No differences found in cumulative percent revision between surgical approaches for THA
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Anterior, lateral and posterior surgical approaches for total hip arthroplasty showed no differences in overall early cumulative percent revision rates, based on published results.
Wayne Hoskins, MBBS(Hons), PhD, FRACS, and colleagues analyzed the Australian Orthopaedic Association National Joint Replacement Registry from January 2015 to December 2018 and categorized 122,345 patients with osteoarthritis who underwent primary conventional THA into groups based on surgical approach, including posterior approach (n=65,791), lateral approach (n=24,468) and anterior approach (n=32,086). Researchers considered the cumulative percent revision for all causes as the primary outcome measure, while major revision and revision for specific diagnoses of fracture, component loosening, infection and dislocation were considered secondary outcome measures. Researchers assessed age, sex, BMI, American Society of Anesthesiologists score, femoral head size and femoral fixation as potential confounders.
Although no differences were identified in the overall cumulative percent revision rate among the approaches studied, results showed a higher rate of major revisions among patients who underwent the anterior approach. After adjusting for confounding variables, researchers also found the anterior approach had a higher rate of femoral complications, including revision for periprosthetic fracture and femoral loosening. However, the anterior approach had a lower rate of revision for infection vs. the posterior approach during the study period and the lateral approach in the first 3 months, according to the results.
Compared with the anterior and lateral approaches in all time periods, researchers noted there was a higher rate of revision for dislocation with the posterior approach. Results showed a lower rate of revision with the anterior approach vs. the lateral approach in the first 6 months.
“These results indicate that there is not a preferred surgical approach for total hip arthroplasty. Surgeons should use this information to improve their surgical technique, modify implant selection and potentially tailor their approach to the patient,” Hoskins, who is an orthopedic surgeon at The University of Melbourne and TraumaPlasty Melbourne, told Orthopedics Today. “Additional studies should determine whether there is a patient and surgeon profile best suited to particular approaches. It remains to be seen whether improvements in surgical training, intraoperative instrumentation and implant selection may help reduce the risks of early THA revision among the various approaches.”
- For more information:
- Wayne Hoskins, MBBS(Hons), PhD, FRACS, can be reached at Grattan St., Parkville VIC 3010, Australia; email: wayne.hoskins@outlook.com.
Perspective
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Hoskins and colleagues should be commended for their robust study on the effect of surgical approach on revision risk after primary THA. While there was no difference among anterior, lateral and posterior approaches in cumulative reoperation rate, component revision was most likely with the anterior approach. The highest risk of femoral complications, including revision for aseptic loosening or periprosthetic fracture, was associated with the anterior approach. Posterior approach, and lateral approach at early time points, was associated with higher risk of infection and dislocation than the anterior approach.
The current study recapitulates the findings of multiple other groups that have reported increased risk of femoral complications with the anterior approach. Based on this evidence, meticulous femoral exposure and stem preparation are critical with the anterior approach and intraoperative fluoroscopy may be a useful adjunct.
The association between THA approach and risk of dislocation or infection is less well-defined in the existing literature. In contrast to this study, several other studies found the risk of dislocation or infection with the posterior approach to be less than or equal to that of the anterior approach.
There is mounting evidence that no THA approach is superior to others across all metrics. Patients may rest assured that surgeons prepared to address the unique intraoperative and postoperative challenges associated with each surgical approach will provide them with favorable outcomes.
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The Australian Joint Registry is a reliable and unbiased source of data and the descriptive statistics used by the authors are presented clearly.
One major finding was a similar cumulative revision risk between anterior, lateral and posterior approaches for THA. The actual rate (2%) was also similar. While low, there seems to be a clear opportunity to evaluate options that might further reduce this risk.
A subsequent analysis found a higher risk of fracture and loosening with anterior approaches. In contrast, posterior and lateral approaches had a higher risk of infection and dislocation. Pick your poison, it seems. The actual difference between approaches for any one complication was remarkably low at most 0.2% (2/1,000). Is this statistical difference clinically important at an individual level? I dont know.
This study assumes all anterior approaches (or posterior or lateral approaches for that matter) are identical with respect to complication risk. My experience is that every surgical approach is nuanced, with innumerable differences even within a single approach between surgeons, any one of which could influence complication risk. This registry database review has limited ability to assess these important issues.
For me, the main value of this large registry study is to support my current understanding of the issue of surgical approach for THA.
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