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Return to Sport After Bilateral Single Stage Total Hip Arthroplasty Using the Direct Anterior Approach: A Case Control Study
The Journal of Arthroplasty xxx (2019) 1e6
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Return to Sport After Bilateral Single Stage Total Hip Arthroplasty Using the Direct Anterior Approach: A Case Control Study cile Batailler, MD a, *, Anouk Rozinthe, MD a, Marcelle Mercier, MD a, Ce bastien Lustig, MD, PhD a Christopher Bankhead, MD b, Romain Gaillard, MD a, Se a b
Orthopedic Surgery Department, Croix Rousse Hospital, Lyon, France Department of Orthopaedics, University of New Mexico, Albuquerque, NM
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 March 2019 Received in revised form 20 June 2019 Accepted 25 June 2019 Available online xxx
Background: Total hip arthroplasty (THA) is currently performed on active patients with increasing functional demands. Single stage bilateral THA is indicated in younger patients in good general health. Our objective is to evaluate the return to sport (RTS) in patients who underwent bilateral single stage THA compared to unilateral THA. Methods: This retrospective case control study was conducted between 2013 and 2017. All patients who underwent bilateral single stage THA were included. The control group had unilateral THA performed and was matched based on age, body mass index, gender, and surgery date (2 controls for each bilateral case). All surgeries were performed by a single senior surgeon using the direct anterior approach. The University of California Los Angeles activity score was collected at the last follow-up. A questionnaire regarding RTS, motivation, and satisfaction was assessed. Results: Thirty-two patients were included in the study, of whom 21 were men. The average age was 60.7 ± 9.6 years, body mass index was 26 ± 4 kg/m2, and mean follow-up was 20.1 ± 11.6 months. Twentyeight patients overall (87%) returned to sport after the procedure. Twenty-five of these (89%) returned to the same sport, and 17 (68%) participated at the same intensity. The average time to RTS was 4 ± 2.8 months. These results were at least as good as those after unilateral THA. The level of motivation of the patient was the only predictive factor for RTS (P < .001). Conclusion: Bilateral single stage THA via a direct anterior approach allows for RTS and to a similar level in the majority of patients in whom this procedure is indicated. Level of Evidence: Comparative retrospective study, Level III. © 2019 Elsevier Inc. All rights reserved.
Keywords: total hip arthroplasty bilateral single stage return to sport direct anterior approach UCLA activity score
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2019.06.054. cile Batailler helped in study design, data collection, Authors' Contributions: Ce statistical analysis, literature review, and manuscript writing; Anouk Rozinthe and Marcelle Mercier helped in data collection, literature review, and manuscript writing; Christopher Bankhead helped in study design, literature review, and manuscript editing; Romain Gaillard helped in study design, statistical analysis, and bastien Lustig helped in study design, supervision, manuscript editing; and Se literature review, and manuscript editing. All authors read and approved the final manuscript. cile Batailler, MD, Orthopedic Surgery Department, Croix* Reprint requests: Ce Rousse Hospital, 103 Grande Rue de la Croix-Rousse, 69004 Lyon, France. https://doi.org/10.1016/j.arth.2019.06.054 0883-5403/© 2019 Elsevier Inc. All rights reserved.
Total hip arthroplasty (THA) is currently a common surgery, and the number of operations performed continues to rise in an increasingly younger population [1,2]. Common indications for bilateral single stage THA include etiologies such as osteonecrosis, rheumatoid arthritis, or dysplasia [3]. Bilateral hip osteoarthritis also frequently occurs. After unilateral THA, the probability of osteoarthritis progressing in the contralateral joint is 79% at 10 years, with the chance of arthroplasty being 54% [4]. Multiple studies have examined the rate of complications after single stage bilateral THA vs 2-stage THA [5e7]. Recent studies, including a large meta-analysis by Shao et al, find no significant difference in complications between 17,762 single stage bilateral THA and 46,147 2stage bilateral THA [7,8]. Bilateral THA performed under a single anesthetic decreases the cost of hospitalization [9], and, according to some studies, allows for a faster recovery and return to daily activities than unilateral THA [10].
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Currently, the goal of a THA is to not only eliminate the hip pain, but also to return the patient to daily activities and if possible to sport [11]. Single stage bilateral THA is performed mostly in patients who are in good general health, many of whom participate regularly in sporting activities [12]. Few studies accurately report the return to sport (RTS) after THA. To our knowledge, no study reports the RTS after simultaneous bilateral THA and important questions remain unanswered. Can patients with simultaneous bilateral THA return to sport quickly, and which sports can they practice? Is the RTS of those patients as good as those with unilateral THA? The aim of this study is to assess the rate of RTS after bilateral single stage THA compared to RTS rate after unilateral THA via direct anterior approach (DAA), to describe the sports to which patients are returning, and to determine predictive factors for this RTS. Materials and Methods Patients This retrospective study included all patients undergoing single stage bilateral THA via DAA between 2013 and 2017 at a single institution. Every patient was included. For each case, 2 control patients were matched based on age (by 10-year periods), body mass index (BMI) (by subgroups: <18.5, 18.5-25, 25-30, 30-35, >35), gender, and surgery date (by 6-month periods). All control patients had a DAA for the THA, as well as a native and asymptomatic contralateral hip. Between 2013 and 2017, 32 patients underwent one stage bilateral THA. During that same time, 643 unilateral primary THAs were performed via DAA and 64 of these were included in the control group. Demographic data of both groups were comparable and are reported in Table 1. In particular, the UCLA score on the practice of sport was similar between both groups (University of California Los Angeles [UCLA] score activity-level rating [13]).
postoperatively after therapeutic education, optimized pain treatment, etc.). Anesthesia technique was the same for bilateral or unilateral THA (spinal anesthesia or general anesthesia was used according to the preference of anesthetist and patient, associated with deep and superficial local infiltrations). For bilateral THA, the surgeon started with the most painful hip. Data Collection The demographic data (BMI, American Society of Anesthesiologists score) were collected, as well as the preoperative Harris Hip Score (HHS) and UCLA score, which was completed systematically by patients before the surgery [13]. At the final follow-up, 3 patientreported outcome scores were determined by completed questionnaires sent through email: postoperative HHS, UCLA score, and Hip disability and Osteoarthritis Outcome Score. The RTS was evaluated by 4 questions on the RTS, the sport type, the impact level of sport, and the delay before RTS. If the patient did not return to sport or returned at a lower level, the reasons were identified. The satisfaction following THA was also assessed (very satisfied, satisfied, disappointed, and dissatisfied). Patients were asked about their participation in different athletic activities as documented in the 2007 American Association of Hip and Knee Arthroplasty Surgeons (AAHKS) survey [15]. Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The Advisory Committee on Research Information Processing in the Field of Health approved this study on June 4, 2015 under number 15-430. For this type of study formal consent is not required.
Surgical Technique Statistical Analysis All THAs included in this study were performed by a single surgeon, using the same surgical techniquedthe DAA of Hueter with a standard orthopedic table, as described by Batailler et al [14]. Intraoperative fluoroscopy was used to confirm appropriate positioning of implants. The implants were cementless, with either a ceramic conventional cup or a dual mobility cup according to the patient age (younger or older than 65 years). The insert of the conventional cup is a Biolox Delta ceramic, like the head. For the dual mobility cup, the head was also a Biolox Delta ceramic. The stem was forged titanium alloy, fully coated with nonporous hydroxyapatite (TARGOS stem with collar, Cargos, or Quattro cup LEPINE) (Fig. 1). No drain was used, and the same accelerated postop recovery protocol was performed for all patients (mobilization on the day of surgery, early discharge at 1 or 2 days
For the statistical analysis, the XLstat software (2015; Addinsoft) was used. The continuous variables were averaged and reported with standard deviation and interval. A Mann-Whitney nonparametric test was performed to assess the evolution of the HHS. Statistical analysis was performed using Student’s t-test or Wilcoxon nonparametric test. The categorical variables were compared using a Fisher’s exact test. Both univariate and multivariate analyses were performed, according to results, to find predictive factors for the RTS. The potential predictive factors assessed were age, gender, American Society of Anesthesiologists score, BMI, UCLA score, Hip disability and Osteoarthritis Outcome Score, motivation, and satisfaction. A P value <.05 was considered statistically significant in each analysis.
Table 1 Demographic Characteristics and Preoperative Scores for Single Stage Bilateral THA and Unilateral THA. Preoperative
Bilateral THA (n ¼ 32)
Unilateral THA (n ¼ 64)
P-Value
Age (y) (mean ± SD) [min; max] BMI (kg/m2) (mean ± SD) [min; max] Gender: men (%) ASA (mean ± SD) [min; max] Preoperative HHS (mean ± SD) [min; max] Preoperative UCLA (mean ± SD) [min; max]
60.7 ± 9.8 [34; 74] 26 ± 4.1 [18; 36] 21 (65.6%) 1.6 ± 0.6 [1; 3] 55.8 ± 13.2 [15; 82] 6.1 ± 1.7 [3; 9]
61.8 ± 10 [38; 79] 25.9 ± 4 [19; 39] 42 (65.6%) 1.8 ± 0.7 [1; 4] 56 ± 14.1 [19; 81] 5.7 ± 1.9 [3; 9]
NS NS NS NS NS NS
THA, total hip arthroplasty; BMI, body mass index; ASA, American Society of Anesthesiologists; SD, standard deviation; HHS, Harris Hip Score; UCLA, University of California Los Angeles; min, minimum; max, maximum; NS, not significant.
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Fig. 1. Bilateral hip osteoarthritis (A) on radiographic anteroposterior view, treated by single stage bilateral THA (B).
Results None were lost to follow-up and all patients in both groups completed the questionnaires. The mean follow-up was 20.9 ± 10.8 months for the bilateral THA group and 28.9 ± 15 months for the control group. The functional outcome scores and the data on RTS are reported in Table 2. In the bilateral THA group, 28 of 32 patients (87.5%) returned to sport after the surgery. The average delay for RTS was 4.2 ± 2.7 months. Among the 4 patients who did not return to sport, the sole reason was a lack of motivation to participate. The reasons to not return to sport, to not practice the same sport, or with the same intensity are described in Figure 2. The majority of practiced sports were low impact (Table 3). At the last follow-up, the rate of very satisfied (n ¼ 27; 84%) or satisfied (n ¼ 4; 12.5%) patients after single stage bilateral THA was very high at 96.5%. Only 1 patient was disappointed (very sportive patient who hoped to increase the intensity of his sports after the surgery). Motivation was the only predictive factor found for RTS (P < .001). In the unilateral THA group, 37 of 64 patients (57.8%) returned to sport after the surgery, at an average delay of 5.4 ± 5.1 months. The reasons to not return to sport are reported in Figure 3. At the last follow-up, the rate of very satisfied (n ¼ 43; 67.2%) or satisfied (n ¼ 16; 25%) patients after unilateral THA was high at 92.2%. No complication or surgical revision has been reported at last follow-up in the 2 groups. Discussion The key finding of this study is a high rate of RTS after one stage bilateral THA via DAA: 87% of patients returned to sport, 89% of those to the same sport, and 68% at the same intensity. To our knowledge, this study is the first to assess the RTS after bilateral
single stage THA. Several studies have assessed the RTS rates after unilateral THA and found an RTS similar to our unilateral control group [11,16e19]. Innmann et al [16], Ollivier et al [11], and Schmidutz et al [17], respectively, found that 89%, 64%, and 98% of their patients had returned to sport after unilateral THA at long term (between 2 and 10 years). The average delay for RTS after one bilateral stage THA was 4 months. This delay was not significantly different of the RTS delay after unilateral THA. This was a faster return than previous similar studies, including Ollivier et al [11] who did not allow RTS before 6 months. Schmidutz et al [17] and Innmann et al [16] evaluated their patients at 2 and 10 years postoperatively, without documenting the timing of initial RTS. The DAA can improve the recovery time [20]. In others studies, the approaches were posterolateral approach, transgluteal approach, or Watson Jones approach [11,16,17]. The most recent recommendations from the Hip Society and AAHKS [15] were established after surveying 760 surgeons. The consensus was an RTS after 3-6 months with only 10% of surgeons saying they would allow a return earlier than 3 months after THA. We could isolate only motivation as a predictive factor for RTS, likely due to the limited number of patients and the criteria necessary to be selected for single stage bilateral THA. Ollivier et al [11] found a correlation among RTS, preoperative HHS, age, and patient satisfaction. In a review of the literature by Jassim et al [21] on the RTS after arthroplasty, 12 of 42 studies focused on THA with an average of 256 patients per study, an average age of 61, and follow-up of 4.7 years. The highest scores (UCLA, Harris, Oxford) were associated with young age, male gender, and low BMI. In this study, among the patients who did not return to the same intensity or returned to a different sport, the primary reason was another source of pain, in particular knee or lower back pain. Ollivier et al [11] report several reasons for patients not returning to the same sport, the most common being fear of component wear
Table 2 Postoperative Functional Results and Return to Sport After Single Stage Bilateral THA Compared to Unilateral THA. Postoperative
Bilateral THA (n ¼ 32)
Unilateral THA (n ¼ 64)
P-Value
Follow-up (mo) (mean ± SD) [min-max] Postoperative HHS (mean ± SD) [min-max] HHS improvement (mean ± SD) [min-max] Postoperative HOOS (mean ± SD) [min-max] Postoperative UCLA (mean ± SD) [min-max] Rate of RTS RTS at same sport RTS at the same intensity Delay to RTS (mo) (mean ± SD) [min-max]
20.9 ± 10.8 [6-48] 88.5 ± 5.1 [68-91] 32.7 ± 13.4 [9-72] 94.5 ± 8.1 [68.8-100] 5.6 ± 1.6 [3-9] 87.5% (n ¼ 28) 89.3% (n ¼ 25/28) 68% (n ¼ 17/25) 4.2 ± 2.7 [1-12]
28.9 ± 15 [6-67] 94.4 ± 9.4 [41-100] 38.4 ± 13.5 [10-64] 90.7 ± 12.7 [36.9-100] 4.9 ± 2.2 [2-9] 57.8% (n ¼ 37) 62.2% (n ¼ 23/37) 56.5% (n ¼ 13/23) 5.4 ± 5.1 [1-24]
<.01 .001 NS NS NS <.001 <.01 NS NS
THA, total hip arthroplasty; SD, standard deviation; HHS, Harris Hip Score; HOOS, Hip disability and Osteoarthritis Outcome Score; UCLA, University of California Los Angeles; min, minimum; max, maximum; NS, not significant; RTS, return to sport.
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Fig. 2. Reasons for not returning to sport, returning at a lower intensity, or returning to another sport after single stage bilateral THA.
(25.4%), fear of dislocation (31.7%), or a cause independent of the hip (29.7%). In our opinion, the DAA allows us to eliminate the fear of dislocation as a reason to limit RTS [14]. With recent advancements in low friction arthroplasties, we authorize all sports without high impact. Other causes independent of the hip often influence the functional results of THA [19], and they also play an important role in our study. Loth et al [22] found that comorbidities significantly influenced functional results after THA, noting that lower back pain especially decreases functional scores. The majority of sports practiced in our series (82%) were lowimpact sports, according to AAHKS recommendations [15]. The patients who performed high impact sports had started well before the THA and were experienced in these sports. The evolution of the practice of these sports was not collected in this study. Schmidutz et al [17] and Innmann et al [16] did evaluate this and concluded that participation in higher impact sports after THA decreases over time. Ollivier et al [23] compared the practice of high impact sports in 70 patients vs low impact sports in 140 patients with a minimum follow-up of 10 years. They reported that high impact sports lead to more long-term mechanical complications such as increased wear rate or revisions for aseptic loosening. We do not report any complications despite participation in sports not authorized by AAHKS [15], including high impact sports. However, the average follow-up in our study was 20 months. This is sufficient to evaluate functional scores and RTS but limited in studying long-term complications. Few studies assessed the RTS after THA using the UCLA score, which has been found to be the most appropriate [24]. This study found an average UCLA score of 5.6 points after bilateral THA, which is comparable to scores that can be found in the literature for unilateral THA and in the control group. Innmann et al [16] described an average UCLA score of 6.2 in 86 patients with an average of 6.3 after 11-year follow-up. Ollivier et al [11] report an average UCLA score of 6.8 points in 815 patients with an average follow-up of 9.8 years, whereas in the study of Schmidutz et al [17] the average UCLA score was 7.6 points in 68 patients with an average age of 55 years and follow-up of 2.7 years.
This study has several limitations. First, the number of patients was small, resulting in a lack of power. Some predictive factors
Table 3 American Association of Hip and Knee Arthroplasty Surgeons Sport Recommendations and the Level of Motivation to Participate in These Sports After Single Stage Bilateral Total Hip Arthroplasty. Motivation Allowed Golf Stationary cycling Swimming Doubles tennis Normal walking Elliptical Step Allowed with experience Cross-country skiing Pilates Fitness Weight machine Bowling Hiking Road cycling Not recommended Jogging Contact sports Gymnastics Squash Snowboard Singles tennis No consensus Downhill skiing Roller/ice skating Weight lifting Dancing Rowing Speed walking Stationary skiing Martial arts
Low
Important
Very Important
Total
4 6 7 1 5 2 2
1 1 6 1 11 1 0
0 1 3 1 9 0 1
5 8 16 3 25 3 3
1 0 0 1 3 3 7
2 3 2 1 0 11 5
0 3 0 1 0 4 3
3 6 2 3 3 18 15
2 0 0 1 0 1
2 2 2 1 0 0
1 0 1 0 1 2
5 2 3 2 1 3
1 1 2 5 1 6 0 0
1 0 3 1 0 3 1 0
3 0 1 2 1 1 0 1
5 1 6 8 2 10 1 1
C. Batailler et al. / The Journal of Arthroplasty xxx (2019) 1e6
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Fig. 3. Reasons for not returning to sport, returning at a lower intensity, or returning to another sport after unilateral THA.
may have been missed due to this limited sample size. Second, the follow-up was too short to evaluate both long-term complications and the change in a patient’s sports participation over time after initial RTS. Nevertheless, our aim was to report the RTS in the postoperative period. The method of data collection by selfcompleted questionnaires can cause bias through inaccurate estimation of sport level. But this questionnaire eliminates any bias related to the observer. Finally, this controlled study was not randomized. The 2 groups are very similar. Nevertheless, even if we find no significant difference between both groups, the patients undergoing single stage bilateral THA are often active patients with very good health. These patients are thus more disposed to RTS.
Conclusion Bilateral simultaneous THA via DAA demonstrates high rate of RTS and allows RTS (4 months on average) in the majority of patients who participated in sports previously. These results are at least equivalent to those after unilateral THA. Patients who did not return to sport or who had changes in postop activity often did so for causes other than functional results of their bilateral THA. A longer term study with a larger cohort of patients would be helpful in identifying additional factors predicting an RTS and analyzing the evolution of patients’ sports practice.
References [1] Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89:780e5. [2] Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet 2007;370:1508e19. [3] Lazansky MG. A method for grading hips. J Bone Joint Surg Br 1967;49: 644e51. [4] Ritter MA, Carr K, Herbst SA, Eizember LE, Keating EM, Faris PM, et al. Outcome of the contralateral hip following total hip arthroplasty for osteoarthritis. J Arthroplasty 1996;11:242e6.
[5] 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 Joint Surg Br 2006;88:298e303. [6] Glait SA, Khatib ON, Bansal A, Hochfelder JP, Slover JD. Comparing the incidence and clinical data for simultaneous bilateral versus unilateral total hip arthroplasty in New York state between 1990 and 2010. J Arthroplasty 2015;30:1887e91. [7] Stavrakis AI, SooHoo NF, Lieberman JR. Bilateral total hip arthroplasty has similar complication rates to unilateral total hip arthroplasty. J Arthroplasty 2015;30:1211e4. [8] Shao H, Chen CL, Maltenfort MG, Restrepo C, Rothman RH, Chen AF. Bilateral total hip arthroplasty: 1-stage or 2-stage? A meta-analysis. J Arthroplasty 2017;32:689e95. [9] Martin GR, Marsh JD, Vasarhelyi EM, Howard JL, Lanting BA. A cost analysis of single-stage bilateral versus two-stage direct anterior total hip arthroplasty. Hip Int 2016;26:15e9. [10] Yoshii T, Jinno T, Morita S, Koga D, Matsubara M, Okawa A, et al. Postoperative hip motion and functional recovery after simultaneous bilateral total hip arthroplasty for bilateral osteoarthritis. J Orthop Sci 2009;14:161e6. [11] Ollivier M, Frey S, Parratte S, Flecher X, Argenson JN. Pre-operative function, motivation and duration of symptoms predict sporting participation after total hip replacement. Bone Joint J 2014;96-B:1041e6. [12] Rasouli MR, Maltenfort MG, Ross D, Hozack WJ, Memtsoudis SG, Parvizi J. Perioperative morbidity and mortality following bilateral total hip arthroplasty. J Arthroplasty 2014;29:142e8. [13] Zahiri CA, Schmalzried TP, Szuszczewicz ES, Amstutz HC. Assessing activity in joint replacement patients. J Arthroplasty 1998;13:890e5. [14] Batailler C, Fary C, Batailler P, Servien E, Neyret P, Lustig S. Total hip arthroplasty using direct anterior approach and dual mobility cup: safe and efficient strategy against post-operative dislocation. Int Orthop 2017;41:499e506. [15] Klein GR, Levine BR, Hozack WJ, Strauss EJ, D'Antonio JA, Macaulay W, et al. Return to athletic activity after total hip arthroplasty. Consensus guidelines based on a survey of the Hip Society and American Association of Hip and Knee Surgeons. J Arthroplasty 2007;22:171e5. [16] Innmann MM, Weiss S, Andreas F, Merle C, Streit MR. Sports and physical activity after cementless total hip arthroplasty with a minimum follow-up of 10 years. Scand J Med Sci Sports 2016;26:550e6. [17] Schmidutz F, Grote S, Pietschmann M, Weber P, Mazoochian F, Fottner A, et al. Sports activity after short-stem hip arthroplasty. Am J Sports Med 2012;40:425e32. [18] Chatterji U, Ashworth MJ, Lewis PL, Dobson PJ. Effect of total hip arthroplasty on recreational and sporting activity. ANZ J Surg 2004;74:446e9. [19] Delasotta LA, Rangavajjula AV, Porat MD, Frank ML, Orozco FR, Ong AC. What are young patients doing after hip reconstruction? J Arthroplasty 2012;27: 1518e1525.e2. [20] Zawadsky MW, Paulus MC, Murray PJ, Johansen MA. Early outcome comparison between the direct anterior approach and the mini-incision posterior approach for primary total hip arthroplasty: 150 consecutive cases. J Arthroplasty 2014;29:1256e60.
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[21] Jassim SS, Douglas SL, Haddad FS. Athletic activity after lower limb arthroplasty: a systematic review of current evidence. Bone Joint J 2014;96-B:923e7. [22] Loth FL, Giesinger JM, Giesinger K, MacDonald DJ, Simpson AHRW, Howie CR, et al. Impact of comorbidities on outcome after total hip arthroplasty. J Arthroplasty 2017;32:2755e61.
[23] Ollivier M, Frey S, Parratte S, Flecher X, Argenson JN. Does impact sport activity influence total hip arthroplasty durability? Clin Orthop Relat Res 2012;470:3060e6. [24] Naal FD, Impellizzeri FM, Leunig M. Which is the best activity rating scale for patients undergoing total joint arthroplasty? Clin Orthop Relat Res 2009;467:958e65.
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Return to Sport After Bilateral Single Stage Total Hip Arthroplasty Using the Direct Anterior Approach: A Case Control Study cile Batailler, MD a, *, Anouk Rozinthe, MD a, Marcelle Mercier, MD a, Ce bastien Lustig, MD, PhD a Christopher Bankhead, MD b, Romain Gaillard, MD a, Se a b
Orthopedic Surgery Department, Croix Rousse Hospital, Lyon, France Department of Orthopaedics, University of New Mexico, Albuquerque, NM
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 March 2019 Received in revised form 20 June 2019 Accepted 25 June 2019 Available online xxx
Background: Total hip arthroplasty (THA) is currently performed on active patients with increasing functional demands. Single stage bilateral THA is indicated in younger patients in good general health. Our objective is to evaluate the return to sport (RTS) in patients who underwent bilateral single stage THA compared to unilateral THA. Methods: This retrospective case control study was conducted between 2013 and 2017. All patients who underwent bilateral single stage THA were included. The control group had unilateral THA performed and was matched based on age, body mass index, gender, and surgery date (2 controls for each bilateral case). All surgeries were performed by a single senior surgeon using the direct anterior approach. The University of California Los Angeles activity score was collected at the last follow-up. A questionnaire regarding RTS, motivation, and satisfaction was assessed. Results: Thirty-two patients were included in the study, of whom 21 were men. The average age was 60.7 ± 9.6 years, body mass index was 26 ± 4 kg/m2, and mean follow-up was 20.1 ± 11.6 months. Twentyeight patients overall (87%) returned to sport after the procedure. Twenty-five of these (89%) returned to the same sport, and 17 (68%) participated at the same intensity. The average time to RTS was 4 ± 2.8 months. These results were at least as good as those after unilateral THA. The level of motivation of the patient was the only predictive factor for RTS (P < .001). Conclusion: Bilateral single stage THA via a direct anterior approach allows for RTS and to a similar level in the majority of patients in whom this procedure is indicated. Level of Evidence: Comparative retrospective study, Level III. © 2019 Elsevier Inc. All rights reserved.
Keywords: total hip arthroplasty bilateral single stage return to sport direct anterior approach UCLA activity score
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2019.06.054. cile Batailler helped in study design, data collection, Authors' Contributions: Ce statistical analysis, literature review, and manuscript writing; Anouk Rozinthe and Marcelle Mercier helped in data collection, literature review, and manuscript writing; Christopher Bankhead helped in study design, literature review, and manuscript editing; Romain Gaillard helped in study design, statistical analysis, and bastien Lustig helped in study design, supervision, manuscript editing; and Se literature review, and manuscript editing. All authors read and approved the final manuscript. cile Batailler, MD, Orthopedic Surgery Department, Croix* Reprint requests: Ce Rousse Hospital, 103 Grande Rue de la Croix-Rousse, 69004 Lyon, France. https://doi.org/10.1016/j.arth.2019.06.054 0883-5403/© 2019 Elsevier Inc. All rights reserved.
Total hip arthroplasty (THA) is currently a common surgery, and the number of operations performed continues to rise in an increasingly younger population [1,2]. Common indications for bilateral single stage THA include etiologies such as osteonecrosis, rheumatoid arthritis, or dysplasia [3]. Bilateral hip osteoarthritis also frequently occurs. After unilateral THA, the probability of osteoarthritis progressing in the contralateral joint is 79% at 10 years, with the chance of arthroplasty being 54% [4]. Multiple studies have examined the rate of complications after single stage bilateral THA vs 2-stage THA [5e7]. Recent studies, including a large meta-analysis by Shao et al, find no significant difference in complications between 17,762 single stage bilateral THA and 46,147 2stage bilateral THA [7,8]. Bilateral THA performed under a single anesthetic decreases the cost of hospitalization [9], and, according to some studies, allows for a faster recovery and return to daily activities than unilateral THA [10].
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Currently, the goal of a THA is to not only eliminate the hip pain, but also to return the patient to daily activities and if possible to sport [11]. Single stage bilateral THA is performed mostly in patients who are in good general health, many of whom participate regularly in sporting activities [12]. Few studies accurately report the return to sport (RTS) after THA. To our knowledge, no study reports the RTS after simultaneous bilateral THA and important questions remain unanswered. Can patients with simultaneous bilateral THA return to sport quickly, and which sports can they practice? Is the RTS of those patients as good as those with unilateral THA? The aim of this study is to assess the rate of RTS after bilateral single stage THA compared to RTS rate after unilateral THA via direct anterior approach (DAA), to describe the sports to which patients are returning, and to determine predictive factors for this RTS. Materials and Methods Patients This retrospective study included all patients undergoing single stage bilateral THA via DAA between 2013 and 2017 at a single institution. Every patient was included. For each case, 2 control patients were matched based on age (by 10-year periods), body mass index (BMI) (by subgroups: <18.5, 18.5-25, 25-30, 30-35, >35), gender, and surgery date (by 6-month periods). All control patients had a DAA for the THA, as well as a native and asymptomatic contralateral hip. Between 2013 and 2017, 32 patients underwent one stage bilateral THA. During that same time, 643 unilateral primary THAs were performed via DAA and 64 of these were included in the control group. Demographic data of both groups were comparable and are reported in Table 1. In particular, the UCLA score on the practice of sport was similar between both groups (University of California Los Angeles [UCLA] score activity-level rating [13]).
postoperatively after therapeutic education, optimized pain treatment, etc.). Anesthesia technique was the same for bilateral or unilateral THA (spinal anesthesia or general anesthesia was used according to the preference of anesthetist and patient, associated with deep and superficial local infiltrations). For bilateral THA, the surgeon started with the most painful hip. Data Collection The demographic data (BMI, American Society of Anesthesiologists score) were collected, as well as the preoperative Harris Hip Score (HHS) and UCLA score, which was completed systematically by patients before the surgery [13]. At the final follow-up, 3 patientreported outcome scores were determined by completed questionnaires sent through email: postoperative HHS, UCLA score, and Hip disability and Osteoarthritis Outcome Score. The RTS was evaluated by 4 questions on the RTS, the sport type, the impact level of sport, and the delay before RTS. If the patient did not return to sport or returned at a lower level, the reasons were identified. The satisfaction following THA was also assessed (very satisfied, satisfied, disappointed, and dissatisfied). Patients were asked about their participation in different athletic activities as documented in the 2007 American Association of Hip and Knee Arthroplasty Surgeons (AAHKS) survey [15]. Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The Advisory Committee on Research Information Processing in the Field of Health approved this study on June 4, 2015 under number 15-430. For this type of study formal consent is not required.
Surgical Technique Statistical Analysis All THAs included in this study were performed by a single surgeon, using the same surgical techniquedthe DAA of Hueter with a standard orthopedic table, as described by Batailler et al [14]. Intraoperative fluoroscopy was used to confirm appropriate positioning of implants. The implants were cementless, with either a ceramic conventional cup or a dual mobility cup according to the patient age (younger or older than 65 years). The insert of the conventional cup is a Biolox Delta ceramic, like the head. For the dual mobility cup, the head was also a Biolox Delta ceramic. The stem was forged titanium alloy, fully coated with nonporous hydroxyapatite (TARGOS stem with collar, Cargos, or Quattro cup LEPINE) (Fig. 1). No drain was used, and the same accelerated postop recovery protocol was performed for all patients (mobilization on the day of surgery, early discharge at 1 or 2 days
For the statistical analysis, the XLstat software (2015; Addinsoft) was used. The continuous variables were averaged and reported with standard deviation and interval. A Mann-Whitney nonparametric test was performed to assess the evolution of the HHS. Statistical analysis was performed using Student’s t-test or Wilcoxon nonparametric test. The categorical variables were compared using a Fisher’s exact test. Both univariate and multivariate analyses were performed, according to results, to find predictive factors for the RTS. The potential predictive factors assessed were age, gender, American Society of Anesthesiologists score, BMI, UCLA score, Hip disability and Osteoarthritis Outcome Score, motivation, and satisfaction. A P value <.05 was considered statistically significant in each analysis.
Table 1 Demographic Characteristics and Preoperative Scores for Single Stage Bilateral THA and Unilateral THA. Preoperative
Bilateral THA (n ¼ 32)
Unilateral THA (n ¼ 64)
P-Value
Age (y) (mean ± SD) [min; max] BMI (kg/m2) (mean ± SD) [min; max] Gender: men (%) ASA (mean ± SD) [min; max] Preoperative HHS (mean ± SD) [min; max] Preoperative UCLA (mean ± SD) [min; max]
60.7 ± 9.8 [34; 74] 26 ± 4.1 [18; 36] 21 (65.6%) 1.6 ± 0.6 [1; 3] 55.8 ± 13.2 [15; 82] 6.1 ± 1.7 [3; 9]
61.8 ± 10 [38; 79] 25.9 ± 4 [19; 39] 42 (65.6%) 1.8 ± 0.7 [1; 4] 56 ± 14.1 [19; 81] 5.7 ± 1.9 [3; 9]
NS NS NS NS NS NS
THA, total hip arthroplasty; BMI, body mass index; ASA, American Society of Anesthesiologists; SD, standard deviation; HHS, Harris Hip Score; UCLA, University of California Los Angeles; min, minimum; max, maximum; NS, not significant.
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Fig. 1. Bilateral hip osteoarthritis (A) on radiographic anteroposterior view, treated by single stage bilateral THA (B).
Results None were lost to follow-up and all patients in both groups completed the questionnaires. The mean follow-up was 20.9 ± 10.8 months for the bilateral THA group and 28.9 ± 15 months for the control group. The functional outcome scores and the data on RTS are reported in Table 2. In the bilateral THA group, 28 of 32 patients (87.5%) returned to sport after the surgery. The average delay for RTS was 4.2 ± 2.7 months. Among the 4 patients who did not return to sport, the sole reason was a lack of motivation to participate. The reasons to not return to sport, to not practice the same sport, or with the same intensity are described in Figure 2. The majority of practiced sports were low impact (Table 3). At the last follow-up, the rate of very satisfied (n ¼ 27; 84%) or satisfied (n ¼ 4; 12.5%) patients after single stage bilateral THA was very high at 96.5%. Only 1 patient was disappointed (very sportive patient who hoped to increase the intensity of his sports after the surgery). Motivation was the only predictive factor found for RTS (P < .001). In the unilateral THA group, 37 of 64 patients (57.8%) returned to sport after the surgery, at an average delay of 5.4 ± 5.1 months. The reasons to not return to sport are reported in Figure 3. At the last follow-up, the rate of very satisfied (n ¼ 43; 67.2%) or satisfied (n ¼ 16; 25%) patients after unilateral THA was high at 92.2%. No complication or surgical revision has been reported at last follow-up in the 2 groups. Discussion The key finding of this study is a high rate of RTS after one stage bilateral THA via DAA: 87% of patients returned to sport, 89% of those to the same sport, and 68% at the same intensity. To our knowledge, this study is the first to assess the RTS after bilateral
single stage THA. Several studies have assessed the RTS rates after unilateral THA and found an RTS similar to our unilateral control group [11,16e19]. Innmann et al [16], Ollivier et al [11], and Schmidutz et al [17], respectively, found that 89%, 64%, and 98% of their patients had returned to sport after unilateral THA at long term (between 2 and 10 years). The average delay for RTS after one bilateral stage THA was 4 months. This delay was not significantly different of the RTS delay after unilateral THA. This was a faster return than previous similar studies, including Ollivier et al [11] who did not allow RTS before 6 months. Schmidutz et al [17] and Innmann et al [16] evaluated their patients at 2 and 10 years postoperatively, without documenting the timing of initial RTS. The DAA can improve the recovery time [20]. In others studies, the approaches were posterolateral approach, transgluteal approach, or Watson Jones approach [11,16,17]. The most recent recommendations from the Hip Society and AAHKS [15] were established after surveying 760 surgeons. The consensus was an RTS after 3-6 months with only 10% of surgeons saying they would allow a return earlier than 3 months after THA. We could isolate only motivation as a predictive factor for RTS, likely due to the limited number of patients and the criteria necessary to be selected for single stage bilateral THA. Ollivier et al [11] found a correlation among RTS, preoperative HHS, age, and patient satisfaction. In a review of the literature by Jassim et al [21] on the RTS after arthroplasty, 12 of 42 studies focused on THA with an average of 256 patients per study, an average age of 61, and follow-up of 4.7 years. The highest scores (UCLA, Harris, Oxford) were associated with young age, male gender, and low BMI. In this study, among the patients who did not return to the same intensity or returned to a different sport, the primary reason was another source of pain, in particular knee or lower back pain. Ollivier et al [11] report several reasons for patients not returning to the same sport, the most common being fear of component wear
Table 2 Postoperative Functional Results and Return to Sport After Single Stage Bilateral THA Compared to Unilateral THA. Postoperative
Bilateral THA (n ¼ 32)
Unilateral THA (n ¼ 64)
P-Value
Follow-up (mo) (mean ± SD) [min-max] Postoperative HHS (mean ± SD) [min-max] HHS improvement (mean ± SD) [min-max] Postoperative HOOS (mean ± SD) [min-max] Postoperative UCLA (mean ± SD) [min-max] Rate of RTS RTS at same sport RTS at the same intensity Delay to RTS (mo) (mean ± SD) [min-max]
20.9 ± 10.8 [6-48] 88.5 ± 5.1 [68-91] 32.7 ± 13.4 [9-72] 94.5 ± 8.1 [68.8-100] 5.6 ± 1.6 [3-9] 87.5% (n ¼ 28) 89.3% (n ¼ 25/28) 68% (n ¼ 17/25) 4.2 ± 2.7 [1-12]
28.9 ± 15 [6-67] 94.4 ± 9.4 [41-100] 38.4 ± 13.5 [10-64] 90.7 ± 12.7 [36.9-100] 4.9 ± 2.2 [2-9] 57.8% (n ¼ 37) 62.2% (n ¼ 23/37) 56.5% (n ¼ 13/23) 5.4 ± 5.1 [1-24]
<.01 .001 NS NS NS <.001 <.01 NS NS
THA, total hip arthroplasty; SD, standard deviation; HHS, Harris Hip Score; HOOS, Hip disability and Osteoarthritis Outcome Score; UCLA, University of California Los Angeles; min, minimum; max, maximum; NS, not significant; RTS, return to sport.
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Fig. 2. Reasons for not returning to sport, returning at a lower intensity, or returning to another sport after single stage bilateral THA.
(25.4%), fear of dislocation (31.7%), or a cause independent of the hip (29.7%). In our opinion, the DAA allows us to eliminate the fear of dislocation as a reason to limit RTS [14]. With recent advancements in low friction arthroplasties, we authorize all sports without high impact. Other causes independent of the hip often influence the functional results of THA [19], and they also play an important role in our study. Loth et al [22] found that comorbidities significantly influenced functional results after THA, noting that lower back pain especially decreases functional scores. The majority of sports practiced in our series (82%) were lowimpact sports, according to AAHKS recommendations [15]. The patients who performed high impact sports had started well before the THA and were experienced in these sports. The evolution of the practice of these sports was not collected in this study. Schmidutz et al [17] and Innmann et al [16] did evaluate this and concluded that participation in higher impact sports after THA decreases over time. Ollivier et al [23] compared the practice of high impact sports in 70 patients vs low impact sports in 140 patients with a minimum follow-up of 10 years. They reported that high impact sports lead to more long-term mechanical complications such as increased wear rate or revisions for aseptic loosening. We do not report any complications despite participation in sports not authorized by AAHKS [15], including high impact sports. However, the average follow-up in our study was 20 months. This is sufficient to evaluate functional scores and RTS but limited in studying long-term complications. Few studies assessed the RTS after THA using the UCLA score, which has been found to be the most appropriate [24]. This study found an average UCLA score of 5.6 points after bilateral THA, which is comparable to scores that can be found in the literature for unilateral THA and in the control group. Innmann et al [16] described an average UCLA score of 6.2 in 86 patients with an average of 6.3 after 11-year follow-up. Ollivier et al [11] report an average UCLA score of 6.8 points in 815 patients with an average follow-up of 9.8 years, whereas in the study of Schmidutz et al [17] the average UCLA score was 7.6 points in 68 patients with an average age of 55 years and follow-up of 2.7 years.
This study has several limitations. First, the number of patients was small, resulting in a lack of power. Some predictive factors
Table 3 American Association of Hip and Knee Arthroplasty Surgeons Sport Recommendations and the Level of Motivation to Participate in These Sports After Single Stage Bilateral Total Hip Arthroplasty. Motivation Allowed Golf Stationary cycling Swimming Doubles tennis Normal walking Elliptical Step Allowed with experience Cross-country skiing Pilates Fitness Weight machine Bowling Hiking Road cycling Not recommended Jogging Contact sports Gymnastics Squash Snowboard Singles tennis No consensus Downhill skiing Roller/ice skating Weight lifting Dancing Rowing Speed walking Stationary skiing Martial arts
Low
Important
Very Important
Total
4 6 7 1 5 2 2
1 1 6 1 11 1 0
0 1 3 1 9 0 1
5 8 16 3 25 3 3
1 0 0 1 3 3 7
2 3 2 1 0 11 5
0 3 0 1 0 4 3
3 6 2 3 3 18 15
2 0 0 1 0 1
2 2 2 1 0 0
1 0 1 0 1 2
5 2 3 2 1 3
1 1 2 5 1 6 0 0
1 0 3 1 0 3 1 0
3 0 1 2 1 1 0 1
5 1 6 8 2 10 1 1
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Fig. 3. Reasons for not returning to sport, returning at a lower intensity, or returning to another sport after unilateral THA.
may have been missed due to this limited sample size. Second, the follow-up was too short to evaluate both long-term complications and the change in a patient’s sports participation over time after initial RTS. Nevertheless, our aim was to report the RTS in the postoperative period. The method of data collection by selfcompleted questionnaires can cause bias through inaccurate estimation of sport level. But this questionnaire eliminates any bias related to the observer. Finally, this controlled study was not randomized. The 2 groups are very similar. Nevertheless, even if we find no significant difference between both groups, the patients undergoing single stage bilateral THA are often active patients with very good health. These patients are thus more disposed to RTS.
Conclusion Bilateral simultaneous THA via DAA demonstrates high rate of RTS and allows RTS (4 months on average) in the majority of patients who participated in sports previously. These results are at least equivalent to those after unilateral THA. Patients who did not return to sport or who had changes in postop activity often did so for causes other than functional results of their bilateral THA. A longer term study with a larger cohort of patients would be helpful in identifying additional factors predicting an RTS and analyzing the evolution of patients’ sports practice.
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