Comparison of Scars from Total Hip Replacements Done with a Standard or a Mini-incision A lateral minimal-incision technique in total hip replacement: a prospective, randomizes, controlled trial. A minimal-incision technique in total hip arthroplasty does not improve early postoperative outcomes. A prospective, randomized, controlled trial. THE FRANK STINCHFIELD AWARD: Muscle Damage after Total Hip Arthroplasty Done with the Two-incision and Mini-posterior Techniques Comparison of early postoperative functional levels following total hip replacement using minimally invasive versus standard incisions. A prospective randomized blinded trial The Mini-incision Direct Lateral Approach in Primary Total Hip Arthroplasty Comparison of skin blood flow between mini- and standard-incision approaches during total hip arthroplasty. Learning curve in tissue sparing total hip replacement: comparison between different approaches The impact of minimally invasive total hip arthroplasty on the standard procedure Which is more invasive—mini versus standard incisions in total hip arthroplasty? Early pain relief and function after posterior minimally invasive and conventional total hip arthroplasty. A prospective, randomized, blinded study. Total Hip Arthroplasty through the Mini-Incision (Micro-Hip) Approach versus the Standard Transgluteal (Bauer) Approach: A Prospective, Randomised Study
Scar cosmesis is one of the proposed benefits of mini-incision total hip replacement as opposed to st and ard-incision procedures ; however , there has been no scientific proof of this clinical outcome . The cosmetic appearances of healed incisions of 34 primary total hip replacement procedures done by one surgeon using either a mini-incision ( 20 procedures ) or a st and ard-length incision ( 14 procedures ) were compared at an average of 2 years postoperatively . Each scar ’s appearance was grade d independently by two plastic surgeons using a st and ardized rating system . Patients answered a question naire regarding their subjective assessment of their scar . The blinded observers found that more mini-scars ( six of 20 ) were rated poor than st and ard scars ( one of 14 ) and that more st and ard-incision patients had scars that were rated good . More mini-incision patients ( two of 20 versus zero of 14 ) had wound-healing problems . All the patients thought that their hip scar was acceptable in appearance , but 30 of 31 patients rated the relief of pain and total hip replacement longevity as higher priorities than scar cosmesis . The cosmesis of mini-incision total hip replacement scars may be inferior to st and ard-incision scars because of skin and soft tissue damage produced by high retractor pressures needed for exposure using a limited skin incision . Level of Evidence : Therapeutic study , Level II-2 ( prospect i ve comparative study ) . See the Guidelines for Authors for a complete description of levels of evidence Minimally invasive surgery has become a trend over the last few years in all aspects of orthopaedic surgery , including total hip arthroplasty . So-called mini-incision techniques involve limiting the length of the skin incision to 10 cm with use of either an anterior , lateral or posterior approach . Between March 2004 and December 2005 one hundred consecutive unilateral total hip replacements were performed by the same senior surgeon in our institute . All patients were r and omly assigned to study group ( group A ) or control group ( group B ) . In group A ( 50 patients ) the  skin incision was 8 cm ; in group B ( 50 patients ) the skin incision was st and ard ( about 12 - 14 cm ) . Patient demographic data , including sex , age , height , weight , BMI , diagnosis and preoperative Harris hip score were recorded . Other criteria evaluated included the perioperative and postoperative complications , the surgical time , the blood loss , the length of the incision , the acetabular and stem positions , the length of hospital stay , Harris Hip Score ( HHS ) and the WOMAC osteoarthritis index at six months . No significant differences were found between the groups with respect to the average surgical time , the acetabular and stem position , the length of hospital stay and the Harris Hip Score ( HHS ) and the WOMAC osteoarthritis index at six months . A significant lower blood loss was found in the mini-incision group . A higher percentage of peri-operative complications was recorded in Group A ( two stupor of sciatic nerve and one fracture of the greater trochanter ) . On the basis of our experience we could speculate that minimally invasive surgery should be directed to the new surgical approach with muscle sparing , instead of a shorter skin incision using st and ard approaches BACKGROUND Minimally invasive total hip arthroplasty has stirred substantial controversy with regard to whether it provides superior outcomes compared with total hip arthroplasty performed through longer incisions . The orthopaedic literature is deficient in well- design ed scientific studies to support the clinical superiority of this approach . The objective of this study was to compare the results of a single mini-incision approach with those of a st and ard-incision total hip arthroplasty in the early postoperative period . METHODS Two hundred and nineteen patients ( 219 hips ) admitted for unilateral total hip arthroplasty between December 2003 and June 2004 were r and omized to undergo surgery through a short incision of < or=10 cm or a st and ard incision of 16 cm .  All patients were blinded to the size of the incision for the duration of the hospital stay . The anesthetic , analgesic , and postoperative physiotherapy protocol s were st and ardized , with the staff also blinded to the technique used . A single surgeon , who had performed more than 300 short-incision hip replacements prior to the start of this study and who performs an average of 415 primary total hip replacements a year , performed all procedures through a single-incision posterior approach using a cementless cup and cemented stem . RESULTS The two groups were matched for age , grade according to the system of the American Society of Anesthesiologists , and body mass index . No significant difference was detected with respect to postoperative hematocrit , blood transfusion requirements , pain scores , or analgesic use . We found no difference in early walking ability or length of hospital stay and no difference in component placement , cement-mantle quality , or functional outcome scores at six weeks . The patient variables significantly associated with a probability of early discharge independent of incision length were patient age and preoperative hemoglobin levels ( p < 0.05 ) . The surgical scars contracted significantly over six weeks ( p < 0.05 ) but by a similar proportion of 11 % to 12 % in both groups . CONCLUSIONS Minimally invasive total hip arthroplasty performed through a single-incision posterior approach by a high-volume hip surgeon with extensive experience in less invasive approaches to the hip is safe and reproducible . However , it offers no significant benefit in the early postoperative period compared with a st and ard incision of 16 cm . As it is not known whether lower-volume and less-experienced surgeons can achieve similar results , the mini-incision technique merits further study before wide dissemination and implementation of this family of surgical approaches can be recommended Some surgeons have suggested that a minimally invasive two-incision approach allows total hip arthroplasty to be done without cutting or damaging any muscle or tendon . To our knowledge that cl aim has not been supported by any published clinical or basic science data . Our purpose in doing this study was to quantify the extent and location of damage to the abductor and external rotator muscles and tendons after two-incision and mini-posterior total hip arthroplasty .  Ten cadavers ( 20 hips ) were studied . In each cadaver one hip r and omly was assigned to the two-incision group and the contralateral hip was assigned to the mini-posterior group . After inserting the total hip arthroplasty components the muscle damage was assessed using a technique described previously . Damage to the muscle of the gluteus medius and gluteus minimus was substantially greater with the two-incision technique than with the mini-posterior technique . Every two-incision total hip replacement caused measurable damage to the abductors , the external rotators , or both . Every mini-posterior hip replacement caused the external rotators to detach during the exposure and had additional measurable damage to the abductor muscles and tendon . We do not support the contention that a two-incision total hip arthroplasty is done without cutting muscle or tendon . None of the two-incision hip replacements were done without cutting , reaming , or damaging the gluteus medius or gluteus minimus muscle or external rotators Objective : To compare the results of single-incision minimally invasive total hip replacement ( ≤ 10 cm ) to st and ard-incision ( 16 cm ) total hip replacement in the early postoperative period with respect to functional and mobilizing ability ( transfers , mobilizing , walking and stair assessment ) . Setting : Orthopaedic wards of a regional orthopaedic centre . Subjects : Two hundred and nineteen total hip replacement patients were tested between December 2003 and June 2004 . Interventions : Patients were r and omized to either total hip replacement through a minimally invasive ( ≤ 10 cm ) or st and ard incision ( 16 cm ) . A single surgeon performed all procedures using the same type of component fixation . Postoperative physiotherapy assessment and treatment was st and ardized . Analgesia was also st and ardized . All patients , physiotherapy staff and assessors were blinded to the incision used . Main outcome measures : Patients were tested two days post operatively and were assessed for the following activities : transfer from supine to sit , transfer from sitting to st and ing , mobilizing , ascending and descending stairs and weight-bearing . Results : The shorter incision offered no significant improvement in patient ability in relation to transfer from lying to sitting , transfer from sitting to st and ing , mobilizing or weight-bearing . Ascending/descending stairs gave a total time for the minimal incision of 38.7 s against 40.8 s for a st and ard incision . There was no difference in walking velocity between the st and ard incision and minimal incision groups two days post operatively ( minimal incision = 0.26 m/s versus st and ard incision = 0.26 m/s ) or six weeks post operatively ( minimal incision = 0.90 m/s versus st and ard incision = 0.93 m/s ) . There was no difference between groups with respect to walking aids at six-week review . The mean length of stay for the minimally invasive approach was 3.65 days ( SD 2.04 ) against 3.68 days ( SD 2.45 ) for the st and ard approach . This was not significantly different . Conclusion : Total hip replacement performed through a minimally invasive incision of ≤ 10 cm compared with a st and ard incision of 16 cm offers no significant benefit in terms of the rate or ability of patients to mobilize and perform functional tasks necessary for safe discharge Patients are inquiring about  mini-incision primary total hip arthroplasty  with increasing frequency . There are no published r and omized controlled trials to substantiate cl aims that the mini-incision direct lateral approach is better than a st and ard approach . The purpose of our study was to review our initial experience with the mini-incision technique through the direct lateral approach , with the intent of implementing a r and omized controlled trial if the approach could be shown as safe and effective . Of importance was determining if there is any difference in component positioning and if there is any difference in intraoperative or postoperative complications between the two groups . We retrospectively compared a consecutive series of 87 primary total hip arthroplasties . Thirty-four total hip arthroplasties were done using a mini-incision direct lateral approach . The mean abduction angle was 45 ° for both groups . The femoral stem alignment was within five degrees of neutral in 97 % of the mini group and 94 % of the st and ard group . There were no dislocations , infections , neurologic or wound complications . There were no differences in medical complications or blood transfusions . A significant decrease was found regarding body mass index , which reflects the bias in patient selection and lack of r and omization . We conclude that it is safe to continue further study with this approach because as there was no increase in complications or component malpositioning . Level of Evidence : Therapeutic study , Level III ( retrospective comparative study ) . See the Guidelines for Authors for a complete description of levels of evidence Twenty patients who underwent total hip arthroplasty were r and omly allocated to have surgery through a mini incision of < or = 8 cm ( mini-incision surgery [ MIS ] group , n = 10 ) or a st and ard incision of 14 cm ( st and ard group , n = 10 ) . A laser Doppler flowmeter was used to measure the intraoperative blood flow of the skin . The measurements were performed at 2 regions , specifically , anterior and posterior regions across the middle points of skin incision . The measurements were taken before making the incision and after implantation . As a control , the skin blood flow over the anterior superior iliac spine was measured . After implantation , mean skin blood flows at both regions in the MIS group were significantly decreased by 32 % and 33 % . However , the corresponding flows in st and ard group and control regions were constant during operation Background The tissue sparing surgery ( TSS ) concept means not only smaller incisions but also less tissue disruption , allowing decreased blood loss and improved function . However , TSS techniques can result in more complications related to the learning curve . The aim of this study was to compare the learning curve of an experienced surgeon with different TSS approaches for total hip replacement ( THR ) from a clinical and surgical point of view , focussing especially on complications related to the use of different geometric stems . Material s and methods Sixty patients scheduled to be operated for a primary THR were enrolled in the study and were r and omly assigned to surgery by one of three different TSS approaches : lateral with mini incision ( group A ) , minimally invasive anterior ( group B ) and minimally invasive antero-lateral ( group C ) . Results from the three TSS groups were compared with a control group of 149 patients ( group D ) . Results Our results reveal significantly reduced blood loss in the TSS groups compared with the control group , with no differences between the TSS groups . We found better early functional scores in the two minimally invasive groups ( anterior and anterolateral ) , and a lower rate of complications with the antero-lateral TSS approach . Conclusion The antero-lateral TSS approach seems to be safer and less dem and ing than st and ard THR surgery , and is suitable for use with different stems 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 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 BACKGROUND Few prospect i ve r and omized studies have demonstrated benefits of minimally invasive total hip arthroplasty when compared with conventional total hip arthroplasty . We hypothesized that patients treated with a posterior mini-incision would have better results than those treated with a posterior long incision with regard to the achievement of established goals for pain relief and functional recovery permitting hospital discharge by the second postoperative day . METHODS Sixty of 231 eligible patients were r and omized ( with thirty in each group ) to have a total hip arthroplasty performed through either a posterior mini-incision ( 10 + /- 2 cm ) or a traditional long incision ( 20 + /- 2 cm ) . After completion of the total hip arthroplasty , the mini-incision group underwent extension of the skin incision to 20 cm . Patients were evaluated on the basis of self-determined pain scores , requirements for pain medicine , need for assistive gait devices , and time until discharge . Gait analysis provided objective functional assessment . RESULTS The average hospital stay was 63.2 + /- 13.3 hours in the mini-incision group and 73.6 + /- 23.5 hours in the long-incision group ( p = 0.04 ) . More patients with a mini-incision were discharged by the second postoperative day ( p = 0.003 ) and more were using just a single assistive device at the time of discharge ( p = 0.005 ) . As scored on a verbal analog scale of 0 to 10 points , patients with a mini-incision had less pain on each postoperative day and the pain score remained significantly lower at the time of discharge ( mean , 2.2 + /- 1.0 points compared with 3.1 + /- 0.9 points in the long-incision group ; p = 0.002 ) . After hospital discharge , there were no clinical differences in pain or function between the two groups of patients . CONCLUSIONS Compared with conventional total hip arthroplasty performed through a posterior incision , posterior minimally invasive total hip arthroplasty result ed in better early pain control , earlier discharge to home , and less use of assistive devices . Subsequent evaluations at six weeks and three months showed equivalency between the clinical results in the two groups . LEVEL OF EVIDENCE Therapeutic Level 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
Compared with st and ard total hip replacement , mini-incision procedures may have small perioperative advantages in terms of less blood loss , shorter operative time , and shorter inpatient stay , but the differences were not clinical ly important .
Few complications were reported , and the complication rate did not differ significantly between groups .
There was insufficient evidence to suggest any major difference in the short-term revision rate , and confidence intervals for surrogate measures for long-term outcome were broad enough to include clinical ly important differences in favor of either approach .
Although there were marginal short-term advantages and disadvantages for each of the surgical techniques , there was no strong evidence either for or against mini-incision compared with st and ard-incision total hip replacement .
Importantly , evidence on longer-term performance , especially the risk of revision arthroplasty , for mini-incision hip arthroplasty is very limited
BACKGROUND Mini-incision total hip replacement continues the current trend in orthopaedics and other specialties toward smaller-incision surgery .
The purpose of this systematic review was to assess the effectiveness and safety of single mini-incision compared with st and ard-incision total hip replacement for treatment of arthritis of the hip .