Mark Pagnano says, “Anterior THA [total hip arthroplasty] results in no difference at two hours, two days, two weeks, two months, or two years…compared to other ways of doing THA.” Jay Parvizi counters, “Future data will show that direct anterior leads to a lower bleeding rate, less postop pain, etc. Direct anterior is here to stay.”
This week’s Orthopaedic Crossfire® debate is “The Direct Anterior Approach: Here Today, Gone Tomorrow.” For the proposition is Mark W. Pagnano, M.D. from Mayo Clinic in Rochester, Minnesota; against the proposition is Javad Parvizi, M.D., F.R.C.S. from the Rothman Institute in Philadelphia, Pennsylvania. Moderating is Daniel J. Berry, M.D. from Mayo Clinic in Minnesota.
Dr. Pagnano: “It’s my contention that the direct anterior total hip replacement (THA) results in no difference at two hours, two days, two weeks, two months, or two years…compared to other ways of doing THA. Recall the introduction of the two incision hip, and the accompanying mainstream media coverage. This generated substantial interest from patients and surgeons, but is noted for a complete lack of scientific, peer-reviewed data during the introductory phase.”
“There were claims that it was a fundamentally different operation, and that no muscle or tendon was damaged. It was accompanied by zealous promotion and a lack of data.”
“What we have subsequently seen is that many of the early claims of minimally invasive hip arthroplasty have been disproved or are still not tested. The most dramatic example is the two incision hip. There are now multiple randomized controlled trials that show no difference in function compared to a contemporary mini posterior approach.”
“It’s certainly possible to do a direct anterior hip in a variety of patients. That’s been demonstrated by multiple orthopedic centers. We must weigh any purported benefits against the price with regard to operative time, equipment and personnel, and complications.”
“Let’s first look at the claim of rapid recovery. For today’s hip replacement there’s no difference based on surgical technique, at two hours, two days, or two weeks…or at two years. There’s likely none at two months.”
“At two hours and two days all patients have excellent pain relief because they’ve gone through a comprehensive protocol. They are all started on a rapid rehabilitation protocol, and can all ambulate with an assistive device. That’s been proven in Jay Parvizi’s study…a randomized trial that showed no difference in analgesic requirements, blood transfusions, length of stay, or discharge to home or rehab. All of our patients get those benefits from the advanced pain management, the rapid rehab protocols, and the patient education initiatives.”
“There’s no difference at two weeks. Contemporary hip replacement patients are all ambulating well with assistive devices; some have gotten rid of those devices. They can climb stairs and do daily activities. That’s true whether it’s a direct anterior, an anterolateral, or a mini posterior.”
“There’s no difference at one or two years. We all assumed that long term differences would be unlikely given the excellent function attained by today’s contemporary THA patients. It’s been demonstrated in Jay Parvizi’s study, a study from Munziger in Zurich, and Nakata from Japan. There was no difference between a mini posterior and a direct anterior at one year in the latter two studies; there was no difference a two years in Jay’s study.”
“And the two-six week interval? Gait analysis from Klausmeir shows us that neither approach—direct anterior nor anterolateral—resulted in faster recovery. Larry Dorr looked at the difference at six weeks and could find no difference. Paul Beaule’s gait analysis found that stair climbing was not better with the direct anterior approach. Is there one study that shows a difference in the two-six week range? Yes. The one from Rothman showed slightly better SF-36 and WOMAC scores with direct anterior at six weeks…and a tiny difference in the time to get rid of a cane (2.4 weeks versus 3.4 weeks).”
“But if you compare that to other contemporary studies the difference is one, two, or three days. Is that clinically important and reproducible? That remains to be determined. Finally, people like to consider direct anterior for better stability. If we combine the data from multiple studies, however, the mean dislocation rate for a direct anterior approach is just under 1%. If we look at contemporary posterior approaches with a capsular repair, again, a mean dislocation rate that’s under 1%.”
“It’s cumbersome, time consuming, expensive, and many times awkward. There are unique complications that can be attributed to this technique, including lateral femoral cutaneous and peroneal nerve injuries. So in conclusion, a direct anterior approach is a success in 2012 for the majority of patients. But the biggest advocates were people who were previously doing direct lateral approaches. It’s relatively uncommon to find a high volume posterior surgeon who is switching.”
Dr. Parvizi: “In life and in medicine you can belong to one of two camps. The status quo camp where you think there is no need for innovation; or the futuristic camp where you strive for a better outcome for patients…and you are an innovator.”
“There is room for innovation in THA in many areas, including surgical approach. We have innovated in surgical approach; remember that total hip replacement used to be done through the greater trochanter osteotomy. A level one study from my institution showed that you could perform the surgery through a direct lateral approach without having to do a trochanteric osteotomy—and these patients did fine.”
“Recently we’ve fallen victim to many innovations that have not advanced our field. There is a learning curve with any of these innovations. But imagine what would have happened if endoscopic vascular surgeons gave up after the first aorta burst when they were trying to do the endovascularized triple A treatment. We would still be flaying open the abdomen in an effort to repair the triple A.”
“I disagree with Dr. Pagnano that you need a fluoroscopy and a special table. At my institution over the past five years we’ve never used a Hana table for any of these direct anterior approaches.”
“I’d also argue that direct anterior is not the two incision technique that Dr. Pagnano articulated…that was over-zealously introduced by some surgeons without proper evaluation. Any of the literature he’s just discussed with the two incision THA does not apply to direct anterior. There’s plenty of evidence—all level one—that shows direct anterior is better than direct lateral.”
“Based on evaluation of every available study direct anterior is as good as direct lateral; in many cases the former is better than the latter. This is particularly true regarding functional results; less postoperative pain, less blood loss. There are many studies showing that direct anterior versus other approaches may have promise. There are two articles in press comparing direct anterior versus posterolateral and found that they both have better outcome with the direct anterior even versus posterolateral.”
“In the future I’m sure the data will show that direct anterior leads to a lower bleeding rate, less post-op pain, shorter length of stay, better functional recovery…and in our hands, a shorter operation time than direct lateral. I think direct anterior is here to stay, and I predict that it will be one of the most popular approaches to THA in the future.”
Moderator Berry: “Mark, a 30-second rebuttal to Jay’s comments?”
Dr. Pagnano: “With the direct anterior we’re no longer in an innovative phase. It’s been around now for at least a half a decade so we no longer have to accept learning curve issues and the like. We can now look at what is the marginal benefit or the marginal cost of that technique versus another. So I’ll give you that perhaps there are some marginal differences at two to six weeks compared to a direct lateral approach; I’m not prepared to give up any differences compared to a contemporary mini posterior approach.”
Dr. Parvizi: “I don’t care about the two months/two years. I think it matters what patients do within the first day, first week, and the first two weeks. So if you were to have a hip replacement the first questions you’d ask would be, ‘When can I get in the car? When am I off narcotics?’ Based on the literature and my experience, there is a much better early functional outcome with direct anterior compared to direct lateral.”
Moderator Berry: “Jay, who is a poor candidate for a direct anterior approach?”
Dr. Parvizi: “Patients with massive abdomens where, for example, the pannus hangs over the wound during the healing process. Another group would be patients with proximal femoral deformities with hardware in place. That is usually placed through a lateral approach so you might as well make a lateral incision in that patient group. Then there are patients with an extremely tough and stiff hip that makes the exposure of the femur difficult.”
Moderator Berry: “Mark, let’s say the functional results are pretty close to the same. Are there some patients in whom you’re so worried about dislocation that it would be nice to preserve the whole posterior capsule?”
Dr. Pagnano: “That’s one of the areas people are focusing on—the dislocation rate. Yet if you go back to the big series that have been published, the dislocation rate is not different. People have been comparing historical posterior approaches where there was a big capsulectomy and no repair of the posterior structures…no one does that today. Everyone does a posterior approach where they repair the posterior capsule.”
Moderator Berry: “Jay, what are the unique complications that can occur with a direct anterior approach?”
Dr. Parvizi: “First is this numbness across the lateral thigh. There have been some strategies to try and minimize it, but it still happens to about 10-15% of patients. It can be a nuisance, but it’s not a major problem. Also, with use of these tables if you’re overzealous with the hook…you put it around the greater trochanter without doing release of the saddle area, you’re likely to fracture the greater trochanter. And if you don’t get a good exposure of the femur you’re likely to get an intraoperative fracture. What I meant by learning curve is if you’ve never done an anterior approach you should be going to cadaver labs and watching surgeons do it, and then implement it in your practice.”
Moderator Berry: “Jay, the direct anterior is probably an approach that requires the surgeon to sneak around the muscles more, so many people will say that it constrains their use of the type of femoral component that they need to use.”
Dr. Parvizi: “Most people say that shorter stems are easier to put through the anterior approach. We’ve never done shorter stems. I don’t think you need to change too many things when you’re bringing the approach in; should be using the stem that you are familiar with.”
Moderator Berry: “Mark, do you agree?”
Dr. Pagnano: “I think it’s fair to say that a straight, double tapered stem is tougher to put in with this type of approach. It’s hard enough to get far enough out into the greater trochanter to get it perfectly down the middle than it would be with some other designs.”
Moderator Berry: “Thank you both.”
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