The Big Flip | Orthopedics This Week
Large Joints and Extremities

The Big Flip

Alice's Adventures in Wonderland/Wikimedia Commons

Across the U.S. hospital press releases and marketing blitzes are being fired off touting the benefits of anterior hip replacement surgery. As orthopedic operating rooms become fitted with operating tables designed for the procedure, patients are catching the bug and requesting the procedure.

The Origin of the Flip

Of course anterior positioning is not a new concept. Hip replacements from the front have been happening since the early 1980s and, some would argue, decades before that.

Joel Matta, M.D., Medical Director of the Hip and Pelvis Institute at the Saint John's Health Center in Santa Monica, is often credited with bringing the procedure to the States but he prefers to assign credit to French surgeon Emile Letournel, M.D., who in fact demonstrated the procedure to Dr. Matta and then proceeded to teach it to him as well.

Its popularity was not exactly an overnight sensation. While it may be gaining support and practitioners now, it had its skeptics in those early years. Matta, a fracture specialist, was not exactly a hip reconstruction insider and that, perhaps as much as anything, kept adoption rates low for many years. Today however anterior may actually be one of the hottest catch phrases in hospitals and more than a few rank and file hip reconstruction-ists are singing its praises to a receptive audience of baby boomer patients looking for an alternative to their grandmother's hip replacement. The timing also seems right because of new advances in the equipment used. More on that later.

Marketing Angle

It's hard to make hip replacements sound sexy. But add the words "new, " "revolutionary" or "break-through" and you may be on the road to something with differentiation. The anterior approach has become a marketing vehicle for individual practices and, increasingly, patients are seeing such ad tag lines as "Less Pain, No Cane" and "Bringing the Future Here." 

Anterior Approach Ad/Abington Memorial Hospital
There are even blogs specifically dedicated to the anterior approach and websites created by physicians and hospitals to take patients through the entire process. Of course these sites often come well stocked with patient’s testimonials which invariably include many stories of patients getting back to actively enjoying life shortly after surgery.

Some enterprising docs have gone so far as to secure such website domain names as if for no other reason than to capitalize on the search engine interest of potential patients. It's clear this is a new development for the tried and true joint surgery. And for patients, this is one of the few times in the procedure's history where there's something to get excited about.

What's All the Hype About?

But what exactly is the fuss all about, the anterior approach does just mean the hip replacement is performed with incisions in the front, rather than side or back of the body. The claim, of course, is that such a small change in location could shorten patient recovery times.

Of course, surgeons have been working with approaches (i.e., the two-incision approach) which promise to reduce the level of muscle and soft tissue trauma. One apparent advantage of the anterior approach is that the primary incision can be made in the front of the thigh, just below the hip. Therefore, to reach the diseased hip joint, the surgeon can more easily move between two primary muscles and reduce the level of muscle trauma and splitting.

In the hands of the experienced anterior practitioner and with proper patient selection, advocates of the anterior approach maintain that patient recovery times can be reduced significantly. But what raises this procedure to a level that might be considered “hot” is that several companies are now supplying advanced instrumentation and equipment that help surgeons perform more routinely successful anterior approaches to hip replacement. "We've been performing anterior approach hip replacements for almost four years and started out with using a conventional table. The results were pretty well received, " says Andrew Star, M.D., Chief of Orthopaedic Surgery, Abington Memorial Hospital, just outside of Philadelphia.

Star says the anterior approach has issues that are not unlike those encountered with traditional hip replacement surgery. "It's not a panacea and it's not a procedure that doesn't involve recovery time." But what is markedly different is that the length and severity of recovery is less. "We consistently see patients getting better much faster and having less anxiety before and after the procedure. There are also fewer restrictions afterwards.

"We can send someone home saying 'use common sense' rather than a list of restrictions. You don't have to worry about how you bend, so all those everyday tasks: getting into the car, going to the bathroom, going to sleep, are all so much easier and that makes recovery significantly easier on the patient and the caregiver."

In fact, Star says that in his practice he has anterior hip replacement patients asking to go home within 24 hours after surgery.

Anterior-Specific Operating Tables

There are a number of tables designed specifically to address the needs of the anterior approach and also take into account the many varied patient body types that surgeons encounter. These tables include Mizuho's PROfx and Trumpf's ArchTable. Abington Hospital has recently invested in Mizuho's Hana table and Star says it is allowing their surgical team to vastly expand the scope of patients that are able to have the anterior approach for their hip replacement surgeries.

"When we first started, we performed 10 to 20% of our hip replacements using the anterior approach. The table has allowed us to increase that number to about 80% of our patients today. The majority of our hip replacements are now performed using the anterior approach.

"We still can't do the tremendously muscular patients or those with severe bone deformities or patients who are extremely obese. But while the patients with extreme body types will still require traditional hip surgery, the line dividing patients for whom the anterior approach may be indicated and those for whom it is not has moved so far over. We are now able to offer it to more people than ever because of having this type of operating table."

Hana Table/Abington Memorial Hospital
Operating tables like the Hana aren't just about positioning. They also have other capabilities. Because, in the case of the Hana table, the material employed is x-ray friendly carbon fiber, the surgeon is able to snap off quick, real time X-rays—essential when performing less-invasive types of procedures. "This helps us to really see where we are putting the cup and with positioning and sizing, " explains Star. "We used to take an X-ray at the end of the surgery, but with this table, we have the ability to make micro-changes as we go and, as a result, we tend to do a better job."

The Anatomy of Innovation

So given the advantages of the anterior approach, why did it take literally decades for it to become quite nearly a main stream approach within the broader hip replacement community?  There are certainly many opinions but one explanation that we heard seems to make sense. In order for any new procedure to make its way into the mainstream of a practice is needs to clear three basic hurdles: first, it needs to be attractive enough to surgeons that they want to perform it; second, the learning curve for the new procedure must be short and relatively flat and third; finally, there must be equipment and instrumentation that helps surgeons to achieve consistency and reliability of outcomes.

Joint replacement surgery, of course, is the poster child of a routinely successful surgery with millions of patients walking satisfactorily on their new hip. Dozens of peer review papers have documented the cost effectiveness and highly successful patient outcomes of traditional hip replacement surgery. So "if it ain't broke, don't fix it" is probably the single biggest hurdle to the anterior approach. If traditional hip replacements work fine and patients are satisfied, why change?

Compounding the problem is that the surgery itself is technically more difficult than traditional hip replacement approaches. "Surgeons are people too, " says Star, "and there is an advantage to repetition and perfecting a technique.

The anterior approach has a harder learning curve; you have to do a lot of these procedures to really become comfortable with the surgery.

"This was enough of a change that people had to relearn their technique and since the current results for traditional hip replacement were good, I think there was a feeling of 'why change?'"

The answer, not surprisingly, appears to be coming from the patient. Less post op pain and faster recovery times are beginning to find their way to the patient. The Genie may well be out of the bottle. Several surgeons have used the anterior approach as an opportunity to create marketing campaigns based on the ideal of a "new" procedure that delivers the hope of speedier recoveries.

A few years ago the two-incision approach was purportedly the latest and greatest development in the hip replacement community, but complications rates turned out to be much higher for this technique than standard surgery. Right now, marketing and anecdotal numbers are all we have to judge the anterior approach's benefits. Until a peer review study is published that focuses on concrete numbers and long-term outcomes of several hundred patients the jury will have to remain out as to whether this alternative is indeed the successor to traditional surgery.


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