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.

 

 

71 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.

    • Jeannie Galliano Posted on November 18, 2015 at 4:49 pm

      Hello Karen,

      I am currently scheduled for anterior THR & feeling a bit anxious. Would you kindly disclose
      whom your surgeon is & if he is in California. It sounds like you have had an fabulous outcome & would like to consider your doctor. Thank you.

      Sincerely,
      Jeannie

    • rose Posted on January 1, 2016 at 12:54 pm

      Who was your doctor?

  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

  20. Daniel Posted on August 1, 2015 at 3:14 pm

    Hello Dr. Leone,

    Very helpful blog discussion. Thank you for taking the time.

    I need a revision surgery due to an aseptic loosening of my prosthetic stem following a full hip replacement 15 months ago. My surgeon has an excellent track record, does not use nor recommend the anterior method, and (like you it sounds) feels that the positives of the two methods are perhaps similar but the negatives favor the mini-posterior approach (my surgeon uses what he calls the “anterolateral” approach). Medicine is not an exact science, so the lack of consensus can be frustrating for a patient but perhaps not unexpected. Your repeated point about choosing the surgeon over the technique is thus well taken.

    I did have a few questions which may not be quite as case-dependent as others (hopefully):

    1. Do you know the overall percentage of failures like mine, namely aseptic loosening of an (uncemented) stem after one year? I’ve heard everything from 2% to less than 1% which seems like too wide a variance. As I (vaguely) understood it, my doc explained that the femur bone never fully welded/grafted itself onto the prosthetic stem, and part of the remedy is to use a more aggressively surfaced stem for the revision surgery.

    2. When you were still doing full hip replacements using the anterior approach, did/would you also recommend this technique for revision surgeries like mine? I’ve read conflicting opinions on this.

    3. I read your comments to the effect that recovery times are not neccesarily dependent on which technique (anterior vs. mini-posterior, etc.) is used. Perhaps it’s marketing, but there seems to be a perception out there that the anterior approach lends itself to much faster recovery with fewer if no restrictions. Is this more dependent on the individual surgeon or are there actual facts supporting this perception?

    Thanks again for this very useful & informative discussion.

    • holycrossleonecenter Posted on August 5, 2015 at 10:02 am

      Dear Daniel,

      The anterolateral approach (also called the Watson-Jones approach) is very well established and many surgeons use it as it does have advantages. I choose not too because it divides the abductor mechanism.

      It sounds like the femoral component that was implanted failed to osseointegrate. That is, bone failed to grow into or onto the stem. When bone fails to grow, fibrous tissue or scar grows instead. Sometimes the scar tissue is good enough and a patient is satisfied but other times pain results from stem instability. Some stems have better track records than others for osseointegrating. The plan to revise your hip sounds appropriate.

      I would encourage your surgeon to use whatever approach and whatever stem he or she feels most confident will deliver the best and most predictable result. The first attempt failed and it’s critically important that this next time is “a winner.” Focus on giving your body time to heal. The key is to build a construct in your body that will last many, many years.

      I wish you the best,
      Dr. William Leone

  21. Nadine Whitinger Posted on October 12, 2015 at 11:26 am

    Hello,
    I guess this is more of questions then comments! I am scheduled to have a total anterior hip replacement. Every day I’m doing research on this. As it is a fairly new procedure! After reading all the articles; pro’s and cons Im totally confused. I am to have it done at Swedish American hospital in Rockford Il by a Dr Antonassi. It is a new procedure for him of 2 yrs. The hospital has purchased the $80,000 Hana table. However he is a excellent orthopedic Dr so I hear and all his patients has seemed to do well! I just thought this was the newest and better solution to hip surgery? After reading all these articles I am in question. I am a healthy 66 yr old female? What to do?

    • holycrossleonecenter Posted on October 19, 2015 at 1:19 pm

      Dear Nadine,

      It is confusing. The lay public is being blasted with all sorts of information. Like everything in life, it’s not that straight forward. The most important decision you have to make is who will do your surgery. You made that decision based on his expertise, reputation, and the feelings you got that he would take very good care of you. I think once you have made that decision then you need to trust that person.

      I wish you a full and excellent recovery.

      Dr. William Leone

  22. Dave Posted on November 10, 2015 at 1:51 pm

    Dear Dr. Leone,

    I’m 68 and in need of a right hip replacement. after reading your article(s), i am convinced that the mini posterior approach is the best. as i live in southern california, would it be too complicated having it done by you in the Bay Area considering the 6+ hours travel time? Could you recommend someone in Southern California?

    thank you,

    Dave

    • holycrossleonecenter Posted on November 24, 2015 at 1:25 pm

      Dear Dave,

      We are so fortunate to live in a country with so many caring and competent professionals. It’s important that you find a surgeon who cares and in whom you have confidence. If you can find that person in your “own back yard,” even better.

      Having a hip replacement and getting it right is a big deal. If you must travel to satisfy your conditions and needs, then do it. I care for so many people from around our country and extensively throughout the Americas and the Caribbean. Because so many folks travel to us for their surgeries, my staff and our hospital is set up to accommodate out-of-towners.

      I wish you full and safe recovery.

      Sincerely,

      Dr. William Leone

      We thank you for your readership. If you would like a personal consultation, please contact our office at 954-489-4584 or by email at LeoneCenter@Holy-cross.com. General comments will be answered in as timely a manner as possible.

  23. Tito Posted on December 7, 2015 at 12:40 am

    Dear Dr. Leone. I’m 43 years old and I was diagnosed with hip dysplasia on my left leg a few years back. I’m 5″3′ and 176 pounds. I’m scheduled for surgery on 02-22-2016 and I asked my surgeon what approach was best for my condition, he recommended the posterior instead of the anterior . He said that my acetabulum was shallow and deformed and he needs to repair it….. I’d to know if he’s correct. Thank you.

    • holycrossleonecenter Posted on December 18, 2015 at 11:30 am

      Dear Tito,

      The approach used to replace the hip is not nearly as important as the doctor who actually is doing your surgery. If you’ve found a physician that you trust and with whom you have already scheduled surgery, trust that he or she will take good care of you.
      I wish you a full and satisfactory recovery.

      Sincerely,

      Dr. William Leone

      We thank you for your readership. If you would like a personal consultation, please contact our office at 954-489-4584 or by email at LeoneCenter@Holy-cross.com. General comments will be answered in as timely a manner as possible.

  24. Janet Posted on January 9, 2016 at 8:02 pm

    I had an anterior total hip replacement 3 years ago at age 69. The surgery went well and my recovery was fast. I have had no problems or concerns until this week. I am fairly active and walk 2 mikes a day. Three days ago I started having discomfort in the same area as before the surgery. Yesterday the pain worsened. Today it is also bad. There is only pain after I stand up and start to walk. The surgeon who did the replacement was recommended by my doctor of 25 years and is a highly respected orthopedic doctor who specializes in hip and knee replacements. Unfortunately we moved 8 months ago and I am no longer in the same area as the surgeon who did the surgery. I am currently looking for an orthopedic doctor in the area of our new home. Of course I want to find a good one but don’t know where to start looking. Can you give me some insight as to what may be causing the pain.

    • holycrossleonecenter Posted on January 29, 2016 at 12:59 pm

      Dear Janet,

      Although an intra-articular hip etiology does have to be considered and then ruled out, other conditions such as a hernia or iliopsoas tendonitis also can cause this. You might begin a search to find an orthopedic surgeon in your new area by discussing this with your primary care physician. That individual may have some recommendations. This is assuming you’ve found a new PCP already. Many patients will search the web for specialists in their area.

      If you’re fortunate enough to know anyone who has had a hip replacement, ask who cared for them. Most of the people who come to see me actually are referred by friends and acquaintances rather than physicians. You might ask your new PCP to have X-rays taken. You then can ask you original surgeon if he/she would review them. He or she might be able to refer you to a colleague in your new area.

      At the end of the day, if you’re worried enough and not getting the care and peace of mind you need in your new location, consider traveling back to see the surgeon who took such great care of you. Once again, many of my patients do just that.

      I wish you a full recovery.

      Dr. William Leone

      We thank you for your readership. If you would like a personal consultation, please contact our office at 954-489-4584 or by email at LeoneCenter@Holy-cross.com. General comments will be answered in as timely a manner as possible.

  25. MzB2U Posted on January 26, 2016 at 10:47 pm

    Dr Leone,
    My hip was replaced in 2007, in 2014, we found I had complications due to metal on metal components and had a revision done, however, it dislocated 3 times and in 2015, a constrainer was placed on ball. 2016, I had a large cyst with fluid surrounding the upper joint and had to have it cleaned out. My question is, I no longer have a muscle for my hip or appliance to attach to, If I understand correctly, it will not grow back, what exactly does that mean for my leg movement and pain?

    • holycrossleonecenter Posted on February 18, 2016 at 10:50 am

      Dear MzB2U,

      It sounds like you’ve had a terrible complication from your metal-on-metal hip which resulted in the destruction of your abductors. These are important muscles that insert on the upper part of the femur (great trochanter) to help prevent your hip from dislocating and stabilize your gait. If this is the case, and your hip repeatedly dislocates, then application of a constrained liner which mechanically links the head to the socket is appropriate. My hope is that your hip is not painful.

      I would assume that you now walk with a significant limp or “lurch” due to abductor weakness. I would also anticipate that your gait would be greatly improved when using a cane in the opposite hand. Indeed, this muscle group will not grow back. Other muscles in the area can be strengthened and help substitute for the deficient abductors, and with time improve motion and gait. However, there always will be some degree of deficiency.
      I wish you the best,

      Dr. William Leone

      We thank you for your readership. If you would like a personal consultation, please contact our office at 954-489-4584 or by email at LeoneCenter@Holy-cross.com. General comments will be answered in as timely a manner as possible.

  26. Kilsis Posted on January 29, 2016 at 4:41 am

    Hello Dr Leon,

    I am currently active duty in the Navy and learned today that I will need bilateral THR. I am utterly devistated despite all the positive comments I find online regarding the success of this procedure. I have been progressively getting stiffer and stiffer. Loosing almost total abduction mobility among other limiting motions. I am in pain all the time, sometimes more severe than others. I desperately want to remain active and have probably compromised my health further in search of fitness.
    I find myself working extra hard in the gym because I don’t feel I have the results I should in some aspects with the training I put in. Only to undestand now that some of the reasons are due to poor posture and flexibility that compromises my form. Yet I find that I am still fit (some areas more than others). The surgeon I saw today is suggesting that I have what I am assuming is this “anterior approach” I keep reading about on your blog. This assumption is merely based on the images he showed me and description of scar location. Maybe he even named it during our conversation. I was honestly blown away and may have missed a lot of what he said. Hence my reaching out to you for clarification and also because I can’t seem to ease my mind and rest. Some of the questions I did not ask during my consultation and which swarmed my mind immediately after driving away are:

    1-Does avascular necrosis contribute or have any connection with fertility problems, or can it?

    2-Will I have a dissabling limp after THR?

    3-I know we loose height as we age but is it normal to have lost 2+ inches at my age or is it directly related to hip problems?

    4- Will I regain my height if so?

    5-scars are an issue for me. Which procedure yields the least visible scaring?

    6-What exercise for strengthening can I do now in the gym before the surgery that may help both my prognosis as well as the surgeon during the procedure ?

    7-What is the percentage of patients who still have mobility problems after the surgery and why is this? What can I do to improve my odds ?

    8-I know it’s no guarantee but will this surgery help my fertility chances?

    9-There is so much information online. I don’t want to drown in the mist of it all and yet need to be a proactive patient. Any advice?

    I’m sorry for the bombardment of questions and I thank you in advance for your attention to my concern.

    Very Respectfully,

    Kilsis

    • holycrossleonecenter Posted on February 18, 2016 at 10:55 am

      Dear Kilsis,

      What is most important is that your total hip replacements are done expertly. If the surgeon with whom you met is super experienced with using the anterior approach versus another approach, then great. I would go with experience and reputation every time. Find out how many THRs your surgeon has performed. Yes, I would suggest you speak to other patients that have had the procedure with your surgeon to learn from their experiences and fine out how happy they are with the results.

      The length of the incision is about the same for all the standard hip approaches, if all other variables are equal. It’s directly related to how much tissue separates your skin from the bones that make up your hip and how flexible you are. Very thick, muscular, stiff people would tend to have a longer incision to accommodate a more difficult and extensive exposure. How the incision ultimately heals is related to how it is closed by your surgeon and to your genetics. If you “heal well,” then most likely your scar will “look great.” If you heal with keloid or hypertrophic scar formation, then despite how good it may look at six weeks, as it matures and scar tissue grows excessively, then it may appear as aesthetically pleasing. This will not interfere with a good result.

      I don’t know how old you are, but you want to establish reasonable expectations for the surgery so you will not be disappointed. I would suggest you discuss this with your surgeon. The level of activity a patient is encouraged to do can vary greatly between surgeons and you should understand what your surgeon recommends. I also would ask you surgeon for “prehab” exercises. That is, exercises you should do prior surgery which can result in a faster recovery. If you click on the pre-op hip booklets on my website, you’ll see what I recommend to my patients.

      Your email suggests that you have developed AVN of both your hips. Having developed AVN or being treated with THRs should not affect your fertility. It is important to understand why you developed AVN in the first place, which may have some bearing on fertility. Again, this is an important discussion to have with your surgeon and general physician or gynecologist.

      I wish you a full recovery.

      Dr. William Leone

      We thank you for your readership. If you would like a personal consultation, please contact our office at 954-489-4584 or by email at LeoneCenter@Holy-cross.com. General comments will be answered in as timely a manner as possible.

  27. Kilsis Posted on February 17, 2016 at 6:10 pm

    Hello Dr Leon,

    I am currently active duty in the Navy and learned today that I will need bilateral THR. I am utterly devistated despite all the positive comments I find online regarding the success of this procedure. I have been progressively getting stiffer and stiffer. Loosing almost total abduction mobility among other limiting motions. I am in pain all the time, sometimes more severe than others. I desperately want to remain active and have probably compromised my health further in search of fitness.
    I find myself working extra hard in the gym because I don’t feel I have the results I should in some aspects with the training I put in. Only to undestand now that some of the reasons are due to poor posture and flexibility that compromises my form. Yet I find that I am still fit (some areas more than others). The surgeon I saw today is suggesting that I have what I am assuming is this “anterior approach” I keep reading about on your blog. This assumption is merely based on the images he showed me and description of scar location. Maybe he even named it during our conversation. I was honestly blown away and may have missed a lot of what he said. Hence my reaching out to you for clarification and also because I can’t seem to ease my mind and rest. Some of the questions I did not ask during my consultation and which swarmed my mind immediately after driving away are:

    1-Does avascular necrosis contribute or have any connection with fertility problems, or can it?

    2-Will I have a disabling limp after THR?

    3-I know we loose height as we age but is it normal to have lost 2+ inches at my age or is it directly related to hip problems?

    4- If this is due to the deterioration of the hips, will I regain my height?

    5-scars are an issue for me. Which procedure yields the least visible scaring?

    6-What exercise for strengthening can I do now in the gym before the surgery that may help both my prognosis as well as the surgeon during the procedure ?

    7-What is the percentage of patients who still have mobility problems after the surgery and why is this? What can I do to improve my odds ?

    8-I know it’s no guarantee but will this surgery help my fertility chances?

    9-There is so much information online. I don’t want to drown in the mist of it all and yet need to be a proactive patient. Any advice?

    I’m sorry for the bombardment of questions and I thank you in advance for your attention to my concern.

    Very Respectfully,

    Kilsis

    • holycrossleonecenter Posted on February 23, 2016 at 10:14 am

      Dear Kilsis,

      What is most important is that your total hip replacements are done expertly. If the surgeon with whom you met is super experienced with using the anterior approach versus another approach, then great. I would go with experience and reputation every time. Find out how many THRs your surgeon has performed. Yes, I would suggest you speak to other patients that have had the procedure with your surgeon to learn from their experiences and fine out how happy they are with the results.

      The length of the incision is about the same for all the standard hip approaches, if all other variables are equal. It’s directly related to how much tissue separates your skin from the bones that make up your hip and how flexible you are. Very thick, muscular, stiff people would tend to have a longer incision to accommodate a more difficult and extensive exposure. How the incision ultimately heals is related to how it is closed by your surgeon and to your genetics. If you “heal well,” then most likely your scar will “look great.” If you heal with keloid or hypertrophic scar formation, then despite how good it may look at six weeks, as it matures and scar tissue grows excessively, then it may appear as aesthetically pleasing. This will not interfere with a good result.

      I don’t know how old you are, but you want to establish reasonable expectations for the surgery so you will not be disappointed. I would suggest you discuss this with your surgeon. The level of activity a patient is encouraged to do can vary greatly between surgeons and you should understand what your surgeon recommends. I also would ask you surgeon for “prehab” exercises. That is, exercises you should do prior surgery which can result in a faster recovery. If you click on the pre-op hip booklets on my website, you’ll see what I recommend to my patients.

      Your email suggests that you have developed AVN of both your hips. Having developed AVN or being treated with THRs should not affect your fertility. It is important to understand why you developed AVN in the first place, which may have some bearing on fertility. Again, this is an important discussion to have with your surgeon and general physician or gynecologist.

      I wish you a full recovery.

      Dr. William Leone

      We thank you for your readership. If you would like a personal consultation, please contact our office at 954-489-4584 or by email at LeoneCenter@Holy-cross.com. General comments will be answered in as timely a manner as possible.

  28. Tanya G Posted on February 29, 2016 at 2:52 am

    Hi Dr. Leone
    I’m a 37 y/o female who underwent two arthroscopic surgeries to repair a torn labrum. With no relief and a lot of pain from both scopes I went to a very well know Dr here in Ft. Myers to decide if a THR was the answer, and after looking at my X-ray he noticed my R hip was dark & losing circulation then he decided I needed a THR. He debate which approach would be best and he choose the anterior approach. Post Op 5 months has been nothing more than pure pain with high doses of narc. I’ve gone back to him several time with all my complaints and to no avail I’d get the “there’s nothing wrong with you” and in a round about way saying my pain was made up. I last seen him in Jan 2016 and was told to come back in 12 months. And I’m to my wits end, I want to see what you think and would I be able to see you about a revision? My surgery was done on Sept 28 2015, Here are my excuritating symptoms…..10 days post staple removal I developed smelly yellow greenish discharge coming out my inscion and I went in and he said there’s nothing wrong with it cleaned it with saline and put a dressing on it….the smell was so intense it stunk up the waiting room.

    My groin is very painful with lumps getting bigger & bigger pcp did a ct then a ultrasound to find the dx is swollen lymph nodes… Which my surgeon call BS
    My implant clicks during certain movements accompanied with a great amt of pain
    My knee has been painfully swollen every since surgery
    I get sharp stabbing pain in my numb thigh at least 10-15 times a day
    And my thigh also is swollen just about every day
    My leg is longer and he said I’d have to live with that but that give me so much pain if feels as if it’s been compressed that I have to get someone to pull on my leg to stretch it back
    My back feels as if it’s in a vice and being compressed so tight it’s unbearable to stand or walk more than 15 mins at a time
    Last my scare gets so painful it feels like it’s going to bust open
    One more thing during surgery the Nurse came out and told my husband “that it was worst than he thought and that’s why it was taking a little longer than promised”. Till this day I can’t get him to tell me what the complications were. I went into surgery about 7:30 and I didn’t get to my room till a little after 2pm.
    I’m a respiratory therapist and I know how those complications are kept hush hush.
    So that’s my miserable life in a nutshell. Would I be able to see you & get your opinion on a hip revision?
    And would I need a referral? Thanks for your time.

  29. Laurie Rosenberg Posted on March 6, 2016 at 6:52 pm

    Dear Dr. Leone,
    I read your article and the questions in this blog with much interest. I am 54, female, 5’4″, 128 lbs. Prior to experiencing hip pain due to osteoarthritis and hip dysplasia, I had been a runner for many years. I had an anterior method THR of the right hip in November, 2014 and recovered well. I was on my bike by May, and trained for a century in October. I walked without pain or many months. My surgeon has been performing anterior THRs for over 7 years, and is responsible for getting the first Hana table into a hospital in Maryland.

    In August I noticed a pulling, deep (deep deep) pain in my right thigh. This pain has worsened steadily. I had a bone scan in January which ruled out loosening of the implant (CORAIL). I have not personally read the results of that scan, and intend to get it tomorrow.

    I am now facing a left THR, scheduled for April 1. The joint pain going into this surgery is far worse than my right hip was just before surgery, so I’m positive it’s time to do this.

    I wonder if the level of discomfort I am in, and the fact that I’m limping and compensating for the pain of the left hip has anything to do with the depth of pain I am experiencing on the right? Could this be muscles/tendons which have not been properly rehabbed and stretched? I find this pain almost unbearable when walking. Various stretches temporarily alleviate the pain, which is why I hope it is muscle/tendon related.

    I’m really concerned about this next surgery, obviously. My surgeon intends to use a different device, Tri-Lock, this time.

    I chose the anterior procedure based on the advice of numerous people in their 40’s and 50’s who extolled the virtues of their rapid recovery, which was true. Does anything about what I have described make you think that I would be better off with the traditional surgery?

    Any additional insight would be tremendously appreciated.

    Sincerely,

    Laurie

    • holycrossleonecenter Posted on March 29, 2016 at 10:39 am

      Dear Laurie,

      I think the etiology of you right hip/thigh pain needs to be understood before embarking on having your other hip replaced. If loosening and infection are ruled out, other etiologies such as soft-tissue impingement or irritation must be considered. It is possible that by compensating for your painful left hip you are causing the right hip/thigh symptoms, but this is a diagnosis of exclusion. Your description of “unbearable” pain in the thigh/hip that was already operated on suggests a different etiology.. Possibly, soft tissues are being irritated when walking rather than other activities due to how the pelvis rotates to compensate when standing or walking. Consider the end of the stem impinging against the inner aspect of the cortex and with activity causing your pain. Consider a mismatch in the flexibility of your femur at the level of the tip of your hip stem, which also can cause thigh pain. In both cases, a bone scan might show some increased local uptake at the end of the hip stem despite the fact that the stem is not loose.

      I assure you that you were able to return to such a high level of activity not because you had your hip put in anteriorly, but because your surgeon did a good job and you were determined. If your hip had been implanted expertly through a different approach, you almost certainly would have been able to achieve the same result and activity level.
      I wish you a full recovery.

      Dr. William Leone

      We thank you for your readership. If you would like a personal consultation, please contact our office at 954-489-4584 or by email at LeoneCenter@Holy-cross.com. General comments will be answered in as timely a manner as possible.

  30. teri urie Posted on March 10, 2016 at 10:24 am

    dr. leone, my daughter needs hip replacements. she is 53 and has osteoarthritis also has lambert eaton. her mri shows avascular necrosis of the femur and deterioration. she does not want to wait until she is older as recommended by her dr. she has had stem cell treatments in the past that have helped for awhile but the last one did nothing and the dr. said it would not help anymore. is it possible to do hip replacement with an underlying lambert eaton condition and get good results?

    • holycrossleonecenter Posted on March 29, 2016 at 11:07 am

      Dear Teri,

      In my experience, patients with Lambert Eaton syndrome or Myasthenic syndrome do well after total hip replacement but there are increased risks. Those patients with this autoimmune disorder for whom I’ve cared over the years were all well controlled. Optimizing the condition before surgery may be appropriate by using a technique called plasma exchange or plasmapheresis. This decision will be made by your daughter’s physicians. Meds help to control the condition, including steroids, which immunosuppress and potentially increase the risk for infection. This condition is characterized by muscular weakness due to antibodies mistakenly attaching nerve cells which results in blocking the release of a chemical transmitter between the nerve cells and the muscle. Patients experience early fatigability. This weakness potentially could result in a fall and after hip replacement result in fracture or dislocation.

      In spite of these potential complications, if your daughter is miserable enough then the benefits of having a THR may outweigh the risks. Assembling the right team to care for her is very important.

      I wish your daughter a full and uneventful recovery.

      Dr. William Leone

      We thank you for your readership. If you would like a personal consultation, please contact our office at 954-489-4584 or by email at LeoneCenter@Holy-cross.com. General comments will be answered in as timely a manner as possible.

  31. Joe Posted on March 11, 2016 at 10:32 am

    I read your blog post “Why I No Longer Use the Anterior Approach for Primary Total Hip Replacement Surgery – See more at: http://holycrossleonecenter.com/blog/longer-use-anterior-approach-primary-total-hip-replacement-surgery/#sthash.P45G9SDK.dpuf” I read your thoughtful post about how you’re a surgeon and how your patients rely on your for their hip replacements. The anterior approach seems to have many disadvantages and no advantages.

  32. Shawn Palmer Posted on March 16, 2016 at 6:20 pm

    As a high volume hip surgeon performing 700 anterior hips per year, I could not disagree more. My intuition tells me that rather than point the finger at an approach, a refinement in technique is more likely necessary. My cases are performed at a surgery center with case times averaging 25 minutes and blood loss is 50-100cc. We have not transfused any patients in the last 5 years. Patients are driving in 3-5 days and back to work at one week. After performing thousands of mini posterior procedures, it is my experience that it does not compare favorably in any way to the anterior approach hip.

    • holycrossleonecenter Posted on April 7, 2016 at 11:41 am

      Dear Dr. Palmer,

      Thanks for you insights. I am delighted that your patients do so well and I’m sure you would agree they do so well because you do a good job. Also, the most important decision that patients must make is “who” does their surgery. During surgery, I emphasize very gentle soft tissue handling, meticulous hemostasis, and absolutely precise implant positioning. I don’t emphasize operative time. I find by knowing what I’m doing, operative times are less.

      Dr. William Leone

  33. Barb Wirick Posted on March 25, 2016 at 3:09 pm

    Dr have you ever preformed a total knee Femur Hip replacement ? I need to have this done, simply because I have a femur implant that is loosening again, now my option is only this procedure. My femur broke 11 years ago from the effects of radiation. I have already had 7 operations because of the broken femur. I have been 15 years cancer free. Looking forward to your thoughts!

    Barb

    • holycrossleonecenter Posted on April 7, 2016 at 11:39 am

      Dear Barb,

      I have, on very rare occasions, performed complete femur replacement. When doing this, it also requires replacing both the knee and hip. While it’s a huge operation, sometimes it is technically easier than revising a multiply operated or compromised femur during total knee or total hip revision surgery. Radiation can have a devastating effect on bone, which leads to prosthetic loosening. If the bone is dead from radiation exposure, replacing that bone or that segment of bone with an artificial one might be the only reasonable option.

      I wish you the very best.

      Dr. William Leone

      We thank you for your readership. If you would like a personal consultation, please contact our office at 954-489-4584 or by email at LeoneCenter@Holy-cross.com. General comments will be answered in as timely a manner as possible.

  34. Ann Colmus Posted on April 26, 2016 at 3:06 pm

    Dear Dr. Leone,

    2015 started out good for me and then took a huge downward spiral into multiple operations one after the other, and I have more in store in the coming year. In 2013, I had an anterior left hip replacement that never stopped hurting in the middle of my thigh and in the groin. The pain got so bad I had to enter into Pain Management. This anterior never felt as great as my right posterior hip done in 2006. Both surgeries were done by different surgeons. who chose the method that was best for me at that time. Even though the anterior was much quicker in terms of recovery, the posterior on the right has given me not one day’s trouble — I just love it! I am sorry I went to a different doctor and hospital, and had the anterior approach performed. My left thigh from the anterior approach always stayed swollen and no one could find the reason. It hurt all the time with sharp stabbing pain in my left groin. I limped when walking. Multiple arthrograms to check for infection as well as CT scans, MRI’s, bone scans, etc., kept coming up negative until May, 2015, when hypertrophic ossification became apparent. By August, 2015, to get some relief from pain, I had removal of the H.O. from my left hip followed by one course of radiation to slow the regrowth. Radiation did not help and new areas have formed in both hips now. 4 days post-op from that surgery, the incision, which had been glued, had numerous areas that had pulled apart and was draining what looked like watered down blood through the bandage and down my leg. No drain had been used after surgery. The entire month of September, the leg stayed in basically the same shape, swollen only now down to my toes, wound open and draining – covered with a bandage, soaking through multiple times a day. The Orthopedist would look at it briefly, and say it’s not infected, and told me it would take a while to heal. Antibiotics were stopped after 10 days pist-operatively because the doctor felt it wasn’t infected. I had no history of wound healing problems EVER. By October 6, the doctor did an I&D of the wound, but by the next day, the wound started draining and continued to be a bright red color. Two more I&D’s were done in the next two weeks, with the last one being sutured closed with very thick Black thread. I guess he was hoping this would control the drainage? All that managed to do was create more pain because the stitches were now pulling and ripping at the skin because of the amount of edema of the entire leg, and the drainage was squeezing out between each suture. Finally, being admitted urgently from the doctor’s office to the hospital, I was told that another I&D would be done in the morning, and I threw my arms up in exasperation! The next morning, another Orthopedist who specializes in post-op infections came to my room by mistake for a consult. Even though she was given the wrong room number, she turned out to be an angel in disguise. I electively told the admitting doctor that I had replaced him with this doctor, and 2 days later I had a PICC line inserted for antibiotics, and the new doctor had to remove my left hip appliance and put in an antibiotic spacer due to the degree of infection. I was healthy prior to August, 2015, but now I was showing abnormal chemistries and blood counts, received 5 transfusions and 2 packed RBC’s, rand I was starting to go into renal failure and very close to having sepsis. The antibiotic infused hip appliance components hurt a lot because a normal polyethylene cup and ball could not be used due to infection. The doctors now tell me I am walking with bone rubbing on cement every step I take. My hip crackles, clicks, and has a chalkboard on nails effect to anyone within 5-10 feet of me. On top of that, on December 14, while at home on IV antibiotics, I stood up to go to the bathroom, and my femur fractured. I then underwent ORIF of the femur fracture with a plate going from my knee to the top of the femur screwed in place. I am getting conflicting opinions concerning the risks associated with removing the cup and ball which is where most of the pain is coming from, and replacing it with a polyethylene cup and ball so I am able to walk without screaming when my hip rubs on the cement cup. One week ago, fluid aspiration from the wound was completely negative although I am on long- term Bactrim-DS. A CT of the femur last week wasn’t that great, and showed: minimal medial displacement of the distal fracture component. The fracture line is radiolucent and no solid osseous union across the fracture is noted. There is minimal hypertrophic ossification posterior and medial to the fracture. One doctor says the head and ball can be exchanged for a more comfortable one, leaving the fracture alone as well as the spacer. Another consult says that I have to be off antibiotics for six weeks, then have an aspiration, and if negative, and if the femur is completely healed, then do the exchange. I understand that the femur probably needs a bone graft to get it to heal, but the question remains can the incision be opened since the aspiration was negative and blood work looks clear, and the “head” changed and a bone graft placed without hiding infection coming out again and infecting the appliance. This is only April, and it is so painful to move that hip/entire leg at all. Something catches in the hip, the hip locks in place, and I am screaming silently until it eventually eases up, and I am able to walk with my walker again. 10/21, my 60th birthday, was the day the hip appliance was taken out and the horrible spacer put in. Why are some doctors saying you have to wait one year before the replacement hip can be done? Which medical/surgical opinion do you follow: wait one year and then check for infection —- or listen to the aspiration results that for me were just negative, and go in and replace just the head so it glides much easier, and do the bone graft at that time. Then, after the femur is healed, go back in and remove the hardware and the spacer, and perform a complete revision at that time. I was saddened when I read your practice is in Florida and I may have a problem coming to you personally. Can you supply me with a few names of doctors in Maryland, Delaware, NJ or NY that you may know and who follow the same principles as yourself when treating patients status-post hip replacement, status-post hip infection, with painful cup of antibiotic spacer? Mine apparently is complicated by the femur fracture. I look forward to hearing your views as well as any other medical provider or patient with views on this subject. Anybody who gets a joint replacement could be in this predicament from something as simple as a tooth abscess or a cat bite. It’s a scary thing the way this snowballs so quickly if antibiotics are not started early on or prophylactically. It is interesting that my right hip with the posterior hip replacement, never got infected and developed no sequelae from these procedures.

    • holycrossleonecenter Posted on May 5, 2016 at 1:11 pm

      Dear Ann,

      I am sorry you have struggled so, following THR. Fortunately, the vast majority of people who undergo THR do remarkably well, but complications can occur. Complications often beget complications and this seems to be the path that you’ve followed.

      Historically when total hips got infected, the prosthetic was removed, the tissue debrided and irrigated, and the individual was left without a hip for one year. Then he or she was treated with IV antibiotics typically for six weeks and then re-implanted with a new hip when there was no further sign of infection. After the hip was removed, the femur migrated upward and most patients reported one and a half to two inches of shortening with external rotation. Remarkably, most were not painful and some were so discouraged with the thought of more surgery that they elected to live with their “girdlestone” or resection arthroplasty. Much has changed since those early days but the goals and priorities have not: cure the infection and don’t re-implant until there is the most certainty that the infection is gone.

      Your first priority must be to get rid of the infection and heal the femur fracture. Once both have occurred, then an elective total hip can be performed. It sounds as if you’re being cared for by a wonderful and supportive team. Your problem is one that can’t be rushed. Focus on the short-term goals, no infection and a healed femur, and then proceed with revision.
      I wish you the very best. Ultimately you can do very well.

      Dr. William Leone

      We thank you for your readership. If you would like a personal consultation, please contact our office at 954-489-4584 or by email at LeoneCenter@Holy-cross.com. General comments will be answered in as timely a manner as possible.

  35. Cherie Posted on April 27, 2016 at 11:47 am

    I had the THR anterior approach on 12 Apr. 2016. Colorado Springs, CO. It’s been 13 days. I am doing great. Walked with arm crutches for 10 days, as recommended. Post-op check at 10 days. Now, one arm crutch. I can walk without crutch, straight, without a limp, if I concentrate. Day 11- harder to do, day 12- easier. Getting stronger all the time. My pin level is just some sore achiness in the thigh muscles and glute muscles. I am appreciating the ease of not having the very hard hip restrictions during recovery. I plan to drive, soon. Right hip. I will back to coaching Gymnastics at 3 weeks, with some limitations on spotting until the muscles get stronger. Should be back to all aspects of coaching at 4 weeks. i am very pleased with the anterior approach that I had!!

    • holycrossleonecenter Posted on May 5, 2016 at 1:11 pm

      Dear Cherie,

      Thanks for sharing your early success. I wish you a full and uneventful recovery.

      Sincerely,

      Dr. William Leone

  36. Mike Posted on April 28, 2016 at 4:41 pm

    Dr. Leone,

    Six months ago I had a THA, anterior approach. Immediately after surgery the toe of the impacted leg was turned in twenty-five degrees and the operative side of the hip was shifted to the rear 1.5 inches. The toe has resloved seventy percent, but the hip is still displaced. One month after surgery then I began having pain in the groin area and progressive difficulty walking. At four months the pain spread to the side and back of the hip. It has been six months since surgery and I now have to use a cane to walk and the pain has continued to increase. My doc has recommended releasing the lliopsoas tendon, but a second opinion doctor opposed the that action and recommended a “full evaluation”. What are the likely causes for the twisted toe and aft shift in the operative hip? Further, what might be causing the pain in the groin, side and back of the hip?

    Best regards,

    Mike

    • holycrossleonecenter Posted on May 5, 2016 at 1:29 pm

      Dear Mike,

      Many patients will experience increased internal rotation of the operative hip/leg during their early postoperative period. Fortunately for most patients, this tendency to in-toe corrects on its own over time. Muscular imbalance and/or the position of the stem in the femoral shaft often are causes. Your history of symptoms worsening with time is concerning. Simply releasing the ileopsoas tendon might be appropriate, but I think a full work-up is indicated and if more surgery is required, then the surgeon has to be prepared to do whatever procedure is necessary at time of surgery in order to solve all of the problems.

      I wish you a full recovery.

      Dr. William Leone

      We thank you for your readership. If you would like a personal consultation, please contact our office at 954-489-4584 or by email at LeoneCenter@Holy-cross.com. General comments will be answered in as timely a manner as possible.

  37. JE Turner Posted on June 13, 2016 at 9:23 pm

    Hi Dr. Leone,
    I had a left-sided THR one year ago using an anterior approach. Overall good results, but still have some nerve damage and numbness, although I believe it is returning, albeit ever so slowly. I expect that I will need to have the right side done eventually. That being said, do you usually recommend using the same (anterior) approach for the 2nd surgery? Or should I possibly consider a posterior? And what might I expect in terms of eventual return to normal nerve and sensation? And finally, would also appreciate your insights on doing a THR as an outpatient procedure vs. inpatient. Many thanks for taking the time to respond to all of us! :)

    • holycrossleonecenter Posted on June 29, 2016 at 12:49 pm

      Dear JE Turner,

      Hopefully your nerve will continue to recover. If a nerve is going to recover, it usually does so over the 12-18 months following the injury. It’s impossible to predict the completeness of the recovery. Nerve injury is most common with the direct anterior approach with the lateral femoral cutaneous nerve commonly is affected. This nerve supplies sensation to the anterolateral thigh.

      I would suggest if your other hip now needs to be replaced that you focus on choosing your surgeon and not the approach. If you are happy with your left THR and the care you received, then discuss with your surgeon your right hip arthritis and his or her opinion regarding your chances of incurring a right-sided nerve injury. At the end of the day, choosing who will do your right hip is a personal decision that only you can make. Just because you had one hip done anteriorly absolutely does not mean you need to have the other hip replaced using the same approach.

      For some patients, I believe out-patient THR is appropriate, however not for everyone. Patient selection, preoperative counseling and careful post-operative planning are very important in order to have a good experience. Few places are doing out-patient THR at this time, so I suggest doing thorough research to be sure there is a well-run system in place to pull it off. It’s always a good idea to speak to another patient who has been through the program and is happy the result.

      I wish you a full and complete recovery.

      Dr. William Leone

      We thank you for your readership. If you would like a personal consultation, please contact our office at 954-489-4584 or by email at LeoneCenter@Holy-cross.com. General comments will be answered in as timely a manner as possible.

  38. Austin Culp Posted on June 20, 2016 at 8:56 am

    Dear Dr. Leone

    My wife had her right hip replaced, using the anterior approach on February 22, 2016. She had a lot of pain afterwards and complained that her right foot canted off to the right. She also felt that her right leg was shorter. As of April 1, she was still unable to walk without a stroller.
    While receiving physical therapy on April 1st, the therapist pulled her leg to the right which caused severe pain. Before he was done he pulled the leg over a second time which caused more pain. A subsequent X-ray showed that the femur was cracked. The surgeon did corrective surgery on the 6th of April. He couldn’t remove the stem from the femur but he placed 3 sets of cables around the femur and changed the ball in order to extend it a little higher.
    Previous X-rays hadn’t shown a crack in the femur, but the stem was set so tight that the doctor couldn’t remove it and replace it with another at the right height, thus he replaced the ball.
    On June 2nd we saw a different hip replacement specialist who, in looking at an X-ray commented that the cup seemed to be quite far to the outside of the right hip. I didn’t have a chance to ask him if he thought that the placement of the cup so far to the side could cause problems as far as muscle and joint pain is concerned.
    Even to my untrained eye, the cup on the right replacement hip was farther to the side than the joint in her original left hip.
    As of June 20th, my wife still can’t walk and place full weight on the right leg. She has lost a lot of muscle in that leg because of lack of use for the last 6 months. She is getting better, her range of motion has increased quite a lot but she has very little strength in the right leg and she still has quite a lot of pain.
    The only thing I can see is that the hip joint is a complicated piece of equipment with muscles and tendons holding it all together. My question is, if the cup is’t in exactly the right location, will that put extra strain on the muscles & tendons that hold the joint together? What is the prognosis for the future?
    As I said, her pain is lessening, but very slowly. Her foot cants off to the right and she still requires a stroller. Progress is being made, but it looks like it will be months before she will be able to put full weight on that leg and walk without a stroller.
    We will probably try to see a revision surgeon in another couple weeks, but another surgery is a last resort. By the way, when something goes wrong, getting pain meds can be a problem.

    • holycrossleonecenter Posted on June 29, 2016 at 12:46 pm

      Dear Austin,

      Despite all of the best intentions, sometimes complications occur and it sounds as if your wife could have post-surgical complications, especially since she still has pain and requires a walker six months after surgery. It could be a problem with her construct and I think it is wise to schedule a consult with a revision hip surgeon for a full evaluation and recommendations. If surgery can correct any problems associated with her hip and produce a better long-term result, then I seriously would consider a revision. Total hip replacements are extremely predictable at relieving pain and improving function when performed optimally.

      I wish your wife a full and satisfactory recovery.

      Dr. William Leone

      We thank you for your readership. If you would like a personal consultation, please contact our office at 954-489-4584 or by email at LeoneCenter@Holy-cross.com. General comments will be answered in as timely a manner as possible.

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