More surgeon stress, strain with direct anterior approach for THA vs. posterior method
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Key takeaways:
- Use of a direct anterior approach in hip arthroplasty was linked with more physiological stress and strain on surgeons vs. a posterior approach.
- These findings may impact surgical schedules and order of cases.
Published results showed the direct anterior approach for total hip arthroplasty was associated with significantly increased physiological stress and strain for surgeons compared with the posterior approach.
Researchers from Rothman Orthopaedic Institute prospectively analyzed 144 THAs, of which 67 were performed with the direct anterior approach and 77 were performed with the posterior approach.
Researchers equipped five high-volume fellowship-trained arthroplasty surgeons with smart vests (Hexoskin smart garment, Hexoskin) that recorded surgeon stress index, heart rate, respiratory rate, ventilation and calorie expenditure. Researchers also factored in patient BMI and operative time, according to the study.
Overall, the direct anterior approach was associated with significantly higher surgeon stress index (17.4 vs. 12.4), heart beats per minute (101 vs. 98.3), ventilation liters per minute (21.7 vs. 18.7) and calorie expenditure per hour (349 vs. 295) compared with the posterior approach.
Researchers also noted the direct anterior approach had a significantly shorter operative time (71.4 minutes vs. 82.1 minutes) compared with the posterior approach.
“These findings should be considered when surgeons assemble their surgical case schedules, determine the order of cases and select a surgical approach,” the researchers wrote in the study. “They may also inform a surgeon’s decision to use lead with fluoroscopy and a specialized orthopedic OR table during [direct anterior approach] cases.”
Perspective
Back to TopTheodore T. Manson, MD, MS, FAAOS, and Joseph T. Moskal, MD, FAAOS, FACS
The authors present an intriguing study comparing surgeon exertion during the performance of anterior and posterior hip replacements. Surgeons performing direct anterior hip replacements had higher heart rates, minute ventilation, energy expenditure and “stress” (presumably measured by heart rate variability) than posterior approach surgeons. This statistical sample consisted of five surgeons, two of whom performed the balance of the procedures.
While a larger sample group is needed to make any definitive conclusion, the perception of surgeons “working harder“ during an anterior hip replacement as opposed to posterior hip replacement is one shared by many surgeons. This may be particularly true during the early portions of the learning curve in mastering this procedure.
Though certainly a source of controversy, most large studies show a lower dislocation rate and more rapid recovery with anterior as opposed to posterior hip replacement. In addition, it should be noted that even patients who have had a lumbar fusion have a low dislocation rate with the anterior approach, without the use of dual-mobility bearing surfaces.
The historical concerns of higher rates of early femoral loosening and periprosthetic fracture with the anterior approach have abated with improved implant selection.
Should we forgo certain procedures because it is more difficult than others? Most of us would agree that the patient outcomes trump difficulty for the surgeon. More “stress” during the procedure is surely a healthy tradeoff for less “stress” over concern for postoperative dislocation.
There are now generations of orthopedic residents who have mastered complex procedures, such as closed femoral nailing, arthroscopic meniscectomy, arthroscopic rotator cuff repair and percutaneous fixation of pelvic ring fractures. These were all procedures that were considered technically daunting on introduction. Those procedures are all now routine.
We should also recall that the posterior approach for hip replacement was considered more challenging (and complication prone) than its forbearer, the transtrochanteric approach during its wide adoption for hip replacement in the late 1970s.
Surgeon ingenuity and surgeon-to-surgeon education are the keys to maximizing patient benefit while minimizing strain on the surgical team.
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