[Direct anterior approach versus posterolateral approach for total hip arthroplasty in the lateral decubitus position]

Which approach of total hip arthroplasty is the best efficacy and least complication?

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.

Acetabular and Femoral Component Positioning Using Direct Anterior Approach Versus Posterior Approach in Total Hip Arthroplasty

PURPOSE

Direct anterior approach (DAA) has recently become popular in total hip arthroplasty (THA). However, irrespective of the surgical approach used, component malposition is an important factor affecting function and complications after THA. This study aims to compare component positioning on the femoral and acetabular side between DAA and posterior approach (PA) to the hip joint. We hypothesized that the two approaches are similar in terms of component positioning.

METHODS

We prospectively studied 50 patients, matched according to age, sex, and body mass index, undergoing THA, divided non-randomly into 2 groups. Group 1 comprised 25 patients (35 hips) undergoing THA using DAA and group 2 comprised 25 patients (25 hips) undergoing THA using PA. Ten patients from group 1 had simultaneous bilateral THA. Radiological parameters studied were acetabular inclination (AI), coronal femoral stem alignment (CFA), leg length difference (LLD), acetabular cup version (AV), and femoral stem version (FV).

RESULTS

There was no significant difference in AI, CFA, LLD, AV, and FV between the two groups. Excellent to good inter and intra-observer reliability expressed in terms of intraclass correlation coefficient (ICC) was noted for all the radiographic measurements.

CONCLUSION

Both DAA and PA for THA achieve comparable radiological component positioning. DAA may not provide any advantage over PA in terms of positioning of the prosthesis.

LEVEL OF EVIDENCE

Level II, non-randomized comparative study.

Direct Anterior Approach Versus Posterolateral Approach in Total Hip Arthroplasty: A Systematic Review and Meta-analysis of Randomized Controlled Studies

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.

Clinical, functional and radiographic outcomes of primary total hip arthroplasty between direct anterior approach and posterior approach: a systematic review and meta-analysis

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.

Total hip arthroplasty by direct anterior approach in the lateral position for the treatment of ankylosed hips

OBJECTIVE

To investigate the clinical efficacy of total hip arthroplasty (THA) via the direct anterior approach (DAA) for the treatment of hip ankylosis in the lateral position.

METHODS

A retrospective analysis was performed on the clinical data of 24 patients (39 hips) who underwent THA via the DAA in the lateral position for the treatment of hip ankylosis between January 2016 and December 2018. We performed bilateral THA for fifteen patients and unilateral THA for nine patients. Operation time, intraoperative blood loss, length of incisions, straight leg-raising time, length of postoperative hospital stay, operation-related complication, prosthesis position, radiological outcomes, postoperative pain relief (evaluated by VAS) and functional rehabilitation [evaluated by Harris hip score and range of motion (ROM)] were analyzed to determine clinical efficacy. These clinical data were compared and statistically analyzed with the clinical data of another 23 patients (28 hips) who underwent THA via the posterolateral approach (PLA) for the treatment of hip ankylosis in the lateral position.

RESULTS

Follow-up was performed at 12-15 months. The incision length in the DAA group and the PLA group was (11.12 ± 1.69 vs. 14.36 ± 3.42) cm, the intraoperative blood loss was (371.25 ± 120.55 vs. 396.80 ± 101.21) ml, the operation time was (122.47 ± 25.40 vs. 138.47 ± 24.45) min, the postoperative hospital stay was (9.59 ± 4.62 vs. 12.08 ± 3.58) days, and the straight leg elevation time was (9.20 ± 2.12 vs. 12.34 ± 3.25) days, respectively. The prosthesis of the two groups was in a good position: The average angle of cup anteversion in the DAA group and the PLA group was (10.76 ± 2.84 vs. 15.36 ± 3.42)°, and the average angle of cup abduction in the DAA group and the PLA group was (40.00 ± 3.45 vs. 41.21 ± 2.85)° (P > 0.05). The VAS score, ROM and Harris score at different follow-up time points were significantly improved in the two groups compared with those before surgery. In the first 3 months after surgery, the VAS score, ROM and Harris score of the DAA group were significantly better than those of the PLA group (P < 0.05), but with the extension of the follow-up time, there was no significant difference in the above indicators between the two groups (P > 0.05). One case of greater trochanteric fracture occurred in the DAA group. Two cases of hip posterior dislocations occurred in the PLA group, and no dislocations occurred after manual closed reduction and hip fixation in bed for 1 month to the last follow-up. No complications such as infection, deep vein thrombosis, fat embolism, prosthesis loosening, limb length inequality or joint dislocation were reported.

CONCLUSION

THA via the DAA for the treatment of hip ankylosis in the lateral position was safe and effective and had the advantage of reduced trauma, quicker recovery of hip function, lower incidence of postoperative dislocation and ability to expose the acetabulum fully and fit the prosthesis properly, providing satisfactory clinical efficacy.