Conversion hip arthroplasty via the direct anterior approach: pearls, pitfalls and personal experience.

OBJECTIVE: Conversion total hip arthroplasty (CTHA) through a direct anterior approach (DAA) in supine position.

INDICATIONS: Failed osteosynthesis of proximal femoral fractures or failed conservative hip surgery, with hardware in situ.

CONTRAINDICATIONS: Decayed general conditions, infection (peri-implant or systemic infection), need for greater trochanter reconstruction, severe proximal femur deformity.

SURGICAL TECHNIQUE: Supine position. Mark DAA and expected limited incisions for hardware removal (HR) with the help of a C-arm. Use guidewire and extraction devices for HR. Perform a DAA with particular attention to a wide release of the femur.

POSTOPERATIVE MANAGEMENT: Full progressive weight-bearing starting on day 1, depending on bone quality. Discharge with crutches following patient walking capability. Precautions for 6 weeks.

RESULTS: In all, 27 conversion THAs through a DAA. Mean age at the time of surgery 59.8 (range 18-81) years. Mean body mass index was 23.5 (range 17-31.6). Reasons of previous surgery failures were avascular necrosis of the femoral head, posttraumatic arthritis and nonunion with or without hardware migration. Mean surgical time was 125.8 min (range 58-190 min, standard deviation [SD] 38.2 min). Mean follow-up time was 6.9 years (range 2-15, SD 5.03 years). Mean pre-Harris Hip Score (mHHs) was 24.4 (range 19-36, SD 5.4), while the mean post-mHHS was 90.3 (range 89-91, SD 0.95). Two patients required postoperative osteosynthesis for periprosthetic fractures due to falls. Overall complication rate was 10%.