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24 Executive Roundtable Sponsored by: Why the Direct Anterior Approach for THA is the Future By Megan Wood O rthopedic surgeons consider several factors before performing outpatient total hip replacement, including which approach to use. Thomas Ellis, MD, of Columbus, Ohio-based Orthopedic One; Coleman Fowble, MD, of Columbia, S.C.-based Midlands Ortho- paedics & Neurosurgery; and John Masonis, MD, of Charlotte, N.C.-based of OrthoCarolina, discuss why they adopted the di- rect anterior approach for THA and the benefits they've seen. Question: Do you utilize the posterior-lateral approach or direct anterior approach when performing total hip re- placement and why? Dr. Thomas Ellis: I now use the anterior approach for almost all my hip replacements. I started learning the anterior approach in 2008. I learned [the anterior approach] because I felt the dis- location was lower with the anterior approach and that it was easier for me to measure leg length. It also had less damage to the gluteal muscles. Dr. Coleman Fowble: [I perform] both approaches; I do my total hips anteriorly, and if I do hip resurfacing, I do posterior approach. Dr. John Masonis: Direct anterior has been my surgical ap- proach for all primary THA cases since 2004. Q: Research yields comparable long-term clinical results for the two approaches, but some studies reveal patients achieve faster recovery with the direct anterior approach — do you agree with this? Would you say more surgeons are adopting the direct anterior technique? JM: Correct. The functional recovery between the posterior and direct anterior approaches seems to equalize between two and six months post surgery. The early recovery period favors the direct anterior approach due to a faster return to normal walking and independence from assistive devices, such as a cane or crutch. The approaches each have their advantages, with the posterior approach having relatively good early hip flexion strength and the direct anterior approach demonstrat- ing good early hip extension strength, which makes walking recovery faster. CF: Twenty percent of the total hip surgeries in the U.S. use an- terior approach; if you go to Paris, France, it's 99 percent an- terior. It's coming from Europe and their teaching models are probably better — more direct surgeon-to-surgeon teaching. They seem to have a better model. TE: I think the surgeons who are currently practicing and busy are comfortable with the posterior-lateral approach, so it's hard for them to change. And when they do want to change, it can be a difficult learning curve to master the anterior ap- proach. It takes time and commitment, and the former is in short supply for most of us. Orthopedic residents/fellows are still primarily exposed to the posterior-lateral approach, but as more are exposed to the anterior approach I think we will see many more surgeons adopt the anterior approach. Q: What are major benefits when considering the direct anterior approach for THA? How does this approach align with MIS principles? JM: In my opinion, the greatest benefit of the anterior approach is not the speed of recovery, [although] patients focus on the rapid recovery and I think for them this is an important element. [But] for me as a surgeon, the greater benefits are threefold: 1. There are no dislocation precautions after surgery, which allow patients to return to normal activity without disloca- tion precautions. "As hospital costs and demand for quality both increase, the percentage of outpatient hip replacements will climb." - Dr. John Masonis Dr. Thomas Ellis Dr. Coleman Fowble Dr. John Masonis