Direct Anterior Approach - Don't Believe the Hype!

Posterior or Postero-Lateral Approach to the Hip Joint

What are the "Old" Approaches to Total Hip Replacement Surgery?

Posterior / Posterolateral

Hardinge / Antero-lateral / Watson-Jones

(,)

What is an "Approach" to a Joint Replacement Procedure?

The Direct Anterior Approach With Caution....

Comparison Between Posterior Approach and Anterior Approach

What Are the Aims of a Total Hip Replacement?

Advantages of AMIS®

AMIS® can potentially provide you with the following benefits:

SMALL SKIN SCAR

With AMIS®, the skin incision is often shorter than with “conventional” surgery and therefore scar tissue is reduced.

REDUCED RISK OF DISLOCATION

As a result of the AMIS® technique the preservation of muscles significantly improves the stability of the hip. The risk of dislocation is minimal and the post-operative limitation of movements, usually prescribed in other techniques, is not necessary. The risk of dislocation is reduced because the anterior approach is performed from the front of your body and dislocation is mainly related to posterior hip structure damage.

2+4/200 = 6/200 = 3%

TOTAL HIP REPLACEMENT

(or "Don't Believe The Hype")

SHORTER HOSPITAL STAY

The AMIS® technique usually significantly reduces the duration of hospital stay. Your surgeon may still recommend you a longer stay depending on your post-operative condition.

LESS BLOOD LOSS

Preservation of muscles and vessels potentially reduces blood loss. Transfusions are rare, blood clots in the legs (deep venous thrombosis) are potentially less likely.

to have a prosthetic hip joint that is:

• painless
• stable
• appropriately aligned
• restoring leg length and lateral offset
• using durable, reputable components
• with the lowest risk of complications

A lot of conflicting reports and "evidence" regarding "superior" result/ no difference / comparable complication profile,

BUT very few direct comparison studies done using the same:

• modern implants,
• perioperative anaesthetic and analgesic technique,
• post-op rehab/"precautions"

And the only difference being the surgical approach used

SHORTER REHABILITATION

Rehabilitation can usually start the day of the operation or the day after, subject to your doctor’s approval, based on your post-operative conditions. Standing up and walking with arm crutches can start immediately, with your doctor’s authorisation as well.

MR DANIEL ROBIN

MBBS (hons) MS FRACS (Orth), FAOrthA

Consultant Orthopaedic Surgeon

OASIS Orthopaedics

What is the "New" Direct Anterior Approach (DAA) to Total Hip Replacement Surgery?

FASTER RETURN TO DAILY ACTIVITIES

The AMIS® technique allows you to return to daily activities in a shorter time frame.

You may drive when able to get in and out of the car comfortably, have excellent control of your legs and are not taking pain medications.

Depending on your general condition and only with approval from your surgeon, you may be driving in 8 -10 days.

DECREASED POST-OPERATIVE PAIN

In comparison with “conventional” surgical techniques, the AMIS approach can reduce the post-operative pain as muscles are not cut.

PREVENTION OF LIMPING

AMIS® is characterised by a surgical technique that protects the various muscles, blood vessels and nerves encountered during exposure of the hip joint. Minimizing muscle and nerve damage reduces the chances of limping.

What is the "New" Direct Anterior Approach (DAA) to Total Hip Replacement Surgery?

NOT "new"!

• Originally described by Heuter in 2nd half of 1850's
• Revived by Smith-Petersen and Judet bros circa 1950
• Re-Revived/Modified by Matta, Keggi and Laude' in mid 1990's - early 2000's using new instruments and operating / traction tables

So Why Do I Say "Approach With Caution"?

• Motivations behind this "new" surgical approach to do even better than an already excellent operation

Does the "Approach" REALLY lead to a significantly better result?

Which patients is it applicable to, and in which patients should it be avoided?

• What kind of surgeons are doing Direct Anterior Approach Total Hip Arthroplasty (in Melbourne)?

• Go back to first principles - what's important in getting a hip replaced?

• Marketing, marketing, marketing
• What has history taught us about direct marketing in the orthopaedic industry?

Patient Factors

Surgeon Factors

Approach Factors

• Which surgeons take up DAA? Why do they take it up?

• surgeon's assessment of own competence/skill level

• surgeons actual competence

• surgeons ability to deal with intra and post operative complications

• effect of learning curve and level of training

how many cases are required to become expert in the technique? -

>100 (Bhandari et al)

>50 (De Steiger & Solomon) before risk of revision normalises!

> 40 or 6/12 in high volume practice (Lombardi)

i.e. how many patients do you want to place at risk before you can offer them a truly good operation without excessive risk of complications?

DAA technically more challenging (and higher risk of complications?) cf PA in patients who:

• are obese (BMI >30) - abdomen gets in the way during femoral broaching, wound infection
• are muscular - "no muscles are divided" so they have to be retracted (?extent of muscle damage)
• have significant anatomic abnormalities - acetabular defects, femoral deformities (short/varus femoral necks) - restoration of joint mechanics

Short Term Differences (first 6-12 weeks):

• Relevant to which patients?
• May have less discomfort and earlier restoration of gait (first 6-12 weeks) - then no different (debatable)
• ?Marginally lower/similar rate of dislocation (debatable)
• ??need for hip precautions??

Long Term Differences (beyond 12 weeks):

• NONE

Utility/Limitations of DAA:

• management of intra-op complications during a DAA or...
• revision total hip replacement, or....
• complex primary hip replacements (dysplasia, previous hardware/surgery)

vast majority of surgeons will opt for / require an extensile posterior approach to manage

Which Surgeons Are Doing DAA in Melbourne?

Complications?

Infection?

?increased in obese

Dislocation?

?probably no less risky

Young

Eager

"Technically Gifted"

Needing to Establish Market Share

"High Volume"

Increased Blood Loss?

in some studies

Intra-operative fractures?

Definitely higher incidence of

• Calcar Fractures
• Trochanteric Fractures
• Femoral Shaft Perforation
• ?Knee ligament injury?
• ?Ankle Fractures?

Older

Bored

Want to try new challenge

Need to Retain Market Share

Neurological Injury?

• Sciatic?
• LFCN?
• Femoral?

Marketing!

Exactly How "Popular" is this Popular "New Approach"?