Abdel v Hamilton: Simultaneous Bilateral Anterior Hips: Double Trouble

So now let’s look at it from the side of the direct anterior total hip arthroplasty and why I say this is “Double Trouble” when you combine the two together.

Here are the top 5 reasons why I go against that particular procedure, particularly in the simultaneous setting.

1. Increased risk of periprosthetic fracture. Some reporting says that it is 2-4%. That might be overestimated. The fact remains that when they do occur, usually at the trochanter and it’s difficult to salvage. (Hartford et al., JOA, 2018)
2. Increased risk of early femoral failure. There are at least 2 papers in the literature recently looking at this. One paper from Meneghini looked at 342 total revision total hip arthroplasties and found that 51% had a direct anterior approach. While this may not be causal, there is association. (Meneghini et al, JBJS AM, 2017)
3. Increased risk of impaired wound healing, particularly in those patients that are obese and undergoing a direct anterior approach. (Watts et al., JOA, 2015). A paper published by one of my partners, Michael Taunton, a skilled direct anterior total hip approach surgeon, found that he had a 4-times increased risk of wound issues in obese patients compared to the posterior lateral approach.
4. What about the lateral femoral cutaneous nerve that we often blow right by? A recent randomized clinical trial from late 2017, found that 83% of patients at 3 months still had neuropraxia of their lateral femoral cutaneous nerve. (Cheng et al., JOA, 2017)
5. Finally, what about traction-related injuries? A recent paper from the Rothman Institute found that their anterior-based approaches had a 14.5-fold increased risk of injury to the femoral nerve. While that number is still low, I would contend to you that I am not willing to take that increased risk for a primary total hip arthroplasty. (Fleischman et al., JOA, 2018)

Finally, the issue of obvious scientific bias. Most of the literature includes people who have simultaneous bilateral total hip arthroplasties that are our youngest, healthiest, most motivated, non-obese patients.

Increased risk of periprosthetic fracture, early femoral failure, potential for increased femoral nerve injury, impaired wound healing, increased blood transfusions and increased mortality in males greater than 75 make this a stop for me.

I’ll stick with my mini-posterior approach in a staged approach. It makes the surgeon happy. Makes my team happy. And most importantly, it makes my patients happy.

Dr. Hamilton: I’m a big fan of this procedure and I’ll explain to you why.

Up to 42% of hip osteoarthritis is bilateral and, in one paper (Sayeed et al., CORR, 2012), one-third of patients at the time of their first surgery had symptoms to justify contralateral total hip arthroplasty.

But only 1% of total hips are bilateral (Rasouli et al., JOA, 2014).

Why is that?

Much of what Matt just said is the common thinking. Greater blood loss, and increased transfusion rate, increased HO [heterotopic ossification]. Some studies show an increased rate of venous thromboembolism. And the other complications that Matt elucidated quite nicely.

But the real reason is that when you do your surgery in the lateral decubitus position, as Matt does from a posterior approach, it’s very cumbersome. If you’re going to do a bilateral surgery, you have to close the wound, you have to dress the wound, you have to flip the patient over. Reprep and redrape.