What about economics? We have shown previously that the anterior exposure is more expensive over a 90-day period.
So, I thought we’d do something interesting. We decided to randomly pick a surgeon from Manhattan and see what his cost was. I can’t actually identify this person, all I can say is he’s an excellent surgeon. He’s passionate about the anterior exposure. And he’s passionate about wearing bow ties. And we’ll abbreviate him with the letters J.R. So, here’s J.R. versus his own group in the same hospital. He was the least expensive surgeon by far at his hospital in 2014 with anyone that had any volume of cases. He was about $3,500 less.
If you look at the superior hips compared to all the hips at our hospital in the same year, they were less expensive $4,100 on average.
If you compare J.R.’s cost with that of the superior hips, he is significantly more expensive with the anterior approach.
If the anterior exposure was a safer operation and patients got better more quickly, it would cost less. It actually costs more.
In summary, I would say based on clinical outcomes, based on complications, based on anatomical studies; based on basic surgery design principles, and based on economic data, the anterior exposure is certainly not the first among equals.
Anterior is not superior.
Moderator Berry: Okay. So, guys the reality is that most surgeons, at least in North America, are making a choice between 3 approaches. One of which is not the superior approach, Steve. It’s either the posterior approach which is used by about 60% of surgeons and anterior lateral which is down to maybe about 10-15%, and direct anterior somewhere around 20-30%.
Jose, you did a nice job and I think pretty honestly of going through the data on the functional results of direct anterior. I think it’s fair to say that there is some very minor advantage for a few days early on. However, if you look at those data, even those seem to be shrinking. In other words, as people do a better job of randomization, the differences between posterior and direct anterior seem to shrink. And we haven’t really ever been able to do a blinded study, so one suspects if you could actually blind the patients the numbers are probably even less since most of them come in with a preconception that direct anterior might be better.
So, as you start to whittle it down, the functional benefit seems to be pretty darned small. Is that a fair statement to say?
Dr. Rodriguez: If I had to have my own hip done, I would much rather have a great posterior surgeon or great superior surgeon, than a bad anterior surgeon, or even a mediocre one. As was said, I do believe that the anterior approach is harder to do. I believe that in my soul. And you have to dedicate time no matter what you do. Even with the superior approach, you have to dedicate time to learn how to do it without hurting people.
Moderator Berry: I think that’s a really good point. Steve, will you concede that most posteriorly based approaches—I know you may not consider your superior approach posteriorly based—have a little bit higher risk of posterior dislocation than anteriorly based approaches? Fair to say?
Dr. Murphy: I would say if you release a lot on the back, you will create potential instability at a higher rate.
Moderator Berry: Do you feel, and I think all the data show, generally speaking, if you do a posterior approach there is a little higher risk of dislocation. That’s the reality. People accept that because of the other potential benefits of it. But if we accept that there is a little higher risk of instability, are there some patients who might just be the candidates where you say, “This is the patient I should send to my colleague who does an anteriorly based approach.” So, they have no disruption of posterior tissues and that whole posterior soft tissue sleeve is kept intact.
Dr. Murphy: I think when you look at the evidence, there’s more release in the back with an anterior exposure than there is with a careful posterior exposure a lot of the time.
I don’t think that an anterior exposure is more preserving of the posterior structures than a posterior exposure is, but many people are evolving their posterior exposure to be more like a superior exposure to be more short rotator preserving; excising the head instead of dislocating; being more meticulous about repairing the hip joint capsule, and so I think the posterior exposure of today, for many people, is a much, much technically superior operation to what it was 20 years ago. And, of course, with more emphasis on component positioning, preoperative planning and larger bearing sizes, certainly dislocation has become much, much less common than it was. I’m not sure if it’s really any more common now than it is through the front.
Moderator Berry: Ladies and gentlemen, please join me in thanking the panelists for an honest and very valuable discussion.
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