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Anterior fix-and-replace strategy using direct anterior and pararectus approaches for acetabular fractures in older
Silviya Ivanova1, Fabian Keel2, Marius Jb Keel3
1Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Switzerland.
Background:
Most reported fix-and-replace procedures use a posterior or lateral approach for total hip arthroplasty (THA) and a Kocher-Langenbeck, anterior intrapelvic, or ilioinguinal approach for acetabular fixation, which may require separate anterior and posterior exposures. Evidence on fully anterior, single-position workflows combining anterior acetabular fixation with THA remains limited.
Aim:
The aim of this study was to assess the outcomes of acute THA through the direct anterior approach (DAA) combined with pararectus in patients considered suitable for a fix-and-replace strategy.
Methods:
This retrospective single-centre case series included 20 patients aged ≥ 60 years (mean age: 82 ± 10 years) selected for a fix-and-replace strategy based on predefined indications - such as acetabular dome destruction, femoral head damage, pre-existing hip degeneration - between 2009 and 2023. All underwent single-stage pararectus fixation and DAA THA in the supine position without posterior exposure or repositioning. Acetabular reconstruction constructs were used in 19 patients and dual-mobility articulation in five patients. The primary outcome was revision surgery within two years. Secondary outcomes included surgical data, 30-day complications, mortality, postoperative weight bearing, radiographic findings, mobility, pain, and patient satisfaction.
Results:
Revision surgery was required in 4 patients (20%) within two years: Two for infection, one for recurrent instability, and one for progressive mechanical failure with persistent non-union. Mean operative time was 216 ± 49 min, and estimated blood loss was 969 ± 537 mL. Four patients had Sink grade ≥ 3 complications within 30 days, including 1 death. Five deaths were counted for the 2-year mortality endpoint. Full weight bearing was prescribed in 6 patients. One additional asymptomatic construct subsidence was managed non-operatively. At latest follow-up, 12/16 patients were ambulatory, 12/14 were pain-free or had only mild pain, and 13/17 were satisfied or very satisfied.
Conclusion:
Acute total hip arthroplasty through the direct anterior approach combined with pararectus fixation is a feasible fully anterior, single-position strategy for selected older patients. The surgical strategy described herein achieved favorable outcomes in the present patient cohort, supporting its continued use as a rational treatment approach in appropriately selected patients.