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Volume:3 Issue:11 Number:3 ISSN#:2563-559X
OE Original

Surgical Approaches for Total Hip Arthroplasty: A Network Meta-Analysis

Authored By: OrthoEvidence

November 17, 2020

How to Cite

OrthoEvidence. Surgical Approaches for Total Hip Arthroplasty: A Network Meta-Analysis. OE Original. 2020;3(11):3. Available from: https://myorthoevidene.com/Blog/Show/103

Total hip arthroplasty (THA) is one of the most common and successful surgical treatment interventions for patients with severe hip arthritis (Learmonth et al., 2007; Moretti et al., 2017). Various surgical approaches have been adopted for THA, including the anterior approach (AA), posterior approach (PA, including posterior and postero-lateral approaches), and lateral approach (LA, including direct lateral and antero-lateral approach) (Moretti et al., 2017; Putananon et al., 2018). 

A considerable number of randomized controlled trials (RCTs) have been conducted to compare the efficacy and safety outcomes between surgical approaches for THA (e.g., Bon et al., 2019; Brismar et al., 2018; Cao et al., 2020; Mjaaland et al., 2019; Moerenhout et al., 2020; Taunton et al., 2018; Zomar et al., 2018). Several systematic reviews and meta-analyses (including network meta-analyses) have also been published to examine the body of evidence (e.g., Cha et al., 2020; Kucukdurmaz et al., 2019; Putananon et al., 2018). 

For example, Putananon et al. (2018) carried out a network meta-analysis mapping different surgical approaches to determine their relative efficacy and complications.Two years have passed since the 2018 network meta-analysis, and many new RCT results have been released (e.g., Bon et al., 2019; Brismar et al., 2018; Cao et al., 2020; Mjaaland et al., 2019; Moerenhout et al., 2020; Taunton et al., 2018; Zomar et al., 2018). In a very recent network meta-analysis, Cha et al. (2020) assessed the current available evidence on the complications of different surgical approaches for THA. 



---- Abbreviations ----

Anterior approach (AA)

95% confidence interval (95% CI)

95% credible interval (95% CrI)

Harris hip score (HHS)

Lateral approach (LA)

Mean difference (MD)

Posterior approach (PA)

Randomized controlled trials (RCTs)

Risk of bias (RoB) 

SUCRA: Surface under the cumulative ranking curve

Total hip arthroplasty (THA)

Visual analogue scale (VAS)



Methods

On top of Putananon’s et al. (2018) previous work, which searched literature in Medline and Scopus from inception to February 1, 2017, we searched Medline and Scopus for RCTs which were published after 2017 in English, and compared the pain [Visual analogue scale (VAS)] and function [Harris hip score (HHS)] outcomes between AA, LA, or PA. We also searched for RCTs from a recently published meta-analysis, which compared AA with other approaches in primary THA (Kucukdurmaz et al., 2019). Risk of bias (RoB) and quality of evidence were assessed using the Cochrane RoB tool and the GRADE approach, respectively. Two independent reviewers conducted the above-mentioned processes.


We ran the network meta-analysis using the GEMTC package for R. The random effects model was adopted. The surface under the cumulative ranking curve (SUCRA) was calculated. SUCRA is a value indicating the overall ranking of each treatment in a network. It ranges from 0 to 1 (or 0 to 100%). The higher the SUCRA value, the higher the possibility that a treatment is in one of the top ranks (Mbuagbaw et al., 2017).


We did not examine safety outcomes between AA, LA, and PA because a network meta-analysis addressing the research question was just published in 2020 (Cha et al., 2020). We summarize the main findings from this study instead.


Results


1. Literature search results

Putananon et al. (2018) included 14 RCTs, from which, we included 8 studies. The reasons for excluding 6 studies were as follows: 2 studies did not provide comparisons between any surgical approaches of interest (i.e., AA, LA, PA); the other 4 studies did not report HHS or pain outcomes.


Kucukdurmaz et al. (2019) included 17 RCTs, of which, we included 10 studies. The reasons for excluding 7 studies were: 1 study did not provide comparisons between any surgical approaches of interest (i.e., AA, LA, PA); 4 studies did not report HHS or pain outcomes; 2 studies were non-English and full texts were not accessible.


Our search of Medline and Scopus generated 658 and 233 records, respectively. Of these, we identified 21 articles reporting HHS (Barrett et al., 2013; Barrett et al., 2019; Bon et al., 2019; Brismar et al., 2018; Cao et al., 2020; Çatma et al., 2017; Christensen et al., 2015; D'Arrigo et al., 2009; De Anta-Díaz et al., 2016; Ji et al., 2012; Mjaaland et al., 2015; Mjaaland et al., 2019; Moerenhout et al., 2020; Restrepo et al., 2010; Rykov et al., 2017; Taunton et al., 2014; Taunton et al., 2018; Witzleb et al., 2009; Yang et al., 2010; Zhao et al., 2017; Zomar et al., 2018) and 13 studies reporting pain (Barrett et al., 2013; Bon et al., 2019; Brismar et al., 2018; Cao et al., 2020; Christensen et al., 2015; Mjaaland et al., 2015; Moerenhout et al., 2020; Nistor et al., 2017; Taunton et al., 2014; Taunton et al., 2018; Yang et al., 2010; Zhao et al., 2017; Zomar et al., 2018). 


2. Network meta-analyses results

2.1 Harris hip score (HHS, range: 0-100, higher score indicates better outcome)


We created 5 networks for HHS, including HHS up to 1 month (Figure 1),  HHS up to 3 months (Figure 2), HHS up to 6 months (Figure 3), HHS up to 12 months (Figure 4), and HHS up to 60 months (Figure 5),


Of 15 comparisons, only 4 demonstrated statistically significant results, including AA vs. PA up to 1 month follow-up [mean difference (MD): 5.94; 95% credible interval (Crl): 0.67 to 9.93; favouring AA; low quality of evidence] and up to 3 months [MD: 2.96; 95% Crl: 0.14 to 5.91; favouring AA; low quality of evidence], as well as AA vs. LA up to 3 months [MD: 3.73; 95% Crl: 0.57 to 6.93; favouring AA; low quality of evidence] and up to 12 months [MD: 3.15; 95% Crl: 0.78 to 5.37; favouring AA; moderate quality of evidence].


According to SUCRA, using AA was most likely to improve HHS (= 12 months) in patients receiving THA, compared with LA and PA. However, for HHS at 60 months, LA showed the highest likelihood to improve function outcomes. 


In terms of quality of evidence, among the 15 comparisons in the 6 networks, most of the comparisons were of low quality of evidence (n = 11), followed by very low (n = 3) and moderate quality of evidence (n = 1).




2.2 Visual analogue scale pain (VAS pain, range: 0-100, higher score indicates worse outcome)


We created 3 networks consisting of 9 comparisons for VAS pain, including VAS pain up to 1 week (Figure 6), VAS pain up to 1 month (Figure 7), and VAS pain up to 3 months. We also conducted head to head meta-analysis for VAS pain up to 6 months, 12 months, and 24 months, 


Only 1 comparison had results with statistical significance [AA vs. PA up to 1 week follow-up; MD: -9.44; 95% Crl: -17.26 to -2.23; favouring AA: moderate quality of evidence].


Like HHS, SUCRA indicated that AA ranked top for all VAS pain outcomes and was most likely to reduce pain (= 3 months) in patients receiving THA, compared with LA and PA. 


In terms of quality of evidence, among the 9 comparisons in the 3 networks, most of the comparisons were of very low quality of evidence (n = 5), followed by low (n = 2) and moderate quality of evidence (n = 2).


Two RCTs (Cao et al., 2020; Moerenhout et al., 2020) investigating AA and PA provided results on VAS pain at 6 months. No difference was found between the 2 surgical approaches [MD: 0; 95% confidence interval (CI): -1.39 to 1.39; low quality of evidence].  


Only Moerenhout et al. (2020) looked into VAS pain at 12 [MD: -3.0; 95% CI: -8.17 to 2.17; very low quality of evidence] and 24 [MD: -5.0; 95% CI: -13.2 to 3.2; very low quality of evidence] months and found no difference in VAS pain between AA and PA.



Discussion

In this OE Original, we conducted an up-to-date network meta-analysis to examine the effects of 3 different surgical approaches (i.e., AA, LA, and PA) on function (i.e., HHS) and pain (i.e., VAS pain) outcomes among patients receiving THA. Five networks including 15 comparison and 3 networks including 9 comparisons were created and analyzed for HHS and VAS pain, respectively. Only a few comparisons reached statistical significance, including AA vs. PA [HHS up to 1 month follow-up; MD: 5.94; 95% Crl: 0.67 to 9.93; favouring AA; low quality of evidence], AA vs. PA [HHS up to 3 months; MD: 2.96; 95% Crl: 0.14 to 5.91; favouring AA; low quality of evidence], AA vs. LA [HHS up to 3 months; MD: 3.73; 95% Crl: 0.57 to 6.93; favouring AA; low quality of evidence], AA vs. LA [HHS up to 12 months; MD: 3.15; 95% Crl: 0.78 to 5.37; favouring AA; moderate quality of evidence], and AA vs. PA [VAS pain up to 1 week follow-up; MD: -9.44; 95% Crl: -17.26 to -2.23; favouring AA: moderate quality of evidence].


Our SUCRA results showed that AA ranked higher than LA and PA in both HHS and VAS pain at all time points except HHS up to 60 months (in which LA ranked the highest and AA the second best), which indicated that using AA was likely to have the highest probability to achieve function improvement and pain reduction in patients who receive THA up to 12 months. Our SUCRA results on function outcomes support the conclusion from the previous network meta-analysis done by Putananon et al. (2018), which also found that AA was the first rank for postoperative HHS. However, different from our analysis identifying AA as the top rank for VAS pain reduction, Putananon et al. (2018) identified AA, following LA, as the second best. 


As previously mentioned, SUCRA ranking is very useful in indicating the likelihood that a treatment is superior to other treatments with lower ranks. However, SUCRA should not be considered as the only factor for decision making, and can be misleading for clinicians if not carefully interpreted. For example, Antoniou et al. (2019) and Mbuagbaw et al. (2017) proposed that chance and the magnitude of difference in treatment effect for each comparison should also be examined along with the SUCRA. If the treatment effect shows no statistical (addressing chance) or clinical significance (addressing magnitude of difference), then the superiority inferred according to SUCRA ranks is uncertain. Moreover, Mbuagbaw et al. (2017), on the other hand, emphasizes the important role of quality of evidence in determining the trustworthiness of SUCRA ranking. If a SUCRA is based on evidence that is of low or very low quality of evidence, clinicians should be careful in trusting the SUCRA ranks. Clinicians need also consider other factors in addition to SUCRA, such as the cost and clinicians’ familiarity with the use of a particular surgical approach (Mbuagbaw et al., 2017).


We did not conduct our own analysis on safety outcomes between AA, LA, and PA because a network meta-analysis addressing a similar research question was just published in 2020 (Cha et al., 2020). Cha et al. (2020) found that blood loss using AA in THA was the highest, compared to LA and PA (P = 0.002). AA ranked the second best based on SUCRA for operation time, following LA. Both AA and LA had significantly longer operation time than PA (P < 0.001). One potential explanation for the inferiority of AA in safety outcomes could be the steep learning curve, as Cha et al. (2020) argued. AA is a relatively newer surgical approach compared to alternatives; therefore, this surgical learning curve may be impacting outcomes. The impacts of the learning curve have been described and discussed in several previous studies (Brun et al., 2018; de Steiger et al., 2015; den Hartog et al., 2016). In their systematic review examining evidence from 64 studies, den Hartog et al. (2016) found that the issue of learning curve for AA was described in 21 studies, and surgeon’s experience with this surgical approach seemed to influence the outcomes (e.g., surgery time, blood loss, hospital stay, etc.). They concluded that the learning curve issue should not be neglected. As for how much AA cases should be performed to flatten the learning curve, the numbers varied greatly in literature from 10 to 200 cases (den Hartog et al., 2016). More studies with high methodological quality are needed to explore the safety outcomes of AA and address the learning curve issue.


This network meta-analysis aimed to provide updated results based on the one previously done by Putananon et al. (2018). Therefore, we searched the same databases (i.e., Medline and Scopus) as Putananon et al. (2018) did. Only searching 2 databases might lead to missing studies, which is one of our major limitations. However, recognizing this limitation, we tried to minimize the risk of missing RCTs by identifying possibly eligible RCTs from a more recent meta-analysis conducted by Kucukdurmaz et al. (2019). Kucukdurmaz et al. (2019) searched more than 6 databases including Medline, Embase, CINAHL, central, and Google Scholar. 


Bottom Line


On the basis of SUCRA ranking, AA showed the highest likelihood of function improvement and pain reduction in patients receiving THA, compared to LA and PA. AA demonstrated statistically significant effects on postoperative function (e.g., HHS was 3.2 higher than LA with 95% CI of 0.8 higher to 5.4 higher HHS, at 12 months’ follow-up) and pain (e.g., 9.4 less pain than PA with 95% CI of 17.3 less to 2.2 less pain, up to 1 week’s follow-up). We did not conduct our own analysis on safety outcomes of these surgical approaches for THA due to a recent network meta-analysis published in 2020 addressing this topic. Results of this NMA showed that AA might result in a higher blood loss, compared with LA and AA. However, a steeper learning curve for AA among surgeons compared to alternate approaches, may, in part, explain observed outcomes. Further research studying the safety outcomes of AA is warranted. Finally, clinicians should not make decisions about which surgical approach should be used solely based on SUCRA ranking from our analysis. Other factors, such as chance, the magnitude of difference in treatment effect, quality of evidence, cost, and even the personal familiarity and expertise with the use of a particular treatment, should also be considered.  



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