Nitiwarangkul L, Hongku N, Pattanaprateep O, Rattanasiri S, Woratanarat P, Thakkinstian A. Which approach of total hip arthroplasty is the best efficacy and least complication? World J Orthop 2024; 15(1): 73-93 [PMID: 38293261 DOI: 10.5312/wjo.v15.i1.73]
Corresponding Author of This Article
Patarawan Woratanarat, MD, PhD, Professor, Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok 10400, Thailand. pataraw@yahoo.com
Research Domain of This Article
Orthopedics
Article-Type of This Article
Meta-Analysis
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Lertkong Nitiwarangkul, Oraluck Pattanaprateep, Sasivimol Rattanasiri, Ammarin Thakkinstian, Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
Lertkong Nitiwarangkul, Orthopaedics Surgery, Police General Hospital, Bangkok 10330, Thailand
Natthapong Hongku, Department of Orthopaedics, Faculty of Medicine Vajira Hospital, Navamindrahiraj University, Bangkok 10300, Thailand
Patarawan Woratanarat, Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
Author contributions: Thakkinstian A and Woratanarat P contributed to acquisition of conception and design of the study; Hongku N contributed to acquisition of content knowledge approval; Nitiwarangkul L and Hongku N contributed to update searching; Nitiwarangkul L contributed to acquisition of data retrieval, analysis, and interpretation; Rattanasiri S contributed to acquisition of statistical analysis; Nitiwarangkul L and Woratanarat P drafted the article; Pattanaprateep O, Rattanasiri S, Thakkinstian A, and Woratanarat P critically revised the manuscript; and all authors have read and approve the final manuscript.
Conflict-of-interest statement: The authors deny any conflict of interest.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2020 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Patarawan Woratanarat, MD, PhD, Professor, Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok 10400, Thailand. pataraw@yahoo.com
Received: November 18, 2023 Peer-review started: November 18, 2023 First decision: December 7, 2023 Revised: December 20, 2023 Accepted: December 29, 2023 Article in press: December 29, 2023 Published online: January 18, 2024 Processing time: 58 Days and 16.8 Hours
Abstract
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.
Core Tip: Total hip arthroplasty (THA) is as an effective intervention to relieve pain and improve hip function. Many minimally invasive surgeries have been proposed to preserve soft tissue and promote early recovery. Direct anterior approach and direct superior approach, the most popular and the newest technique, respectively have been explored about pros and cons to compare with previous conventional techniques. The results are still inconclusive. This is the first umbrella review that has included all systematic reviews and meta-analysis comparing the efficacy and complications among approaches of THA for patients in term of post-operative functional score and post-operative complications.
