Does the Surgical Approach Affect the Revision Rate in THA?
Using data from the Australian Orthopaedic Association National Joint Replacement Registry, researchers evaluated whether the surgical approach was associated with differences in early revision rates in primary total hip arthroplasty patients.
Nathan Jia, MD, and Ajit Deshmukh, MD
Hoskins W, Bingham R, Lorimer M, Hatton A deSteiger RN. Early rate of revision of total hip arthroplasty related to surgical approach: an analysis of 122,345 primary total hip arthroplasties. J Bone Joint Surg Am. 2020 Aug 4. doi: 10.2106/JBJS.19.01289. Online ahead of print.
Total hip arthroplasty (THA) is one of the most successful surgical procedures, with excellent long-term survivorship. Numerous surgical approaches can be employed to perform THA; however, there is no clear agreement on which is the best.
Hoskins et al retrospectively collected data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) to evaluate differences in early revision rates in primary THA patients based on the surgical approach used. Data were collected for a 3-year period, 2015 through 2018. The researchers included all patients who underwent a THA via the anterior, lateral, or posterior approach during this time period, excluding those with metal-on-metal bearings.
The primary outcome measure was the cumulative percent revision (CPR) for all causes. Secondary outcome measures were major revisions involving a change of femoral and/or acetabular component or revision for a specific diagnosis, including fracture, femoral component loosening, infection, and dislocation.
A total of 122,345 primary THAs were included in the study, 54% by the posterior approach, 20% by the lateral approach, and 26% by the anterior approach. No difference was seen in the overall CPR among the approaches. However, there were differences in types of revision and the reasons for revisions among the approaches:
- The anterior approach was associated with a higher rate of major revisions when compared with the posterior or lateral approach.
- The anterior approach was also associated with higher rates of revision for periprosthetic fracture and femoral component loosening compared with the other 2 approaches.
- In terms of infection, the anterior approach was superior, with significantly lower rates of revision compared with the lateral approach for the first 3 months, and at all time points compared with the posterior approach.
- The posterior approach was associated with a higher rate of revision secondary to dislocation compared with both other approaches at all time points.
Surgeons have multiple options for the surgical approach for THA, but whether a particular approach is superior to others is controversial. This study helps to identify potential complications associated with 3 approaches, which can aid in surgical planning.
When choosing a surgical approach, it is important to bear in mind patient risk factors and use an approach that minimizes potential complications. For example, patients at higher risk for infection and dislocation, such as those with end-stage renal disease, may benefit from an anterior rather than a posterior approach THA.
Similarly, surgeons should be aware of the risks associated with the given approach and plan accordingly to minimize complications. When performing THA via an anterior approach, for example, particular care should be taken during canal preparation and stem placement, thereby protecting against loosening and periprosthetic fracture. A dual mobility implant may be considered for patients at high risk of dislocation who are undergoing a posterior approach THA.
Given that no significant differences are found in the overall revision rates among the surgical approaches for THA, an argument can be made that in most cases, surgeons should choose the approach with which they are most familiar. A previous analysis of AOANJRR data showed an early learning curve for the anterior approach, and those new to the approach may see higher complication rates overall. 
This study contributes to a large body of data examining outcomes of THA related to specific surgical approaches. As described in other studies, overall rates of revision are the same, although indications for revision differ for each approach. The approach should ultimately be selected after considering the risk profile of the patient, risk profile of the approach, and surgeon familiarity with the approach.
Nathan Jia, MD, is an orthopedic surgery resident at NYU Langone Orthopedic Hospital, New York, New York. Ajit Deshmukh, MD, is a Clinical Associate Professor of Orthopedic Surgery in the Division of Adult Reconstruction at NYU Langone Orthopedic Hospital, New York, New York.
Disclosures: The authors have no disclosures relevant to this article.
- deSteiger RN, Lorimer M, Solomon M.What is the learning curve for the anterior approach for total hip arthroplasty? Clin Orthop Relat Res. 2015 December;473(12): 3860-6.