An anterior hip replacement is a total hip replacement performed through a special approach that utilizes a muscle interval in the front of the hip (anterior) and allows access to the joint without violating any muscles. This approach has been known for many years, but more recently has become utilized for total hip replacement surgery.
This cannot be answered clearly with yes or no. A posterior approach is a very good approach to do a hip replacement surgery. It provides the surgeon with a lot of options. Through a posterior approach, any implant can be used, while the anterior approach requires special implants. Also, through a posterior approach, both cemented as well as uncemented fixation is possible while through an anterior approach cemented fixation can only be utilized if the approach is extend. This can be of importance for patients with very poor bone stock. Similarly, the posterior approach allows better access to the cup, which can be helpful for patients with severe developmental dysplasia of the hip or during revision hip replacement. The posterior approach can also be easily extended to access more distal parts of the femur and can be used for more complex femoral revisions, as well as fixation of femoral periprosthetic fractures.The anterior approach does however not require any muscle releases and therefore often is leads to a faster postoperative recovery, does not require hip precautions (the posterior approach does) and an overall results in a more stable hip that is especially important for older patients and patients that engage in Yoga or dancing.
The main advantage of the anterior approach is that the early rehabilitation is faster. You can get out of bed faster and usually feel more comfortable with the hip. That does not necessarily mean that you are going to walk further than patients with a posterior approach. However, the handling of the leg is usually less inhibited. In addition, patients with an anterior approach do not need to follow standard hip precautions. That means with some minor restrictions, patients after an anterior approach can sit on regular chairs, they can drive a car once they are comfortable and they do not need to use a pillow between their legs at night when sleeping. Therefore, the anterior approach is often an interesting alternative for patients that need to return to work early, have a job that involves commuting by car or patients that value the independence of not needing to follow the precautions. Although recent published dislocation rates between the anterior and posterior approach do not vary we are more comfortable to let our patients engage in Yoga, ballet or activities that require more extreme motions of the hip. Since none of the main stabilizing muscles is released during the surgery these hips do feel more stable early on.
The main disadvantages of an anterior approach are the following:
The lateral femoral cutaneous nerve crosses in the front of the thigh and can be injured during an anterior total hip replacement. This can result in numbness over the lateral aspect of the thigh and rarely nerve pain. The anterior location of the incision can also be problematic for patients that have a large belly or a skin fold since the incision might then be localized in a moist tissue fold, which could predispose it to infection. In general, the downside of anterior surgery is that it is not as versatile. If the surgeon encounters a situation that requires more complex reconstructions, there are limits to what can be done through an anterior approach and not all implants can be inserted from the front.
Since the access to the femur is more difficult through an anterior approach we usually use shorter and curved. While with the standard anterior approach, no straight stems can be utilized, more excessive releases can facilitate the insertion of a straight stem or revision hip replacement even through an anterior approach.
Well usually after you undergo medical clearance you are admitted to the hospital the day of your surgery. You will then undergo a spinal anesthesia, a regional anesthesia that allows us to control your pain during surgery and has less risks than general anesthesia. The surgery itself takes about 45-60 minutes and after the surgery you initially will be transferred to a postoperative recovery room where your vital signs and the weaning of the anesthesia is monitored by an anesthesiologist. You are then transferred to the floor where the day of your surgery physical therapy and rehabilitation will start. Usually within one to two days you are able to leave the hospital. Dr. Boettner in general recommends that you go home after surgery where he will provide you with a therapist that will check on you during the week to make sure that you achieve adequate physical therapy. By the time you leave the hospital, you should be able to walk 100 feet with either a cane or walker and you should be able to walk a flight of stairs. By the time of discharge, your incision should be dry.
There is a small risk of dislocation following anterior total hip replacement. Certain extreme motions are not advised after surgery. Dr. Boettner estimates the risk of postoperative dislocation after an anterior approach to be less than 1%. Further complications of an anterior approach can include things like intraoperative fracture, deep implant infection, blood loss requiring blood transfusion, leg length discrepancy, wound drainage, early femoral component loosening, implant loosening over time secondary to wear of the components or loss of fixation as well as numbness or pain from injury to the lateral femoral cutaneous nerve or injury to one of the other nerves around the hip that can result in pain and weakness. Medical complications like deep venous thrombosis are possible and you will be placed on a blood thinner (usually aspirin). More serious complications like a pulmonary emboli, heart attack and stroke, etc. as well as bleeding complications are relatively rare. Our preoperative clearance program reduces the risk of serious complications significantly, and almost all of our patients today will avoid major medical complications because of our thorough preoperative medical work up.
By the time you go home you should be able to move inside your house and go for short walks. We do close the incisions with resorbable stitches covered by surgical glue and therefore you should be able to shower right after you get home. Do NOT bath or swim. During the day, you will be required to do a basic set of exercises. Dr. Boettner also recommends that you increase your walk distance every day and come off the cane once you are comfortable to walk without a limp. Limit your walking to 1-2 mile for the first 4 weeks. Remember even if you feel great the implant needs to heal, doing strenuous exercises or hikes is not recommended! Also we DO NOT want you to do straight leg raises or hip flexion exercises in the first 4 weeks to not cause groin pain. By one week you should be off all narcotic pain medication. You can return to work and drive when you are comfortable. Remember do not drive as long as you take narcotic pain medications.
Dr. Boettner trained with an anterolateral approach during his Residency in Germany. He then switched to doing posterior approach for most of his Fellowship training in the US and pretty much exclusively used the posterior approach until 2012. In early 2012, Dr. Boettner started to attend training courses for anterior hip replacement and visited a number of surgeons to learn from their experience in anterior hip replacement surgery. We performed the first anterior hip replacement surgery in the summer of 2012. Since 2014, we have been using the HANA table for anterior hip replacement surgery.
Currently, I do about 75% of my hip replacements through an anterior approach. Dr. Boettner performs approximately 300 total hip replacements and resurfacings per year.
Dr. Boettner has been excited about the ability to rehab patients faster and let them return to work earlier and with less restrictions. Today we can not envision a practice without anterior total hip replacement, however, we do see some extremely complicated hip replacements and also value the options the posterior approach offers. Which way to go is an individual decision. We are specialist in minimal invasive total hip replacement and resurfacing and our experience in anterior and posterior approaches allows us to select what is right for you rather than to do a “one fits all” approach. During your preoperative appointment we will take the time to discuss the pros and cons of each approach and will guide you to make the right decisions for your upcoming hip replacement.