Over the past few years, the debate regarding what approach is the "best" for primary (first-time) total hip replacement has intensified. Surgeons generally fall in two camps and unfortunately, patients are caught in the middle. While the longer-term studies have yet to demonstrate overwhelming evidence in one direction or the other, in my humble opinion, there are definite advantages to anterior approach hip replacement that have been supported by clinical evidence and certainly by my own patient population. During my training as a resident, I was fortunate enough to have mentors who taught me all of the approaches to hip replacement surgery and was thus able to objectively see the results of these surgeries first-hand while not being "biased" to a particular approach beforehand. This allowed me to see for myself how well patients did after surgery and how many of the pitfalls of previous approaches to hip replacement could be overcome simply by changing the "approach" to it.
I think the main advantages have to do with achieving proper "leg-length" and "stability" as well earlier functional recovery. For starters, with anterior approach hip replacement, the patient is placed on their back on the operating table (supine position). This gives the distinct advantage of being able to perform intraoperative radiographic imaging which allows for precise positioning of implants as well as making sure that the leg-lengths are as close to equal as possible. This is much harder to do when a patient is placed on their side as traditionally is the case with other approaches (ie posterior and anterolateral approaches). This restoration of leg-length likely contributes to improved stability of the hip in that the "normal" muscle and ligament balance of the hip are "restored." Most patients report that their leg-lengths "feel" equal and thus almost never feel they are "too long" or "too short" on one side versus the other.
In addition, by using a "muscle-sparing" approach with "anterior approach" surgery, the muscle attachments around the hip are not disrupted or "cut" to allow for the placement of the implants during surgery. I believe this ultimately allows patients to have less pain immediately post-operatively as well as (mostly) avoids the problem of an unstable hip replacement after surgery. While posterior approach surgery has been reported to have dislocation rates in the literature of approximately 2-6%, anterior approach hip replacement is likely to lead to much less of a chance of this. While there are certainly patients who can have an unstable hip replacement after anterior approach, it is much less likely in my own particular hands and thus one of the main reasons I prefer it.
Overall, while a skilled surgeon will likely give a patient a functional, painless hip replacement, the approach can have a significant impact in the overall outcome. Regardless of the approach though, it is very important that the surgeon has adequate training in this technique as there are numerous potential pitfalls in any surgery and particularly anterior approach if one is not fully aware of all of them.
If you or your loved ones would like to learn more about anterior approach hip replacement, please feel free to contact my office for an appointment at 808.522.4232 or reach out at our email - drvhawaii@gmail.com
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