I initially looked at switching to the anterior approach (going into the hip from the front rather than the side or back of the hip) because the PAs (physician assistants), nurses, and physical therapists in my hospital all told me that they felt that the patients who had anterior approaches were having significantly less pain and were able to rehabilitate faster. I have a partner who was one of the first people in the Seattle area to do anterior approach THR and the hospital staff could watch the difference in how the patients recovered after their surgery.
Finally one day I asked our head PA how she would want her total hip done and she said definitely by the anterior approach. At that point I knew I had to learn more about it and whether it was reasonable for a surgeon that has always done THR through a posterior approach to change to a dramatically different technique and still be confident that my patients would benefit.
I first observed the technique in the operating room and then studied the anatomy of the anterior approach. The first obvious benefit is that the approach to the hip from the front is anatomically easy and does not involve cutting any major structures to get to the hip. You simply spread the interval between two muscles and you are down onto the hip capsule. When you go in from the back you have to divide the gluteus maximus (butt) muscle and split part of the ilio-tibial band on the side of the hip and then cut several small tendons off the back of the hip.
The thing that stops a lot of surgeons from doing this approach is that it is so different from what they are used to. The other thing that stops them is the special technique that is necessary to place the stem into the femur (upper thigh bone). When you approach the hip from the back, it is fairly easy to place the stem of the implant into the femur. From the anterior approach most surgeons use a special table called a fracture table that allows you to position the leg in a very specific way. In my case, all of the operating room staff and my assistants were used to doing this approach and that made my job a lot easier.
Once I decided that I wanted to learn this technique, I went to a lab where you can practice on cadavers. I was surprised at how easy the approach was and how well I could get good exposure of the socket and the femur to do the surgery. Once I had the exposure, the actual placement of the implants was exactly what I had been doing from the posterior approach.
I have now been doing all of my hips using the anterior approach, and although the first few that I did made me a little anxious, after about 10 hips I knew that I would never go back. For me to switch, I had to feel that it was an advantage to my patients and that I could do as good or better job implanting the components. I have definitely found both to be true.
I have found that my patients have less pain and are ready to leave the hospital sooner. After an anterior hip there are no hip position precautions like there are after a posterior approach. This means no pillows between the legs and you can bend over as far as you want. My patients who have had one hip done through the posterior approach and one through the anterior approach tell me that not having to follow specific hip position precautions is one of the biggest positive differences that they noticed and they feel that it helped them recovery more quickly.
From my standpoint as a surgeon, I love the approach because I don’t have to cut any major structures to get to the hip, and also when it is done through the anterior approach it is easy to use fluoroscopy (real time x-ray) to check the position of the hip components while you are putting them in. This allows the cup position to be optimal and allows the surgeon to check the leg length to be sure it is the same as the other leg.
I am very happy that I was pushed to learn this new approach to THR. Total hip replacement surgery is one of the most rewarding surgeries that we do. No matter how it is done, as long as it is done well, patients have wonderful results. This is exactly why many surgeons don’t feel the need to change. They are doing an operation with excellent results and they don’t want to take a chance on having problems while learning a new way of doing it. Fortunately for me, I was able to see a good surgeon and support staff doing this procedure and it convinced me to change.
My last thoughts for anyone reading this who is contemplating having their hip replaced is to know that the most important thing for a successful hip replacement is having a good surgeon and a hospital that does hip replacement surgery routinely. I do think the anterior approach has advantages over the posterior approach for both the patient and the surgeon and that’s why I switched.