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.|
McElroy, Mark J.
Johnson, Aaron J.
Mont, Michael A.
Bonutti, Peter M.
|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|
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).
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.
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.
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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