“Direct anterior total hip arthroplasty has comparable results with posterior approach. Choice of surgical approach for hip replacement should be based on patient factors, surgeon preference, and exper
——
Tze e. Cheng et al. –A Prospective Randomized Clinical Trial in Total Hip Arthroplasty—Comparing Early Results Between the Direct Anterior Approach and the Posterior Approach. The Journal of Arthroplasty, vol. 32, no. 3, 2017
Which Hip Incision Is Right For You?
Total hip is the most successful of all joint replacements. To most patients, once fully healed the new hip feels “normal” and will have full range of motion and strength. The hip joint has the quickest recovery, and with the advent of new bearing materials it is one of the most durable. The most significant advances in hip replacement surgery since it was introduced have been related to our improved understanding of bearing materials, bone fixation, joint stability and implant design.
Hip replacement can be successfully performed using one of a number of safe surgical approaches. There are four approaches that are still routinely used by orthopedic surgeons all over the world: the posterolateral, the direct lateral, the anterolateral, and the anterior. None of these approaches are remotely new and they have been in use for decades. Each surgical approach has inherent advantages and disadvantages, each carries a specific set of risks and benefits and each approach has a certain degree of technical difficulty. When properly executed and if patient body-type has been properly selected all of these approaches will give you an excellent surgical outcome.
Recently, the surgical approach is being hailed as the primary factor determining the success of this intervention. The direct anterior approach is being widely marketed to patients with claims of less muscle damage, improved stability, less pain, faster recovery, and greater overall superiority when compared to all other surgical approaches. These claims of superiority are not founded in what the peer-reviewed literature has shown. Unfortunately, the public’s perception of this approach has been biased by this intense marketing effort and today patients come to surgeons’ offices with a preconceived notion that anything different from the anterior approach would be a serious compromise in the quality of their surgery and outcomes.
Despite these claims and the positive public perception of the anterior approach, there are no studies that establish long-term clinical benefits. Several studies that have positively viewed the anterior approach have been biased and/or scientifically flawed. Both approaches have benefits and carry certain risks. In fact, in expert and experienced hands there is little difference, if any, between the anterior and the mini-posterior hip approaches with regards to short and medium-term results. Predictably, marketing for the anterior approach exaggerate its purported benefits and most omit to mention its associated risks.
The most unfortunate consequence of all this marketing is that it is unfairly shifting the focus away from the real goal of any joint replacement procedure which is to PROVIDE YOU WITH A STABLE, PAIN-FREE AND DURABLE JOINT. To achieve this goal your surgeon will carefully choose the surgical technique and the implants used based on safety, experience, quality and an excellent track record of implant durability. The choices you make regarding this surgery must focus primarily on safety and excellent LONG-TERM outcomes.
Most of the hype regarding the anterior hip approach stems from surgeons, hospitals and manufacturing companies that advertise and market their skills in a constant effort to gain market share. The ethical implications of this exercise are unclear. What is clear is that there is no solid and convincing scientific evidence that one surgical approach is superior to the other. Hospital stay, postoperative narcotic requirements, speed of rehab, time spent on a walker or cane, time back to sports and work, and other parameters of judging a successful result are similar when the operation is performed by an experienced hip surgeon. Your preoperative medical fitness and pain control techniques used postoperatively will determine how quickly you will be returning home, not the incision.
While a modest, early functional benefit of the direct anterior approach may be real, recent scientific papers point to an increase in fractures, femoral implant loosening, early need for revision surgery, bleeding and wound healing problems with the anterior approach. Furthermore, we do not have long-term data regarding the success of the anterior hip approach and the novel implants created to facilitate it.
Therefore, you need to choose your surgeon based on other factors, such as experience, trust and complication rates. Let your chosen surgeon decide on the technology and surgical technique based on his professional experience. That will guarantee you, the patient, a quick and successful recovery and a durable pain-free hip replacement.
For a side to side comparison of the anterior and mini-posterior surgical approaches click the the button
