The most effective surgical approach for total hip arthroplasty (THA) remains controversial. Comparisons of surgical approach based on patient-reported outcome measures (PROMs) have been limited to short- to mid-term outcomes or the comparison of only 2 approaches. The aim of this study was to compare PROMs for the 3 main approaches for THA with up to 10 years follow-up.
Methods:
A total of 906 patients who underwent primary THA at a single hospital between 2009 and 2020 through an anterior (312), lateral (211) or posterior (383) approach were evaluated using the Oxford Hip Score (OHS), EuroQoL-5-Dimension (EQ-5D-5L) and visual analogue scale/verbal rating scale for pain (VAS/VRS). PROMs were prospectively collected before surgery and routinely at 6 weeks, 6 months and 1, 2, 5 and 10 years after surgery.
Results:
There was no significant difference in demographics or comorbidities between the 3 groups. All 3 approaches resulted in a significant improvement in overall PROMs after THA, and plateaued after 6 months postoperatively, with no difference between the approaches (OHS, p < 0.01;EQ-5D-5L Index, p < 0.01;VAS/VRS, p < 0.01). The EQ-5D-5L mobility dimension showed that the lateral approach resulted in 20% more patients reporting problems with mobility than the posterior and anterior approaches at the 6-week, 6-month, 2-year and 10-year follow-up.
Conclusions:
This study shows that all 3 common THA approaches substantially and similarly improve the OHS, EQ-5D-5L Index and VRS between 6 months and 10 years postoperatively. However, patient-reported mobility was poorer after a lateral approach and continued to be so at long-term follow-up.
EthgenOBruyèreORichyF, et al. Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature. J Bone Joint Surg Am2004; 86: 963–974.
2.
ChangRWPellisierJMHazenGB.A cost-effectiveness analysis of total hip arthroplasty for osteoarthritis of the hip. JAMA1996; 275: 858–865.
3.
PetisSHowardJLLantingBL, et al. Surgical approach in primary total hip arthroplasty: anatomy, technique and clinical outcomes. Can J Surg2015; 58: 128–139.
4.
GibsonA.Posterior exposure of the hip joint. J Bone Joint Surg Br1950; 32-B: 183–186.
5.
Smith-PetersenMN.Evolution of mould arthroplasty of the hip joint. J Bone Joint Surg Br1948; 30B: 59–75.
6.
HardingeK.The direct lateral approach to the hip. J Bone Joint Surg Br1982; 64: 17–19.
7.
O’BrienRM.The technic for insertion of femoral head prosthesis by the straight anterior or Hueter approach. Clin Orthop1955; 6: 22–26.
8.
FinchDJMartinBIFranklinPD, et al. Patient-reported outcomes following total hip arthroplasty: a multicenter comparison based on surgical approaches. J Arthroplasty2020; 35: 1029–1035.e3.
9.
GravesSCDropkinBMKeeneyBJ, et al. Does surgical approach affect patient-reported function after primary THA?Clin Orthop Relat Res2016; 474: 971–981.
10.
LindgrenJVWretenbergPKärrholmJ, et al. Patient-reported outcome is influenced by surgical approach in total hip replacement: a study of the Swedish Hip Arthroplasty Register including 42,233 patients. Bone Joint J2014; 96-B: 590–596.
11.
JollesBMBogochER.Posterior versus lateral surgical approach for total hip arthroplasty in adults with osteoarthritis. Cochrane Database Syst Rev2004; 1: CD003828.
12.
ChechikOKhashanMLadorR, et al. Surgical approach and prosthesis fixation in hip arthroplasty world wide. Arch Orthop Trauma Surg2013; 133: 1595–1600.
13.
Australian Orthopaedic Association National Joint Replace-ment Registry (AOANJRR). Hip, knee & shoulder arthroplasty: 2021 annual report. Adelaide, Australia: AOA, 2021, pp.1–432.
14.
BerendKRLombardiAVJrSengBE, et al. Enhanced early outcomes with the anterior supine intermuscular approach in primary total hip arthroplasty. J Bone Joint Surg Am2009; 91(Suppl. 6): 107–120.
15.
TauntonMJMasonJBOdumSM, et al. Direct anterior total hip arthroplasty yields more rapid voluntary cessation of all walking aids: a prospective, randomized clinical trial. J Arthroplasty2014; 29: 169–172.
16.
den HartogYMMathijssenNMVehmeijerSB.The less invasive anterior approach for total hip arthroplasty: a comparison to other approaches and an evaluation of the learning curve - a systematic review. Hip Int2016; 26: 105–120.
17.
ChristensenCPKarthikeyanTJacobsCA.Greater prevalence of wound complications requiring reoperation with direct anterior approach total hip arthroplasty. J Arthroplasty2014; 29: 1839–1841.
18.
KwonMSKuskowskiMMulhallKJ, et al. Does surgical approach affect total hip arthroplasty dislocation rates?Clin Orthop Relat Res2006; 447: 34–38.
19.
MasonisJLBourneRB.Surgical approach, abductor function, and total hip arthroplasty dislocation. Clin Orthop Relat Res2002; 405: 46–53.
20.
GreidanusNVChihabSGarbuzDS, et al. Outcomes of minimally invasive anterolateral THA are not superior to those of minimally invasive direct lateral and posterolateral THA. Clin Orthop Relat Res2013; 471: 463–471.
21.
KiyamaTNaitoMShinodaT, et al. Hip abductor strengths after total hip arthroplasty via the lateral and posterolateral approaches. J Arthroplasty2010; 25: 76–80.
22.
KhanTKnowlesD.Damage to the superior gluteal nerve during the direct lateral approach to the hip: a cadaveric study. J Arthroplasty2007; 22: 1198–1200.
23.
HarrisPATaylorRThielkeR, et al. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform2009; 42: 377–381.
24.
HarrisPATaylorRMinorBL, et al. The REDCap consortium: building an international community of software platform partners. J Biomed Inform2019; 95: 103208.
25.
RamadanovNBueschgesSLazaruP, et al. A meta-analysis on RCTs of direct anterior and conventional approaches in total hip arthroplasty. Sci Rep2021; 11: 20991.
26.
PutananonCTuchindaHArirachakaranA, et al. Comparison of direct anterior, lateral, posterior and posterior-2 approaches in total hip arthroplasty: network meta-analysis. Eur J Orthop Surg Traumatol2018; 28: 255–267.
27.
GalmicheRPoitrasSDobranskyJ, 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 Surg2020; 63: E181–E189.
28.
RosenlundSBroengLHolsgaard-LarsenA, et al. Patient-reported outcome after total hip arthroplasty: comparison between lateral and posterior approach. Acta Orthop2017; 88: 239–247.
29.
SibiaUSTurnerTRMacDonaldJH, et al. The impact of surgical technique on patient reported outcome measures and early complications after total hip arthroplasty. J Arthroplasty2017; 32: 1171–1175.
30.
BarrettWPTurnerSELeopoldJP.Prospective randomized study of direct anterior vs postero-lateral approach for total hip arthroplasty. J Arthroplasty2013; 28: 1634–1638.
31.
JudgeAArdenNKKiranA, et al. Interpretation of patient-reported outcomes for hip and knee replacement surgery: identification of thresholds associated with satisfaction with surgery. J Bone Joint Surg Br2012; 94: 412–418.
32.
GouldVCBlomAWWyldeV.Long-term patient-reported outcomes after total hip replacement: comparison to the general population. Hip Int2012; 22: 160–165.
33.
WyldeVBlomAWWhitehouseSL, et al. Patient-reported outcomes after total hip and knee arthroplasty: comparison of midterm results. J Arthroplasty2009; 24: 210–216.
34.
MurrayDWFitzpatrickRRogersK, et al. The use of the Oxford hip and knee scores. J Bone Joint Surg Br2007; 89: 1010–1014.
35.
OstendorfMvan StelHFBuskensE, et al. Patient-reported outcome in total hip replacement. A comparison of five instruments of health status. J Bone Joint Surg Br2004; 86: 801–808.
36.
LimCRHarrisKDawsonJ, et al. Floor and ceiling effects in the OHS: an analysis of the NHS PROMs data set. BMJ Open2015; 5: e007765.
37.
JanssonKGranathF.Health-related quality of life (EQ-5D) before and after orthopedic surgery. Acta Orthop2011; 82: 82–89.
38.
AdamiakG. Methods for the economic evaluation of health care programmes, 3rd ed. J Epidemiol Community Health2006; 60: 822–823.
39.
ToogoodPAAbdelMPSpearJA, et al. The monitoring of activity at home after total hip arthroplasty. Bone Joint J2016; 98-B: 1450–1454.
40.
YooJIChaYHKimKJ, et al. Gait analysis after total hip arthroplasty using direct anterior approach versus anterolateral approach: a systematic review and meta-analysis. BMC Musculoskelet Disord2019; 20: 63.
41.
JudgeAArdenNKBatraRN, et al. The association of patient characteristics and surgical variables on symptoms of pain and function over 5 years following primary hip-replacement surgery: a prospective cohort study. BMJ Open2013; 3: e002453.
42.
MüllerMTohtzSDeweyM, et al. Age-related appearance of muscle trauma in primary total hip arthroplasty and the benefit of a minimally invasive approach for patients older than 70 years. Int Orthop2011; 35: 165–171.
43.
QuintanaJMEscobarAAguirreU, et al. Predictors of health-related quality-of-life change after total hip arthroplasty. Clin Orthop Relat Res2009; 467: 2886–2894.
44.
PetersRMvan BeersLvan SteenbergenLN, et al. Similar superior patient-reported outcome measures for anterior and posterolateral approaches after total hip arthroplasty: postoperative patient-reported outcome measure improvement after 3 months in 12,774 primary total hip arthroplasties using the anterior, anterolateral, straight lateral, or posterolateral approach. J Arthroplasty2018; 33: 1786–1793.
