“Posterior is NOT a four letter word!” says Brad Penenberg. “Why choose an option that’s almost guaranteed to result in a life-altering complication?” john keggi retorts, “the DA (direct anterior approach) is here to stay; it is safe and easy, and has been around for 130 years.”
This week’s Orthopaedic Crossfire® debate is “The Direct Anterior Approach: Here Today, Gone Tomorrow.” For the proposition is Brad L. Penenberg, M.D. of Cedars Sinai Medical Center in Beverly Hills, California; against the proposition is John M. Keggi, M.D. from the Orthopaedics New England in Middlebury, Connecticut. Moderating is Robert T. Trousdale, M.D. from the Mayo Clinic.
Dr. Penenberg: “The direct anterior (DA) approach. Is it the only choice? Is the learning curve worth the price? But what we’re seeing in the hospital, is that maintained?”
“The attraction is accelerated recovery. The idea of unlimited activity immediately postop is another attraction to the concept of a soft tissue sparing approach such as the DA. But you can achieve the same results are possible through a modified posterior approach. This is not a big, open, transgluteal, traditional Moore approach with multiple tendon releases. But posterior is NOT a four letter word!”
“First of all, there is a 2013 study from Christopher T. Martin supporting the accelerated recovery and shortened length of stay with anterior versus posterior approaches. But if you look at it closer it is in comparison to the more extended tendon release approach. It also brings up the possibility of a significant number of lateral femoral cutaneous nerve injuries.”
“The pressure is on in the office as patients come in with articles from the lay press and we are forced to react. One option is to consider the ‘direct posterior’ approach. In 2008 I published some of the aspects of this technique in JBJS; there were no nerve injuries, no ankle fractures, only the rare trochanteric fracture, rare dislocation, no wound problems, no heterotopic ossification, 90% of patients were discharged after two nights, and 90% required no narcotics at discharge. These results have been duplicated by other authors in the last couple of years.”
“The appeal to this approach is the familiar orientation of the patient—lateral decubitus position. The concept that varies now is the gluteal window or transgluteal approach, leaving the iliotibial band (ITB) intact and with a limited short external rotator…release the conjoined tendon only sparing piriformis obturator externus. This affords direct access to the femoral canal, in-line preparation, and in-line implantation. Another option is to use the tip of the greater trochanter as a reference point for insertion of the femoral component.”
“The acetabulum is fully and circumferentially visualized and access can be afforded through two options. One is a portal with an 8mm reamer drive shaft; other authors have described access with offset or 90 degree reamers. One of the great advantages is achieving the same results, but that this approach is readily extensile.”
“It’s also a myth that direct anterior is the only option permitting no postop precautions. Several papers (AAOS, Robertson, 2013; JBJS, Penenberg, 2008; Curr Rev MS Med, Chow, 2011) have found no postop precautions.”
“Also, we’re asked to believe that there’s a finite learning curve with DA. There is an example where the surgeon had done over 100 DA procedures using limited intraoperative fluoroscopy; postop X-rays revealed unsatisfactory results with limited fluoroscopy. Another patient operated on by a surgeon who had done over 300 of these cases came to me after being in a wheelchair for six months with a subsided stem, two large incisions, and a big open reduction and internal fixation (ORIF). And a 2011 study by Jewitt shows us that wound problems continued, even after his 800 cases. So my observation is that the learning curve for the DA is an opportunity to turn routine THA [total hip arthroplasty] into a catastrophe.”
“There is no literature supporting use of the DA with severe hip disease and high BMI [body mass index] patients. Any paper from the 21st century shows similar dislocation rates with both approaches. Also, a significant capital investment is not required with a modified posterior approach.”
“It’s OK not to offer a high risk procedure. And when telling the patient you can reference The New York Times article from February 2010 that discusses alternatives to the DA. Why choose an option that’s almost guaranteed to result in a life-altering complication?”
Dr. Keggi: “The DA is here to stay; it is safe, easy, and I have always done it that way. The anterior approach has been around for 130 years and it’s been around for 42 years in the modern arthroplasty era.”
“Briefly, it’s an anterior incision; the skin is folded down. Once you’re down on the hip you can excise or incise the capsule; the osteotomy is performed in situ. You take out a napkin ring of bone, remove the head and you have a great view of the acetabulum…better than with any other approach.”
“The releases that Dr. Penenberg mentioned always involve the posterior capsule and sometimes involve the conjoined tendon of the obturator internis. The anterior approach has increasing use. At least 25% of surgeons who perform more than 50 hip replacements a year use the DA some of the time; at least 20% use it routinely.”
“The DA gives you good visibility at all times, the sciatic nerve is well out of your way, as is the femoral bundle. It has a documented lower risk of DVT; anesthesia likes it and likes you for it, and you have good X-ray access.”
“We published our results in the early 2000s on all patients (2, 132) from 80 to 400lbs. The dislocation rate was 0.1%; fractures requiring fixation were 1%; DVT and PEs were 0.8%. And you don’t need any special tools like an expensive table or special OR bed. If you bounce rooms and use two rooms the table is much more expensive. No special instruments or positioning are required; the latter is easy and quick in the OR. The setup is simply a gel bump underneath the SI joint on the affected side; no peg board is necessary. And because the patient is supine you always know where the pelvis is.”
“Despite what my colleague said the anterior approach is definitely extensile. We’ve shown that in our JBJS revision paper; even if you have a complication intraoperatively with your anterior primary you can always extend. There is nothing you can’t do through the anterior approach, and there’s nothing you can’t do safely through the anterior approach.”
“It does have proven functional benefits…in physical parameters (Nakata, Journal of Arthroplasty, 2009). Restrepo’s study from 2010 in the Journal of Arthroplasty showed improved SF-36 and WOMAC scores. It’s more reliable for placing your cup (Nakata, Journal of Arthroplasty, 2009), and there are lower CPK (creatine phosphokinase) levels as a marker of muscle damage (Bergin, 2011 JBJS). And Bremer’s 2011 work in JBJS found that there was less soft tissue damage on an MRI at one year postop compared to other approaches. Oldenrijk’s 2010 study in Acta Orthopaedica found that the gluteal damage was the least with the DA approach.”
“The DA has the lowest dislocation rate, in part because it relieves the anterior capsular contracture; and you maintain the posterior sling of soft tissue. My colleague has become very skilled at the transgluteal posterior approach. It does spare the iliotibial band and releases the conjoined tendon only versus a more extensive external rotation release; and it is gluteal sparing. But these are core features of the DA approach and have been for the last 40 years!”
“His approach, the percutaneous assisted total hip, is cool…but I would argue that it is a posterior hip with an anterior technique. The direct anterior approach is here to stay.”
Moderator Trousdale: “Brad, why don’t you address his issue with safety?”
Dr. Penenberg: “Safety equates with familiarity and a learning curve. If a surgeon starts off in an orientation and soft tissue anatomy that he’s familiar with then he’s more likely to be able to avoid risk and complications. The complications I’ve seen are when surgeons stray from familiar territory; all of a sudden they’re not able to see. So being able to scale down in a stepwise fashion and bale out at any moment is where safety comes in.”
Dr. Keggi: “A lot of focus gets put on the anterior approach, but troch fractures, etc., exist with all approaches. It’s highly surgeon-dependent.”
Moderator Trousdale: “That’s true. So you must look at randomized, prospective trials. If you examine the data you have to almost get down to muscle enzyme measurements to see a difference between a posterior approach and an anterior approach. So let’s take a 40- or 50-year-old surgeon that does 200 hips per year and is good at one approach…are the advantages of the DA strong enough that this surgeon should go through the learning curve of the operation?”
Dr. Penenberg: “Yes. Going forward a lot of people will learn it in residency and it will be one of their familiar approaches. But for the 40-year-old surgeon who is entertaining a change I would say that of those who have changed very few change back.”
Moderator Trousdale: “Is there anyone you wouldn’t do the DA on? Brad?”
Dr. Penenberg: “There’s no concern. I think we can start with a restricted approach posteriorly/transgluteally, and if it’s a deep protrusio just cut the neck in situ and we can still retain the IT band. With obese patients it’s a longer incision, but the angular access is identical. Those patients can have the same postoperative success so I think it is immediately extensile if necessary, but it still allows the same access and results regardless of the disease severity or BMI.”
Moderator Trousdale: “John, do you do the DA on a 400lb patient?”
Dr. Keggi: “We do. We do it on everyone. We do our revisions and resurfacings that way. If you’re starting the anterior approach the easiest patients are tall patients, and females that have a relative laxity in anteversion. The most difficult patients are short, compact males with retroversion.”
Moderator Trousdale: “Are wound complications higher in obese patients?”
Dr. Keggi: “Yes, but they are for every approach.”
Moderator Trousdale: “Radiation issues…what’s your average radiation time?
Dr. Keggi: “Zero. We take postoperative films. When someone is starting out there is definitely a benefit to taking an X-ray during the case or using fluoro. I would just take a plain film to confirm component position. It’s not mandatory to use X-ray; many people are now using X-ray for the posterior approach as well.”
Moderator Trousdale: “Thank you both.”
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