a systematic review and meta-analysis of the standard versus mini-incision posterior approach to...

The Journal of Arthroplasty xxx (2014) xxx–xxx

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The Journal of Arthroplasty

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A Systematic Review and Meta-Analysis of the Standard VersusMini-Incision Posterior Approach to Total Hip Arthroplasty

James R. Berstock, MBChB, MRCS , Ashley W. Blom, MD, PhD, FRCS (Tr&Orth), Andrew D. Beswick, BScUniversity of Bristol Musculoskeletal Research Unit, AOC (Lower Level), Southmead Hospital, Bristol, UK

a b s t r a c ta r t i c l e i n f o

The Conflict of Interest statement associated with thidx.doi.org/10.1016/j.arth.2014.05.021.

Reprint requests: James Berstock, MBChB, MRCS, UnivResearch Unit, AOC (Lower Level), Southmead HospitaBS10 5NB.

http://dx.doi.org/10.1016/j.arth.2014.05.0210883-5403/© 2014 Elsevier Inc. All rights reserved.

Please cite this article as: Berstock JR, et al,to Total Hip Arthroplasty, J Arthroplasty (2

Article history:Received 19 February 2014Accepted 22 May 2014Available online xxxx

Keywords:arthroplastyreplacementhipmeta-analysisreview

The mini-incision posterior approach may appeal to surgeons comfortable with the standard posteriorapproach to the hip. We present the first systematic review and meta-analysis of these two approaches.Twelve randomised controlled trials and four non-randomised trials comprising of 1498 total hiparthroplasties were included. The mini-incision posterior approach was associated with an earlyimprovement in Harris hip score of 1.8 points (P b 0.001), reduced operating time (5 minutes, P b 0.001),length of hospital stay (14 hours, P b 0.001), intraoperative and total blood loss (63 ml, P b 0.001 and 119 ml,P b 0.001 respectively). There were no statistically significant differences in the incidence of dislocation,nerve injury, infection or venous thromboembolic events. The minimally invasive posterior approach appearsto provide a safe and acceptable alternative to the standard incision posterior approach.

s article can be found at http://

ersity of Bristol Musculoskeletall, Westbury-on-Trym, Bristol,

A Systematic Review and Meta-Analysis of the014), http://dx.doi.org/10.1016/j.arth.2014.05

© 2014 Elsevier Inc. All rights reserved.

Standard incision total hip arthroplasty has consistently proveditself with excellent long-term outcomes [1–3], and so an appropriatescepticism towards minimally invasive approaches exists [4]. Thosereluctant to adopt minimally invasive approaches cite an increase incomplications such as dislocation, fracture, lateral femoral cutaneousnerve injury, increased operative time, component malposition due toreduced access and visualisation, and a steep learning curve [5–8].Advocates of minimally invasive techniques describe shorter stays inhospital, expedited postoperative rehabilitation and recovery, re-duced blood loss and diminished postoperative pain [9–12]. Most ofthese supporting studies are small and underpowered to investigateserious but uncommon complications such as dislocation, nerve injuryor fracture.

One of the challenges which exists when considering minimallyinvasive approaches is the variety of different techniques which allclaim to be minimally invasive. The lack of an overarching definitionof ‘minimally invasive’ also makes the discussion of such techniquesimprecise. Recently many authors have adopted 10 cm as the cut-offincision length for minimally invasive arthroplasty. Despite theadoption of this clear definition, most would agree that the degreeof deeper muscle and soft tissue dissection is a more relevant factordetermining outcomes [13].

Numerous minimally invasive approaches have been developedand can be classified as either muscle sparing or mini-incision. Musclesparing approaches avoid cutting or releasing muscles or tendons.Examples of muscle sparing approaches are the two-incisionapproach, which uses a modified Smith–Petersen anterior approachcombined with a small posterior incision [14], the anterolateral mini-approach, the modified anterolateral Watson–Jones approach [15],and the direct anterior mini-approach [9,16,17]. Mini-incisionapproaches use short incisions and may involve less muscledetachment than their standard incision equivalents. Examples ofmini-incision approaches include the mini-anterolateral [18], mini-lateral and the mini-posterior approach [19–22]. Piriformis andquadratus femoris sparing surgery are also possible with the mini-posterior approach [23].

We present a systematic review and meta-analysis of complica-tion rates, functional and radiographic outcomes from RCTs andnon-randomised trials comparing the mini-incision posteriorapproach with the standard incision posterior approach for totalhip arthroplasty.

Materials and Methods

We conducted the systematic review and meta-analysis usingmethods described in the Cochrane Handbook for Systematic Reviewsof Interventions [24] and in accordance with Preferred Items forSystematic Reviews and Meta-analyses (PRISMA) guidelines [25]. Theprotocol for this systematic review is registered and available on theProspero database CRD42013004943.

Standard Versus Mini-Incision Posterior Approach.021

http://dx.doi.org/10.1016/j.arth.2014.05.021





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Table 1Formal Search Strategy.

Search Terms Results

1 arthroplasty, replacement, hip.mp.or exp Arthroplasty, Replacement, Hip/

31486

2 Hip Prosthesis 292693 hip/or hip joint/or hip.tw. 2332804 1 or 2 515065 4 and 3 424436 posterior.tw. 4423397 posterolateral.tw. 167158 Moore.tw. 59479 Southern.tw. 81877310 Gibson.tw. 202011 6 or 7 or 8 or 9 or 10 127813312 mini$.mp. [mp = ab, hw, ti, ot, bt, sh,

tn, dm, mf, dv, kw, nm, kf, ps, rs, an, ui]1760529

13 classic.tw. 12092614 standard.tw. 149512515 conventional.tw. 80781816 technique.mp. [mp = ab, hw, ti, ot, bt, sh,

tn, dm, mf, dv, kw, nm, kf, ps, rs, an, ui]2290793

17 incision.mp. [mp = ab, hw, ti, ot, bt, sh, tn,dm, mf, dv, kw, nm, kf, ps, rs, an, ui]

102021

18 invasive.tw. 54427019 MIS.tw. 1653520 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 624968921 5 and 11 and 20 84622 prospective.tw. 85783123 approach.tw. 191508224 22 and 23 4242025 24 and 5 and 20 15826 25 or 21 941

MEDLINE (1950 to 3rd January 2014), Embase (1980 to 2013 Week 52), AMED (Alliedand Complementary Medicine 1985 to January 2014), CAB Abstracts (1973 to 2013Week 51).

Table 2Characteristics of Included Studies.

Author, YearCountryDate of StudyStudy Design

Study/Participant Characteristics

MIS Posterior Group Standard Posterior Group

Khan et al, 2012Australia2005–2007RCT

100 patients randomised.Exclusions: previous hip surgery, post-traumatic OA,b60 years old. Single surgeon performed or supervised.Same implants and rehabilitation protocols used.Piriformis sparing MIS approach,mean incision length 12.6 cmN = 48 (OA = 91.7%)N = 44 followed up (92%)

As per MIS but longer incision(mean 19.3 cm) and piriformisreleasedN = 52 (OA = 96.2%)N = 45 followed up (87%)

Mean age 72.3 (SEM 1.0)Female 50.0%Mean follow up 37.5 months(SD 10)

Mean age 72.8 (SEM 1.1)Female 63.5%Mean follow up 38.3 months(SD 9.2)

Goosen et al, 2011Netherlands2005–2007RCT

60 patients, single-centre double-blind block-randomisedcontrolled trial.Exclusions: BMI N30, previous ipsilateral hip surgery, age N75.1 year follow up.6 surgeonsAll procedures were performed using a Bi-Metric porous-coateduncemented stem and a metal-metal Magnum femoralhead and acetabular shell.Reduced incision and soft tissuedissection as per Howell 2004.7.8 cm mean incision length,then lengthened to 18 cm uponcompletion.N = 30 (OA = 90%)N = 29 followed up (97%)Mean age 60 (SD 6.3)Female 50%

Gibson's description of theposterior approach.18 cm mean incision.N = 30 (OA = 97%)N = 29 followed up (97%) onpatient with cup revisionexcluded from analysis.Mean age 62 (SD 6.3)Female 57%

2 J.R. Berstock et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx

Please cite this article as: Berstock JR, et al, A Systematic Review and Meto Total Hip Arthroplasty, J Arthroplasty (2014), http://dx.doi.org/10.10

Search Strategy

Electronic searches of literature published in any languagewere performed in January 2014. Details of the full Medlinesearch strategy are provided in Table 1. We also searched theCochrane Central Register of Controlled Trials (on 3rd January2014), the reference lists of relevant studies, and the Web ofScience citation tracking facility to identify further studies.Handsearching of abstracts and proceedings from the annualmeetings of the British Hip Society annual meeting, EuropeanFederation of National Associations of Orthopaedics and Trauma-tology, and the American Academy of Orthopaedic Surgeons wasalso undertaken.

Study Selection, Data Extraction, and Assessment of Risk of Bias

Relevant studies included RCTs and prospective non-randomisedtrials comparing the standard posterior or mini-incision (approx-imately 10 cm or shorter) posterior approach in the setting of adultparticipants (N19 years old) undergoing primary total hip arthro-plasty surgery, for the treatment of degenerative hip disease.Studies performed in the setting of hip fracture, infection, revisionsurgery, hemiarthroplasty or resurfacing arthroplasty were exclud-ed. The primary outcome measure was dislocation of the prosthetichip joint, as a presumed surrogate of the adequacy of the approach.Secondary outcome measures were operating time, length ofhospital stay, intraoperative blood loss, total perioperative bloodloss, postoperative Harris hip score, WOMAC score, intraoperativefemoral fracture, nerve injury infection and thromboembolic events.Other outcomes such as limb length discrepancy, pain scores andradiographic findings such as cup inclination and stem alignment

Primary Study Outcomes Other Outcomes Reported

SF-12, OHS, Iowa Level ofAssistance Scale (ILOA)Ability to walk unaided.

Mean operation time, mean fall inhaemoglobin on postoperative day 1, meanVAS scores for satisfaction and pain, meannumber of transfusions required, leglengthening N1 cm, mean CRP on day 2,mean pain score at day 2, Barrack grading,acetabular component inclination,acetabular component anteversion, femoralcomponent coronal alignment, mortality,dislocation, infection, DVT, PE, femoralfracture,perceivedsurgical challengeonVAS.

Mean distance walked insix minutes at 2 weeks,six weeks and three monthsreview.

Mean length of stay

6 weeks and 1 year; Harris HipScore, WOMAC score, OHS, SF 36

Mean surgical time, initial incision lengthwith hip in flexion, initial incision lengthwith hip in extension, final incisionlength with hip in flexion, final incisionlength with hip in extension, length ofhospital stay, proximal femoral fracture,massive venous bleeding, sciatic nervepalsy, infection, stem revision, cuprevision, cup inclination, leg lengthdiscrepancy, heterotopic ossification.Blood parametersPreop and day 1; Hb, CK, myoglobin

e

ta-Analysis of the Standard Versus Mini-Incision Posterior Approach16/j.arth.2014.05.021


Table 2 (continued)



Primary Study Outcomes Other Outcomes ReportedMIS Posterior Group Standard Posterior Group

Varela-Egocheagaet al, 2010Spain2006–2007RCT

50 patients randomisedExclusions: developmental dysplasia, previous surgery, BMI N40.1 year follow upAll patients received Bihapro acetabular component with 28 mmpoly liner, Cerafit uncemented femur, and ceramic 28 mm head.

Perioperative bleeding:number of patients transfused,units transfused per patient,surgical drainage, preop 6 hoursand 48 hours Hb.Harris hip score at 3 monthsand 12 months.

Number of patients requiring analgesicsfor pain on day 1 and 2, volume ofmetamizol administration, day of onsetof ambulation (first day in which thepatient was able to walk 10 steps in arow), length of hospital stay, operativetime (skin to skin), economic costing.Postop complications: dislocation,wound seroma, leg length discrepancy.Radiographic outcomes: cup inclination,stem alignment, Barrack grading.

Sculco technique, incision b10 cm

N = 25 (OA = 88%)N = 25 followed up (100%)Mean age 60.8 (SD 11.1)Female 44%

Technique as per Mooreand GibsonN = 25 (OA = 84%)N = 25 followed up (100%)Mean age 61.3 (SD 10.7)Female 56%

Fink et al, 2010GermanyNot recordedMatched prospectivecohort

100 patients matched, prospective cohort study.Exclusions: previous surgery, spinal anaesthesia, patientsunable to comply with standardised analgesia protocol.Both groups received cementless acetabular (Allofit)and a cemented stem (Optan).Maximum follow up 6 weeks.

Blood parametersPreop, 24 hours and 48 hours:CPK, CKMM, myoglobin. Preopand day 3 CRP.

Operation time, blood loss (intraoperativeand post-operative drainage), autologousretransfusion from cell saver, transfusionof allogenic blood, Pain at rest and motion,unaided mobility, completion of stairs,SF 36, WOMAC, OHS.Complications: dislocation, fracture, nerveinjury, infection, deep vein thrombosis.Radiographic outcomes: Cup inclination,cup anteversion, stem alignment,cementation, offset and leg lengthdiscrepancy.

Inaba approach, quadratus sparingN = 50 (OA = 88%)N = 50 followed up (100%)Mean age 71.9 (SD 6.1)Female 54%

Standard posterior approachN = 50 (OA = 88%)N = 50 followed up (100%)Mean age 71.5 (SD 5.6)Female 50%

Shitama et al, 20092003–2005JapanRCT

39 patients, randomised blinded study.Exclusions: history of previous surgery on the affected hipand inflammatory polyarthritis.Maximum follow up 6 months. Most patients had OA secondaryto DDH, average age of patient 59 years.Prior experience of N100 mini-incision cases.

Preop and 24 hour IL-6, CRP, Hb. Mean operating time, fissure fractureof the proximal femur, pulmonaryembolism, deep infection, dislocation,preoperative and postoperativeHarris hip score

b10 cm incisionN = 19 no loss to follow upMean age 58.3 (SD 3.0)Female approx. 85%

Standard incision 15 cmN = 20 no loss to follow upMean age 61.3 (SD 10.7)Female approx. 86%

Kiyama et al, 2008JapanRCT

20 patients enrolled in this randomised blinded study.Quazi randomised “Patients assigned odd numbers underwentsurgery through a mini-incision approach, whereas patientsassigned even numbers underwent surgery through astandard-incision approach.”Exclusions: A history of surgery on the affected hip and thepresence of inflammatory polyarthritis.Maximum follow up 6 months.Prior experience of N150 mini-incision cases.

Intraoperative measurement ofskin blood flow.Fitzpatrick grading ofscar cosmesis.

Surgical time, postoperative woundcomplications, wound discharge,superficial infections.

≤8 cm mini incision(mean 7.3 cm)N = 10 (OA 80%)Mean age 60.3 (range 47–82)Female 90%

Standard incision 14 cm

N = 10 (OA 90%)Mean age 63.8 (range 49–79)Female 80%

No loss to follow up No loss to follow upFarr et al, 2008UKRCT

216 patients randomised.Maximum follow up 1 yearArticle appears as an abstract, authors contacted foradditional data.

Operative time, blood losslength of stay, 1 year postoperativeWOMAC, Harris Hip, Merle d'Aubigneand SF-12 scores

N = 97 N = 119Dorr et al, 20072004–2005USARCT

60 patients were randomised.The exclusion criteria included previous surgery on the affectedhip, a pathological condition of the hip that required an extensileexposure, same-day bilateral total hip replacement, andinflammatory polyarthritis.6 month maximum follow up.Two surgeons with prior experience of N400 andN100 mini-incision cases.

Pain scores on day 1 and2 postoperatively.Six week and 6 monthHarris hip scoreLength of hospital stay

Pre and post-op haemoglobin andhaematocrit, total blood loss, intraoperativeblood loss, surgical time. Requirements forpain medicine, need for assistive gaitdevices, length of hospital stay, gait analysis.Radiographic outcomes: cup inclination, cupanteversion, limb length discrepancy, offset.

Mini-incision posterior10 cm ± 2 cmN = 30Mean age 73.4 (SD 9.7)Female 43%No loss to follow up

Standard posterior20 cm ± 2 cmN = 30Mean age 63.9 (SD 13.6)Female 53%No loss to follow up

Kim et al, 20062002–2003KoreaRCT

The laterality of MIS and standard procedures wasrandomised in 70 patients (140 hips) undergoingsimultaneous bilateral THA.26.4 months mean follow up (range 24–36 months).There were 53 men and 17 women.Prior experience of N50 mini-incision cases.

Average surgical timeAverage intra-operativeestimated blood loss

Infection, dislocation, peroneal nerve injury,wound drainage, weight of soakeddressings, mean hemovac suction drainage,average transfusion requirement (allogenicand autologous), pre and post-operativeHb,haematocrit, range of motion, VAS for pain.

(continued on next page)

3J.R. Berstock et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx

Please cite this article as: Berstock JR, et al, A Systematic Review and Meta-Analysis of the Standard Versus Mini-Incision Posterior Approachto Total Hip Arthroplasty, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.05.021


https://www.researchgate.net/publication/23792532_Which_is_more_invasive-mini_versus_standard_incisions_in_total_hip_arthroplasty?el=1_x_8&enrichId=rgreq-50477abb-08d8-4f10-b5b9-dead696617d6&enrichSource=Y292ZXJQYWdlOzI2MjgwNzAyMjtBUzoxMjk5OTQxNzcxMjY0MDFAMTQwODAwNDQzNTY5Mw==

https://www.researchgate.net/publication/5322075_Comparison_of_Skin_Blood_Flow_Between_Mini-_and_Standard-Incision_Approaches_During_Total_Hip_Arthroplasty?el=1_x_8&enrichId=rgreq-50477abb-08d8-4f10-b5b9-dead696617d6&enrichSource=Y292ZXJQYWdlOzI2MjgwNzAyMjtBUzoxMjk5OTQxNzcxMjY0MDFAMTQwODAwNDQzNTY5Mw==

https://www.researchgate.net/publication/45388166_Comparison_of_a_minimally_invasive_posterior_approach_and_the_standard_posterior_approach_for_total_hip_arthroplasty_A_prospective_and_comparative_study?el=1_x_8&enrichId=rgreq-50477abb-08d8-4f10-b5b9-dead696617d6&enrichSource=Y292ZXJQYWdlOzI2MjgwNzAyMjtBUzoxMjk5OTQxNzcxMjY0MDFAMTQwODAwNDQzNTY5Mw==

https://www.researchgate.net/publication/6291905_Early_Pain_Relief_and_Function_After_Posterior_Minimally_Invasive_and_Conventional_Total_Hip_ArthroplastyA_Prospective_Randomized_Blinded_Study?el=1_x_8&enrichId=rgreq-50477abb-08d8-4f10-b5b9-dead696617d6&enrichSource=Y292ZXJQYWdlOzI2MjgwNzAyMjtBUzoxMjk5OTQxNzcxMjY0MDFAMTQwODAwNDQzNTY5Mw==

Table 2 (continued)




Radiographic outcomes: cup abduction andanteversion angles, the stem alignment, andthe fit and fill of the cementless femoralcomponents, femoral offset, and limblength discrepancy.

8-cm minimally invasiveposterior approachN = 70Mean age 70.3 (SD 9.7)Female 43%No losses to follow up reported

15- to 20-cm standardposterolateral incisionN = 70Mean age 63.9 (SD 13.6)Female 53%No losses to follow up reported

Sharma et al, 2006NRUKRCT

40 patients with BMI b30 randomised. Pilot study onlyNo records of loss to follow-up or % female

Complications: Dislocation,superficial infection, deepinfection, intra-operativefracture, nerve injury.

Pain score on day 1, mean operatingtime, drop in Hb, haematocrit, daysto mobilisation with Zimmer frame,length of stay

Mini-incision was thediameter of the femoralhead plus 2 cmN = 20Mean age 67

Standard incision was 12 cm

N = 20Mean age 69

Chimento et al, 20051999–2000USARCT

60 patients were randomised.Exclusions: BMI N30, prior hip surgery,A press-fit monoblock elliptical acetabular componentwas used in all cases. Femoral components were eithercemented or press fit, based on the surgeon's discretion.Smaller specialised retractors were required in the MIS group.Follow up 2 yearsPrior experience of 1300 mini-incision cases.

Duration of surgery, intraoperativeblood loss, total blood loss, volumeof patient-controlled epiduralanaesthesia (PCEA), oralnarcotic requirement.2 year Harris hip score(no variance reported).

Mean increase in IL-6,Radiographic outcomes: cementationgrade, stemmalalignment, acetabularinclination angle, requirement for acane at 6 weeks, persistent limp at6 weeks, limp at 1 year, length ofstay, discharge destination,Postop complications: atrial flutter,sciatic pain, visual hallucinations, rash,analgesic confusion, nerve injury,infections, thromboembolic events,dislocation, revision.

8 cm incisionN = 28 (OA 100%)Mean age 67.2 (SD 8.6)Female 43%Loss to followup = 1 at 2 years

15 cm incisionN = 32 (OA 100%)Mean age 65.6 (SD 10.5)Female 59%Loss to follow up = 1 at2 years

Hart et al, 20052000–2002Czech RepublicRCT

120 cemented primary THAs were performed through aposterolateral approach. 60 of these cases were “randomlyselected for operation with a minimally invasive technique.”Randomisation method unclear.Exclusions: BMI N35, Hb b12 g/dl, age b65, or coagulation disorders.Smaller specialised retractors were required in the MIS group.Components were the same in both groups.Procedures performed by 2 experienced senior surgeonsThe mean follow-up was 39 months (range: 32–46)Overall median age 72.4 (range 66–78)Females 67%.

Radiographic outcomes: cupinclination and anteversionangles, stem alignment.

Duration of the surgery from incision towound closure, mean intraoperative bloodloss, mean postoperative blood loss intodrainage, Charnely's modification of Merled'Aubigné's score preoperatively, at6 weeks, 6 and 12 months postoperatively.

9–10 cm incisionN = 60 (OA 100%)No loss to follow-up

20 cm incisionN = 60 (OA 100%)No loss to follow-up

Ogonda et al, 20052003–2004UKRCT(including Lawloret al 2005, andBennett et al 2007)

219 patients randomisedExclusion criteria: a history of previous surgery on theaffected hip and inflammatory polyarthritis if the severity ofthe disease was likely to compromise postoperativemobility. Smaller specialised retractors were not requiredin the MIS group.Maximum follow-up 6 weeks4 lost to follow up at 6 weeksPrior experience of N300 mini-incision cases.

Harris hip score, WOMAC,OHS, SF-12 at six weeks.

Mid-thigh circumference, depth ofsubcutaneous fat, incision at start andend of case, estimated intraoperativeblood loss, haematocrit at 8 hours,mean total blood transfusion, postoperativepain scores and morphine use, baseline and48 hour CRP, mean operative time, meanstride length, mean step length, meancadence, mean walking speed, length ofhospital stay, discharge destination.Timed 6 and 10 metre walk at 6 weeks.Six week scar measurement.Radiographic outcomes: mean stemalignment, cementation grade.Complications: Death, intra-operativefracture, deep infection, superficialinfection, dislocation, DVT

Short incisionof ≤10 cmN = 109 (OA 98%)Mean age 67.4 (SD 9.8)Females 55%

Standard incision of 16 cm

N = 110 (OA 97%)Mean age 65.9 (SD 10.3)Females 47%

Wright et al, 20041996–1997USA

Patients were not formally randomised to the 2 groups.The decision to curtail the length of the surgical incisionfor certain patients depended on the presence or absenceof a particular group of assistant surgeons.There were no statistical differences in baselinepatient characteristics (age, preop HHS, height)between the groups, apart from a lower BMI in theMIS group.Identical implants and hybrid component fixation wereused in both groups.Smaller specialised retractors were required in the

Harris hip score, cosmeticappearance rating.

Estimated blood loss, operative time,length of hospital stay, componentmalposition, wound complications(septic and aseptic), dislocations,cementation grading, cup alignment,stem alignment, nerve palsy.




https://www.researchgate.net/publication/7944142_Component_position_following_total_hip_arthroplasty_through_a_miniinvasive_posterolateral_approach?el=1_x_8&enrichId=rgreq-50477abb-08d8-4f10-b5b9-dead696617d6&enrichSource=Y292ZXJQYWdlOzI2MjgwNzAyMjtBUzoxMjk5OTQxNzcxMjY0MDFAMTQwODAwNDQzNTY5Mw==

https://www.researchgate.net/publication/7838471_Minimally_invasive_total_hip_arthroplasty_-_A_prospective_randomized_study?el=1_x_8&enrichId=rgreq-50477abb-08d8-4f10-b5b9-dead696617d6&enrichSource=Y292ZXJQYWdlOzI2MjgwNzAyMjtBUzoxMjk5OTQxNzcxMjY0MDFAMTQwODAwNDQzNTY5Mw==

Table 2 (continued)




MIS group.Mean 5 year follow-up.8.8 cm incisionN = 42 (OA 88%)Mean age 64.2 (SD 15.1)Loss to follow up: 2 diedin first 5 years, and 3 werelost to F/U.

23.0 cm incisionN = 42 (OA 93%)Mean age 65.0 (SD 8.2)Loss to follow up: 2 diedin first 5 years, and 1 waslost to F/U.

Chung et al, 2004AustraliaProspective matchedcohort

120 patients, prospective matched cohorts but not randomised.Exclusions: Patients weighing N100 kg, semi-ankylosed joints,severe protrusio, or dysplasia were excluded from the study.Mean follow-up period was 14 months.No patients lost to follow up.

Operating time, blood loss, narcotic use,length of hospital stay, period withwalking aids, Harris hip score at14 months, component malposition,dislocations, DVTs.

Mean 9.2 cm incision,posterior approachN = 60 (OA 100%)Mean age 61(range 41–83)Female 60%

Southern approach,20 cm incisionN = 60 (OA 100%)Mean age 64 (48–81)Female 53%

DiGioia et al, 20031998-USAProspective cohort

Thirty-three patients (35 hips; group 1) were selected of 121patients who had undergone a mini-incision THA matched bydiagnosis, gender, average age, and preoperative Harris HipScore (HHS) to 33 patients (35 hips; group 2) of 120 patientswho had undergone THA using the traditional posterior approach.Navigation was used for both groups. Baseline patientcharacteristics were similar in both groups. Same cup butdifferent femoral components used. Smaller specialisedretractors were not required in the MIS group.

Dislocations, nerve injuries,length of hospital stay,blood transfusion average,mean Harris hip score at3, 6 and 12 months.

Operating time.Radiographic outcomes:cup abduction and anteversion.

8–12 cmN = 35 (in 33 patients,100% OA)Mean age 65 (range 49–80)Female 58%

N = 35 (in 33 patients,100% OA)Mean age 65 (range19–76)Female 58%


were also noted when they were reported. Information regardingindividual study characteristics was recorded in Table 2, andinformation regarding the standardisation of study methodologywas recorded in Table 3. The risk of bias for each study was assessedusing the Cochrane risk of bias tool [24], see Table 4. The reporting ofoutcomes is summarised in Table 5, and a summary of study type,participants and follow-up periods for each study is provided inTable 6.

Two authors (JB and ADB) independently reviewed all the titlesand abstracts of studies identified from the literature searches. Fulltexts of any potentially useful studies were obtained and reviewedin detail. Disagreements regarding which studies to include wereresolved by the third author (AWB). Data regarding the primaryand secondary outcomes of interest to this meta-analysis wereextracted in duplicate by two authors (JB and ADB), using astandardised form.

We contacted authors of studies to provide clarification and fulldatasets including means and standard deviations when these werelacking. We also requested information on outcomes not reported inthe publications. Three authors responded and the additional datawere included [26–28]. If variances were not available from theoriginal articles or by contacting authors, we estimated them fromranges with the assumption of a normal outcome distribution [29].

Recommendations have been considered in accordance withthe guidance from the Grading of Recommendations Assessment,Development, and Evaluation (GRADE) working group [30].

Meta-Analysis

Meta-analysis was performed using RevMan version 5 softwareif three or more studies reported a particular outcome. A classical,


frequentist statistical approach with a fixed-effects model wasused for the analysis to create odds ratios for dichotomousvariables and mean differences for continuous variables. Peto'sodds ratio method [31] was used for dichotomous events becauseof the rarity of the complications being investigated [32]. Standarderrors for the pooled intervention effect were used to derive 95%confidence intervals and P values to quantify the strength ofevidence against the null hypothesis. The intervention effectestimate was calculated using weighted averages of study effectsize according to the number of people in each study. Where onlydata ranges were reported, the method of Walter and Yao wasused to estimate standard deviations [29]. Zero total event studieshave been included in the meta-analysis to take account of thesample sizes [33]. Statistical heterogeneity was analysed by chi-squared tests, with the I2 statistic to quantify inconsistency [34]. Anarrative review of the outcomes with insufficient data for meta-analysis is provided.

Results

Literature searches identified 941 articles and after screening induplicate, 16 studies published between 2003 and 2014 wereincluded in the review. An additional three records report differentaspects of the same RCT [35–37], and have therefore been amalgam-ated to avoid duplication of data. Progress of articles through thisreview is summarised as a flow diagram in Fig. 1.

Characteristics of Included Studies

Studies included were 12 randomised controlled trials[12,23,26–28,35,38–43], and four prospective non-randomised trials



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Table 3Assessment of Methodological Quality.

Author and Year

Khan 2012 Goosen 2011Varela-Egocheaga2010 Fink 2010 Shitama 2009 Kiyama 2008 Farr 2008 Dorr 2007

Explicit standardised surgicaltechnique described.

✓ ✓ ✓ ✓ NR ✓ NR ✓

Previous experience withmini-incision technique?

✓ ✗ NR NR ✓ ✓ NR ✓

MIS group incision (≤10 cm) ✗ 12.6 cm ✓ ✓ NR ✓ ✓ NR ✓

Piriformis sparing in MIS group? ✓ ✗ ✗ ✗ ✗ ✗ NR ✗

Quadratus sparing in MIS group? Partial ✗ ✓ ✓ NR ✗ NR ✓

Single surgeon performing/supervisingall cases?

✓ ✗ ✓ ✗ ✗ ✓ NR ✗

Specialised retractors used? NR ✓ ✓ NR NR ✓ NR ✓

Same implants for both groups? ✓ ✓ ✓ ✓ NR NR NR ✗

Same bearing size for both groups? NR NR ✓ NR NR NR NR ✗

Same bearing material for both groups? NR ✓ ✓ NR NR NR NR ✗

Trans-osseous capsulotendinousrepair for both groups?

✓ NR NR NR ✓ ✓ NR ✗

MIS grouponly

Standardised suture materialfor closure?

✓ ✓ NR NR NR ✓ NR NR

Standardised anaesthetic? ✓ NR ✓ ✓ ✓ ✓ NR ✗

Standardised perioperative analgesia? ✓ NR ✓ ✓ NR NR NR ✓

Standardised thromboprophylaxis? ✓ ✓ ✓ NR NR NR NR ✓

Same rehabilitation protocoland precautions for both groups?

✓ NR ✓ ✓ NR NR NR ✓

Intention to treat analysis ✓ ✗

Patient excludedfor cup revision

✓ ✗

Patient excluded if requiredadditional analgesia

✓ ✓ NR ✓

Minimal loss to follow up ✓

11%✓ ✓ ✓ ✓ ✓ NR ✓

Author and Year

Kim 2006 Sharma 2006 Chimento 2005 Hart 2005 Ogonda 2005 Wright 2004 Chung 2004 DiGioia 2003

Explicit standardised surgicaltechnique described.

✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Previous experience withmini-incision technique?

✓ NR ✓ NR ✓ ✓ ✗ ✗

MIS group incision (≤10 cm) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✗

11.7 cmPiriformis sparing in MIS group? ✗ NR ✗ ✗ ✗ ✗ ✗ ✗

Quadratus sparing in MIS butnot standard group?

✓ NR ✓ NR NR ✗ ✓ ✗

Single surgeon performing/supervisingall cases?

✓ NR ✓ ✗ ✓ ✓ ✓ ✓

Specialised retractors used? ✓ NR ✓ ✗ ✗ ✗ ✗ ✗

Same implants for both groups? ✓ NR ✗ ✓ ✗ ✓ ✓ ✗

Same bearing size for both groups? ✓ NR ✗ NR NR NR NR ✗

Same bearing material for both groups? ✓ NR ✗ NR NR NR NR ✗

Trans-osseous capsulotendinousrepair for both groups?

✓ NR ✓ ✗ ✓ ✓ NR ✓

Standardised suture material for closure? NR NR NR NR NR NR NR NRStandardised anaesthetic? ✓ NR ✓ NR ✓ NR ✓ NRStandardised perioperative analgesia? ✓ NR ✓ NR ✓ NR ✓ NRStandardised thromboprophylaxis? NR NR ✓ NR NR NR ✓ NRSame rehabilitation protocol andprecautions for both groups?

✓ NR ✓ NR ✓ ✓ ✓ ✓

Intention to treat analysis ✓ NR ✓ ✓ ✓ NR ✓ ✓

Minimal loss to follow up ✓ NR ✓ ✓ ✓ ✓ ✓ ✓

Legend: ✓, robust methodology; ✗, differences in methodology exist between the groups; NR, not recorded.


[44–47], involving a total of 1498hip arthroplasties in 1424participants,see Table 6. The primary outcome, dislocation, was reported in 13studies. A summary of themeta-analysis results is provided in Table 7. Aconstant adjustment for the meta-analysis of zero total event studies isprovided for reference in Table 8.

We acknowledge that RCTs provide the best source of evidence forour review, however we included four prospective, non-randomisedtrials (nRCTs) where group allocation may have been open to risk ofbias. All four authors attempted to limit patient selection bias. Fink


and colleagues [44] considered a trial difficult due to anticipatedpatient preference for minimally invasive surgery and chose a studydesign with matched cohorts. Chung and colleagues [46] used asimilar study design. Wright and colleagues [45] reported thatpatients were assigned to groups based on attendance of assistantsurgeons with an interest in minimal incision surgery but with noother selection guidelines. In the study reported by DiGioia [47], allpatients were operated on by the same surgeon and groups werematched for key preoperative factors.



Table 4Risk of Bias.

Author Khan Goosen Varela–

Egocheaga

Fink Shitama Kiyama Farr Dorr

Year 2012 2011 2010 2010 2009 2008 2008 2007

Random sequence generation

Blinding of participants

Blinding of outcome assessment

Incomplete outcome data (attrition bias)

Selective reporting

Author

Year

Kim

2006

Sharma

2006

Chimento

2005

Hart

2005

Ogonda

2005

Wright

2004

Chung

2004

DiGioia

2003

Random sequence generation

Blinding of participants

Blinding of outcome assessment

Incomplete outcome data (attrition bias)

Selective reporting

Grading system: unclear risk of bias; Low risk of bias.

Allocation concealment has been removed from this risk of bias table as it is not applicable for surgical intervention studies.

High risk of bias;


Quality and Bias Assessment

For each study, we assessed the standardisation of variables suchas implant bearing sizes, prior experience with the mini-invasiveapproach, length of mini-invasive wound, analgesia and rehabilitationprotocols. These data are summarised in Table 3.

Twelve studies were RCTs, of which 10 reported adequategeneration of allocation sequences. In the four nRCTs there was ahigher risk of selectionbias, however the baselinepatient characteristicswere similar. Blinding of patients was achieved in 5/16 studies. Otherpotential biases have been assessed in Table 4. Overall, the 12RCTshad alow risk of bias, and the nRCTs have a moderate risk of bias.


Sensitivity Analysis

A post hoc sensitivity analysis, with the removal of the four nRCTshad minimal impact on the findings of this review, i.e. all statisticallysignificantfindings remained so. This is because the four nRCTs generallyconcurwith theRCTs, andasbaselinepatient characteristicswere similarin both groups, these studies have not been excluded from this review.

Analysis of Heterogeneity

Heterogeneity (I2) ranged from 0% to 94% for the outcomesreported in this meta-analysis. To investigate the cause we removed



Table 5Summary of Study Outcomes.

Author

Type Dislocation OperatingTime

Lengthof Stay

Intra-OperativeBlood Loss

TotalBloodLoss

HarrisHipScore

WOMAC NerveInjury

Fracture Infection ThromboembolicEvent

LimbLengthDiscrepancy

CoronalStemAlignment

CupInclination

Khan RCT Y Y Y Y Y Y Y YGoosen RCT Y Y Y Y Y Y Y Y Y YVarela-Egocheaga

RCT Y Y Y Y Y Y Y

Fink nRCT Y Y Y Y Y Y Y Y Y Y Y Y YShitama RCT Y Y Y Y Y YKiyama RCT YFarr RCT Y Y Y Y YDorr RCT Y Y Y Y Y Y Y Y Y YKim RCT Y Y Y Y Y Y Y YSharma RCT Y Y Y YChimento RCT Y Y Y Y Y Y Y Y YHart RCT Y Y Y Y Y Y Y YOgonda RCT Y Y Y Y Y Y Y Y Y YWright nRCT Y Y Y Y Y YChung nRCT Y Y Y Y YDiGioia nRCT Y Y Y


the nRCTs from the most frequently reported outcome, operatingtime. Heterogeneity was not affected by removal of nRCTs, suggestingthat the differences in reported outcomes are not related to studydesign. It is more likely that clinical rather than statistical heteroge-neity exists as a result of differing surgical practise and patientdemographics between studies.

Analysis of Publication Bias

Funnel plots were inspected for the primary outcome measuredislocation (see Fig. 2) and the most commonly reported secondaryoutcomemeasure, operating time. The symmetrical plot for dislocationsuggests an absence of publication bias, however the asymmetrical plotfor operating time (see Fig. 3) raises the possibility of some publicationbias in favour of studies reporting a shorter operating time for thestandard approach, contrasting with the findings of this meta-analysis.

Meta-Analysis

DislocationDislocation was reported in 13 studies (9 RCTs, and 4 nRCTs)

following 1198 arthroplasties (see Fig. 4). Follow-up periods for thesestudies range from 6 weeks to 60 months. Only two studies explicitlystated that the same bearing size was used in both groups [28,38].There were 7 dislocations (1.2%) occurring in the mini-posteriorapproach group, and 6 (1.0%) following the standard posterior

Table 6Study Type, Participants and Follow-Up.

Author Year of Publication Type

Khan 2012 RCTGoosen 2011 RCTVarela-Egocheaga 2010 RCTFink 2010 nRCTShitama 2009 RCTKiyama 2008 RCTFarr 2008 RCTDorr 2007 RCTKim 2006 RCTSharma 2006 RCTChimento 2005 RCTHart 2005 RCTOgonda 2005 RCTWright 2004 nRCTChung 2004 nRCTDiGioia 2003 nRCT


approach. As shown in Fig. 4, the higher dislocation rate followingthe mini-incision approach was not statistically significant, Peto oddsratio 1.20 (95% CI 0.40, 3.58 P = 0.74). Sensitivity analysis with theremoval of data from nRCTs did not significantly alter the findings,Peto odds ratio 1.55 (95% CI 0.45, 5.39; P = 0.49).

Operating TimeOperating time, as recorded from skin incision to completion of skin

closure, was reported in 14 studies (11 RCTs and 3 nRCTs) including1386 arthroplasties (see Fig. 5). Overall, the mini-posterior approachwas found to reduce operating time by a mean of 3 minutes and24 seconds per case, mean difference−3.40 minutes (95% CI−4.53,−2.28; P b 0.00001).

Length of Hospital StayLength of hospital stay was reported in 8 studies (6 RCTs and 2

nRCTs) including 925 arthroplasties (see Fig. 6). The mini-posteriorapproach reduced the length of stay by a mean of 14 hours, meandifference −0.57 days (95% CI −0.79, −0.36; P b 0.00001).

Intraoperative Blood LossTen studies report intraoperative blood loss (7 RCTs and 3 nRCTs)

for 1177 arthroplasties (see Fig. 7). The mini-posterior approachreduced blood loss by a mean of 82 ml (95% CI −92.57, −71.86;P b 0.00001).

No. of Participants No. of Hips Follow Up (Months)

100 100 38 mean60 60 12 mean50 50 12 max100 100 1.5 max39 39 6 max20 20 6 max216 216 12 max60 60 6 max70 140 26 mean40 40 NR60 60 24 max120 120 39 mean219 219 1.5 max84 84 60 mean120 120 14 mean66 70 12 max



Fig. 1. Study flow diagram.

Table 7Summary of Meta-Analysis Results.

Outcome No. of Studies No. of Hips Effect Size 95% Confidence Interval P Value

Dislocation 13 1198 1.20 [PO] 0.40, 3.58 0.74Operating time (min) 14 1386 −3.40 [MD] −4.53, −2.28 b0.00001Length of stay (days) 8 925 −0.57 [MD] −0.79, −0.36 b0.00001Intraoperative blood loss (ml) 10 1177 −82.21 [MD] −92.57, −71.86 b0.00001Total perioperative blood loss (ml) 3 220 −119.06 [MD] −174.78, −63.35 b0.0001Harris hip score 8 874 1.75 [MD] 1.06, 2.45 b0.00001WOMAC score 4 591 −1.01 [MD] −3.52, 1.51 0.43Intraoperative femoral fracture 7 679 1.02 [PO] 0.14, 7.30 0.98Nerve injury 8 670 2.73 [PO] 0.38, 19.44 0.42Infection 11 1022 2.47 [PO] 0.56, 10.95 0.23Thromboembolic events 8 828 0.50 [PO] 0.16, 1.60 0.24Limb length discrepancy 4 268 −0.20 [MD] −0.97, 0.56 0.61Coronal stem alignment 6 510 0.29 [MD] 0.03, 0.54 0.03Cup inclination 9 904 0.03 [MD] −0.13, 0.50 0.68

Legend: PO; Peto odds ratio. MD; inverse variance mean difference. Odds ratio effect sizes greater than 1 suggest that the outcome is more likely with the mini-invasive posteriorapproach. Negative mean differences suggest that an outcome is reduced with the mini-invasive approach.

Table 8Adjusted Odds Ratios to Account for Zero Cell Counts.

Outcome Effect Size 95% Confidence Interval P Value

Dislocation 1.11 [PO] 0.49, 2.54 0.80Intraoperative femoral fracture 1.01 [PO] 0.32, 3.15 0.99Nerve injury 1.36 [PO] 1.36, 3.90 0.57Infection 1.38 [PO] 0.58, 3.26 0.47Thromboembolic events 0.68 [PO] 0.28, 1.65 0.39

Legend: PO; Peto odds ratio.


Total Perioperative Blood LossThree studies report intra-operative blood loss (2 RCTs and 1

nRCT) for 220 arthroplasties. The mini-incision posterior approachreduced blood loss by a mean of 119 ml (95% CI −174.78, −63.35;P b 0.0001), see Fig. 8.

Harris Hip ScoreEight studies (6 RCTs and 2 nRCTs) including 874 arthroplasties

with follow up ranging from 6 weeks to 60 months contribute data.



Fig. 2. Funnel plot for dislocation.

Fig. 3. Funnel plot for operating time.


The mini-incision group experienced a mean 1.8 point additionalimprovement over the standard incision group postoperatively (95%CI 1.06, 2.45; P b 0.00001), see Fig. 9.

WOMAC ScoreFour studies (3 RCTs and 1 nRCT) report postoperative WOMAC

scores, two at six weeks [45,44] and two at one year [26,27]. Therewas no significant difference between the groups, see Fig. 10.

Fig. 4. Forest plot f


Other OutcomesTherewereno statistically significant differences between approaches

for intraoperative femoral fracture, nerve injury, infection, thromboem-bolic events, limb length discrepancy, coronal stem alignment or cupinclination, as summarised in Table 7.

Four RCTs report early postoperative pain scores, all showingconsistently higher pain following the standard incision approach[12,23,35,41]. Individually these findings were not statisticallysignificant. Meta-analysis was not performed due to the differentassessment methods used.

Discussion

This systematic review and meta-analysis is based on the highestquality evidence from RCTs and nRCTs, and broadly demonstratesclinical equivalence between the standard and mini-incision poste-rior approaches.

Several systematic reviews investigatingminimally invasive ormini-incision surgery have been reported previously [48,49]. These reviewsgroup together all the different minimally invasive approaches makingthe findings too generalised. Our review specifically examines only theposterior approach to the hip.

Every effort has been made to assess methodological standardisa-tion, and determine the potential for risk of biaswithin studies (Tables 3and 4). These factors may account for some of the differences in clinicaloutcomes observed in this study. Whilst we are able to comment onimportant early postoperative outcomes and adverse events, weacknowledge that long-term outcomes such as implant failure, revisionand mortality may be better addressed via large registry studies [50],however our use of data from clinical trials only reduces the risk ofselection biases inherent in such cohort studies.

When compared with the standard posterior approach to hiparthroplasty, the mini-incision posterior approach demonstratesimproved early Harris hip scores and reduced operating time, lengthof hospital stay and perioperative blood loss. Although the 1.8 pointimprovement in Harris Hip scorewas strongly statistically significant(P b 0.0001), in the context of a minimal important clinicaldifference of four points [51], it is of doubtful clinical significance.These clinically small but statistically significant advantages may notout-weigh the possible increased risk of adverse events such asdislocation, nerve injury and infection. Such adverse events wereslightly more prevalent following the mini-posterior approach butthe differences did not reach statistical significance given their rarity.Further investigation and careful monitoring by surgeons who adoptthis technique are justified, particularly because most of the studiescontributing to this review cite some experience with the mini-invasive approach prior to commencing a clinical trial. This study

or dislocation.



Fig. 5. Operating time (min).

Fig. 6. Length of hospital stay (days).

Fig. 7. Intraoperative blood loss (ml).

Fig. 8. Total blood loss (ml).




Fig. 9. Postoperative Harris hip score.

Fig. 10. Postoperative WOMAC score.


demonstrates an adequate body of evidence suggesting overallequivalence between the standard and a mini-incision (approximately10 cm) posterior approach. We are unable to comment on moreextreme minimally invasive approaches.

Acknowledgments

We are grateful for the assistance of study authors whocontributed additional information to our systematic review andmeta-analysis: David Farr, Jon Goosen and Young-Hoo Kim.

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