Our joint replacement surgeons are often asked about the latest developments in arthritis surgery. With the advent of minimally invasive techniques in orthopedic surgery, joint surgeons at Tucson Orthopaedic Institute (TOI) are performing hip replacement through the front (anterior) of the hip as opposed to the more traditional posterior, or backside approach. TOI physicians currently using this approach with some patients are Kevin W. Bowers, MD, and Edward P. Petrow, Jr., DO.
The logic behind anterior hip replacement is to try to minimize muscle damage by working through the natural intervals between muscles to gain access to the front of the hip, as opposed to detaching and repairing the muscles to gain access to the hip joint from behind. However, some questions still remain relating to the anterior approach.
Is anterior hip replacement a new technique?
No. The anterior hip approach was first described by Smith-Petersen in 1917. It was used by the French surgeon, Robert Judet, in 1947 to perform an isolated femoral head replacement. This later evolved into other French surgeons performing complete hip joint replacements through an anterior exposure in the 1960s.
Why all the interest if this technique has been in existence since the 1960s?
Early surgeons found that the visualization of the hip socket was excellent through the front of the hip; however, it was very difficult to insert a long straight metal stem down the femur through an anterior approach. If complications occurred during surgery, it was very difficult to change or extend the anterior approach to overcome difficult surgeries and provide for better visualization. Therefore, most surgeons opted to perform hip replacement through posterior, or posterior and lateral (anterolateral) exposures.
The posterior approach has become the most popular way to perform hip replacement since that time. However, the posterior approach has historically been associated with a higher dislocation rate, while the anterolateral method can leave the repaired muscle weaker and can cause a limp as compared to replacements performed through the front of the hip.
By using specialized instrumentation, newer generation hip implants, a custom operating table, and real-time intra-operative X-ray equipment, anterior hip replacement has made a resurgence. These additions have allowed the anterior approach to become easier and more reliable to perform than before.
What are the benefits of anterior hip replacement?
Since anterior total hip replacement does not require the detachment or splitting of any muscles about the hip, thus preserving muscle strength, patients report less pain as well as a quicker return of function after surgery (see Figure 1.0).
Richard Murlless, a 65-year-old Sahuarita resident, found this to be true after undergoing anterior hip replacement in February with Dr. Petrow. Murlless could bear weight and walk, using a walker, within the first week following surgery. Murlless explains that soon after surgery he had “less pain than what I was suffering before surgery.”
Murlless opted to wait until a new surgical table was available at the hospital to have his hip replaced because he did not want to be “incapacitated” for several months with the conventional approach. Both Dr. Petrow and Dr. Bowers, who uses this special operating table and real-time intra-operative X-rays, have the ability to position the replaced hip components more accurately and reproduce the hip’s natural anatomy (see Figure 2.0).
For example, the table is designed to allow extension of a patient’s leg downward, which gives frontal access to the hip that is not possible with conventional tables. It also allows the use of intra-operative X-ray, which gives a more accurate recreation of the patient’s leg length.
Dorothy Krieger, of Saddlebrooke, Arizona, had a similar experience in her recovery following anterior THA back in March. Krieger felt her left hip was “unreliable” and eventually she was unable to walk because of constant pain. When discussing with friends, they were confident in Dr. Bowers’ skills and gave encouraging testimonials for this procedure. Krieger said those comments were the “driving force behind my decision to have surgery.”
The 62-year-old underwent anterior total hip replacement on March 2 and was able to walk without an assistive device after one week; then she completed physical therapy 4 weeks after that. Krieger says she is happy with the result and is able to enjoy activities again, like hiking.
What hip approach is recommended?
Since every hip exposure has specific pros and cons (see Figure 3.0), it is recommended to discuss your options with your surgeon. It is the job of the surgeon to match each individual patient’s need to the specific approach. Patients and surgeons want to minimize pain and speed recovery, yet the main objective of hip replacement is to provide patients with a well done operation, with good component position, and the expectation that it will last for the next 20 years.
Figure 3.0 Advantages associated with the anterior approach compared to conventional surgery.