Patient Clinical Outcomes and Healthcare Resource Utilization Using a Computer-Assisted Fluoroscopy-Based Navigation System with Anterior Approach Compared to Posterior Approach Manual Surgery for Total Hip Arthroplasty

Patient Clinical Outcomes and Healthcare Resource Utilization Using a Computer-Assisted Fluoroscopy-Based Navigation System with Anterior Approach Compared to Posterior Approach Manual Surgery for Total Hip Arthroplasty | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Patient Clinical Outcomes and Healthcare Resource Utilization Using a Computer-Assisted Fluoroscopy-Based Navigation System with Anterior Approach Compared to Posterior Approach Manual Surgery for Total Hip Arthroplasty Erik Severson, Ziyu Tan, Mina Kabiri, Adam English, John Reimer, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6925135/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Introduction: Clinical outcomes and healthcare resource utilization were compared for patients undergoing primary total hip arthroplasty (THA) with direct anterior approach (DAA) using computer-assisted fluoroscopy-based navigation technology (fTHA) vs. posterior approach manual surgery (mTHA). Materials and Methods: A pre/post analysis reviewed electronic medical records from a single surgeon at a US critical access hospital from 2014-2022; fTHA began in October of 2015. The primary outcome was a patient-reported outcome measure (PROM) for pain and the secondary outcome was procedure time. Exploratory outcomes were hospital length of stay (LOS), 30-day readmissions and complications, and changes in disability and osteoarthritis. Results: Among 485 patients (mean [standard deviation (SD)] age 67.1 [10.6] years, 52.8% female), 390 (80.4%) received fTHA and 95 (19.6%) received mTHA. In unadjusted analyses, mTHA patients had greater mean (SD) pain (4.2 [2.0] vs. 3.0 [2.2]; p<0.001), procedure time (65.6 [12.6] vs. 61.1 [16.2] minutes; p=0.013), and LOS (mean [SD]: 1.9 [0.8] vs. 1.3 [1.1] days and median 2.0 vs. 1.0 days). No readmission occurred with fTHA whereas readmission for mTHA was 3.2%. fTHA also showed a reduced complication rate vs. mTHA (0.5% vs. 10.5%). Hip Disability and Osteoarthritis Outcome Score changes were the same, with an average increase of 24.4 [19.9]. Multivariate analyses found mTHA had 1.3 times higher pain intensity PROM (p<0.001), similar procedure time (p=0.103), and 1.6 times longer hospital LOS (p<0.001) compared to fTHA. Conclusions: Using a computer-assisted fluoroscopy-based navigation technology with DAA may facilitate a statistically significant reduction in pain and procedure time. computer-assisted fluoroscopy-based navigation manual surgery total hip arthroplasty pain length of stay procedure time Introduction Total hip arthroplasty (THA) is one of the most common surgeries performed worldwide for osteoarthritis of the hip [ 1 ]. THA is typically a successful surgical procedure with the majority of patients reporting satisfactory clinical outcomes with THA even after 15- to 20-years of follow-up [ 2 ]. While one of the main objectives of THA is to reduce pain, the interventions to reduce post-operative pain due to the procedure itself could impact patients’ well-being. Opioids are the foundation of pain management following THA procedures [ 3 – 5 ]; however, published studies have shown several challenges with opioid usage, from side effects and dependency/abuse for patients to increased overdose rates and the opioid epidemic in the Unites States (US), which has been identified as a public health crisis [ 6 – 9 ]. THA surgical technique and the use of computer-assisted technology has the potential to impact patient outcomes, including pain levels, and healthcare resource utilization. Computer-assisted navigation techniques are used to optimize component placement and alignment in THA and thereby improve patient outcomes [ 9 – 11 ]. Computer-assisted fluoroscopy-based navigation with direct anterior approach (fTHA) aims to improve procedure accuracy, patient outcomes, and efficiency. Given that this technology is relatively new, there are few studies to date that have investigated its associated health economic outcomes. The primary objective of this study was to evaluate patient post-operative pain associated with fTHA vs. posterior approach manual surgery (mTHA) among patients undergoing elective primary THA. The secondary objective was to evaluate procedure time associated with the use of fTHA vs. mTHA. Exploratory objectives were to evaluate hospital LOS, readmissions within 30 days, complications within 30 days, and patient-reported disability and osteoarthritis associated with the use of fTHA vs. mTHA. Materials and Methods Study Design This retrospective observational study identified consecutive patients undergoing THA from a single site and single surgeon from 2014–2022. Electronic medical records (EMRs) were reviewed to evaluate the patient outcomes and healthcare resource utilization of patients receiving mTHA via a posterior approach or fTHA using VELYS™ Hip Navigation (Johnson & Johnson MedTech) with the direct anterior approach. Study Population Subjects were included in the study if they underwent mTHA or fTHA as an elective, primary procedure between March 1, 2014 and December 31, 2022. The index date was defined as the admission date for the THA surgery (equivalent to service day for same-day/outpatient procedures). Subjects were required to be aged ≥ 18 years. Subjects were excluded if they had bilateral procedures on or within 90 days of index or if their records indicated the use of any other computer-assisted or robotic navigation system. Cases included in the mTHA cohort were conducted between March 1, 2014 to September 2015, prior to the adoption of direct anterior approach with computer-assisted fluoroscopy-based navigation. Records for mTHA cases prior to March 2014 were not accessible due to the EMR system change. Cases included in the fTHA cohort were conducted post-adoption of the direct anterior approach with navigation technology since October 2015. Patients in the fTHA group required records documenting the use of computer-assisted fluoroscopy-based navigation intraoperatively. Outcome Measures The baseline patient characteristics that were evaluated included age, sex, body mass index (BMI), and American Society of Anesthesiology (ASA) score. The primary outcome was a patient-report outcome measure (PROM) for pain, measured via the visual analog scale [ 12 ] (0 being no pain and 10 being the worst pain). The secondary outcome of interest was procedure time. Exploratory outcomes included hospital LOS, readmissions within 30 days, complications within 30 days (cardiac, pulmonary embolism, gastrointestinal, genitourinary, respiratory, and renal), and patient-reported disability and osteoarthritis, reported as changes in the Hip Disability and Osteoarthritis Outcome Score (HOOS pre- and post-operative). Statistical Analysis Sample size and statistical power for this study were evaluated based on the sequential testing of the primary endpoint, pain intensity (first day) among those who had fTHA vs. mTHA, and then the secondary endpoint, procedure time. A previous internal study found fTHA patients had a lower pain intensity (first day) at 2.9 compared to mTHA at 3.3 (± 2.2), on average. Assuming a 1:1 ratio for fTHA and mTHA cases in this study, using a 1-sided z test for testing two proportions, type I error = 0.05 for the primary endpoint, the required sample size to achieve ≥ 80% statistical power was calculated to be 95 per group. We expected to have at least 95 patients in each study group for this study from 2014 to 2022, and, therefore, we expected to have enough statistical power to test the primary hypothesis. A previous internal study found that fTHA patients had a higher operative time of 82.8 (± 18.5) compared to mTHA patients 63.3 (± 12.9), on average. Assuming a 1:1 ratio for fTHA and mTHA cases in this study, using a 2-sided z test for testing two proportions, type I error = 0.05 for the primary endpoint, the required sample size to achieve ≥ 80% statistical power was calculated to be 16 per group. We expected to have at least 95 patients in each study group for this study from 2014 to 2022, and, therefore, we expected to have enough statistical power to test the secondary hypothesis. Descriptive analyses were performed comparing the fTHA and mTHA cohorts on baseline characteristics as well as on the clinical and healthcare resource utilization outcomes of interest. Continuous variables were presented in terms of means and standard deviations (SD) and binary outcomes were presented as proportions. Continuous variables, i.e., primary and secondary outcomes for pain and procedure time, were compared through bivariate analyses using Student t-tests. Following bivariate analyses, separate General Linear Models (GLM) tailored to the empirical distribution of outcomes were used to test for statistically significant differences in outcomes (pain and procedure time), adjusting for possible confounding variables. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated as measures of strength of association and precision, respectively. In all analyses, a p-value < 0.05 was the threshold by which differences were statistically significant. Statistical significance was evaluated for the primary and secondary outcome (i.e., patient pain and procedure time); statistical testing was not performed for exploratory outcomes. The study was reviewed by the local Cuyuna Regional Medical Center Institutional Review Board and was determined to be exempt from review. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. Results Baseline Patient Demographic and Clinical Characteristics The study included 485 distinct patients receiving THA between March 1, 2014 and December 31, 2022. Of these, 390 patients (80.4%) were in the fTHA group and 95 patients (19.6%) received mTHA. The mean (SD) age of all patients in the study at baseline was 67.1 (10.6) years and a slightly greater proportion of the patients were female (52.8%) (Table 1 ). Mean (SD) BMI was 31.5 (6.8) and median BMI was 30.5. According to ASA scores, most patients had mild systemic disease (45.0%) or severe systemic disease, no emergency (53.7%), and few were categorized as healthy (1.1%) or having incapacitating disease (0.2%). Compared to patients who received mTHA, patients who received fTHA were slightly younger (66.6 vs. 69.2 years). The proportions who were male as well as BMI and ASA scores were similar for cohorts. Table 1 Baseline demographic and clinical characteristics Baseline characteristic Total Hip Arthroplasty mTHA (N = 95) fTHA (N = 390) Total (N = 485) Sex, n (%) Female 52 (54.7%) 204 (52.3%) 256 (52.8%) Male 43 (45.3%) 186 (47.7%) 229 (47.2%) Body mass index Mean (SD) 32.7 (6.0) 31.3 (6.9) 31.5 (6.8) Median 32.3 30.1 30.5 Min - Max 22.4–53.0 18.4–61.3 18.4–61.3 Age Mean (SD) 69.2 (7.9) 66.6 (11.2) 67.1 (10.6) Median 69.0 67.0 68.0 Min - Max 51.0–86.0 21.0–94.0 21.0–94.0 American Society of Anesthesiology Score, n (%) 1 0 (0.0%) 5 (1.3%) 5 (1.1%) 2 45 (47.4%) 165 (44.4%) 210 (45.0%) 3 50 (52.6%) 201 (54.0%) 251 (53.7%) 4 0 (0.0%) 1 (0.3%) 1 (0.2%) fTHA, direct anterior approach total hip arthroplasty with computer-assisted fluoroscopy-based navigation technology; mTHA, posterior approach manual total hip arthroplasty; SD, standard deviation. Clinical Outcomes and Healthcare Resource Utilization Unadjusted bivariate analyses demonstrated that, compared to patients with fTHA, patients with mTHA had greater mean [SD] pain (4.2 [2.0] vs. 3.0 [2.2]; p < 0.001), a longer mean [SD] procedure time (65.6 [12.6] vs. 61.1 [16.2] minutes; p = 0.013), and a greater mean [SD] and median hospital LOS (mean 1.9 [0.8] vs. 1.3 [1.1] days and median 2.0 vs. 1.0 days; Table 2 ). Table 2 Unadjusted bivariate analyses of health and economic outcomes Outcome mTHA (N = 95) fTHA (N = 390) Total (N = 485) p-value a Pain Mean (SD) 4.2 (2.0) 3.0 (2.2) 3.3 (2.2) < 0.001 Median 4.0 3.0 3.0 Min - Max 0.0–9.0 0.0–9.0 0.0–9.0 Procedure time (minutes) Mean (SD) 65.6 (12.6) 61.1 (16.2) 62.0 (15.6) 0.013 Median 64.0 59.0 59.0 Min - Max 47.0–136.0 7.0–135.0 7.0–136.0 Hospital length of stay (days) Mean (SD) 1.9 (0.8) 1.3 (1.1) 1.4 (1.1) - Median 2.0 1.0 1.1 Min - Max 1.0–4.0 0.3–13.1 0.3–13.1 Readmission, n (%) Yes 3 (3.2%) 0 (0.0%) 3 (0.6%) - No 92 (96.8%) 390 (100.0%) 482 (99.4%) Complications, n (%) Post-Operative Urinary Retention 6 (6.3%) 0 (0.0%) 6 (1.2%) - Delayed Wound Healing 0 (0.0%) 2 (0.5%) 2 (0.4%) Hypokalaemia 1 (1.1%) 0 (0.0%) 1 (0.2%) Pulmonary Embolism 1 (1.1%) 0 (0.0%) 1 (0.2%) Pneumonia 1 (1.1%) 0 (0.0%) 1 (0.2%) Wound Dehiscence 1 (1.1%) 0 (0.0%) 1 (0.2%) None 85 (89.5%) 388 (99.5%) 473 (97.5%) Hip Disability and Osteoarthritis Outcome Score (HOOS) change from baseline Mean (SD) n/a 24.4 (19.9) 24.4 (19.9) - Median n/a 26.3 26.3 Min - Max n/a 37.7–76.8 37.7–76.8 fTHA, direct anterior approach total hip arthroplasty with computer-assisted fluoroscopy-based navigation technology; mTHA, posterior approach manual total hip arthroplasty; n/a, not applicable; SD, standard deviation. a Bolded values denote statistical significance at p < 0.05. No readmission occurred in the fTHA group whereas the readmission rate for the mTHA group was 3.2% within 30 days post-surgery. The fTHA group also showed a reduced 30-day complication rate compared to the mTHA group (0.5% vs. 10.5%). HOOS changes from baseline were the same for both groups (increased by 24.4 [± 19.9] on average). Adjusted multivariate analyses showed that the mTHA group reported a 1.3 times higher pain intensity PROM (p < 0.001), similar procedure time (p = 0.103), and 1.6 times longer hospital LOS compared to the fTHA group (Table 3 ). Table 3 Adjusted multivariable analyses of health and economic outcomes Outcomes # mTHA # fTHA Odds Ratio (mTHA vs. fTHA) Lower Confidence Limit Upper Confidence Limit p-value a Pain 91 279 1.3 1.1 1.5 < 0.001 Procedure time (minutes) 95 370 1.0 1.0 1.1 0.103 Hospital length of stay (days) 95 372 1.6 1.4 1.9 - fTHA, direct anterior approach total hip arthroplasty with computer-assisted fluoroscopy-based navigation technology; mTHA, posterior approach manual total hip arthroplasty. a Bolded values denote statistical significance at p < 0.05. Discussion To our knowledge, this is the first large retrospective observational study to compare the clinical and healthcare resource utilization outcomes associated with fTHA vs. mTHA among patients undergoing THA. Study findings indicated that fTHA surgery was associated with reductions in pain and procedure time. Adjusted multivariate analyses showed that mTHA surgery had 1.3 times higher pain intensity PROM (p < 0.001), similar procedure time (p = 0.103), and 1.6 times longer hospital LOS compared to the fTHA group. No readmission occurred in the fTHA group within 30 days whereas the readmission rate for mTHA was 3.2%. The fTHA group also showed a reduced 30-day complication rate compared to mTHA (0.5% vs. 10.5%). The findings of the current study are consistent with other published studies that found favourable clinical and resource utilization outcomes with fTHA. A systematic review and meta-analysis of 13 prospective studies by Miller et al. (2018)[ 9 ] showed that anterior approach was associated with lower pain intensity (p < 0.001), lower narcotic use (p < 0.001) and better hip function (p = 0.002) compared to posterior approach THA. In another study, O’Leary and colleagues (2022) [ 13 ] prospectively assessed 100 consecutive patients who received direct anterior approach THA, including 50 cases with computer-assisted fluoroscopic navigation system, and 50 cases with manual surgery and unaided standard fluoroscopy. The authors found that the average difference between planned and actual limb lengthening was significantly lower (p < 0.02) and a greater proportion of patients were within 3 mm of the intended plan (p < 0.01) when digital fluoroscopic navigation was used. A retrospective review by Goodell and colleagues (2022) [ 14 ] compared operative outcomes for direct anterior approach THA with computer-assisted fluoroscopic navigation (n = 58) vs. direct anterior approach manual surgery with overlay technique (n = 51) within a single surgeon practice. Results showed that using navigation decreased both the average radiation dose (8.17 ± 6.09 mGy vs. 13.17 ± 7.75 mGy; p < 0.02) and operative time (80 ± 18 vs. 120 ± 32 minutes; p < 0.01) when compared to the conventional overlay technique. The ultimate goal of THA is to replace the native anatomy with a prosthetic joint that is stable, painless, durable, and is associated with high patient satisfaction. Computer-assisted navigation techniques used in conjunction with direct anterior approach may improve patient outcomes, including reducing pain levels and healthcare resource utilization [ 10 ]. New THA procedural methods and technologies should be evaluated to ascertain their real-world clinical and economic outcomes as studies have shown variations in THA complications, learning curve, and hospital LOS. A strength of this study is the utilization of real-world, clinically and economically meaningful outcomes for assessing the impact of fTHA. The primary outcome of interest was pain intensity. Severe pain is common among patients with THA [ 15 ] and pain management is an integral component of post-THA care given its impact on rehabilitation, timely discharge, and patient satisfaction [ 16 , 17 ]. Given the opioid crisis, there is an urgent need for strategies to reduce pain and/or opioid use in this high-risk patient population. The secondary outcome of interest was procedure time [ 6 ]. Procedure time is a main driver of cost to the hospital, including the costs associated with the functioning of the operating room and the costs associated with the time required for operating room staff, including nurses and surgical technologists [ 18 ]. Our study also evaluated hospital LOS in multivariate analyses. Hospital LOS is a quality metric that health systems use as a proxy of efficient hospital management as evidence has shown that reducing hospital LOS improves financial, operational, and clinical outcomes [ 19 ]. The use of observational data in this study has both its strengths and limitations. Observational studies leverage data originating from clinical practice and better reflect real-world conditions. Although randomized controlled trials have a high degree of internal validity, they have reduced external validity as the study populations, protocols, and circumstances may not be relevant to the 'real-world' or to diverse populations [ 20 , 21 ]. Real-world evidence assists consumers, clinicians, purchasers, and policymakers in making informed individual- and population-level decisions [ 20 , 21 ]. However, a challenge of observational studies is appropriately making comparisons between treatment arms for assessing the incremental changes afforded by the new healthcare technologies or interventions [ 22 ]. Although the present study carefully applied statistical analysis techniques (i.e., adjusted multivariable analyses) to improve causal inference of comparative treatment effects, the study was still retrospective and observational in design and causality cannot be established for the observed relationships. Additionally, our results highlight the combined effect of surgical approach change and adoption of computer-assisted navigation technology. We cannot separate out the effect of surgical approach from navigation technology on outcomes since the surgeon had previously used the posterior approach. The use of EMR data for this study enabled the efficient evaluation of quality of care for individuals who received THA. EMR datasets capture a variety of patient-level data that represent integral components of care that may not necessarily be available through other retrospective database sources such as administrative claims databases or patient registries (e.g., information on the specific type of endoprosthesis used) [ 23 ],[ 24 ]. EMRs also provide efficient access to detailed longitudinal data that would otherwise be difficult to collect [ 25 , 26 ]. However, limitations of EMR data include coding errors or incomplete information for clinical visits and subsequent follow-up. The patients selected for this study represent a sample from a single site and single surgeon, which ensured that the comparison was not biased by differing surgeon or site characteristics between the comparator arms. However, as is found in any study of a new surgical approach and technology, the comparison may be biased against the new approach and technology due to the learning curve associated with its use by the individual surgeon [ 27 ]. The limitation of using data from a single surgeon site is that patients, treatment methods, and institutional policies may differ in other settings of care, therefore limiting the generalizability of results. Further, the study sample for the posterior approach manual cohort was smaller than the anterior approach navigation cohort due to the facility’s EMR system change. Studies with larger cohorts of patients at multiple sites are needed to confirm these findings. Nonetheless, the findings contribute to the mounting evidence for the real-world clinical and economic benefits of fTHA. Conclusions The use of direct anterior approach using computer-assisted fluoroscopy-based navigation technology aims to enable patient-specific THA alignment and provides real-time feedback to the surgeon, to help with increased accuracy and surgical reproducibility. This study evaluated real-world patient-reported pain, procedure time, and hospital LOS. Results showed that direct anterior approach THA with computer-assisted fluoroscopy-based navigation may facilitate a reduction in the use of pain medication, reduce procedure time, shorten hospital LOS, and potentially reduce readmissions and complications within 30 days. Further studies with larger cohorts of patients at multiple sites are warranted. Declarations Funding The study was funded by Johnson & Johnson MedTech. Competing Interests MK, LG, and KE are employees of Johnson & Johnson (J&J). ZT was employed by J&J when the study was conducted. J&J employees were involved in the conduction of the study and the preparation of the manuscript. The authors had full control of the manuscript and provided their final approval of all content. Authors' Contributions ES, ZT, MK, LG, and KE participated in the conception and design of the study, the data collection, analysis and interpretation of the data, manuscript writing, and the review and final approval of the manuscript. AE and JM participated in the data collection, analysis and interpretation of the data, manuscript writing, and the review and final approval of the manuscript. Ethics Approval This retrospective review of electronic medical records from a single surgeon at a US critical access hospital was determined to be exempt from review by the local Cuyuna Regional Medical Center Institutional Review Board. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. Consent to Participate Consent to participate was not required for this study as it used data from an anonymous, de-identified, EMR database compliant with the Health Insurance Portability and Accountability Act of 1996. Data Availability The data that support the findings of this study were obtained from Dr. Erik Severson’s practice and are not publicly available. References Cross M, Smith E, Hoy D, Nolte S, Ackerman I, Fransen M, Bridgett L, Williams S, Guillemin F, Hill CL, et al. The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014;73(7):1323–30. Karachalios T, Komnos G, Koutalos A. Total hip arthroplasty: Survival and modes of failure. EFORT Open Rev. 2018;3(5):232–9. Grace TR, Choo KJ, Patterson JT, Khanna K, Feeley BT, Zhang AL. A Review of Inpatient Opioid Consumption and Discharge Prescription Patterns After Orthopaedic Procedures. J Am Acad Orthop Surg. 2020;28(7):279–86. 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The authors had full control of the manuscript and provided their final approval of all content. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 27 Jul, 2025 Reviewers invited by journal 21 Jul, 2025 Editor invited by journal 25 Jun, 2025 Editor assigned by journal 20 Jun, 2025 Submission checks completed at journal 20 Jun, 2025 First submitted to journal 18 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6925135","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":488275510,"identity":"5ed03f6c-34c9-47d0-a829-721e7c4a4f59","order_by":0,"name":"Erik Severson","email":"","orcid":"","institution":"Cuyuna Regional Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Erik","middleName":"","lastName":"Severson","suffix":""},{"id":488275511,"identity":"d1d876e7-af9f-4f47-a97e-090f5ea3c4a6","order_by":1,"name":"Ziyu Tan","email":"","orcid":"","institution":"Johnson \u0026 Johnson MedTech","correspondingAuthor":false,"prefix":"","firstName":"Ziyu","middleName":"","lastName":"Tan","suffix":""},{"id":488275512,"identity":"fc92ba0d-5ec1-4ee6-b768-6f1cf843f054","order_by":2,"name":"Mina Kabiri","email":"","orcid":"","institution":"Johnson \u0026 Johnson MedTech","correspondingAuthor":false,"prefix":"","firstName":"Mina","middleName":"","lastName":"Kabiri","suffix":""},{"id":488275513,"identity":"e50dd731-bd1c-4f29-9d7e-e6ec821b49cf","order_by":3,"name":"Adam English","email":"","orcid":"","institution":"Cuyuna Regional Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Adam","middleName":"","lastName":"English","suffix":""},{"id":488275514,"identity":"259ba472-1ec9-46ed-aa34-56a444c98bdc","order_by":4,"name":"John Reimer","email":"","orcid":"","institution":"Cuyuna Regional Medical Center","correspondingAuthor":false,"prefix":"","firstName":"John","middleName":"","lastName":"Reimer","suffix":""},{"id":488275515,"identity":"8c627771-2e52-429f-b267-4adbaa8d73c4","order_by":5,"name":"Laura Goldstein","email":"","orcid":"","institution":"Johnson \u0026 Johnson MedTech","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Goldstein","suffix":""},{"id":488275516,"identity":"725f39c0-3296-4c3a-b0fa-a49d2c63af8b","order_by":6,"name":"Katherine Etter","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYBACCQhlIyc///kDhso2OWK0MDM2MDCkGbMx8xgwSB5jI1rL4cQ2Zh4GBslnRGiRbO8//uDjHuZ0uBb+9u4EvFqkeQ4zNs54xpbbxsz+gEFyGxuDxJmzG/BqkZNIZmzmOcAD1MJgANZiIJFLQIv8Y8bmPwck0tnAWuYRoUVagpmxmeGAQQJIC6NknxthLZI9yYYzew4kGAK9b3BwY18OD0G/SBw/+ODDjwP/5eWb2R8+eNhmIcff3otfCwo4AMQ8xCsfBaNgFIyCUYATAAC6WkBX+v9HIQAAAABJRU5ErkJggg==","orcid":"","institution":"Johnson \u0026 Johnson MedTech","correspondingAuthor":true,"prefix":"","firstName":"Katherine","middleName":"","lastName":"Etter","suffix":""}],"badges":[],"createdAt":"2025-06-18 17:23:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6925135/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6925135/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87440313,"identity":"20f1c2e9-7c88-43cb-a70c-938f03c6ed36","added_by":"auto","created_at":"2025-07-23 19:38:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":876839,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6925135/v1/343e9034-3283-48b3-a348-05c384cd6f1d.pdf"}],"financialInterests":"Competing interest reported. MK, LG, and KE are employees of Johnson \u0026 Johnson (J\u0026J). ZT was employed by J\u0026J when the study was conducted. J\u0026J employees were involved in the conduction of the study and the preparation of the manuscript. The authors had full control of the manuscript and provided their final approval of all content.","formattedTitle":"Patient Clinical Outcomes and Healthcare Resource Utilization Using a Computer-Assisted Fluoroscopy-Based Navigation System with Anterior Approach Compared to Posterior Approach Manual Surgery for Total Hip Arthroplasty","fulltext":[{"header":"Introduction","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTotal hip arthroplasty (THA) is one of the most common surgeries performed worldwide for osteoarthritis of the hip [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. THA is typically a successful surgical procedure with the majority of patients reporting satisfactory clinical outcomes with THA even after 15- to 20-years of follow-up [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While one of the main objectives of THA is to reduce pain, the interventions to reduce post-operative pain due to the procedure itself could impact patients\u0026rsquo; well-being. Opioids are the foundation of pain management following THA procedures [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]; however, published studies have shown several challenges with opioid usage, from side effects and dependency/abuse for patients to increased overdose rates and the opioid epidemic in the Unites States (US), which has been identified as a public health crisis [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTHA surgical technique and the use of computer-assisted technology has the potential to impact patient outcomes, including pain levels, and healthcare resource utilization. Computer-assisted navigation techniques are used to optimize component placement and alignment in THA and thereby improve patient outcomes [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eComputer-assisted fluoroscopy-based navigation with direct anterior approach (fTHA) aims to improve procedure accuracy, patient outcomes, and efficiency. Given that this technology is relatively new, there are few studies to date that have investigated its associated health economic outcomes. The primary objective of this study was to evaluate patient post-operative pain associated with fTHA vs. posterior approach manual surgery (mTHA) among patients undergoing elective primary THA. The secondary objective was to evaluate procedure time associated with the use of fTHA vs. mTHA. Exploratory objectives were to evaluate hospital LOS, readmissions within 30 days, complications within 30 days, and patient-reported disability and osteoarthritis associated with the use of fTHA vs. mTHA.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis retrospective observational study identified consecutive patients undergoing THA from a single site and single surgeon from 2014\u0026ndash;2022. Electronic medical records (EMRs) were reviewed to evaluate the patient outcomes and healthcare resource utilization of patients receiving mTHA via a posterior approach or fTHA using VELYS\u0026trade; Hip Navigation (Johnson \u0026amp; Johnson MedTech) with the direct anterior approach.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Population\u003c/h3\u003e\n\u003cp\u003eSubjects were included in the study if they underwent mTHA or fTHA as an elective, primary procedure between March 1, 2014 and December 31, 2022. The index date was defined as the admission date for the THA surgery (equivalent to service day for same-day/outpatient procedures). Subjects were required to be aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years. Subjects were excluded if they had bilateral procedures on or within 90 days of index or if their records indicated the use of any other computer-assisted or robotic navigation system.\u003c/p\u003e\u003cp\u003eCases included in the mTHA cohort were conducted between March 1, 2014 to September 2015, prior to the adoption of direct anterior approach with computer-assisted fluoroscopy-based navigation. Records for mTHA cases prior to March 2014 were not accessible due to the EMR system change. Cases included in the fTHA cohort were conducted post-adoption of the direct anterior approach with navigation technology since October 2015. Patients in the fTHA group required records documenting the use of computer-assisted fluoroscopy-based navigation intraoperatively.\u003c/p\u003e\n\u003ch3\u003eOutcome Measures\u003c/h3\u003e\n\u003cp\u003eThe baseline patient characteristics that were evaluated included age, sex, body mass index (BMI), and American Society of Anesthesiology (ASA) score. The primary outcome was a patient-report outcome measure (PROM) for pain, measured via the visual analog scale [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] (0 being no pain and 10 being the worst pain). The secondary outcome of interest was procedure time. Exploratory outcomes included hospital LOS, readmissions within 30 days, complications within 30 days (cardiac, pulmonary embolism, gastrointestinal, genitourinary, respiratory, and renal), and patient-reported disability and osteoarthritis, reported as changes in the Hip Disability and Osteoarthritis Outcome Score (HOOS pre- and post-operative).\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eSample size and statistical power for this study were evaluated based on the sequential testing of the primary endpoint, pain intensity (first day) among those who had fTHA vs. mTHA, and then the secondary endpoint, procedure time. A previous internal study found fTHA patients had a lower pain intensity (first day) at 2.9 compared to mTHA at 3.3 (\u0026plusmn;\u0026thinsp;2.2), on average. Assuming a 1:1 ratio for fTHA and mTHA cases in this study, using a 1-sided z test for testing two proportions, type I error\u0026thinsp;=\u0026thinsp;0.05 for the primary endpoint, the required sample size to achieve\u0026thinsp;\u0026ge;\u0026thinsp;80% statistical power was calculated to be 95 per group. We expected to have at least 95 patients in each study group for this study from 2014 to 2022, and, therefore, we expected to have enough statistical power to test the primary hypothesis. A previous internal study found that fTHA patients had a higher operative time of 82.8 (\u0026plusmn;\u0026thinsp;18.5) compared to mTHA patients 63.3 (\u0026plusmn;\u0026thinsp;12.9), on average. Assuming a 1:1 ratio for fTHA and mTHA cases in this study, using a 2-sided z test for testing two proportions, type I error\u0026thinsp;=\u0026thinsp;0.05 for the primary endpoint, the required sample size to achieve\u0026thinsp;\u0026ge;\u0026thinsp;80% statistical power was calculated to be 16 per group. We expected to have at least 95 patients in each study group for this study from 2014 to 2022, and, therefore, we expected to have enough statistical power to test the secondary hypothesis.\u003c/p\u003e\u003cp\u003eDescriptive analyses were performed comparing the fTHA and mTHA cohorts on baseline characteristics as well as on the clinical and healthcare resource utilization outcomes of interest. Continuous variables were presented in terms of means and standard deviations (SD) and binary outcomes were presented as proportions. Continuous variables, i.e., primary and secondary outcomes for pain and procedure time, were compared through bivariate analyses using Student t-tests. Following bivariate analyses, separate General Linear Models (GLM) tailored to the empirical distribution of outcomes were used to test for statistically significant differences in outcomes (pain and procedure time), adjusting for possible confounding variables. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated as measures of strength of association and precision, respectively.\u003c/p\u003e\u003cp\u003eIn all analyses, a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was the threshold by which differences were statistically significant. Statistical significance was evaluated for the primary and secondary outcome (i.e., patient pain and procedure time); statistical testing was not performed for exploratory outcomes.\u003c/p\u003e\u003cp\u003eThe study was reviewed by the local Cuyuna Regional Medical Center Institutional Review Board and was determined to be exempt from review. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eBaseline Patient Demographic and Clinical Characteristics\u003c/h2\u003e\u003cp\u003eThe study included 485 distinct patients receiving THA between March 1, 2014 and December 31, 2022. Of these, 390 patients (80.4%) were in the fTHA group and 95 patients (19.6%) received mTHA.\u003c/p\u003e\u003cp\u003eThe mean (SD) age of all patients in the study at baseline was 67.1 (10.6) years and a slightly greater proportion of the patients were female (52.8%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Mean (SD) BMI was 31.5 (6.8) and median BMI was 30.5. According to ASA scores, most patients had mild systemic disease (45.0%) or severe systemic disease, no emergency (53.7%), and few were categorized as healthy (1.1%) or having incapacitating disease (0.2%). Compared to patients who received mTHA, patients who received fTHA were slightly younger (66.6 vs. 69.2 years). The proportions who were male as well as BMI and ASA scores were similar for cohorts.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline demographic and clinical characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eBaseline characteristic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003eTotal Hip Arthroplasty\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003emTHA (N\u0026thinsp;=\u0026thinsp;95)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003efTHA (N\u0026thinsp;=\u0026thinsp;390)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eTotal (N\u0026thinsp;=\u0026thinsp;485)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eSex, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52 (54.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e204 (52.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e256 (52.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43 (45.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e186 (47.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e229 (47.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eBody mass index\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32.7 (6.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31.3 (6.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e31.5 (6.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e30.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMin - Max\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.4\u0026ndash;53.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18.4\u0026ndash;61.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e18.4\u0026ndash;61.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69.2 (7.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e66.6 (11.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e67.1 (10.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e67.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e68.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMin - Max\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51.0\u0026ndash;86.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21.0\u0026ndash;94.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e21.0\u0026ndash;94.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eAmerican Society of Anesthesiology Score, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5 (1.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45 (47.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e165 (44.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e210 (45.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50 (52.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e201 (54.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e251 (53.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (0.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1 (0.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003efTHA, direct anterior approach total hip arthroplasty with computer-assisted fluoroscopy-based navigation technology; mTHA, posterior approach manual total hip arthroplasty; SD, standard deviation.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eClinical Outcomes and Healthcare Resource Utilization\u003c/h3\u003e\n\u003cp\u003eUnadjusted bivariate analyses demonstrated that, compared to patients with fTHA, patients with mTHA had greater mean [SD] pain (4.2 [2.0] vs. 3.0 [2.2]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a longer mean [SD] procedure time (65.6 [12.6] vs. 61.1 [16.2] minutes; p\u0026thinsp;=\u0026thinsp;0.013), and a greater mean [SD] and median hospital LOS (mean 1.9 [0.8] vs. 1.3 [1.1] days and median 2.0 vs. 1.0 days; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eUnadjusted bivariate analyses of health and economic outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003emTHA (N\u0026thinsp;=\u0026thinsp;95)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003efTHA (N\u0026thinsp;=\u0026thinsp;390)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;485)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep-value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003ePain\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.2 (2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.0 (2.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.3 (2.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMin - Max\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0\u0026ndash;9.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0\u0026ndash;9.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.0\u0026ndash;9.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eProcedure time (minutes)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65.6 (12.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e61.1 (16.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e62.0 (15.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003e0.013\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e59.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e59.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMin - Max\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47.0\u0026ndash;136.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.0\u0026ndash;135.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.0\u0026ndash;136.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eHospital length of stay (days)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.9 (0.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.3 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.4 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMin - Max\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0\u0026ndash;4.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.3\u0026ndash;13.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.3\u0026ndash;13.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eReadmission, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (3.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3 (0.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e92 (96.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e390 (100.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e482 (99.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e\u003cp\u003e\u003cb\u003eComplications, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePost-Operative Urinary Retention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (6.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6 (1.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"6\" rowspan=\"7\"\u003e\u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDelayed Wound Healing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2 (0.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2 (0.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHypokalaemia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1 (0.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePulmonary Embolism\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1 (0.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePneumonia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1 (0.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWound Dehiscence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1 (0.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e85 (89.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e388 (99.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e473 (97.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eHip Disability and Osteoarthritis Outcome Score (HOOS) change from baseline\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003en/a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e24.4 (19.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e24.4 (19.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003en/a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e26.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e26.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMin - Max\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003en/a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e37.7\u0026ndash;76.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e37.7\u0026ndash;76.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003efTHA, direct anterior approach total hip arthroplasty with computer-assisted fluoroscopy-based navigation technology; mTHA, posterior approach manual total hip arthroplasty; n/a, not applicable; SD, standard deviation.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ea\u003c/sup\u003e Bolded values denote statistical significance at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eNo readmission occurred in the fTHA group whereas the readmission rate for the mTHA group was 3.2% within 30 days post-surgery. The fTHA group also showed a reduced 30-day complication rate compared to the mTHA group (0.5% vs. 10.5%). HOOS changes from baseline were the same for both groups (increased by 24.4 [\u0026plusmn;\u0026thinsp;19.9] on average).\u003c/p\u003e\u003cp\u003eAdjusted multivariate analyses showed that the mTHA group reported a 1.3 times higher pain intensity PROM (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), similar procedure time (p\u0026thinsp;=\u0026thinsp;0.103), and 1.6 times longer hospital LOS compared to the fTHA group (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAdjusted multivariable analyses of health and economic outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcomes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e# mTHA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e# fTHA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOdds Ratio (mTHA vs. fTHA)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLower Confidence Limit\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eUpper Confidence Limit\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ep-value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePain\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e279\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProcedure time (minutes)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e370\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.103\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHospital length of stay (days)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e372\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003efTHA, direct anterior approach total hip arthroplasty with computer-assisted fluoroscopy-based navigation technology; mTHA, posterior approach manual total hip arthroplasty.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003ea\u003c/sup\u003e Bolded values denote statistical significance at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this is the first large retrospective observational study to compare the clinical and healthcare resource utilization outcomes associated with fTHA vs. mTHA among patients undergoing THA. Study findings indicated that fTHA surgery was associated with reductions in pain and procedure time. Adjusted multivariate analyses showed that mTHA surgery had 1.3 times higher pain intensity PROM (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), similar procedure time (p\u0026thinsp;=\u0026thinsp;0.103), and 1.6 times longer hospital LOS compared to the fTHA group. No readmission occurred in the fTHA group within 30 days whereas the readmission rate for mTHA was 3.2%. The fTHA group also showed a reduced 30-day complication rate compared to mTHA (0.5% vs. 10.5%).\u003c/p\u003e\u003cp\u003eThe findings of the current study are consistent with other published studies that found favourable clinical and resource utilization outcomes with fTHA. A systematic review and meta-analysis of 13 prospective studies by Miller et al. (2018)[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] showed that anterior approach was associated with lower pain intensity (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), lower narcotic use (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and better hip function (p\u0026thinsp;=\u0026thinsp;0.002) compared to posterior approach THA. In another study, O\u0026rsquo;Leary and colleagues (2022) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] prospectively assessed 100 consecutive patients who received direct anterior approach THA, including 50 cases with computer-assisted fluoroscopic navigation system, and 50 cases with manual surgery and unaided standard fluoroscopy. The authors found that the average difference between planned and actual limb lengthening was significantly lower (p\u0026thinsp;\u0026lt;\u0026thinsp;0.02) and a greater proportion of patients were within 3 mm of the intended plan (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) when digital fluoroscopic navigation was used. A retrospective review by Goodell and colleagues (2022) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] compared operative outcomes for direct anterior approach THA with computer-assisted fluoroscopic navigation (n\u0026thinsp;=\u0026thinsp;58) vs. direct anterior approach manual surgery with overlay technique (n\u0026thinsp;=\u0026thinsp;51) within a single surgeon practice. Results showed that using navigation decreased both the average radiation dose (8.17\u0026thinsp;\u0026plusmn;\u0026thinsp;6.09 mGy vs. 13.17\u0026thinsp;\u0026plusmn;\u0026thinsp;7.75 mGy; p\u0026thinsp;\u0026lt;\u0026thinsp;0.02) and operative time (80\u0026thinsp;\u0026plusmn;\u0026thinsp;18 vs. 120\u0026thinsp;\u0026plusmn;\u0026thinsp;32 minutes; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) when compared to the conventional overlay technique.\u003c/p\u003e\u003cp\u003eThe ultimate goal of THA is to replace the native anatomy with a prosthetic joint that is stable, painless, durable, and is associated with high patient satisfaction. Computer-assisted navigation techniques used in conjunction with direct anterior approach may improve patient outcomes, including reducing pain levels and healthcare resource utilization [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. New THA procedural methods and technologies should be evaluated to ascertain their real-world clinical and economic outcomes as studies have shown variations in THA complications, learning curve, and hospital LOS.\u003c/p\u003e\u003cp\u003eA strength of this study is the utilization of real-world, clinically and economically meaningful outcomes for assessing the impact of fTHA. The primary outcome of interest was pain intensity. Severe pain is common among patients with THA [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and pain management is an integral component of post-THA care given its impact on rehabilitation, timely discharge, and patient satisfaction [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Given the opioid crisis, there is an urgent need for strategies to reduce pain and/or opioid use in this high-risk patient population. The secondary outcome of interest was procedure time [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Procedure time is a main driver of cost to the hospital, including the costs associated with the functioning of the operating room and the costs associated with the time required for operating room staff, including nurses and surgical technologists [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Our study also evaluated hospital LOS in multivariate analyses. Hospital LOS is a quality metric that health systems use as a proxy of efficient hospital management as evidence has shown that reducing hospital LOS improves financial, operational, and clinical outcomes [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe use of observational data in this study has both its strengths and limitations. Observational studies leverage data originating from clinical practice and better reflect real-world conditions. Although randomized controlled trials have a high degree of internal validity, they have reduced external validity as the study populations, protocols, and circumstances may not be relevant to the 'real-world' or to diverse populations [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Real-world evidence assists consumers, clinicians, purchasers, and policymakers in making informed individual- and population-level decisions [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, a challenge of observational studies is appropriately making comparisons between treatment arms for assessing the incremental changes afforded by the new healthcare technologies or interventions [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Although the present study carefully applied statistical analysis techniques (i.e., adjusted multivariable analyses) to improve causal inference of comparative treatment effects, the study was still retrospective and observational in design and causality cannot be established for the observed relationships. Additionally, our results highlight the combined effect of surgical approach change and adoption of computer-assisted navigation technology. We cannot separate out the effect of surgical approach from navigation technology on outcomes since the surgeon had previously used the posterior approach.\u003c/p\u003e\u003cp\u003eThe use of EMR data for this study enabled the efficient evaluation of quality of care for individuals who received THA. EMR datasets capture a variety of patient-level data that represent integral components of care that may not necessarily be available through other retrospective database sources such as administrative claims databases or patient registries (e.g., information on the specific type of endoprosthesis used) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e],[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. EMRs also provide efficient access to detailed longitudinal data that would otherwise be difficult to collect [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, limitations of EMR data include coding errors or incomplete information for clinical visits and subsequent follow-up.\u003c/p\u003e\u003cp\u003eThe patients selected for this study represent a sample from a single site and single surgeon, which ensured that the comparison was not biased by differing surgeon or site characteristics between the comparator arms. However, as is found in any study of a new surgical approach and technology, the comparison may be biased against the new approach and technology due to the learning curve associated with its use by the individual surgeon [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The limitation of using data from a single surgeon site is that patients, treatment methods, and institutional policies may differ in other settings of care, therefore limiting the generalizability of results. Further, the study sample for the posterior approach manual cohort was smaller than the anterior approach navigation cohort due to the facility\u0026rsquo;s EMR system change. Studies with larger cohorts of patients at multiple sites are needed to confirm these findings. Nonetheless, the findings contribute to the mounting evidence for the real-world clinical and economic benefits of fTHA.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe use of direct anterior approach using computer-assisted fluoroscopy-based navigation technology aims to enable patient-specific THA alignment and provides real-time feedback to the surgeon, to help with increased accuracy and surgical reproducibility. This study evaluated real-world patient-reported pain, procedure time, and hospital LOS. Results showed that direct anterior approach THA with computer-assisted fluoroscopy-based navigation may facilitate a reduction in the use of pain medication, reduce procedure time, shorten hospital LOS, and potentially reduce readmissions and complications within 30 days. Further studies with larger cohorts of patients at multiple sites are warranted.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was funded by Johnson \u0026amp; Johnson MedTech.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMK, LG, and KE are employees of Johnson \u0026amp; Johnson (J\u0026amp;J). ZT was employed by J\u0026amp;J when the study was conducted. J\u0026amp;J employees were involved in the conduction of the study and the preparation of the manuscript. The authors had full control of the manuscript and provided their final approval of all content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eES, ZT, MK, LG, and KE participated in the conception and design of the study, the data collection, analysis and interpretation of the data, manuscript writing, and the review and final approval of the manuscript. AE and JM participated in the data collection, analysis and interpretation of the data, manuscript writing, and the review and final approval of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective review of electronic medical records from a single surgeon at a US critical access hospital was determined to be exempt from review by the local Cuyuna Regional Medical Center Institutional Review Board. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent to participate was not required for this study as it used data from an anonymous, de-identified, EMR database compliant with the Health Insurance Portability and Accountability Act of 1996.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study were obtained from Dr. Erik Severson’s practice and are not publicly available.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCross M, Smith E, Hoy D, Nolte S, Ackerman I, Fransen M, Bridgett L, Williams S, Guillemin F, Hill CL, et al. The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014;73(7):1323\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKarachalios T, Komnos G, Koutalos A. Total hip arthroplasty: Survival and modes of failure. EFORT Open Rev. 2018;3(5):232\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrace TR, Choo KJ, Patterson JT, Khanna K, Feeley BT, Zhang AL. A Review of Inpatient Opioid Consumption and Discharge Prescription Patterns After Orthopaedic Procedures. J Am Acad Orthop Surg. 2020;28(7):279\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAtwood K, Shackleford T, Lemons W, Eicher JL, Lindsey BA, Klein AE. Postdischarge Opioid Use after Total Hip and Total Knee Arthroplasty. Arthroplast Today. 2021;7:126\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShah R, Kuo Y-F, Westra J, Lin Y-L, Raji MA. 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Pain. 2016;157(6):1259\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMiller LE, Gondusky JS, Bhattacharyya S, Kamath AF, Boettner F, Wright J. Does Surgical Approach Affect Outcomes in Total Hip Arthroplasty Through 90 Days of Follow-Up? A Systematic Review With Meta-Analysis. J Arthroplasty. 2018;33(4):1296\u0026ndash;302.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePerry JJ, Cooper AJ. Navigation Technologies for the Anterior Approach in Total Hip Arthroplasty. In: \u003cem\u003eAnterior Hip Replacement: From Origin to Current Advanced Techniques.\u003c/em\u003e edn. Edited by Matta JM, Sah AP. Cham: Springer International Publishing; 2022: 463\u0026ndash;476.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSeah S, Quinn M, Tirosh O, Tran P. Postoperative Opioid Consumption After Total Hip Arthroplasty: A Comparison of Three Surgical Approaches. J Arthroplasty. 2019;34(11):2676\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHayes M. Experimental development of the graphic rating method. Psychol Bull. 1921;18:98\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eO'Leary R, Saxena A, Arguelles W, Hernandez Y, Osondu CU, Suarez JC. Digital Fluoroscopic Navigation for Limb Length Restoration During Anterior Total Hip Arthroplasty. Arthroplast Today. 2022;18:11\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGoodell P, Ellis S, Kokobun B, Wilson H, Kollmorgen RC. Computer Navigation vs. Conventional Overlay Methods in Direct Anterior Total Hip Arthroplasty: A Single Surgeon Experience. Cureus. 2022;14(10):e29907.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCook DJ, Kaskovich SW, Pirkle SC, Mica MAC, Shi LL, Lee MJ. 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J Am Med Inf Assoc. 2013;20(e2):e206\u0026ndash;211.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWeng C, Appelbaum P, Hripcsak G, Kronish I, Busacca L, Davidson KW, Bigger JT. Using EHRs to integrate research with patient care: promises and challenges. J Am Med Inf Assoc. 2012;19(5):684\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCook JA. The challenges faced in the design, conduct and analysis of surgical randomised controlled trials. Trials. 2009;10:9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"computer-assisted fluoroscopy-based navigation, manual surgery, total hip arthroplasty, pain, length of stay, procedure time","lastPublishedDoi":"10.21203/rs.3.rs-6925135/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6925135/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003eClinical outcomes and healthcare resource utilization were compared for patients undergoing primary total hip arthroplasty (THA) with direct anterior approach (DAA) using computer-assisted fluoroscopy-based navigation technology (fTHA) vs. posterior approach manual surgery (mTHA).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods: \u003c/strong\u003eA pre/post analysis reviewed electronic medical records from a single surgeon at a US critical access hospital from 2014-2022; fTHA began in October of 2015. The primary outcome was a patient-reported outcome measure (PROM) for pain and the secondary outcome was procedure time. Exploratory outcomes were hospital length of stay (LOS), 30-day readmissions and complications, and changes in disability and osteoarthritis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAmong 485 patients (mean [standard deviation (SD)] age 67.1 [10.6] years, 52.8% female), 390 (80.4%) received fTHA and 95 (19.6%) received mTHA. In unadjusted analyses, mTHA patients had greater mean (SD) pain (4.2 [2.0] vs. 3.0 [2.2]; p\u0026lt;0.001), procedure time (65.6 [12.6] vs. 61.1 [16.2] minutes; p=0.013), and LOS (mean [SD]: 1.9 [0.8] vs. 1.3 [1.1] days and median 2.0 vs. 1.0 days). No readmission occurred with fTHA whereas readmission for mTHA was 3.2%. fTHA also showed a reduced complication rate vs. mTHA (0.5% vs. 10.5%). Hip Disability and Osteoarthritis Outcome Score changes were the same, with an average increase of 24.4 [19.9]. Multivariate analyses found mTHA had 1.3 times higher pain intensity PROM (p\u0026lt;0.001), similar procedure time (p=0.103), and 1.6 times longer hospital LOS (p\u0026lt;0.001) compared to fTHA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eUsing a computer-assisted fluoroscopy-based navigation technology with DAA may facilitate a statistically significant reduction in pain and procedure time.\u003c/p\u003e","manuscriptTitle":"Patient Clinical Outcomes and Healthcare Resource Utilization Using a Computer-Assisted Fluoroscopy-Based Navigation System with Anterior Approach Compared to Posterior Approach Manual Surgery for Total Hip Arthroplasty","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-23 19:22:46","doi":"10.21203/rs.3.rs-6925135/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"91359384964462040502450161677317725469","date":"2025-07-27T22:32:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-21T05:18:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-25T20:44:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-20T07:08:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-20T07:06:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-06-18T17:09:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fe6ec90c-d18f-4cb0-947a-f181ced0ca3a","owner":[],"postedDate":"July 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-23T19:22:46+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-23 19:22:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6925135","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6925135","identity":"rs-6925135","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}