Anterior Approach Linked to Greater Risks During Total Hip Arthroplasty

Daniel Pincus, MD, PhD

An anterior surgical approach was associated with a small, statistically significant increased risk of major surgical complications, according to a new study comparing the anterior approach with the posterior or lateral approach.

Daniel Pincus, MD, PhD, and colleagues from Toronto, Canada, determined whether an anterior surgical approach was associated with lower risk complications in patients undergoing total hip arthroplasty than a lateral or posterior approach. The findings could help inform decisions about the surgical approach used for hip arthroplasty.

Pincus, from the orthopedic surgery division at University of Toronto, and his colleagues studied all adults in Ontario, Canada, who underwent primary total hip arthroplasty for osteoarthritis between April 2015-March 2018. Patients were >18 years old and were followed up for 1 year.

The investigators grouped together patients who underwent lateral and posterior approaches to compare with the anterior approach.

Pincus and the team’s primary outcome was the occurrence of a major surgical complication within 1 year. They defined a composite complication as a priori as the primary measure. The composite included revision arthroplasty, deep surgical site infection requiring surgery, and hip dislocation requiring open or closed reduction.

Secondary measures consisted of length of stay considered as a continuous variable in days; surgery duration measured as total time elapsed in minutes between entry into ad exit out of operating room; readmission to any Ontario hospital within 30 days; and presentation to any emergency department in Ontario within 30 days.

The team matched patients who had an anterior approach to those who had a lateral or posterior approach 1-to-1. Potential confounders included sociodemographics, patient health status, and physician and hospital characteristics.

After matching, primary and secondary outcomes were compared between the 2 groups.

Overall, 30,098 patients (mean age, 67 years old; 16,079 women [53.4%]) underwent total hip arthroplasty. Of them, 2995 (10%) underwent the anterior approach, while 21,248 (70%) underwent the lateral approach and 5855 (20%) had the posterior approach.

Patients who had an anterior approach were younger (mean age 65 vs 67 years old); had lower rates of morbid obesity (4.8% vs 7.6%), diabetes (14.2% vs 19.9%), and hypertension (53.4% vs 62.9%); and were treated by higher-volume surgeons (median range, 111 procedures; IQR, 69-172 vs 77 procedures; IQR, 50-119 in the prior year), compared to those who underwent posterior or lateral approaches.

Before patient matching, those who underwent the anterior approach were at a significantly higher risk of a major complication within 1 year (61 of 2995 [2%] vs 398 of 27,103 [1.5%]; absolute RD, .57%; 95% CI, .04-1.09%; HR, 1.41; 95% CI, 1.08-1.85).

When matched for propensity scores, compared with 2993 patients who underwent a lateral or posterior approach, the same amount of patients who had an anterior approach had a significantly greater risk of a major surgical complication (61 patients [2%] vs 29 patients [1%]; absolute risk difference, 1.07%; 95% CI, .46-1.69; HR, 2.07; 95% CI, 1.48-2.88).

Additional research could lead to a better understanding of pain and functional outcomes.

The study, “Association Between Surgical Approach and Major Surgical Complications in Patients Undergoing Total Hip Arthroplasty,” was published online in JAMA.