Mini-Posterior Approach for Hip Replacement: Advantages and Disadvantage

Categories: Hips

By Dr. Leone

In my last post, I listed the advantages and disadvantages of the anterior approach to hip replacement surgery.  Now, let’s discuss the mini-posterior approach.

The mini-posterior approach to hip replacement surgery involves dividing the muscle by separating – not cutting – muscle fibers at the side or the back of the hip.  This method insures that muscle function is preserved.

 

Advantages of the Mini-Posterior Approach for Hip Replacement

  1. As with the anterior approach, the mini-posterior approach is muscle splitting and not muscle cutting. 
  2. Many believe the mini-posterior approach to be the simplest and easiest approach, thereby providing the greatest safety margin for the patient. 
  3. The speed of recovery is equal to the anterior approach. 
  4. Exposure of both the hip socket and the femur is straightforward.
  5. Due to ease of exposure, there is minimal risk of femoral fracture or poor positioning of the implant. 
  6. The risk of neurologic injury is less.  
  7. Because of ease of exposure, any component system and any type of fixation can be used.
  8. No special surgical equipment is required. 
  9. The majority of major teaching institutes in the United States continue to perform and teach the posterior approach as their primary approach, and it is also the most common approach used by surgeons throughout the world.

Disadvantage of the Mini-Posterior Approach for Hip Replacement

Higher postoperative dislocation rates have been reported with the mini-posterior approach.  However, the incidence of dislocation has been dramatically diminished by improved technology and improved surgical techniques. I have recently performed over 1,000 consecutive primary total hip replacements using the posterior approach.  No patient has experienced a dislocation.

In the hands of an experienced surgeon, both the anterior and the mini-posterior approaches can produce excellent results, and the recovery time is the same for both approaches. 

I believe it is important to stay focused on the important issues:  excellent long-term results and minimizing risk of injury or complication in the short term or long term.  Though it is important to discuss new procedures and technology with your surgeon, in the end, you need trust that the surgeon you have chosen will choose what is best for you. My advice is to pick your surgeon based on reputation, experience, and the feeling of trust and personal connection you get. 

As always, if you have questions or personal experiences to share, please leave a comment below.  I would love to hear from you!

11 Responses to "Mini-Posterior Approach for Hip Replacement: Advantages and Disadvantage"

  1. Dominique L. Posted on June 15, 2010 at 9:30 am

    Dear Dr. Leone,

    I need to undergo THR, and I’m in touch with two surgeons. One is using Mini-Posterior and the other says that he has usedall approaches but only the Posterolateral approach gives the possibility for a perfect positioning of the implant.

    I was wondering what is your opinion regarding the differences between the two approaches?

    Thank you,
    Dominique

    • drleone Posted on June 23, 2010 at 5:36 pm

      An experienced surgeon can achieve excellent component positioning with both approaches. Many surgeons who approach the hip anteriorly will use flouroscopy which assists the surgeon in achieving the acetabular component positioning they desire. Indeed, it is more difficult to achieve the precise femoral component anteversion or forward twist. It is also more difficult for the surgeon to achieve precise axial alignment down the canal, but this aspect he/she can check with the flouroscope.

      It may actually be more difficult to consistently achieve perfect acetabular positioning when using the posterior approach and hence the need for the PAL which I developed.

      The bigger issue when using the anterior approach is that because placing the femur component more difficult, more complications may be associated with this aspect of the procedure. These include femoral fracture or not achieving component stability. Surgeons and prosthetic companies may be compromising to make this part easier by developing and releasing new designs in which the stems are shorter and curved. This new designs, which are being implanted in people, are for the most part not test with time.

      Critical to both approaches and the ultimate success of the outcome is the experience and skill level of the surgeon.

  2. Jim Posted on November 28, 2010 at 7:59 pm

    Dear Dr. Leone,

    I will need a THR and read the “Advantages & Disadvantages” for both the Anterior & Mini-Posterior Approaches for hip replacement on this site.

    Having also viewed an animation for the anterior approach at a different site on the web, your comments regarding not having much room to maneuver make sense.

    So, again read the Posterior & Mini-Posterior advantages & disadvantages. Seems the mini-posterior has the most advantages. Do you do both types? How do you decide? The PAL is definitely something I would want.

    Jim

  3. Joan Posted on January 18, 2012 at 7:32 pm

    I wanted to add that I have had both procedures…the right hip anterior and the left the mini-posterior approach. The first was not done by Dr. Leone and was a terrible experience. The after-pain was horrific, and I was left with the unoperated leg being longer than the other. The doctor told me this would correct itself, but it never did. Needless to say, I did not go back to the first surgeon when the second hip needed replacing five months later(it actually worsened from my uneven gait). Dr. Leone not only used the mini-posterior approach for the left leg, but also both legs now touch the floor at the same time. The pain, too, was much less.

  4. marjory hochman Posted on February 25, 2013 at 1:34 pm

    Dear Dr. Leone,
    My husband needs a hip replacement. He has a Protein S deficiency and has been on Coumadin since he is 15 y/o; he is now 72 y/o. He has also had a kidney removed due to a malignant tumor which limits the anti-coagulation therapies which are available for him. Which type of hip replacement surgery would you recommend for him?

    Thank you for your help.

    Sincerely,
    Marjory Hocman

    • admin Posted on February 26, 2013 at 2:29 pm

      Dear Mrs. Hocman,

      Protein S deficiency increases your husband’s risk of a post-operative blood clot or DVT. It will be necessary for him to stop his anticoagulant (Coumadin) prior to his surgery. Usually this is five days prior to surgery so clotting factors in his blood can recover. It may be necessary for him to take another anticoagulant which has a much shorter half life and can “bridge” this interval after stopping the Coumadin. Lovinox often is chosen and prescribed at a lower dosage to patients with renal insufficiency. The bottom line is there definitely are methods that can address his special anticoagulation needs.

      The actual type of hip replacement chosen is a completely different issue and not really based on these medical problems or type of anticoagulant. My recommendation is to find an orthopedic surgeon who feels comfortable with these issues and with whom you and your husband feel comfortable.

      Dr Leone.

  5. Lois Pozsar Posted on July 11, 2013 at 4:36 pm

    Dear Dr. Leone:

    I am so happy I found this site. I had my right hip anterior and had excellent results, it took six weeks to be totally functioning, but very little pain. Now 5 years later, I have to have the left hip and the doctor no longer accepts my insurance. Can not find anyone to do the anterior and this mini posterior sounds good….but I’m so confused and so scared about the whole thing. I am 60 years old and I live in Rockland County, next to Westchester and New Jersey, and suggestions. I really need help. I can hardly walk and have to work.

    Thank you for advice on surgery and any doctors! Lois

  6. Karen Posted on June 8, 2014 at 7:03 pm

    Dear Dr. Leone,

    I’m a fit 52 year old woman in need of a total hip replacement. After much internet research, it seems to me that the mini-posterior approach is the way to go. I live in Dallas, Texas. Do you know any orthopedic surgeons in my area who are experienced in this procedure? If not, I’m able to travel for surgery and would like to know if you accept out-of-state patients.

    Thank you,
    Karen

    • holycrossleonecenter Posted on June 19, 2014 at 9:21 am

      Dear Karen,

      While I do prefer the mini-posterior approach for the many reasons I wrote about, what I think is most important is choosing the individual surgeon who will operate and then direct your care after surgery, not just the specific approach. In the right hands, an excellent result can be obtained with many different approaches. Choose the best surgeon and then trust him to make those decisions. I also would emphasize choosing a premier hospital. A hospital which has earned a great reputation based on an excellent track record, including low complication and readmission rates. I am very fortunate the many patients travel from around the U.S., Canada, the Caribbean and Central and South America for my care.

      William A. Leone

  7. Anna Posted on September 10, 2014 at 2:36 pm

    Dr. Leone,

    I had a severe case of Legg-Calve-Perthes at the age of 2, which caused me a Stulberg Class IV outcome, a very shallow acetabulum. I have a LLD of 2,5cm and now at only 35, I am in constant pain, I have lost most of range of motion I had in my teens and walking down the street is a challenge. I am generally healthy, although now overweight from lack of exercising and constant pain.

    Could I possibly be a candidate for a mini-posterior approach? I fear that considering the amount of work required in my hip joint that an more invasive approach may be necessary. What are your thoughts?

    • holycrossleonecenter Posted on September 22, 2014 at 6:57 am

      Dear Anna,

      From your description of your hip pathology and present plight, it sounds like you may be helped with a total hip replacement.

      Whatever approach is used to reconstruct your hip, it’s critical that the underlying pathology that led to the secondary arthritis is corrected and your hip mechanics restored as anatomically as possible. This means that the new hip joint center needs to be restored as close as possible to its anatomic position and the relationship or off-set between the femur and acetabulum also recreated.

      Many times leg length inequality can also be corrected or improved after THR, but this will have to be a discussion you should have with your surgeon. Because your hip problems started when you were only 2 years old, your sciatic nerve has been in a shortened position for a lifetime and that may limit how much lengthening can be accomplished. Sometimes it is even necessary for the surgeon to shorten the femur (called a shortening femoral osteotomy) to prevent excess tension on the nerve and re-create appropriate relationships and soft tissue tension.

      Also, if your acetabulum is too shallow to support a hemispherical cup, then the surgeon may elect to use your own femoral head as a structural bone graft. This will have the effect of provisionally supporting the new cup and augmenting the acetabular bone stock with time. Typically, if bone grafting the acetabum is necessary and/or osteotomizing the upper femur, then more dissection and soft tissue exposure is required. Also a longer and more complicated rehabilitation.

      I don’t know if you are a candidate for a mini posterior approach. I think your question is an appropriate one and I would recommend discussing it with your surgeon. I think it’s important to find a qualified surgeon and have a frank discussion regarding the benefits of surgery as well as the risks.

      I wish you the best of luck.
      WAL

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