If you are heading for a total hip replacement procedure you may be wondering about the details of the operation and your recovery – will the incision heal fast, will you be able to walk without a cane and go up and down the stairs. We wrote about preparation for a hip replacement in our prior blog. In this one, we wanted to talk about different approaches that surgeons may take for your hip replacement.
Hip replacement is one of the most successful operations in all medicine. The first metallic hip replacement was performed in 1940 by an American surgeon, Dr. Austin Moore. In 2016-2017 in Canada a total number of 55,981 hip replacements were performed. That is quite an increase from 47,541 done in 2012-2013.
Different approaches and techniques exist when it comes to replacing your hip. The two things that often are asked about are how big is the incision and what muscles, tendons or fascia are cut to get to the diseased joint.
By far the most common approach is the posterior approach. It is done on a traditional operating room table. You will be laying on your side. The incision curves backward into the buttock area. The size of the incision is about 10 to 12 inches long. The hip is reached by cutting several tendons that come out of the pelvis called short external rotator muscles. This allows for an excellent exposure and visualization of the femur and the socket of the hipbone, which in turn allows for precise component (new hip parts) positioning. A common risk to this method cited in the medical literature is increased dislocation rates and risk of a sciatic nerve injury.
A variation of this approach is called mini-posterior approach. It does not cut the muscles but instead separates them and the incision is smaller. This is considered a minimally invasive approach.
This is the second most common approach. The incision is made directly on the side, over the bony prominence that is against the mattress if you are a side sleeper. You can be laying on your side or on your back. A standard operating room table can be used or depending if operative imaging is needed, radiolucent (transparent to X- rays) table is used. A large muscle called gluteus medius is then split in order to access the hip joint from the front side.
This method allows for good exposure femur and hip bone socket, minimizes the risk of dislocation and sciatic nerve injury. The risk here is damage to abductor mechanism. Medical studies suggest that the lateral approach has an increased incidence of abductor insufficiency when compared to posterior approach. Abductor muscles of the hip help us pull the leg away from the midline of the body. We use this action every day when we step to the side, get out of bed or get out of the car.
Direct Anterior Approach
This approach is not new. In fact, it has been in use US since the 80-ies. However, new instrumentation allowing it to be performed using smaller incisions has made it increasingly sought after. The cut is made on the front to access the hip. The posterior capsule and muscles are not cut, but are moved aside along their natural tissue planes, without detaching any tendons. The size of the incision is about 4-5 inches long. This approach allows the surgeon to work between the muscles without detaching them from the femur.
The direct anterior approach is generally considered a minimally invasive approach because of its muscle sparing nature. You would be on your back and a specialized or standard radiolucent table can be utilized. Some surgeons prefer to use specialized X-rays during this procedure. These X-rays allow them to see images on the monitor in real-time, very much like a movie. That aids in new joint placement.
Surgeons face a steep learning curve for this procedure. The anterior incision provides a restricted view of the hip joint, making it a technically demanding procedure. Depending on the surgeon’s experience, this surgery may not be appropriate for obese or very muscular patients, because the additional soft tissue can make it difficult for the surgeon to access the hip joint.
What is right for you?
It is much discussed in the medical literature which approach is better. The researchers at Mayo Clinic found that Mayo Clinic patients who underwent direct anterior approach hip replacement procedure had objectively faster recovery than patients who had a mini-posterior approach. According to the Mayo clinic study, the recovery time with the anterior approach is approximately 5 days ahead.
The study also documented quicker recovery by direct approach patients compared with mini-posterior approach patients in:
- Discontinuing use of a walker (10 days after surgery versus 14.5 days)
- Discontinuing use of all gait aids (17.3 versus 23.6 days)
- Discontinuing use of narcotics (9.1 versus 14 days)
- Ascending stairs with gait aid (5.4 versus 10.3 days)
- Walking six blocks (20.5 versus 26 days)
When discussing the type of approach your surgeon will be using keep in mind that the first two have been used by many doctors for many years. They are therefore considered traditional and safe. Anterior approach will require that your surgeon has specific training and experience to handle the operation successfully. Your surgeon should be able to tell you why he or she recommends one approach over the other. Go to the doctor you can trust and have a conversation with about your total hip replacement needs and expectations.
In our next blog, we will be talking about the use of robotics in total hip replacement. Stay tuned and as always if you have any questions please reach out to us by toll-free or email: 1 877 344 3544 or firstname.lastname@example.org