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Scientific Articles   |    
Comparison of Minimally Invasive Direct Anterior Versus Posterior Total Hip Arthroplasty Based on Inflammation and Muscle Damage Markers
Patrick F. Bergin, MD1; Jason D. Doppelt, MD2; Curtis J. Kephart, MD3; Michael T. Benke, MD3; James H. Graeter, MD4; Andrew S. Holmes, MD3; Hana Haleem-Smith, BS5; Rocky S. Tuan, PhD6; Anthony S. Unger, MD7
1 Department of Orthopaedic Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. E-mail address: patbergin@gmail.com
2 Orthopaedic Surgery Associates of Marquette, P.C., 1414 West Fair Avenue, Suite 190, Marquette, MI 49855
3 Department of Orthopaedic Surgery, George Washington University, 2150 Pennsylvania Avenue N.W., Washington, DC 20037
4 Washington Circle Orthopaedic Associates, 3 Washington Circle, Suite 404, Washington, DC 22037
5 National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Department of Health and Human Services, Building 10, CRC, Room 1-5256, Bethesda, MD 20892
6 Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, 450 Technology Drive, Room 221, Pittsburgh, PA 15219
7 Washington Orthopaedics and Sports Medicine, 2021 K Street, #400, Washington, DC 20006
View Disclosures and Other Information
Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by the authors of this work are available with the online version of this article at jbjs.org.

  • Disclosure statement for author(s): PDF

Investigation performed at the Department of Orthopaedic Surgery, George Washington University, and the National Institutes of Health, Washington, DC
A commentary by Paul Manner, MD, is linked to the online version of this article at jbjs.org.

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Aug 03;93(15):1392-1398. doi: 10.2106/JBJS.J.00557
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Abstract

Background: 

A number of surgical approaches are utilized in total hip arthroplasty. It has been hypothesized that the anterior approach results in less muscle damage than the posterior approach. We prospectively analyzed biochemical markers of muscle damage and inflammation in patients treated with minimally invasive total hip arthroplasty with an anterior or posterior approach to provide objective evidence of the local soft-tissue injury at the time of arthroplasty.

Methods: 

Twenty-nine patients treated with minimally invasive total hip arthroplasty through a direct anterior approach and twenty-eight patients treated with the same procedure through a posterior approach were prospectively analyzed. Perioperative and radiographic data were collected to ensure cohorts with similar characteristics. Serum creatine kinase (CK), C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-1 beta (IL-1β), and tumor necrosis factor-alpha (TNF-α) levels were measured preoperatively, in the post-anesthesia-care unit (except for the CRP level), and on postoperative days 1 and 2. The Student t test and Fisher exact test were used to make comparisons between the two groups. Independent predictors of elevation in levels of markers of inflammation and muscle damage were determined with use of multivariate logistic regression analysis.

Results: 

The levels of the markers of inflammation were slightly decreased in the direct-anterior-approach group as compared with those in the posterior-approach group. The rise in the CK level in the posterior-approach group was 5.5 times higher than that in the anterior-approach group in the post-anesthesia-care unit (mean difference, 150.3 units/L [95% CI, 70.4 to 230.2]; p < 0.05) and nearly twice as high cumulatively (mean difference, 305.0 units/L [95% CI, −46.7 to 656.8]; p < 0.05).

Conclusions: 

We believe that the anterior total hip arthroplasty approach used in this study caused significantly less muscle damage than did the posterior surgical approach, as indicated by serum CK levels. The clinical importance of the rise in the CK level needs to be delineated by additional clinical studies. The overall physiologic burden, as demonstrated by measurement of inflammation marker levels, appears to be similar between the anterior and posterior approaches. Objective measurement of muscle damage and inflammation markers provides an unbiased way of determining the immediate effects of surgical intervention in patients treated with total hip arthroplasty.

Level of Evidence: 

Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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