Anterior Approach to Hip Replacement Surgery Something New at Sarah Bush

Total hip arthroplasty has become a safe and reliable operation for the treatment of degenerative disease of the hip. The most common cause of disability in the United States is arthritis. It is estimated that one in five people have some form of arthritis. Two-thirds of those diagnosed with arthritis are under the age of 65.

Sir John Charnley pioneered the modern techniques used in hip arthroplasty in 1967 and many improvements have been adapted since his time. Sir Charnley used a Tran osseous approach to the hip cutting off the greater trochanter to access the hip joint. He then wired the bone back at the end of the operation. Postoperative pain and risk of the bone not healing led to the development of the posterior approach to total hip surgery.  

Posterior Approach - In the traditional posterior approach the patient is laid on his or her side during surgery and incision is made over the gluteal muscle. This muscle is then split in half and the external rotator muscles are elevated off the posterior femur exposing the hip capsule. The hip replacement may then be performed. This is the most common method of hip replacement in the United States. It has been very effective, however complications still occur. Lateral positioning makes intra-operative X-ray challenging and may lead to mistakes in implant positioning with resultant permanent leg length discrepancy, premature wear of the prosthesis, or instability. Surgery through the gluteal and external rotator muscle has been shown to lead to a greater period of hip in stability, as much as 1/100. Adherence to posterior hip precautions is needed to keep the joint from dislocating.

Anterior Lateral Approach - To address the instability risks of the posterior approach the anterior-lateral approach was developed. In this method, the patient is still positioned on his or her side, but the incision is made over the side of the leg. The ileotibial band is split and then the abductor muscle is elevated off the femur exposing the anterior hip capsule. The danger in this technique is the viability of the abductor muscle is put at risk. A weak abductor, or poorly healed abductor repair places the patient at risk 1/250 for a permanent irreversible limp.

Anterior Approach - The anterior approach to total hip arthroplasty is a solution to the challenges and complications of the prior methods of surgery. During an anterior approach the patient lies on his or her back and a special surgical table aids in the positioning of the hip joint. The incision is made on the front of the thigh just past the inguinal crease. The tensor fascial muscle is pulled laterally and the Sartorius muscle is pulled medially exposing the anterior hip capsule. The anterior approach is a muscle sparing approach to the hip. This leads to less post-operative pain and weakness. The risk of dislocation is reduced from 1/100 to 1/1000. Therefore hip precautions are no longer needed after surgery. The risks of a permanent abductor lurch or limp as been diminished. In the supine position X-ray may easily be used during the operation to ensure optimal positioning of the prosthesis. While further study is needed, this may prove to increase the longevity of the hip replacement as wear rates are minimized.  

Challenges and Benefits - The challenges in performing an anterior approach to the hip are as real as the benefits. Specialized equipment is required that is quite expensive. The learning curve for this approach is significant. Instruction by a current user of the anterior approach is highly encouraged as few surgeons are used to this surgical interval as a means to access the ace tabular socket and proximal femur. Improper technique may lead to nerve muscle, or bone injury. 

The anterior approach is considered as muscle saving, tissue sparing. The potential benefits of the anterior approach are:

• Possible accelerated recovery time because key muscles are not detached during the operation
• Standard postoperative hip precautions are eliminated.
• Possible better outcomes as implant position is improved
• Less tissue disruption
• As with any surgery, risks include infection, DVTs, pneumonia, and bleeding to name a few.
  The skin incision must be kept dry and clean especially if it lies under a large abdominal fold.

In summary, the anterior approach to total hip arthroplasty is an excellent method to address hip degeneration in all types of patients. It is an especially attractive option for active patients who are still working and playing. Allowing these individuals a safe and rapid return to their routine has clear benefits to the quality of their life.

Aaron C. Eubanks, MD, FAAOS,
Orthopedics and Sports Medicine of Sarah Bush Lincoln 

Resources

Sendtner, E., Borowiak, K., Schuster, T., Woerner, M., Grifka, J., & Renkawitz, T. (2011). Tackling the learning curve: comparison between the anterior, minimally invasive (Micro-hip (R) and the lateral, transgluteal (Bauer) approach for primary total hip replacement. Archives of Orthopaedic and Trauma Surgery, 131(5), 597-602.

Parker, M. (2008). Surgical approaches for inserting hemiarthroplasty of the hip. Cochrane Database of Systematic Reviews, (1),

van Oldenrijk, J., Hoogland, P., Tuijthof, G., Corveleijn, R., Noordenbos, T., & Schafroth, M. (2010). Soft tissue damage after minimally invasive THA. Acta Orthopaedica, 81(6), 696-702.

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