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Comparison of direct anterior, lateral, posterior and posterior-2 approaches in total hip arthroplasty: network meta-analysis

  • Original Article • HIP - ARTHROPLASTY
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European Journal of Orthopaedic Surgery & Traumatology Aims and scope Submit manuscript

Abstract

Total hip arthroplasty (THA) is generally considered to be one of the most successful orthopedic surgical procedures. THA patients continue to experience symptoms, most commonly pain, which prevent their return to full function and activity. Possible causes include failure of fixation, instability and damage to soft tissues, associated with the trauma of the surgical procedure. Choosing the optimal surgical approach can minimize these risks and therefore improve the outcome of THA. Surgical approaches in THA include anterior, lateral [anterolateral (Hardinge) and direct lateral (Watson–Jones)], posterior (posterolateral and posterior) and posterior-2 techniques. However, there is no current consensus regarding which approach is the most suitable. Therefore, we conducted a systematic review and network meta-analysis to compare the postoperative outcomes and complications among THA approach and identify which approach is the best for THA. We searched all RCT studies that compared intra-operative and postoperative outcomes of anterior, lateral [anterolateral (Hardinge) and direct lateral (Watson–Jones)], posterior (posterolateral and posterior) and posterior-2 approaches for THA from the PubMed and Scopus databases up to February 1, 2017. Data were independently extracted by two reviewers. A network meta-analysis was applied to assess treatment outcomes. Probability of being the best treatment was estimated using surface under the cumulative ranking curves (SUCRA). Fourteen RCTs (N = 1017 patients) met inclusion criteria. Interventions were anterior (N = 233 patients), lateral (N = 334 patients), posterior (N = 405 patients) and posterior-2 (N = 45 patients) approaches. A network meta-analysis showed that effects of anterior approach were higher to lateral, posterior and posterior-2 approaches with the pooled mean postoperative within 1 month and last follow-up of HHS of 2.56 (95% CI − 0.79, 5.91), 4.80 (95% CI 1.33, 8.26), 10.80 (95% CI 2.10, 19.49) and 6.40 (95% CI 0.72, 12.09), 2.22 (95% CI − 3.21, 7.66), 4.22 (95% CI − 6.81, 15.25), respectively. For VAS, lateral approach was lower to anterior, posterior and posterior-2 approaches. In terms of complication, posterior approach was the lowest risk with RR of 0.39 (95% CI 0.19, 0.81), 0.57 (95% CI 0.21, 1.57) and 1.74 (95% CI 0.36, 8.33) when compared to anterior, followed by lateral and posterior-2 approaches. Results of SUCRA indicated anterior and lateral approaches were the first and second ranks for postoperative HHS and VAS score, while posterior and lateral approaches were the first and second ranks for postoperative complications. We recommended using lateral approach that has an acceptable postoperative pain, function and complications (second rank for all outcomes) as a surgical technique for THA.

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Abbreviations

THA:

Total hip arthroplasty

HHS:

Harris hip scores

VAS:

Visual analog score

RCTs:

Randomize controlled trials

UMD:

Unstandardized mean difference

RR:

Relative risk

BMI:

Body mass index

SUCRA:

Surface under the cumulative ranking curves

Posterior-2:

Posterior two incision

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Acknowledgements

All authors declare no funding source or sponsor involvement in the study design, collection, analysis and interpretation of the data, in writing the manuscript and in submission of the manuscript for publication.

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Authors and Affiliations

  1. Orthopedics Department, Police General Hospital, Bangkok, Thailand

    Chinundorn Putananon & Alisara Arirachakaran

  2. Orthopedic Department, Bangkok Metropolitan Administration General Hospital, Bangkok, Thailand

    Harit Tuchinda

  3. Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

    Siwadol Wongsak

  4. Orthopedic Department, Bhumibol Adulyadej Hospital, Bangkok, Thailand

    Thana Narinsorasak

  5. Sport and orthopedic center, Samitivej Hospital, Bangkok, Thailand

    Jatupon Kongtharvonskul

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  1. Chinundorn Putananon
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Contributions

CP participated in conception and design, analysis and interpretation of the data, drafting of the article, critical revision of the article for important intellectual content, final approval of the article, collection and assembly of data. AA involved in conception and design, drafting of the article, critical revision of the article for important intellectual content, final approval of the article, collection and assembly of data. HT took part in conception and design, drafting of the article, critical revision of the article for important intellectual content, final approval of the article.SW involved in conception and design, drafting of the article, critical revision of the article for important intellectual content, final approval of the article. TN participated in conception and design, drafting of the article, critical revision of the article for important intellectual content, final approval of the article. JK took part in conception and design, analysis and interpretation of the data, drafting of the article, critical revision of the article for important intellectual content, final approval of the article, collection and assembly of data.

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Correspondence to Jatupon Kongtharvonskul.

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Appendix

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Search term and search strategy

  • #1 THR

  • #2 total hip arthroplasty

  • #3 #1 OR #2

  • #4 approach

  • #5 anterior

  • #6 posterior

  • #7 anterolateral

  • #8 posterolateral

  • # 9 #5 OR #6 OR #7 OR #8

  • #10 clinical trial

  • # 11 #3 AND #4 AND #9 AND #10

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Putananon, C., Tuchinda, H., Arirachakaran, A. et al. Comparison of direct anterior, lateral, posterior and posterior-2 approaches in total hip arthroplasty: network meta-analysis. Eur J Orthop Surg Traumatol 28, 255–267 (2018). https://doi.org/10.1007/s00590-017-2046-1

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