orthop Sci. 2017;22(6):1102-1106.

[20] Tongdee T, Keawaen P, Tongdee R. Evaluation of standard liver volume in adult Thai population using CT volumetric measurement. J Med Assoc Thai. 2013;96(2):217-2124.

[21] Dandachli W, Islam UL, Tippettr R, et al. Analysis of acetabular version in the native hip: comparison between 2D axial CT and 3D CT measurements. Skeletal Radiol. 2011;40(7):877-883.

[22] Pankal A, Mittal A, Chawla A. The validity and reproducibility of cross table radiographs compared with CT scans for the measurement of anteversion of the acetabular component after total hip arthroplasty. Bone Joint J. 2017;99-b(8):1006-1011.

[23] Nomura T, Naito M, Nakamura Y, et al. An analysis of the best method for evaluating anteversion of the acetabular component after total hip replacement on plain radiographs. Bone Joint J. 2014;96-b(5):597-603.

[24] Shemesh S, Robinson S, Keswani A, et al. The accuracy of digital templating for primary total hip arthroplasty: is there a difference between direct anterior and posterior approaches? J Arthroplasty. 2017;32(6):1884-1889.

[25] Hartford JM, Knowles SB. Risk factors for perioperative femoral fractures: cementless femoral implants and the direct anterior approach using a fracture table. J Arthroplasty. 2016;31(9): 2013-2018.

[26] Wang Z, Hou JZ, Wu CH, et al. A systematic review and meta-analysis of direct anterior approach versus posterior approach in total hip arthroplasty. J Orthop Surg Res. 2018;13(1): 229-240.

[27] Cheng TE, Wallis JA, Taylor NF, et al. A prospective randomized clinical trial in total hip arthroplasty-comparing early results between the direct anterior approach and the posterior approach. J Arthroplasty. 2017;32(3):883-890.

[28] Cadossi M, Sambri A, Tedesco G, et al. Anterior approach in total hip replacement. Orthopedics. 2017;40(3):e553-556.

[29] Pilliar RM, Leeand J, Maniatopoulos C. Observations on the effect of movement on bone ingrowth into porous-surfaced implants. Clin Orthop Relat Res. 1986;(208):108-113.

[30] Fehring K, Owen A. Kurdin A, et al. Initial stability of press-fit acetabular components under rotational forces. J Arthroplasty. 2014;29(5):1038-1042.

[31] Markel D, Horaand N, Grimm M. Press-fit stability of uncemented hemispheric acetabular components: a comparison of three porous coating systems. Int Orthop. 2002;26(2):72-75.

[32] Saleh K, Bear B, Wright T, et al. Initial stability of press-fit acetabular components: an in vitro biomechanical study. Am J Orthop. 2008;37(10):519.

[33] Kim YH. Acetabular Cup Revision. Hip Pelvis. 2017;29(3):155-158.

[34] Lingaraj K, Teoand YH, Bergman N. The management of severe acetabular bone defects in revision hip arthroplasty using modular porous metal components. J Bone Joint Surg Br. 2009;91(12):1555-1560.

[35] Meneghini RM, Elston AS, Chen AF, et al. Direct anterior approach: risk factor for early femoral failure of cementless total hip arthroplasty: a multicenter study. J Bone Joint Surg Am. 2017;99(2):99-105.

[36] Homma Y, Baba T, Sano K, et al. Lateral femoral cutaneous nerve injury with the direct anterior approach for total hip arthroplasty. Int Orthop. 2016;40(8):1587-1593.

[37] Eto S, Hwang K, Huddleston JI, et al. The direct anterior approach is associated with early revision total hip arthroplasty. J Arthroplasty. 2017;32(3):1001-1005.

[38] Ozaki Y, Homma Y, Baba T, et al. Spontaneous healing of lateral femoral cutaneous nerve injury and improved quality of life after total hip arthroplasty via a direct anterior approach. J Orthop Surg. 2017;25(1) 1-7.

引言

材料方法

Design

A retrospective study.

Time and setting

The study was finished at the Department of Joint Surgery, Fuzhou Second Hospital of Xiamen University from October 2015 to December 2017.

Materials
Material properties of implants were shown in Table 1.

Patients

The trial has been approved by the Ethics Committee of FuZhou Second Hospital of Xiamen University on June 1, 2017. We searched the medical records of patients, perioperative hip joint CT image (Philips, Medical System, Netherlands; 120 kV, 300 mA, slice thickness, 5 mm, scan time 2.53 seconds), and collected the information of age, gender, body mass index, diagnosis and operative approach. The patients in the both groups were operated from October 2015 to December, 2017, in which PLA group completion from October 2015 to February 2016, and DAA group completion from July 2017 to December 2017. All THAs were performed by a senior doctor who has extensive clinical experience in both DAA and PLA, including more than 10 years’ experience of PLA, and more than 100 cases experience of DAA. The cases of PLA group were all collected before the point of time when we began to adopt DAA for part of patients. All patients signed the written informed consents. The patient’s primary diagnosis was shown in Table 2.

Inclusion criteria

(1) Primary hip arthroplasty; (2) Primary diagnosis with femoral head aseptic necrosis or hip osteoarthritis; (3) Complete CT data of hip before and after operation.

Exclusion criteria

(1) Body mass index > 32 kg/m² (the DAA may be difficult to perform in these patients); (2) Prior hip surgery and obsolescence fracture of the hip; (3) Surgery completed while the surgeon was still learning the procedure (DAA < 100 cases); (4) Hip dysplasia or the ring of acetabulum incomplete; (5) Simultaneous ankylosing spondylitis which will affect image measurement; (6) An intraoperative complication that may have affected acetabulum complete and acetabular prosthesis implanted.

Surgical technique

DAA: It was performed as reported using the distal part of the Smith–Petersen approach with the patient was in the supine position^{[10, 17]}. We made use of a regular table that the patient was positioned with the pelvis located over the table break, which could be angled to allow hyperextension at the hip joint. As required, a bump was used to be placed under the sacrum to further elevate the pelvis. The anterior incision was initiated 2 cm posterior and distal to the anterior superior iliac spine, extending distally approximately 6-10 cm over the tensor fasciae latae, which oriented to the fibular head (Figure 1). The intermuscular interval was identified and separated to expose and incised the anterior hip capsule, and the femoral head was then exposed. The level of femoral neck osteotomy was identified according to the preoperative plan. The acetabulum was then exposed with the assistance of retractors placed around the anterior, posteroinferior, and superior edges. The acetabulum was sequentially reamed using straight reamers until the reamers were clamped by anterior and posterior columns of the acetabulum that felt by operator, and a healthy bony bed was obtained as a socket for a press-fit. We then impacted a cup into the acetabulum at approximately (40±5)° of abduction and (15±5)° of anteversion; the acetabular cup was positioned by straight handles with a protractor and was verified under fluoroscopy. The acetabular cup was affixed with screws in the superior acetabular quadrant for adjunctive fixation if necessary.

PLA: All posterior THAs were performed with a uniform technique as described in the literatures^{[1, 9]}. The operation was completed in a lateral decubitus position on an operating table with pelvic positioners placed posteriorly (sacrum) and anteriorly (pubic symphysis and rami). A curvilinear incision 10- to 15-cm-long that extended 5 cm distal from greater trochanter at the lateral center of the femoral diaphysis to proximally along the posterior border of greater trochanter and then curves toward the posterior superior iliac spine for approximately 7 cm. The iliotibial band was identified and incised, and the gluteus maximus was split along the fibers. The piriformis and the other short external rotators was identified that were tagged with suture and reflected, which could protect the nearby sciatic nerve and expose the posterior hip capsule. Then the capsule was exposed and incised. Along with flexion, adduction, internal rotation of the leg, in order to allows for hip dislocation. Next, the osteotomized level in femoral neck was identified, which was determined from a preoperative plan, and further performed using an oscillating saw. Before the routine acetabular reaming the labrum, pulvinar and any loose soft tissues should be excised. The subsequent preparation of routine acetabular reaming was similar to that of the DAA. The posterior hip capsule was repaired, and the external rotators were reattached during closure.

Both groups of patients performed the same standard of rehabilitation after operation: 6 hours postoperatively, rapid rehabilitation exercise was conducted under the professional guidance of rehabilitation doctors, and all cases were discharged within 3-5 days after surgery.

Main measurements

Using the cross-sectional area (CSA) in CT images as a surrogate for various tissue volume was reliable and applied in clinical research^[18-20]. First, we defined the parameters representing the bone stock that possibly be affected by the surgical approach, including the CSA of the anterior and posterior column of the acetabulum, which be considered as a surrogate for bone volume^[18], the height of the anterior and posterior column, acetabular diameter and anteversion. Two independent reviewers were blinded to the approach and given a spreadsheet to measure and record the result. A Picture Archiving and Communication System (YiLianZong, version 3.6, China) was used for radiographic measurement (Figure 2). In order to ensure the same cross-sections measured pre-and post-operation, the most important step was to find the equator section of the acetabulum^{[21, 22]}: connecting the bilateral rotation center of the acetabulum (using a template), which defined as the distinction between the anterior and posterior columns, terming the “line A”. The tangent lines through the medial column of the acetabulum, perpendicular to the “line A”, as the base of the anterior and posterior columns, were termed “line B1” and “line B2”, which were parallel but discontinuous. The height of the anterior and posterior columns was defined as the length of a perpendicular line extending from the top point of the anterior and posterior column to the lines B1 and B2. Then, the vertical distance from anterior to posterior as the diameter of the acetabulum was termed line C, plane with the largest distance was defined as the equatorial section. The tangential line across the open face of the cup connecting the anterior and posterior margins of the acetabulum was termed line D, The anteversion of the acetabulum was obtained by subtracting this angle that composed by line D and A from 90°^[21-23]. The CSA of the anterior and posterior column was measured by the curve function of Picture Archiving and Communication System (S1 and S2). The same method was used to measure the upper and next sections, and the mean values of the parameters measured in these three sections of the anterior and posterior were calculated and recorded.

Statistical analysis

Data were expressed as the mean±SD or n(%). A statistical analysis of the data was performed using SPSS 18.0 software. Two-sample t-test was used on continuous scale of age, body mass index, CSA, height of the anterior and posterior columns, anteversion, acetabulum diameter between DAA and PLA groups both pre- and-post- operatively. Chi-square tests were applied to compare gender, diagnosis and laterality in both groups. Pre- and post-operative parameters in intra-group DAA or PLA were compared using a paired t-test. Wilcoxon rank-sum test was used to compare bone loss by surgery between DAA and PLA groups as it no accordance with normality and equal variance. In addition, the data were assessed by multivariate linear regression analysis to detect factors including approach, gender, laterality, body mass index, age primary diagnosis associated with cross-sectional area loss of anterior, posterior column, anterior-posterior column respectively. A value of P < 0.05 was considered statistically significant, and all tests were two-sided.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

讨论

There are many different approaches for THA with their own advantages and disadvantages. DAA for THA has become popular worldwide over the past decade. An American Association of Hip and Knee Surgeons survey in 2014 showed that 26% of US surgeons employ the DAA for THA, while in 2003, this value was only 1%^[24]. Currently, the study of DAA technology mainly focuses on the evaluation of the incision length, intraoperative blood loss, fluoroscopy of acetabular prosthesis, postoperative pain, recovery and functional scores, and it generally described as a minimally invasive approach for it often provides a better outcomes than other surgical approaches, especially in the early-term period^{[7-12, 25-26]}. Wang et al.^[26] reported that compared with PA, DAA was associated with an early functional recovery and lower pain scores. It is worth mentioning that before conducting this study there were two studies on DAA for THA in our institution, and the results are similar to the most of current researches^{[8, 10, 12, 27]}. However, none has studied whether DAA for THA has any effect on the bone reserve of acetabular wall^{[6, 15]}. As the DAA has been extensively applied in THA, it is necessary to acquire precise exact data to clarify whether there is any difference in bone reserve of acetabulum between DAA and PLA.

In this study, we found that the CSA of acetabulum, height and diameter of acetabulum had significant changes. It shows that the bone stock around the acetabulum was loss attribute to the reaming during the operation. However, the CSA of the anterior column of the acetabulum post-operation in the DAA group was larger than that in the PLA group, and no significant difference in CSA of the posterior, height of the anterior and posterior column, acetabulum diameter and anteversion post-operation. Meanwhile, for multivariate linear regression analysis, the approach was the only independent variable for the loss of bone stock attribute to surgery.

Then, what caused this phenomenon? By repeatedly observing the reaming process, we identified some potential factors contributing to the result: The first factor is the reaming posture with the DAA. Owing to the patients are on supine position, during reaming process the auxiliary hand of the surgeons are positioned at the front of the handle (relative to the patient), producing a force directed to the posterior (Figure 3), which will produce a tendency eccentric reaming to posterior column which meaning of protecting the bone stock of the anterior column. Conversely, the reaming posture in the PLA: as the surgeon is standing in front of the patient, the surgeon’s hands have a tendency to shrink to the body, which is a risk factor for eccentric reaming to the anterior column. This trend is more obvious when the patient’s body is far away from the edge of the operation table. In this case, the surgeon’s auxiliary hand is positioned on the near side of the handle (relative to the patient), which will produce a force directed to the inferior column of the acetabulum. In summary, the resultant force of these two directions is a risk factor for eccentric reaming of the anterior column (Figure 3).

There are some measures to avoid eccentric reaming: about surgical technical, for DAA, one of the most important is to create sufficient operating space as follows: on the one hand, the acetabular lip and obstructing osteophytes should be removed so that a straight reamer can be used with adequate exposure, and careful attention should be paid to avoid applying leverage to the anterior acetabulum or the femoral shaft. On the other hand, one of an assistant may be needed to apply slight traction to the limb and make the knee is externally rotated by 90°, which is facilitated by hooking the femoral canal and pulling the femur laterally by another assistant to avoid bone impingement between the femur and the acetabulum^[28]. Supposing that the operating space and view of exposure are still insufficient, we should further release the soft tissue around the femur, increase the dose of anesthetic to relax muscles, and extend the surgical incision. Second, We believe specialized offset instruments are more likely to lead to eccentric reaming than a straight reamer, and the reamer can be positioned head first to avoid the difficult of position the reamer to acetabular as Post et al.^[10] recommended. Finally, in the process of reaming the auxiliary hand of the surgeon should not apply any pressure to the handle, except to maintain a proper anteversion and inclination. In addition, preoperative preparation and detailed surgical planning also play an important role in avoiding eccentric reaming. First, to facilitate intraoperative adjustment, we make use of a regular table that the patient was positioned with the pelvis located over the table break, which can be angled to allow hyperextension at the hip joint. As required, a bump was used to be placed under the sacrum, to further elevate the pelvis. Second, an undesirable operation posture including the oversized distance from operation center to surgeons, and an inappropriate height of operation center relative to the surgeons may be a risk of eccentric reaming. For this point, we recommend that the patient should be positioned as close to the edge of the table as possible, and the height of the operation center is about the level of the navel of the surgeons.

What is the clinical significance of sufficient bone stock in the wall of acetabulum? It is the initial and long-term stability or when revision is needed in the future. The acetabular prosthesis is mainly fixed by the clamping of the anterior and posterior columns, which is determined by elastic recoil forces that are produced by the process of detracting and expanding the bone acetabulum. Only the bone acetabulum is intact and will provide sufficient strength to maintain the initial stability of the prosthesis that as a prerequisite of bony ingrowth at the bone-prosthesis interface^[29-31], which will maintain long-term stability of the prosthesis^[32]. Second, regarding future revision surgeries, revision surgeries will become inevitable for various reasons. The remaining supportive bone of the acetabulum plays an important role in the success rate of the revision and in the classification of acetabular bone defects^[33-34].

Although numerous authors have described perfect and successful performance of DAA^[7-12]. However, we still can't ignore that there are some negative reports about DAA for THA, which with long learning curve and pitfalls that may affect implant longevity and complication rate comparing with other approaches^{[13, 35-37]}. There are three patients in DAA group suffered from lateral femoral cutaneous nerve injury and all recovered at 6 months. The lateral femoral cutaneous nerve injury is a common and unique complication of DAA as high rate as it were reported, which will decreased quality of life of patients^[37-38]. In summary, surgeons should combine characteristics of patients with theirs own experience, choosing the optimal surgical approach for THA to minimize the risks of failure and thereby improve the outcome.

Inevitably, this study has some limitations. First, this is a retrospective study, the surgeons chooses the approach based on various patient characteristics, not a randomize design, and we did not have a supplementary examination of bone mineral density that will increase the financial burden of patients, and patients with osteoporosis may have an impact on the results of the study. In this study, we chose cases completed at different period to minimize the selective bias of surgeons and bias of osteoporosis distribution of patients. Second, only one surgeon performed the surgeries, so operator’s experience, personal postures and habits can impact the outcomes. Third, our results are limited to the DAA performed on the supine position, while the lateral decubitus position may produce a different result and requires further study.

There are two primary strengths in our study. First, we innovatively defined and proposed a method for measuring the CSA of the anterior and posterior columns of the acetabulum in CT images. Second, we are the first to study the difference in the bone stock of the anterior and posterior columns of the acetabulum between these two THA approaches. We provide clinical data for DAA in THA.

To conclude, DAA for THA is not a risk factor for eccentric reaming to the anterior column of acetabulum. Our conclusion needs to be confirmed by multicenter, prospective randomized controlled trials.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

直接前侧入路全髋关节置换是否导致髋臼前壁偏心磨挫？

Whether direct anterior approach for total hip arthroplasty is a risk factor of eccentric reaming to the anterior column of the acetabulum?

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