Abstract
Background
Total hip arthroplasty (THA) is a surgery widely used to reduce pain, improve function and quality of life in older people after femur fracture due to osteoporosis. The evident success of THA, especially in the long term, continues in relation to the different types of surgical approach, given the little understanding in older people. The aim of this study was to evaluate and compare the effect of THA between two surgical access routes, anterior and posterolateral, on the clinical, functional, and biomechanical parameters of older people after osteoporotic femur fracture.
Methods
Prospective and retrospective cohort study, in which 24 older people with femur fracture, who underwent THA in a Public Hospital, between the years 2020 and 2022, were evaluated. The older people were divided into two groups: THA via anterolateral surgical (n = 12) and THA via posterolateral surgery (n = 12). The following clinical information was collected from the patients' records. After the surgery, pain was evaluated using the visual analogue scale and function by the Harris Hip Score questionnaire, as well as hip and knee mobility (goniometer). For the radiographic parameters, acetabular component positioning, De Lee Zone, and the offset of the femoro-acetabular component were evaluated. A pressure platform was used for the biomechanical assessment of gait and balance.
Results
Older adults who underwent THA via the posterolateral route showed a reduction in chronic pain (p = 0.001), and greater functionality (p = 0.001), joint mobility of the hip (flexion and extension, p = < 0,001) and knee (extension) when compared to THA via the anterolateral. In relation to the gait, a reduction in plantar overload on the forefoot (peak pressure p = 0.007) and medial and lateral rearfoot areas (peak pressure p = 0.004 and p = 0.009, respectively; maximum force p = 0.021 and p = 0.015 respectively;) was observed, as well as a reduction in the contact area on the forefoot (p = 0.001) in older people who underwent THA by the posterolateral when compared to the anterolateral. An increase in body sway (p = 0.002) and medio-lateral sway (p = 0.020) was observed in older adults who underwent THA using the posterolateral route when compared to the anterolateral route, such as distance and velocity balance (p = 0.001).
Conclusion
Total hip arthroplasty via the posterolateral approach proved to be more successful when associated with reducing chronic pain, improving functional parameters and hip joint mobility, as well as facilitating a more efficient gait pattern with lower rates of plantar overload and enhanced body balance in older adults undergoing total hip arthroplasty after osteoporotic femur fracture. These findings are clinically relevant as they indicate that this approach not only provides significant pain relief but also improves the patients' quality of life by restoring hip functionality and mobility, while reducing the risk of falls and complications related to postural imbalance. The combination of these benefits suggests that the posterolateral approach could be a preferred option for elderly patients with osteoporotic fractures, aiming to optimize postoperative outcomes and improve long-term functional recovery.
Keywords: Older, Arthroplasty, Hip, Surgery, Pain, Function, Gait, Balance
Background
The older population has been growing exponentially, reaching rates of 3.26% per year, and becoming a global phenomenon [1]. It is estimated that by 2025, there will be a total of approximately 1.2 billion people over the age of 60, reaching 2 billion by 2050 [1, 2]. However, bone fragility resulting from the senescence process, associated with reduced body balance and the absence of homes adapted for older adults are potential risk factors for the occurrence of femur fractures in this population [3–6]. Femur fractures in older adults have seen a significant rise in prevalence, with a recent Lancet study (2021) reporting around 10 million cases per year globally, contributing to a substantial financial burden on health systems for clinical care of older patients after fractures due to osteoporosis or falls [3, 4]. Hip fractures, in particular, are a catastrophic event, with approximately 30% of patients dying within the first year and survivors experiencing an ongoing burden that severely impacts their quality of life [7–9]. Within one year of the fracture, only 40 to 60% of older patients return to their pre-fracture functional level [8, 9].
The global health challenge of femoral fractures in older adults is becoming more pressing, as the prevalence of these fractures is expected to increase by approximately 6.26 million cases by 2050 [8, 10], particularly affecting females. [11, 12]. This rise in incidence presents significant costs to healthcare systems, comprising 0.1% of the global disease burden, with major expenses related to surgical procedures like hip arthroplasty (THA), medications, and rehabilitation [7–10]. A large part of these costs are associated with the surgical procedure (hip prosthesis), analgesic/anti-inflammatory medications, and post-surgical rehabilitation to restore function in the older adult [3–6]. Given the high costs, functional limitations, and elevated mortality rate of older adults after proximal femur fractures, Total Hip Arthroplasty (THA) followed by early rehabilitation is highly valuable [13]. While stages I and II fractures can be treated with closed reduction and internal fixation, stages III and IV require THA [14–16]. THA is considered one of orthopedics'greatest triumphs [16–19] and a major advancement in medicine and healthcare [20–22], transforming the lives of those with severe hip diseases who were once condemned to live in constant pain, with over one million THAs performed annually worldwide [22]. Correct positioning of the acetabular component is essential for the biomechanical stability of the THA, ensuring long survival and avoiding dislocation, which occurs when the head of the femoral component becomes detached from the acetabular component [23, 24]. To perform this type of surgery, there are three more common types of surgical approaches: anterior, lateral and posterior, however there is no consensus in the literature regarding the criteria for choosing the orthopedic approach when performing THA in older adults [25–27].
Total Hip Arthroplasty (THA) has evolved with various surgical approaches since its introduction. In 1949, the anterior approach via the iliofemoral region was first used, involving a long incision from the iliac crest to the anterior superior iliac spine, requiring extensive dissection of muscles such as the gluteus medius and minimus, which led to long rehabilitation periods, especially for older adults. The posterior approach was introduced in 1952 by Moore, utilizing a lateral decubitus position with an incision from the posterior superior iliac spine to the greater trochanter, involving the disinsertion of the gluteus maximus and external rotator muscles [25]. The direct lateral (anterolateral) approach, described by Hardinge in 1982, involved a different incision centered on the greater trochanter, focusing on the gluteal aponeurosis and iliotibial tract [28]. Over time, surgeon expertise has increasingly influenced the choice of access route in THA procedures.
Recent studies comparing various THA approaches have highlighted several key differences and outcomes. Ang et al. (2023) [28], found that the direct anterior (AD) approach led to better functionality and shorter hospital stays compared to the posterolateral (PL) and anterolateral (AL) approaches. However, the AD approach was also associated with a higher risk of lateral femoral cutaneous nerve injury. Jin et al. (2023) [29], found that the direct anterior approach (AD) for total hip arthroplasty in femoral neck fractures in older adults was linked to a higher incidence of lateral femoral cutaneous nerve injury but a lower rate of postoperative dislocation compared to the posterolateral (PL) approach. Patel and Golwala et al. (2023) [30], identified infection as a common complication with the AD approach, along with increased bone resorption, whereas the PL approach remained the most popular due to its lower infection rates and ease of access. Further studies, including those by Zhou et al. (2022) [31], and Yang et al. (2021) [32], confirmed superior early postoperative hip function and lower pain in the AD approach. However, dislocation rates between the AD and PL approaches were similar, and both approaches demonstrated functional improvements [33]. Scientific evidence revealed that THA using the direct anterior approach (AD) showed increased function according to the Harris Hip Score questionnaire and a shorter hospital stay, as well as reduced pain and increased function compared to the posterolateral (PL) approach [34, 35]. Migliorini et al. (2020) [36], also noted that the AL approach offered good acetabular alignment and functional improvements. These findings underline that the choice of THA approach is often tailored to the surgeon's expertise and patient needs, with the AD approach generally showing better outcomes in terms of function and pain reduction.
Despite the established benefits of total hip arthroplasty (THA) for improving pain and function, particularly with the right anterolateral access route, there is still limited understanding regarding the comparison of different surgical access routes for THA in older adults with femoral fractures due to osteoporosis, the most vulnerable population for this procedure. Faldini et al. (2017) [37], highlighted the need for further comparisons to assess the advantages of the direct anterior approach over the posterolateral approach, especially with longer follow-up periods. While THA's success is evident, there is a lack of clarity regarding the clinical and functional aspects related to gait and balance biomechanics in older patients with femoral fractures following THA via the anteroposterior and posterolateral approaches.Thus, is aim this study was to evaluate and compare the effect of THA between two surgical access routes, anterior and posterolateral, on the clinical, functional, and biomechanical parameters of older people after osteoporotic femur fracture. This justifies the clinical relevance of the present study which proposes to analyze, in the long term, clinical, functional, and biomechanical aspects of older people with osteoporotic femur fractures who underwent THA, using different surgical access routes, in order to improve clinical treatment and rehabilitation of affected older people.
Methods
Study type and sample selection
This is a cohort study with an implementation perspective and prospective analysis, in which older people who underwent hip THA after a femur fracture due to osteoporosis, between 2020 and 2022, were evaluated at a public hospital. The older adults were divided into two groups: older adults who underwent uncemented THA via the anterolateral surgical approach and older adults who underwent uncemented THA via the posterolateral surgical approach. The primary outcomes of the study included pain levels, radiographic parameters, and gait (peak pressure) and secondary mobility, function and balance.
This study was previously submitted to the Research Ethics Committee of the local Universidade, and obtained approval under opinion number: 5.418.226. All older people who participated in the study previously signed the free and informed consent form and the assent form of their guardian, prepared in accordance with resolution 466/12 of the National Health Council.
The eligibility criteria for participation in the study were: patients with femoral fracture who underwent THA; have an uncemented total hip prosthesis; aged between 60 and 85 years; be a patient undergoing regular follow-up at the orthopedics outpatient clinic at a public hospital; with preserved cognitive capacity; and availability to attend periodic reevaluations. The exclusion criteria were: presenting cemented THA; THA other than through the anterior and posterior access routes; non-ambulatory patients using a wheelchair or restrictive orthoses; patients with mental and/or cognitive alterations; presenting or having had postoperative infection or ischemia; having presented prosthetic dislocation, early or late (24 months after surgery) [38].
Analysis of clinical parameters
Retrospective analysis was conducted on the clinical parameters and X-ray imaging results and prospective analyses focused on mobility, function, gait, and balance. During a period of 36 months, referring to the years 2020 to 2022 (SARS-COV-2/COVID-19 pandemic period), a survey of the medical records of patients who underwent uncemented total hip arthroplasty (THA) performed at a public hospital. The survey of medical records was carried out virtually using the access and login of the SoulMV system governed by the Hospital's medical record files. The surgical procedure was performed by two surgeons with experience in each surgical technique evaluated, using cemented polyethylene acetabular cups with the surgical procedure being performed after one day of hospitalization.
A total of 100 medical records were recruited, to collect information including: sex, age, dates of hospitalization and surgical technique procedure, post-surgery time, type and size of the prosthesis, complications related to component instabilities and their clinical complications, fixation success (osteointegration), and component positioning in the outpatient postoperative period [38] (Fig. 1).
Fig. 1.
Representation of the flowchart of the recruitment and evaluation protocol of older people after uncemented THA between two surgical access routes: anterolateral and posterolateral
Evaluation of radiographic parameters: positioning and inclinations of the acetabular component
The patient was invited to attend a medical consultation, to which they were instructed to take the first THA postoperative radiograph, followed by other radiographic images of the surgical procedure. In these radiographic imaging exams, the position and positioning of the acetabular component were evaluated. In the radiographic image exams, after the THA surgical procedure, the positioning of the acetabular component was evaluated. To measure the acetabular position, the patient was positioned in the supine position with the radius centered over the pubic symphysis, showing both hips (obturator foramen equal on both sides) and including the proximal third of the femur. To verify the positioning of the acetabular component, the angle was measured between a line that joined the tuberosities of the ischium and a line that crossed the long axis of the acetabular component, determined through the axis of the largest diameter formed by the projection of the metal rim on the radiograph [38] (Fig. 2).
Fig. 2.
Measurement of the positioning angle of the acetabular component. a – line that touches the ischial tuberosities; (b) – line through the axis of the largest diameter formed by the projection of the metal rim on the radiograph; (c) – acetabular angle
Another important parameter evaluated was the De Lee Zone, characterized by the area with localized loss of trabecular bone or cortical erosion, as long as it was not identified on radiographs taken in the immediate postoperative period. Thus, the location and extent of the lesions were evaluated using the De Lee and Charnley system (1976) [38] (Fig. 3). The femoral offset was also evaluated, which is defined as the distance from the center of rotation of the femoral head to a line drawn on the long axis of the femur. This measurement varies depending on hip rotation [38] (Fig. 3).
Fig. 3.
Radiographic areas of acetabular displacement (De Lee and Charnley, 1976)
Next, the offset of the femoral component was measured, characterized by the horizontal deviation of the distance from the center of the femoral head to the axis line of the distal part of the shaft. Inadequate restoration of the offset shortens the abductor muscle lever and results in increased joint reaction force, laxity, and contact with the bone, which can result in joint dislocation [38] (Fig. 4).
Fig. 4.
Femur offset - distance from the center of rotation of the femoral head to a line drawn on the long axis of the femur. Offset of the femoral component, distance from the center of the femoral head to the axis line of the distal part of the shaft
Hip assessment: functional parameters
For functional analysis of the hip, the Harris Hip Score (HHS) questionnaire was applied, a specific instrument for evaluating the hip, with regard to the domains of pain, function, gait, deformities, and range of movement, in patients undergoing PTHA. The questionnaire consists of a scale that varies from 0 to 100 points, considering each of its domains. The maximum score for each domain is as follows: pain: 44 points; function: 47 points, this item being subdivided into Activities of Daily Living (ADL) 14 points (climbing stairs, getting on public transport, sitting, tying shoes/putting on socks) and gait: 33 points (lameness, use of support, and distance); deformities: 4 points; and range of movement: 5 points. The total HHS score is considered bad if the sum is less than 70 points; regular, between 70 and 79 points; good, between 80 and 89 points; and excellent, between 90 and 100 points [38].
Hip and knee assessment: joint mobility parameters
The goniometer used in this study was the so-called universal goniometer, manually. We took as a basis the values followed by the American Academy of Orthopedic Surgeons (1965), and the Veterans Administration of United States of North America (1963). All patients were evaluated for joint range of motion (ROM) of the hip and knee [38]. To measure the range of hip flexion, the older person remained in the supine position, in which the following positioning of the goniometer was considered: axis to the coxofemoral joint, fixed arm: parallel to the longitudinal axis of the trunk, in the line of the greater trochanter of the femur and movable arm: placed on the lateral midline of the femur (direction of the lateral epicondyle). In terms of hip extension range, the same positioning of the goniometer was considered, however, with the older person in the prone position. To measure abduction and adduction, the goniometer axis was positioned on the anterior surface of the coxofemoral joint, the fixed arm was placed parallel to the anterior superior iliac spine, and the movable arm was placed on the anterior surface of the thigh, parallel to the anterior midline of the femur, towards the midline of the patella.
For the measurements of external and internal rotations, the older person was positioned in a sitting position and the axis of the goniometer was considered to be on the anterior surface of the patella, the fixed arm was positioned on the anterior line of the tibia and the movable arm was towards a point equidistant between the malleoli. To measure knee joint range of motion in flexion and extension, the older person remained in the supine position. Extension represents the return from knee flexion. The goniometer axis was positioned on the joint line of the knee joint, with the fixed arm parallel to the lateral surface of the femur, directed towards the greater trochanter, and the movable arm parallel to the lateral surface of the fibula, directed towards the lateral malleolus, where the knee joint angles were [38].
Biomechanics assessment: gait and balance
The biomechanical assessment of the older adults was carried out at the UNISA Biomechanics and Musculoskeletal Rehabilitation Laboratory. In this laboratory, the patients'gait was analyzed using a pressure platform (Loran®, Italy), to verify the distribution of plantar pressure during gait. Part of the equipment contains resistive pressure sensors, homogeneously distributed. The platform was connected to a desktop notebook to transmit data collected at a frequency of 100 Hz.
The patients walked at a pre-established cadence. To ensure that they had reached this cadence, plantar pressure acquisitions were monitored using a stopwatch. Patients were initially familiarized with the collection environment and instruments to reduce the retroactive effect. After the familiarization, patients walked on a flat synthetic rubber track for a distance of 20 m. The steps performed in the intermediate 10 m were timed and valid for collections, thus totaling approximately 12 steps, captured in 2 attempts39 (Fig. 5). To analyze body balance, the pressure platform was also used, in which the following were evaluated: body oscillation, anteroposterior and mediolateral oscillation, the velocity of oscillation, and distance from the center of pressure.
Fig. 5.
Demonstration of gait analysis on the plantar pressure platform and body balance oscillation
The plantar pressure variables that were analyzed and measured during walking were: 1) Peak pressure per selected area: the maximum pressure value (expressed in kPa) in the 3 regions of the foot; 2) Mean Maximum Pressure: the mean maximum pressure value (expressed in kPa) in the 3 regions of the foot; 3) Foot contact area: the area in which the sensors were activated (pressed) in each step (expressed in cm2). All plantar pressure variables were analyzed in 3 plantar areas. To do this, the foot was divided into three areas: hindfoot (30% of foot length), midfoot (30% of foot length), and forefoot and toes (40% of foot length) [39].
Statistical analysis
All statistical analyses were performed using SPSS version 24 (IBM, Chicago, IL, USA). Calculation of the sample size of 24 patients was conducted based on the mean of the pre-ATH load rate (peak pressure), using the G-Power 3.0 software. A moderate effect size (f = 0.25), an 80% power, and a 5% significance level were used in the calculation. The normality of the data was verified using the Shapiro–Wilk test. The anthropometric, clinical, and functional variables, and radiographic and biomechanical measurements were compared between groups using a Student's t-test. A significance level of 5% for all tests was considered significant.
Results
Initially, 100 older people were recruited to participate in this study, through a survey of medical records between the years 2020 and 2022; 80 were excluded due to study criteria or lack of information in the medical records. Thus, a total of 24 older people, who underwent uncemented THA through one of two surgical access routes: anterolateral and posterolateral, participated and completed the clinical, functional, and biomechanical evaluation process proposed in the study (Fig. 1).
Surgical treatment of THA, between two surgical access routes (anterolateral and posterolateral), did not differ in anthropometric variables, or clinical characteristics related to surgery time and post-surgical physiotherapy sessions. Another important point was the greater use of THA in older males, with musculoskeletal dysfunction being the most commonly used for performing THA after femur fracture (after a fall from a height). The reduction in comorbidities such as Arterial Hypertension and Diabetes Mellitus, between both surgical access routes for THA performed in a public hospital in the southern region of the state of São Paulo, Brazil was also observed (Table 1).
Table 1.
Comparison of anthropometric and surgical aspects one year after total hip arthroplasty (THA) via anterolateral and posterolateral surgical access routes in older people
| Variables | THA anterolateral (n = 12) |
THA posterolateral (n = 12) |
p* |
|---|---|---|---|
| Age (years) | 63.6 ± 17.1 | 67.5 ± 15.0 | 0.635 |
| Weight (Kg/cm2) | 75.4 ± 20.2 | 65.2 ± 15.2 | 0.218 |
| Height (cm) | 1.70 ± 0.1 | 1.62 ± 0.3 | 0.184 |
| BMI (Kg/m2) | 25.9 ± 7.5 | 24.2 ± 5.6 | 0.562 |
| Sex (Female and Male %) | F (30.0); M (70.0) | F (49.0); M (51.0) | - |
| Surgery time (months) | 12.8 ± 3.1 | 13.5 ± 2.9 | 0.276 |
| Comorbidities: AH and DM (Yes and No %) | 40.5 (S); 50.5 (N) | 40.0 (S); 60 (N) | - |
| Physiotherapy sessions (immediate post-surgery %) | 12.7 ± 4.2 | 15.0 ± 3.8 | 0.671 |
Acronyms: THA Hip arthroplasty, BMI Body mass index, OA Hip osteoarthritis, FF Femur fracture, AH Arterial hypertension and DM Diabetes mellitus
*Student t test, unpaired, significant differences p < 0.05
The older adults did not differentiate in the radiographic parameters of the THA post-surgery between the two surgical access routes, showing the effectiveness of both surgical access routes for positioning the implants, with maintenance of the acetabular and femoral inclination angles after prosthesis (Table 2).
Table 2.
Comparison of radiographic aspects one year after total hip arthroplasty (THA) through two surgical access routes: anterolateral and posterolateral in the older adults
| Radiographic examination | THA anterolateral (n = 12) |
THA posterolateral (n = 12) |
p* |
|---|---|---|---|
| Acetabular tilt (degrees) | 43.0 ± 5.0 | 41.2 ± 7.5 | 0.570 |
| Femoral implant offset (mm) | 48.1 ± 4.6 | 47.0 ± 4.7 | 0.583 |
| De Lee Charnley Zone (cm) | 1.1 ± 0.3 | 1.5 ± 0.7 | 0.119 |
*Student t test, unpaired, significant differences p < 0.05
Regarding the aspects of the Harris Hip Score (HHS), it was observed that the older adults who performed the THA via the posterolateral approach presented greater functionality and gait and a reduction in chronic pain when compared to the older adults who underwent THA via the anterolateral approach, except for the deformity domain, which did not present differences between the surgical routes, showing the effectiveness of acetabular maintenance of the prosthesis in both THA surgical routes (Table 3).
Table 3.
Comparison of functional aspects by Harris Hip Score (HHS) domains one year after total hip arthroplasty (THA) through two surgical access routes: anterolateral and posterolateral in older adults
| HHS domains | THA anterolateral (n = 12) |
THA posterolateral (n = 12) |
p |
|---|---|---|---|
| Pain (cm) | 41.3 ± 3.5 | 20.7 ± 8.5 | 0.001* |
| Function (domain/HHS) | 10.8 ± 2.0 | 14.7 ± 1.5 | 0.001* |
| Gait (domain/HHS) | 21.5 ± 4.0 | 32.1 ± 3.5 | 0.001* |
| Deformity (domain/HHS) | 3.1 ± 1.0 | 3.5 ± 1.0 | 0.323 |
| Harris Hip Score (score/HHS) | 73.6 ± 12.1 | 80.3 ± 13.0 | 0.020* |
* Student t test, unpaired, significant differences p < 0.05
Another highlight was the increase in hip joint mobility for flexion and extension movements, as well as knee joint mobility for extension movement in older people who underwent THA via the posterolateral approach compared to the anterolateral approach (Table 4).
Table 4.
Comparison of aspects of hip and knee joint mobility one year after total hip arthroplasty (THA) through two surgical access routes: anterolateral and posterolateral in older adults
| Hip and knee mobility | THA anterolateral |
THA posterolateral |
p |
|---|---|---|---|
| Hip flexion R (degrees) | 71.7 ± 21.4 | 75.2 ± 22.5 | 0.001* |
| Hip flexion L (degrees) | 70.8 ± 22.0 | 81.4 ± 20.6 | < 0.001* |
| Hip extension R (degrees) | 8.8 ± 5.0 | 14.4 ± 7.1 | 0.005* |
| Hip extension L (degrees) | 9.4 ± 5.3 | 12.3 ± 4.1 | 0.003* |
| Hip abduction R (degrees) | 18.4 ± 9.3 | 18.2 ± 8.8 | 0.962 |
| Hip abduction L (degrees) | 20.8 ± 8.6 | 20.2 ± 9.6 | 0.886 |
| Hip adduction R (degrees) | 13.6 ± 4.2 | 15.6 ± 5.4 | 0.371 |
| Hip adduction L (degrees) | 14.5 ± 5.5 | 16.0 ± 6.0 | 0.570 |
| Medial rotation of the hip R (degrees) | 18.2 ± 9.7 | 16.2 ± 8.9 | 0.639 |
| Medial rotation of the hip L (degrees) | 18.8 ± 9.0 | 16.8 ± 5.0 | 0.548 |
| Lateral rotation of the hip R (degrees) | 18.7 ± 10.6 | 18.6 ± 10.5 | 0.922 |
| Lateral rotation of the hip L (degrees) | 18.6 ± 11.4 | 19.2 ± 11.5 | 0.806 |
| Knee flexion R (degrees) | 95.4 ± 23.9 | 96.0 ± 23.0 | 0.922 |
| Knee flexion L (degrees) | 94.2 ± 30.0 | 93.0 ± 29.8 | 0.806 |
| Knee extension R (degrees) | 47.0 ± 18.1 | 66.6 ± 42.5 | 0.008* |
| Knee extension L (degrees) | 50.1 ± 18.7 | 67.6.0 ± 41.3 | 0.001* |
*Student t test, unpaired, significant differences p < 0.05
Considering biomechanical data related to the distribution of plantar load during gait, a reduction in plantar overload (peak pressure and maximum force) on the forefoot and rearfoot areas (medial and lateral) can be observed, as well as a reduction in the contact area over the forefoot in older people who underwent THA using the posterolateral approach when compared to the anterolateral approach (Table 5). These observations show the greater effectiveness of THA via the posterolateral route in the evaluated older adults, given the better gait performance with reduced rates of plantar overload (Table 5). This finding may explain the increase in hip functionality and knee mobility, favoring better physical performance in the older adults, as seen in Table 3.
Table 5.
Comparison of the biomechanical aspects of foot plantar pressure distribution during gait one year after total hip arthroplasty (THA) between two surgical access routes: anterolateral and posterolateral in older adults
| Biomechanical variables | Foot Regions | THA anterolateral |
THA posterolateral |
p |
|---|---|---|---|---|
| Contact Area (cm2) | Forefoot | 10.5 ± 2.0 | 9.5 ± 1.6 | 0.007* |
| Midfoot | 10.4 ± 5.3 | 14.8 ± 6.4 | 0.290 | |
| Medial hindfoot | 19.9 ± 4.0 | 18.6 ± 2.8 | 0.223 | |
| Lateral hindfoot | 20.0 ± 4.0 | 19.8 ± 2.7 | 0.941 | |
|
Peak Pressure (KPa) |
Forefoot | 311.6 ± 86.0 | 271.0 ± 67.9 | 0.010* |
| Midfoot | 84.6 ± 51.8 | 111.3 ± 68.5 | 0.114 | |
| Medial hindfoot | 314.2 ± 85.7 | 265.4 ± 71.6 | 0.004* | |
| Lateral hindfoot | 308.5 ± 87.2 | 261.5 ± 72.4 | 0.009* | |
| Maximum force (N/BW) | Forefoot | 15.8 ± 5.9 | 12.0 ± 3.2 | 0.015* |
| Midfoot | 6.0 ± 2.5 | 9.9 ± 3.0 | 0.249 | |
| Medial hindfoot | 31.6 ± 16.7 | 24.6 ± 8.6 | 0.021* | |
| Lateral hindfoot | 30.7 ± 13.7 | 26.0 ± 9.1 | 0.015* |
*Student t test, unpaired, significant differences p < 0.05
With respect to body balance, an increase in body oscillation and medio-lateral oscillation was observed, as well as an increase in the distance and velocity of oscillations in older people who underwent THA via the posterolateral route when compared to the anterolateral route, as observed in Table 6, showing the effectiveness of the posterolateral surgical approach to better adjust the body balance of the evaluated older adults.
Table 6.
Comparison of body balance one year after total hip arthroplasty (THA) between the two surgical access routes: anterolateral and posterolateral in older adults
| Body balance parameters | THA anterolateral |
THA posterolateral |
p |
|---|---|---|---|
| Body oscillation to center of gravity (area/mm) | 166.7 ± 285.3 | 231.1 ± 27.4 | 0.002* |
| Anteroposterior oscillation (mm/amplitude) | 45.1 ± 21.8 | 41.5 ± 30.1 | 0.135 |
| Mediolateral oscillation (mm/amplitude) | 32.2 ± 21.4 | 55.0 ± 28.3 | 0.020* |
| Distance (cm) | 154.0 ± 54.9 | 182.6 ± 59.7 | 0.001* |
| Velocity (m/sec.) | 7.6 ± 2.5 | 9.1 ± 2.9 | 0.001* |
*Student t test, unpaired, significant differences p < 0.05
Discussion
The purpose of the current study was to evaluate clinical, radiological, functional, and biomechanical aspects after performing total hip arthroplasty (THA) using two surgical access routes to the hip: anterolateral and posterolateral, in older people who had suffered a femur fracture. Based on this theme, the main results showed a greater predominance of males for both surgical access routes for THA after femur fracture in a public hospital in the southern region of São Paulo. The older adults evaluated showed no differences in radiographic parameters between the two surgical access routes for THA, demonstrating the maintenance of acetabular and femoral positioning angles (femoral off set and De Lee zone) after prosthesis. Another important finding was that THA via the posterolateral route proved to be more effective in reducing chronic pain and increasing functionality, as well as increasing joint mobility for hip flexion and extension and knee extension, when compared to older people who underwent THA via the anterolateral approach. Regarding gait, a reduction in plantar overload on the forefoot and rearfoot areas (medial and lateral) was observed in THA via the posterolateral route when compared to the anterolateral route, showing the better walking performance of the older adults. Considering body balance, increases in body sway and medio-lateral sway were also observed for older people who underwent THA via the posterolateral approach.
Similarly, study found that the surgical outcomes between the anterolateral and posterolateral access routes for THA in older adults were similar, with both techniques effectively maintaining acetabular positioning one year after the procedure. Although the study sample was small, a systematic review and meta-analysis of 17 studies involving 2,302 participants showed that the choice of surgical approach for THA depends on factors such as patient characteristics, surgeon experience, and preferences of both the surgeon and the patient. The authors suggest that these findings should guide decision-making until more rigorous, randomized evidence becomes available, as no statistical differences were observed in the radiographic parameters for acetabular component positioning [40]. A prospective study involving 224 adult patients who underwent THA with a minimally invasive posterior approach (103 patients) versus a direct lateral access approach (121 patients) found statistical differences in implant positioning and patient functionality [41]. Unlike the other studies, the present study specifically focused on older adults following femur fractures and extended the analysis beyond radiographic parameters to include functional and biomechanical aspects related to gait and balance-key activities for maintaining independence in older individuals.
Regarding functional results, posterolateral THA proved to be more effective in reducing chronic pain and increasing functionality (Harris Hip Score), as well as increasing joint mobility for hip flexion and extension and knee extension, when compared to older people who underwent THA via the anterolateral approach, showing the better effectiveness of the posterolateral approach versus the anterolateral approach. Although it was not the focus of this study, much of the current scientific evidence is directed towards understanding THA using the direct anterior access route in relation to the posterior access route in the older adults [40, 42–44]. In this direction, Moerenhout et al. (2020) [42], observed that older people who underwent direct anterior versus posterior THA, five years after surgery, showed better functionality and reduced chronic pain for both surgical routes. Other scientific evidence, also comparing anterior versus posterior THA, revealed a reduction in pain and increased function, as well as gait speed parameters better favored by the direct anterior THA approach [40, 42–44].
This study focused on standardizing THA for older adults following femur fractures, using lateral surgical access (anterior or posterior), and a consistent one-year post-surgery rehabilitation program with physiotherapy. These methodological choices were deemed essential for a comprehensive understanding of surgical access routes for THA in this population, particularly regarding biomechanical assessments like gait and balance. The study noted a gap in the literature regarding such careful methodological approaches. Additionally, since most of the surgeons involved had not received specific training for direct anterior access, the study suggests that future research could compare this approach with others. In comparisons of three surgical access routes (anterior, anterolateral, and posterolateral) for THA, a study by Moyer et al. (2018) [45] found a significant increase in hip adduction following the posterolateral approach compared to the anterolateral approach in early post-surgery monitoring of older adults. However, a two-year follow-up study by Afonso et al. (2008) [46] found no significant differences in hip movements or Trendelenburg parameters during gait between the anterolateral and posterolateral approaches.
In contrast to previous studies, the current study found that the posterolateral approach was more effective for improving hip mobility in flexion and extension, as well as knee extension. However, there were no differences in other joint movements between the anterior and posterolateral approaches for THA. This difference may be due to the fact that the posterolateral approach does not involve disinsertion of the gluteus medius muscle, which helps stabilize the pelvis. This preservation likely contributed to improved hip and knee mobility, especially during daily walking activities.
Additionally, older adults who underwent THA via the posterolateral approach showed a gait pattern with reduced plantar load rates on the forefoot and rearfoot (medial and lateral heel) compared to those who underwent the anterolateral approach. A study by Yoo et al. (2019) [47] found that the anterolateral approach was less effective than the direct anterior approach in terms of gait speed, after a three-month post-surgery monitoring period.
The clinical significance of this study lies in understanding the force vectors for plantar overload during gait in older adults who underwent THA through two different surgical routes. The key difference between the routes was the disinsertion of the gluteus medius tendon in the anterolateral approach, versus the non-disinsertion in the posterolateral approach, which better stabilized the pelvis throughout the one-year post-surgery period. This stabilization with the posterolateral approach resulted in a gait pattern characterized by lower plantar overload rates, especially on the heel, and improved body oscillation to maintain balance in key sensorimotor components. The findings contribute to reducing the mortality impact of femur fractures one year post-THA and improving the functional capacity and quality of life of older adults [7–9]. Another important discovery was that body balance improved more significantly in those who had THA via the posterolateral approach compared to the anterolateral approach. This improvement in balance likely stemmed from the preservation of the gluteus medius, which helped reduce fall risks associated with aging, due to better plantar proprioception and enhanced body balance after surgery [48].
According to a study carried out by Ikutomo et al. (2018) [49], patients undergoing THA had an increased risk of falls during the first postoperative year. However, the risk factors for falls after THA remain unclear, and health professionals, especially doctors and physiotherapists, must remain attentive to changes in gait and balance in older adults to prevent complications, such as prosthesis dislocation or periprosthetic fracture after a fall. Therefore, in the current study, the posterolateral route of THA in older adults was shown to be an important surgical option for the doctor, as it is an effective surgical choice for improving pain, functionality, and biomechanical aspects of gait and balance, biomechanical patterns that offer protection against a greater risk of falls, and which are highly considered in strength training programs and gait performance for the older people who underwent THA in the short term postoperative period [50, 51].
The clinical implications were: a) Older adults demonstrating the maintenance of acetabular and femoral positioning angles after two surgical access routes for THA; b) THA via the posterolateral showed reducing chronic pain, increasing functionality and joint mobility for hip (flexion and extension) and knee extension when compared to older people who underwent THA via the anterolateral approach; c) During gait was observed in THA via the posterolateral a reduction in plantar overload on the forefoot and rearfoot areas and increase medio-lateral body sway when compared to the via anterolateral.
The important limitation of this study was that the evaluation process was carried out only in the period after the THA, without pre-surgical data focused on functional and biomechanical parameters, but as the sample was recruited from a public hospital with a high demand for assistance, it was not possible to carry out these evaluations in the hospital environment. In addition, another limitation was the relatively low proportion of analyzed patients in comparison to the total number of patients who underwent surgery, which may have introduced a selection bias affecting the generalizability of the results. Survival rate represents a fundamental outcome in the context of hip fracture surgery among older adults; however, due to data limitations, it was not possible to assess this outcome in the present study. Future studies to incorporate control groups, as comparing the different surgical techniques for total hip arthroplasty (THA) with a control population could provide more robust insights into their effects on pain, survival rate, function, gait, and balance, particularly in the elderly.
Conclusion
Total hip arthroplasty via the posterolateral approach proved to be more successful when associated with reducing chronic pain, improving functional parameters and hip joint mobility, as well as facilitating a more efficient gait pattern with lower rates of plantar overload and enhanced body balance in older adults undergoing total hip arthroplasty after osteoporotic femur fracture. These findings are clinically relevant as they indicate that this approach not only provides significant pain relief but also improves the patients'quality of life by restoring hip functionality and mobility, while reducing the risk of falls and complications related to postural imbalance. The combination of these benefits suggests that the posterolateral approach could be a preferred option for elderly patients with osteoporotic fractures, aiming to optimize postoperative outcomes and improve long-term functional recovery.
Acknowledgements
The authors acknowledge the help and support of all the older participants of the Public Hospital (Grajaú General Hospital) in the South Region of the city of São Paulo-SP, Brazil.
Abbreviations
- THA
Total hip arthroplasty
- HHS
Harris Hip Score questionnaire;
- ADL
Activities of Daily Living
- ROM
Joint range of motion
Authors’ contributions
M.A.L.P.P. and A.P.R. contributed substantially to the conception or design of the manuscript; M.A.L.P.P., G.T.B.P., M.A.R.S.U., C.A.M. and A.P.R. contributed substantially to the acquisition, analysis, and interpretation of the data. All authors participated in drafting the manuscript. M.A.L.P.P. and A.P.R. revised the manuscript critically. All authors contributed equally to the manuscript and read and approved the final version of the manuscript.
Funding
The authors report no involvement in the research by the sponsor that could have influenced the outcome of this work.
Data availability
Data is provided within the manuscript or supplementary information files. The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The This study was previously submitted to the Research Ethics Committee of the local Universidade, and obtained approval under opinion number: 5.418.226. All older people who participated in the study previously signed the free and informed consent form and the assent form of their guardian, prepared in accordance with resolution 466/12 of the National Health Council.
Consent for publication
All participants/patient gave written informed consent for their personal or clinical details along with any identifying images to be published in this study.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data is provided within the manuscript or supplementary information files. The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.