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Dr. Stephen J. Incavo

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Total Hip Replacement (THR)

Hips

Total Hip Replacement: Which approach is best for you?

These are several different surgical approaches and techniques for total hip replacement (THR), also referred to as total hip arthroplasty (THA). Each one offers unique benefits and is determined based on the patient’s specific situation. In general, there are three popular approaches: Direct Anterior, Anterolateral, and Posterior.

There is no comparative study that provides convincing proof that one approach is superior to another and the best approach to use when performing THR remains controversial. There is an increased focused on minimally invasive techniques and smaller incisions. However, the long term success of the implanted hip replacement while avoiding complications is by far the most important aspect of the surgery.

Based on Dr. Incavo’s experience and study of the scientific information available, he currently prefers the posterior approach for most patients, but he also performs the other procedures based on the specific situation.

Posterior Total Hip Replacement Approach

This is the most common surgical approach used in Dr. Incavo’s practice for routine hip replacement. This technique offers a small amount of muscle dissection. A small incision which heals easily may be used. One potential complication of this approach is damage to the sciatic nerve, which runs along the back of the hip and can result in nerve damage affecting the lower leg and foot (foot drop) postoperatively. However, this is very unlikely (0.1%-0.5%).

The risk of dislocation (the ball coming out of the socket) has been historically greater with the posterior approach when compared with the other approaches, but this has been minimized with modern instruments and improved techniques and entails less soft tissue dissection. The present rate of dislocation is now comparable to other approaches (0.5%-1%). Patients undergoing this particular procedure, however, must follow hip precautions and restricted activities for the first six weeks, to allow healing of the soft tissue repair.

Direct Anterior Total Hip Replacement Approach

The direct anterior approach is one of the more technically demanding approaches from a surgeon’s viewpoint because of the decreased visualization of the patient’s anatomy. Also, this approach often uses live x-ray (fluoroscopy) during surgery to ascertain the position of the components, exposing both the patient and surgeon to additional radiation exposure. The major benefit of this approach is that patient recovery may progress more quickly in the first two to four weeks. One of the potential complications of this approach is damage to a skin nerve in the front of the thigh (the lateral femoral cutaneous nerve), which may result in numbness or burning over the front and side of the thigh. The anterior incision can take longer to heal since it is close to the groin area. The biggest concern with the direct anterior approach compared to other THR approaches is that femur fracture during surgery is more likely because of the positioning of the femur bone during the procedure. If this occurs the patient’s postoperative rehabilitation is prolonged, and the ultimate result may be less than optimal.

This approach preserves the posterior soft tissue, therefore there are fewer postoperative restrictions. Most average sized people are candidates for this approach, but it is more difficult to do in large or overweight people, particularly men with large thigh muscles. Moreover, patients with severe deformities or severe hip joint damage are better treated using an approach that allows better exposure.

Anterolateral Total Hip Replacement Approach

The anterolateral approach is thought by many surgeons to afford a lower dislocation rate than the posterior approach. Dr. Incavo frequently uses this approach for hip fracture patients, because they have an increased risk of dislocation. One potential complication of this approach is that patients may limp for a prolonged period of time while the abductor muscles heal (gluteus medius and gluteus minimus). Occasionally, the muscles do not heal properly.

This approach offers easier postoperative precautions for the patient to follow with minimal restrictions. It is also indicated in patients with torn hip abductor tendons (common in older patients), which makes it easier to identify and repair. It also has reduced risk of complications such as dislocation of the hip prosthesis and nerve damage.

Palan W, Beard DJ, Murray DW, Andrew JG, Nolan J. Which approach is best for total hip arthroplasty: anterolateral or posterior? Clin Orthop Relat Res. 2009;467:473–7.