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11/18/2015 Mini-PosteriorBetter From the Back? Ken Mathis, MD Associate Professor University of Texas Health Science Center Houston Department of Orthopedics Disclosures Zimmer: royalties, Joint Development, LLC: consulting Anterior vs. Posterior My Experience: 2001-2006 DA Disadvantages • Special table(s) $$$$ (run 2 rooms?) • Longer surgical times and set up time • Learning curve issues • Table can break • How good are you at extensile app for DA? • Intraoperative fluoroscopy and wear lead DA Marketing Issues • Google search yielded 222,000 results • Over 60% are private practice MD’s • No long term follow up data • False claims not supported – better outcomes, “no muscle cut”, more rapid recovery – Reminds me of the patented MIS “two incision ” claims 1 11/18/2015 Anterior vs. Posterior Approach for Total Hip Arthroplasty, a Systematic Review and Metaanalysis Higgins, et.al. JOA 30(2015) • 17 studies totaling 2302 participants • Pooled data showed difference in LOS and dislocations favoring DA approach • Postop pain and function – Anterior approach favored in only 4 studies • “No clear superiority of either approach” Dislocations Blood Loss and Wounds Higgins, et.al. 2 11/18/2015 Fractures and OR Time Higgins, et.al. • 222 consecutive patients – Same implants used • 126 DA and 96 MP • Both experienced surgeons – DA over 300 cases experience – MP older, experienced Direct Anterior • DA at 14 days had higher VAS pain scores, more req. gait aids • @ 8 weeks had HHS=95, but lower return to work, and driving Mini Posterior • MP had shorter OR time • @ 8 weeks HHS=89 • More superficial wound problems (none required return to OR) 3 11/18/2015 No Differences • • • • • component position, LOS, DC home, feet walked, ADL’s OR Time • • • • • • • Assume extra 20 minutes avg per case Busy surgeon with 250 hips/yr 250 X 20 = 5,000 minutes (83.3 hours/yr) Assume avg 54 minutes/case for posterior THR 5,000 min/54 min per case = 92.6 extra cases 93 cases @ $1400/case = $130,200/yr 10 more years of practice X $130,200 = $1,302,000 Conclusions • No clear differences for any parameter in the best clinical trial done at Mayo Clinic • Equivalent results are possible with either approach • For me to wear lead all day, get irradiated, and spend more time in the OR, results need to be significantly different 4 11/18/2015 Thank You 5