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The learning curve for the direct anterior total hip arthroplasty: a systematic review

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Abstract

Background

The direct anterior approach (DAA) for total hip arthroplasty (THA) is a muscle-sparing approach thought to have less post-operative pain and quicker recovery, with similar functional outcomes to other approaches. However, it is technically challenging and transitioning surgeons may experience increased complication rates. The purpose of this systematic review is to identify reported learning curves associated with the DAA.

Methods

Three databases (MEDLINE, Embase, and Web of Science) were searched using terms including “total hip arthroplasty,” “direct anterior approach,” and “learning curve.” Study characteristics, patient demographics, learning curve analyses, and complications were abstracted.

Results

Twenty-one studies met inclusion criteria, with a total of 9738 patients (60% female), an average age of 63.7 years (range: 13–94), body mass index of 27.0 kg/m2 (range: 16.8–58.9), and follow-up of 19 months (range: 1.5–100). There were five retrospective cohort studies and 13 case series representing fair methodological quality. Six studies depicted a true learning curve, with mean operative time of 156.59 ± 41.71 minutes for the first case, 93.18 ± 14.68 minutes by case 30, and 80.45 ± 12.28 minutes by case 100. Mean complication rate was 20.8 ± 12.7% in early groups and decreased to 7.6 ± 7.1% in late groups.

Conclusion

This review demonstrated a substantial learning curve associated with the DAA to THA. Operative time plateaued after approximately 100 cases. Complication rates decreased substantially from early to late groups.

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Authors and Affiliations

  1. Michael G. DeGroote School of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON, L8N 3Z5, Canada

    Leah Nairn, Lauren Gyemi & Kyle Gouveia

  2. Division of Orthopaedic Surgery, McMaster University, 1200 Main Street West, Hamilton, ON, L8N 3Z5, Canada

    Seper Ekhtiari & Vickas Khanna

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  1. Leah Nairn
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  2. Lauren Gyemi
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  4. Seper Ekhtiari
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Contributions

LN and LG performed study screening and data extraction and assessed study quality. LN and KG drafted the manuscript. SE designed the study and coordinated data extraction and manuscript preparation. VK edited the manuscript and provided key expert input. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Leah Nairn.

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Ethics approval

Ethics approval was not required for this systematic review.

Consent to participate and consent for publication

As this was a systematic review, data from individual participants was not obtained and will not be published.

Competing interests

Author VK is a paid consultant for Stryker Canada and Zimmer Biomet. The other authors have no competing interests to disclose.

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Level of Evidence: IV

Appendix

Appendix

 

MEDLINE

Embase

Web of Science

Search strategy

Total hip arthroplasty

Direct anterior approach

Direct anterior

Anterior approach

Smith Petersen

Smith-Petersen

Learning curve

Learning

Clinical competence

Treatment outcome

Experience

Motor skills

Outcome

Outcome assessment

Complication

Intraoperative complications

Postoperative complications

2 OR 3 OR 4 OR 5 OR 6

7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17

1 AND 18 AND 19

Total hip arthroplasty

Direct anterior approach

Direct anterior

Anterior approach

Smith Petersen

Smith-Petersen

Learning curve

Learning

Clinical competence

Treatment outcome

Experience

Motor skills

Outcome

Outcome assessment

Complication

Intraoperative complications

Postoperative complications

2 OR 3 OR 4 OR 5 OR 6

7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17

1 AND 18 AND 19

(((((direct anterior approach) OR direct anterior) OR anterior approach) OR Smith Petersen) OR Smith-Petersen) AND (total hip arthroplasty) AND (((((((((((learning curve) OR learning) OR clinical competence) OR treatment outcome) OR experience) OR motor skills) OR outcome) OR outcome assessment) OR complication) OR intraoperative complications) OR postoperative complications)

Number of articles retrieved

307

528

947

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Nairn, L., Gyemi, L., Gouveia, K. et al. The learning curve for the direct anterior total hip arthroplasty: a systematic review. International Orthopaedics (SICOT) 45, 1971–1982 (2021). https://doi.org/10.1007/s00264-021-04986-7

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