Are physical therapy pain levels affected by surgical approach in total hip arthroplasty? A randomized controlled trial

Abstract

The main objective of this study was to evaluate the difference in pain levels during postoperative physical therapy pathways in patients who underwent a cement less total hip replacement either through a muscle sparing direct anterior approach (DAA), or the classic trans-gluteal lateral approach (LA). One hundred and twelve (112) patients were randomized into two equal groups. Baseline values of myoglobin levels were acquired prior to surgery and repeated at 6 hours postoperatively as a biomarker for muscle damage. Pain levels during the first passive and consecutive 3 active physical therapy sessions were noted using a visual analogue-numeric scale (VAS). Pain levels were also acquired at 6 weeks, 3 months, 6 months and 1 year, following a 20-meter (65.6 feet) walking test. Postoperative myoglobin (ng/mL) levels were significantly higher (p< 0.05) in the LA group (335.05±83.54) then the DAA group (237.71±57.54). Pain levels were significantly lower (p<0.001) in the DAA group for both passive (2.5±1.45 vs. 4.28±2.19) and active physical therapy sessions and there was a positive correlation between postoperative myoglobin levels and pain levels until 6 postoperative weeks. There was no significant difference in demographics between the two groups except for gender distribution. The direct anterior approach’s main advantage of being a minimally invasive muscle sparing technique is showing a better rehabilitation experience with lower pain levels during passive and active physical therapy when compared to the classic trans-gluteal lateral approach.

Comparing direct anterior approach versus posterior approach or lateral approach in total hip arthroplasty: a systematic review and meta-analysis

“…Hence, muscle splitting is avoided and soft tissue injury is minimised [8,43]. This is supported by biochemical and radiological evidence, with reports of lower levels of early post-operative creatine kinase or myoglobin, which are indicators of muscle damage, in DAA compared to other approaches [28,34,38,39]. Post-operative MRI studies also noted less muscle and tendon damage in DAA than LA [34].…”

“…Overall, 14 of 24 RCTs involved surgeons experienced in DAA, [ 19 – 22 , 24 – 27 , 29 , 30 , 32 , 35 , 40 , 42 ]. The remainder either involved surgeons still within the learning curve [ 28 , 31 , 33 , 36 – 38 , 41 ] or did not specify surgeon experience [ 23 , 34 , 39 ]. Complication risks during the learning curve of DAA can potentially be reduced with adequate supervision and guidance by experienced surgeons and by performing initial cases on less complex patients [ 48 ].…”

“…Twenty-eight full-text articles were assessed for eligibility. Eventually, 24 randomized controlled trials were included of which 12 compared DAA versus PA [19][20][21][22][23][24][25][26][27][28][29][30] and 12 compared DAA versus LA [31][32][33][34][35][36][37][38][39][40][41][42].…”

Which approach of total hip arthroplasty is the best efficacy and least complication?

“…Most studies were from USA, Europe and China. The numbers of included studies were thirteen PA vs DAA[ 53 , 54 , 56 - 58 , 69 , 75 , 84 , 85 , 87 , 88 , 94 , 96 ], thirteen LA vs DAA[ 55 , 59 , 61 , 67 , 71 , 74 , 76 , 77 , 79 , 81 , 82 , 86 , 97 ], seven PA vs LA[ 63 , 65 , 83 , 90 - 92 , 95 ], one PA vs two-incision[ 60 ], one PA vs LA vs two-incision[ 72 ], three LMIS vs LA[ 66 , 70 , 80 ], seven DSA/SuperPath vs PA[ 18 , 19 , 64 , 68 , 73 , 78 , 93 ] and two DSA/SuperPath vs LA[ 62 , 89 ]. The mean age was 51 to 76 years, BMI 21-31 kg/m 2 , 13%-65% male and 20%-100% had hip osteoarthritis (Table 2 ).…”

Unsupervised Home Exercises Versus Formal Physical Therapy After Primary Total Hip Arthroplasty: A Systematic Review

“…Copay affordability, scheduling outpatient appointments, and arranging transportation have been demonstrated to be legitimate barriers to accessibility to outpatient PT for THA patients after discharge [ 10 , 11 ]. PT exercises can also be painful, as one of the most commonly asked questions regarding PT in the postoperative period after THA is about pain expectations [ 26 ]. Additionally, Yayac et al demonstrated that TJA patients who underwent supervised PT had a significantly higher readmission rate than those who were discharged with self-directed home exercise regimens [ 9 ].…”