Question: What is the effectiveness and cost-effectiveness of minimal-incision total hip replacement (THR) compared with standard total hip replacement?
Data sources: MEDLINE, EMBASE/Excerpta Medica, BIOSIS, Science Citation Index, Cochrane Library and additional systematic review databases, key surgical journals, recent conference proceedings, reference lists of relevant studies, national orthopaedic registries, professional organizations, and manufacturers.
Study selection and assessment: Randomized controlled trials (RCTs) or quasi-RCTs and studies of less rigorous design (e.g., nonrandomized comparative studies, single cohort studies, case series, and national registries) in English, Chinese, or Japanese were included. Participants were adults who were eligible for standard THR for the treatment of arthritis. Interventions were primary THR with use of a single-incision minimally invasive technique (as compared with the standard technique) or primary THR with use of a 2-incision minimally invasive technique (as compared with the standard technique or the single-incision minimally invasive technique). The methodological quality of the RCTs and other included studies was assessed with use of the Delphi criteria.
Main outcome measures: Outcomes of interest concerned clinical performance (e.g., implant migration and revision rates), safety (e.g., blood loss, infection, and risk of thrombosis), resource use (e.g., duration of operation, length of stay, and staffing), patient-centered outcomes (quality-of-life measures), and cost-effectiveness.
Main results: 12 RCTs, 22 nonrandomized comparative studies, and 8 case series met the inclusion criteria. 32 studies, including 9 RCTs, were relevant to the comparison of the single-incision minimally invasive technique with the standard technique; 1 RCT compared the 2-incision minimally invasive technique with the standard technique; and 9 studies, including 2 RCTs, were relevant to the comparison of the 2-incision minimally invasive technique with the single-incision minimally invasive technique. Meta-analysis showed that the single-incision minimally invasive technique was associated with less blood loss and shorter operative time and length of hospital stay when compared with the standard technique (Table). The single-incision minimally invasive technique was also associated with less time spent using walking aides (Table). The groups did not differ with regard to any other outcomes.
Limited RCT evidence was available for the comparison of the 2-incision minimally invasive technique with either the standard technique or the single-incision minimally invasive technique. In 1 trial, in comparison with the standard technique, the 2-incision minimally invasive technique was associated with a shorter length of stay and a better quality-of-life score (Harris hip score) for short-term pain; however, the 2-incision technique was associated with more blood loss and longer operative time. 1 published and 1 unpublished study met the inclusion criteria for evaluating cost-effectiveness. In the unpublished study, total costs were less with the single-incision and 2-incision minimally invasive techniques than they were with the standard technique. The incremental effectiveness of the single-incision and 2-incision minimally invasive techniques as compared with the standard technique was 0.023 and 0.037 quality-adjusted life years gained, respectively. The published study did not include results regarding incremental benefits; however, the average hospital costs per patient were lower with use of the single-incision technique than they were with the standard technique (€11,534.40 vs €13,511.00).
Conclusions: When compared with standard-incision THR, single-incision minimally invasive THR offers some perioperative advantages, including less blood loss, shorter operative time, and shorter length of stay. Little evidence exists with regard to any long-term differences between single-incision minimally invasive THR and standard-incision THR. Evidence is limited and inconclusive on the benefit of 2-incision minimally invasive THR. Data comparing the cost-effectiveness of the three techniques are limited.
Conventional total hip replacement is widely recognized as a clinically efficacious and cost-effective intervention1 with a relatively low risk for complications and a high degree of success2. "Minimally invasive" techniques have recently been introduced and offer the promise of reduced perioperative morbidity and earlier return to function after total hip replacement3.
While controversy continues to exist among hip surgeons regarding the risks and benefits of minimal-incision total hip replacement, the systematic review by de Verteuil et al. underscores the fact that the perceived advantages of minimal-incision total hip replacement are limited to a decrease in perioperative morbidity (blood loss, operative time, and length of stay) and recovery time following total hip replacement. Even strong proponents of minimal-incision total hip replacement admit that there are no expected long-term benefits in terms of improved patient function or implant survivorship. Furthermore, although it was initially believed that the perioperative benefits of minimal-incision compared with standard total hip replacement were attributable to differences in surgical technique, it has now become widely recognized that most, if not all, of the benefits are related to changes in the perioperative management of patients undergoing total hip replacement, including increased use of preemptive analgesia, changes in regional anesthetic techniques and perioperative pain management, and modifications of postoperative rehabilitation protocols, including earlier walking and the relaxation of postoperative weight-bearing and dislocation precautions4, details unfortunately lacking in most of the studies reviewed in this systematic review.
An operation that reduces operative time and length of stay and hastens return to function would be expected to also be associated with a decrease in short-term episode-of-care costs. However, any short-term cost savings should be considered in light of potential increased costs related to an increase in complications and revision rates associated with minimal-incision total hip replacement. Therefore, the most clinically relevant conclusions related to the economic modeling studies are the thresholds for changes in perioperative morbidity and revision rates, which would be required to realize the potential cost-savings associated with minimal-incision total hip replacement.
In conclusion, this systematic review provides a comprehensive summary of the clinical literature related to minimal-incision total hip replacement. However, clinicians and policy makers should be cognizant of the role of changes in the perioperative management of patients undergoing total hip replacement and of assumptions regarding the short and long-term clinical and economic risks and benefits associated with minimal-incision total hip replacement when interpreting the conclusions of this valuable review.
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