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

And how about outpatient hip replacement? I’ve been doing that with the posterior approach since 2005. Today, all the excited people doing hip replacement with outpatient surgery using an anterior approach think they invented it with that approach. But our articles on the posterior approach were published some time ago. And we basically all know that the reason we’re able to do much more rapid discharges is because of our multimodal pain management, which we’ve all converted to over the last 10 years.

Tissue inflammation occurs no matter what operation you do on somebody—as soon as you cut then you’ve got it. And when you injure the bone you’ve really got it. And by the way the best treatment for that is not the approach, but just give them ice for the first couple of weeks after surgery.

Lastly function. Is it really better if you don’t cut any muscles? At three weeks postoperatively with the posterior approach: 98% of our patients could walk a mile…which is the only therapy I use…I just tell them to walk. And two-thirds of them were back at work. Isn’t that the ultimate recovery for somebody who wants to be productive when they do the operation? I don’t think I’ve seen any data published, not any, with the anterior approach as good as that data.

How about outcome? I told you that there aren’t studies with the direct anterior approach. But there are three, at 10 years, with the posterior approach: ours (J Arthroplasty2016), one from Mayo Clinic (Abdel et al, J Arthroplasty2017), and Beverland’s (Stevenson et al, JBJS-Am2017). They all showed excellent results.

My conclusion is that if you do the posterior approach to a hip replacement you should be proud: you’re among the majority, your results are the best, and when you walk out of here today, just walk out with your hands like this (raising fist).

Moderator Trousdale: Larry, I do the posterior approach and I’m feeling proud. Michael is my friend and partner and I think he’s going to give you a reasonable argument for why some surgeons should consider the direct anterior approach.

Dr. Taunton: In the early 2000s we saw that less invasive procedures can cause less muscle damage, can improve early outcomes, while maintaining radiographic outcomes, a low complication rate, and acceptable long-term outcomes. In 2017, we demonstrate, among the AAHKS members, an eminence of the posterior approach, with 56% of the surgeons utilizing that approach. I would say a majority would consider that as a less invasive approach than the approach they were using 10 years ago.

There is a lot of evidence and scientific rigor that has been applied to the miniposterior approach. Dr. Sculco in 2005 demonstrated decreased length of stay (LOS), limp and blood loss (J Arthroplasty). And Dr. Dorr in 2007 (JBJS-Am) showed decreased LOS, gait aids, and pain. My partner, Mark Pagnano, in 2008 found a decreased need for gait aids and improved early activity (JBJS-Am). But we can see that over the last nine years the change has been coming in the eminence. While the posterior approach is still pre-eminent, the direct anterior approach has made gains.

Given that the posterior approach has been very well studied and the direct anterior approach has not been studied as well, we need to look at things a little bit closer. My prediction is that the eminence of the posterior approach will fade as the direct anterior approach is clinically superior.

But is there evidence?

I designed a prospective randomized trial on the direct anterior approach and the mini posterior approach, looking at in-hospital outcomes, the patient’s early gains in daily activities, radiographic outcomes, and one-year complications.

All patients received the same standardized perioperative pain and physical therapy (PT) protocols. Patients were recruited from the practices of surgeons participating in the study. They were randomized for surgeon, age, gender, and body mass index (BMI). I performed all of the direct anterior approaches no matter who the initial consulting surgeon was, and likewise with the posterior approach, the posterior approach surgeons performed those surgeries. The initial consulting surgeon continued to follow the patient postoperatively no matter what approach was performed.