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In primary total hip arthroplasty, the direct anterior approach leads to higher levels of creatine kinase and lower levels of C-reactive protein compared to the posterolateral approach: a propensity score matching analysis of short-term follow-up data

Journal of Orthopaedic Surgery and Research volume 18, Article number: 594 (2023) Cite this article

Abstract

Background

This retrospective study compares the invasiveness of the direct anterior approach (DAA) and the posterolateral approach (PLA) in total hip arthroplasty (THA) by assessing three widely used inflammation-related serum markers in the first ten post-operative days.

Methods

The database of our institution was mined for primary THAs conducted by the DAA or the PLA from February 2020 to June 2022. Demographics and creatine kinase (CK), C-reactive protein (CRP), and white blood cells were compared. Propensity Score Matching (PSM) analysis (1:1 ratio) was conducted based on multiple variables.

Results

PSM analysis yielded 44 pairs of DAA and PLA patients. CK was significantly higher (p < 0.001) in the DAA than in the PLA group on postoperative day (POD) 2, 5 and 10. The POD2, POD5 and POD10 CK/preoperative CK ratio was 12.9, 5.0 and 0.8 in DAA and 8.8, 3.3 and 0.6 in PLA (p = 0.017, p = 0.012 and p = 0.025, respectively). The POD2, POD5 and POD10 CRP/preoperative CRP ratio was 95.1, 65.6 and 22.8 in PLA and 34.7, 23.3 and 8.9 in DAA (p < 0.001, p = 0.002 and p < 0.001, respectively).

Conclusion

PSM analysis of early postoperative CK and CRP values demonstrated that the DAA should be considered as a less stressful approach, not as a muscle-sparing or a minimally invasive THA approach.

Background

Total hip arthroplasty (THA), one of the most effective orthopedic procedures devised in recent decades, is the treatment of choice for symptomatic end-stage osteoarthritis [1]. Over time, clinical outcomes have continuously improved and implant survival rates have increased to over 95% at ten years [2, 3]. As population aging and the spread of obesity boost the requirements for THA procedures, there is as yet no agreement on the best surgical approach to the hip joint for primary THA, since all methods have advantages as well as drawbacks [4]. In recent years, “minimally invasive” approaches, which offer faster recovery and less postoperative pain, though involving a learning curve, have become increasingly popular [5,6,7,8,9,10]. In particular, the direct anterior approach (DAA), where joint exposure is performed through internervous and intermuscular planes [11], has been reported to provide better early postoperative outcomes [12,13,14], although the literature is inconclusive.

C-reactive protein (CRP) is currently employed as a useful measure of inflammation and infection, being considered as a more reliable marker of infection-related surgical complications than erythrocyte sedimentation rate and white blood cell (WBC) count [15,16,17]. The CRP response objectifies the surgical trauma and can thus be used to quantify its invasiveness, assess tissue damage, and monitor perioperative stress [18]. THA and total knee arthroplasty induce leukocytosis. In THA, total leukocyte counts have been reported to peak on postoperative day (POD)1, whereas the WBC count appeared to decline on POD5, but did not revert to preoperative values [19, 20].

Serum enzymes have recently been proposed as objective measures of the muscle damage and inflammation induced by surgical procedures [21,22,23,24]. Indeed, elevation of serum creatine kinase (CK) after orthopedic surgery has been described even in the absence of myocardial damage [25, 26]. The claim that the DAA to the hip joint, which avoids muscle resection by passing through intermuscular and internervous planes, is a minimally invasive approach has been substantiated by the lower CK levels found in DAA patients compared to individuals subjected to posterior approaches. However, conflicting findings were previously reported. Additionally, large heterogeneity was found in the comparison groups making the findings hard to generalize.

Therefore, this study aimed to the first study that uses Propensity Score Matching analysis to examine whether the DAA is less invasive than the PLA by comparing three widely used serum markers of inflammation over 10-day follow-up.

Methods

Patient selection

The records of the patients who underwent primary THA by the DAA or the PLA from February 2020 to June 2022 and for whom a follow-up of at least 10 days was available were retrospectively retrieved from the institutional database. The data collected included demographics, body mass index (BMI), medical history, current treatments, preoperative diagnosis, inpatient history, American Society of Anesthesiologists (ASA) class, type of anesthesia, operative time, pre- and postoperative serum CK, CRP, and WBC values, any intraoperative complications, and any infections up to 3 months after surgery.

Inclusion and exclusion criteria:

Participants were patients aged 18–70 years who underwent THA (by the DAA or the PLA) for primary degenerative hip osteoarthritis. Exclusion criteria were unwillingness to participate; a BMI ≥ 35; inflammatory arthropathy, autoimmune or rheumatic disease; previous procedures involving the affected hip; bilateral hip arthroplasty; contralateral THA and any arthroplasty procedure; a diagnosis of congenital/acquired muscle disease, ischemic cardiac disease, or end-stage renal failure; hepatitis, liver disease, or malignancy; a history of cerebrovascular disease; peripheral neuropathy; cognitive deficits; a recent history of rhabdomyolysis; current treatment with immunosuppressive or myotoxic drugs; urinary tract infection; contact with COVID-19 patients during hospitalization; internal or surgical intraoperative complications requiring cement or cerclage; postoperative wound or upper/lower respiratory tract infection; implant infection up to 3 months after THA; postoperative complications such as venous thrombosis, hematoma or fever (> 38 °C). Patients whose serum samples had been analyzed elsewhere were excluded. Patients older than 70 years were also excluded, due to their atypical response to surgical stress [27] moreover, since these subjects might already suffer from muscle damage, they are hypersensitive to even minor muscle injury [28, 29]. All patients provided their signed informed consent.

Indications for surgery

All patients had been diagnosed with hip osteoarthritis based on history, physical examination, and imaging findings. If after three months of conservative treatment (physical therapy, intra-articular cortisone injections, rest, and anti-inflammatory drugs) they still complained of significant pain, they were offered hip arthroplasty by the DAA or the PLA and given the same preoperative education program.

Surgical procedure

THA was performed by two senior orthopedic surgeons (MS for DAA, AG for PLA), whose extended experience in the respective approach (> 15 years) far exceeds the learning curve [30, 31]. All patients received dual-mobility implants with an uncemented acetabular component (Acorn Primary Dual Mobility), an uncemented femoral component (Exacta short, lateralized or standard femoral stem), a 28 mm metal femoral head (ceramic in patients with metal allergy or sensitivity), and a polyethylene insert (ACORN dual mobility cup insert), all from Permedica, Merate, Italy.

Perioperative procedures

All patients received perioperative antibiotic prophylaxis (cefazolin 2 g) and 1 g intravenous tranexamic acid 20 min before the skin incision and anesthesia (general or spinal). Postoperative pain control included intravenous tramadol 20 mg + metoclopramide 10 mg for 24 h. Over the next few days oral paracetamol or oral tramadol were administered as needed. Postoperative thromboembolic prophylaxis was ensured by low molecular weight heparin and use of elastic stockings (both limbs). Physiotherapy was begun on POD1. Weightbearing and walking with aids were allowed the next morning, after an x-ray check of implant positioning and bone integrity. In POD 2, all patients were transferred to the hospital's rehabilitation department where they continued their inpatient physical therapy course.

Serum levels

The aim of the study was to compare the serum values of three widely used inflammatory markers before and after the procedure and between the DAA and the PLA. CK and CRP were determined before the operation and on PODs 2, 5 and 10, whereas WBC was evaluated preoperatively and on PODs 1, 2, 5, and 10 [32, 33]. The ratio of postoperative to preoperative levels of the three markers was calculated and compared in the two groups.

Statistical analysis

All analysis were conducted using Microsoft Excel (Microsoft) with the XLSTAT resource pack (XLSTAT-Premium, Addinsoft, New York, USA). A Propensity Score Matching (PSM) analysis was conducted to adjust for the differences in known covariates between the groups [34]. Patients treated by the DAA and the PLA were matched 1:1 using an optimal matching algorithm [35] which determines the matched samples with the smallest average absolute distance across all matched pairs. This type of matching, which is considered as an ideal method to assess differences between treatment groups was used to reduce the effect of potential confounding variables between DAA and PLA individuals [36]. Patients were eligible for matching if the difference of the propensity score between DAA and PLA was within the caliper radius of 0.01 × sigma. The strength of the association was estimated with 95% confidence intervals. The variables on which the two groups were matched included gender, type of anesthesia, and use of drainage (categorical data) and age, BMI, operative time and preoperative levels of CK, CRP and WBC (quantitative data). The Shapiro–Wilk test was performed to assess whether the data showed a normal distribution. Calculated mean values and SMD (standardized mean difference) were also reported for all continuous data. A non-parametric test (Mann–Whitney for unpaired data and Wilcoxon signed rank for paired data) was applied to assess continuous variables for significant differences between the groups. The categorical data were subjected to the chi-square test. Imbalances between the DAA and PLA groups were identified by comparing the SMD before and after the matching. A group was considered imbalanced for a particular covariate if SMD was > 0.2 [34].

A p value < 0.05 was considered significant. The statistical analyses were conducted using Microsoft Excel (Microsoft) and the XLSTAT resource pack.

Results

According to the institutional database, 510 THAs with 10-day follow-up, 314 conducted by the DAA and 196 by the PLA, were performed at our institution from February 2020 to June 2022. A total number of 92 DDA patients and 74 PLA patients met the inclusion/exclusion criteria. PSM analysis yielded 44 pairs of patients who were successfully matched for gender, type of anesthesia, drainage use, age, BMI, operative time and preoperative levels of CK, CRP and WBC (Fig. 1).

Fig. 1
figure 1

Patient selection flowchart. THA: total hip arthroplasty

Full size image

Patient data

Before PSM analysis, the two groups (92 DAA and 74 PLA patients) were imbalanced regarding BMI and operative time with SMD values of 0.82 and 0.45 respectively. The two groups had significantly different BMI (p < 0.001), ASA class (p < 0.001), and operative time (p < 0.001). PSM analysis, where patients were matched 1:1, yielded two similar groups that did not have significantly different preoperative, perioperative or postoperative features (Table 1).

Table 1 Preoperative, perioperative, and postoperative data of the THA patients
Full size table

After PSM analysis, a residual imbalance remained regarding BMI (SMD = 0.30), but there were no significant differences (p = 0.201).

Serum marker values

Before matching, the DAA and PLA group were imbalanced regarding preoperative CRP values (SMD = 0.30); after matching a residual imbalance remained (SMD = 0.28).

The DAA and PLA groups had not significantly different levels of preoperative CK, CRP, or WBC either before or after matching.

As regards the postoperative values, serum CK on POD2 was 1619.5 ± 936.0 IU/l (range, 344.0–3902.0) in the DAA group and 740.9 ± 401.7 IU/l (range, 124.0–1756.0) in the PLA group (p < 0.001). Serum CK on POD5 was 690.5 ± 489.0 IU/l (range, 98.0–2453.0) in the DAA group and 326.4 ± 260.9 IU/l (range, 66.0–993.0) in the PLA group (p < 0.001). Serum CK on POD10 was 103.3 ± 65.6 IU/l (range, 44.0–353.0) in the DAA group and 74.3 ± 55.3 IU/l (range 22.0–234.0) in the PLA group (p < 0.001). The ratio of POD2 CK to preoperative CK was 12.9 ± 8.2 (range, 3.4–44.3) in the DAA group and 8.8 ± 8.3 (range, 1.1–36.6) in the PLA group (p = 0.017). The ratio of POD5 CK to preoperative CK was 5.0 ± 3.4 (range, 1.8–16.4) in the DAA group and 3.3 ± 3.2 (range, 0.4–16.8) in the PLA group (p = 0.012). The ratio of POD10 CK to preoperative CK was 0.8 ± 0.5 (range, 0.2–1.9) in the DAA group and 0.6 ± 0.2 (range, 0.2–1.0) in the PLA group (p = 0.025).

Serum CRP on POD2 was 3.7 ± 0.6 mg/dl (range, 2.1–6.5) in the DAA group and 8.6 ± 1.5 mg/dl (range, 6.1–11.6) in the PLA group (p < 0.001). Serum CRP on POD5 was 2.6 ± 1.0 mg/dl (range, 0.7–4.3) in the DAA group and 5.7 ± 1.2 mg/dl (range, 4.0–8.1) in the PLA group (p < 0.001), whereas on POD10 it was 1.0 ± 0.6 mg/dl (range, 0.3–2.3) in the DAA group and 2.5 ± 1.0 mg/dl (range, 0.8–4.8) in the PLA group (p < 0.001). The POD2 CRP/preoperative CRP ratio was 34.7 ± 24.1 (range 4.7–114.0) in the DAA group and 95.1 ± 174.5 (range, 13.8–1116.0) in the PLA group (p < 0.001). The POD5 CRP/preoperative CRP ratio was 23.3 ± 19.1 (range 3.9–95.7) in the DAA group and 65.6 ± 124.5 (range, 8.0–764.0) in the PLA group (p = 0.002). The POD10 CRP/preoperative CRP ratio was 8.9 ± 7.2 (range, 1.5–30.5) in the DAA group and 22.8 ± 25.2 (range 1.6–135.0) in the PLA group (p < 0.001).

No significant differences in WBC values and ratios were found in serum except for POD1 and POD5 WBC/preoperative WBC ratio (p = 0.041 and p = 0.022, respectively) (Table 2).

Table 2 Comparison between DAA and PLA group
Full size table

Discussion

This study set out to compare the invasiveness of THA, conducted by the DAA or the PLA, by analyzing three widely used serum markers of inflammation and muscle injury in a sample of DAA and PLA patients matched by PSM analysis. Our chief finding was that the DAA involved significantly higher CK and significantly lower CRP values than the PLA. In particular, serum CK was significantly higher on POD2, POD5 and POD10 in the DAA group, where the ratio of POD 2 and POD5 CK to preoperative CK was higher that the PLA group. As regards CRP, on POD2, POD5 and POD10 it was significantly higher in the PLA group, where the POD2 and POD5 CRP/preoperative CRP ratio was about more than 3 times greater, while the POD10 CRP/preoperative CRP ratio was almost twice compared to that of the DAA group. In contrast, the WBC counts never showed significant differences, suggesting that this measure may not be critical for the assessment of procedure invasiveness. Data analysis highlighted that the two patient groups showed no significant differences in serum CK or CRP both before and after matching. Far from being a drawback or a bias, this finding demonstrates that before THA the two groups were in fact very similar.

In recent years, “minimally invasive” THA approaches have gained considerable popularity for their ability to ensure a swifter recovery and a less painful postoperative course, despite a not negligible risk of complications. In particular, the DAA has been reported to provide better clinical outcomes, reduced painkiller use, and shorter hospital stays [5], although it is burdened by a long learning curve and a higher risk of lateral femoral cutaneous nerve injury and iatrogenic fractures compared with other approaches [37].

CRP has been proposed as a measure of the overall invasiveness of surgical procedures, particularly of tissue damage and perioperative stress [18, 33]. Our DAA patients had significantly lower postoperative CRP than the PLA group both before and after matching; this contrasts with several studies describing comparable CRP values in patients managed by the two approaches [38, 39]. As regards CK, reports of its value as a measure of invasiveness are inconsistent [23, 24, 38, 40,41,42,43]. In particular, one study has demonstrated that patients managed by the PLA had higher CK levels in the early postoperative days than patients managed by the DAA [41], whereas another found that in the immediate postoperative period CK values were 5.5 times higher in PLA patients [24]. In a prospective randomized study of patients subjected to DAA or PLA, [38] CK and CRP did not show significant differences between the groups either before surgery and at 6 weeks. The CK values found in our patients are in line with those described by Maezawa et al. [39], who measured CK and CRP preoperatively, immediately after surgery, and then on PODs 1 and 4 in patients managed by the DAA or the PLA. This finding may be explained by the stress induced by the retraction of the tensor fasciae latae, rectus femoris, sartorius, and gluteus medius, despite the fact that the DAA does not involve muscle resection. Furthermore, any injury to these muscles during broaching of the proximal femur or stem implantation results in serum marker elevation [40, 41, 44, 45].

For these reasons, the DAA has a greater potential for muscle damage than other approaches [40], as demonstrated by Meneghini et al. [46] for the rectus femoris and the tensor fasciae latae and by Van Oldenrijk et al. [47] for the lateral femoral cutaneous nerve. In contrast, Frye et al. [48] found that muscle injury in the DAA is more frequent in men patients with a high BMI. As regards the WBC count, values were not significantly different in the two groups. However, the change after THA was in line with the one reported by Hughes et al. [19] and Høgevold et al. [20].

In our opinion THA through DAA should not be considered as a muscle-sparing or minimally invasive approach, but mainly as a less stressful approach for the patient. Indeed, CRP, which assesses the systemic response to surgical stress, was consistently lower, while CK, marker of locally produced muscle damage, was significantly higher. These data may suggest proposing THA through DAA in patients with increased surgical risk, as it has less impact on the systemic response to surgery.

To the best of our knowledge, this is the first work where the PSM strategy is applied to compare three widely used serum markers in DAA and PLA patients subjected to primary THA. The main strength of our study is that the procedures were performed by two high-volume surgeons with strong experience in their chosen approach [49, 50] on patients who followed the same preoperative protocol, received the same implant, and were managed by the same rehabilitation protocol. Other significant advantages are the application of exacting inclusion and exclusion criteria, which ensured a very homogeneous patient sample, and the use of PSM, which further reduced confounding biases, although it clearly yielded a small number of patient pairs.

The chief limitation of our study is its retrospective and non-randomized design. Pair matches obtained were only 44, and the study may be underpowered. However, considering an effect size of 0.3, and α level with p = 0.05, the Post hoc power analysis was 86% (G-Power version 3.1, Düsseldorf, Germany) [51].

That fact that we did not examine patients’ clinical outcomes may also be considered as a limitation; however, since the only purpose of the study was to compare the invasiveness of the two THA approaches, the reader is referred to the literature for the functional outcomes [52]. Moreover, the length of skin incision was not considered in the statistical analysis. Finally, the decision to analyze CK, CRP, and WBC, but not other serum markers such as interleukins, myoglobin, and tumor necrosis factor alpha [23, 24, 32, 41, 53], stems from the inconclusive data on their value.

Age plays a well-documented role in serum enzyme levels [27]. To minimize its influence, we excluded patients aged more than 70 years, who show atypical responses to surgical stress [27], and applied the PSM strategy, which further reduced confounding biases. Since biochemical markers can be affected a variety of factors, further approaches capable of quantifying tissue damage should be developed and honed [54,55,56]. For instance, diagnostic imaging methods such as MRI can supply additional useful information on the invasiveness of surgical procedures in general and of THA approaches in particular.

Conclusions

In conclusion, the main finding of this study was that two widely used serum markers of inflammation and muscle injury increase in the first postoperative days both in THA patients managed by the DAA and in those managed by the PLA. In the DAA group, CRP was consistently lower, whereas CK was significantly higher on POD5 and then reverted to baseline within 10 days. For these reasons, the DAA should be considered as a less stressful rather than as a minimally invasive THA approach.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author, LDB, on reasonable request.

Abbreviations

DAA:

Direct anterior approach

THA:

Total hip arthroplasty

PLA:

Posterolateral approach

CK:

Creatine kinase

CRP:

C-reactive protein

WBC:

White blood cells

PSM:

Propensity score matching

POD:

Postoperative day

References

  1. Migliorini F, Driessen A, Eschweiler J, Tingart M, Maffulli N. No benefits of minimally invasive total hip arthroplasty via Watson-Jones approach: a retrospective cohort study. Surgeon. 2022;20:e241–7.

    PubMed  Google Scholar 

  2. Esler Peter Howard Alun John Matthew Porteous C, Goldberg Ro Kulkarni Professor Amar Rangan Professor Jonathan Rees A, Beaumont James Thornton Elaine Young R, McCormack Anita Mistry Claire Newell Martin Pickford Martin Royall Mike Swanson V, Yoav Ben Shlomo Professor Ashley Blom Emma Clark Professor Paul Dieppe Linda Hunt Garry King Michèle Smith Michael Whitehouse P. 2015 12th Annual Report Healthcare Quality Improvement Partnership NJR Management Team and NJR Communications National Joint Registry | 12th Annual Report [Internet]. Available from: www.njrcentre.org.uk

  3. Garellick G, Kärrholm J, Lindahl H, Malchau H, Rogmark C, Rolfson O. The Swedish Hip Arthroplasty Register Annual Report 2014.

  4. Alecci V, Valente M, Crucil M, Minerva M, Pellegrino CM, Sabbadini DD. Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: perioperative findings. J Orthop Traumatol. 2011;12:123–9.

    PubMed  PubMed Central  Google Scholar 

  5. Goebel S, Steinert AF, Schillinger J, Eulert J, Broscheit J, Rudert M, et al. Reduced postoperative pain in total hip arthroplasty after minimal-invasive anterior approach. Int Orthop. 2012;36:491–8.

    PubMed  Google Scholar 

  6. Bon G, Kacem EB, Lepretre PM, Weissland T, Mertl P, Dehl M, et al. Does the direct anterior approach allow earlier recovery of walking following total hip arthroplasty? A randomized prospective trial using accelerometry. Orthop Traumatol Surg Res. 2019;105:445–52.

    PubMed  Google Scholar 

  7. Moerenhout K, Benoit B, Gaspard HS, Rouleau DM, Laflamme GY. Greater trochanteric pain after primary total hip replacement, comparing the anterior and posterior approach: a secondary analysis of a randomized trial. Orthop Traumatol Surg Res. 2021;107:102709.

    PubMed  Google Scholar 

  8. Mahmood A, Zafar MS, Majid I, Maffulli N, Thompson J. Minimally invasive hip arthroplasty: a quantitative review of the literature. Br Med Bull. 2007;84:37–48.

    PubMed  Google Scholar 

  9. Capuano N, Del Buono A, Maffulli N. Gewebeerhaltende Hüft-TEP-operation mit superiorer Kapsulotomie. Oper Orthop Traumatol. 2015;27:334–41.

    CAS  PubMed  Google Scholar 

  10. Migliorini F, Pintore A, Eschweiler J, Oliva F, Hildebrand F, Maffulli N. Factors influencing the outcomes of minimally invasive total hip arthroplasty: a systematic review. J Orthop Surg Res. 2022;17:281.

    PubMed  PubMed Central  Google Scholar 

  11. Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res. 2005;441:115–24.

    PubMed  Google Scholar 

  12. Nakata K, Nishikawa M, Yamamoto K, Hirota S, Yoshikawa H. A clinical comparative study of the direct anterior with mini-posterior approach. Two consecutive series. J Arthroplasty. 2009;24:698–704.

    PubMed  Google Scholar 

  13. Bernard J, Razanabola F, Beldame J, van Driessche S, Brunel H, Poirier T, et al. Electromyographic study of hip muscles involved in total hip arthroplasty: surprising results using the direct anterior minimally invasive approach. Orthop Traumatol Surg Res. 2018;104:1137–42.

    PubMed  Google Scholar 

  14. den Daas A, Reitsma EA, Knobben BAS, ten Have BLEF, Somford MP. Patient satisfaction in different approaches for total hip arthroplasty. Orthop Traumatol Surg Res. 2019;105:1277–82.

    Google Scholar 

  15. Choudhry RR, Rice RP, Triffitt PD, Harper WM, Gregg PJ. Plasma viscosity and C-reactive five protein after total hip and knee arthroplasty. J Bone Jt Surg Br. 1992;74:523–4.

    CAS  Google Scholar 

  16. Ellitsgaard N, Andersson AP, Jensen KV, Jorgensen M. Changes in C-reactive protein and erythrocyte sedimentation rate after hip fractures. Int Orthop (SICOT). 1991;15:311–4.

    CAS  Google Scholar 

  17. Ettinger M, Calliess T, Kielstein JT, Sibai J, Brückner T, Lichtinghagen R, et al. Circulating biomarkers for discrimination between aseptic joint failure, low-grade infection, and high-grade septic failure. Clin Infect Dis. 2015;61:332–41.

    CAS  PubMed  Google Scholar 

  18. Neumaier M, Braun KF, Sandmann G, Siebenlist S. Current concepts review souborný referát C-reactive protein in orthopaedic surgery C-reaktivní protein v ortopedické chirurgii. / Acta Chir. orthop. Traum. čech. 2015.

  19. Hughes SF, Hendricks BD, Edwards DR, Maclean KM, Bastawrous SS, Middleton JF. Total hip and knee replacement surgery results in changes in leukocyte and endothelial markers [Internet]. 2010. Available from: http://www.journal-inflammation.com/content/7/1/2

  20. Høgevold H, Lyberg T, Reikerås O. Changes in leukocyte subpopulations following total hip replacement surgery. Effects of high doses of corticosteroids. J Clin Lab Invest. 1991. https://doi.org/10.3109/00365519109091638.

    Article  Google Scholar 

  21. Grande M, Tucci GF, Adorisio O, Barini A, Rulli F, Neri A, et al. Systemic acute-phase response after laparoscopic and open cholecystectomy. Surg Endosc Other Interv Tech. 2002;16:313–6.

    CAS  Google Scholar 

  22. Chimento GF, Pavone V, Sharrock N, Kahn B, Cahill J, Sculco TP. Minimally invasive total hip arthroplasty: a prospective randomized study. J Arthroplasty. 2005;20:139–44.

    PubMed  Google Scholar 

  23. de Anta-Díaz B, Serralta-Gomis J, Lizaur-Utrilla A, Benavidez E, López-Prats FA. No differences between direct anterior and lateral approach for primary total hip arthroplasty related to muscle damage or functional outcome. Int Orthop. 2016;40:2025–30.

    PubMed  Google Scholar 

  24. Bergin PF, Doppelt JD, Kephart CJ, Benke MT, Graeter JH, Holmes AS, et al. Comparison of minimally invasive direct anterior versus posterior total hip arthroplasty based on inflammation and muscle damage markers. J Bone Jt Surg. 2011;93:1392–8.

    Google Scholar 

  25. Healey JH, Kagen LJ, Velis KP, Levine DBMD. Creatine kinase MB in Skeletal muscle and serum of spine-fusion patients.

  26. Laurence AS. Serum myoglobin and creatine kinase following surgery. Br J Anaesth. 2000;84:763–6.

    CAS  PubMed  Google Scholar 

  27. Vester H, Huber-Lang MS, Kida Q, Scola A, van Griensven M, Gebhard F, et al. The immune response after fracture trauma is different in old compared to young patients. Immun Ageing. 2014;11:1–8.

    Google Scholar 

  28. Merritt EK, Stec MJ, Thalacker-Mercer A, Windham ST, Cross JM, Shelley DP, et al. Heightened muscle inflammation susceptibility may impair regenerative capacity in aging humans. J Appl Physiol. 2013;115:937–48.

    CAS  PubMed  PubMed Central  Google Scholar 

  29. Thalacker-Mercer AE, Dell’italia LJ, Cui X, Cross JM, Bamman MM. Differential genomic responses in old vs. young humans despite similar levels of modest muscle damage after resistance loading. Physiol Genom. 2010;40:141–9.

    CAS  Google Scholar 

  30. Seng BE, Berend KR, Ajluni AF, Lombardi AV. Anterior-supine minimally invasive total hip arthroplasty: defining the learning curve. Orthop Clin North Am. 2009;40:343–50.

    PubMed  Google Scholar 

  31. Müller DA, Zingg PO, Dora C. Anterior minimally invasive approach for total hip replacement: five-year survivorship and learning curve. Hip Int. 2014;24:277–83.

    PubMed  Google Scholar 

  32. Brancaccio P, Lippi G, Maffulli N. Biochemical markers of muscular damage. Clin Chem Lab Med. 2010;48:757–67.

    CAS  PubMed  Google Scholar 

  33. Neumaier M, Metak G, Scherer MA. C-reactive protein as a parameter of surgical trauma: CRP response after different types of surgery in 349 hip fractures. Acta Orthop. 2006;77:788–90.

    PubMed  Google Scholar 

  34. Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivar Behav Res. 2011;46:399–424.

    Google Scholar 

  35. Rosenbaum PR. Optimal matching for observational studies. J Am Stat Assoc. 1989;84:1024–32.

    Google Scholar 

  36. Austin PC. Some methods of propensity-score matching had superior performance to others: results of an empirical investigation and monte carlo simulations. Biom J. 2009;51:171–84.

    PubMed  Google Scholar 

  37. Spaans AJ, van den Hout JAAM, Bolder SBT. High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach. Acta Orthop. 2012;83:342–6.

    PubMed  PubMed Central  Google Scholar 

  38. Rykov K, Reininga IHF, Sietsma MS, Knobben BAS, ten Have BLEF. Posterolateral vs direct anterior approach in total hip arthroplasty (POLADA Trial): a randomized controlled trial to assess differences in serum markers. J Arthroplasty. 2017;32:3652-3658.e1.

    PubMed  Google Scholar 

  39. Maezawa K, Nozawa M, Gomi M, Sugimoto M, Maruyama Y. Changes in serum creatine kinase and C-reactive protein after posterior and direct anterior approaches in total hip arthroplasty. Hip Int. 2022;32:591–5.

    PubMed  Google Scholar 

  40. Mjaaland KE, Kivle K, Svenningsen S, Pripp AH, Nordsletten L. Comparison of markers for muscle damage, inflammation, and pain using minimally invasive direct anterior versus direct lateral approach in total hip arthroplasty: a prospective, randomized, controlled trial. J Orthop Res. 2015;33:1305–10.

    PubMed  Google Scholar 

  41. Poehling-Monaghan KL, Taunton MJ, Kamath AF, Trousdale RT, Sierra RJ, Pagnano MW. No correlation between serum markers and early functional outcome after contemporary THA. Clin Orthop Relat Res. 2017;475:452–62.

    PubMed  Google Scholar 

  42. Suzuki K, Kawachi S, Sakai H, Nanke H, Morita S. Mini-incision total hip arthroplasty: a quantitative assessment of laboratory data and clinical outcomes. J Orthop Sci. 2004;9:571–5.

    PubMed  Google Scholar 

  43. Cohen RG, Katz JA, Skrepnik NV. The relationship between skeletal muscle serum markers and primary THA: a pilot study. Clin Orthop Relat Res. 2009;467:1747–52.

    PubMed  PubMed Central  Google Scholar 

  44. Müller M, Tohtz S, Winkler T, Dewey M, Springer I, Perka C. MRI findings of gluteus minimus muscle damage in primary total hip arthroplasty and the influence on clinical outcome. Arch Orthop Trauma Surg. 2010;130:927–35.

    PubMed  Google Scholar 

  45. Reichert JC, Volkmann MR, Koppmair M, Rackwitz L, Lüdemann M, Rudert M, et al. Comparative retrospective study of the direct anterior and transgluteal approaches for primary total hip arthroplasty. Int Orthop. 2015;39:2309–13.

    PubMed  Google Scholar 

  46. Meneghini RM, Pagnano MW, Trousdale RT, Hozack WJ. Muscle damage during MIS total hip arthroplasty: Smith–Peterson versus posterior approach. Clin Orthop Relat Res. 2006;453:293–8.

    PubMed  Google Scholar 

  47. van Oldenrijk J, Hoogland PVJM, Tuijthof GJM, Corveleijn R, Noordenbos TWH, Schafroth MU. Soft tissue damage after minimally invasive THA: a comparison of 5 approaches. Acta Orthop. 2010;81:696–702.

    PubMed  PubMed Central  Google Scholar 

  48. Frye BM, Berend KR, Lombardi AV, Morris MJ, Adams JB. Do sex and BMI predict or does stem design prevent muscle damage in anterior supine minimally invasive THA? Clin Orthop Relat Res. 2015;473:632–8.

    PubMed  Google Scholar 

  49. Stone AH, Sibia US, Atkinson R, Turner TR, King PJ. Evaluation of the learning curve when transitioning from posterolateral to direct anterior hip arthroplasty: a consecutive series of 1000 cases. J Arthroplasty. 2018;33:2530–4.

    PubMed  Google Scholar 

  50. de Steiger RN, Lorimer M, Solomon M. What is the learning curve for the anterior approach for total hip arthroplasty? Clin Orthop Relat Res. 2015;473:3860–6.

    PubMed  PubMed Central  Google Scholar 

  51. Faul F, Erdfelder E, Lang A, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39:175–91.

    PubMed  Google Scholar 

  52. Murphy SB, Tannast M. Conventional vs minimally invasive total hip arthroplasty. A prospective study of rehabilitation and complications. Orthopade. 2006;35:761–8.

    CAS  PubMed  Google Scholar 

  53. White J, Kelly M, Dunsmuir R. C-reactive protein level after total hip and total knee replacement. J Bone Jt Surg. 1998;80:909–11.

    CAS  Google Scholar 

  54. Bremer AK, Kalberer F, Pfirrmann CWA, Dora C, Surgeon O. Soft-tissue changes in hip abductor muscles and tendons after total hip replacement comparison between the direct anterior and the transgluteal approaches. J Bone Jt Surg. 2011;93:886–9.

    CAS  Google Scholar 

  55. Müller M, Tohtz S, Dewey M, Springer I, Perka C. Evidence of reduced muscle trauma through a minimally invasive anterolateral approach by means of MRI. Clin Orthop Relat Res. 2010;468:3192–200.

    PubMed  PubMed Central  Google Scholar 

  56. Müller M, Tohtz S, Springer I, Dewey M, Perka C. Randomized controlled trial of abductor muscle damage in relation to the surgical approach for primary total hip replacement: minimally invasive anterolateral versus modified direct lateral approach. Arch Orthop Trauma Surg. 2011;131:179–89.

    PubMed  Google Scholar 

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Open Access funding enabled and organized by Permedica (Merate, Italy).

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Author notes

  1. Luca De Berardinis, Marco Senarighi, Luca Farinelli, Fjorela Qordja & Antonio Pompilio Gigante

    Present address: Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Via Tronto, 10/a, 60126, Ancona, AN, Italy

  2. Alberto Gallo & Marco Spezia

    Present address: Orthopedic Unit, Habilita Casa di Cura I Cedri, Via Don Guanella, 1, 28073, Fara Novarese, NO, Italy

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    1. Luca De Berardinis
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    2. Marco Senarighi
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    Contributions

    APG, AG, MSp and LDB collaborated on the conception and design the study; LDB and MSe contributed to the collection of the data. LDB, MSe and LF performed the statistical analysis. LDB, MSe and FQ drafted the manuscript. All authors participated in interpretation of the data, read, gave input to and approved the final manuscript.

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    Correspondence to Luca De Berardinis.

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    Ethical approval was waived by the local Ethics Committee of University Politecnica delle Marche, Ancona, Italy, in view of the retrospective nature of the study and all the procedures being performed were part of the routine care. Informed consent was obtained from all individual participants included in the study.

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    De Berardinis, L., Senarighi, M., Farinelli, L. et al. In primary total hip arthroplasty, the direct anterior approach leads to higher levels of creatine kinase and lower levels of C-reactive protein compared to the posterolateral approach: a propensity score matching analysis of short-term follow-up data. J Orthop Surg Res 18, 594 (2023). https://doi.org/10.1186/s13018-023-04084-x

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    Keywords

    Journal of Orthopaedic Surgery and Research

    ISSN: 1749-799X