Investigation on the quality of life after anterior minimally invasive total hip arthroplasty: Commentary on recent findings

Abstract

This editorial critically evaluated the recent study by Ishikura et al, which examined the impact of anterior minimally invasive total hip arthroplasty (MIS-THA) on postoperative quality of life, with a specific focus on the timeline and influencing factors for return to work and resumption of driving. Ishikura et al's research demonstrated that anterior MIS-THA could shorten recovery time, reduce postoperative pain, and significantly enhance patients' quality of life and productivity. Their findings identified occupational type and work intensity as key determinants of postoperative recovery. By synthesizing evidence from multiple studies, this analysis systematically evaluated the clinical advantages of anterior MIS-THA—including reduced soft tissue trauma and accelerated functional recovery—while acknowledging its limitations, such as a steep surgical learning curve and early postoperative complication risks. The discussion emphasized the necessity of designing personalized rehabilitation protocols that accounted for patients' occupational demands. Notably, while current findings primarily derived from retrospective analyses, the article highlighted the need for prospective cohort studies to validate these observations. The commentary also addressed ongoing debates in the field, particularly the elevated complication rates associated with the direct anterior approach compared to posterior techniques, thereby underscoring the critical role of surgeon expertise in optimizing procedural safety. Collectively, this evaluation advanced our understanding of postoperative recovery dynamics in anterior MIS-THA and provides evidence-based insights to refine clinical rehabilitation frameworks.

Key Words: Total hip arthroplasty; Minimally invasive; Return to work; Resumption of driving; Postoperative rehabilitation

Core Tip: Although minimally invasive total hip arthroplasty is safe, effective, reliable and conducive to rapid recovery of patients, few studies have focused on its impact on return to work and resumption of driving, which are key factors affecting postoperative quality of life.

INTRODUCTION

Total hip arthroplasty (THA), frequently referred to as the "surgery of the century"[1], remains a highly effective treatment modality for end-stage hip joint diseases[2,3]. Traditional surgical approaches to THA include the anterior, anterolateral, direct lateral and posterolateral techniques[3]. With the advent of minimally invasive surgery and the principles of rapid rehabilitation, minimally invasive THA (MIS-THA) had garnered significant attention in contemporary clinical practice. Current evidence did not suggest that any one THA method was superior to others. The selection of a specific method primarily depended on the surgeon's expertise and experience, as well as the individual patient's characteristics, with each method demonstrating distinct advantages and disadvantages (Table 1)[3,4]. Recent advancements in minimally invasive techniques, particularly the anterior approach utilizing intermuscular intervals for hip joint access, had significantly reduced soft tissue damage while preserving hip musculature integrity. These developments had been shown to decrease complication risks and accelerate postoperative functional recovery[5-8].

Table 1 Comparison of minimally invasive total hip arthroplasty with traditional total hip arthroplasty.

	MIS-THA	Traditional THA
Advantages	Reduced trauma and faster recovery, shorter hospital stay, smaller incision and better aesthetics	Excellent surgical field of vision and broader application range, mature technology with simpler operative procedures
Disadvantages	Higher surgical complexity and steeper learning curve	Greater trauma and longer recovery time, more extensive tissue damage
Long-term efficacy and outcomes	Superior early rehabilitation outcomes, comparable to traditional THA	Stable long-term efficacy

THA: Total hip arthroplasty; MIS-THA: Minimally invasive total hip arthroplasty.

Nakata et al[7] demonstrated that the direct anterior approach (DAA) significantly enhances early postoperative recovery compared to the minimally invasive posterolateral approach (PLA), particularly in hip stability, ambulation capacity, and functional outcomes. Bergin et al[9] revealed markedly lower levels of inflammatory biomarkers (serum creatine kinase, CRP, IL-6, IL-1, TNF-α) in DAA patients compared to those in the standard PLA group during the acute postoperative phase. The PLA group exhibited a fivefold elevation in creatine kinase levels, indicating substantially reduced muscle trauma associated with the anterior minimally invasive technique. Therefore, compared with the traditional PLA, the minimally invasive anterior approach had been shown to significantly shorten recovery time for postoperative ambulation, attenuate systemic inflammatory responses, and enhance the accuracy of prosthesis positioning[10,11]. Despite these advantages, the technique exhibited a steep learning curve, and the incidence of early complications, such as incision-related issues and femoral fractures, was relatively high. These challenges necessitated optimization through structured surgical training programs and individualized postoperative care protocols[12,13]. Yi et al[14] reported an intraoperative complication rate of 8.2% among patients, all instances occurring during the early operative phase. Subsequent studies indicated that novice surgeons are more susceptible to complications such as greater trochanteric fractures and femoral bone marrow cavity perforations[15]. Furthermore, comparative research had demonstrated a higher incidence of incision-related com-plications with the anterior approach compared to the posterior approach (1.4% vs 0.2%). This discrepancy could be attributed to factors including smaller incision dimensions, anatomical constraints, and increased risks of soft tissue injury due to operator inexperience[16]. This article critically evaluated the research by Ishikura et al[17], which examined the impact of anterior MIS-THA on patients' postoperative quality of life. The analysis specifically focused on the potential of anterior MIS-THA to facilitate early return to work (RTW) and resumption of driving (ROD), while systematically investigating associated influencing factors. These findings provided an evidence base for developing precise rehabilitation strategies in clinical practice.

RTW and ROD are critical determinants of postoperative quality of life for patients undergoing THA. However, limited research had examined the impact of MIS approaches on these outcomes. Ishikura et al[17] conducted a retrospective analysis of 124 patients who underwent anterior MIS-THA, gathering data on demographics, occupational characteristics, work intensity, and the duration to RTW and ROD. They utilized a standardized scoring system to assess clinical outcomes, including pain levels, functional status, and patient satisfaction, thereby elucidating the timeline and influencing factors associated with RTW and ROD following anterior MIS-THA. The study concluded that anterior MIS-THA facilitates earlier RTW and ROD, particularly for patients in occupations with lower work intensity. These findings underscored the necessity of incorporating occupational profiles and workload assessments into postoperative care strategies. It was important to consider the influence of additional factors, including patient age, comorbidities, preoperative functional status, adherence to rehabilitation protocols, psychological condition, choice of implant, and specifics of the postoperative care plan. In addition, several limitations warranted consideration: The moderate sample size (n = 124) and the absence of a control group undergoing alternative surgical approaches constrained the generalizability of the findings. Additionally, the relatively short follow-up duration (mean 12 months) limited the comprehensive evaluation of long-term occupational sustainability, especially work continuity over 3 to 5 years postoperatively. Additionally, incorporating occupational therapists, psychologists, and rehabilitation teams into the study design could provide a more comprehensive understanding of postoperative recovery. In conclusion, this research provided compelling evidence supporting the benefits of anterior MIS-THA, such as shortened recovery periods, reduced postoperative pain, and enhanced patient quality of life and productivity. These findings assisted clinicians in developing more personalized postoperative care plans and offering precise recovery time estimates based on individual occupational and work intensity profiles.

The rehabilitation program for MIS-THA patients was tailored to meet occupational demands, with specific strategies designed for varying work intensities. For individuals in low-intensity occupations, such as office work or driving, the focus was on gradually restoring sitting tolerance through structured protocols. In addition, for those in driving-specific roles, deep vein thrombosis prevention measures were incorporated, including the use of anti-thrombotic stockings and regular ankle pump exercises. Patients engaged in medium-to-high-intensity occupations that required physical labor, such as healthcare workers or manual laborers, undergo progressive load training combined with vocational simulation exercises. This advanced training system integrated essential functional movements relevant to occupational tasks, such as controlled squatting, standing transitions, and staircase navigation, ensuring a safe return to physically demanding work environments. In addition, appropriate policy support could significantly enhance postoperative recovery for patients: (1) Establish a "medical-enterprise" collaboration mechanism to facilitate light-duty job transitions and provide ergonomic equipment; (2) Strengthen legislative protection by incorporating postoperative functional impairments into occupational protection laws and prohibiting dismissal during the rehabilitation period; and (3) Expand medical insurance coverage to include multidisciplinary rehabilitation services and subsidies for workplace modifications.

CONCLUSION

Advancements in THA technology have significantly improved long-term outcomes for patients. However, increasing attention is now being paid to the timing and feasibility of returning to work and driving following surgery. Restoring daily mobility is critical for enhancing patients' quality of life and maintaining economic stability. Future research should incorporate prospective cohort studies with rigorously defined inclusion/exclusion criteria: Inclusion criteria must encompass patients ≥ 18 years undergoing anterior MIS-THA or conventional surgical approaches, while exclusion criteria should eliminate subjects with significant comorbidities, preoperative cognitive deficits, or noncompliance with follow-up protocols. Primary endpoints must systematically evaluate postoperative RTW, ROD, and complication profiles (including prosthesis loosening and surgical site infections). Secondary endpoints should quantify functional recovery through validated scoring systems, pain metrics using standardized scales, and patient-reported satisfaction outcomes. The follow-up protocol should incorporate sequential evaluations: Initial phase assessments at 1, 3, and 6 months post-operation to capture functional rehabilitation dynamics, complemented by longitudinal monitoring at 1, 3, and 5 years to assess implant longevity and occupational reintegration sustainability. Further studies focusing on the specific determinants and long-term trajectories of RTW and ROD outcomes are urgently needed to refine clinical guidelines and enhance patient-centered care.