Evaluation of the relationship between muscle-tendon preservation and gait analysis in total hip arthroplasty

Ryuichi Sato; Hajime Sugiyama; Yohei Matsushita; Tatsuya Kanno; Yasunori Kashihara; Hisahiro Tonotsuka; Tetsuo Hayama; Mitsuru Saito

doi:10.1016/j.jor.2025.05.029

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doi:

10.1016/j.jor.2025.05.029

Evaluation of the relationship between muscle-tendon preservation and gait analysis in total hip arthroplasty

Ryuichi Sato^a,c,, Hajime Sugiyama^a,c, Yohei Matsushita^a,c, Tatsuya Kanno^b, Yasunori Kashihara^b, Hisahiro Tonotsuka^a,c, Tetsuo Hayama^c, Mitsuru Saito^c

a Department of Orthopaedic Surgery, Kanagawa Rehabilitation Hospital, Kanagawa, 243-0121, Japan

b Department of Rehabilitation Engineering, Kanagawa Rehabilitation Hospital, Kanagawa, 243-0121, Japan

c Department of Orthopaedic Surgery, Jikei University School of Medicine, Tokyo, 105-8461, Japan

⁎Corresponding author: Ryuichi Sato. korisato5151@yahoo.co.jp

Received: 2025-5-7, Accepted: 2025-5-18, Published: 2025-5-21

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

For total hip arthroplasty (THA), minimally invasive surgery (MIS) has been reported to enhance early functional recovery. The conjoined tendon-preserving posterior (CPP) approach is a posterior MIS-THA technique designed to minimise muscle-tendon dissection while preserving the piriformis muscle, conjoined tendon, and the joint capsule covered by the conjoined tendon. This approach is expected to facilitate early postoperative functional recovery; however, clinical outcomes remain unreported. This study aimed to evaluate the impact of muscle preservation on walking ability by comparing THA performed using the CPP and posterolateral (PL) approaches through gait analysis and patient-reported outcome measures (PROMs).

Seventy-two patients who underwent THA with preoperative and postoperative gait analyses were included. To minimise physical bias, sex, age, height, and weight were matched between groups using propensity score matching, resulting in 14 participants per approach. Walking velocity, cadence, step length, and hip motion angle were assessed preoperatively, as well as at 3, 6, and 12 months postoperatively. Additionally, PROMs were evaluated using the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) at each time point.

At 3 months postoperatively, the CPP group exhibited significantly higher walking velocity (CPP: 120.4 ± 17.1 cm/s; PL: 103.2 ± 22.5 cm/s, p = 0.041) and cadence (CPP: 118.0 ± 6.1 steps/min; PL: 110.3 ± 9.4 steps/min, p = 0.012) compared to the PL group. However, no significant differences were observed after 6 months. Among the JHEQ scores, only the ‘movement’ domain was significantly higher in the CPP group at 3 months, mirroring the gait analysis results, with no significant differences thereafter.

Compared to the PL approach, the CPP approach enhanced walking velocity, cadence, and movement-related PROMs during the early postoperative period of up to 3 months.

Keywords

Total hip arthroplasty

Gait analysis

Muscle-tendon preservation

Conjoined tendon-preserving posterior approach

Postoperative recovery

Patient-reported outcome measures (PROMs)

THA

CPP

PL

PROM

OA

ROM

MIS

PI

CT

JHEQ

AL

1 Introduction

Osteoarthritis (OA) of the hip is characterised by pain, restricted joint mobility, and altered gait patterns, including reduced walking velocity, step length, hip range of motion (ROM), and limping during walking.^1–3 Total hip arthroplasty (THA), the most common reconstructive hip surgery, is effective in relieving pain, improving walking ability, and providing favourable long-term outcomes.^4–6 Gait analysis is a key tool for evaluating postoperative gait function, with studies demonstrating improvements in walking velocity, step length, and hip ROM following THA compared to preoperative levels.³^,⁵^,⁷

Since the early 2000s, minimally invasive surgery (MIS)-THA has gained widespread adoption due to its reported benefits in early functional recovery.^8–11 However, gait analysis studies have shown no significant differences in walking velocity at 6 weeks and 3 months postoperatively when comparing MIS-THA and conventional THA performed via the anterior approach.¹² Similarly, no significant gait improvements were observed at 6 months when comparing MIS-THA with an anterior approach to conventional posterior THA.¹³ These findings suggest that MIS-THA via the anterior approach may not provide superior gait outcomes compared to conventional techniques.

The conjoined tendon-preserving posterior (CPP) approach is a posterior MIS-THA technique designed to minimise muscle-tendon dissection by preserving the piriformis muscle (PI), conjoined tendon (CT), and the joint capsule covered by the CT.¹⁴ Introduced in 2021, this approach has been reported to reduce postoperative dislocation rates following femoral hemiarthroplasty.¹⁴ THA using the CPP approach is expected to promote early postoperative functional recovery; however, clinical outcomes remain unreported.

We hypothesised that reduced muscle-tendon dissection would accelerate postoperative gait recovery and improve patient satisfaction compared to THA performed via the conventional posterolateral (PL) approach. Therefore, this study aimed to assess the impact of muscle-tendon preservation on walking ability and patient-reported outcome measures (PROMs) by comparing THA performed using the CPP and PL approaches through gait analysis.

2 Patients and methods

2.1

2.1 Patients

This retrospective cross-sectional study was conducted at a single institution, in accordance with the ethical standards of the Institutional Research Committee and the 1964 Declaration of Helsinki and its subsequent amendments. Ethical approval was obtained from the relevant institutional ethics committee. Patients who underwent robotic-arm-assisted THA between January 2021 and December 2023 were included. All procedures were performed with the patient in the lateral recumbent position, and hip OA was the primary diagnosis. All patients underwent primary THA and preoperative computed tomography for surgical planning and navigation after providing informed consent.

2.2

2.2 Surgical procedure of THA and postoperative rehabilitation

THA was performed in the lateral position using the Mako system (Stryker, Kalamazoo, MI, US) by a single surgeon with experience in over 200 TH A procedures. A 10-cm curvilinear incision was made midway between the apex of the greater trochanter and the apex of the innominate tubercle. The gluteus maximus was bluntly separated to expose the short external rotator muscles. The incision sites for the short rotator muscles and posterior capsule varied depending on the surgical approach.

In the PL approach, the incision began at the proximal PI. The PI, CT, quadriceps femoris, external obturator muscle, and ischiofemoral ligament were collectively resected in an ‘L’ shape at the greater trochanter attachment and inverted. The hip joint was then dislocated posteriorly. In the CPP approach, the original method, which Nakamura et al. have previously reported, was followed.¹⁴ 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 is incised along the caudal margin of the inferior gemellus muscle, distal to the IFL. The hip was inferiorly dislocated in 90° hip flexion, maximal abduction, and maximal internal rotation positions. After hip dislocation, the subsequent surgical steps were identical for both approaches.

Implantation was performed using the Mako system in accordance with the preoperative plan. After implantation, the short external rotator muscles and posterior capsule ligament were repaired at the femoral limbus, and the capsule was sutured laterally.

Postoperatively, patients underwent gait training without weight-bearing restrictions, along with strength and ROM exercises within pain tolerance. Patients were discharged once they could walk independently without a cane.

2.3

2.3 Gait analysis

Preoperative and postoperative walking abilities were assessed using gait analysis. A single surgeon explained the procedure to patients during their preoperative outpatient visit. Only those who provided informed consented were included. Gait analysis was performed preoperatively, as well as at 3, 6, and 12 months postoperatively.

An eight-camera motion capture system (Vicon Motion Systems Ltd., Oxford, UK) was used.¹⁵ The Vicon Plug-In-Gait model was applied for marker placement. Markers were positioned according to the Plug-In-Gait Lower Body model. Each shoulder had one marker, with an additional marker on the back. Ten markers per side were attached to the pelvis, thighs, lower legs, and feet (Fig. 1). Two experienced examiners placed reflective markers at anatomical landmarks.

Marker placement in the Plug-In-Gait Lower Body model A marker was placed on each shoulder, with an additional marker positioned on the back. Ten markers per side were placed on the pelvis, thighs, lower legs, and feet.

Subsequently, marker positions were calibrated with participants standing on force platforms using eight MX T10 cameras (Vicon Motion Systems Ltd., Oxford, UK). Initial joint positions at the hip, knee, and ankle were registered using Vicon Nexus TM software version 2.11 (Vicon Motion Systems Ltd., Oxford, UK). Participants then walked along a force plate with markers. Walking speed and posture were not prescribed; participants walked comfortably in their shoes. Gait parameters were measured over six or more round trips along a 7-m walking lane (Fig. 2). All participants walked unaided for approximately 10 min before surgery. Data from the eight MX T10 cameras were recorded using Vicon Nexus TM software version 2.11.

Gait recording using an 8-camera motion system Trials were considered valid only if the entire foot contacted each platform, and the process was repeated until at least ten valid trials per leg were obtained. Data from eight cameras were recorded simultaneously using Vicon Nexus TM 2.11 (Vicon Motion System Ltd., Oxford, UK).

2.4

2.4 Assessment parameters and data analysis

This study included 42 patients treated with the PL approach and 30 with the CPP approach. Exclusion criteria included: (1) patients lacking gait analysis data; (2) patients with previous hip osteotomy; (3) patients with hip OA on the nonoperative side. Exclusion criteria were applied, and physical bias was minimised by matching sex, age, height, and weight between groups using propensity score matching. Ultimately, 14 participants per group were selected for analysis. No significant differences in demographic data were observed between the two approaches (Table 1).

Table 1 Demographic data of study participants.

	the PL approach (n = 14)	the CPP approach (n = 14)	p-value
Sex^b	Man: 0; Woman: 14	Man: 0; Woman: 14	NA
Age (years) ^a	67.3 (7.3; 52–79)	66.6 (9.6; 46–78)	1.000
Height (cm) ^a	155.9 (6.4; 147.0–165.2)	156.3 (5.6; 144.8–166.8)	0.909
Weight (kg) ^a	53.7 (5.4; 46.4–63.0)	55.2 (8.3; 40.5–70.5)	0.550
The amount of leg extension due to THA (cm) ^a	4.9 (5.1; −1.0–17.0)	3.3 (2.6; 0.0–8.0)	0.563
Bilateral THA at one- or two-stage^b	3	3	NA

a Wilcoxon's signed-rank test.

b Chi-squared test"There were no significant differences."

In addition to age and body size, leg extension due to THA and the number of bilateral THAs (one- or two-stage) were evaluated. Gait analysis parameters assessed during free walking included walking velocity (cm/sec), cadence (steps/min), step length (cm) on both sides, and hip ROM (degrees) on both sides. The mean values from ten or more valid trials were analysed. Step length, expressed as a percentage of leg length, was defined as the distance between the anterior superior iliac spine and medial malleolus.¹⁵ Cadence was calculated as the total distance walked per minute divided by the sum of step lengths on both sides.

Patient-reported outcomes were assessed using the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) at each evaluation period.¹⁶ The JHEQ consists of three subscales—pain, movement, and mental state—each scored from 0 to 28, with higher scores indicating better outcomes. Patient dissatisfaction was measured on a visual analogue scale from 0 mm (complete satisfaction) to 100 mm (complete dissatisfaction).

2.5

2.5 Statistical analysis

The Wilcoxon signed-rank test was used for statistical analysis of all variables except sex and the number of bilateral THAs, which were analysed using the chi-squared test. All analyses were conducted using JMP version 14.0 (SAS Institute, Cary, NC, USA). Statistical significance was set at p < 0.05.

3 Results

Gait analysis parameters for the PL and CPP approaches are presented in Table 2. No significant differences were observed in preoperative gait parameters, and all parameters showed improvement over time, from the preoperative period to one year postoperatively.

Table 2 Assessment parameters of gait analysis in the PL and CPP approaches. Each p-value represents a paired comparison of each parameter between the two groups at the preoperative period, as well as at 3, 6, and 12 months postoperatively.

					Step length (cm)				Hip motion angle (degree)
	Walking velocity (cm/sec)	p value	Cadence (steps/min)	p value	on the operative side	p value	on the nonoperative side	p value	on the operative side	p value	on the nonoperative side	p value
preoperative period
the PL approach	85.4 (28.9; 31.0–130.0)	0.067	101.7 (20.2; 64.9–124.4)	0.141	50.0 (10.9; 27.4–68.2)	0.141	48.4 (10.2; 29.9–68.4)	0.060	30.3 (8.8; 14.8–46.9)	0.291	35.7 (7.8; 22.8–47.6)	0.629
the CPP approach	105.0 (24.7; 64.6–137.4)		113.5 (8.1; 93.4–125.8)		55.1 (7.9; 40.5–67.0		55.2 (8.0; 42.5–67.4)		33.6 (5.9; 17.1–40.7)		36.9 (6.4; 21.1–47.6)
3-month postoperative period
the PL approach	103.2 (22.5; 55.2–138.2)	0.041 ^a	110.3 (9.4; 96.0–129.3)	0.012 ^a	55.4 (8.7; 32.5–67.1)	0.060	56.1 (9.1; 31.3–69.9)	0.089	37.6 (5.6; 25.1–44.9)	0.448	40.4 (4.6; 34.0–47.2)	0.312
the CPP approach	120.4 (17.1; 87.3–152.9)		118.0 (6.1; 107.9–128.1)		61.3 (7.8; 45.8–79.0)		60.9 (6.9; 49.3–76.1)		38.8 (5.0; 28.3–45.1)		42.3 (6.3; 28.8–50.0)
6-month postoperative period
the PL approach	113.2 (16.9; 89.0–145.0)	0.130	113.1 (9.9; 98.1–134.1)	0.124	59.4 (5.6; 49.9–67.2)	0.290	60.2 (5.4; 48.9–67.8)	0.383	39.4 (4.9; 27.9–47.2)	0.982	41.5 (3.6; 33.4–47.1)	0.270
the CPP approach	122.4 (16.9; 96.1–158.6)		117.4 (4.0; 109.8–124.4)		62.5 (7.8; 52.5–82.0)		62.4 (7.2; 48.8–77.2)		39.6 (4.7; 29.4–46.7)		42.6 (5.3; 32.7–48.4)
12-month postoperative period
the PL approach	118.4 (17.0; 83.3–150.6)	0.408	114.8 (10.2; 97.1–134.8)	0.142	61.7 (6.3; 48.6–71.5)	0.765	61.8 (4.6; 52.9–69.6)	0.927	41.0 (5.2; 29.6–47.7)	0.395	42.3 (4.1; 31.0–46.8)	0.800
the CPP approach	123.6 (16.8; 94.0–149.4)		119.3 (5.5; 105.2–126.1)		62.0 (7.3; 51.6–78.5)		62.1 (7.2; 49.8–75.9)		40.2 (4.3; 35.1–47.4)		42.8 (5.3; 32.9–51.5)

a Wilcoxon's signed-rank test.

At 3 months postoperatively, walking velocity and cadence were significantly higher in the CPP group than that in the PL group (walking velocity: p = 0.041; cadence: p = 0.012). However, after 6 months postoperatively, no significant differences in walking velocity or cadence were observed. Other gait parameters showed no significant differences at any postoperative evaluation.

JHEQ scores for both approaches are summarised in Table 3. At 3 months postoperatively, the CPP group had higher movement and total scores than the PL group. By 6 months, patient dissatisfaction in the CPP group was lower than that in the PL group.

Table 3 JHEQ scores at each evaluated period for the PL approach and the CPP approach. Each p-value represents a paired comparison of each parameter between the both groups at the preoperative period, as well at 3, 6, and 12 months postoperatively.

	Dissatisfaction, mean (SD; range)	p value	Pain, mean (SD; range)	p value	Movement, mean (SD; range)	p value	Mental, mean (SD; range)	p value	Total score, mean (SD; range)	p value
preoperative period
the PL approach	79.4 (25.0; 5–100)	0.660	6.6 (5.2; 0–18)	0.289	7.1 (5.3; 0–15)	0.661	8.1 (4.9; 0–16)	0.102	21.9 (13.0; 3–43)	0.154
the CPP approach	71.0 (32.0; 15–100)		8.2 (5.0; 0–16)		8.1 (5.3; 0–17)		12.7 (7.1; 2–25)		29.1 (13.7; 2–54)
3-month postoperative period
the PL approach	11.1 (20.6; 0–78)	0.302	22.2 (7.1; 9–28)	0.204	14.5 (7.0; 4–28)	0.022 ^a	19.9 (7.2; 6–28)	0.077	56.6 (17.9; 25–82)	0.022 ^a
the CPP approach	3.7 (6.7; 0–20)		25.9 (2.8; 19–28)		20.4 (6.1; 5–28)		24.6 (4.8; 11–28)		70.9 (9.5; 48–82)
6-month postoperative period
the PL approach	14.1 (18.6; 0–72)	0.009 ^a	23.9 (5.3; 11–28)	0.162	17.2 (6.0; 7–28)	0.259	19.8 (7.0; 7–28)	0.209	60.9 (14.3; 25–84)	0.129
the CPP approach	2.9 (5.0; 0–15)		26.6 (2.6; 19–28)		19.7 (6.0; 8–28)		22.9 (5.5; 11–28)		69.3 (11.7; 47–84)
12-month postoperative period
the PL approach	12.8 (21.5; 0–71)	0.230	25.4 (3.8; 17–28)	0.142	18.1 (6.7; 7–26)	0.196	22.0 (6.8; 9–28)	0.927	65.6 (12.9; 36–82)	0.098
the CPP approach	2.1 (3.5; 0–12)		27.6 (0.8; 25–28)		21.5 (5.7; 11–28)		24.3 (4.7; 11–28)		73.4 (8.2; 61–84)

a Wilcoxon's signed-rank test.

4 Discussions

This study demonstrated that THA using the CPP approach significantly improved walking velocity and cadence compared with the PL approach within 3 months postoperatively; however, these differences diminished by 12 months. The movement subscale of the JHEQ followed a similar trend. These findings suggest that patients with end-stage hip OA and minimal preoperative gait impairment achieve comparable gait function and hip satisfaction after 3 months, regardless of the surgical approach.

With the widespread use of MIS-THA, gait analysis has become increasingly important in assessing postoperative recovery.^12.13 Despite expectations of superior early functional recovery, prior studies found no significant differences in walking ability between MIS-anterolateral (AL) and PL approaches at 6 months postoperatively.¹³ Similarly, no significant differences were observed when comparing MIS-PL and PL approaches.¹² However, this study found significant improvements in walking velocity and cadence at 3 months postoperatively with the CPP approach. Since walking velocity and step length are influenced by factors such as sex, age, and body mass index,^17–19 we minimised potential biases using propensity score matching, allowing for a more accurate assessment of the impact of muscle-tendon and joint capsular ligament preservation on postoperative function.

The significant improvement in walking velocity with the CPP approach at 3 months suggests a potential advantage in early functional recovery. However, differences in walking velocity and cadence between the CPP and PL approaches gradually decreased from 3 to 12 months postoperatively. These findings indicate that the benefits of MIS-THA in gait recovery are limited to the early postoperative phase, reinforcing the clinical viability of the conventional PL approach.

A previous study found no significant differences in hip flexion at heel strike or peak hip flexion at 6 weeks post-THA using the PL approach compared to the AL and direct lateral approaches.⁴ Similarly, no significant differences in step length or hip ROM were observed within 6 months post-THA between the PL and AL approaches.^5.13 In this study, step length and hip ROM improved over time in both the CPP and PL groups, but no significant differences were found at any evaluation period. These findings support previous reports suggesting that soft tissue incision in the posterior approach does not influence postoperative step length or the recovery of hip ROM.

PROMs were assessed alongside gait improvements. Studies have evaluated postoperative satisfaction using PROMs across different THA approaches.¹⁰^,^20–24 In this study, the JHEQ was used to compare the CPP and PL approaches. The JHEQ is particularly relevant in Asian populations and is also applicable to Western populations requiring deep flexion for daily activities.²⁵ Interestingly, the CPP approach showed superiority only in the ‘movement’ score at 3 months postoperatively. A similar trend was observed in walking velocity and cadence, suggesting that the benefits of MIS-THA in the posterior approach are limited to early recovery, with effects diminishing beyond 3 months.

This study has some limitations. First, the small sample size may have influenced the findings, as the number of patients per group was lower than required for a power analysis. A larger sample is needed to confirm whether the findings are generalisable beyond this population. Second, most participants had some preoperative walking ability, which may have influenced recovery. Patients with severe preoperative gait impairment may not achieve the similar outcomes. Finally, missing data affected nearly half of the patients, largely due to the time-consuming nature of gait analysis, leading to participant withdrawal. Missing data were notably more frequent in the PL approach group, reducing the number of cases available for propensity score matching.

5 Conclusion

The CPP approach, which involves reduced muscle-tendon dissection, led to greater improvements in walking velocity, cadence, and the ‘movement’ score in PROMs compared with the conventional PL approach, but only within the first 3 months postoperatively. These findings suggest that in patients with end-stage hip OA and minimal preoperative gait impairment, long-term gait function and hip satisfaction remain comparable between MIS-THA and conventional THA at 12 months postoperatively. A larger sample size, longer follow-up, and inclusion of patients with more severe gait impairment are needed to validate these findings in future studies.

Author 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. Kanno: Data curation, Formal analysis, Investigation, Writing – review & editing. Y. Kashihara: 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.

Ethical approval

Funding

This work was supported by JSPS KAKENHI Grant Number JP 24K19595.

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Introduction

Patients and methods

Patients
Surgical procedure of THA and postoperative rehabilitation
Gait analysis
Assessment parameters and data analysis
Statistical analysis

Results

Discussions

Conclusion

Consent to participate

Author contributions

Ethical approval

Funding

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Evaluation of the relationship between muscle-tendon preservation and gait analysis in total hip arthroplasty

Abstract