Discussions of ‘best’ THR surgical approaches are unnecessary
As someone who has been in orthopaedic surgery for nearly 4 decades, I certainly welcome both evolution and innovation. However, I also prefer stability in my orthopaedic practice and tend to be patient when it comes to new advances in the specialty. As a hip surgeon, I have reflected on the implants, surgical techniques, pain management and rehabilitation programs used and the attitudes of the surgeons and patients in 1982, when I began my practice.
In many respects, evolution and innovation have brought us, and the patients who undergo total hip replacement, to another, better level of care than was possible 37 years ago. However, this progress did not occur without several bumps in the road, namely the consequences that patients with poorer outcomes have experienced and that they somehow feel their expectation of receiving a high-level professional medical treatment was not met.
Of course, several reasons may be given for and discussed about those “bumps.” However, I frequently have noticed there are financial benefits to industry and individual surgeons associated with some of the changes that affect how TJR is performed. In addition, I also have noticed that as professionals, orthopaedic surgeons sometimes lose sight of how we should best introduce new techniques or implants — in a gradual, stepwise fashion — and just jump onboard without first having the needed experience or knowledge to appropriately implement new technology.
Evolution in THA approaches
In each of the 4 decades in which I have practiced, different approaches to the hip for THA have been identified with the standard posterolateral (PL) approach probably being the most frequently used worldwide. Even in the 1990s, one might have had discussions with colleagues who were not using the PL approach but were happy enough with and had good experiences and outcomes with an approach that is comparable to the PL approach.
However, something happened around 2004 to 2005. Either due to promotion by industry or by some key leading surgeons, we were introduced to the idea of using smaller incisions and were told these incisions were better and less painful for the patient and that the small incisions allowed patients to rehab more quickly. This information also reached the internet and mainstream media, which brought the “need” for small THR incisions to the attention of patients. This led to patients requesting treatment by a surgeon who would perform their THR using a specific approach and a specific technique.
Randomized THR study
At my institution, we also encountered such patients. Therefore, we decided to jump on the bandwagon of performing the direct anterior (DA) approach. We trained two senior high-volume surgeons who had extensive career-long experience with the PL approach on the DA approach through cadaver training, site visitations, as well as reverse visitation. Then, we started performing the DA approach in collaboration with another clinic, which allowed us to randomize patients to undergo THR either with the PL or DA approach.
Among a total of 60 patients, which included patients who were part of our DA-approach learning curve, we noticed patients’ outcomes were comparable in all respects regardless of the approach used after both the 3-month and 12-month follow-up. However, we also noticed the problems we had related to the DA approach, especially in lifting up the femur for an adequate exposure without cutting the lesser rotator muscles, which was touted as one of the benefits of doing the DA approach. After that finding, it was an easy decision to make at our two institutions to just use the approach that worked best in the surgeons’ hands because, as experienced hip surgeons, the DA approach did not ultimately offer patients any extra benefit compared to the standard PL approach. For us, the decision was made.
Today, however, the type of surgical approach for THR is still discussed and widely debated at national and international meetings. I wonder why. Perhaps it is because some surgeons are not yet convinced which approach to use and our patients still demand we use a specific THR approach — sometimes one that is not our standard technique. Perhaps there is another reason the debate continues. Given the published literature on the subject, I wonder why we continue to take time at valuable educational sessions to discuss this topic. Published data show that a change to another approach requires a learning curve and can result in more complications. Furthermore, surgeons may even feel uncomfortable or awkward performing a new technique that is far different from the one they were trained in and with which they have extensive experience and a significant number of cases.
Use a familiar technique
To me, the choice is simple and clear. If you “grew up” with and were taught the DA approach, it should be your main THR approach. The same is true for the PL and other approaches to the hip. Perform the approach you know best and keep performing it until you have perfected it in such a way that it clearly benefits all the patients whom you treat because the literature also is clear about this point concerning the DA vs. the PL approach: There are no important differences between results of the two approaches when they are used by high-volume surgeons.
Therefore, my recommendation to my colleagues who perform THR is to continue to use the approach in which you have been educated and trained. It is with that approach that you will provide your patients with the best and safest treatment.
- Statz JM, et al. J Arthroplasty. 2019;doi:10.1016/j.arth.2019.03.020.
- Taunton MJ, et al. Clin Orthop Relat Res. 2018;doi:10.1007/s11999.0000000000000112.
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- Per Kjaersgaard-Andersen, MD, is Chief Medical Editor of Orthopaedics Today Europe. He can be reached at Orthopaedics Today Europe, 6900 Grove Road, Thorofare, NJ 08086, USA; email: firstname.lastname@example.org.
Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.