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.

Efficacy of plain cholecalciferol versus ergocalciferol in raising serum vitamin D level in Thai female healthcare workers

Objectives

To compare the efficacy of cholecalciferol and ergocalciferol in raising 25-hydroxyvitamin D (25(OH)D) level in Thai female healthcare workers.

Methods

A randomized control trial was conducted in healthy female healthcare workers. Randomization allocated the participants into vitamin D2 group (N = 43), receiving ergocalciferol 20,000 IU weekly and vitamin D3 group (N = 40), receiving cholecalciferol 1000 IU daily for 12 months. Venous blood sample was collected at baseline, 6 and 12 months for serum 25(OH)D, parathyroid hormone and calcium. Compliance was also assessed.

Results

The mean age of the participants was 50.6 ± 9.9 and 50.9 ± 8.4 years in vitamin D2 and D3 groups (P = 0.884). The mean 25(OH)D levels were 16.91 ± 6.07 ng/mL and 17.62 ± 4.39 ng/mL (P = 0.547), respectively. Both groups had significant improvement in 25(OH)D level at 6 months (from 16.91 ± 6.07 to 21.67 ± 5.11 ng/mL and 17.62 ± 4.39 to 26.03 ± 6.59 ng/mL in vitamin D2 and D3 group). Improvement was significantly greater with cholecalciferol (P = 0.018). The level plateaued afterwards in both groups. Only cholecalciferol could increase 25(OH)D in participants without vitamin D deficiency (6.88 ± 4.20 ng/mL increment). Compliance was significantly better in vitamin D2 group (P = 0.025).

Conclusions

Daily cholecalciferol supplementation resulted in a larger increase in serum 25(OH)D level during the first 6 months comparing to weekly ergocalciferol. While vitamin D3 could increase serum 25(OH)D level in all participants, vitamin D2 could not do so in participants without vitamin D deficiency.

Fracture fixation versus hemiarthroplasty for unstable intertrochanteric fractures in elderly patients: A systematic review and network meta-analysis of randomized controlled trials

INTRODUCTION

There are three common types of operative options for unstable intertrochanteric fracture (ITF), i.e. dynamic hip screw (DHS), proximal femoral nail (PFN), and bipolar hemiarthroplasty (BHA). Results of these operations are still inconclusive. This systematic review and network meta-analysis was therefore conducted to compare the efficacy among those operative strategies.

HYPOTHESIS

These three operative techniques (i.e., DHS, PFN, and BHA) were not different in operative failure, reoperation, and Harris Hip Score (HHS) for unstable ITF.

MATERIAL AND METHODS

Randomized controlled trials (RCTs) comparing outcomes among DHS, PFN, and BHA in patients with unstable ITFs were searched from Medline and Scopus databases. Primary outcomes included operative failure, reoperation, and HHS. Direct meta-analysis (DMA) and network meta-analysis (NMA) were performed to compare among three operative techniques. Qualitative and quantitative evidences of all included studies were tested for heterogeneity, transitivity, and consistency in NMA. The surface under the cumulative ranking curve (SUCRA) was used to estimate the probability of being the best in lowering poor clinical outcomes, but high HHS.

RESULTS

Seven RCTs (n=528) were eligible. DMA showed that DHS and PFN were significantly higher risk of operative failure compared with BHA with risk ratio (RR) and 95% confidence interval of 7.98 (1.35, 47.06) and 3.08 (1.00, 9.51), respectively. Compared with BHA, PFN was 4.47 (1.04, 21.60) times significantly higher risk of reoperation, and lower HHS at 3-6months [mean difference (MD)=-5.41 (-15.91, 5.10)], but higher HHS at>6-12months [MD 11.67 (2.98, 20.36)], although these HHSs were not significant. NMA and SUCRA demonstrated the highest ranks for operative failure and reoperation were DHS and PFN, whereas the highest HHS was BHA.

DISCUSSION

In specific group of unstable ITF, BHA might be the best operative technique in term of lower operative failure and reoperation, and highest HHS during short to intermediate period comparing with PFN and DHS. However, PFN had higher long-term HHS than BHA.

LEVEL OF EVIDENCE

I, meta-analysis of RCTs.