Go With What Has Been Around and You Know: Posterior Hip is a Slam - PowerPoint PPT Presentation

Go With What Has Been Around and You Know: Posterior Hip is a Slam Dunk! Michael P. Bolognesi, MD Professor of Orthopaedic Surgery Division Chief, Adult Reconstruction Duke University Medical Center Division of Adult Reconstruction

Disclosures • Amedica - Stock Options, Surgical Advisory Board • Zimmer Biomet - Royalties, Consulting Payments, Resident Educational Support, Design Surgeon, Research Support • Total Joint Orthopedics - Stock and Stock Options, Advisory Board Member, Resident Educational Support, Consultant Payments, Design Surgeon • Depuy - Research Support, Resident Educational Support, Principal Investigator • Exactech- Research Support, Resident Educational Support • Stryker - Resident Educational Support • Smith and Nephew- Resident Educational Support • SPR- Research Support • Omega - Fellowship Support- Fellowship Director • North American Specialty Hopsital- Advisory Board

Real Disclosures I am not really against the anterior approach.. I brag about our Fellowship program offering multiple approaches to the Fellows I do think there has been some adoption of this approach in order to compete for volume I think we still are lacking definitive clinical evidence that demonstrates superiority of one approach…..

THA Approach Options Do Exist… • Posterior • Direct lateral/ Hardinge • Watson-Jones/ Rottinger • Smith-Peterson/ Direct Yorkhospital.com Wright Medical Technology Anterior • SuperCap/SuperPath Jointreconstruction.com

What are we trying to fix? • THA is a great operation! • Predictable results and survivorship • Reproducible • How much room is there for improvement?

What is Ultimate Goal of THA? 900 The Forest • Pain relief 800 • Function 700 • Prosthetic longevity 600 – Technique- 500 dependent Series1 400 • Low complication rate 300 • How important are 200 the first couple of 100 weeks? The Trees 0 1 2 6 weeks vs. 15 years

Proposed Posterior Advantages • Relatively straightforward…. Any primary • Extensile….. Any revision • I think I can teach it well (single assistant)… • No special table required…. • You can use any femoral component… • It works…. And it “spares” the abductors • History is on its side…. Modifications, retractors, equipment, etc.

Disadvantages • Dislocation • You split the gluteus maximus • You cut through muscles (SER)! • Body habitus and size can make you use a large incision.. • The acetabular exposure is “harder” • Post-operative precautions

How bad is the dislocation situation? • Direct health care costs – Most common reason for revision (Bozic, JBJS 2009) • May change as more Anterior hips done • Fixation and bearings have improved • Patient stress • Mitigated by – Current implants • Head size, offset, neck modularity – Posterior repair • 1-3% rate most series – 1/3 of these will require revision for dislocation White, CORR 2001; Stamos, JOA 2004; Weeden, JOA 2003; Pellicci, CORR 1998 www.totaljoints.info

What is the Safe Zone? • Stability vs. Wear – Different optimal zones • Wear may not be the issue it used to be… • Surgical approach – More anteversion for posterior • For Stability: • Anteversion target less forgiving than abduction • Lumbar spine/pelvic tilt – Dynamic vs. fixed

We have to figure out the spine… • It matters…..

Anterior Approach for THA ? Matta Anterior ABMS Anterior

80-20 Rule vs. Learning Curve • Most THAs NOT done by high-volume or fellowship-trained surgeons – 60% primary THA done by surgeons doing < 25/ year • 2004 Medicare database (Manley, JBJS 2008) • 10-50 cases? (Berry, JBJS 2003; Woolson, JBJS 2004; Archibeck, CORR 2005; Asayama, J Arthroplasty 2006) • “Learning curve” might not be worth it – 37 cases ASI THA (Berend, Orthop Clin NA 2009) • Handpicked easiest cases early on (<50% of primary THA)

So there must be a learning curve…. • Complications do occur….. • Matta et al., CORR 2005 • Anterior fracture table approach, 494 primary THA • 9 femur fractures (3 GT, 4 calcar, 2 shaft), 3 ankle fractures • Bradbury et al. (personal experience, TJO Park City Meeting) • 1505 cases- 33 intra-operative fractures, 9 deep infections, 5 dislocations (4 anterior and 1 posterior), 6 unstable stems, 5 transient femoral nerve palsies, 2 LFC nerve palsies

Same approach, 5 community adopters, 247 primary THA (Woolson, J Arthroplasty 2009) Avg EBL (858 mL) 9% major complication rate (6.5% femur fx intraop) 21% cup alignment outliers (despite intraop fluoro) 3% femoral loosening at 1 year

– Anterior THA 19/800 troch fx, 3 perforations, 7 dislocations (Jewett, CORR 2011)

– Anterior THA 8/ first 100 femur fracture, 2% dislocation (both requiring revision) (Wayne, Orthop Rev 2009)

• 11,810 DAA hip procedures • Most common complication nerve dysfunction (2.8%) followed by intraoperative fractures (2.3%). • Postoperative dislocation, wound complications, and revision THA within the first 12 months were reported in 1.2% of cases.

Gait Recovery No difference at 6 weeks… One year results…. Similar story

There was no systematic advantage of direct anterior THA versus miniposterior THA. Very modest functional advantages early in recovery after direct anterior THA compared to posterior-approach THA.

No difference in dislocation rate based on approach (0.4% DAA vs. 0.4% PA). Procedure duration was increased with the DAA (100.94 38.00 min DAA vs. 76.35 27.72 min, p<0.005). No statistically significant differences in fracture rate, blood loss, hematoma, length of stay (LOS) or readmission. The surgical approach for total hip arthroplasty showed no noticeable differences in post acute care service utilization or cost.

Are Patient-Reported Outcomes Different after Direct Anterior Versus Posterior Approach to Total Hip Arthroplasty? Surgical approach had no bearing on 6 month post-op PRO The impact of surgical approach on short-term patient outcomes in total hip arthroplasty Ant and post approaches had higher FCS compared to the lateral approach at 6- weeks.. Higher complication rate of lateral femoral cutaneous nerve sensory deficits in the anterior group Is Obesity Putting Anterior Approach Hips at Higher Risk of Infection? Alarming increase in rate of wound problems and infection in the obese patient compared to the non-obese in DAA THA High Risk of Wound Complications Following Direct Anterior Total Hip Arthroplasty in Obese Patients Obesity was a major risk factor for wound complication following direct anterior THA…. Increased re-operation.

Pick your Poison! • Posterior Approach: – Dislocations • Hardinge Approach: – Limp/ abductor repair failure • Anterior Approach: – Femur fracture?/ Technical difficulty?/Obese patients and infection/wound issues?

So all of these approaches are pretty good.…….

Thanks!

Moving forward. Climbing higher.