Orthopedics

Feature Article 

Comparison of Complications in Single-incision Minimally Invasive THA and Conventional THA

Ning Li, MD; Yu Deng, MD; Liaobin Chen, MD, PhD

Abstract

The purpose of this meta-analysis was to investigate whether single-incision minimally invasive total hip arthroplasty (THA) is superior to conventional incision THA by comparing postoperative complication rates, Harris Hip Scores, and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores. Randomized, controlled trials comparing single-incision minimally invasive THA and conventional THA were reviewed. The methodological quality of each randomized, controlled trial was assessed using the Physiotherapy Evidence Database (PEDro) scale (Centre for Evidence-based Physiotherapy, The George Institute for Global Health, New South Wales, Australia). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to determine the quality of the evidence. Fourteen studies involving 1254 patients (1329 hips) were included in the meta-analysis, comprising 659 single-incision minimally invasive THAs (mean patient age, 63.9 years) and 670 conventional incision THAs (mean patient age, 65.0 years). A funnel plot of postoperative complication rates showed that a slight publication bias existed in the study.

According to the meta-analysis, no significant statistical difference was observed in complication rates in no more than 3 postoperative years (odds ratio=1.06; 95% confidence interval, 0.69 to 1.63; P=.79), in Harris Hip Scores in no more than 2 postoperative years (weighted mean difference=0.71; 95% confidence interval, −3.09 to 4.51; P=.71), and in WOMAC scores at 6 weeks postoperatively (weighted mean difference=−0.55; 95% confidence interval, −3.54 to 2.44; P=.72) between single-incision minimally invasive THA and conventional THA. Therefore, single-incision minimally invasive THA is not superior to conventional THA in early postoperative recovery, hip function, and complication rate.

Drs Li, Deng, and Chen are from the Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, People’s Republic of China.

Drs Li, Deng, and Chen have no relevant financial relationships to disclose.

Correspondence should be addressed to: Liaobin Chen, MD, PhD, Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, 430071, People’s Republic of China (lbchen@whu.edu.cn).

Abstract

The purpose of this meta-analysis was to investigate whether single-incision minimally invasive total hip arthroplasty (THA) is superior to conventional incision THA by comparing postoperative complication rates, Harris Hip Scores, and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores. Randomized, controlled trials comparing single-incision minimally invasive THA and conventional THA were reviewed. The methodological quality of each randomized, controlled trial was assessed using the Physiotherapy Evidence Database (PEDro) scale (Centre for Evidence-based Physiotherapy, The George Institute for Global Health, New South Wales, Australia). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to determine the quality of the evidence. Fourteen studies involving 1254 patients (1329 hips) were included in the meta-analysis, comprising 659 single-incision minimally invasive THAs (mean patient age, 63.9 years) and 670 conventional incision THAs (mean patient age, 65.0 years). A funnel plot of postoperative complication rates showed that a slight publication bias existed in the study.

According to the meta-analysis, no significant statistical difference was observed in complication rates in no more than 3 postoperative years (odds ratio=1.06; 95% confidence interval, 0.69 to 1.63; P=.79), in Harris Hip Scores in no more than 2 postoperative years (weighted mean difference=0.71; 95% confidence interval, −3.09 to 4.51; P=.71), and in WOMAC scores at 6 weeks postoperatively (weighted mean difference=−0.55; 95% confidence interval, −3.54 to 2.44; P=.72) between single-incision minimally invasive THA and conventional THA. Therefore, single-incision minimally invasive THA is not superior to conventional THA in early postoperative recovery, hip function, and complication rate.

Drs Li, Deng, and Chen are from the Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, People’s Republic of China.

Drs Li, Deng, and Chen have no relevant financial relationships to disclose.

Correspondence should be addressed to: Liaobin Chen, MD, PhD, Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, 430071, People’s Republic of China (lbchen@whu.edu.cn).

Minimally invasive total hip arthroplasty (THA) has experienced a recent surge in public perception and in the orthopedic community during the past decade. However, whether minimally invasive THA is superior to conventional incision THA remains controversial. Studies have shown that compared with conventional THA, the advantages of minimally invasive THA include smaller skin incisions, less soft tissues trauma, less postoperative pain, and faster recovery.1–3 However, other studies have reported that minimally invasive THA is more prone to complications, mainly due to component malpositioning with an increased risk of dislocation,4 in addition to an increased risk of neurovascular complications and excessive skin trauma.5

The evaluation of any new medical therapy must include a detailed evaluation of safety outcomes. No published literature comparing minimally invasive and conventional THA is adequately powered to report a statistical comparison of complication rates and functional hip scores. Therefore, the purpose of this meta-analysis was to investigate whether single-incision minimally invasive THA is superior to conventional incision THA by comparing postoperative complication rates, Harris Hip Scores, and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores.

Materials and Methods

Eligibility Criteria

Studies were eligible if (1) patients underwent single-incision THA, (2) minimally invasive THA and conventional THA were compared, (3) surgical complications were described, (4) a randomized, controlled trial design was used, and (5) they were published in English or Chinese.

Search Strategy

Two researchers (N.L., Y.D.) independently completed a computerized search of the following databases: Medline, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang Data, and Chongqing VIP, supplemented with manual searching of relevant journals published up to May 2011. The following search words were used: total hip arthroplasty or total hip replacement, minimally invasive surgery, and randomized controlled trial.

Quality Assessment

The 2 researchers independently assessed the trial quality of each study using the Physiotherapy Evidence Database (PEDro) scale (Centre for Evidence-based Physiotherapy, The George Institute for Global Health, New South Wales, Australia).6 The 11 items are based on the Delphi list.7 Each item is scored yes or no with a maximum score of 10 (criterion 1 is not scored). The PEDro score has demonstrated moderate inter-rater reliability (intraclass correlation coefficient=0.68; 95% confidence interval [CI], 0.57–0.76) for clinical trials.8 A trial with a score of 6 or more was considered high quality and consistent with previous reviews.9,10 Conflicts were calculated through consensus with the corresponding author.

Data Extraction

The 2 researchers extracted relevant data, including sample size, study design, patient age, sex, preoperative diagnosis, body mass index, surgical approach, and length of follow-up. Complications were defined as any adverse event, including wound healing complications, infection, aseptic loosening, dislocation, and fracture.

Statistical Analysis

The meta-analysis was conducted with Cochrane Collaboration Review Manager (RevMan) version 5.1 software (Cochrane Collaboration, Copenhagen, Denmark). For continuous data, a weighted mean difference and 95% CI were used. For dichotomous outcomes, an odds ratio (OR) and 95% CI were calculated as the summary statistics. Statistical heterogeneity was tested with the chi-square test and I2 test. I2<25% was considered low statistical heterogeneity, I2<50%, moderate statistical heterogeneity, and I2>75%, high statistical heterogeneity.11 The source of high heterogeneity was investigated by subgroup analysis of different methodological qualities after clinical heterogeneity of the included studies was excluded.

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was applied to each analysis performed to determine the quality of evidence.12 This approach entailed downgrading the evidence from high to moderate to low to very low quality based on the following criteria: the PEDro score was <6 for the majority of trials in the meta-analysis; the statistical heterogeneity was high or very high (I2>50%); or large confidence intervals indicated a small number of participants. A footnote was used to explain the reasons for the grade applied to each meta-analysis.

Results

Study Selection

A literature search initially yielded 207 relevant trials. Basing on the title/abstract searching mode, 201 studies did not meet the predetermined eligibility criteria. Thirty-six trials were then retrieved in full text, among which 15 studies were not randomized, controlled trails, leaving 21 eligible trials. Four studies did not describe the number of complications. Three studies had duplicated data from other trials. Finally, 14 studies met the predetermined inclusion criteria, and a summary of the review process was presented (Figure 1). The included studies were all randomized, controlled trials, 12 published in English13–24 and 2 in Chinese.25,26

Flow chart summarizing the selection process of randomized, controlled trials (RCTs).

Figure 1: Flow chart summarizing the selection process of randomized, controlled trials (RCTs).

A funnel plot of postoperative complication rates was used to assess publication bias, which was generally symmetrical. Six of the included studies plotted at the top of the funnel plot; therefore, only a slight publication bias existed (Figure 2).

Funnel plot assessing publication bias for postoperative complication rate. Abbreviations: OR, odds ratio; SE, standard error.

Figure 2: Funnel plot assessing publication bias for postoperative complication rate. Abbreviations: OR, odds ratio; SE, standard error.

Study Characteristics

The demographic characteristics of the 14 studies are presented in Table 1. The dataset included 1254 patients (1329 hips). The study included 659 single-incision minimally invasive THAs involving 206 men and 249 women with a mean age of 63.9 years, compared with 670 conventional incision techniques involving 209 men and 254 women with a mean age of 65.0 years. The underlying pathology was osteoarthritis in most cases. Most orthopedic surgeons were experienced in THA. No computer-assisted technique was used for THA. The most common surgical approach for both minimally invasive and conventional THA was posterolateral. Follow-up ranged from 6 weeks to 3 years.

Study Characteristics

Table 1: Study Characteristics

Study Quality

The methodological quality of each study was assessed according to the PEDro scale. Of the 14 randomized, controlled trials, 6 were low quality and 8 were high quality (Table 2). All studies used the randomized method, and half clearly described the randomized method. Baseline comparability was used in 13 studies. The blinding method was used in 7 studies, and no studies could conduct therapist blinding. All studies had more than 85% follow-up. Six studies used intention-to-treat analysis. All studies offered the number of complications and statistical analysis methods.

PEDro Critical Appraisal Scores

Table 2: PEDro Critical Appraisal Scores

Outcomes

The forest plot of complication rates indicated no statistical difference between the single-incision minimally invasive and conventional THAs with low statistical heterogeneity (P=.74; I2=0%) (Figure 3). Forty-five complications occurred in single-incision minimally invasive THA and 43 occurred in conventional incision THA (Table 3).

Forest plot for postoperative complication rate between single-incision minimally invasive (MIS) and conventional (Conv) total hip arthroplasty. Abbreviations: CI, confidence interval; M-H, Mantel-Haenszel.

Figure 3: Forest plot for postoperative complication rate between single-incision minimally invasive (MIS) and conventional (Conv) total hip arthroplasty. Abbreviations: CI, confidence interval; M-H, Mantel-Haenszel.

Complications Results

Table 3: Complications Results

Eleven studies reported Harris Hip Scores in the period 3 years postoperatively, and 7 studies reported standard deviations. Thus, a meta-analysis was performed on these 7 studies. Because high statistical heterogeneity existed among these studies (P<.01; I2=92%), a subgroup analysis based on the study quality was conducted. The forest plot showed no statistical difference in Harris Hip Scores for the high-quality subgroup with high statistical heterogeneity (P=.02; I2=66%) and the low-quality subgroup with very high statistical heterogeneity (P<.01; I2=97%) (Figure 4).

Forest plot for postoperative Harris Hip Scores between single-incision minimally invasive (MIS) total hip arthroplasty and conventional (Conv) total hip arthroplasty. Abbreviations: CI, confidence interval; IV, inverse variance.

Figure 4: Forest plot for postoperative Harris Hip Scores between single-incision minimally invasive (MIS) total hip arthroplasty and conventional (Conv) total hip arthroplasty. Abbreviations: CI, confidence interval; IV, inverse variance.

Three studies reported WOMAC scores 6 weeks postoperatively, and 2 studies reported standard deviations. Thus, a meta-analysis was performed on these 2 studies. The forest plot showed no statistical difference between the 2 groups with low statistical heterogeneity (P=.30; I2=5%) (Figure 5).

Forest plot for postoperative Western Ontario and McMaster Universities Arthritis Index scores between single-incision minimally invasive (MIS) total hip arthroplasty and conventional (Conv) total hip arthroplasty. Abbreviations: CI, confidence interval; IV, inverse variance.

Figure 5: Forest plot for postoperative Western Ontario and McMaster Universities Arthritis Index scores between single-incision minimally invasive (MIS) total hip arthroplasty and conventional (Conv) total hip arthroplasty. Abbreviations: CI, confidence interval; IV, inverse variance.

According to the GRADE approach, the quality of evidence of complication rates, Harris Hip Scores, and WOMAC scores was moderate, low, and high, respectively. However, the quality of evidence of Harris Hip Scores for the high-quality subgroup was moderate (Table 4).

GRADE Quality Assessment of Trials for Minimally Invasive vs Conventional THA

Table 4: GRADE Quality Assessment of Trials for Minimally Invasive vs Conventional THA

Discussion

The debate over the benefits of minimally invasive THA continues. It is unclear whether minimally invasive THA or conventional THA is superior. Because the goals of THA are to relieve pain and restore function with minimal complications and adverse events, this meta-analysis compared the functional scores and complication rates of minimally invasive THA and conventional THA in an effort to objectively evaluate the efficacy of the 2 techniques.

Regarding hip functional score, the results showed that minimally invasive THA resulted in similar Harris Hip Scores compared with conventional incision THA, consistent with those in published reports.27,28 This demonstrates that minimally invasive THA is not superior to conventional THA for postoperative hip function. Although 6 weeks postoperatively was early for follow-up, WOMAC scores at this stage can represent early rehabilitation for those who underwent THA. The current study indicated no statistical difference in WOMAC scores 6 weeks postoperatively between minimally invasive THA and conventional THA, which demonstrates that minimally invasive THA was not superior to conventional THA for early postoperative rehabilitation. It can be concluded that minimally invasive THA does not have faster functional recovery and more rapid rehabilitation than conventional THA, which is not in consistent with the published opinion.29

The current study showed that the postoperative complication rate for minimally invasive THA (7.0% [46/659]) and conventional THA (6.6% [44/670]) was low. Major complications of both techniques were heterotopic ossification, dislocation, aseptic loosening, and infection. The study results showed no statistical difference in total number and type of complications between minimally invasive THA and conventional THA. Minimally invasive THA did not increase complications, which differs from the results of Berry et al,5 who reported an increased risk of dislocation and neurovascular complications with minimally invasive THA.

The current meta-analysis had several strengths. Based on a thorough search of the published literature, the included trials had only a slight publication bias. All 14 included studies were randomized, controlled trials, 8 of which were prospective with high methodological quality. All minimally invasive THAs were performed with a single-incision approach, which could decrease influence factors because this technique is significantly different from a 2-incision approach.30

This study also had several limitations. The approaches, including posterior, posterolateral, lateral, and anterolateral, were not the same for the minimally invasive and conventional techniques. Four trials were comparative studies of not only minimally invasive THA and conventional THA, but also of different approaches (eg, anterior minimally invasive approach vs posterolateral approach, anterolateral minimally invasive approach vs posterolateral approach). This may have interfered with the research outcomes. Among the 14 included trials, 6 were low quality. Implementation bias and measurement bias may exist, which could affect the objectiveness of the outcome. Among the trials, differences existed in the aspects of body mass index, preoperative diagnosis, and length of follow-up.

Conclusion

Based on the results of Harris Hip Scores, WOMAC scores, and complication rates, this study demonstrates that single-incision minimally invasive THA is not superior to conventional THA with regard to early postoperative recovery, hip function, and complication rate. For a more objective outcome, more trials with the same minimally invasive and conventional approaches and longer follow-up period are needed.

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Study Characteristics

Study Sample Size, No.
THA Type, No.
Mean Age, y
Male/Female, No.
Preoperative Diagnosis
BMI, kg/m2
Surgical Approach
FU
Patients Hips MIS Conv MIS Conv MIS Conv MIS Conv MIS Conv MIS Conv
Chimento et al13 60 60 28 32 67.2±8.6 65.6±10.5 16/12 13/19 NA NA 25.2±3.1 24.8±2.5 PL PL 2 y
Dorr et al14 60 60 30 30 70.3±9.7 63.9±13.6 17/13 14/16 NA NA 27.6±4.5 30.2±6.5 P P 6 mo
Goosen et al15 120 120 30 30 60±6.3 62±6.3 15/15 13/17 92% OA 98% OA 26.6±2.6 26.8±2.7 PL PL 1 y
30 30 60±7.4 62±6.9 15/15 16/14 26.7±3.1 26.1±2.8 AL AL
Hart et al16 120 120 60 60 72.4 40/80 100% OA 100% OA 27.6 <35 PL PL 1.5 mo
Kim17 70 140 70 70 52 61 53/17 14% OA, 80% ON 25.6 PL PL 1 y
Martin et al18 79 83 42 41 66.7±10.1 63.1±10.2 12/30 14/27 88% OA 90% OA 30.6±6.1 29.4±5.5 AL L 1 y
Mazoochian et al19 51 52 26 26 NA NA NA NA NA NA 26.6±4.5 26.4±3.7 L L 3 mo
Ogonda et al20 219 219 109 110 67.4 65.85 49/60 58/52 98% OA 97% OA 28.2±4.3 28.9±4.3 P P 1.5 mo
Roy et al21 56 56 25 31 79.5 84.0 7/18 4/27 100% FNF NA NA P P 2 y
Shitama et al22 39 39 19 20 58.3 61.3 NA NA 87% DD 23.2±3.6 23.0±3.7 PL PL 6 mo
Speranza et al23 100 100 50 50 65.0 66.2 20/26 23/21 92% OA 90% OA 28 29 L L 6 mo
Yang et al24 110 110 55 55 55.8±13.9 59.5±13.2 30/25 26/29 13% OA 27% OA 23.1±3.2 22.4±3.9 AL PL 3 y
Huang et al25 50 50 25 25 71.5 NA NA 100% FNF NA NA P PL 6 mo
Zhang et al26 120 120 60 60 61.0 62.5 25/35 28/32 60% OA 58% OA <27 A PL 2.5 y

PEDro Critical Appraisal Scores

Study PEDro Criteriaa
Total
1 2 3 4 5 6 7 8 9 10 11
Chimento et al13 Y Y N Y N N Y Y Y Y Y 7
Dorr et al14 Y Y N Y Y N Y Y Y Y Y 8
Goosen et al15 Y Y Y Y Y N Y Y Y Y Y 9
Hart et al16 N Y N Y N N N Y Y Y Y 6
Kim17 Y Y N Y Y N Y Y Y Y Y 8
Martin et al18 Y Y N Y N N Y Y N Y Y 6
Mazoochian et al19 Y Y N Y N N N Y N Y Y 5
Ogonda et al20 Y Y Y Y Y N Y Y N Y Y 8
Roy et al21 N Y Y Y N N N Y N Y Y 6
Shitama et al22 Y Y N Y N N N Y N Y Y 5
Speranza et al23 N Y N Y N N N Y N Y Y 5
Yang et al24 Y Y Y Y Y N Y Y Y Y Y 9
Huang et al25 N Y N N N N N Y N Y Y 4
Zhang et al26 N Y N Y N N N Y N Y Y 5

Complications Results

Complication No. of Studies No. of Patients
No. of Complications (%)
MIS Conv MIS Conv
Wound healing 1 26 26 0 (0) 1 (3.8)
Infection 12 499 510 6 (1.2) 1 (0.2)
Peroneal nerve palsy 2 112 111 1 (0.9) 1 (0.9)
Aseptic loosening 2 102 101 6 (5.9) 3 (3.0)
Stress-induced gastrointestinal disease 2 81 81 1 (1.2) 1 (1.2)
Sciatic nerve palsy or pain 4 180 183 3 (1.7) 0 (0)
Dislocation 11 489 500 6 (1.2) 4 (0.8)
Fracture 6 276 275 3 (1.1) 2 (0.7)
Pulmonary embolism 4 133 138 1 (0.8) 0 (0)
Deep vein thrombosis 6 321 321 0 (0) 6 (1.9)
Heterotopic ossification 4 187 186 17 (9.1) 20 (10.8)
Myocardial infarction 2 135 136 0 (0) 2 (1.5)
Hypersomnia 1 60 60 0 (0) 1 (1.7)
Psoas tendinitis 1 42 41 1 (2.4) 1 (2.4)
Other 1 25 31 1 (4.0) 1 (3.2)
Total 46 (7.0) 44 (6.6)

GRADE Quality Assessment of Trials for Minimally Invasive vs Conventional THA

Quality Assessment
No. of Patients
Effect
Quality Importance
No. of Studies Design Risk of Bias Inconsistency Indirectness Imprecision Other Consid MIS Control Relative (95% CI) Absolute
Complication Rates
14 RT Seriousa No serious inconsistency No serious indirectness No serious imprecision None 46/659 (7%) 44/670 (6.6%) OR 1.06 (0.69–1.63) 4 more per 1000 (19 fewer to 37 more) Mod Critical
3.6% 2 more per 1000 (11 fewer to 21 more)
HHSb
7 RT Seriousc Seriousd No serious indirectness No serious imprecision None 350 350 MD 0.71 higher (3.09 lower to 4.51 higher) Low Important
HHS – High-quality Subgroupb
5 RT No serious risk Seriouse No serious indirectness No serious imprecision None 291 297 MD 0.04 higher (2.61 lower to 2.69 higher) Mod Important
WOMACb
2 RT No serious risk No serious inconsistency No serious indirectness No serious imprecision None 169 170 MD 0.55 lower (3.54 lower to 2.44 higher) High Important

10.3928/01477447-20120725-12

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