Anterior Approach Total Hip Replacement
The anterior approach to total hip replacement is a surgical technique where the removal and replacement of a diseased or damaged hip joint is made through a small incision in the front of the hip near the upper thigh. The normal incision is about four inches but may vary according to a patient's body size. Though small incisions are often considered desirable by patients, it should be kept in mind that the degree and type of tissue disturbance beneath the skin is a more important factor. Using the anterior approach, the hip joint is exposed by spreading muscle groups through their natural intervals, without cutting through muscles, or detaching tendons from bone. In the anterior approach, the gluteal and abductor muscles that attach to the posterior and lateral pelvis and femur are left undisturbed.
Lack of disturbance of the lateral and posterior soft tissues accounts for immediate stability of the hip and a low risk of dislocation. Rehabilitation is accelerated and recovery time decreased because the hip is replaced without detachment of muscle from the pelvis or femur. Following the anterior approach, patients are immediately allowed to bend their hip freely. Should a patient require bilateral hip replacements, this can be performed during a single operative session. Possible complications of anterior hip replacement surgery include infection, injury to nerves or blood vessels, fractures, hip dislocation, and the need for revision surgery.
Not everyone is a candidate for the anterior approach to total hip replacement; therefore it is important to extensively discuss the advantages and disadvantages of this approach with the physician. The physician will help decide the best approach based on the individual's characteristics and conditions.
The hip is one of the largest joints in the human body and is a ball-and-socket joint. The ball is the femoral head, which is the upper end of the femur (thighbone). The socket is formed by the acetabulum, which is part of the large pelvis bone. The bone surfaces of the ball and socket are covered with articular cartilage, a smooth, white connective tissue that enables the bones of a joint to easily glide over one another with very little friction allowing easy movement. The remaining surfaces of the hip joint are covered by the synovial membrane, which is a thin tissue lining that releases fluid that lubricates the cartilage, reducing the friction within the hip joint. Large ligaments (tough bands of tissues) connect the ball and the socket in order to stabilize the joint by preventing excessive movement.
When an individual has arthritis of the hip, the underlying bone develops spurs and irregularities which can cause severe pain and loss of motion. A total hip replacement (also referred to as total hip arthroplasty) has the ability to relieve pain and restore normal function in patients whose hip joint has been significantly damaged by overuse or trauma. In this type of surgery, the damaged hip ball-and-socket of the femur is replaced by man-made, prosthetic implants. Total hip replacement surgery has been done routinely for the past 50+ years with the main objective being to restore the natural, pain-free movement of the hip joint and allowing patients to return to their desired level of activity. Of all the joints currently replaced in the human body, total hip replacement has had the most success, is the most durable (lasting upwards of 30 years), and has the quickest recovery period.
Individuals who require a total hip replacement surgery typically experience these symptoms:
- Persistent pain in the hip region that worsens with walking or bending
- Persistent pain in the hip region that interferes with rest and sleep
- Limited or restricted range of motion making going up or down stairs or rising from a seated position difficult
Severe hip pain should not be ignored. Paying a visit to a physician is highly recommended if an individual experiences the symptoms mentioned above despite the use of pain medication.
Arthritis of the hip can be diagnosed with a combination of physical examination as well as imaging studies. After gathering information about the individual's general health and the extent of his or her hip pain and how it affects their ability to perform day-to-day activities, the physician may examine the hip to assess the motion, stability, strength, and overall alignment of the hip joint. The physician may order X-rays to assess the extent of deformity or damage in the hip joint or an MRI scan to determine the condition of the tissues and bones of the hip and identify the type of arthritis. The physician will educate you on the benefits from this surgery as well as what to expect post-operatively.
Arthritis is the most common cause of chronic hip pain and disability. Although there are many types of arthritis that cause pain, the most common that often lead to a total hip replacement are the following:
- Osteoarthritis - Osteoarthritis is the most common form of arthritis and occurs when the protective cartilage on the ends of your bones wears down over time. It's often called a degenerative joint disease where the cartilage experiences a significant amount of wear and tear over a long period of time, generally occurring in individuals over the age of 50.
- Rheumatoid Arthritis (RA) - Rheumatoid arthritis is quite possibly the most serious form of arthritis as it is a major crippling disorder. Unlike osteoarthritis, rheumatoid arthritis affects the synovial membrane (lining of the joints), causing a painful swelling, resulting in joint deformity and bone erosion. Rheumatoid arthritis is three to four times more likely to occur in women and may affect various systems of the body such as eyes, heart, lungs, skin, and the nervous system.
- Post-Traumatic Arthritis - Traumatic arthritis is caused by repeated trauma to the articular cartilage. This is most common among individuals who were/are athletic or active. Injuries to joints such as a fracture or sprain can cause major damage to the articular cartilage, which leads to arthritic changes in the joint over time.
- Avascular Necrosis - Avascular necrosis occurs when the blood supplied to the femoral head is limited due to an injury such as a dislocation or fracture to the hip. The lack of blood can cause the surface of the bone to breakdown, resulting in arthritis.
A total hip replacement entails the removal of the damaged bone and cartilage of the hip ball-and-socket and replacement with man-made prosthetic components. A total hip replacement procedure takes anywhere between one to two hours to complete and occurs in the following order:
- Entering the Joint - An incision is made near the front of the hip and the muscles, tendons, and other tissues are moved away from the joint to expose the femoral head (ball) and acetabulum (socket). The hip is then positioned to expose or open up the joint.
- Removal of Femoral Head - During this step, the head and neck of the femoral head is removed and the acetabulum is cleaned out in preparation for the replacement components.
- Femoral Canal Preparation - Once the acetabulum is cleaned out, an acetabular metal shell component is fit into the space along with a plastic liner to surround the prosthetic femoral head to allow or a smooth gliding surface. The femur is then hollowed out in preparation for the femoral stem insertion.
- Femoral Placement - The femoral stem may be secured with the use of cement or be "press-fit" into the hollow center of the femur. A carefully fitted metal or ceramic ball is then secured to the top of the femoral stem.
- Rejoining the Hip Joint - The hip joint is then rejoined and all the surrounding muscle and tissues are repaired back to position and the procedure is completed.
Recovery after a total hip replacement will depend heavily on how well the individual follows home care and precautions after the surgery. After a total hip replacement surgery, there will be some pain, but the medical team will provide the proper medication to make the patient as comfortable as possible. Walking and hip movement will begin soon after the surgery where a physical therapist will provide instructions on the specific exercises to strengthen the leg and restore hip movement to allow for walking and other activities post operatively. Major part of the recovery process will occur at home where proper care must be taken in terms of wound care, diet, and activity as prescribed by the physician and physical therapist. Patients who have undergone total hip replacement surgery generally resume normal activities three to six weeks post operatively. Each patient is unique, so the recovery period will vary depending on the level of activity the individual hopes to return to; this should be discussed with the physician as well as the physical therapist.
FAQs by Dr. Denes
FAQs Answered by Alec E. Denes, M.D.
- When can I drive after hip replacement?
Driving is safe once you are fully bearing weight on the new hip, and no longer taking any narcotic pain medications. This could be as early as 5-7 days after surgery. Make sure you try driving in a safe area first to test out your strength and mobility.
- What about having sex?
Sexual intercourse may be resumed at any time as long as it is comfortable.
- When is it safe to travel?
It is recommended to avoid any travel over 2 hours for the first 4 weeks following surgery. Major travel means extended sedentary periods, often in the pressurized cabin of an airplane, both of which increase the risk of blood clots.
- How long are the TED stockings needed?
You should wear the compression stockings for two (2) weeks after surgery to prevent blood clots. It's fine to wear them longer to control swelling, if necessary.
- How soon can I swim or use a hot tub?
You should wait four (4) weeks after surgery until you submerge the incision in a pool or hot tub. It is OK to shower normally 3 days after surgery.
- Do I need physical therapy?
You will have physical and occupational therapy daily while in the hospital. This will be primarily directed at regaining mobility and normal daily activity. Your main goal in the first few weeks should be the same.
Because the anterior approach preserves the major muscles around the hip joint, most patients do not require visits with a physical therapist.
If you feel that you need physical therapy as an outpatient, please discus and concerns you may have with me. Remember (and remind the therapists) that you may move your hip in any way that is comfortable for you and you can put full weight on your leg.
- What limitations will I have after hip replacement?
You will have NO restrictions on hip motion. You may move and position your new hip however is comfortable. This is due to the anterior approach technique performed.
I recommend waiting until 6 weeks post-surgery to resume regular gym exercise, or any sports. After that, you may return to low-impact aerobic exercise and any weight machines. I recommend avoiding any impact exercise (such as running or jumping) permanently to minimize the wear and tear on your new hip. You may return to hiking, biking, golf, swimming, skiing, horseback riding, etc. My goal is to get you back to an active lifestyle, so send me photos and/or stories of you enjoying your new hip!
- What type of implants do you use?
The implants I currently use for hip replacements are the Corail or TriLock stems, and the Pinnacle cup. All are products of DePuy Synthes, a subsidiary of Johnson & Johnson. These are titanium implants with a rough surface that bonds to the surrounding bone through a biological "ingrowth" process, and no cement is used. The "bearing" surface is either ceramic-on-plastic or metal-on-plastic, depending on your age and activity level. I have never used the metal-on-metal implants that have been in the news due to being recalled.
- Is it normal to have numbness in my thigh after surgery?
Some numbness surrounding the incision and upper thigh is expected after anterior approach hip replacement. This typically improves gradually over the first several months.
- Why does my thigh hurt after surgery?
It is common to experience thigh soreness, swelling, and/or bruising. The bruising often does not peak until you are 1 week or more post-op, and may appear all the way down to or below your knee. It may take a month or two for the swelling and bruising to resolve.
Your swelling and pain may increase if you are too active in the first few weeks after surgery. For that reason, it is best to take it easy for the first 2 weeks, practice the exercises from the hospital physical therapist, and practice walking. Remember to ice your hip after activity during the first 2 weeks after surgery. This will help control the pain and swelling.
- Are follow-up appointments needed after surgery?
You should schedule an appointment for six (6) weeks after surgery to check your incision, take x-rays of the new hip implants, and evaluate your progress. Additional visits are typically scheduled at 1, 2, and 5 years after surgery for repeat x-rays to check the implants. If any urgent matters arise, call to schedule an appointment with me or with Danielle, my PA.
- I need both hips replaced. Can you do both at once?
It is possible to do both hip replacements during the same surgery, but this is only appropriate for younger, active, and healthy patients. I can discuss this with you personally, but typically I recommend doing the two surgeries separately, about six weeks apart.
Benefits of the Anterior Technique
Benefits of the New Anterior Approach Hip Replacement Technique
So you need a hip replacement, and are ready to get relief from the pain and grinding of bone-on-bone arthritis in your hip. The great news is that you, like most patients, are probably a candidate for the new "anterior approach" technique, which in my experience, has resulted in dramatic improvements in the recovery after hip replacement surgery. After a few years of performing both this and other techniques, I have now switched to use the anterior approach as my preferred method for all hip replacements. I am now doing several anterior approach hip replacements every week at Providence St. Vincent Medical Center - Total Joint Program.
Traditional hip replacement techniques involve cutting through the gluteal muscles and the external rotators, two important muscle groups for the function and stability of the hip joint. There can be pain and weakness as a result, and these muscles must heal before full activity is resumed. Additionally, patients must be careful of avoiding certain movements with the hip, in order to prevent a dislocation of the new joint.
The anterior approach involves making an incision on the front of the hip, rather than through the buttocks or side of the hip. A natural interval between muscles can be used to access the hip joint, and they go right back together after the procedure. A special operating table, called the HANA table, was developed which allows me move the hip easily, so I can place the implants safely through a small incision. The table also allows me to use an x-ray machine during the procedure as necessary, to confirm proper implant position, and to ensure accurate leg lengths. I learned this technique in my fellowship, an additional year of training after residency, and subsequently attended multiple courses practicing on cadavers. I used the technique occasionally for my own patients in the first few years, to gradually hone my skills. Now, over 500 anterior total hip replacements later, I have had no patients dislocate, and only one infection (0.2% rate). I use titanium implants, which are not cemented, but instead a biological bond is formed when your bone grows onto the rough surface of the implant. The bearing surface is either metal-on-plastic or ceramic-on-plastic, depending on your age and activity level. I have never used the metal-on-metal hips that are in the news due to being recalled. Most patients go home the day after surgery, however, based on your individual case, you may go home on the same day as the surgery. My patients have gone back to surfing, mountain climbing, golfing, biking, water-skiing, tennis, racquetball, yoga, kite-surfing, even ballet.
This technique is gaining popularity, but still is only offered by a small percentage of surgeons nationwide. I do rarely see patients who are not candidates for the anterior approach technique, but those are typically only ones with severe congenital or post-traumatic deformities.
If you have more questions, check out the links below, and call our office to make an appointment.
Medical Assistant: (503) 214-5283
KPTV featured two separate anterior approach patients in their “Health Watch” series:
Michael, who had double hip replacement (both hips) on the same day
Charles, who surfs regularly after his hip replacement
More information from Dr. Joel Matta, the pioneer of this technique:
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