Minimally Invasive Two-incision Total Hip Replacement

Technology description

Minimally invasive two-incision total hip replacement involves supplanting a damaged hip socket (acetabulum) and top of the thigh bone (femoral head and neck) with a prosthesis. Minimally invasive two-incision total hip replacement involves making one 3.8 to 8 cm incision for acetabular preparation and a second 1.5 to 6 cm incision to implant the femoral prosthesis. During this procedure, the surgeon does not dissect muscles but separates them along their natural intervals using fingertips and retractors. This muscle sparing aspect is the procedure’s key distinguishing feature.

Purported advantages of minimally invasive two-incision total hip replacement or minimally invasive one-incision total hip replacement over conventional total hip replacement include the following:

• Reduced muscle trauma
• Less pain and blood loss
• Reduced hospital stay
• Better cosmesis with smaller and less visible incisions
• Quicker return to work and activities of daily living

Purported advantages of minimally invasive two-incision total hip replacement over minimally invasive one-incision total hip replacement include the following:

• Quicker recovery
• Lower dislocation rates
• Minimized muscle and tendon damage
• Increased stability

A potential disadvantage of these minimally invasive approaches compared to conventional total hip replacement is the restricted view of the surgical area, which makes the procedure more difficult and increases the likelihood of femoral fractures. To enhance the surgical view, some surgeons use computer-assisted navigation software for accurate component positioning.

ECRI Institute searches identified numerous manufacturers of cemented and non-cemented femoral stems, acetabular components, computer assistance software, and specialized instruments that can be used for minimally invasive total hip replacement.

Hospitals considering offering minimally invasive two-incision total hip replacement should consider that the procedure appears to be more difficult to perform than minimally invasive one-incision total hip replacement and conventional total hip replacement. Therefore, facilities should ensure the availability of surgeon training, which is available through manufacturer-sponsored training programs. Also, operating room schedules for the orthopedic service area may be affected by introducing minimally invasive two-incision total hip replacement because the procedure may take longer to perform than minimally invasive one-incision total hip replacement.

Key questions

Findings for each of the key questions are as follows:

1. How do the clinical efficacy outcomes of minimally invasive two-incision total hip replacement compare to minimally invasive one-incision total hip replacement and conventional hip replacement?

In studies that compared efficacy outcomes of minimally invasive two-incision total hip replacement patients to minimally invasive one-incision total hip replacement patients one year after surgery, none of four studies found a significant difference between groups in function on the Harris Hip Score. None of three studies found significant differences between groups in quality of life. Two studies did not find any differences in pain between groups.

2. How do the perioperative outcomes of minimally invasive two-incision total hip replacement compare to minimally invasive one-incision total hip replacement and conventional hip replacement?

Evidence suggests that minimally invasive two-incision total hip replacement may be associated with longer operative times than either minimally invasive one-incision total hip replacement or conventional total hip replacement and greater intraoperative blood loss than minimally invasive one-incision total hip replacement, but it is not clear that the size of these differences is clinically important. Minimally invasive two-incision total hip replacement patients returned to walking sooner than minimally invasive one-incision total hip replacement patients, but the difference was half a day in one study and a day and a half in the other study reporting this outcome; therefore, the clinical importance of these results is unclear.

3. How do the adverse event rates of minimally invasive two-incision total hip replacement compare to minimally invasive one-incision total hip replacement and conventional total hip replacement?

In the studies assessed, none of the individual adverse events occurred at statistically significant different rates between groups, but the evidence base may have been underpowered to detect between-group differences of infrequent events.

4. What are the reported adverse events associated with minimally invasive two-incision total hip replacement?

Serious adverse events reported included any complication requiring reoperation, specifically implant loosening, substantial subsidence, dislocation, fracture, and deep infection or other wound problems. Deep vein thrombosis and pulmonary embolism did occur infrequently. Less serious adverse events included superficial wound infections and transient nerve symptoms.

In the United States, surgeons perform more than 250,000 total hip replacements each year. An estimated two-thirds of patients with hip arthritis may be eligible for a minimally-invasive hip replacement procedure. Experts predict that by 2030, the number of total hip replacements will increase by 174 percent to about 572,000 procedures. As the orthopedic industry intensifies its use of direct-to-patient marketing, a growing proportion of patients who need total hip replacement can be expected to request minimally invasive total hip replacement, including minimally invasive two-incision total hip replacement.

Excerpted with permission from ECRI Institute’s database of Emerging Technology Evidence Reports. To download the full report, visit www.ecri.org/managedcare.

For inquiries about this report or membership in ECRI Institute’s Health Technology Assessment Information Service, send e-mail to [email protected].