In this episode of PodMD, Orthopaedic Surgeon Dr Jason Hockings will be discussing the topic of the direct anterior approach to hip replacement. We discuss why the anterior approach to hip replacement surgery has gained popularity, specific patient populations suitable for the surgery, post-operative management, what GPs should look out for, and more.
- Transcript
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*As always, all in this PodMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Jason Hockings.
Dr Jason Hockings is a Victorian-trained orthopaedic surgeon with subspecialist expertise in hip, knee and shoulder surgery. Jason completed his orthopaedic training in Victoria in 2021 and has since undertaken multiple post-fellowship training programs. You can read more about Jason on his profile page on our PodMD website.
Today, we’ll be discussing the topic of current concepts in best practice in hip replacement surgery focusing on the direct anterior approach.
*Please listen to our disclosure at the end of this podcast
Jason, thanks for talking with us on PodMD today.
Jason: Thank you for having me.
Okay, so we’re talking about anterior approach to hip surgery. So why has this gained popularity in recent years, Jason?
Jason Look, there are a number of reasons why this is becoming more popular. It’s something that patients have been doing their own research on. So I find patients actually come and ask me about the anterior approach now, which is really interesting. It’s an approach that’s been around for quite a while. It was actually first described over 100 years ago, and it’s been done in France for quite a long time. But in the Anglosphere countries, it’s only really been gaining in popularity in the last 10 or 20 years.
The big advantages of it for patients, unlike the posterior approach, you don’t have to cut any muscles to get down to the hip joint to perform the hip replacement. So that means it can be done through a smaller incision. There’s much less pain after the operation with a much faster recovery. Patients are up and going much faster, less opiate use, less time in hospital, all those things that are really important to get a good outcome for the patients.
So when you say much faster, et cetera, what are we talking in terms of time and so forth?
Jason: Look, it does vary. So I tailor it to the patient’s own individual needs. I certainly don’t rush patients out of hospital. But there are centres in the US that have started doing this as a day case. That’s how quickly people can recover. So they can have their operation in the morning and they can be out later that day. That’s not something we do in Australia very much.
But certainly I’ve had many patients that go home the next day. A lot of patients do prefer to stay in hospital for two or even three nights just to get really comfortable, and that’s completely fine with me. But if they are motivated to get home early, they can often go home the next day.
You mentioned pain and pain’s reduced as well. So what are we talking there?
Jason: So if you look at the pain scores afterwards, it’s about half as much as with the posterior hip. And often anecdotally, the patients the next day say they have almost no pain at all in the hip. So they have a little bit of incisional pain around where I’ve done the approach. But in terms of muscular pain and pain deep in the joint, they have almost none a lot of the time. They’re up walking usually that day.
So if I do the operation in the morning, they’re up walking that afternoon once the spinal anesthetics worn off and are relatively pain-free. And when I see them at 2 weeks to check their wound and how they’re progressing, almost universally, they’re off all the strong painkillers. They’re just taking paracetamol and maybe an anti-inflammatory and that’s it.
Are there specific patient populations that are better candidates for this type of surgery?
Jason: Yeah, that’s a great question. Initially, the indications for the anterior approach were a bit selective, but they’ve broadened over time. For me, I offer it to almost every patient. So there’s no age restriction on it. It can be offered to anyone, young and old.
The one group of patients where it can cause a problem is patients with a BMI over about 45. And that’s just because of the location of the incision presents issues with wound healing. So in that group of patients, I have the discussion with them about whether the anterior or posterior approach is better, or if it’s worth getting the BMI down a bit before they go ahead with the surgery.
When you talk about the wound healing, what is the actual difference?
Jason: The difference is in the location. So if people have a…large abdominal pannus over the wound, it can cause issues with wound healing and it presents an increased risk of infection, which is obviously something we go out of our way to avoid with a prosthetic joint replacement.
So with the surgery as well, are there any other contraindications?
Jason: No, there’s not. When people started doing the anterior approach, one of the problems they had was the risk of fracture. And that’s a legitimate concern. If you look at the joint registry, that has shown up as a higher rate of revision for fracture in the anterior approach compared to the posterior approach. And that was one of the main concerns when people started doing it. We’ve come a long way since then. So one of the reasons for that was we didn’t have the appropriate instrumentation to do the approach. That’s changed now as technology’s improved.
The other thing that’s changed is we’re much more comfortable cementing a stem in rather than using a press fit stem. And we know from the data that a cemented stem has a lower fracture rate. So the patients where this is a concern is elderly patients with osteoporosis. So that’s what I meant by when people started doing this approach, they were reluctant to do it on elderly patients with osteoporosis. For me, I have a conversation with that group of patients. We’re much better at avoiding fracture now for the reasons I’ve discussed, but I would offer them both approaches and sort of collaborate with them on which one they prefer.
Are there any other trials underway at the moment for further development of the surgery?
Jason: Look, there’s always trials going on, but the data is pretty much settled. So over the last five years, there have been a lot of really big studies on it, looking at patient-reported outcomes and also looking at registry data. And for those who don’t know, registries is a sort of collection of all the joint replacements that are done in an area. So Australia has a national joint registry, it’s one of the most robust in the world, it’s very well respected the world over, so as surgeons, we sort of rely on that for a lot of our decision-making. Our registry data is conclusive. The revision rate for anterior approach is actually a bit lower than the other approaches. So that gives us a lot of reassurance in terms of using the approach.
The differences in cause of revision are also interesting. So there’s a lower rate of revision for dislocation and for infection. And the dislocation one particularly is really relevant for younger patients because they don’t want to have to worry about hip precautions. They want to get back to activities like skiing, snowboarding, Pilates, et cetera. So it’s a real advantage for them. In terms of the rest of the studies, the patient-reported outcomes show a massive difference in the first three to six months. So patients have less pain, have better patient-reported outcomes in that time period. By about 12 months, they converge with the posterior approach. But for people that want that faster recovery and that enhanced recovery post-op, the data is very conclusive now.
I presume there’s physio and so forth post-operatively that the patient undergoes?
Jason: Yeah, absolutely. So it’s a real integrated care approach now. So I encourage my patients to see a physio pre-operatively. I’ve got a physio I work closely with, but often they’ve already got a physio they’ve got a good relationship with, so I just link in with them. I encourage them to do a bit of prehab and get used to the exercises they’re going to be doing post-operatively.
When they’re in hospital, the physios on the ward go through all that with them and do the exercise with them over the first couple of days post-operatively, make sure they’re safe to go home. And then they have about 6 to 12 weeks of rehab with their chosen physio. And by the end of it, the goal is that they’ve essentially forgotten they’ve had a hip replacement and just feels normal and they’re back to doing all their normal activities pain-free.
So, in relation to the GP, what would you like the GP to look out for and monitor post-operatively after this surgery?
Jason: Yeah, so I really try to keep my lines of communication very open with GPs. So I like to follow up my patients myself very closely. So I see them at two weeks and check the wing myself. It’s not something I ask the GPs to do unless there’s a specific reason. I then see them again at six weeks with an X-ray and assess their progress. Often by six weeks, they’ve completely recovered and they finish their physio. And at that point, I don’t make a routine follow-up for them unless there’s an issue.
If they’re still recovering, then I see them at three months. And at all those points, the GP know how they’re going. So really for the GPs, it would just be if the patient presented with a problem. And as I say, I keep the lines of communication very open and I encourage them to just let me know straight away so I can get on top of it.
So Jason, for our listeners today, particularly our GPs, what would your three take home messages be?
Jason: Look, my three take home messages would be that the anterior approach has come a long way in terms of both technique and popularity over the last 10 years. And it’s a really good approach for almost every patient undergoing a hip replacement.
The second take home would be I would particularly encourage it in younger, higher demand patients that are going to be doing activities that present a risk of dislocation. That’s where the anterior approach really comes into its own and they will really benefit from that.
And the third take home point would be just to be a little bit more wary of it in patients with a significantly elevated BMI or in very elderly osteoporotic patients. Those are the patients where I would have a discussion with them about the pros and cons of the anterior versus the posterior approach.
Absolutely. Well, look, thank you so much for your time and insights today. We’ll also be recording a podcast on with Jason in relation to knee replacement surgery. So listen out for that too. So again, thank you for your time, Jason.
Jason: Thank you very much for having me. It was a pleasure.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD. If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
