Why I No Longer Use the Anterior Approach for Primary Total Hip Replacement Surgery

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As a surgeon with a specialty practice in hip and knee replacement surgery, patients rely on my expertise.  Recently, a patient asked me why I no longer use the anterior approach for total hip replacement.  I stopped performing this procedure because in my experience there are no advantages to the surgery, rather a number of potential disadvantages.  Simply, I couldn’t continue to use a procedure that I could not trust to deliver every time.

With the mini-posterior approach, there is significantly less bleeding which reduces post-operative anemia. In my experience, recovery is more consistent because patients feel better and stronger more quickly.  Also, the need for a blood transfusion is minimized. In fact, I find in my practice that having to transfuse someone after surgery is rare. However, there is increased blood loss associated with the anterior approach and more patients develop symptomatic anemia, increasing the likelihood of a transfusion.

Exposing the femur for reconstruction is more difficult with the anterior approach. As a result, many surgeons will use a special table to aid in this technique. Regardless, the positioning of standard-length, time-tested stems is more difficult when approaching anteriorly. Because of this, most of the major orthopedic manufacturing companies now are producing new, shorter stems which are much easier to place.  How these stems will perform over the years remains to be seen, as with all new prosthetics being devised. The surgical community has hope that this new crop of short stems will do well. Time will tell.

Another reason I discontinued use of the anterior approach is I felt limited as to what type of femoral stem I could use. When approaching the hip anteriorly, I would choose a “press fit” stem rather than a “cemented” Exeter stem. A “press fit” stem achieves its initial stability by being tightly wedged into the bone of the upper femur in the hope that with time, bone will grow into or onto the stem. A “cemented” stem is fixed within the bone of the upper femur by bone cement, which is a time-tested acrylic grout and for some people with specific types of bone or anatomy, it is the preferred choice. The Exeter stem is the gold standard in the industry, has a 45-year track record and remains the most commonly used implant in the world. Reconstructing through a mini posterior approach, I am able to use the Exeter stem for some patients. I am building a construct in a patient’s body that hopefully will last 20 years or more and I don’t want the approach to determine which type of stem I use.  With the mini posterior approach, I can choose the best stem for the patient, not the procedure.

As a revision surgeon, I also carefully consider every next step and “what if” as I construct an implant. No matter how carefully a surgery is performed, when you do enough procedures, at some point the femur will fracture. If a fracture occurs during an anterior approach, it is much more difficult to fix and often requires a separate incision. I’ve also seen a number of patients who were treated with the anterior approach by other doctors and developed complications associated with a non-recognized fracture that became apparent during the post-operative course. If a fracture occurs during a mini posterior approach, I believe it is easier to assess and also relatively simple to lengthen the existing incision to fix the fracture.

The mini-posterior approach involves separating the muscle fibers of the large buttock muscle located at the side and the back of the hip. Because the muscle fibers are separated, not cut, the nerve path is not disturbed. There are a number of studies that have gauged the muscle damage resulting from both approaches by measuring the levels of specific muscle enzymes that elevate when muscle is harmed.  Many of these studies do not show a significant difference between either approach.  The amount of muscle damage in an individual case is directly related to a surgeon’s experience, technique and how gently tissues are handled. It’s also related to the specific patient’s anatomy.

One slight disadvantage to the mini posterior approach is that I ask patients not to place the newly implanted leg in certain positions for the first six weeks after surgery. I do encourage them to be very active and most stop using a cane, can drive their cars and are exercising in the pool, just two weeks after surgery.  However, even these minimal position restrictions now are being challenged and a number of surgeons no longer curb patient movements in any way if the range of motion at the time of surgery meets a certain level. I’m moving in this direction.

Patients continue to “teach” us what they can and cannot do. When components are optimally positioned, the soft tissue is reconstructed well, and the mechanics are optimized, the incidence of dislocation after a first-time total hip replacement is very small.  Fortunately, I have had only one patient out of thousands during the past six years who had a post-operative dislocation.  My very athletic patient simply lost his footing and fell down a flight of stairs. I saw him recently and he is doing well.

Finally, I’ve spoken to a number of orthopedic surgeons who will offer the anterior approach to their patients if requested. They privately have shared with me that the decision to perform the anterior approach stemmed from patient demand and the need to remain competitive in the surgical community. While I understand, I am not willing to continue to use a procedure that I feel cannot deliver consistently optimal results.

As with any surgery, choosing the right surgeon is as important as the procedure.  Talk candidly with your surgeon about his or her experience, success rates, incidence of short- and long-term complications and what procedure, technologies and prostheses will be right for you. Most importantly, you need to feel comfortable not only with the orthopedic surgeon but with the entire staff as well.  At the Leone Center for Orthopedic Care, we use a team approach to provide state-of-the-art orthopedic care combined with a high level of personal attention to make your entire experience comfortable with the best possible outcome.

 

 

33 Responses to "Why I No Longer Use the Anterior Approach for Primary Total Hip Replacement Surgery"

  1. Calin Moucha, MD Posted on February 21, 2014 at 11:57 am

    Very well written! A true and honest evaluation of the anterior approach! Congratulations!

  2. Jane Posted on July 12, 2014 at 10:36 pm

    Dr. Leone,
    According to my research on approaches, I agree that the ‘mini’ posterior approach as you describe here is preferable to the anterior one. In this approach do they have to dislocate the hip to remove the femoral head? There is another approach described by Dr. Stephen Murphy where he cuts the superior aspect of the capsule surrounding the head and then removes the head WITHOUT DISLOCATING the femor bone. I realize this would be harder to do for most and that it’s this guy’s ‘signature surgery’. In the mini posterior approach, is it possible to remove the head of the femor first and not dislocate to do that?

    • holycrossleonecenter Posted on July 14, 2014 at 1:54 pm

      Hi Jane,

      The femoral head first is dislocated from within the acetabulum when reconstructing the hip using the mini posterior approach as I described. Similar to the other approach that you question, it certainly is possible to remove the head from the socket without dislocation, by first removing a “napkin ring” of bone from the neck (similar to the other method advocated) and then removing the head directly. I occasionally do this when reconstructing a hip that I can’t dislocate safely, due to the type or severity of the destruction (for example with severe acatabular protrussio). I do this routinely when reconstructing an unstable femoral neck fracture to a partial or total hip replacement, because in these cases straight-forward dislocation is not possible.

      The main reason I dislocate the head, as a routine prior to resecting the femoral neck, is that it greatly facilitates the procedure. I do not think it compromises in any way the reconstruction or the short- or long-term rehabilitation and absolutely does not compromise the final result. It also allows me to make a much more accurate initial resection through the femoral neck. Simply, not dislocating the head prior to head resection does not make the procedure more “minimally invasive,” only more difficult.

      WAL

  3. Jane Posted on July 18, 2014 at 12:18 am

    Hi Dr. Leone,

    I consulted today with a doc who is conversant in the anterior approach, (Meigel in Boston). I brought forth that I had come across many critics of this approach in the ‘rank and file’ of his peers, things like high incidence of cutaneous femoral nerve damage, limitations as to cementing the stem in there. He confirmed that it was not uncommon for there to be numbness to the anterior thigh and also, he press fits the stem and does not cement. I asked why he ‘defaulted’ to this approach and did not also do the posterior mini (I thought he did both because his office staff said he did, hence my consult) and the answer was: ‘My patients like this approach’. Now if the patients are ‘liking this approach’, it could mean they are responding to the marketing of it or are just not the types to ‘get into it’ as to read what other orthos say about this among their own peer group.

    He was aware I ‘did my research’ (or did more than a lot of patients do). But with that, he was very reticent to say much at all to me. For example when I asked about the orientation of the osteophytes I had mimicking the morphology of FAI and hence why I initially tested positive to that with the PT, he declined to make much comment at all and just said: ‘You have arthritis’.

    Did I do something ‘wrong’ in the consult? I was considering the doc but I was looking for some kind of ‘rapport’ or communication on a higher level and he was just very reticent. Is it common for ortho docs not liking it if the patient does research on their condition and has less ‘simple’ questions than the average one. Do most of them just want the patient to go in there and ask; ‘Can I have hip surgery’ as opposed to questions about their method of doing it?

    • holycrossleonecenter Posted on July 24, 2014 at 9:17 am

      Hi Jane,

      Physicians, specifically orthopedic surgeons, are like everyone else and come in all shapes and sizes, with assorted personalities, needs, likes and dislikes. Like patients, some are super detail oriented, some not so much. Some enjoy patients who are intellectually curious and challenging. Others are put off. Certainly there is no right answer. I think what is important is that you find an orthopedic surgeon to whom you can relate and from that relationship get what you need. If that includes being willing to have an in-depth and honest discussion regarding your care, with hopeful benefits as well as risks and other options, then that is reasonable.

      Sadly, for many reasons, it is becoming more difficult to find doctors willing and eager to do this. The U.S. system is, for the most part, still based on a private-practice, competition model. But this is changing rapidly as new rules and fee schedules continue to come out of Washington, and as many doctors are opting for employment models with big corporations and hospitals. That said, it’s still out there, you just have to keep looking until you find the right individual.

      What you mentioned about “patients specifically wanting the anterior approach” is true. Some patients begin their search with a mindset which to a large part is based on marketing. I know many doctors who now “offer” the anterior approach to their patients for just this reason. Personally, I struggle with this; but I do understand it.

      I also know that when I meet someone who has “done a lot of research” about what he or she thinks is their problem and what the best solution is, it requires much more energy and time on my part. I’m sure for some doctors, it also becomes more intimidating: “expert being challenged mentality.” Some doctors just don’t want to deal with this type of patient, and I fully understand this as well.

      My advice to you is to keep looking, interviewing, and learning until you find that individual with whom you are comfortable and confident.

      WAL

  4. Jane Posted on August 10, 2014 at 8:23 pm

    Dr. Leone,

    If I can indulge you in another question:

    Is it common for orthos to ‘boiler plate’ in a litany of tests and their results when the doctor does not actually do those tests?

    I was just reviewing my exam notes from Dr. Miegel (who does anterior method) and found a litany of tests for which he listed the ‘findings’ but did not actually perform on me. For example, he’s got all the ROM values filled out but did no ROM test on me. The only hands on test he did was the ‘log rolling’ test which ironically he does not list on my chart as having done. Other examples involve documenting exactly what my dorsal pedalis pulse was and exactly what my great toe extension was. But the facts were he never had me take off my bulky sneakers to have ever have performed the tests. Likewise with measures of Achilles reflexes and knee reflexes where at no time were the areas ever striked with either a rubber mallet of heal of hand. I noticed I had some false negatives on my chart due to his not really doing the tests but saying he did. Like I test positive for crepitis and leg length discrepancy when the practitioner really tests for those things. Yet now, because he did not test for those things and instead INTERPOLATED the results via some boiler plate computer program designed to do so, I’ve got some false negatives on my chart.

    Most of my chart consists of boiler plated in tests not performed on me in which the ‘results’ are interpolated from other information. For example, I went in there for hip evaluation. So, knee evaluations are boiler plated in with the results of ‘negative’, I guess because it can be assumed that a patient not having any specific complaints about knees during hip evaluation will test ‘negative’ for ligament tears to the knees and all tests to that regard are boiler plated into the chart AS IF they were really part of the exam.

    Is this a COMMON practice for orthos as to load a patients chart with phony results of tests they did not actually do?

  5. Susan Leatham Posted on August 25, 2014 at 2:51 pm

    Two weeks ago today my healthy vibrant 64 year old mother went in for a left total hip arthroplasty. The anterior approach was used.. My mother had a lot of unexplained blood loss during the surgery and her heart stopped. They were able to get it started again with CPR but due to injury to her spleen she went into DIC and passed away. I am still in shock and I cannot even express the grief I feel. I can’t believe my mom is gone. I can’t believe this horrible thing happened to her and I hope somehow I can learn from this and help others. I am a nurse. I wish I could have saved my mom. She died the same day Robin Williams took his life and I kept thinking my mom’s death should be on the news and not Robin Williams. I still can’t believe she’s gone, and to make things even worse I had a baby three weeks before her surgery. Now my son will not know her and she will not be around to see him grow up. It seems so cruel.

    • holycrossleonecenter Posted on August 28, 2014 at 10:06 am

      Dear Susan,

      I am very sorry for your loss. If you have unanswered questions, my suggestion would be to discuss them with your mother’s surgeon.

      Sincerely,

      Dr. William A. Leone

    • Marlene Posted on December 9, 2014 at 11:56 am

      Susan, I am sorry for your loss. I lost my Mom after surgery as well. Can you tell me where your mother had her surgery? I need a hip replacement and was going to Dr. Matta in LA and he does the anterior approach and now I am not so sure.

  6. Mary Posted on August 29, 2014 at 12:09 pm

    Hi Dr. Leone:

    My active sister (62), had an Anterior Total Hip Replacement Surgery last year.
    She has extreme pain similar to the pain before the surgery. The original
    doctor said everything is fine and does not consider her pain. She went to
    other doctors for a revision, but one doctor saw the recent MRI and said
    that type of surgery causes a lot of problems to other areas while trying to
    get to the femur and joint, and nothing can be done to fix it. She has
    titanium and ceramic. She had the surgery in NYC by a very reputable doctor.

    We are trying to find out how she can be helped for the other damages or
    whatever is wrong. Needless to say, she is devastated by the news.

    Would you explain the other types of damages that occur during the
    Anterior surgery and if she would be able to get any relief? In this day
    and age, it is hard to believe that nothing can be done to help her.

    I wanted to mention that she woke up twice during the surgery. The
    second time she woke up she asked for her doctor, and the staff
    around her said he was in the other operating room. Maybe the
    surgeon rushed the surgery and caused unnecessary stress or
    injury to the nearby muscles, tendons, ligaments, etc.? In any
    case, it is sad to see her in such misery and such despair. She
    runs a business and travels a lot, even in this pain.

    We are not sure where to turn at this point. I would like to take
    her to Columbia Presbyterian Hospital on 168 Street, in NYC.
    I have seen other people get relief there after they have had a
    botched surgery.

    Mary

    • holycrossleonecenter Posted on September 5, 2014 at 12:40 pm

      Dear Mary,

      I’m sorry to learn that your sister still is in pain following her hip replacement. I think every effort should be made to try and find the cause. Usually if a specific etiology (cause) can be diagnosed, then it can be corrected.

      The pain might be due to local muscle and soft tissue damage from difficulty with the approach, but this is a diagnosis of exclusion. Many other diagnoses should be considered first. You mentioned that the “extreme pain” she has now is “similar” to the pain she had prior to surgery. If the pain she was having before surgery was not originating from the hip joint, then replacing the joint did not relieve it. Other considerations include a neurologic etiology, a gynecology problem or even a hernia.

      The nature of the pain needs to be characterized. For instance, is it constant or episodic; sharp or dull; do certain activities like getting up from a seated position to a standing position increase the pain; and it worse with walking or weight bearing? What relieves the pain, if anything? Does she require narcotics for the pain? Does pain awaken her at night?

      Answers to these questions can give the physician a clue as to the etiology. Did she ever do well after the surgery? If she did well for a short time and then the pain came back, it suggests the operation was done for the correct diagnosis and then something changed. Is there any evidence of nerve damage such as a decrease in sensation to part of the thigh or muscle weakness? Does she have a history of significant back issues or sciatica? Component instability and component position have to be considered, as well as underlying infection.

      My advice is to go back the surgeon who performed the surgery and ask to re-explore the surgical outcome and why your sister remains in so much pain. If that does not produce any meaningful results, then seek other capable and caring physicians.

      I hope your sister finds her answers and relief.

      Sincerely,

      Dr. William A. Leone

    • Marlene Posted on December 9, 2014 at 11:57 am

      Mary,
      I live in NYC and am looking for a surgeon for a total hip replacement. Can you itell me who your surgeon was?

  7. Mary Posted on September 5, 2014 at 10:14 pm

    Dear Dr. Leone:

    Thank you for such an informative reply. I really appreciate your
    input.

    I have to report that my sister did go back to the doctor, and he said
    everything was fine, but sent her for an MRI. The MRI mentioned tendinitis.
    The first doctor still said everything was fine. She went to a second doctor and the second doctor said the problem was with Anterior surgery and that he does not do it
    because it injures so many other things. He also said the doctor only glued
    the replacement and did not cement it and nothing can be done now. My
    sister said the second doctor hardly looked at the paperwork so she was not sure
    how he knew about the glue only.

    The question I was trying to ask you in the first letter was what other injuries
    would occur, outside of the hip and implant. I asked that because I wanted
    to know what kind of doctor to seek depending on what the secondary
    problems would be. If she should go to a neurologist, etc. I think we are
    not quite sure which direction to go since she already went to another
    doctor to try to get help.

    All of the above questions you asked pertain to her. She recovered a bit,
    but getting out of a chair and some other motions are impossible or very
    difficult. I can perhaps have her write to you, herself.

    Again, thank you very much for your cordial and prompt reply. We both
    appreciate it.

    Mary

    • holycrossleonecenter Posted on September 9, 2014 at 7:39 am

      Hello Mary,

      My advice is to seek the evaluation of yet another surgeon, preferably one that limits his or her practice strictly to adult reconstruction (hip and knee replacement) and who also is a revision surgeon, for a fresh look to see if there is something that can be corrected.

      Sincerely,

      Dr. William A. Leone

  8. Valerie Posted on March 11, 2015 at 5:17 pm

    Dr Leone,
    Just want to thank you for an excellent informative article. I need a total hip replacement and I have been hearing from “others” that the anterior approach is the way to go. I am glad to know that it may not be the way to go! My brother had a hip replacement one year ago and it turns out it was an anterior approach and he has had multiple problems starting with dislocation accompanied by an MI. Second and third dislocation, revision which left one leg shorter than the other, and the stem remains loose in the femur and he is need of a second revision. He is only 60yrs and a total invalid until he gets the next revision. We are praying this will fix his hip.
    Thank you for this information. I feel better able to partner with my ortho surgeon in deciding the best approach.
    God bless you.

    • holycrossleonecenter Posted on March 12, 2015 at 10:47 am

      Dear Valerie,

      I’m glad that you found this blog post so helpful.

      Good luck with you THR,
      William A. Leone

  9. holycrossleonecenter Posted on March 24, 2015 at 10:12 am

    Dear Diane,

    Most partial hip replacements are preformed to treat hip fractures. Many patients just 4 ½ months after their surgery still struggle with crossing their legs to put on shoes and socks. The majority of people who have had this surgery eventually do regain this ability, but not all. I would not be too concerned that there is still some discomfort with sitting, but I would expect it to be progressively improving. Similarly, I would also not be surprised if you feel some degree of stiffness and even experience a slight limp for the first few steps when getting up from a sitting position. I would anticipate that this also will resolve itself over time.

    I would be more concerned if the pain you’re experiencing while sitting is in the groin rather than posteriorly (back or rear area of your hip) and if you’re continuing to have pain with walking. Recognize that not only was the bone broken during the fracture, the surrounding soft tissues were also damaged at least to some degree. The tissues were further damaged (despite how careful the surgeon was) during the act of implanting the partial hip replacement. Frequently, patients who undergo an elective THR recover faster than patients who fracture the hip and are treated with a partial hip.

    If you are continuing to improve with time, then I’d be patient. If the symptoms are worsening or plateaued and you’re frustrated, then I would suggest you share these concerns with your surgeon and seek his or her advice.
    I wish you a full recovery.

    Dr. William Leone

  10. Jane marie Posted on March 27, 2015 at 3:12 pm

    Dear Dr. Leone,
    I have posted a question on the blog about arthroscope, but here I found very detailed information through the questions and responses about THR. One quick question on this blog: Is what is termed a ” minimally invasive procedure” with 2-3 incisions the same as a mini-posterior approach? Thank you!

  11. holycrossleonecenter Posted on April 9, 2015 at 9:15 am

    Hello Jane Marie,

    “Minimally invasive surgery” is a difficult-to-define and loaded term. The definition for what constitutes a “minimally invasive surgery” is not even agreed upon by surgeons. Everyone who requires a surgery wants that surgery to be minimally invasive. Does one incision accomplish a surgery less invasively than two or three incisions? An excellent surgical experience with a fast recovery and successful outcome depends on so many important variables, especially how gently the tissues are handled.

    Many surgeons advertise that their techniques are minimally invasive to market their practices. I fully understand this. There has been a tremendous amount of pressure exerted by the general public and media, stressing the “little incision” and “minimally invasive techniques.” This also has produced a lot of compromised results.

    In my practice, I emphasis absolutely precise implant positioning and soft tissue balance because this consistently produces the best results that last the longest. The surgery needs to be accomplished through the smallest incision with the least and gentlest soft tissue dissection and I emphasize meticulous soft tissue handling and closure. Buyer beware, I recommend you choose your surgeon and not the approach or prosthesis.

    With regard to your second comment, if imaging studies (plain X-rays or MRIs) demonstrated arthritis with joint space narrowing, then I would not expect your symptoms to be improved with an arthroscopy. I suspect the goal of the anterior injection recommended by your doctor will be to place a local anesthetic and possibly a steroid into the joint. If, even temporarily, the pain is relieved and function and motion are improved because it no longer hurts, then that would be good evidence that you are being disabled from the arthritis in the joint and a THR might be a very reasonable and appropriate next step.

    I hope this helps.

    All the best,
    Dr. William Leone

  12. arlene Posted on April 30, 2015 at 10:21 pm

    I am deciding on total hip replacement and am stunned to see that orthopedists are divided over anterior v. Posterior approach. Generally speaking, which one has faster recuperation time and least painful recovery?
    I had heart attack in June 2014 due, most likely, obstructive hypertrophic cardiomyopathy. My hip problem is due to osteoarthritis and aging (I am 67). I am a busy career woman with a sick husband and need a procedure which may offer quickest and B least painful recovery…..
    I welcome your thoughts. Thank you.

    • holycrossleonecenter Posted on May 6, 2015 at 9:24 am

      Dear Arlene,

      The anterior approach certainly does not result in faster healing or a quicker return to full activities any more than the posterior approach. Each approach has advantages and disadvantages. My earnest advice is to choose your surgeon and not the approach. As with all of my patients, there are so many other considerations to care. In your case, it’s more than just hip arthritis but also your cardiac condition complicated further with recent MI, being the primary caretaker of your husband and your perceived need to return to the work place as soon as possible.

      All of your medical and life needs must be taken into account and taken care of, not just your hip. You need to find a hospital with a top track record for caring for many patients with complex medical histories like yours and where a lot of hip replacements are done. I would suggest you speak to your surgeon and share your concerns and needs. I often encourage my patients to speak to other patients with similar issues and concerns to find out about their experiences.

      The very best of luck to you,
      Dr. William Leone

  13. Arlene Posted on May 1, 2015 at 8:39 am

    I am trying to decide between posterior & anterior hip surgery. I am 67 and need a left hip replacement due to arthritis, aging, etc. (no fracture). I have in the past few years developed a heart condition (obstructive hypertrophic cardiomyopathy) and take medication. I had a heart attack in June 2014. I am also a busy professional with a very sick husband and so I need to be able to get back to work ASAP post-surgery.

    I have been told that the anterior procedure results in faster healing and much less painful aftermath. Yes? No? I was under the impression that the posterior procedure was old-fashioned, so I was surprised to learn that you have returned to the posterior procedure.

    Your comments would be most welcome!

    Thank you! Arlene

    • holycrossleonecenter Posted on May 6, 2015 at 9:23 am

      Dear Arlene,

      The anterior approach certainly does not result in faster healing or a quicker return to full activities any more than the posterior approach. Each approach has advantages and disadvantages. My earnest advice is to choose your surgeon and not the approach. As with all of my patients, there are so many other considerations to care. In your case, it’s more than just hip arthritis but also your cardiac condition complicated further with recent MI, being the primary caretaker of your husband and your perceived need to return to the work place as soon as possible.

      All of your medical and life needs must be taken into account and taken care of, not just your hip. You need to find a hospital with a top track record for caring for many patients with complex medical histories like yours and where a lot of hip replacements are done. I would suggest you speak to your surgeon and share your concerns and needs. I often encourage my patients to speak to other patients with similar issues and concerns to find out about their experiences.

      The very best of luck to you,
      Dr. William Leone

  14. Darcy Posted on May 11, 2015 at 11:24 pm

    As a PT in Boulder CO, all I see are anterior approach hip replacements, all my patients do extremely well with such a short post op rehab regime and no precautions to be worried by, I have never heard of all the cons. I seriously wonder if this group of surgeons just know what they’re doing? And, those post op precautions are SO much easier for the confused elderly. Hmmmm ….. Gotta wonder.

  15. Karen Posted on May 19, 2015 at 11:54 am

    I had an anterior hip replacement two weeks ago, and I was out of hospital next day, driving in 3 days, and at the gym in 4 days. The recovery is a little slower this second week, and I am still using the cane for stability. I was EXTREMELY happy with the outcome. I had NO pain, or any other problems. My Dr. has performed many of this type of hip replacement approach, and prefers it to any other. I agree that you should pick the Dr. rather than the approach, but I have heard nothing but good things regarding the anterior approach and the shorter recovery period.

  16. Jean Posted on May 30, 2015 at 8:14 am

    I had anterior THR on March 25, 2015 and it’s been a rough recovery. The hip and thigh feel fine but one leg is or feels longer than the other and my knee on the operative leg is getting shredded! – not the joint but the tendons and ligaments within the knee and along the sides.

    Doctor won’t acknowledge any problems and says leg length and outcome is “perfect.” Before surgery he said recovery time was 2 weeks – after surgery he says recovery time is 1 year.

    What’s done is done – maybe legs are same length, maybe hip components are placed incorrectly, maybe I have a slight scoliosis or asymmetry that wasn’t factored into the equation – whatever. Hopefully nothing more than a shoe insert will minimize the problem.

    I thought I’d be walking around Italy by now but I’m hobbling around like a disabled person. It is a little better than having the hip pain. My expectations were high having read many patients’ accounts of an easy fast recovery and my doctor’s experience and reputation.

    • holycrossleonecenter Posted on June 8, 2015 at 8:14 am

      Dear Jean,

      I’m sorry to learn that you are struggling after your THR. Unfortunately, experiencing a leg length difference after hip replacement is a known complication. More commonly, the operated leg feels longer. The good news is that in the vast majority of patients who perceive this, the difference decreases with time and most no longer feel, or at least complain about it six months post-operatively. If a shoe lift on the short side relieves discomfort and makes the legs feel more nearly equal, I would support this. It has not been my experience that a shoe modification or a lift stops or slows the tendency for the leg length difference to feel more equal with time. If the leg length difference is disabling enough and not improving with time and exercise, then a hip revision may be appropriate.

      I wish you the very best,
      Dr. William Leone

  17. Alyse Posted on June 1, 2015 at 6:49 am

    Hi Dr Leone- can u please explain the difference between hip replacement and hip revision recovery?thank you

    • holycrossleonecenter Posted on June 8, 2015 at 8:11 am

      Hello Alyse,

      A revision THR describes a situation when a person who already has had a total hip replacement needs further surgery on the hip to correct a problem. There are a variety of reasons why the hip would require more surgery. For example, a THR with a loose femoral stem or socket; a THR which repeatedly dislocates; or if one leg feeling longer or shorter after the surgery and is not correcting on its own with time. Revision also might be necessary if an infection develops in the hip, with the hope of salvaging that total hip or removing the infected total hip and implanting a new one. Also, bone loss (osteolysis) can develop around the THR components often from plastic or metal ware debris. These are just a few of the more common indications why a “re-do” THR or revision THR may be indicated.

      Best,
      Dr. William Leone

  18. Kim Posted on June 9, 2015 at 1:59 pm

    I have had two anterior approaches and recommend them and my doctor highly. I was off walker in 2 weeks and off cane at 3. The last surgery I flew to my sons 2 1/2 weeks post op to help with grandkids. My last surgery was on Thurs and I was at both church services on Sunday. Check the doctors training, knowledge and comfort with this procedure. Anterior approach has been around in Europe for 50 years.

    • holycrossleonecenter Posted on June 24, 2015 at 9:12 am

      Dear Kim,

      I’m so pleased to learn that you are doing so well following your bilateral hip replacements. Total hip replacement is a remarkable procedure that when done well truly helps a tremendous number of people. I think the approach used to implant the procedure is much less important than the individual who performs the surgery. It sure sounds like you did your homework and ultimately were cared for by a wonderful surgeon.

      A little background: The anterior approach to the hip, also called the Smith-Peterson Approach, was developed more 100 years ago when all of our progressive approaches to the hip were developed. Brilliant surgeons figured out how to gain access to the hip in order to operate on it in tandem with the development of anesthesia. Traditionally, it was used to treat pelvic fractures and perform osteotomies. Fifty plus years ago, it was used to implant total hips when this field was just developing. Most surgeons abandoned it for other approaches due to associated complications, especially neurologic. There has been a resurgence of interest with the development of new surgical tables designed to treat pelvic fractures. Choose your surgeon, not the approach.
      I wish you the best of luck.

      Sincerely,
      Dr. William Leone

  19. virginia Posted on July 7, 2015 at 9:04 pm

    Dear Dr. Leone,

    I am a 64 y old woman who has been active all her life gardening, cycling and walking. For 40 years, I have kept a consistent yoga practice and my joints are flexible. However, I had an incident 9 months ago wherein a labral tear occurred and I’ve had pain and difficulty walking. I have now been diagnosed with several labral tears, hip dysplasia and impingement, hip arthritis, a degenerating acetabular with edema. Two surgeons said I needed a THR and the pain is driving me to do it. The first surgeon I saw only performs an anterior approach. I investigated another surgeon and am now scheduled for THR surgery at HSS in NY with the mini posterior approach (Stryker duo mobility) . This surgeon expressed similar concerns about the anterior approach as yours. But I have read about arthroscopy and the chance to save the hip and treat the dysplasia. Is my condition appropriate for thist?

    My biggest fear is that I will not be as flexible after recuperation from the THR. Is one approach to THR better than another in terms of patient flexibility in the long run? One of my friends took 7 months to tie his shoes and feels he is much tighter now than before surgery. Is this due to cutting muscles during surgery and waiting for them to repair? I want to do my yoga and feel my hip stretch and open again. Do you think this possible?

    • holycrossleonecenter Posted on July 24, 2015 at 11:49 am

      Dear Virginia,

      From what you describe, you will be a wonderful candidate for THR. I do not believe one approach is “better” than another. Each has its unique advantages and disadvantages. The most important variable is who does your surgery. The “human factor” is critical to a successful and desired outcome. Also, where the surgery is done plays an important role and HSS enjoys a wonderful reputation. There is a huge, spectrum of flexibility among people, determined by genetics. Activities such as Yoga can then extend someone’s potential flexibility. It’s been my experience that if you are very flexible, and most yoga instructors are, prior to THR, then you quickly will regain your motion postoperatively. That being said, there may be some yoga positions that greatly exceed the mechanical limits of the prosthesis and should not be done. “Good judgment” still needs to be used. It’s quite possible that you further injured your hip over the years with some extreme yoga positions that caused impingement. This should not be repeated with your prosthesis. Extreme positions potentially could lead to a hip dislocation.

      I wish you a full and speedy recovery.

      Dr. William Leone

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