Is there a better way to perform hip surgery?

Total hip arthroplasty: the anterior approach

By Dr. Phillip Stiver

Total hip arthroplasty was first popularized in the 1960s by John Charnley, MD. What was then breakthrough technology has now become one of the most frequently performed and most successful reconstructive procedures in orthopaedic surgery. By 2030, it is estimated that 571,000 total hip arthroplasties (THA) will be preformed each year in the United States. In the past, THA was reserved for people 60 and older. But thanks to newer technologies, implant designs, and surgical procedures, younger patients are receiving the benefits THA can provide. However, with younger patients comes an increased demand for higher functioning implants and quicker recovery.

Patients desire surgical approaches that injure less tissue and preserve function with quicker recovery. In spite of the successful history with total hip replacement surgery, complications do occur which include dislocation, leg-length discrepancy, and residual muscle weakness. Dislocation of the THA remains the leading early complication in 0.4 to 11 percent of patients. Of those patients, about 25 percent require further surgery to correct the dislocation problem. Surgical approaches and implant position are the main recognized factors influencing total hip stability.

The most popular approach to the hip is the posterolateral approach. This approach requires dividing the hip capsule on the back of the hip and cutting the external rotator muscles to have access to the hip joint. Also, the large buttock muscle (the gluteus maximus) is split to reach the deeper tissues. This approach has the highest dislocation rate. Another approach is the anterolateral approach, which involves getting to the hip through the side. This surgical approach involves detaching the dome of the abductor muscles from the top of the thigh bone (greater trochanter) to gain access to the hip. These muscles are sewn back to the bone at the end of the surgery. Though this approach reduces dislocation rates, it can leave the repaired muscle weaker and can cause a limp in as high as 20 percent of patients. Is there a surgical approach that will reduce dislocation rates, promote faster healing, and preserve tissue and strength? Thankfully, the answer is yes – the anterior approach.

Anterior approach

Developed in France in 1947 by Henri Judet, MD, the anterior approach has been refined through the years to allow exposure of the hip through a single anterior (front) incision that does not require release of any muscles or tendons from the pelvis or femur. The back or posterior structures of the hip are left intact, decreasing the instability and dislocations associated with the release of these structures, which was required for the traditional posterior approach. The surgeon can simply work through the natural interval between muscles. The important muscles for hip function on the back of the hip are left undisturbed and, therefore, do not require healing. Muscle strength is preserved and postoperative limp is diminished as a result. The incision is considered minimally invasive because a typical incision is only 3 to 4 inches long. The anterior approach is a better approach to a larger or heavier patient as the hip joint is closer to the front area of the groin (anterior). In a larger patient, less fatty tissue exists in the groin and anterior area of the hip versus the back (buttock) or outside (lateral) area of the hip joint. The skin incision is closed with skin glue and dissolvable sutures are used in the deeper tissues. Showering and getting the wound wet is allowed on the second day.

Post-surgical mobility

Conventional posterolateral or posterior approaches for hip replacement typically require strict precautions for the patient. They must limit hip flexion and extreme motions for six to eight weeks after surgery. This makes average activities such as sitting in a chair, putting on shoes, and getting into a car difficult. Simply climbing stairs can also be more difficult. The anterior approach allows patients to bend their hip freely immediately and bear full weight when comfortable, resulting in a more rapid return to normal function. They do not have cumbersome restrictions and are encouraged to use their hip normally. They do not have to wear a brace or sleep with a pillow between their legs. They can bend and sit in normal chairs. As a result, the patient experiences less anxiety about “dos and don’ts.”

The perfect operating table

Joel Matta, MD, based in Los Angeles, popularized the anterior approach in 1996. He developed a technologically advanced operative table used with the anterior approach to facilitate the surgical technique. Using this table allows surgeons to minimize trauma under the skin by precise patient positioning, something not possible with conventional tables. For example, the patient’s leg is extended downward to allow frontal access to the hip while minimizing tissue damage. It allows for X-ray imaging during surgery to control implant placement and leg length more accurately. Unfortunately, not all patients are candidates for anterior approach hip surgery. A patient can be excluded as a candidate because of congenital deformities around the pelvis, a previous trauma that caused a deformity, deficiency of the bone around the pelvis, a tumor, or prior surgery. Though, not all physicians offer the anterior approach because additional education and surgical training are required, Tri-State Orthopaedics offers this exciting advancement in hip replacement surgery. What’s more, St. Mary’s Medical Center is currently the only hospital in the area with the new technology operating table. Contact Tri-State Orthopaedics Surgeons to learn more about this advancement in total hip arthroplasty.

Fig 1. A special surgical table aids the surgeon

Fig 2. Potential advantages of the anterior approach