The Journal of Arthroplasty xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
A Tale of Two Approaches With great interest I have read the paper "Prospective Randomized Study of Direct Anterior vs Postero-Lateral Approach for Total Hip Arthroplasty" by William P. Barrett MD, et al. After experiencing a right hip resurfacing (BHR) in Spring 2011 through a posterolateral approach and a left THA by the direct anterior approach 9 days ago, I would like to offer some feedback to the authors. Contrary to a widely marketed and published belief that the anterior approach is performed through a minimally invasive internervous and intermuscular plane between the lateral based tensor fascia latae muscle and the medial based sartorius and rectus muscles, the lateral femoral cutaneous nerve (LFCN) resides in the field of dissection. Dr. Barrett fails to discuss that the LFCN is often traumatized during the muscle splitting and often vigorous muscle retraction needed to expose the anterior hip capsule. Reports of LFCN injury range from 15% to 67% for THA with anterior approach in two recent studies by highly experienced hip surgeons [1,2]. The nerve pathway is highly variable as it emerges most commonly under the inguinal ligament and passes over the sartorius and through the tensor interval before arborizing into an anterior and posterior branch. The LFCN gives sensation to the anterior–lateral half of the thigh from the groin to just above the knee. Although LFCN injury is regarded by some surgeons as an annoying and transient sensory nerve complication with minimal functional loss, it is not pleasant to feel like if someone were to stab my thigh with a Buck knife. I would not know it! Recovery of sensation takes many months, years, and some never resolve. If a neuroma develops like in meralgia paraesthetica (uncommon) it is a disabling problem. From the outcome measures Dr. Barrett used in his prospective randomized study design, the anterior approach THA patients have an accelerated discharge home, less pain on day of surgery through day one, and quicker return to functional activities. Based my personal experience I would not agree. My opinion is that there is an inherent expectation or interviewer bias in measuring the outcome data. Response bias (where the patient gives favorable information or pushes further to validate the expected outcome) also may have played a role in the collection of the study data. With the randomized design, selection bias does not appear to a factor.
Each hip approach has certain drawbacks. After the posterior– lateral approach, sitting comfortably is a real issue. Remember the Seinfeld episode where George Costanza was resting on an overstuffed wallet? After a week that posterior discomfort dramatically improves as the gluteal swelling resolves. With the anterior approach, Dr. Barrett did not have any inquiry as to the common post op problem of quad pain and hip flexor soreness. Because of the tensor fascia latae soreness, there is a tendency to abduct the hip with walking and transition movements so that ITB tendonitis may develop. For the last week, I feel that someone slammed a Louisville slugger into my anterior thigh. The tensor fascia muscle group (laterally retracted) feels sore and stiff and makes stair descent uncomfortable. Both approaches involve activity and range of motion restrictions in the early post op period. Because of the quad, tensor fascia latae, and need to protect excessive active flexion of the iliopsoas, anterior approach patients cannot comfortably sit in any low positions. Extension and external hip rotation range of motion is restricted because of the anterior capsule repair. When presenting outcomes on early post op recovery, I suggest that these subtleties be recognized. Is the posterior–lateral approach with an enhanced capsular repair and 36 mm head as comfortable and potentially as stable as the same implant with an anterior approach? So far, I am not convinced that the anterior approach is all that its advocates wish it to be. Pick your poison....surgeon and patient… caveat emptor! Stuart L. Gordon MD Division Head Hip and Knee Replacement Cooper University Hospital Available online xxxx References 1. Bhargava T, Goytia RN, Jones LC, et al. Lateral femoral cutaneous nerve impingement after direct anterior approach for total hip arthroplasty. Orthopedics 2010;33(7):472. 2. Goulding K, Beaule PE, Kim PR, et al. Incidence of lateral femoral cutaneous nerve neuropraxia after anterior approach hip arthroplasty. Clin Orthop Relat Res 2010;468(9):2397.
The Conflict of Interest statement associated with this article can be found at http:// dx.doi.org/10.1016/j.arth.2014.01.028. 0883-5403/0000-0000$36.00/0 – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.arth.2014.01.028
Please cite this article as: Gordon SL, A Tale of Two Approaches, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.01.028
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
A Tale of Two Approaches With great interest I have read the paper "Prospective Randomized Study of Direct Anterior vs Postero-Lateral Approach for Total Hip Arthroplasty" by William P. Barrett MD, et al. After experiencing a right hip resurfacing (BHR) in Spring 2011 through a posterolateral approach and a left THA by the direct anterior approach 9 days ago, I would like to offer some feedback to the authors. Contrary to a widely marketed and published belief that the anterior approach is performed through a minimally invasive internervous and intermuscular plane between the lateral based tensor fascia latae muscle and the medial based sartorius and rectus muscles, the lateral femoral cutaneous nerve (LFCN) resides in the field of dissection. Dr. Barrett fails to discuss that the LFCN is often traumatized during the muscle splitting and often vigorous muscle retraction needed to expose the anterior hip capsule. Reports of LFCN injury range from 15% to 67% for THA with anterior approach in two recent studies by highly experienced hip surgeons [1,2]. The nerve pathway is highly variable as it emerges most commonly under the inguinal ligament and passes over the sartorius and through the tensor interval before arborizing into an anterior and posterior branch. The LFCN gives sensation to the anterior–lateral half of the thigh from the groin to just above the knee. Although LFCN injury is regarded by some surgeons as an annoying and transient sensory nerve complication with minimal functional loss, it is not pleasant to feel like if someone were to stab my thigh with a Buck knife. I would not know it! Recovery of sensation takes many months, years, and some never resolve. If a neuroma develops like in meralgia paraesthetica (uncommon) it is a disabling problem. From the outcome measures Dr. Barrett used in his prospective randomized study design, the anterior approach THA patients have an accelerated discharge home, less pain on day of surgery through day one, and quicker return to functional activities. Based my personal experience I would not agree. My opinion is that there is an inherent expectation or interviewer bias in measuring the outcome data. Response bias (where the patient gives favorable information or pushes further to validate the expected outcome) also may have played a role in the collection of the study data. With the randomized design, selection bias does not appear to a factor.
Each hip approach has certain drawbacks. After the posterior– lateral approach, sitting comfortably is a real issue. Remember the Seinfeld episode where George Costanza was resting on an overstuffed wallet? After a week that posterior discomfort dramatically improves as the gluteal swelling resolves. With the anterior approach, Dr. Barrett did not have any inquiry as to the common post op problem of quad pain and hip flexor soreness. Because of the tensor fascia latae soreness, there is a tendency to abduct the hip with walking and transition movements so that ITB tendonitis may develop. For the last week, I feel that someone slammed a Louisville slugger into my anterior thigh. The tensor fascia muscle group (laterally retracted) feels sore and stiff and makes stair descent uncomfortable. Both approaches involve activity and range of motion restrictions in the early post op period. Because of the quad, tensor fascia latae, and need to protect excessive active flexion of the iliopsoas, anterior approach patients cannot comfortably sit in any low positions. Extension and external hip rotation range of motion is restricted because of the anterior capsule repair. When presenting outcomes on early post op recovery, I suggest that these subtleties be recognized. Is the posterior–lateral approach with an enhanced capsular repair and 36 mm head as comfortable and potentially as stable as the same implant with an anterior approach? So far, I am not convinced that the anterior approach is all that its advocates wish it to be. Pick your poison....surgeon and patient… caveat emptor! Stuart L. Gordon MD Division Head Hip and Knee Replacement Cooper University Hospital Available online xxxx References 1. Bhargava T, Goytia RN, Jones LC, et al. Lateral femoral cutaneous nerve impingement after direct anterior approach for total hip arthroplasty. Orthopedics 2010;33(7):472. 2. Goulding K, Beaule PE, Kim PR, et al. Incidence of lateral femoral cutaneous nerve neuropraxia after anterior approach hip arthroplasty. Clin Orthop Relat Res 2010;468(9):2397.
The Conflict of Interest statement associated with this article can be found at http:// dx.doi.org/10.1016/j.arth.2014.01.028. 0883-5403/0000-0000$36.00/0 – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.arth.2014.01.028
Please cite this article as: Gordon SL, A Tale of Two Approaches, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.01.028
