September 2, 2021

The choice between posterior and direct anterior approaches, both effective and safe, boils down to surgeon preference.

CREDIT: Patrick Toy
WHICHEVER WORKS Surgeons are split on their preferred approach to knee replacements, but fortunately both primary options are clinically effective.

What's the best surgical approach to replace hips: posterior or direct anterior? Both techniques come with inherent advantages and disadvantages, but the literature and anecdotal debate largely find basic agreement that both approaches are safe and effective — it’s really all about what the surgeon feels most comfortable doing.

Posterior approach. With this method, the incision is made on the side of the hip, above the greater trochanter of the femur, and the dissection goes behind the abductor muscles. Daniel Pincus, BA&Sc, MD, PhD, FRCSC, a joint replacement specialist and an assistant professor at the University of Toronto Sunnybrook Holland Orthopaedic Centre, says patients operated on with this approach usually recover with no risk for long-term abductor dysfunction or chronic limping. "The posterior approach is also the most extensile, making it the primary option for revision surgery," he says.

Joshua C. Rozell, MD, a hip and knee reconstruction specialist at NYU Langone Orthopedic Center in New York City and NYU Langone Ambulatory Care Bay Ridge in Queens, says the posterior approach is generally easier to perform because the hip is more accessible from the back than from the front. "Surgeons achieve easy extensibility of the incision and greater exposure for better access to the implant's femoral stems," he says.

Other advantages of the posterior approach include less blood loss, faster surgical times, less anesthesia prep time, and the fact that fluoroscopy and a specialized hip table are not required, says R. Michael Meneghini, MD, director of the Indiana University Health Hip and Knee Center and professor of clinical orthopedic surgery at Indiana University School of Medicine in Indianapolis. He believes this gives the approach a leg up in surgery centers.

Disadvantages include higher rates of post-op joint instability and slower recoveries than the anterior approach. Concerns about intraoperative dislocations have eased, but improved surgical technique and implants with large diameter bearing surfaces have lowered rates to levels on par with the anterior approach, says Dr. Pincus.

Direct anterior approach. With this technique, surgeons enter the joint through the internervous plane and between the abductor muscles, leaving external rotators and tendons intact. Dr. Pincus says this muscle-sparing approach facilitates faster early recovery in theory, but more data is needed to confirm this. Dr. Rozell says this approach allows surgeons to better measure leg length, which he says is more difficult to do with the posterior approach. He believes the anterior approach is cleaner and that its preservation of soft tissue makes it more conducive to outpatient procedures. "Anecdotally," he adds, "I've found joint stability is typically better than with the posterior approach."

Dr. Meneghini says disadvantages associated with the anterior approach include increased risks of femoral fracture, nerve injuries, infection, femoral component loosening, anterior groin pain, iliopsoas impingement and wound complications. Another disadvantage involves the location of the incision near the groin. "The skin and underlying tissue and fascia are less robust for closure compared with the side of the hip where the posterior approach is performed, which has led to an increased risk of wound breakdown and prosthetic joint infection," he says.

Dr. Pincus says the direct anterior approach limits the femoral access needed for inserting the implant's stem, but surgical techniques and technology are addressing this limitation.

Approaches to the hip are typically based on the preferences of surgeons, who often use the one they're most comfortable performing or the one they were taught during residency. “The way surgeons are trained plays a big role in the approach they choose,” says Dr. Rozell. Adds Dr. Pincus, "Despite all our work on this topic, I still believe the choice of surgeon is much more important than the choice of approach."

Here's what it takes to make it happen at your facility.

HIP TO BE DISCHARGED Same-day hip replacement surgeries can be performed in an hour, but serious planning is required to ensure superior outcomes.

Devastating hip pain hasn’t gone away for many individuals during the pandemic. With elective hip replacement surgeries again being postponed in hospital environments or avoided by fearful patients because of the dangers of COVID-19, many continue to suffer in silence waiting for the hospital to be "safe" again. Fortunately, the safety and efficacy of outpatient same-day hip replacement surgery in non-hospital environments can provide them relief.

Tremendous strides have been made in the quality and efficiency of same-day hips, and an ever-growing list of outpatient facilities offer them, says Steven Dellose, MD, an orthopedic surgeon at Delaware Orthopedic Specialists in Wilmington, who with his partner performs nearly 1,000 hip and knee replacements and revisions each year — the largest annual volume of primary and revision joint replacement surgeries in the state of Delaware.

To execute same-day hips, your facility should employ high-volume orthopedic surgeons who possess a long track record of performing the procedures efficiently and safely. “One major reason we're able to perform such a high volume of cases is specialization,” says Dr. Dellose. "I don't perform upper-extremity procedures, and our joint replacement team is made up of sub-specialized, fellowship-trained surgeons."

Same-day total hips require extra work and commitment from surgeons, he notes. "The preoperative process and postoperative follow-up protocols are much more involved, but the extra steps are necessary to make sure patients aren't admitted to the hospital or suffer avoidable complications," says Dr. Dellose, who notes that a comprehensive clinical pathway is needed to perform same-day outpatient hips successfully. It often takes Dr. Dellose a mere 35 minutes to perform these surgeries, but for less experienced orthopods, it takes about an hour, he says.

Surgeons can access the hip through various techniques, commonly the anterior or posterior methods. Dr. Dellose prefers a third technique, the anterolateral approach, which allows him to operate through a single small incision and work between muscle groups to minimize soft tissue trauma in the joint. As a result, he says, patients can ambulate sooner after surgery and prepare for discharge in just a few hours.

Advancements in post-op pain control and anesthesia techniques are also enabling same-day hip replacements. Dr. Dellose, like surgeons in numerous specialties, has embraced a multimodal approach that provides effective postoperative pain relief while greatly reducing opioid consumption. He usually employs regional spinal anesthesia and periarticular blocks that lead to faster recovery times.

Another key is patient optimization. "Before surgery, my patients receive a preoperative evaluation that includes a physical therapy session during which they become familiar with what will be required of them to help advance the healing process after surgery," says Dr. Dellose. "Patients go to physical therapy the day after surgery and typically schedule sessions three days a week for two to six weeks post-op. It really is a remarkably quick recovery process."

Concludes Dr. Dellose, "It takes a high level of commitment from all providers involved to make same-day hip replacement program work, but the benefits to your facility, the healthcare system and, of course, patients are undeniable."

This life-altering procedure is growing in popularity in outpatient surgery facilities.

CREDIT: Bone Foam Inc.
Illustration of how consistent patient positioning is achieved using the Hippy.

A same-day total hip replacement seems like a daunting surgery to perform. According to an article in Outpatient Surgery Magazine, "Same-Day Hips Are a Recipe for Success,"" the prediction is that case volumes are expected to surge as more total joint procedures move to the outpatient setting. Tremendous strides have been made in the quality and efficiency of this life-altering procedure, and there is an ever-growing list of outpatient facilities that are performing these surgeries with great success, thanks to new techniques and comprehensive patient care.¹

According to Dr. Steven Delloise, "Hip replacement is a game-changing treatment for patients who often consult with a surgeon on the heels of several failed conservative interventions. Many patients who opt for surgery have already tried several treatment options before their surgeons recommend finally fixing the underlying cause of their joint discomfort."¹

This game-changing surgery requires careful planning and equipment to safely offer this surgical procedure and ensure successful outcomes, whether the setting is in the hospital or the outpatient setting. Proper patient positioning is among the top challenges for hip replacements that surgeons and their OR teams face.

According to a current practice trends review from 2009-2018, the use of the direct anterior (DA) total hip arthroplasty (THA) approach increased by 28%, while the posterior approach decreased by 18%.²

Bone Foam's new tabletop Hippy^™Anterior Hip Positioning System simplifies patient positioning for anterior hip replacement on any operative table. Consistent, repeatable, and stable pelvic positioning is easily mastered by all OR staff. The system reduces hospital cost with a reusable postless design. It increases surgical access to the acetabulum with removable hip bolsters and decreases OR prep time with an efficient method for patient positioning.

This innovative design reduces injury risk to the perinium by providing counter traction during distraction without the use of a post, while stabilizing the pelvis and torso. The Hippy has bilateral removable hip bolsters, which improve surgical access to the acetabulum and creates a stable pelvis for cup impaction. Stable and consistent positioning for patients of all sizes is achieved with the Hippy.

Note: For more information, please go to www.bonefoam.com.

References:

1. Outpatient Surgery Magazine, Same-Day Hips Are a Recipe for Success - Orthopedic Surgery - September, 2020 (aorn.org)

2. Abdel, Mathew P. et. al., Current Practice Trends in Primary Hip and Knee Arthroplasties Among Members of the American Association of Hip and Knee Surgeons: A Long-Term Update.” The Journal of Arthroplasty, Volume 34, Issue 7, S24-S27

The possibility of pressure injury requires specialized placement of protective padding.

If your staff isn’t overly concerned with pressure injury prevention because patients who undergo outpatient procedures are relatively healthy and have fairly normal BMIs and low ASA scores, it’s time to for them to reconsider their positions on positioning protocols.

Your staff should pay extra attention to high-risk areas when positioning and padding patients before surgery. For every position, however, the affected anatomy and strategies are different. Here is a quick overview of the high-risk areas for the common patient positions, based on AORN's Pressure Injury Prevention Toolkit:

• Supine. Occiput, scapulae, elbows, thoracic vertebrae, lumber area, sacrum/coccyx, buttocks and heels.
• Prone. Forehead, eyes, ears, chin, chest or breasts, iliac crest, genitalia, knees, shins, dorsa of the feet and toes.
• Lateral. Side of the face, shoulder on the vulnerable side, dependent axilla, hip, leg, knee, ankle and foot.
• Lithotomy. Occiput, scapulae, elbows, thoracic vertebrae, lumber area, sacrum/coccyx, buttocks, and lateral aspects of the legs and heels. Do not extend the buttocks over the break of the bed, protect the lateral aspect of the upper fibula, and apply boot stirrups to support the legs and reduce the stretching of nerves.
• Beach chair. Occiput, scapulae, ischial tuberosities, backs of the knees and the calcaneus.
• Trendelenburg. Occiput, scapula, arms, elbows, vertebra, lumbar area, sacrum/coccyx, buttocks and heels. To prevent sliding, don’t secure the patient without shoulder braces or chest straps, which can lead to injury; instead, a protective pad designed to prevent slippage is an effective option.

“Pressure injury risk in the outpatient setting is an underreported and underrated problem," says Diane Kimsey, MSN, MHA, RN, CNOR, CMLSO, WTA, perioperative educator at Einstein Medical Center Montgomery in East Norriton, Pa. "Your entire care team must ensure appropriate skin assessments take place, and follow protocols to identify high-risk patients and apply extra protection to their skin to protect it from harm."