ARTHROPLASTY
Mini-Incision versus Standard Incision Total Hip Arthroplasty Regarding Surgical Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
OrthoEvidence Journal (OE Journal) - ACE Report
OE Journal. 2014;2(4):8 PLoS One. 2013 Nov 12;8(11)Fourteen prospective randomized control trials in which patients received total hip arthroplasty through mini-incision (MI) or standard incision (SI) were pooled to determine if mini-incision THA was superior to standard incision THA in general, or through a specific surgical approach. The results of the study indicated that mini-incision THA reduced total blood loss and length of hospital stay. Subgroup analysis of the two treatment methods by surgical approach demonstrated that posterior mini-incision THA led to perioperative advantages in surgical duration, blood loss, and hospital stay. A lateral approach MI THA was also noted to be significantly shorter in surgical duration compared to SI THA. No significant differences in pain medication dose, functional outcomes, radiographic outcomes, or complications were found.
Were the search methods used to find evidence (original research) on the primary question or questions stated?
Was the search for evidence reasonably comprehensive?
Were the criteria used for deciding which studies to include in the overview reported?
Was the bias in the selection of studies avoided?
Were the criteria used for assessing the validity of the included studies reported?
Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?
Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?
Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?
How would you rate the scientific quality of this evidence?
Oui = 1
Incertain = 0,5
Non pertinent = 0
Non = 0
L'évaluation des critères de rapport permet d'évaluer la transparence avec laquelle les auteurs rapportent les caractéristiques méthodologiques et les caractéristiques de l'essai dans la publication. L'évaluation est divisée en cinq catégories qui sont présentées ci-dessous.
4/4
Introduction
4/4
Accessing Data
4/4
Analysing Data
4/4
Results
3/4
Discussion
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
L'indice de fragilité est un outil qui aide à l'interprétation des résultats significatifs, en fournissant une mesure de la force d'un résultat. L'indice de fragilité représente le nombre d'événements consécutifs qui doivent être ajoutés à un résultat dichotomique pour que le résultat ne soit plus significatif. Un petit nombre représente un résultat plus faible et un grand nombre un résultat plus fort.
Pourquoi cette étude était-elle nécessaire maintenant ?
The introduction of mini-incision (MI) (defined as 10cm or smaller for the purposes of this study) to total hip arthroplasty remains controversial despite a large amount of existing studies addressing the topic. MI THA may lead to less soft tissue trauma, reduced blood loss, and fewer blood transfusions, along with less postoperative pain after surgery. However, while there are these benefits with the MI treatment, certain risks have been suggested to be associated with its use, such as increased complications due to component malpositioning. Studies comparing MI THA to standard incision (SI) THA have provided varying results on the two treatment methods, possibly due to a lack of exclusion or separation of surgical approach methods. The goal of this meta-analysis was to determine if MI THA was superior to SI THA in general, or through a specific surgical approach.
Quelle était la principale question de recherche ?
Is mini-incision THA superior to standard incision THA in general, or through a specific surgical approach?
Quels sont les résultats importants ?
- Eleven studies (n=1039) were included in a meta-analysis of surgical duration. Overall, no significant difference was found between the MI and SI THA regarding surgical duration (WMD -2.32 min [95%CI -6.98, 2.33]; p=0.33, I-squared=90%). Based on surgical approach, significantly shorter surgical durations were noted for MI THA using a posterior approach (WMD, -5.56 min [95%CI -8.45. -2.67] p<0.001; I-squared=0%) or lateral approach (WMD -15.56 min [95%CI -20.91, -10.21]; p<0.001; I-squared=0%). The difference between groups was not significant for postero- or anterolateral approaches (p>0.05)
- Eleven trials (n=556) were suitable for meta-analysis for total blood loss. Overall, total blood loss was significantly lower in the MI group compared to SI THA (WMD -111.51 mL [95%CI -201.83, -21.18]; p=0.02; I-squared= 84%). Based on approach subgroups, the only approach which displayed statistically significantly lower total blood loss with MI THA was a posterior approach (WMD -54.46 mL [95%CI -107.20, -1.73]; p=0.04; I-squared= 0%).
- Six trials (n=528) were pooled to analyze doses of pain medication. No significant difference regarding pain medication doses between treatment arms were found (SMD -0.14 [95%CI -0.47, 0.19]; p=0.40; I-squared= 68%). Pooling was only possible for the posterior approach subgroup, which also displayed no significant differences between MI and SI THA (SMD -0.08 [95%CI -0.40, 0.24]; p=0.61, I-squared 42%)
- Results from 5 studies (n=522) indicated a significantly reduced length of hospital stay with MI THA when compared to patients receiving SI THA (WMD -0.38 days [95%CI -0.67, -0.08]; p=0.01). Subgroup analysis of two RCTs revealed a significant difference between groups for posterior approach in terms of hospital stay (WMD -0.40 days [95% CI -0.74, -0.06]; p=0.002).
- Ten trials (n=917) were pooled to compare functional outcome in the two treatment arms. No significant difference between the groups was found (WMD 0.72 [95%CI -0.79 to 2.23]; p=0.35). Subgroup analyses based on surgical approaches also revealed no significant difference.
- No significant differences between MI and SI groups were found when looking at outliers of acetabular cup abduction (5 trials; p=0.56), outliers of cup anteversion (2 trials; p=0.69), outliers of femoral prosthesis position (9 trials; p=0.27), femoral offset (3 trials; p=0.15), or leg length discrepancy (4 trials; p=0.75). Results from one study indicated a significant difference between posterolateral MI and SI subgroups regarding femoral offset (WMD 3.00mm [95%CI 0.40, 5.60]; p=0.02).
- No significant difference between groups regarding infection (p=0.25), dislocation (p=0.60), nerve injury (p=0.24) proximal femoral fracture (p=0.61), DVT (p=0.25) component loosening (p=0.38), revision (p=0.40) or heterotopic ossification (p=0.58) were found.
De quoi dois-je me souvenir en priorité ?
Results of the meta-analysis indicated that mini-incision THA reduced total blood loss and length of hospital stay, particularly when a posterior approach was used. Mini-incision THA using a lateral surgical approach also appeared to significantly reduce operative time. No significant differences in pain medication dose, functional outcomes, radiographic outcomes, or complications were found.
Comment cela affectera-t-il les soins prodigués à mes patients ?
While no definite conclusion can be made on the superiority of mini-incision THA to standard incision THA, the evidence presented suggests that posterior mini-incision THA may reduce surgical duration, blood loss, and hospital stay. The follow-up durations of the included studies ranged from 1.5 months to 5 years; thus subsequent long-term analyses of mini-incision versus standard incision THA are warranted to determine the efficacy of these treatments over an extended period of time. More sufficiently-powered trials are also needed to gain a better perspective of the potential differences between these treatment methods.
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