The Impact of Surgical Approach on Hip Replacement Outcomes: Is the Anterior Approach Better?

The best surgical approach to total hip replacement has been a matter of debate with some proponents arguing that the direct anterior approach has a more rapid recovery and other surgeons arguing that it has a higher complication rate with no other clear advantages. There has been much written on the internet about this topic, some of which likely amounts to false claims not backed by scientific data. Such claims are often made to attract patients who are researching a procedure, implying that one surgeon’s method is superior to another’s in hopes of increasing “market share” for the growing number of people who require joint replacement surgery.

In the April 2020 issue of the Journal of Arthroplasty, Finch and colleagues performed a multi-center comparison of patient-reported outcomes follow total hip replacement using different surgical approaches including the anterior and posterior approaches. A total of 2640 patients were evaluated at 1 month, 3 months and 6 months after surgery using the Hip Osteoarthritis Outcome Score (HOOS). The study found that at each time point, there were no differences in outcomes between patients regardless of the surgical approach. These results have been corroborated by other surgeon and suggest that surgical approach should be left to the surgeon discretion in the absence of conclusive data suggesting that one yields superior outcomes.

What we have discovered in our focused joint replacement practice, is that outcomes depend on much more than surgical technique. While good technique and proper implant placement is important to prevent complications and maximize implant longevity, many other factors play in equally important role. These include patient preparation for surgery, patient motivation for a full recovery, participation in physical therapy to regain lost strength and function, optimization of nutrition, adequate pain management and others. We like to say that the joint replacement simply sets the stage for what patients can achieve through participation in the recovery program. It is a team effort.

We have many patients that present to us having done abundant online research about different hip surgical approaches, some of whom have a fixed idea in their mind of how their surgery has to be done. There are certain cases that favor one approach over others depending on body habitus, hip anatomy, prior surgery and underlying diagnosis. We tend to customize the approach to the patient with the goal of performing the best surgery in a tissue-friendly capacity. The results of this study hopefully demonstrate that patients can have excellent outcomes regardless of whether the hip is done through the front or through the back. The anterior approach is not better like it has often been hyped and patients need to be aware when reading online information, which is backed by well-performed clinical outcome studies and which is simply opinion based on summary observation rather than careful analysis.

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