More Infection With Direct Anterior Hip Cases?

New work from NYU Hospital for Joint Diseases and NYU Langone Medical Center has examined the impact of using the direct anterior (DA) versus other total hip arthroplasty (THA) approaches on the risk of prosthetic joint infection (PJI). The team also looked at the impact of new perioperative protocols on PJI rates after all approaches.

Co-author Vinay K. Aggarwal, M.D., a fellow at NYU Langone explained to OTW why they wanted to dive into the increasingly popular topic of prosthetic joint infection risk, “When we examined all complications at our center broken down by approach group (a separate published study), we saw a significantly higher number of superficial and deep infections in the anterior approach group. This led us to do a ‘deep dive’ into the infection rates (or PJI) after THA comparing our direct anterior and non-anterior THAs. Specifically, we wanted to see if this was a real phenomenon and if so, how big the effect of surgical approach was on PJI rates.”

“As such we performed a multivariate analysis to control for surgical approach independently as a risk factor for PJI after THA. Most importantly, we found PJI rates of 1.22% with the direct anterior group and 0.63% with the non-anterior group; but more specifically after controlling for other risk factors such as age and BMI [body mass index] among others, we found the direct anterior approach led to a 2.2 higher odds of developing PJI than non-anterior THA. Secondary results from our study are that use of infection prevention strategies such as using betadine lavage in wounds and vancomycin powder in joints may result in a decreased infection rate for THA regardless of approach used. These secondary results are being studied now in a randomized control trial to obtain more definitive recommendations.”

“Total hip replacement has been an incredibly successful operation for several decades, being cited as the 2nd most satisfactory surgery from a patient outcomes perspective only behind cataract surgery. So when there was a significant increase in the amount of marketing and conversation taking place with regards to improvements in THA outcomes with use of the direct anterior approach, we wanted to take a look and see exactly what the effects of surgical approach were on the complications after THA.”

“Clinically we were in agreement with literature results showing faster recovery for the first two weeks with direct anterior THA—an approach for hip surgery that I should say has actually been around for more than five decades, but only became increasingly popular for THA since the early 2010s.”

“Practically speaking, we tell our patients the following based on this work and the work of several others that concur (some out of the Mayo Clinic and out of Anderson Clinic) that with the anterior approach there is a higher risk of superficial wound infection after THA. Specifically, with our obese patients of BMI > 40 we recommend against anterior approach surgery citing higher deep PJI rates in this group likely due to larger overhanging pannus. Patients should know that there are risks and benefits to everything including approaches regardless of the marketing and significant hype regarding the direct anterior approach that we have seen over the past 10 years.”