Salesmanship and Advertising in Orthopedic Surgery

Salesmanship and Advertising in Orthopedic Surgery

The current trend in Orthopedic Surgery is the promotion and marketing of the “Anterior Approach” in Total Hip Replacement. The enthusiasts of this approach are devoting extended resources in its promotion to the public. It is being sold as “new, advanced, revolutionary, superior, cutting edge, faster rehab, lower dislocation risk...etc. By implication, those surgeons not using it must be old fashioned and behind the times of medical advancement. It is my concern, however, that the public will misconstrue this information as valid, highly scientific, well accepted fact within the circles of orthopedic medicine. This is far from true.

As when many new procedures or implants come to the market, the early favorable literature is typically from the “enthusiasts”, who may have difficulty eliminating the influence of personal bias which is present in all forms of scientific publications. Some early literature does support the benefits of the Anterior Approach. However there are many studies to the contrary, that show no significant difference in outcomes, as well as other complication risks as a tradeoff.( Ref list) The promotion of : a)only the potential advantages, b) the supposed benefit on the ease of actual recovery, and c) the influence on the successful long term outcome , are being highly distorted. I believe this process has been a disservice to the public. Rather than an altruistic informational service, this promotional effort should be seen for what it is: Salesmanship in an effort to gain higher market share of patients.

In my 25 yrs of Orthopedic practice in the field of Joint Replacement, I have seen many “trendy” things come and go in their marketing peaks. We have seen the “Hip Resurfacing”, “Unicompartmental Knee”, “Computer Assisted Surgery”, and “Mini Incision Surgery” among others. Physicians, who are eager to perform their craft seeking to satisfy the demand, may start relaxing the appropriateness of the indications, leading to less than ideal results. Gradually a more realistic perspective of the procedure becomes clear over time. The above mentioned items all have a role as legitimate treatment options when applied under the correct circumstances and explained in an accurate and realistic manner.

No doubt, the “Anterior Approach” is here to stay. In fact, it has been around for many decades. The recent modifications involve smaller incisions, better perioperative pain medicine, and more rapid rehabilitation protocols. By the way, “Lateral” and “Posterior” incisions that have undergone similar updated modifications. It is misleading to compare the “new” Anterior Approach to the “old” data with the other incisions. The Anterior Approach requires extensive stretching of muscles. In the Posterior Approach, small less important muscles are released from the bone and then securely reattached. It is debatable whether extensive stretching to some muscles ( in order to be able to say they were not “cut”) is any less injurious than releasing small less important muscles and reattaching them. In fact the Anterior Approach, actually can decrease access to the bone and affect the selection of implants to be used.

All approaches to the hip have advantages and disadvantages. It is not necessarily a bad thing to have highly motivated enthusiasts advocate their interests and opinions. However, when it comes to medicine, the public may have difficulty separating “advertising” from generally accepted medical facts. I will admit that these are my “opinions” and may have my “bias”, but I ask those on the other side of the argument to admit the same. The qualities and skill of the surgeon are far more important than which surgical approach is used. I urge patients to fully examine all the options available them, seek more than one opinion, and make a choice, but not based on “marketing” as fact.

John G. Mayer M.D.
Libertyville, Illinois

Reference List:

Papers from 2013 American Academy of Orthopedic Surgeons (AAOS)

On Surgical Approach

“Is there faster Recovery after Direct Anterior Approach (DAA) than Posterior Approach Total Hip Arthroplasty?”

Author: Deshmukh M.D. et al

Conclusion: “Functional recovery was faster in patients with DAA on the basis of TUG and M- FIM scores up to 2 wks. No differences were observed between groups at 6 wks, 12 wks, and one year. Complications of DAA included one fracture and 4 pts with groin pain due to psoas tendon impingement. In PA groups, one patient had a dislocation and 2 had groin pain.”

“Similar Improvement in Gait Parameters with Direct Anterior and Posterior Approach Total Hip Arthroplasty”

Author: Orishimo MS and Kremenic M.D. et al

Conclusion: “THA performed via DAA and PA offer similar improvement in gait parameters up to one year follow up with the exception of internal/ external ROM.”

“Which Muscle Sparing Approach is Better- Direct Anterior or Antero-lateral in total hip Arthroplasty?”

Author: Iwaki M.D. et al

“No significant difference with respect to strength up to 3 wks… or in clinical scores.” Conclusion: We found no differences between DAA and MIS-AL approach clinically except for cup anteversion which is more accurate in the DAA group compared to the MIS-AL group.

“Differences in Hip Strength Recovery with Direct Anterior and Posterior Approach Total Hip Arthroplasty”

Author: Rathop M.D. et al

Conclusion: “Both DAA and PA THA offer similar recovery in hip muscle strength up to one year with the exceptions of persistent ER strength deficit in PA group, and flexion strength deficit in the DAA group at 6 wks. This may be related to the release of the external rotators in PA group and hip flexor irritation in the DAA groups.”

Symposium : The Anterior Approach Is the Answer: AGAINST

Author: Haddad, BSc, MCh, FRCS, FFSEM; London

Excerpts:

“The perceived benefits are minimal soft tissue damage, avoidance of the abductors, optimal visualization of the acetabulum, and preservation of the posterior capsule and external rotators. There is however very little evidence that it reduces dislocation.

“Pellici et al described an “enhanced posterior repair” which drastically reduces the number of dislocations following THR through a posterior approach. The authors found their dislocations fell from 4% to 0% in one study of 395 cases, and from 6.2% to 0.8% in 124 cases.”

“This enhanced repair is described by Suh et al. The dislocation rate without repair was 6.4% in 250 primary THR’s, but was maintained at 1% in 96 augmented with the posterior repair.” Clin Orthop Relat Res 2004; 162

Siguier et al reviewed 1037 primary THR’s carried out through a minimally invasive anterior approach and reported a dislocation rate of 0.96% “The anterior approach has a learning curve and is found difficult by many, and hence may sacrifice component orientation and soft tissue balance if undertaken inexpertly.”

A specialized fracture table is often required and intra operative XR fluoroscopy, due to more difficult access to the femur…”fractures may occur” and “must be performed carefully”.

“The anterior approach is considered a difficult procedure to adopt when compared to posterior or trans gluteal exposures.” Spaans et al described their learning curve through their first 46 cases. They found the operative times nearly doubled, increased blood loss and greater complication rates…” Even as they gained experience their results did not improve significantly. Masonis et al demonstrated the use of fluoroscopy and operative time was shown to have a learning curve in the first 100 cases. Lateral Cutaneous Femoral Nerve injury (LFCN) is at risk from the retraction of the tissue required. Patients may complain of “parasthesias” in the lateral thigh or a burning pain or dysesthesia. Bhargava et al found in his series of 81 THR’s,..the incidence of LFCN neuropraxia was 14.8 %.

Conclusion: The disadvantages of the anterior approach are its labor intensiveness, learning curve, a specialized operating table and intra-operative fluoroscopy.“Further analysis is required so that we can understand the risk-benefit ratio of the anterior approach. At present the evidence that this is the answer to the dislocation risk that we run for every THR is lacking. The Anterior Approach should stay in the hands of enthusiasts while we continue to optimize existing approaches to improve patient outcomes.”

Papers from 2012 American Academy of Orthopedic Surgeons (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.

Anterior vs Posterior Approach

Author: Dorr

Approach is not important for outcome of THR operation, Technique of surgeon is more important for soft tissue result. Component positions and biomechanical reconstruction determine the longevity of the operation and quality of the outcome. Soft tissue injury is surgeon-dependent, not approach-dependent. Component positioning is dependent on three-dimensional conceptualization of the surgeon.

  • Manual component precision is the same with all techniques.
  • Dislocation (new published results) is currently the same with all techniques. 
  • Gait analysis shows recovery is the same with all techniques. 
In Posterior Approach:

  • Pain relief for the patient is better. 
  • Blood loss is less. 
  • Fractures are less. 
  • Marketing budget is less.