Comparative evaluation of the clinical efffcacy and safety of surgical approaches in total hip arthroplasty

Background Advanced coxarthrosis is a leading cause of disability in patients. Total arthroplasty is regarded as the "gold standard" for the treatment of hip pathologies that are not amenable to conservative treatment. Arthroplasty introduced into clinical practice has significantly improved functional status of patients. The data are largely contradictory and indicate certain difficulties and risks at the stages of treatment and rehabilitation of patients after surgery. The shortcomings can be overcome by improving the treatment methods for the cohort of patients based on the results of large-scale comparative studies exploring the effectiveness of different approaches to all stages of treatment of arthroplastic patients.

The objective was to search for the most justified and promising surgical approaches in terms of clinical efficacy and safety of total hip arthroplasty (THA).

Material and methods The search for publications was produced using the databases of Scopus, PubMed and the electronic scientific library eLIBRARY in Russian and English languages using the keywords: total hip arthroplasty, minimally invasive approach, anterolateral approach in THA, direct lateral approach in THA, posterior approach in THA, comparative assessment of approaches in hip arthroplasty, advanced replacement techniques, incidence of postoperative complications in THA, direct anterior approach in THA.

Results and discussion A number of studies have shown that interventions using direct anterior access (DAA) are characterized by less blood loss, less frequent blood transfusions, less operating time and shorter hospital stay. There was a more rapid recovery of the hip function during early postoperative period with less need for opioid analgesics with DAA. Complication rate was higher with DAA than in the comparison group, which directly correlated with the learning curve.

Conclusion DAA was shown to be an advanced approach that resulted in enhanced clinical efficacy and safety of surgical treatment in the majority of patients with coxarthrosis with sufficient experience of the surgeon. The method can be considered as low-traumatic. Unlike other approaches, DAA was accompanied by less injury to intact tissues; smaller skin incision; less blood loss; precipitated postoperative rehabilitation; less severity of postoperative pain and less need for opioid analgesia. However, DAA is inferior to classical approaches in primarily complicated hip pathologies.

1. Salaffi F, Farah S, Di Carlo M. Frailty syndrome in rheumatoid arthritis and symptomatic osteoarthritis: an emerging concept in rheumatology. Acta Biomed. 2020;91(2):274-296. doi: 10.23750/abm.v91i2.9094

2. Long H, Liu Q, Yin H, et al. Prevalence trends of site-specific osteoarthritis from 1990 to 2019: findings from the global burden of disease study 2019. Arthritis Rheumatol. 2022;74(7):1172-1183. doi: 10.1002/art.42089

3. Neuprez A, Neuprez AH, Kaux JF, et al. Total joint replacement improves pain, functional quality of life, and health utilities in patients with late-stage knee and hip osteoarthritis for up to 5 years. Clin Rheumatol. 2020;39(3):861-871. doi: 10.1007/s10067-019-04811-y

4. Schwartz AJ, Clarke HD, Sassoon A, et al. The clinical and financial consequences of the centers for medicare and medicaid services’ two-midnight rule in total Joint arthroplasty. J Arthroplasty. 2020;35(1):1-6.e1. doi: 10.1016/j.arth.2019.08.048

5. Prokhorenko VM, Azizov MZ, Shakirov KK. Comorbidities in patients with revision hip arthroplasty. Acta Biomedica Scientifica. 2017;2(5(1)):136 140. (In Russ.) doi: 10.12737/article_59e85b6a9149f2.80265222

6. Lakomkin N, Goz V, Lajam CM, et al. Higher modified Charlson Index scores are associated with increased incidence of complications, transfusion events, and length of stay following revision hip arthroplasty. J Arthroplasty. 2017 Apr;32(4):1121-1124. doi: 10.1016/j.arth.2016.11.014

7. Alabut AV, Sikilinda VD. Influence of comorbidity on the choice of tactics for the treatment of patients with diseases of the musculoskeletal system. Chief Physician of the South of Russia. 2016; (2(49)):35-40. (In Russ.)

8. Schmolders J, Friedrich MJ, Michel R, et al. Validation of the Charlson comorbidity index in patients undergoing revision total hip arthroplasty. Int Orthop. 2015;39(9):1771-1777. doi: 10.1007/s00264-015-2810-y

9. Fullam J, Theodosi PG, Charity J, Goodwin VA. A scoping review comparing two common surgical approaches to the hip for hemiarthroplasty. BMC Surg. 2019;19(1):32. doi: 10.1186/s12893-019-0493-9

10. Ries MD. Relationship between functional anatomy of the hip and surgical approaches in total hip arthroplasty. Orthopedics. 2019;42(4):e356-e363. doi: 10.3928/01477447-20190624-03

11. Galakatos GR. Direct anterior total hip arthroplasty. Mo Med. 2018 Nov-Dec;115(6):537-541.

12. Talia AJ, Coetzee C, Tirosh O, Tran P. Comparison of outcome measures and complication rates following three different approaches for primary total hip arthroplasty: a pragmatic randomised controlled trial. Trials. 2018;19(1):13. doi: 10.1186/s13063-017-2368-7

13. McLawhorn AS, Christ AB, Morgenstern R, et al. Prospective evaluation of the posterior tissue envelope and anterior capsule after anterior total hip arthroplasty. J Arthroplasty. 2020;35(3):767-773. doi: 10.1016/j.arth.2019.09.045

14. Post ZD, Orozco F, Diaz-Ledezma C, et al. Direct anterior approach for total hip arthroplasty: indications, technique, and results. J Am Acad Orthop Surg. 2014;22(9):595-603. doi: 10.5435/JAAOS-22-09-595

15. Moreau P. Minimally invasive total hip arthroplasty using Hueter's direct anterior approach. Eur J Orthop Surg Traumatol. 2018;28(5):771-779. doi: 10.1007/s00590-018-2158-2

16. Cichos KH, Mabry SE, Spitler CA, et al. Comparison between the direct anterior and posterior approaches for total hip arthroplasty performed for femoral neck fracture. J Orthop Trauma. 2021;35(1):41-48. doi: 10.1097/BOT.0000000000001883

17. van der Sijp MPL, van Delft D, Krijnen P, et al. Surgical approaches and hemiarthroplasty outcomes for femoral neck fractures: a meta-analysis. J Arthroplasty. 2018;33(5):1617-1627.e9. doi: 10.1016/j.arth.2017.12.029

18. Wang Z, Hou JZ, Wu CH, et al. A systematic review and meta-analysis of direct anterior approach versus posterior approach in total hip arthroplasty. J Orthop Surg Res. 2018;13(1):229. doi: 10.1186/s13018-018-0929-4

19. Kunkel ST, Sabatino MJ, Kang R, et al. A systematic review and meta-analysis of the direct anterior approach for hemiarthroplasty for femoral neck fracture. Eur J Orthop Surg Traumatol. 2018;28(2):217-232. doi: 10.1007/s00590-017-2033-6

20. Wroblewski A, Hoffman D, Miller ET. Direct anterior approach for hip hemiarthroplasty. J Orthop Trauma. 2019;33 Suppl 1:S17-S18. doi: 10.1097/BOT.0000000000001528

21. Zhou Z, Li Y, Peng Y, et al. Clinical efficacy of direct anterior approach vs. other surgical approaches for total hip arthroplasty: A systematic review and meta-analysis based on RCTs. Front Surg. 2022;9:1022937. doi: 10.3389/fsurg.2022.1022937

22. Kucukdurmaz F, Sukeik M, Parvizi J. A meta-analysis comparing the direct anterior with other approaches in primary total hip arthroplasty. Surgeon. 2019;17(5):291-299. doi: 10.1016/j.surge.2018.09.001

23. Thaler M, Dammerer D, Krismer M, et al. Extension of the direct anterior approach for the treatment of periprosthetic femoral fractures. J Arthroplasty. 2019;34(10):2449-2453. doi: 10.1016/j.arth.2019.05.015

24. Meneghini RM, Elston AS, Chen AF, et al. Direct anterior approach: risk factor for early femoral failure of cementless total hip arthroplasty: a multicenter study. J Bone Joint Surg Am. 2017;99(2):99-105. doi: 10.2106/JBJS.16.00060

25. Corten K, Holzapfel BM. Direct anterior approach for total hip arthroplasty using the "bikini incision". Oper Orthop Traumatol. 2021;33(4):318 330. doi: 10.1007/s00064-021-00721-y

26. Realyvasquez J, Singh V, Shah AK, et al. The direct anterior approach to the hip: a useful tool in experienced hands or just another approach? Arthroplasty. 2022;4(1):1. doi: 10.1186/s42836-021-00104-5

27. Nogler MM, Thaler MR. The direct anterior approach for hip revision: accessing the entire femoral diaphysis without endangering the nerve supply. J Arthroplasty. 2017;32(2):510-514. doi: 10.1016/j.arth.2016.07.044

28. Thaler M, Corten K, Nogler M, et al. Femoral revision with the direct anterior approach. Oper Orthop Traumatol. 2022;34(3):189- 202. doi: 10.1007/s00064-022-00768-5

29. Krismer M, Nogler M, Huber D, Oberaigner W. Cemented ABG-II prosthesis: 5-year results. Hip Int. 2015;25(1):56-60. doi: 10.5301/hipint.5000185

30. Krismer M, Nogler M. Revision arthroplasty of the hip: direct anterior approach. Orthopade. 2017;46(2):121-125. doi: 10.1007/s00132-016-3376-0

31. Rudert M, Horas K, Hoberg M, et al. The Wuerzburg procedure: the tensor fasciae latae perforator is a reliable anatomical landmark to clearly identify the Hueter interval when using the minimally-invasive direct anterior approach to the hip joint. BMC Musculoskelet Disord. 2016;17:57. doi: 10.1186/s12891-016-0908-z

32. Putzer D, Haselbacher M, Hörmann R, et al. The deep layer of the tractus iliotibialis and its relevance when using the direct anterior approach in total hip arthroplasty: a cadaver study. Arch Orthop Trauma Surg. 2017;137(12):1755-1760. doi: 10.1007/s00402-017-2820-x

33. Xu Z, Zhang J, Li J, Zhang Y. Direct anterior approach in total hip arthroplasty: more indications and advantages than we found. Arthroplasty. 2022;4(1):29. doi: 10.1186/s42836-022-00130-x

34. 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(1):69. doi: 10.1186/s13018-021-02218-7

35. Higgins BT, Barlow DR, Heagerty NE, Lin TJ. Anterior vs. posterior approach for total hip arthroplasty, a systematic review and meta-analysis. J Arthroplasty. 2015;30(3):419-34. doi: 10.1016/j.arth.2014.10.020

36. Higgins JP, Chandler J, Cumpston M (eds.). Cochrane handbook for systematic reviews of interventions version 6.0 (updated July 2019). Cochrane. 2019. Available at: http://www.training.cochrane.org/handbook.

37. Sheth D, Cafri G, Inacio MC, et al. Anterior and anterolateral approaches for THA are associated with lower dislocation risk without higher revision risk. Clin Orthop Relat Res. 2015;473(11):3401-8. doi: 10.1007/s11999-015-4230-0

38. Rodriguez JA, Deshmukh AJ, Rathod PA, et al. Does the direct anterior approach in THA offer faster rehabilitation and comparable safety to the posterior approach? Clin Orthop Relat Res. 2014;472(2):455-63. doi: 10.1007/s11999-013-3231-0

39. Taunton MJ, Mason JB, Odum SM, Springer BD. Direct anterior total hip arthroplasty yields more rapid voluntary cessation of all walking aids: a prospective, randomized clinical trial. J Arthroplasty. 2014;29(9 Suppl):169-72. doi: 10.1016/j.arth.2014.03.051

40. Eto S, Hwang K, Huddleston JI, et al. The direct anterior approach is associated with early revision total hip arthroplasty. J Arthroplasty. 2017;32(3):1001-1005. doi: 10.1016/j.arth.2016.09.012

41. Graves SC, Dropkin BM, Keeney BJ, et al. Does surgical approach affect patient-reported function after primary THA? Clin Orthop Relat Res. 2016;474(4):971-81. doi: 10.1007/s11999-015-4639-5

42. Hart A, Wyles CC, Abdel MP, et al. Thirty-day major and minor complications following total hip arthroplasty-A comparison of the direct anterior, lateral, and posterior approaches. J Arthroplasty. 2019;34(11):2681-2685. doi: 10.1016/j.arth.2019.06.046

43. Martusiewicz A, Delagrammaticas D, Harold RE, et al. Anterior versus posterior approach total hip arthroplasty: patient-reported and functional outcomes in the early postoperative period. Hip Int. 2020;30(6):695-702. doi: 10.1177/1120700019881413

44. Radoicic D, Zec V, Elassuity WI, Azab MA. Patient's perspective on direct anterior versus posterior approach total hip arthroplasty. Int Orthop. 2018;42(12):2771-2775. doi: 10.1007/s00264-018-4002-z

45. Lin TJ, Bendich I, Ha AS, et al. A comparison of radiographic outcomes after total hip arthroplasty between the posterior approach and direct anterior approach with intraoperative fluoroscopy. J Arthroplasty. 2017;32(2):616-623. doi: 10.1016/j.arth.2016.07.046

46. Cheng TE, Wallis JA, Taylor NF, et al. A prospective randomized clinical trial in total hip arthroplasty-comparing early results between the direct anterior approach and the posterior approach. J Arthroplasty. 2017;32(3):883-890. doi: 10.1016/j.arth.2016.08.027

47. Luo ZL, Chen M, Shang XF, et al. Direct anterior approach versus posterolateral approach for total hip arthroplasty in the lateral decubitus position. Zhonghua Yi Xue Za Zhi. 2016;96(35):2807-2812. doi: 10.3760/cma.j.issn.0376-2491.2016.35.009

48. Jia F, Guo B, Xu F, et al. A comparison of clinical, radiographic and surgical outcomes of total hip arthroplasty between direct anterior and posterior approaches: a systematic review and meta-analysis. Hip Int. 2019;29(6):584-596. doi: 10.1177/1120700018820652

49. Miller LE, Gondusky JS, Kamath AF, et al. Influence of surgical approach on complication risk in primary total hip arthroplasty. Acta Orthop. 2018;89(3):289-294. doi: 10.1080/17453674.2018.1438694

50. Peng L, Zeng Y, Wu Y, et al. 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(1):338. doi: 10.1186/s12891-020-03318-x

51. Gazendam A, Bozzo A, Ekhtiari S, et al. Short-term outcomes vary by surgical approach in total hip arthroplasty: a network metaanalysis. Arch Orthop Trauma Surg. 2022;142(10):2893-2902. doi: 10.1007/s00402-021-04131-4

52. Kaefer M, Castagnetti M, Herbst K, et al. Evidence-based medicine III: level of evidence. J Pediatr Urol. 2019;15(4):407-408. doi: 10.1016/j.jpurol.2019.04.012

53. Miller LE, Kamath AF, Boettner F, Bhattacharyya SK. In-hospital outcomes with anterior versus posterior approaches in total hip arthroplasty: meta-analysis of randomized controlled trials. J Pain Res. 2018;11:1327-1334. doi: 10.2147/JPR.S166058

54. Nogler M, Randelli F, Macheras GA, Thaler M. Hemiarthroplasty of the hip using the direct anterior approach. Oper Orthop Traumatol. 2021;33(4):304-317. doi: 10.1007/s00064-021-00727-6

55. Sibia US, Turner TR, MacDonald JH, King PJ. The impact of surgical technique on patient reported outcome measures and early complications after total hip arthroplasty. J Arthroplasty. 2017;32(4):1171-1175. doi: 10.1016/j.arth.2016.10.031

56. Zhao HY, Kang PD, Xia YY, et al. Comparison of early functional recovery after total hip arthroplasty using a direct anterior or posterolateral approach: a randomized controlled trial. J Arthroplasty. 2017;32(11):3421-3428. doi: 10.1016/j.arth.2017.05.056

57. Galmiche R, Poitras S, Dobransky J, et al. Does surgical approach influence mid- to long-term patient-reported outcomes after primary total hip replacement? A comparison of the 3 main surgical approaches. Can J Surg. 2020;63(22):E181-E189. doi: 10.1503/cjs.008919

58. Li SL, Yang XT, Tian XB, Sun L. Early functional recovery of direct anterior approach versus anterolateral approach for total hip arthroplasty. Beijing Da Xue Xue Bao Yi Xue Ban. 2019;51(2):268-272. (In Chinese). doi: 10.19723/j.issn.1671-167X.2019.02.013

59. Bourget-Murray J, Horton I, Meniawy SE, et al. The direct anterior approach is safe and shortens hospital length of stay following hemiarthroplasty for neck of femur fracture. Injury. 2023;54(4):1186-1190. doi: 10.1016/j.injury.2023.02.016

60. Faldini C, Perna F, Mazzotti A, et al. Direct anterior approach versus posterolateral approach in total hip arthroplasty: effects on early post-operative rehabilitation period. J Biol Regul Homeost Agents. 2017;31(4 suppl 1):75-81.

61. Pugely AJ, Martin CT, Gao Y, et al. The Incidence of and risk factors for 30-day surgical site Infections following primary and revision total joint arthroplasty. J Arthroplasty. 2015;30(9 Suppl):47-50. doi: 10.1016/j.arth.2015.01.063

62. George J, Mahmood B, Sultan AA, et al. How fast should a total knee arthroplasty be performed? An Analysis of 140,199 Surgeries. J Arthroplasty. 2018;33(8):2616-2622. doi: 10.1016/j.arth.2018.03.012

63. Gulbrandsen TR, Muffly SA, Shamrock A, et al. Total hip arthroplasty: direct anterior approach versus posterior approach in the first year of practice. Iowa Orthop J. 2022;42(1):127-136.

64. Gofton WT, Ibrahim MM, Kreviazuk CJ, et al. Ten-year experience with the anterior approach to total hip arthroplasty at a tertiary care center. J Arthroplasty. 2020;35(5):1281-1289.e1. doi: 10.1016/j.arth.2019.12.025

65. Slotkin EM, Patel PD, Suarez JC. Accuracy of fluoroscopic guided acetabular component positioning during direct anterior total hip arthroplasty. J Arthroplasty. 2015;30(9 Suppl):102-6. doi: 10.1016/j.arth.2015.03.046

66. Harrison CL, Thomson AI, Cutts S, et al. Research synthesis of recommended acetabular cup orientations for total hip arthroplasty. J Arthroplasty. 2014;29(2):377-82. doi: 10.1016/j.arth.2013.06.026

67. Makhdom AM, Hozack WJ. Direct anterior versus direct lateral hip approach in total hip arthroplasty with the same perioperative protocols one year post fellowship training. J Orthop Surg Res. 2023;18(1):216. doi: 10.1186/s13018-023-03716-6