Total hip replacement surgery is regarded as among the most valued developments in the history of orthopedics. The procedure relieves pain and restores mobility to people whose joints have been damaged by trauma or degenerative diseases such as hip arthritis. This article discusses a particular method for total hip replacement called the anterior approach.
Surgeons and researchers at Hospital for Special Surgery, where more knee replacements and hip surgeries are performed than at any other hospital in the United States, continually work to improve upon the success of joint replacement surgery by developing, evaluating and refining existing and new surgical procedures and processes. As a result, today orthopedic surgeons have a range of surgical approach options. During the surgery, the hip joint can be accessed through:
Of these approaches, the posterior approach is the most common. However, in recent years, the anterior approach has re-emerged as a preferable option for certain patients. This is because it can be performed with smaller incisions by using specialized instruments.
The posterior approach, the dominant surgical method for many years, is used in the majority of surgeries performed in the United States. It involves accessing the hip joint through an incision made close to the buttocks. This approach provides doctors with a good view of the hip capsule, allowing for optimum placement of implants. Over the years, doctors have refined this procedure so that it is less invasive to body tissues by reducing the size of the incisions while still maintaining the safety and effectiveness of the technique. These minimally invasive techniques – pioneered at HSS – have helped to diminish trauma, reduce length of hospital stay, and limit adverse reactions to anesthesia.
The anterior approach (sometimes called the "mini-anterior approach" or "muscle-sparing hip replacement") has been used to some degree since the 1980s. However, it was the introduction of new instrumentation allowing it to be performed using smaller incisions that has increasingly made it a viable alternative to the more popular posterior approach. The procedure involves the surgeon making a four-inch incision through the front of the leg, rather than the back.
The decision is made on a case-by-case basis, but certain patients are not well-suited for this procedure, and if they do undergo it, it may require longer incisions. This includes people who have:
"I will use a minimally invasive approach whenever it will give the best result for the patient," says Michael Alexiades, MD, an orthopedic surgeon at Hospital for Special Surgery and an early adopter of the anterior technique. "The anterior approach is relatively new in its new form, so it’s important for patients to find an experienced surgeon to perform their procedure who is also skilled in appropriate patient selection. While many patients are candidates for the technique, it should be used selectively in very heavy individuals, or large men with significant musculature."
Frontal entry makes it possible to reach the hip joint by separating rather than cutting and then reattaching muscles. The anterior hip replacement may also result in a swifter recovery and shorter hospital stay for patients, perhaps due to less muscular damage. Leg length and implant position are also able to be measured with the anterior approach.
Due to the different nature of the approach, there are fewer but different precautions to follow to prevent dislocation, which may occur more often with the posterior approach.
"The anterior approach allows for a good view of the hip socket and preserves all muscles," says Dr. Alexiades. "Fluoroscopy is required and one does not have to use a specific implant using this approach. Also, patients undergoing the anterior hip replacement often experience a quicker recovery and shorter hospital stay than with other techniques."
Disadvantages to the anterior approach are both practical and medical.
It is important to note that the results of total hip arthroplasty are outstanding in terms of relief of pain and improvement in function. There has been, to date, no clinical study demonstrating the superiority of one surgical approach over another. The possible short term benefits of one surgical approach over another must always be balanced with the possible untoward side effects unique to that approach.
Recently, improvements in surgical technique, instrumentation, and patient selection have made the anterior hip replacement a viable option for patients considering total hip replacement. Currently, if performed by an experienced surgeon on the properly selected patient, an anterior hip replacement can result in a rapid recovery during the weeks after surgery and different precautions for patients to follow to prevent dislocation, which may be more common with the posterior approach. The selection of the appropriate patient for anterior arthroplasty is crucial to the overall success of the surgery. As with all surgical procedures, the advantages and disadvantages of a specific approach should be discussed with your surgeon.
Summary by Andrea Disario