A New Retractor Minimizes Muscle Damage and Reduces Total Hip Arthroplasty-related Inflammatory Response via Direct Anterior Approach

A New Retractor Minimizes Muscle Damage and Reduces Total Hip Arthroplasty-related Inflammatory Response via Direct Anterior Approach | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A New Retractor Minimizes Muscle Damage and Reduces Total Hip Arthroplasty-related Inflammatory Response via Direct Anterior Approach Shenghao Cai, Qirui Chen, Yong Xia, Bin Zhou, Shen Hu, Xiaoling Fu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3904675/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Total hip arthroplasty (THA) is the most effective treatment for severe hip disease. Orthopedic surgeons prefer using the Direct Anterior Approach (DAA) technique for THA as it is muscle-sparing and less invasive for the hip joint. It is noted that muscular damage, especially to the tensor fascia lata muscle (TFLM), elicits an inflammatory response, negating DAA's beneficial effects. To prevent damage to the TFLM and reduce inflammation during surgical procedures, a specialized retractor was explicitly developed and intended for use during the operation. Purpose To investigate whether the new retractor may reduce muscle injury and post-operative inflammation. Methods Fifty-six patients undergoing DAA-based THA were randomly divided into two groups. The observation group used the new retractor to prevent muscle strain during femur lifting. In the control group, gauze was the only protection during the surgery. The two groups were compared over time by measuring their C-reactive protein (CRP), interleukin-6 (IL-6), and creatine kinase (CK) serum levels. The Harris hip score and the visual analog scale (VAS) were used to assess the difference between the two groups. Result No significant differences were found in the CRP, IL-6, and CK pre-operative levels. Moreover, the observation group exhibited significantly lower serum levels of the tested parameters than the control group on days 1, 3, and 5 post-operation ( p < 0.05). Additionally, the VAS score in the control group was significantly lower than in group A ( p < 0.05). A month post-surgery, the Harris score of the control group exhibited a significantly greater value than the observation group ( p < 0.05). However, no significant differences were observed at 3 and 6 months post-surgery. Conclusion Utilizing the self-designed retractor system in DAA THA mitigates the risk of muscle damage and reduces the extent of post-operative inflammatory reaction. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Introduction Total hip arthroplasty (THA) was widely recognized as an effective treatment modality in the 20th century. Evidence has demonstrated that it effectively alleviates pain in individuals with end-stage hip joint disease while improving hip joint functionality and overall quality of life for patients [ 1 ] . Although there have been substantial advances in the clinical outcomes of THA [ 2 ] , there has concurrently been an increasing need for patient rehabilitation [ 3 ] . In order to improve the efficacy of THA, there has been a growing focus on the utilization of minimally invasive surgical methods [ 4 ] . The DAA has garnered increasing interest in contemporary discourse on minimally invasive surgery for THA [ 5 ] . This minimally invasive procedure involves a muscle-sparing dissection to preserve the abductors and minimize posterior dissection [ 6 ] . Using DAA THA is theoretically expected to provide several benefits, such as safeguarding dynamic hip stability, mitigating the danger of posterior dislocation, facilitating expedited recovery, alleviating post-operative discomfort, and reducing hospitalization duration [ 7 , 8 ] . Nevertheless, a multi-center clinical investigation revealed that the length of hospitalization, functional outcome, pain levels, implant placement, and occurrence of complications were similar to those observed with the posterior approach [ 9 ] . There is an ongoing debate about the degree to which DAA may cause less soft tissue damage than other surgical methods. The occurrence of muscle damage was prevalent in individuals who had DAA THA. Frye [ 10 ] observed a notable occurrence of apparent muscle damage in the majority of hips following anterior supine intermuscular hip arthroplasty. Mjaaland et al. [ 11 ] compared the direct lateral approach (DLA) with the DAA and found that participants in the DAA group had significantly higher levels of blood creatine kinase (CK). Previous studies conducted on cadavers examined several minimally invasive and tissue-sparing approaches, revealing that the DAA could result in less injury to the gluteal musculature. However, it is essential to note that some damage could still be seen in the tensor fasciae latae and rectus femoris muscles [ 12 , 13 ] . Comparable alterations have also been shown in the magnetic resonance imaging (MRI)-based investigation [ 14 ] . The leading cause of muscle injury is the extrusion and stretching of muscular tissues. Various strategies were employed to reduce the frequency of injuries during DAA THA. These included the utilization of gauze, plastic sheets, an orthostatic retractor device, a traction table, and a capsular tissue cushion. However, the extensive use of these technologies has been impeded by several factors, such as inadequate protective measures, time-intensive implementation processes, intricate operational procedures, and substantial financial investments [ 15 , 16 ] . A new retractor was constructed (Figs. 1 and 2 ), and a national patent was obtained (patent No. 202023038475.X)(Figure 3 ). This research aims to investigate the potential impact of implementing the retractor in the DAA THA and assess whether using this retractor may effectively mitigate muscle damage and diminish post-operative inflammation. Additionally, the influence of this intervention on post-operative pain levels and hip scores was also assessed. Material and Methods Between June 2018 and July 2019, sixty patients with THA were allocated into two groups using the random number table approach. The observational group comprised thirty patients who employed a self-designed retractor, whereas the control group consisted of thirty individuals who utilized a standard retractor. The inclusion criteria for this study included individuals with AVN, dysplasia, osteoarthritis of Crowe Ⅰ-Ⅱ, fracture of the femoral neck, and those who have had uncemented prosthesis placement. The exclusion criteria were those with a BMI more than 40 kg/m 2 , those diagnosed with dysplasia osteoarthritis of Crowe Ⅲ-Ⅳ, individuals with post-traumatic arthritis, those who had undergone bilateral THA, individuals with known systemic inflammatory diseases, and those with abnormal pre-operative blood tests. The study received permission from the hospital's Medical Ethical Committee. All patients received either general anesthesia or spinal anesthesia prior to surgical procedures. Patients in each group were given intravenous tranexamic acid (1 g). The second-generation cephalosporin antibiotics or clindamycin were routinely provided to the patients as a prophylactic measure against infection within 0.5 to 1 hour before the operation. A consistent team of surgeons conducted all surgical procedures using the DAA. The participants were positioned supine on a standard table, with their hips aligned above the table break. This positioning facilitated the flexion of the hip joint, enabling hyperextension. A typical 8–10 cm incision was made from 2 cm distally and laterally of the anterior superior iliac spine along the medial edge of the tensor fascia lata muscle (TFLM). The dissection procedure revealed the overlaying fascia TFLM. After confirming the position of the TFLM, a surgical cut was performed in the fascia covering it. The HUNTER space, positioned between the TFLM and the rectus femoris muscle, was identified by blunt finger dissection beneath the medial fascia. The ascending segment of the lateral circumflex femoral artery was dissected, cut, and cauterized. The anterior capsule was adequately exposed and completely removed in all study participants. The femoral neck osteotomy can be subsequently conducted by a single incision, so easing the removal of the femoral head. An anterior, posterior, and posteroinferior retractor was utilized to expose the acetabulum. The surgical procedure included the removal of rim osteophytes and the labrum, along with the excision of the ligamentum flavum stump and the surrounding soft tissue. The acetabular component was placed using a standardized procedure. In every instance, the acetabular component was secured utilizing screw fixation. The femoral exposure was accomplished by extending the extremities by reflexing the table and placing the leg in a figure-four posture beneath the opposing leg and knee. Surgical intervention was performed to release the soft tissue in the piriformis fossa and greater trochanter areas. A hook device was utilized to evaluate the effectiveness of the release. The new retractor was positioned underneath the greater trochanter in the observational cohort. In contrast, a conventional retractor was put on the femur's medial side next to the neck incision, facilitating the exposure of the proximal femur (Fig. 4 ). Two conventional retractors were utilized in the control group (Fig. 5 ). An uncemented femoral stem was placed using the same procedure. The positioning and dimensions of the implants were assessed using fluoroscopy. Subsequently, the TFL fascia was closed using a running suture technique. The subcutaneous tissue and skin were closed with absorbable sutures. Each step was executed cautiously to avoid potential damage to the lateral femoral cutaneous nerve. There was no drain placement for the procedure. No urethral catheterization was utilized unless spinal anesthesia was requested. Prior to the operation, antibiotics were administered for 48 hours, and nadroparin calcium was administered within 6 hours following the surgery to avoid the occurrence of deep vein thrombosis. Patients were encouraged to start ambulation on the first day post-surgery, utilizing a walker for support. C-reactive protein (CRP), interleukin-6 (IL-6), and CK levels in the blood were tested 1, 3, and 5 days following surgery. The visual analog scale (VAS) was employed to measure pain levels at 1, 3, and 5 days post-operatively. Harris scores of patients were obtained after 1, 3, and 6 months after surgery. Statistical analysis To evaluate the differences between the study's observational and control groups, the Student's paired t-test was used. The statistical significance was assessed at a p < 0.05. Statistical Package for the Social Sciences (SPSS) version 18.0 was utilized for all data analysis. Results The demographics and results of pre-operative laboratory testing did not show any significant variations between the two groups. Both groups had similar BMI. Table 1 displays patient demographics at baseline. Serum levels of CRP, CK, and IL-6 in the observation group were significantly lower than in the control group at 1, 3, and 5 days after surgery. (Fig. 6 a, 6 b, 6 c; each p < 0.05). At 1, 3, and 5 days post-operation, the VAS scores were higher in the observation group (Fig. 7 ; p < 0.01, p < 0.01, p < 0.01, and p < 0.05, respectively). After one month of surgery, the control group showed significantly higher Harris hip scores (Fig. 8 ; p 0.05). Discussion Research has shown that muscles can still be damaged despite claims that the DAA is a muscle-sparing technique [ 12 , 13 ] . When exposing the acetabulum, elevating the proximal femur, and implanting the femoral stem, it is essential to be cautious of the periarticular muscles, particularly the TFLM. Applying pressure as a fulcrum of the retractor can potentially cause injury to these muscles. Furthermore, the blades of the saw, the retractor's edge, and the excessive stretching of muscles can all contribute to possible damage. Iatrogenic muscle damage can lead to various consequences, such as an inflammatory reaction, heightened post-operative pain, and a prolonged recovery time. Therefore, it is necessary to understand methods for reducing muscle damage prior to utilizing DAA. Much research has been done on how to prevent muscular damage. A study by Gongyin Zhao utilized the anterior capsule as a protective layer (capsular tissue pad) to prevent injury to the tensor fascia lata muscle. However, the process of separating the medial joint capsule requires a significant amount of time and expertise [ 15 ] , although it may successfully minimize muscle damage. Protective agents, such as gauze, plastic sheets, curved abdominal retractors, and orthostatic retractors, have been utilized to prevent damage to the TFLM [ 16 ] . Nevertheless, the stress fulcrum could potentially remain on the muscle, whether it's through direct or indirect means, leading to potential damage when the femur is lifted using a retractor. As a result, these methods have not proven to be sufficiently compelling. Compression over the TFLM is avoided to prevent injury owing to the retractor's ingenious design, which shifts the fulcrum of femur lifting to the retractor's metal scaffold. Once the femur was positioned correctly, the retractor's nut was securely tightened to provide stability and alleviate the assistant's workload. Muscles contain significant levels of CK when they undergo damage, whether due to heart and muscular diseases or trauma, and a substantial amount of the enzyme (CK) gets released into the bloodstream [ 17 ] . As a result, CK is often used as an indicator of muscle damage severity [ 18 ] . The current research showed that at 1, 3, and 5 days post-operation, the serum CK concentrations in the observation group were significantly lower than in the control group, suggesting that the custom-made retractor is more successful in minimizing muscle damage than the standard one. In order to measure the extent of inflammation, the CRP and IL-6 were quantified as reliable indicators of inflammation. CRP is a well-established infection marked by the development of systemic inflammatory response syndrome. A high CRP value indicates an inflammatory response and is usually employed to measure surgical stress. IL-6 is a proinflammatory cytokine and has been shown to act as a myokine that rapidly responds to muscle contraction and injury [ 19 ] . Compared to the control group, the study participants within the observation group had significantly lower levels of CRP and IL-6 at 1, 3, and 5 days after surgery in the present research. DAA THA using new retractor resulted in significantly lower peak levels. The peaks were also observed at distinct times in the two groups. According to the current findings, the peak value was shown in the observation group one day after surgery and declined afterward. In contrast, the control group showed a peak value three days after surgery. The new retractor was associated with a lower level of post-operative inflammation. The body's inflammatory response significantly influences post-operative pain and function. Like the inflammatory reaction, the most intense pain was felt on the initial day and gradually decreased. There are some limitations to the research. Initially, there was a lack of uniformity in the anesthetic modalities used, as they were dependent on the patient's condition and the preferences of the anesthesiologists. Different anesthetic modes had varying levels of muscular relaxation during surgery, which could have influenced the reported outcomes to some extent. Furthermore, exploring alternative methods for measuring tissue damage is crucial, considering the influence of different factors on biochemical indicators. In addition, a magnetic resonance imaging (MRI) scan, which was not done in the present study, could have provided a more detailed insight into tissue damage. Additionally, it is essential to conduct further investigations into the long-term effects of this self-designed retractor due to the limited number of patients involved in this study. Conclusions In conclusion, our new retractor efficiently reduced iatrogenic muscle damage, inflammation, and post-operative discomfort after DAA THA. Declarations Ethics Statement The medical ethics committee of Nanchang University's Second Affiliated Hospital reviewed and approved the studies involving human participants. Each patient involved in this study provided written informed consent. Consent for publication All participants agreed to the publication of the paper. Availability of data and materials All data and materials are available in the Supplementary Materials to support the data and information. Competing interests The authors declare that they have no competing interests. Funding The present study was supported by Key research and development plan of Jiangxi Province（Grant No:20202BBG72001），Science and Technology plan of Jiangxi Provincial Health Commission（Grant No:202130504）and Science and technology project of Jiangxi Provincial Health Commission (Grant No. 202130504). Author Contribution The experimental work was designed by XF and SC. QC and BZ collected the data, analyzed figures and tables. The experimental procedures were conducted by SC and QC. The main text was written by XF, SC and QC. All authors approved the final manuscript. References Varacallo M, Luo TD, Johanson NA. Total Hip Arthroplasty Techniques. 2023 Aug 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 29939641. Pilz V, Hanstein T, Skripitz R. 2018. Projections of primary hip arthroplasty in Germany until 2040. Acta orthopaedica 89:308–313. Westby MD, Brittain A, Backman CL. Expert consensus on best practices for post-acute rehabilitation after total hip and knee arthroplasty: a Canada and United States Delphi study. Arthritis Care Res (Hoboken). 2014;66(3):411 – 23. doi: 10.1002/acr.22164 . PMID: 24023047. Xu CP, Li X, Song JQ, et al. 2013. Mini-incision versus standard incision total hip arthroplasty regarding surgical outcomes: a systematic review and meta-analysis of randomized controlled trials. PloS one 8:e80021. Post ZD, Orozco F, Diaz-Ledezma C, et al. 2014. Direct anterior approach for total hip arthroplasty: indications, technique, and results. The Journal of the American Academy of Orthopaedic Surgeons 22:595–603. Galakatos GR. 2018. Direct Anterior Total Hip Arthroplasty. Missouri medicine 115:537–541. Nakata K, Nishikawa M, Yamamoto K, et al. 2009. A clinical comparative study of the direct anterior with mini-posterior approach: two consecutive series. The Journal of arthroplasty 24:698–704. Barrett WP, Turner SE, Leopold JP. 2013. Prospective randomized study of direct anterior vs postero-lateral approach for total hip arthroplasty. The Journal of arthroplasty 28:1634–1638. Moerenhout K, Derome P, Laflamme GY, et al. 2020. Direct anterior versus posterior approach for total hip arthroplasty: a multicentre, prospective, randomized clinical trial. Canadian journal of surgery Journal canadien de chirurgie 63:E412-e417. Frye BM, Berend KR, Lombardi AV, Jr., et al. 2015. 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Contraction-induced myokine production and release: is skeletal muscle an endocrine organ? Exercise and sport sciences reviews 33:114–119. Tables Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table.pdf prsim.pzfx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3904675","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":270041251,"identity":"db14a705-d128-4fae-8a33-9f7afa90d2ff","order_by":0,"name":"Shenghao Cai","email":"","orcid":"","institution":"The Second Affiliated Hospital of Nanchang University","correspondingAuthor":false,"prefix":"","firstName":"Shenghao","middleName":"","lastName":"Cai","suffix":""},{"id":270041252,"identity":"c4b3e1df-ade4-4deb-abbe-044b19adb00a","order_by":1,"name":"Qirui Chen","email":"","orcid":"","institution":"The Second Affiliated Hospital of Nanchang 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arthroplasty (THA) was widely recognized as an effective treatment modality in the 20th century. Evidence has demonstrated that it effectively alleviates pain in individuals with end-stage hip joint disease while improving hip joint functionality and overall quality of life for patients \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Although there have been substantial advances in the clinical outcomes of THA \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e, there has concurrently been an increasing need for patient rehabilitation \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. In order to improve the efficacy of THA, there has been a growing focus on the utilization of minimally invasive surgical methods \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe DAA has garnered increasing interest in contemporary discourse on minimally invasive surgery for THA \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. This minimally invasive procedure involves a muscle-sparing dissection to preserve the abductors and minimize posterior dissection \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Using DAA THA is theoretically expected to provide several benefits, such as safeguarding dynamic hip stability, mitigating the danger of posterior dislocation, facilitating expedited recovery, alleviating post-operative discomfort, and reducing hospitalization duration \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Nevertheless, a multi-center clinical investigation revealed that the length of hospitalization, functional outcome, pain levels, implant placement, and occurrence of complications were similar to those observed with the posterior approach \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. There is an ongoing debate about the degree to which DAA may cause less soft tissue damage than other surgical methods. The occurrence of muscle damage was prevalent in individuals who had DAA THA. Frye \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e observed a notable occurrence of apparent muscle damage in the majority of hips following anterior supine intermuscular hip arthroplasty. Mjaaland et al. \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e compared the direct lateral approach (DLA) with the DAA and found that participants in the DAA group had significantly higher levels of blood creatine kinase (CK). Previous studies conducted on cadavers examined several minimally invasive and tissue-sparing approaches, revealing that the DAA could result in less injury to the gluteal musculature. However, it is essential to note that some damage could still be seen in the tensor fasciae latae and rectus femoris muscles \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Comparable alterations have also been shown in the magnetic resonance imaging (MRI)-based investigation \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe leading cause of muscle injury is the extrusion and stretching of muscular tissues. Various strategies were employed to reduce the frequency of injuries during DAA THA. These included the utilization of gauze, plastic sheets, an orthostatic retractor device, a traction table, and a capsular tissue cushion. However, the extensive use of these technologies has been impeded by several factors, such as inadequate protective measures, time-intensive implementation processes, intricate operational procedures, and substantial financial investments \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA new retractor was constructed (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), and a national patent was obtained (patent No. 202023038475.X)(Figure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). This research aims to investigate the potential impact of implementing the retractor in the DAA THA and assess whether using this retractor may effectively mitigate muscle damage and diminish post-operative inflammation. Additionally, the influence of this intervention on post-operative pain levels and hip scores was also assessed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003eBetween June 2018 and July 2019, sixty patients with THA were allocated into two groups using the random number table approach. The observational group comprised thirty patients who employed a self-designed retractor, whereas the control group consisted of thirty individuals who utilized a standard retractor. The inclusion criteria for this study included individuals with AVN, dysplasia, osteoarthritis of Crowe Ⅰ-Ⅱ, fracture of the femoral neck, and those who have had uncemented prosthesis placement. The exclusion criteria were those with a BMI more than 40 kg/m\u003csup\u003e2\u003c/sup\u003e, those diagnosed with dysplasia osteoarthritis of Crowe Ⅲ-Ⅳ, individuals with post-traumatic arthritis, those who had undergone bilateral THA, individuals with known systemic inflammatory diseases, and those with abnormal pre-operative blood tests. The study received permission from the hospital's Medical Ethical Committee.\u003c/p\u003e \u003cp\u003eAll patients received either general anesthesia or spinal anesthesia prior to surgical procedures. Patients in each group were given intravenous tranexamic acid (1 g). The second-generation cephalosporin antibiotics or clindamycin were routinely provided to the patients as a prophylactic measure against infection within 0.5 to 1 hour before the operation.\u003c/p\u003e \u003cp\u003eA consistent team of surgeons conducted all surgical procedures using the DAA. The participants were positioned supine on a standard table, with their hips aligned above the table break. This positioning facilitated the flexion of the hip joint, enabling hyperextension. A typical 8\u0026ndash;10 cm incision was made from 2 cm distally and laterally of the anterior superior iliac spine along the medial edge of the tensor fascia lata muscle (TFLM). The dissection procedure revealed the overlaying fascia TFLM. After confirming the position of the TFLM, a surgical cut was performed in the fascia covering it. The HUNTER space, positioned between the TFLM and the rectus femoris muscle, was identified by blunt finger dissection beneath the medial fascia. The ascending segment of the lateral circumflex femoral artery was dissected, cut, and cauterized. The anterior capsule was adequately exposed and completely removed in all study participants. The femoral neck osteotomy can be subsequently conducted by a single incision, so easing the removal of the femoral head. An anterior, posterior, and posteroinferior retractor was utilized to expose the acetabulum. The surgical procedure included the removal of rim osteophytes and the labrum, along with the excision of the ligamentum flavum stump and the surrounding soft tissue. The acetabular component was placed using a standardized procedure. In every instance, the acetabular component was secured utilizing screw fixation.\u003c/p\u003e \u003cp\u003eThe femoral exposure was accomplished by extending the extremities by reflexing the table and placing the leg in a figure-four posture beneath the opposing leg and knee. Surgical intervention was performed to release the soft tissue in the piriformis fossa and greater trochanter areas. A hook device was utilized to evaluate the effectiveness of the release. The new retractor was positioned underneath the greater trochanter in the observational cohort. In contrast, a conventional retractor was put on the femur's medial side next to the neck incision, facilitating the exposure of the proximal femur (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Two conventional retractors were utilized in the control group (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). An uncemented femoral stem was placed using the same procedure. The positioning and dimensions of the implants were assessed using fluoroscopy. Subsequently, the TFL fascia was closed using a running suture technique. The subcutaneous tissue and skin were closed with absorbable sutures. Each step was executed cautiously to avoid potential damage to the lateral femoral cutaneous nerve.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThere was no drain placement for the procedure. No urethral catheterization was utilized unless spinal anesthesia was requested.\u003c/p\u003e \u003cp\u003ePrior to the operation, antibiotics were administered for 48 hours, and nadroparin calcium was administered within 6 hours following the surgery to avoid the occurrence of deep vein thrombosis. Patients were encouraged to start ambulation on the first day post-surgery, utilizing a walker for support.\u003c/p\u003e \u003cp\u003eC-reactive protein (CRP), interleukin-6 (IL-6), and CK levels in the blood were tested 1, 3, and 5 days following surgery. The visual analog scale (VAS) was employed to measure pain levels at 1, 3, and 5 days post-operatively. Harris scores of patients were obtained after 1, 3, and 6 months after surgery.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eTo evaluate the differences between the study's observational and control groups, the Student's paired t-test was used. The statistical significance was assessed at a \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Statistical Package for the Social Sciences (SPSS) version 18.0 was utilized for all data analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe demographics and results of pre-operative laboratory testing did not show any significant variations between the two groups. Both groups had similar BMI. Table\u0026nbsp;1 displays patient demographics at baseline.\u003c/p\u003e \u003cp\u003eSerum levels of CRP, CK, and IL-6 in the observation group were significantly lower than in the control group at 1, 3, and 5 days after surgery. (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003ea, \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eb, \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003ec; each \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAt 1, 3, and 5 days post-operation, the VAS scores were higher in the observation group (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, and \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, respectively). After one month of surgery, the control group showed significantly higher Harris hip scores (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). However, this significance was not noted three months after surgery (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e;p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eResearch has shown that muscles can still be damaged despite claims that the DAA is a muscle-sparing technique \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. When exposing the acetabulum, elevating the proximal femur, and implanting the femoral stem, it is essential to be cautious of the periarticular muscles, particularly the TFLM. Applying pressure as a fulcrum of the retractor can potentially cause injury to these muscles. Furthermore, the blades of the saw, the retractor's edge, and the excessive stretching of muscles can all contribute to possible damage. Iatrogenic muscle damage can lead to various consequences, such as an inflammatory reaction, heightened post-operative pain, and a prolonged recovery time. Therefore, it is necessary to understand methods for reducing muscle damage prior to utilizing DAA.\u003c/p\u003e \u003cp\u003eMuch research has been done on how to prevent muscular damage. A study by Gongyin Zhao utilized the anterior capsule as a protective layer (capsular tissue pad) to prevent injury to the tensor fascia lata muscle. However, the process of separating the medial joint capsule requires a significant amount of time and expertise \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e, although it may successfully minimize muscle damage. Protective agents, such as gauze, plastic sheets, curved abdominal retractors, and orthostatic retractors, have been utilized to prevent damage to the TFLM \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Nevertheless, the stress fulcrum could potentially remain on the muscle, whether it's through direct or indirect means, leading to potential damage when the femur is lifted using a retractor. As a result, these methods have not proven to be sufficiently compelling. Compression over the TFLM is avoided to prevent injury owing to the retractor's ingenious design, which shifts the fulcrum of femur lifting to the retractor's metal scaffold. Once the femur was positioned correctly, the retractor's nut was securely tightened to provide stability and alleviate the assistant's workload.\u003c/p\u003e \u003cp\u003eMuscles contain significant levels of CK when they undergo damage, whether due to heart and muscular diseases or trauma, and a substantial amount of the enzyme (CK) gets released into the bloodstream \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. As a result, CK is often used as an indicator of muscle damage severity \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. The current research showed that at 1, 3, and 5 days post-operation, the serum CK concentrations in the observation group were significantly lower than in the control group, suggesting that the custom-made retractor is more successful in minimizing muscle damage than the standard one.\u003c/p\u003e \u003cp\u003eIn order to measure the extent of inflammation, the CRP and IL-6 were quantified as reliable indicators of inflammation. CRP is a well-established infection marked by the development of systemic inflammatory response syndrome. A high CRP value indicates an inflammatory response and is usually employed to measure surgical stress. IL-6 is a proinflammatory cytokine and has been shown to act as a myokine that rapidly responds to muscle contraction and injury \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Compared to the control group, the study participants within the observation group had significantly lower levels of CRP and IL-6 at 1, 3, and 5 days after surgery in the present research. DAA THA using new retractor resulted in significantly lower peak levels. The peaks were also observed at distinct times in the two groups. According to the current findings, the peak value was shown in the observation group one day after surgery and declined afterward. In contrast, the control group showed a peak value three days after surgery. The new retractor was associated with a lower level of post-operative inflammation. The body's inflammatory response significantly influences post-operative pain and function. Like the inflammatory reaction, the most intense pain was felt on the initial day and gradually decreased.\u003c/p\u003e \u003cp\u003eThere are some limitations to the research. Initially, there was a lack of uniformity in the anesthetic modalities used, as they were dependent on the patient's condition and the preferences of the anesthesiologists. Different anesthetic modes had varying levels of muscular relaxation during surgery, which could have influenced the reported outcomes to some extent. Furthermore, exploring alternative methods for measuring tissue damage is crucial, considering the influence of different factors on biochemical indicators. In addition, a magnetic resonance imaging (MRI) scan, which was not done in the present study, could have provided a more detailed insight into tissue damage. Additionally, it is essential to conduct further investigations into the long-term effects of this self-designed retractor due to the limited number of patients involved in this study.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, our new retractor efficiently reduced iatrogenic muscle damage, inflammation, and post-operative discomfort after DAA THA.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe medical ethics committee of Nanchang University\u0026apos;s Second Affiliated Hospital reviewed and approved the studies involving human participants. Each patient involved in this study provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants agreed to the publication of the paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data and materials are available in the Supplementary Materials to support the data and information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study was supported by Key research and development plan of Jiangxi Province（Grant No:20202BBG72001），Science and Technology plan of Jiangxi Provincial Health Commission（Grant No:202130504）and Science and technology project of Jiangxi Provincial Health Commission (Grant No. 202130504).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe experimental work was designed by XF and SC. QC and BZ collected the data, analyzed figures and tables. The experimental procedures were conducted by SC and QC. The main text was written by XF, SC and QC. All authors approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eVaracallo M, Luo TD, Johanson NA. Total Hip Arthroplasty Techniques. 2023 Aug 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan\u0026ndash;. PMID: 29939641.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePilz V, Hanstein T, Skripitz R. 2018. Projections of primary hip arthroplasty in Germany until 2040. Acta orthopaedica 89:308\u0026ndash;313.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWestby MD, Brittain A, Backman CL. Expert consensus on best practices for post-acute rehabilitation after total hip and knee arthroplasty: a Canada and United States Delphi study. 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Muscle damage during MIS total hip arthroplasty: Smith-Petersen versus posterior approach. Clinical orthopaedics and related research 453:293\u0026ndash;298.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Oldenrijk J, Hoogland PV, Tuijthof GJ, et al. 2010. Soft tissue damage after minimally invasive THA. Acta orthopaedica 81:696\u0026ndash;702.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBremer AK, Kalberer F, Pfirrmann CW, et al. 2011. Soft-tissue changes in hip abductor muscles and tendons after total hip replacement: comparison between the direct anterior and the transgluteal approaches. The Journal of bone and joint surgery British volume 93:886\u0026ndash;889.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao G, Zhu R, Jiang S, et al. 2020. Using the anterior capsule of the hip joint to protect the tensor fascia lata muscle during direct anterior total hip arthroplasty: a randomized prospective trial. BMC musculoskeletal disorders 21:21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOpsomer GJ, Vandeputte FJ, Sarac C. 2020. Orthostatic retractor placement reduces operating time and post-operative inflammatory response during the learning curve of anterior approach THA. Journal of orthopaedics 22:503\u0026ndash;512.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpeicher CE. 1991. Clinical Diagnosis and Management by Laboratory Methods. JAMA 266:2621\u0026ndash;2622.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClarkson PM, Nosaka K, Braun B. 1992. Muscle function after exercise-induced muscle damage and rapid adaptation. Medicine and science in sports and exercise 24:512\u0026ndash;520.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFebbraio MA, Pedersen BK. 2005. Contraction-induced myokine production and release: is skeletal muscle an endocrine organ? Exercise and sport sciences reviews 33:114\u0026ndash;119.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3904675/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3904675/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTotal hip arthroplasty (THA) is the most effective treatment for severe hip disease. Orthopedic surgeons prefer using the Direct Anterior Approach (DAA) technique for THA as it is muscle-sparing and less invasive for the hip joint. It is noted that muscular damage, especially to the tensor fascia lata muscle (TFLM), elicits an inflammatory response, negating DAA's beneficial effects. To prevent damage to the TFLM and reduce inflammation during surgical procedures, a specialized retractor was explicitly developed and intended for use during the operation.\u003c/p\u003e\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo investigate whether the new retractor may reduce muscle injury and post-operative inflammation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFifty-six patients undergoing DAA-based THA were randomly divided into two groups. The observation group used the new retractor to prevent muscle strain during femur lifting. In the control group, gauze was the only protection during the surgery. The two groups were compared over time by measuring their C-reactive protein (CRP), interleukin-6 (IL-6), and creatine kinase (CK) serum levels. The Harris hip score and the visual analog scale (VAS) were used to assess the difference between the two groups.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eNo significant differences were found in the CRP, IL-6, and CK pre-operative levels. Moreover, the observation group exhibited significantly lower serum levels of the tested parameters than the control group on days 1, 3, and 5 post-operation (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, the VAS score in the control group was significantly lower than in group A (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). A month post-surgery, the Harris score of the control group exhibited a significantly greater value than the observation group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, no significant differences were observed at 3 and 6 months post-surgery.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eUtilizing the self-designed retractor system in DAA THA mitigates the risk of muscle damage and reduces the extent of post-operative inflammatory reaction.\u003c/p\u003e","manuscriptTitle":"A New Retractor Minimizes Muscle Damage and Reduces Total Hip Arthroplasty-related Inflammatory Response via Direct Anterior Approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-01 16:13:23","doi":"10.21203/rs.3.rs-3904675/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9eca1307-3575-4c9f-9173-39831ed72f23","owner":[],"postedDate":"February 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-12T09:30:00+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-01 16:13:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3904675","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3904675","identity":"rs-3904675","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}