Efficacy of artificial intelligence preoperative planning for two patients who underwent bilateral hip joint replacement via anterior or posterior approaches for the same disease respectively

doi:10.21203/rs.3.rs-4708426/v1

Download PDF

Research Article

Efficacy of artificial intelligence preoperative planning for two patients who underwent bilateral hip joint replacement via anterior or posterior approaches for the same disease respectively

https://doi.org/10.21203/rs.3.rs-4708426/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Objective

To summarize the diagnostic and treatment experiences of two patients who underwent bilateral hip joint replacement via anterior or posterior approaches for the same disease

Methods

Between August 2021 and April 2023, two patients with bilateral hip comorbidities were admitted. The ages of the patients were 58 and 46 years, the Harris scores were 31.3 and 34.0 on the anterior hip replacement side and 32.5 and 33.3 on the posterior hip replacement side, respectively, and the visual analog scale (Vas) was 5 on both sides. Anterior and posterior approach arthroplasties were performed on both sides of the patient's hip joints

Results

The patients' postoperative incisions healed well, with Harris scores of 45.5 and 53.0 on the anterior approach hip replacement side and 50.0 and 44.5 on the posterior approach hip replacement side at 1 week after surgery. At 3 months after surgery, the Harris scores on the side of anterior approach hip replacement were 95.0 and 91.0, respectively and the Harris scores on the side of posterior approach hip replacement were 90.5 and 83.5, respectively. The Vas score was 0 at 3 months after surgery, and no complications such as lower extremity venous thrombosis, dislocation, or infection occurred in either patient

Conclusion

For patients who undergo bilateral hip joint replacement surgery, anterior and posterior approaches can be adopted flexibly according to patient needs

Total hip arthroplasty

anterior approach

posterior approach

Harris score

The patients included 1 female and 1 male, aged 58 and 46 years, respectively. The diagnosis was confirmed by preoperative pelvic orthopantomogram and CT measurements, and there was one case of bilateral hormonal necrosis of the femoral head (ONFH) and one case of bilateral developmental dysplasia of the hip (DDH). At the time of admission, the hip impingement test was positive, the spinal curvature was normal, and there was no combination of ankylosing spondylitis, etc. The Harris scores of the two patients on the anterior approach side of hip replacement were 31.25 and 34, the Harris scores on the posterior approach side were 32.5 and 33.25, and the visual analog scores (Vas) were both 5.

The surgery was performed by the same experienced surgeon from the Department of Orthopedics and Traumatology of Jiangsu Provincial Hospital of Traditional Chinese Medicine, and the prosthesis was made by the total hip joint system (acetabular Pinnacle cup + femoral Corail stem) of the American Johnson & Johnson Company. After general anesthesia, the patients were placed in the lateral position, and hip replacement surgery was performed via the direct anterior approach (DAA) and posterolateral approach (PLA). ① DAA approach: A longitudinal incision was made in front of the thigh at approximately 1 cm below the anterior superior iliac spine and approximately 3 cm lateral to the anterior superior iliac spine, and the subcutaneous tissue and fascial layer were incised in turn. The subcutaneous tissue and fascial layer were incised, and the joint capsule was exposed from the gap between the vastus tensor fasciae latae muscle and the rectus femoris muscle. The joint capsule was incised along the base of the femoral neck in a T-shape, the femoral head was removed by osteotomy, an appropriately sized acetabular cup was inserted, and a ceramic liner was inserted after secure fixation. The medulla was expanded, the femoral stem and the corresponding ceramic head were inserted, and the joint mobility, stability and length of both lower limbs were checked without any abnormalities. Then, the joint capsule, subcutaneous, and skin were sutured, and arthroplasty was completed. ② In the PLA approach, the greater trochanter is taken as the center from the posterior iliac supraspinous spine, the skin is cut along the posterior margin of the greater trochanter in an arc, and part of the attached externally rotated muscles is cut along the posterior margin of the greater trochanter to expose the joint capsule. Part of the posterior joint capsule was resected, the femoral head was removed by osteotomy, an appropriately sized acetabular cup was inserted, and a ceramic liner was inserted after secure fixation. The medulla oblongata was expanded, the femoral stem and the corresponding ceramic head were inserted, the joint mobility, stability and length of both lower limbs were checked without any abnormalities, and then the joint capsule, external rotator group, broad fascia tensor, subcutaneous, skin, and complete the joint replacement were sutured.

After the operation, patients were given routine treatments, such as anti-sensory, anti-coagulation, acid-suppressing and gastric protection, phlegm dissolution, and anti-inflammatory and analgesic agents, and postoperative complications were actively prevented. The patients could walk in bed with the assistance of a walker on the first postoperative day, and the affected limb on the anterior approach replacement side could be fully weight-bearing for 2 weeks; the affected limb on the posterior approach replacement side could be fully weight-bearing for 6 weeks. The patients' postoperative incisions healed well, and the Harris scores of the anterior approach hip replacement side were 45.5 and 53 points at 1 week after the operation; the Harris scores of the posterior approach hip replacement side were 50 and 44.5 points, respectively. At 3 months after surgery, the Harris scores on the anterior approach hip replacement side were 95 and 91, respectively; the Harris scores on the posterior approach hip replacement side were 90.5 and 83.5, respectively. The Vas score was 0 at 3 months after surgery, and no complications, such as lower extremity venous thrombosis, dislocation, or infection, occurred in either patient. See Fig. 1 and Fig. 2..

Currently, the most popular surgical approaches for total hip arthroplasty (THA) are the direct anterolateral approach (DAA) and the posterolateral approach (PLA). The PLA approach, as the earliest and most widely used clinical approach, is also known as the traditional approach and is still widely used in hospitals in China. The DAA approach was proposed by Huter in 1881 and gradually became popularized by Smith et al. The DAA approach can use the gap between the vastus tensor fasciae latae muscle and the rectus femoris muscle and protect the surrounding muscles, blood vessels, nerves and other tissues as much as possible, thus avoiding the need to cut or loosen the muscles, as in the PLA approach. The DAA approach can utilize the gap between the tensor fascia lata muscle and rectus femoris muscle to protect the surrounding muscles, blood vessels, nerves and other tissues as much as possible, thus avoiding the need to cut or loosen the muscles as in the PLA approach and accelerating patient recovery. Due to the popularity of minimally invasive surgery and rapid recovery, the DAA approach is gradually becoming mainstream in clinical practice. At present, the DAA approach has not yet been able to replace the traditional PLA approach in clinical practice because of the long learning curve, the possible increase in operating time, and the imperfections in the study of medium- and long-term therapeutic efficacy.

There are many clinical articles on comparative studies of the efficacy of the two approaches for THA, but there are no valid data to support which approach can definitively affect the placement of the prosthesis [1]. Many studies have shown [2, 3] that the DAA approach is significantly better than the PLA approach in promoting early functional recovery in patients. A domestic study on the efficacy of bilateral hip joint arthroplasty in 106 patients who underwent anterior or posterior approach arthroplasty revealed [4] that THA via the DAA was superior to THA via the PLA in terms of blood transfusion, hospitalization time, one-week postoperative improvement in pain, and early recovery of hip function and that there was no significant difference between the two approaches in terms of operation time or postoperative complications. The authors concluded that the data of the two patients in this report conformed to the above research pattern. A recent foreign study comparing the mid- and long-term efficacy of the two approaches revealed [5] that the anterior approach had a greater rate of lateral femoral revision (periprosthetic fracture and aseptic loosening) and a lower rate of early infection and dislocation, suggesting that the DAA approach is still questionable in terms of mid- and long-term efficacy.

Clinically, we should consider the surgical approach that is most appropriate for THA, and we should strive to minimize the higher revision rates and associated complications that are specific to the use of a particular approach based on the orthopedic surgeon's own level of experience with each approach and patient selection. We have summarized our experience in both prosthesis placement and joint capsule management.

The placement of the prosthesis at the appropriate abduction and anterior tilt angles is a major factor in preventing dislocation of the prosthesis after THA. The current clinical placement angles of the acetabular prosthesis recognized by most clinicians are as follows: abduction, 45° (± 5°), and anterior tilt, 20° (± 5°). Most clinicians position the acetabulum at 40–45° abduction and 15–20° anterior tilt based on bony landmarks. Although the safety zone for acetabular anterior tilt (15 ± 10°) is the gold standard, this safety zone is not applicable in cases of abnormal femoral anterior tilt or severe pelvic tilt when combined anterior tilt is considered. The generally accepted intraoperative combined anterior tilt angle should be between 25° and 50°, with 20° to 30° for men and 30° to 45° for women. If the joint anterior tilt angle is too small, posterior dislocation is likely to occur after surgery; if the joint anterior tilt angle is too large, anterior dislocation is likely to occur. Wang Yuan et al. [6] reported that for patients with ankylosing spondylitis affecting the hip joint, the use of the joint anterior tilt technique during surgery can improve the accuracy of prosthesis implantation, promote kinetic recovery of the hip joint, and reduce the occurrence of postoperative complications. In the author's opinion, the anterior approach mainly involves exposing the anterior joint capsule, taking the anterolateral view of the hip joint for prosthesis replacement, and the operator's visual judgment to adjust the position of the prosthesis is prone to cause the anterior tilt angle of the socket cup to be too small. We can slightly adjust the anterior socket cup placement angle according to the bony landmarks; similarly, we can adjust the posterior socket cup anterior tilt angle to achieve the optimal fitting position. In addition, to more accurately adopt the combined anterior inclination technique for prosthesis replacement, a protractor or three-dimensional goniometer [7] can be used intraoperatively to measure and adjust the femoral anterior inclination and acetabular anterior inclination, respectively, to achieve the maximum fit between the prosthesis and the affected limb.

Dislocation of the hip joint prosthesis is a serious complication of THA surgery, which not only causes secondary trauma to the patient but also may lead to revision surgery, which can increase the economic burden on the patient. Clinically, many doctors tend to rely on the mobility and stability of the joint prosthesis itself and habitually resect the ligaments around the hip joint and the peripheral joint capsule, seriously ignoring the protective and restrictive effect of the joint capsule on the hip joint. The joint capsule has a role in limiting hip hyperextension, external rotation, abduction, flexion, internal rotation and resistance to longitudinal traction, which can maintain the stability of the joint at the limit of activity and limit the separation of the head and socket. Previous studies have shown [8] that the dislocation rate in THA patients who did not have the joint capsule preserved was as high as 4.8% with the posterior-lateral approach, while the dislocation rate in THA patients who had the repaired joint capsule preserved was only 0.7%. In addition, after THA, due to the reduction in acetabular head volume and other reasons and intraoperative preservation of the joint capsule alone, the postoperative joint capsule binding force is still decreased, and the failure of the joint capsule limiting function has a greater impact on the posterior joint capsule, while the intraoperative repair of the joint capsule is able to partially restore the limiting effect. In the author's opinion, for the treatment of the joint capsule, we can adopt THA under the posterior approach, preserving the anterior joint capsule and repairing the tight posterior joint capsule; THA under the anterior approach, repairing the anterior joint capsule and preserving the posterior joint capsule; and THA under the direct lateral approach, which is preserved at the time of visualization and repairs the joint capsule at the time of suture, to maximize protection and recovery of postoperative hip joint function.

Ethical statement

This study protocol was approved by the Medical Ethics Committee of the Affiliated Hospital of Nanjing Medical University (2024NL-044-02)

Availability of data and material

The data can be obtained from the corresponding author according to reasonable requirements

Interests

The authors declare that they have no competing interests

Funding

This study was supported by the Chinese Medicine Administration (CMA) (ZD202315). The funding source did not play a role in the investigation

Agree to publish

Photographs of patients used in typical cases were obtained and agreed upon for publication

Statement of Author Contributions

JZ, TX, and HH contributed to the conception and design of the study. JZ and HH collected the data. JZ, TX, and HH performed the data analysis. JZ and TX drafted the manuscript SZ. JS critically revised the manuscript for important intellectual content. All authors reviewed the manuscript

Confirmation

Not applicable

STOLARCZYK A, STOLARCZYK M, STĘPIŃSKI P, et al. The Direct Anterior Approach to Primary Total Hip Replacement: Radiological Analysis in Comparison to Other Approaches [J]. Journal of clinical medicine, 2021, 10(11).
MEAD P A, BUGBEE W D. Direct Anterior Approach to Total Hip Arthroplasty Improves the Likelihood of Return to Previous Recreational Activities Compared with Posterior Approach [J]. Journal of the American Academy of Orthopaedic Surgeons Global research & reviews, 2022, 6(1).
LATIJNHOUWERS D, LAAS N, VERDEGAAL S H M, et al. Activities and participation after primary total hip arthroplasty; posterolateral versus direct anterior approach in 860 patients [J]. Acta orthopaedica, 2022, 93: 613-22.
JIN X, CHEN G, CHEN M, et al. Comparison of postoperative outcomes between bikini-incision via direct anterior approach and posterolateral approach in simultaneous bilateral total hip arthroplasty: a randomized controlled trial [J]. Scientific reports, 2023, 13(1): 7023.
HOSKINS W, BINGHAM R, LORIMER M, et al. Early Rate of Revision of Total Hip Arthroplasty Related to Surgical Approach: An Analysis of 122,345 Primary Total Hip Arthroplasties [J]. The Journal of bone and joint surgery American volume, 2020, 102(21): 1874-82.
Wang Yuan, Pei Fang, Wan Feng, et al. The efficacy of combined anterior tilt technique in artificial total hip arthroplasty for ankylosing spondylitis involving the hip joint J Chinese Journal of Prosthetic and Reconstructive Surgery [J]. 2024, 38(01): 15-21.
Li Zhaowen, Li Xugui, Tang Zhuan, et al. Design of a three-dimensional angulometer and its evaluation in total hip arthroplasty J Biological Orthopaedic Materials and Clinical Research [J]. 2024, 21(01): 75-8.
WHITE R E, JR., FORNESS T J, ALLMAN J K, et al. Effect of posterior capsular repair on early dislocation in primary total hip replacement [J]. Clinical orthopaedics and related research, 2001, (393): 163-7.

No competing interests reported.

Download PDF

Editor assigned by journal
09 Jul, 2024
Submission checks completed at journal
09 Jul, 2024
First submitted to journal
08 Jul, 2024

You are reading this latest preprint version

Efficacy of artificial intelligence preoperative planning for two patients who underwent bilateral hip joint replacement via anterior or posterior approaches for the same disease respectively

Status:

Version 1

Abstract

Objective

Methods

Results

Conclusion

Figures

Case presentation

Discussion

Declarations

References

Additional Declarations

Status:

Version 1