A study out of our institution where we looked at 12 different parameters, prospectively randomized by a single surgeon. The only difference was quicker cessation of gait aids with the direct anterior approach. The mental scores favored posterior approach. And there was no difference in any other parameter at any other time point during this study that was measured.
And in the study that Jose brought up at AAHKS I was able to get a hold of the paper…again if you read the abstract you’d have swooned. A hundred patients randomized DA [direct anterior] or posterior approach, but if you look at the numbers only a three to six-day difference in gait aids and walking distance. They did have better advanced activity at two weeks, but no difference in any parameter beyond two weeks.
And I think part of this is that these are expert surgeons doing these cases.
When you read the literature, you have to take into account expertise bias. That’s a surgeon with a higher competency and a higher volume, has better familiarity and is more likely to have better outcomes.
But is this generalizable to the community where 60% of primary total hips are done by surgeons that do less than 25 a year?
We’ve seen concerns in the literature for community surgeons adopting direct anterior approach with, I would argue, extremely high complication rates.
Other data:
No difference in resource utilization on post-acute care.
No difference in patient-reported outcome measures.
Higher wound and infection complications in the direct anterior approach particularly in the obese patient population.
Early proximal femoral fractures in the total hips with the direct anterior approach.
And I would also argue that I think the femoral side of this approach is a real problem, both with fractures and loosening.
We went back and looked at nearly 7,000 primary total hips. Very low overall revision rate between the two groups—1.5-2%—and these were all patients that had early revisions at less than five years. No difference in the overall revision rate by approach; slightly higher in the direct anterior group. But a dramatically higher rate of femoral failures for aseptic loosening, particularly in the Dorr Type A femurs along with a higher rate of return to the operating room and revisions for other reasons in the anterior approach group.
Remember, total hip replacement was deemed the operation of the century and we should not let short-term objectives compromise our long-term performance.
Let’s be honest about a high risk, no reward operation that essentially serves as a great marketing tool. And not forget the principles of total hip, which are long-term fixation; low wear; and be very careful about allowing a small part of the procedure—the approach—to dictate the whole procedure.
