There Is No "Free Lunch" with Total Hip Arthroplasty Incisions: It Is the Pathways and the Procedure, Not the Surgical Approach!: Commentary on the article by Wayne Hoskins, MBBS(Hons), FRACS, PhD, et al.: "The Effect of Surgical Approach and Femoral Prosthesis Type on Revision Rates Following Total Hip Arthroplasty. An Analysis of the Most Commonly Utilized Cementless Stems".

Abstract

Commentary Surgical approach in total hip arthroplasty has been a particularly hot topic recently. The purported benefits of the anterior approach, including a more rapid recovery and better outcomes, are apparent to many patients with an easy Google search. This has seemingly prompted many surgeons to adopt and promote this approach in their practices. Despite this increased awareness and use of the anterior approach, the comparative data that exist seem to paint a different picture. A meta-analysis on the use of this approach in total hip arthroplasty reported no benefit of one surgical approach over another1. A recent Charnley Award-winning paper also showed that there were no differences in outcomes between the anterior and posterior approaches2. So why the big push for the use of this incision? Both fellowship programs and implant companies are promoting this approach, with the latter linking this incision to robotic surgery or marketing traction tables to assist with this approach during surgery. A multicenter study by Meneghini et al. showed that the anterior approach had higher rates of both dislocation and femoral stem revision than either the anterolateral or posterior approaches3. With use of data from the Australian Orthopaedic Association National Joint Replacement Registry, the study by Hoskins et al. highlights similar problems with the anterior approach. Although there was no difference in the cumulative percent revision between the anterior and posterior surgical cohorts, the anterior approach was characterized by a higher rate of femoral revision for either loosening or periprosthetic fracture. The authors also identified apparent differences in outcomes between the 5 cementless stems when the anterior approach was utilized. An earlier study by Hoskins et al. assessed all 3 surgical approaches among a larger number of patients with use of data from the same joint registry. In that study, Hoskins et al. found higher rates of revisions for periprosthetic fracture and femoral loosening among procedures performed via the anterior approach; however, that study of >122,000 patients also showed a higher rate of dislocation among procedures performed via the posterior approach4. Additionally, many of these same authors have also reported on a greater learning curve with the anterior approach5. For the present study by Hoskins et al., conclusions must be tempered with the limitations of the study design, which include statistical problems as a result of comparing only 5 stems. Another concern was the lack of control regarding surgeon experience, which may have affected approach-specific findings. A possible limitation of this study might be selection bias between the 2 cohort patient demographics between the anterior and posterior cohort groups. There is more to take from this study than just the statistics regarding the stem design and the higher femoral-sided complication rate with the anterior approach. First, we have to acknowledge a learning curve with the anterior approach. Is it worth enduring such a learning curve for a surgical approach that has no documented outcomes-related benefits? Second, surgeons need to temper their preference for a particular approach with the realization that overpromising and failing to meet unrealistic expectations is a problem for our profession as a whole. The pathways that have been developed for outpatient surgery and the tremendous long-term track record of total hip arthroplasty are what is driving modern day arthroplasty, not the approach6. All approaches have inherent problems. Promoting 1 approach over another is just marketing without substantial proof of superiority. Sticking with evidence-based medicine should be the highest priority for our patients. We should continue to pursue research models that assess implant design in order to help surgeons utilize their preferred approach, with the end goal of providing the best possible care to each individual patient. Certainly surgical technique, clinical experience, and modern-day pathways play the most substantial roles in providing excellent care during total hip arthroplasty. In the future, surgical residents and fellows may consider becoming familiar with all 3 surgical approaches; however, it is unclear whether the typical case volume would allow proficiency in light of the learning curves of each approach. The goal of teaching programs should be to encourage surgeons to tailor surgical approach on a case-by-case basis in order to achieve the best outcomes. Presently, all surgical approaches allow surgeons to successfully perform this remarkable surgical procedure in an outpatient setting in most healthy patients.