Evaluation of Comparative Efficacy and Safety of Surgical Approaches for Total Hip Arthroplasty: A Systematic Review and Network Meta-analysis

Abstract

Importance: Each approach for primary total hip arthroplasty (THA) has a long learning curve, so a surgeon's choice to change their preferred approach needs to be guided by clear justifications. However, current evidence does not suggest that any of the THA approaches are more beneficial than others, and the choice of approach is mainly based on the knowledge and experience of the surgeon and individual patient characteristics.

Objective: To assess the efficacy and safety associated with different surgical approaches for THA.

Data sources: A comprehensive search of PubMed, EMBASE, and Cochrane databases from inception to March 26, 2022; reference lists of eligible trials; and related reviews.

Study selection: Randomized clinical trials (RCTs) comparing different surgical approaches, including the 2-incision approach, direct anterior approach (DAA), direct lateral approach (DLA), minimally invasive direct lateral approach (MIS-DLA), minimally invasive anterolateral approach (MIS-ALA), posterior approach (PA), minimally invasive posterior approach (MIS-PA), and supercapsular percutaneously assisted total hip arthroplasty (SuperPath), for primary THA.

Data extraction and synthesis: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, 2 reviewers independently extracted data on study participants, interventions, and outcomes as well as assessed the risk of bias using the Cochrane risk of bias tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation framework. A frequentist framework was used to inform a series of random-effects network meta-analyses.

Main outcomes and measures: The outcomes were hip score (range, 0-100, with higher scores indicating better overall hip condition), pain score (range, 0-100, with higher scores indicating more pain), hospitalization time, operation time, quality of life score, blood loss, cup abduction angle, and cup anteversion angle.

Results: Of 2130 retrieved studies, 63 RCTs including 4859 participants (median [IQR] age, 64.0 [60.3-66.5] years; median [IQR] percentage male, 46.74% [38.64%-54.74%]) were eligible for analysis. Eight surgical approaches were evaluated. For hip score, DAA (mean difference [MD], 4.04; 95% CI, 1.92 to 6.16; moderate certainty), MIS-ALA (MD, 3.00; 95% CI, 0.43 to 5.59; moderate certainty), MIS-DLA (MD, 3.37; 95% CI, 1.05 to 5.68; moderate certainty), MIS-PA (MD, 4.46; 95% CI, 1.60 to 7.31; moderate certainty), PA (MD, 4.37; 95% CI, 1.87 to 6.88; high certainty), and SuperPath (MD, 5.00; 95% CI, 0.58 to 9.42; high certainty) were associated with greater improvement in hip score compared with DLA. DLA was associated with lower decrease in pain score than SuperPath (MD, 1.16; 95% CI, 0.13 to 2.20; high certainty) and MIS-DLA (MD, 0.90; 95% CI, 0.04 to 1.76; moderate certainty). PA was associated with shorter operation times compared with 2-incision (MD, -23.85 minutes; 95% CI, -36.60 to -11.10 minutes; high certainty), DAA (MD, -13.94 minutes; 95% CI, -18.79 to -9.08 minutes; moderate certainty), DLA (MD, -10.50 minutes; 95% CI, -16.07 to -4.94 minutes; high certainty), MIS-ALA (MD, -6.76 minutes; 95% CI, -12.86 to -0.65 minutes; moderate certainty), and SuperPath (MD, -13.91 minutes; 95% CI, -21.87 to -5.95 minutes; moderate certainty). The incidence of 6 types of complications did not differ significantly between the approaches.

Conclusions and relevance: In this study, moderate to high certainty evidence indicated that compared with PA, all surgical approaches except DLA were associated with similar improvements of hip score but longer operation time. DLA was associated with smaller improvement of hip score. The safety of the different approaches did not show significant differences. These findings will help health professionals and patients with better clinical decision-making and also provide references for policy makers.

Figure 1.. Study Flow Diagram of Study Selection Process

RCT indicates randomized clinical trials.

Figure 2.. Network Plots Comparing Approaches in Primary Total Hip Arthroplasty for 8 Outcome Measures

The line width is proportional to the number of studies comparing each pair of treatments, and the size of each node is proportional to the number of participants (sample size). DAA indicates direct anterior approach; DLA, direct lateral approach; MIS-ALA, minimally invasive anterolateral approach; MIS-DLA, minimally invasive direct lateral approach; MIS-PA, minimally invasive posterior approach; PA, posterior approach; QOL, quality of life; SuperPath, supercapsular percutaneously assisted total hip arthroplasty.

Figure 3.. League Tables of Hip Score Change, Pain Score Change, Hospitalization Time, and Operation Time

The relative effect sizes are measured as a mean difference along with 95% CIs. Bold indicates statistical significance. The color of each cell indicates the certainty of evidence according to Grading of Recommendations, Assessment, Development, and Evaluation. The treatments are listed in alphabetical order. Comparisons between treatments should be read from left to right and the estimate is in the cell in common between the column-defining treatment and the row-defining treatment. For pain score change, hospitalization time, and operation time, a mean difference lower than 0 favors the column-defining treatment. For hip score change, a mean difference lower than 0 favors the row-defining treatment. In the left lower half, a mean difference lower than 0 favors the column-defining treatment and in the upper right half, a mean difference lower than 0 favors the row-defining treatment. DAA indicates direct anterior approach; DLA, direct lateral approach; MIS-ALA, minimally invasive anterolateral approach; MIS-DLA, minimally invasive direct lateral approach; MIS-PA, minimally invasive posterior approach; NA, not applicable; PA, posterior approach; SuperPath, supercapsular percutaneously assisted total hip arthroplasty.

Figure 4.. League Tables of Quality of Life Score Change, Blood Loss, Cup Abduction Angle, and Cup Anteversion Angle

The league tables show the relative effect sizes of each approach, measured as a standardized mean difference for quality of life score change and mean difference for all other outcomes, along with 95% CIs. Bold indicates statistical significance. The color of each cell indicates the certainty of evidence according to Grading of Recommendations, Assessment, Development, and Evaluation. Treatments are listed in alphabetical order. Comparisons between treatments should be read from left to right, and the estimate is in the cell in common between the column-defining treatment and the row-defining treatment. For the quality of life score change, blood loss, and cup abduction angle, a mean difference lower than 0 favors the column-defining treatment. For cup anteversion angle, a mean difference lower than 0 favors the row-defining treatment. DAA indicates direct anterior approach; DLA, direct lateral approach; MIS-ALA, minimally invasive anterolateral approach; MIS-DLA, minimally invasive direct lateral approach; MIS-PA, minimally invasive posterior approach; PA, posterior approach; SuperPath, supercapsular percutaneously assisted total hip arthroplasty.

Figure 5.. Summary of Relative Effect Sizes for Outcomes of Total Hip Arthroplasty Approaches on 8 Outcomes

The certainty of evidence was rated by Grading of Recommendations, Assessment, Development, and Evaluation criteria, including imprecision. Imprecision was rated down only when the 95% CI crossed null effect. Approaches were categorized and certainty of evidence was rated in 1 of 2 ways: whether the intervention was clearly better or worse than the posterior approach (PA; the mean effect size exceeding or less than the null effect and the 95% CI not crossing the null effect threshold) or possibly better or worse than PA (the point estimate greater or less than the null effect and the 95% CI crossing the threshold). Bold text represents statistical significance. DAA indicates direct anterior approach; DLA, direct lateral approach; MIS-ALA, minimally invasive anterolateral approach; MIS-DLA, minimally invasive direct lateral approach; MIS-PA, minimally invasive posterior approach; MD, mean difference; NA, not available; SMD, standardized mean difference; SuperPath, supercapsular percutaneously assisted total hip arthroplasty.