Evaluation of the association between the conjoined tendon-preserving posterior approach in total hip arthroplasty and early postoperative functional recovery: a retrospective cross-sectional study.

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Ryuichi Sato, Hajime Sugiyama, Yohei Matsushita, Tetsuya Yokoyama, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4511404/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: This study aimed to assess the impact of the conjoined tendon-preserving posterior (CPP) approach in total hip arthroplasty (THA) in reducing the number of days to independent walking and early postoperative clinical outcomes compared with conventional posterolateral (PL) and piriformis muscle-sparing PL (P-PL) approaches. Methods: In total, 91 patients who underwent robotic arm-assisted THA using the PL, P-PL, or CPP approaches were included in this study. Clinical outcomes, including the modified Harris Hip Score (mHHS) and Japanese Orthopaedic Association (JOA) hip score, were evaluated preoperatively and at 3 and 6 months postoperatively. Furthermore, the number of days to independent walking with two canes after surgery (T1) and the number of days to independent walking with a single cane after surgery (T2) were compared among the three approaches. Results: Following the PL approach, T1 and T2 were 11.1 and 24.6 days, respectively. Following the P-PL approach, T1 and T2 were 9.1 and 24.5 days, respectively. Following the CPP approach, T1 and T2 were 5.3 and 15.6 days, respectively. In each period of walking independence, CPP was significantly shorter than the others (T1, P <0.001 and T2, P <0.001). Clinical outcomes, including walking ability and activities of daily living, consistently favored the CPP approach for up to 6 months postoperatively. Intraoperative complications were observed in the PL and P-PL approaches. The CPP approach showed better results for postoperative pain at 3 months postoperatively. Conclusions: The CPP approach in THA significantly reduced the number of days to independent walking and exhibited superior early postoperative clinical outcomes compared to PL and P-PL approaches. total hip arthroplasty minimally invasive surgery conjoined tendon-preserving posterior approach clinical outcome Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Over the years, surgeons have explored various approaches and modifications to mitigate the risk of postoperative dislocation and enhance early functional recovery after total hip arthroplasty (THA) [ 1 – 5 ]. Postoperative dislocation rates associated with the posterior approach without soft tissue repair have been reported to range from 2.3–6.4% [ 5 – 10 ]. This is because THA using the posterior approach requires the release of the short external rotator muscles and posterior capsule from the greater trochanter. One cadaver study revealed that dissection of the posterior joint capsule affects the laxity of the hip joints [ 11 ]. Preservation or repair of the short external rotator muscles and posterior capsular ligament remains an important issue. THA using a posterior approach with posterior repair improves the postoperative dislocation rate by approximately 1% [ 8 – 10 ]. Furthermore, THA using anterior or lateral approaches, wherein the short external rotator muscles and posterior capsular ligament are not released from the femoral bone, reduced the postoperative dislocation rate compared to a posterior approach [ 2 , 3 , 12 ]. Since the 2000s, minimally invasive surgery (MIS) techniques for performing THA have been widely adopted, with the reported decrease of postoperative dislocation and advantage of early functional recovery [ 7 , 13 – 16 ]. MIS-THA was initially focused on reducing the size of the skin incision but has gradually come to focus on preserving muscle tendons [ 15 , 17 , 18 ]. However, studies comparing postoperative function between THA with MIS techniques and conventional techniques have been inconsistent in their conclusions, with some reporting significant improvement with MIS-THA, others reporting a limited advantage, and others finding no significant difference between MIS-THA and conventional THA. [ 18 – 23 ]. The conjoined tendon-preserving posterior (CPP) approach is also a minimally invasive posterior approach that preserves short external rotator muscles, except for the quadratus femoris and obturator externus muscles, and the posterior and anterior capsular ligaments without cutting them [ 24 ]. This approach was first reported in 2021 and has been reported to reduce the postoperative dislocation rates after femoral hemiarthroplasty [ 24 ]. THA with the CPP approach is also expected to reduce the postoperative dislocation rate and provide early postoperative functional recovery; however, clinical results for THA have not yet been reported. This study aimed to evaluate whether THA performed using the CPP approach could reduce the number of days to independent walking and improve early postoperative clinical outcomes compared with conventional posterolateral (PL) and piriformis muscle-sparing PL (P-PL) approaches. Methods Patients This was a retrospective cross-sectional study conducted at a single center. All procedures involving human participants were conducted in accordance with the ethical standards of the Institutional Research Committee and the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Patients who underwent robotic arm-assisted THA performed by a single surgeon from January 2021 were included in this study. All patients underwent THA in the lateral position with the PL approach were mainly selected in 2021, the P-PL approach were mainly selected in 2022, and the CPP approach were mainly selected since December 2022. The patients underwent THA due to osteoarthritis, osteonecrosis of the femoral head, and rapidly destructive coxarthropathy. All patients were scheduled for primary THA and underwent preoperative computed tomography for surgical planning and navigation. All participants had agreed to long-term hospitalization in the hope of being able to live independently at home. Surgical procedure of THA and postoperative rehabilitation A single surgeon with experience of over 100 THA cases performed all procedures with the patient in the lateral position, using the Mako system (Stryker, Kalamazoo, MI, USA). Prior to skin incision, three pins were placed on the superior lateral aspect of the iliac crest and attached to the pelvic array. A skin incision was made in the shape of a 10-cm wiggle with respect to the midpoint between the apex of the greater trochanter and the apex of the innominate tubercle. In the original method, a straight skin incision of approximately 9 cm was made from the center of the vastus ridge in a proximal posterior direction, with the body axis tilted at approximately 30° [ 24 ]. Our technique was different from the original method because we used the same skin incision but changed the amount of muscle and capsular ligament incisions for each approach. The gluteus maximus (GM) was then bluntly separated to expose the short external rotator muscles. After separating the GM, a femoral array was attached to the greater trochanter. The incision sites for the short rotator muscles and the posterior capsule were modified using each approach (Fig. 1 ). In the PL approach, the incision was initiated from the proximal aspect of the piriformis muscle (PI). The PI, conjoined tendon (CT), quadriceps femoris (QF), external obturator muscle, and ischiofemoral ligament (IFL) were resected collectively in an “L” shape at the greater trochanter attachment site and inverted. After resection of the muscles and ligaments, the hip joint was dislocated backwards. In the P-PL approach, the incision was initiated from the proximal aspect of the CT, while preserving the PI. the CT, the QF), external obturator muscle, and part of the IFL were resected collectively in an “L” shape at the greater trochanter attachment site and inverted. After resection of the muscles and ligaments, the hip joint was dislocated backwards. In the CPP approach, the QF and external obturator muscles were first resected from the femur, and the IFL was identified beneath the muscle layer. The joint capsule was then incised along the caudal margin of the inferior gemellus muscle distal to the IFL. After the joint was dislocated, the hip was inferiorly dislocated at 90° of hip flexion, maximal abduction, and maximal internal rotation (Flynn's reduction maneuver). The surgical technique after hip dislocation was identical for all approaches. Soft tissues in the acetabulum were removed and the acetabular bone was reamed. Implantation was performed using the Mako system, according to the preoperative plan. The femur was manipulated using the same procedure for all approaches, and the THA stems were inserted as planned. All patients received the same cementless cup (Trident II acetabular system, Stryker Inc., Mahwah, NJ, USA) and cementless femoral stem (Accolade II, Stryker Inc., Mahwah, NJ, USA). After implantation, the short external rotator muscles and posterior capsular ligament were repaired at the femoral limbus and the capsule was sutured laterally. Postoperatively, the patient underwent gait training without weight restriction, or strength and range of motion (ROM) training within the limits of pain tolerance. Postoperative gait rehabilitation started with walking with two canes and was gradually changed to walking with a single cane and walking without a cane. The following two criteria were used for the change in walking style: (1) the patient has the endurance to walk 50 meters continuously with or without a walking aid, and (2) the limping does not worsen during walking over 50 meters. In all patients, the two criteria were evaluated by physical therapists specializing in rehabilitation of the hip region. The patients were discharged from the hospital when they could walk independently with or without a cane. Assessment parameters Patients with leg extension within 11 mm, which was the maximum leg extension for THA with the CPP approach during preoperative planning, were selected from each approach in this study. All eligible patients were assessed using the modified Harris Hip Score (mHHS) and Japanese Orthopaedic Association (JOA) hip score preoperatively and at the 3-month and 6-month postoperative outpatient visits [ 25 , 26 ]. The JOA hip score consists of four subcategories: Pain, ROM, ability to walk, and activities of daily life (ADL) [ 26 ]. The higher the score, the better the clinical outcome (Fig. 2 ). Patients without preoperative or postoperative mHHS or JOA hip scores were excluded from the study. Finally, 32 patients who underwent THA using the PL approach, 34 using the P-PL approach, and 25 using the CPP approach were included in the study. The following data were collected: age at surgery, sex, height, weight, number of causative diseases, operative time, intraoperative blood loss, number of one- or two-stage bilateral THAs, frequency of complications, number of days to independent walking with two canes after surgery (T1), number of days to independent walking with a single cane after surgery (T2), mHHS, and JOA hip score. The mean values of the mHHS and JOA hip score were compared between the three groups at each evaluated period. In addition, the inter- and intra-examiner errors of the two physical therapists were evaluated for the presence of limping during postoperative gait. Data analysis Statistical analysis was performed using Steel-Dwass's multiple comparison test for items other than sex, number of causative diseases, number of one- or two-stage bilateral THAs, and frequency of complications. The remaining parameters of the demographic data were analyzed using the chi-square test. All statistical analyses were performed using the JMP version 14.0 (SAS Institute, Cary, NC, USA). Statistical significance was set at p < 0.05. Reliability of the limping after THA To assess the intra- and inter-measurer (measurers A and B) reliability of limping after THA, we randomly selected 40 patients who had undergone gait analysis after THA were selected. Video data of their gait posture taken 1–3 months postoperatively were used to assess limping (Fig. 3 ). One physical therapist (Y) evaluated the presence of limping twice within an interval of two weeks. Intra- and inter-class correlation coefficients ((ICCs; 1.1 and 2.1, respectively) were determined. Results Demographic data of the study participants are presented in Table 1 . There was a significant difference in the sex distribution (p = 0.011), and the mean operation time for the P-PL approach was shorter than that for the other approaches (the PL approach, p = 0.010; the CPP approach, p = 0.005). However, the remaining parameters in the demographic data were not significantly different between the three approaches. Intraoperative and postoperative complications were observed in the PL and P-PL approaches: loosening of the femoral arrays in the PL approach and postoperative dislocation and trochanteric fracture in the P-PL approach. Table 1 Demographic data of study patients PL approach (n = 32) P-PL approach (n = 34) CPP approach (n = 25) p-value Sex # Male: 7; Female: 25 Male: 5; Female: 29 Male: 0; Female: 25 0.011 Mean age, years (SD; range) $ 64.4 (13.3; 59.6–69.2) 68.9 (7.8; 66.1–71.6) 64.2 (9.8; 60.2–68.3) 0.947 † , 0.168 †† , 0.283 ††† Mean height, cm (SD; range) $ 158.1 (8.8; 154.9–161.3) 155.6 (8.2; 152.7–158.4) 156.1 (5.5; 153.8–158.4) 0.744 † , 0.913 †† , 0.532 ††† Mean weight, kg (SD; range) $ 58.1 (9.0; 54.8–61.3) 56.4 (11.1; 52.5–60.3) 54.2 (6.9; 51.3–57.0) 0.213 † , 0.959 †† , 0.605 ††† Causative disease # OA: 30; ONFH: 2; RDC: 0 OA: 33; ONFH: 0; RDC: 1 OA: 25; ONFH: 0; RDC: 0 0.184 Bilateral THA at one- or two-stage # 10 9 11 0.362 Mean operation time, min (SD; range) $ 87.3 (22.6; 79.8–96.1) 78.5 (16.7; 72.7–84.3) 90.3 (15.5; 83.9–96.7) 0.594 † , 0.005 †† , 0.010 ††† Mean intraoperative blood loss, cc (SD; range) $ 396.1 (244.1; 308.1–484.1) 318.6 (196.1; 250.2–387.0) 336.4 (94.7; 297.3–375.5) 0.213 † , 0.959 †† , 0.605 ††† The frequency of complications # 0 1 2 0.414 $ Steel-Dwass's multiple comparison test, # chi-squared test, † CPP vs PL, †† CPP vs P-PL, ††† PL vs P-PL Boldface numbers indicate significant differences. PL, posterolateral; P-PL, piriformis muscle-sparing posterolateral; CPP, conjoined tendon-preserving posterior; THA, total hip arthroplasty; OA, osteoarthritis; ONFH, osteonecrosis of the femoral head; RDC, rapidly destructive coxarthropathy. The number of days of independent walking is shown in Fig. 4 . In each period of walking independence, the CPP approach was significantly shorter than the others (T1: vs the PL approach of p < 0.001 and vs the P-PL approach of p < 0.001; T2: vs the PL approach of p < 0.001 and vs the P-PL approach of p < 0.001). Preoperatively, there were no significant differences in mHHS and JOA hip scores (Table 2 ). Three months postoperatively, clinical outcomes other than ROM of the JOA hip score were better with the CPP approach than with the other two approaches. (Table 3 ). Six months postoperatively, there was a significant difference in the total mHHS and JOA hip scores (Table 4 ). In terms of the functional parameters of the mHHS, ability to walk, and ADL of the JOA hip score, the CPP approach also showed better results than the other two approaches. On the other hand, for pain, there were no significant differences in the three approaches for both clinical outcomes. Regarding the reliability of limping after THA, intra- and inter-measurer reliabilities were good (ICC ≥ 0.750939), irrespective of the groups analyzed (Table 5 ). Table 2 Preoperative mHHS and JOA hip score as baseline data PL approach P-PL approach CPP approach p-value mHHS Pain, mean (SD; range) 17.2 (10.8; 13.3–21.1) 13.8 (9.9; 10.4–17.3) 12.4 (12.0; 7.4–17.4) 0.187 † , 0.761 †† , 0.299 ††† Function: Gait, mean (SD; range) 22.1 (6.0; 20.0–24.3) 19.9 (6.5; 17.6–22.1) 23.6 (5.7; 21.3–26.0) 0.547 † , 0.006 †† , 0.372 ††† Functional activities, mean (SD; range) 9.3 (2.4; 8.4–10.1) 9.4 (1.3; 9.0–9.9) 9.0 (1.7; 8.2–9.7) 0.829 † , 0.603 †† , 0.983 ††† Total score, mean (SD; range) 53.4 (16.0; 47.6–59.2) 47.4 (14.6; 42.3–52.5) 49.5 (16.6; 42.6–56.4) 0.670 † , 0.804 †† , 0.351 ††† JOA hip score Pain, mean (SD; range) 17.2 (9.8; 0.0–35.0) 13.7 (9.5; 0.0–35.0) 11.8 (10.7; 0.0–35.0) 0.126 † , 0.732 †† , 0.223 ††† ROM, mean (SD; range) 13.6 (3.6; 5.0–20.0) 14.4 (5.0; 3.0–20.0) 14.8 (3.2; 8.0–20.0) 0.432 † , 0.927 †† , 0.377 ††† Ability to walk, mean (SD; range) 10.7 (4.8; 1.0–18.0) 10.6 (4.7; 5.0–18.0) 12.3 (4.3; 5.0–20.0) 0.470 † , 0.390 †† , 0.999 ††† ADL, mean (SD; range) 13.1 (3.1; 6.0–20.0) 12.7 (2.6; 8.0–16.0) 11.3 (2.8; 6.0–16.0) 0.095 † , 0.172 †† , 0.842 ††† Total score, mean (SD; range) 54.6 (14.5; 30.0–81.0) 51.4 (15.4; 21.0–83.0) 50.1 (15.6; 24.0–82.0) 0.634 † , 0.949 †† , 0.801 ††† Steel-Dwass's multiple comparison test, † CPP vs PL, †† CPP vs P-PL, ††† PL vs P-PL Boldface numbers indicate significant differences. PL, posterolateral; P-PL, piriformis muscle-sparing posterolateral; CPP, conjoined tendon-preserving posterior; mHHS: modified Harris Hip Score; JOA: Japanese Orthopaedic Association; ROM, range of motion; ADL, activities of daily life Table 3 mHHS and JOA hip score in the 3-month postoperative period PL approach P-PL approach CPP approach p-value mHHS Pain, mean (SD; range) 41.8 (5.3; 39.8–43.7) 41.8 (5.2; 39.9–43.6) 44.0 (0.0; 44.0–44.0) 0.022 † , 0.016 †† , 0.994 ††† Function: Gait, mean (SD; range) 28.8 (6.0; 26.7–31.0) 30.5 (4.3; 29.0–32.0) 32.9 (0.6; 32.6–33.1) < 0.001 † , 0.006 †† , 0.514 ††† Functional activities, mean (SD; range) 11.8 (2.4; 11.0–12.7) 10.8 (2.5; 9.9–11.7) 13.2 (1.5; 12.6–13.8) 0.037 † , < 0.001 †† , 0.198 ††† Total score, mean (SD; range) 90.6 (11.8; 86.4–94.9) 91.4 (11.4; 87.4–95.3) 99.1 (2.1; 98.2–99.9) < 0.001 † , < 0.001 †† , 0.605 ††† JOA hip score Pain, mean (SD; range) 37.8 (4.6; 20.0–40.0) 37.9 (4.3; 20.0–40.0) 40.0 (0.0; 40.0–40.0) 0.022 † , 0.016 †† , 0.999 ††† ROM, mean (SD; range) 17.9 (2.3; 9.0–20.0) 17.8 (3.0; 8.0–20.0) 18.8 (1.8; 15.0–20.0) 0.101 † , 0.261 †† , 0.776 ††† Ability to walk, mean (SD; range) 15.8 (4.2; 5.0–20.0) 17.0 (4.1; 10.0–20.0) 19.7 (1.1; 15.0–20.0) < 0.001 † , 0.009 †† , 0.369 ††† ADL, mean (SD; range) 17.9 (2.4; 12.0–20.0) 17.0 (2.7; 8.0–20.0) 19.4 (1.2; 16.0–20.0) 0.017 † , < 0.001 †† , 0.359 ††† Total score, mean (SD; range) 89.4 (9.4; 53.0–100.0) 21.0 (13.5; 57.0–100.0) 25.2 (13.7; 91.0–100.0) < 0.001 † , < 0.001 †† , 0.949 ††† Steel-Dwass's multiple comparison test, † CPP vs PL, †† CPP vs P-PL, ††† PL vs P-PL Boldface numbers indicate significant differences. PL, posterolateral; P-PL, piriformis muscle-sparing posterolateral; CPP, conjoined tendon-preserving posterior; mHHS: modified Harris Hip Score; JOA: Japanese Orthopaedic Association; ROM, range of motion; ADL, activities of daily life Table 4 mHHS and JOA hip score in the 6-month postoperative period PL approach P-PL approach CPP approach p-value mHHS Pain, mean (SD; range) 42.1 (5.4; 40.2–44.1) 43.5 (1.3; 43.1–44.0) 44.0 (0.0; 44.0–44.0) 0.105 † , 0.189 †† , 0.836 ††† Function: Gait, mean (SD; range) 30.5 (4.9; 28.8–32.3) 31.9 (3.3; 30.7–33.1) 32.9 (0.6; 32.6–33.1) 0.008 † , 0.181 †† , 0.246 ††† Functional activities, mean (SD; range) 11.7 (2.6; 10.8–12.7) 11.6 (2.1; 10.9–12.4) 13.0 (1.4; 12.4–13.5) 0.227 † , 0.037 †† , 0.947 ††† Total score, mean (SD; range) 92.8 (11.3; 88.7–96.9) 95.8 (6.0; 93.7–97.9) 98.8 (1.8; 98.1–99.6) 0.027 † , 0.024 †† , 0.877 ††† JOA hip score Pain, mean (SD; range) 38.4 (4.3; 20.0–40.0) 39.4 (1.6; 20.0–40.0) 40.0 (0.0; 40.0–40.0) 0.105 † , 0.189 †† , 0.836 ††† ROM, mean (SD; range) 18.6 (2.0; 13.0–20.0) 18.6 (1.9; 13.0–20.0) 19.4 (1.3; 15.0–20.0) 0.032 † , 0.096 †† , 0.912 ††† Ability to walk, mean (SD; range) 17.6 (4.2; 5.0–20.0) 18.8 (3.4; 5.0–20.0) 19.9 (0.4; 18.0–20.0) 0.001 † , 0.984 †† , 0.047 ††† ADL, mean (SD; range) 18.0 (2.4; 10.0–20.0) 17.8 (2.6; 8.0–20.0) 19.3 (1.5; 16.0–20.0) 0.034 † , 0.025 †† , 0.466 ††† Total score, mean (SD; range) 92.6 (9.6; 56.0–100.0) 94.6 (6.6; 65.0–100.0) 98.6 (2.4; 93.0–100.0) < 0.001 † , 0.002 †† , 0.109 ††† Steel-Dwass's multiple comparison test, † CPP vs PL, †† CPP vs P-PL, ††† PL vs P-PL Boldface numbers indicate significant differences. PL, posterolateral; P-PL, piriformis muscle-sparing posterolateral; CPP, conjoined tendon-preserving posterior; mHHS: modified Harris Hip Score; JOA: Japanese Orthopaedic Association; ROM, range of motion; ADL, activities of daily life Table 5 Reliability of the limping after THA Reliability of measurements of the limping after THA (95% CI) ICC 95% CI p value Intra-measurer ICC (1, 1) 0.750939 0.573612 to 0.861032 < 0.001 Intra-measurer ICC (2, 1) 0.816497 0.677241 to 0.899278 < 0.001 All p-values have significant differences. CI, confidence interval; ICC, intra- and inter-class correlation coefficients; THA, total hip arthroplasty. Discussion The present study aimed to assess the impact of the CPP approach in THA on early postoperative clinical outcomes compared with the PL and P-PL approaches. Our findings indicated that THA with the CPP approach significantly reduced the number of days to independent walking and demonstrated superior early postoperative clinical outcomes compared with the PL and P-PL approaches. Preservation of the CT and IFL in the CPP approach contributes to enhanced joint stability, leading to improved functional recovery in the early postoperative period. Although further prospective studies and long-term follow-up are warranted, our findings suggested that the CPP approach had the potential to optimize outcomes and patient satisfaction in THA. Previous studies have reported dislocation rates of 2.3–6.4% with the PL approach without soft tissue repair, and posterior repair has been used primarily to prevent postoperative dislocation[ 5 – 10 , 12 ]. Subsequently, following the widespread use of MIS-THA, which preserves the musculotendons mainly through an anterior approach, the benefits of early functional recovery as well as a reduction in postoperative dislocation have been reported[ 7 , 13 , 15 – 18 ]. Recently, the external rotator preservation (ERP) approach and the supercapsular percutaneously assisted approach in THA (Super PATH), which are posterior MIS-THA approaches, have been reported to provide good clinical outcomes after THA[ 15 , 27 ]. THA with the ERP approach has been reported to obtain better total scores in HHS than the conventional PL approach, with or without posterior repair, at 1 year after THA[ 15 ]. THA with Super PATH also showed better pain visual analogue scale (VAS) and total scores in HHS than the conventional PL approach at 3 months postoperatively, but no difference was reported between the two approaches at 1 year postoperatively[ 27 ]. In this study, mHHS and JOA hip scores were compared in the CPP, PL, and P-PL approaches, which are posterior MIS-THAs. The results showed that postoperative pain was better with the CPP approach for up to 3 months postoperatively. This may indicate that postoperative pain can be reduced by preserving the posterior tissue, similar to THA with Super PATH. Functional parameters, such as walking ability and ADL, consistently favored the CPP approach up to 6 months postoperatively. Patients who underwent THA with the CPP approach showed improved functional parameters, suggesting a possible advantage in restoring normal hip function and quality of life. In contrast, THA with Super PATH was reported to have comparable HHS to THA with the conventional PL approach at 1 year post-operatively[ 27 ]. Although this study evaluated the results up to 6 months postoperatively, significant differences between the three groups might disappear at one year postoperatively. This study also evaluated the early postoperative period with regard to each period of walking independence. The CPP approach was shown to be consistently favored and superior in gaining the ability to walk postoperatively. Previous studies have reported an average postoperative hospital stay of around 1 week, regardless of whether MIS-THA or conventional THA, anterior or posterior approach was used [ 7 , 18 , 20 , 27 , 28 ]. One of the reasons for the longer postoperative hospital stay in this study was that participants needed to live alone without anyone support after discharge. Therefore, they required to be able to walk independently and agreed to long-term hospitalization. Another reason was that the improvement in limping, which took a long time, was considered important for the change in gait style in our institution. The presence or absence of limping was assessed by each physical therapist, but there was a concern that errors in assessment between them might affect the postoperative assessment. In this study, the validity of the assessment method was evaluated by assessing inter- and intra-examiner errors between physical therapists and it showed good results. Therefore, we believe that the comparative results and postoperative hospital stays of this study were objectively validated. Furthermore, we speculated that the CPP approach had a significantly shorter time to independent walking because of the preservation of posterior soft tissue and improved joint stability, which facilitated early mobilization. This study had some limitations. First, this was a retrospective study. Second, the relatively small sample size may have affected our results. Notably, the number of patients in each group was lower than that required for power analysis. A larger series is required to ensure that the findings are not limited to the observed population. Third, the follow-up period was short. At 6 months postoperatively, pain and some functional parameters were not significantly different between the CPP approach and other approaches. Therefore, it is possible that clinical outcomes will not differ significantly between THA using the CPP approach and THA using the other approaches more than 1 year postoperatively. The long-term outcomes and potential complications associated with the CPP approach require further investigation to establish its efficacy and safety. Finally, the CPP approach limits indications for patients in whom THA can be performed. Takao et al. found that before the posterior capsule was dissected, the maximum joint laxity was about 11 mm [ 11 ]. We selected cases indicated for the CPP approach according to the report. Therefore, the existence of bias in this study cannot be ruled out. This study demonstrated that THA with the CPP approach significantly reduced the number of days to independent walking and exhibited superior early postoperative clinical outcomes compared with the PL and P-PL approaches. Although further prospective studies and long-term follow-up are warranted, our findings suggest that the CPP approach has the potential to optimize outcomes and patient satisfaction in THA. Conclusion The CPP approach in THA significantly reduced the number of days to independent walking and exhibited superior early postoperative clinical outcomes compared to PL and P-PL approaches. Preservation of the conjoined tendon and joint capsular ligaments in the CPP approach contributes to enhanced joint stability, leading to improved functional recovery in the early postoperative period. Abbreviations ADL, activities of daily life CPP, conjoined tendon-preserving posterior CT, conjoined tendon ERP, external rotator preservation GM, gluteus maximus ICCs, inter-class correlation coefficients IFL, ischiofemoral ligament JOA, Japanese Orthopaedic Association mHHS, modified Harris Hip Score MIS, minimally invasive surgery P-PL, piriformis muscle-sparing posterolateral PI, piriformis muscle PL, posterolateral QF, quadriceps femoris ROM, range of motion Super PATH, supercapsular percutaneously assisted approach in THA THA, total hip arthroplasty VAS, visual analogue scale Declarations Ethics approval and consent to participate All procedures involving human participants were conducted in accordance with the ethical standards of the Institutional Research Committee and the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards (Approval number: khr-2023-012, date: 12/7/2023). All patients signed informed consent before participating in the trial. Consent for publication Consent was obtained from the individuals used in Figure to publish the information in a manner that protects their personal data. Availability of data and materials All data generated or analysed during this study are included in this published article. Competing interests The authors declare that they have no competing interests Funding No funding was received for conducting this study. Authors' contributions R. Sato: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. H. Sugiyama: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing. Y. Matsushita: Data curation, Formal analysis, Writing – review & editing. T. Yokoyama: Data curation, Formal analysis, Investigation, Writing – review & editing. E. Okawa: Data curation, Formal analysis, Investigation, Writing – review & editing. H. Tonotsuka: Data curation, Formal analysis, Writing – review & editing. T. Hayama: Data curation, Formal analysis, Writing – review & editing. M. Saito: Data curation, Formal analysis, Project administration, Supervision, Writing – review & editing. Acknowledgements Not applicable. Authors' information R. Sato, MD, PhD, Orthopaedic Surgeon H. Sugiyama, MD, PhD, Orthopaedic Surgeon Y. Matsushita, MD, Orthopaedic Surgeon H. Tonotsuka, MD, PhD, Orthopaedic Surgeon Department of Orthopaedic Surgery, Kanagawa Rehabilitation Hospital, Kanagawa, 243-0121, Japan; Department of Orthopaedic Surgery, Jikei University School of Medicine, Tokyo, Japan. T. Yokoyama, PT E. Okawa, PT Department of Physiotherapy, Kanagawa Rehabilitation Hospital, Kanagawa, 243-0121, Japan. T. Hayama, MD, PhD, Orthopaedic Surgeon M. Saito, MD, PhD, Orthopaedic Surgeon Department of Orthopaedic Surgery, Jikei University School of Medicine, Tokyo, Japan. References Dixon MC, Scott RD, Schai PA, Stamos V. A Simple Capsulorrhaphy in a Posterior Approach for Total Hip Arthroplasty. J Arthroplasty. 2004;19(3):373–76. Mallory TH, Lombardi AVJ, Fada RA, Herrington SM, Eberle RW. Dislocation after total hip arthroplasty using the anterolateral abductor split approach. Clin Orthop Relat Res. 1999(358):166–72. Demos HA, Rorabeck CH, Bourne RB, MacDonald SJ, McCalden RW. Instability in Primary Total Hip Arthroplasty With the Direct Lateral Approach. Clin Orthop Relat Res. 2001;393:168–80. Pai VS. A comparison of three lateral approaches in primary total hip replacement. Int Orthop. 1997;21(6):393–8. Ritter MA, Harty LD, Keating ME, Faris PM, Meding JB. A Clinical Comparison of the Anterolateral and Posterolateral Approaches to the Hip. Clin Orthop Relat Res. 2001(385):95–9. Woolson ST, Rahimtoola ZO. Risk Factors for Dislocation During the First 3 Months After Primary Total Hip Replacement. J Arthroplasty. 1999;14(6):662–8. Wright JM, Crockett HC, Delgado S, Lyman S, Madsen M, Sculco TP. Mini-incision for total hip arthroplasty: a prospective, controlled investigation with 5-year follow-up evaluation. J Arthroplasty. 2004;19(5):538–45. Pellicci PM, Bostrom M, Poss R. Posterior Approach to Total Hip Replacement Using Enhanced Posterior Soft Tissue Repair. Clin Orthop Relat Res. 1998(355):224–8. Suh KT, Park BG, Choi YJ. A Posterior Approach to Primary Total Hip Arthroplasty With Soft Tissue Repair. Clin Orthop Relat Res. 2004(418):162–7. White REJ, Forness TJ, Allman JK, Junick DW. Effect of posterior capsular repair on early dislocation in primary total hip replacement. Clin Orthop Relat Res. 2001(393):163–7. Takao M, Otake Y, Fukuda N, Sato Y, Armand M, Sugano N. The Posterior Capsular Ligamentous Complex Contributes to Hip Joint Stability in Distraction. J Arthroplasty. 2018;33(3):919–24. Kwon MS, Kuskowski M, Mulhall KJ, Macaulay W, Brown TE, Saleh KJ. Does surgical approach affect total hip arthroplasty dislocation rates? Clin Orthop Relat Res. 2006;447:34–8. Pfluger G, Junk-Jantsch S, Scholl V. Minimally invasive total hip replacement via the anterolateral approach in the supine position. Int Orthop. 2007;31(Suppl 1):S7–11. Bertin KC, Rottinger H. Anterolateral mini-incision hip replacement surgery: a modified Watson-Jones approach. Clin Orthop Relat Res. 2004(429):248–55. Kim YS, Kwon SY, Sun DH, Han SK, Maloney WJ. Modified posterior approach to total hip arthroplasty to enhance joint stability. Clin Orthop Relat Res. 2008;466(2):294–9. Nam D, Meyer Z, Rames RD, Nunley RM, Barrack RL, Roger DJ. Is the Direct Superior, Iliotibial Band-Sparing Approach Associated With Decreased Pain After Total Hip Arthroplasty? J Arthroplasty. 2017;32(2):453–57. Nakamura S, Matsuda K, Arai N, Wakimoto N, Matsushita T. Mini-incision posterior approach for total hip arthroplasty. Int Orthop. 2004;28(4):214–7. Ogonda L, Wilson R, Archbold P, Lawlor M, Humphreys P, O'Brien S, Beverland D. A minimal-incision technique in total hip arthroplasty does not improve early postoperative outcomes. A prospective, randomized, controlled trial. J Bone Joint Surg Am. 2022;87(4):701–10. Liu H, Yin L, Li J, Liu S, Tao Q, Xu J. Minimally invasive anterolateral approach versus direct anterior approach total hip arthroplasty in the supine position: a prospective study based on early postoperative outcomes. J Orthop Surg Res. 2022;17(1):230. Wang T, Zhou Y, Li X, Gao S, Yang Q. Comparison of postoperative effectiveness of less invasive short external rotator sparing approach versus standard posterior approach for total hip arthroplasty. J Orthop Surg Res. 2021;16(1):46. Shen J, Ji W, Shen Y, He S, Lin Y, Ye Z, Wang B. Comparison of the early clinical efficacy of the SuperPath approach versus the modified Hardinge approach in total hip arthroplasty for femoral neck fractures in elderly patients: a randomized controlled trial. J Orthop Surg Res. 2023;18(1):215. Bohm H, Hagemeyer D, Thummerer Y, Kipping R, Stockle U, Scheuerer K. Rehabilitation of gait in patients after total hip arthroplasty: Comparison of the minimal invasive Yale 2-incision technique and the conventional lateral approach. Gait Posture. 2016;44:110–5. Goosen JH, Kollen BJ, Castelein RM, Kuipers BM, Verheyen CC. Minimally invasive versus classic procedures in total hip arthroplasty: a double-blind randomized controlled trial. Clin Orthop Relat Res. 2011;469(1):200–8. Nakamura T, Yamakawa T, Hori J, Goto H, Nakagawa A, Takatsu T, Naoki O, Saito A, Keisuke H, Mouri K. Conjoined tendon preserving posterior approach in hemiarthroplasty for femoral neck fractures: A prospective multicenter clinical study of 322 patients. J Orthop Surg (Hong Kong). 2021;29(3):23094990211063963. Byrd JW, Jones KS. Prospective analysis of hip arthroscopy with 2-year follow-up. Arthroscopy. 2000;16(6):578–87. Kuribayashi M, Takahashi KA, Fujioka M, Ueshima K, Inoue S, Kubo T. Reliability and validity of the Japanese Orthopaedic Association hip score. J Orthop Sci. 2010;15(4):452–8. Xie J, Zhang H, Wang L, Yao X, Pan Z, Jiang Q. Comparison of supercapsular percutaneously assisted approach total hip versus conventional posterior approach for total hip arthroplasty: a prospective, randomized controlled trial. J Orthop Surg Res. 2017;12(1):138. Meng W, Huang Z, Wang H, Wang D, Luo Z, Bai Y, Gao L, Wang G, Zhou Z. Supercapsular percutaneously-assisted total hip (SuperPath) versus posterolateral total hip arthroplasty in bilateral osteonecrosis of the femoral head: a pilot clinical trial. BMC Musculoskelet Disord. 2019;21(1):2. Additional Declarations No competing interests reported. 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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-4511404","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":314279950,"identity":"5f918777-3ae8-4cc4-aaee-3abd5e8adb1f","order_by":0,"name":"Ryuichi Sato","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAklEQVRIie3Rv0rEMBzA8V8IpEt6WRsO+gyBDnKD+ioJgpu3HIjgwRUKcam61re4R2j4Qbs5O+obxEU6HGI9DsWhtqNIvhD4QfhA/gCEQn+wpF/153BaiOfaA+jDBhsjClTEiaumEtgTwSnybzKcvLl9cd16lx7RuMZje7IUUU68h9lyiMx5q5A3KlsUM40X9mwly5rKCthqiKTJOSAwZXIE1RNqtk+aUQ7M5L8Q170fyMJuxsm8J3VsldkiV0gsjhNZNoDxXZbJgmlXPrbmoXSFrNTwXZLW0tfuLU2FQPTd5bW5jwrn/VUz+GI/I/sPJP2RVKOnEdh9TeupJBQKhf5/H4ZyWI07HGRaAAAAAElFTkSuQmCC","orcid":"","institution":"Kanagawa Rehabilitation Hospital","correspondingAuthor":true,"prefix":"","firstName":"Ryuichi","middleName":"","lastName":"Sato","suffix":""},{"id":314279951,"identity":"294a230f-3968-49ac-9181-d710e41499cd","order_by":1,"name":"Hajime Sugiyama","email":"","orcid":"","institution":"Kanagawa Rehabilitation Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hajime","middleName":"","lastName":"Sugiyama","suffix":""},{"id":314279952,"identity":"3d80200c-f8e0-4dd9-a29a-14273e4e2553","order_by":2,"name":"Yohei Matsushita","email":"","orcid":"","institution":"Kanagawa Rehabilitation Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yohei","middleName":"","lastName":"Matsushita","suffix":""},{"id":314279953,"identity":"58f084af-126a-4d14-aced-a5a173e7f899","order_by":3,"name":"Tetsuya Yokoyama","email":"","orcid":"","institution":"Kanagawa Rehabilitation Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tetsuya","middleName":"","lastName":"Yokoyama","suffix":""},{"id":314279954,"identity":"7f2c2122-1639-46bb-ba53-df781b3f47a5","order_by":4,"name":"Eriko Okawa","email":"","orcid":"","institution":"Kanagawa Rehabilitation Hospital","correspondingAuthor":false,"prefix":"","firstName":"Eriko","middleName":"","lastName":"Okawa","suffix":""},{"id":314279955,"identity":"1f75d02f-f2b3-412b-8b81-78507af44c25","order_by":5,"name":"Hisahiro Tonotsuka","email":"","orcid":"","institution":"Kanagawa Rehabilitation Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hisahiro","middleName":"","lastName":"Tonotsuka","suffix":""},{"id":314279956,"identity":"fac78bb5-9f93-4165-b529-9c1eed15e24a","order_by":6,"name":"Tetsuo Hayama","email":"","orcid":"","institution":"Jikei University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Tetsuo","middleName":"","lastName":"Hayama","suffix":""},{"id":314279957,"identity":"bb1539c9-bcfa-41b2-a260-9786e2e6e663","order_by":7,"name":"Mitsuru Saito","email":"","orcid":"","institution":"Jikei University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Mitsuru","middleName":"","lastName":"Saito","suffix":""}],"badges":[],"createdAt":"2024-06-01 01:08:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4511404/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4511404/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60185037,"identity":"bd60fde7-3f89-4e86-99f8-99103d17ee33","added_by":"auto","created_at":"2024-07-12 18:39:38","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2207499,"visible":true,"origin":"","legend":"\u003cp\u003eIncision location for each approach.\u003cstrong\u003e (A)\u003c/strong\u003e In the PL approach, the incision is started from the proximal aspect of the piriformis muscle. The piriformis muscle (PI), conjoined tendon (CT), quadriceps femoris (QF), and external obturator muscle are resected collectively in an “L” shape at the greater trochanter attachment site and inverted (yellow dotted line). In the P-PL approach, the incision was initiated from the proximal aspect of the CT, while preserving the PI. The CT, quadriceps femoris (QF), external obturator muscle, and a part of the ischiofemoral ligament (IFL) were resected collectively in an “L” shape at the greater trochanter attachment site and inverted (green dotted line). In the CPP approach, only the QF and external obturator muscles are resected from the femur (blue dotted line). \u0026nbsp;\u003cstrong\u003e(B)\u003c/strong\u003e In the PL approach, the ischiofemoral ligament (IFL) is resected in an “L” shape at the greater trochanter attachment site and inverted (yellow dotted line). In the P-PL approach, a part of the ischiofemoral ligament (IFL) is resected in an “L” shape at the greater trochanter attachment site and inverted (green dotted line). In the CPP approach, the joint capsule is incised along the caudal margin of the inferior gemellus muscle distal to the IFL (blue dotted line).\u003c/p\u003e\n\u003cp\u003ePL, posterolateral; P-PL, piriformis muscle-sparing posterolateral; CPP, conjoined tendon-preserving posterior; GT, greater trochanter; G med, gluteus medius muscle; PI, piriformis muscle; CT, conjoined tendon; QF, quadriceps femoris; G min, gluteus minimus muscle; FN, femoral neck; IFL, ischiofemoral ligament.\u003c/p\u003e","description":"","filename":"figure1abps.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4511404/v1/4d198d4eda7e7099df4249a0.jpg"},{"id":60186148,"identity":"22edb280-6a79-4f7e-8103-9d618881ba20","added_by":"auto","created_at":"2024-07-12 18:47:38","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3682190,"visible":true,"origin":"","legend":"\u003cp\u003eJapanese Orthopaedic Association (JOA) hip score consists of four subcategories: pain, range of motion (ROM), ability to walk, and activities of daily life (ADL). Pain is 40 points, ROM is 12 points for flexion, 8 points for abduction, 20 points for Ability to walk and 4 points for each of the five ADLs, for a total of 100 points.\u003c/p\u003e","description":"","filename":"figure2ps.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4511404/v1/2902573a49360b33041c7e78.jpg"},{"id":60185040,"identity":"e3aee2ba-c42d-4d3d-8b8f-26c6fa482dc1","added_by":"auto","created_at":"2024-07-12 18:39:38","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1501165,"visible":true,"origin":"","legend":"\u003cp\u003eVideo data on the patient's gait taken 1-3 months after total hip arthroplasty. The patient's post-operative course is assessed on the basis of pre- and post-operative gait analysis in our institution. In the left panel, the red dotted lines are not equilibrium. If the horizontal axis of both shoulders was not parallel to the floor or if there was compensatory tilting of the pelvis during the stance phase, the patient was evaluated as having a limping. On the other hand, in the right panel, there is no compensatory tilting of the pelvis, and the blue dotted lines indicates equilibrium. In this case, the patient was evaluated as having no limping.\u003c/p\u003e","description":"","filename":"figure3ps.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4511404/v1/230af0dbd2b05d1c5df36818.jpg"},{"id":60185041,"identity":"8e5ec5f7-859e-4952-a441-d61ab49322c4","added_by":"auto","created_at":"2024-07-12 18:39:39","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":98718,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of days to walking independence. Following the PL approach, T1 and T2 were 11.1 and 24.6 days, respectively. Following the P-PL approach, T1 and T2 were 9.1 and 24.5 days, respectively. Following the CPP approach, T1 and T2 were 5.3, 15.6 days, respectively. These values were significantly shorter in the CPP approach than in the other groups in each period.\u003c/p\u003e\n\u003cp\u003ePL, posterolateral; P-PL, piriformis muscle-sparing posterolateral; CPP, conjoined tendon-preserving posterior.\u003c/p\u003e","description":"","filename":"figure4ps.png","url":"https://assets-eu.researchsquare.com/files/rs-4511404/v1/de16052dc2c2a3ea039da474.png"},{"id":64671362,"identity":"8982867e-a753-4e84-bec2-92f3d0c68edb","added_by":"auto","created_at":"2024-09-17 10:31:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":8236519,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4511404/v1/a4f968f9-70c1-41e7-b914-dfbf5069dc32.pdf"},{"id":60185038,"identity":"744b3978-004a-45e0-8238-9119d9df325a","added_by":"auto","created_at":"2024-07-12 18:39:38","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":44703,"visible":true,"origin":"","legend":"","description":"","filename":"tableBMCMSD.docx","url":"https://assets-eu.researchsquare.com/files/rs-4511404/v1/f94809ae22e5fcfa27af0baf.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of the association between the conjoined tendon-preserving posterior approach in total hip arthroplasty and early postoperative functional recovery: a retrospective cross-sectional study.","fulltext":[{"header":"Background","content":"\u003cp\u003eOver the years, surgeons have explored various approaches and modifications to mitigate the risk of postoperative dislocation and enhance early functional recovery after total hip arthroplasty (THA) [\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Postoperative dislocation rates associated with the posterior approach without soft tissue repair have been reported to range from 2.3\u0026ndash;6.4% [\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This is because THA using the posterior approach requires the release of the short external rotator muscles and posterior capsule from the greater trochanter. One cadaver study revealed that dissection of the posterior joint capsule affects the laxity of the hip joints [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Preservation or repair of the short external rotator muscles and posterior capsular ligament remains an important issue. THA using a posterior approach with posterior repair improves the postoperative dislocation rate by approximately 1% [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Furthermore, THA using anterior or lateral approaches, wherein the short external rotator muscles and posterior capsular ligament are not released from the femoral bone, reduced the postoperative dislocation rate compared to a posterior approach [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSince the 2000s, minimally invasive surgery (MIS) techniques for performing THA have been widely adopted, with the reported decrease of postoperative dislocation and advantage of early functional recovery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. MIS-THA was initially focused on reducing the size of the skin incision but has gradually come to focus on preserving muscle tendons [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, studies comparing postoperative function between THA with MIS techniques and conventional techniques have been inconsistent in their conclusions, with some reporting significant improvement with MIS-THA, others reporting a limited advantage, and others finding no significant difference between MIS-THA and conventional THA. [\u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The conjoined tendon-preserving posterior (CPP) approach is also a minimally invasive posterior approach that preserves short external rotator muscles, except for the quadratus femoris and obturator externus muscles, and the posterior and anterior capsular ligaments without cutting them [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This approach was first reported in 2021 and has been reported to reduce the postoperative dislocation rates after femoral hemiarthroplasty [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. THA with the CPP approach is also expected to reduce the postoperative dislocation rate and provide early postoperative functional recovery; however, clinical results for THA have not yet been reported.\u003c/p\u003e \u003cp\u003eThis study aimed to evaluate whether THA performed using the CPP approach could reduce the number of days to independent walking and improve early postoperative clinical outcomes compared with conventional posterolateral (PL) and piriformis muscle-sparing PL (P-PL) approaches.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThis was a retrospective cross-sectional study conducted at a single center. All procedures involving human participants were conducted in accordance with the ethical standards of the Institutional Research Committee and the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Patients who underwent robotic arm-assisted THA performed by a single surgeon from January 2021 were included in this study. All patients underwent THA in the lateral position with the PL approach were mainly selected in 2021, the P-PL approach were mainly selected in 2022, and the CPP approach were mainly selected since December 2022. The patients underwent THA due to osteoarthritis, osteonecrosis of the femoral head, and rapidly destructive coxarthropathy. All patients were scheduled for primary THA and underwent preoperative computed tomography for surgical planning and navigation. All participants had agreed to long-term hospitalization in the hope of being able to live independently at home.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical procedure of THA and postoperative rehabilitation\u003c/h2\u003e \u003cp\u003eA single surgeon with experience of over 100 THA cases performed all procedures with the patient in the lateral position, using the Mako system (Stryker, Kalamazoo, MI, USA). Prior to skin incision, three pins were placed on the superior lateral aspect of the iliac crest and attached to the pelvic array. A skin incision was made in the shape of a 10-cm wiggle with respect to the midpoint between the apex of the greater trochanter and the apex of the innominate tubercle. In the original method, a straight skin incision of approximately 9 cm was made from the center of the vastus ridge in a proximal posterior direction, with the body axis tilted at approximately 30\u0026deg; [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Our technique was different from the original method because we used the same skin incision but changed the amount of muscle and capsular ligament incisions for each approach. The gluteus maximus (GM) was then bluntly separated to expose the short external rotator muscles. After separating the GM, a femoral array was attached to the greater trochanter. The incision sites for the short rotator muscles and the posterior capsule were modified using each approach (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn the PL approach, the incision was initiated from the proximal aspect of the piriformis muscle (PI). The PI, conjoined tendon (CT), quadriceps femoris (QF), external obturator muscle, and ischiofemoral ligament (IFL) were resected collectively in an \u0026ldquo;L\u0026rdquo; shape at the greater trochanter attachment site and inverted. After resection of the muscles and ligaments, the hip joint was dislocated backwards. In the P-PL approach, the incision was initiated from the proximal aspect of the CT, while preserving the PI. the CT, the QF), external obturator muscle, and part of the IFL were resected collectively in an \u0026ldquo;L\u0026rdquo; shape at the greater trochanter attachment site and inverted. After resection of the muscles and ligaments, the hip joint was dislocated backwards. In the CPP approach, the QF and external obturator muscles were first resected from the femur, and the IFL was identified beneath the muscle layer. The joint capsule was then incised along the caudal margin of the inferior gemellus muscle distal to the IFL. After the joint was dislocated, the hip was inferiorly dislocated at 90\u0026deg; of hip flexion, maximal abduction, and maximal internal rotation (Flynn's reduction maneuver). The surgical technique after hip dislocation was identical for all approaches. Soft tissues in the acetabulum were removed and the acetabular bone was reamed. Implantation was performed using the Mako system, according to the preoperative plan. The femur was manipulated using the same procedure for all approaches, and the THA stems were inserted as planned. All patients received the same cementless cup (Trident II acetabular system, Stryker Inc., Mahwah, NJ, USA) and cementless femoral stem (Accolade II, Stryker Inc., Mahwah, NJ, USA). After implantation, the short external rotator muscles and posterior capsular ligament were repaired at the femoral limbus and the capsule was sutured laterally.\u003c/p\u003e \u003cp\u003ePostoperatively, the patient underwent gait training without weight restriction, or strength and range of motion (ROM) training within the limits of pain tolerance. Postoperative gait rehabilitation started with walking with two canes and was gradually changed to walking with a single cane and walking without a cane. The following two criteria were used for the change in walking style: (1) the patient has the endurance to walk 50 meters continuously with or without a walking aid, and (2) the limping does not worsen during walking over 50 meters. In all patients, the two criteria were evaluated by physical therapists specializing in rehabilitation of the hip region. The patients were discharged from the hospital when they could walk independently with or without a cane.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAssessment parameters\u003c/h2\u003e \u003cp\u003ePatients with leg extension within 11 mm, which was the maximum leg extension for THA with the CPP approach during preoperative planning, were selected from each approach in this study. All eligible patients were assessed using the modified Harris Hip Score (mHHS) and Japanese Orthopaedic Association (JOA) hip score preoperatively and at the 3-month and 6-month postoperative outpatient visits [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The JOA hip score consists of four subcategories: Pain, ROM, ability to walk, and activities of daily life (ADL) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The higher the score, the better the clinical outcome (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePatients without preoperative or postoperative mHHS or JOA hip scores were excluded from the study. Finally, 32 patients who underwent THA using the PL approach, 34 using the P-PL approach, and 25 using the CPP approach were included in the study. The following data were collected: age at surgery, sex, height, weight, number of causative diseases, operative time, intraoperative blood loss, number of one- or two-stage bilateral THAs, frequency of complications, number of days to independent walking with two canes after surgery (T1), number of days to independent walking with a single cane after surgery (T2), mHHS, and JOA hip score. The mean values of the mHHS and JOA hip score were compared between the three groups at each evaluated period. In addition, the inter- and intra-examiner errors of the two physical therapists were evaluated for the presence of limping during postoperative gait.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using Steel-Dwass's multiple comparison test for items other than sex, number of causative diseases, number of one- or two-stage bilateral THAs, and frequency of complications. The remaining parameters of the demographic data were analyzed using the chi-square test. All statistical analyses were performed using the JMP version 14.0 (SAS Institute, Cary, NC, USA). Statistical significance was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eReliability of the limping after THA\u003c/h2\u003e \u003cp\u003eTo assess the intra- and inter-measurer (measurers A and B) reliability of limping after THA, we randomly selected 40 patients who had undergone gait analysis after THA were selected. Video data of their gait posture taken 1\u0026ndash;3 months postoperatively were used to assess limping (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). One physical therapist (Y) evaluated the presence of limping twice within an interval of two weeks. Intra- and inter-class correlation coefficients ((ICCs; 1.1 and 2.1, respectively) were determined.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDemographic data of the study participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. There was a significant difference in the sex distribution (p\u0026thinsp;=\u0026thinsp;0.011), and the mean operation time for the P-PL approach was shorter than that for the other approaches (the PL approach, p\u0026thinsp;=\u0026thinsp;0.010; the CPP approach, p\u0026thinsp;=\u0026thinsp;0.005). However, the remaining parameters in the demographic data were not significantly different between the three approaches. Intraoperative and postoperative complications were observed in the PL and P-PL approaches: loosening of the femoral arrays in the PL approach and postoperative dislocation and trochanteric fracture in the P-PL approach.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic data of study patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePL approach (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-PL approach (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCPP approach (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex \u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale: 7; Female: 25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale: 5; Female: 29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale: 0; Female: 25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age, years (SD; range) \u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.4 (13.3; 59.6\u0026ndash;69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.9 (7.8; 66.1\u0026ndash;71.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64.2 (9.8; 60.2\u0026ndash;68.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.947 \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.168 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.283 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean height, cm (SD; range) \u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e158.1 (8.8; 154.9\u0026ndash;161.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e155.6 (8.2; 152.7\u0026ndash;158.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e156.1 (5.5; 153.8\u0026ndash;158.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.744 \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.913 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.532 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean weight, kg (SD; range) \u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58.1 (9.0; 54.8\u0026ndash;61.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.4 (11.1; 52.5\u0026ndash;60.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54.2 (6.9; 51.3\u0026ndash;57.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.213 \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.959 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.605 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCausative disease \u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOA: 30; ONFH: 2; RDC: 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOA: 33; ONFH: 0; RDC: 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOA: 25; ONFH: 0; RDC: 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.184\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral THA at one- or two-stage \u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.362\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean operation time, min (SD; range) \u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87.3 (22.6; 79.8\u0026ndash;96.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.5 (16.7; 72.7\u0026ndash;84.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90.3 (15.5; 83.9\u0026ndash;96.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.594 \u003csup\u003e\u0026dagger;\u003c/sup\u003e, \u003cb\u003e0.005\u003c/b\u003e \u003csup\u003e\u003cb\u003e\u0026dagger;\u0026dagger;\u003c/b\u003e\u003c/sup\u003e, \u003cb\u003e0.010\u003c/b\u003e \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean intraoperative blood loss, cc \u003c/p\u003e \u003cp\u003e(SD; range) \u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e396.1 (244.1; 308.1\u0026ndash;484.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e318.6 (196.1; 250.2\u0026ndash;387.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e336.4 (94.7; 297.3\u0026ndash;375.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.213 \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.959 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.605 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe frequency of complications \u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.414\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e$\u003c/sup\u003e Steel-Dwass's multiple comparison test, \u003csup\u003e#\u003c/sup\u003e chi-squared test, \u003csup\u003e\u0026dagger;\u003c/sup\u003e CPP vs PL, \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e CPP vs P-PL, \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e PL vs P-PL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eBoldface numbers indicate significant differences.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003ePL, posterolateral; P-PL, piriformis muscle-sparing posterolateral; CPP, conjoined tendon-preserving posterior; THA, total hip arthroplasty; OA, osteoarthritis; ONFH, osteonecrosis of the femoral head; RDC, rapidly destructive coxarthropathy.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe number of days of independent walking is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. In each period of walking independence, the CPP approach was significantly shorter than the others (T1: vs the PL approach of p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and vs the P-PL approach of p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; T2: vs the PL approach of p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and vs the P-PL approach of p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePreoperatively, there were no significant differences in mHHS and JOA hip scores (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Three months postoperatively, clinical outcomes other than ROM of the JOA hip score were better with the CPP approach than with the other two approaches. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Six months postoperatively, there was a significant difference in the total mHHS and JOA hip scores (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). In terms of the functional parameters of the mHHS, ability to walk, and ADL of the JOA hip score, the CPP approach also showed better results than the other two approaches. On the other hand, for pain, there were no significant differences in the three approaches for both clinical outcomes. Regarding the reliability of limping after THA, intra- and inter-measurer reliabilities were good (ICC\u0026thinsp;\u0026ge;\u0026thinsp;0.750939), irrespective of the groups analyzed (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative mHHS and JOA hip score as baseline data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePL approach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-PL approach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCPP approach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emHHS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.2 (10.8; 13.3\u0026ndash;21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.8 (9.9; 10.4\u0026ndash;17.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.4 (12.0; 7.4\u0026ndash;17.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.187 \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.761 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.299 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunction: Gait, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.1 (6.0; 20.0\u0026ndash;24.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.9 (6.5; 17.6\u0026ndash;22.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.6 (5.7; 21.3\u0026ndash;26.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.547 \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.006 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.372 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunctional activities, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.3 (2.4; 8.4\u0026ndash;10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.4 (1.3; 9.0\u0026ndash;9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.0 (1.7; 8.2\u0026ndash;9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.829 \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.603 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.983 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53.4 (16.0; 47.6\u0026ndash;59.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.4 (14.6; 42.3\u0026ndash;52.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.5 (16.6; 42.6\u0026ndash;56.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.670 \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.804 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.351 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJOA hip score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.2 (9.8; 0.0\u0026ndash;35.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.7 (9.5; 0.0\u0026ndash;35.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.8 (10.7; 0.0\u0026ndash;35.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.126 \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.732 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.223 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eROM, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.6 (3.6; 5.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.4 (5.0; 3.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.8 (3.2; 8.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.432 \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.927 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.377 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbility to walk, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.7 (4.8; 1.0\u0026ndash;18.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.6 (4.7; 5.0\u0026ndash;18.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.3 (4.3; 5.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.470 \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.390 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.999 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eADL, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.1 (3.1; 6.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.7 (2.6; 8.0\u0026ndash;16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.3 (2.8; 6.0\u0026ndash;16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.095 \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.172 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.842 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.6 (14.5; 30.0\u0026ndash;81.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.4 (15.4; 21.0\u0026ndash;83.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.1 (15.6; 24.0\u0026ndash;82.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.634 \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.949 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.801 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eSteel-Dwass's multiple comparison test, \u003csup\u003e\u0026dagger;\u003c/sup\u003e CPP vs PL, \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e CPP vs P-PL, \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e PL vs P-PL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eBoldface numbers indicate significant differences.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003ePL, posterolateral; P-PL, piriformis muscle-sparing posterolateral; CPP, conjoined tendon-preserving posterior; mHHS: modified Harris Hip Score; JOA: Japanese Orthopaedic Association; ROM, range of motion; ADL, activities of daily life\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003emHHS and JOA hip score in the 3-month postoperative period\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePL approach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-PL approach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCPP approach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emHHS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.8 (5.3; 39.8\u0026ndash;43.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.8 (5.2; 39.9\u0026ndash;43.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.0 (0.0; 44.0\u0026ndash;44.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.022\u003c/b\u003e \u003csup\u003e\u0026dagger;\u003c/sup\u003e, \u003cb\u003e0.016\u003c/b\u003e \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.994 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunction: Gait, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.8 (6.0; 26.7\u0026ndash;31.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.5 (4.3; 29.0\u0026ndash;32.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.9 (0.6; 32.6\u0026ndash;33.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e \u003csup\u003e\u0026dagger;\u003c/sup\u003e, \u003cb\u003e0.006\u003c/b\u003e \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.514 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunctional activities, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.8 (2.4; 11.0\u0026ndash;12.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.8 (2.5; 9.9\u0026ndash;11.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.2 (1.5; 12.6\u0026ndash;13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.037\u003c/b\u003e \u003csup\u003e\u0026dagger;\u003c/sup\u003e, \u003cb\u003e\u0026lt; 0.001\u003c/b\u003e \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.198 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90.6 (11.8; 86.4\u0026ndash;94.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.4 (11.4; 87.4\u0026ndash;95.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e99.1 (2.1; 98.2\u0026ndash;99.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e \u003csup\u003e\u0026dagger;\u003c/sup\u003e, \u003cb\u003e\u0026lt; 0.001\u003c/b\u003e \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.605 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJOA hip score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.8 (4.6; 20.0\u0026ndash;40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.9 (4.3; 20.0\u0026ndash;40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.0 (0.0; 40.0\u0026ndash;40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.022\u003c/b\u003e \u003csup\u003e\u0026dagger;\u003c/sup\u003e, \u003cb\u003e0.016\u003c/b\u003e \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.999 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eROM, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.9 (2.3; 9.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.8 (3.0; 8.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.8 (1.8; 15.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.101 \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.261 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.776 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbility to walk, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.8 (4.2; 5.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.0 (4.1; 10.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.7 (1.1; 15.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e \u003csup\u003e\u0026dagger;\u003c/sup\u003e, \u003cb\u003e0.009\u003c/b\u003e \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.369 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eADL, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.9 (2.4; 12.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.0 (2.7; 8.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.4 (1.2; 16.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.017\u003c/b\u003e \u003csup\u003e\u0026dagger;\u003c/sup\u003e, \u003cb\u003e\u0026lt; 0.001\u003c/b\u003e \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.359 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89.4 (9.4; 53.0\u0026ndash;100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.0 (13.5; 57.0\u0026ndash;100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.2 (13.7; 91.0\u0026ndash;100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e \u003csup\u003e\u0026dagger;\u003c/sup\u003e, \u003cb\u003e\u0026lt; 0.001\u003c/b\u003e \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.949 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eSteel-Dwass's multiple comparison test, \u003csup\u003e\u0026dagger;\u003c/sup\u003e CPP vs PL, \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e CPP vs P-PL, \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e PL vs P-PL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eBoldface numbers indicate significant differences.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003ePL, posterolateral; P-PL, piriformis muscle-sparing posterolateral; CPP, conjoined tendon-preserving posterior; mHHS: modified Harris Hip Score; JOA: Japanese Orthopaedic Association; ROM, range of motion; ADL, activities of daily life\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003emHHS and JOA hip score in the 6-month postoperative period\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePL approach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-PL approach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCPP approach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emHHS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.1 (5.4; 40.2\u0026ndash;44.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.5 (1.3; 43.1\u0026ndash;44.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.0 (0.0; 44.0\u0026ndash;44.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.105 \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.189 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.836 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunction: Gait, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.5 (4.9; 28.8\u0026ndash;32.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.9 (3.3; 30.7\u0026ndash;33.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.9 (0.6; 32.6\u0026ndash;33.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.181 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.246 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunctional activities, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.7 (2.6; 10.8\u0026ndash;12.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.6 (2.1; 10.9\u0026ndash;12.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.0 (1.4; 12.4\u0026ndash;13.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.227 \u003csup\u003e\u0026dagger;\u003c/sup\u003e, \u003cb\u003e0.037\u003c/b\u003e \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.947 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92.8 (11.3; 88.7\u0026ndash;96.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.8 (6.0; 93.7\u0026ndash;97.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e98.8 (1.8; 98.1\u0026ndash;99.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.027\u003c/b\u003e \u003csup\u003e\u0026dagger;\u003c/sup\u003e, \u003cb\u003e0.024\u003c/b\u003e \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.877 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJOA hip score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.4 (4.3; 20.0\u0026ndash;40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.4 (1.6; 20.0\u0026ndash;40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.0 (0.0; 40.0\u0026ndash;40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.105 \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.189 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.836 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eROM, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.6 (2.0; 13.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.6 (1.9; 13.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.4 (1.3; 15.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.032\u003c/b\u003e \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.096 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.912 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbility to walk, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.6 (4.2; 5.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.8 (3.4; 5.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.9 (0.4; 18.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e \u003csup\u003e\u0026dagger;\u003c/sup\u003e, 0.984 \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, \u003cb\u003e0.047\u003c/b\u003e \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eADL, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.0 (2.4; 10.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.8 (2.6; 8.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.3 (1.5; 16.0\u0026ndash;20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.034\u003c/b\u003e \u003csup\u003e\u0026dagger;\u003c/sup\u003e, \u003cb\u003e0.025\u003c/b\u003e \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.466 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score, mean (SD; range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92.6 (9.6; 56.0\u0026ndash;100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.6 (6.6; 65.0\u0026ndash;100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e98.6 (2.4; 93.0\u0026ndash;100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e \u003csup\u003e\u0026dagger;\u003c/sup\u003e, \u003cb\u003e0.002\u003c/b\u003e \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e, 0.109 \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eSteel-Dwass's multiple comparison test, \u003csup\u003e\u0026dagger;\u003c/sup\u003e CPP vs PL, \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e CPP vs P-PL, \u003csup\u003e\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e PL vs P-PL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eBoldface numbers indicate significant differences.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003ePL, posterolateral; P-PL, piriformis muscle-sparing posterolateral; CPP, conjoined tendon-preserving posterior; mHHS: modified Harris Hip Score; JOA: Japanese Orthopaedic Association; ROM, range of motion; ADL, activities of daily life\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReliability of the limping after THA\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReliability of measurements of the limping after THA (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eICC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntra-measurer ICC (1, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.750939\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.573612 to 0.861032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntra-measurer ICC (2, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.816497\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.677241 to 0.899278\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eAll p-values have significant differences.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eCI, confidence interval; ICC, intra- and inter-class correlation coefficients; THA, total hip arthroplasty.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study aimed to assess the impact of the CPP approach in THA on early postoperative clinical outcomes compared with the PL and P-PL approaches. Our findings indicated that THA with the CPP approach significantly reduced the number of days to independent walking and demonstrated superior early postoperative clinical outcomes compared with the PL and P-PL approaches. Preservation of the CT and IFL in the CPP approach contributes to enhanced joint stability, leading to improved functional recovery in the early postoperative period. Although further prospective studies and long-term follow-up are warranted, our findings suggested that the CPP approach had the potential to optimize outcomes and patient satisfaction in THA.\u003c/p\u003e \u003cp\u003ePrevious studies have reported dislocation rates of 2.3\u0026ndash;6.4% with the PL approach without soft tissue repair, and posterior repair has been used primarily to prevent postoperative dislocation[\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Subsequently, following the widespread use of MIS-THA, which preserves the musculotendons mainly through an anterior approach, the benefits of early functional recovery as well as a reduction in postoperative dislocation have been reported[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Recently, the external rotator preservation (ERP) approach and the supercapsular percutaneously assisted approach in THA (Super PATH), which are posterior MIS-THA approaches, have been reported to provide good clinical outcomes after THA[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. THA with the ERP approach has been reported to obtain better total scores in HHS than the conventional PL approach, with or without posterior repair, at 1 year after THA[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. THA with Super PATH also showed better pain visual analogue scale (VAS) and total scores in HHS than the conventional PL approach at 3 months postoperatively, but no difference was reported between the two approaches at 1 year postoperatively[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In this study, mHHS and JOA hip scores were compared in the CPP, PL, and P-PL approaches, which are posterior MIS-THAs. The results showed that postoperative pain was better with the CPP approach for up to 3 months postoperatively. This may indicate that postoperative pain can be reduced by preserving the posterior tissue, similar to THA with Super PATH. Functional parameters, such as walking ability and ADL, consistently favored the CPP approach up to 6 months postoperatively. Patients who underwent THA with the CPP approach showed improved functional parameters, suggesting a possible advantage in restoring normal hip function and quality of life. In contrast, THA with Super PATH was reported to have comparable HHS to THA with the conventional PL approach at 1 year post-operatively[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Although this study evaluated the results up to 6 months postoperatively, significant differences between the three groups might disappear at one year postoperatively.\u003c/p\u003e \u003cp\u003eThis study also evaluated the early postoperative period with regard to each period of walking independence. The CPP approach was shown to be consistently favored and superior in gaining the ability to walk postoperatively. Previous studies have reported an average postoperative hospital stay of around 1 week, regardless of whether MIS-THA or conventional THA, anterior or posterior approach was used [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. One of the reasons for the longer postoperative hospital stay in this study was that participants needed to live alone without anyone support after discharge. Therefore, they required to be able to walk independently and agreed to long-term hospitalization. Another reason was that the improvement in limping, which took a long time, was considered important for the change in gait style in our institution. The presence or absence of limping was assessed by each physical therapist, but there was a concern that errors in assessment between them might affect the postoperative assessment. In this study, the validity of the assessment method was evaluated by assessing inter- and intra-examiner errors between physical therapists and it showed good results. Therefore, we believe that the comparative results and postoperative hospital stays of this study were objectively validated. Furthermore, we speculated that the CPP approach had a significantly shorter time to independent walking because of the preservation of posterior soft tissue and improved joint stability, which facilitated early mobilization.\u003c/p\u003e \u003cp\u003eThis study had some limitations. First, this was a retrospective study. Second, the relatively small sample size may have affected our results. Notably, the number of patients in each group was lower than that required for power analysis. A larger series is required to ensure that the findings are not limited to the observed population. Third, the follow-up period was short. At 6 months postoperatively, pain and some functional parameters were not significantly different between the CPP approach and other approaches. Therefore, it is possible that clinical outcomes will not differ significantly between THA using the CPP approach and THA using the other approaches more than 1 year postoperatively. The long-term outcomes and potential complications associated with the CPP approach require further investigation to establish its efficacy and safety. Finally, the CPP approach limits indications for patients in whom THA can be performed. Takao et al. found that before the posterior capsule was dissected, the maximum joint laxity was about 11 mm [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. We selected cases indicated for the CPP approach according to the report. Therefore, the existence of bias in this study cannot be ruled out.\u003c/p\u003e \u003cp\u003eThis study demonstrated that THA with the CPP approach significantly reduced the number of days to independent walking and exhibited superior early postoperative clinical outcomes compared with the PL and P-PL approaches. Although further prospective studies and long-term follow-up are warranted, our findings suggest that the CPP approach has the potential to optimize outcomes and patient satisfaction in THA.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe CPP approach in THA significantly reduced the number of days to independent walking and exhibited superior early postoperative clinical outcomes compared to PL and P-PL approaches. Preservation of the conjoined tendon and joint capsular ligaments in the CPP approach contributes to enhanced joint stability, leading to improved functional recovery in the early postoperative period.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eADL, activities of daily life\u003c/p\u003e\n\u003cp\u003eCPP, conjoined tendon-preserving posterior\u003c/p\u003e\n\u003cp\u003eCT, conjoined tendon\u003c/p\u003e\n\u003cp\u003eERP, external rotator preservation\u003c/p\u003e\n\u003cp\u003eGM, gluteus maximus\u003c/p\u003e\n\u003cp\u003eICCs, inter-class correlation coefficients\u003c/p\u003e\n\u003cp\u003eIFL, ischiofemoral ligament\u003c/p\u003e\n\u003cp\u003eJOA, Japanese Orthopaedic Association\u003c/p\u003e\n\u003cp\u003emHHS, modified Harris Hip Score\u003c/p\u003e\n\u003cp\u003eMIS, minimally invasive surgery\u003c/p\u003e\n\u003cp\u003eP-PL, piriformis muscle-sparing posterolateral\u003c/p\u003e\n\u003cp\u003ePI, piriformis muscle\u003c/p\u003e\n\u003cp\u003ePL, posterolateral\u003c/p\u003e\n\u003cp\u003eQF, quadriceps femoris\u003c/p\u003e\n\u003cp\u003eROM, range of motion\u003c/p\u003e\n\u003cp\u003eSuper PATH, supercapsular percutaneously assisted approach in THA\u003c/p\u003e\n\u003cp\u003eTHA, total hip arthroplasty\u003c/p\u003e\n\u003cp\u003eVAS, visual analogue scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures involving human participants were conducted in accordance with the ethical standards of the Institutional Research Committee and the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards (Approval number: khr-2023-012, date: 12/7/2023). All patients signed informed consent before participating in the trial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent was obtained from the individuals used in Figure to publish the information in a manner that protects their personal data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article.\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\u003eNo funding was received for conducting this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eR. Sato: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eH. Sugiyama: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eY. Matsushita: Data curation, Formal analysis, Writing \u0026ndash; review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eT. Yokoyama: Data curation, Formal analysis, Investigation, Writing \u0026ndash; review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eE. Okawa: Data curation, Formal analysis, Investigation, Writing \u0026ndash; review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eH. Tonotsuka: Data curation, Formal analysis, Writing \u0026ndash; review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eT. Hayama: Data curation, Formal analysis, Writing \u0026ndash; review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eM. Saito: Data curation, Formal analysis, Project administration, Supervision, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eR. Sato, MD, PhD, Orthopaedic Surgeon\u003c/p\u003e\n\u003cp\u003eH. Sugiyama, MD, PhD, Orthopaedic Surgeon\u003c/p\u003e\n\u003cp\u003eY. Matsushita, MD, Orthopaedic Surgeon\u003c/p\u003e\n\u003cp\u003eH. Tonotsuka, MD, PhD, Orthopaedic Surgeon\u003c/p\u003e\n\u003cp\u003eDepartment of Orthopaedic Surgery, Kanagawa Rehabilitation Hospital, Kanagawa, 243-0121, Japan; Department of Orthopaedic Surgery, Jikei University School of Medicine, Tokyo, Japan.\u003c/p\u003e\n\u003cp\u003eT. Yokoyama, PT\u003c/p\u003e\n\u003cp\u003eE. Okawa, PT\u003c/p\u003e\n\u003cp\u003eDepartment of Physiotherapy, Kanagawa Rehabilitation Hospital, Kanagawa, 243-0121, Japan.\u003c/p\u003e\n\u003cp\u003eT. Hayama, MD, PhD, Orthopaedic Surgeon\u003c/p\u003e\n\u003cp\u003eM. Saito, MD, PhD, Orthopaedic Surgeon\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDepartment of Orthopaedic Surgery, Jikei University School of Medicine, Tokyo, Japan.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDixon MC, Scott RD, Schai PA, Stamos V. A Simple Capsulorrhaphy in a Posterior Approach for Total Hip Arthroplasty. J Arthroplasty. 2004;19(3):373\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMallory TH, Lombardi AVJ, Fada RA, Herrington SM, Eberle RW. Dislocation after total hip arthroplasty using the anterolateral abductor split approach. Clin Orthop Relat Res. 1999(358):166\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDemos HA, Rorabeck CH, Bourne RB, MacDonald SJ, McCalden RW. Instability in Primary Total Hip Arthroplasty With the Direct Lateral Approach. Clin Orthop Relat Res. 2001;393:168\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePai VS. A comparison of three lateral approaches in primary total hip replacement. Int Orthop. 1997;21(6):393\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRitter MA, Harty LD, Keating ME, Faris PM, Meding JB. A Clinical Comparison of the Anterolateral and Posterolateral Approaches to the Hip. Clin Orthop Relat Res. 2001(385):95\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoolson ST, Rahimtoola ZO. Risk Factors for Dislocation During the First 3 Months After Primary Total Hip Replacement. J Arthroplasty. 1999;14(6):662\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWright JM, Crockett HC, Delgado S, Lyman S, Madsen M, Sculco TP. Mini-incision for total hip arthroplasty: a prospective, controlled investigation with 5-year follow-up evaluation. J Arthroplasty. 2004;19(5):538\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePellicci PM, Bostrom M, Poss R. Posterior Approach to Total Hip Replacement Using Enhanced Posterior Soft Tissue Repair. Clin Orthop Relat Res. 1998(355):224\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuh KT, Park BG, Choi YJ. A Posterior Approach to Primary Total Hip Arthroplasty With Soft Tissue Repair. Clin Orthop Relat Res. 2004(418):162\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhite REJ, Forness TJ, Allman JK, Junick DW. Effect of posterior capsular repair on early dislocation in primary total hip replacement. Clin Orthop Relat Res. 2001(393):163\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTakao M, Otake Y, Fukuda N, Sato Y, Armand M, Sugano N. The Posterior Capsular Ligamentous Complex Contributes to Hip Joint Stability in Distraction. J Arthroplasty. 2018;33(3):919\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwon MS, Kuskowski M, Mulhall KJ, Macaulay W, Brown TE, Saleh KJ. Does surgical approach affect total hip arthroplasty dislocation rates? Clin Orthop Relat Res. 2006;447:34\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePfluger G, Junk-Jantsch S, Scholl V. Minimally invasive total hip replacement via the anterolateral approach in the supine position. Int Orthop. 2007;31(Suppl 1):S7\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBertin KC, Rottinger H. Anterolateral mini-incision hip replacement surgery: a modified Watson-Jones approach. Clin Orthop Relat Res. 2004(429):248\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim YS, Kwon SY, Sun DH, Han SK, Maloney WJ. Modified posterior approach to total hip arthroplasty to enhance joint stability. Clin Orthop Relat Res. 2008;466(2):294\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNam D, Meyer Z, Rames RD, Nunley RM, Barrack RL, Roger DJ. Is the Direct Superior, Iliotibial Band-Sparing Approach Associated With Decreased Pain After Total Hip Arthroplasty? J Arthroplasty. 2017;32(2):453\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakamura S, Matsuda K, Arai N, Wakimoto N, Matsushita T. Mini-incision posterior approach for total hip arthroplasty. Int Orthop. 2004;28(4):214\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOgonda L, Wilson R, Archbold P, Lawlor M, Humphreys P, O'Brien S, Beverland D. A minimal-incision technique in total hip arthroplasty does not improve early postoperative outcomes. A prospective, randomized, controlled trial. J Bone Joint Surg Am. 2022;87(4):701\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu H, Yin L, Li J, Liu S, Tao Q, Xu J. Minimally invasive anterolateral approach versus direct anterior approach total hip arthroplasty in the supine position: a prospective study based on early postoperative outcomes. J Orthop Surg Res. 2022;17(1):230.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang T, Zhou Y, Li X, Gao S, Yang Q. Comparison of postoperative effectiveness of less invasive short external rotator sparing approach versus standard posterior approach for total hip arthroplasty. J Orthop Surg Res. 2021;16(1):46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShen J, Ji W, Shen Y, He S, Lin Y, Ye Z, Wang B. Comparison of the early clinical efficacy of the SuperPath approach versus the modified Hardinge approach in total hip arthroplasty for femoral neck fractures in elderly patients: a randomized controlled trial. J Orthop Surg Res. 2023;18(1):215.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBohm H, Hagemeyer D, Thummerer Y, Kipping R, Stockle U, Scheuerer K. Rehabilitation of gait in patients after total hip arthroplasty: Comparison of the minimal invasive Yale 2-incision technique and the conventional lateral approach. Gait Posture. 2016;44:110\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoosen JH, Kollen BJ, Castelein RM, Kuipers BM, Verheyen CC. Minimally invasive versus classic procedures in total hip arthroplasty: a double-blind randomized controlled trial. Clin Orthop Relat Res. 2011;469(1):200\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakamura T, Yamakawa T, Hori J, Goto H, Nakagawa A, Takatsu T, Naoki O, Saito A, Keisuke H, Mouri K. Conjoined tendon preserving posterior approach in hemiarthroplasty for femoral neck fractures: A prospective multicenter clinical study of 322 patients. J Orthop Surg (Hong Kong). 2021;29(3):23094990211063963.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eByrd JW, Jones KS. Prospective analysis of hip arthroscopy with 2-year follow-up. Arthroscopy. 2000;16(6):578\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuribayashi M, Takahashi KA, Fujioka M, Ueshima K, Inoue S, Kubo T. Reliability and validity of the Japanese Orthopaedic Association hip score. J Orthop Sci. 2010;15(4):452\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXie J, Zhang H, Wang L, Yao X, Pan Z, Jiang Q. Comparison of supercapsular percutaneously assisted approach total hip versus conventional posterior approach for total hip arthroplasty: a prospective, randomized controlled trial. J Orthop Surg Res. 2017;12(1):138.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeng W, Huang Z, Wang H, Wang D, Luo Z, Bai Y, Gao L, Wang G, Zhou Z. Supercapsular percutaneously-assisted total hip (SuperPath) versus posterolateral total hip arthroplasty in bilateral osteonecrosis of the femoral head: a pilot clinical trial. BMC Musculoskelet Disord. 2019;21(1):2.\u003c/span\u003e\u003c/li\u003e\u003c/ol\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":"total hip arthroplasty, minimally invasive surgery, conjoined tendon-preserving posterior approach, clinical outcome","lastPublishedDoi":"10.21203/rs.3.rs-4511404/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4511404/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThis study aimed to assess the impact of the conjoined tendon-preserving posterior (CPP) approach in total hip arthroplasty (THA) in reducing the number of days to independent walking and early postoperative clinical outcomes compared with conventional posterolateral (PL) and piriformis muscle-sparing PL (P-PL) approaches.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eIn total, 91 patients who underwent robotic arm-assisted THA using the PL, P-PL, or CPP approaches were included in this study. Clinical outcomes, including the modified Harris Hip Score (mHHS) and Japanese Orthopaedic Association (JOA) hip score, were evaluated preoperatively and at 3 and 6 months postoperatively. Furthermore, the number of days to independent walking with two canes after surgery (T1) and the number of days to independent walking with a single cane after surgery (T2) were compared among the three approaches.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Following the PL approach, T1 and T2 were 11.1 and 24.6 days, respectively. Following the P-PL approach, T1 and T2 were 9.1 and 24.5 days, respectively. Following the CPP approach, T1 and T2 were 5.3 and 15.6 days, respectively. In each period of walking independence, CPP was significantly shorter than the others (T1, P \u0026lt;0.001 and T2, P \u0026lt;0.001). Clinical outcomes, including walking ability and activities of daily living, consistently favored the CPP approach for up to 6 months postoperatively. Intraoperative complications were observed in the PL and P-PL approaches. The CPP approach showed better results for postoperative pain at 3 months postoperatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The CPP approach in THA significantly reduced the number of days to independent walking and exhibited superior early postoperative clinical outcomes compared to PL and P-PL approaches.\u003c/p\u003e","manuscriptTitle":"Evaluation of the association between the conjoined tendon-preserving posterior approach in total hip arthroplasty and early postoperative functional recovery: a retrospective cross-sectional study.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-12 18:39:33","doi":"10.21203/rs.3.rs-4511404/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":"669cceb8-070f-40e2-87d7-c3cd270c59fc","owner":[],"postedDate":"July 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-17T10:23:08+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-12 18:39:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4511404","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4511404","identity":"rs-4511404","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}