Steve Fuller, DO , Alabama Orthopedic Institute
The vast majority of surgeons use the posterior approach for hip replacement, entering at the butt and cutting through the large gluteus maximus muscle, then detaching the deep muscles, as well as the small muscles controlling hip rotation, to reach the hip joint. It's major surgery, with muscle cut from the bone and an extensive recovery period, but it's been the preferred method, in large part, because the hip joint is well exposed.
However, several years ago, Joel Matta, MD, the Chair of Orthopedic Surgery at Good Samaritan Hospital in Los Angeles helped design a surgical table that has increased the viability of the anterior approach, which is much less invasive, allowing the surgeon to replace the hip without detaching muscle from the pelvis or femur.
Steve Fuller, DO with Alabama Orthopedic Institute in Cullman has been using the anterior approach for a few years and finds that his patients recover much quicker. "I did an (anterior approach) hip replacement yesterday on a lady who right now has no pain," he said. "Another patient was parasailing three weeks after surgery."
Jack Featheringill, MD with Orthopaedic Specialists of Alabama in Birmingham has also had smoother patient recoveries with the anterior approach. "The nursing staff and physical therapists who work with these patients will tell you there is a dramatic difference in how they do post op," Featheringill said. "I've had several patients who have had the first hip done from the back, and without exception, they say that the anterior one was better to get over."
Generally, posterior approach recoveries take around six weeks, sometimes longer, while most surgeons see anterior approach patients doing much better in as little as two weeks. "I think patients recover quicker with this approach because this method is the only approach to the hip in which no muscles are cut," Featheringill said. "The interval goes between the muscle layers, so no muscle healing or protection has to occur."
In addition to quicker recoveries, the anterior approach surgery facilitates a smoother convalescence because there is better stability. "It's almost impossible to dislocate this hip," Fuller said. "By comparison, in the recovery period with a posterior hip approach, patients have to be so careful. They have to sleep with a pillow between their legs for six to eight weeks. They're not allowed to roll on their side or to bring their leg up. There are a ton of restrictions, whereas there are minimal restrictions — almost none — with anterior approach recoveries."
Featheringill notes several other advantages to the anterior approach. "There is also less risk of a blood clot (DVT) with this approach," he said, "presumably because the leg isn't twisted as much or for as long as with the posterior approach. When we're putting the socket side in (half of the operation) the leg is held straight, whereas it's twisted 90 degrees the whole time from the back. The twisting of the vessels is a factor in clot formation."
"Another advantage," Featheringill said, "is that we are able to assess each step of the procedure easily with a C-arm X-ray image if we want, and at the end make an X-ray comparing the operative to the non-operative leg, which makes getting the leg length right more accurate than with other methods."
Although there are numerous advantages to the approach, Fuller acknowledges that it takes some time to get used to. "I almost gave up during the first couple of procedures," he said. "It was frustrating because I wasn't used to going that way. There's a steep learning curve, but once you're over that, it goes much easier."
Fuller also says that the anterior hip replacement takes longer. "I do a posterior hip in an hour, whereas an anterior hip is consistently two plus hours," he said. "There are more steps involved. With a posterior approach, you basically get down on it and all the movements are minimal. Whatever you have to do to dislocate the hip is done right there. With the anterior, you have to do a lot of things with the table. You need the nurse at the end of the table to drop the leg, move the leg over, bring it up; a number of things that take time."
Nonetheless, Fuller believes the procedure will increasingly gain acceptance with other surgeons. "It's an expensive table," he said. "So most hospitals are reluctant to invest money in it, unless they have a surgeon willing to do the operation. There are probably six to seven of us doing it in Alabama now, a few doctors in Huntsville and a couple in Birmingham. Over time, as new residents are taught this procedure, I believe the majority of surgeons will switch over to it. I think this will be a revolution, but it'll happen over about 15 years."