Evidence PICO heup benaderingen voor THP: anterieur vs posterolateraal

Anterieure vs Posterolaterale

benadering bij primaire THP

Veltman / Poolman

23 augustus 2016

Intro

• THP zeer succesvolle operatie• >90% tevreden over resultaat

• Ruim 28.000 THP jaarlijks in NL• Meest gebruikte benaderingen posterolateraal (62%), direct

lateraal (20%) en anterieur (12%)

• Optimale benadering onderwerp van discussie• Spierkracht

Benadering

• Posterolateraal

• Anterieur

Anterieur vs PosterieurVoordelen• Laag luxatierisico• Weinig spierschade• Minder pijn postoperatief• Snellere revalidatie• Operatie in rugligging

Nadelen• Langere leercurve (100pt)• Meer femur fracturen• Meer bloedverlies• Langere operatieduur• Revisie benadering

Voordelen• Korte leercurve (50pt)• Bewezen goede lange termijn

resultaten• Weinig bloedverlies

Nadelen• Meer spierschade• Groter luxatierisico

PICO

• P: patiënten totale heup prothese• I: anterieure benadering• C: posterolaterale benadering• O: uitkomst (OK, functie, tevredenheid, complicaties)

Search• ("arthroplasty, replacement, hip"[MeSH Terms] OR

("arthroplasty"[All Fields] AND "replacement"[All Fields] AND "hip"[All Fields]) OR "hip replacement arthroplasty"[All Fields] OR ("total"[All Fields] AND "hip"[All Fields] AND "arthroplasty"[All Fields]) OR "total hip arthroplasty"[All Fields]) AND ((anterior[All Fields] AND approach[All Fields]) OR (posterolateral[All Fields] AND approach[All Fields]))

Resultaten• 598 studies

• Higgins et al: systematic review 2015 (2 RCT, 5 prospectief vergelijkend, 10 retrospectief vergelijkend)

Sindsdien:• Malek et al• Maratt et al• Winther et al

Uitkomsten HHS, VAS, SF36, loopafstand

Anterieur vs Posterieur

• 448 patients undergoing unilateral primary THA

• 265 patients (age 71, 117 male) direct anterior approach

• 183 patients (age 70, 86 male) posterior approach

• No difference in age, gender, ASA grade, BMI, the side of the operation, pre-operative Oxford Hip Score (OHS) and attendance at ‘Joint school’.

• 2147 DAA THA patients were matched with PA THA based on age, gender, BMI and ASA using data from a state joint replacement registry

In 60 patients leg press and abduction strength were evaluated 2 weeks or less preoperatively, 2 and 8 days postoperatively, and at 6-week and 3-month follow-up.

Discussion• Leercurve anterieure benadering langer• Luxatie risico gelijk• Anterieure benadering mogelijk meer femur fracturen en

meer bloedverlies• Posterieure benadering langere opname (1 dag)• Functionele uitkomst (op middel- en lange termijn) gelijk

• Beide benaderingen goede optie in ervaren handen• Placebo effect

Referenties• LROI jaarverslag 2014• Higgins BT, et al. Anterior vs. Posterior Approach for Total Hip Arthroplasty, a

Systematic Review and Meta-analysis. The Journal of Arthroplasty 30 (2015) 419–434• Malek IA, et al. A comparison between the direct anterior and posterior approaches for

total hip arthroplasty. Bone Joint J 2016;98-B:754–60.• Maratt JD, et al. No Difference in Dislocation Seen in Anterior Vs Posterior Approach

Total Hip Arthroplasty. The Journal of Arthroplasty. DOI 10.1016/j.arth.2016.02.071• Winther SB, et al. Muscular strength after total hip arthroplasty. A prospective

comparison of 3 surgical approaches. Acta Orthopaedica 2016; 87 (1): 22–28• De Anta-Díaz B, et al. No differences between direct anterior and lateral approach for

primary total hip arthroplasty related to muscle damage or functional outcome. International Orthopaedics (SICOT). DOI 10.1007/s00264-015-3108-9