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.

18 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?

  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

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