My surgeon talks about “approach.” What is this?
The way a surgeon gains access to the hip during hip replacement surgery is referred to as an “approach”. There are various types of approaches named according to the direction that the surgery is performed. The most common approach today is referred to as the “posterior approach,” which is done from the back of the hip. Another variation that is becoming more popular is known as the “Anterior Approach”. An Anterior Approach Hip Replacement procedure is completed from the front surface of the hip. The lateral approach is a much less frequently used procedure. There are pros and cons of each type of hip replacement approach. Surgeons often tend to have a preferred approach or comfort level with one particular approach based on their training and experience. The bottom line is that often the best approach for your hip replacement is the one your doctor is most comfortable with to allow safe and precise implantation of your hip replacement components. A conversation with a board certified, experienced surgeon should help you decide which hip replacement approach is best for your situation.
anterior hip vs. Posterior (traditional) hip replacement
The main difference between Anterior Hip Replacement and Posterior Hip Replacement is the location of the initial surgical incision. The location of the incision determines which muscles will have to be cut or pushed aside to complete the surgery. Anterior Hip Replacement involves an incision at the font of the hip. More traditional hip replacements use incisions at either the back of the hip (posterior incision) or the side of the hip (lateral incision).
Compared to Posterior Hip Replacement, an Anterior Hip Replacement often involves less damage to muscles and other soft tissues. However, the anterior approach is considered a more technically challenging surgery. In a study at Mayo Clinic in Rochester, Minnesota, patients who underwent Anterior Hip Replacement had objectively faster recovery than patients who had Posterior Hip Replacement. According to the study, Anterior Hip Replacement patients showed improved recovery by: Discontinuing use of a walker (10 days after surgery versus 14.5 days), Discontinuing use of all gait aids (17.3 versus 23.6 days), Discontinuing use of narcotics/pain medications (9.1 versus 14 days), Climbing stairs with gait aid (5.4 versus 10.3 days), and Walking six blocks (20.5 versus 26 days).
Anterior Hip Replacement is considered less invasive that Posterior or Lateral approaches. People generally think of a minimally invasive surgery as one that requires a smaller incision(s). Although Anterior Hip Replacement surgery typically uses a standard-sized incision, it is often referred to as minimally invasive. The reason Anterior Hip Replacement is considered less invasive is because it involves much less or no muscle damage and cutting. Experts agree that the amount of damage to muscles and other soft tissues during surgery is a main factor in recovery and post-surgical function. Less muscle damage during hip replacement is usually associated with a faster and less painful recovery.
*Anterior Hip Replacement Incision Location. Source: https://www.mayoclinic.org/
location of incision and muscles affected
Anterior Hip Replacement is accomplished via an incision that typically starts at the top of the pelvic bone (iliac crest) and extends down toward the top of the thigh. Less commonly, the incision is made horizontally. Once the surgical incision is made, muscles are pushed aside or cut to access and help visualize the hip’s ball-and-socket joint. Anterior Hip Replacement is more challenging since it requires the surgeon to work between the muscles to gain access to the hip joint. However, the natural anatomical separation at the front of the hip allows ready access to the hip joint with minimal or no muscle cutting.
All hip replacements require dislocation of the hip and shaping the bones of the ball and socket joint in order to implant the prosthetic hip joint components. Since the anterior approach to hip replacement provides the surgeon with a more limited view of the hip joint during surgery, the surgery is technically challenging and requires an experienced surgeon. Compared to a more traditional Posterior Hip Replacement, Anterior Hip Replacement involves less damage to the muscles and other soft tissues around the hip. Even though the anterior approach is a technically much more challenging for surgeons, it is becoming the more popular choice for many. When considering Anterior Hip Replacement, it is imperative to consult with a surgeon that has extensive training and experience with anterior hip replacement.
Possible Complications of Surgery
With any major surgery, there is a risk of complications. The complication rate following hip replacement surgery is very low. Serious complications, such as joint infection, typically occur in fewer than 2% of patients. More significant medical complications, such as heart attack or stroke, occur much less frequently. Your physical condition prior to surgery and chronic illnesses may increase the potential for complications following joint replacement. Although uncommon, when these post-surgical complications occur they can prolong recovery and impact surgery outcomes.
Your surgical team will provide detailed instructions to limit your risk of infection following joint replacement. Infection may occur superficially in the wound or (less frequently) in the deep around the prosthetic hip components. Infection is a risk while in the hospital and after you return home. Ther are times that infection can even occur years later. Minor infections of the wound are generally treated with antibiotics and topical wound care. More major or deep tissue infections may even require additional surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement, so caution must always be used following joint replacement surgery.
Joint replacement surgery puts patients at increased risk of developing blood clots. Blood clots in the leg veins or pelvis are one of the most common complications of hip replacement surgery. Blood clots can even be life-threatening if untreated and able to break free and travel to your lungs. Your orthopedic surgeon will outline a prevention program which may include blood thinning medications, lower leg support hose, inflatable leg coverings, exercises, and an emphasis on early mobilization after surgery. You will be given detailed instructions to contact medical professionals with any signs of blood clots or pulmonary embolism (blood clots that travel to the lungs). Common warning signs of blood clots in your leg can include pain in your calf /leg that is unrelated to your incision, tenderness/redness of your calf, or new/increasing swelling of your thigh, calf, ankle, or footThe warning signs that a blood clot has traveled to your lung
Additional complication risks following joint replacement include nerve and blood vessel injury, bleeding, fracture, and joint stiffness. The risk of fracture during surgery is usually very low, but there is an increased risk if you have osteoporosis (a thinning of bones). Surgeons work to lower risk of fracture with advanced surgical techniques, highly specialized table/instrumentation and post-surgical physical therapy and precautions.
A fall during the first few weeks after surgery can damage your new hip and may result in a need for more surgery. Stairs are a particular hazard until your hip is strong and mobile. You should use a cane, crutches, a walker, or handrails or have someone help you until you improve your balance, flexibility, and strength. Your orthopedic surgeon and physical therapist will help you decide which assistive aides will be required following surgery, and when those aides can safely be discontinued. Other Precautions to assure proper recovery and prevent dislocation of the prosthesis, you may be asked to take special precautions when sitting, bending, or sleeping — usually for the first 6 weeks after surgery. These precautions will vary from patient to patient, depending on the surgical approach your surgeon used to perform your hip replacement. Prior to discharge from the hospital, your surgeon and physical therapist will provide you with any specific precautions you should follow.
anterior hip replacement surgical procedure
The surgeon makes the incision at the front of the hip instead of through the buttocks or the side of the hip. This approach permits the doctor to reach the hip socket without cutting through major muscle groups. For some patients an Anterior Approach Hip Replacement procedure results in less pain and fewer complications for patients than standard hip replacement.
hip replacement recovery
The success of your surgery will depend in large part on how well you follow your orthopedic surgeon's instructions regarding home care during the first few weeks after surgery and your physical condition prior to surgery. Most surgeons and hospitals today emphasize getting you out of bed quickly. Most people are walking with the assistance of a walker on the day after surgery. Early ambulation has been shown to reduce the risk of a post-operative blood clot and is an important part of your recovery. Progression to using a cane or nothing at all typically occurs within the first month or two after surgery and depends on each individual’s progress. You may have stitches or staples along your wound or even a suture beneath the skin. The stitches or staples are typically removed approximately 2 weeks after surgery. Initially you will be instructed to keep the wound covered and dry. You may continue to bandage the wound to prevent irritation from clothing or support stockings. Some loss of appetite is common for some following surgery. A balanced and healthy diet is important to promote proper tissue healing and restore muscle strength.
Most surgeons and hospitals today emphasize getting you out of bed quickly. Most people are walking with the assistance of a walker on the day after surgery. Early ambulation has been shown to reduce the risk of a post-operative blood clot and is an important part of your recovery. Progression to using a cane or nothing at all typically occurs within the first month or two after surgery and depends on each individual’s progress. Despite the rapid progression to moving without assistance, it is typically not recommended that you return to sporting activities until the third month after surgery. Most surgeons allow patients to drive at four to six weeks after surgery, and sometimes sooner if the operative leg is the left leg. There is some literature that states that your reaction time will not be back to normal prior to six weeks. You should not drive while on narcotics, and should discuss returning to driving with your operating surgeon. Returning to work is highly dependent on your general health, activity level and demands of your job. If you have a sedentary job, such as computer work, you can expect to return to work in four to six weeks. If you have a more demanding job that requires lifting, walking, or travel, you may need up to three months for full recovery.
physical therapy and recovery following hip replacement
Initially, you will receive some physical therapy while in the hospital. Depending on your preoperative conditioning and support, you may or may not need additional therapy as an outpatient. Much of the therapy after hip replacement is walking with general stretching and thigh muscle strengthening, which you can do on your own without the assistance of a physical therapist. To assure proper recovery and prevent dislocation of the prosthesis, you may be asked to take special precautions when sitting, bending, or sleeping — usually for the first 6 weeks after surgery. These precautions will vary from patient to patient, depending on the surgical approach your surgeon used to perform your hip replacement.Prior to discharge from the hospital, your surgeon and physical therapist will provide you with any specific precautions you should follow.
To assure proper recovery and prevent dislocation of the prosthesis, you may be asked to take special precautions when sitting, bending, or sleeping — usually for the first 6 weeks after surgery. These precautions will vary from patient to patient, depending on the surgical approach your surgeon used to perform your hip replacement.Prior to discharge from the hospital, your surgeon and physical therapist will provide you with any specific precautions you should follow.
You may feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending. These differences often diminish with time, and most patients find these are minor compared with the pain and limited function they experienced prior to surgery.Your new hip may activate metal detectors required for security in airports and some buildings. Tell the security agent about your hip replacement if the alarm is activated. You may ask your orthopedic surgeon for a card confirming that you have an artificial hip.
follow-up following hip replacement
It is important to follow up with your surgeon after your joint replacement. In most cases, joint replacements last for many years. You need to meet with your treating doctor after surgery to ensure that your replacement is continuing to function well. In some cases, the replaced parts can start to wear out or loosen. The frequency of required follow up visits is dependent on many factors including the age of the patient, the demand levels placed on the joint, and the type of replacement. Your physician will consider all these factors and tailor a follow-up schedule to meet your needs. In general seeing your surgeon every three to five years is recommended.
Source: American Academy of Orthopaedic Surgeons, https://orthoinfo.aaos.org/; American Association of Hip and Knee Surgeons, https://hipknee.aahks.org/total-hip-replacement/
Cory Calendine, MD is an Orthopedic Surgeon and founding partner of the Bone and Joint Institute of Tennessee at
Williamson County Hospital in Franklin, TN. Dr. Calendine is an expert in Joint Replacement, specializing in Hip and Knee Surgery. From diagnosis through treatment, the Orthopedic Surgical experts at the Bone and Joint Institute use the latest techniques and technology to improve care for people with musculoskeletal problems. For more information, please contact our office
or schedule your appointment today.