Short and standard stem prostheses are both viable options for minimally invasive total hip arthroplasty.
Abstract: Minimally invasive total hip arthroplasty (MIS THA) has recently increased in popularity. Concurrently, newly developed short femoral components are being used. These short components may make insertion during MIS approaches easier and preserve more bone than traditional femoral stems, while providing a more anatomic stress distribution in the proximal femur. Our purpose was to review the literature concerning MIS THA, to determine if using short stems over standard femoral components is beneficial and if surgical approach affects the ability to use any type of stem. Successful clinical survivorship and functional outcomes have been reported with both short and standard length femoral implant types for all MIS approaches. Therefore, the type of implant should be chosen based on other factors, such as diagnosis, bone type and condition, patient age, and surgeon preference.
Subject: Implants, Artificial (Standards)
Prosthesis (Standards)
Authors: McElroy, Mark J.
Johnson, Aaron J.
Mont, Michael A.
Bonutti, Peter M.
Pub Date: 01/01/2011
Publication: Name: Bulletin of the NYU Hospital for Joint Diseases Publisher: J. Michael Ryan Publishing Co. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 J. Michael Ryan Publishing Co. ISSN: 1936-9719
Issue: Date: Jan, 2011 Source Volume: 69 Source Issue: 1
Topic: Event Code: 350 Product standards, safety, & recalls
Product: SIC Code: 3842 Surgical appliances and supplies
Accession Number: 289216159
Full Text: Minimally invasive total hip arthroplasty (MIS THA) continues to increase in popularity as a modification to the traditional surgical approach. Surgeons are being trained in the techniques, healthcare facilities are advertising their offerings, and patients are welcoming the potential for more cosmetically-appealing incisions and possibly quicker recoveries. Smaller femoral implants are also becoming more widespread in use, due to their potential ease in application for MIS THA and their ability to potentially distribute stresses more anatomically and to conserve bone in younger patients who may eventually require revision surgery. Our purpose was to examine the published results of short and standard length femoral components inserted using MIS techniques, to determine if one type of implant is preferable and if the specific surgical approach affects outcome.

Materials and Methods

A complete search of the MEDLINE database was performed using the search terms ["minimally invasive" OR "MIS" OR "minimal incision"] AND ["short" OR "short stem" OR "short femoral component"] AND ["hip" OR "THA" OR "hip arthroplasty"]. The reference lists of reports were also reviewed to include any further relevant studies that may have been missed by the search criteria. Review articles and articles not in English were excluded. The search returned a total of 41 reports, with eight on MIS THA using the anterior approach, (1-8) eight using the anterolateral approach, (2,9-15) eight using the direct lateral approach, (4,9,16-21) eight using a multi-incision approach, (16,22-28) and eight using a posterior approach. (6,24,26,28-32) Six of these studies describe the use of short stem prostheses. (2,4,11,14,20,31)

Short Femoral Implants

The concept of short femoral implants is not new, (33) but more manufacturers have begun to offer these types of stems as an option over the last decade. Trends show that patients are presenting for THA at younger ages. (34) Therefore, it may be desirable to use the least invasive prosthesis that preserves bone.

Short implants can be roughly categorized into three groups: femoral neck implants, stems engaging the lateral cortex, and stems utilizing the lateral trochanteric flare. (35) Some of the most commonly reported models are the Mayo[R] (Zimmer Orthopaedics, Warsaw, Indiana), Proxima[TM] (Depuy Orthopaedics, Warsaw, Indiana), TaperLoc[R] Microplasty[TM] (Biomet, Parsippany, New Jersey), Metha[R] (B. Braun, Melsungen, Germany), and Link CFP[R] (Waldemar Link GmbH & Co. KG, Hamburg, Germany).

Minimally Invasive Total Hip Arthroplasty

MIS THA has been debated often in recent years. Internet sites and surgical device manufacturers proclaim benefits of these procedures over standard approaches, and many patients assume that a less invasive surgical approach inherently leads to superior results. No clear definition exists for what constitutes MIS THA, but there is a relative consensus that hip arthroplasties performed with any incision less than 10 centimeters can be included. However, some investigators contend that "minimal incision" is a more appropriate description than "minimally invasive," since the shorter incision does not necessarily lead to less muscle and connective tissue displacement in all approaches.

Proponents of MIS THA believe that this approach leads to a faster functional recovery, faster hospital discharge, and increased patient satisfaction. Opponents point to the lack of long-term follow-up in the literature and believe that the short-term recovery benefits are overshadowed by the potential for higher complication rates, due to restricted access with poor visualization. Both groups agree that MIS techniques are technically demanding and should likely be left to experienced, high-volume hip surgeons.

For this report, MIS hip approaches were divided into five categories: anterior, anterolateral, direct lateral, twoincision, and posterior (including both posterolateral and direct posterior). All of these approaches are modifications of traditional exposures, with the exception of the two-incision technique, which was developed specifically for MIS THA. According to a survey of members of the Hip Society, the posterior approach is the most widely used, followed by the anterolateral, two-incision, and anterior approaches. (36) The usage of the lateral approach was not specified.

Anterior (Smith-Peterson) Approach

The anterior approach to MIS THA is a modification of the Smith-Peterson approach and was described by Howell and colleagues. (37) It uses an intermuscular and internervous plane to expose the hip joint. Studies have shown successful results using both short and standard femoral implants, with standard length stems being more widely investigated.

Ghera and Pavan (2) reported on this technique using the Depuy Proxima[TM] short femoral implant. They performed 65 unilateral arthroplasties on a consecutive group of 45 females and 20 males, with a mean age of 70 years (range, 46 to 87 years). The MIS approach was anterior in 50 patients and anterolateral in 15 patients. However, data was not stratified between anterior and anterolateral. At a mean follow-up of 2 years (range, 1 to 4 years), the mean Harris hip score (HHS) increased from 51 points (range, 36 to 64 points) before surgery to 91 points (range, 50 to 99 points), and the mean Oxford hip score decreased from 43 points before surgery to 12 points. No thigh pain was reported. The investigators concluded that the early results are encouraging, but longer term follow-up is needed to confirm the findings. One other study also reported success using the anterior approach with a short implant, which was the Biomet TaperLoc[R] Microplasty[TM]. (4)

Successful outcomes have also been reported in larger patient populations and longer follow-up periods using the anterior approach with MIS THA and standard length femoral stems. Siguier and coworkers (8) reported their results using a cemented Smith and Nephew Charnley LFA MKII stem in a series of 1037 arthroplasties (926 patients), with a mean age of 68 years (range, 23 to 93 years). Patients were fully weightbearing within the first 2 postoperative days and, on average, discontinued the use of walking aids between 8 days and 3 weeks after surgery. There were only 10 reported dislocations at a minimum follow-up of 4 years. The investigators concluded that the anterior approach allows for adequate component positioning and muscle preservation. Table 1 contains a summary of other studies that have achieved success with the anterior approach.

Anterolateral (Modified Watson Jones) Approach

The anterolateral approach to MIS THA is a modification of the conventional Watson-Jones technique and was described by Berger. (38) Multiple reports exist documenting the results of this approach, including several studies utilizing small femoral components.

Lazovic and Zigan (11) achieved successful functional results and high survivorship using the B. Braun Aesculup Metha[R] conservative implant in 55 hips. Twenty-eight were performed with the B. Braun Aesculup OrthoPilot[R] navigation system, and 27 were performed without navigation. The group consisted of 29 males and 26 females, with a mean age of 48 years (range, 30 to 61 years). The mean HHS improved from 43 points before surgery to 92 points at 6-month follow-up. The investigators concluded that short-term results showed promise, with no dislocations, good functional outcomes, and a low rate of complications. Another studies used a short femoral component, the Depuy Proxima[TM], and had similar excellent results. (2)

The use of standard stems with the anterolateral approach was examined by Jerosch and associates, (10) who used the Synergy[R] and CPCS[R] stems (Smith and Nephew, Memphis, Tennessee). The investigators performed 75 consecutive unilateral anterolateral MIS THAs with standard instruments. Patients ranged in age from 52 to 90 years and were followed for a minimum of 12 months (range, 12 to 18 months). Their mean HHS improved from 44 points (range, 32 to 51 points) before surgery to 90 points (range, 85 to 100 points) at 12-month follow-up, and the mean Merle d'Abugine score improved from 7 points (range, 5 to 9 points) before surgery to 17 points (range, 13 to 18 points) at 12-month follow-up. No dislocations occurred. Positive results have been achieved in other published studies using standard stems, which are summarized in Table 2.

Direct Lateral Approach

The direct lateral MIS THA was described by Ilizaliturri and colleagues. (39) Only two studies were found that utilized this approach with a small femoral component, but numerous studies exist using a standard stem. Lombardi and co-workers (4) used this approach with a short femoral component (Biomet TaperLoc[R] Microplasty[TM]) in 640 hips (591 patients). An MIS lateral approach was performed in 363 hips, an MIS anterior approach was performed in 251 hips, and a conventional lateral approach was performed in 25 hips. Patient information and results were only published for the cohort as a whole. The mean age of the 332 females and 259 males was 63 years (range, 27 to 91 years), and mean follow-up was 7 months (range, 1 to 38 months). The mean HHS improved from 50 points before surgery to 80 points at most recent follow-up. Six femoral components required revision (99% survivorship). The investigators commented that the early results were promising, but longer follow-up would be required to reach a definitive conclusion.

Multiple studies have examined standard length femoral stems with the lateral approach. Dutka and associates (18) assessed five different standard femoral stems in 50 females and 10 males, with a mean age of 46 years (range, 40 to 67 years). They compared the results to a group of 60 patients treated with a standard incision lateral approach. The MIS group's mean HHS improved from 45 points (range, 42 to 48 points) before surgery to 92 points (range, 87 to 95 points) at 3-month follow-up. Clinical and radiographic outcomes and incidence of complications were similar between the two groups, leading to the conclusion that the MIS approach provides comparable outcomes to standard approaches using standard length femoral stems. Other investigators have also used similar stems with this approach, although some have found a higher complication rate when compared to larger incisions (Table 3).

Multi-Incision Approach

The multi-incision approach to MIS THA, as described by Berger and colleagues, (23) uses separate incisions to implant the acetabular and femoral components. No studies could be found using this approach with a short femoral implant, but many studies exist that show excellent functional results and survivorship with standard length stems.

Berger and coworkers (23) used this approach with the Zimmer Versys[R] FullCoat femoral stem in a consecutive group of 74 males and 26 females, with a mean age of 56 years (range, 41 to 75 years). Using an accelerated rehabilitation protocol, all patients were discharged within 23 hours of surgery and were able to transition from in-home to outpatient physical therapy within 2 weeks. The mean HHS improved from a pre-operative value of 56 points (range, 32 to 77 points) to 91 points (range, 61 to 100 points), 94 points (range, 79 to 100 points), and 96 points (range, 74 to 100 points) at 3-, 6-, and 12-week follow-up (p < 0.001 for all improvements). There were no readmissions, dislocations, or infections during this 12-week follow-up period. The investigators concluded that a rapid rehabilitation protocol with multi-incision MIS THA is safe and beneficial. Other studies also showed favorable results with the multi-incision approach and standard femoral stems (Table 4), although most investigators caution that the procedure may be technically demanding.

Mini Posterior and Mini Posterolateral Approaches

The posterior approach for MIS THA can be considered to include both the direct posterior and posterolateral techniques. Details regarding these techniques are described by Howell and associates (37) for the posterior approach, and Goldstein and colleagues (40) for the posterolateral approach. Only one study was found that utilized a short femoral component with either of these approaches, but many show successful results with standard stems.

Rohrl and colleagues (31) performed a study with short femoral components and the posterior MIS approach using the Waldemar Link CFP[R] in 26 consecutive patients. There were 15 females and 11 males, with median age of 54 years (range, 40 to 66 years). The HHS increased from a pre-operative mean of 42 points (range, 19 to 65 points) to 93 points (range, 88 to 98 points) at 2-year follow-up. The investigators measured the stem's migration pattern over the follow-up period to be low and concluded that the early results were encouraging but would need to be verified over a longer period.

Floren and Lester (29) reported on their results using a posterior approach MIS THA with a standard femoral stem at a minimum 10-year (range, 10 to 13 years) follow-up, which is substantially longer than most other reports of MIS THA results. Ninety implants were performed on 48 females and 31 males, with a mean age of 62 years (range, 22 to 87 years). The implant used in all cases was the Zweymuller[TM] Alloclassic[R] prosthesis from Zimmer. At final follow-up, the mean HHS was 92 points (range, 66 to 99 points). No dislocations or infections were reported. The investigators compared the findings with other published studies using the same femoral stem with conventional approaches and concluded that the MIS approach had not compromised long-term clinical and radiographic results. Most other reports using this approach with standard stems also report favorable results and are summarized in Table 5.

Conclusion

The purpose of this literature review was to examine the existing evidence about MIS THA and to determine if either short or standard femoral components led to better results. Several conclusions can be drawn based on the results of this review. Most studies report only short- to mid-term results, with long-term data just starting to become available. Despite this, numerous high quality studies do exist, and nearly all of them show excellent positive short-term results with any device. Therefore, the decision of which type of implant to use should be based on other factors, such as a patient's bone condition, age, lifestyle, desired activities, hobbies, and the likelihood of revision.

Disclosure Statement

M.A. Mont, M.D. is a paid consultant for Stryker Orthopaedics and Wright Medical Technologies, receives royalties from Stryker Orthopaedics and has received institutional or research support from: Stryker Orthopaedics, Wright Medical Technologies, Biomet, BrainLab, DePuy, Finsbury, Smith and Nephew, and Salient Surgical Technologies. None of the remaining authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony. No external financial support was provided in support of the preparation of this work.

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Mark J. McElroy, M.S., Aaron J. Johnson, M.D., and Michael A. Mont, M.D., are from the Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland. Peter M. Bonutti, M.D., is from the Bonutti Clinic, Effingham, Illinois.

Correspondence: Michael A. Mont, M.D., Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Reconstruction, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, Maryland 21215; mmont@lifebridgehealth. org.
Table 1 Sample of Reports Investigating Minimally Invasive Total
Hip Arthroplasty by the Anterior Approach

                                              No. of
                                              Hips
                        Femoral Component     (No. of      Age
Study                   Type (Model)          Patients)    (Years)

Ghera and Pavan (2)     Short (Depuy          50 (50)      70.1
(2009)                  Proxima [TM])                      (range,
                                                           46-87)
Lombardi et al. (4)     Short (Biomet         251 (NR)     62.7
(2009)                  Taper-Loc [R]                      (range,
                        Microplasty [TM])                  27-91)
Siguier et al. (8)      Standard (Smith       1037 (926)   67.8
(2004)                  and Nephew                         (range,
                        Charnley LFA MKII)                 23-93)
Kennon et al. (3)       Standard              2132         65.7
(2003)                  (approximately        (1828)       (range,
                        20 models)                         16-94)

Oinuma et al. (7)       Standard (B. Braun    99 (95)      62.5
(2007)                  Melsungen AG                       (range,
                        Bicontact [R],                     46-84)
                        Stryker CentPillar
                        [R])
Nakata et al. (6)       Standard (Stryker     99 (NR)      62.9
(2009)                  CentPillar [R] and                 [+ or -]
                        Super Secur-Fit                    1.2
                        Plus, Corin CTi II)
Bal and Vallurupalli    Standard (Zimmer      100 (100)    61
(1) (2008)              M/L Taper [R])                     (range,
                                                           33-91)
Mayr et al. (5)         Standard (Stryker     16 (16)      66
(2009)                  Accolade TMFZ [R])                 [+ or -]
                                                           10

Study                   Methods

Ghera and Pavan (2)     65 patients (45 females, 20
(2009)                  males) treated primarily for
                        osteoarthritis. Approaches:
                        50 MIS anterior, 15 MIS
                        anterolateral. Data reported
                        for whole group.
Lombardi et al. (4)     640 Hips in 591 patients (332
(2009)                  females, 259 males) treated
                        primarily for osteoarthritis.
                        Approaches: 363 MIS lateral, 251
                        MIS anterior, 25 conventional
                        lateral. Data provided for whole
                        group.
Siguier et al. (8)      Same approach used to treat
(2004)                  primarily osteoarthritis in
                        large, consecutive series over
                        7 years.
Kennon et al. (3)       Same approach used, with 1281
(2003)                  cemented and 851 non-cemented
                        stems in large consecutive
                        series of patients.
Oinuma et al. (7)       82 females and 13 males treated
(2007)                  on standard surgical table.
Nakata et al. (6)       Consecutive patient group.
(2009)                  Results compared with patients
                        treated via MIS posterior.
Bal and Vallurupalli    First 100 consecutive cases
(1) (2008)              performed via MIS anterior
                        approach. Minimum follow-up 10
                        months.
Mayr et al. (5)         Gait analysis performed in 11
(2009)                  females and 5 males. Results
                        compared to 17 patients treated
                        via traditional anterolateral
                        approach.

Study                   Results

Ghera and Pavan (2)     At mean follow-up of 1.7 years
(2009)                  (range, 1-3.5), mean HHS
                        improved from 51 (range, 36-64)
                        pre-operatively to 91 (range,
                        50-99) and mean Oxford hip
                        score improved from 42.5
                        pre-operatively to 12.4.
                        No reported thigh pain.
Lombardi et al. (4)     At mean follow-up of 7.3
(2009)                  months (range, 1-38), mean
                        Harris hip pain score improved
                        from 13 pre-operatively to 37,
                        and mean HHS improved from
                        50 pre-operatively to 80.
Siguier et al. (8)      Patients achieved full
(2004)                  weightbearing on treated leg
                        in first 2 postoperative days
                        and discontinued use of walking
                        aids an average of 8 days to
                        3 weeks after surgery. Ten hips
                        dislocated.
Kennon et al. (3)       28 dislocations but no injuries
(2003)                  to femoral or sciatic nerve.
Oinuma et al. (7)       Mean Japanese Orthopaedic
(2007)                  Association score improved from
                        47.2 (range, 18-63)
                        pre-operatively to 94.2 (range,
                        72-100 months) at mean follow-up
                        of 17 months (range, 9-26).
Nakata et al. (6)       Mean hip function scores by
(2009)                  Merle d'Aubigne and Postel
                        scale improved from 8.2 [+ or -]
                        0.2 pre-operatively to 16.7
                        [+ or -] 0.2 at 6-month follow-up.
                        MIS anterior may lead to more
                        rapid recovery of hip function
                        and gait ability than MIS
                        posterior.
Bal and Vallurupalli    Clinical and radiographic
(1) (2008)              outcomes similar to historical
                        data on standard approach.
Mayr et al. (5)         MIS patients improved in larger
(2009)                  number of gait parameters,
                        especially between 6- and 12-week
                        follow-up.

HHS, Harris hip score; MIS, minimally invasive surgery;
NR, not reported.

Table 2 Sample of Reports Investigating Minimally Invasive
Total Hip Arthroplasty by the Anterolateral Approach

                                         No. of
                                         Hips
                   Femoral Component     (No. of     Age
Study              Type (Model)          Patients)   (Years)

Lazovic and        Short (B. Braun       55 (55)     48
Zigan (11) (2006)  Aesculup Metha [R])               (range,
                                                     30-61)
Ghera and Pavan    Short (Depuy Proxi-   NR (15)     70.1
(2) (2009)         ma [TM])                          (range,
                                                     46-87)
Walde and Waldel   Short and Standard    19 (NR)     63
(4) (2006)         (B. Braun Aesculup                (range,
                   Metha [R] (8) and                 51-77)
                   Bicontact [R] (11))
Jerosch et al.     Standard (Smith and   75 (75)     NR
(10) (2006)        Nephew, Synergy [R]               (range,
                   and CPCS [R])                     52-90)
Pfluger et al.     Standard (Smith &     50 (50)     68
(12) (2007)        Nephew SL-PLUS [R])               (range,
                                                     47-93)
Yang et al. (15)   Standard (Zimmer      55 (55)     59.47
(2010)             VerSys [R])                       [+ or -]
                                                     13.24
Pospischill et     Standard (NR)         20 (20)     61.9
al. (13) (2010)                                      (NR)
d                  Standard (Depuy       47 (47)     NR
(9) (2010)         Summit [R])                       (NR)

Study              Methods

Lazovic and        55 total cases in which
Zigan (11) (2006)  28 used navigation.
Ghera and Pavan    Consecutive group of 65
(2) (2009)         patients (45 females, 20
                   males) treated primarily for
                   osteoarthritis. Approaches:
                   50 MIS anterior, 15 MIS
                   anterolateral. Data reported
                   for whole group.
Walde and Waldel   Consecutive group of 10
(4) (2006)         females and 9 males treated
                   using navigation system and
                   short or standard stem.
(10) (2006)        females and 35% males treated
                   with incision of 6-8 cm.
                   Minimum follow-up 12 months.
Pfluger et al.     50 patients treated with
(12) (2007)        MIS anterolateral approach
                   compared to 50 patients
                   treated with conventional
                   anterolateral approach.
Yang et al. (15)   55 patients treated with MIS
(2010)             anterolateral approach
                   compared to 55 patients
                   treated with conventional
                   posterolateral approach.
Pospischill et     Gait analysis of 20 patients
al. (13) (2010)    treated with MIS anterolateral
                   approach compared to 20
                   patients treated with
                   conventional transgluteal
                   approach.
Bernasek et al.    47 patients treated with
(9) (2010)         MIS anterolateral approach
                   compared to 45 patients
                   treated with modified
                   Hardinge approach.

Study              Results

Lazovic and        Mean HHS increased from
Zigan (11) (2006)  43 before surgery to 92
                   at 6-month follow-up. No
                   dislocations. Navigation
                   used successfully with
                   short implant.
Ghera and Pavan    At mean follow-up of 1.7
(2) (2009)         years (range, 1-3.5), mean
                   HHS improved from 51 (range,
                   36-64) pre-operatively to
                   91 (range, 50-99) and mean
                   Oxford Hip Score improved
                   from 42.5 pre-operatively
                   to 12.4. No cases of
                   thigh pain.
Walde and Waldel   Positive results achieved
(4) (2006)         at the expense of slight
                   increase in surgical time.
Jerosch et al.     No dislocations. Mean HHS
(10) (2006)        improved from 44 (range,
                   32-51) before surgery to 90
                   (range, 85-100) at 12-month
                   follow-up. Approach gives
                   excellent orientation for
                   component positioning and
                   allows for early
                   rehabilitation.
Pfluger et al.     Blood loss and operative
(12) (2007)        time nearly identical between
                   groups. MIS approach did not
                   compromise technical success
                   of procedure.
Yang et al. (15)   Fewer traumas, lower blood
(2010)             loss, and more rapid recovery
                   using MIS approach.
Pospischill et     No significant benefit from
al. (13) (2010)    MIS approach with respect
                   to gait kinematics at 3-month
                   follow-up.
Bernasek et al.    Higher incidence of varus
(9) (2010)         stem outliers in anterolateral
                   approach. Otherwise, similar
                   results in both groups.

HHS, Harris hip score; MIS, minimally invasive surgery;
NR, not reported.

Table 3 Sample of Reports Investigating Minimally Invasive
Total Hip Arthroplasty by the Lateral Approach

                                        No. of
                                        Hips
                   Femoral Component    (No. of     Age
Study              Type (Model)         Patients)   (Years)

Lombardi et al.    Short (Biomet        363 (NR)    62.7
(4) (2009)         TaperLoc [R]                     (range,
                   Microplasty [TM])                27-91)
Pipino (20)        Short (Waldemar      NR (65)     60
(2004)             Link CFP [R])
Dutka et al.       Standard             60 (60)     46
(18) (2007)        (5 models)                       (range,
                                                    40 to 67)
Bal et al.         Standard (NR,        96 (96)     57.4
(2005) (16)        identical to                     (range,
                   Zimmer M/L Taper)                25-87)
Smit (21)          Standard (Wright     NR (235)    65.5
(2009)             Profemur [R])                    (range,
                                                    29.4-90.8)
de Beer et al.     Standard (Stryker    30 (30)     71
(17) (2004)        Omnifit [R] HA                   (range,
                   and EON [R])                     45-86)
Bernasek et al.    Standard (Depuy      45 (45)     NR
(9) (2010)         Summit [R])                      (NR)
Han et al. (19)    Standard             20 (18)     53
(2009)             (B. Braun Aesculup               (range,
                   Bicontact [R],                   43-68)
                   Stryker Accolade
                   [R])

Study              Methods

Lombardi et al.    640 Hips in 591 patients (332
(4) (2009)         females, 259 males) treated
                   primarily for osteoarthritis.
                   Approaches: 363 MIS lateral,
                   251 MIS anterior, 25 conventional
                   lateral. Data reported for whole
                   group.
Pipino (20)        368 patients (390 hips) treated
(2004)             with conservative stem. Incision
                   less than 10 cm in 65 patients
                   Patients followed from 1 to 7
                   years. Data reported for whole
                    group.
Dutka et al.       Group of 50 females and 10
(18) (2007)        males followed for 8.5 months
                   (range, 6-12). Results compared
                   to conventional lateral approach
                   in 60 patients.
Bal et al.         Group of 50 females and 46
(2005) (16)        males treated primarily for
                   osteoarthritis. Results compared
                   to multi-incision MIS approach
                   in 96 patients.
Smit (21)          Large, anatomically sized
(2009)             femoral head used in 132
                   females and 103 males.
de Beer et al.     Group of 20 females and 10
(17) (2004)        males compared with group of
                   30 patients undergoing
                   conventional lateral approach.
Bernasek et al.    45 patients treated with MIS
(9) (2010)         lateral approach compared to
                   45 patients treated with MIS
                   anterolateral approach.
Han et al. (19)    Consecutive group of 16 males
(2009)             and 2 females compared to 19
                   patients who received standard
                   incision lateral approach.

Study              Results

Lombardi et al.    At mean follow-up of 7.3
(4) (2009)         months (range, 1-38), mean
                   Harris hip pain score improved
                   from 13 pre-operatively to 37
                   and mean HHS improved from
                   50 pre-operatively to 80.
Pipino (20)        HHS at final follow-up was
(2004)             between 90-100 in 321 patients,
                   80-89 in 20 patients, 70-79 in 8
                   patients, and < 70 in 4 patients.
                   96% of patients returned to
                   normal lifestyle.
Dutka et al.       No dislocations or intraoperative
(18) (2007)        complications. Mean HHS improved
                   from 44.5 (range, 42-48) before
                   surgery to 92 (range, 87-95) at
                   3-month follow-up. Clinical and
                   radiographic outcomes similar
                   between MIS and conventional
                   approach.
Bal et al.         Complications occurred in 6
(2005) (16)        hips, which was significantly
                   lower rate of complication
                   than in the multi-incision MIS
                   group.
Smit (21)          No complications or dislocations
(2009)             Mean HHS improved from 49.1
                   before surgery to 89.9 at 1-year
                   follow-up. All clinical
                   evaluations showed statistically
                   significant improvement at 1-year
                   follow-up.
de Beer et al.     Mean HHS improved from
(17) (2004)        36.8 [+ or -] 12 before surgery
                   to 71.1 [+ or -] 9.8 at 6-week
                   follow-up. No short-term clinical
                   advantage seen from MIS over
                   conventional approach.
Bernasek et al.    Higher incidence of varus
(9) (2010)         stem outliers in anterolateral
                   approach. Otherwise, similar
                   results in both groups.
Han et al. (19)    MIS approach achieved early
(2009)             gains that dissolved at 6 weeks
                   after surgery but also led to
                   several major complications
                   not seen with standard incision.

HHS, Harris hip score; MIS, minimally invasive surgery;
NR, not reported.

Table 4 Sample of Reports Investigating Minimally Invasive
Total Hip Arthroplasty by the Multi-Incision Approach

                                      No. of
                                      Hips
                  Femoral Component   (No. of     Age
Study             Type (Model)        Patients)   (Years)

Berger et al.     Standard            100 (100)   56
(23) (2004)       (Zimmer VerSys                  (range,
                  [R] FullCoat)                   41-75)
Archibeck and     Standard            851 (831)   61
White (22)        (Zimmer VerSys                  (range,
(2004)            [R], ZMR [R],                   21-100)
                  and Epoch [R])
Diwanji et al.    Standard            124 (62)    44.8
(25) (2009)       (Zimmer Cone                    [+ or -]
                  and M/L Taper)                  11.4
Pagnano et al.    Standard            36 (36)     67
(26) (2008)       (Zimmer VerSys                  [+ or -]
                  [R] FullCoat)                   10.6
Williams et al.   Standard            67 (NR)     58.28
(27) (2008)       (Zimmer VerSys                  [+ or -]
                  [R])                            11.6
Bal et al. (16)   Standard            89 (87)     58.5
(2005)            (Zimmer VerSys                  (range,
                  [R] Fiber Metal                 24-85)
                  Taper, VerSys [R]
                  Beaded FullCoat
                  Plus, M/L Taper)
Yoon et al.       Standard            50 (50)     45.3
(28) (2009)       (Stryker Accolade               (range,
                  [R])                            20 to 68)

Study             Methods

Berger et al.     Rapid rehabilitation protocol
(23) (2004)       used on consecutive group of
                  74 males and 26 females.
Archibeck and     Data collected from first 10
White (22)        or less cases performed by
(2004)            159 surgeons who completed
                  Zimmer training on multi-
                  incision approach.
Diwanji et al.    Bilateral simultaneous cases
(25) (2009)       performed on 47 males and
                  15 females to treat primarily
                  avascular necrosis.
Pagnano et al.    Randomized clinical trial in
(26) (2008)       which multi-incision approach
                  used to treat 20 males and 16
                  females and MIS posterior
                  approach used to treat 36
                  patients.
Williams et al.   Postoperative radiographs
(27) (2008)       compared to 28 conventional
                  lateral arthroplasties to
                  assess component placement.
Bal et al. (16)   Consecutive series of 50
(2005)            males and 37 females patients
                  treated primarily for
                  osteoarthritis. Results
                  compared to MIS lateral.
Yoon et al.       42 males and 8 females
(28) (2009)       treated with MIS two-incision
                  approach. Results compared to
                  MIS posterolateral.

Study             Results

Berger et al.     All patients discharged within
(23) (2004)       23 hours, transitioned from
                  in-home to outpatient physical
                  therapy within 2 weeks. HHS
                  improved from 56 (range,
                  32-77) before surgery to 96
                  (range, 74-100) at 12-week
                  follow-up.
Archibeck and     From first to tenth case,
White (22)        investigators found significant
(2004)            decrease in mean operative
                  and fluoroscopy times, but no
                  systematic decrease in key
                  complications. Learning curve
                  may last beyond 10 cases.
Diwanji et al.    From before surgery to latest
(25) (2009)       follow-up (mean, 41 months),
                  mean HHS improved from 41.8
                  (range, 10-59) to 95.3 (range,
                  73-100). Satisfactory clinical,
                  radiological, and functional
                  results achieved.
Pagnano et al.    Mean time to pass various
(26) (2008)       physical therapy milestones
                  and return to various daily
                  activities quicker in MIS
                  posterior group. Rate of
                  complications same.
Williams et al.   Both approaches resulted
(27) (2008)       in acceptable component
                  positioning, and no significant
                  differences were found
                  between them.
Bal et al. (16)   Complication rate higher
(2005)            in MIS multi-incision than
                  MIS lateral. Complications
                  decreased as experience gained,
                  but concluded approach is
                  technically demanding.
Yoon et al.       From before surgery to
(28) (2009)       1-year follow-up, mean HHS
                  increased from 49.6 (range,
                  21-76) to 94.13 [+ or -] 6.92
                  and mean WOMAC decreased from
                  70.9 (range, 54-82) to 12.67
                  [+ or -] 5.04. MIS multi-incision
                  achieved better results than
                  MIS posterior.

HHS, Harris hip score; MIS, minimally invasive surgery;
NR, not reported; WOMAC, Western Ontario and McMaster
Universities Arthritis Index.

Table 5 Sample of Reports Investigating Minimally Invasive
Total Hip Arthroplasty by the Posterior and Posterolateral
Approaches

                                        No. of
                                        Hips
                 Femoral component      (No. of     Age
Study            type (model)           Patients)   (Years)

Rohrl et al.     Short (Waldemar        26 (26)     54
(31) (2006)      Link CFP [R])                      (range,
                                                    40-66)
Floren and       Standard (Zimmer       90 (79)     62.1
Lester (29)      Zweymuller [TM]                    [+ or -]
(2006)           Alloclassic [R])                   12.8
Swanson (32)     Standard (Stelkast     1000        623.3
(2005)           Proclass [R],          (759)       [+ or -]
                 Smith and Nephew                   13.5
                 Synergy [R] and
                 SL-Plus [R])
Lin et al.       Standard (Zimmer       85 (79)     55.58
(30) (2007)      VerSys [R])                        [+ or -]
                                                    15.84
Yoon et al.      Standard (Stryker      63 (63)     47.4
(28) (2009)      Accolade [R])                      (range,
                                                    24-74)
Della Valle      Standard               35 (35)     63.8
et al. (24)      (Zimmer VerSys [R]                 [+ or -]
(2010)           Epoch [R] FullCoat)                8.2
Pagnano et al.   Standard (Zimmer       36 (36)     66
(26) (2008)      VerSys [R] FullCoat)               [+ or -]
                                                    12
Nakata et al.    Standard (Stryker      96 (NR)     65.6
(6) (2009)       CentPillar [R] and                 [+ or -]
                 Super Secur-Fit                    1.2
                 Plus, Corin CTi II)

Study            Methods

Rohrl et al.     MIS posterolateral approach
(31) (2006)      in 15 females and 11 males
                 primarily to treat
                 osteoarthritis.
Floren and       90 MIS posterior hips followed
Lester (29)      for minimum of 10 years.
(2006)           Results compared to published
                 studies using same femoral
                 stem with conventional surgical
                 techniques.
Swanson (32)     MIS posterior approach used
(2005)           by single surgeon in large
                 population.
Lin et al.       MIS posterolateral approach
(30) (2007)      used in consecutive group of
                 46 females and 33 males to
                 primarily treat osteoarthritis
                 and osteonecrosis.
Yoon et al.      MIS posterolateral approach
(28) (2009)      used in 40 males and 23
                 females. Results compared
                 with 50 patients receiving MIS
                 two-incision approach.
Della Valle      MIS posterior approach used to
et al. (24)      treat osteoarthritis in 24
(2010)           females and 11 males. Results
                 compared to MIS multi-incision.
Pagnano et al.   Randomized clinical trial in
(26) (2008)      which MIS posterior approach
                 used to treat 20 males and 16
                 females and MIS two-incision
                 approach used to treat 36
                 patients.
Nakata et al.    Consecutive patient group.
(6) (2009)       Results compared with patients
                 treated via MIS anterior.

Study            Results

Rohrl et al.     Mean HHS increased from
(31) (2006)      pre-operative value of 42
                 (range, 19-65) to 93 [+ or -]
                 5.5 at 2-year follow-up. Stem's
                 migration pattern was low, but
                 longer follow-up needed to
                 verify positive results.
Floren and       At final follow-up, mean HHS
Lester (29)      was 92.3 [+ or -] 7.9 (range,
(2006)           66-99). No dislocations or
                 infections. Clinical and
                 radiographic results comparable
                 to other studies using same
                 femoral stem with conventional
                 surgical techniques.
Swanson (32)     Mean follow-up 37 months
(2005)           (range, 24-62). HHS improved
                 from 34 [+ or -] 12 before
                 surgery to 92 [+ or -] 9.
                 Satisfactory results shown
                 through acceptably low rate
                 of complications and component
                 malpositioning.
Lin et al.       Early results at mean follow-up
(30) (2007)      of 13.1 [+ or -] 3.4 months show
                 low complication rate and good
                 functional recovery.
Yoon et al.      HHS improved from 49.8
(28) (2009)      (range, 28-73) to 90.25 [+ or -]
                 8.57 at 1-year follow-up. MIS
                 two-incision approach resulted
                 in faster rehabilitation.
Della Valle      HHS improved from pre-
et al. (24)      operative value of 50 [+ or -]
(2010)           12 to 91 [+ or -] 5 at 1-year
                 follow-up. Approach was safe
                 and all key outcome variables
                 comparable to MIS multi-incision
                 approach.
Pagnano et al.   Mean time to pass various
(26) (2008)      physical therapy milestones
                 and return to various daily
                 activities quicker in MIS
                 posterior group. Rate of
                 complications same.
Nakata et al.    Mean hip function scores by
(6) (2009)       Merle d'Aubigne and Postel
                 scale improved from 7.8 [+ or -]
                 0.2 pre-operatively to 16.3
                 [+ or -] 0.2 at 6-month
                 follow-up. MIS anterior may
                 lead to more rapid recovery
                 for hip function and gait
                 ability than MIS posterior.

HHS, Harris hip score; MIS, minimally invasive surgery;
NR, not reported.
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