Does Approach Matter for Hip Replacement?

In the past few years, there has been a debate among physicians and patients regarding the “optimal” approach for hip replacement. If fact, considerable marketing has been deployed to attract patients to a surgical approach, citing rapid recovery, minimal or no pain, muscle-sparing exposure, and return to unrestricted activity. The frank reality is that these outcomes are possible with almost any of the common approaches today. The American Academy of Hip and Knee Surgeons (AAHKS), which is the largest collection of fellowship-trained specialists in total joint replacement, has concluded that “the best approach is the one your doctor is most comfortable with to allow safe and precise implantation of your hip replacement components.” As a patient, you should choose the surgeon and trust on their decision regarding the approach.

Surgical Hip Approaches https://musculoskeletalkey.com/the-hip-5/

I personally prefer the direct anterior approach for most of my primary hip replacement procedures. In certain circumstances, I will also utilize a direct lateral or posterior approach, but I plan for each and every case on an individual basis based on specific patient characteristics. There are benefits and disadvantages to every approach, and despite what marketing campaigns have proposed, no approach is infallible.

The direct anterior approach allows for a patient to be positioned on his/her back. Some surgeons require a special table to help with exposure, though I avoid this additional table to limit more moving parts and complexity in the operating room. Having a patient supine (on their back) is beneficial for anesthesia and allows me to directly compare leg lengths during surgery. It also makes using intraoperative xray to confirm desired component placement a whole lot easier and more reliable. For the patient, multiple high quality studies have proven that the anterior approach is better than posterior and lateral approaches with regards to pain and mobility in the first 6 weeks after surgery. The reality is that this published benefit is equalized by 6 weeks after surgery. With the anterior approach, there are no motion or position-related restrictions after surgery. The main complications attributed to this approach are numbness along the thigh and an increased risk of fracture of the bone during surgery. Despite the media promoting this as the solution to dislocations more commonly associated with the posterior approach (2-4%), there are a very small number of anterior hip dislocations that occur as well (<1%). Critics also cite a more difficult ability to extend the exposure during complex cases, however this approach has been used by the vast majority of European surgeons for decades for all primary and revision cases without issue. Extension is absolutely possible and extension in this position still offers the benefit of a visible assessment of leg lengths and easy xray confirmation of component position.

Posterior and lateral approaches are the workhorse approaches for most surgeons in complex cases and the majority of primary procedures in the US (>80%). They easily allow for wide exposure and can be readily extended if the case dictates a change in plan. The common critique is that the posterior approach has a higher rate of dislocation after surgery, and many patients are frustrated with the mobility restrictions during recovery. The lateral approach involves moving and reattaching muscles around the hip. It is excellent for exposure and the rate of dislocation after this approach is minimal at best. The major critique is pain, sometimes chronic, with pressure on the side of the hip which can be associated with an occasional limp. There are also immediate motion restrictions in most cases after this approach.

One additional approach, the superior approach, is also being used by select surgeons. This approach adopts a muscle-sparing variation to the posterior approach. It requires specialized instrumentation, but proposes the benefits of a very low dislocation and fracture rate. The patient is typically lying on his/her side during this procedure which makes direct assessment of leg lengths more difficult.

Patients should choose their surgeon based on their personal comfort and after weighing the risks and benefits of each option. My preferred approach is direct anterior because I believe it helps my patients more quickly become active, and I prefer to directly evaluate leg length during the surgery using cues from the hip anatomy, xray confirmation, and also direct comparison with the opposite leg.

We are happy to review your case and discuss surgical and nonsurgical options. Contact Dr. Werger at The Bone and Joint Center for a consultation.

(617) 779-6500.

1. Bergin PF, Doppelt JD, Kephart CJ, Benke MT, Graeter JH, Holmes AS, Haleem-Smith H, Tuan RS, Unger AS. Comparison of minimally invasive direct anterior versus posterior total hip arthroplasty based on inflammation and muscle damage markers. J Bone Joint Surg Am. 2011; 93(15):1392-8.
2. Rodriguez JA, Cooper HJ, Robinson J. Direct anterior approach to THR: what it is and what it is not. Current Reviews in Musculoskeletal Medicine. 2013;6(4):276-278
3. Sheth D, Cafri G, Inacio MC, Paxton EW, Namba RS. Anterior and Anterolateral Approaches for THA Are Associated With Lower Dislocation Risk Without Higher Revision Risk. Clin Orthop. 2015; 473(11):3401-8.
4. Taunton, Michael J. et al. Direct Anterior Total Hip Arthroplasty Yields More Rapid Voluntary Cessation of All Walking Aids: A Prospective, Randomized Clinical Trial. J Arthroplasty. 2014; 29(9):169-72.