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SICOT e-Newsletter

Issue No. 71 - December 2014

Expert Corner

Direct Anterior Approach for Total Hip Replacements

Javad Parvizi
Philadelphia, United States

Physicians in general and orthopaedic surgeons in particular are innovators. Thanks to these innovations, orthopaedic procedures are now among the most rewarding, cost-effective, and successful surgical procedures. One area of innovation in total joint arthroplasty relates to the surgical approach. Total hip arthroplasty, in its early era, used to be performed through the greater trochanter osteotomy. A randomised, prospective study by Dr Rothman from the Rothman Institute showed that there was no need to perform GT osteotomy during a routine THA. Thus, abandoning the GT osteotomy during THA led to simplicity in surgical approach and improvement of the care for patients. The desire to improve on surgical approach and other aspects of hip replacement has continued. One desire has been to seek a surgical approach that can allow THA to be performed without violating the periarticular muscles.

The direct anterior approach appears to fulfill the latter criterion [1]. The direct anterior THA has been performed by some surgeons for many decades. So what exactly has led to the resurgence of interest in this surgical approach? I believe there are three main reasons for the popularity of THA performed through the direct anterior approach. The first relates to the fact that we are performing THA in younger and more active patients, majority of whom also happen to be fully employed. Their desire for early return to work and activities has been one impetus [1]. The direct anterior approach, based on numerous level one studies, is superior to other approaches in terms of early return to function and patient satisfaction [2-7]. The other reason is that patient population undergoing THA, because of easier access to information, are much more informed today. These patients engage in extensive research about the procedure before choosing a surgeon and undergoing a procedure [1, 5]. Thus, patients have been seeking out surgeons who offer THA through direct anterior approach. The third and an interlinked reason to the latter relates to marketing [1, 5].

In an effort to prevent the disasters that have ensued as a result of false marketing or unintended damage caused by innovations that did not deliver on their promises, the direct anterior approach needs to be carefully evaluated. Many surgeons who use this approach have been engaged in generating data to support the superiority of the direct anterior approach, at least in the short term. Let’s not dismiss the importance of early functional outcome such as ability to return to work, start driving, sleeping on the side, or walking without an aid. The demographics of patients undergoing THA today are indeed very different to those that received THA in previous decades.

I embraced direct anterior approach for a different reason. I have been using the direct anterior approach for many years to perform joint preservation procedures of the hip such as the pelvic osteotomy and the impingement surgery. It is not infrequent that I encounter patients with dysplasia undergoing pelvic osteotomy exhibiting severe cartilage delamination during intraoperative inspection of the joint. The ability to perform THA rather than osteotomy in these borderline patients under the same anaesthesia was the driving factor for me to embrace the direct anterior approach. The ability to perform THA using the direct anterior approach then allowed me to avoid using a second incision for patients who had undergone a prior impingement surgery and developed subsequent arthritis. As I performed more and more THA using the direct anterior approach, I began to appreciate its superiority and embrace the DA approach fully. I also began to appreciate other advantages of this approach. Performing the surgery in a supine position allowed for better assessment of the limb length, expedited patient positioning, and reduced operative time, particularly for the wound closure [1, 4, 5]. However, I, or more accurately, my patients paid a price. During the learning curve a few complications occurred. Because of the complete excision of the capsule in the early years to allow exposure of the femur and possibly not limiting the activity of the patients, some patients dislocated. The greater trochanter was fractured intraoperatively in another patient [8].

Although I believe direct anterior approach is here to stay, I do urge those thinking of embracing this approach to thoroughly assess the advantages and disadvantages of using this approach versus their try and tested routine approach. The best way to become familiar with this approach, in my opinion, is during the fellowship when methodical training can be delivered. We owe it to our patients to balance the gains against the increased complications that are likely to occur during the learning curve.


References
  1. Post ZD, Orozco F, Diaz-Ledezma C, Hozack WJ, Ong A. Direct Anterior Approach for Total Hip Arthroplasty: Indications, Technique, and Results. J Am Acad Orthop Surg. 2014 Sep;22(9):595-603.
  2. Barrett WP, Turner SE, Leopold JP. Prospective randomized study of direct anterior vs. postero-lateral approach for total hip arthroplasty. J Arthroplasty. 2013 Oct;28(9):1634-8.
  3. Horwitz BR, Rockowitz NL, Goll SR, Booth RE, Jr., Balderston RA, Rothman RH, et al. A prospective randomized comparison of two surgical approaches to total hip arthroplasty. Clin Orthop Relat Res. 1993 Jun(291):154-63.
  4. Reininga IH, Stevens M, Wagenmakers R, Boerboom AL, Groothoff JW, Bulstra SK, et al. Comparison of gait in patients following a computer-navigated minimally invasive anterior approach and a conventional posterolateral approach for total hip arthroplasty: a randomized controlled trial. J Orthop Res. 2013 Feb;31(2):288-94.
  5. Restrepo C, Parvizi J, Pour AE, Hozack WJ. Prospective randomized study of two surgical approaches for total hip arthroplasty. J Arthroplasty. 2010 Aug;25(5):671-9 e1.
  6. Mayr E, Nogler M, Benedetti MG, Kessler O, Reinthaler A, Krismer M, et al. A prospective randomized assessment of earlier functional recovery in THA patients treated by minimally invasive direct anterior approach: a gait analysis study. Clin Biomech (Bristol, Avon). 2009 Dec;24(10):812-8.
  7. Zhang XL, Wang Q, Jiang Y, Zeng BF. [Minimally invasive total hip arthroplasty with anterior incision]. Zhonghua Wai Ke Za Zhi. 2006 Apr 15;44(8):512-5.
  8. Hartog YM, Mathijssen NM, Peters SJ, Vehmeijer SB. The anterior supine intermuscular approach for total hip arthroplasty: reducing the complication rate by improving the procedure. Hip Int. 2014 Sep 1:0.