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.

 

 

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

  1. Stuart Charner Posted on December 5, 2013 at 11:11 pm

    Thursday,Dec.5,2013
    Dr.Leone,
    I’ve carefully read the above synopsis as to why you prefer mini- posterior approach as opposed to the anterior approach.When you initially met with me on Nov. 26,we did not engage in a detailed discussion about my upcoming operative procedure on Jan.6,2014. However,after having read the above informative explanation,I’m thoroughly convinced that with your surgical expertise,which includes the term “REVISIONIST” Surgeon,I pray and hope that my body chemistry will be highly receptive to the implant.What especially captivated my attention was the explanation that specifies that the “Muscle fibers are separated,not cut,and therefore the nerve path is not disturbed”.Over the last 9-12 months I’ve experienced “A WEAKENING PAIN” in my right leg and buttock that at times is excruciating,and to say the least debilitating. Please Dr. Leone,I’m confident that a total HIP REPLACEMENT,utilizing the most durable PROSTHETIC,as well as incorporating the most modernized surgical technique known to mankind will help me regain my lower and upper body strength that I have been deprived of since the onset of this affliction. Help me Dr. Leone,for I so desperately want to regain a normal lifestyle once again.You can do it!!
    Sincerely,
    Mr. Stuart Charner

  2. 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!

  3. 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

  4. 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

  5. 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?

  6. 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.

  7. 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?

  8. 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

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