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. Some more recent improvements to this approach (small incision and less tissue trauma) have been called “mini posterior approach.” Another currently popular approach is known as the “Anterior Approach,” which is performed from the front of the hip. The lateral approach is less frequently used but a viable approach for the surgery. There are pros and cons of each approach and little science to endorse one over the other. Surgeons tend to have a preference and comfort level with one particular approach over the others. The bottom line is that the best approach is the one your doctor is most comfortable with to allow safe and precise implantation of your hip replacement components. A conversation with your surgeon should help decide which approach is best for you.
Posterior hip replacement
The main difference between posterior and anterior approach hip replacement is the location of the surgical incision. The location of the incision determines which muscles will be cut or pushed aside during surgery. Posterior Hip Replacement surgery uses a curved incision on the side and back of the hip. The incision curves just behind the greater trochanter, the knobby bit of bone that sticks out at the side from the top of the femur (thigh bone).
The posterior hip replacement approach requires surgeons to cut muscles and other soft tissue at the back of the hip, including: The tensor fascia lata, which is a wide piece of fibrous soft tissue at the top of the outer thigh. It works with the iliotibial band (IT band) to help stabilize the hip and knee. The large gluteus maximus muscle, which is attached to the fascia lata. The gluteus maximus allows a person to extend and rotate the thigh outward. It also helps stabilize the pelvis and keep the body erect. The external rotators of the hip, which are small, short muscles that connect the top of the femur to the pelvis. These muscles provide hip stability, preventing the femur from dislocating out the back of the hip socket.
*Posterior Approach Hip Replacement Incision Location.
Posterior hip replacement procedure
Posterior hip replacement is a minimally invasive hip surgery performed to replace the hip joint. It is also referred to as muscle sparing surgery because no muscles are cut to access the hip joint, enabling a quicker return to normal activity. The posterior approach is traditionally the most common approach used to perform total hip replacement.In posterior hip replacement, the surgeon makes the hip incision at the back of the hip close to the buttocks. The incision is placed so the abductor muscles, the major walking muscles, are not cut.
Posterior hip replacement surgery involves the following steps: The procedure is performed under general anesthesia. You will lie face down on a special operating table that enables the surgeon to perform the surgery from the back of the hip. An incision is made close to the buttocks beyond the abductor muscles. The surgeon detaches the muscles and tendons to gain access to the hip joint. Once the artificial components are fixed in place, the instruments are withdrawn, soft tissues are re-approximated, and the incisions are closed with sutures and covered with a sterile dressing.
The advantages of posterior approach for some surgical candidates include: a high success rate, minimally invasive incision, limited muscle damage, and the more precise placement of implants with excellent visibility of the joint.
Possible Complications of Surgery
With any major surgery, there are risks of complications. The complication rate following hip replacement surgery is low. Serious complications, such as joint infection, occur in less than 2% of patients. Major medical complications, such as heart attack or stroke, occur even less frequently. However, chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur they can prolong or limit full recovery.
Infection may occur superficially in the wound or deep around the prosthesis. It may happen while in the hospital or after you go home. It may even occur years later. Minor infections of the wound are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement.
Blood clots in the leg veins or pelvis are one of the most common complications of hip replacement surgery. These clots can be life-threatening if they break free and travel to your lungs. Your orthopedic surgeon will outline a prevention program which may include blood thinning medications, support hose, inflatable leg coverings, ankle pump exercises, and early mobilization.
Additional risks include nerve and blood vessel injury, bleeding, fracture, and joint stiffness. Although low, there is risk of fracture during surgery, particularly if you have osteoporosis. A highly specialized table and careful, experienced surgical technique help minimize the risk.
Avoiding Problems After Surgery
Avoid Blood Clots: Follow your orthopedic surgeon's instructions carefully to reduce the risk of blood clots developing during the first several weeks of your recovery. He or she may recommend that you continue taking the blood thinning medication you started in the hospital. Notify your doctor immediately if you develop any of the following warning signs.
Warning signs of blood clots. The warning signs of possible blood clot in your leg include: Pain in your calf and leg that is unrelated to your incision tenderness or redness of your calf, or new/increasing swelling of your thigh, calf, ankle, or foot
Warning signs of pulmonary embolism. The warning signs that a blood clot has traveled to your lung include: Sudden shortness of breath, Sudden onset of chest pain, and/or Localized chest pain with coughing
Warning signs of infection. A common cause of infection following hip replacement surgery is from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections. Following surgery, patients with certain risk factors may need to take antibiotics prior to dental work, including dental cleanings, or before any surgical procedure that could allow bacteria to enter your bloodstream. Your orthopedic surgeon will discuss with you whether taking preventive antibiotics before dental procedures is needed in your situation. Notify your doctor immediately if you develop any of the following signs of a possible hip replacement infection: Persistent fever (higher than 100°F orally); Shaking chills; Increasing redness, tenderness, or swelling of the hip; wound drainage from the hip wound; or Increasing hip pain with both activity and rest.
Avoiding Fall Risk: 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.
Posterior hip replacement surgical procedure
During Posterior Hip Replacement, you will lie face down on a special operating table that enables the surgeon to perform the surgery from the back of the hip. An incision is made close to the buttocks beyond the abductor muscles.The surgeon detaches the muscles and tendons to gain access to the hip joint.Once the artificial components are fixed in place, the instruments are withdrawn, soft tissues are re-approximated, and the incisions are closed with sutures and covered with a sterile dressing.
hip replacement recovery
The success of your surgery will depend in large measure on how well you follow your orthopedic surgeon's instructions regarding home care during the first few weeks after surgery. You may have stitches or staples running along your wound or a suture beneath your skin. The stitches or staples will be removed approximately 2 weeks after surgery. Avoid getting the wound wet until it has thoroughly sealed and dried. You may continue to bandage the wound to prevent irritation from clothing or support stockings. Some loss of appetite is common for several weeks after surgery. A balanced diet, often with an iron supplement, is important to promote proper tissue healing and restore muscle strength. Be sure to drink plenty of fluids. The majority of people who undergo total hip replacement are able to participate in a majority of their daily activities by six weeks. By three months, most people have regained much the endurance and strength lost around the time of surgery, and can participate in daily activities without restriction. While daily activities have resumed, it is important to avoid high impact activities to give you the best long-term outcome with your hip.
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/; Arthritis-health,
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.