The Case Against Anterior Approach for Primary Total Hip Arthroplasty

Donald S. Garbuz M.D., MHSc, FRCSC
Professor and Head
Division of Lower Limb Reconstruction and Oncology
Department of Orthopaedics
University of British Columbia
Vancouver, BC 

Over the last ten years several "new" surgical approaches have been introduced for use in total hip arthroplasty. These started with the MIS movement. According to their advocates, all these approaches will speed recovery and improve patient outcomes. These improvements were based on the theory that these approaches will be superior due to minimal damage to the muscles and soft tissues around the hip. Two of the more widely "touted" approaches were the 2-incision approach and the mini Watson-Jones. 

 

The 2-incision approach launched the era of minimally invasive hip surgery. Its advocates touted the soft tissue sparing nature of this approach. Claims were also made that recovery was quicker. The proponents of this approach published articles highlighting its advantages. However independent studies did not back up these claims. One study out of the Mayo Clinic looked at the muscle damage associated with the 2-incision and unlike the proponents of this approach; this study found that there was marked damage to muscle groups. In addition a RCT from the Mayo Clinic found no clinical advantage over the posterior approach when comparing it with the 2-incision. Lastly, like all new approaches, there is a learning curve. For some approaches such as the 2-incision this can be very steep and one has to be cognizant of this when adopting any new approach. 

The next approach that was touted as superior was the mini Watson-Jones. This approach was intermuscular and again claimed to result in superior outcomes due to minimal, if any, muscle damage. At our centre we did adopt this approach and then conducted an RCT against the mini posterior and mini direct lateral. In this study by non-advocates, we found no difference in clinical outcomes and no difference in recovery rates between groups. The only significant findings in our study were a higher subsidence rate and a higher intraoperative fracture rate with the mini Watson-Jones. Due to the unpredictable exposure gained with this approach, and the results of this study, we abandoned this approach in total hip arthroplasty. 

The two examples above show that claims about new approaches should be put to the scientific test. The downside of a steep learning curve may be acceptable if there is some benefit to the patient after the surgeon gets through the learning curve. As has been seen with the 2-incision and mini Watson-Jones, research studies have not supported claims of benefit. For these reasons these two approaches have largely been abandoned at most centres. They still have a small role as "niche" approaches by select surgeons on select patients. 

The 'new kid on the block' for surgical approaches is the anterior supine approach to the hip. Advocates for other MIS approaches claim its merits based on minimal muscle damage. Other advantages have already been highlighted. 

There are some significant downsides. The first is it may require the use of a special table costing several hundred thousand dollars. Advocates now claim that this is not necessary. Another downside is a significant number of patients will have damage to the lateral cutaneous nerve of the thigh. While not a major complication, it can be a nuisance especially if this new approach does not add benefit. 

To date, no comparative study has been published showing the benefit of this approach or even that it is as safe as other approaches. No data is available on learning curve. We do not know if this is an approach for all surgeons or just high volume arthroplasty surgeons. These are important factors to know before it is more widely adopted. 

Am I against this approach? No, I am not, but we should be cautious about widespread adoption. We must learn its limitations in terms of both patients and surgeon selection. I think in the right surgeon with the right patient it works, but to date there is no evidence that it works any better. I am not against it, I even sent my mother-in-law to a colleague where she had a successful total hip through the anterior approach. Does this mean it works? In this surgeon's hands and in this patient, yes - but let's be cautious before we adopt it widely.

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