Dorr v. Taunton: The Mini-Posterior Approach: Evidence Over Eminence

This week’s Orthopaedic Crossfire® debate was part of the 34th Annual Current Concepts in Joint Replacement® (CCJR®), Winter meeting, which took place in Orlando. This week’s topic is “The Mini-Posterior Approach: Evidence Over Eminence.” For is Lawrence D. Dorr, M.D.,Keck Medical Center of USC, Los Angeles, California. Opposing is Michael J. Taunton, M.D., Mayo Clinic, Rochester, Minnesota. Moderating is Robert T. Trousdale, M.D.,Mayo Clinic, Rochester, Minnesota.

Dr. Dorr: I think I’ll begin by using my closing summary, which is that I really don’t care which approach anybody uses to do a hip replacement as long as you do it well.

I think the elephant in the room is whether the marketing for direct anterior approach is making them believe they have to have that operation to get a good hip replacement. Why are surgeons pressured to think they have to do that approach to attract patients? Why do we in orthopedics—when we have such an honored profession—have to promote an approach that is 10% of the operation that we do…and have the public believe that it gives better outcomes when there is no data on the outcomes.

Do you know that there is not one paper published with good patient results past six months to one year for the direct anterior approach?

It seems to me that it’s kind of weird that a surgeon will do a new operation that has no outcome data, has a long learning curve, has no better dislocation rate and more fractures…and actually has the only data in the literature saying that it’s better during the first two weeks.

I’ve never had a patient come in and say, “I just want a two-week operation.”

Where have the stewards of orthopedics been with this controversy? Why haven’t we heard from the AAOS or AAHKS as to rebut all the marketing that says that incision gives a better hip replacement. Sixty percent of the membership does a posterior approach…that 60% right now is under the bus. So, I stand here today to speak for the posterior surgeons and to say that the 10% of the operation that you do allows you to very well do 100% of the reconstruction.

The issues are three: one is muscle injury. I think the tag line, “No muscle cut” was what really started this whole charade.

Interestingly, there isn’t any real difference if we look at the muscle damage done as judged by gait analysis. Interestingly, Joel Matta has often told me the big advantage of the direct anterior approach is that it doesn’t cut the obturator internus muscle, and that’s the most important external rotator. But a paper published in August 2017 (Kawasaki et al, J Arthroplasty) showed that the muscle damage was greatest—of all the muscles—to the obturator internus. That’s ironic.

Recovery has been a big issue too, but we all know that what we tell the patients is what they are going to do. If you tell the patient they’ll go home the same day then they will go home the same day. If you say they’ll stay five days, then they’ll stay five days.