Pain and rehabilitation after total hip arthroplasty are approach dependent: a multisurgeon, single-center, prospective cohort study

Surgeons Experience Greater Physiologic Stress and Strain in the Direct Anterior Approach Than the Posterior Approach for Total Hip Arthroplasty

INTRODUCTION

The direct anterior approach (DAA) and posterior approach (PA) for total hip arthroplasty (THA) have advantages and disadvantages, but their physiologic burden to the surgeon has not been quantified. This study was conducted to determine whether differences exist in surgeon physiological stress and strain during DAA in comparison to PA.

METHODS

We evaluated a prospective cohort of 144 consecutive cases (67 DAA and 77 PA). There were five, high-volume, fellowship-trained arthroplasty surgeons who wore a smart-vest that recorded cardiorespiratory data while performing primary THA DAA or PA. Heart rate (beats/minute), stress index (correlates with sympathetic activations), respiratory rate (respirations/minute), minute ventilation (liters/min), and energy expenditure (calories) were recorded, along with patient body mass index and operative time. Continuous data was compared using T-tests or Mann Whitney U tests, and categorical data was compared with Chi-square or Fischer's exact tests.

RESULTS

There were no differences in patient characteristics. Compared to PA, performing THA via DAA had a significantly higher surgeon stress index (17.4 versus 12.4; P < 0.001), heart rate (101 versus 98.3; P = 0.007), minute ventilation (21.7 versus 18.7; P < 0.001), and energy expenditure per hour (349 versus 295; P < 0.001). However, DAA had a significantly shorter operative time (71.4 versus 82.1; P = 0.001).

CONCLUSION

Surgeons experience significantly higher physiological stress and strain when performing DAA compared to PA for primary THA. This study provides objective data on energy expenditure that can be factored into choice of approach, case order, and scheduling preferences, and provides insight into the work done by the surgeon.

No clinically significant differences in patient-reported outcome measures across total hip arthroplasty approaches

INTRODUCTION

As recent studies demonstrate an ongoing debate surrounding outcomes and complications with respect to different total hip arthroplasty (THA) approaches, patient-reported outcome measures (PROMs) may provide valuable information for clinician and patient decision-making. Therefore, our systematic review aimed to assess how surgical approach influences patient-reported outcomes.

METHODS

5 online databases were queried for all studies published between January 1, 1997 and March 4, 2022 that reported on PROMs across various surgical approaches to THA. Studies reporting on PROMs in primary THA patients segregated by surgical approach were included. Articles reporting on revision THA, hip resurfacing, and arthroscopy were excluded. Mantel-Haenszel (M-H) models were utilised to calculate the pooled mean difference (MDs) and 95% confidence interval (CIs).

RESULTS

No differences between the DAA and other approaches were observed when evaluating HOOS (MD -0.28; 95% CI, -1.98-1.41; p = 0.74), HHS (MD 2.38; 95% CI, -0.27-5.03; p = 0.08), OHS (MD 1.35; 95% CI, -2.00-4.71; p = 0.43), FJS-12 (MD 5.88; 95% CI, -0.36-12.12; p = 0.06), VAS-pain (MD -0.32; 95% CI, -0.68-0.04; p = 0.08), and WOMAC-pain (MD -0.73; 95% CI, -3.85-2.39; p = 0.65) scores. WOMAC (MD 2.47; 95% CI, 0.54-4.40; p = 0.01) and EQ-5D Index (MD 0.03; 95% CI, 0.01-0.06; p = 0.002) scores were found to significantly favour the DAA cohort over the other approaches. Only the EQ-5D index score remained significant following sensitivity analysis.

CONCLUSIONS

Superiority of any 1 approach could not be concluded based on the mixed findings of the present analysis. Although our pooled analysis found no significant differences in outcomes except for those measured by the EQ-5D index, a few additional metrics, notably the WOMAC, HHS, FJS-12, and VAS-pain scores, leaned in favour of the DAA.

Pain and rehabilitation after total hip arthroplasty are approach dependent: results 6 weeks and 2 years after surgery in a multisurgeon, single-center, and prospective cohort study

PURPOSE

The aim of this study was the evaluation of pain, function, and overall satisfaction after total hip arthroplasty (THA) using three different standard surgical approaches (DAA (direct anterior approach), lateral, and posterior approach) 2 years postoperatively. Additionally, we compared the results with recently published results of the same study population 6 weeks postoperatively.

METHODS

In a multisurgeon, prospective, single-center cohort study, a total of initial 188 patients who underwent total hip arthroplasty (THA) between February 2019 and April 2019 were analyzed on pain, function, and satisfaction within the first days, 6 weeks, and 2 years postoperatively according to three different approaches (DAA, lateral, and posterior approach). Our research group recently published results directly and 6 weeks postoperatively. We evaluated the same study collectively 2 years postoperatively and compared the results with the data 6 weeks postoperatively. One hundred twenty-five patients could be included. Outcome parameters for the present study were the pain level according to the visual analogue scale (VAS), the modified Harris hip score (mHHS), and an overall satisfaction scale 2 years postoperatively.

RESULTS

Mean overall satisfaction 2 years postoperatively was 9.7 ± 1 (3-10). Satisfaction was significantly better for the DAA than for the lateral approach (p = 0.005). There were no significant differences between the lateral and posterior approaches (p = 0.06) and between the DAA and the posterior approaches (p = 0.11). In total, the mean pain level was 0.4 ± 0.9 (0-5) at 6 weeks and 0.5 ± 1.1 (0-7) at 2 years postoperatively (p = 0.3). Regarding the different approach groups, pain levels 6 weeks and 2 years postoperatively were significantly lower for the DAA than for the lateral approach (p = 0.02). There were no significant differences between DAA and posterior approach (p = 0.05) and the lateral and posterior approach (p = 0.26). The mean mHHS significantly increased from 84.7 + 14.5 (37.4-100) 6 weeks to 95 + 12.5 (23.1-100.1) 2 years postoperatively (p < 0.0001). Regarding the different approaches, mHHS was significantly higher for the DAA than for the lateral approach (p = 0.03). Differences between the DAA and the posterior approach (p = 0.11) and between the lateral and posterior approaches (p = 0.24) were insignificant.

CONCLUSION

At 2 years postoperative, DAA showed significantly better overall satisfaction, pain level, and mHHS than the lateral approach. The differences between DAA and the posterior approach and lateral and posterior approaches were insignificant. Whether the superior results of the DAA to the lateral approach persist over a longer period must be clarified by further studies.

STUDY DESIGN

Prospective cohort study, level of evidence 2.

Use of a novel imageless navigation system reduced fluoroscopy exposure and improved acetabular positioning in anterior approach total hip arthroplasty: a case-control study

INTRODUCTION

Direct anterior approach (DAA) for total hip arthroplasty (THA) frequently utilizes fluoroscopy. The purpose of this study is to assess the impact of using a novel, imageless THA navigation system on radiation exposure and acetabular cup placement consistency.

MATERIALS AND METHODS

This was a retrospective, single-surgeon cohort study of a consecutive group of patients who underwent DAA THA for osteoarthritis. An optic-based imageless navigation system was used to determine intraoperative acetabular inclination and anteversion angles referenced off of a generic coronal and sagittal plane in 71 cases (study group). These were compared with 71 manual cases (control group) for fluoroscopy exposure, operative duration, and acetabular placement variation. Cohorts were similar in their distributions of sex, race, ethnicity, and body mass index. Comparisons between groups were made using independent samples t tests. Alpha error was 0.05.

RESULTS

Study patients experienced significantly less fluoroscopy exposure time {3.59 [Standard Deviation (SD) 1.95] vs. 9.15 (SD 5.98) seconds; p < 0.001} and dosage (0.30 [SD 0.23] vs. 0.78 [SD 0.63] mGy; p < 0.001). Study and control patients had similar operative times [82.69 (SD 11.70) vs. 89.54 (SD 14.60) minutes; p = 0.09]. The study group had a significantly lower radiographic variation for inclination and anteversion, based on mean proximity to the centroid of each cohort [3.55 (SD 1.88) vs. 5.39 (SD 3.51); p < 0.001] and also a greater proportion of cases that fell within 1 SD of the mean cohort inclination and anteversion (40.8% vs. 21.1%; p = 0.009).

CONCLUSIONS

Use of a novel imageless navigation system for DAA THA significantly reduced fluoroscopic radiation exposure and improved consistency in acetabular cup placement.

Equivalent radiation exposure with robotic total hip replacement using a novel, fluoroscopic-guided (CT-free) system: case-control study versus manual technique

Accurate and precise positioning of the acetabular cup remains a prevalent challenge in total hip arthroplasty (THA). Robotic assistance for THA has increased over the past decade due to the potential to improve the accuracy of implant placement. However, a common criticism of existing robotic systems is the requirement for preoperative computerized tomography (CT) scans. This additional imaging increases patient radiation exposure, as well as cost, and requires pin placement during surgery. The goal of this study was to analyze the radiation burden associated with a novel, CT-free robotic THA system compared to an unassisted manual THA approach (n = 100/arm). On average, the study cohort had a higher number of fluoroscopic images captured (7.5 vs. 4.3 images; p < 0.001), radiation dose (3.0 vs. 1.0 mGy; p < 0.001), and a longer duration of radiation exposure (18.8 vs. 6.3 s; p < 0.001), per procedure, than the control group. Additionally, no learning curve was detected by CUSUM analysis with respect to the number of fluoroscopic images taken during the adoption of the robotic THA system. While statistically significant, in comparison to published literature, the radiation exposure of the CT-free robotic THA system was comparable to that of unassisted manual THA approach and less than that of CT-based robotic approaches. Thus, the novel CT-free robotic system likely poses no clinically significant increase in radiation exposure to the patient compared to manual approaches.

Short-term outcomes vary by surgical approach in total hip arthroplasty: a network meta-analysis

BACKGROUND

The direct anterior approach (DAA) has increased in popularity in recent years. Proponents cite its muscle-sparing approach and purported reduction in pain and improvement in function when compared to the traditional surgical approaches. There remains controversy surrounding the validity of these claims. The objective of this study was to compare the common total hip surgical approaches in terms of pain scores, functional outcomes, opioid use and complications within the first 12 weeks postoperatively.

METHODS

A network meta-analysis of randomized controlled trials (RCT) comparing postoperative outcomes of different surgical approaches in primary THA up to 12 weeks was performed. PubMed, MEDLINE, Embase, Web of Science and SCOPUS were systematically searched from inception to May 2020. Outcomes included pain scores, functional outcome scores, length of stay (LOS), complications and opioid consumption.

RESULTS

Twenty-five RCTs (n = 2339) were included. The DAA demonstrated statistically significant improvement in Harris Hip Scores at 6 weeks when compared to the posterior and direct lateral approaches. The DAA reduced pain scores on postoperative day 2 and at 2 weeks compared to the direct lateral approach. The anterolateral approach was found to have a significantly shorter LOS compared to the other major surgical approaches. The differences in functional outcomes or pain scores did not surpass conventional cutoffs for a minimal clinically important difference.

CONCLUSION

The DAA led to functional improvements at 6 weeks compared to the posterior and direct lateral approaches and reduced postoperative pain compared to the direct lateral approach. However, these improvements failed to reach clinical significance. All major surgical approaches led to large improvements in function by 12 weeks with relatively low complication rates. Whether a short-term statistically significant improvement in function is sufficiently patient important to recommend DAA as a standard remains uncertain.