Statement on Surgical Approach

Statement on Surgical Approach

Recent trends have highlighted surgical approach as an important consideration in joint replacement. Most believe the marketing efforts have distorted the importance of approach in the overall success of this procedure. All approaches have risks and trade offs. There is no “free lunch”.

The American Academy of Orthopedic Surgeons (AAOS) does not recognize any incision as superior to another. All of the dozen experts on the Symposium 2018 panel at the Orthopedic Academy agreed there is not enough independent scientific data to recommend one approach over another.

Common perceptions of this marketing trend would suggest that the Direct Anterior Approach (DAA) has “faster recovery” and doesn’t “cut the muscles” and have a lower “dislocation risk”. Essentially all studies would show that DAA and enhanced Posterior Approach(PA) are equivalent by 6 weeks. Some of the studies shows marginally better statistics of recovery for DAA in some parameters in the first 2 weeks by minor percentages. The overwhelming reason why faster recovery takes place has to do with pre operative preparation, setting expectations, perioperative medicines for pain control, and rapid post operative mobilization. There are some studies that show no differences between the two approaches.

The concept “muscle sparing” could be a little misleading. In the Posterior Approach, small muscles are released from the bone, then re-attached to bone using drill holes in a secure fashion. In the DAA, larger muscle groups need greater forces of retraction that also cause some level of muscle injury.

Both types of approaches have risk of dislocation. Historically, the posterior approach has had a greater risk. Current studies on modern Enhanced Posterior Approach with capsular repair has risk percentage equivalent or close to within 1% difference when compared to DAA.

The potential trade offs for the DAA include; longer surgery times, greater blood loss, often larger incisions, higher risk for intra-operative fracture, early stem loosening and significant percentage of thigh nerve irritation.

I would submit that the early enthusiasts of DAA did so for “marketing” reasons. Subsequently others jumped on board to compete with the trend and be able to offer what patients had been cultivated to ask for, not because it had been proven to be a superior approach for success.

The most important factors for successful long term results of hip replacement have nothing to do with approach. The Surgeons expertise, judgement, and skill are the most important factors regardless of the surgical approach used.