Which surgical approach, exactly, will deliver a safer, more consistent total hip arthroplasty outcome? Is it the anterior approach? The answer from a 2,888-patient study may well surprise you.
Citing the snarl of statistics regarding this very subject in the literature, a team from New York’s Hospital for Special Surgery (HSS) designed a study to, they hoped, settle the issue of the optimal (if not also appropriate) total hip arthroplasty (THA) surgical approach.
Their work, “Complication Rate after Primary Total Hip Arthroplasty Using the Posterior Approach and Enabling Technology: A Consecutive Series of 2,888 Hips,” appears in the April 21, 2023, edition of The Journal of Arthroplasty.
In order to compare dislocation rates of the posterior versus the direct anterior approach, the investigators reviewed 2,888 consecutive, primary THAs performed via the posterior approach between 1/1/18 and 9/30/21. The procedures were performed by one of four orthopedic surgeons.
The team collected data on all patients who experienced a dislocation following a primary THA as well as information on patients who had complications for various reasons (infection, fracture, dislocation, other).
Jonathan M. Vigdorchik, M.D., a hip and knee surgeon at HSS, described the study methodology to OTW, “We did not use any fancy software, only a standardized series of X-rays for hip-spine analysis: AP [anteroposterior] pelvis, a standing lateral and a sitting lateral X-ray including the hip and spine. We used computer navigation and robotics to perform the surgery and execute the preoperative plans.”
In three years of follow-up, 39 patients (39 hips) had some form of musculoskeletal issue (dislocation, infection, periprosthetic fracture, or other) related to the involved joint.
“The total complication rate was 1.1%., the dislocation rate was 0.35% and the risk of infection was 0.24%,” stated Dr. Vigdorchik to OTW. “These rates are the lowest in the literature for hip replacement surgery, regardless of surgical approach.”
“We were thankful that the complication rates were so low because all intensity goes into performing a procedure with the lowest risk of anything bad happening. The national average for infection is ~1%; the national average for dislocation is ~1.5%. When looking at the registry data, the most common complications of a total hip replacement are infection, dislocation, and fracture, in that order.”
“In our series, we found that our most common complication was periprosthetic fracture, then dislocation, and infection. Interestingly, when you stratify patients by their hip-spine classification, the dislocation rate in a normal spine is less than 1 in 1,000 with the posterior approach. We have now also taken steps to reduce our incidence of periprosthetic fracture by changing stem designs to a collared stem, which further decreased our complications rates (in a study that is being submitted).”
“These results conclusively support the use of posterior approach as having equal if not lower complication rates than any other surgical approach in the literature. The debate regarding surgical approaches needs to stop, and the focus should turn to good preoperative planning and correct surgical execution, regardless of surgical approach. Today, in 2023, it does not matter which surgical approach you choose, as long as you do it well! Many of these complications are preventable with thoughtful planning and precise surgical execution.”
Excellente
Thank you
I had a primary L THA on 2/9/23. Played 18 holes of golf on 2/28. Enough said. 71yrs old
During my 36 year surgical career I used a modified Hardinge antero lateral approach and I did a T’d capsular incision which I repaired at the end of the procedure. My theory was the capsular repair provided increased stability, feedback and proprioception. In the thousands I did I had no dislocations, deep infections or re-do’s.
No infections or dislocations in 36 years. You may have the best results ever in orthopedics. Congratulations.
Did you avoid the metal on metal phase?
I am 84 years old have rheumatoid arthritis and had a right THR 22 years ago and left THR 11 years ago both were posterior approaches by two different surgeons and have had no complications.
This study DOES NOT show that posterior is a better approach than anterior. It merely shows that the national average for complications in THA may be improved upon. If the same surgeons performed 2888 THA with an anterior approach, perhaps they would have a complication rate of 0.55%. Without at least randomization, and performance of both anterior and posterior approaches by the same team, it is almost meaningless.
I agree, this study does not comment on recovery rate, rehab time, blood loss, days in hospital etc
Agreed. As with the beancounters, one can make “data” say anything you want, if not controlled, randomized, and directly comparative between these two approaches.
If perprosthetic fracture is the most common complication maybe your surgeon should be getting Dexa scan preoperatively to evaluate the degree of osteoporosis in these patients. It may change type of surgical implant cemented versus non-cemented or start appropriate treatment perioperatively.