The Pros and Cons of Two Approaches to Hip Replacement: Mini-Posterior and Direct Anterior

Categories: Hip Replacement,Hip Replacement Surgery,News

In my last blog post, I discussed minimally invasive surgery with regard to hip replacement.  While new techniques, instruments and prostheses have been developed specifically for minimally invasive surgeries, there are many well-established approaches to hip replacement. Two which are receiving the most attention are the traditional posterior approach and the direct anterior approach. I would like to share my  experience with both procedures.

The traditional posterior approach is the most commonly used in the United States and throughout the world (about 70 percent). The majority of teaching institutions in the United States continue to instruct as well as perform the traditional posterior as their primary approach. The mini posterior approach essentially is the same as the traditional posterior, however a smaller incision is made and less soft tissue is exposed. Very important with both the traditional posterior and the mini-posterior approaches, if the surgeon is not able to visual critical structure adequately, or if a problem were to arise such as a fracture, then either approach easily be adjusted.

Over the last six years, I have performed more than 2000 primary or first-time total hip replacements using the mini-posterior approach and I am aware of only one patient who dislocated his hip because he fell down stairs. His hip ball was put back in the socket and he has done beautifully since.

Mini-Posterior Approach

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 and the muscle is not injured. Advantages of this procedure include:

  • The mini-posterior is considered a more straightforward approach then the anterior, resulting in lesser complication rates.
  • There is significantly less bleeding with the mini-posterior approach, notably reducing the necessity of a blood transfusion after the surgery.
  • In my experience, there is a faster and more-consistent recovery with the mini-posterior.
  • I have seen a number of patients who were reconstructed with the anterior approach who developed painful anterior scarring after the procedure. This then becomes  a very difficult problem to solve.
  • Because the mini-posterior is more straightforward, many surgeons think it provides an increased margin of safety for the patient, because the incision can easily be extended if exposure is poor, or if a fracture occurs.
  • Because of the straightforward exposure of the femur, there is less risk of femoral fracture or poor implant positioning. Should one of these events occur during a mini-posterior procedure, they are easier to recognize and correct.
  • Because visualizing the femur is easier, an experienced surgeon can choose the most appropriate femoral implant rather than just the one that is easiest to implant, taking into account the patient’s bone quality, activity level and age.
  • There is less risk of neurological injury.
  • No special surgical equipment is required when performing a mini posterior.

Direct Anterior Approach

The direct anterior approach involves dissecting between the natural intervals of the two main muscles located at the front of the hip and upper thigh. Because the patient is lying on his back, it facilitates using a fluoroscope or moving x-ray throughout the procedure. This does expose the patient to more radiation but can help with component positioning and sizing. There tends to be a lesser incidence of posterior instability with the anterior approach. On the other hand, there may be a slightly increased incidence of anterior instability. Along these same lines, there is a smaller incidence of sciatic nerve injury with the anterior approach but an increased incidence of femoral nerve injury. This is because the nerve is located in front of the hip. Also, because technically it is easier, many patients are being reconstructed with very short stems which are press fit into the bone during an anterior approach. These stems are a new design, and therefore do not have an established track record. Historically short press fit stems have not done well. The hope is that these new designs will, but time will tell.

Disadvantages of the anterior approach include:

  • The nerve which supplies sensation to the front and side of the thigh is vulnerable.
  • The intended interval between the front thigh muscles can be difficult to recognize and there has been an associated increase in injury to the femoral nerve or vessels.
  • The physical build of some patients increases the difficulty. This is particularly true if the person is overweight, has very muscular thighs or is short.
  • It also is more difficult for patients with some patterns of arthritis such as “protrusio,” which causes the worn out ball to migrate inward rather than upward into the socket.
  • As noted above, because the femur is difficult to visualize, component positioning, sizing, and stability are more likely to be compromised. Also, the choice of femoral stem is more likely to be influenced by the approach and not the person’s anatomy and hip mechanics.
  • More soft tissue trauma can result do to this increased difficulty in exposure and then gaining more exposure if necessary. Occasionally this even requires making a second, separate incision.

Although I am trained in both approaches and have trained surgeons in both approaches, I have stopped using the anterior approach because I saw my patients get well faster, bleed less, and have a more predictable result when I performed the surgery using a mini-posterior approach. I’ve come to the conclusion that perceived benefits do not outweigh the risks with the anterior approach, especially when I can achieve the same or more using the mini-posterior.

It is so important to stay focused on the outcome of your hip replacement surgery: excellent results both short- and long-term with minimal risk of injury or complication, and not lose sight of the real goal, which is to create a perfectly positioned reconstructed hip that is stable, balanced and has the best possible chance of lasting more than twenty years.

Ultimately, you and your surgeon should discuss all procedures and technologies available and then trust that your surgeon will choose the best course of treatment and surgical procedure for you.

I know the most important decision you will make is choosing the doctor who will perform your surgery. You should not proceed unless you know in your heart that you will be taken care of in a manner that has the best chance of giving you as perfect a result as possible.

48 Responses to "The Pros and Cons of Two Approaches to Hip Replacement: Mini-Posterior and Direct Anterior"

  1. Marta Posted on December 11, 2013 at 7:12 am

    Thank you for this! My husband, who is only 35, has to consider a THA in the near future and I’m very torn over which approach as the surgeon we really like dos a posterior but I am concerned about dislocation rates in posterior vs anterior. But this blog was a nice nudge toward the posterior. Like you said, consistent outcome is important and this surgeon is excellent and I have great faith in him (I’m a physical therapist and see his patients post-op so get to see the, at least short term, results myself). We have an appointment today to discuss the plan of action.

  2. Tina Posted on December 15, 2013 at 3:56 pm

    Had a total hip replacement aug 2013. Woke up with
    No feeling in my leg and no movement
    Above the ankle to the thigh.Had to use leg brace to
    Remain upright . 4 mts later am using
    Walker to get around. Having physio
    2 x week. Very slow recovery. Also had
    Femor fracture. Nobody wanted to talk
    About this injury to me. . Hospitsl staff
    Would not make eye contact. Very strange
    Behavior. If was 3 weeks after discharge
    That I knew this recovery may take 1-2
    Years!! Felt very uninformed and left
    In the dark to find out about this myself

    • Tina A Posted on March 30, 2014 at 9:35 pm

      Tina, which procedure did you have? Posterior, mini posterior or anterior?

    • Lynn Posted on May 9, 2015 at 9:23 am

      Very sorry to hear of the difficulties you experienced! Have you recovered by now? Which approach did the doctor take? Posterior or Anterior?

  3. John Decker Posted on March 6, 2014 at 10:09 am

    I had the mini-posterior at MGH hospital. Stay was 2.5 days. Tossed the cane at three weeks and went back to work. I am 5 weeks out and have been doing beautifully! Still going to rehab to reduce stiffness and increase strength but I am in better shape now than before surgery

    • Herb Posted on August 31, 2014 at 1:09 pm

      Who was your surgeon at the MGH?

  4. Sharon Posted on April 29, 2014 at 7:48 am

    Thank you for this information. I am having the mini posterior done in June and my surgeon gave me the pros & cons of both. He is well known as a top doc for 20 yrs & I was persuaded because the mini posterior has less chance of nerve damage & the surgeon has more options for types of spikes, which your article explains well. Even though I was positive I wanted this method done, I was still questioning my decision. Your article has made it clear I made the correct decision, especially since my daughter had nerve damage from an operation years ago.

  5. Annette Posted on June 15, 2014 at 7:46 pm

    I am scheduled for total hip replacement in about 3 weeks, and none of these procedures/options were discussed with me………….the surgeon just said that it was a risky surgery and he could not guarantee anything!

    Since I previously had both knees replaced (by another surgeon) about 5 years ago and still have problems with the knees i.e. crackling noise/pain, cannot bend them or kneel in church or get on the floor to do exercises, I am very afraid to ending up in a wheelchair or having to use a walker the rest of my life………….I am a very active 65 year old, and very, very worried about the hip surgery. Also, the surgeon said that I would end up having one leg shorter than the other… is this true? ………I am already limping when walking and was hoping that the limp would disappear after the hip surgery.
    Also, I am diabetic and have had two organ transplants and am extremely worried about infections, etc. My question is: should I just tolerate the pain and limp, or take a chance with the hip replacement. Can you suggest any pain medication that would not interfere with anti rejection drugs?

    • holycrossleonecenter Posted on June 19, 2014 at 9:20 am

      Dear Annette,

      I think it’s vitally important that you go into surgery truly believing in your heart that you are going to do well, and that you are with the best surgeon and team who will help you. Having diabetes and two organ transplants does significantly increase your risk for post-op infection as well as other complications. I would look at the published track record of the hospital where the surgery is scheduled to be sure its performance record is good and its incidence of infection is low. In my experience, most patients who undergo a total hip replacement don’t limp after their surgery and most feel their legs are the same length. There always are conditions or circumstances that may predispose one to limp or feel as if their legs are not the same length after surgery, but in my experience this is the exception. Most importantly, I would meet with your surgeon and discuss all of these concerns. By far the most important variable is the doctor who is doing your surgery and managing your post-op care.

      No, I would not tolerate the pain and immobility, if there is a reasonable way to relieve it. Total hip replacement is one of the most successful operations ever developed and is a remarkably predictable way to relieve pain from arthritic conditions. If your surgeon has recommended surgery, I assume you’re no longer getting adequate relief of pain or able to remain active with conservative measures. I would research and find the physician and hospital that will give you the best chance of doing well. Yes, you do have increase risks. Yes, you can do very well.

      William A. Leone

  6. joy Posted on July 27, 2014 at 2:53 pm

    I had an anterior right hip replacement in late 2010, I was 72. Had horrible groin pain issues and opted for the antior, I knew of nothing else as I consulted with a surgeon who was trained in anterior.

    I had good results into 5th month post op and then everything went downhill.

    I deal with major nerve damage on front of thigh, almost whole thigh. Iliotibial (IT band) damage, had 2 months of ART release work on this issue.

    It’s been a nightmare for me going into 4 yrs post op soon.

    Granted I do deal with lower back OA and right knee OA and now all worse and now foot/ankle mess, all on right hip side.

    I was so against doing this surgery but groin pain was very bad and crushed bone in the groin. No groin pain NOW….but all the other mess of it all.

    I’m so against any other replacements as I have other issues, but working with alternative treatments, out of pocket money, as my hip replacement has been a horrible drama/saga.

    • holycrossleonecenter Posted on August 20, 2014 at 9:44 am

      Dear Joy,

      I’m sorry to learn that you are so disappointed with your hip replacement. I think it is important to define and isolate why you’re doing so poorly. Other conditions, to which you alluded, such as having a back condition and an arthritic knee and foot, all can masquerade what the real or most debilitating problem is. These other conditions need to be defined and hopefully ruled out as the primary source of pain.

      I find it curious that you report having a good result for the first five months after your surgery as this suggests that the surgery was done for the right indication, i.e., you did well and were pleased for the first five months after THR. This suggests that something changed after five months. For example, the stability of the components could have been achieved initially, but then proved inadequate so you developed either a loose cup and/or a loose stem. I also think infection must be investigated and ruled out. The first step to rule out infection is to have two simple blood studies done, an ESR and CRP. If these values are elevated, further investigation with hip aspiration should be considered.

      Unfortunately, injury to the lateral femoral cutaneous nerve is a common complication after the anterior approach for hip replacement. This most often leaves the patient with an area of decreased or uncomfortable sensation or numbness over the anterolateral thigh (top, outside area of the thigh), not the entire thigh. Also, if this nerve injury occurred, I would expect these symptoms to be present immediately surgery, not five months post-op. If they did develop five months post-op, then you have to consider that it could be a manifestation of back pathology compromising a nerve root. Femoral nerve function also should be assessed.

      I’m not sure why you developed a problem with your IT band. The anterior approach typically does not violate this structure. Possibly, it’s secondary to an altered gait pattern or hip mechanics.

      My recommendation is to go back to your surgeon and share your concerns and issues to see if a fresh and thorough reevaluation won’t help define the problem(s) and solutions.

      Good luck,
      WAL

  7. Larry Posted on September 2, 2014 at 9:19 am

    On July 17th, I had a left THR. The doctor used the posterior procedure. I’m now 6 weeks out and doing good. Not wanting to go through all the restrictions, I was considering anterior for my right hip, which would require not having it done locally since doctors here have been doing it for only 1 year. After reading your articles, I have decided not to have anterior. My doctor does not do mini posterior, therefor I have a 6″ incision. Not putting you on the spot, but would it be advantageous for me to drive 200 miles to have a consultation done by you?

    • holycrossleonecenter Posted on September 12, 2014 at 1:15 pm

      Hello Larry,

      If your surgeon did a great job, that is something to respect. The actual length of the incision really is not important, but rather how well the components were implanted and the hip mechanics restored. It sounds like he did fabulous job. That being said, you should have the additional surgery where you feel you will have the best chance of doing well.

      The size of the incision is determined by how large and tight the hip/thigh is and how much tissue (fat and muscle) exists between the bones of the hip and the overlying skin. Sometimes, when a surgeon is working too hard to reconstruct through a very small incision, the ends of the incision tear and the tissues are traumatized. This often leads to a less than optimal component position. Remember, what you’re hoping to do is have a hip construct that will last 20 years or more. My strategy is to make as small an incision as possible, but one that allows for excellent exposure and reconstruction without brutalizing the tissues.

      Best,

      Dr. William A. Leone

  8. Jeff Posted on September 30, 2014 at 8:05 pm

    Do either of your techniques require the traditional anterior or posterior precautions? The information I have gathered seems to indicate the anterior approach is more inherently stable, making precautions unnecessary. The posterior approach, then, is less inherently stable but may or may not require precautions. What determines the differences?

    • holycrossleonecenter Posted on October 17, 2014 at 11:24 am

      Dear Jeff,

      Most doctors have and continue to implant hips through the posterior approach. Historically, higher dislocation rates were reported with the posterior approach, but it still was used for its many other advantages. Currently, the incidence of dislocation after the posterior approach has been greatly reduced due to technique and other refinements.

      Because of the marked improvement in modern plastics, there is greater longevity and durability of acetabular plastic liners and larger femoral heads are used routinely which results in an improved the head/neck ratio and therefore the jumping distance for a hip to dislocate. Enhanced soft tissue techniques also have been developed which more securely close the tissue around the newly placed prosthesis and set the stage for healing.

      The development of a complete and secure surrounding scar tissue wall or pseudo capsule is critical for stability. Optimal component positioning also is critically important for the best stability and longevity. Further, the extent of dissection is more minimally invasive, which also improves stability.

      Because of the concerns of posterior dislocation, in the past patients were taught certain positions to avoid. Over the years, these precautions and the length of time to adhere to these limits have been challenged both by clinicians and patients. Depending on the stability and range of motion observed at time of surgery, some doctors don’t advise their patients to avoid any positions. Others continue to follow traditional guidelines.

      I, personally, have not had a patient dislocate following a primary total hip replacement in many years. My advice is to consult with your surgeon regarding how stable the replaced hip is and the most appropriate rehab to follow post-operatively.

      Dr. William A. Leone

  9. LL Posted on October 30, 2014 at 8:45 pm

    My acyive 60 year old husband is scheduled to have Mini posterior total hip replacement in 6 weeks. Our second opinion doctor performs traditional and Birmingham hip replacement. Because my husband has circulation problems in his leg and vein removed for open heart surgery last year…his surgeon recommended the Mini posterior surgery. After reading your blog I’m thankful he suggested this approach. Have you ever performed the Mini on a patient 1 year after major open heart surgery? My husband has a plastic valve (done in ’86) and synthetic assending aorta and triple bypass (done in 2013)…very successful surgery. We have to get ok from cardiologist and get ekg, chest xray, etc. Just need reassurance…I am stressing he is fine. Thanks

    • holycrossleonecenter Posted on December 12, 2014 at 10:21 am

      Dear LL,

      I have cared for many patients over the years with significant heart and peripheral vascular disease. It is important that these medical and cardiac conditions be optimized by your PCP and cardiologist preoperatively. Surgery carries increased risks because of these conditions, but by defining the risks and optimizing any underlying conditions, the risks can be minimized and hopefully managed. Similarly, an engaged medical team needs to be available to help with care after surgery. Although, personally I would feel strongly about reconstructing the hip through the mini posterior approach (there tends to be considerably less bleeding with this approach), other very caring and competent surgeons might feel just as strongly about using a different approach. I would recommend having an honest discussion with the surgeons you are considering.
      Ultimately, you and your husband need to choose the surgeon who you both feel will provide the possible best care, based on reputation and your personal comfort level. I also recommend that you look at the track record and reputation of the hospital where the surgery will be performed, especially considering the underlying cardiac and vascular issues.

      All the best,
      Dr. William Leone

  10. holycrossleonecenter Posted on November 11, 2014 at 8:50 am

    Question from Kevin Lee:

    Does the “mini” posterior hip replacement conserve more femur and allow for future surgeries if needed ? I read about this type of mini hip replacement being done in the UK and just wondering if mini hip replacement means the same thing in the US .

    Answer from Dr Leone:

    Dear Kevin,

    “Mini posterior” refers to the approach or tissue interval the surgeon uses to implant the Total Hip. A mini posterior approach is a modification of the classical posterior approach. It exploits the same soft intervals but it typically accomplishes prosthetic implantation and soft tissue balancing through a smaller incision and, more importantly, with less underlying soft tissue dissection.

    If a mini posterior approach is used and the resultant total hip has optimally positioned components and balanced soft tissues, and was implanted through a smaller incision with less underlying soft tissue dissection and trauma, then I believe it is a benefit. Potentially there also is less pain and a quicker recovery. If the tissues are traumatized and / or the final components are not optimally positioned, then it certainly is not an advantage.

    When the stem is placed in the femur, it still destroys the same amount of bone for implantation, regardless of which approach is used. If a revision were necessary, even more bone must be destroyed to remove it. Many modern-day femoral stems are considerably smaller or “more bone sparing” than well-functioning stems of the past. Some in the early period have good track records, others do not.

    Sincerely,

    William A. Leone

  11. joy Posted on November 24, 2014 at 7:08 pm

    It’s been a couple months and I thought I’d drop in with an update…..over 4 yrs post op and I deal with Femoral nerve damage from Anterior, and found others who deal with the same….it may lessen with more years but who knows….Somewhere I read 15% or so end up with this..I talked 2 other people in my city, same surgeon and they have had this issue to.

    Now the IT band, why who knows….

    I deal with OA lower back “mess” so know I see most likely how all this has played into the surgery.

    My knee and foot and ankle are messed up too since leg ended up at least 3/4″ shorter….I wear a shoe lift, but probably needed it sooner than I realized the shorter issue…

    My knee is pretty stiff and pain when I walk too much, but I deal with it, it bends good, I sleep good, no pain when I do nothing, so I’m working all to do NO knee surgery…

    This hip was ENOUGH to last a lifetime….. I’m 76 and use a lot of supplements to save knee and OA in general…..I am looking at other protocols for the knee too….not insurance covered, what else is new….if it’s good, it’s out of pocket…. J

  12. Sally Kuhn Posted on January 9, 2015 at 10:18 am

    Dear Dr. Leone,
    Thanks so much for this information! I am an obese female and will be 62 in February. I have dealt with my hip pain and limping for over a year, can no longer perform my daily activities, and cannot sleep well anymore. I exhausted all other non-surgical options, such as physical therapy and meds but to no avail, so now plan to have a THR in March. My surgeon uses the posterior approach. After reading a few articles on anterior vs posterior including yours, I know now that his decision to use the posterior approach is the best one for me!

  13. Mary Fishburne Posted on February 15, 2015 at 7:43 pm

    I have had problems with my hip for the last several yrs. It was discovered that I had a torn Labrum. They thought surgery to repair it would give me about 5 yrs. It turned out to be more torn than they thought and they had to cut about a forth of it out. The pain in my hip is strange in that I can hike uphill and down hill, bike and X-country ski but have a very hard time walking on the flat, especially after sitting for awhile or getting out of bed. Sometimes the pain goes away as I walk and sometimes it doesn’t. I never seem to know when I am going to get hit with pain. I am scheduled to have total hip replacement surgery in 2 weeks. My question is, I am a very active 67 yr old. I ski, hike (steep terrain) with a pack -about 25 pds, kayak, horse back ride, swim, water ski and bike, which is getting increasingly more difficult. Will I still be able to do all of these things? If not, what will my restrictions be? My doctor does the Posterior approach, he didn’t say anything about the mini part.

    • holycrossleonecenter Posted on February 20, 2015 at 10:46 am

      Dear Mary,
      It does sound as if proceeding with a THR is appropriate, since your attempt to repair the joint arthroscopically did not pan out. Many times, the depth of the destruction that is found during surgery is much more advanced than initially anticipated, particularly as we age.

      Your symptoms still sound mechanical, positional and episodic. I would not anticipate them improving with time, but rather worsening, and I can’t imagine you being able to resume the activities you described without having surgery to treat this.

      Since a significant amount labrum has been removed, I think another attempt at arthroscopy would prove very disappointing and I would not recommend it.

      I suspect there is significant underlying osteoarthritis related to your labral pathology. Often, as the labrum is torn, it leads to a lifting off of hyaline articular cartilage where these two tissues meet, called delamination. Once again, I think your decision to proceed with THR is the most reasonable.

      I also think it’s reasonable to look forward to returning to all of the listed activities that you enjoy. Specific protocols, therapy and what positions you will be asked to avoid after surgery and for how long will be directed by your surgeon. Your surgeon will know better than anyone else just how stable your new hip is immediately after your surgery and how securely the surrounding tissues were repaired after the reconstruction.

      Just because hardware in your foot needed to be removed after repairing what sounds like a calcaneal (heel) fracture, absolutely does not mean that your body rejected the metal / hardware or that your body will reject the prosthesis your surgeon will implant to reconstruct your hip.

      My advice is to have a frank discussion with your surgeon and share these concerns. It’s been my experience that patients who go into surgery well informed have a better experience and seem to rehabilitate more quickly.

      I wish you the best of luck,
      William Leone.

  14. Mary Fishburne Posted on February 15, 2015 at 7:59 pm

    In May of 2015, I had a Labial tear repaired. They thought it would give me about 5 yrs. but it was more torn than they thought and they had to cut out about 1/4 of it. I am still a very active 67 yr old, I like to ski, bike, hike (steep terrain) with about 25 pds. I ride horses, water ski and kayak. The pain I get is in the groin and a sharp pain in the buttocks, that feels like muscle pain. The pain is really inconsistent, one min I will be walking fine and the next it catches and is very painful, then it may go away or may not. I seem to be able to hike just fine up hill and down but not always on the flat. Sitting seems to irritate it the most. The doctor has scheduled me for total hip replacement in two weeks and he uses the Posterior approach, he didn’t say anything about the mini part. I am temped to wait but it is getting worse. My question is, what will my restrictions be? Will I still be able to do the things I like to do? Also, after an accident, I had 12 screw and an L shaped plate in my heel. After awhile the screws started shifting and poking up under the skin and they removed them. Does this mean my body may reject the metal of the post or cup? Thank you so much for your answer, I appreciate your taking the time to care about others.

  15. Pam Posted on February 17, 2015 at 6:04 pm

    Dear Dr. Leone,
    I am a 49-year-old female. I am about to have a hip replacement and would like to know what kind of limitations I’ll have afterward. I’m hoping to play tennis, go dancing and horseback riding once I’ve healed. I already have an artificial knee that is doing great. Are these expectations realistic?
    Pam

    • holycrossleonecenter Posted on March 5, 2015 at 8:57 am

      Dear Pam,

      I should think that all your expectations are appropriate for the activities you look forward to, especially considering you’ve already done so well after your knee replacement. I advise both my total hip and my total knee patients to avoid repetitive impact activities like distance running. I think tennis, dancing and horseback riding are fine. In general, I would encourage you to consider all of your prosthetic joints a remarkable modern day miracle that must be cared for and respected. If your “little voice” is questioning if you are overdoing it or hurting yourself, then listen to it and ease up.

      I wish you well.
      Dr. William Leone

  16. jason Posted on February 18, 2015 at 2:35 pm

    Hi guys im 43 and live in Australia and due to have hip replacement in 7 weeks but im so confused as my surgeon is doing the posterior and im off work for 6 weeks where i here people having the anterior and going back sooner and no restrictions on hospital discharge any advice

    • holycrossleonecenter Posted on March 5, 2015 at 8:56 am

      Hello Jason,

      In my experience the approach used to replace a hip does not effect how quickly a patient recovers. How the soft tissues are handled and respected, the patient’s expectations before the surgery and the surgeons experience do. In my practice, patients who undergo a THR using a mini posterior or posterior approach:

      1. Are expected to be out of bed (hips and knees patients) the afternoon of their surgery and at least taking a few steps if not walking.

      2. Typically, most are eager to go home the very next day; many have already progressed to a cane, which they will not use very long.

      3. I emphasize continuing exercises at home especially walking. Most THR patients do not need significant supervised physical therapy after surgery; they simply do well when their surgery is done well.

      4. If possible and a pool available, I encourage my patients to walk and exercise in a pool and / or swim, starting at two weeks when their suture is removed.

      5. Return to the work place is an individual decision. The most important variable is how quickly the person is motivated to return to work. In general, if someone is dedicated to the job, the return is very quick. Many in business or who own their own businesses will stay home for only one week and then return to their work place because they are bored and would rather be productive and busy. Other jobs, which tend to be more structured and / or more physical, may require more time off. The vast majority of my patients return to work one to three weeks post-operatively. Six weeks or longer is the exception.

      Regarding restrictions after your hip replacement, this too is an area that has changed drastically over my 25 year career. In my experience, the restrictions (or those positions we ask our patients to avoid after surgery) have become much less limiting and are off limits for a much shorter period of time. I would encourage you to discuss your expected recuperation time and specific restrictions with your surgeon.

      I hope you do well.
      Dr. William Leone

  17. FD Posted on February 18, 2015 at 10:45 pm

    I am 37 and have suffered from AVN since I was 14.(I have SCD) It has now become unbearable and I am preparing for surgery. First, I am a little bit scared. The doctor is planning a traditional posterior. I dont want a long recovery time as I am very active. I have insurance with very high deductible and I am scared of the debts I might incur afterwards too ( where I am planning to do it – I might not have to pay any money). About how much does this cost? Should I go for this – or should I opt for the mini posterior. Also, how about hip restructuring instead of Total Hip Replacement. Can I make an appointment with you. I am female and I weigh 115 pounds

    • holycrossleonecenter Posted on March 5, 2015 at 8:54 am

      Dear FD,

      It is 100 percent normal and expected to be “scared” before surgery. Everyone is. You should feel good that you are aware of your fears and that it hasn’t paralyzed you into not acting.

      Nobody wants a long recovery. In my 25 years of practice, the variable that seems to have changed the most is how quickly people recover from this surgery when done well. It is normal to want to recover quickly and return to a very active lifestyle without pain. These are all realistic goals. I would encourage you to discuss your concerns with you surgeon. I find that patients who are well informed and know what to expect prior to surgery get well even faster.

      I also would encourage you to choose your surgeon first – not the procedure, approach or prosthesis. Further, I would contact your insurance carrier and the hospital so you will not be surprised with any unexpected costs. If possible, try to get in writing any verbal promises made. This too will lower your anxiety and improve your experience.

      I think researching the hospital where you will have your surgery is very important. If possible, choose a hospital that specializes in joint replacement and can back that up with excellent statistics and reputation.

      I wish you only the best.
      Dr. William Leone

  18. Elizabeth Weaver Posted on February 25, 2015 at 5:56 pm

    I just want to thank you for the information on this site. I am Australian so no business from me but it has helped me become happier with my prospective surgeon’s judgement that he will offer me a posterior THR (hopefully the minimally invasive) when my insurance allows the procedure to occur.

  19. Kent Littleton Posted on March 14, 2015 at 9:16 pm

    Is a prerequisite for THR to have a MRI or Pet Scan? Or are x-rays definitive for determining the exact reason for THR? How does it affect the actual success of the
    THR if a MRI or Pet Scan isn’t done? Thru X-rays I’ve been told both hips are bone on bone!
    Does anyone ever attempt to do both at the same time if THR is determined?
    What are your thoughts with regard to Stem cell therapy in lieu of THR?

    • holycrossleonecenter Posted on April 2, 2015 at 8:49 am

      Dear Kent,

      If your X-rays reveal that you already have “bone on bone” due to osteoarthritis, then you typically don’t need either an MRI or Pet Scan, unless another diagnosis is suspected. Getting those studies will not change the reality that you will need THRs. Historically in my practice I performed many Bilateral THR and TKR and have backed away from that practice. I think there may be increased associated complications. I prefer reconstructing the most symptomatic side first. I then stage the second surgery as early as 2 ½ or 3 weeks post-operatively. I would rather my patient get half as much anesthesia. Most receive a simple spinal with sedation. With a bilateral procedure during a single anesthetic, the blood loss would be double and there would be a much higher likelihood that my patient would need transfusion post-operatively.

      I very rarely transfuse any patients now. One of the biggest changes that I’ve seen in my practice over the past 25 years is how quickly patients get well and go home. Being discharged to a rehab unit is now the exception. Most patients after a bilateral procedure would not go home but rather a rehab unit. Most of my patients now go home the day after their surgery or the next.

      I think stem cell injections will have little chance of doing any good if indeed your hip condition has already progressed to “bone on bone.”
      I wish you the best of luck with your care.

      Sincerely,
      Dr. William Leone

  20. Lisa Posted on March 18, 2015 at 11:01 pm

    I’m a 50 year old female whose been dealing with hip, leg and back pain for many years, recently diagnosed with OA, and finding that I need a right THR. I have the hospital but am deciding on the surgeon and which approach is best. I saw a surgeon who does the posterior approach only and will see another on 4/14/15 who does both approaches. The surgeon I saw said that my body structure and gait does not affect which approach would be ideal for my body. My right leg is already a bit longer than the left. I weigh 185 and am 5’4″ and realize it’s ideal to lose weight prior to surgery (working on it as always). My main concern is that I have a tilted sacrum and a very sway back. My gait is off partially due to my hip but also I believe because of my body structure. I’ve done PT and plan to continue working on strengthening my core and flexibility of those large muscles. I also regularly receive Rolfing treatments which has helped me manage pain and maintain what mobility I have. So my question is in relation to my body structure. Does it really not matter which approach I have, posterior or anterior? I have a tilted sacrum, sway back and a very large posterior.
    Thank you, Lisa

    • holycrossleonecenter Posted on April 2, 2015 at 8:51 am

      Dear Lisa,

      What is most important is that you find a surgeon who understands the particular complexities with your problem and whom you trust. I would then let that person decide with what approach they think they can best accomplish the surgery and deliver the best result. Choose your surgeon and not the approach or prosthesis.

      That said, in general people who are longer, more flexible and thin are more easily constructed anteriorly than individuals who are very stiff, contracted, thick, and have acetubular protrusion (a condition when the femoral head wears away the central cartilage and bone of the acetabulum). Also, patients with shorter femur necks and genu varus (lower angle between the shaft of the femur and the femoral neck) are more difficult anteriorly. Either and all body types lend themselves to the posterior approach because it is more extensile (can make it bigger and release more soft tissue structure if needed).

      Losing weight and strengthening your muscles pre-operatively will make surgery easier and greatly facilitate your rehab.

      I wish you the best,
      Dr. William Leone

  21. Tracey Posted on March 20, 2015 at 2:15 am

    When asking a prospective surgeon about the anterior vs posterior approach he told me that it is necessary to use a smaller prosthesis which would not be as stable with the anterior approach and did not recommend it for this reason. After reading your article I see there are many reasons to go with the posterior approach but nothing about having to use a smaller prosthesis with the anterior approach. Please comment.

    Also if the mini posterior approach is so effective when would it not be preferred over the regular posterior approach? What reasons would there be to use the regular over the mini? Thank you

  22. holycrossleonecenter Posted on April 2, 2015 at 8:54 am

    Dear Tracey,

    Because the femur is more difficult to expose during the anterior approach vs. the posterior approach, many surgeons will select a shorter femoral component to facilitate reconstruction and lessen chance of fracture. Many manufacturers are responding to the surgeons’ desire for shorter stems and many are now available on the market. Many of these stems have very little if any long term follow-up, although some appear to be doing well in the short term. When we quote probability of longevity after hip replacement based on following people who had the operation, it is based on standard length stems. Time will tell if this generation of shorter press-fit stems fares as well.
    There does appear to be an increased incidence of stem instability when implanted through the anterior approach, but I believe this is largely a function of the surgeon experience. Also, in the U.S., nearly all stems which are being implanted through the anterior approach are press-fit rather than cemented. In my practice, I cement an Exeter stem in a significant percentage of my patients who undergo THR . I do not want the approach to dictate the optimal construct which I hope will last 20 years and more.

    A miniposterior approach uses the same intervals as the standard posterior approach but simply less tissue is released for the exposure. Every patient needs to have as limited an approach and dissection as possible that does not compromise the final implant position or create excessive trauma to the soft tissues. Operating through too small an incision and not releasing tissue that would improve exposure and result in a more balanced joint in my opinion does a disservice. It is much better to precisely release and cut rather than tear or fracture. The art of surgery should mimic a well rehearsed ballet or symphony. If it’s a struggle, then the situation needs to be reassessed. Patients who are significantly overweight (I specifically assess the amount of tissue between the skin overlying the lateral hip and the greater trochanter), who have significant long-standing contractures and restricted ROM, congenital dislocation, and marked acetabular protrusion (when the femoral head wears centrally into the acetabulum) typically require a larger incision and more soft tissue releases. This does not necessarily mean they will have more pain or take longer to get well.
    I wish you a full and speedy recovery.

    Sincerely,
    Dr. William Leone

  23. Don Sasen Posted on April 9, 2015 at 12:19 pm

    Everything does point to posterior being the better of the two, but first i was’nt given a choice, and much easier said to shop for surgeon, than to do it, when only one in this area takes my insurance. So im going back to the surgeon that did my left hip and left me in agonizing pain for 2 months after procedure. I actually was supposed to get both done at roughly same time but its been 3yrs with this bad right hip, mainly i was in great fear of going through that pain again, but now i think that pain will be better than this everyday pain!!

    • holycrossleonecenter Posted on April 17, 2015 at 9:08 am

      Dear Don,

      I’m sorry to hear that you struggled after your first, anterior-approach THR. Having a THR is a major undertaking and it is reasonable to expect the hip construct to function optimally for twenty and more years. I would encourage you to discuss with your surgeon the difficulties and pain you experienced after the first surgery, and together explore if another plan can be created for a better outcome the second time around. That being said, in order to meet your goals, if need to leave your area and consult with surgeons in other areas, I think that is reasonable also.

      I wish you the best,
      Dr. William Leone

  24. Doug Posted on April 16, 2015 at 12:24 pm

    Hi,
    I had an anterior approach hip replacement. I’m a very healthy long distance bicycle rider. I’m 56 years of age, 6′ 1” and 180 pounds. Last summer I wiped out on my bike and snapped off the top of my right femur, with a diagonal break. I have/had arthritis in my hips. I went with a total hip replacement. I’m getting close to needing my left hip done. I can still do 30-45 mile rides, but I need to take something before each ride, because of the undone left hip. About my surgery: I had to wait 30 hours before surgery, two days later I was released, within two more days I stopped using my walker. In another day I was able to take short walks without any limping, etc.. I was released to go back to work after only 10 days. I needed no physical therapy at all. I was told to wait 6 weeks before I resumed my exercise regiment. My first bike ride was 22 miles without any problems. It’s been 8 months now. The only problem I’ve had post hip replacement is some on/off again groin pain. I had to cut some strength exercises out— leg lifts, hip sled. The leg lifts really aggravate the front of the hip. I’m considering this mini posterior approach. Should I be though? It would be interesting to hear what you have to say… Doug

    • holycrossleonecenter Posted on April 23, 2015 at 8:49 am

      Dear Doug,

      Overall, it sounds as if you’ve had an excellent result and wonderful recovery following your hip replacement. My clinical impression is that more patients experience some degree of residual groin discomfort or tightness after the anterior approach as compared to the posterior approach, but that it tends to resolve with time. To have your other hip replaced through a different approach is a decision you need to make with your surgeon. If you feel confident in your surgeon, I would discuss it frankly follow his or her guidance as to which approach and prosthesis are most appropriate to give you the best result.

      I wish you the best.
      Dr. William Leone

  25. Stan Posted on May 1, 2015 at 8:58 am

    Dear Doctor,

    In 2013 I had a THA done on the left hip. Back then my surgeon advised me to perform a posterior surgery as opposed to anterior saying that I was overweight, short and a very muscular person and it would be easier and safer to do so. Considering I had no idea about differences between the two approaches, I said OK and surgery did go well and I was back on my feet in no time.

    In 2014 I had to do another THA, this time on my right side. When discussing the options, my surgeon all of a sudden suggested performing anterior approach. She provided all kinds of “benefits” with this approach, as faster recovery, less motion restrictions et.al. For risks she mentioned all the usual I knew about from the first surgery – blood clots/loss, dislocation, etc. She never though mentioned an increased risk of damaging femoral cutaneous nerve or possible muscle damage that would turn into improperly heeled muscle as a result.

    After reading your article on disadvantages of anterior approach and also doing extensive online search about this subject, I came to realize that anterior approach was definitely a wrong choice considering my physical build – short, muscular, overweight. Results of the surgery – numbness in the right thigh, inability to stand on the right leg, muscle atrophy – all confirmed by EMG and second orthopedic surgeon. My two questions are:

    1. Are my findings that posterior approach in my situation would have been more appropriate?

    2. What, if anything, can be done to revive femoral nerve and get my thigh muscles back in normal?

    It’s been six months since surgery, my operating doctor keeps feeding me with “let’s wait another month” stuff. But I feel that time could be lost and all my symptoms may become irreversible.
    In hopes that THA would let me live my normal life without arthritis, instead I can barely walk more than 100 yards without having to stop, my gait is crooked causing lower back problems and my personal life is less than perfect.

    Sincerely,

    Stan

  26. Lisa Blumthal Posted on May 1, 2015 at 11:21 am

    Dear Dr. Leone,
    After a slip and fall at work 2 1/2 years ago I need a THR on my left hip. I have been in excruiting pain and unable to do everyday normal activities. I have been doing ALOT of research about the different approaches to THR and looking for the absolute best surgeon. One thing I do not want is any muscles or tendons cut in the procedure. Your article is the first I’ve read in which no muscle or tendons are cut in any approach other than the direct anterior approach. A couple of things I am hoping you will explain using laymans termology. What do you mean by painful anterior scarring and soft tissue exposure and trauma? Also I have read that there is a sharp learning curve that must take place in order to do the direct anterior approach. Why is that? Lastly, where can I find a great surgeon that takes FL Workmans Comp? Thank you, Lisa Blumthal

    • holycrossleonecenter Posted on May 12, 2015 at 9:11 am

      Dear Lisa,

      Your primary goal should be to find a surgeon in whom you trust and who will take the workman’s compensation insurance. Once you find that doctor, then you need to put your trust in him or her to help you solve this horrible problem so you can return to being active and productive.

      The anterior approach exploits an interval between muscles that cross the front of your hip and thigh. This interval must be developed and the muscles must be separated in order to reconstruct the hip. In some individuals, it takes much more force and dissection in order to accomplish this (typically, there is significantly more bleeding from an anterior approach compared to a mini-posterior approach). Some people also tend to form scar tissue and contracture more readily than others. Also, some body structures or anatomy makes approaching a hip anteriorly much more difficult than others. Because the dissection is over the front of the hip, a number of patients will experience residual pain and tightness anteriorly (in the front of the hip) at least early on.

      Surgeons do not cut across muscles. “No Muscles Cut” is for billboards. Intervals between muscles are separated or muscles are separated in line with their fibers without injuring the muscles’ innervation. The most important thing is that tissue is handled gently and trauma is minimized, whichever approach is used. Don’t let PR marketing confuse the big picture.

      I again suggest you concentrate on finding a surgeon in whom you have faith and then trust that doctor.

      The best of luck,
      Dr. William Leone

  27. holycrossleonecenter Posted on May 6, 2015 at 9:28 am

    Dear Stan,

    The femoral nerve functions to extend the knee and also is responsible for sensations over the anterior and medial aspects of the thigh, medial shin, and arch of the foot. The hope is that your nerve injury will recover with time. The rule of thumb is that recovery occurs over a 12-18 month period following injury. The earlier the recovery begins, the better chance for a more-complete recovery. Also, be aware that as the nerve recovers, the smallest C fibers within the nerve recover first, which can cause a burning discomfort. This is actually a good sign. Depending on the degree of injury, you may need a knee brace to lock you knee in extension when walking until the quad function returns.

    Therapy is often appropriate for stretching, strengthening and electrical stimulation which helps maintain the motor end plates, structures on the muscles that the nerve branches must re-innervate. Pain modifying drugs as well and as a course of NSAIDs might also be appropriate. In my experience, people recover from femoral nerve injures more frequently and completely than from sciatic nerve injuries.

    Therapy hopefully will help any contractures and scaring within your muscles that might have developed after surgery. I would stay away from narcotics. They are addictive, can cause depression, their analgesic effects are short lived and if the condition persists, you will require an increasingly higher dose to relieve the pain. What you can do is keep as good an attitude as possible and keep rehabilitating your leg. I also would encourage pool walking or swimming. It will help desensitize and help get your muscles working in synchrony.

    I wish you the very best,
    Dr. William Leone

  28. Lynn Posted on May 9, 2015 at 9:33 am

    Going in for THR in July. Posterior approach. Doc says once recovered I should avoid flexion with adduction and internal rotation. I am very athletic and active even with many years of pain from bone on bone arthritis so I am worried about restrictions since I’ll probably forget or something. Can’t afford a dislocation or other complications cause I’m sole caregiver for severely handicapped son. THOUGHTS?

    • holycrossleonecenter Posted on May 15, 2015 at 3:48 pm

      Dear Lynn,

      Fortunately, the incidence of hips dislocating after THR is very small, especially after first-time hip replacement. Irrespective of the approach that is used to implant the prosthesis, the tissues that surround the new prosthetic hip must heal and mature if the hip is to achieve stability. This complete wall of tissue that surrounds the new hip imparts stability. The healing and maturation of this tissue takes time.

      Today, everything from tools to techniques has improved. We now have less-invasive techniques, better surgical methods of closing soft the tissue and more experience. Also available today are larger modular heads, made possible because our plastics are so much better than years prior. What all this means for patients is a more optimum outcome and faster healing, which can reduce time interval to return to normal activities. I ask my patients to restrict certain positions that exceed the mechanical limits of the artificial hip for the first six weeks. Most of the restrictions are removed at that time, although I still advise “common sense,” particularly for the first three or four months. Each surgeon approaches these issues individually. The particular surgeon who did your hip is also uniquely qualified to advise you with regard to the postoperative stability of your particular hip, because he or she physically tested your hip intra-operatively. In my experience, after four to six months most patients simply return to normal activity.

      I wish you the best.
      Dr. William Leone

  29. Christine Posted on May 12, 2015 at 3:18 pm

    I have congenital hip dysplasia which has gradually caused more pain as I’ve gotten older. I am 56 now and find that physical therapy and chiropractic care don’t seem to be helping anymore. Is THR something that can help? My problem isn’t from a worn-down joint with no cartilage. It’s from a malformation. I worry that replacing it with a differently configured socket could make things worse rather than helping.

    • holycrossleonecenter Posted on May 15, 2015 at 3:50 pm

      Hello Christine,

      The most common reason or diagnosis that leads me to replace the hips of young women is hip dysplasia. Often in this group of patients, their X-rays show only minimal cartilage space compromise (it may appear thinned and irregular) and I observe at time of surgery that the labrum appears hypertrophied (to compensate for lack of head coverage) and often torn. The hip replacement needs to correct the abnormal hip mechanics that lead to the arthritis. The new prosthetic socket must be medialized (placed further toward the midline) and sometimes through the medial wall of the native socket. This effectively moves the hip joint center, toward the bladder or midline, and improves hip mechanics. It also helps to stabilize the acetabular shell and prevent soft tissue irritation on the out edge of the cup. In severe cases, I will use my patient’s own femoral head, which is removed as a bone graft to help stabilize the new cup and “garden” new bone for the future. These are some of the most grateful patients in my practice.

      I wish you the best of luck.
      Dr. William Leone

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