This week’s Orthopaedic Crossfire® debate was part of the 35th Annual Current Concepts in Joint Replacement® (CCJR®), Winter meeting, which took place in Orlando. This week’s topic is “The Anterior Approach: Better, Faster, Cost Effective.” For is William G. Hamilton, M.D., Anderson Orthopaedic Research Institute, Alexandria, Virginia. Opposing is R. Michael Meneghini, M.D., Indiana University School of Medicine, Indianapolis, Indiana. Moderating is Thomas S. Thornhill, M.D., Harvard Medical School, Boston, Massachusetts
Dr. Hamilton: For those of you naysayers out there who thought that the anterior approach was a flash in the pan, a survey found that 40% of AAHKS [American Association of Hip and Knee Surgeons] members now use this as their primary approach.
Why is it so popular and so attractive?
Well, it’s intermuscular, avoids violation of the abductor, minimal detachment of the posterior stabilizing structures, low dislocation rate, and facilitates the use of fluoroscopy in the supine position. And it preserves the hip deltoid, the combination of gluteus maximus and tensor fascia lata. Maybe this is why patients seem to have a little bit better post-op functional recovery.
There is a learning curve. So, if you’re a 50-year-old surgeon and you adopt this in your practice, we know that there’s an issue with longer operative times, wound complications, increased blood loss and femur fracture.
But…newsflash…if you take on a new activity in life and you do not possess the skills set and you don’t practice, catastrophe can result.
What happens after the learning curve when you reach steady state in your practice? I participated in a study with 5,000 consecutive anterior approach total hips, I reported low rates of femur fracture and infection, and extremely low rates of dislocation (Barnett, et al., JOA, 2015).
In my fellowship they get 6 months of anterior approach training, 6 months of posterior approach training, over the last 10 years I’ve trained 40 fellows and of those 40 fellows 39 are currently using the anterior approach as their primary approach of practice. I guess there is something in the Kool-Aid.
The supine position makes using fluoroscopy quite easy. Can also help to improve implant position. When I looked at my own data, by switching from posterior approach where 21% of our cases were outliers of the safe zone, we went to 10% outliers in my first 100, 4% outliers in my second 100 (Goodman, et al., Hip International 2017). And now with the addition of this onscreen positioning software over the last 200 cases, 99% of my cases are within the safe zone in both anteversion and abduction This is relatively easy to employ and fairly cost effective.
Does it result in a better recovery? Let’s look at some of the head-to-head comparative studies. A 2015 meta-analysis that looked at 17 studies and 2,300 patients found that 9 of those reported short-term pain in functional outcomes; 4 of them favored the anterior approach and 5 really showed no difference. In secondary outcomes the anterior approach was favored in length of stay and dislocation with significant reduction of those measures (Higgins, et al., JOA 2015).
Dr. Meneghini seems to have made his reputation by reporting the bad results of the anterior approach. He touts his use of the posterior approach but does not report his results regarding alignment, leg length and dislocation. He does not mention use of an alternative approach for cases of spasticity(cerebral palsy etc.)where a posterior approach is contra-indicated. He seems to have a prejudice for the posterior approach rather than an objective view in my opinion.