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