Approaches

Alexander P. Sah

Over time, many different surgical approaches have been explored, each with its own specific advantages and disadvantages.  The lateral, or side, hip surgical approach historically involved a controlled fracture (osteotomy) of the trochanter including the insertion of the hip abductor muscles (analogous to the rotator cuff of the shoulder).  This required bone reattachment which carried associated risks of improper bone healing and a postoperative limp.  An anterolateral, slightly more anterior, approach avoided bone osteotomy, but instead detaches the anterior third of the hip abductor muscle off of the bone.  While the approach provides excellent hip stability, it also leads to at least a temporary limp, because of the dissection through the hip abductor musculature.  An approach again just slightly forward to this one, a modified Watson-Jones anterolateral approach, promotes many of the same advantages, and avoids abductor damage because it enters the hip joint just in front of this muscle group.  However, the technique is challenging for exposure in the operating room, requiring multiple assistants and extensive leg manipulation.  Because exposure is more difficult, it can be more challenging for accurate component placement.  I have performed each of these approaches, but have found the advantages to not be as great as other surgical techniques. 

An anterior hip approach is promoted to be muscle splitting rather than cutting, with fewer precautions after surgery.  Most of the proposed advantages are a result of marketing, and have not been proven in the literature.  Our national Orthopedic Association has evaluated the outcomes of anterior versus mini-posterior (described below) approaches, and found no differences or benefits of one approach over another at 4-6 weeks after surgery.  Nerve injury is also reported specifically with this approach that can lead to permanent numbness, or even pain, in the front of the thigh.  Nonetheless, this approach has gained public interest, even without concrete evidence to support it.  In select patients, this approach may be appropriate, but factors such as hip stiffness, severity of hip disease, and body habitus can influence risks and complications.  I have been trained in this technique and will perform the procedure on carefully selected patients.  I am the only surgeon at the Institute performing anterior hip replacement.  In my experience, patients have seemed to have less pain and a faster recovery with this surgical technique. Discussing this approach with a surgeon who performs the procedure would best determine whether a particular patient is a proper candidate.

The mini-posterior approach is a modification of the standard posterior hip surgical technique.  It is reduced to typically a 3-4 inch incision with less soft tissue dissection to the hip joint.  In contrast to the standard approach, more muscle and soft tissue is left intact, and any small tendons or capsule are repaired at the end of the case.  These techniques lower the hip dislocation rate to be comparable to the other approaches.  In addition, because this modified approach is based on the traditional posterior technique, it is easily extensile if needed, thereby allowing appropriate hip exposure in the rare occurrence of an intraoperative complication, unexpected complex hip anatomy, or revision procedures.  Recovery is reliable with immediate weight-bearing in patients ranging from 40 to 90 year-old patients.  Since 2008, patients have been able to safely be discharged home the day following surgery.  In 2017, following the pattern of my partial and total knee replacement patients, outpatient hip replacement is planned for select patients.