title: Minimally Invasive versus Classic Procedures in Total Hip Arthroplasty: A Double-blind Randomized Controlled Trial Randomized controlled trial of abductor muscle damage in relation to the surgical approach for primary total hip replacement: minimally invasive anterolateral versus modified direct lateral approach Prospective randomized study of direct anterior vs postero-lateral approach for total hip arthroplasty. In-Hospital Cost Analysis of Total Hip Arthroplasty: Does Surgical Approach Matter? Can the Length of Hospital Stay After Total Hip Arthroplasty be Predicted by Preoperative Physical Function Characteristics? Anterolateral mini-invasive versus posterior mini-invasive approach for primary total hip replacement. Comparison of exposure and implant positioning Patient-reported outcome after total hip arthroplasty: comparison between lateral and posterior approach A minimal-incision technique in total hip arthroplasty does not improve early postoperative outcomes. A prospective, randomized, controlled trial. Neither pre-operative education or a minimally invasive procedure have any influence on the recovery time after total hip replacement Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe. Total Hip Arthroplasty through the Mini-Incision (Micro-Hip) Approach versus the Standard Transgluteal (Bauer) Approach: A Prospective, Randomised Study Comparison of minimally invasive direct anterior versus posterior total hip arthroplasty based on inflammation and muscle damage markers. Learning curve in tissue sparing total hip replacement: comparison between different approaches The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Blood Loss in the Minimally Invasive Posterior Approach to Total Hip Arthroplasty: A Comparative Study Does the Direct Anterior Approach in THA Offer Faster Rehabilitation and Comparable Safety to the Posterior Approach? [Minimally invasive total hip arthroplasty with anterior incision]. [Anterolateral minimally-invasive total hip arthroplasty: a clinical comparative study of 110 cases]. Tackling the learning curve: comparison between the anterior, minimally invasive (Micro-hip®) and the lateral, transgluteal (Bauer) approach for primary total hip replacement [Comparison of total hip arthroplasty via a posterior mini-incision versus a classic anterolateral approach]. Minimal-invasive posterior approach for total hip arthroplasty versus standard lateral approach. Are clinical and patient assessed outcomes affected by reducing length of hospital stay for total hip arthroplasty? Comparison of Early Functional Recovery After Total Hip Arthroplasty Using a Direct Anterior or Posterolateral Approach: A Randomized Controlled Trial. Anterolateral minimally invasive total hip arthroplasty: a prospective randomized controlled study with a follow-up of 1 year. Greater prevalence of wound complications requiring reoperation with direct anterior approach total hip arthroplasty. Patient’s perspective on direct anterior versus posterior approach total hip arthroplasty Direct anterior versus anterolateral approach in one-stage supine total hip arthroplasty. Focused on nerve injury: A prospective, randomized, controlled trial. [Minimally invasive posterior approach for total hip arthroplasty]. Posterolateral vs Direct Anterior Approach in Total Hip Arthroplasty (POLADA Trial): A Randomized Controlled Trial to Assess Differences in Serum Markers.
abstract: Background For total hip arthroplasty ( THA ) , minimally invasive surgery ( MIS ) uses a smaller incision and less muscle dissection than the classic approach ( CLASS ) , and may lead to faster rehabilitation . Questions / purpose sDoes minimally invasive hip arthroplasty result in superior clinical outcomes ? Patients and Methods In this double-blind r and omized controlled trial , 120 consecutive primary noncemented THAs in 120 patients were assigned to one of two groups ( MIS or CLASS ) . The r and omization sequence was stratified for two groups of surgeons , ie , those using a posterolateral approach ( PL-CLASS or PL-MIS ) and those using an anterolateral approach ( AL-CLASS or AL-MIS ) . Length of the incisions was 18 cm for the CLASS procedures . MIS incisions were extended at the skin level to 18 cm at the end of the procedure . The primary end point was the Harris hip score ( HHS ) at 6 weeks postoperatively . Patient-centered question naires were obtained preoperatively and after 6 weeks and 1 year . Results For the patients in the MIS group ( average 7.8 cm incision length ) , statistically significant increased mean HHSs were seen compared with the CLASS group at 6 weeks and 1 year . This difference was small and mainly caused by the favorable results of the PL-MIS . In the MIS group , surgical time was longer . A learning curve was observed based on operation time and complication rate . Although not statistically significant , the perioperative complication rate was rather high in the ( anterolateral ) MIS group . Conclusions The minimal invasive approach in THA did not show a clinical ly relevant superior outcome in the first postoperative year . Level of Evidence Level I , therapeutic study . See Guidelines for Authors for a complete description of levels of evidence Introduction Minimally invasive total hip arthroplasty ( THA ) is cl aim ed to be superior to the st and ard technique , due to the potential reduction of soft tissue damage via a smaller and tissue-sparing approach . As a result of the lack of objective evidence of fewer muscle and tendon defects , controversy still remains as to whether minimally invasive total hip arthroplasty truly minimizes muscle and tendon damage . Therefore , the objective was to compare the influence of the surgical approach on abductor muscle trauma and to analyze the relevance to postoperative pain and functional recovery . Material s and methods Between June 2006 and July 2007 , 44 patients with primary hip arthritis were prospect ively included in the study protocol . Patients underwent cementless unilateral total hip arthroplasty either through a minimally invasive anterolateral approach ( ALMI ) ( n = 21 ) or a modified direct lateral approach ( mDL ) ( n = 16 ) . Patients were evaluated clinical ly and underwent MR imaging preoperatively and at 3 and 12 months postoperatively . Clinical assessment contained clinical examination , performance of abduction test and the survey of a function score using the Harris Hip Score , a pain score using a numeric rating scale ( NRS ) of 0–10 , as well as a satisfaction score using an NRS of 1–6 . Additionally , myoglobin and creatine kinase were measured preoperatively , and 6 , 24 and 96 h postoperatively . Evaluation of the MRI images included fatty atrophy ( rating scale 0–4 ) , tendon defects ( present/absent ) and bursal fluid collection of the abductor muscle . Results Muscle and tendon damage occurred in both groups , but more lateral gluteus medius tendon defects [ mDL 3/12mth . : 6 (37%)/4 ( 25 % ) ; ALMI : 3 (14%)/2 ( 9 % ) ] and muscle atrophy in the anterior part of the gluteus medius [ mean-st and ard ( 12 ) : 1.75 ± 1.8 ; mean-MIS ( 12 ) : 0.98 ± 1.1 ] were found in patients with the mDL approach . The clinical outcome was also poorer compared to the ALMI group . Significantly , more Trendelenburg ’s signs were evident and lower clinical scores were achieved in the mDL group . No differences in muscle and tendon damage were found for the gluteus minimus muscle . A higher serum myoglobin concentration was measured 6 and 24 h postoperatively in the mDL group ( 6 h : 403 ± 168 μg/l ; 24 h : 304 ± 182 μg/l ) compared to the ALMI group ( 6 h : 331 ± 143 μg/l ; 24 h : 268 ± 145 μg/l ) . Conclusion Abductor muscle and tendon damage occurred in both approaches , but the gluteus medius muscle can be spared more successfully via the minimally invasive approach and is accompanied by a better clinical outcome . Therefore , going through the intermuscular plane , without any detachment or dissection of muscle and tendons , truly minimizes perioperative soft tissue trauma . Furthermore , MRI emerges as an important imaging modality in the evaluation of muscle trauma in THA Benefits of a direct anterior approach ( DAA ) versus a posterior-lateral ( PA ) approach to THA were assessed in a single-surgeon , IRB-approved , prospect i ve , r and omized clinical study . Subjects ( 43 DAA and 44 PA ) were evaluated at 6 weeks , and 3 , 6 and 12 months . The primary end point was ability to climb stairs normally and walk unlimited at each time point . Secondary end points included assessment by several outcome instruments . DAA subjects performed better during the immediate post-operative period ; they had lower VAS pain scores on the first post-operative day , more subjects climbing stairs normally and walking unlimited at 6 weeks , and higher HOOS Symptoms scores at 3 months . There were no significant differences between groups at later time points . Findings confirm previous reports of benefits of DAA versus PA in early post-operative phases The purpose s of this study were to determine the impact of surgical approach on costs of  total hip arthroplasty ( THA )  from a hospital perspective and to provide an up date d cost estimation of THA . A prospect i ve , microcosting analysis was performed on 118 patients undergoing a THA through an anterior , lateral , or posterior approach .  We determined that overall costs ( intraoperative costs and hospital stay ) were significantly less for the anterior ( $ 7300.22 ; 95 % confidence interval [ CI ] , 7064.49 - 7535.95 ) vs lateral ( $ 7853.10 ; 95 % CI , 7577.29 - 8128.91 ; P = .031 ) and anterior vs posterior approach ( $ 8287.46 ; 95 % CI , 7906.42 - 8668.51 ; P < .001 ) . A reduction in hospital length of stay when THA was performed through an anterior approach contributed significantly to an overall reduction in costs from a hospital perspective Objective The aim of the present study was to identify independent preoperative hip function characteristics sensitive for preoperative intervention that are predictive of an extended length of hospital stay ( LOS ) after primary total hip arthroplasty ( THA ) .  Design This is a longitudinal cohort study . A retrospective chart analysis was conducted on prospect ively collected data of patients ( 158 ) who underwent unilateral primary elective cemented THA in a 4-yr period . The main outcome measure was LOS after primary THA . Results The median LOS was 6.0 days . The authors found an 18.5 % increased chance of requiring an LOS of more than 6 days ( odds ratio , 2.15 ; 95 % confidence interval , 1.03–4.50 ) for the patients who needed to use a walking aid preoperatively and a 23.6 % increased chance ( odds ratio , 2.74 ; 95 % confidence interval , 1.31–5.74 ) for the patients who had difficulties managing stairs . Sex , age , body mass index , comorbidity , and preoperative pain did not reach the level of significance in the multivariate analysis . Conclusions Patients who are at risk for a longer stay in the hospital after THA can be identified preoperatively on simple physical function characteristics . These findings enable the identification of appropriate patients for preoperative training to improve functional recovery and decrease the LOS after primary THA Introduction We conducted a prospect i ve study to compare the exposure and implant positioning in primary total hip replacement through the anterolateral minimally invasive ( ALMI ) approach versus the posterior minimally invasive ( PMI ) approach . Material s and methods We applied these techniques to 2 consecutive groups ( 33 and 43 patients , respectively ) comparable preoperatively . All the patients received the same cementless stem and acetabular component . Results There were neither significant difference in femoral or acetabular component positioning nor in limb-length discrepancy . Acetabular exposure was easy through the ALMI approach . Femoral exposure was more difficult as fractures of the trochanter and femoral perforation in our study show . Conclusion For us , exposure and implant positioning through the ALMI approach and the PMI approach are comparable and reliable . However , we recommend caution during the initial learning curve in osteoporotic patients due to the higher rate of peroperative complications for the ALMI approach Background and purpose — Criticism of the lateral approach ( LA ) for hip arthroplasty is mainly based on the risk of poor patient-reported outcomes compared to the posterior approach ( PA ) . However , there have been no controlled studies comparing patient-reported outcomes between them . In this r and omized controlled trial , we tested the hypothesis that patient-reported outcomes are better in patients who have undergone total hip arthroplasty ( THA ) with PA  than in those who have undergone THA with LA , 12 months postoperatively . Patients and methods — 80 patients with hip osteoarthritis ( mean age 61 years ) were r and omized to THA  using  PA or the modified direct LA . We recorded outcome measures preoperatively and 3 , 6 , and 12 months postoperatively using the Hip Disability and Osteoarthritis Outcome Score – Physical Function Short Form ( HOOS-PS ) as the primary outcome . Secondary outcomes were HOOS-Pain , HOOS- Quality -Of-Life , EQ-5D , UCLA Activity Score , and limping . Results — We found no statistically significant difference in the improvements in HOOS-PS between the treatment groups at 12-month follow-up . All secondary outcomes showed similar results except for limping , where PA patients improved significantly more than LA patients . Interpretation — Contrary to our hypothesis , patients treated with PA did not improve more than patients treated with LA regarding physical function , pain , physical activity , and quality of life 12 months postoperatively . However , limping was more pronounced in the LA patients BACKGROUND Minimally invasive total hip arthroplasty has stirred substantial controversy with regard to whether it provides superior outcomes compared with total hip arthroplasty performed through longer incisions . The orthopaedic literature is deficient in well- design ed scientific studies to support the clinical superiority of this approach . The objective of this study was to compare the results of a single mini-incision approach with those of a st and ard-incision total hip arthroplasty in the early postoperative period . METHODS Two hundred and nineteen patients ( 219 hips ) admitted for unilateral total hip arthroplasty between December 2003 and June 2004 were r and omized to undergo surgery through a short incision of < or=10 cm or a st and ard incision of 16 cm .  All patients were blinded to the size of the incision for the duration of the hospital stay . The anesthetic , analgesic , and postoperative physiotherapy protocol s were st and ardized , with the staff also blinded to the technique used . A single surgeon , who had performed more than 300 short-incision hip replacements prior to the start of this study and who performs an average of 415 primary total hip replacements a year , performed all procedures through a single-incision posterior approach using a cementless cup and cemented stem . RESULTS The two groups were matched for age , grade according to the system of the American Society of Anesthesiologists , and body mass index . No significant difference was detected with respect to postoperative hematocrit , blood transfusion requirements , pain scores , or analgesic use . We found no difference in early walking ability or length of hospital stay and no difference in component placement , cement-mantle quality , or functional outcome scores at six weeks . The patient variables significantly associated with a probability of early discharge independent of incision length were patient age and preoperative hemoglobin levels ( p < 0.05 ) . The surgical scars contracted significantly over six weeks ( p < 0.05 ) but by a similar proportion of 11 % to 12 % in both groups . CONCLUSIONS Minimally invasive total hip arthroplasty performed through a single-incision posterior approach by a high-volume hip surgeon with extensive experience in less invasive approaches to the hip is safe and reproducible . However , it offers no significant benefit in the early postoperative period compared with a st and ard incision of 16 cm . As it is not known whether lower-volume and less-experienced surgeons can achieve similar results , the mini-incision technique merits further study before wide dissemination and implementation of this family of surgical approaches can be recommended Purpose The purpose of this study was to evaluate pre-operative education versus no education and mini-invasive surgery versus st and ard surgery to reach complete independence . Methods We conducted a four-arm r and omized controlled trial of 209 patients . The primary outcome criterion was the time to reach complete functional independence . Secondary outcomes included the operative time , the estimated total blood loss , the pain level , the dose of morphine , and the time to discharge . Results There was no significant effect of either education ( HR : 1.1 ; P = 0.77 ) or mini-invasive surgery ( HR : 1.0 ; 95 % ; P = 0.96 ) on the time to reach complete independence . The mini-invasive surgery group significantly reduced the total estimated blood loss ( P = 0.0035 ) and decreased the dose of morphine necessary for titration in the recovery ( P = 0.035 ) . Conclusions Neither pre-operative education nor mini-invasive surgery reduces the time to reach complete functional independence .  Mini-invasive surgery significantly reduces blood loss and the need for morphine consumption BACKGROUND The purpose of this study was to assess current practice s in blood management in elective orthopedic surgery in Europe . STUDY DESIGN AND METHODS For this 225-center prospect i ve survey , data were collected on 3996 patients .  Actual perioperative blood loss was compared to preoperative estimates . Differences in Hb levels and other outcome variables for patients receiving allogeneic versus autologous transfusions  were evaluated . The probability of allogeneic transfusion  based on selected predictor variables was estimated . RESULTS A total of 2640 ( 67 % ) hip and 1305 ( 33 % ) knee arthroplasty patients were evaluated .  Estimated blood loss ( median , 750 mL ) was significantly lower than computed blood loss ( median , 1944 mL ) . A total of 2762 ( 69 % ) patients received  transfusions  , including 1393 ( 35 % ) autologous-only and 1024 ( 25 % ) allogeneic-only . The probability of allogeneic transfusion  decreased with increasing baseline Hb , but differentially so for men and women . Transfusion triggers were Hb levels of 8.93 + /- 1.83 g per dL for allogeneic transfusions , and 21 percent of these occurred when the Hb level was greater than 10 g per dL. Autologous blood transfusion was associated with a significantly lower rate ( 1 % ) of wound infections than allogeneic blood transfusion ( 4.2 % ) . CONCLUSION Accurate assessment of preoperative Hb levels , better estimation of perioperative blood loss , efficient use of autologous blood , adherence to transfusion guidelines , and pharmacologic alternatives contribute to effective and comprehensive blood and anemia management Purpose . To compare outcome after  total hip arthroplasty ( THA )  through the mini-incision approach versus the st and ard transgluteal approach . Methods . 80 women and 63 men aged 33 to 89 ( mean , 62 ) years with primary osteoarthritis of the hip were r and omised to undergo unilateral THA through a mini-incision approach ( Micro-hip , n=55 ) or st and ard , lateral , transgluteal approach  ( Bauer , n=88 ) . Levels of haemoglobin , haematocrit , serum creatine kinase , and C-reactive protein , length of hospital stay , mobilisation , and any complication were recorded . Visual analogue scale ( VAS ) for pain was assessed . Hip function was assessed using the Harris Hip Score and the Oxford Hip Score , whereas general health was assessed using the EQ-5D general health question naire . The cup inclination and varus/ valgus of the stem position were measured using a goniometer . Results . The Micro-hip group achieved a significantly lower mean incision length ( 9.3 vs. 13.4 cm , p<0.001 ) , mean surgical time ( 60 vs. 68 minutes , p=0.021 ) , mean reduction in haemoglobin level ( 2.1 vs. 2.8 g/dl , p<0.001 ) , and mean VAS for pain from hour 6 to day 6 ( all p<0.05 ) . One patient in the Micro-hip group developed early aseptic loosening of the cup and underwent revision surgery at month 4 . Three patients in the Bauer group and one patient in the Micro-hip group sustained intra-operative non-displaced fractures of the proximal femur , which were fixed with cerclages . Two patients in the Micro-hip group developed deep vein thrombosis during week 1 . Conclusion . THA through the Micro-hip approach achieved faster pain relief BACKGROUND A number of surgical approaches are utilized in total hip arthroplasty . It has been hypothesized that the anterior approach results in less muscle damage than the posterior approach . We prospect ively analyzed biochemical markers of muscle damage and inflammation in patients treated with minimally invasive total hip arthroplasty with an anterior or posterior approach  to provide objective evidence of the local soft-tissue injury at the time of arthroplasty . METHODS Twenty-nine patients treated with minimally invasive total hip arthroplasty through a direct anterior approach and twenty-eight patients treated with the same procedure through a posterior approach  were prospect ively analyzed . Perioperative and radiographic data were collected to ensure cohorts with similar characteristics . Serum creatine kinase ( CK ) , C-reactive protein ( CRP ) , interleukin-6 ( IL-6 ) , interleukin-1 beta ( IL-1ß ) , and tumor necrosis factor-alpha ( TNF-a ) levels were measured preoperatively , in the post-anesthesia-care unit ( except for the CRP level ) , and on postoperative days 1 and 2 . The Student t test and Fisher exact test were used to make comparisons between the two groups . Independent predictors of elevation in levels of markers of inflammation and muscle damage were determined with use of multivariate logistic regression analysis . RESULTS The levels of the markers of inflammation were slightly decreased in the direct-anterior-approach group as compared with those in the posterior-approach group . The rise in the CK level in the posterior-approach group was 5.5 times higher than that in the anterior-approach group in the post-anesthesia-care unit ( mean difference , 150.3 units/L [ 95 % CI , 70.4 to 230.2 ] ; p < 0.05 ) and nearly twice as high cumulatively ( mean difference , 305.0 units/L [ 95 % CI , -46.7 to 656.8 ] ; p < 0.05 ) . CONCLUSIONS We believe that the anterior total hip arthroplasty approach used in this study caused significantly less muscle damage than did the posterior surgical approach , as indicated by serum CK levels . The clinical importance of the rise in the CK level needs to be delineated by additional clinical studies . The overall physiologic burden , as demonstrated by measurement of inflammation marker levels , appears to be similar between the anterior and posterior approaches . Objective measurement of muscle damage and inflammation markers provides an unbiased way of determining the immediate effects of surgical intervention in patients treated with total hip arthroplasty Background The tissue sparing surgery ( TSS ) concept means not only smaller incisions but also less tissue disruption , allowing decreased blood loss and improved function . However , TSS techniques can result in more complications related to the learning curve . The aim of this study was to compare the learning curve of an experienced surgeon with different TSS approaches for total hip replacement ( THR ) from a clinical and surgical point of view , focussing especially on complications related to the use of different geometric stems . Material s and methods Sixty patients scheduled to be operated for a primary THR were enrolled in the study and were r and omly assigned to surgery by one of three different TSS approaches : lateral with mini incision ( group A ) , minimally invasive anterior ( group B ) and minimally invasive antero-lateral ( group C ) . Results from the three TSS groups were compared with a control group of 149 patients ( group D ) . Results Our results reveal significantly reduced blood loss in the TSS groups compared with the control group , with no differences between the TSS groups . We found better early functional scores in the two minimally invasive groups ( anterior and anterolateral ) , and a lower rate of complications with the antero-lateral TSS approach . Conclusion The antero-lateral TSS approach seems to be safer and less dem and ing than st and ard THR surgery , and is suitable for use with different stems QUESTIONS Does the PEDro scale measure only one construct ie , the method ological quality of clinical trials ? What is the hierarchy of items of the PEDro scale from least to most adhered to ? Is there any effect of year of publication of trials on item adherence ? Are PEDro scale ordinal scores equivalent to interval data ? DESIGN Rasch analysis of two independent sample s of 100 clinical trials from the PEDro data base scored using the PEDro scale . RESULTS Both sample s of PEDro data showed fit to the Rasch model with no item misfit . The  PEDro scale item hierarchy was the same in both sample s , ranging from the most adhered to item r and om allocation , to the least adhered to item therapist blinding . There was no differential item functioning by year of publication . Original PEDro ordinal scores were highly correlated with transformed PEDro interval scores ( r = 0.99 ) . CONCLUSION The PEDro scale is a valid measure of the method ological quality of clinical trials . It is valid to sum PEDro scale item scores to obtain a total score that can be treated as interval level measurement and subjected to parametric statistical analysis AIMS Our primary aim was to evaluate whether there is really less bleeding in patients for whom the minimally invasive posterior approach is used in comparison with the direct lateral approach for primary total hip arthroplasty . Our secondary aim was to evaluate the clinical functional results after six months as well as the postoperative radiographic result . METHODS In a comparative non-r and om prospect i ve study , 76 adult patients underwent elective total hip arthroplasty using one of two approaches . The minimally invasive posterior approach ( 34 cases ; mini-incision group ) was compared with the st and ard direct lateral approach ( 42 cases ; control group ) . RESULTS Lower total estimated bleeding ( means of 1083.5 ml versus 1682.3 ml ; p < 0.001 ) and lower intraoperative bleeding ( means of 745.6 ml versus 1282.8 ml ; p < 0.001 ) were found in the mini-incision group . There was , however , no difference in the volume of blood drained after the operation ( means of 340 ml and 399 ml ; p = 0.77 ) . There was also a difference between the two groups regarding the need for allogenic transfusion ( 8.8 % in the mini-incision group versus 28.6 % , p = 0.02 ) . We observed a better clinical result in the mini-incision group ( p = 0.002 ) despite the lack of difference between the two groups in relation to the radiographic result . DISCUSSION Our results draw attention to the possibility that other authors may have underestimated blood losses when using minimally invasive approaches . CONCLUSION The minimally invasive approach gave rise to a positive final impression with regard to lower blood loss Background Newer surgical approaches to THA , such as the direct anterior approach , may influence a patient ’s time to recovery , but it is important to make sure that these approaches do not compromise reconstructive safety or accuracy . Questions / purpose sWe compared the direct anterior approach and conventional posterior approach in terms of ( 1 ) recovery of hip function after primary THA  , ( 2 ) general health outcomes , ( 3 ) operative time and surgical complications , and ( 4 ) accuracy of component placement . Methods In this prospect i ve , comparative , nonr and omized study of 120 patients ( 60 direct anterior THA , 60 posterior THAs )  , we assessed functional recovery using the VAS pain score , timed up and go ( TUG ) test , motor component of the Functional Independence Measure ™ ( M-FIM ™ ) , UCLA activity score , Harris hip score , and patient-maintained subjective milestone diary and general health outcome using SF-12 scores . Operative time , complications , and component placement were also compared . Results Functional recovery was faster in patients with the direct anterior approach on the basis of TUG and M-FIM ™ up to 2 weeks ; no differences were found in terms of the other metrics we used , and no differences were observed between groups beyond 6 weeks . General health outcomes , operative time , and complications were similar between groups . No clinical ly important differences were observed in terms of implant alignment . Conclusions We observed very modest functional advantages early in recovery after direct anterior THA compared to posterior-approach THA . R and omized trials are needed to vali date these findings , and these findings may not generalize well to lower-volume practice setting s or to surgeons earlier in the learning curve of direct anterior THA.Level of Evidence Level II , therapeutic study . See Instructions for Authors for a complete description of levels of evidence OBJECTIVE To report the clinical outcome of minimally invasive total hip arthroplasty  with anterior incision . METHODS One hundred and twenty cases were r and omly divided into two groups . Sixty cases ( group 1 ) who had undergone a mini-invasive THA  were compared with 60 cases ( group 2 ) who had undergone THA with st and ard posterolateral incision .  The operation time , length of incision , blood loss , anteversion angle of acetabulum cup , Harris score and complications were observed . RESULT The average operation time was almost the same ; The average length of incision for group 1 was 7.9 cm ( 7.4 - 9.0 cm ) and 16.3 cm ( 14 - 22 cm ) for group 2 ( P < 0.01 ) . The average blood loss for group 1 was 350 ml ( 250 - 530 ml ) and 650 ml ( 400 - 1200 ml ) for group 2 , there was significant difference between two groups ( P < 0.05 ) . According to the postoperative X-ray , the mean anteversion angles of cup were 24 degrees ( 19 degrees - 27 degrees ) for group 1 and 19 degrees ( 15 degrees - 22 degrees ) for group 2 . The average length of post-operative hospital stay was 7 days ( 5 - 8 days ) in group 1 and 13.5 days ( 12 - 16 days ) in group 2 ( P < 0.05 ) . The Harris score of group 1 was 91.4 ( 67 - 94 ) and 78.5 ( 67 - 91 ) for group 2 at the 3 month follow-up ( P < 0.05 ) . At the last follow up , there were no significant difference ( P > 0.05 ) , but the average ROM of group 1 were definitely more greater than that of group 2 ( 110.0 degrees + /- 3.2 degrees vs. 90.0 degrees + /- 2.9 degrees P < 0.05 ) . There was 1 case of cup reinsertion in group 1 because of large anteversion angle ; 2 cases of symptomatic DVT and 1 case of lethargy because of cerebral infa rct ion happened in group 2 . CONCLUSIONS Minimally invasive total hip arthroplasty using anterior approach is a safe and effective technique with the advantages of less soft tissue damage and less blood loss OBJECTIVE To explore the indications and key points of anterolateral minimally-invasive total hip arthroplasty . METHODS 110 baseline indexes matched patients admitted for unilateral total hip arthroplasty were r and omly assigned to 2 equal groups to undergo surgery through a short anterolateral incision of < or = 10 cm or a st and ard posterolateral incision . All operations were done by the same surgeon . The demographic data , perioperative indexes , and postoperative function indexes were recorded and statistically analyzed . RESULTS No significant differences were detected with respect to operation time , abduction angle , anteversion angle , stem alignment , and stem fixation between these 2 groups . The incision length , blood loss , perioperative transfusion , and 100 - mm visual analogue pain scale ( VAS ) score at the first 24 hours of the anterolateral approach group were ( 7.49 + /- 0.86 ) cm , ( 376.18 + /- 168.30 ) ml , ( 410.09 + /- 136.46 ) ml , and ( 30.76 + /- 21.77 ) respectively , all significantly shorter , less , or lower than those of the st and ard posterolateral approach group [ ( 15.2 + /- 1.8 ) cm , ( 605.0 + /- 225.1 ) ml , ( 629.5 + /- 232.9 ) ml , and ( 50.3 + /- 13.7 ) respectively , all P < 0.01 ] . The Harris hip score and Barthel index 3 months after operation of the anterolateral approach group were ( 83.80 + /- 5.64 ) and ( 93.45 + /- 6.37 ) respectively , both significantly higher than those of the st and ard posterolateral approach group [ ( 75.0 + /- 7.5 ) and ( 94.6 + /- 7.5 ) respectively , both P < 0.01 ) ] , however , there were not significant differences in the Harris hip score and Barthel index 3 years after operation between these 2 groups . CONCLUSIONS Fewer traumas , less blood loss and rapid recovery can be obtained through this new total hip arthroplasty approach . But experienced doctors and special instruments are prerequisite Background and purpose There is still conflicting evidence about the true benefit of minimally invasive ( MI ) techniques in total hip replacement ( THR ) . The aim of this prospect i ve study was to evaluate the safeness of a MI approach during the learning curve of a single surgeon . Second , clinical and radiographic results among the  MI THR group were compared with the results using a st and ard transgluteal ( Bauer ) approach . Methods 86 primary unilateral total hip arthroplasties ( THAs ) through a MI , anterior ( Micro-hip ® ) approach were performed by a single senior surgeon ( ES ) , representing a consecutive series of patients after beginning with the MI technique . Cases were compared to a matched cohort of patients who were treated with a st and ard transgluteal ( Bauer ) approach .  Operation time , incision length , perioperative blood loss , haemoglobin level and blood transfusions were monitored . Complications were documented and followed up 1 year postoperatively . The Harris Hip Score ( HHS ) , range of motion , use of analgetics , the Trendelenburg sign , sensibility of the lateral femoral cutaneous nerve and the acetabular/femoral component placement as well as potential heterotopic ossifications were analysed in both the groups after 12 months postoperatively . Results 74 MI THR patients and 60 st and ard THR patients were available for the one year follow-up . Operative time was significantly longer in the MI group , reduction in the haemoglobin level during the first 24 h was significant and the length of skin incision was significantly shorter . No significant differences were found for HHS , range of motion , use of analgetics , the Trendelenburg sign , and the acetabular/femoral component placement , heterotopic ossifications and intra- and postoperative complications . Sensibility of the lateral femoral cutaneous nerve was affected in three patients in the MI group . Radiographic evaluation revealed no component migration , implant subsidence or radiolucency signs in both the groups . DicussionConsistent with recent meta- analysis we found reduced blood loss , similar clinical /radiographic outcome and similar complication rates compared to st and ard THA . Our study shows , that MI THR is a safe procedure during the learning curve of an experienced surgeon Surgical approaches to the hip for total hip arthroplasty ( THA ) are termed minimally invasive when allowing for a skin incision length of 10 cm or less . The aim of this study was to explore if a minimally invasive posterior approach compared to a classic anterolateral approach negatively influenced surgical time , blood loss , implant position , or perioperative complications .  Two groups of THA patients mainly differing with respect to the surgical approach were compared . Results of 76 consecutive THA via a posterior mini-incision approach were recorded prospect ively and those of 76 controls operated via a classic anterolateral approach were recorded retrospectively .  THA was performed by the same surgeon in every case . Surgical time or intraoperative blood loss were not different among the groups . Total 24-h blood loss was significantly less in patients undergoing THA via minimally invasive posterior  approaches . Median cup inclination was 45 degrees in both groups . Cup anteversion was 15 degrees ( classic anterolateral ) and 12 degrees ( minimally invasive posterior ) , respectively . Stem position was regarded as neutral in 80 % of THA through classic anterolateral and in 76 % through minimally invasive dorsal incisions . Complications occurred in 8 % ( classic anterolateral ) and 9 % ( minimally invasive posterior ) of THA patients . Surgical time , blood loss , risk of malpositioned implants , or complications were not increased for THA patients operated through minimally invasive posterior incisions compared to those operated via classic anterolateral approaches In this prospect i ve study we compared clinical and radiological results and rehabilitation progress of 64 patients who underwent total hip arthroplasty using the st and ard lateral approach with 64 patients operated with a minimal-invasive ( MIS ) posterior approach .  The outcome of our study did not show any significant differences with regard to patient 's safety such as complication rate and radiological assessment of the cup position . There was no difference in the duration of surgery , blood loss , hospital stay and postoperative leg length discrepancy . Rehabilitation milestones were achieved earlier by MIS patients and three and six months postoperatively , the Harris Hip Score of the MIS group was significantly higher This prospect i ve observational study investigated the relationship between the length of hospital stay ( LOS ) and outcomes at 3 months for primary total hip arthroplasty for osteoarthritis . Mean length of postoperative stay was 9.5 + /- 2.8 days . Predictors of LOS were patient 's age , sex , and number of comorbidities ; preoperative Charnley scores and Nottingham Health Profile measures ; complications ; and hospital in which surgery took place . LOS was found to have a small negative correlation with outcome . The dominant association with improved outcome was the severity of the patients ' impairment preoperatively . These data suggest that in situations in which adequate rehabilitation and support are available after discharge , a marginal reduction in postoperative LOS -- from the average of 10.3 days observed at 1 hospital to the average of 8 days observed at another -- would not adversely affect the short-term outcome BACKGROUND Controversy exists as to whether early functional outcomes differ after total hip arthroplasty performed using the direct anterior approach ( DAA ) or the posterolateral approach ( PLA ) . METHODS One hundred twenty patients were enrolled in this study and were divided into 2 groups based on surgical approach . Group A included patients who had a total hip arthroplasty with a DAA , whereas group B included those with a PLA .  Patients were r and omized into the DAA or PLA groups ( n = 60 ) , and perioperative and postoperative outcomes were recorded . RESULTS When compared with the PLA , the DAA had a shorter incision length ( 9.1 vs 13.1 cm ; P < .01 ) , shorter hospital stay ( 2.8 vs 3.3 days , P = .04 ) , and lower self-reported pain . Both serum inflammatory and muscle damage markers were lower in the DAA group . However , the PLA had shorter operative times ( 65.5 vs 83.3 min , P = .03 ) and less intraoperative blood loss ( 123.8 vs 165.9 mL , P = .04 ) . The DAA had significantly lower variance in cup inclination and anteversion . Similar rates of intraoperative complications were identified in the 2 groups . The DAA was associated with better functional recovery at 3 months based on the Harris hip score , University of California Los Angeles activity score , and gait analysis ; however , functional recovery at 6 months was similar between the 2 groups . CONCLUSION We found functional advantages in early recovery after the DAA compared with the PLA . The DAA can offer rapid functional recovery with less muscle damage , greater pain relief , and lower variance in cup inclination and anteversion . However , no functional difference was found at 6 months follow-up Anterolateral minimally invasive hip surgery ( ALMIS ) is a challenging procedure that is thought to offer a more expedient and a better functional outcome . Seventy-nine patients receiving primary hip arthroplasty were r and omized .  Röttinger ALMIS technique was used for 42 patients , whereas 41 received the st and ard lateral transgluteal Hardinge approach .  Operative time was longer with ALMIS ( P = .000078 ) , whereas blood loss was less ( P = .008 ) . Surgical and postoperative complication rates , morphine consumption , and length and cost of hospitalization were similar . At 1 year , Harris , Postel and Merle d'Aubigné , and Short Form-36v1 scores were similar . Gait analysis revealed similar results . Computed tomographic analysis revealed no significant difference in implant position , heterotopic ossification , and loosening .  Röttinger ALMIS is a valid approach for hip arthroplasty . However , it offers no advantages at 1 year The purpose of this retrospective study was to compare wound complication rates between primary THAs performed via a posterior or direct anterior approach .  From our prospect i ve outcomes registry , we identified 1288 primary THAs performed via a posterior approach and 505 via a direct anterior approach .  The direct anterior approach result ed in a significantly greater number of wound complications that required reoperation than the posterior approach ( 7/505 ( 1.4 % ) vs. 3/1,288 ( 0.2 % ) , P=0.007 ) . As such , patients should be counseled on the potential increased risk of early wound complications with the direct anterior approach , and future research is needed to determine if alternative closure techniques can reduce the risk of wound complication Purpose Total hip arthroplasty approach comparison focused on patient ’s perspective . The direct anterior approach ( DAA ) has gained immense popularity in the last decade and is widely advocated as a superior approach in terms of quicker recovery and better overall outcome . However , the question if the level of DAA promotion is justified seems to be rarely posed . Methods A single-surgeon consecutive series of patients who underwent bilateral THA , one in DAA and the other in posterior approach ( PA ) .  The same implant design and same component sizes were used for the both sides . All the operations were performed by a single surgeon under the same pre- and post-operative care protocol . Results Twenty-one patients underwent bilateral THA , mean age 60.09 years .  Oxford Hip Score ( OHS ) was used for functional outcome assessment . There were no statistically significant differences between two approaches in terms of functional outcome ( mean OHS for DAA series was 42.95 and that for the PA was 43.38 , p 0.07 at an alpha level of 0.05 ) . Fifteen patients gave the advantage to PA , and six patients favoured DAA . Conclusion By study design , we tried to reduce the biases and acquire approach appraisal from patient ’s perspective . We anticipated the outcome in favour of DAA , but the results favoring PA came as a surprise . Future prospect i ve r and omized studies on evaluation of DAA and other approaches not only from surgeon ’s or industry ’s point of view , performed on a larger and more uniform groups , are warranted to further explore the subjective differences between DAA and PA BACKGROUND The difference in clinical results between the direct anterior approach ( DAA ) and the anterolateral approach ( ALA ) for  total hip arthroplasty ( THA ) is still unclear . The purpose of this study was to compare clinical results , including nerve injuries , between DAA and ALA in one-stage bilateral THA in a prospect i ve , r and omized controlled trial . METHODS Thirty patients were recruited for primary bilateral THAs from 2014 to 2016 . The left and right hips of each patient were r and omly assigned to DAA and the others to ALA . We prospect ively compared the clinical results , incidence of lateral femoral cutaneous nerve ( LFCN ) injury , and tensor fascia lata ( TFL ) atrophy considered to be related to superior gluteal nerve injury between both approaches . RESULTS No significant difference was found in the clinical results between both sides at postoperative 1 year . Temporary symptom of LFCN injury was observed only in DAA sides ( 7/30 , 23.3 % ) . The ratio of 3-month postoperative to preoperative cross-sectional area of TFL on computed tomography was significantly lower on the side subjected to DAA ( DAA side , 78.8 ± 22.8 % ) than on the side subjected to ALA ( ALA side , 90.7 ± 17.7 % ) ( p < 0.01 ) . In magnetic resonance imaging at postoperative 1 year , the mean grade of fatty atrophy of TFL by Goutalier classification was significantly higher in DAA sides ( 2.00 ± 1.6 ) than in ALA sides ( 1.1 ± 1.3 ) ( p = 0.03 ) . CONCLUSIONS Excellent clinical results for both DAA and ALA were achieved . LFCN injury was found only in DAA sides . Although TFL atrophy was found in both approaches , it was found significantly more in DAA sides . Our study suggested that ALA should be used rather than DAA in terms of the risk of nerve injuries The mini-posterior approach for total hip arthroplasty ( THA )  belongs to the mini-incision approaches . In comparison to st and ard approaches , less muscle trauma result ing in less pain , less blood loss and faster rehabilitation in the early postoperative period are attributed to this approach , as known for all other minimally invasive approaches . In a prospect i ve study of 100 cases of THA it could be shown that this is true when comparing the mini-posterior approach with the posterolateral approach . Lower levels of muscle enzymes as a parameter for muscle trauma , could not be seen BACKGROUND The direct anterior approach ( DAA ) for total hip arthroplasty has cl aim ed to be a true tissue-sparing minimally invasive approach that has less tissue damage and a faster recovery when compared to the posterolateral approach ( PLA ) . The aim of this r and omized controlled trial is to measure the differences in serum markers and functional outcomes between the DAA and PLA for total hip arthroplasty . METHODS Forty-six patients were prospect ively included and r and omized for either the DAA ( n = 23 ) or PLA ( n = 23 ) . All surgical procedures were performed by 3 well-trained orthopedic surgeons . The degree of tissue damage was assessed by measuring creatine kinase ( CK ) and C-reactive protein levels ( CRP ) preoperatively and 2 hours , 1 day , 2 weeks , and 6 weeks postoperatively . Generalized linear mixed models analyses were used to assess differences between serum markers over time ; correction for possible confounding factors was performed . The Hip disability and Osteoarthritis Outcome Score and the Harris Hip Score were assessed preoperatively and 6 weeks postoperatively . RESULTS There were no differences in patient demographics . The DAA had a longer operative time ( P = .001 ) . CK and CRP levels increased postoperatively , but no significant differences between the groups were found on any of the time points . Functional outcomes were also similar in both approaches . CONCLUSION No difference in tissue damage measured with serum markers CK and CRP were found between the DAA and PLA for total hip arthroplasty
target: The posterolateral approach reported the lowest value for the surgical duration .
  The posterolateral approach reported the shortest hospitalization length .
  The posterolateral approach reported shorter surgical duration and hospitalization length .
  Concerning the analysis of total estimated blood loss , no significant result was obtained .
background: Despite the numerous studies , there is no consensus concerning the best approach for  total hip arthroplasty ( THA )  , and debates are ongoing .
  The purpose of this study was to perform a Bayesian network meta- analysis ( NMA ) comparing several approaches for primary THA .
  The focus was on peri-operative outcomes : surgical duration , total estimated blood loss , and length of the hospitalization .