By Dr. Leone

There are many well-established surgical approaches to the hip.  Two surgical approaches for total hip that have gained recent notoriety are the direct anterior approach and the minimally invasive or mini-posterior approach.

The direct anterior approach involves splitting the fibers between the two main muscles located at the front of the hip and working through the natural interval between the muscles.

Advantages of the Anterior Approach

  1. Because the anterior approach avoids cutting through muscle, it is hoped it will lead to a quicker recovery.  This has not yet been show to be true or false through scientific study.   Most agree that any short term benefits are not apparent after the initial healing period.
  2. Some feel the approach is more minimally invasive than other approaches, but honestly, the definition of minimally invasive is not clear or agreed upon.  It is not related to the length of the incision, which is about the same for both approaches.
  3. The hip dislocation rate may be lower due to the preservation of the muscles at the side and the back of the hip.
  4. The hip socket is exposure is straight forward.

 Disadvantages of the Anterior Approach

  1. Nerve injury is possible, which decreases sensation to the outside of the thigh. 
  2. There is an increased risk of complication on side of the hip where the femur is located due to increased difficulty in exposing and visualizing the femur.
  3. It is difficult for the surgeon to see enough of the femur to fix a fracture if it were to occur.  With some femoral fractures, it would be necessary to abandon the approach and expose the femur through a different approach using a new incision.

In my next post, I will list the advantages and one main disadvantage of the mini-posterior approach.  In the meantime, feel free to join the discussion by leaving a comment or question below.

9 Responses to "Anterior Approach for Hip Replacement: Advantages and Disadvantages"

  1. Cari Daugherty
    Cari Daugherty Posted on February 14, 2010 at 12:06 am

    Dr. Leone,

    Does this mean the muscles are cut during the mini-posterior approach surgery? If so, long does it take for the muscles to heal?

    • drleone
      drleone Posted on February 17, 2010 at 2:22 pm

      Dear Cari: Minimal muscle is cut with both the anterior and the posterior approach. In both approaches, a small attachment (origin) of one of the muscles that make up the quadriceps muscle (reflected head of the rectus femoris) is released to facilitate exposure of the acetabulum (socket). In both approaches, to allow optimal placement of the femoral stem down the upper femur, the piriformis muscle insertion is released. With both approaches, the release of these muscles does not seem to make a “clinical” difference in terms of how quickly someone gets well or how well they do in the long term.

      In my experience, the factors that are most important for how quickly a particular person gets well is related to their motivation, how physically fit they are before their surgery and how gently the tissues are handled during surgery. The surgical approach is only one part of the final “big picture” of how quickly someone gets well and how well they do over the next many years. – Dr. Leone

      • Cari Daugherty
        Cari Daugherty Posted on February 27, 2010 at 10:51 pm

        Dr. Leone,
        Thanks for the thorough explanation to a question I forgot to ask prior to my surgery. I want to thank you for what turned out to be a life changing surgery for me. I spent alot of time prior to my hip replacement, trying to convince myself that the pain was not that bad, and that I really did not need hip replacement yet. This was simply due to the fear of the unknown. You and your staff were patient and caring, answering all of my questions and concerns, which allowed me to proceed with confidence.

        Three months post-op, I am pain free and able to fully participate in activities with my two young children again. Last week I was able to volunteer in my daughter’s kindergarten class for the first time, without worrying if I could keep up, or would need to sit down to ease the pain. She was smiling all day. I am also planning a summer trip with my girls to the Grand Canyon, which would not have been possible three months ago. My only regret is that I did not have the bad hip replaced sooner, and wasted to much time in pain and avoiding activities. So a big thanks to you and your wonderful staff for allowing me to enjoy my life again.
        Cari Daugherty

  2. michael J kapp
    michael J kapp Posted on August 23, 2010 at 11:37 pm

    Dr Leon Ihad my first hip replacement in 1995.I was about 37.It did’nt take long for me to be walking again .I’d say about 1 month .It was a lateral approach to surgery .I had been without pain for about 15 years and recentley in febuary and march or 2010 there was pain .I think I may have abused the hip , being youbg and active .Well I just had a revision surgery in june of 2010.It is august 23 and I am not pain free yet .I wonder why the surgeon chose the anterior approach ,is there a reason ?although I had’nt had much therapy afterwards,I am up and walking and moving much better and improveing everday.I am now 51 .I guess recovery time is longer cuz of my age but it hasn’t been 3 whole months yet please respond ans to the disadvantages of the anterior approach .Is it possible that the stem could be loose on the knee side of the post. thank you
    Michael J Kapp M.L.T (ascp)

    • drleone
      drleone Posted on August 30, 2010 at 8:33 pm

      There are many acceptable and established approaches to preform hip replacement; either as a first time endeavor or as a re-do or revision surgery. If your surgeon preformed your revision through the anterior approach, it is because he or she felt comfortable with that approach and that they could accomplish the job efficiently. Revision surgery clearly carries a higher incidence of post operative dislocation compared to primary surgery and the incidence of posterior dislocation after your procedure may be less. This is because the posterior pseudocapsule was left intact. I suspect that only your acetabular component needed revision and not your femoral stem. Approaching the acetabular component is relatively straight forward with the anterior approach. Revising the femoral component could present some difficult challenges.

      Three months after revision surgery is very soon. The fact that your continuing to get well is positive. It sounds like you doctor did a very good job. My advise is to give your body time to heal.

  3. brand gould
    brand gould Posted on March 28, 2011 at 7:39 pm

    Dr. Leone,
    I have heard that the anterior approach to hip replacement does not allow for as long an implant into the femur as the posterior approach, which may lead to a less strong bond between the bone and the implant, with a resulting greater possibility of loosening, and perhaps less strength overall. I am relatively young (54) and quite active, and am hoping for a result that will be dependable in a variety of activities such as snow boarding, biking, mountaineering, walking, etc. Do you have any thoughts on this aspect of the different approaches?

    Thank you,

    Brand Gould

  4. marion cerrato
    marion cerrato Posted on October 8, 2014 at 11:48 pm

    Dear Dr. Leone: I am going to have posterior hip replacement surgery in January. I am a belly dancer and also do weightlifting. As a belly dancer I use my hips quite a bit, but the whole body is used. My doctor said I wont be able to squat or deadlift after the surgery. He also told me I had the option of having anterior. So he gave me the names of two other surgeons. I am 77 yrs. old, but if I can ‘t dance, I will be very unhappy. He also said quicker recovery with anterior has not been proven. I am very active and don’t feel my age. I am having a problem making a decision. I really like my doctor who does posterior. Thank you, Marion Cerrato

    • holycrossleonecenter
      holycrossleonecenter Posted on October 17, 2014 at 11:22 am

      Dear Ms. Cerrato,

      Consistently, my best results have been with a mini posterior approach. The anterior approach has the initial advantage of being more stable posteriorly. That said, once the soft tissues around the new prosthetic hip heal, whether the hip was implanted though an anterior or posterior approach, it is stable. Also, with modern prosthetics, an excellent soft tissue closure and optimal component positioning, the risk of dislocation with either approach is very small.

      Although this healing process is progressive, I advise patients to avoid certain positions for the first several months. Most of my patients return to whatever activities that they want to after that period, although I still advise against repetitive running for exercise (some of my patients still do) or extreme limb position like one occasionally sees with yoga (unfortunately some still do this as well). Returning to belly dancing after the recommended healing time sounds fine.

      I wish you the best.

      Dr. William A. Leone

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