No Difference in Outcomes Between Anterior and Posterior Surgical Approaches for Outpatient Total Hip Replacement
Outcomes were equivalent for patients who had a total hip replacement with either an anterior incision approach or a posterior incision approach, according to an analysis of data from a matched group of patients who were treated at Hospital for Special Surgery (HSS) and discharged the same day.
Time to walking, length of surgery, pain at discharge and rates of complications and readmissions at 90 days after surgery were clinically and statistically the same for patients who had surgery with either approach. This study is available online as part of the AAOS 2020 Virtual Education Experience.
Anterior and posterior approaches are the two most common incision locations for performing a hip replacement. Both are located mostly on the side of the body, with some slight differences. Anterior incisions are more to the front of the hip and are visible when standing facing a mirror. Posterior incisions are further around the curve of the hip and are not visible from the front. Surgeons at HSS use an anterior or a posterior approach according to their preference, training and expertise.
Results from previous studies comparing the two surgical approaches have been unclear. Some used comparison groups that were not matched for age and body-mass index; others did not compare surgeries from the same period.
“Today’s advertising can be confusing, as it creates a mixed message about whether there are clinical benefits with a particular surgical approach. We wanted to find out what the evidence shows when the approaches are appropriately compared,” explains senior author Michael P. Ast, MD, a hip and knee surgeon at HSS. “Our results showed that surgical approach didn’t matter. At HSS, both methods provided the same excellent outcomes for our patients.”
Dr. Ast and surgical colleagues examined outcomes for 138 patients who had hip replacements at HSS in 2019 and were discharged the same day. Patients received the same care before, during and after surgery, according to HSS protocols. The researchers grouped patients according to whether they had received an anterior or a posterior incision, with 69 in each group. Age, sex and body-mass index of each group were matched.
There were no statistically significant differences in outcomes between the two groups at any timepoint within the first 90 days post-surgery. There were no reoperations in either group and complications were very low, affecting only two patients in the anterior approach group and three patients in the posterior approach group. For all patients, early ambulation was associated with earlier discharge and decreased use of pain medication while still in the hospital.
“We now have evidence to show that incision location does not matter in total hip replacement,” says Dr. Ast. “What does matter is surgical expertise, careful patient selection for outpatient procedures and high-level care before, during and after surgery.”
To corroborate these findings with a larger study, Dr. Ast and colleagues continue to collect patient outcome data for the two groups in their prospective database. Their goal is to re-run the analysis when they have data for 500 patients in each group. “At HSS, we perform about 4,000 hip replacements every year, so we are excited to continue this study to meet that goal,” Dr. Ast says.
HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the 11th consecutive year), No. 4 in rheumatology by U.S. News & World Report (2020-2021), and the best pediatric orthopedic hospital in NY, NJ and CT by U.S. News & World Report “Best Children’s Hospitals” list (2021-2022). HSS is ranked world #1 in orthopedics by Newsweek (2020-2021). Founded in 1863, the Hospital has the lowest complication and readmission rates in the nation for orthopedics, and among the lowest infection rates. HSS was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center five consecutive times. The global standard total knee replacement was developed at HSS in 1969. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Global Innovation Institute was formed in 2016 to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is a trusted leader in advancing musculoskeletal knowledge and research for physicians, nurses, allied health professionals, academic trainees, and consumers in more than 130 countries. The institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally. www.hss.edu.