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Do Sex and BMI Predict or Does Stem Design Prevent Muscle Damage in Anterior Supine Minimally Invasive THA?

  • Symposium: 2014 Hip Society Proceedings
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Cadaveric and clinical studies have suggested that, despite being touted as muscle-sparing, the direct anterior approach is still associated with muscle damage, particularly to the tensor fascia lata (TFL). Patient body mass index (BMI) and/or sex may also influence this parameter.

Questions/purposes

The purposes of the study were to determine if using a shorter femoral component reduces TFL damage or if patient sex or increasing BMI increases intraoperative TFL damage in direct anterior THA.

Methods

Over a 1-year period, 599 direct anterior THAs were performed by three experienced anterior hip surgeons; of those, 421 direct anterior hips had complete data (70%) and were included in the study. The amount of visible damage to the TFL was recorded before closure. Two stem types were used, a standard-length flat-wedge taper (standard) or a 3-cm shortened version of the same stem (short). Stem selection was based on timeframe of the surgery, surgeon preference, or matching a previous implant type. During the study period, the three surgeons performed an additional 225 primary THAs with other approaches such that the direct anterior approach represented 73% of the THAs performed. A member of the operating team, either a fellow or physician assistant, graded the extent of damage based on a 0 to 3 scale. On this scale, 0 represented no muscle fiber damage, 1 superficial tearing, 2 deep tearing or maceration, and 3 complete tear or severe damage. Patient sex and BMI were recorded and compared with stem type and muscle damage scores. An ordinal logistic regression model was used for statistical analysis.

Results

After controlling for relevant confounding variables using logistic regression, we found that mean muscle damage was associated with male sex (0.93, SD 0.76 versus 0.70, SD 0.68; p < 0.001) and increasing BMI levels (p < 0.001). As BMI increased, more muscle damage also was found in men compared with women (p = 0.05; odds ratio [OR], 1.029; 95% confidence interval [CI], 1.000–1.060). There was no overall difference in mean muscle damage between short and standard-length stems (0.78, SD 0.77 versus 0.85, SD 0.69, p = 0.32); however, as BMI increased, less damage was seen with a short stem (p = 0.04; OR, 0.968; 95% CI, 0.931–0.997).

Conclusions

Visible muscle damage occurred in most hips during anterior supine intermuscular hip arthroplasty. The clinical importance of this muscle damage requires further study, because some evidence suggests earlier restoration of gait and cessation of walking aids with direct anterior THA despite this damage; however, this was not studied here. Surgeons performing this approach can expect more difficulty and as a result possibly more damage to the TFL in patients with male sex and increased BMI. The use of a short stem can be considered for patients with increased BMI to limit damage to the TFL.

Level of Evidence

Level III, therapeutic study.

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Acknowledgments

We thank Gerald Hobbs PhD, for his assistance in performing statistical analysis for this study.

Author information

Authors and Affiliations

  1. WVU Healthcare Center for Joint Replacement, Morgantown, WV, USA

    Benjamin M. Frye MD

  2. Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, WV, USA

    Benjamin M. Frye MD

  3. Joint Implant Surgeons, Inc, 7277 Smith’s Mill Road, Suite 200, New Albany, OH, 43054, USA

    Keith R. Berend MD, Adolph V. Lombardi Jr MD, Michael J. Morris MD & Joanne B. Adams BFA

  4. Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA

    Keith R. Berend MD & Adolph V. Lombardi Jr MD

  5. Mount Carmel Health System, New Albany, OH, USA

    Keith R. Berend MD, Adolph V. Lombardi Jr MD & Michael J. Morris MD

Authors
  1. Benjamin M. Frye MD
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  2. Keith R. Berend MD
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  3. Adolph V. Lombardi Jr MD
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  4. Michael J. Morris MD
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  5. Joanne B. Adams BFA
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Corresponding author

Correspondence to Keith R. Berend MD.

Additional information

One of the authors (KRB) certifies that he has or may receive payments or benefits, in any one year, an amount in excess of USD 1,000,000 from Biomet, Inc (Warsaw, IN, USA). One of the authors (AVL) certifies that he has or may receive payments or benefits, in any one year, an amount in excess of USD 1,000,000, from Biomet, Inc and Innomed, Inc (Savannah, GA, USA). The institution of the authors has received institutional research support from Biomet, Inc, Stryker (Mahwah, NJ, USA), and a grant from the Piedmont Orthopaedic Society (Durham, NC, USA).

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research ® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use.

Each author certifies that his or her institution has approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at Joint Implant Surgeons, Inc, New Albany, OH, USA.

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Frye, B.M., Berend, K.R., Lombardi, A.V. et al. Do Sex and BMI Predict or Does Stem Design Prevent Muscle Damage in Anterior Supine Minimally Invasive THA?. Clin Orthop Relat Res 473, 632–638 (2015). https://doi.org/10.1007/s11999-014-3991-1

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  • DOI: https://doi.org/10.1007/s11999-014-3991-1

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