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Chen M, Kayani B, Masri BA. CORR® Synthesis: To What Degree Does the Direct Anterior Approach Improve Outcomes in THA? A Systematic Evaluation of Meta-analyses. Clin Orthop Relat Res 2024:00003086-990000000-01749. [PMID: 39330942 DOI: 10.1097/corr.0000000000003195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 06/28/2024] [Indexed: 09/28/2024]
Affiliation(s)
- Maio Chen
- AO Foundation Innovation Translation Center, Davos, Switzerland
| | - Babar Kayani
- University College Hospital, London, England, UK
- University of British Columbia, Vancouver, BC, Canada
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Hoseth JM, Husby OS, Lian ØB, Myklebust TÅ, Aae TF. Less inflammatory response in the direct anterior than in the direct lateral approach in patients with femoral neck fractures receiving a total hip arthroplasty: exploratory results from a randomized controlled trial. Acta Orthop 2024; 95:440-445. [PMID: 39145606 PMCID: PMC11325853 DOI: 10.2340/17453674.2024.41242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 07/04/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND AND PURPOSE It is still debatable which is the least invasive approach to the hip joint in arthroplasty for a femoral neck fracture (FNF). We compared the traditional direct lateral approach (DLA) with the direct anterior approach (DAA) regarding creatine kinase (CK), C-reactive protein (CRP), and hemoglobin (Hb). METHODS In a randomized controlled trial, 130 elderly patients with dislocated FNFs treated with total hip arthroplasty (THA) were included. CK, CRP, and Hb were measured preoperatively and on postoperative days 1 to 4 and were compared between the DAA and DLA groups using repeated measures mixed-effect models. RESULTS The CK level was significantly higher on the 1st postoperative day in the DLA group, 597 U/L (95% confidence interval [CI] 529-666) vs 461 U/L (CI 389-532), estimated mean difference (MD) 136 U/L (CI 38-235). The CRP levels were significantly higher on postoperative days 3 and 4 in the DLA group, 207 mg/L (CI 189-226) vs 161 mg/L (CI 143-180), estimated MD 46 mg/L (CI 19-72) and 162 mg/L (CI 144-181) vs 121 (CI 102-140), estimated MD 41 mg/L (CI 15-68). Blood loss, expressed as difference in Hb, did not differ between the groups. CONCLUSION In an elderly population with FNFs, we found that the DAA, compared with the DLA, results in less CK and CRP increase, but no change in Hb.
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Affiliation(s)
- John Magne Hoseth
- Department of Orthopaedic Surgery, Health Møre and Romsdal HF, Kristiansund Hospital, Kristiansund; Faculty of Medicine and Health Sciences, NTNU, Trondheim
| | - Otto Schnell Husby
- Department of Orthopaedic Surgery, Health Møre and Romsdal HF, Kristiansund Hospital, Kristiansund; Department of Neuromedicine and Movement Science, NTNU, Trondheim
| | - Øystein Bjerkestrand Lian
- Department of Orthopaedic Surgery, Health Møre and Romsdal HF, Kristiansund Hospital, Kristiansund; Department of Neuromedicine and Movement Science, NTNU, Trondheim
| | - Tor Åge Myklebust
- The Clinical Research Unit, Health Møre and Romsdal HF, Ålesund; The Cancer Registry of Norway, Oslo, Norway
| | - Tommy Frøseth Aae
- Department of Orthopaedic Surgery, Health Møre and Romsdal HF, Kristiansund Hospital, Kristiansund; Department of Neuromedicine and Movement Science, NTNU, Trondheim; The Clinical Research Unit, Health Møre and Romsdal HF, Ålesund
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Wang H, Liu JF, Wang F, Yuan T, Jiang H, Wei Z, Zhang Y, Meng J. A comparison of the clinical efficacy of total hip arthroplasty via direct anterior approach and posterior approach: A meta-analysis. Medicine (Baltimore) 2024; 103:e39237. [PMID: 39121305 PMCID: PMC11315513 DOI: 10.1097/md.0000000000039237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 07/18/2024] [Indexed: 08/11/2024] Open
Abstract
BACKGROUND The approach of total hip arthroplasty (THA) has long been controversial, and many studies have compared different approaches. However, there is still a lack of consistent conclusions and comprehensive, systematic comparisons and evaluations. METHODS This study retrieved 7 databases: PubMed, Web of Science, Embase, Cochrane Library, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, and Wanfang Database. The search time ranged from the establishment of each database to November 1, 2023. Data analysis was performed using Review Manager 5.4, and outcome was presented as the weighed mean difference for continuous data and risk/odds ratio for dichotomous data. We used the Mantel-Haneszel method and random effects model to obtain the overall effects of the differences in the impact of 2 surgical methods on clinical outcomes in all included studies. RESULTS A total of 33 articles were included in this study, including 14478 participants, 4911 participants in DAA group and 9567 participants in PA group. The visual analogue scale scores of the DAA group at 1 day and 2 days after THA were significantly lower than those of the PA group (mean difference [MD] = -0.56, 95% confidence interval [CI]: -0.83 to -0.30, P < .01) at 1 day and (MD = -0.67, 95% CI: -1.16 to -0.17, P = .01) at 2 days. The risk of intraoperative fracture (odds ratio = 2.18, 95% CI: 1.11-4.29, P = .05) and lateral femoral nerve injury (risk ratio = 7.84, 95% CI: 1.69-36.42, P < .01) in the DAA group was significantly higher than that of the PA group. The number of prostheses in the Lewinnek safe zone of the DAA group was significantly higher than that of the PA group (risk ratio = 1.13, 95% CI: 1.00-1.27, P = .05). The results showed no significant difference between the DAA group and the PA group in the time to stop using walking aids, dislocation rate, groin pain, incision complications, heterotopic ossification, intraoperative blood loss, and acetabular anterior (P > .05). CONCLUSION Compared with the PA group, patients in the DAA group showed more ideal anatomical and imaging results, shorter hospital stay, and showing advantages in postoperative pain, but with a higher incidence of intraoperative complications.
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Affiliation(s)
- Hao Wang
- Xiangya School of Medicine, Central South University, Changsha, China
| | - Jin-Feng Liu
- Department of Oncology, Rizhao Hospital of Traditional Chinese Medicine, Rizhao, China
| | | | - Tiange Yuan
- Xiangya School of Medicine, Central South University, Changsha, China
| | - Hengduo Jiang
- Xiangya School of Medicine, Central South University, Changsha, China
| | - Zhuoqi Wei
- Xiangya School of Medicine, Central South University, Changsha, China
| | - Yang Zhang
- Xinjiang Medical University, Urumqi, China
| | - Jiahao Meng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
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Ramadanov N, Voss M, Hable R, Prill R, Hakam HT, Salzmann M, Dimitrov D, Diquattro E, Ostojic M, Królikowska A, Becker R. Indirect comparisons of traction table versus standard table in total hip arthroplasty through direct anterior approach: a systematic review and frequentist network meta-analysis. J Orthop Surg Res 2024; 19:384. [PMID: 38951886 PMCID: PMC11218227 DOI: 10.1186/s13018-024-04852-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/13/2024] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND It remains unclear whether the use of an orthopaedic traction table (TT) in direct anterior approach (DAA) total hip arthroplasty (THA) results in better outcomes. The aim of this systematic review and network meta-analysis was to compare the THA outcomes through DAA on a standard operating table and the THA outcomes through DAA on a TT. METHODS PubMed, Epistemonikos, and Google Scholar were searched for relevant randomized controlled trials (RCTs) up to 01 January 2024. An indirect comparison in network meta-analysis was performed to assess treatment effects between DAA on a TT and DAA on a standard table, using fixed-effects and random-effects models estimated with frequentist approach and consistency assumption. Standardized mean differences (SMDs) with 95% confidence intervals (CIs) were estimated for continuous variables and odds ratios (ORs) with 95% CIs were estimated for binary variables. RESULTS The systematic review of the literature identified 43 RCTs with a total of 2,258 patients. DAA with TT had a 102.3 mL higher intraoperative blood loss and a 0.6 mmol/L lower Hb 3 days postoperatively compared with DAA without TT (SMD = 102.33, 95% CI 47.62 to 157.04; SMD = - 0.60, 95% CI - 1.19 to - 0.00). DAA with TT had a 0.15 lower periprosthetic fracture OR compared with DAA without TT (OR 0.15, 95% CI 0.03 to 0.86). There were no further significant differences in surgical, radiological, functional outcomes and in complication rates. CONCLUSION Based on our findings and taking into account the limitations, we recommend that particular attention be paid to the risk of periprosthetic fracture in DAA on a standard operating table and blood loss in DAA with TT. Since numerous other surgical, radiological, functional outcome parameters and other complication rates studied showed no significant difference between DAA on a standard operating table and DAA with TT, no recommendation for a change in surgical technique seems justified. LEVEL OF EVIDENCE Level I evidence, because this is a systematic review and meta-analysis of randomized controlled trials.
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Affiliation(s)
- Nikolai Ramadanov
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg/Havel, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany.
- Faculty of Health Science Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany.
| | - Maximilian Voss
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg/Havel, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
| | - Robert Hable
- Faculty of Applied Computer Science, Deggendorf Institute of Technology, Deggendorf, Germany
| | - Robert Prill
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg/Havel, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
- Faculty of Health Science Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
| | - Hassan Tarek Hakam
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg/Havel, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
- Faculty of Health Science Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
| | - Mikhail Salzmann
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg/Havel, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
| | - Dobromir Dimitrov
- Department of Surgical Diseases, Faculty of Medicine, Medical University of Pleven, Pleven, Bulgaria
| | - Emanuele Diquattro
- Orthopaedics,Traumatology and Prosthetic Surgery and Revisions of Hip and Knee Implants, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Marko Ostojic
- Department of Orthopaedics and Traumatology, University Hospital Mostar, Mostar, Bosnia and Herzegovina
| | - Aleksandra Królikowska
- Ergonomics and Biomedical Monitoring Laboratory, Wroclaw Medical University, Wrocław, Poland
| | - Roland Becker
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg/Havel, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
- Faculty of Health Science Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
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Rohe S, Böhle S, Matziolis G, Layher F, Brodt S. Elastic Compression Dressing after Total Hip Replacement Slightly Reduces Leg Swelling: A Randomized Controlled Trial. J Clin Med 2024; 13:2207. [PMID: 38673482 PMCID: PMC11050482 DOI: 10.3390/jcm13082207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 04/01/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Even minor adverse reactions after total hip replacement (THR), including lymphedema, postoperative leg swelling, and blood loss, compromise patient comfort in times of minimally invasive fast-track surgery. Compression dressings are commonly used in surgical practice to reduce swelling or blood loss. However, the use of spica hip compression dressings after primary THR is controversial, and prospective studies are lacking. Methods: We conducted a prospective, single-center, two-arm, randomized controlled trial (RCT) of patients undergoing THR for primary osteoarthritis. A total of 324 patients were enrolled; 18 patients were excluded, and 306 patients were finally analyzed. Leg swelling as primary endpoint was measured pre- and postoperatively with a rotating 3D infrared body scanner. Secondary endpoints were transfusion rate and blood loss, estimated by Nadler and Gross formulas. Results: Postoperative leg swelling was lower in the compression group (241 ± 234 mL vs. 307 ± 287 mL; p = 0.01), even after adjustment for surgery time and Body-Mass-Index (BMI) (p = 0.04). Estimated blood loss was also lower in the compression group on the first (428 ± 188 mL vs. 462 ± 178 mL; p = 0.05) and third (556 ± 247 mL vs. 607 ± 251 mL; p = 0.04) postoperative days and leveled off on the fifth postoperative day, but lost significance after adjustment for BMI and surgery time. Neither group received a transfusion. Conclusions: Compression dressing after THR in the context of minimally invasive surgery slightly reduces leg swelling, but has no effect on blood loss or blood transfusion rate. So, this method could not generally be recommended in primary hip replacement.
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Affiliation(s)
- Sebastian Rohe
- Orthopedic Department of the Waldkliniken Eisenberg, Professorship of the University Hospital Jena, 07607 Eisenberg, Germany; (S.B.); (G.M.); (F.L.); (S.B.)
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Yang W, Gao T, Liu X, Shen K, Lin F, Weng Y, Lin B, Liang D, Feng E, Zhang Y. Clinical application of artificial intelligence-assisted three-dimensional planning in direct anterior approach hip arthroplasty. INTERNATIONAL ORTHOPAEDICS 2024; 48:773-783. [PMID: 37964157 PMCID: PMC10902092 DOI: 10.1007/s00264-023-06029-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 10/24/2023] [Indexed: 11/16/2023]
Abstract
PURPOSE The objective of this study was to investigate the efficacy of an artificial intelligence-assisted 3D planning system (AIHIP) in total hip arthroplasty by direct anterior approach and assess the reliability of the AIHIP preoperative program in terms of both interobserver and intraobserver agreement. METHODS A retrospective analysis was conducted on patients who underwent unilateral primary THA via direct anterior approach from June 2019 to March 2022. Participants were randomly assigned to receive either the AIHIP system (n = 220) or the 2D template (control group) (n = 220) for preoperative planning. The primary outcome aimed to evaluate the correspondence between the prosthesis selected intro-operation and the one planned preoperatively, as well as to calculate the intraclass correlation coefficient (ICC). Secondary outcomes included operation time, intraoperative blood loss, fluoroscopy times, Harris hip score (HHS), lower limb length difference (LLD), femoral offset (FO), and bilateral femoral offset difference. RESULTS No significant differences were observed in gender, age, body mass index (BMI), aetiology, and American Society of Anesthesiologists (ASA) score between the two groups. Both planning methods exhibited good intraobserver agreement for component planning (ICC: 0.941-0.976). Interobserver agreement for component planning was comparable between the two methods (ICC: 0.882-0.929). In the AIHIP group, the accuracy of acetabular cup and femoral stem prosthetics planning significantly improved, with accuracies within the size range of ± 0 and ± 1 being 76.8% and 90.5% and 79.5% and 95.5%, respectively. All differences between two groups were statistically significant (p < 0.05). Patients receiving AIHIP preoperative planning experienced shorter operation times, reduced intraoperative blood loss, fewer fluoroscopy times, and lower leg length discrepancy (LLD) (p < 0.05). Moreover, they demonstrated a higher Harris hip score (HHS) at three days post-surgery (p < 0.05). However, no significant differences were found in femoral offset (FO), difference of bilateral femoral offsets, and HHS at 1 month after the operation. CONCLUSION Utilizing AIHIP for preoperative planning of direct anterior approach THA can significantly enhance the accuracy of prosthetic sizing with good reliability, decrease operation time, reduce intraoperative blood loss, and more effectively restore the length of both lower limbs. This approach has greater clinical application value.
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Affiliation(s)
- Weihua Yang
- Department of Arthrosis Surgery, Fuzhou Second Hospital, Fuzhou, China
| | - Tianyi Gao
- Longwood Valley MedTech, No.2 Ronghua South Road, Daxing District, Beijing, China
| | - Xingyu Liu
- Longwood Valley MedTech, No.2 Ronghua South Road, Daxing District, Beijing, China
| | - Kaiwei Shen
- Department of Arthrosis Surgery, Fuzhou Second Hospital, Fuzhou, China
| | - Feitai Lin
- Department of Arthrosis Surgery, Fuzhou Second Hospital, Fuzhou, China
| | - Yan Weng
- Department of Arthrosis Surgery, Fuzhou Second Hospital, Fuzhou, China
| | - Bei Lin
- Department of Arthrosis Surgery, Fuzhou Second Hospital, Fuzhou, China
| | - Deng Liang
- Department of Arthrosis Surgery, Fuzhou Second Hospital, Fuzhou, China
| | - Eryou Feng
- Department of Arthrosis Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Gulou District, Fuzhou, China.
| | - Yiling Zhang
- Longwood Valley MedTech, No.2 Ronghua South Road, Daxing District, Beijing, China.
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Nitiwarangkul L, Hongku N, Pattanaprateep O, Rattanasiri S, Woratanarat P, Thakkinstian A. Which approach of total hip arthroplasty is the best efficacy and least complication? World J Orthop 2024; 15:73-93. [PMID: 38293261 PMCID: PMC10824060 DOI: 10.5312/wjo.v15.i1.73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/20/2023] [Accepted: 12/29/2023] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND Total hip arthroplasty is as an effective intervention to relieve pain and improve hip function. Approaches of the hip have been exhaustively explored about pros and cons. The efficacy and the complications of hip approaches remains inconclusive. This study conducted an umbrella review to systematically appraise previous meta-analysis (MAs) including conventional posterior approach (PA), and minimally invasive surgeries as the lateral approach (LA), direct anterior approach (DAA), 2-incisions method, mini-lateral approach and the newest technique direct superior approach (DSA) or supercapsular percutaneously-assisted total hip (SuperPath). AIM To compare the efficacy and complications of hip approaches that have been published in all MAs and randomized controlled trials (RCTs). METHODS MAs were identified from MEDLINE and Scopus from inception until 2023. RCTs were then updated from the latest MA to September 2023. This study included studies which compared hip approaches and reported at least one outcome such as Harris Hip Score (HHS), dislocation, intra-operative fracture, wound complication, nerve injury, operative time, operative blood loss, length of hospital stay, incision length and VAS pain. Data were independently selected, extracted and assessed by two reviewers. Network MA and cluster rank and surface under the cumulative ranking curve (SUCRA) were estimated for treatment efficacy and safety. RESULTS Finally, twenty-eight MAs (40 RCTs), and 13 RCTs were retrieved. In total 47 RCTs were included for reanalysis. The results of corrected covered area showed high degree (13.80%). Among 47 RCTs, most of the studies were low risk of bias in part of random process and outcome reporting, while other domains were medium to high risk of bias. DAA significantly provided higher HHS at three months than PA [pooled unstandardized mean difference (USMD): 3.49, 95% confidence interval (CI): 0.98, 6.00 with SUCRA: 85.9], followed by DSA/SuperPath (USMD: 1.57, 95%CI: -1.55, 4.69 with SUCRA: 57.6). All approaches had indifferent dislocation and intraoperative fracture rates. SUCRA comparing early functional outcome and composite complications (dislocation, intra-operative fracture, wound complication, and nerve injury) found DAA was the best approach followed by DSA/SuperPath. CONCLUSION DSA/SuperPath had better earlier functional outcome than PA, but still could not overcome the result of DAA. This technique might be the other preferred option with acceptable complications.
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Affiliation(s)
- Lertkong Nitiwarangkul
- Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
- Orthopaedics Surgery, Police General Hospital, Bangkok 10330, Thailand
| | - Natthapong Hongku
- Department of Orthopaedics, Faculty of Medicine Vajira Hospital, Navamindrahiraj University, Bangkok 10300, Thailand
| | - Oraluck Pattanaprateep
- Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Sasivimol Rattanasiri
- Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Patarawan Woratanarat
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Ammarin Thakkinstian
- Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
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Wu N, Ma J, Xiong X, Luo X, Ma X, Yang X, Wang W, Wang Y, Wang Z, Ma F. The influence of direct anterior approach and postero-lateral approach on wound complications after total hip arthroplasty: A meta-analysis. Int Wound J 2024; 21:e14395. [PMID: 37699722 PMCID: PMC10784622 DOI: 10.1111/iwj.14395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/26/2023] [Accepted: 08/31/2023] [Indexed: 09/14/2023] Open
Abstract
To date, we have reviewed the synthesis literature critically through four databases: PubMed, Embase, Cochrane Library and Web of Science. Eight relevant studies were examined after compliance with the criteria for inclusion and exclusion, as well as documentation quality evaluation. This report covered all randomised, controlled studies of total hip arthroplasty (THA) comparing the direct anterior approach (DAA) with the postero-lateral approach (PLA). The main result was surgical site infection rate. The secondary results were duration of the operation, length of the incision and VAS score after surgery. The results of the meta-analyses of wound infections in the present trial did not show any statistically significant difference in DAA versus PLA (between DAA and PLA) (OR = 1.42, 95%CI: 0.5 to 4.04, p = 0.51). Compared with PLA, DAA had shorter surgical incision (WMD = -3.2, 95%CI: -4.00 to -2.41; p < 0.001) and longer operative times(WMD = 14. 67, 95%CI: 9.24 to 20.09; p < 0.001). Postoperative VAS scores were markedly lower in DAA compared with PLA within 6 weeks of surgery (p < 0.05), with low heterogeneities(I2 = 0). We found that DAA did not differ significantly from PLA in terms of the risk of wound infection for THA and that the surgical incisions was shorter and less postoperative pain after surgery, even though DAA surgery takes longer.
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Affiliation(s)
- Ning Wu
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
- The Third Clinical Medical CollegeNingxia Medical UniversityYinchuanChina
| | - Jingzu Ma
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
| | - Xianghua Xiong
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
- The Third Clinical Medical CollegeNingxia Medical UniversityYinchuanChina
| | - Xiaohai Luo
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
| | - Xiaolin Ma
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
- The Third Clinical Medical CollegeNingxia Medical UniversityYinchuanChina
| | - Xiao Yang
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
- The Third Clinical Medical CollegeNingxia Medical UniversityYinchuanChina
| | - Wei Wang
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
- The Third Clinical Medical CollegeNingxia Medical UniversityYinchuanChina
| | - Yuhai Wang
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
| | - Zhaofu Wang
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
- The First Clinical Medical CollegeLanzhou UniversityLanzhouChina
| | - Feng Ma
- Orthopedic CenterPeople's Hospital of Ningxia Hui Autonomous RegionYinchuanChina
- The Third Clinical Medical CollegeNingxia Medical UniversityYinchuanChina
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Ang JJM, Onggo JR, Stokes CM, Ambikaipalan A. Comparing direct anterior approach versus posterior approach or lateral approach in total hip arthroplasty: a systematic review and meta-analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2773-2792. [PMID: 37010580 PMCID: PMC10504117 DOI: 10.1007/s00590-023-03528-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/13/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND There are several approaches to THA, and each has their respective advantages and disadvantages. Previous meta-analysis included non-randomised studies that introduce further heterogeneity and bias to the evidence presented. This meta-analysis aims to present level I evidence by comparing functional outcomes, peri-operative parameters and complications of direct anterior approach (DAA) versus posterior approach (PA) or lateral approach (LA) in THA. PATIENTS AND METHODS A comprehensive multi-database search (PubMed, OVID Medline, EMBASE) was conducted from date of database inception to 1st December 2020. Data from randomised controlled trials comparing outcomes of DAA versus PA or LA in THA were extracted and analysed. RESULTS Twenty-four studies comprising 2010 patients were included in this meta-analysis. DAA has a longer operative time (MD = 17.38 min, 95%CI: 12.28, 22.47 min, P < 0.001) but a shorter length of stay compared to PA (MD = - 0.33 days, 95%CI: - 0.55, - 0.11 days, P = 0.003). There was no difference in operative time or length of stay when comparing DAA versus LA. DAA also had significantly better HHS than PA at 6 weeks (MD = 8.00, 95%CI: 5.85, 10.15, P < 0.001) and LA at 12 weeks (MD = 2.23, 95%CI: 0.31, 4.15, P = 0.02). There was no significant difference in risk of neurapraxia for DAA versus LA or in risk of dislocations, periprosthetic fractures or VTE between DAA and PA or DAA and LA. CONCLUSION The DAA has better early functional outcomes with shorter mean length of stay but was associated with a longer operative time than PA. There was no difference in risk of dislocations, neurapraxias, periprosthetic fractures or VTE between approaches. Based on our results, choice of THA approach should ultimately be guided by surgeon experience, surgeon preference and patient factors. LEVEL OF EVIDENCE I Meta-analysis of randomised controlled trials.
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Affiliation(s)
- James Jia Ming Ang
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800 Australia
| | - James Randolph Onggo
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800 Australia
- Department of Orthopaedic Surgery, Box Hill Hospital, Victoria, Australia
| | - Christopher Michael Stokes
- Department of Orthopaedic Surgery, Box Hill Hospital, Victoria, Australia
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Victoria, Australia
| | - Anuruban Ambikaipalan
- Department of Orthopaedic Surgery, Box Hill Hospital, Victoria, Australia
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Victoria, Australia
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Ramadanov N, Ostojic M, Lazaru P, Liu K, Hable R, Marinova-Kichikova P, Dimitrov D, Becker R. Risk Factors and Predictors for Functional Outcome and Complication Rate in Total Hip Arthroplasty through Minimally Invasive and Conventional Approaches: A Systematic Review and Meta-Regression Analysis of 41 Randomized Controlled Trials. J Clin Med 2023; 12:5895. [PMID: 37762836 PMCID: PMC10531834 DOI: 10.3390/jcm12185895] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 08/27/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVE To investigate and identify risk factors and predictors for the difference in functional outcome and complications between total hip arthroplasty (THA) through minimally invasive and conventional approaches, using a meta-regression analysis of randomized controlled trials (RCTs). METHODS A systematic review of the literature up to 31 July 2022 was performed. A meta-regression was conducted based on a random effects meta-analysis using the Hartung-Knapp-Sidik-Jonkman method. RESULTS A total of 41 RCTs with 3607 patients were found. The following predictors of HHS ≥ 6 months postoperatively were identified: patient age (predictor estimate = 0.14; p < 0.01), avascular necrosis of the femoral head (predictor estimate = -0.03; p = 0.04); incision length (predictor estimate = -0.82; p < 0.01). The following predictors of complication rate were identified: osteoarthritis (predictor estimate = 0.02; p = 0.02); femoral neck fracture (predictor estimate = -0.02; p = 0.02); SuperPATH (predictor estimate = -1.72; p < 0.01). CONCLUSIONS Patient age, avascular necrosis of the femoral head, and incision length were identified as predictors of the effect size of the HHS ≥ 6 months postoperatively; and osteoarthritis, femoral neck fracture, and SuperPATH as predictors of the effect size of the complication rate. Based on these findings, we recommend that more frequent use of minimally invasive THA in elderly patients should be considered. LEVEL OF EVIDENCE I a systematic review of all relevant randomized controlled trials. Registered in PROSPERO on 10 August 2022 (CRD42022350287).
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Affiliation(s)
- Nikolai Ramadanov
- Center of Orthopaedics and Traumatology, Brandenburg Medical School, University Hospital Brandenburg an der Havel, 14770 Brandenburg an der Havel, Germany;
| | - Marko Ostojic
- Department of Orthopedics, University Hospital Mostar, 88000 Mostar, Bosnia and Herzegovina;
| | - Philip Lazaru
- Department of General and Visceral Surgery, Minimally Invasive Surgery and Coloproctology, St. Marien Hospital, 12249 Berlin, Germany;
| | - Kuiliang Liu
- Department for Orthopaedics and Trauma Surgery, Siloah St. Trudpert Hospital, 75179 Pforzheim, Germany;
| | - Robert Hable
- Faculty of Applied Computer Science, Deggendorf Institute of Technology, 94469 Deggendorf, Germany;
| | - Polina Marinova-Kichikova
- Department of Surgical Propaedeutics, Faculty of Medicine, Medical University of Pleven, 5800 Pleven, Bulgaria;
| | - Dobromir Dimitrov
- Department of Surgical Diseases, Faculty of Medicine, Medical University of Pleven, 5800 Pleven, Bulgaria;
| | - Roland Becker
- Center of Orthopaedics and Traumatology, Brandenburg Medical School, University Hospital Brandenburg an der Havel, 14770 Brandenburg an der Havel, Germany;
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11
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De Berardinis L, Senarighi M, Farinelli L, Qordja F, Gallo A, Spezia M, Gigante AP. In primary total hip arthroplasty, the direct anterior approach leads to higher levels of creatine kinase and lower levels of C-reactive protein compared to the posterolateral approach: a propensity score matching analysis of short-term follow-up data. J Orthop Surg Res 2023; 18:594. [PMID: 37568175 PMCID: PMC10416395 DOI: 10.1186/s13018-023-04084-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/07/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND This retrospective study compares the invasiveness of the direct anterior approach (DAA) and the posterolateral approach (PLA) in total hip arthroplasty (THA) by assessing three widely used inflammation-related serum markers in the first ten post-operative days. METHODS The database of our institution was mined for primary THAs conducted by the DAA or the PLA from February 2020 to June 2022. Demographics and creatine kinase (CK), C-reactive protein (CRP), and white blood cells were compared. Propensity Score Matching (PSM) analysis (1:1 ratio) was conducted based on multiple variables. RESULTS PSM analysis yielded 44 pairs of DAA and PLA patients. CK was significantly higher (p < 0.001) in the DAA than in the PLA group on postoperative day (POD) 2, 5 and 10. The POD2, POD5 and POD10 CK/preoperative CK ratio was 12.9, 5.0 and 0.8 in DAA and 8.8, 3.3 and 0.6 in PLA (p = 0.017, p = 0.012 and p = 0.025, respectively). The POD2, POD5 and POD10 CRP/preoperative CRP ratio was 95.1, 65.6 and 22.8 in PLA and 34.7, 23.3 and 8.9 in DAA (p < 0.001, p = 0.002 and p < 0.001, respectively). CONCLUSION PSM analysis of early postoperative CK and CRP values demonstrated that the DAA should be considered as a less stressful approach, not as a muscle-sparing or a minimally invasive THA approach.
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Affiliation(s)
- Luca De Berardinis
- Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Via Tronto, 10/a, 60126, Ancona, AN, Italy.
| | - Marco Senarighi
- Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Via Tronto, 10/a, 60126, Ancona, AN, Italy
| | - Luca Farinelli
- Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Via Tronto, 10/a, 60126, Ancona, AN, Italy
| | - Fjorela Qordja
- Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Via Tronto, 10/a, 60126, Ancona, AN, Italy
| | - Alberto Gallo
- Orthopedic Unit, Habilita Casa di Cura I Cedri, Via Don Guanella, 1, 28073, Fara Novarese, NO, Italy
| | - Marco Spezia
- Orthopedic Unit, Habilita Casa di Cura I Cedri, Via Don Guanella, 1, 28073, Fara Novarese, NO, Italy
| | - Antonio Pompilio Gigante
- Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Via Tronto, 10/a, 60126, Ancona, AN, Italy
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12
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Awad ME, Farley BJ, Mostafa G, Darwiche HF, Saleh KJ. The risk of hospital readmission, revision, and intra- and postoperative complications between direct anterior versus posterior approaches in primary total hip arthroplasty: a stratified meta-analysis and a probability based cost projection. Hip Int 2023; 33:442-462. [PMID: 35437055 DOI: 10.1177/11207000211066454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION This study presents stratified meta-analysis and projected cost per case analysis of direct anterior approach (DAA) versus posterior approach (PA) in total hip arthroplasty (THA) to determine the best surgical approach and guarantee hip joint longevity. METHODS Several online databases were searched for clinical trials comparing DAA and PA in primary THA. The stratified analysis was conducted to test for confounding and biases across the different types of included trials. The average cost and probability were used to determine projected added costs of medical and surgical management for complications. RESULTS 30 clinical trials included 11,562 patients who underwent THA. Almost 50% of these patients performed DAA. As compared to PA, both non-stratified and stratified analyses demonstrated that DAA has a significant higher incidence of the overall intra- and postoperative complications (non-stratified, OR 1.64; p = 0.003) (stratified, OR 4.12; p = 0.005), nerve injury (non-stratified, OR 22.0; p < 0.00001) (stratified, OR 0.28; p < 0.00001), higher rate of revision surgery (non-stratified; OR 1.54; p = 0.01) (stratified, OR 7.37; p = 0.006), and higher incidence of surgical wound complications (non-stratified; OR 1.67; p = 0.002) as compared to PA following primary THA. In addition, DAA demonstrated higher trends of incidence (non-statistically significant) of femur fracture (Non-stratified, OR 1.32, p = 0.10) and thrombo-embolic complications (Retrospective studies, OR 1.39, p = 0.69). However, PA demonstrated higher trends of incidence (non-statistically significant) of hip joint dislocation, as compared to DAA. (Stratified RCTs, OR 0.63, p = 0.65]. Collectively, this amounts a $421,068.68 surplus in DAA complication costs. CONCLUSIONS PA may provide a more lucrative, safer approach to those undergoing THA given its comparable postoperative outcomes, reduced complication rates, and lower overall cost relative to DAA.
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Affiliation(s)
- Mohamed E Awad
- Resident Research Partnership, Detroit, MI, USA
- Michigan State University, College of Osteopathic Medicine, Detroit, MI, USA
- FAJR Scientific, Northville, MI, USA
| | - Brendan J Farley
- Resident Research Partnership, Detroit, MI, USA
- FAJR Scientific, Northville, MI, USA
- Central Michigan University, College of Medicine, Mount Pleasant, MI, USA
| | - Gamal Mostafa
- Wayne State University, School of Medicine, Detroit, MI, USA
| | - Hussein F Darwiche
- Department of Orthopedic Surgery, Detroit Medical Center, Detroit, MI, USA
| | - Khaled J Saleh
- Resident Research Partnership, Detroit, MI, USA
- Michigan State University, College of Osteopathic Medicine, Detroit, MI, USA
- FAJR Scientific, Northville, MI, USA
- Central Michigan University, College of Medicine, Mount Pleasant, MI, USA
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13
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Wilke BK, Guier C, Applewhite A, Garner HW, Stanborough RO, Spaulding A, Sebro RA. Is Heterotopic Ossification Associated With Surgical Approach in Total Hip Arthroplasty? J Am Acad Orthop Surg 2023; 31:e385-e393. [PMID: 36749886 DOI: 10.5435/jaaos-d-22-00639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 12/29/2022] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Although risk factors for heterotopic ossification (HO) have been defined, the effect from surgical approach is not fully understood. The primary objective of our study was to evaluate the effect that surgical approach has on the risk for developing severe HO after total hip arthroplasty (THA) and compare this with other known risk factors. We hypothesized that there would be no difference in HO formation based on the surgical approach. METHODS We retrospectively reviewed all patients who underwent primary THA at our hospital between March 2011 and March 2021. Patients with HO documented in the radiology reports were cross-referenced with our THA data set and manually reviewed to determine Brooker classification. Patient demographics, medical comorbidities, surgical details, and medication information were collected from the electronic medical record and compared. RESULTS Of 3,427 patients who underwent THA, 677 (19.8%) developed HO postoperatively. A multivariable analysis confirmed that surgical approach was independently associated with increased odds for HO development. The anterolateral (odds ratio [OR], 3.43; P < 0.001) and posterior (OR, 2.24; P < 0.001) approaches had increased odds for developing HO compared with the direct anterior approach. However, only the anterolateral approach (OR, 1.85; P = 0.033) demonstrated an increased association with the development of severe HO (Brooker 3, 4) postoperatively. CONCLUSION Although the use of the direct anterior approach had the lowest overall OR for developing HO after THA, this is likely only clinically notable when compared with the anterolateral approach. LEVEL OF EVIDENCE III.
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14
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Shen J, Ji W, Shen Y, He S, Lin Y, Ye Z, Wang B. Comparison of the early clinical efficacy of the SuperPath approach versus the modified Hardinge approach in total hip arthroplasty for femoral neck fractures in elderly patients: a randomized controlled trial. J Orthop Surg Res 2023; 18:215. [PMID: 36935491 PMCID: PMC10024840 DOI: 10.1186/s13018-023-03713-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/14/2023] [Indexed: 03/21/2023] Open
Abstract
PURPOSE To investigate the clinical efficacy and advantages of the SuperPath approach for total hip arthroplasty in the treatment of femoral neck fractures in the elderly population. METHODS From February 2018 to March 2019, 120 patients were randomly divided into two groups with 60 patients each: the SuperPath group and the conventional group. The results evaluated included the general operation situation, serum markers, blood loss, pain score, hip function and prosthesis location analysis. RESULTS There was no demographic difference between the two groups. Compared with the conventional group, the SuperPath group had a shorter operation time (78.4 vs. 93.0 min, p = 0.000), a smaller incision length (5.8 vs. 12.5 cm, p = 0.000), less intraoperative blood loss (121.5 vs. 178.8 ml, p = 0.000), a shorter hospitalization time (8.0 vs. 10.8 days, p = 0.000) and less drainage volume (77.8 vs. 141.2 ml, p = 0.000). The creatine kinase level in the SuperPath group was significantly lower than that in the conventional group, while there was no difference in the C-reactive protein level and erythrocyte sedimentation rate level. The visual analog scale score was lower one month postoperatively, and the Harris hip score was higher three months postoperatively in the SuperPath group (p < 0.05). There was no difference in the cup abduction angle or anteversion angle of the two groups. CONCLUSION We found better clinical efficacy after using the SuperPath approach with less muscle damage, less postoperative pain and better postoperative function than after using the modified Hardinge approach. Trial registration The randomized clinical trial was retrospectively registered at the Chinese Clinical Trial Registry on 31/12/2020 (ChiCTR-2000041583, http://www.chictr.org.cn/showproj.aspx?proj=57008 ).
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Affiliation(s)
- Jiquan Shen
- Department of Orthopaedics, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, 323000, Zhejiang, China
| | - Weiping Ji
- Department of Orthopaedics, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, 323000, Zhejiang, China.
| | - Yonghui Shen
- Department of Orthopaedics, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, 323000, Zhejiang, China
| | - Shijie He
- Department of Orthopaedics, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, 323000, Zhejiang, China
| | - Youbin Lin
- Department of Orthopaedics, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, 323000, Zhejiang, China
| | - Zhijun Ye
- Department of Orthopaedics, The People's Hospital of Yunhe, Lishui, 323000, Zhejiang, China
| | - Bo Wang
- Department of Orthopaedics, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, 323000, Zhejiang, China.
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15
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Patel N, Golwala P. Approaches for Total Hip Arthroplasty: A Systematic Review. Cureus 2023; 15:e34829. [PMID: 36919077 PMCID: PMC10008322 DOI: 10.7759/cureus.34829] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2023] [Indexed: 02/12/2023] Open
Abstract
These surgical procedures have their own challenges, limitations, and success rate. The choice of surgical approach will depend on many factors including the surgeon's choice, type of pathology, bone stock, age of the patient, and experience of the surgeon. Whichever approach is used for total hip arthroplasty (THA), the primary goals of the surgery would be pain relief and enhancement in the quality of the patient's life suffering from hip pathologies. To further understand the advantages and potential pitfalls associated with different surgical approaches, we conducted a review study comparing different surgical approaches for THA in terms of their clinical and functional outcomes. All the studies done on surgical approaches used in THA published articles in the English language and from 2015 onward were included in the review. The databases searched were COCHRANE, MEDLINE, PEDRO, CINHAL, etc. Search engines that were searched were Google Scholar, Pub Med, and Science Direct. As per the inclusion criteria, out of 50 studies, 26 studies were included in the study which underwent critical analysis. Considering all the factors reviewed from the literature, the posterior approach or posterolateral approach is optimally beneficial.
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Affiliation(s)
- Niketa Patel
- Department of Physiotherapy, Sumandeep Vidyapeeth Deemed to be University, Vadodara, IND
| | - Paresh Golwala
- Department of Orthopedics, Sumandeep Vidyapeeth Deemed to be University, Vadodara, IND
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16
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Jungwirth-Weinberger A, Do HT, Krell EC, Valle AGD, Chalmers BP, Boettner F. Blood management in direct anterior versus posterior primary total hip arthroplasty using tranexamic acid: a matched cohort study. Arch Orthop Trauma Surg 2023; 143:91-95. [PMID: 34152489 DOI: 10.1007/s00402-021-03965-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 05/18/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Proponents of the direct anterior approach (DAA) for THA claim patients recover faster compared to primary THA through the posterior approach (PA). Blood loss and transfusion have substantially declined with the use of tranexamic acid (TXA). However, it is still controversial if hemoglobin drops and transfusion rates are affected by the surgical approach when TXA is routinely used. MATERIALS AND METHODS 2418 patients undergoing DAA THA were matched 1:1 with patients undergoing PA THA according to preoperative hemoglobin (± 1 g/dl), age (± 5 years), sex, BMI (± 5 kg/m2) and year of surgery (± 2 years). All patients received perioperative TXA. None of the patients donated autologous blood. Hemoglobin levels, drain placement and output, blood transfusion rates and volume as well as length of stay were recorded. RESULTS A closed suction drain was used in 121 (5.0%) DAA and in 135 (5.6%) PA THAs (p = 0.369). Mean drain output was higher in the DAA compared to the PA group (134 ml (0-520 ml) versus 92.3 ml (0-600 ml), p = 0.004). There was no difference in hemoglobin drop [2.6 g/dl versus 2.6 g/dl (p = 0.143)] and transfusion rate [n = 31 (1.3%) versus n = 29 (1.2%), p = 0.793)] between DAA and PA THA. Mean transfusion amounts were 421.8 ml (250-1120.8 ml) in the DAA and 353.9 ml (250-560 ml) in the PA group (p = 0.801). The length of stay was shorter in the DAA group with a mean 1.6 days versus 2.1 days in the PA group (p ≤ 0.001). CONCLUSION In this large matched cohort study, there was no difference in the perioperative hemoglobin drop, the transfusion rate and the transfusion amount between DAA and PA THA.
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Affiliation(s)
- Anna Jungwirth-Weinberger
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedics and Traumatology, Cantonal Hospital Baden, Im Ergel 1, 5404, Baden, Switzerland
| | - Huong T Do
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Ethan C Krell
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | | | - Brian P Chalmers
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Friedrich Boettner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
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17
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Kraus KR, Dilley JE, Ziemba-Davis M, Meneghini RM. Procedure Duration, Time Under Anesthesia, and Readmissions in Direct Anterior and Posterior Approach Total Hip Arthroplasty. J Arthroplasty 2022; 37:2387-2393. [PMID: 35798136 DOI: 10.1016/j.arth.2022.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 06/27/2022] [Accepted: 06/29/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Operative time is related to complications in primary total hip arthroplasty (THA). This study compared operative time in direct anterior (DA) and posterior approach THA and whether differences were related to increased hospital readmissions within 90 days of discharge. METHODS Prospectively documented data on 3,152 consecutively performed THAs by 16 surgeons at a large Midwestern United States academic healthcare system were retrospectively reviewed. All surgeons were beyond their learning curve. Cases characterized by factors extending operative time were excluded. A total of 1,235 analysis cases were performed with the DA approach and 1,608 with the posterior approach. DA patients had lower mean body mass index (P < .001), were more likely to be classified as American Society of Anesthesiologists Physical Status 1 or 2 (P < .001), and more likely to have surgery in an ambulatory setting (P < .001). RESULTS Time under anesthesia was significantly longer for DA procedures by 19 to 27 minutes in hospital and ambulatory settings, respectively (P < .001). Increasing body mass index had a greater impact on anesthesia time for DA patients (P = .020). There were no differences in nontraumatic readmissions within 90 days of surgery based on surgical approach (P ≥ .480); however, significantly more DA patients classified as ASA-PS 3 or 4 were readmitted compared to those classified as ASA-PS 1 or 2 (P < .001), a difference not observed for posterior approach patients. CONCLUSION Anesthesia time is a modifiable risk factor for patient safety and an important factor in healthcare resource utilization. Consideration of ways to reduce DA operative times is encouraged.
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Affiliation(s)
- Kent R Kraus
- Medical Resident, Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Julian E Dilley
- Medical Resident, Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mary Ziemba-Davis
- Orthopedic Research Director, Indiana University Health Hip & Knee Center, Saxony Hospital, Fishers, Indiana
| | - R Michael Meneghini
- Professor of Clinical Orthopaedic Surgery, Indiana University School of Medicine, Department of Orthopaedic Surgery, Indianapolis, Indiana
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18
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Some aspects of the choice of surgical approach for triple pelvic osteotomy in the treatment of hip dysplastic instability in children. TRAUMATOLOGY AND ORTHOPEDICS OF RUSSIA 2022. [DOI: 10.17816/2311-2905-1981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Aim - on the basis of clinical and laboratory data, to analyze the degree of muscle injury during triple pelvic osteotomy with various approaches in patients with hip dysplasia
Matherials and methods.
The study included 70 patients aged 12 to 18 years with dysplasia Crowe I grade treated between 2020 and 2021. All children were divided into two groups - I - 35 patients who underwent triple pelvic osteotomy from an anterolateral approach, group II - 35 patients who underwent triple pelvic osteotomy from two approaches (medial and bikini"). In addition to standard radiometry of hip joints, such indicators as the severity of pain syndrome on the VAS scale were evaluated, as well as biochemical analysis of markers of muscle injury (LDH, CPK, creatinine, AST, C-reactive protein) before surgery and on the 3rd and 7th days after surgery.
Results.
The intensity of the pain syndrome according to the questionnaire data was more pronounced (p0.05) in patients who underwent surgery from an anterolateral access, and the values of CPK and C-reactive protein significantly (p0.05) exceeded those in patients who underwent triple pelvic osteotomy from two surgical approaches. The data obtained indicate greater surgical aggression against the muscles of the hip joint area during the anterolateral approch for triple pelvic osteotomy.
Conslusion.
A comparative analysis of the traumaticity of surgical approaches during triple pelvic osteotomy in children with hip dysplasia Crowe I degree, based on the assessment of biochemical indicators of markers of muscle injury and the intensity of pain syndrome in the postoperative period showed that the use of anteriorlateral approach significantly (p0.05) has a greater injury to muscle tissue than the use of two surgical accesses (medial and bikini), as evidenced by significant increases in CPK and CRP in the blood, as well as a more pronounced pain syndrome in the immediate postoperative period.
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19
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Ramadanov N, Bueschges S, Liu K, Lazaru P, Marintschev I. Direct and indirect comparisons in network meta-analysis of SuperPATH, direct anterior and posterior approaches in total hip arthroplasty. Sci Rep 2022; 12:16778. [PMID: 36202828 PMCID: PMC9537282 DOI: 10.1038/s41598-022-20242-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 09/12/2022] [Indexed: 12/05/2022] Open
Abstract
SuperPATH is a novel approach to the hip joint that needs to be compared to other known surgical approaches. To conduct a network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing short-term outcomes of SuperPATH, direct anterior (DAA), and posterior/ posterolateral approaches (PA) in total hip joint arthroplasty (THA). We performed a systematic review on PubMed, CNKI, Embase, The Cochrane Library, Clinical trials, and Google Scholar up to November 30th, 2021. We assessed treatment effects between SuperPATH, DAA, and PA by performing a frequentist NMA, including a total of 20 RCTs involving 1501 patients. SuperPATH showed a longer operation time (MD = 16.99, 95% CI 4.92 to 29.07), a shorter incision length (MD = −4.71, 95% CI −6.21 to −3.22), a lower intraoperative blood loss (MD = −81.75, 95% CI −114.78 to −48.72), a higher HHS 3, 6 and 12 months postoperatively (MD = 2.59, 95% CI 0.59–4.6; MD = 2.14, 95% CI 0.5–3.77; MD = 0.6, 95% CI 0.03–1.17, respectively) than PA. DAA showed a higher intraoperative blood loss than PA and SuperPATH (MD = 91.87, 95% CI 27.99–155.74; MD = 173.62, 95% CI 101.71–245.53, respectively). No other relevant differences were found. In conclusion, the overall findings suggested that the short-term outcomes of THA through SuperPATH were statistically superior to PA. DAA and PA as well as SuperPATH and DAA showed indifferent results.
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Affiliation(s)
- Nikolai Ramadanov
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg an der Havel, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany.
| | - Simon Bueschges
- Faculty of Medicine, Department of Statistics, University of Salamanca, Salamanca, Spain
| | - Kuiliang Liu
- Department for Orthopaedics and Trauma Surgery, Siloah St. Trudpert Hospital, Pforzheim, Germany
| | - Philip Lazaru
- Center for Surgery, Evangelical Hospital Ludwigsfelde-Teltow, Ludwigsfelde, Germany
| | - Ivan Marintschev
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Friedrich Schiller University, Jena, Germany
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Acuña AJ, Do MT, Samuel LT, Grits D, Otero JE, Kamath AF. Periprosthetic joint infection rates across primary total hip arthroplasty surgical approaches: a systematic review and meta-analysis of 653,633 procedures. Arch Orthop Trauma Surg 2022; 142:2965-2977. [PMID: 34595547 DOI: 10.1007/s00402-021-04186-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 09/19/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Evidence demonstrates comparable clinical outcomes across the various surgical approaches to primary total hip arthroplasty (THA). However, high-quality contemporary data regarding periprosthetic joint infection (PJI) risk between direct anterior approach (DAA) and other (THA) approaches is lacking. This systematic review and meta-analysis evaluated PJI rates reported in the literature between the DAA and other approaches. MATERIALS AND METHODS Five online databases were queried for all studies published from January 1st, 2000 through February 17th, 2021 that reported PJI rates between DAA and other surgical approaches. Studies reporting on primary THAs for osteoarthritis (OA) and that included PJI rates segregated by surgical approach were included. Articles reporting on revision THA, alternative THA etiologies, or minimally invasive techniques were excluded. Mantel-Haenszel (M-H) models were utilized to evaluate the pooled effect of surgical approach on infection rates. Validated risk of bias and methodological quality assessment tools were applied to each study. Multiple sensitivity analyses were conducted to evaluate the robustness of analyses. RESULTS 28 articles reporting on 653,633 primary THAs were included. No differences were found between DAA cohorts and combined other approaches (OR: 0.95; 95% CI 0.74-1.21; p = 0.67) as well as segregated anterolateral approach cohorts (OR: 0.82, 95% CI 0.64-1.06; p = 0.13). However, DAA patients had a significantly reduced risk of infection compared to those undergoing posterior (OR: 0.66, 95% CI 0.58-0.74; p < 0.0001) and direct lateral (OR: 0.56, 95% CI 0.48-0.65; p < 0.00001) approaches. CONCLUSION The DAA to primary THA had comparable or lower PJI risk when compared to other contemporary approaches. The results of the most up-to-date evidence available serve to encourage adult reconstruction surgeons who have already adopted the DAA. Additionally, orthopaedic surgeons considering adoption or use of the direct anterior approach for other reasons should not be dissuaded over theoretical concern for a general increase in the risk of PJI. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Alexander J Acuña
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Michael T Do
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Linsen T Samuel
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Daniel Grits
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Jesse E Otero
- OrthoCarolina Hip and Knee Center, 1915 Randolph Road, Charlotte, NC, 28207, USA
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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Maezawa K, Nozawa M, Gomi M, Sugimoto M, Maruyama Y. Changes in serum creatine kinase and C-reactive protein after posterior and direct anterior approaches in total hip arthroplasty. Hip Int 2022; 32:591-595. [PMID: 33290100 DOI: 10.1177/1120700020978643] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Some studies reported that measuring serum creatine kinase (CK) level is an objective method with which to determine the relative invasiveness of surgery. The purpose of this study was to evaluate the change in postoperative serum CK levels as a measure of whether the direct anterior approach (DAA) is less invasive than the posterior approach (PA) regarding postoperative rehabilitation. MATERIALS AND METHODS We prospectively recruited 71 women who were undergoing total hip arthroplasty, 47 were treated by the PA and 24 by the DAA. Serum CK and C-reactive protein (CRP) levels were measured preoperatively and 3 hours and 1, 4, 7, 10, and 14 days after the operation. RESULTS The serum CK levels were significantly higher in the DAA group than in the PA group on postoperative days 1, 4, 7, 10, and 14. On postoperative day 4 and 7, the percentage of patients whose serum CK levels were above the normal range was 46.8% and 8.5% in the PA group and 95.2% and 45.5% in the DAA group. CONCLUSIONS CK levels were significantly higher in the 2 weeks after THA by a DAA than after the same procedure by a PA indicating that DAA causes prolonged muscle damage. Although the DAA is considered to be a muscle-sparing approach this may not be the case and DAA may not actually be a minimally-invasive approach.
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Affiliation(s)
- Katsuhiko Maezawa
- Orthopaedic Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Masahiko Nozawa
- Orthopaedic Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Motoshi Gomi
- Orthopaedic Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Munehiko Sugimoto
- Orthopaedic Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Yuichiro Maruyama
- Orthopaedic Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
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22
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Minimally Invasive Intermuscular Approaches Versus Conventional Approaches in Total Hip Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty 2022; 37:1658-1666. [PMID: 35346808 DOI: 10.1016/j.arth.2022.03.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/22/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND To date, the literature has not yet revealed superiority of Minimally Invasive (MI) approaches over conventional techniques. We performed a systematic review to determine whether minimally invasive approaches are superior to conventional approaches in total hip arthroplasty for clinical and functional outcomes. We performed a meta-analysis of level 1 evidence to determine whether minimally invasive approaches are superior to conventional approaches for clinical outcomes. METHODS All studies comparing MI approaches to conventional approaches were eligible for analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were adhered to throughout this study. Registries were searched using the following MeSH terms: 'minimally invasive', 'muscle-sparing', 'THA', 'THR', 'hip arthroplasty' and 'hip replacement'. Locations searched included PubMed, the Cochrane Library, ClinicalTrials.gov, the European Union (EU) clinical trials register and the International Clinical Trials Registry Platform (World Health Organisation). RESULTS Twenty studies were identified. There were 1,282 MI total hip arthroplasty (THAs) and 1,351 conventional THAs performed. There was no difference between MI and conventional approaches for all clinical outcomes of relevance including all-cause revision (P = .959), aseptic revision (P = .894), instability (P = .894), infection (P = .669) and periprosthetic fracture (P = .940). There was also no difference in functional outcome at early or intermediate follow-up between the two groups (P = .38). In level I studies exclusively, random-effects meta-analysis demonstrated no difference in aseptic revision (P = .461) and all other outcomes between both groups. CONCLUSION Intermuscular MI approaches are equivalent to conventional THA approaches when considering all-cause revision, aseptic revision, infection, dislocation, fracture rates and functional outcomes. Meta-analysis of level 1 evidence supports this claim.
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Serum biomarkers for the assessment of muscle damage in various surgical approaches in primary total hip arthroplasty: a systematic review of comparative studies. INTERNATIONAL ORTHOPAEDICS 2022; 46:1681-1692. [PMID: 35641792 DOI: 10.1007/s00264-022-05442-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 05/10/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Using serum biomarkers, this systematic review assessed soft tissue injury following different total hip arthroplasty surgical approaches. The purposes were to determine if there is any advantage between the standard and minimal invasive approaches, and to compare tissue damage of the respective surgical approaches using biomarkers such as creatine kinase, myoglobin, c-reactive protein, erythrocyte sedimentation rate, skeletal troponin and interleukins. METHOD A search in Pubmed/MEDLINE, Scopus and Web of Science databases was conducted in October 2021 with the use of PRISMA guidelines. Search items were ("biomarkers" OR "markers" OR "tissue damage" OR "muscle damage") AND "approach" AND ("total hip arthroplasty" OR "total hip replacement"). Inclusion criteria were prospective, randomized, controlled trials or prospective, comparative studies, comparing serum markers for muscle damage in two or more surgical approaches for primary total hip arthroplasty. Exclusion criteria were study protocols, case reports, systematic reviews, meta-analyses, studies in non-English language or without available full text, and studies not recording biomarkers of muscle damage. RESULTS Initial search revealed 508 studies; after subtraction of duplicates, and exclusion criteria, 31 studies remained for analysis. No advantage between different approaches was found when evaluating biomarkers, and no specific biomarkers had a distinct role in tissue damage in total hip arthroplasty. Anterior and minimally invasive approaches were associated with lower values of soft tissue (creatine kinase) and inflammation (c-reactive protein) biomarkers compared to the standard approaches. CONCLUSION Measurement of serum biomarkers after primary total hip arthroplasty for the estimation of tissue damage has unclear or little clinical value. TRIAL REGISTRATION PROSPERO Registration: CRD42022303959.
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Shen K, Feng E, Lin F, Weng Y, Chen J. Learning Curve of Total Hip Arthroplasty in Direct Anterior Approach without Requiring Corrective Osteotomy for Hip Dysplasia. Orthop Surg 2022; 14:840-850. [PMID: 35388599 PMCID: PMC9087452 DOI: 10.1111/os.13231] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To explore the learning curve of total hip arthroplasty in direct anterior approach (DA-THA) without requiring corrective osteotomy for patients with unilateral developmental dysplasia of the hip (DDH) through the evaluation of clinical and radiographic results. METHOD From December 2015 to January 2021, we retrospectively evaluated a surgeon's first 100 patients with unilateral hip dysplasia (Crowe I-III) who underwent DA-THA. All procedures were performed by a fellowship-trained joint surgeon. Cementless hemispheric porous-coated acetabular cups and tapered cementless stems were used in all hips. The radiographic data, including leg length, the height of the center of rotation, femoral head offset, the cup anteversion and inclination angle, were measured. The cumulative sum analysis (CUSUM) and risk-adjusted cumulative sum analysis (RA-CUSUM) were used to determine the learning curve of DA-THA for each patient's operation time. By analyzing the operation time, complication rate, postoperative length of hospitalization and creatine kinase (before surgery and the third day after surgery), estimated blood loss, Harris score, radiographic data were compared between the different stages of the learning curve. RESULTS The mean follow-up time was 35.45 ± 16.82 months. The CUSUM method obtained the maximum turning point of the curve at 43 cases, which divided the learning curve into Learning Period and Mastery Period. The CUSUM learning curve was best modeled as a cubic curve with the equation: CUSUM (min) = 0.001x3 - 0.495x2 + 33.60x - 10.00, which had a higher R2 value of 0.967. The pre-operative data, creatine kinase, estimated blood loss and postoperative Harris scores of the two stages were not statistically significant (P > 0.05). The mean operation time was 118 min in the Learning Period and 87 min in the Mastery Period. Statistically significant differences were detected in the operation time (P < 0.001), postoperative length of hospitalization(P = 0.024), and postoperative leg length discrepancy (P = 0.012) between the two stages. The overall complication rates were 27.9% in the Learning Period and 12.3% in the Mastery Period (p = 0.049). The overall outliers of radiographic data were 34 cases in the Learning Period and 31 cases in the Mastery Period (79.07% vs 54.39%, P = 0.010). CONCLUSIONS The DA-THA is a valuable alternative to achieve satisfactory clinical results for mild-to-moderate DDH patients. Furthermore, accurate analysis of the learning curve of DA-THA for hip dysplasia by the CUSUM method showed that the surgeons need to finish about 43 cases to master the technique.
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Affiliation(s)
- Kaiwei Shen
- Department of Arthrosis Surgery, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, China
| | - Eryou Feng
- Department of Arthrosis Surgery, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, China
| | - Feitai Lin
- Department of Arthrosis Surgery, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, China
| | - Yan Weng
- Department of Arthrosis Surgery, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, China
| | - Jinhua Chen
- Medical Department of Fujian Medicine University Union Hospital, Fuzhou, China
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Tottas S, Ververidis A, Kougioumtzis I, Tilkeridis K, Tsigalou C, Karaglani M, Drosos G. MINIMA Short Stem Versus Standard Profemur (TL) Stem in Primary Total Hip Replacement: A Comparative Study. Cureus 2022; 14:e23771. [PMID: 35509762 PMCID: PMC9062282 DOI: 10.7759/cureus.23771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2022] [Indexed: 12/28/2022] Open
Abstract
Background: The objective of our study was to compare a novel squared section, tapered design - with four conicity - short stem, the MINIMA® short stem with the cementless Profemur® TL standard femoral stem in primary total hip arthroplasty (THA) in terms of functional outcomes, radiologic evaluation and other peri-operative and post-operative data. Material and methods: This is a comparative study including 46 patients undergoing primary THA. In 23 patients, the MINIMA® short stem was used. These patients were matched with another 23 patients in whom a cementless Profemur® TL standard femoral stem was used. The levels of the pain were evaluated according to the Visual Analog Scale/Numerical Rating Scale (VAS/NRS). The functional and clinical evaluation of the patients was performed with Harris Hip Score (HHS), Charnley’s Hip score, EuroQol (EQ-5D)-(EQ-100), Patient Health Questionnaire (PHQ-9), and neuropathic pain questionnaire (DN-4). The rest of the comparison data included demographic data, the American Society of Anesthesiologists score (ASA), Charlson Index score, the pre-operative diagnosis, radiographic evaluation, the days of hospitalization, the operating time, incision length, blood loss, and blood transfusion requirements and complication rates. Results: The two cohorts had comparable results regarding all patients’ peri-operative data. The radiographic assessment revealed considerable higher levels of femoral offset and femoral subsidence for the MINIMA group, but within acceptable limits for both cohorts. The majority of the functional and other scores did not give strong prominence to one specific femoral stem. Conclusion: Our comparative study underlined the efficacy of the MINIMA® short stem, due to the fact that it revealed comparable and, in some cases, relatively better short-term outcomes compared with the TL standard femoral stem. Yet, more well-designed long-term research is required in order to further establish its effectiveness.
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Affiliation(s)
- Stylianos Tottas
- Orthopeadics, University General Hospital of Alexandroupolis/Democritus University of Thrace, Alexandroupolis, GRC
| | - Athanasios Ververidis
- Orthopeadics, University General Hospital of Alexandroupolis/Democritus University of Thrace, Alexandroupolis, GRC
| | - Ioannis Kougioumtzis
- Orthopeadics, University General Hospital of Alexandroupolis/Democritus University of Thrace, Alexandroupolis, GRC
| | - Konstantinos Tilkeridis
- Orthopeadics, University General Hospital of Alexandroupolis/Democritus University of Thrace, Alexandroupolis, GRC
| | - Christina Tsigalou
- Medical-Molecular Microbiology, University General Hospital of Alexandroupolis/Democritus University of Thrace, Alexandroupolis, GRC
| | - Makrina Karaglani
- Laboratory of Pharmacology, Medical School/Democritus University of Thrace, Alexandroupolis, GRC
| | - Georgios Drosos
- Orthopeadics, University General Hosital of Alexandroupolis/Democritus University of Thrace, Alexandroupolis, GRC
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Buis N, Esfandiari H, Hoch A, Fürnstahl P. Overview of Methods to Quantify Invasiveness of Surgical Approaches in Orthopedic Surgery—A Scoping Review. Front Surg 2022; 8:771275. [PMID: 35155547 PMCID: PMC8825480 DOI: 10.3389/fsurg.2021.771275] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/23/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Comparison of the Early Results of Lateral Direct Anterior Approach (L-DAA) and Traditional Posterolateral Approach (PLA) in Hip Arthroplasty. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2021:1187011. [PMID: 34976102 PMCID: PMC8716204 DOI: 10.1155/2021/1187011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/23/2021] [Accepted: 12/03/2021] [Indexed: 12/04/2022]
Abstract
Objective To evaluate the early results of lateral direct anterior approach (L-DAA) and traditional posterolateral approach (PLA) in hip arthroplasty. Methods A total of 24 patients who underwent hip replacement from 2018 to 2021 were divided into PLA group (N = 12) and L-DAA group (N = 12) according to the method of random table number. Outcomes were evaluated between the two groups. Results The length of incision was shorter; the amount of bleeding was less in the L-DAA group than that in the PLA group. The visual analogue scale (Vas) pain scores for the L-DAA group were significantly lower than that for the PLA group at 24 h, 72 h, and 1 month after operation, and Harris hip scores in the L-DAA group were significantly high in the PLA group at 1 month after operation. In addition, there are no statistically significant differences in acetabular anteversion, abduction, and angle between the two groups. Conclusion L-DAA was superior to PLA for early recovery after hip arthroplasty.
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Nambiar M, Cheng TE, Onggo JR, Maingard J, Troupis J, Pope A, Armstrong MS, Singh PJ. No Difference in Functional, Radiographic, and Survivorship Outcomes Between Direct Anterior or Posterior Approach THA: 5-Year Results of a Randomized Trial. Clin Orthop Relat Res 2021; 479:2621-2629. [PMID: 34237041 PMCID: PMC8726547 DOI: 10.1097/corr.0000000000001855] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/13/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Both the direct anterior approach (DAA) and posterior approach (PA) to THA have known advantages and disadvantages. The comparison between DAA and PA THA has been widely explored during the early postoperative period. However, few randomized trials have compared these approaches at a minimum follow-up of 5 years; doing so would be important to establish any differences in mid-term outcomes or complications. QUESTIONS/PURPOSES We performed a randomized trial comparing DAA and PA in THA in terms of (1) patient-reported outcome scores, (2) quality of life and functional outcomes assessed by the EQ-5D and 10-meter walk test results, (3) radiographic analysis, and (4) survivorship and surgical complications at a minimum of 5 years follow-up. METHODS Two hip specialist surgeons performed both DAA and PA THA using the same THA components at two hospital sites. One hundred twelve patients on the elective THA surgical waitlist were invited to participate in the study. Thirty-four patients did not meet the study's inclusion criteria and were excluded, and three patients declined to participate in the study. The remaining 75 patients who were eligible were randomized into DAA and PA groups. Thirty-seven patients were initially randomized to receive DAA THA, but two did not and were excluded, resulting in 48% (35 of 73) of patients who received DAA THA; 52% (38 of 73) of patients were randomized into and received PA THA. Over a minimum 5 years of follow-up, 3% (1 of 35) of DAA patients were lost to follow-up, and none of the patients undergoing PA THA were lost. A per-protocol analysis was adopted, resulting in further patients being excluded from analysis. Of the 73 study patients, 99% (72; DAA: 35, PA: 37) were analyzed at 1 year, 95% (69; DAA: 34, PA: 35) were analyzed at 2 years, and 72% (52; DAA: 23, PA: 29) were analyzed at 5 years. The primary outcome was the Oxford Hip Score (OHS) and WOMAC score. Secondary outcomes included the EQ-5D and EQ-5D VAS scores, 10-meter walk test results, radiographic evidence of loosening (femoral: lucency > 2 mm at the implant-bone interface, subsidence > 2 mm; acetabular: migration or change in inclination), 5-year survivorship analysis from all-cause revisions, and surgical complications. The study was powered to detect a 10-point difference in the WOMAC score, which is equivalent to the minimum clinically important difference (MCID). RESULTS There were no differences in primary outcomes (OHS and WOMAC scores) or secondary outcomes (EQ-5D scores, EQ-5D VAS scores, and 10-meter walk test result) between the DAA and PA groups at the 5-year follow-up interval. The median (range) OHS at 5 years was 46 (16 to 48) for DAA and 47 (18 to 48) for PA groups (p = 0.93), and the median WOMAC score was 6 (0 to 81) for DAA and 7 (0 to 59) for PA groups (p = 0.96). The median EQ-5D score was 1 (0.1 to 1) for DAA and 1 (0.5 to 1) for PA groups (p = 0.45), and the median EQ-5D VAS score was 85 (60 to 100) for DAA and 95 (70 to 100) for PA groups (p = 0.29). There were no cases of component loosening on radiographs. There was no difference in component survival between the two approaches at 5 years (DAA: 97% [95% CI 85% to 100%] versus PA: 97% [95% CI 87% to 100%]). Eight of 23 patients in the DAA group reported decreased sensation in the lateral femoral cutaneous nerve distribution. CONCLUSION DAA and PA are both effective approaches in performing primary THA. Each approach has its associated risks and complications. The choice of THA should be based on individual patient factors, surgeon experience, and shared decision-making. Early registry data indicate DAA and PA THA are comparable, but longer-term data with larger numbers of patients will be required before one can safely conclude equal survivorship between both approaches. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Mithun Nambiar
- Department of Orthopaedic Surgery, Box Hill Hospital, Box Hill, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Tze E. Cheng
- Department of Orthopaedic Surgery, Box Hill Hospital, Box Hill, Victoria, Australia
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - James R. Onggo
- Department of Orthopaedic Surgery, Box Hill Hospital, Box Hill, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Julian Maingard
- Monash Imaging, Monash Medical Centre, Clayton, Victoria, Australia
| | - John Troupis
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
- Monash Imaging, Monash Medical Centre, Clayton, Victoria, Australia
| | - Alun Pope
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Michael S. Armstrong
- Department of Orthopaedic Surgery, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Parminder J. Singh
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
- Department of Orthopaedic Surgery, Maroondah Hospital, Ringwood, Victoria, Australia
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Ramadanov N, Bueschges S, Liu K, Lazaru P, Marintschev I. Direct anterior approach vs. SuperPATH vs. conventional approaches in total hip replacement: A network meta-analysis of randomized controlled trials. Orthop Traumatol Surg Res 2021; 107:103058. [PMID: 34536596 DOI: 10.1016/j.otsr.2021.103058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/09/2021] [Accepted: 04/23/2021] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Nikolai Ramadanov
- Department of Emergency Medicine, University Hospital Jena, Friedrich Schiller University, Am Klinikum 1, 07747 Jena, Germany.
| | - Simon Bueschges
- Faculty of Medicine, Department of Statistics, University of Salamanca, Calle Espejo 2, 37007 Salamanca, Spain
| | - Kuiliang Liu
- Department for Orthopaedics and Trauma Surgery, Siloah St. Trudpert Hospital, Wilferdinger Str. 67, 75179 Pforzheim, Germany
| | - Philip Lazaru
- Center for Surgery, Evangelical Hospital Ludwigsfelde-Teltow, Albert-Schweizer-Str. 40-44, 14974 Ludwigsfelde, Germany
| | - Ivan Marintschev
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Friedrich Schiller University, Am Klinikum 1, 07747 Jena, Germany
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FAGOTTI LORENZO, FALOTICO GUILHERMEGUADAGNINI, MARANHO DANIELAUGUSTO, AYENI OLUFEMIR, EJNISMAN BENNO, COHEN MOISES, ASTUR DIEGOCOSTA. POSTERIOR VERSUS ANTERIOR APPROACH TO TOTAL HIP ARTHROPLASTY: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS. ACTA ORTOPEDICA BRASILEIRA 2021; 29:297-303. [PMID: 34849093 PMCID: PMC8601379 DOI: 10.1590/1413-785220212906244610] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 10/20/2020] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To perform a systematic review and meta-analysis to compare clinical and surgical outcomes of posterior versus anterior approach to primary total hip arthroplasty (THA). METHODS This study followed the standard methodology established by the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two independent reviewers searched for randomized controlled trials comparing posterior an anterior approach to primary THA with at least one quantifiable functional outcome published in the PubMed, Cochrane, and Virtual Health Library databases. RESULTS The analysis included ten randomized controlled trials conducted with 774 patients. The posterior approach was associated with shorter operative time (mean of 15.98 minutes shorter, 95% CI 11.21 to 20.76, p < 0.00001) while the anterior approach was associated with shorter length of hospital stay (0.31 days or about eight hours shorter, 95% CI 0.12 to 0.51, p = 0.002) and greater earlier improvement in functional outcomes up to six months from the procedure (mean Harris Hip Score of 4.06 points greater, 95% CI 2.23 to 5.88, p < 0.0001). CONCLUSION Whereas the posterior approach to primary THA is associated with a shorter operative time, the anterior approach has the potential to decrease the length of stay and provide greater short-term functional restoration. Level of evidence I, Systematic Review and Meta-Analysis.
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Affiliation(s)
- LORENZO FAGOTTI
- Universidade Federal de São Paulo, Brazil; Hospital Sírio-Libanês, Brazil
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Ramadanov N, Bueschges S, Lazaru P, Dimitrov D. A meta-analysis on RCTs of direct anterior and conventional approaches in total hip arthroplasty. Sci Rep 2021; 11:20991. [PMID: 34697357 PMCID: PMC8546071 DOI: 10.1038/s41598-021-00405-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 10/12/2021] [Indexed: 12/14/2022] Open
Abstract
To conduct a systematic review and meta-analyses on short-term outcomes between total hip arthroplasty (THA) through direct anterior approach (DAA) compared to THA through conventional approaches (CAs) in treatment of hip diseases and fractures. We performed a systematic literature search up to March 1, 2021 to identify RCTs, comparing THA through DAA with THA through CAs. We calculated mean differences (MDs) with 95% confidence intervals (CIs) for continuous outcomes, using the DerSimonian and Laird method and a random effects model. We calculated odds ratios (ORs) with 95% CIs for dichotomous outcomes, using the Mantel–Haenszel method and a random effects model. Ten RCTs met the criteria for final meta-analysis, involving 1053 patients. Four studies were blinded RCTs with a level I evidence, the other 6 studies were non-blinded RCTs with a level II evidence. DAA had a longer operation time than CAs (MD = 17.8, 95% CI 4.8 to 30.8); DAA had similar results compared to CAs for incision length (MD = − 1.1, 95% CI − 4.1 to 1.8), for intraoperative blood loss (MD = 67.2, 95% CI − 34.8 to 169.1), for HHS 3 months postoperatively (MD = 2.4, 95% CI − 0.7 to 5.5), for HHS 6 months postoperatively (MD = 0.8, 95% CI − 1.9 to 3.5), for HHS 12 months postoperatively (MD = 0.9, 95% CI − 0.7 to 2.5), for pain VAS 1 day postoperatively (MD = − 0.9, 95% CI − 2.0 to 0.15), for acetabular cup anteversion angle (MD = − 4.3, 95% CI − 5.2 to − 3.5), for acetabular cup inclination angle (MD = − 0.5, 95% CI − 2.1 to 1.1) and for postoperative complications (OR = 2.4, 95% CI 0.5 to 12.4). Considering the overall results of our meta-analysis, we can conclude that THA through DAA showed similar short-term surgical, functional, radiological outcomes and postoperative complications compared to THA through CAs.
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Affiliation(s)
- Nikolai Ramadanov
- Department of Emergency Medicine, University Hospital Jena, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany.
| | - Simon Bueschges
- Faculty of Medicine, Department of Statistics, University of Salamanca, Calle Espejo 2, 37007, Salamanca, Spain
| | - Philip Lazaru
- Center for Surgery, Evangelical Hospital Ludwigsfelde-Teltow, Albert-Schweitzer-Str. 40-44, 14974, Ludwigsfelde, Germany
| | - Dobromir Dimitrov
- Department of Surgical Propaedeutics, Faculty of Medicine, Medical University of Pleven, Bulgaria, ul. Sveti Kliment Ohridski 1, 5800, Pleven, Bulgaria
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Rykov K, Meys TWGM, Knobben BAS, Sietsma MS, Reininga IHF, Ten Have BLEF. MRI Assessment of Muscle Damage After the Posterolateral Versus Direct Anterior Approach for THA (Polada Trial). A Randomized Controlled Trial. J Arthroplasty 2021; 36:3248-3258.e1. [PMID: 34116911 DOI: 10.1016/j.arth.2021.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/26/2021] [Accepted: 05/07/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There is controversy in literature whether the direct anterior approach (DAA) results in less muscle damage compared with the posterolateral approach (PLA) for total hip arthroplasty. The aim of this randomized controlled trial was to assess muscle damage between these two approaches. METHODS Forty-six patients were included. Muscle atrophy, determined with the Goutallier classification, and muscle surface of twelve muscles were analyzed on magnetic resonance imaging images made preoperatively and one year postoperatively. Differences in component placement after DAA or PLA were assessed on radiographs. Harris hip scores and Hip disability and Osteoarthritis and Outcome Score were used as functional outcomes. RESULTS External rotator musculature was damaged in both approaches. After PLA, the obturator muscles showed significantly more atrophy and a decrease in muscle surface. After DAA, the tensor fascia latae showed an increased muscle atrophy and the psoas muscle showed a decreased muscle surface. An increase in muscle surface was seen for the rectus femoris, sartorius, and quadratus femoris after both approaches. The muscle surface of the gluteus medius and iliacus was also increased after PLA. No difference in muscle atrophy was found between the approaches for these muscles. The inclination angle of the cup in PLA was significantly higher. No differences were found in functional outcomes. CONCLUSION Different muscle groups were affected in the two approaches. After PLA, the external rotators were more affected, whereas the tensor fascia latae and psoas muscles were more affected after DAA.
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Affiliation(s)
- Kyrill Rykov
- Department of Orthopaedic Surgery, Martini Hospital Groningen, the Netherlands
| | - Tim W G M Meys
- Department of Radiology, Martini Hospital Groningen, the Netherlands
| | - Bas A S Knobben
- Department of Orthopaedic Surgery, Martini Hospital Groningen, the Netherlands
| | - Maurits S Sietsma
- Department of Orthopaedic Surgery, Martini Hospital Groningen, the Netherlands
| | - Inge H F Reininga
- Department of Trauma Surgery, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Bas L E F Ten Have
- Department of Orthopaedic Surgery, Martini Hospital Groningen, the Netherlands
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Lazaru P, Bueschges S, Ramadanov N. Direct anterior approach (DAA) vs. conventional approaches in total hip arthroplasty: A RCT meta-analysis with an overview of related meta-analyses. PLoS One 2021; 16:e0255888. [PMID: 34428236 PMCID: PMC8384214 DOI: 10.1371/journal.pone.0255888] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/26/2021] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES Several systematic reviews and meta-analyses on short-term outcomes between total hip arthroplasty (THA) through direct anterior approach (DAA) compared to THA through conventional (including anterior, anterolateral, lateral transgluteal, lateral transtrochanteric, posterior, and posterolateral) approaches (CAs) in treatment of hip diseases and fractures showed contradicting conclusions. Our aim was to draw definitive conclusions by conducting both a fixed and random model meta-analysis of quality randomized controlled trials (RCTs) and by comparison with related meta-analyses. DESIGN We performed a systematic literature search up to May 2020 to identify RCTs, comparing THA through DAA with THA through CAs and related meta-analyses. We conducted risk of bias and level of evidence assessment in accordance with the Cochrane's Risk of Bias 2 tool and with the guidelines of the Centre for Evidence-Based Medicine. We estimated mean differences (MD) with 95% confidence intervals (CI) through fixed and random effects models, using the DerSimonian and Laird method. Heterogeneity was assessed using tau-square (τ2). Our conclusions take into account the overall results from related meta-analyses. RESULTS Nine studies on THA through DAA met the criteria for final meta-analysis, involving 998 patients. Three studies were blinded RCTs with a level I evidence, the other 6 studies were non-blinded RCTs with a level II evidence. We came to the following results for THA through DAA compared to THA through CAs: operation time (I2 = 92%, p<0.01; fixed: MD = 15.1, 95% CI 13.1 to 17.1; random: MD = 18.1, 95% CI 8.6 to 27.5); incision length (I2 = 100%, p<0.01; fixed: MD = -2.9, 95% CI -3.0 to -2.8; MD = -1.1, 95% CI -4.3 to 2.0); intraoperative blood loss (I2 = 87%, p<0.01; fixed: MD = 51.5, 95% CI 34.1 to 68.8; random: MD = 51.9, 95% CI -89.8 to 193.5); VAS 1 day postoperatively (I2 = 79%, p = 0.03; fixed: MD = -0.8, 95% CI -1.2 to -0.4; random: MD = -0.9, 95% CI -2.0 to 0.15); HHS 3 months postoperatively (I2 = 52%, p = 0.08; fixed: MD = 2.8, 95% CI 1.1 to 4.6; random: MD = 3.0, 95% CI -0.5 to 6.5); HHS 6 months postoperatively (I2 = 0%, p = 0.67; fixed: MD = 0.9, 95% CI -1.1 to 2.9; random: MD = 0.9, 95% CI -1.1 to 2.9); HHS 12 months postoperatively (I2 = 0%, p = 0.79; fixed: MD = 0.7, 95% CI -0.9 to 2.4; random: MD = 0.7, 95% CI -0.9 to 2.4). We compared our findings with 7 related meta-analyses. CONCLUSIONS Considering the results of our meta-analysis and the review of related meta-analyses, we can conclude that short-term outcomes of THA through DAA were overall better than THA through CAs. THA through DAA had a shorter incision length, a tendency towards a lower pain VAS 1 day postoperatively and better early postoperative functional outcome than THA through CAs. The intraoperative blood loss showed indifferent results. THA through DAA had a longer operation time than THA through CAs.
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Affiliation(s)
- Philip Lazaru
- Center for Surgery, Evangelical Hospital Ludwigsfelde-Teltow, Ludwigsfelde, Germany
| | - Simon Bueschges
- Faculty of Medicine, Department of Statistics, University of Salamanca, Salamanca, Spain
| | - Nikolai Ramadanov
- Department of Emergency Medicine, University Hospital Jena, Friedrich Schiller University, Jena, Germany
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Awad ME, Farley BJ, Mostafa G, Saleh KJ. Direct anterior approach has short-term functional benefit and higher resource requirements compared with the posterior approach in primary total hip arthroplasty : a meta-analysis of functional outcomes and cost. Bone Joint J 2021; 103-B:1078-1087. [PMID: 34058867 DOI: 10.1302/0301-620x.103b6.bjj-2020-1271.r1] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS It has been suggested that the direct anterior approach (DAA) should be used for total hip arthroplasty (THA) instead of the posterior approach (PA) for better early functional outcomes. We conducted a value-based analysis of the functional outcome and associated perioperative costs, to determine which surgical approach gives the better short-term outcomes and lower costs. METHODS This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and the Cochrane Handbook. Several online databases were searched. Non-stratified and stratified meta-analyses were conducted to test the confounding biases in the studies which were included. The mean cost and probability were used to determine the added costs of perioperative services. RESULTS The DAA group had significantly longer operating times (p < 0.001), reduced length of hospital stay by a mean of 13.4 hours (95% confidence interval (CI) 9.12 to 18; p < 0.001), and greater blood loss (p = 0.030). The DAA group had significantly better functional outcome at three (p < 0.001) and six weeks (p = 0.006) postoperatively according to the Harris Hip Score (HHS). However, there was no significant difference between the groups for the HHS at six to eight weeks (p = 0.230), 12 weeks (p = 0.470), six months (p = 0.740), and one year (p = 0.610), the 12-Item Short Form Survey (SF-12) physical score at six weeks (p = 0.580) and one year (p = 0.360), SF-12 mental score at six weeks (p = 0.170) and one year (p = 0.960), and University of California and Los Angeles (UCLA) activity scale at 12 weeks (p = 0.250). The mean non-stratified and stratified difference in costs for the operating theatre time and blood transfusion were $587.57 (95% CI 263.83 to 1,010.29) to $887.04 (95% CI 574.20 to 1,298.88) and $248.38 (95% CI 1,003.40 to 1,539.90) to $1,162.41 (95% CI 645.78 to 7,441.30), respectively, more for the DAA group. However, the mean differences in costs for the time in hospital were $218.23 and $192.05, respectively, less for the DAA group. CONCLUSION The use of the DAA, rather than the PA, in THA has earlier benefits for function and pain. However, these are short-lasting, with no significant differences seen at later intervals. In addition the limited benefits were obtained with higher cumulative costs for DAA. Cite this article: Bone Joint J 2021;103-B(6):1078-1087.
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Affiliation(s)
- Mohamed E Awad
- Resident Research Partnership, Detroit, Michigan, USA.,NorthStar Anesthesia, Detroit Medical Center, Detroit, Michigan, USA.,School of Medicine, Wayne State University, Detroit, Michigan, USA
| | - Brendan J Farley
- Resident Research Partnership, Detroit, Michigan, USA.,College of Medicine, Central Michigan University, Mount Pleasant, Michigan, USA
| | - Gamal Mostafa
- School of Medicine, Wayne State University, Detroit, Michigan, USA.,Surgical Outcomes Research Institute, Detroit, Michigan, USA
| | - Khaled J Saleh
- Resident Research Partnership, Detroit, Michigan, USA.,Surgical Outcomes Research Institute, Detroit, Michigan, USA.,College of Osteopathic Medicine, Michigan State University, Detroit, Michigan, USA
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Ramadanov N, Bueschges S, Liu K, Lazaru P, Marintschev I. 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. J Orthop Surg Res 2021; 16:324. [PMID: 34016136 PMCID: PMC8136223 DOI: 10.1186/s13018-021-02315-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 02/18/2021] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Nikolai Ramadanov
- Clinic for Emergency Medicine, University Hospital Jena, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany.
| | - Simon Bueschges
- Faculty of Medicine, Department of Statistics, University of Salamanca, Calle Espejo 2, 37007, Salamanca, Spain
| | - Kuiliang Liu
- Department for Orthopaedics and Trauma Surgery, Siloah St. Trudpert Hospital, Wilferdinger Str. 67, 75179, Pforzheim, Germany
| | - Philip Lazaru
- Center for Surgery, Evangelical Hospital Ludwigsfelde-Teltow, Albert-Schweitzer-Str. 40-44, 14974, Ludwigsfelde, Germany
| | - Ivan Marintschev
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany
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Migliorini F, Trivellas A, Eschweiler J, Driessen A, Lessi F, Tingart M, Aretini P. Nerve palsy, dislocation and revision rate among the approaches for total hip arthroplasty: a Bayesian network meta-analysis. Musculoskelet Surg 2021; 105:1-15. [PMID: 32372300 DOI: 10.1007/s12306-020-00662-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 04/18/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Total hip arthroplasty (THA) is one of the most performed intervention in orthopaedics surgery. Currently, there is no unanimous approval concerning the best approach for THA in terms of nerve palsies, dislocations and further revisions. Hence, a Bayesian network meta-analysis was conducted. METHODS The present study was conducted according to the PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of healthcare interventions. The literature search was performed in September 2019. The NMA was performed through the STATA Software/MP routine for Bayesian hierarchical random-effects model analysis. RESULTS Data from 10,675 THA were collected. The mean follow-up was 10 months. The anterior approach reported the lowest risk to incur a post-operative dislocation (overall inconsistency P = 0.99). The posterolateral approach reported the lowest risk to incur a nerve palsy (overall inconsistency P = 0.77). The funnel plot revealed a low risk of publication bias. The lateral approach was found to have the lowest risk of resulting in a revision surgery (overall inconsistency P = 0.90). CONCLUSION According to our network comparisons, the posterolateral approach for THA represent the favourable exposure with regards to nerve palsy, further dislocations and revision surgeries.
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Affiliation(s)
- F Migliorini
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - A Trivellas
- Department of Orthopaedics, David Geffen School of Medicine at UCLA, Suite 755, Los Angeles, CA, 90095, USA
| | - J Eschweiler
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - A Driessen
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - F Lessi
- Fondazione Pisana Per La Scienza, Via Ferruccio Giovannini 13, 56017, Pise, Italy
| | - M Tingart
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - P Aretini
- Fondazione Pisana Per La Scienza, Via Ferruccio Giovannini 13, 56017, Pise, Italy
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Meng W, Gao L, Huang Z, Wang H, Wang D, Luo Z, Bai Y, Wang G, Zhou Z. Supercapsular percutaneously-assisted total hip (SuperPath) versus mini-incision posterolateral total hip arthroplasty for hip osteoarthritis: a prospective randomized controlled trial. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:392. [PMID: 33842613 PMCID: PMC8033341 DOI: 10.21037/atm-20-1793a] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Supercapsular percutaneously-assisted total hip (SuperPath) arthroplasty has been proposed to be minimally invasive and tissue sparing, with possible superior postoperative outcomes compared with conventional approaches for total hip arthroplasty (THA). However, previous studies have underlined the shortcomings of conventional THA approaches, including higher dislocation, more blood loss, longer incisions, more tissue damage, and delayed postoperative rehabilitation. In the present study, we compared the short-term outcomes of unilateral THA with those of SuperPath and the mini-incision posterolateral approach (PLA) for hip osteoarthritis (OA). Methods Patients with unilateral hip OA were prospectively recruited and underwent either SuperPath (SuperPath group) or mini-incision PLA THA (PLA group). Perioperative status [operative time, incision length, intraoperative blood loss, soft tissue damage, and length of hospital stay (LOS)], and postoperative function outcomes, including range of motion (ROM), pain visual analog scale (VAS), and Harris Hip Score (HHS), were evaluated and compared between the groups at scheduled time points within 12 months postoperatively. Results Compared with the PLA group, the SuperPath group yielded a significantly shorter incision length (7.83 vs. 12.45 cm, P<0.001), longer operative time (102.72 vs. 66.22 min, P<0.001), more blood loss (1,007.38 vs. 844.55 mL, P=0.005), and more soft tissue damage (creatine kinase: 1,056.05 vs. 821.50 U/L, P=0.006) on postoperative day 3. The SuperPath group also showed deficient acetabular cup positioning (abduction angle: 36.94° vs. 42.66°, P=0.004) and a greater decrease in ROM (flexion: 107.66° vs. 114.44°, P=0.004; 109.83° vs. 116.11°, P=0.002; 111.66° vs. 118.88°, P<0.001) on postoperative days 1, 3, and 14, as well as severe early-term pain symptoms (pain VAS on postoperative day 3: 7.05 vs. 6.55, P=0.041). However, the LOS, C-reactive protein levels, erythrocyte sedimentation rate (within 2 weeks postoperatively), and HHS were comparable between the groups during the 12 months postoperatively. Conclusions SuperPath may be a promising, minimally invasive technique for the treatment of OA in the future. Further investigation is necessary to evidence the possible superiority of SuperPath over other conventional mini-incision THA approaches.
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Affiliation(s)
- Weikun Meng
- Department of Orthopaedics, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China.,Center of Experimental Orthopaedics, Saarland University Medical Center, Homburg/Saar, Germany.,Sino Euro Orthopaedics Network (SEON), Homburg/Saar, Germany
| | - Liang Gao
- Center of Experimental Orthopaedics, Saarland University Medical Center, Homburg/Saar, Germany.,Sino Euro Orthopaedics Network (SEON), Homburg/Saar, Germany
| | - Zhong Huang
- Department of Orthopaedics, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China.,Sino Euro Orthopaedics Network (SEON), Homburg/Saar, Germany
| | - Haoyang Wang
- Department of Orthopaedics, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Duan Wang
- Department of Orthopaedics, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Zeyu Luo
- Department of Orthopaedics, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Yang Bai
- Department of Immunization, Yunnan Center for Disease Control and Prevention, Kunming, China
| | - Guanglin Wang
- Department of Orthopaedics, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Zongke Zhou
- Department of Orthopaedics, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
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Sun X, Zhao X, Zhou L, Su Z. Direct anterior approach versus posterolateral approach in total hip arthroplasty: a meta-analysis of results on early post-operative period. J Orthop Surg Res 2021; 16:69. [PMID: 33468181 PMCID: PMC7816494 DOI: 10.1186/s13018-021-02218-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 01/07/2021] [Indexed: 12/30/2022] Open
Abstract
Background This study was performed to compare the advantage and disadvantage of posterolateral approach (PLA) and direct anterior approach (DAA) in total hip arthroplasty (THA). Methods Relevant trials were identified via a search of the Cochrane Central Register of Controlled Trials and PubMed from inception to 1 June 2019. A meta-analysis was performed to compare postoperative perioperative and radiographic outcomes between DAA and PLA in THA with respect to the hospital stay, blood loss, incision length, operative time, complications, and femoral and cup component position. The Harris Hip Score (HHS) was also assessed before and after 6 months postoperatively. Results Nine eligible studies involving 22698 adult patients (DAA group, n = 2947; PLA group, n = 19751) were identified for analysis. Compared with the PLA group, the DAA group had shorter hospital stay and achieved better HHS within 6 months after operation (P < 0.05), but the HHS was no significant differences between the two groups over 6 months (P > 0.05). The DAA group had significantly longer operative time, more blood loss, and complications than the PLA group (P < 0.05). In addition, the femoral component positioned in neutral and cup component inclination angle was comparable between both groups (P > 0.05); however, cup component anteversion angle was significantly larger in the PLA group (P < 0.05). Conclusion Patients in the DAA group had higher HHS within 6 months and shorter hospital stay. The DAA could offer rapid early functional recovery after THA compared with the PLA. However, the DAA group often required longer operative time and had more blood loss. Furthermore, there was a higher early complication rate. Therefore, we believe that the direct anterior approach was a more difficult technique. The surgeon should be a well-trained joint surgeon with extensive prior hip replacement experience before performing THA through a DAA, and DAA was not suitable for beginners performing THA. In addition, we did not observe the difference with regard to the femoral component position and cup component inclination angle except for the smaller cup component anteversion angle in DAA group.
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Affiliation(s)
- Xuedong Sun
- Departments of Orthopaedics, Weifang People's Hospital, no. 151 Guangwen Road, Weifang, 260041, China
| | - Xueli Zhao
- Department Rheumatology, Weifang People's Hospital, no. 151 Guangwen Road, Weifang, 260041, China
| | - Licheng Zhou
- Departments of Orthopaedics, Weifang People's Hospital, no. 151 Guangwen Road, Weifang, 260041, China
| | - Zheng Su
- Department of Medical Oncology, Weifang People's Hospital, no. 151 Guangwen Road, Weifang, 260041, China.
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Martin JR, Masonis JL, Mason JB. Anatomic Total Hip Component Position Is More Reproducible With the Direct Anterior Approach Using Intraoperative Fluoroscopy. Arthroplast Today 2020; 6:777-783. [PMID: 32964086 PMCID: PMC7490589 DOI: 10.1016/j.artd.2020.07.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 11/19/2022] Open
Abstract
Background Total hip arthroplasty (THA) has demonstrated excellent results regardless of the surgical approach. However, the approach used may be a factor in final positioning of implants. We hypothesized that the direct anterior approach (DAA) with fluoroscopy would be associated with more anatomic implant positioning than the posterior approach (PA). Methods A retrospective review of 200 patients was performed. One hundred patients underwent THA utilizing the PA, and 100 patients, with the DAA. All patients had an anterior-posterior pelvis radiograph preoperatively and postoperatively with a magnification marker present to standardize each radiograph. Exclusion criteria included contralateral THA or any pelvic or femoral deformity. Results Preoperative radiographs demonstrated identical cohorts with respect to leg length, femoral offset, and total offset. Postoperatively, the DAA achieved more accurate anatomic restoration of leg length (1.6 mm vs 5.5 mm; P < .0001), femoral offset (4.8 mm vs 9.3 mm; P < .0001), and total offset (0.5 mm vs 4.7 mm; P < .0001) compared with the PA. Ideal cup abduction and anteversion were significantly superior to the DAA (96% vs 78%, P = .0002, and 69% vs 24%, P < .0001, respectively). Conclusions This study is the first to compare anatomic implant positioning between patients undergoing THA with these 2 approaches. All parameters were significantly closer to anatomic implant positioning with the DAA. There are at least 2 potential explanations for this: (1) The DAA implant positioning was performed under fluoroscopic guidance, whereas the PA was not. (2) The PA disrupts the posterior capsule and external rotators, and therefore, increased offset or leg length may be necessary to achieve comparable hip stability with the DAA.
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Affiliation(s)
| | | | - J. Bohannon Mason
- OrthoCarolina Hip and Knee Center, Charlotte, NC, USA
- Corresponding author. OrthoCarolina Hip and Knee Center, 2001 Vail Avenue, Charlotte, NC 28207, USA. Tel.: +1 704 323 2564.
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Chen W, Sun JN, Zhang Y, Zhang Y, Chen XY, Feng S. Direct anterior versus posterolateral approaches for clinical outcomes after total hip arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res 2020; 15:231. [PMID: 32576223 PMCID: PMC7310458 DOI: 10.1186/s13018-020-01747-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/16/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The main objective of our study was to compare the intraoperative and postoperative outcomes of direct anterior approach (DAA) with posterolateral approaches (PLA). METHODS We searched Cochrane library, Web of Science, and PubMed for literatures comparing DAA with PLA. On the basis of inclusion and exclusion criteria, relevant literatures were selected. Two members independently screened qualified literatures, evaluated the literature quality, and extracted data information. RESULTS Eighteen randomized controlled trials (RCTs) and non-RCTs totaling 34,873 patients (DAA = 9636, PLA = 25237) were contained in this systematic review and meta-analysis. The results showed that DAA were reduced in terms of length of hospital stay (weighted mean difference (WMD) = -0.43, 95% confidence interval (CI) -0.78 to -0.09, P = 0.01), LLD (WMD = -2.00, 95% CI -2.75 to -1.25, P < 0.00001), PE/DVT (WMD = 0.36, 95% CI 0.15 to 0.85, P = 0.02), dislocation (WMD = 0.42, 95% CI 0.30 to 0.59, P < 0.00001) and visual analog scale (VAS) (WMD = -0.57, 95% CI -0.91 to -0.23, P = 0.0009) compared with PLA; however, DAA compared with the PLA was increasing in terms of operative time (WMD = 14.81, 95% CI 7.18 to 22.44, P = 0.0001), intraoperative blood loss (WMD = 105.13, 95% CI 25.35 to 184.90, P = 0.01), fracture (WMD = 1.46, 95% CI 1.00 to 2.11, P = 0.05), and Harris hip score (HHS) (WMD = 1.19, 95% CI 0.77 to 1.61, P < 0.00001). CONCLUSIONS DAA was preferable effectiveness to PLA in early pain relief and functional recovery; however, PLA has a shorter operation time, intraoperative less blood loss and fracture. TRIAL REGISTRATION Registration ID, CRD42020151208.
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Affiliation(s)
- Wang Chen
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, Xuzhou, 221002, Jiangsu, China
| | - Jian-Ning Sun
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, Xuzhou, 221002, Jiangsu, China
| | - Ye Zhang
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, Xuzhou, 221002, Jiangsu, China
| | - Yu Zhang
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, Xuzhou, 221002, Jiangsu, China
| | - Xiang-Yang Chen
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, Xuzhou, 221002, Jiangsu, China.
| | - Shuo Feng
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, Xuzhou, 221002, Jiangsu, China.
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Yang XT, Huang HF, Sun L, Yang Z, Deng CY, Tian XB. Direct Anterior Approach Versus Posterolateral Approach in Total Hip Arthroplasty: A Systematic Review and Meta-analysis of Randomized Controlled Studies. Orthop Surg 2020; 12:1065-1073. [PMID: 32558261 PMCID: PMC7454221 DOI: 10.1111/os.12669] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 03/08/2020] [Accepted: 03/11/2020] [Indexed: 01/19/2023] Open
Abstract
Objective To compare the early rehabilitation effects of total hip arthroplasty (THA) with the direct anterior approach (DAA) versus the posterior approach (PA). Methods We searched PubMed, Embase, Web of Science, the Cochrane Library, and Google databases from inception to June 2019 to select studies that compared the DAA and PA for THA. Only randomized controlled trials (RCT) were included. Two researchers independently screened studies for inclusion, extracted data, and assessed the methodological quality. A meta‐analysis was conducted using RevMan 5.3 software provided by Cochrane Assisted Network. Results A total of 932 patients underwent THA. There were 467 cases in group DAA and 465 cases in group PA. There was a significant difference in the incidence of lateral femoral cutaneous nerve injury between DAA and PA groups (RR = 38.97, 95% CI: 7.89–192.57, P < 0.05). DAA was associated with less pain compared with PA [WMD = −0.65, 95% CI (−0.91–0.38), P < 0.05]. There was no significant difference in operation time, hospitalization stay, and intraoperative bleeding volume. Moreover, in supplementary data, the number of acetabular prostheses in Lewinnek's safety zones in DAA was more than that in the PA group (RR = 1.20, 95% CI [1.04–1.39], P < 0.05), and the time of discontinuation of walking aids in the DAA group was earlier than that in the PA group (WMD = −11.05, 95% CI [−17.79–4.31], P < 0.05). Conclusion The DAA total hip arthroplasty has comparable results with PA, with earlier postoperative functional recovery, less postoperative pain scores, and higher incidence of lateral femoral cutaneous nerve injury. The results need to be validated by large‐sample, high‐quality RCT studies, and long‐term follow‐up of complications.
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Affiliation(s)
- Xian-Teng Yang
- Department of Orthopaedics, People's Hospital of Guizhou Province, Guiyang, Guangzhou, China.,Medical College of Guizhou University, Guiyang, China
| | - Hai-Feng Huang
- Department of Orthopaedics, People's Hospital of Guizhou Province, Guiyang, Guangzhou, China.,Medical College of Guizhou University, Guiyang, China
| | - Li Sun
- Department of Orthopaedics, People's Hospital of Guizhou Province, Guiyang, Guangzhou, China
| | - Zhen Yang
- Department of Orthopaedics, People's Hospital of Guizhou Province, Guiyang, Guangzhou, China.,Medical College of Guizhou University, Guiyang, China
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Peng L, Zeng Y, Wu Y, Zeng J, Liu Y, Shen B. Clinical, functional and radiographic outcomes of primary total hip arthroplasty between direct anterior approach and posterior approach: a systematic review and meta-analysis. BMC Musculoskelet Disord 2020; 21:338. [PMID: 32487060 PMCID: PMC7265223 DOI: 10.1186/s12891-020-03318-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 04/28/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The purpose of this systematic review and meta-analysis was to compare the direct anterior approach and posterior approach for primary total hip arthroplasty in terms of the clinical, functional and radiographic outcomes. METHODS We searched the PubMed and EMBASE databases and Cochrane Library from their inception to November 1, 2019. We searched for previously published articles and meta-analyses of randomized controlled trials. RESULTS A total of 7 randomized controlled trials with 600 participants met the inclusion criteria. Among these patients, 301 and 299 were included in the DAA and PA groups, respectively. The DAA was associated with a longer surgery by a mean duration of 13.74 min (95% CI 6.88 to 20.61, p < 0.0001, I2 = 93%). The postoperative early functional outcomes were significantly better in the DAA group than in the PA group, such as the Visual Analogue Scale (VAS) score at 1 day postoperatively (MD = -0.65, 95% CI - 0.91 to - 0.38, p < 0.00001, I2 = 0%), VAS score at 2 days postoperatively (MD = -0.67, 95% CI - 1.34 to - 0.01, p = 0.05, I2 = 88%) and Harris Hip Score (HHS) at 6 weeks postoperatively (MD = 6.05, 95% CI 1.14 to 10.95, p = 0.02, I2 = 52%). There was no significant difference between the DAA and PA groups in the length of the incision, hospital length of stay (LOS), blood loss, transfusion rates or complication rates. We found no significant difference between the two groups regarding late functional outcomes, such as the VAS score at 12 months postoperatively or the HHS scores at 3, 6, and 12 months postoperatively. A significant difference in the radiographic outcomes was not detected. CONCLUSIONS The DAA requires a longer surgery time than does the PA in primary total hip arthroplasty. The DAA yields better early functional recovery than does the PA. There was no significant difference between the two groups in terms of other clinical, complication-related, late functional or radiographic outcomes. The evidence on the superiority of the DAA is insufficient and needs to be studied further.
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Affiliation(s)
- Linbo Peng
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, People's Republic of China
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Yi Zeng
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, People's Republic of China
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Yuangang Wu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, People's Republic of China
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Junfeng Zeng
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, People's Republic of China
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Yuan Liu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, People's Republic of China
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Bin Shen
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, People's Republic of China.
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China.
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Cao J, Zhou Y, Xin W, Zhu J, Chen Y, Wang B, Qian Q. Natural outcome of hemoglobin and functional recovery after the direct anterior versus the posterolateral approach for total hip arthroplasty: a randomized study. J Orthop Surg Res 2020; 15:200. [PMID: 32487264 PMCID: PMC7268999 DOI: 10.1186/s13018-020-01716-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 05/20/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Total hip arthroplasty (THA) is one of the most successful orthopedic surgeries. There are many common surgical approaches for THA. The direct anterior approach (DAA) and posterolateral approach (PLA) were compared, leading to controversial results. METHODS We report on a prospective randomized study which compared the changes of perioperative hemoglobin (Hb), the Harris hip score (HHS) and a visual analog scale (VAS) pain score following THA using DAA or PLA. A total of 130 participants were randomly divided into two groups (65 DAA versus 65 PLA). Perioperative ΔHb and other clinical outcomes were recorded. RESULTS A total of 130 participants completed follow-up, while 14 patients were not recorded in blood outcomes due to blood transfusions and complications. The average Hb decrease immediately after surgery in the DAA group was greater than that in the PLA group (21.1 versus 15.8 g/L, P < .001). However, post-operative Hb descent velocity was slower in the DAA group, and the lowest point was reached earlier. No significant differences in ΔHb levels could be observed after 1 month in the two groups. When compared with the PLA group, the DAA group had a shorter incision (9.1 versus 13.5 cm, P < .001) and shorter hospital stay (4.2 versus 4.7 days, P = .004). However, the operation time of the DAA group was longer (88.0 versus 66.8 min, P < .001). The DAA group had a better HHS and VAS pain score at 6 weeks post-surgery. However, no significant differences were observed at later time points. CONCLUSION We concluded that DAA performed better on enhanced recovery after surgery (ERAS) than PLA in THA, while both DAA and PLA could result in a positive, similar result after 3 months. TRIAL REGISTRATION The study was registered by the Chinese Clinical Trial Registry (ChiCTR1900020770, 19 January 2019).
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Affiliation(s)
- Jia Cao
- Department of Joint Surgery and Sports Medicine, Shanghai Changzheng Hospital, Second Military Medical University, No.415, Fengyang Road, Shanghai, 200003, China
| | - Yiqin Zhou
- Department of Joint Surgery and Sports Medicine, Shanghai Changzheng Hospital, Second Military Medical University, No.415, Fengyang Road, Shanghai, 200003, China
| | - Wei Xin
- Department of Joint Surgery and Sports Medicine, Shanghai Changzheng Hospital, Second Military Medical University, No.415, Fengyang Road, Shanghai, 200003, China
| | - Jun Zhu
- Department of Joint Surgery and Sports Medicine, Shanghai Changzheng Hospital, Second Military Medical University, No.415, Fengyang Road, Shanghai, 200003, China
| | - Yi Chen
- Department of Joint Surgery and Sports Medicine, Shanghai Changzheng Hospital, Second Military Medical University, No.415, Fengyang Road, Shanghai, 200003, China.
| | - Bo Wang
- Department of Joint Surgery and Sports Medicine, Shanghai Changzheng Hospital, Second Military Medical University, No.415, Fengyang Road, Shanghai, 200003, China.
| | - Qirong Qian
- Department of Joint Surgery and Sports Medicine, Shanghai Changzheng Hospital, Second Military Medical University, No.415, Fengyang Road, Shanghai, 200003, China.
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Cha Y, Yoo JI, Kim JT, Park CH, Choy W, Ha YC, Koo KH. Disadvantage during Perioperative Period of Total Hip Arthroplasty Using the Direct Anterior Approach: a Network Meta-Analysis. J Korean Med Sci 2020; 35:e111. [PMID: 32383362 PMCID: PMC7211512 DOI: 10.3346/jkms.2020.35.e111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 02/27/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The purpose of this study was to analyze complications of complete hip arthroplasty through systematic review and network meta-analysis of comparative studies of direct anterior approach (DAA), anterolateral approach (LA), and posterolateral approach (PA). METHODS Prospective randomized controlled trials (RCTs) or quasi-experimental designs evaluating clinical outcomes of DAA, LA, and PA for complete hip arthroplasty are valid if they meet the following criteria: 1) Comparison of clinical outcomes between the three methods for main complete hip arthroplasty (total hip arthroplasty, THA); 2) Compared at least one of the following outcomes: blood loss, operating time, and transfusion volume; 3) Sufficient data were available to extract and pool, i.e., mean reported, standard deviation and number of subjects. A network meta-analysis was used to determine the results of treatment across various surgical approaches. Indirect comparisons between the two surgical approaches was made by borrowing details from the standard comparator (i.e., the posterior approach). RESULTS Eight prospective RCTs were included in the meta-analysis of the network. The operation time of the LA was longer than that of PA (standardized mean difference [SMD], 0.96; 95% confidence interval [CI], 0.74-1.18; P < 0.001). DAA also had significantly longer operation time than PA (SMD, 0.45; 95% CI, 0.24-0.66; P < 0.001). However, blood loss of the DAA was the highest compared to other approaches (SMD, 0.60; 95% CI, 0.39-0.82; P = 0.002). CONCLUSION When performing THA with DAA, we should pay attention to increased operation time and blood loss.
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Affiliation(s)
- Yonghan Cha
- Department of Orthopaedic Surgery, Gyeongsang National University Hospital, Jinju, Korea
| | - Jun Il Yoo
- Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, Korea.
| | - Jung Taek Kim
- Department of Orthopedic Surgery, Ajou Medical Center, Ajou University School of Medicine, Suwon, Korea
| | - Chan Ho Park
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Daegu, Korea
| | - Wonsik Choy
- Department of Orthopaedic Surgery, Gyeongsang National University Hospital, Jinju, Korea
| | - Yong Chan Ha
- Department of Orthopedic Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Kyung Hoi Koo
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
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Migliorini F, Trivellas A, Eschweiler J, El Mansy Y, Mazzanti MC, Tingart M, Aretini P. Hospitalization length, surgical duration, and blood lost among the approaches for total hip arthroplasty: a Bayesian network meta-analysis. Musculoskelet Surg 2020; 104:257-266. [PMID: 32248344 DOI: 10.1007/s12306-020-00657-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/27/2020] [Indexed: 01/16/2023]
Abstract
Despite the numerous studies, there is no consensus concerning the best approach for total hip arthroplasty (THA), and debates are ongoing. The purpose of this study was to perform a Bayesian network meta-analysis (NMA) comparing several approaches for primary THA. The focus was on peri-operative outcomes: surgical duration, total estimated blood loss, and length of the hospitalization. This Bayesian network meta-analysis was conducted according to the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of health care interventions. In October 2019, the main databases were accessed. All the clinical trials comparing two or more different approaches for primary THA were assessed. For the methodology quality assessment, the PEDro score was performed. The Software STATA MP was used for the statistical analyses. The NMA was performed through the routine for Bayesian hierarchical random-effects analysis with the inverse variance statistic method for continuous variables. Data from 4843 procedures was analysed. Between patient's demographic, good baseline comparability was found. The comparison total estimated blood loss detected statistically significant inconsistency (P = 0.01). The posterolateral approach reported the lowest value for the surgical duration. The test for overall inconsistency was statistically significant (P = 0.4). The posterolateral approach reported the shortest hospitalization length. The test for overall inconsistency was statistically significant (P = 0.9). The posterolateral approach reported shorter surgical duration and hospitalization length. Concerning the analysis of total estimated blood loss, no significant result was obtained. Data must be considered in the light of the limitations of the present study.
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Affiliation(s)
- F Migliorini
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - A Trivellas
- Department of Orthopaedics, David Geffen School of Medicine at UCLA, Suite 755, Los Angeles, CA, 90095, USA
| | - J Eschweiler
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Y El Mansy
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany.,Department of Orthopedics and Traumatology, University of Alexandria, Alexandria, Egypt
| | - M C Mazzanti
- Fondazione Pisana per la Scienza, Via Ferruccio Giovannini 13, 56017, Pisa, Italy
| | - M Tingart
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - P Aretini
- Fondazione Pisana per la Scienza, Via Ferruccio Giovannini 13, 56017, Pisa, Italy
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Vajapey SP, Morris J, Li D, Greco NG, Li M, Spitzer AI. Outcome Reporting Patterns in Total Hip Arthroplasty. JBJS Rev 2020; 8:e0197. [DOI: 10.2106/jbjs.rvw.19.00197] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Mostello AJ, Tenpenny W, Lingamfelter M, Wu ES. Daily Postoperative Complete Blood Counts After Primary Total Joint Arthroplasty May Not Always Be Necessary. Orthopedics 2020; 43:e31-e36. [PMID: 31693744 DOI: 10.3928/01477447-20191031-08] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 12/11/2018] [Indexed: 02/03/2023]
Abstract
As the incidence of primary total hip and knee arthroplasties increases and reimbursement models shift toward a more quality-based model, orthopedic surgeons must focus on maintaining quality while containing costs. With current blood conservation strategies, serial laboratory testing after total joint arthroplasty (TJA) may not always be necessary. This study investigated the need for routine postoperative complete blood counts (CBCs) by determining preoperative and postoperative day 1 hemoglobin values that predict the need for a postoperative blood transfusion. Data were used to estimate potential cost savings. The medical records of all patients who underwent primary unilateral TJA performed by a single surgeon between October 2014 and September 2017 were reviewed. Patient demographic and procedural data were recorded, and statistical and cost analyses were performed. Of 108 TJAs, 9 (8.3%) patients received a blood transfusion during their postoperative inpatient stay. A preoperative hemoglobin value of 12.5 g/dL or less and a postoperative day 1 hemoglobin value of 10 g/dL or less were strong predictors of meeting the threshold transfusion trigger for a postoperative blood transfusion (area under the curve, 0.845 and 0.943, respectively). A 56% cost reduction ($845) could have been achieved by eliminating CBCs performed after postoperative day 1 in patients at low risk for transfusion. Patients with preoperative hemoglobin value levels greater than 12.5 g/dL and postoperative day 1 hemoglobin value levels greater than 10 g/dL may not require routine serial CBC monitoring after primary TJA. The cost savings in a high-volume joint center could be significant. [Orthopedics. 2020; 43(1): e31-e36.].
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A meta-analysis comparing the direct anterior with other approaches in primary total hip arthroplasty. Surgeon 2019; 17:291-299. [DOI: 10.1016/j.surge.2018.09.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 09/14/2018] [Accepted: 09/20/2018] [Indexed: 02/06/2023]
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Ries MD. Relationship Between Functional Anatomy of the Hip and Surgical Approaches in Total Hip Arthroplasty. Orthopedics 2019; 42:e356-e363. [PMID: 31323107 DOI: 10.3928/01477447-20190624-03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 09/12/2018] [Indexed: 02/03/2023]
Abstract
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.].
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Bon G, Kacem EB, Lepretre PM, Weissland T, Mertl P, Dehl M, Gabrion A. Does the direct anterior approach allow earlier recovery of walking following total hip arthroplasty? A randomized prospective trial using accelerometry. Orthop Traumatol Surg Res 2019; 105:445-452. [PMID: 30853454 DOI: 10.1016/j.otsr.2019.02.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 01/21/2019] [Accepted: 02/01/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In total hip arthroplasty (THA), the anterior approach is attractive, being intermuscular, with theoretic functional benefit. Such benefit has been frequently claimed, but there are few data from randomized comparative studies using more precise metrics than patient satisfaction. We therefore conducted a randomized trial comparing early functional results between anterior and posterior approaches on gait analysis and functional scores. HYPOTHESIS The study hypothesis was that there is no difference between the two approaches in terms of early recovery of walking. MATERIALS AND METHOD A single-center single-surgeon prospective randomized study was conducted between February 2017 and April 2018. Inclusion criteria comprised: age<85 years, body-mass index (BMI)<32, and hip osteoarthritis with indication for THA. Preoperatively, the 2 groups were comparable for age, gender, BMI, Charnley, Harris, Postel-Merle-d'Aubigné and Oxford-12 scores and locomotor parameters (triaxial acceleration, step regularity and walking power). Preoperative and 3-, 6- and 12-week assessment comprised triaxial acceleration in walking and Postel-Merle-d'Aubigné, Harris and Oxford SF-12 scores. RESULTS One hundred patients were randomized to the anterior approach (AA: n=50) and posterior approach (PA: n=50) groups. Hospital stay was comparable between groups: PA, 2.8±1.78 days [range, 2.29-3.31 days]; AA, 2.84±1.25 days [range, 2.48-3.2 days] (p=0.8). Operative time was significantly longer in AA: 70.1±11 minutes vs. 56.7±11.79 (p<0.0001). There were no significant differences in locomotor parameters (p 0.122 to 0.987) or functional scores (p 0.052 to 0.968) over the 3-month follow-up. There was no difference in cup inclination: PA, 39.6±6.87° [range, 37.65-41.55°] vs. AA, 37.74±4.2° [range, 36.55-38.93°] (p=0.09). There were 8/50 cases (16%) of neurapraxia of the lateral cutaneous nerve of the thigh in the AA group; rates for other complications did not differ between groups. CONCLUSION Early functional results and especially objective locomotor parameters following THA were comparable between anterior and posterior approaches at 3 to 12 weeks. The approach should be chosen according to the surgeon's experience. LEVEL OF EVIDENCE II, low-power prospective randomized study.
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Affiliation(s)
- Gautier Bon
- Service de chirurgie orthopédique et traumatologique, Centre Hospitalo-Universitaire d'Amiens Picardie, Amiens, France.
| | - Elias Ben Kacem
- Service de chirurgie orthopédique et traumatologique, Centre Hospitalo-Universitaire d'Amiens Picardie, Amiens, France
| | - Pierre Marie Lepretre
- Service de chirurgie orthopédique et traumatologique, Centre Hospitalo-Universitaire d'Amiens Picardie, Amiens, France
| | - Thierry Weissland
- Service de chirurgie orthopédique et traumatologique, Centre Hospitalo-Universitaire d'Amiens Picardie, Amiens, France
| | - Patrice Mertl
- Service de chirurgie orthopédique et traumatologique, Centre Hospitalo-Universitaire d'Amiens Picardie, Amiens, France
| | - Massinissa Dehl
- Service de chirurgie orthopédique et traumatologique, Centre Hospitalo-Universitaire d'Amiens Picardie, Amiens, France
| | - Antoine Gabrion
- Service de chirurgie orthopédique et traumatologique, Centre Hospitalo-Universitaire d'Amiens Picardie, Amiens, France
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