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 percutaneouslyassisted 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 compliData 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.

Functional and clinical outcome with modified lateral approach total hip arthroplasty in stiff hips with ankylosing spondylitis

BACKGROUND Ankylosing spondylitis at total hip arthroplasty(THA)has significant hip stiffness with flexion deformity,restricted mobility,and function.Range of movement(ROM)improvement with good functional outcome is seen following THA in these hips.The modified Hardinge approach without abductor compromise is helpful in these stiff hips with associated flexion deformity.AIM To assess improvement in ROM and functional outcomes with a modified lateral approach THA in ankylosing spondylitis with stiff hips.METHODS A total of 69 hips that underwent THA with a modified Hardinge approach in 40 patients were evaluated at a mean follow-up of 38.33 mo.All individuals ambulated with weight-bearing as tolerated and ROM exercises from the 1st postoperative day.Modified Harris hip score and ROM were assessed during follow-up.Quality of life assessments using the 36-item and 12-item short form health surveys were done along with clinical and functional outcomes at followup.SPSS 22.0 was used for statistical analysis.The correlation of ROM and functional score change was performed using Pearson’s correlation coefficient.RESULTS Sixty-nine hips with a significant decrease in ROM preoperatively with 32 clinically fused hips showed significant improvement in flexion range.The mean flexion in 69 hips improved from 29.35±31.38 degrees to 102.17±10.48 degrees.The mean difference of 72.82 with a P value<0.0001 was significant.In total,45 out of 69 hips had flexion deformity,with 13 hips having a deformity above 30 degrees.The flexion during the follow-up was below 90 degrees in 3 hips.Eleven hips had flexion of 90 degrees at follow-up,while the remaining 55 hips had flexion above 100 degrees.Modified Harris hip score improved from 17.03±6.02 to 90.66±7.23(P value<0.0001).The 36-item short form health survey at the follow-up indicated health status in 40 patients as excellent in 11,very good in 20,good in 5,fair in 3,and poor in 1.The mean mental health score was 84.10±11.58.Pain relief was good in all 69 hips.Altogether,28/40 patients(70%)had no pain,9 patients(22%)had occasional pain,and 3 patients(8%)had mild to moderate pain with unusual activity.Heterotopic ossification was seen in 21 hips with Brooker class 1 in 14 hips.CONCLUSION Modified Hardinge approach THA in ankylosing spondylitis with stiff hips with flexion deformity significantly improved ROM,Harris hip score,and quality of life indicated by the 36-item and 12-item short form health surveys.

Early Outcomes of Primary Total Hip Arthroplasty for Osteonecrosis of the Femoral Head in Patients with Human Immunodeficiency Virus in China

Background：Studies have reported that patients with human immunodeficiency virus （HIV） have a high incidence of osteonecrosis of the femoral head （ONFH）.Total hip arthroplasty （THA） is an effective management of ONFH.However,little data exist regarding the use of THA for the HIV patients with ONFH in China.This study reviewed the outcomes of HIV-positive patients who underwent THA for ONFH,compared with HIV-negative individuals.Methods：The patients who underwent THA for ONFH from September 2012 to September 2014 in Beijing Ditan Hospital,Capital Medical University were retrospectively studied.Twenty-eight HIV-positive patients and 35 HIV-negative patients underwent 48 THAs and 45 THAs with cementless components,respectively.Medical records and follow-up data were reviewed.Harris Hip Score （HHS） was applied to evaluate the pain and function of the hips before and after THA.Complications such as wound healing,surgical site infection,deep venous thrombosis,pulmonary embolism,sepsis,mortality,and complications from the prosthesis were reviewed.The operation time,blood loss,and hospital stay were compared between the two groups.Results：The mean follow-up period was 19.5 ± 5.8 months （ranging from 6 to 30 months）.The mean age of the HIV-positive patients with osteonecrosis at the time of surgery was 35 years old,which was significantly lower than that of the HIV-negative group （42 years old） （P 〈 0.05）.The HIV-positive patients underwent surgery a mean of 2.5 years after their original symptoms,which was significantly shorter than the HIV-negatives＇ （mean 4 years） （P 〈 0.05）.Among HIV-positive patients,the prevalence of being male and rate of bilateral procedures were significantly higher than those in the HIV-negative group （P 〈 0.05）.The operation time in HIV-positive patients was significantly longer than that in HIV-negative patients （P 〈 0.05）.There were no significant differences in blood loss or hospital stay between the two groups （P 〉 0.05）.The HHSs of two groups significantly improved after THAs （P 〈 0.05）,without significant difference between two groups.No wound complication,sepsis,mortality,prosthesis complication,and occupational exposure occurred,except for two cases of heterotopic ossification and one case of humeral head necrosis.Conclusions：ONFH is more likely to occur bilaterally in younger HIV-positive males.The development of osteonecrosis seems faster in HIV-positive patients than in HIV-negative patients.This should be cautionary for asymptomatic HIV-positive patients with low viral RNA level and in the primary HIV stage.Despite longer operation times in the HIV-positive patients than in the HIV-negative patients,THA is still a safe and efficient approach to treat ONFH in HIV-positive patients.The incidence of complications is much lower than previously reported.However,the long-term follow-up is needed.

Influence of the femoral head size on early postoperative gait restoration after total hip arthroplasty

Background We investigated the effects of using large-diameter femoral heads in total hip prostheses on early postoperative gait restoration in patients undergoing total hip arthroplasty （THA）. Methods We collected data for 19 primary THAs using 28-mm metal-on-polyethylene heads （conventional group） and for 12 THAs （BHR group） using metal-on-metal femoral heads with an average size of 45 mm （range, 40-49mm）. All patients had unilateral femoral head avascular necrosis. All patients underwent Harris Hip Scores evaluation and gait analysis with the IDEEA device at the same 3 time points which were before surgery and then at 1 month and again at 3 months after surgery, and the parameters measured were walking speed, stride length （SL）, single limb support （SLS）, cycle duration （CD）, and swing power （SP）. Harris Hip Scores and gait analysis parameters for both groups were compared. Results Intraclass comparison indicated that Harris Hip Scores, speed scores, and gait parameter measures in both groups improved significantly with the passage of time; Interclass comparison showed no significance between Harristm postop - HarriSpreop and Harris3m postop- HarriSpreop in both groups. The speed in the BHR group at 1 month and at 3 months after surgery was significantly higher than that of conventional group. At 1 month after surgery, each mean for SLnormal - SLaffected, （SLSnormal - SLSaffected）/CD, and SPnormal - SPaffected in the BHR group was significantly lower than that for the conventional group. At 3 months after surgery, the differences between means for both groups for SLnormal - SLaffected, （SLSnormal- SLSaffected）/CD, and SPnormal - SPaffected were not significant, but the mean of SPnorrnal - SPaffected in the BHR group was significantly lower than that in the conventional group. Conclusions Our data suggest that large-diameter femoral heads in THA provide better early gait restoration than conventional-size femoral heads.