A prospective randomized assessment of earlier functional recovery in THA patients treated by minimally invasive direct anterior approach: A gait analysis study
Introduction
Despite the success of total hip arthroplasty (THA) in terms of pain relief, quality of life, and physical function, some THA patients still do not achieve normal gait at 1 year or more after surgery (Long et al., 1993, McCrory et al., 2001, Murray et al., 1972, Perron et al., 2000, Rigas and Xenakis, 1988, Ritter et al., 2001, Stauffer et al., 1974). This might be explained by the effect of the surgical approach on the function of those muscles in the vicinity of the hip joint. The anterolateral (AL) surgical approach is done using the transgluteal route, which involves the gluteus medius, vastus lateralis, and external rotators (Rachbauer, 2006). Anatomically, the gluteus muscles are responsible for controlling pelvic obliquity during gait and hip abduction (Crenshaw, 1992). The effect of the surgical approach on the function of hip abductor muscles was addressed extensively (Baker and Bitounis, 1989, Downing et al., 2001, Gore et al., 1982, Murray et al., 1971, Stauffer et al., 1974, Tanaka, 1998, Vaz et al., 1993, Vicar and Coleman, 1984), and positive results for the AL approach were shown in the static Trendelenburg test, which indicates postoperative hip abductor dysfunction.
More recently, minimally invasive surgical approaches in THA have been introduced and are currently being discussed widely in the medical community (Goldstein et al., 2003, Howell et al., 2004, Keggi et al., 1993, Ogonda et al., 2005, Rachbauer, 2006). This is accomplished by minimizing cutting through the muscles. In an effort to potentially minimize muscle trauma during surgery, a minimally invasive direct anterior (DA) approach via the ‘Smith-Peterson’ interval was developed at our department (Nogler et al., 2008, Rachbauer, 2006). This approach, which requires the use of special instruments, allows exposure and implantation of the prosthesis components without cutting through hip muscles. It uses the intermuscular plane between the gluteus and the tensor muscles laterally, and the sartorius and rectus muscles medially.
The clinical outcome of both AL and DA approaches is encouraging, but quantitative data, particularly those concerning postoperative functional differences during gait, are very limited (Tanaka, 1998, Keggi et al., 1993, Ritter et al., 1995). Gait analysis is now an established technique, and has been used successfully to quantify the effect of various surgical orthopedic treatments on patients with coxarthrosis (Hurwitz et al., 1997). Most recently it has been used to try to demonstrate possible advantages of common and minimally invasive surgical approaches in THA (Bennett et al., 2007, Meneghini et al., 2008, Whatling et al., 2008, Ward et al., 2008) but these did not succeed to demonstrate functional advantages related to surgical procedure. In addition, functional outcome of the DA approach has been limitedly assessed quantitatively as the only paper reporting on this and other minimally invasive approaches (Ward et al., 2008) used a simple device for the monitoring of the physical activities, reporting only time–distance parameters.
The purpose of this study was to test the hypothesis that patients operated on by the minimally invasive DA approach have an earlier return to normal function than patients operated on by the traditional AL approach. This was evaluated using gait analysis data set collected over a large cohort of THA patients at early follow-ups.
Section snippets
Methods
Patients in this prospective, randomized study were evaluated preoperatively and at 6 and 12 weeks postoperatively. Time–distance and segment and joint kinematics were obtained by gait analysis on two groups of adult patients. The study was conducted in accordance with current Austrian regulations, and written informed consent was obtained from all patients. All patients had unilateral hip disease. Co-morbidities of the lower extremity, such as osteoarthritis or misalignment at other joints
Sample characteristics
In the DA group the median age was 66 (±10) years, median weight 76 kg, and median height 168.0 cm. In the AL group these values were, respectively, 68 (±10) years, 84 kg, height 168.5 cm. No significant differences were found in WOMAC in the dimension of pain, stiffness and function between the two groups as well as for LLD at any follow-up (Table 1) .
Surgical information
In the DA group, the mean surgical time was 70 min (range of 60–85 min), and the mean blood loss was 264 cc (range of 150–450 cc). In the AL group these
Discussion
State-of-the-art gait analysis was used to investigate postoperatively the functional assessment of patients who had undergone THA either by the traditional AL approach or the minimally invasive DA approach. The former approach is known to affect the abductor muscles, which stabilize the pelvis (Crenshaw, 1992), whereas the DA approach should cause no harm to the muscles (Rachbauer, 2006, Krismer and Rachbauer, 2004, Meneghini et al., 2006). With this approach, an anterolateral flap of the
Conflict of interest
The authors declare that they do not have any financial or personal relationships with other people or organizations that could have inappropriately influenced this study.
Acknowledgements
The authors would like to thank Markus Ertl, PhD, for performing the statistical analysis, Stefan Fischler for his support in the Innsbruck gait laboratory, and Stefania Ingrosso, MEng, for the data processing in Bologna.
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