The Hype of Surgical Approach in Total Hip Replacement

The Hype of Surgical Approach in Total Hip Replacement

2012 AAOS

Primary total hip arthroplasty using a direct anterior vs. posterolateral approach; a comparative study.
Author Bhadra et al.

Direct anterior (DA) group had a better postoperative day 2 walking distance and better pain scores. Direct anterior group had complications in 11 patients (27.5%) Thigh lateral femoral cutaneous nerve pain in seven ...

Direct anterior approach is more effective than posterolateral approach for every early functional recovery and pain control but at a higher complication rate.

Prospective randomized multicenter study of a "new" approach to MIS THA; stem subsidence an issue.
Author: Greidanus et al.

... Five sub-specialized hip surgeons at three academic centers participated in the study of a "new" anterolateral minimally invasive (MIS) approach to THR. It was a multicenter prospective randomized trial comparing it to the "standard" limited incision approaches already in use. Cup and stem alignment were satisfactory with no difference between the group but there was a highly significant difference in stem subsidence, with a mean migration of 4.23 mm in the "new" group. Also there were four trochanteric fractures in this group. Furthermore, the risk of painful stem subsidence and fracture was increased. The authors have returned to the standard surgical approaches in use before the trial.

Gait analysis after total hip arthroplasty – minimally invasive anterolateral vs. conventional lateral approach.
Author: Landgraeber et al.

Minimally invasive (MIS) total hip arthroplasty is claimed to be superior to the standard technique because it reduces operative trauma but there is still controversy as to whether minimally invasive total hip arthroplasty enhances the postoperative outcome.

... the mean difference was not significantly better in MIS than the conventional group. Physical examination also revealed no differences between the two groups. Both physical examination and gait analysis showed that the conventional approach and the minimally invasive approach led to equally good operative results

Early complications of total hip arthroplasty using the anterior supine approach on the orthopedic table.
Author: Yi et al.

Anterior supine intermuscular (ASI) total hip arthroplasty performed on a fracture table has been increasingly used for primary total hip arthroplasty (THA); however, a high complication rate, particularly during a surgeon's learning curve, has been reported.

Intraoperative complications included three trochanteric fractures and two calcar fractures, four of which required cable fixation during the original operation. One patient sustained an injury of the lateral femoral cutaneous nerve.

There is a high incidence of complications during the early learning curve of the anterior supine THA using the fracture table in an academic setting.

Posterior Approach.
Author: Dorr

  1. Approach is not important for outcome of THR operation.
    1. Technique of surgeon is more important for soft tissue result.
    2. Component positions and biomechanical reconstruction determine the longevity of the operation and quality of the outcome.
  2. Soft tissue injury is surgeon-dependent, not approach-dependent.
  3. Component positioning.
    1. Dependent on three-dimensional conceptualization of the surgeon.
  4. Posterior approach is superior because;
    *Manual component precision is the same with all techniques.
    *Dislocation (published results) is currently the same with all techniques.
    *Gait analysis shows recovery is the same with all techniques.
    *Pain for the patient is better.
    *Blood loss is less.
    *Fractures are less.
    *Marketing budget is less.

2012 American Academy of Orthopedic Surgeons (AAOS) Meeting – San Francisco; selected excerpts.

-JGM