July 9, 2014 Pelvic PT Distance Journal
Club
Purpose of the study: to
investigate whether the posterior approach (PA) total hip arthroplasty (THA)
differs from the anterior approach (AA) THA in influence on urinary
incontinence (UI)
·
Study was
done at the Department of Orthopedic Surgery, Juntendo University School of
Medicine, Tokyo, Japan
Background:
·
PA
description
o
Patient
position is lateral recumbent
o
Surgical
method thought to be safer, provides wider visual field
o
Differences
in muscle strength and walking ability compared to the AP were limited to the
early post-op period; muscle strength at 6-12 months do not differ between PA
and AP
o
Gluteus
maximus is divided, short external rotators (ER) including the obturator
internus are detached
o
T-shaped
incision in the articular capsule, femoral head resected, prosthetic implanted
o
Short ER are
sutured to their original position as much as possible
·
AA
description
o
Intermuscular
approach, also known as the Smith-Peterson approach; considered minimally
invasive (MIS)
o
Muscle
strength and walking ability recover earlier; dislocation rate is low
o
Patient
position is supine
o
Fascia of
the tensor fascia lata (TFL) is incised 2 cm lateral to the skin incision,
preventing lateral femoral cutaneous nerve injury
o
Intermuscular
space between the TFL and sartorius bluntly entered
o
Anterior
articular capsule exposed, incised, resected to expose the femoral head
o
Implant size
is confirmed by fluoroscopy
·
Hypothesis
o
PA
dissection of the short ER, including OI which connects to the levator ani
muscles, negatively affects symptoms of UI post-op THA
o
AA may
improve ER contracture of the hip joint and leg length, increasing tension of
the OI, which in turn would increase tension of the pelvic floor muscles (PFM)
and improve UI post-op THA
Subjects:
·
76 Japanese
females who underwent THA between 2011-2012
o
AA- 36
females
§
Mean age
64.2 + 12.5 years
§
Those with
UI pre-op mean age 70.1 + 9.7 years
§
Those w/o UI
pre-op mean age 62.5 + 10.1 years
§
Diagnoses:
OA = 32, osteonecrosis of femoral head = 2, RA = 2
o
PA- 40
females
§
Mean age
64.2 + 9.4 years
§
Those with
UI pre-op mean age 70.1 + 8.2 years
§
Those w/o UI
pre-op mean age 62.8 + 12.8 years
Methods:
·
ICIQ-SF by
way of direct interview before surgery and within 1-1.6 years post surgery
o
Five step
evaluation of score change from pre to post-op
§
Decrease by
3+ points = improved
§
Decrease by
1-2 points = slightly improved
§
No change =
unchanged
§
Increase by
1-2 points = slightly aggravated
§
Increase by
3+ points = aggravated
·
Statistics
o
Mann-Whitney
U
o
T-test
o
P < 0.05
regarded as significant
Results:
·
Age was
slightly higher in patients with pre-op UI in both groups, but not considered
significant per t-test
·
AA group
o
UI improved
post-op in 8, slightly improved in 1, remained unchanged in 26, slightly
aggravated 1, aggravated in 0 (Table 1)
o
Of 13
patients with UI pre-op, it improved post-op in 9, remained unchanged in 4,
aggravated in 0 (Table 2)
o
Of 23
patients w/o UI pre-op, it remained unchanged post-op in 22, slightly
aggravated in 1 (Table 2)
o
In the 13
patients who reported UI pre-op (one patient could give more than one symptom)
§
SUI with
cough/ sneeze = 9
§
SUI with
exercise = 2
§
UUI before
reaching toilet = 3
o
In the 9
patients in whom UI improved post-op but still had some symptoms
§
SUI with
cough/ sneeze = 7
·
PA group
o
UI improved post-op
in 1, remained unchanged in 30, slightly aggravated in 4, aggravated in 5
(Table 1)
o
Of 9
patients with UI pre-op, it improved in 1, remained unchanged in 3, aggravated
in 5 (Table 2)
o
Of 31
patients w/o UI pre-op, it remained unchanged in 27, aggravated in 4 (Table 3)
o
In the 9
patients who reported pre-op UI
§
SUI with
cough/ sneeze = 7
§
UUI before
reaching toilet = 4
o
In 9
patients reporting UI aggravation post-op
§
SUI with
cough/ sneeze = 9
·
UI improved
with AA THA and aggravated with PA THA
o
Mann-Whitney
U p = 0.0057
Conclusion:
·
As
predicted, a significant difference was noted in post-op UI between the AA and
PA
·
Authors
assumed that surgery through AA improved ER of the hip joint and leg length
leading to increased tension of the OI and hence the PFM which improved UI
o
Figure 2
axial view of CT scan of OI in patient undergoing AA showing maintenance of OI
volume (a pre and b post-op)
·
PA approach
dissects the OI and despite suturing, may not have been able to maintain normal
strength leading to UI aggravation
o
Figure 2
axial view of CT scan of OI in patient undergoing PA showing atrophied OI (c
pre and d post-op)
·
It is
possible that conservation of the short ER promotes recovery of their strength
and improves UI; this may be an advantage of the AA long-term in addition to
short-term advantages for hip joint function
Limitations:
·
Retrospective
self-evaluating survey with questionnaire only
·
No medium to
long term comparison of AA with PA
o
Although
they surveyed 40 PA patients an average of 5 years post-op (mean age 64.6) and
16 (40%) reported aggravation of UI, mostly SUI
Journal Club Discussion:
·
What other
limitations do you identify with this study?
·
What are the
clinical applications of this study?
·
How does
this study compare to the one done at Funabashi Orthopedic Hospital?
No comments:
Post a Comment
Note: Only a member of this blog may post a comment.