Orthopaedic Surgeon - Canada

I agree that outcomes following DAA compared to LA are superior for the reasons mentioned. With the use of fluoro I would say I am more accurate with sizing, placement and limb length and find it uncommon to be in varus. There are certainly times where I choose not to go to bigger size given appearance on fluoro and limb length which may appear under sized. Blood loss, wound maceration, LFCN palsy, femoral palsy, surgical length are all downsides to this approach in addition to hip flexor tendonitis. I feel these are far better tolerated given the downsides to other approaches (LA-limp, PA-instability or LLD bc of perceived instability and lengthening limb) Bottom line is that a THA is a good operation and current outcome measures cannot differentiate these approaches.

Orthopaedic Surgeon - Canada

Interesting read for sure, my anecdotal experience would agree with the findings as I do all 3 approaches, with lateral almost completely phased out. I was huge on the AA for 4-5 years and now have transitioned to the PA as my workhorse. My question would be, are the differences really clinically significant? I see a difference in the first week or 2 for AA vs PA for pain but after that they are very close. My issue with AA is the catastrophic complications, albeit rare, such as femoral nerve palsy which is disabling, where a sciatic nerve palsy is an annoyance. The learning curve is real and not overcome by some surgeons, varus stems are almost the norm in some hands. My love of the AA has dwindled, although I still do one every week or so but less than I did before.

Orthopaedic Surgeon - Canada

While there is definitely a signal there that AA holds some merit, I would not say the majority of surgeons yet are ready to transition to anterior because of the tradeoffs mentioned. There is still a very steep learning curve fraught with some bad complications, high blood loss, difficulty extending your exposure, cherry picking of patients by many surgeons (slimmer, younger often) which may be skewing the data and the long term outcomes aren't overwhelmingly in favor of AA.

Orthopaedic Surgeon - Canada

I agree with the bottom line that AA certainly has its advantages. I don’t believe that the AA is the be all and end all of approaches. It has its advantages including minimal pain and rapid recovery. I, myself, have been doing them for a few years now and don’t see a lot of them back for follow up. They tend to disappear after 6 weeks (which differs from the lateral group). There is a massive learning curve and the “nuisance” complaints that go with all joint replacements tend to be different for AA. Mainly tight flexors causing thigh pain (typically from over use). The biggest benefit in my eyes is the massive reduction in opioid consumption in the post op period. I would say, the amount of narcotics used is almost negligible. This is my main reason for transitioning to this approach. The other issue with AA is that perhaps the Proms data is not sensitive enough to see the difference between the approaches. I have been wondering if we are asking patients the wrong questions. HHS score and proms ask very generalized questions about functional ability. And overall the approaches all do reasonably well But AA patients overall seems to be further ahead. I think the expectations is that instead of asking “can you climb a flight of stairs” the question is “can you run up the stairs”. The answer to the first questions is yes for all approaches. The answer to the second questions is not necessarily yes for all approaches. Anyways, the article is good and I agree with the bottom line.

Orthopaedic Resident/Intern - Canada

Analyzing function and quality of life in this context is tremendously challenging. The SUCRA score in my opinion has limited use. Clinicians should be able to interpret the findings of multiple outcomes (and/or composite) and be able to make determinations about superiority. The issue lies with patients with complications. You group is trying to determine the efficacy of the approach on functional outcome and pain. Yet, are the differences observed generated or mitigated by associated complications? The DAA may in fact be associated with faster recovery and earlier restoration of function. However, how does one capture that signal with groups of patients incurring complications in each group which may chance the data. The results therefore may not be external valid to those that have an uneventful THA. it is a mishmash of results of those with complications and those that do not. For that reason, application of this analysis is tricky.

Physiotherapist - Canada

Physical Therapist - Bow Valley, Alberta - anecdotal - the pts with the AA have been very happy and are all very active (with one complication of perhaps a dozen) . As one comment made in this forum ---don't ask- can you walk up the stairs but rather can you run up the stairs. Several of my pts in the last couple years are mountain guides and ski tourers and literally the question is how well do you do at going uphill for five hours on skis. Many also climb and do these sports after. They are all slim and fit. In my study of one that had a posterior approach then an anterior on the contralateral hip feels the anterior was functional faster and after a few months stronger than the posterior - as the gluts were strong but never completely returned. I also have one pt. with impingement from the anterior approach who is looking at the ramifications of a redo. I don't know if this is only a problem with the AA or is due to his anatomy and size. On my end I appreciate the skill and experience needed and the difficult decisions for the surgeon and how many factors you need to look at to choose your best approach for that pt. On my end we take whatever approach you have used and work with the range, strength, function, balance, goals and pain.

Orthopaedic Resident/Intern - Canada

Analyzing function and quality of life in this context is tremendously challenging. The SUCRA score in my opinion has limited use. Clinicians should be able to interpret the findings of multiple outcomes (and/or composite) and be able to make determinations about superiority. The issue lies with patients with complications. You group is trying to determine the efficacy of the approach on functional outcome and pain. Yet, are the differences observed generated or mitigated by associated complications? The DAA may in fact be associated with faster recovery and earlier restoration of function. However, how does one capture that signal with groups of patients incurring complications in each group which may chance the data. The results therefore may not be external valid to those that sustain a complication. They may do horribly which needs to be looked at independently. This could be in the form of a subgroup graphing of the HRQOL in conjunction with recurrent event analyses (as one complication such as periprothetic fracture or dislocation predisposes patients to more adverse events and reopertions which can be captured by this approach). it is a mishmash of results of those with complications and those that do not. For that reason, application of this analysis is tricky.