Literally the same day Biloine Young, senior writer for Orthopedics This Week, was going under the knife for an anterior hip arthroplasty The Wall Street Journal was publishing a lead story touting the increased popularity of the same procedure.
The Journal’s article (by Lucette Lagnado) described a single patient, a 54-year-old man (Billie Young is about 30 years older), receiving his anterior hip arthroplasty at the Hospital for Joint Diseases, NYU Langone Medical Center (Billie had her surgery at Regions Hospital in St. Paul, Minnesota) and then walking on crutches down the hospital hall by 4pm the same day.
Billie walked the equivalent of a football field the morning after her surgery.
The Wall Street Journal’s patient left the hospital 6pm on the day of the surgery.
Billie left the day after—30 hours after her surgery.
Is Anterior Hip Arthroplasty for Real?
Remember the 2-incision hip?
That was another technically challenging technique which promised same day hip arthroplasty. But those challenges combined with too many re-admissions put the 2-incision back on the shelf.
The traditional hip arthroplasty approach—a posterior approach—gives the surgeon good visualization and reduced error rates. But it subjects the patient to significant muscle, tendon and other tissue trauma—hence the lure of a less invasive approach.
The anterior approach is definitely less invasive. It only requires a 4-inch incision and the surgeon navigates between muscles, not through them.
The surgeon mentioned in The Wall Street Journal story, Dr. Roy Davidovitch, has performed the anterior approach about 100 times.
Billie’s surgeon, Dr. Gavin Pittman, has also performed about 100 anterior hip arthroplasties.
According to The Wall Street Journal, about 26% of U.S. surgeons can perform anterior approach.
After such highly optimistic articles like The Wall Street Journal’s, more and more surgeons will no doubt feel the pressure to learn the anterior approach.
It won’t be a smooth road.
The Issues
When The Wall Street Journal asked Dr. Jay Lieberman, president of American Association of Hip and Knee Surgeons (AAHKS), whether the anterior or the posterior approach was superior, he told them: “we don’t know which is the best approach.”
At the first Brazilian Current Concepts in Joint Repair meeting held in September 2014, Dr. William J. Maloney III, M.D., of Stanford Hospital & Clinics raised the following concerns regarding the anterior approach:
“[With an anterior approach] it’s difficult to visualize the femur, the femoral cutaneous nerve often gets injured, there’s radiation exposure for both patient and surgeon, leg length equalization is difficult if you use the fracture table, and the learning curve is long.”
“Steve Wilson did a study in a community hospital where they introduced the anterior approach; five surgeons compared this approach to the standard length posterior approach. They started the anterior approach mostly for marketing reasons because they were getting pressure from patients to do minimally invasive hip replacement and to reduce their dislocation rates. Four of the five surgeons went and worked with Joel Matta to figure out how to do the operation. They did it Joel’s way; they used fluoroscopy and used a fracture table.”
“This is what happens in a real world community practice…not at a high volume center where people usually do studies. They accomplished their goal, i.e., they grew their volume. One surgeon’s volume increased five times. They increased the percentage of cementless fixation and they started using larger heads—which is primarily the reason for the reduced dislocation and more hard bearings. They used more regional anesthesia and had to use more drains because they were losing more blood, and they allowed the patients to progress quicker. Their surgical time was high. Few studies show that you can do the anterior approach faster than a mini posterior approach.”
“For a standard posterior approach it was about two hours and 164 minutes for the anterior approach. Anesthesia time was longer, the LOS decreased by a day, and patients lost more blood. The high volume surgeon probably did the best in terms of decreasing LOS (4 to 2.2 days).”
“The fracture rate was high: 5% in the first 20 cases and about 3% after that. Some of these fractures were significant in terms of delaying patient rehab and affecting the long term outcome. If you examine major complications, it was 9% with anterior versus 2.6% standard posterior approach.”
“A study from Mark Pagnano at Mayo on two high volume surgeons who are way past the learning curve; same pain protocol and same rehab protocol comparing direct anterior and mini-posterior approaches. They were pretty much the same, with some slight advantages for the posterior approach in some of the categories. But basically there were insignificant differences.”
“The most important thing is getting the parts in right.”
Then in May 2015 Dr. Maloney updated his comments saying:
“The problem that I have with this technology is that it’s played out in the marketing data and not in the scientific data.
A paper done by our faculty and fellows (Woolson, et al., 2008) looked at what happens when you introduce new technology into a community practice. Remember in North America, more than 50% of the hips are done by people who do one or two hip replacements a year.
The study was a cohort study that looked at a standard posterior approach in a group of five surgeons and compared that to an anterior approach. It was consecutive. It used the data from hospital charts. Inpatient data as well as data on readmissions.
We asked the surgeons, ‘Why did you do it?’ The #1 reason was competition from minimally invasive surgeons in the community. Four of the five surgeons in this group visited one of the innovators and none of them had cadaver or lab training.
If you look at their data the use of regional anesthesia went up. The use of drains went up. There was a higher chance of a hematoma. Post-op protocols changed but screws and cups stayed the same. If you look at the hospital results in terms of the surgical time for a standard posterior approach the anterior approach took significantly longer.
Anesthesia time significantly longer.
Length of stay, significantly shorter.
What about the learning curve? The learning curve did improve from the first 52 cases to the second 52 cases. Time went down. Length of stay went down and estimated blood loss went down.
What about the fracture rate? Well, they had a fairly high fracture rate through a standard posterior approach—about 3%. It was about double that in terms of the prevalence during the learning curve with the anterior approach and calcar fractures were pretty low. The greater trochanteric fractures are a problem.
There are some problems—and this is true of every approach, but I think when you change your approach, it’s more likely to happen.”
The Data
Steven Barnett, M.D. of the Hoag Orthopedic Institute in Irvine, California, set out to compile actual anterior hip arthroplasty patient data and he wound up compiling data for 5, 000 patients.
Here is what he found.
“We set out to look at patients from the day of surgery until 90 days postop and examine the safety of this approach. Our retrospective chart review included 5, 000 patients from three centers: The Hoag Orthopedic Institute (along with Dr. Robert Gorab and Dr. Jay Patel), St. John’s Health Center (where we worked with Joel Matta, M.D.), and The Anderson Orthopaedic Clinic (where we worked with William Hamilton, M.D.).”
“We found an overall complication rate of 3.28%, which is equal to if not lower than that of other approaches. If you break that number down, the rate of medical complications was 1.36%; and surgical complication rate was 1.9% (hematomas, infection, deep vein thrombosis/pulmonary embolism, intraoperative fractures, dislocations). The dislocation rate for the entire cohort was 0.23%. These are short term results, so we can’t comment on functional comparisons of patients down the road. We can say, however, that using an anterior approach to hip replacement is safe and has a reasonable complication rate.”
“Our goal now is to continue to track these patients out to five to ten years in order to determine how they are faring functionally. I’m pleased to be able to say to my naturally cautious colleagues, that if they are considering this approach, they can move forward. My own patients who are five years postop are doing as well if not better than those on whom I used a posterior approach. At this point in my career, I do 100% of my total hip patients with an anterior approach.”
Anterior Approach is Popular
Billie is doing well. She’s home, sleeping well, walking around the house, dressing, bathing, cooking, cleaning and writing every day. She’s at the early stages of her rehab and hurts every day, but gets better every day too.
She’s delighted that she chose the anterior approach. It was everything she hoped it would be.
Despite the issues, the anterior approach is clearly a hot topic and rising swiftly in popularity among patients.
But there are issues which every surgeon must attend to if they choose to learn the anterior approach.
Because there are different surgeons, different hospital systems and different patients, there will be, appropriately, different surgical approaches.
In closing, it is worth repeating Dr. Jay Lieberman’s answer when asked by The Wall Street Journal whether the anterior or the posterior approach was superior: “we don’t know which is the best approach.”
In other words, it depends.
