Short-term Effectiveness Study Of One-stage Bilateral Total Hip Arthroplasty By Direct Anterior Approach

Background:With the accelerating of aging process and the increase of pathogenic factors,the incidence of hip joint disease shows a trend of increase gradually year by year.In addition,about 15~20%patients with hip diseases have bilateral lesions in clinical.As an important hinge joint connecting human trunk and lower limbs,hip joint plays a vital role in a series of sports while helping people complete standing and bearing heavy load of the body.Therefore,the maximum reconstruction and recovery of hip function is an important prerequisite for improving the quality of life of the patients.Artificial hip arthroplasty has become the most effective and valuable treatment for non infectious hip end-stage lesions,and is becoming more and more mature.But for patients with severe bilateral hip joint lesions,choose the simultaneous or staged bilateral hip replacement?choose what kind of surgery to accept?There are still many disputes on how to make a choice.In the past,due to the relatively backward medical conditions and technical means,most scholars advocated staged replacement to reduce the risk of perioperative period,and lacked confidence in its efficacy and safety.In recent years,with the deepening of minimally invasive and enhanced recovery after surgery(ERAS)concept,the rapid development of artificial joint research and the rapid development of surgical technology,more and more Orthopaedic Surgeons have started to enjoy the simultaneous bilateral hip replacement.To seek a safe,efficient and minimally invasive surgical approach is therefore the key to solving this problem.To this end,we will try to apply direct anterior approach(DAA)to the simultaneous bilateral total hip replacement,and compare the clinical efficacy with that of traditional posterolateral approach,to investigate the application value of DAA in one-stage bilateral total hip arthroplasty,and to provide sufficient confidence for the clinicians to carry out the simultaneous bilateral hip replacement more widely.This paper is to evaluate the safety and effectiveness of bilateral hip replacement by systematic evaluation using multicenter and large sample clinical data,and compare the effectiveness of one-stage bilateral total hip arthroplasty by DAA and by posterolateral approach,to investigate the application value of DAA in one-stage bilateral total hip arthroplasty.This research consists of two parts:Part I Clinical efficacy and safety of simultaneous versus staged bilateral hip arthroplasty:a meta-analysisAjective:To systematically evaluate the clinical efficacy and safety of simultaneous versus staged bilateral hip arthroplasty.Methods:According to the proposed retrieval strategy of Cochrane cooperation network.Pubmed database and Cochrane Library database,Embase database China national knowledge infrastructure(CNKI),Chinese biomedical database(CBM),VIP and Databases of Wangfang were searched with computer,Orthopedics-related journals were searched manually.The studies of comparison of clinical efficacy and safety of simultaneous versus staged bilateral hip arthroplasty were collected comprehensively.According to the established inclusion and exclusion,reading the titles,abstracts or full texts,after that we used Jadad or Newcastle-Ottawa scale(NOS)scoring system to evaluate the quality of documents,and Pick out high-quality and highly relevant literatures.Then,Information such as basic information,research objects,intervention measures,outcome indicators,baseline data and other information were extracted from the included studies.Meta-analysis on operation time,total amount of blood loss,total blood transfusion volume,hospitalization time,hip function score at the last follow-up,leg length discrepancy of postoperative,patient satisfaction rate,complication rate,revision rate and other index data in literatures were performed using Review Manager 5.3 statistical analysis software.The sensitivity analysis of the results of the unstable meta analysis was carried out,and the publication bias was estimated by Begg's funnel plot test.Results:Finally,a total of 14 documents were obtained,including 3randomized controlled trials(randomized controlled trial,RCT),2 prospective cohort studies,and 9 retrospective cohort studies.The operation time[WMD=-15.27,95%CI(-25.13,-5.41),P=0.002],total amount of blood loss[WMD=-63.54,95%CI(-124.85,-2.24),P=0.04],hospitalization time[WMD=-6.13,95%CI(-8.21,-4.04),P<0.00001]of simultaneous group were significantly lower than those of staged group,on the Contrary,The total volume of blood transfusion[WMD=0.35,95%CI(0.03,0.68),P=0.03]in simultaneous group was greater than that in staged group.There were no significant differences in patient satisfaction rate[RR=1.19,95%CI(0.87,1.64),P=0.28],hip function score at the last follow-up[WMD=0.54,95%CI(-1.85,2.93),P=0.66],leg length discrepancy of postoperative[WMD=0.00,95%CI(-0.06,0.06),P=0.97],system complications rate[RR=1.11,95%CI(0.49,2.51),P=0.81],local complications rate[RR=1.12,95%CI(0.86,1.46),P=0.41]and revision rate[RR=1.60,95%CI(0.34,7.56),P=0.55]between the case and the control group.The sensitivity analysis showed that the meta-analysis results on operation time,total amount of blood loss,total blood transfusion volume,hospitalization time,hip function score at the last follow-up,leg length discrepancy of postoperative,patient satisfaction rate,system complication rate,local complications rate and revision rate were relatively stable,According to the funnel plot generated by the incidence of local complications,the distribution of each data point is basically symmetrical,indicating that the possibility of publication bias in this study is small.Conclution:On the basis of the existing evidence,from the analysis of clinical curative effect:Compared with staged bilateral hip replacement,The operation time,total amount of blood loss,hospitalization time of simultaneous bilateral hip replacement were lower,but the total volume of blood transfusion was greater.There were no significant differences in patient satisfaction rate,hip function score at the last follow-up,leg length discrepancy of postoperative between the two groups.from the safety analysis,there was also no significant difference in the rate of revision,system and local complications system complications rate between the two groups.Therefore,we must strictly control operative indication,perform with minimally invasive surgery technology and apply ERAS concept to enhance perioperative management.In general,simultaneous replacement is safe and feasible,even superior to phased replacementPart II Short-term effectiveness analysis of one-stage bilateral total hip arthroplasty by direct anterior approachAjective:To compare the effectiveness of one-stage bilateral total hip arthroplasty by direct anterior approach(DAA)and by posterolateral approach,and to investigate the application value of DAA in one-stage bilateral total hip arthroplasty.Methods:The clinical data of 69 patients who underwent one-stage bilateral total hip arthroplasty by DAA or posterolateral approach between June2010 and June 2016 were analyzed retrospectively.DAA was used in 37 cases(group A)and posterolateral approach was used in 32 cases(group B).There was no significant difference in the gender,age,body mass index,preoperative hemoglobin level,etiology,disease duration,preoperative Harris score,and preoperative visual analogue scale(VAS)score between 2 groups(P>0.05)with comparability.The incision length,operation time,intraoperative blood loss,total blood transfusion volume,hospitalization time,early postoperative complications,Harris score,and VAS score were recorded and compared between 2 groups.The simple Likert scale method was applied to evaluate the patient satisfaction,and the imaging evaluation was used.Results:The incision length,operation time,intraoperative blood loss,total blood transfusion volume,and hospitalization time of group A were significantly less than those of group B(P<0.05).The patients were followed up 15~49 months(mean,28.3 months)in group A and 12~53 months(mean,29.6 months)in group B.The overall incidence of complications related to surgery in group A(9.5%)was significantly lower than that of group B(21.9%)(?~2=4.100 P=0.043).The acetabular anteversion and abduction angle were in the normal range of 2 groups except 1 hip of group A had a higher acetabular anteversion than normal value.Unstable fixed prosthesis happened in 1 hip of groups A and B respectively,and the remaining femoral calcar had no obvious bone resorption and fixed stably.The Harris score and VAS score at each time point after operation of 2 groups were significantly improved when compared with preoperative scores(P<0.05),and the differences between the time points after operation were also significant(P<0.05).The Harris score at 1 and 3months after operation and the VAS score at 3 days after operation of group A were significantly better than those of group B(P<0.05),but no significant difference was found at last follow-up between 2 groups(P>0.05).According to the simple Likert scale method to analyze patient satisfaction,comprehensive satisfaction of group A(89.3%,33/37)was significantly higher than that of group B(68.8%,22/32)(?~2=4.43,P=0.035).Conclution:The application of DAA in one-stage bilateral total hip arthroplasty can significantly relieve the pain,accelerate the recovery of hip joint function,and improve the patient satisfaction.But in clinical application,more attentions should be paid to strictly grasp the indications and prevent the early complications.The long-term effectiveness needs to be further observed.