A systematic review and meta-analysis of the standard versus mini-incision posterior approach to total hip arthroplasty

Exploring the clinical value of direct anterior approach THA for short-term hip function improvement: A single-center retrospective analysis of short-term outcomes

To investigate the outcomes of the direct anterior approach (DAA) in total hip arthroplasty (THA) and its impact on improving hip joint function. This retrospective analysis included 94 patients who underwent THA between December 2017 and December 2020 at Dongguan Hospital, Guangzhou University of Chinese Medicine. The study group comprised 50 patients who received the DAA, while the control group comprised 44 patients who received the postero-lateral approach (PA). The follow-up period was 12 months. A comparison was made between the 2 groups based on perioperative indicators (operation time, intraoperative blood loss, hospitalization time, bed rest time, incision length, pain score), duration of walker use, incidence of postoperative complications, hip joint function (Harris score), quality of life (SF-36), and activities of daily living (ADL). The treatment effectiveness rate was higher in the study group (P < .05). The study group had a longer operation time, lower intraoperative blood loss, shorter hospitalization and bed rest time, smaller incision length, and lower visual analog scale (VAS) score after treatment, with statistically significant differences (P < .05). The study group also had a shorter duration of walker use after surgery (P < .05). The Harris score after treatment was higher in the study group compared to the control group (P < .05). Additionally, the study group had higher SF-36 scores and ADL scores after treatment (P < .05). There was no significant difference in the incidence of postoperative complications between the 2 groups (P > .05). The DAA in THA resulted in reduced pain and intraoperative blood loss, contributing to the promotion of postoperative recovery in patients with good short-term outcomes. This procedure warrants further promotion.

Superior Transverse Atraumatic Reconstruction (STAR) approach provides a better-compared outcome to standard Direct Superior Approach (DSA): a matched, prospective comparative single-surgeon study

INTRODUCTION

The Direct Superior Approach (DSA) is a muscle-sparing hip approach that does not protect the piriformis and the other short external rotators. We present a DSA modification we named STAR (Superior Transverse Atraumatic Reconstruction), which has DSA advantages but always preserves piriformis. Our study compared the early postoperative, radiological, and functional results of patients undergoing primary total hip arthroplasty (THA) through the STAR approach with a matched DSA group performed by a senior surgeon.

METHODS

Each group, DSA, and STAR included 200 elective primary unilateral THAs performed by the surgeon between 2016-2017 and 2020-2021, respectively. Patients were included in both groups using the same inclusion criteria. Both groups were matched for age and sex. The same postoperative pain management, chemoprophylaxis, and physiotherapy protocols were followed in both groups. Two independent orthopaedic surgeons performed the clinical and radiological follow-up.

RESULTS

The STAR group had significantly lower mean incision length (p = 0.042) and hospital stay (p = 0.002) than the DSA group. The mean intraoperative blood loss (p = 0.085) and the need for blood transfusion (p = 0.228) were less for the STAR than the DSA group. The mean postoperative functional scores improvement was significantly higher for the STAR than the DSA group at the end of the first and third postoperative months.

CONCLUSIONS

The STAR approach offers earlier functional improvement, shorter hospital stay and less transfusion need than DSA for patients undergoing primary THA. Both approaches showed a limited complication risk and an outstanding acetabular and femoral access enabling the procedure.

Comparison of a Minimally Invasive Tissue-Sparing Posterior Superior (TSPS) Approach and the Standard Posterior Approach for Hip Replacement

Purpose

The purpose of this study is to compare the functional and clinical outcomes, blood loss, complication rate, and hospital length of stay (LOS) of total hip replacement (THR) using a minimally invasive tissue-sparing posterior superior (TSPS) approach and the standard posterior approach.

Materials and Methods

This retrospective, observational, double-centered study included 38 patients undergoing hip replacement. The patents were divided into two groups: control group (19 patients), who underwent surgery with the standard posterior approach, and treatment group (19 patients), who received the same type of implant with ceramic-on-ceramic bearing via the TSPS approach. Hemoglobin level was assessed preoperatively, on first and second postoperative days, and on discharge day. Harris hip score and Western Ontario and McMaster Universities Arthritis Index were used to measure the clinical and functional outcomes. Hospital LOS and incidence of early and late complications were assessed in both groups. Postoperative anteroposterior pelvis X-ray was performed to assess the correct positioning of implants.

Results

Better early clinical outcomes (p = 0.0155), lesser blood loss (p < 0.0001), and reduced hospital LOS (p < 0.0001) were observed in the TSPS group than in the control group. No major adverse effects occurred in both groups, and a satisfactory implant orientation was achieved in all patients.

Conclusions

The TSPS approach is a reliable minimally invasive procedure for THR as it allows an accurate orientation of the components and provides better early postoperative functional outcomes, faster recovery, significantly lower blood loss, and shorter hospital LOS than the standard posterior approach. However, further research is needed to confirm the promising results and cost-effectiveness of the TSPS approach in larger cohorts with a longer follow-up period.

Factors influencing the outcomes of minimally invasive total hip arthroplasty: a systematic review

Introduction

The present systematic review investigated possible factors which may influence the surgical outcome of minimally invasive surgery for total hip arthroplasty (MIS THA).

Methods

In January 2022, the Embase, Google Scholar, PubMed, and Scopus databases were accessed. All the clinical trials investigating the clinical outcome of MIS THA were considered.

Results

Data from 9486 procedures were collected. Older age was moderately associated with greater Visual Analogue Scale (VAS) (P = 0.02) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (P = 0.009) at last follow-up, and shorter surgical duration (P = 0.01). Greater body mass index (BMI) at baseline was moderately associated with greater cup anteversion (P = 0.0009), Oxford Hip Score (OHS) at last follow-up (P = 0.04), longer surgical duration (P = 0.04), increased leg length discrepancy (P = 0.02), and greater rate of infection (P = 0.04). Greater VAS at baseline was weakly associated with greater VAS at last follow-up (P < 0.0001), total estimated blood lost (P = 0.01), and lower value of Harris Hip Score (HHS) (P = 0.0005). Greater OHS at baseline was associated with greater post-operative VAS (P = 0.01). Greater WOMAC at baseline was associated with lower cup anteversion (P = 0.009) and greater VAS (P = 0.02). Greater HHS at baseline was associated with shorter hospitalisation (P = 0.001).

Conclusion

Older age and greater BMI may represent negative prognostic factors for MIS THA. The clinical outcome is strongly influenced by the preoperative status of patients.

Earlier functional recovery and discharge from hospital for THA patients operated on via direct superior compared to standard posterior approach: a retrospective frequency-matched case-control study

BACKGROUND

The direct superior hip approach (DSA) has been less researched than other approaches in the literature. We retrospectively compared the early postoperative and functional outcomes of patients with hip osteoarthritis undergoing total hip arthroplasty (THA) via DSA with a matched control group using a standard posterior approach (SPA).

METHODS

The DSA group comprised 100 THAs performed via DSA by a senior surgeon between January 2018 and May 2019. Patients with primary osteoarthritis and ASA score ⩽3 who were eligible for surgery were included. The DSA group was compared to a matched cohort of 100 patients operated on with a SPA in the same period by another chief surgeon. Patients were matched for age, sex, and ASA score. All patients received the same postoperative chemoprophylaxis, pain management and physiotherapy. 2 independent attending arthroplasty surgeons assessed the incision length, operative time, blood loss, hospital stay, and complications. VAS, HHS, and HOOS scores were also evaluated for a year postoperatively.

RESULTS

Mean incision length and hospital stay were significantly lower in the DSA group. DSA patients had non-significantly lower intraoperative blood loss, transfusion needs, and postoperative pain than SPA patients. Mean operation time and complication rate did not differ between groups. The DSA group demonstrated significantly greater functional scores than the SPA group at the first postoperative month. No differences in scores were recorded following the third month.

CONCLUSIONS

The DSA approach may provide earlier functional recovery and hospital discharge for THA patients compared with SPA. DSA was equivalent to SPA concerning pain and blood loss, showing minimal complication rates.

An Updated Meta-Analysis of Randomized Controlled Trials on Total Hip Arthroplasty through SuperPATH versus Conventional Approaches

The object was to conduct a systematic review and meta‐analysis of randomized controlled trials (RCTs) up to the present to draw reliable conclusions in the comparison between short‐term outcomes of total hip arthroplasty (THA) through supercapsular percutaneously assisted approach in THA (supercapsular percutaneously‐assisted total hip (SuperPATH)) versus conventional approaches (CAs). A systematic literature search was performed to identify RCTs comparing primary and secondary outcomes of THA through SuperPATH vs. CAs. Mean differences (MDs) were calculated for continuous outcomes and odds ratios (ORs) for dichotomous outcomes, using the DerSimonian and Laird method, the Mantel–Haenszel method and random effects model. A total of 14 RCTs involving 1021 patients met the inclusion criteria. Primary outcomes: SuperPATH reduced intraoperative blood loss (MD = −61.4, 95% CI −119.1 to −3.8). SuperPATH increased Harris hip score (HHS) 3, 6 and 12 months postoperatively (MD = 2.4, 95% CI 0.6–4.2; MD = 2.1, 95% CI 0.6–3.6; MD = 0.7, 95% CI 0.1–1.3; resp.). Both approaches did not differ in postoperative complication rates (OR = 0.7, 95% CI 0.2–3.3). Secondary outcomes: SuperPATH reduced pain visual analogue scale (VAS) 1 day and 3 days postoperatively (MD = −1.0, 95% CI −1.8 to −0.2; MD = −1.2, 95% CI −1.8 to −0.5; resp.). SuperPATH reduced incision length (MD = −5.2, 95% CI −7.0 to −3.4). SuperPATH increased operation time (MD = 14.3, 95% CI 3.7–24.8). Both approaches did not differ relevantly in acetabular cup inclination (MD = −1.8, 95% CI −3.8–0.2) and acetabular cup anteversion (MD = −0.6, 95% CI −1.2 to −0.1) angles. The overall findings of this meta‐analysis (Meta‐SuCAs‐2) suggested that the short‐term outcomes of THA through SuperPATH were superior to CAs. In the primary outcome, SuperPATH had a lower intraoperative blood loss and a higher HHS. Both approaches did not differ in postoperative complications. In the secondary outcome, SuperPATH had a lower pain VAS and a shorter incision length. Both approaches showed sufficient results in acetabular cup positioning. CAs had a shorter operation time than SuperPATH.

Evaluation of the Proximal Tibia as a Donor Site of Cancellous Bone for Intraoral Grafting Procedures-A Retrospective Study

Background: Autogenous bone grafts remain the “gold standard” in maxillofacial reconstructive procedures. The objective of this study was to evaluate the proximal tibia as a donor site of cancellous bone for bone grafting procedures of the mandible on the basis of intraoperative parameters and clinical observations. Methods: The study was based on a medical record search of 40 patients who underwent surgical procedures because of benign pathological lesions of the jaws resulting in 3-wall bone defects of the mandible and qualified for surgical removal of the lesion with simultaneous bone grafting of the defect with autogenous cancellous bone harvested from the proximal tibia. Results: The use of the proximal tibia for bone grafting procedures enables large amounts of cancellous bone (15.09 cc in average) to be obtained. The procedure is characterized by a low risk of early and late complications, which include excessive bleeding, wound infection, lengthy healing time, scars, a loss of sensation around the scars, aching, a dip in bone, swelling and tenderness. Conclusions: The ability to obtain large amounts of cancellous bone and a low risk of intra- and postoperative complications make the proximal tibia an attractive donor site for the bone grafting procedures in maxillofacial surgery.

Overview of Methods to Quantify Invasiveness of Surgical Approaches in Orthopedic Surgery—A Scoping Review

Background

There is a trend toward minimally invasive and more automated procedures in orthopedic surgery. An important aspect in the further development of these techniques is the quantitative assessment of the surgical approach. The aim of this scoping review is to deliver a structured overview on the currently used methods for quantitative analysis of a surgical approaches' invasiveness in orthopedic procedures. The compiled metrics presented in the herein study can serve as the basis for digitization of surgery and advanced computational methods that focus on optimizing surgical procedures.

Methods

We performed a blinded literature search in November 2020. In-vivo and ex-vivo studies that quantitatively assess the invasiveness of the surgical approach were included with a special focus on radiological methods. We excluded studies using exclusively one or multiple of the following parameters: risk of reoperation, risk of dislocation, risk of infection, risk of patient-reported nerve injury, rate of thromboembolic event, function, length of stay, blood loss, pain, operation time.

Results

The final selection included 51 articles. In the included papers, approaches to 8 different anatomical structures were investigated, the majority of which examined procedures of the hip (57%) and the spine (29%). The different modalities to measure the invasiveness were categorized into three major groups “biological” (23 papers), “radiological” (25), “measured in-situ” (14) and their use “in-vivo” or “ex-vivo” was analyzed. Additionally, we explain the basic principles of each modality and match it to the anatomical structures it has been used on.

Discussion

An ideal metric used to quantify the invasiveness of a surgical approach should be accurate, cost-effective, non-invasive, comprehensive and integratable into the clinical workflow. We find that the radiological methods best meet such criteria. However, radiological metrics can be more prone to confounders such as coexisting pathologies than in-situ measurements but are non-invasive and possible to perform in-vivo. Additionally, radiological metrics require substantial expertise and are not cost-effective. Owed to their high accuracy and low invasiveness, radiological methods are, in our opinion, the best suited for computational applications optimizing surgical procedures. The key to quantify a surgical approach's invasiveness lies in the integration of multiple metrics.

Direct anterior approach vs. SuperPATH vs. conventional approaches in total hip replacement: A network meta-analysis of randomized controlled trials

BACKGROUND

Two minimally invasive approaches showed some advantages in outcomes compared to conventional approaches (CAs) - the direct anterior approach (DAA) and the supercapsular percutaneously assisted approach in THA (SuperPATH). To the best of our knowledge, these three approaches have never been ranked in a network meta-analysis (NMA) before. Therefore, we conducted a systematic review and NMA of randomized controlled trials comparing short-term outcomes of DAA, SuperPATH and CAs in total hip joint arthroplasty (THA), using CAs as common comparator.

METHODS

A systematic literature search up to February 2021 was performed to identify randomized controlled trials (RCTs) comparing DAA with CAs and SuperPATH with CAs in THA. We measured surgical, functional and radiological outcomes. A NMA, using frequentist methods was performed to assess treatment effects between DAA, SuperPATH and CAs. Information was borrowed from the above-mentioned RCTs, using the CA group as a common comparator.

RESULTS

A total of 24 RCTs involving 2,074 patients met the inclusion criteria, six trials with a level I evidence, 18 trials with level II evidence. SuperPATH reduced operation time (fixed effects model: MD=8.1, 95% CI: 5.7 to 10.4), incision length (fixed effects model: MD=2.7, 95%CI: 2.5 to 2.9; random effects model: MD=4.1, 95%CI: 0.6 to 7.6), intraoperative blood loss (fixed effects model: MD=157, 95%CI: 139.2 to 174.2; random effects model: MD=129, 95%CI: 11.5 to 245.7) and early pain intensity (VAS 1 day postoperatively with a fixed effects model: MD=0.8, 95%CI: 0.4 to 1.2) compared to DAA. The two approaches did not differ in functional outcome and in acetabular cup inclination positioning.

CONCLUSIONS

Our overall findings suggest that short-term outcomes of THA through SuperPATH were superior to DAA and CAs and that short-term outcomes of THA through DAA were superior to CAs.

LEVEL OF EVIDENCE

II; systematic review with level I studies and level II studies.

Comparison of short-term outcomes between direct anterior approach (DAA) and SuperPATH in total hip replacement: a systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Two minimally invasive approaches showed some advantages in outcomes compared to conventional approaches (CAs)-the direct anterior approach (DAA) and the supercapsular percutaneously assisted approach in THA (SuperPATH). To the best of our knowledge, DAA and SuperPATH have never been compared, neither in clinical studies, nor in a meta-analysis. To conduct a systematic review and network meta-analysis of randomized controlled trials comparing short-term outcomes of DAA and SuperPATH in total hip joint arthroplasty (THA).

METHODS

A systematic literature search up to May 2020 was performed to identify randomized controlled trials (RCTs) comparing SuperPATH with CAs and DAA with CAs in THA. We measured surgical, functional, and radiological outcomes. A network meta-analysis, using frequentist methods, was performed to assess treatment effects between DAA and SuperPATH. Information was borrowed from the above-mentioned RCTs, using the CA group as a common comparator.

RESULTS

A total of 16 RCTs involving 1392 patients met the inclusion criteria, three trials with a level I evidence, 13 trials with a level II evidence. The overall network meta-analysis showed that SuperPATH reduced operation time (fixed effect model: MD = 12.8, 95% CI 9.9 to 15.7), incision length (fixed effect model: MD = 4.3, 95% CI 4.0 to 4.5; random effect model: MD = 4.3, 95% CI 0.2 to 8.4), intraoperative blood loss (fixed effect model: MD = 58.6, 95% CI 40.4 to 76.8), and early pain intensity (VAS 1 day postoperatively with a fixed effect model: MD = 0.8, 95% CI 0.4 to 1.2). The two approaches did not differ in acetabular cup positioning angles and in functional outcome.

CONCLUSIONS

Our overall findings suggested that the short-term outcomes of THA through SuperPATH were superior to DAA. SuperPATH showed better results in decreasing operation time, incision length, intraoperative blood loss, and early pain intensity. DAA and SuperPATH were equal in functional outcome and acetabular cup positioning.

Is two-incision approach superior to the mini-posterior approach in total hip arthroplasty?: a meta-analysis

BACKGROUND

Whether there is any clinical superiority for the two-incision total hip arthroplasty (THA) over the mini-posterior THA remains controversial. The present meta-analysis aimed to comprehensively compare the clinical outcomes between the two mini-invasive THAs.

METHODS

Two authors searched the database of Web of Science, PubMed, EMBASE and Cochrane Library to screen eligible studies individually. The quality evaluation of included studies was performed according to the principle of risk-of-bias of the Cochrane Library. The pooled results were analysed by Review Manager 5.3 software.

RESULTS

A total of seven prospective studies (including five randomized controlled trials) with 423 hips were finally included for meta-analysis. The pooled results revealed that the mini-posterior THA outperformed the two-incision THA in shortening operative times, reducing blood loss and postoperative fracture risks, while no significant difference was found between the two surgery methods with respect to HSS scoring, SF-12 scoring, postoperative function recovery and other postoperative complications.

CONCLUSION

Based on the pooled results, we suggested the mini-posterior THA as a preferable choice for patients suffering from severe advanced hip diseases.

Transosseous versus transmuscular repair of the posterior soft tissue in primary hip arthroplasty: a meta-analysis

Background

During the posterior approach, it has been shown that a significant reduction in dislocation rate can be achieved with the repair of the posterior soft tissue. However, no consensus exists about the best way to perform this repair. This review aimed to compare the transosseous with transmuscular repair of the posterior soft tissue in total hip arthroplasty (THA).

Methods

We conducted a meta-analysis to identify studies involving transosseous versus transmuscular repair of the posterior soft tissue in THA in electronic databases, including Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, CNKI, VIP, Wanfang database, up to July 2020. Finally, we identified 1417 patients (1481 hips) assessed in seven studies.

Results

Compared with transmuscular repair, transosseous repair resulted in less incidence of dislocation (P = 0.003), less blood loss during operation (P < 0.00001) and lower VAS score within 3 months (P = 0.02). There were no significant differences in terms of trochanteric fracture rate (P = 0.56), Harris hip score at 3 months (P = 0.35) and 6 months (P = 0.89), VAS score within 6 months (P = 0.53), and operation time (P = 0.70) between two groups.

Conclusion

The lower dislocation rate, less blood loss, and lower VAS scores after operation supported transosseous repair's superiority to transmuscular repair. Besides, no additional medical cost and operating time were associated with transosseous repair compared with transmuscular repair. Hence, we recommend that transosseous repair be chosen first by orthopedists when performing reconstruction of the posterior soft tissue in THA via a posterolateral approach. Given the relevant possible biases in our meta-analysis, we required more adequately powered and better-designed RCT studies with long-term follow-up to reach a firmer conclusion.

Direct anterior versus posterior approach for total hip arthroplasty: a multicentre, prospective, randomized clinical trial

BACKGROUND

The ideal approach for a total hip arthroplasty (THA) would be kind to soft tissues, have the lowest complication rates and be easily reproducible. Although there have been several attempts to find the best approach for THA in the last decade, a definitive answer has not been found. We performed a prospective study to compare the direct anterior and posterior approaches for THA in terms of hospital length of stay, functional outcome, pain, implant position, complications and surgical time.

METHODS

A prospective, randomized, multicentre clinical study was conducted between February 2011 and July 2013, with an average follow-up of 55 months. Patients undergoing the direct anterior or posterior approach for THA were enrolled. Hospital length of stay, surgical time and complications were documented. The Harris Hip Score and visual analogue scale were used to monitor functional outcome and pain until 5 years postoperatively. Radiologic analysis was used to assess implant position.

RESULTS

Fifty-five patients (28 undergoing the direct anterior approach, 27 undergoing the posterior approach) were enrolled in this study. Length of stay, functional outcome, pain, implant position and complications were similar for the 2 approaches. There was a trend toward a better functional outcome for patients who underwent the direct anterior approach in the first 3 months postoperatively, with a peak at 4 weeks (Harris Hip Score 76.7 v. 68.7; p = 0.08). Average surgical time for the direct anterior approach was significantly longer (69.9 v. 45.7 min; p = 0.002).

CONCLUSION

The direct anterior approach for THA appears to be a safe and effective option. However, there is no significant difference in hospital length of stay or postoperative recovery between the 2 approaches.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, no. NCT03673514.

Acute Deterioration of Kidney Function after Total Hip Arthroplasty

Introduction:

Post-operative acute kidney injury is a serious complication and identifying modifiable factors could assist in peri-operative management. This study aimed to identify the pre-operative and intra-operative factors associated with the incidence of post-operative acute kidney injury and acute deterioration of kidney function after total hip arthroplasty.

Materials and methods: This single-center, retrospective, observational study included 203 patients who underwent unilateral primary total hip arthroplasty. Acute kidney injury was determined using biochemical markers according to the risk, injury, failure, loss of kidney function, and end-stage kidney disease (RIFLE) criteria. Acute deterioration of kidney function was defined as the reduction of estimated glomerular filtration rate by ≥10ml/min/1.73m².

Results:

Prior to total hip arthroplasty, 20% of all patients met the chronic renal dysfunction criterion of glomerular filtration rates <60ml/min/1.73m² (glomerular filtration rate categories G3a-G5). Incidence rates of acute kidney injury and acute deterioration of kidney function after total hip arthroplasty were 0.49% and 6.9%, respectively. Multivariate regression analysis showed that diabetes mellitus and use of nonsteroidal anti-inflammatory drugs before total hip arthroplasty were significant risk factors for acute deterioration of kidney function. Advanced age, preoperative renal dysfunction, antihypertensive, diuretics, or statin use, operation time, total blood loss, type of anesthetic, and body mass index were not significant risk factors.

Conclusion:

Diabetes mellitus and use of nonsteroidal anti-inflammatory drugs were controllable risks, and multidisciplinary approaches are a reasonable means of minimising peri-operative acute kidney injury or acute deterioration of kidney function.

Comparison of short-term outcomes between SuperPATH approach and conventional approaches in hip replacement: a systematic review and meta-analysis of randomized controlled trials

Background

It remains uncertain if the new SuperPATH approach benefits patients in artificial hip joint replacement. We conducted a systematic review and meta-analysis of randomized controlled trials to compare the short-term outcome of SuperPATH approach and conventional approaches in hip joint replacement.

Methods

A systematic literature search up to April 2020 was performed to identify randomized controlled trials comparing SuperPATH with conventional approaches in hip joint replacement. We measured surgical, functional, and radiological outcomes. Mean differences or odds ratios with 95% confidence intervals were calculated and pooled using random effects models and the Hartung-Knapp-Sidik-Jonkman method.

Results

A total of 12 RCTs involving 726 patients met the inclusion criteria, one trial with a level I evidence, 11 trials with level II evidence. The overall meta-analysis showed that SuperPATH approach reduced incision length (MD = − 4.84, 95% CI − 7.04 to − 2.64, p < 0.01), pain VAS 7 day postoperatively (MD = − 1.39, 95% CI − 2.57 to − 0.21, p = 0.03), and HHS 7 day postoperatively (MD = 10.24, 95% CI 0.27 to 20.21, p = 0.05). The two approaches did not differ in acetabular cup positioning angles, intra- and postoperative blood loss, hospitalization period, and postoperative complications. Hip replacement via SuperPATH approach had a longer operation time than hip replacement via conventional approaches.

Conclusions

SuperPATH approach showed better results in decreasing incision length and early pain intensity as well as improvement of short-term functional outcome. Long-term outcomes of SuperPATH approach need to be investigated.

Direct superior approach with standard instrumentation for total hip arthroplasty: safety and efficacy in a prospective 200-case series

INTRODUCTION

Direct Superior Approach (DSA) is a muscle sparing approach for total hip arthroplasty (THA) implemented using special instrumentation. There is a lack of information in the literature concerning DSA with standard instrumentation.

MATERIALS AND METHODS

238 patients were recruited for primary THA by a single surgeon from January 2016 until May 2017. 209 patients underwent THA through DSA approach with non-offset acetabular reamers and femoral broaches. We evaluated accuracy of implantation, complications and early functional results. Independent orthopaedic surgeons performed the clinical and radiographic assessments.

RESULTS

200 patients were followed for a year. 3 different implants were used. No sciatic nerve palsies, hip dislocations or fractures were recorded. There was one acute deep and superficial wound infection. The mean functional score was significantly improved at all follow-ups (p < 0.001). 97% of stems were inserted into the neutral coronal and 96% in neutral sagittal alignment. All cups fell within a safe zone of inclination and 91% of anteversion. 2 hips demonstrated heterotopic ossification, Brooker class I. Obese patients had no increased risk of complications.

CONCLUSIONS

DSA with standard instrumentation is safe and efficacious for THA. It offers fast recovery and facilitates correct implantation of different implants, can be useful even for hip dysplasia and obese patients with minimal complication rates.

SuperPATH Minimally Invasive Approach to Total Hip Arthroplasty of Femoral Neck Fractures in the Elderly: Preliminary Clinical Results

Objective

To investigate the clinical efficacy and advantages of the SuperPATH minimally invasive approach to total hip arthroplasty in the treatment of femoral neck fractures in the elderly.

Methods

From January 2016 to September 2018, 110 cases of elderly patients with femoral neck fractures were included in the present study. According to the method of operation, the patients were divided into two groups for comparison. There were 55 cases of the SuperPATH minimally invasive approach to total hip arthroplasty and 55 cases with the conventional posterolateral approach to total hip arthroplasty. The operation time, the length of incision, the amount of operative blood loss, the hospitalization time, and the hospitalization cost were compared between the two groups. The position of total hip prosthesis was observed during the follow‐up period. All patients were evaluated for the degree of hip joint pain and the function of the hip joint using the visual analog score (VAS) and the Harris score at 1 week, 1 month, 3 months, 6 months, and 12 months after the operation.

Results

All patients were followed up for at least 12 months. The operation time was 108.58 ± 15.87 min in the SuperPATH group and 102.51 ± 19.61 min in the conventional group. The length of incision was 6.65 ± 1.53 cm in the SuperPATH group and 17.08 ± 1.40 cm in the conventional group. The amount of operative blood loss was 147.51 ± 28.84 mL in the SuperPATH group and 170.22 ± 25.34 mL in the conventional group. The hospitalization time was 10.05 ± 2.52 days in the SuperPATH group and 13.36 ± 3.39 days in the conventional group. The hospitalization cost was 6871.78 ± 141.63 dollars in the SuperPATH group and 7791.09 ± 184.88 dollars in the conventional group. Compared with the conventional group, the SuperPATH group had shorter incision length, less blood loss, shorter hospitalization time, and lower hospitalization cost. There was significant difference between the two groups (P < 0.05). In the two groups, there were no complications such as infection, lower extremity venous thrombosis, prosthesis loosening, periprosthetic fracture, and dislocation during the follow‐up period. The VAS score was 4.45 ± 0.94 in the SuperPATH group and 4.89 ± 0.79 in the conventional group at 1 week after the operation. There was significant difference between the two groups (P < 0.05). The Harris score was 75.36 ± 3.36 and 80.25 ± 3.09 in the SuperPATH group and 68.80 ± 3.25 and 77.35 ± 3.77 in the conventional group at 1 week and 1 month after the operation, respectively. There was significant difference between the two groups (P < 0.05). In the analysis of the operation time, the VAS score at 1 month, 3 months, 6 months, and 12 months after the operation, and the Harris score at 3 months, 6 months, and 12 months after surgery, there was no significant difference between the two groups (P > 0.05).

Conclusion

The SuperPATH minimally invasive approach to total hip arthroplasty is an ideal method for the treatment of femoral neck fractures in the elderly. This method has the advantages of the relatively simple operation, short incision, less blood loss, and less trauma. The patients had short hospitalization times, low hospitalization costs, and good recovery of hip joint function.

Relationship Between Functional Anatomy of the Hip and Surgical Approaches in Total Hip Arthroplasty

Multiple surgical approaches have been used successfully for total hip arthroplasty. Minimally invasive surgery, defined by the length of the incision, has been associated with less blood loss and shorter length of stay compared with conventional total hip arthroplasty. Differences in early functional outcomes, as well as the risk of early and long-term complications, have been observed between different anatomic surgical approaches. However, no single surgical approach has been established that achieves both the shortest functional recovery and the lowest rate of complications after total hip arthroplasty. [Orthopedics. 2019; 42(4):e356-e363.].

Incidence and treatment of abductor deficiency during total hip arthroplasty using the posterior approach: repair with direct suture technique and gluteus maximus flap transfer

AIMS

The aims of this study were to assess the exposure and preservation of the abductor mechanism during primary total hip arthroplasty (THA) using the posterior approach, and to evaluate gluteus maximus transfer to restore abductor function of chronically avulsed gluteus medius and minimus.

PATIENTS AND METHODS

A total of 519 patients (525 hips) underwent primary THA using the posterior approach, between 2009 and 2013. The patients were reviewed preoperatively and at two and five years postoperatively. Three patients had mild acute laceration of the gluteus medius caused by retraction. A total of 54 patients had mild chronic damage to the tendon (not caused by exposure), which was repaired with sutures through drill holes in the greater trochanter. A total of 41 patients had severe damage with major avulsion of the gluteus medius and minimus muscles, which was repaired with sutures through bone and a gluteus maximus flap transfer to the greater trochanter.

RESULTS

Abductor strength was maintained in the normal hips, but lateral hip pain progressed significantly, five years postoperatively (p < 0.0001). In the 54 patients with mild abductor tendon damage treated with simple repair, lateral hip pain also increased significantly during follow-up (p = 0.002). In the 35 patients with severe avulsion but good muscle repaired using a gluteus maximus flap transfer, abductor function was restored. The six patients with complete avulsion and poor muscle did not regain strong abductor power, but lateral hip pain decreased.

CONCLUSION

The posterior approach offered excellent exposure and preservation of the abductor mechanism during primary THA. Augmentation of the repair with a gluteus maximus flap provided stable reconstruction of the abductor muscles and seemed to restore function in the hips with functioning muscles. Cite this article: Bone Joint J 2019;101-B(6 Supple B):116-122.

Short stems in total hip replacement: evidence on primary stability according to the stem type

BACKGROUND:

As the prevalence of total hip replacement is increasing in younger patients, less invasive implants (short stems) are becoming more favourable. However, despite the advantages of these stems, clinical results with a follow-up of more than 10 years are limited to a very few stem designs. There has been an increase in publications recently - mechanical and clinical studies - concerning the primary stability of short stems. Primary stem stability is an important factor as it reflects final stem stabilisation and is related to the clinical results of the prosthesis.

METHOD:

We conducted a systematic review of the literature to retrieve evidence concerning primary implant stability in short stems - as expressed by implant micromotion and stem subsidence - according to our previously proposed short-stem classification.

RESULTS:

Mechanical in vitro studies on stem micromotion are very few and limited to type 2 "partial collum" short stems. The results are comparable to those of stems with a known long-term excellent clinical course. Clinical results concerning stem migration patterns are also limited to some of the commercially available short stems. Although comparative studies are very few, the results for most of the short stems are similar to those of standard stems.

CONCLUSION:

There are promising results concerning biomechanical studies of the initial micromotion of short stems, as well as clinical results of stem migration patterns. Long-term clinical studies are needed in order to confirm these findings. The existing literature concerns very few of the many commercially available implants.

Piriformis-Sparing Minimally Invasive Versus the Standard Posterior Approach for Total Hip Arthroplasty: A 10-Year Follow-Up of a Randomized Control Trial

BACKGROUND

Despite the popularity of minimally invasive approaches in total hip arthroplasty, studies regarding their impact on soft tissues and long-term benefits are lacking. This study aims to compare the 10-year functional outcome of the piriformis-sparing minimally invasive approach to the standard posterior approach for total hip arthroplasty surgery.

METHODS

Hundred patients were randomized, 48 patients to the piriformis-sparing approach and 52 to the standard approach. Primary outcomes were hip function and piriformis muscle volume and grade on magnetic resonance imaging. Secondary outcomes were pain, satisfaction score, and complications. Evaluators were blinded to allocation. Participants were followed up to 10 years.

RESULTS

Ten years following surgery, both groups reported excellent pain relief, improved hip function, and high satisfaction. The significant differences were improvement in piriformis muscle volume (P = .001) and muscle grade (P = .007) in the piriformis-sparing group compared to the standard group. There were no significant differences in all other outcomes.

CONCLUSION

Aside from being less injurious to the piriformis muscle, the piriformis-sparing approach offered the same long-term functional benefits as the standard posterior approach at 10 years.

Quality assessment of systematic reviews on total hip or knee arthroplasty using mod-AMSTAR

Background

Increasing numbers of systematic reviews (SRs) on total knee arthroplasty (TKA) and total hip arthroplasty (THA) have been published in recent years, but their quality has been unclear. The purpose of this study is to evaluate the methodological quality of SRs on TKA and THA.

Methods

We searched Ovid-Medline, Ovid-Embase, Cochrane Databases (including HTA, DARE, and CDSR), CBM, CNKI, Wang Fang, and VIP, from January 2014 to December 2015 for THA and TKA. The quality of SRs was assessed using the modified 25-item “Assessment of Multiple Systematic Reviews” (mod-AMSTAR) tool, which was based on the AMSTAR scale. A T-test, nonparametric test, and linear regression were conducted to assess the relationship between bibliographical characteristics and methodological quality.

Results

Sixty-three SRs were included, from which the majority of SRs (50, 79.4%) were conducted in Asia. Only 4 reviews were rated as high quality, and most were weak in providing a priori design (6, 9.5%), not limiting the publication type (8, 13%), providing an excluded primary studies list (4, 6.3%) and reporting support for the included primary studies (1, 1.6%). Reviews published in English journals performed better than did Chinese journals in duplicate data extraction (81.3% vs 46.7%, p = 0.017; 70.8% vs 33.3%, p = 0.009) and providing source of support for the SR (87.5% vs 33.3%, P < 0.001). Reviews published in journals with a higher impact factor were associated with a higher mod-AMSTAR score (regression coefficient: 0.38, 95%CI: 0.11–0.65; P = 0.006).

Conclusion

The methodological quality of the included SRs is far from satisfactory. Authors of SRs should conform to the recommendations outlined in the mod-AMSTAR items. Areas needing improvement were providing a priori design, not limiting the publication type, providing an excluded primary studies list, and reporting conflicts of interest.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0488-8) contains supplementary material, which is available to authorized users.

Interventions for treating displaced intracapsular femoral neck fractures in the elderly: a Bayesian network meta-analysis of randomized controlled trials

Displaced intracapsular femoral neck (AO type 31 B2/3) fractures have various treatments, including internal fixation (IF), unipolar uncemented hemiarthroplasty (HA), bipolar uncemented HA, unipolar cemented HA, bipolar cemented HA, uncemented total hip replacement (THR), and cemented THR. Systematic literature retrieval was performed from the databases to compare them in a network meta-analysis. Forty studies (85 arms) containing 6141 patients were included. Overall, our network meta-analysis rank the orders of 7 procedures in reoperation, mortality, dislocation and infection, which indicates that IF may provide the highest reoperation incidence, unipolar cemented HA may provide the lowest reoperation incidence; uncemented THR contributes the highest dislocation incidence; and bipolar uncemented HA provides the lowest infection incidence. No differences in mortality were observed among the treatments. This conclusion is indirect; higher-quality direct comparisons are required.

Randomized Clinical Trial of 2-Incision vs Mini-Posterior Total Hip Arthroplasty: Differences Persist at 10 Years

BACKGROUND

A previous randomized clinical trial at our institution demonstrated slower recovery of 35 2-incision total hip arthroplasties (THAs) when compared with 36 mini-posterior THAs at 2 years. The primary aim of the present study was to report concise 10-year follow-up results.

METHODS

We retrospectively reviewed the 71 patients in the previous randomized clinical trial, comparing clinical outcomes, revisions, reoperations, and implant survivorship between the 2-incision and the mini-posterior THAs.

RESULTS

At the most recent follow-up, the mean Harris hip score was 85 in the 2-incision group and 87 in the mini-posterior group (P = .4). There were 4 revisions and 2 reoperations (16%) in the 2-incision group vs 1 revision and 3 reoperations (11%) in the mini-posterior group (P = .5). Ten-year survivorship free of aseptic revision or reoperation was 77% in the 2-incision group vs 90% in the mini-posterior group (P = .15).

CONCLUSION

There were no improvements in early or midterm clinical outcomes with the 2-incision technique. However, there was a clinical trend toward a higher rate of aseptic revisions in the 2-incision THA group.

The SPAIRE technique allows sparing of the piriformis and obturator internus in a modified posterior approach to the hip

INTRODUCTION

The Sparing Piriformis and Internus, Repair Externus (SPAIRE) technique allows a muscle sparing mini-posterior approach to the hip.

METHOD

We present in this article a description of an adaptation of the familiar posterior approach (PA) in which the only tendon released is obturator externus. Termed SPAIRE, this muscle sparing technique enables preservation of the piriformis tendon and conjoint insertion of obturator internus and the gemelli. The technical description allows for safe and reliable replication by any surgeon familiar with the posterior approach (PA) to the hip without reliance on additional equipment, and without compromising the ability to convert into a more extensile approach.

CONCLUSIONS

This technical description and brief discussion of rationale outlines the ongoing work of the authors in developing the SPAIRE technique as part of the spectrum of the posterior approach to the hip. The senior author now uses this technique routinely for total hip replacements and hemiarthroplasty. Patients are mobilised with no postoperative restrictions whatsoever. Other potential advantages include improved gait, more anatomical restoration of hip function, and enhanced stability. Projects have been initiated in our unit to objectively assess the possible clinical advantages relating to use of the SPAIRE technique using gait analysis, objective measurement of muscle power and studies of hip stability.

Efficacy of Hybrid Plasma Scalpel in Reducing Blood Loss and Transfusions in Direct Anterior Total Hip Arthroplasty

BACKGROUND

Allogeneic blood transfusions have inherent risk and direct cost in total hip arthroplasty. Anterior total hip arthroplasty has grown in popularity with increased utilization. This approach may offer an enhanced recovery but has been associated with increased blood loss. Several technologies have been developed including the Canady Hybrid Plasma Scalpel (CHPS) and Aquamantys Bipolar Sealer (BS) to decrease blood loss.

METHODS

Two hundred forty-four consecutive patients undergoing anterior supine intermuscular total hip arthroplasty were separated by intraoperative cautery device (CHPS vs BS). Exclusion criteria included blood dyscrasias and contraindication to tranexamic acid. Demographic data, blood loss, transfusion requirements, and Harris Hip Scores were obtained. Differences between groups were evaluated using the Student t-test or Wilcoxon rank-sum test for continuous variables and chi-square test for categorical variables.

RESULTS

There were no differences in demographic data between the groups. Patients in the CHPS group had a significantly smaller decrease in postoperative hemoglobin (-2.3 mg/dL vs -2.7 mg/dL, P < .05), estimated blood loss (240.3 mL vs 384.4 mL, P < .001), and calculated actual blood loss (1.11 L vs 2.47 L, P < .001). There were 12 transfusions in the BS group and none in CHPS group (P < .001).

CONCLUSION

The use of the hybrid plasma scalpel resulted in significantly less blood loss and transfusions than the BS. Additionally, patients treated with the hybrid plasma scalpel had significantly shorter operative times and reduced hospital length of stay. The hybrid scalpel shows promise in reducing blood loss in anterior total hip arthroplasty and is a valuable tool in the multimodal approach to avoiding transfusions.

The result of transmuscular versus transosseous repair of the posterior capsule on early dislocations in primary hip arthroplasty

PURPOSE

Dislocation is a concerning complication of the posterolateral approach for total hip arthroplasty (THA). Use of a larger size femoral head and a correct repair of the posterior structures can reduce the risk on dislocation of the hip prosthesis. In this study we investigated if there was a difference in dislocation rate between transmuscular and transosseous repair of the posterior soft tissues with use of 36 mm heads.

METHODS

A power analysis showed that with a standardised effect size of 0.3 and p-value of 0.05, each group should include at least 174 patients. A total of 465 consecutive primary THAs with a posterolateral approach were performed in patients with primary osteoarthritis by 3 orthopaedic surgeons. There were 246 patients operated using transmuscular repair, the other 219 by using transosseous repair. All patients were given the same prostheses.

RESULTS

Dislocation rate was 1.7% in all patients with at least 1 year follow-up. No significant difference was found in dislocation between both reconstruction techniques. Clinical outcome scores were comparable between the groups.

CONCLUSIONS

Transosseous and transmuscular repair were equally effective techniques in closing the posterior soft tissues after THA through the posterolateral approach, without difference in dislocation rate or complication rate.

The effect of a low radiation CT protocol on accuracy of CT guided implant migration measurement: A cadaver study

The current study compared the impact of low radiation CT protocols on the accuracy, repeatability, and inter- and intra-observer variability of implant migration studies in total hip arthroplasty. Two total hip replacements were performed in two human cadavers and six tantalum beads were inserted into the femur similar to radiostereometric analysis. Six different 28 mm heads (-3 mm, 0 mm, 2.5 mm, 5.0 mm, 7.5 mm, and 10 mm) were added to simulate five reproducible translations (maximum total point migration) of the center of the head. Three CT scans with varying levels of radiation were performed for each head position. The effective dose (mSv) was 3.8 mSv for Protocol A (standard protocol), 0.7 mSv for Protocol B and 1.6 mSv for Protocol C. Implant migration was measured in a 3-D analysis software (Geomagic Studio 7). The accuracy was 0.16 mm for CT Protocol A, 0.13 mm for Protocol B and 0.14 mm for Protocol C; The repeatability was 0.22 mm for CT Protocol A, 0.18 mm for Protocol B and 0.20 mm for Protocol C; ICC for inter observer reliability was 0.89, intra observer reliability was 0.95. The difference in accuracy between standard protocol A and the two low radiation protocols (B, C) was less than 0.05 mm. The accuracy, inter- and intra-observer reliability of all three CT protocols is comparable to radiostereometric analysis. Reducing the CT radiation exposure to numbers similar to an AP Pelvis radiograph (0.7 mSv protocol B) does not affect the accuracy of implant migration measurements.

Posterior Mini-Incision With Primary Total Hip Arthroplasty: A Nine to Ten Year Follow Up Study

The question has been raised as to whether small incision surgery will compromise long term results of total hip arthroplasty. We report nine to ten years' outcome with posterior mini-incision. Radiographs were measured for component position, polyethylene wear, fixation, and osteolysis. Sixty-two of the original 86 patients (76 of 100 hips) were alive and available for study with 17 patients deceased (with known results) and seven (8%) lost to follow-up. The result was rated as excellent in 70 of 75 remaining hips (93%). Eighty-nine of 93 hips (96%) with known results had the original implants. Radiographically, wear was a mean 0.015 ± 0.009 mm/year, and no hip had impending failure. There were four revisions, 2 for dislocation, 1 for fracture, and 1 for loose cup.

Posterior mini-incision total hip arthroplasty controls the extent of post-operative formation of heterotopic ossification

Heterotopic ossification (HO) is the formation of bone at extra-skeletal sites. Reported rates of HO after hip arthroplasty range from 8 to 90 %; however, it is only severe cases that cause problems clinically, such as joint stiffness. The effects of surgical-related controllable intra-operative risk factors for the formation of HO were investigated. Data examined included gender, age of patient, fat depth, length of operation, incision length, prosthetic fixation method, the use of pulsed lavage and canal brush, and component size and material. All cases were performed by the same surgeon using the posterior approach. A total of 510 cases of hip arthroplasty were included, with an overall rate of HO of 10.2 %. Longer-lasting operations resulted in higher grades of HO (p = 0.047). Incisions >10 cm resulted in more widespread HO formation (p = 0.021). No further correlations were seen between HO formation and fat depth, blood loss, instrumentation, fixation methods or prosthesis material. The mini-incision approach is comparable to the standard approach in the aetiology of HO formation, and whilst the rate of HO may not be controllable, a posterior mini-incision approach can limit its extent.