Time course and extent of functional recovery during the first postoperative year after minimally invasive total hip arthroplasty with two different surgical approaches--a randomized controlled trial. New two-incision minimally invasive total hip arthroplasty: comparison with the one-incision method [Comparison of total hip arthroplasty via a posterior mini-incision versus a classic anterolateral approach]. Which is more invasive—mini versus standard incisions in total hip arthroplasty? Total Hip Arthroplasty through the Mini-Incision (Micro-Hip) Approach versus the Standard Transgluteal (Bauer) Approach: A Prospective, Randomised Study Mini-incision technique for total hip arthroplasty with navigation. Tackling the learning curve: comparison between the anterior, minimally invasive (Micro-hip®) and the lateral, transgluteal (Bauer) approach for primary total hip replacement Minimally Invasive versus Classic Procedures in Total Hip Arthroplasty: A Double-blind Randomized Controlled Trial [Minimally invasive posterior approach for total hip arthroplasty]. [Minimally invasive total hip arthroplasty with anterior incision]. Negative pressure wound therapy to prevent seromas and treat surgical incisions after total hip arthroplasty Early Discharge and Recovery with Three Minimally Invasive Total Hip Arthroplasty Approaches: A Preliminary Study The impact of minimally invasive total hip arthroplasty on the standard procedure Component position following total hip arthroplasty through a miniinvasive posterolateral approach. Prevention of postoperative wound infections by covering the surgical field with iodine-impregnated incision drape (Ioban® 2) Antero-lateral minimal invasive (ALMI) approach for total hip arthroplasty technique and early results Fast-track hip and knee replacement — what are the issues? The Early and Delayed Analgesic Effects of Ketamine After Total Hip Arthroplasty: A Prospective, Randomized, Controlled, Double-Blind Study The Frank Stinchfield Award: Dislocation in Revision THA: Do Large Heads (36 and 40 mm) Result in Reduced Dislocation Rates in a Randomized Clinical Trial? Causes for revision of dual-mobility and standard primary total hip arthroplasty
UNLABELLED While others have reported short-term comparisons between various minimally invasive surgical ( MIS ) approaches to  total hip arthroplasty ( THA ) and their conventional analogues , longer-term data is lacking , as is information indicating whether MIS approaches to THA provide a biomechanically complete recovery . Furthermore , different MIS approaches have not been compared . Our approaches of interest were a one-incision modified Watson-Jones , and a two-incision approach . HYPOTHESES ( 1 ) There are significant differences in gait recovery patterns between the two surgical groups and ( 2 ) THA subjects have significant differences in function one year after surgery compared to control subjects . To test these hypotheses , THA c and i date s ( n=26 ) were r and omized to receive one of these MIS approaches and evaluated preoperatively , and postoperatively at 3 weeks , and at 3 , 6 and 12 months . Evaluations included three-dimensional gait analysis and 24-hour step-counts . The same data were obtained from 25 control subjects .  Recovery time-course was assessed using repeated measures ANOVA . T-tests were used to compare controls with the pooled group of THA subjects . We found no differences between the two THA surgical groups regarding the time-course of recovery ( p≥0.591 ) . Although recovery was statistically complete by 3 months postoperatively for all variables , there were significant differences from controls at 12 months . Most notably , the external hip adduction moment , which reflects hip abductor function , was more than one st and ard deviation below normal ( p<0.001 ) . THA subject inactivity could not explain the gait differences , since one year after surgery daily step counts were not significantly different from controls ( p=0.346 ) . More work is necessary to determine ways to improve biomechanical outcomes for today 's patients with high expectations for function and implant longevity Background There has been increasing interest in performing total hip arthroplasty ( THA ) with minimally invasive surgery ( MIS ) . This study was conducted to examine the effectiveness of MIS-THA using the new two-incision technique versus the one-incision technique . Methods A consecutive series of 113 patients who underwent MIS-THAs ( 63 one-incision cases , 50 two-incision cases ) were studied .  One-incision THA was performed with a posterolateral approach . For the two-incision , the first incision for cup insertion was made over the anterolateral side of the hip . Intermuscular dissection was performed between the gluteus medius and the tensor fascia lata . The second incision , for stem insertion , was made on the posterolateral side of the hip along the fiber of the gluteus maximus . Intermuscular dissection was made between the gluteus medius and the piriformis . Results Postoperative rehabilitation was significantly more rapid in the new two-incision group compared to the group with one incision . Postoperatively , the Harris Hip Score and the Western Ontario and the McMaster Universities Osteoarthritis Index score were significantly different between the two groups , especially the functional sections . Conclusions The findings of this study show that our new two-incision MIS-THA is an excellent surgical modality that allows early rehabilitation Surgical approaches to the hip for total hip arthroplasty ( THA ) are termed minimally invasive when allowing for a skin incision length of 10 cm or less . The aim of this study was to explore if a minimally invasive posterior approach compared to a classic anterolateral approach negatively influenced surgical time , blood loss , implant position , or perioperative complications .  Two groups of THA patients mainly differing with respect to the surgical approach were compared . Results of 76 consecutive THA via a posterior mini-incision approach were recorded prospect ively and those of 76 controls operated via a classic anterolateral approach were recorded retrospectively .  THA was performed by the same surgeon in every case . Surgical time or intraoperative blood loss were not different among the groups . Total 24-h blood loss was significantly less in patients undergoing THA via minimally invasive posterior  approaches . Median cup inclination was 45 degrees in both groups . Cup anteversion was 15 degrees ( classic anterolateral ) and 12 degrees ( minimally invasive posterior ) , respectively . Stem position was regarded as neutral in 80 % of THA through classic anterolateral and in 76 % through minimally invasive dorsal incisions . Complications occurred in 8 % ( classic anterolateral ) and 9 % ( minimally invasive posterior ) of THA patients . Surgical time , blood loss , risk of malpositioned implants , or complications were not increased for THA patients operated through minimally invasive posterior incisions compared to those operated via classic anterolateral approaches In this study , interleukin-6 ( IL-6 ) , C-reactive protein ( CRP ) , and haemoglobin levels were evaluated to compare the degree of surgical invasion between mini and st and ard incisions in total hip arthroplasty ( THA ) . Sixty-two patients admitted for primary cementless THA were enrolled in this r and omised study . The patients were allocated to have surgery through either a mini incision of < 10 cm or a st and ard incision of 15 cm . In each group , inflammatory responses were evaluated by IL-6 , CRP , and haemoglobin levels before operation and one day after operation . Significant differences were not found in IL-6 , CRP , and haemoglobin levels between both groups . At six months after surgery , there were no significant differences in postoperative Harris hip scores or radiographic evaluations between both groups . In conclusion , a 5.0 cm difference in the skin incision to the hip joint seemed to have no influence on the degree of surgical invasion during THA.RésuméAfin de mesurer l ’ importance de l’agression chirurgicale tissulaire dans les prothèses totales de hanche , incision st and ard , versus mini-invasifs , les niveaux d’Interleukin 6 ( IL-6 ) de protéine C-réactive ( CRP ) et d’hémoglobine doivent être appréciés . 62 patients devant bénéficier d’une prothèse totale de hanche primaire sans ciment ont été enrôlés dans cette étude r and omisée . Ces patients devaient bénéficier soit d’une mini-incision inférieure à 10 cm , soit d’une incision st and ard supérieure à 15 cm . Chaque groupe a été évalué avec ces différents facteurs biologiques avant l’intervention et un jour après intervention . Il n’a été trouvé aucune différence significative dans les deux groupes avec ces différents marqueurs Inteleukin , CRP et hémoglobine . Six mois après la chirurgie pas de différence significative non plus au niveau des scores de Harris ou au niveau de l’évaluation radiographique . En conclusion , la différence d’incision cutanée de 5 cm ne semble pas avoir d’influence sur l ’ importance des lésions des parties molles au cours d’une prothèse totale de hanche Purpose . To compare outcome after  total hip arthroplasty ( THA )  through the mini-incision approach versus the st and ard transgluteal approach . Methods . 80 women and 63 men aged 33 to 89 ( mean , 62 ) years with primary osteoarthritis of the hip were r and omised to undergo unilateral THA through a mini-incision approach ( Micro-hip , n=55 ) or st and ard , lateral , transgluteal approach  ( Bauer , n=88 ) . Levels of haemoglobin , haematocrit , serum creatine kinase , and C-reactive protein , length of hospital stay , mobilisation , and any complication were recorded . Visual analogue scale ( VAS ) for pain was assessed . Hip function was assessed using the Harris Hip Score and the Oxford Hip Score , whereas general health was assessed using the EQ-5D general health question naire . The cup inclination and varus/ valgus of the stem position were measured using a goniometer . Results . The Micro-hip group achieved a significantly lower mean incision length ( 9.3 vs. 13.4 cm , p<0.001 ) , mean surgical time ( 60 vs. 68 minutes , p=0.021 ) , mean reduction in haemoglobin level ( 2.1 vs. 2.8 g/dl , p<0.001 ) , and mean VAS for pain from hour 6 to day 6 ( all p<0.05 ) . One patient in the Micro-hip group developed early aseptic loosening of the cup and underwent revision surgery at month 4 . Three patients in the Bauer group and one patient in the Micro-hip group sustained intra-operative non-displaced fractures of the proximal femur , which were fixed with cerclages . Two patients in the Micro-hip group developed deep vein thrombosis during week 1 . Conclusion . THA through the Micro-hip approach achieved faster pain relief This prospect i ve study compares a mini-incision technique and traditional posterior approach for total hip arthroplasty ( THA ) . Thirty-three patients who had undergone a mini-incision THA were matched by diagnosis , gender , average age , and preoperative Harris Hip Score ( HHS ) to 33 patients who had undergone THA using the traditional posterior approach .  The average length of the incision for group 1 was 11.7 cm ( range , 7.3 - 13.0 ) and for group 2 was 20.2 cm ( range , 14.8 - 26.0 ) . At the 3-month follow-up , patients in the mini-incision group had significant improvement in limp ( P<.05 ) and ability to climb stairs ( P < .01 ) compared with the traditional group . At the 6 month follow-up , the mini-incision group was significantly better in terms of limp ( P < .05 ) , distance walked ( P<.001 ) , and stairs ( P < 0.001 ) . There was no significant difference between groups for pain , function , or range of motion at the 1-year follow-up examination Background and purpose There is still conflicting evidence about the true benefit of minimally invasive ( MI ) techniques in total hip replacement ( THR ) . The aim of this prospect i ve study was to evaluate the safeness of a MI approach during the learning curve of a single surgeon . Second , clinical and radiographic results among the  MI THR group were compared with the results using a st and ard transgluteal ( Bauer ) approach . Methods 86 primary unilateral total hip arthroplasties ( THAs ) through a MI , anterior ( Micro-hip ® ) approach were performed by a single senior surgeon ( ES ) , representing a consecutive series of patients after beginning with the MI technique . Cases were compared to a matched cohort of patients who were treated with a st and ard transgluteal ( Bauer ) approach .  Operation time , incision length , perioperative blood loss , haemoglobin level and blood transfusions were monitored . Complications were documented and followed up 1 year postoperatively . The Harris Hip Score ( HHS ) , range of motion , use of analgetics , the Trendelenburg sign , sensibility of the lateral femoral cutaneous nerve and the acetabular/femoral component placement as well as potential heterotopic ossifications were analysed in both the groups after 12 months postoperatively . Results 74 MI THR patients and 60 st and ard THR patients were available for the one year follow-up . Operative time was significantly longer in the MI group , reduction in the haemoglobin level during the first 24 h was significant and the length of skin incision was significantly shorter . No significant differences were found for HHS , range of motion , use of analgetics , the Trendelenburg sign , and the acetabular/femoral component placement , heterotopic ossifications and intra- and postoperative complications . Sensibility of the lateral femoral cutaneous nerve was affected in three patients in the MI group . Radiographic evaluation revealed no component migration , implant subsidence or radiolucency signs in both the groups . DicussionConsistent with recent meta- analysis we found reduced blood loss , similar clinical /radiographic outcome and similar complication rates compared to st and ard THA . Our study shows , that MI THR is a safe procedure during the learning curve of an experienced surgeon Background For total hip arthroplasty ( THA ) , minimally invasive surgery ( MIS ) uses a smaller incision and less muscle dissection than the classic approach ( CLASS ) , and may lead to faster rehabilitation . Questions / purpose sDoes minimally invasive hip arthroplasty result in superior clinical outcomes ? Patients and Methods In this double-blind r and omized controlled trial , 120 consecutive primary noncemented THAs in 120 patients were assigned to one of two groups ( MIS or CLASS ) . The r and omization sequence was stratified for two groups of surgeons , ie , those using a posterolateral approach ( PL-CLASS or PL-MIS ) and those using an anterolateral approach ( AL-CLASS or AL-MIS ) . Length of the incisions was 18 cm for the CLASS procedures . MIS incisions were extended at the skin level to 18 cm at the end of the procedure . The primary end point was the Harris hip score ( HHS ) at 6 weeks postoperatively . Patient-centered question naires were obtained preoperatively and after 6 weeks and 1 year . Results For the patients in the MIS group ( average 7.8 cm incision length ) , statistically significant increased mean HHSs were seen compared with the CLASS group at 6 weeks and 1 year . This difference was small and mainly caused by the favorable results of the PL-MIS . In the MIS group , surgical time was longer . A learning curve was observed based on operation time and complication rate . Although not statistically significant , the perioperative complication rate was rather high in the ( anterolateral ) MIS group . Conclusions The minimal invasive approach in THA did not show a clinical ly relevant superior outcome in the first postoperative year . Level of Evidence Level I , therapeutic study . See Guidelines for Authors for a complete description of levels of evidence The mini-posterior approach for total hip arthroplasty ( THA )  belongs to the mini-incision approaches . In comparison to st and ard approaches , less muscle trauma result ing in less pain , less blood loss and faster rehabilitation in the early postoperative period are attributed to this approach , as known for all other minimally invasive approaches . In a prospect i ve study of 100 cases of THA it could be shown that this is true when comparing the mini-posterior approach with the posterolateral approach . Lower levels of muscle enzymes as a parameter for muscle trauma , could not be seen OBJECTIVE To report the clinical outcome of minimally invasive total hip arthroplasty  with anterior incision . METHODS One hundred and twenty cases were r and omly divided into two groups . Sixty cases ( group 1 ) who had undergone a mini-invasive THA  were compared with 60 cases ( group 2 ) who had undergone THA with st and ard posterolateral incision .  The operation time , length of incision , blood loss , anteversion angle of acetabulum cup , Harris score and complications were observed . RESULT The average operation time was almost the same ; The average length of incision for group 1 was 7.9 cm ( 7.4 - 9.0 cm ) and 16.3 cm ( 14 - 22 cm ) for group 2 ( P < 0.01 ) . The average blood loss for group 1 was 350 ml ( 250 - 530 ml ) and 650 ml ( 400 - 1200 ml ) for group 2 , there was significant difference between two groups ( P < 0.05 ) . According to the postoperative X-ray , the mean anteversion angles of cup were 24 degrees ( 19 degrees - 27 degrees ) for group 1 and 19 degrees ( 15 degrees - 22 degrees ) for group 2 . The average length of post-operative hospital stay was 7 days ( 5 - 8 days ) in group 1 and 13.5 days ( 12 - 16 days ) in group 2 ( P < 0.05 ) . The Harris score of group 1 was 91.4 ( 67 - 94 ) and 78.5 ( 67 - 91 ) for group 2 at the 3 month follow-up ( P < 0.05 ) . At the last follow up , there were no significant difference ( P > 0.05 ) , but the average ROM of group 1 were definitely more greater than that of group 2 ( 110.0 degrees + /- 3.2 degrees vs. 90.0 degrees + /- 2.9 degrees P < 0.05 ) . There was 1 case of cup reinsertion in group 1 because of large anteversion angle ; 2 cases of symptomatic DVT and 1 case of lethargy because of cerebral infa rct ion happened in group 2 . CONCLUSIONS Minimally invasive total hip arthroplasty using anterior approach is a safe and effective technique with the advantages of less soft tissue damage and less blood loss Purpose The purpose of this study was to evaluate the use of negative pressure wound therapy ( NPWT ) to improve  wound healing after total hip arthroplasty ( THA ) and its influence on the development of postoperative seromas in the wound area . Material sThe study is a prospect i ve r and omised evaluation of NPWT in patients with large surgical wounds after THA , r and omising patients to either a st and ard dressing ( group A ) or a NPWT ( group B ) over the wound area . The wound area was examined with ultrasound to measure the postoperative seromas in both groups on the fifth and tenth postoperative days . Results There were 19 patients r and omised in this study . Ten days after surgery , group A ( ten patients , 70.5 ± 11.01 years of age ) developed seromas with an average size of 5.08 ml and group B ( nine patients , 66.22 ± 17.83 years of age ) 1.97 ml . The difference was significant ( p = 0.021 ) . Conclusion NPWT has been used on many different types of traumatic and non traumatic wounds . This prospect i ve , r and omised study has demonstrated decreased development of postoperative seromas in the wound and improved wound healing Abstract Purported advantages of THA performed with minimally invasive surgical approaches include less muscle damage and faster recovery . The purpose of this preliminary investigation was to determine if differences existed between minimally invasive approaches in hospital discharge and early functional recovery in THA patients with a rapid rehabilitation protocol . Twenty-four consecutive patients were r and omized to one of three minimally invasive surgical approaches ( two-incision , mini-posterior , and mini-anterolateral )  and enrolled in an aggressive postoperative rehabilitation program .  Hospital discharge , early functional milestone recovery , and vali date d outcome measures ( SF-36 , WOMAC , Harris hip score , lower extremity activity scale ) were collected . All patients met hospital discharge criteria no later than the first postoperative day . There was no difference in hospital discharge , functional milestone recovery , or vali date d outcome measures during the first year after surgery with the numbers available . There were no complications directly related to early hospital discharge or the aggressive rehabilitation protocol . While the data suggest earlier hospital discharge and rapid rehabilitation protocol s may be implemented successfully we found no difference between the three minimally invasive approaches in early hospital discharge or early functional recovery utilizing a rapid rehabilitation protocol . Level of Evidence : Level IV , therapeutic study . See the Guidelines for Authors for a complete description of levels of evidence Minimally invasive total hip arthroplasty  using a short skin incision is a subject of much debate in the literature . The present study estimates the possible minimal length of the exposure in an unselected patient cohort and compares the lateral mini-incision technique and traditional total hip arthroplasty ( THA ) .  One hundred and two patients were divided into three groups according to the type of surgery and length of incision : mini-incision ( less than 10  cm ) was performed in 38 patients ; midi-incision ( 10–14 cm ) in 43 ; and  st and ard-incision ( longer than 14 cm ) in 21 patients . No statistical difference was found with regard to intraoperative and total blood loss , the rate of complications , and postoperative recovery . Significantly decreased body mass index ( BMI ) , shorter operative time , and higher number of hips with malpositioning of the acetabular cup were found in the mini-incision group . These patients , however , experienced less pain in the early postoperative period and were highly satisfied with the cosmetic results . The length of incision was shortened and optimized ( less than 14 cm ) in 82 % of patients , and mini-incision was performed in 38 patients of this unselected cohort . Because of the underst and able dem and of the patients for less invasive intervention , the surgeon should use a smaller but not necessarily mini-incision with minimal soft tissue trauma that still allows him to perform the procedure well , without compromising the type of implants and the otherwise excellent long-term results . R and omized prospect i ve studies are needed to explore the real value of the minimally invasive total hip arthroplasty . RésuméLa chirurgie arthroplastie de la hanche par voie mini invasive est un sujet de débat et de controverse dans la littérature . Cette étude a pour but d’estimer la longueur minimale de la voie d’abord sur une suite de patients non sélectionnés et de comparer la technique de mini incision avec la technique d’incision traditionnelle antérolatérale .  Cent deux patients ont été divisés en trois groupes , en fonction du type de chirurgie et en fonction de la longueur d’incision . Premier groupe : mini incision moins de 10 cm chez 38 patients , deuxième groupe : incision moyenne 10 à 14 cm chez 43 patients et troisième groupe : incision st and ard , supérieure à 14 cm chez 21 patients . Aucune différence statistique n’a été trouvée pour la perte sanguine et sur le taux des complications post-opératoires . Dans le groupe des mini incisions peu de sujets avaient une surcharge pondérale , par contre , il existait un gr and nombre de hanches avec une mal position de la cupule . Ces patients ont cependant présenté moins de douleur dans la période post-opératoire et ont été très satisfaits du résultat cosmétique . La longueur de l’incision dans la chirurgie prothétique de la hanche peut être raccourcie et la longueur optimum peut être de moins de 14 cm chez 82 % des patients . Une mini incision a été réalisé dans cette série , chez 38 patients du fait de la dem and e des patients pour une chirurgie mini invasive , les chirurgiens ont utilisé une petite incision avec un minimum de traumatisme des tissus mous . Cette mini incision doit donc permettre au chirurgien de réaliser son intervention correctement sans compromission sur le type d ’ implants , ni sur la qualité des résultats à long terme . Il n’y a pas besoin pour cela nécessairement d’une mini incision néanmoins des études prospect ives r and omisées doivent être réalisées pour explorer le vrai résultat de la chirurgie arthroplastie par voie mini invasive Implant malposition and poor fixation are potential risks of compromising long-term results after total hip arthroplasty performed with a minimally invasive technique . Between September 2000 and February 2002 , 120 cemented primary total hip arthroplasties were performed at the authors ' institutions in patients with primary osteoarthritis of the hip and with BMI lower than 35 . In 60 of these cases selected at r and om , a posterolateral incision no longer than 10 cm was used . The other 60 THA 's were performed through a st and ard posterolateral approach . The inclination and anteversion of the cup and the position of the femoral stem were assessed on radiographs and statistically evaluated . In the miniinvasive group , the average inclination angle of the cup was 42.3 degrees ( range : 36 to 52 degrees ) and the anteversion angle 13.6 degrees ( range : 6 to 29 degrees ) . The coronal alignment of the femoral component was within 3 degrees of neutral in 54 cases ( 90.0 % ) . Following conventional implantation in the other group , the average cup inclination angle was 42.4 degrees ( range : 35 to 50 degrees ) and the anteversion angle 13.6 degrees ( range : 8 to 24 degrees . A total of 53 stems ( 88.3 % ) were implanted optimally . Statistical analysis found no significant difference between the two groups regarding components position . These findings suggest that using a smaller posterolateral incision as was done in this study does not introduce a potential risk of compromising long-term results The literature is used to analyse the significance of the use of iodine-impregnated incision drape ( Ioban ® 2 ) for the prevention of  postoperative wound infections ( SSI ) .  The drape has a microbiocidal effect in vitro . Consequently an antiseptic effect also occurs under the incision drape when it is applied to the skin ; at the same time , bacterial wound contamination is reduced . Overall , based on the efficacy strength of the antiseptic incision drape , a reduction of the SSI rate can , however , be confirmed only with a large sample size . A meta analysis which evaluated four prospect i ve studies and one retrospective study was able to provide significant confirmation of a reduction in the SSI rate . There are no limitations in terms of the biocompatibility of the iodine-impregnated incision drape Introduction : Minimally invasive surgery represents one of the most recent techniques to have emerged within THA . In conventional THA , the incision typically measures 15–20 cm . Minimal invasive approach defined as less invasive to the skin , muscles , or bone may reduce complications and improve recovery time . A number of different approaches and methods have been described in literature . Purpose : This is a prospect i ve study describing the technique and early results of the modified antero-lateral minimal invasive ( ALMI ) approach and comparing our results to the results of other investigators interested in minimal invasive THA . Material s and methods : Seventy-five consecutive primary total hip arthroplasties ( cemented and cementless ) were done through a modified ALMI approach ( 6–8 cm ) , in which we kept the hip abductors intact . Neither special instruments nor specially design ed prostheses were needed . Minimum follow-up was 12 months . Results : The mean Harris hip score for patients after 12-month follow-up was 90 while the mean Merle d’Abugine mean score was 16.5 . Both scores reached almost the maximum values within 3 months after surgery . The cup abduction angle for 70 % patients was between 35 ° and 45 ° . No femoral stem mal-alignment was recorded . The mean operative time of cemented prosthesis was 65 min while that of the cementless prosthesis was 55 min . No wound complications or dislocations were recorded . All the patients were allowed to weight bear in the second post-operative day and involved in an early rehabilitation program . Conclusion : ALMI hip approach with sparing of hip abductors is safe and gives excellent orientation for positioning of prosthesis components . It also allows early and smooth post-operative rehabilitation with fast recovery of the patient in terms of weight bearing Surgical injury is followed by pain , stress-induced catabolism , impairment of organ function , and a risk of thromboembolism and impaired cognitive function . These events may contribute to complications , a need for prolonged hospitalization , postoperative fatigue , delayed convalescence , and the need for rehabilitation . Optimization of the individual care components in perioperative care ( the fast-track methodology ) reduces the need for hospitalization , morbidity , and prolonged convalescence , with subsequent economic savings ( Kehlet and Wilmore 2008 ) . Correspondingly , improvement in perioperative care has led to a reduced stay in hospital after total hip arthroplasty ( THA ) and total knee arthroplasty ( TKA ) , which is now only about 3 days in many centers . The main question that remains to be answered is whether further improvement can be made and whether these operations can be performed on an ambulatory or semi-ambulatory basis without any increased risk of morbidity or cardiopulmonary and thromboembolic complications , long-term cognitive dysfunction , pain , and need for rehabilitation . Thus , a multidisciplinary collaboration has been established in 5 dedicated public Danish hospitals with established fast-track THA and TKA in order to optimize perioperative care to require only 1–2 days of hospitalization with no increase in post-discharge pain , morbidity , and rehabilitation requirements ( Figure ) . To this end , we concentrated on  perioperative pain management , optimization of transfusion strategies , strategies for postoperative rehabilitation , requirements for postoperative thromboembolic prophylaxis , and safety aspects ( re-admissions , hip dislocation , and knee stiffness ) . Effective postoperative pain relief is a prerequisite for a successful fast-track recovery . Although continuous peripheral nerve blocks are currently the most effective analgesic techniques ( Ilfeld et al. 2008a , b ) , they are dem and ing in terms of expertise and there is a risk of muscle paralysis . Efforts have therefore been made recently to improve local wound infiltration and infusion techniques . Although promising , more research is required to better define these techniques regarding dose-volume relationships , placement and types of catheters , duration , and safety aspects ( Rostlund and Kehlet 2007 ) . There will be more focus on post-discharge pain , which remains a problem in many patients . Furthermore , research will concentrate on mechanisms and predictors of the large inter-individual variability in the degree of postoperative pain , which may be related to the inflammatory response and genes associated with pain . Such knowledge should facilitate pain management , leading to differential use of analgesic principles in low pain responders and high-pain responders . Blood transfusion is indicated when a patient 's limit concerning — or physiological adaptation to — progressive normovolemic anemia is reached , but there are no specific data from THA and TKA . Data from hip fracture surgery have shown that postoperative anemia impedes functional mobility and that a liberal transfusion strategy reduces morbidity ( Foss et al. 2009 ) . Since modern blood transfusion is safer than before , large r and omized studies with high and low transfusion thresholds will be performed in cardiovascular high-risk patients after THA , with morbidity and functional recovery as primary outcome measures . Postoperative rehabilitation after THA and TKA has been st and ard despite the fact that there has been little evidence on the optimal type of physiotherapy , when it should be started , and for how long ( Minns Lowe et al. 2007 , 2009 ) . Previous r and omized studies have been inconclusive and they were based on relatively long-term hospitalization ( 7–12 days ) ; they are therefore not applicable to fast-track THA and TKA . Over the last decade , many industry-sponsored trials have documented the need for prolonged thromboembolic prophylaxis ( 10–30 days ) , mostly based on surrogate outcomes and with relatively small effects on clinical manifestations of thromboembolism ( Geerts et al. 2008 ) . A common characteristic of these studies has been a relatively long hospital stay ( 6–12 days or more ) . Since postoperative immobilization is a well-known risk factor for postoperative thromboembolism , the need for prolonged thromboembolic prophylaxis after implementation of fast-track surgery with early mobilization might be question ed . The fast-track group will therefore focus on a large ( n = 5,000 ) prospect i ve , detailed 90-day follow-up study with prophylaxis only until discharge ( 1–3 days ) . It is well-documented that cognitive function declines after THA and TKA in elderly patients ( Maze et al. 2008 ) . A fast-track setup may reduce cognitive dysfunction due to less postoperative sleep disturbances , less pain , and less opioid requirements , all of which may impair cognitive function . Finally , in the fast-track THA and TKA setting , safety aspects will be assessed regarding the risk of hip dislocation , and knee stiffness after TKA . In summary , despite major improvements in care and short-term outcome after THA and TKA , several issues remain to be answered in order to optimize fast-track treatment BACKGROUND : Ketamine has been shown to have a morphine-sparing effect soon after surgery . Nevertheless , whether this effect still exists after being combined with nonsteroidal antiinflammatory drugs and acetaminophen , and whether ketamine can decrease chronic pain after nononcologic surgery remain unclear . Thus , we design ed a study to assess ketamine ’s effect on acute and chronic postoperative pain when combined with multimodal analgesia after total hip arthroplasty ( THA ) . METHODS : Patients scheduled for primary nononcologic THA using st and ardized general anesthesia were r and omized . They received IV ketamine before incision ( 0.5 mg/kg ) , and a 24-h infusion ( 2 & mgr;g · kg−1 · min−1 ) or a similar blinded saline bolus and infusion . Postoperative analgesia included IV acetaminophen , ketoprofen , plus morphine/droperidol patient-controlled analgesia for 48 h. Data pertaining to pain scores , morphine consumption , and need for crutches were collected for 6 mo after THA . Our primary outcome was 24-h morphine consumption . RESULTS : One hundred fifty-four patients were included ( placebo , 75 ; ketamine , 79 ) . Patients and operative data were similar in both groups . Ketamine  decreased morphine consumption at 24 h from 19 ± 12 mg to 14 ± 13 mg ( P = 0.004 ) . At Day 30 , ketamine decreased the proportion of patients needing 2 crutches or a walking frame from 56 % to 31 % ( P = 0.0035 ) . From Day 30 to Day 180 , ketamine decreased the proportion of patients with persistent pain at rest in the operated hip ( P = 0.008 ) . At Day 180 , 21 % of placebo group patients ( 15 of 70 ) experienced pain at rest in the operated hip versus 8 % ( 6 of 72 ) in the ketamine group ( P = 0.036 , odds ratio 0.33 , 95 % confidence interval 0.12–0.91 , risk reduction 67 % ) . CONCLUSIONS : Ketamine had a morphine-sparing effect after THA , even when morphine was combined with multimodal systemic analgesia . It also facilitated rehabilitation at 1 mo and decreased postoperative chronic pain up to 6 mo after surgery Background Dislocation after revision THA is a common complication . Large heads have the potential to decrease dislocation rate , but it is unclear whether they do so in revision THA . Questions / purpose sWe therefore determined whether a large femoral head ( 36 and 40 mm ) result ed in a decreased dislocation rate compared to a st and ard head ( 32 mm ) . Methods We r and omized 184 patients undergoing revision THA to receive either a 32-mm head ( 92 patients ) or 36- and 40-mm head ( 92 patients ) and stratified patients by surgeon . The two groups had similar baseline demographics . The primary end point was dislocation . Quality -of-life ( QOL ) measures were WOMAC and SF-36 . The mean followup for dislocation was 5 years ( range , 2–7 years ) ; the mean followup for QOL was 2.2 years ( range , 1.6–4 years ) . Results In the 36- and 40-mm head group , the dislocation rate was 1.1 % ( one of 92 ) versus 8.7 % ( eight of 92 ) for the 32-mm head . There was no difference in QOL outcomes between the two groups . Conclusions Our observations confirm a large femoral head ( 36 or 40 mm ) reduces dislocation rates in patients undergoing revision THA at short-term followup . We now routinely use large heads with a highly crosslinked polyethylene acetabular liner in all revision THAs . Level of Evidence Level I , therapeutic study . See Guidelines for Authors for a complete description of levels of evidence Introduction The causes for revision of primary total hip arthroplasty ( THA ) are various and quite well known . The developing use of dual-mobility THA ( DM-THA ) seems a relevant option to decrease the risk of instability . Due to lack of long-term follow-up , this innovative retentive concept is suspected to increase the risk of polyethylene ( PE ) wear . the aim of the study was to analyse the causes for  DM-THA revision and assess whether or not its occurrence is different from that of fixed-st and ard ( FS ) THA , particularly for aseptic loosening or wear and /or osteolysis . Material s and methods The SoFCOT group conducted an observational prospect i ve multicentre study from 1 January 2010 to 31 December 2011 . Inclusion criteria comprised an exhaustive collection of 2044 first-revision THAs with 251 DM-THAs and 1793 FS-THAs . After excluding complications linked to patient factors ( infection and periprosthetic fractures ) , we performed a matched case – control study ( matching ratio 1:1 ) comparing two groups of 133 THAs . Results Revisions for aseptic loosening or osteolysis/wear were as frequent in DM-THA ( 58.7 % ) as in FS-THA ( 57.1 % ) ( p 0.32 ) ; 7.5 % of DM-THA were revised for dislocation versus 19.5 % of FS-THA ( p 0.007 ) . Discussion Revision for osteolysis/wear and aseptic loosening were as frequent in DM-THA as in FS-THA ;  revision for dislocation was less frequent in DM-THA . This confirms the efficiency of the DM concept regarding the risk of dislocation . Causes for revision were different between groups , and revisions for dislocation were less frequent in DM-THA . Only prospect i ve comparative studies could provide reliable information that may support broader use of the DM concept
There was no major difference in the rate of complications .
Conclusions Short-term recovery favors limited incision over st and ard incision THA .
Background The literature comparing  limited incision and st and ard incision THAs  is confusing regarding whether limited incision THA improves short-term recovery without compromising long-term durability and survival .
Further , previously published meta-analyses can not conclude that limited incision THA is better .
With new data , we seek to discover if the answers now exist .
Purpose We used meta- analysis to compare surgical and hospitalization data , clinical outcomes , and complication rates , and thus ( 1 ) confirm whether limited incision THA is at least comparable to st and ard incision THA ; and ( 2 ) determine whether limited incision THA is an improvement over st and ard incision THA .