[Advantages of minimal invasive total hip replacement in the early phase of rehabilitation]. [Comparison of total hip arthroplasty via a posterior mini-incision versus a classic anterolateral approach]. New two-incision minimally invasive total hip arthroplasty: comparison with the one-incision method Early Discharge and Recovery with Three Minimally Invasive Total Hip Arthroplasty Approaches: A Preliminary Study Enhanced early outcomes with the anterior supine intermuscular approach in primary total hip arthroplasty. 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. Antero-lateral minimal invasive (ALMI) approach for total hip arthroplasty technique and early results Minimally Invasive versus Classic Procedures in Total Hip Arthroplasty: A Double-blind Randomized Controlled Trial Minimally invasive hip arthroplasty: what role does patient preconditioning play? [Prospective and comparative study of minimally invasive posterior approach versus standard posterior approach in total hip replacement]. Early functional results after Hemiarthroplasty for femoral neck fracture: a randomized comparison between a minimal invasive and a conventional approach Modified direct anterior approach in minimally invasive hip hemiarthroplasty in a geriatric population: a feasibility study and description of the technique A lateral minimal-incision technique in total hip replacement: a prospective, randomizes, controlled trial. Surgical access and damage extent after total hip arthroplasty influence early gait pattern and guide rehabilitation treatment. A randomized, prospective study of 3 minimally invasive surgical approaches in total hip arthroplasty: comprehensive gait analysis. [Minimally invasive posterior approach for total hip arthroplasty]. A minimal-incision technique in total hip arthroplasty does not improve early postoperative outcomes. A prospective, randomized, controlled trial. Minimally Invasive Subvastus Approach: Improving the Results of Total Knee Arthroplasty: A Prospective, Randomized Trial Tackling the learning curve: comparison between the anterior, minimally invasive (Micro-hip®) and the lateral, transgluteal (Bauer) approach for primary total hip replacement The impact of minimally invasive total hip arthroplasty on the standard procedure The effect of total hip arthroplasty surgical approach on postoperative gait mechanics. Reproducibility of femoral offset following short stem and straight stem total hip arthroplasty. Reduced patient restrictions following total hip arthroplasty: study protocol for a randomized controlled trial [Measurement of ground reaction forces after total hip arthroplasty using different surgical approaches]. Fast-track hip and knee replacement — what are the issues? Minimally-invasive total hip arthroplasty will improve early postoperative outcomes: a prospective, randomized, controlled trial
UNLABELLED In arthroplasty the term " minimal invasive " not only refers to the length of the skin incision but more so to its soft tissue and thereby muscle-protecting features . STUDY AIM The aim of this study is to compare the early postoperative mobilisation and rehabilitation of the different surgical approaches in cementless total hip arthroplasty . METHODS 27 patients underwent a total hip replacement ( Trilogy cup , MAYO stem ) via a ventral minimal invasive approach ( one incision technique ) ( MIS group ) . 23 patients underwent a total hip replacement with the same implant via a anterolateral transgluteal approach ( st and ard group ) . We evaluated the Harris Hip Score ( HHS ) , the visual analogue scale ( VAS ) for pain and patient satisfaction preoperatively as well as 3 days , 10 days , 6 weeks and 3 months postoperatively . RESULTS After 3 and 10 days the MIS group showed better scores for pain , gait and mobilisation as well as for the overall HHS compared to the st and ard group . These differences could not be shown 6 weeks postoperatively . The MIS group had a significantly higher rate of complications with 22 % transient impairment of the lateral cutaneous nerve . CONCLUSION The patients of the MIS group showed a better mobilisation and rehabilitation during the early postoperative period . This can be attributed to the lessened intraoperative damage of to soft tissue and especially muscle damage . Due to the increased rate of nerve irritations , we modified our surgical approach . The minimal invasive approach to modern hip joint arthroplasty remains a non-st and ard technique . Compared to the st and ard approach it carries additional risks ( like nerve damage and malpositioning of the implants and thus should remain in the h and s of the experienced orthopaedic surgeon in specialised orthopaedic centres 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 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 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 The advantages of minimally invasive surgical approaches for total hip arthroplasty are reported to include reduced blood loss , less pain , and shorter hospital stays , which combine to afford a faster recovery1 - 4 . However , other studies have failed to show any significant advantage over the use of st and ard surgical approaches ( Fig. 1)5 - 8 . Reported disadvantages of minimally invasive techniques are the substantial learning curve required and an increased risk of early complications3,9 - 12 . In addition , the long-term outcomes of minimally invasive procedures in terms of implant fixation and longevity remain unproven . Fig. 1 The st and ard direct lateral approach to the hip previously described by Frndak et al.21 is performed with the patient in the lateral decubitus position . ( Printed with permission of Joint Implant Surgeons , Inc. ) There are three basic categories of so-called minimally invasive total hip arthroplasty approaches : an abbreviated incision ( small incision ) , modifications of st and ard approaches with smaller incisions and less soft-tissue dissection ( less invasive ) , and novel approaches that reportedly do not cut muscle ( minimally invasive ) . We have had a broad experience , over the past seven years , with a less invasive modification of the direct lateral approach ( a modified Hardinge approach ) ( Fig. 2 ) . We previously reported less blood loss and a shorter hospital stay in association with this approach13 . Others have argued that the less invasive direct lateral approach does not provide an advantage over the traditional approach5 . Importantly , the soft-tissue dissection still requires removing and repairing the abductor musculature . Fig. 2 The less invasive direct lateral approach is performed with the patient in the lateral decubitus position . This approach employs an abbreviated skin and fascial incision with a limited abductor muscle dissection13 . ( Printed with permission of Joint Implant Surgeons , Inc. ) Several recent reports have 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 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 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 BACKGROUND The benefits of minimally invasive total hip arthroplasty continue to be debated . The objective of this study was to investigate the role of patient education , accelerated rehabilitation , and improved pain control on the outcome of  total hip arthroplasty  performed through a small incision . METHODS One hundred patients undergoing total hip arthroplasty at our institution were r and omized into one of four groups on the basis of the size of the incision , preoperative counseling , the type of preoperative and postoperative rehabilitation , and the analgesia protocol . The operative parameters , complications , time to discharge to home , functional improvement , and patient satisfaction were assessed . RESULTS The demographic distribution among the four groups was similar . The extent of functional improvement at the time of discharge to home , patient satisfaction , and walking ability at the time of discharge were better in patients who had received an accelerated preoperative and postoperative rehabilitation regimen regardless of the size of the incision . There was no difference in estimated blood loss , mean operative time , transfusion needs , or complications among the groups . CONCLUSIONS This study highlights the importance of factors such as family education , patient preconditioning , preemptive analgesia , and accelerated preoperative and postoperative rehabilitation in influencing the outcome of total hip arthroplasty . The aforementioned factors , and not the surgical technique per se , may play a major role in imparting the better outcome after minimally invasive total hip arthroplasty that has been reported by various investigators PURPOSE OF THE STUDY There have been few prospect i ve studies comparing minimally invasive approaches for total hip replacement . We wanted to ascertain the contribution of the minimally invasive posterior approach in comparison with the st and ard posterolateral approach in terms of early outcome . MATERIAL S AND METHODS This was prospect i ve comparative consecutive series of patients . Patients with major architectural problems or undergoing revision arthroplasty were excluded . One hundred ten patients ( 116 hips ) were divided into two groups which were comparable for number of patients , gender , age , body mass index , indication for surgery , and preoperative function scores . The preoperative ASA score was lower in the minimally invasive group ( p=0.04 ) . The patients were in the lateral reclining position for the two approaches and classical instrumentation using the same implants ( stems and cemented or non-cemented cups ) were used . We noted operative time and blood loss ( using the Brecher method based on the hematocrit at day 1 and 5 and the number of blood transfusions ) , postoperative pain , and implant position . Functional outcome was assessed with the modified Harris score and the WOMAC index ( at 6 weeks and 3 and 6 months ) . Statview(R ) was used to search for statistical significance considering p<0.05 as significant . RESULTS Mean length of incision was 8.5 cm versus 15.1 cm . Mean blood loss was significantly less in the minimally invasive group ( p=0.027 ) as was the level of postoperative pain as confirmed by the lesser consumption of morphine analgesics ( p=0.006 ) . Other operative variables as well as implant position were comparable . There were no major complications in the minimally invasive group . In the st and ard group , there was one case of common peroneal nerve palsy , two dislocations , and two fractures related to falls after prosthesis implantation . The WOMAC index was better after the minimally invasive approach at six weeks and at three months ( p<0.05 ) . The modified Harris score was better only at six weeks . Functional outcome and pain became comparable thereafter . DISCUSSION AND CONCLUSION The minimally invasive posterior approach does not require an orthopedic table nor specific instrumentation . A minute procedure is required with ligature of the posteromedial circumflex artery of the thigh to improve exposure and limit intraoperative bleeding . It enables satisfactory reproducible implant positioning . Conversion to an open posterolateral approach is possible if needed . The minimally invasive posterior approach enables a reduction in intraoperative bleeding and in postoperative pain while allowing earlier more rapid rehabilitation . Early clinical outcome is better but beyond six weeks , the functional results are comparable for the two approaches . The minimally invasive posterior approach is a reliable reproducible approach with a progressive learning curve Background A minimal invasive approach for elective hip surgery has been implemented in our institution in the past . It is widely hypothesized that implanting artificial hips in a minimal invasive fashion decreases surgical trauma and is helpful in the rehabilitation process in elective hip surgery . Thereby geriatric patients requiring emergency hip surgery also could theoretically benefit from a procedure that involves less tissue trauma . Methods Sixty patients who sustained a fractured neck of femur were r and omly assigned into two groups . In the minimal invasive arm , the so called “ direct anterior approach ” ( DAA ) was chosen , in the conventional arm the Watson-Jones-Approach was used for implantation of a bipolar hemi-arthroplasty . Primary outcome parameter was the mobility as measured by the four-item-Barthel index . Secondary outcome parameters included pain , haemoglobin-levels , complications , duration of surgery , administration of blood transfusion and external length of incision . Radiographs were evaluated . Results A statistically significant difference ( p = 0,009 ) regarding the mobility as measured with the four-item Barthel index was found at the 5th postoperative day , favouring the DAA . Evaluation of the intensity of pain with a visual analogue scale ( VAS ) showed a statistically significant difference ( p = 0,035 ) at day 16 . No difference was evident in the comparison of radiographic results . Conclusions Comparing two different approaches to the hip joint for the implantation of a bipolar hemi-arthroplasty after fractured neck of femur , it can be stated that mobilization status is improved for the DAA compared to the WJA when measured by the four-item Barthel index , there is less pain as measured using the VAS . There is no radiographic evidence that a minimal invasive technique leads to inferior implant position . Level of Evidence : Level II therapeutic study Introduction The direct anterior approach ( DAA ) is generally accepted method for minimal invasive arthroplasty of the hip . As good results for total hip arthroplasty are already published , there is a lack of evidence for the implantation of bipolar hip hemiarthroplasty ( BHH ) in elderly patients with osteoporosis after femoral neck fracture . Material s and methods For hip arthroplasty using a direct anterior approach ( DAA ) in elderly patients with femoral neck fractures , a number of modifications of the original technique are being described . The modified DAA considers in particular the co-morbidity and the bone quality of the geriatric patient population . A consecutive series of 16 hemiarthroplasties using this technique is presented . In all 16 cases , the BHH was implanted in modified DAA technique . Mobility measured by 4-item Barthel Index , pain via visual analogue scale ( VAS ) , duration of surgery , external length of incision and blood loss were evaluated . Results There was no major operative complication during the procedures . The pain level decreased from 7 ( preoperatively ) to 0 at postoperative day 40 . The Barthel Index increased from 5 at first postoperative day to 40 at day 40 . Early postoperative mobilisation is efficiently accelerated . Mean operating time was 71 min ; the medium skin incision length was 8 cm . The mean haemoglobin level decreased from 118 g/dl preoperatively to 101 g/dl at first postoperative day . Conclusion The described modifications of the DAA help to implant a BHH gently in elderly patients with increasing risk of complications like iatrogenic fractures , wound or prosthesis infections and haematoma . This will hopefully lead to a faster rehabilitation and lower mortality rate for patients with femoral neck fractures in the future 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 AIM Different surgical approaches are used in total hip arthroplasty . The present study confronted two surgical techniques , analysing functional recovery in terms of activities of daily living , and ambulation using gait analysis , after a st and ardized rehabilitation protocol . Our hypothesis was that the increased surgical damage could modify the gait pattern and functional recovery . METHODS Thirty patients were r and omly assigned to two homogeneous groups : Group A was treated with intermuscular minimally invasive surgery ( MIS ) ; Group B was treated with st and ard lateral transmuscular approach . Follow up was planned at 30 and 90 days . Instrumental evaluation using gait analysis and functional evaluation using vali date d scales were performed at follow up . RESULTS No differences could be found as for functional scales . At the first follow up , the MIS approach proved to be the most favourable : data showed a longer duration of the swing phase , an improved range of motion of the non-treated hip , a reduced adduction ( all P<0.005 ) and a correct timing of activation of the gluteus medium muscle on the treated side . At the second evaluation , gait analysis demonstrated some benefits of the intermuscular approach ( a better flexion of both hips , and a minor obliquity of the pelvis during the terminal stance ) , but also advantages in the transmuscular group ( better hip extension ) . CONCLUSION Gait pattern after THA seems to be strictly dependent on surgical access and on the extent and location of surgical damage . It appears important to consider these elements in order to correctly manage the rehabilitation treatment after surgery Purported advantages of total hip arthroplasty performed with minimally invasive surgical ( MIS ) approaches are less muscle damage and faster recovery . There are little data scientifically evaluating these cl aims . Twenty-four consecutive hips were r and omized to total hip arthroplasty through 1 of 3 MIS approaches ( 2-incision , mini-posterior , and mini-anterolateral ) . Each patient underwent preoperative and postoperative gait analysis . Gait parameters included vertical ground reaction force , velocity , single-leg stance time , limb-loading rate , and abductor torque . All 3 groups demonstrated overall improvements in gait parameters at 6 weeks postoperatively . The anterolateral approach patients showed a decrease in the vertical ground reaction force at mid-stance , whereas the 2-incision and posterior approaches demonstrated no significant change . These results fail to demonstrate any significant advantage of the 2-incision approach over the posterior approach in kinetic gait parameters . Furthermore , the anterolateral approach demonstrates a gait pattern consistent with abductor muscle injury in the early recovery period , despite the MIS approach 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 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 Background Minimally invasive knee arthroplasty seeks to diminish the problems of traditional extensile exposures aim ing for more rapid rehabilitation of patients after surgery . Questions / purpose s To determine if the subvastus approach results in less perioperative pain and blood loss , shorter hospital stay , and improved function at both early and long-term followup . Methods One hundred patients were enrolled in a prospect i ve , r and omized trial . Fifty were operated on using a minimally invasive subvastus approach and the other 50 by a conventional , peripatellar approach .  Minimum followup was 3 years . A repeated- measures analysis of variance was used to compare the Knee Society score and range of motion during followup . Results The minimally invasive approach result ed in greater perioperative bleeding but no increase in transfusions . No differences were found in postoperative pain between groups nor did hospital stay show any differences . The range of motion on the third day after surgery was greater in the minimally invasive group . No differences were found in surgical time , femoral or tibial component orientation or outliers , or complication rates . Both Knee Society score and range of motion were superior using the minimally invasive subvastus approach during followup out to 36 months . Conclusions The minimally invasive subvastus approach can result in improved long-term Knee Society scores and range of motion of total knee arthroplasty without increased risk of component malalignment , surgical time , or complication rate . Level of Evidence Level I , therapeutic study . See Guidelines for Authors for a complete description of levels of evidence 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 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 Surgical approach for total hip arthroplasty ( THA ) is determined by clinician preference from limited prospect i ve data . This study aim ed to examine the effect of surgical approach ( direct lateral , posterior , and anterolateral ) on 6-week postoperative gait mechanics . Thirty-five patients ( direct lateral , 8 ; posterior , 12 ; anterolateral , 15 ) were tested preoperatively and 6 weeks after THA .  Patients underwent a gait analysis at a self-selected walking speed . A 2-way analysis of variance was used for analysis . Stride length , step length , peak hip extension , and walking speed increased after THA . The 3 surgical approach variables were not significantly different for any of the study variables after THA . All patients showed some increase in selected variables after THA regardless of surgical approach . In this study , surgical approach did not appear to significantly influence the early postoperative gait mechanics that were quantified Bone stock-preserving short stem prostheses have gained importance in  total hip arthroplasty ( THA ) with the use of minimally invasive surgical procedures . Because of their metaphyseal fixation and their dependency on the calcar radius , it is unknown whether the femoral offset can be reproduced with the same accuracy following short stem vs st and ard stem THA . This study clarifies whether it is possible to restore the femoral offset using a short stem prosthesis ( Fitmore ; Zimmer , Warsaw , Indiana ) compared with a conventional straight stem prosthesis ( CLS ; Zimmer ) following minimally invasive implantation using an anterolateral approach . In a prospect i ve , r and omized , double-blinded study , 80 patients underwent THA using a short stem ( SS group ; n=40 ) or CLS implant ( control group ; n=40 ) . Follow-up examinations were conducted 6 weeks postoperatively . Radiological and functional outcomes were measured . Subjective assessment of quality of life was evaluated using the Harris Hip Score ( HHS ) , the Short Form 36-item health survey ( SF-36 ) , and the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) . Pre- and postoperative comparison of the groups ' change in offset showed no significant differences ( SS group difference from pre- to postoperative , 6.1±6.5 mm ; control group difference from pre- to postoperative , 6.5±7.1 mm ; P=.93 ) . Group comparison after 6 weeks revealed no significant differences in HHS , SF-36 , or WOMAC . Based on these data , an equivalent reproducibility of the femoral offset was demonstrated following short stem and straight stem THA using a minimally invasive anterolateral approach . If the long-term results of short stems show a comparable survival , they represent a sensible alternative to st and ard stems Background Total hip arthroplasty ( THA ) is a very common procedure in orthopedic surgery . In the Netherl and s , 25,642 primary THAs were performed in 2013 . Postoperative hip dislocation is one of the major complications and has been reported in 0.5 to 10.6 % of patients after primary THA.Several reports regarding the use of an anterolateral surgical approach have shown that a non-restriction or reduced restriction protocol does not increase the dislocation rate . For the posterolateral surgical approach it has been suggested that patient restrictions might be unnecessary but the amount of available literature is scarce . As such , r and omized controlled trials aim ed at investigating restrictions following THA using a posterior approach are strongly recommended . The aim of this prospect i ve r and omized controlled trial is to investigate the non-inferiority hypothesis concerning the early dislocation rate after THA in patients with and without the use of a reduced restriction protocol . Methods / Design After providing informed consent a group of 456 patients with symptomatic coxarthrosis will be r and omized to receive a THA either with care as usual , i.e. receiving postoperative restrictions including the advice to sleep in a supine position for the first 8 weeks postoperatively , or reduced restrictions with no recommendations regarding the position during sleeping . Primary outcome measure will be the percentage of early dislocations within the first 8 weeks after THA . Secondary outcome measures will be patient satisfaction , time to functional recovery , quality of sleep and patient ’s self-reported compliance with postoperative instructions . Discussion To our knowledge this will be the first r and omized controlled trial that compares a reduced restriction protocol with a restricted protocol following THA using a posterolateral surgical approach . Our hypothesis is that a reduced restriction protocol following THA with use of a posterolateral surgical approach has no influence on the early dislocation rate compared to a restricted protocol . Instead , embracing a reduced restriction protocol might even contribute to a higher quality of sleep , thereby facilitating a faster uptake and return to daily functions in patients after THA.Trial registration Clinical Trials.gov NCT02107248 , registration date 3 April 2014 AIM Benefits of less damage of soft tissues and muscles in minimally invasive hip replacement lead to expectations of better results in gait rehabilitation . The aim of the study is to evaluate post-operative walking ability in terms of different surgical approaches . METHOD 16 patients underwent a minimally invasive total hip replacement ( MIS group ) and 16 other patients got a THA using a transgluteal approach ( st and ard group ) . Differences in functional indices of ground reaction forces and symmetry indices were measured one day pre-operatively as well as 8 , 14 and 28 weeks post-operatively . The results were compared between the surgical approaches and to an age-matched healthy control group . RESULTS There are significantly reduced pain symptoms and a higher functional ability in both surgical groups 8 weeks post-operatively . There are no differences in gait parameters between the surgical groups after 28 weeks . Trends in gait velocity , temporal parameters and in functional indices of ground reaction forces show advantages for the minimally invasive group 8 and 14 weeks post-operatively . Patients do not reach the age-matched control group . CONCLUSION Obviously the immediate post-operative advantages of minimally invasive hip replacement provide better chances for gait rehabilitation compared to the transgluteal approach . Due to the complexity of the problem clinical and gait analysis studies should be linked more closely 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 The rehabilitation of patients for total hip arthroplasty is unsatisfactory , especially the prolonged rehabilitation . Aims To explore indications and key points of anterolateral minimally-invasive total hip arthroplasty . Methods 110 patients admitted for unilateral total hip arthroplasty were r and omly selected for surgery with either anterolateral minimally-invasive incision or st and ard posterolateral incision .  Demographic data , perioperative index and postoperative function index were recorded and statistically analyzed . Results No significant difference was detected in operation time , abduction angle , anteversion angle , stem alignment and stem fixation . The incision length , blood loss , perioperative transfusion and 100-mm VAS score at the first 24 h in minimally-invasive group were significantly lower . The Harris hip score and Barthel index were significantly higher in minimally-invasive group at 3 months ’ follow-up , but not significantly different 3 years after operation . Conclusions There are fewer traumas , fewer blood losses and more rapid recovery in this approach
The meta- analysis of the current evidence base showed that minimally invasive THA is associated with a significantly increased risk of transient lateral femoral cutaneous nerve palsy ( p = 0.006 ) with no significantly better outcome
Over the past decade , minimally invasive surgery has gained popularity as a means of optimising early postoperative rehabilitation and increasing patient satisfaction and cosmesis following  total hip arthroplasty ( THA ) .
However , this surgical exposure has also been associated with increased risk of iatrogenic nerve injury and implant mal-positioning due to limited visibility compared to conventionally larger surgical incisions .
The purpose of this meta- analysis was to compare the outcomes of these two surgical exposures .