Anterior hip replacement in the ASC: 7 key questions with Dr. Andrew Wickline

Orthopedic surgeon Andrew Wickline, MD, of New Hartford, N.Y.-based Genesee Orthopedics & Plastic Surgery Associates introduced the anterior approach to hip replacement into his surgical practice in 2007. 

Now, his practice performs more than 300 of the procedures each year and the vast majority of patients go home the same day. He spoke with Becker's ASC Review about how the procedure transformed his practice.

Note: Responses have been edited for length and clarity.

Question: How did you introduce the anterior approach into your surgical practice?

Dr. Andrew Wickline: In 2007, I started doing anterior hip without a table because I couldn't get my hospital to get on board with the table, but I found it to be difficult. We purchased our table in 2009. [When I introduced the approach] I had someone come fly in and spend a day with me to help me with live surgery on my patients and make sure I was getting it done correctly. Now, I do 99 percent of my hips through the direct anterior approach.

When I first started, my x-ray technician in the office didn't realize I had switched the approaches. She came to me after three months and said, 'Dr. Wickline, patients can get on or off the x-ray table much easier now — what are you doing differently?' That's when I knew I was onto something.

Q: What makes the anterior approach superior to the posterior approach?

AW: Posterior hip approach is a great approach for revisions, extensive surgery that might be necessary for patients with previous hardware, fractures and so forth, but there are a number of issues — particularly, the dislocation rate. Patients are told not to sit in a certain position for at least six weeks. That risk makes patients with the posterior approach rehab slower because they're concerned.

For anterior hip replacement patients, there aren't any precautions. We're not cutting any muscle; they just need to let it heal. They don't have to worry about bending over or how to put their socks and shoes on. When they don't have to worry about dislocation, patients have less anxieties, and therefore, they do better.

I have experience with all the other approaches — posterior approach, direct lateral approach, anterior — and I think they're good. At six weeks or three months, all the patients kind of equal out. But early on, this wins. Hands-down. I have a bad hip, and I'm having an anterior hip replacement because I see how the patients do better.

Q: What kind of success have you had with this technique?

AW: I've only ever had two dislocations in my entire practice in 16 years. We've been fortunate to get some patients back to work the same week. There's good data suggesting the first three weeks after anterior approach procedures are easier [for patients than after other approaches] so it's easier from an outpatient standpoint. My length of stay is less than one day for hips and knees, all-comers, no matter the age. I'm able to provide narcotic-free joint replacement for hips and knees in at least one-third of my patients, and another third use 10 pills or less.

Q: How can surgeons who are used to the posterior approach make the transition to anterior?

AW: You start with the easy cases first, kind of get used to it and then you can start expanding as you see fit. When you first start this approach, you definitely need to have some mentors to help you. You want to go to some classes, watch someone operate. If you're going to switch your practice, it's important to give yourself every opportunity for success.

Q: How does the technology you use help optimize the anterior technique?

AW: Using the table makes it very user-friendly. One of the benefits to using the [Mizuho OSI] Hana Table is that it has a C-arm, so I can identify the cup placement, the offset and whether or not the leg length is where I want it. The table offers the ability to have excellent component position. The small adjustments make [femoral] exposure so much better. Now, I even do heavily muscled males because I've got a table that helps me get the exposure I need. Investment in the technology over the long-term makes a significant improvement in the consistency from case to case, so you don't have the variability you do without using the table and x-ray.

Q: What are some industry perceptions of the anterior hip approach?

AW: There are definitely naysayers. There's a group of surgeons that say, 'Look at the learning curve for anterior hip — it's 100 cases.' I would look at it differently. If you spend five years in residency, and say it's a posterior approach residency like mine was, you do hundreds and hundreds of hips. So, what's the real learning curve for the posterior approach?

Q: What's the cost comparison between the anterior and posterior approach?

AW: If you're able to have patients leave sooner [with the anterior approach], you're decreasing your risk to yourself and you're decreasing costs for the episode of care. If you're doing outpatient therapy, that's $2,000 on average for Medicare. Plus, the patient has co-pays of $40 a visit, so for six weeks of therapy, patients are seeing $720 out-of-pocket. By using this approach, the majority of patients do not need that therapy.

More articles on orthopedics/total joint replacement:
Viewpoint: orthopedic surgeons should perform hip and knee replacements in the outpatient setting to control costs — 4 key takeaways
What do orthopedic surgeons think about the decision to remove TKA from the Medicare Inpatient Only list?
Wisconsin hospital opens bone and joint center — 3 insights

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