Post on 19-Feb-2017
Anterior vs Posterolateral
Surgical Approaches in Primary Total Hip Arthroplasty
E.S. Veltman / R.W. Poolman
23 augustus 2016
Introduction
• THA very succesful procedure• >90% patients satisfied
• Over 28.000 THA yearly in the Netherlands• Most frequently used approaches posterolateral (62%),
straight lateral (20%) en anterior (12%)
• Optimal approach remains topic of discussion • Most discussion concerning postoperative muscle strength
Comparing approaches
• Posterolateral
• Anterior
Anterior vs PosteriorAdvantages• Low dislocation risk• Minimal muscle damage• Less postoperative pain• Swift rehabilitation• Surgery in supine position
Disadvantages • Long learning curve (100pt)• Peroperative femur fractures• More blood loss• Longer duration of surgery• Different approach for revision
Advantages • Short learning curve (50pt)• Proven excellent long term
outcome• Little blood loss
Disadvantages• More muscle damage• Higher dislocation risk
PICO
• P: patients receiving THA• I: anterior approach• C: posterolateral approach• O: outcome (surgery, function, patient satisfaction,
complications)
Search• ("arthroplasty, replacement, hip"[MeSH Terms] OR
("arthroplasty"[All Fields] AND "replacement"[All Fields] AND "hip"[All Fields]) OR "hip replacement arthroplasty"[All Fields] OR ("total"[All Fields] AND "hip"[All Fields] AND "arthroplasty"[All Fields]) OR "total hip arthroplasty"[All Fields]) AND ((anterior[All Fields] AND approach[All Fields]) OR (posterolateral[All Fields] AND approach[All Fields]))
Results• 598 studies
• Higgins et al: systematic review 2015 (2 RCT, 5 prospective comparative studies, 10 retrospective comparative studies)
New in 2015/16:• Malek et al• Maratt et al• Winther et al
Measured outcome HHS, VAS, SF36, walking distance
Anterior vs Posterior
• 448 patients undergoing unilateral primary THA
• 265 patients (age 71, 117 male) direct anterior approach
• 183 patients (age 70, 86 male) posterior approach
• No difference in age, gender, ASA grade, BMI, the side of the operation, pre-operative Oxford Hip Score (OHS) and attendance at ‘Joint school’.
• 2147 DAA THA patients were matched with PA THA based on age, gender, BMI and ASA using data from a state joint replacement registry
In 60 patients leg press and abduction strength were evaluated 2 weeks or less preoperatively, 2 and 8 days postoperatively, and at 6-week and 3-month follow-up.
Discussion• Learning curve anterior approach is longer• Comparable risk of dislocation • More peroperative blood loss and femoral fractures in
anterior approach• Longer in-hospital stay with posterolateral approach (1
day, possibly due to placebo effect)• Functional outcome (at mid- and longterm follow-up)
comparable
• Both approach are safe in experienced surgeons• Placebo effect
References• LROI anual report 2014• Higgins BT, et al. Anterior vs. Posterior Approach for Total Hip Arthroplasty, a
Systematic Review and Meta-analysis. The Journal of Arthroplasty 30 (2015) 419–434• Malek IA, et al. A comparison between the direct anterior and posterior approaches for
total hip arthroplasty. Bone Joint J 2016;98-B:754–60.• Maratt JD, et al. No Difference in Dislocation Seen in Anterior Vs Posterior Approach
Total Hip Arthroplasty. The Journal of Arthroplasty. DOI 10.1016/j.arth.2016.02.071• Winther SB, et al. Muscular strength after total hip arthroplasty. A prospective
comparison of 3 surgical approaches. Acta Orthopaedica 2016; 87 (1): 22–28• De Anta-Díaz B, et al. No differences between direct anterior and lateral approach for
primary total hip arthroplasty related to muscle damage or functional outcome. International Orthopaedics (SICOT). DOI 10.1007/s00264-015-3108-9