Reducing Complications and Enhancing the Functional Outcome of Total Hip Arthroplasty without Increasing Operation Time by Repairing Posterolateral Soft Tissues.

Total hip arthroplasty (THA) surgeries are increasing annually. Despite continuous improvements in the surgical technique and prosthetic design, there is still no consensus on whether it is beneficial to reconstruct the posterolateral soft tissue. This paper systematically reviews randomized controlled trials (RCTs) addressing the efficacy and safety of posterolateral soft tissue during total hip replacement to provide evidence-based guidance for clinical practice. We searched PubMed, EMBASE, Cochrane Library, CNKI, and Wanfang databases for RCTs. Experimental results show that repair of the posterolateral soft tissue can reduce complications and improve the function of total hip arthroplasty without increasing operative time.

1. Introduction

The curative efficacy of total hip replacement surgery for restoration of the hip joint function is well validated in clinical practice, and its application is increasing for treatment of end-stage hip joint diseases. The surgery can be conducted using an anterior, lateral, or posterior approach. The accuracy of prosthesis placement has also greatly improved due to advances in equipment and the learning curve is becoming shorter. Posterior approach requires less tissue separation, clear surgical field, and low heterotopic ossification rate. It is still a commonly used surgical method in clinical practice.

However, the posterior approach requires incision of the posterolateral soft tissue to fully expose the surgical field, and the removal of rear soft tissue may increase the risk of dislocation, especially during flexion, internal rotation, or adduction. The repair of the posterolateral soft tissue extends the operative time but does not provide protection against dislocation, so the value of soft tissue repair remains controversial. Therefore, we conduct a meta-analysis of randomized controlled trials on the efficacy and safety of posterolateral soft tissue repair during total hip replacement surgery to aid in clinical decision making.

The rest of this paper is organized as follows: Section 2 discusses related work. Section 3 discusses the study selection and assessment of methodological quality. The quality of the studies and meta-analysis are discussed in Section 4. Section 5 concludes the paper with summary.

2. Related Work

The capsule was surrounded by multiple ligaments, including the iliofemoral ligament, pubofemoral ligament, sitting femoral ligament, and orbicularis band. The iliofemoral ligament and sitting femoral ligament in the posterior capsule provided dynamic mechanical support during hip joint movement and posterior dislocation was the most frequent complication after hip replacement, observed in 2%–10% of all studies. The dislocation rate in the current study was about 4.9%, comparable to a previous meta-analysis [1], underscoring the importance of the posterior joint for dynamic stability. Many factors influenced dislocation risk in addition to soft tissue repair [2], including patient condition, surgical approach, and incorrect prosthesis position [3, 4]. With improvements in surgical techniques and prosthesis design, the dislocation rate has been effectively reduced [5]. To reduce the incidence of hip joint dislocation further, surgeons have attempted various joint capsule reconstruction techniques. Wu et al. [6] obtained satisfactory results by suture of the gluteus medius muscle tendon and trochanter perforator to rebuild the posterior capsule. Tsai et al. [7] suggested that posterior capsule repair was critical for the success of the posterolateral approach. Pellicci et al. [8] reported that suturing the joint capsule and external rotator muscle after total hip arthroplasty via the posterolateral approach reduced dislocation rates from 4% to 0% and from 6.2% to 0.8% in two surgical series. A biomechanical study by Mihalko and Whiteside [9] reported that the postoperative load curve was closer to the normal healthy load curve of the hip joint following complete capsule repair due to the improved static support and prevention of excessive internal rotation. A magnetic resonance imaging and biomechanical study of 36 patients also concluded that strengthening the joint capsule effectively prevented the femoral head from sliding to the rear [10].

The Harris score was an important index to evaluate the outcome of hip surgery [11] and was used by most of the included studies. However, due to the different statistical methods, the number of patients that could be pooled for analysis was relatively small. Nonetheless, pooled results indicated that repairing the joint capsule significantly increased the Harris score. Reconstructing the joint capsule might be expected to increase the operation time and intraoperative blood loss. However, operation time did not increase because the main sources of bleeding during hip arthroplasty were rubbing the acetabulum and reaming the marrow [12].

3. Study Selection and Assessment of Methodological Quality

Two researchers independently searched the MEDLINE/PubMed, Embase, Cochrane Library, CNKI, Wanfang, and other databases from inception until June 2020. We also performed manual searches of the reference lists for additional studies.

Research selection was developed and implemented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement (PRISMA).

Studies were selected based on the following inclusion criteria: (1) Study design: randomized controlled trial (RCT). (2) Patients diagnosed with femoral neck fracture. (3) Intervention: repair posterolateral soft tissue vs. nonrepair posterolateral soft tissue. (4) Patients over 50 years of age.

We screened the titles and abstracts of the studies and selected applicable studies for full-text review. The selection of articles was performed based on reviewer consensus. Disagreements over the literature selection were resolved by a third reviewer.

Two reviewers independently evaluated the methodological quality of the included studies. Risk of bias was assessed using the Cochrane Collaboration tool for RCTs based on the following six potential bias sources: (1) Sequence generation. (2) Allocation concealment. (3) Blinding of personnel and participants. (4) Completeness of data. (5) Selective reporting. (6) Blinding of outcome assessment. When there was insufficient information to allow a definitive judgment, we considered the risk of bias as unclear.

We extracted the following data from the selected studies: first author name, publication date, country, number of patients, average age at surgery, sex, patient-reported outcomes, complications, and revision rate. The patient-report and complication analyzed in this study were the latest follow-up results for each study. The continuity variables include the sample size, mean value, and standard deviation. The dichotomous variables include the sample size of occurrence, sample size without occurrence, and total sample size.

RevMan 5.3 was used to conduct the meta-analyses. Pooled measurement data are expressed as mean difference (MD) and pooled count data are expressed as risk ratio (RR). Each metric is accompanied by a 95% confidence interval (CI). Heterogeneity among studies is expressed by I2. The analysis model was chosen according to I2. If I2 < 50%, a fixed-effects model is used. While if I2 > 50%, the source of heterogeneity is first examined by the one-by-one removal method, followed by subgroup analysis or sensitivity analysis. After excluding obvious sources of heterogeneity, a random-effects model is adopted.

4. Quality of the Studies and Meta-Analysis

A total of 289 related documents are obtained, which are pared down to 164 by removing duplicates. As shown in Figure 1, full-text RCTs are included in the final meta-analysis, after the detailed evaluation.

Figure 1

Flowchart of literature retrieval.

Table 1 displays the basic information on the included studies. It is clearly evident from Table 1 that the baseline values of the included studies are comparable.

Table 1

Basic information on the included studies.

Studies	Area	Sample size		Average age		Sex (male/female)		Outcomes∗
		Repair	Without repairing	Repair	Without repairing	Repair	Without repairing
Chiu et al. [13]	USA	96	84	51	54	59/39	51/33	①②
Tarasevicius et al. [14]	USA	134	141	N/A	N/A	N/A	N/A	②
Liu et al. [15]	China	40	80	69.8 ± 4.1	69.9 ± 3.8	21/19	46/34	②
Sun et al. [16]	China	40	40	61.9 ± 5.1	62.8 ± 4.6	23/17	24/16	①②
Zhou et al. [17]	China	48	48	78.3 ± 5.2	79.2 ± 5.5	28/20	29/19	②③④
Zhang et al. [18]	China	60	60	65.4 ± 2.6	64.9 ± 2.7	31/29	27/33	③④
Yang et al. [19]	China	30	31	77	77	16/20	13/18	②
Wang [20]	China	36	35	68.4 ± 1.6	68.6 ± 1.5	17/19	18/17	③④
Shen [21]	China	50	50	65.7 ± 2.5	65.2 ± 2.7	27/24	25/26	③④
Chen et al. [22]	China	43	44	66.5 ± 8.5	64.5 ± 7.3	19/22	20/22	①③④
Chen and Li [23]	China	20	20	72.1 ± 10.6	73.9 ± 11.3	5/15	8/12	②③④
Tarasevicius et al. [24]	USA	18	15	70 ± 5.7	71 ± 2.7	1/8	8/7	②

Table 1 shows the risk of bias assessment. It is clearly evident from Table 2 that the data are complete and the most of adequate allocation concealment is unclear.

Table 2

Risk of bias assessment.

Studies	Adequate randomization	Adequate allocation concealment	Blinding	Data integrity	Selective reporting	Other biases
Chiu et al. [13]	Y	Y	Y	Y	N/A	N/A
Tarasevicius et al. [14]	Y	Unclear	Y	Y	N/A	N/A
Liu et al. [15]	Y	Unclear	Unclear	Y	N/A	N/A
Sun et al. [16]	Y	Unclear	Unclear	Y	N/A	Unclear
Zhou et al. [17]	Y	Y	Unclear	Y	N/A	Unclear
Zhang et al. [18]	Unclear	Unclear	Y	Y	N/A	Unclear
Yang et al. [19]	Unclear	Unclear	Unclear	Y	N/A	Unclear
Wang [20]	Unclear	Y	Unclear	Y	Unclear	Unclear
Shen [21]	Y	Unclear	Y	Y	N/A	Unclear
Chen et al. [22]	Y	Unclear	Unclear	Y	N/A	Unclear
Chen and Li [23]	Unclear	Unclear	Unclear	Y	N/A	Unclear
Tarasevicius et al. [24]	Y	Unclear	Y	Y	N/A	N/A

The Harris scores are reported in two studies including 136 repaired posterolateral soft tissue and 124 unrepaired posterolateral soft tissue.

Figure 2 shows the Harris score between the two groups. It is clearly evident from Figure 2 that there is no significant heterogeneity among the three studies (P=0.12, I2 = 59%). The Harris score is significantly higher in the repair group than in the nonrepair group.

Figure 2

The Harris score between the two groups.

Figure 3 displays the dislocation rate between the two groups. It is clearly evident from Figure 3 that there is no significant heterogeneity among studies (P=0.96, I2 = 0%) and the risk of dislocation is significantly lower in the repair group.

Figure 3

Dislocation rate between the two groups.

Figure 4 shows the operation time between the two groups. It is clearly evident from Figure 4 that there is no significant heterogeneity among studies (P < 0.00001, I2 = 85%) and there is no significantly between the groups in operation time.

Figure 4

Operation time between the two groups.

Figure 5 shows the intraoperative blood loss between the two groups. It is clearly evident from Figure 5 that there is significant heterogeneity among studies (P < 0.00001, I2 = 97%) and there is no significant difference between the groups.

Figure 5

Intraoperative blood loss between the two groups.

Figure 6 shows the postoperative drainage between the two groups. It is clearly evident from Figure 6 that there is significant heterogeneity among studies (P < 0.00001, I2 = 94%).

Figure 6

Postoperative drainage between the two groups.

5. Conclusion

The current evidence shows that the repaid posterolateral soft tissue can reduce the incidence of dislocation after posterior total hip arthroplasty and improve hip joint function without increasing operation time or intraoperative blood loss. However, conclusions are limited by the number and quality of the included studies. These results require further verification by multicenter RCTs of higher quality, larger sample size, and longer follow-up time. While this study includes the most recent studies comparing the outcomes of total hip replacement with or without joint capsule repair, there are still limitations. First, few of the studies are of high quality. Second, patient age influences both the initial condition and rehabilitation progress but no age subgroup analysis is possible. Finally, the methods of outcome evaluation are not consistent.