Comparative outcomes between collared versus collarless and short versus long stem of direct anterior approach total hip arthroplasty: a systematic review and indirect meta-analysis

IntroductionEarly research shows several advantages of the direct anterior approach (DAA) in THA that claimed to be as effective but less invasive than the posterior approach. However, due to the difficult femoral exposure and possible complications related to femoral preparation, this approach may result in a higher rate of undersized stems when compared to other approaches. The present authors believe that the femoral implant design (collar or collarless stem, short or long stem) in a collared femoral stem may relate to lower rates of stem subsidence and limb length discrepancy (LLD) in mid-term to long-term follow-up when compared to collarless femoral stems. However, currently, there is no consensus as to which femoral implant design is the most suitable for DAA in THA.MethodsThis systematic review and meta-analysis aim to assess and compare postoperative complications (neurapraxia, wound infection, LFCN, hematoma, artery injury, cup malposition, embolism, fracture and implant loosening) and revision rates due to dislocation, periprosthetic fracture and implant migration after DAA using collared compared to collarless femoral stem and short femoral stem compared to long femoral stem in THA. These clinical outcomes consist of the postoperative complications and revision femoral stem due to neurapraxia, wound, LFCN and LLD. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.ResultsRelevant studies that reported postoperative complications and revision of either implant were identified from Medline and Scopus from inception to June 6, 2018. Thirty-four studies were included for the analysis of DAA in THA; 23 studies were retrospective cohorts, four studies were prospective cohorts, and seven studies were RCTs. Thirty-one studies and three studies were included for analysis of collarless and collared femoral stems. Twenty-six studies were long femoral stems and eight studies were short femoral stems. Overall, there were 6825 patients (6457 in the collarless group and 368 in the collared group, 4280 in long stem and 2545 in short stem). A total of 469 and 66 patients had complications and revisions in the collarless group, and no patient had complications and revisions in the collared stem group. The total complication and revision rate per patient were 5% (95%CI 3.3%, 7%) and 0.9% (95%CI 0.6%, 1.2%) in all patients. The complication rate and revision rate were 5.7% (95%CI 3.8%, 7.7%) and 0.9% (95%CI 0.6, 1.2) in the collarless group. There was no prevalence of complications and revisions in the collared stem group. The complication rate and revision rate were 10.2% (95%CI 9%, 11.4%), 0.7% (95%CI 0.3%, 1%) and 5.2% (95%CI 3.1, 7.2), 1.5% (95%CI 1%, 2%) in short and long femoral stems, respectively. Indirect meta-analysis shows that collared femoral stem provided a lower risk of complications of 0.02 (95%CI 0.001, 0.30) when compared to collarless femoral stem. Long femoral stems had a lower risk of having complications of 0.57 (95%CI 0.48, 0.68) when compared to short femoral stems. In terms of revision, there is no statistically significant difference in collared femoral stem compared to collarless femoral stem and long femoral stem compared to short femoral stem.ConclusionIn DAA THA, collared femoral stem and long femoral stem had decreased complication rates when compared to collarless femoral stem and short femoral stem by both direct and indirect meta-analysis methods. However, in terms of revision rates, there were no differences between all femoral stems (short versus long and collared versus collarless). Prospective randomized controlled studies are needed to confirm these findings as the current literature is still insufficient.