When it comes to total hip replacements (THR), there is a lot of debate about the relative risks and benefits between two popular surgical techniques – the anterior approach versus the posterior approach. A study presented in March 2016 at the American Academy of Orthopaedic Surgeons’ annual meeting found that as long as a surgeon is accomplished in a given technique (or approach), there is no meaningful difference in outcome for the patient.
“Our data show it may not be the approach that matters, but the surgeon’s experience that makes the real difference… in achieving successful outcomes after hip replacement,” says study co-author John Grady-Benson, MD, an orthopaedic surgeon and medical director of the Center for Outcomes Research at the Connecticut Joint Replacement Institute at St. Francis Hospital and Medical Center, in Hartford, Connecticut.
Proponents of the direct anterior approach – through the front of the hip – claim the initial postoperative recovery time is quicker, resulting in a faster hospital discharge and an earlier transition home.
The posterolateral or posterior approach is the more conventional approach that allows the surgeon to go through the back of the hip, which can allow better visualization of the joint, without disturbing hip abductor muscles.
The researchers say there have been numerous studies comparing the two approaches – looking at outcomes such as adverse events, the length of hospital stay, the need for opioid painkillers or physical therapy – but none has specifically used patient-reported outcomes, until now.
They compared the outcomes of 137 patients who underwent surgery via direct anterior approach (by two surgeons who only perform those surgeries) with 137 patients who underwent posterolateral procedures (by two other surgeons who specialize in that technique).The patients were asked a series of questions about their activities of daily living, pain, symptoms, involvement in sports and recreation, and their quality of life both before their operations and six months after.
Patients in both groups had similar average scores on the questionnaires before surgery. And, regardless of the surgical approach, the average scores of both groups improved equally after surgery in all of the categories measured. Additionally, operative times, length of hospital stay and complication rates were similar.
“Patients are often getting confusing information about this,” says Dr. Grady-Benson. “There’s a lot of Internet and marketing media that states the anterior approach is better. It’s a controversial topic and patients become confused about how to evaluate that. Our study shows if the surgeon uses one approach and is very confident with that, equivalent results with no difference in adverse events can be achieved either way.”
Michael Alexiades, MD, a hip and knee surgeon at Hospital for Special Surgery, in New York City, specializes in the anterior approach. He agrees that patients should go with the approach their surgeon has the most experience with. He says that in his view, while both surgeries produce the same results long term, he believes differences are visible in the first six weeks after surgery – a time period not evaluated in this or other studies.
“The chief goal of any of the approaches is that five, 10 or 15 years down the line, the procedure is still holding up and patients all are doing the same. When we get into arguments of which is better, you are looking at the very short-term results,” Dr. Alexiades explains. “To the patient that wants to get back to normal daily activities, they will seek out surgeons adept at doing the anterior approach. For the retired patient who may not be in a rush to get back to working or driving sooner, it may not make that much of a difference. And with the anterior approach there can be complications in older individuals with osteoporosis such as fractures at time of surgery.”
He also notes that the anterior approach may not be the best option for someone who is obese or has muscular thighs, because extra soft tissue can make it harder for the surgeon to reach the hip joint.
Says Dr. Grady-Benson: “Understand that both approaches can yield excellent and equivalent results as reported by patients six months later. So ask your surgeon his or her preference and then go through a shared decision-making discussion that goes through risks and benefits. And just remember, it’s not the approach itself that is of paramount importance but the surgeon’s experience that makes a real difference.”
Author: Jennifer Davis for the Arthritis Foundation