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Rivera RJ, Karasavvidis T, Pagan C, Haffner R, Ast MP, Vigdorchik JM, Debbi EM. Functional assessment in patients undergoing total hip arthroplasty. Bone Joint J 2024; 106-B:764-774. [PMID: 39084648 DOI: 10.1302/0301-620x.106b8.bjj-2024-0142.r1] [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] [Indexed: 08/02/2024]
Abstract
Aims Conventional patient-reported surveys, used for patients undergoing total hip arthroplasty (THA), are limited by subjectivity and recall bias. Objective functional evaluation, such as gait analysis, to delineate a patient's functional capacity and customize surgical interventions, may address these shortcomings. This systematic review endeavours to investigate the application of objective functional assessments in appraising individuals undergoing THA. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were applied. Eligible studies of THA patients that conducted at least one type of objective functional assessment both pre- and postoperatively were identified through Embase, Medline/PubMed, and Cochrane Central database-searching from inception to 15 September 2023. The assessments included were subgrouped for analysis: gait analysis, motion analysis, wearables, and strength tests. Results A total of 130 studies using 15 distinct objective functional assessment methods (FAMs) were identified. The most frequently used method was instrumented gait/motion analysis, followed by the Timed-Up-and-Go test (TUG), 6 minute walk test, timed stair climbing test, and various strength tests. These assessments were characterized by their diagnostic precision and applicability to daily activities. Wearables were frequently used, offering cost-effectiveness and remote monitoring benefits. However, their accuracy and potential discomfort for patients must be considered. Conclusion The integration of objective functional assessments in THA presents promise as a progress-tracking modality for improving patient outcomes. Gait analysis and the TUG, along with advancing wearable sensor technology, have the potential to enhance patient care, surgical planning, and rehabilitation.
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Affiliation(s)
- Richard J Rivera
- Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Theofilos Karasavvidis
- Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Cale Pagan
- Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Rowan Haffner
- Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Michael P Ast
- Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Jonathan M Vigdorchik
- Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Eytan M Debbi
- Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
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Sarhan O, Megalla M, Imam N, Ren AN, Redfern RE, Klein GR. Improved patient reported outcomes with the direct anterior approach versus the posterior approach for total hip arthroplasty in the early post-operative period. Arch Orthop Trauma Surg 2024; 144:2373-2380. [PMID: 38520548 DOI: 10.1007/s00402-024-05271-z] [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: 08/29/2023] [Accepted: 03/05/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Patients undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA) may experience faster recovery but may also have better baseline health than those who undergo THA with the posterior approach (PA). This study aimed to compare patient-reported outcome measures (PROMs) between the DAA and PA while controlling for baseline factors. METHODS This is a secondary data analysis from a prospective cohort study of patients utilizing a smartphone-based care management platform following THA. The primary outcomes were HOOS JR and EQ-5D-5L through 1 year and change from baseline. Longitudinal regression models were created to control for baseline characteristics and investigate the impact of surgical approach on PROMs. RESULTS Of 1364 THAs evaluated, 731 (53.6%) were female, and 840 (61.6%) used the PA. Patients in the PA group were of similar age but had higher body mass index and comorbidity scores. Pre-operative HOOS JR and EQ-5D-5L were comparable, but higher post-operatively in the DAA group through 6 months (p = 0.03 and p = 0.005). At 1 year post-operatively, HOOS JR and EQ-5D-5L did not vary between groups (p = 0.48 and p = 0.56), nor did changes from baseline (p = 0.47 and p = 0.11). After controlling baseline characteristics, DAA was significantly associated with higher average HOOS JR through 6 months (p = 0.03) and EQ-5D-5L through 3 months (p = 0.005), but not at 12 months (p = 0.89 and p = 0.56). CONCLUSION THA patients undergoing DAA demonstrate earlier improvements in HOOS JR and EQ-5D-5L. However, these differences may not be clinically significant and are not evident at 1-year post-operative. Patient selection and surgeon training may continue to affect outcomes by surgical approach.
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Affiliation(s)
- Omar Sarhan
- Rothman Orthopedic Institute, Hackensack, NJ, USA
| | | | - Nareena Imam
- Rothman Orthopedic Institute, Hackensack, NJ, USA
| | - Anna N Ren
- Zimmer Biomet, 345 E Main St, Warsaw, IN, 46580, USA
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Cankaya D, Inci F, Karakuş D, Turker HB, Kahve Y, Neyisci C. Isokinetic performance and function are similar after total hip arthroplasty applied with a posterior or anterolateral approach: a randomised controlled trial. Hip Int 2023; 33:67-72. [PMID: 33896243 DOI: 10.1177/11207000211012989] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND There are ongoing debates on the effects of surgical approach on outcome after total hip arthroplasty (THA). It was hypothesised that with the anterolateral approach, trauma to the abductor arm can occur and related detrimental effects can diminish the postoperative outcomes. In this first randomised controlled trial in the literature on this subject, isokinetic performance and patient-reported functional outcomes were evaluated in patients undergoing THA with a posterior approach (PA) and an anterolateral approach (ALA). METHODS A total of 48 patients scheduled to undergo THA were randomised to ALA or PA groups. The patients were evaluated preoperatively and at 6 and 12 months postoperatively, with flexion, extension and abduction strength measurements and the Harris Hip Score (HHS). The physiatrist performing isokinetic tests and the patients were blinded to the study groups. RESULTS Both groups were similar in respect of age, body mass index (BMI), gender and preoperative isokinetic performance and HHS. Both groups demonstrated similar isokinetic performance (p < 0.05) and there was no difference in HHS (p < 0.05) at the 6- and 12-months follow-up evaluations. CONCLUSION Although there is concern about potential abductor muscle damaging during ALA, the results of this randomised controlled study demonstrated that ALA can produce similar isokinetic performance and functional outcome to PA at 6 and 12 months, despite the close proximity to the abductor arm. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT04640740 (retrospectively registered).
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Affiliation(s)
- Deniz Cankaya
- Department of Orthopaedics and Traumatology, Gulhane Teaching and Research Hospital, Ankara, Turkey
| | - Fatih Inci
- Department of Orthopaedics and Traumatology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Dilek Karakuş
- Department of Physical Medicine and Rehabilitation, School of Medicine, Ordu University, Ankara, Turkey
| | - Hasan Bozkurt Turker
- Department of Orthopaedics and Traumatology, Gulhane Teaching and Research Hospital, Ankara, Turkey
| | - Yakup Kahve
- Department of Orthopaedics and Traumatology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Cagri Neyisci
- Department of Orthopaedics and Traumatology, Gulhane Teaching and Research Hospital, Ankara, Turkey
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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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Chung YY, Lee SM, Baek SN, Park TG. Direct Anterior Approach for Total Hip Arthroplasty in the Elderly with Femoral Neck Fractures: Comparison with Conventional Posterolateral Approach. Clin Orthop Surg 2022; 14:35-40. [PMID: 35251539 PMCID: PMC8858892 DOI: 10.4055/cios21008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 07/01/2021] [Accepted: 07/01/2021] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The aim of this study was to determine if it was feasible and safe to perform total hip arthroplasty (THA) using the direct anterior approach (DAA) when compared with the conventional posterolateral approach (PA) in patients with femoral neck fractures. The time required to start walking was investigated to identify advantages of the muscle-sparing approach. Safety of the approach was judged based on the incidence and nature of all complications. METHODS We retrospectively reviewed 67 THA cases due to femoral neck fractures from October 2015 to January 2019. The PA was used in 31 cases, and the DAA was used in 36 cases. The average operative time and amount of bleeding were evaluated. Cup inclination, anteversion, and leg length discrepancy (LLD) were also measured on radiographs. The time to start walking and complications (e.g., intraoperative fracture, infection, and dislocation) were recorded. RESULTS The mean operative time was 84.35 ± 13.95 minutes in PA group and 99.22 ± 20.33 minutes in DAA group (p = 0.010). But after experiencing 20 cases using the DAA, there was no statistically significant difference in the operative time between the groups. The mean volume of bleeding was 428.73 ± 207.26 mL in the PA group and 482.47 ± 150.14 mL in the DAA group. There was no difference in the acetabular cup position between two groups. Ambulation was started at 3.94 days after surgery on average in the PA group and 3.14 days in the DAA group, showing a statistically significant difference. Intraoperative fracture and infection were not observed in either group. The incidence of LLD was 1 in each group. The dislocation rate was 3.2% (1 case) in the PA group and 5.5% (2 cases) in the DAA group. CONCLUSIONS Although the DAA for THA was similar to the PA in terms of operative time, volume of bleeding, and complications, the DAA showed a great advantage in early rehabilitation as a muscle-sparing procedure in the elderly with femoral neck fractures.
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Affiliation(s)
- Young-Yool Chung
- Department of Orthopedic Surgery, Kwangju Christian Hospital, Gwangju, Korea
| | - Sang-Min Lee
- Department of Orthopedic Surgery, Kwangju Christian Hospital, Gwangju, Korea
| | - Sung-Nyun Baek
- Department of Orthopedic Surgery, Kwangju Christian Hospital, Gwangju, Korea
| | - Tae-Gyu Park
- Department of Orthopedic Surgery, Kwangju Christian Hospital, Gwangju, Korea
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The Direct Anterior Approach to Primary Total Hip Replacement: Radiological Analysis in Comparison to Other Approaches. J Clin Med 2021; 10:jcm10112246. [PMID: 34064295 PMCID: PMC8196856 DOI: 10.3390/jcm10112246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 12/23/2022] Open
Abstract
Total hip arthroplasty (THA) is currently considered the most effective treatment for end-stage hip osteoarthritis (OA). The surgery can be performed via a number of different approaches, including direct anterior (DAA; Smith–Petersen; Hueter), anterolateral (ALA; Watson–Jones), direct lateral (LA; Bauer), posterior (PA; Kocher–Langenbeck), and posterolateral (PLA). There is still a dispute over the optimal technique. The aim of this systematic review was to assess how different surgical approaches toward a THA influence the prosthesis elements’ positioning. We conducted a literature search of Scopus, ScienceDirect, PubMed, Embase, and The Cochrane Library. We evaluated studies in terms of the first author’s name, country, publication year, type of surgical approach being compared to the direct anterior approach, any significant differences at baseline, sample size, and radiographic analysis. A subanalysis of each approach in comparison to the DAA revealed differences in terms of all analyzed implant positioning radiographic parameters. There is still an insufficient number of randomized controlled studies that include radiological analyses comparing THRs (total hip replacements) performed using DAA with other approaches. Implant placement is a crucial step during a THR and surgeons must be aware that the approach they use might impact their judgment on angles and spaces inside the joint and thus alter the implant positioning.
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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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Early improvement in physical activity and function after total hip arthroplasty: Predictors of outcomes. Turk J Phys Med Rehabil 2020; 65:379-388. [PMID: 31893275 DOI: 10.5606/tftrd.2019.4695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 09/18/2018] [Indexed: 12/27/2022] Open
Abstract
Objectives This study aims to assess early changes in physical activity and function after total hip arthroplasty (THA) using both subjective and objective methods, and to identify predictors of outcomes of THA. Patients and methods Between October 2014 and October 2015, a total of 50 patients (14 males, 36 females; mean age 57.1±13.0 years; range, 31 to 75 years) with end-stage primary hip osteoarthritis who were scheduled for THA and 50 age- and sex-matched controls (10 males, 40 females; mean age 52.9±9.3 years; range, 36 to 75 years) were included in the study. Pain was evaluated using the Numeric Rating Scale (NRS), physical function using the Lequesne Index, physical capacity using the Six-Minute Walking Test (6MWT), and physical activity using both International Physical Activity Impact Questionnaire Short Form (IPAQ-SF) and step count monitor. Data at baseline and six weeks and six months were recorded. Results Pain severity was significantly lower after THA at six weeks and six months (NRS scores: 2.83 and 0.82, respectively; p<0.001), compared to baseline. Physical function, capacity, and activity significantly improved after THA at six weeks and six months with a mean Lequesne Index score of 2.62 and 1.02, respectively. The mean 6MWT distance was 272.62 at six weeks and 326.16 at six months. The mean IPAQ and 6MWT results were similar between the patient and control groups at six weeks and six months. Age, presence of comorbidities, and baseline Lequesne Index score were found to be effective on functional outcomes of THA. Age and baseline 6MWT scores were correlated with physical capacity after THA. Conclusion Our study showed a significant early improvement in pain severity and physical activity and function at six weeks and six months after THA, compared to baseline values. Baseline values and age were the positive predictors of improved postoperative function and physical capacity.
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Gala L, Kim PR, Beaulé PE. Natural history of lateral femoral cutaneous nerve neuropraxia after anterior approach total hip arthroplasty. Hip Int 2019; 29:161-165. [PMID: 30810069 DOI: 10.1177/1120700019827201] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIM: The aim of this study was to examine the natural history of lateral femoral cutaneous nerve (LFCN) neuropraxia in a previously reported cohort of individuals after direct anterior approach (DAA). METHODS: 99 patients (107 hips) with LFCN neuropraxia were identified, out of which 82 patients (87 hips) (83.1%) completed functional outcomes questionnaires at mean follow-up of 5.5 years (4.4-6.9 years). 5 patients were excluded from the study due to intra-articular source of pain and/or revision surgery. The total sample was composed of 77 patients (31 total hip replacements and 51 hip resurfacings) and functional outcomes scores were obtained for all patients. RESULTS: At average 5.46-year follow-up, 55 patients (60 hips 73%) still reported symptoms of LFCN neuropraxia but their Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were not inferior to those who had resolution for pain, function and stiffness: p values of 0.716, 0.171, and 0.238, respectively. The mean score on visual analogue scale decreased from 2.32 (SD 2.11) to 1.76 (SD 1.99). 1 patient (1.2%) reported his activities were limited by his symptoms. CONCLUSION: Although the majority of patients still report symptoms related to LFCN neuropraxia, symptoms do improve over time and there are no functional limitations. Even if LFCN neuropraxia following DAA does not lead to functional limitations, all patients should be made aware in order to alleviate any long-term functional concerns.
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Affiliation(s)
- Luca Gala
- Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ontario, Canada
| | - Paul R Kim
- Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ontario, Canada
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ontario, Canada
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Pincheira PA, De La Maza E, Silvestre R, Guzmán-Venegas R, Becerra M. Comparison of total hip arthroplasty surgical approaches by Statistical Parametric Mapping. Clin Biomech (Bristol, Avon) 2019; 62:7-14. [PMID: 30639965 DOI: 10.1016/j.clinbiomech.2018.12.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/15/2018] [Accepted: 12/31/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The most common surgical approaches in use for total hip arthroplasty are the lateral and posterior. When comparing these approaches in terms of gait biomechanics, studies usually rely on pre-defined discrete variables related to the events of gait cycle. However, this analysis may miss differences in other parts of the movement pattern that are not explored. We applied Statistical Parametric Mapping to compare hip kinematics between patients who underwent arthroplasty using either a lateral or posterior approach, contrasting these results with discrete variable analysis. METHODS Twenty-two participants (11 lateral, 11 posterior; age between 50 and 80 years) underwent gait analysis before, 3 weeks and 12 weeks after hip arthroplasty. One-dimensional (e.g. time-varying) trajectories and zero-dimensional (e.g. peak extension) discrete variables were used to assess differences between groups in each plane of hip movement (sagittal, frontal, and transverse). FINDINGS One-dimensional and zero-dimensional analyses found no significant differences between groups. Statistical Parametric Mapping revealed that both groups presented significant changes over time in hip adduction at 11-43% of the gait cycle. Zero-dimensional analysis seems to overstate sagittal plane changes over time since no such changes were found by Statistical Parametric Mapping. INTERPRETATION Our results agreed with previous studies suggesting that surgical approach do not affect hip kinematics at the early post-operative stage after arthroplasty. However, Statistical Parametric Mapping revealed changes in frontal plane kinematics over time that were underestimated by the zero-dimensional variables. These findings suggest hip adduction impairment up to 12 weeks after arthroplasty.
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Affiliation(s)
- Patricio A Pincheira
- Facultad de Ciencias, Escuela de Kinesiología, Universidad Mayor, Camino la pirámide 5750, Huechuraba, Santiago, Chile; Facultad de Medicina, Escuela de Kinesiología, Laboratorio Integrativo de Biomecánica y Fisiología del Esfuerzo (LIBFE), Universidad de los Andes, Mons. Álvaro del Portillo 12455, Las Condes, Santiago, Chile; School of Human Movement and Nutrition Sciences, Centre for Sensorimotor Performance, The University of Queensland, Blair Dr, Building 26b, St Lucia, Brisbane, Australia.
| | - Eduardo De La Maza
- Instituto Traumatológico Dr. Teodoro Gebauer, San Martín 771, Santiago Centro, Santiago, Chile
| | - Rony Silvestre
- Unidad de Biomecánica Deportiva, Clínica Meds, Isabel La Católica 3740, Providencia, Santiago, Chile
| | - Rodrigo Guzmán-Venegas
- Facultad de Medicina, Escuela de Kinesiología, Laboratorio Integrativo de Biomecánica y Fisiología del Esfuerzo (LIBFE), Universidad de los Andes, Mons. Álvaro del Portillo 12455, Las Condes, Santiago, Chile
| | - Manuel Becerra
- Instituto Traumatológico Dr. Teodoro Gebauer, San Martín 771, Santiago Centro, Santiago, Chile
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Do Postoperative Results Differ in a Randomized Trial Between a Direct Anterior and a Direct Lateral Approach in THA? Clin Orthop Relat Res 2019; 477:145-155. [PMID: 30179928 PMCID: PMC6345297 DOI: 10.1097/corr.0000000000000439] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The direct lateral approach to THA provides good exposure and is associated with a low risk of dislocations, but can result in damage to the abductor muscles. The direct anterior approach does not incise muscle, and so recovery after surgery may be faster, but it has been associated with complications (including fractures and nerve injuries), and it involves a learning curve for surgeons who are unfamiliar with it. Few randomized trials have compared these approaches with respect to objective endpoints as well as validated outcome scores. QUESTIONS/PURPOSES The purpose of this study was to compare the direct anterior approach with the direct lateral approach to THA with respect to (1) patient-reported and validated outcomes scores; (2) frequency and persistence of abductor weakness, as demonstrated by the Trendelenburg test; and (3) major complications such as infection, dislocation, reoperation, or neurovascular injury. METHODS We performed a randomized controlled trial recruiting patients from January 2012 to June 2013. One hundred sixty-four patients with end-stage osteoarthritis were included and randomized to either the direct anterior or direct lateral approach. Before surgery and at 3, 6, 12, and 24 months, a physiotherapist recorded the Harris hip score (HHS), 6-minute walk distance (6MWD), and performed the Trendelenburg test directly after the 6MWD. The patients completed the Oxford Hip Score (OHS) and the EQ-5D. The groups were not different at baseline with respect to demographic data and preoperative scores. Both groups received the same pre- and postoperative regimes. Assessors were blinded to the approach used. One hundred fifty-four patients (94%) completed the 2-year followup; five patients from each group were lost to followup. RESULTS There were few statistical differences and no clinically important differences in terms of validated or patient-reported outcomes scores (including the HHS, 6MWD, OHS, or EQ-5D) between the direct anterior and the lateral approach at any time point. A higher proportion of patients had a persistently positive Trendelenburg test 24 months after surgery in the lateral approach than the direct anterior approach (16% [12 of 75] versus 1% [one of 79]; odds ratio, 15; p = 0.001). Irrespective of approach, those with a positive Trendelenburg test had statistically and clinically important worse HHS, OHS, and EQ-5D scores than those with a negative Trendelenburg test. There were four major nerve injuries in the direct anterior group (three transient femoral nerve injuries, resolved by 3 months after surgery, and one tibial nerve injury with symptoms that persist 24 months after surgery) and none in the lateral approach. CONCLUSIONS Based on our findings, no case for superiority of one approach over the other can be made, except for the reduction in postoperative Trendelenburg test-positive patients using the direct anterior approach compared with when using the direct lateral approach. Irrespective of approach, patients with a positive Trendelenburg test had clinically worse scores than those with a negative test, indicating the importance of ensuring good abductor function when performing THA. The direct anterior approach was associated with nerve injuries that were not seen in the group treated with the lateral approach. LEVEL OF EVIDENCE Level I, therapeutic study.
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Schultz K, Ewbank ML, Pandit HG. Changing practice for hip arthroplasty and its implications. ACTA ACUST UNITED AC 2018; 26:1238-1244. [PMID: 29240467 DOI: 10.12968/bjon.2017.26.22.1238] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
This overview provides insight into changes in clinical practice and the implications for nursing staff and clinicians who are involved in the management of patients undergoing primary total hip arthroplasty. The review highlights commonly used surgical approaches, their advantages, their associated risks and how to manage complications if they occur.
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Affiliation(s)
- Katherine Schultz
- Medical Student, Indiana University School of Medicine, Indianapolis, USA
| | - Mei-Ling Ewbank
- Medical Student, Indiana University School of Medicine, Indianapolis, USA
| | - Hemant G Pandit
- Professor of Orthopaedics and Honorary Consultant, Chapel Allerton Hospital, University of Leeds, and Professor of Orthopaedic Surgery, Nuffield Department of Orthopaedics, Rhuematology and Muscoloskeletal Sciences, University of Oxford
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Nistor DV, Caterev S, Bolboacă SD, Cosma D, Lucaciu DOG, Todor A. Transitioning to the direct anterior approach in total hip arthroplasty. Is it a true muscle sparing approach when performed by a low volume hip replacement surgeon? INTERNATIONAL ORTHOPAEDICS 2017; 41:2245-2252. [PMID: 28439629 DOI: 10.1007/s00264-017-3480-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 04/03/2017] [Indexed: 01/17/2023]
Abstract
PURPOSE We conducted this study to establish if the transition from a lateral approach (LA) to the direct anterior approach (DAA) for a low volume hip arthroplasty surgeon during the steep learning curve can be performed maintaining the muscle sparing approach of the DAA without increasing the complication rates. METHODS In this controlled, prospective, randomized clinical study we investigated 70 patients (35 DAA, 35 LA) with similar demographics that underwent a total hip arthroplasty. Assessment of the two approaches consisted of determining the invasiveness through serum markers for muscle damage (i.e. myoglobin, creatine kinase and lactate dehydrogenase), the operative parameters such as post-operative pain and rescue medication consumption, the component positioning and complication rates. RESULTS Post-operative myoglobin levels were higher (p < 0.001) in the LA group (326.42 ± 84.91 ng/mL) as compared to the DAA group (242.80 ± 71.03 ng/mL), but with no differences regarding other biomarkers for muscle damage. Pain levels were overall lower in the DAA group, with a statistical and clinical difference during surgery day (p < 0.001) associated with lower (p < 0.001) rescue medication consumption (median 1 (1; 3) mg morphine vs. 3 (2; 4) mg morphine). Most patients in the LA group reported chronic post-operative pain throughout all three evaluated months, while the majority of patients in the DAA group reported no pain after week six. Component positioning did not differ significantly between groups and neither did complication rates. CONCLUSION The DAA can be transitioned from the LA safely, without higher complication rates while maintaining its muscle spearing advantages when performed by a low volume hip arthroplasty surgeon.
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Affiliation(s)
- Dan-Viorel Nistor
- Department of Orthopaedics, Traumatology and Paediatric Orthopaedics, Iuliu Haţieganu University of Medicine and Pharmacy, 47 Traian Mosoiu street, Cluj-Napoca, 400132, Romania.
| | - Sergiu Caterev
- Department of Orthopaedics, Traumatology and Paediatric Orthopaedics, Iuliu Haţieganu University of Medicine and Pharmacy, 47 Traian Mosoiu street, Cluj-Napoca, 400132, Romania
| | - Sorana-Daniela Bolboacă
- Department of Medical Informatics and Biostatistics, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Dan Cosma
- Department of Orthopaedics, Traumatology and Paediatric Orthopaedics, Iuliu Haţieganu University of Medicine and Pharmacy, 47 Traian Mosoiu street, Cluj-Napoca, 400132, Romania
| | - Dan Osvald Gheorghe Lucaciu
- Department of Orthopaedics, Traumatology and Paediatric Orthopaedics, Iuliu Haţieganu University of Medicine and Pharmacy, 47 Traian Mosoiu street, Cluj-Napoca, 400132, Romania
| | - Adrian Todor
- Department of Orthopaedics, Traumatology and Paediatric Orthopaedics, Iuliu Haţieganu University of Medicine and Pharmacy, 47 Traian Mosoiu street, Cluj-Napoca, 400132, Romania
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