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Journal of Orthopaedic Surgery and Research logoLink to Journal of Orthopaedic Surgery and Research
. 2022 May 18;17:281. doi: 10.1186/s13018-022-03168-4

Factors influencing the outcomes of minimally invasive total hip arthroplasty: a systematic review

Filippo Migliorini 1,✉, Andrea Pintore 2, Joerg Eschweiler 1, Francesco Oliva 2, Frank Hildebrand 1, Nicola Maffulli 2,3,4
PMCID: PMC9118783  PMID: 35585545

Abstract

Introduction

The present systematic review investigated possible factors which may influence the surgical outcome of minimally invasive surgery for total hip arthroplasty (MIS THA).

Methods

In January 2022, the Embase, Google Scholar, PubMed, and Scopus databases were accessed. All the clinical trials investigating the clinical outcome of MIS THA were considered.

Results

Data from 9486 procedures were collected. Older age was moderately associated with greater Visual Analogue Scale (VAS) (P = 0.02) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (P = 0.009) at last follow-up, and shorter surgical duration (P = 0.01). Greater body mass index (BMI) at baseline was moderately associated with greater cup anteversion (P = 0.0009), Oxford Hip Score (OHS) at last follow-up (P = 0.04), longer surgical duration (P = 0.04), increased leg length discrepancy (P = 0.02), and greater rate of infection (P = 0.04). Greater VAS at baseline was weakly associated with greater VAS at last follow-up (P < 0.0001), total estimated blood lost (P = 0.01), and lower value of Harris Hip Score (HHS) (P = 0.0005). Greater OHS at baseline was associated with greater post-operative VAS (P = 0.01). Greater WOMAC at baseline was associated with lower cup anteversion (P = 0.009) and greater VAS (P = 0.02). Greater HHS at baseline was associated with shorter hospitalisation (P = 0.001).

Conclusion

Older age and greater BMI may represent negative prognostic factors for MIS THA. The clinical outcome is strongly influenced by the preoperative status of patients.

Keywords: Hip, Arthroplasty, Replacement, Minimally invasive

Introduction

Minimally invasive surgery (MIS) for total hip arthroplasty (THA) has become popular [1]. The definition of MIS in THA is controversial. Currently, MIS surgery refers to a tissue sparring approach [2]; [3]. During the last decade, a variety of MIS approaches have been described. MIS THA has been introduced in an effort to speed recovery and decrease the length of hospitalisation [4–11]. MIS THA has been advocated to reduce the length of the surgical procedure, quadriceps damage, and the total estimated blood loss [12–16]. MIS THA can be performed in a single incision using the posterior [15]; [17], lateral [18]; [19], anterolateral [20] and anterior approach [21]. Also, multiple incisions MIS THA procedures have been described, such as the two-incision approach [22]; [23], and the minimally invasive anterior approach with accessory incision [21]. However, based on current available evidence, there are no clinically relevant benefits of MIS THA over traditional approaches in terms of functional outcome and components orientation, and MIS THA carries high rate of complications [12]; [15]; [24]; [25]. Nevertheless, MIS THA remains of special interest of patients and surgeons. To date, though the current literature includes several thousands of scientific reports, there is paucity of evidence concerning the role of prognostic factors for MIS THA. The goal of the present study was to investigate potential associations between the patient characteristics at admission, peri-operative data, imaging findings, and the clinical and functional outcome, and complications. A multiple linear regression analysis was conducted to identify possible prognostic factors which may influence the clinical outcome.

Material and methods

Search strategy

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [26]. The PICO algorithm was preliminarily set out:

  • P (Population): end-stage OA;

  • I (Intervention): MIS THA;

  • C (Comparison): patients characteristics at admission;

  • O (Outcomes): PROMs, radiological findings, complications;

Data source and extraction

Two authors (F.M. and A.P.) independently performed the literature search in January 2022 accessing the following databases: PubMed, Google Scholar, Embase, and Scopus. The following keywords were used and combined for the search: hip, total, arthroplasty, replacement, prosthesis, instrumentation, surgery, intervention, BMI, age, sex. The resulting abstracts were screened by the two authors and, if of interest, the full-text was accessed. The bibliographies were also screened by hand. Disagreement was debated and solved by the senior author (N.M.).

Eligibility criteria

All the clinical trials investigating the outcomes of MIS THA were accessed. Only studies comparing traditional versus MIS THA approaches were considered eligible. Given the authors languages capabilities, articles in English, German, Italian, French and Spanish were eligible. Only levels I to III of evidence, according to the Oxford Centre of Evidence-Based Medicine [27], were eligible. Reviews, letters, opinions, editorials, and technical notes were not considered, nor were abstracts and national registries. Animal, computational, biomechanics, cadaveric studies were not eligible. Studies reporting results from experimental surgeries and/ or pre- and/ or post-operative protocols were not included. Only articles reporting quantitative data under the outcomes of interest were considered for inclusion. Missing data under the outcomes of interest warranted the exclusion from this study.

Outcomes of interest

Two authors (F.M. and A.P.) independently performed data extraction. Study generalities (author, year, journal, study design, length of the follow-up) were collected. Data concerning the following endpoints at baseline were collected:

  • Patient demographics: number of procedures, mean BMI and age, percentage of female;

  • PROMs: Visual Analogue Scale (VAS), Oxford Hip Score (OHS), The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Harris Hip Score (HHS).

    The present study investigated whether the aforementioned endpoints were associated with the outcome. Thus, every single endpoint was independently analysed, and its association with the following data at last follow-up assessed:

  • Peri-operative data: surgical duration, total estimated blood loss, and length of hospital stay;

  • Radiographic measures: mean cup inclination and anteversion, mean stem alignment, and limb length discrepancy;

  • PROMs: Visual Analogue Scale (VAS), Oxford Hip Score (OHS), The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Harris Hip Score (HHS);

  • Complications: dislocations, revisions, deep infections, aseptic loosening, fractures.

Methodology quality assessment

The methodological quality assessment was made by two independent reviewers (F.M. and A.P.). The risk of bias graph tool of the Review Manager Software 5.3 (The Nordic Cochrane Collaboration, Copenhagen) was used. The following risk of bias was assessed for each included study: selection, detection, attrition, reporting, and other source of bias.

Statistical analysis

The statistical analyses were performed by the main author (F.M.). For the analytical statistics, STATA MP 16 software (StataCorp, College Station, TX) was used. The Shapiro–Wilk test was performed to investigate data distribution. For normal data, mean and standard deviation (SD) were calculated. For nonparametric data, median and interquartile range (IQR) were calculated. A multivariate analysis was performed through a multiple pairwise correlations according to the Pearson product-moment correlation coefficient r. According to the Cauchy–Schwarz inequality, the final effect ranks between + 1 (positive linear correlation) and − 1 (negative linear correlation). Values of 0.1 < r< 0.3 and 0.3 < r< 0.5 and r> 0.5 were considered to have poor, moderate and strong correlation, respectively. Potential associations between one the endpoints and the outcomes of interest were evaluated singularly for each endpoint. Overall significance was evaluated using the χ2 test, with values of P > 0.05 considered statistically significant.

Results

Search result

The literature search resulted in 684 articles. Of them, 277 were excluded because they were duplicates. A further 297 articles were excluded since they did not match our eligibility criteria. Another 36 articles were not included because they did not report quantitative data under the outcomes of interest. This left 74 studies for the present study: 33 randomised, 29 prospective, and 17 retrospective studies. The literature search results are shown in Fig. 1.

Fig. 1.

Fig. 1

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Flow chart of the literature search

Methodological quality assessment

The risk of bias summary evidenced some limitations of the present study. Approximately half of the studies were randomised, and approximately one fifth were retrospective. This leads to a moderate risk of selection bias. Given the overall lack of blinding, the risk of detection bias was moderate-high. The authors' judgements about the risk of attrition, reporting and other bias presented across all included studies was moderate. Concluding, the overall risk of bias was moderate, attesting to this study good quality assessment (Fig. 2).

Fig. 2.

Fig. 2

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Methodological quality assessment

Patient demographics

Data from 9626 procedures were collected. 57% (5487 of 9626 patients) were women. The median follow-up was 12 (IQR 9) months. The mean age was 63.0 (SD 4.9), the mean BMI 27.1 (SD 2.3) kg/m2. Generalities and patient baseline of the included studies are shown in Table 1.

Table 1.

Generalities and patients baseline of the included studies

Author Journal Design Follow up (months) Procedures (n) Women (%) Mean age Mean BMI Approach
Abdel et al. [7] Arthroplasty Randomised 102.0 36 44.4 66.0 30.0 P MIS
35 45.7 66.0 30.0 2 incision
Alecci et al. [82] J Orthop Traumatol Retrospective 0.5 221 54.8 70.7 A MIS
198 62.1 70.1 L
Barrett et al. [83] Arthroplasty Randomised 12.0 43 32.6 61.4 30.7 A
44 56.8 63.2 29.1 P
Bennett et al. [11] Arthroplasty Prospective 12.0 43 58.1 66.1 29.6 Minimal invasive
52 46.2 64.6 29.2 Total incision
Berend et al. [84] Bone Joint Surg Randomised 1.5 258 56.4 63.0 28.9 A (ASI)
372 56.4 63.0 30.4 L MIS (LIDL)
Bergin et al. [60] Bone Joint Surg Prospective 1.0 29 66.0 68.8 26.3 A
28 50.0 65.1 27.8 P
Berstock et al. [85] J Othopaedics Retrospective 37.0 116 56.0 71.4 L OMEGA
152 71.1 74.5 P
Biau et al. [86] Int Orthop Randomised 0.3 105 56.2 68.0 25.0 P MIS
102 59.8 66.0 25.0 P
Chen et al. [87] Arthroplasty Retrospective 24.0 83 44.6 53.5 24.5 MIS-2 THA
83 50.6 55.0 25.3 Conventional THA
Cheng et al. [88] Arthroplasty Randomised 3.0 35 57.0 59.0 27.7 A
37 53.0 62.5 28.3 P
Chimento et al. [13] Arthroplasty Randomised 24.0 28 42.9 67.2 25.2 8 cm incision
32 59.4 65.6 24.8 15 cm incision
Della Valle et al. [89] Clin Orthop Rel Res Randomised 12.0 35 68.6 63.8 27.3 P MIS
37 67.6 61.2 27.6 2 incision
Dienstknecht et al. [14] J Orthop Surg Randomised 3.0 55 60.0 61.9 27.6 A MIS
88 53.4 61.3 30.1 L
DiGioia et al. [90] Arthroplasty Prospective 12.0 33 57.6 65.0 27.0 Mini-incision
33 57.6 65.0 28.0 L
Dorr et al. [15] Bone Joint Surg Randomised 6.0 30 43.3 70.3 27.6 Mini-incision
30 53.3 63.9 30.2 Long-incision
Downing et al. [91] Acta Orthop Scand Prospective 12.0 49 51.0 67.0 P
51 58.8 65.0 L
Engdal et al. [92] Am J Phys Med Rehab Prospective 0.2 21 61.9 56.8 25.8 L
19 42.1 55.5 26.7 P
20 75.0 56.4 25.8 A
Fink et al. [93] Orthopäde Prospective 1.5 50 54.0 71.5 28.0 PL
50 50.0 71.9 27.0 Mini-posterior
Fransen et al. [94] Acta Orthop Belg Retrospective 12.0 38 62.9 62.6 27.6 PL
45 66.7 64.2 25.0 A
Goebel et al. [55] Int Orthop Retrospective 3.0 100 53.0 64.5 26.7 Minimal A
100 58.0 67.0 28.6 L
Goosen et al. [95] Clin Orthop Rel Res Randomised 12.0 30 50.0 60.0 26.7 AL MIS
30 56.7 62.0 26.8 PL
30 50.0 60.0 26.4 PL MIS
30 46.7 62.0 26.1 AL
Hananouchi et al. [96] Int J Med Robotics Comput Assist Surg Prospective 12.0 20 90.0 55.1 22.2 A MIS
20 90.0 57.0 21.0 P MIS
Howell et al. [96] Orthop Clin N Am Prospective 0.5 50 32.0 59.8 26.2 MIS-AL
57 52.6 62.3 28.8 AL
Ilchmann et al. [97] Orthop Rev Prospective 24.0 142 47.0 70.0 27.4 L
113 47.0 70.0 27.4 A MIS
Ji et al. [98] Arthroplasty Prospective 37.9 99 45.5 51.0 24.3 P
97 40.2 52.0 24.3 L
Joseph et al. [99] Arthroplasty Today Prospective 6.0 98 54.1 61.1 30.4 A
69 50.7 62.9 30.7 P
Khan et al. [100] Bone Joint Surg Randomised 24.0 52 63.5 72.8 28.9 P
48 50.0 72.3 28.5 Piriformis-sparing
Ki et al. [101] Clin Orthop Surg Retrospective 51.5 34 38.2 61.0 22.3 PL MIS
26 26.9 57.5 21.6 2 incision
Kim et al. [102] Arthroplasty Randomised 26.4 35 24.3 55.6 25.6 PL MIS
35 24.3 55.6 25.6 PL
Kiyama et al. [103] Arthroplasty Randomised 6.0 10 90.0 60.3 23.4 PL MIS
10 80.0 63.8 23.5 PL
Krych et al. [104] Clin Orthop Rel Res Randomised 1.5 10 38.1 63.0 30.0 P MIS
11 38.1 63.0 30.0 2 incision
Laffosse et al. [105] Rev Chir Orthop Prospective 6.0 58 39.7 55.0 25.0 AL MIS
58 43.1 59.7 26.2 P
Lafosse et al. [106] Arch Orthop Trauma Surg Prospective 6.0 33 39.4 56.8 25.9 AL MIS
43 34.9 55.7 25.2 P MIS
Leuchte et al. [107] Z Orthop Retrospective 7.0 16 59.7 26.7 AL MIS
16 62.6 28.6 L
Lawlor et al. [108] Clin Rehab Randomised 1.5 109 55.0 67.4 28.2 P MIS
110 47.3 65.9 28.9 P
Malek et al. [109] Bone Joint Surg Retrospective 18.1 265 55.8 70.8 28.5 A
183 53.0 70.0 29.0 P
Martin et al. [110] Arthroplasty Randomised 12.0 42 71.4 66.7 30.6 AL MIS
41 65.9 63.1 29.4 L
Martin et al. [111] Arthroplasty Retrospective 6.0 47 65.0 63.0 28.5 A
41 55.0 57.0 34.1 P
Mazoochian et al. [112] Arch Orthop Trauma Surg Randomised Prospective 3.0 26 56.0 26.6 LA MIS
26 65.4 26.4 LA/ Bauer
Migliorini et al. [113] Surgeon Restrospective 24 70 78.6 67.2 26.9 AL MIS
70 84.3 66.1 27.6 AL
Mjaaland et al. [114] Clin. Ortho Rel Reas Randomised 24.0 84 70.0 67.0 28.0 A
80 62.0 66.0 28.0 L
Müller et al. [115] Arch Orthop Trauma Surg Randomised 12.0 24 50.0 66.0 28.0 AL MIS
20 60.0 64.0 26.0 L
Nakata et al. [116] Arthroplasty Retrospective 12.0 99 83.8 62.9 22.9 A
96 86.5 65.6 23.3 P MIS
Ogonda et al. [9] Bone Joint Surg Randomised 1.5 109 55.0 67.4 28.2 P MIS
110 47.3 65.9 28.9 P
Palan et al. [117] Clin Orthop Rela Res Prospective 60.0 699 60.9 68.4 27.5 AL
390 64.1 67.4 27.0 P
Petis et al. [118] Arthroplasty Prospective 0.1 40 62.5 66.9 27.9 A
40 65.0 66.7 28.2 P
40 65.0 65.5 29.1 L
Poehling-Monaghan et al. [63] Clin Orth Rel Res Prospective 2.0 50 48.0 63.0 31.0 A
50 56.0 63.0 30.0 P MIS
Pogliacomi et al. [119] Hip Int Retrospective 12.0 30 53.3 68.6 27.3 L
30 50.0 67.7 27.0 A MIS
Pospischill et al. [3] Bone Joint Surg Randomised 3.0 20 60.0 61.9 25.7 AL MIS
20 40.0 60.6 25.7 L
Queen et al. [120] Arthroplasty Prospective 12.0 10 n.a 60.0 26.6 Direct lateral
10 n.a 57.0 26.3 P
10 n.a 57.6 28.8 AL
Radoicic et al. [121] Int Orthop Prospective 6.0 21 61.9 60.9 A
21 61.9 60.9 P
Rathod et al. [122] Arthroplasty Retrospective 12.0 11 45.5 58.0 25.9 DA
11 45.5 61.8 25.4 P
Reichert et al. [123] BMC Musculoskelet Disorders Randomised 12.0 73 43.8 62.5 28.3 A
50 52.0 62.2 28.7 L
Rittmeister et al. [124] Orthopäde Retrospective 0.2 76 69.7 60.0 28.0 P MIS
76 69.7 65.0 27.0 AL
Rodriguez et al. [125] Clin Orth Related Res Prospective 12.0 60 53.3 60.0 27.0 A
60 56.7 59.0 28.0 P
Rosenlund et al. [126] Acta Orthop Randomised 12.0 38 31.6 60.0 27.0 L
39 33.3 62.0 28.0 P
Rykov et al. [61] Arthroplasty Randomised 1.5 23 65.2 62.8 29.0 A
23 52.2 60.2 29.3 PL
Schleicher et al. [127] Acta Orthop Prospective 6.0 64 68.7 69.1 28.8 L
64 75.0 68.3 27.1 P MIS
Sendtner et al. [128] Arch Orthop Trauma Surg Prospective 12.0 74 32.4 68.1 28.8 A MIS
60 30.0 67.9 29.1 L (Bauer)
Sershon et al. [129] Arthroplasty Randomised 98.0 31 67.7 73.4 28.2 P MIS
32 71.9 70.9 28.7 2 incision
Shitama et al. [10] Int Orthop Randomised 6.0 15 85.3 61.7 23.2 MIS TL
19 85.3 58.3 23.2 MIS PL
8 85.7 53.4 23.0 Translateral
20 85.7 61.3 23.0 PL
Spaans et al. [130] Acta Orthopaedica Prospective 12.0 46 47.8 69.0 25.0 DAA MIS
46 69.6 68.0 29.0 PL
Sugano et al. [131] Orthop Clin N Am Prospective 24.0 39 92.3 57.0 23.0 P MIS
33 87.8 56.0 23.0 A MIS
Szendri et al. [132] Int Orthop Randomised 3.0 38 64.0 26.0 L MIS < 10 cm
43 62.0 28.0 MIS > 10 cm
21 57.0 29.5  > 14 cm L
Takada et al. [133] J Orthop Sci Randomised 12.0 30 86.7 62.6 24.4 DL
30 86.7 62.6 24.4 AL
Taunton et al. [134] Arthroplasty Randomised 12.0 27 51.9 66.4 29.2 P MIS
27 55.6 62.1 27.7 A
Varelaegochaega et al. [8] Eur J Orth Sur Traumatol Randomised 60.0 25 52.0 64.8 28.3 MIS L
25 52.0 63.8 27.8 L
Vicente et al. [135] Clinics Retrospective 6.0 34 32.2 50.0 27.0 P MIS
42 38.1 57.0 27.0 L
Wayne et al. [136] Orthop Rev Prospective 100 66.0 68.0 27.0 L
100 71.0 68.0 26.6 A MIS
Wohlrab et al. [137] Z Orthop Retrospective 3.0 27 59.3 58.8 27.2 P MIS
23 52.2 61.9 29.3 L
Wright et al. [138] Arthroplasty Randomised 60.0 42 64.2 24.4 MIS L
42 65.0 28.3 L
Yang et al. [139] Ir J Med Scien Randomised 36.0 55 52.7 59.5 23.1 AL MIS
55 45.5 55.8 22.4 PL
Zawadsky et al. [140] Arthroplasty Retrospective 0.5 50 70.0 56.0 27.9 P MIS
50 56.0 60.8 28.6 A
Zhao et al. [141] Arthroplasty Randomised 6.0 60 60.0 64.9 24.4 A
60 56.0 62.2 25.6 PL
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Outcomes of interest

Female gender was strongly associated with lower cup anteversion (r =  − 0.52; P = 0.0002). Older age was moderately associated with reduced surgical time (r =  − 0.28; P = 0.01), and with greater VAS (r = 0.42; P = 0.02) and WOMAC scores (r = 0.52; P = 0.009) at last follow-up. Greater BMI at baseline was associated with greater cup anteversion (r = 0.47; P = 0.0009), greater OHS at last follow-up (r = 0.47; P = 0.04), longer surgical duration (r = 0.20; P = 0.04), greater leg length discrepancy (r = 0.47; P = 0.02), and greater rate of deep infection (r = 0.44; P = 0.04). Greater VAS at baseline was associated with greater VAS at last follow-up (r = 0.98; P < 0.0001), greater overall estimated blood lost (r = 0.11; P = 0.01), and lower value of HHS (r =  − 0.98; P = 0.0005). Greater OHS at baseline was associated with post-operative greater VAS (r = 0.88; P = 0.01). Greater WOMAC at baseline was associated with lower cup anteversion (r = 0.89; P = 0.009) and greater VAS at last follow-up (r = 0.88; P = 0.02). Greater HHS at baseline was associated with shorter hospitalisation (r = 0.50; P = 0.001). No other statically significant associations were evidenced. The results of the multivariate analyses are shown in greater detail in Table 2.

Table 2.

Overall results of the multivariate analyses

Sex—baseline Age—baseline BMI—baseline VAS—baseline OHS—baseline WOMAC—baseline HHS—baseline
r P r P r P r P r P r P r P
Cup inclination  − 0.16 0.2  − 0.05 0.7  − 0.15 0.2 0.45 0.5  − 0.32 0.3  − 0.23 0.5  − 0.02 0.9
Cup anteversion  − 0.53 0.0002 0.20 0.2 0.47 0.001 1.00 1.0 0.04 0.9  − 0.89 0.009 0.07 0.8
Stem alignment  − 0.04 0.9  − 0.15 0.5  − 0.07 0.7 0.29 0.4  − 0.81 0.1  − 0.39 0.2
VAS  − 0.26 0.2 0.42 0.02 0.17 0.4 0.98 0.00001 0.88 0.01 0.88 0.02 0.16 0.5
OHS  − 0.06 0.8 0.52 0.009 0.47 0.04  − 0.20 0.5 0.91 0.1  − 0.57 0.1
WOMAC 0.04 0.9  − 0.47 0.1  − 0.45 0.1 0.65 0.1 0.75 0.1 0.81 0.3
HHS  − 0.08 0.5  − 0.28 0.01  − 0.01 0.9  − 0.98 0.0005  − 0.34 0.3  − 0.66 0.1 0.36 0.05
Surgical time 0.07 0.5  − 0.19 0.1 0.20 0.04 0.65 0.1  − 0.03 0.9 0.53 0.1 0.07 0.6
Estimated blood lost 0.15 0.3  − 0.06 0.7  − 0.15 0.3 0.11 0.01 0.18 0.6 0.50 0.1 0.19 0.3
Leg length difference 0.11 0.6  − 0.20 0.3 0.47 0.02  − 1.00 1.0 0.33 0.4  − 0.08 0.9  − 0.43 0.1
Hospitalisation 0.20 0.1 0.11 0.3  − 0.22 0.1 0.94 0.1  − 0.51 0.2  − 0.55 0.2  − 0.50 0.001
Dislocation  − 0.17 0.3 0.13 0.4  − 0.05 0.8 1.00 1.0 0.44 0.3  − 0.29 0.2
Revision 0.10 0.6 0.36 0.1 0.05 0.8 0.90 0.3  − 0.37 0.4  − 1.00 1.0 0.13 0.7
Deep infection  − 0.08 0.7 0.30 0.2 0.44 0.04 0.61 0.6  − 0.98 0.2 0.00 1.0
Aseptic loosening 0.07 0.9  − 0.28 0.5  − 0.51 0.1 0.42 0.6  − 1.00 1.0 0.24 0.7
Fractures  − 0.06 0.7 0.08 0.6  − 0.04 0.8 0.41 0.5  − 0.24 0.5 0.54 0.3 0.24 0.3
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Discussion

According to the main findings of this systematic review, older age and greater BMI were negative prognostic factors for the outcome of MIS THA. The analyses of the PROMs suggested that the clinical outcome is strongly related to the preoperative status of the patient.

The role of age is controversial. Previous studies observed greater improvements in pain and function after THA in older patients [28–32], while others demonstrated no substantially better clinical outcome [33–35]. Muscle trauma in older patients via MIS approach should be minimised to improve the functional outcome [36]; [37]. The greater rates of complication and overall worse outcome in patients with BMI exceeding 30 kg/m2 has been extensively investigated. The negative influence of obesity for THA was likewise demonstrated by previous studies [38–42]. Lower PROMs scores, longer hospitalisation, greater blood loss, higher rate of wound complications, deep venous thrombosis, and infection are the most common complications [38–42]. The reduced access to the operative field, extensive bleeding surfaces, and greater force of retraction do not seem to have relevant influence in terms of component malpositioning, prolonged operative times, and higher intraoperative blood loss in obese patients during MIS THA [43–45]. Timing of mobilisation, length of hospitalisation, and functional outcome were similar between obese and non-obese patients [45], and obese patients should be strongly encouraged to lose weight prior to THA. However, it has been hypothesised that only bariatric surgery in obese patients before arthroplasty could realistically cut down complications [46–51]. Female gender was strongly associated with lower cup anteversion. However, the native anteversion of the femoral neck differs between males and females, with a physiological mean acetabular anteversion of approximately 16° and 12.5°, respectively [52]; [53]. Gender-specific anatomical differences increase data variability and may lead to inconsistency in results. Furthermore, to investigate the cup anteversion malpositioning, the acetabular inclination angle must also be considered [54]. MIS THA has been advocated to reduce consumption of pain medications [15]; [55]. High post-operative pain negatively influences the clinical outcome and predisposes to chronic pain [56]. Greater post-operative pain and the fear of it may lead to immobility and delayed post-operative rehabilitation [57]; [58]. The reduced surgical incision and tissues trauma may reduce pain and the blood loss and represent the main motivation to opt for a MIS approach [2]; [12]; [59]. However, previous studies did not evidence clinically relevant difference between standard and MIS THA in pain and total estimated blood lost [2]; [12]; [59]. The reduced damage to the tissues of the MIS approaches has been advocated to improve functional outcomes, and inflammation markers have been employed to evaluate soft tissue damage [60]; [61]. Recent evidence showed no significant differences in serum markers of muscle damage and inflammation between minimally and standard THA approaches [62]. Furthermore, serum markers did not predict early pain/function after THA and were not associated with early functional outcomes either in-hospital or post-discharge [63].

The present systematic review certainly has limitations. The current published literature lacks high-quality studies which analysed the influence of prognostic factors for MIS THA, and the limited number of included studies represent an important limitation. Several studies (277 of 683, 41%) were excluded for redundancy. To improve data pooling, both prospective and retrospective studies were included in the analysis, which inevitably increases the risk of selection bias. A limitation of this study is represented by the relative short length of the mean follow-up. Half of studies were randomised, but, given the overall lack of blinding methods, the risk of detection bias was moderate-high. Furthermore, the different approaches for THA were not considered separately, nor were the different implant designs [64–81]. Given these limitations, data from the present study must be interpreted with caution. Strengths of this work were the study size, the description of diagnosis and surgical techniques which were stated and adequate. Another strength of the present systematic review is the comprehensive nature of the literature search and rigorous assessment of methodological quality of the current available data.

Conclusion

Older age and greater BMI were negative prognostic factors for MIS THA. The analyses of the PROMs suggested that the clinical outcome is strongly related to the preoperative performance status of the operated patients. There is no compelling evidence that MIS THA offers advantages over traditional approaches, especially when modern analgesia techniques and accelerated rehabilitation programmes are considered.

Acknowledgements

None.

Abbreviations

MIS

Minimally invasive surgery

THA

Total hip arthroplasty

PROMs

Patient-reported outcome measures

PRISMA

Preferred reporting items for systematic reviews and meta-analyses

VAS

Visual Analogue Scale

OHS

Oxford Hip score

WOMAC

Western Ontario and McMaster Universities Osteoarthritis Index

HHS

Harris Hip Score

SD

Standard deviation

IQR

Interquartile range

Author contributions

FM contributed to the literature search, data extraction, methodological quality assessment, statistical analyses, and writing; NM was involved in the supervision, revision and the final approval; AP helped in the literature search, data extraction, and methodological quality assessment; JE contributed to the supervision; FO contributed to the supervision. FH contributed to the supervision. All authors read and approved the final manuscript.

Funding

Open Access funding enabled and organized by Projekt DEAL. The authors received no financial support for the research, authorship, and/or publication of this article.

Availability of data and materials

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

Declarations

Ethics approval and consent to participate

This study complies with ethical standards.

Consent to publication

Not applicable.

Competing interests

Professor Maffulli is the Editor in Chief of the Journal of Orthopaedic Surgery and Research.

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

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

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