- Email: [email protected]
Comparison of patient satisfaction after unilateral or simultaneous bilateral total hip arthroplasty through a direct anterior approach: Evaluation using the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire
Journal of Orthopaedic Science xxx (2016) 1e4
Contents lists available at ScienceDirect
Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Original article
Comparison of patient satisfaction after unilateral or simultaneous bilateral total hip arthroplasty through a direct anterior approach: Evaluation using the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire Hiroyuki Yoshii*, Kazuhiro Oinuma, Tatsuya Tamaki, Yoko Miura, Ryutaku Kaneyama, Hideaki Shiratsuchi Funabashi Orthopedic Hospital, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 1 August 2015 Received in revised form 23 January 2016 Accepted 25 January 2016 Available online xxx
Background: The aim of this study was to compare patients' perception of treatment outcome after unilateral or simultaneous total hip arthroplasty (THA) using the newly developed Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ). Methods: This study included 429 patients treated with primary THA using a direct anterior approach, namely 304 cases of in the unilateral THA (58 males and 246 females; mean age, 62.3 years) and 125 cases of in the simultaneous bilateral THA (24 males and 101 females; mean age, 58.3 years). Items for evaluation included clinical outcomes and all four aspects of the JHEQ score, namely visual analog scale (VAS), pain, movement, and mental status. Results: The mean operative time per hip was 51.3 ± 19.4 min (range, 22e180 min) in unilateral group and 46.2 ± 15.1 min (range, 26e106 min) in simultaneous bilateral group. The mean operative blood loss per hip was 421.2 ml ± 232.1 ml (range, 70e1300 ml) in unilateral group and 200.8 ± 149.8 ml (range, 30e1040 ml) in simultaneous bilateral group. The total JHEQ score (pain/motion/mental status) improved from 26.5 ± 13.6 (preoperative, 10.1/6.8/9.6) to 69.4 ± 14.8 (1 year postoperatively, 25.1/ 20.5/23.8) in unilateral group and from 21.0 ± 8.2 (preoperative, 11.9/2.3/6.9) to 74.9 ± 9.5 (1 year postoperatively, 27.2/22.6/25.0) in simultaneous bilateral group. These results demonstrated a significant improvement before and after surgery for patients in both groups. There were not major complications such as dislocation, bone fracture, nerve palsy or symptomatic pulmonary embolism were observed. Conclusion: In this study, we observed greater improvement in JHEQ in patients treated with bilateral simultaneous THA than in those treated with unilateral THA. These findings demonstrated that bilateral simultaneous THA was related to high patient satisfaction as well as high safety. © 2016 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
1. Introduction Total hip arthroplasty (THA) remains the main treatment option for advanced hip arthritis. The direct anterior, direct lateral, and posterior approaches are the most commonly used techniques [1]. The direct anterior (DA) approach is gaining popularity among
* Corresponding author. Funabashi Orthopedic Hospital, 1-833 Hazama, Funabashi, Chiba 274-0822, Japan. Tel.: þ81 47 425 5585; fax: þ81 47 425 6592. E-mail address: [email protected] (H. Yoshii).
experienced orthopedic surgeons because it does not require specialized equipment. In addition, the DA approach is also associated with a better prognosis due to the smaller incision and muscle-sparing nature of the procedure. The literature describes the DA approach for unilateral THA [2,3] and simultaneous bilateral THA [4,5]. However, no study to date has compared the prognosis and clinical outcome of unilateral and simultaneous bilateral THA using the DA approach. The Harris Hip Score [6], the Japanese Orthopaedic Association and Postel score [8] (JOA) hip score [7], and the Merle d'Aubigne are often used as methods to evaluate the functionality of the
http://dx.doi.org/10.1016/j.jos.2016.01.008 0949-2658/© 2016 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Yoshii H, et al., Comparison of patient satisfaction after unilateral or simultaneous bilateral total hip arthroplasty through a direct anterior approach: Evaluation using the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.01.008
2
H. Yoshii et al. / Journal of Orthopaedic Science xxx (2016) 1e4
hip joint by healthcare providers. Additional methods for the evaluation of hip joint function, include the Short-Form 36 Health Survey (SF-36) [9] and the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) [10], which involves the self-evaluation of health-related quality of life (QOL). However, Pacault-Legendre et al. reported that patient self-evaluations and overall satisfaction were not always in agreement with the evaluations performed by health-care providers, and that the QOL questionnaire alone was not sufficient for obtaining subjective patient evaluations [11]. In recent years, the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) [12] has become a popular evaluation tool for patients who have had THA [13,14]. The Japanese JHEQ consists of seven questions regarding pain, movement, and mental status (21 questions total) and a visual analog scale (VAS) that is used to assess hip joint function. The JHEQ is a diseasespecific appraisal method that includes the subjective evaluation of patients. While there are several published reports on unilateral THA [13,14], no reports to date have used the JHEQ to evaluate the clinical outcome of patients who underwent simultaneous bilateral THA. Therefore, the objective of this retrospective study was to compare the early clinical outcome of patients who underwent unilateral THA or simultaneous bilateral THA using a DA approach based on the JHEQ. 2. Materials and methods 2.1. Study description The present study consisted of assessing the outcome of 668 consecutive patients who underwent unilateral THA or simultaneous bilateral THA from January 2013 and January 2014, using the JHEQ questionnaire. The exclusion criteria were as follows: a history of hip surgery before the present procedure and a lack of information on their questionnaire. This study was conducted with the approval of the institutional review board of our institution. A signed informed consent form to participate was obtained from all patients. 2.2. Patient details Among the 668 consecutive cases of THA performed at our institution from January 2013 to January 2014, 521 patients underwent unilateral THA and 147 patients received simultaneous bilateral THA. We excluded 57 patients due to a history of osteotomy or trauma, 16 cases of reoperation, and 85 cases that required two-stage bilateral THA. In the unilateral group, 43 cases of osteoarthritis on the contralateral side were excluded because it could affect their recovery. Thus the contralateral side was normal or consisted of a dysplastic hip without osteoarthritis change in this group. In the simultaneous bilateral group, there were no cases of a unilateral side as the final condition. We excluded 13 cases with a history of osteotomy and 2 cases of reoperation. A total of 11 cases could not be followed up for more than one year after surgery, and 12 cases did not adequately complete the questionnaire. Therefore, the present study compared 304 cases of unilateral THA and 125 cases (250 hips) of simultaneous bilateral THA. 2.3. Surgical procedures All surgical procedures were performed using the DA approach with the patients in the supine position on a standard surgical table [15e17]. We proactively performed a simultaneous bilateral THA when indicated at our hospital because it is a safe and
effective surgery that has been recommended by several reports [18e20]. At our hospital, the fitness of the patients was categorized based on the American Society of Anaesthesiologists' (ASA) rating. Simultaneous bilateral THA was indicated for low risk patients (an ASA grade 1 or 2) but was rejected if the patients were not stable enough to undergo this procedure(an ASA grade 3 or 4). In the bilateral group, the side requiring the most severe osteoarthritic changes was operated first. The contralateral side was subsequently operated after blood loss was quantified and hemodynamic stability confirmed for the first side. In the bilateral group, preoperative autologous blood donation was performed on 58 patients, and intraoperative blood salvage was performed on all patients. 2.4. Assessment of patient outcome All patients followed the same postoperative rehabilitation program starting the day after surgery. The program included gait training with full weight bearing using a walker, followed by walking with a T-cane and navigating stairs. This program was completed prior to discharge of the patient 4e10 days post-surgery. Excessive extension and flexion of the hip were limited until three weeks after surgery to prevent early dislocation, and no particular limits were set after three months. The outcome parameters included standard measurements consisting of operative time per hip, blood loss per hip, allogeneic blood transfusion, and complications. In addition, all patients filled out the JHEQ preoperatively and one year after the THA surgery to assess individual improvement rate. The JHEQ includes questions addressing four aspects of the hip joint: 1) hip joint condition using the visual analog scale (VAS); 2) pain; 3) movement; and 4) mental status [12]. 2.5. Statistical analysis The data obtained for the unilateral and bilateral groups were expressed as the mean ± standard deviation (SD) and were compared using Student t-tests. Differences were considered statistically significant if p < 0.05. 3. Results 3.1. The patient characteristics were similar between groups Table 1 compares the demographic data of the two groups. No significant differences were observed between the two groups regarding the frequency distribution of the types of preoperative diagnosis. Overall, the most common diagnosis was osteoarthritis of the hip (94.4%), followed by avascular necrosis of the femoral head (4.2%), and rheumatoid arthritis (1.4%). The intraoperative
Table 1 Demographic data of patients receiving THA surgery.
Number of patients Age (years) Gender (M/F) Diagnosis Osteoarthritis Avascular necrosis Rheumatoid arthritis Operative time per hip Blood loss Follow-up period (months)
Unilateral
Bilateral
p Value
304 62.3 ± 10.1 58/246
125 58.3 ± 9.7 24/101
p ¼ 0.0016
289 11 4 51.3 ± 19.4 421.2 ± 232.1 13.1 ± 2.4
116 7 2 46.2 ± 15.1 200.8 ± 149.8 12.5 ± 1.8
p ¼ 0.0038 p < 0.0001 p ¼ 0.1986
Please cite this article in press as: Yoshii H, et al., Comparison of patient satisfaction after unilateral or simultaneous bilateral total hip arthroplasty through a direct anterior approach: Evaluation using the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.01.008
H. Yoshii et al. / Journal of Orthopaedic Science xxx (2016) 1e4 Table 2 Results for each JHEQ criterion and the changes before and after surgery. Preoperative scores Unilateral VAS Pain Motion Mental Total
79.0 10.1 6.8 9.6 26.5
± ± ± ± ±
17.5 6.1 4.9 5.4 13.6
One year follow-up
Bilateral 93.0 11.9 2.3 6.9 21.0
± ± ± ± ±
7.2 3.3 1.9 4.3 8.2
p Value
Unilateral
0.007 0.319 0.002 0.014 0.181
4.8 25.1 20.5 23.8 69.4
± ± ± ± ±
8.5 5.3 6.9 4.9 14.8
Bilateral 5.4 27.2 22.6 25.0 74.9
± ± ± ± ±
6.6 1.7 6.7 3.6 9.5
p Value 0.736 0.169 0.356 0.433 0.232
time per hip was lower for the simultaneous bilateral group compared to the unilateral group (p ¼ 0.0038). Another advantage of simultaneous bilateral THA was lower intraoperative blood loss per hip, compared to unilateral THA (p < 0.0001). In the unilateral group, intraoperative blood salvage was performed in 42 patients. No patient required an allogeneic blood transfusion. The mean follow-up period was 12.9 ± 3.1 months. During this time, none of the patients developed major complications, such as hip dislocation, bone fracture, nerve palsy, or venous thromboembolism. 3.2. Patient preoperative status between THA surgical groups The preoperative status of the patients scheduled for unilateral THA or simultaneous bilateral THA was assessed using the JHEQ completed by each patient before the procedure. Table 2 shows that there was no significant difference between groups regarding the overall pain level. In contrast, the other scores were consistent with the more severe status of patients with bilateral hip pain. This was particularly the case for a significantly higher VAS (p ¼ 0.007) with lower scores for motion (p ¼ 0.002) and mental status (p ¼ 0.014), than for the unilateral group. One year after the THA, there was no significant difference in the total JHEQ score or individual scores between the two groups. 3.3. Patient postoperative status between THA surgical groups All patients reported a significant improvement in their condition after both types of THA (Table 3). The percent improvement for the total JHEQ score was significantly higher for the simultaneous bilateral group than for the unilateral group (p ¼ 0.004). This result reflected all aspects of the questionnaire, except for the similar reduction in pain level reported by both groups. Additionally, Table 4 shows the age-matched subgroup analysis. These results were similar to the overall results. 4. Discussion This is the first study to demonstrate a significantly greater satisfaction in bilateral simultaneous THA cases in comparison to unilateral THA cases. Clinical outcomes based on objective evaluations, including operative time, blood loss, and complications have been reported previously. However, clinical THA outcome based on subjective evaluations, including the JHEQ have only occasionally been described. Furthermore, to our knowledge there are no reports on the clinical outcome of patients who underwent simultaneous bilateral THA. The JHEQ can also be used to evaluate motions that are unusual among Japanese patients, such as deep flexion of the hip, and evaluating patient satisfaction after THA. In previous studies of simultaneous bilateral THA, only the safety of the procedure and the economic aspects were reported. Alfaro-Adrian et al. [21] reported that simultaneous bilateral THA
3
was advantageous in that it only required a single anesthesia and therefore, the risks associated with anesthesia could be reduced. Additionally, Parvizi et al. [22] reported that the period of hip joint dysfunction could be reduced when simultaneous bilateral THA was performed. Both Eggli et al. [18] and Ritter et al. [23] reported a decrease in the duration and cost of hospitalization with simultaneous bilateral THA. The JHEQ results from this study indicated that the degree of improvement in the condition of the hip joint was significantly higher in the bilateral group based on the VAS, motion, and mental status. This is most likely due to the bilateral morbidity, as the VAS indicating the hip joint condition and the total JHEQ score (including the mental category) were lower in the bilateral cases before surgery. Since the postoperative satisfaction level has increased more significantly in the bilateral group, it seems that this study resulted in these outcomes. In addition, there was a higher ratio of younger people in the bilateral simultaneous group. Moreover, when compared by age, the postoperative status was better in the bilateral simultaneous group, despite the fact that the patients had a lower preoperative status. Therefore, we consider age to be a factor in this discrepancy. On the other hand, complications, including deep vein thrombosis, blood transfusion, dislocation, and infection have also been reported and remain controversial. Several reports have demonstrated no significant difference in the incidence of deep vein thrombosis between simultaneous bilateral and unilateral patient groups [18,21,24]. It has also been reported that allogeneic blood transfusion was required for 20e66% of patients [20,21]. However, in our study, no patients required an allogenic blood transfusion. In the Bilateral Simultaneous operation, we feel the second side is easier than the first side because of the anatomical similarity, which may result in the shorter operation time and smaller amount of bleeding on the second side. Many studies have reported no difference in the incidence of postoperative hip dislocation between patients who underwent simultaneous bilateral or unilateral THA [19,23,24]. In line with these reports, we did not observe any postoperative dislocations in either group. There were some limitations to this study. First, there was a significantly lower mean age in the simultaneous bilateral group. This could be explained by the fact that simultaneous bilateral THA is typically performed in comparatively younger patients who are in better condition. Nevertheless, this age difference does not affect the conclusion that bilateral cases have a higher JHEQ improvement rate. Secondly, this study had a short follow-up period. However, a good long-term outcome can be also expected regardless of the short follow-up period because loosening of the implant or sinking of the stem by X-ray were not observed. While further follow-up is required, the fact that there was a significant difference in the short-term results remains despite any future changes. This study suggests that simultaneous bilateral THA is a surgical procedure that can result in a high level of postoperative patient satisfaction. Our results demonstrated significant improvements based on the JHEQ in the bilateral group compared to the unilateral group.
Table 3 Improvement rate (%) for each JHEQ criterion. Unilateral VAS Pain Motion Mental Total
76.2 71.3 51.8 64.1 63.1
± ± ± ± ±
32.5 57.9 34.8 30.6 27.5
Bilateral 87.1 79.9 60.8 74.5 70.5
± ± ± ± ±
15.8 27.7 24.3 23.3 20.1
p Value p ¼ 0.013 n.s p < 0.001 p ¼ 0.003 p ¼ 0.004
Please cite this article in press as: Yoshii H, et al., Comparison of patient satisfaction after unilateral or simultaneous bilateral total hip arthroplasty through a direct anterior approach: Evaluation using the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.01.008
4
H. Yoshii et al. / Journal of Orthopaedic Science xxx (2016) 1e4
Table 4 Results for each item of the JHEQ and the changes before and after surgery (age-matched subgroup analysis). Preoperative scores Unilateral <50 yrs VAS Pain Motion Mental Total 50e59 yrs VAS Pain Motion Mental Total 60e69 yrs VAS Pain Motion Mental Total 70 yrs< VAS Pain Motion Mental Total
One year follow-up Bilateral
p Value
Unilateral
Bilateral
p Value
78.8 9.4 6.6 9.7 25.7
± ± ± ± ±
12.9 7.0 4.9 4.6 10.9
87.0 12.8 2.4 7.2 21.6
± ± ± ± ±
11.3 3.5 3.9 3.1 8.1
0.035 0.048 0.025 0.058 0.274
4.7 25.9 21.4 24.3 71.5
± ± ± ± ±
7.1 1.9 6.7 4.5 10.6
5.3 26.6 23.7 25.2 75.6
± ± ± ± ±
3.7 2.1 4.8 2.9 7.5
0.386 0.384 0.507 0.821 0.385
80.6 10.7 6.9 9.7 26.6
± ± ± ± ±
16.8 4.9 4.2 5.8 10.6
93.1 10.6 2.2 6.8 19.6
± ± ± ± ±
9.9 4.3 2.5 4.3 7.9
0.001 0.869 0.004 0.014 0.015
4.9 25.8 21.6 24.8 72.6
± ± ± ± ±
8.3 4.4 5.9 5.2 13.8
4.9 26.8 22.9 26.9 76.5
± ± ± ± ±
7.1 2.6 5.7 3.3 9.1
0.727 0.329 0.427 0.556 0.359
80.7 10.2 6.7 9.7 26.6
± ± ± ± ±
21.4 6.4 5.5 6.3 15.4
92.6 11.8 3.5 7.1 20.8
± ± ± ± ±
8.4 4.9 2.7 5.0 10.7
0.008 0.155 0.016 0.035 0.032
4.9 25.1 20.2 24.1 69.9
± ± ± ± ±
9.1 5.6 6.2 5.2 14.9
5.4 26.8 22.8 25.1 74.7
± ± ± ± ±
6.8 1.9 4.9 2.5 11.1
0.519 0.269 0.431 0.869 0.139
79.8 9.3 6.9 8.9 26.1
± ± ± ± ±
18.9 4.9 4.6 5.5 8.4
88.5 11.9 2.0 6.5 21.5
± ± ± ± ±
11.8 5.3 2.6 5.9 9.5
0.045 0.081 0.002 0.042 0.029
4.4 25.0 20.2 22.6 67.2
± ± ± ± ±
5.7 4.4 6.1 6.0 15.2
5.5 26.5 22.1 23.2 72.8
± ± ± ± ±
12.2 3.1 5.7 3.5 7.3
0.608 0.311 0.514 0.845 0.126
Conflict of interest The authors declare that they have no conflict of interest.
References [1] Petis S, Howard JL, Lanting BL, Vasarhelyi EM. Surgical approach in primary total hip arthroplasty: anatomy, technique and clinical outcomes. Can J Surg 2015 Apr;58(2):128e39. [2] Hallert O, Li Y, Brismar H, Lindgren U. The direct anterior approach: initial experience of a minimally invasive technique for total hip arthroplasty. J Orthop Surg Res 2012 Apr 25;7:17. [3] Russo MW, Macdonell JR, Paulus MC, Keller JM, Zawadsky MW. Increased complications in obese patients undergoing direct anterior total hip arthroplasty. J Arthroplasty 2015 Aug;30(8):1384e7. [4] Lanting BA, Odum SM, Cope RP, Patterson AH, Masonis JL. Incidence of perioperative events in single setting bilateral direct anterior approach total hip arthroplasty. J Arthroplasty 2015 Mar;30(3):465e7. [5] Parvizi J, Rasouli MR, Jaberi M, Chevrollier G, Vizzi S, Sharkey PF, Hozack WJ. Does the surgical approach in one stage bilateral total hip arthroplasty affect blood loss? Int Orthop 2013 Dec;37(12):2357e62. [6] Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Jt Surg Am 1969 Jun;51(4):737e55. [7] Imura S. The Japanese Orthopaedic Association: evaluation chart of hip joint functions. J Jpn Orthop Assoc 1995;69:864e7. [8] D'aubigne RM, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Jt Surg Am 1954 Jun;36-A(3):451e75. [9] Ware Jr JE, Sherboume CD. The MOS 36-item short-form health survey (SF36). I. Conceptual framework and item selection. Med Care 1992 Jun;30(6): 473e83. [10] Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 1988 Dec;15(12): 1833e40. [11] Pacault-Legendre V, Courpied JP. Survey of patients satisfaction after total arthroplasty of the hip. Int Orthop 1999;23(1):23e30.
[12] Matsumoto T, Kaneuji A, Hiejima Y, Sugiyama H, Akiyama H, Atsumi T, Ishii M, Izumi K, Ichiseki T, Ito H, Okawa T, Ohzono K, Otsuka H, Kishida S, Kobayashi S, Sawaguchi T, Sugano N, Nakajima I, Nakamura S, Hasegawa Y, Fukuda K, Fujii G, Mawatari T, Mori S, Yasunaga Y, Yamaguchi M. Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ): a patient-based evaluation tool for hip-joint disease. The Subcommittee on Hip Disease Evaluation of the Clinical Outcome Committee of the Japanese Orthopaedic Association. J Orthop Sci 2012 Jan;17(1):25e38. [13] Nakamura S, Kanezaki S, Nishino H, Matsushita T. JHEQ for evaluation of total hip arthroplasty. Hip Jt 2013;13(39):45e8 [in Japanese]. [14] Usuda K, Mizuochi H, Tanaka J, Yamamoto M, Sawaguchi T, Sakagoshi D. Evaluation of correlation between JHEQ and JOA score for total hip arthroplasty. Hip Jt 2013;13(39):77e80 [in Japanese]. [15] Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res 2005 Dec;441: 115e24. [16] Kennon RE, Keggi JM, Wetmore RS, Zatorski LE, Huo MH, Keggi KJ. Total hip arthroplasty through a minimally invasive anterior surgical approach. J Bone Jt Surg Am 2003;85-A(Suppl. 4):39e48. [17] Oinuma K, Eingartner C, Saito Y, Shiratsuchi H. Total hip arthroplasty by a minimally invasive, direct anterior approach. Oper Orthop Traumatol 2007 Aug;19(3):310e26. [18] Eggli S, Huckell CB, Ganz R. Bilateral total hip arthroplasty: one stage versus two stage procedure. Clin Orthop Relat Res 1996 Jul;328:108e18. [19] Berend ME, Ritter MA, Harty LD, Davis KE, Keating EM, Meding JB, Thong AE. Simultaneous bilateral versus unilateral total hip arthroplasty: an outcomes analysis. J Arthroplasty 2005 Jun;20(4):421e6. [20] Kim YH, Kwon OR, Kim JS. Is one-stage bilateral sequential total hip replacement as safe as unilateral total hip replacement? J Bone Jt Surg Br 2009 Mar;91(3):316e20. [21] Alfaro-Adrian J, Bayona F, Rech JA, Murray DW. One- or two-stage bilateral total hip replacement. J Arthroplasty 1999 Jun;14(4):439e45. [22] Parvizi J, Pour AE, Peak EL, Sharkey PF, Hozack WJ, Rothman RH. One-stage bilateral total hip arthroplasty compared with unilateral total hip arthroplasty: a prospective study. J Arthroplasty 2006 Sep;21(6 Suppl. 2):26e31. [23] Ritter MA, Stringer EA. Bilateral total hip arthroplasty: a single procedure. Clin Orthop Relat Res 1980 Jun;149:185e90. [24] Bhan S, Pankaj A, Malhotra R. One- or two-stage bilateral total hip arthroplasty: a prospective, randomised, controlled study in an Asian population. J Bone Jt Surg Br 2006 Mar;88(3):298e303.
Please cite this article in press as: Yoshii H, et al., Comparison of patient satisfaction after unilateral or simultaneous bilateral total hip arthroplasty through a direct anterior approach: Evaluation using the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.01.008
Contents lists available at ScienceDirect
Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Original article
Comparison of patient satisfaction after unilateral or simultaneous bilateral total hip arthroplasty through a direct anterior approach: Evaluation using the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire Hiroyuki Yoshii*, Kazuhiro Oinuma, Tatsuya Tamaki, Yoko Miura, Ryutaku Kaneyama, Hideaki Shiratsuchi Funabashi Orthopedic Hospital, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 1 August 2015 Received in revised form 23 January 2016 Accepted 25 January 2016 Available online xxx
Background: The aim of this study was to compare patients' perception of treatment outcome after unilateral or simultaneous total hip arthroplasty (THA) using the newly developed Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ). Methods: This study included 429 patients treated with primary THA using a direct anterior approach, namely 304 cases of in the unilateral THA (58 males and 246 females; mean age, 62.3 years) and 125 cases of in the simultaneous bilateral THA (24 males and 101 females; mean age, 58.3 years). Items for evaluation included clinical outcomes and all four aspects of the JHEQ score, namely visual analog scale (VAS), pain, movement, and mental status. Results: The mean operative time per hip was 51.3 ± 19.4 min (range, 22e180 min) in unilateral group and 46.2 ± 15.1 min (range, 26e106 min) in simultaneous bilateral group. The mean operative blood loss per hip was 421.2 ml ± 232.1 ml (range, 70e1300 ml) in unilateral group and 200.8 ± 149.8 ml (range, 30e1040 ml) in simultaneous bilateral group. The total JHEQ score (pain/motion/mental status) improved from 26.5 ± 13.6 (preoperative, 10.1/6.8/9.6) to 69.4 ± 14.8 (1 year postoperatively, 25.1/ 20.5/23.8) in unilateral group and from 21.0 ± 8.2 (preoperative, 11.9/2.3/6.9) to 74.9 ± 9.5 (1 year postoperatively, 27.2/22.6/25.0) in simultaneous bilateral group. These results demonstrated a significant improvement before and after surgery for patients in both groups. There were not major complications such as dislocation, bone fracture, nerve palsy or symptomatic pulmonary embolism were observed. Conclusion: In this study, we observed greater improvement in JHEQ in patients treated with bilateral simultaneous THA than in those treated with unilateral THA. These findings demonstrated that bilateral simultaneous THA was related to high patient satisfaction as well as high safety. © 2016 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
1. Introduction Total hip arthroplasty (THA) remains the main treatment option for advanced hip arthritis. The direct anterior, direct lateral, and posterior approaches are the most commonly used techniques [1]. The direct anterior (DA) approach is gaining popularity among
* Corresponding author. Funabashi Orthopedic Hospital, 1-833 Hazama, Funabashi, Chiba 274-0822, Japan. Tel.: þ81 47 425 5585; fax: þ81 47 425 6592. E-mail address: [email protected] (H. Yoshii).
experienced orthopedic surgeons because it does not require specialized equipment. In addition, the DA approach is also associated with a better prognosis due to the smaller incision and muscle-sparing nature of the procedure. The literature describes the DA approach for unilateral THA [2,3] and simultaneous bilateral THA [4,5]. However, no study to date has compared the prognosis and clinical outcome of unilateral and simultaneous bilateral THA using the DA approach. The Harris Hip Score [6], the Japanese Orthopaedic Association and Postel score [8] (JOA) hip score [7], and the Merle d'Aubigne are often used as methods to evaluate the functionality of the
http://dx.doi.org/10.1016/j.jos.2016.01.008 0949-2658/© 2016 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Yoshii H, et al., Comparison of patient satisfaction after unilateral or simultaneous bilateral total hip arthroplasty through a direct anterior approach: Evaluation using the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.01.008
2
H. Yoshii et al. / Journal of Orthopaedic Science xxx (2016) 1e4
hip joint by healthcare providers. Additional methods for the evaluation of hip joint function, include the Short-Form 36 Health Survey (SF-36) [9] and the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) [10], which involves the self-evaluation of health-related quality of life (QOL). However, Pacault-Legendre et al. reported that patient self-evaluations and overall satisfaction were not always in agreement with the evaluations performed by health-care providers, and that the QOL questionnaire alone was not sufficient for obtaining subjective patient evaluations [11]. In recent years, the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) [12] has become a popular evaluation tool for patients who have had THA [13,14]. The Japanese JHEQ consists of seven questions regarding pain, movement, and mental status (21 questions total) and a visual analog scale (VAS) that is used to assess hip joint function. The JHEQ is a diseasespecific appraisal method that includes the subjective evaluation of patients. While there are several published reports on unilateral THA [13,14], no reports to date have used the JHEQ to evaluate the clinical outcome of patients who underwent simultaneous bilateral THA. Therefore, the objective of this retrospective study was to compare the early clinical outcome of patients who underwent unilateral THA or simultaneous bilateral THA using a DA approach based on the JHEQ. 2. Materials and methods 2.1. Study description The present study consisted of assessing the outcome of 668 consecutive patients who underwent unilateral THA or simultaneous bilateral THA from January 2013 and January 2014, using the JHEQ questionnaire. The exclusion criteria were as follows: a history of hip surgery before the present procedure and a lack of information on their questionnaire. This study was conducted with the approval of the institutional review board of our institution. A signed informed consent form to participate was obtained from all patients. 2.2. Patient details Among the 668 consecutive cases of THA performed at our institution from January 2013 to January 2014, 521 patients underwent unilateral THA and 147 patients received simultaneous bilateral THA. We excluded 57 patients due to a history of osteotomy or trauma, 16 cases of reoperation, and 85 cases that required two-stage bilateral THA. In the unilateral group, 43 cases of osteoarthritis on the contralateral side were excluded because it could affect their recovery. Thus the contralateral side was normal or consisted of a dysplastic hip without osteoarthritis change in this group. In the simultaneous bilateral group, there were no cases of a unilateral side as the final condition. We excluded 13 cases with a history of osteotomy and 2 cases of reoperation. A total of 11 cases could not be followed up for more than one year after surgery, and 12 cases did not adequately complete the questionnaire. Therefore, the present study compared 304 cases of unilateral THA and 125 cases (250 hips) of simultaneous bilateral THA. 2.3. Surgical procedures All surgical procedures were performed using the DA approach with the patients in the supine position on a standard surgical table [15e17]. We proactively performed a simultaneous bilateral THA when indicated at our hospital because it is a safe and
effective surgery that has been recommended by several reports [18e20]. At our hospital, the fitness of the patients was categorized based on the American Society of Anaesthesiologists' (ASA) rating. Simultaneous bilateral THA was indicated for low risk patients (an ASA grade 1 or 2) but was rejected if the patients were not stable enough to undergo this procedure(an ASA grade 3 or 4). In the bilateral group, the side requiring the most severe osteoarthritic changes was operated first. The contralateral side was subsequently operated after blood loss was quantified and hemodynamic stability confirmed for the first side. In the bilateral group, preoperative autologous blood donation was performed on 58 patients, and intraoperative blood salvage was performed on all patients. 2.4. Assessment of patient outcome All patients followed the same postoperative rehabilitation program starting the day after surgery. The program included gait training with full weight bearing using a walker, followed by walking with a T-cane and navigating stairs. This program was completed prior to discharge of the patient 4e10 days post-surgery. Excessive extension and flexion of the hip were limited until three weeks after surgery to prevent early dislocation, and no particular limits were set after three months. The outcome parameters included standard measurements consisting of operative time per hip, blood loss per hip, allogeneic blood transfusion, and complications. In addition, all patients filled out the JHEQ preoperatively and one year after the THA surgery to assess individual improvement rate. The JHEQ includes questions addressing four aspects of the hip joint: 1) hip joint condition using the visual analog scale (VAS); 2) pain; 3) movement; and 4) mental status [12]. 2.5. Statistical analysis The data obtained for the unilateral and bilateral groups were expressed as the mean ± standard deviation (SD) and were compared using Student t-tests. Differences were considered statistically significant if p < 0.05. 3. Results 3.1. The patient characteristics were similar between groups Table 1 compares the demographic data of the two groups. No significant differences were observed between the two groups regarding the frequency distribution of the types of preoperative diagnosis. Overall, the most common diagnosis was osteoarthritis of the hip (94.4%), followed by avascular necrosis of the femoral head (4.2%), and rheumatoid arthritis (1.4%). The intraoperative
Table 1 Demographic data of patients receiving THA surgery.
Number of patients Age (years) Gender (M/F) Diagnosis Osteoarthritis Avascular necrosis Rheumatoid arthritis Operative time per hip Blood loss Follow-up period (months)
Unilateral
Bilateral
p Value
304 62.3 ± 10.1 58/246
125 58.3 ± 9.7 24/101
p ¼ 0.0016
289 11 4 51.3 ± 19.4 421.2 ± 232.1 13.1 ± 2.4
116 7 2 46.2 ± 15.1 200.8 ± 149.8 12.5 ± 1.8
p ¼ 0.0038 p < 0.0001 p ¼ 0.1986
Please cite this article in press as: Yoshii H, et al., Comparison of patient satisfaction after unilateral or simultaneous bilateral total hip arthroplasty through a direct anterior approach: Evaluation using the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.01.008
H. Yoshii et al. / Journal of Orthopaedic Science xxx (2016) 1e4 Table 2 Results for each JHEQ criterion and the changes before and after surgery. Preoperative scores Unilateral VAS Pain Motion Mental Total
79.0 10.1 6.8 9.6 26.5
± ± ± ± ±
17.5 6.1 4.9 5.4 13.6
One year follow-up
Bilateral 93.0 11.9 2.3 6.9 21.0
± ± ± ± ±
7.2 3.3 1.9 4.3 8.2
p Value
Unilateral
0.007 0.319 0.002 0.014 0.181
4.8 25.1 20.5 23.8 69.4
± ± ± ± ±
8.5 5.3 6.9 4.9 14.8
Bilateral 5.4 27.2 22.6 25.0 74.9
± ± ± ± ±
6.6 1.7 6.7 3.6 9.5
p Value 0.736 0.169 0.356 0.433 0.232
time per hip was lower for the simultaneous bilateral group compared to the unilateral group (p ¼ 0.0038). Another advantage of simultaneous bilateral THA was lower intraoperative blood loss per hip, compared to unilateral THA (p < 0.0001). In the unilateral group, intraoperative blood salvage was performed in 42 patients. No patient required an allogeneic blood transfusion. The mean follow-up period was 12.9 ± 3.1 months. During this time, none of the patients developed major complications, such as hip dislocation, bone fracture, nerve palsy, or venous thromboembolism. 3.2. Patient preoperative status between THA surgical groups The preoperative status of the patients scheduled for unilateral THA or simultaneous bilateral THA was assessed using the JHEQ completed by each patient before the procedure. Table 2 shows that there was no significant difference between groups regarding the overall pain level. In contrast, the other scores were consistent with the more severe status of patients with bilateral hip pain. This was particularly the case for a significantly higher VAS (p ¼ 0.007) with lower scores for motion (p ¼ 0.002) and mental status (p ¼ 0.014), than for the unilateral group. One year after the THA, there was no significant difference in the total JHEQ score or individual scores between the two groups. 3.3. Patient postoperative status between THA surgical groups All patients reported a significant improvement in their condition after both types of THA (Table 3). The percent improvement for the total JHEQ score was significantly higher for the simultaneous bilateral group than for the unilateral group (p ¼ 0.004). This result reflected all aspects of the questionnaire, except for the similar reduction in pain level reported by both groups. Additionally, Table 4 shows the age-matched subgroup analysis. These results were similar to the overall results. 4. Discussion This is the first study to demonstrate a significantly greater satisfaction in bilateral simultaneous THA cases in comparison to unilateral THA cases. Clinical outcomes based on objective evaluations, including operative time, blood loss, and complications have been reported previously. However, clinical THA outcome based on subjective evaluations, including the JHEQ have only occasionally been described. Furthermore, to our knowledge there are no reports on the clinical outcome of patients who underwent simultaneous bilateral THA. The JHEQ can also be used to evaluate motions that are unusual among Japanese patients, such as deep flexion of the hip, and evaluating patient satisfaction after THA. In previous studies of simultaneous bilateral THA, only the safety of the procedure and the economic aspects were reported. Alfaro-Adrian et al. [21] reported that simultaneous bilateral THA
3
was advantageous in that it only required a single anesthesia and therefore, the risks associated with anesthesia could be reduced. Additionally, Parvizi et al. [22] reported that the period of hip joint dysfunction could be reduced when simultaneous bilateral THA was performed. Both Eggli et al. [18] and Ritter et al. [23] reported a decrease in the duration and cost of hospitalization with simultaneous bilateral THA. The JHEQ results from this study indicated that the degree of improvement in the condition of the hip joint was significantly higher in the bilateral group based on the VAS, motion, and mental status. This is most likely due to the bilateral morbidity, as the VAS indicating the hip joint condition and the total JHEQ score (including the mental category) were lower in the bilateral cases before surgery. Since the postoperative satisfaction level has increased more significantly in the bilateral group, it seems that this study resulted in these outcomes. In addition, there was a higher ratio of younger people in the bilateral simultaneous group. Moreover, when compared by age, the postoperative status was better in the bilateral simultaneous group, despite the fact that the patients had a lower preoperative status. Therefore, we consider age to be a factor in this discrepancy. On the other hand, complications, including deep vein thrombosis, blood transfusion, dislocation, and infection have also been reported and remain controversial. Several reports have demonstrated no significant difference in the incidence of deep vein thrombosis between simultaneous bilateral and unilateral patient groups [18,21,24]. It has also been reported that allogeneic blood transfusion was required for 20e66% of patients [20,21]. However, in our study, no patients required an allogenic blood transfusion. In the Bilateral Simultaneous operation, we feel the second side is easier than the first side because of the anatomical similarity, which may result in the shorter operation time and smaller amount of bleeding on the second side. Many studies have reported no difference in the incidence of postoperative hip dislocation between patients who underwent simultaneous bilateral or unilateral THA [19,23,24]. In line with these reports, we did not observe any postoperative dislocations in either group. There were some limitations to this study. First, there was a significantly lower mean age in the simultaneous bilateral group. This could be explained by the fact that simultaneous bilateral THA is typically performed in comparatively younger patients who are in better condition. Nevertheless, this age difference does not affect the conclusion that bilateral cases have a higher JHEQ improvement rate. Secondly, this study had a short follow-up period. However, a good long-term outcome can be also expected regardless of the short follow-up period because loosening of the implant or sinking of the stem by X-ray were not observed. While further follow-up is required, the fact that there was a significant difference in the short-term results remains despite any future changes. This study suggests that simultaneous bilateral THA is a surgical procedure that can result in a high level of postoperative patient satisfaction. Our results demonstrated significant improvements based on the JHEQ in the bilateral group compared to the unilateral group.
Table 3 Improvement rate (%) for each JHEQ criterion. Unilateral VAS Pain Motion Mental Total
76.2 71.3 51.8 64.1 63.1
± ± ± ± ±
32.5 57.9 34.8 30.6 27.5
Bilateral 87.1 79.9 60.8 74.5 70.5
± ± ± ± ±
15.8 27.7 24.3 23.3 20.1
p Value p ¼ 0.013 n.s p < 0.001 p ¼ 0.003 p ¼ 0.004
Please cite this article in press as: Yoshii H, et al., Comparison of patient satisfaction after unilateral or simultaneous bilateral total hip arthroplasty through a direct anterior approach: Evaluation using the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.01.008
4
H. Yoshii et al. / Journal of Orthopaedic Science xxx (2016) 1e4
Table 4 Results for each item of the JHEQ and the changes before and after surgery (age-matched subgroup analysis). Preoperative scores Unilateral <50 yrs VAS Pain Motion Mental Total 50e59 yrs VAS Pain Motion Mental Total 60e69 yrs VAS Pain Motion Mental Total 70 yrs< VAS Pain Motion Mental Total
One year follow-up Bilateral
p Value
Unilateral
Bilateral
p Value
78.8 9.4 6.6 9.7 25.7
± ± ± ± ±
12.9 7.0 4.9 4.6 10.9
87.0 12.8 2.4 7.2 21.6
± ± ± ± ±
11.3 3.5 3.9 3.1 8.1
0.035 0.048 0.025 0.058 0.274
4.7 25.9 21.4 24.3 71.5
± ± ± ± ±
7.1 1.9 6.7 4.5 10.6
5.3 26.6 23.7 25.2 75.6
± ± ± ± ±
3.7 2.1 4.8 2.9 7.5
0.386 0.384 0.507 0.821 0.385
80.6 10.7 6.9 9.7 26.6
± ± ± ± ±
16.8 4.9 4.2 5.8 10.6
93.1 10.6 2.2 6.8 19.6
± ± ± ± ±
9.9 4.3 2.5 4.3 7.9
0.001 0.869 0.004 0.014 0.015
4.9 25.8 21.6 24.8 72.6
± ± ± ± ±
8.3 4.4 5.9 5.2 13.8
4.9 26.8 22.9 26.9 76.5
± ± ± ± ±
7.1 2.6 5.7 3.3 9.1
0.727 0.329 0.427 0.556 0.359
80.7 10.2 6.7 9.7 26.6
± ± ± ± ±
21.4 6.4 5.5 6.3 15.4
92.6 11.8 3.5 7.1 20.8
± ± ± ± ±
8.4 4.9 2.7 5.0 10.7
0.008 0.155 0.016 0.035 0.032
4.9 25.1 20.2 24.1 69.9
± ± ± ± ±
9.1 5.6 6.2 5.2 14.9
5.4 26.8 22.8 25.1 74.7
± ± ± ± ±
6.8 1.9 4.9 2.5 11.1
0.519 0.269 0.431 0.869 0.139
79.8 9.3 6.9 8.9 26.1
± ± ± ± ±
18.9 4.9 4.6 5.5 8.4
88.5 11.9 2.0 6.5 21.5
± ± ± ± ±
11.8 5.3 2.6 5.9 9.5
0.045 0.081 0.002 0.042 0.029
4.4 25.0 20.2 22.6 67.2
± ± ± ± ±
5.7 4.4 6.1 6.0 15.2
5.5 26.5 22.1 23.2 72.8
± ± ± ± ±
12.2 3.1 5.7 3.5 7.3
0.608 0.311 0.514 0.845 0.126
Conflict of interest The authors declare that they have no conflict of interest.
References [1] Petis S, Howard JL, Lanting BL, Vasarhelyi EM. Surgical approach in primary total hip arthroplasty: anatomy, technique and clinical outcomes. Can J Surg 2015 Apr;58(2):128e39. [2] Hallert O, Li Y, Brismar H, Lindgren U. The direct anterior approach: initial experience of a minimally invasive technique for total hip arthroplasty. J Orthop Surg Res 2012 Apr 25;7:17. [3] Russo MW, Macdonell JR, Paulus MC, Keller JM, Zawadsky MW. Increased complications in obese patients undergoing direct anterior total hip arthroplasty. J Arthroplasty 2015 Aug;30(8):1384e7. [4] Lanting BA, Odum SM, Cope RP, Patterson AH, Masonis JL. Incidence of perioperative events in single setting bilateral direct anterior approach total hip arthroplasty. J Arthroplasty 2015 Mar;30(3):465e7. [5] Parvizi J, Rasouli MR, Jaberi M, Chevrollier G, Vizzi S, Sharkey PF, Hozack WJ. Does the surgical approach in one stage bilateral total hip arthroplasty affect blood loss? Int Orthop 2013 Dec;37(12):2357e62. [6] Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Jt Surg Am 1969 Jun;51(4):737e55. [7] Imura S. The Japanese Orthopaedic Association: evaluation chart of hip joint functions. J Jpn Orthop Assoc 1995;69:864e7. [8] D'aubigne RM, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Jt Surg Am 1954 Jun;36-A(3):451e75. [9] Ware Jr JE, Sherboume CD. The MOS 36-item short-form health survey (SF36). I. Conceptual framework and item selection. Med Care 1992 Jun;30(6): 473e83. [10] Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 1988 Dec;15(12): 1833e40. [11] Pacault-Legendre V, Courpied JP. Survey of patients satisfaction after total arthroplasty of the hip. Int Orthop 1999;23(1):23e30.
[12] Matsumoto T, Kaneuji A, Hiejima Y, Sugiyama H, Akiyama H, Atsumi T, Ishii M, Izumi K, Ichiseki T, Ito H, Okawa T, Ohzono K, Otsuka H, Kishida S, Kobayashi S, Sawaguchi T, Sugano N, Nakajima I, Nakamura S, Hasegawa Y, Fukuda K, Fujii G, Mawatari T, Mori S, Yasunaga Y, Yamaguchi M. Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ): a patient-based evaluation tool for hip-joint disease. The Subcommittee on Hip Disease Evaluation of the Clinical Outcome Committee of the Japanese Orthopaedic Association. J Orthop Sci 2012 Jan;17(1):25e38. [13] Nakamura S, Kanezaki S, Nishino H, Matsushita T. JHEQ for evaluation of total hip arthroplasty. Hip Jt 2013;13(39):45e8 [in Japanese]. [14] Usuda K, Mizuochi H, Tanaka J, Yamamoto M, Sawaguchi T, Sakagoshi D. Evaluation of correlation between JHEQ and JOA score for total hip arthroplasty. Hip Jt 2013;13(39):77e80 [in Japanese]. [15] Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res 2005 Dec;441: 115e24. [16] Kennon RE, Keggi JM, Wetmore RS, Zatorski LE, Huo MH, Keggi KJ. Total hip arthroplasty through a minimally invasive anterior surgical approach. J Bone Jt Surg Am 2003;85-A(Suppl. 4):39e48. [17] Oinuma K, Eingartner C, Saito Y, Shiratsuchi H. Total hip arthroplasty by a minimally invasive, direct anterior approach. Oper Orthop Traumatol 2007 Aug;19(3):310e26. [18] Eggli S, Huckell CB, Ganz R. Bilateral total hip arthroplasty: one stage versus two stage procedure. Clin Orthop Relat Res 1996 Jul;328:108e18. [19] Berend ME, Ritter MA, Harty LD, Davis KE, Keating EM, Meding JB, Thong AE. Simultaneous bilateral versus unilateral total hip arthroplasty: an outcomes analysis. J Arthroplasty 2005 Jun;20(4):421e6. [20] Kim YH, Kwon OR, Kim JS. Is one-stage bilateral sequential total hip replacement as safe as unilateral total hip replacement? J Bone Jt Surg Br 2009 Mar;91(3):316e20. [21] Alfaro-Adrian J, Bayona F, Rech JA, Murray DW. One- or two-stage bilateral total hip replacement. J Arthroplasty 1999 Jun;14(4):439e45. [22] Parvizi J, Pour AE, Peak EL, Sharkey PF, Hozack WJ, Rothman RH. One-stage bilateral total hip arthroplasty compared with unilateral total hip arthroplasty: a prospective study. J Arthroplasty 2006 Sep;21(6 Suppl. 2):26e31. [23] Ritter MA, Stringer EA. Bilateral total hip arthroplasty: a single procedure. Clin Orthop Relat Res 1980 Jun;149:185e90. [24] Bhan S, Pankaj A, Malhotra R. One- or two-stage bilateral total hip arthroplasty: a prospective, randomised, controlled study in an Asian population. J Bone Jt Surg Br 2006 Mar;88(3):298e303.
Please cite this article in press as: Yoshii H, et al., Comparison of patient satisfaction after unilateral or simultaneous bilateral total hip arthroplasty through a direct anterior approach: Evaluation using the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.01.008