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Popular hip replacement approach shows surprising results

June 19, 2020


Sunnybrook and ICES research suggests a popular approach to hip replacement surgery has been shown to have an increased risk of complications.

"Controversy exists among arthroplasty surgeons and patients about the best surgical approach for total hip arthroplasty (THA). In the last few years, the direct anterior approach has become increasingly popular compared to posterior and lateral approaches, partially as a result of advertising to patients,” says Dr. Bheeshma Ravi, senior author of a recent study and an orthopaedic surgeon at the Holland Bone and Joint Program at Sunnybrook Health Sciences Centre and adjunct scientist at ICES.

Many surgeons have been advocating for research to compare the surgical approaches to help clinicians and patients determine which method is preferable. In this study, the authors sought to determine whether a direct anterior surgical approach was associated with lower surgical complications compared to lateral and posterior approaches.

“Our findings suggest the opposite – a significantly increased risk of major surgical complications with the direct anterior approach,” says Dr. Daniel Pincus, lead author of the paper and an orthopaedic surgeon at the Holland Program at Sunnybrook. “The approach has a risk profile that is different from its public perception.”

The study, published in JAMA (the Journal of the American Medical Association), looked at all adults in Ontario who received elective THA between April 2015 and March 2018 – over 30,000 patients with disabling hip pain caused by osteoarthritis. Of them, 10 per cent had the direct anterior approach done, 70 per cent had the lateral approach, and 20 per cent had the posterior approach. The surgeries were conducted at 73 hospitals by 298 surgeons, and all patients were followed for one year after their surgery.

After matching, patients that had the direct anterior approach had a significantly greater risk of a major surgical complication within one year (two per cent versus one per cent). Complications included: three times the risk for deep infection requiring surgery, two times the risk for dislocation requiring closed or open reduction, and two times the risk for revision arthroplasty.

“That there was still a higher risk despite the patients who received the direct anterior approach being younger, healthier and operated on by higher volume surgeons – situations where we typically expect fewer complications – adds further support that the findings are accurate,” Dr. Pincus added.

The researchers noted several possible explanations for the increased complication risk including: proximity of the wound to the groin or abdominal folds, less fascia available for deep closure, longer operative times, more challenging anatomy/femoral exposure, use of fluoroscopy/traction tables, and extensive tendon and capsular releases.

“These findings are based on current data from a large diverse population and may help inform clinical decision-making for the increasing number of patients with hip arthritis and surgeons performing THA,” adds Dr. Ravi, also an assistant professor at the University of Toronto. “More research is needed to understand pain and functional outcomes, which also need to be considered in choosing a surgical approach.”

Performance of direct anterior THAs in the United States was estimated to have increased from 12 per cent in 2009 to 40 per cent in 2018. In Ontario, the anterior approach became increasingly common from 8 per cent of all THAs in 2015 to 12 per cent in 2017.


Media contacts:

Nadia Norcia Radovini
Communications Advisor, Sunnybrook Health Sciences Centre

Deborah Creatura
Media Advisor, ICES