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.