This muscle and exposed the joint capsule by

This study is randomized controlled trial
that was conducted in Berlin, Germany between June 2006 and July 2007 including
forty-four patients with primary hip arthritis who were prospectively involved
in the study. The study was approved by the institutional review board and
registered in a clinical trial registry. Informed consent was obtained from all
patients before the study was conducted. Patients were randomly matched into
either a minimally invasive anterolateral approach group or a modified direct
lateral approach group. A dice was thrown to randomly select the patients who
had primary hip arthritis requiring surgery. Those who got an uneven number, the
direct lateral approach was used for THA and those who got an even number went through
the minimally invasive anterolateral approach. A sealed packet was opened
before surgery to decide the patient group. People who were excluded from the
study had, “major malformation, hip fractures, history of previous surgery to
that hip, inflammatory polyarthritis, arthroplasty of the contralateral side or
any physical or mental disability” (Muller, Thotz, Springer, Dewey, Perka,
2011). There were five patients who dropped out, three of them had claustrophobia
for MRI imaging, and the other two withdrew without any reason. Those patients
were not accounted in the study.

Twenty-one patients underwent unilateral
total hip arthroplasty through a minimally invasive anterolateral approach and
sixteen underwent modified direct lateral approach. For lateral approach,
surgeons used a 10 cm incision and incised the major gluteus medius muscle and
exposed the joint capsule by separating the third of the gluteus medius
together with gluteus minimus from the trochanter major. On the other hand, for
minimally invasive anterolateral approach, the major muscle integrity was
preserved as the surgeons used intermuscular plane between gluteus medius and
the tensor fascia latae and did not separate any of the major muscles. All
randomly included patients experienced the same postop care, narcotic and pain
management and rehab. SCDs and antithrombotic ppx were also used among all patients.
PT was initiated on first postop day. After wound healing, all patients were
transferred to a rehab clinic for a 3-week recovery program which included
exercises for lower extremity, ankle and knee and all the muscles surrounding
the hip joint. The goal was that all the patients regain full ROM, strength,
endurance and flexibility. No further therapy was provided after the
rehabilitation program. The study was unbiased, both groups were treated fairly
and both paid the same cost of treatment.

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After surgery, patients were evaluated
clinically and postoperatively through MRI imaging. Clinically, a Harris Hip
score, a pain score and satisfaction score were calculated. Trendelenburg sign
was also used to estimate and test the function of abductor muscle. Muller, M
was the observer for this clinical part of the study and he was blinded to the
patients. For all MRI images that included fatty atrophy, tendon defects and
bursal fluid collection of the abductor muscle, were evaluated by Springer, I
and Perka, C. They both were blinded towards the approach that was used for
each group.

The results of this study demonstrated
that people who underwent minimally invasive approach had higher and better
values in scoring system and abduction test. However, it may not be sufficient
as the study had very small number of people. On the other hand, MRI turned out
to be the most sensitive method in the interpretation of surgical approach on
muscle damage. MRI demonstrated that more pathological findings were found for
gluteus medius muscle in patients with direct lateral approach, together with
more tendon defect and fatty atrophy in the same group. This could be due to
the fact that major muscles were dissected from greater trochanter during the initial
preparation for direct lateral approach. Trendelenburg signs were also more positive
in direct lateral patient group and damaged was seen in gait, pain and
satisfaction of the patient after surgery during the early rehab period. Patients
who underwent minimally invasive approach had better clinical result, higher
clinical score and lower Trendelenburg signs, showing significantly less muscle
and tendon defect.

In conclusion, abductor muscle damage and
tendon defect was much less in patients who underwent minimally invasive
anterolateral approach as demonstrated by this study. MRI was the best tool
during this study which showed more atrophy, tendon defects and fluid
collection around the bursa when direct lateral approach was used as compared
to minimally invasive approach. The study would affect the way surgeons decide
as to which approach should be used for the patients requiring THA and it would
be better to use an intermuscular plane without detaching any major muscles and
tendons to minimize the trauma in THA and have faster and better recovery with
minimal muscle damage.  


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