Posterior versus lateral surgical approach for total hip arthroplasty in adults with osteoarthritis
Abstract
Background
Osteoarthritis of the hip is a progressive condition that has no cure and requires a total hip arthroplasty (THA). The principal methods for THA are the posterior and direct lateral approaches. The posterior approach is generally considered to be easy to access, using less extensive tissue dissection and considered to be associated with less problems with gait. However, increased rates of dislocation have been reported. The direct lateral approach facilitates cup positioning which may decrease rates of hip dislocation and diminishes the risk of injury to the sciatic nerve. However, there is an increased risk of limp.
Dislocation of a hip prosthesis is a clinically important complication after THA, in terms of morbidity implications and costs. The influence of the surgical approach of the hip on the dislocation rate has often been debated but no clear consensus has been established and no systematic review on the topic has previously been published.
Objectives
To determine, based on evidence from randomised trials, the risks of prosthesis dislocation, postoperative Trendelenburg gait and sciatic nerve palsy after a posterior approach, compared to a direct lateral approach, for adult patients undergoing THA for primary osteoarthritis.
Search methods
Relevant randomised controlled trials were selected from those identified by a general literature search strategy of MEDLINE, EMBASE, CINHAL and Cochrane databases. No language restrictions were applied.
Selection criteria
Published randomised controlled trials comparing posterior and direct lateral surgical approaches to THA in participants 18 years and older with a diagnosis of primary hip osteoarthritis. Quasi‐randomised trials and trials in which the treatment allocation was inadequately concealed were included.
Data collection and analysis
Retrieved articles were assessed for their methodological quality independently by the two reviewers, using a 17 items scale. Data were extracted independently too.
Main results
Four studies involving 241 participants met the inclusion criteria. The primary outcome, dislocation, was reported in two studies. No significant difference between posterior and direct lateral surgical approach was found (relative risk 0.35, 95% confidence intervals 0.04 to 3.22). The presence of postoperative Trendelenburg gait was not significantly different between these surgical approaches. The risk of nerve palsy or injury was significantly higher among the direct lateral approaches (relative risk 0.16, 95% confidence intervals 0.03 to 0.83). However, there were no significant differences when comparing this risk nerve by nerve for both approaches, in particular for the sciatic nerve. For the other outcomes under study, only the average range of internal rotation in extension of the hip was significantly higher (weighted mean difference 16 degrees, 95% confidence interval 8 to 23) in the posterior approach group (mean 35°, standard deviation 13°) compared to the direct lateral approach (mean 19°, standard deviation 13°).
Authors' conclusions
The quality and quantity of information extracted from the trials performed to date are insufficient to make any firm conclusion on the optimum choice of surgical approach in adult patients undergoing primary THA for osteoarthritis.
PICOs
Plain language summary
Is the lateral or posterior approach better in total hip replacement surgery for osteoarthritis of the hip?
To answer this question, scientists found and analyzed 4 studies that tested over 200 people with osteoarthritis of the hip. These people had total hip replacement surgery that was either done from the posterior (back of the hip) or from a lateral approach (side of the hip). These studies provide the best evidence we have today.
What is osteoarthritis of the hip and what types of total hip replacement surgery are there?
Osteoarthritis (OA) is the most common form of arthritis that can affect the hips. In some people, the damage and pain in the hip may be severe enough for surgery. In these people, the whole hip joint can be replaced by an artificial joint with total hip replacement surgery.
In total hip replacement surgery, the surgeon can make the cut from the posterior (back) or lateral (side) of the hip. Some surgeons believe that the posterior approach is better because people have less problems walking after surgery. Other surgeons believe that the lateral approach is better because people have less chance of nerve damage and less chance of dislocating their hip after surgery. Dislocating a hip causes pain and people may need to go to hospital to put the hip back in place.
What did the studies show?
Two studies show that the number of people who dislocated their hip after surgery was about the same with either the posterior or lateral approach:
• 1 out of 100 people dislocated their hip after surgery with the posterior approach
• 4 out of 100 people dislocated their hip after surgery with the lateral approach.
Three studies show that people had about the same difficulties with walking with either the posterior or lateral approach. Two studies found less nerve damage overall in people with surgery from the posterior approach (but these studies were small). Another study found that the range of motion of the hip was better in people with the posterior approach.
What is the bottom line?
The level of quality of the four studies in this review is "silver".
There is not enough evidence to tell whether the posterior (back) or the lateral (side) approach to total hip replacement surgery is better.
