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.

 

 

6 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

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