Evaluating Approaches in Total Hip Replacement Surgery

(Newswire.net — December 20, 2017) Bend, Oregon — Total hip replacement is one of the most common joint replacement procedures performed today. There has been much debate recently about the risks and benefits of the two most widely used techniques; the anterior approach versus the posterior approach. Proponents of the anterior approach and marketing media report that the anterior approach is better and offers quicker recovery times. However, there are many factors that should be considered when evaluating these methods.  

The most commonly utilized total hip replacement is the posterior approach (through the back of the hip), which has been performed successfully for decades and provides the greatest patient safety. The majority of patients are candidates for this type of surgery. The patient is positioned on his or her side during surgery, which takes 60-70 minutes. This technique allows the surgeon full visual view of the hip cup and femur, resulting in a very low risk of fracture. The main incision goes through the gluteus maximus and will heal without repair. Muscles that are used to externally rotate the hip are detached during the procedure and later reattached to bone, and will heal without complication. When performed with the Mako Robotic-Arm, there is a high-degree of precision of implant placement to recreate the patient’s natural anatomy.

The anterior approach (through the front of the hip) has been utilized as long as the posterior approach, but its popularity has grown in the U.S. over the past 10-15 years. The procedure takes 90-100 minutes. The patient is positioned on his or her back on a special surgical table so the surgeon can manipulate the leg during surgery. Candidates for this approach are not significantly overweight, have normal pelvis anatomy, and no femur deformities. This is a technically challenging procedure so patients should find a surgeon very experienced in this approach. The surgeon’s view of the femur is limited, which requires muscle and capsule release. There is a higher risk of femur fracture due to this more difficult exposure. Intraoperative x-rays are often used to confirm placement of the implant.

“Contrary to popular opinion, the anterior approach is not entirely muscle sparing,” said Michael Caravelli, MD, total joint surgeon. “Due to the risk of nerve damage, the incision enters the compartment of the hip abductor muscle to expose the hip safely. The indirect head of the rectus femoris muscle is released to allow entry into the hip. The external rotator muscles are cut and not reattached during this approach. In addition, most surgeons cut and do not repair the joint capsule.”

Discuss the post-operative precautions for both procedures with your surgeon. There is a low risk of dislocation when performed by a specialty trained surgeon with a high volume of hip replacements. The hospital stay is the same for both approaches, as are the postoperative complications, which include risk to structures, blood clots, infection, death and anesthesia risks.

The return to activity can be quicker for the anterior approach. For the posterior approach, a patient can expect to return to sedentary work in two weeks, light activity such as walking or a stationary bike in six weeks, physical work in 6-16 weeks, and return to sports in three months. For the anterior approach, a patient can expect to return to sedentary work in two weeks, light activity such as walking or a stationary bike in 4-6 weeks, physical work in 6-16 weeks, and return to sports in three months. “Patients typically discontinue use of a walking device 1-3 weeks sooner than a posterior approach,” commented Dr. Caravelli. 

A study presented at the American Academy of Orthopedic Surgeons in 2016 found that outcomes were similar to both approaches six months after surgery, as long as the surgeon performing the procedure is experienced in that technique. Patients should ask their surgeon their preference in approach and determine the risks and benefits of the procedure for their age, health and goals.