Performing the hip replacement operation from the anterior approach has a few advantages.

1. It allows the surgeon to do X-rays during surgery. Conventional hip replacement surgery does not allow high quality xrays to be done during surgery due to positioning.
2. Allows surgeon to preserve posterior capsule and muscle, decreasing risk of dislocation.
3. Allows surgeon to preserve hip abductors. Dysfunction of the abductor would cause prolonged, if painless, limping.
4. Patients typically heal faster.

The important thing to remember is that anterior approach hip replacement is still a hip replacement.

What are the other approaches to the hip?

In order to perform a hip replacement, the hip joint can be approached in several different ways:

1. Transtrochanteric approach
2. Posterior approach: also known as transgluteal approach, as well as posterolateral approach.
3. The anterolateral approach: also known as the lateral approach, or sometimes as the Hardinge approach.
4. Last but not least the direct anterior approach.

A little bit of history

Hip replacement operations have been done successfully since the 1960's. Dr John Charnley, in England, was the first to routinely perform successful hip replacements. In order to get into the hip joint and perform the replacement, Dr Charnley performed a trochanteric osteotomy, which he then repaired with wires at the end of the surgery. The osteotomized trochanter had to be allowed to heal for several months after hip replaccement.

Glossary

Osteotomy = Cutting of bone. This is done with saws, chisels, and other such tools. Trochanter = is the prominence of bone in the proximal femur that serves as attachment for the hip abductor muscles.

In current practice, we almost never perform trochanteric osteotomy for hip replacement. Although a trochanteric osteotomy is sometimes needed for a revision hip replacement surgery, an uncomplicated hip replacement is nowadays almost never done via a transtrochanteric approach. Instead the surgeons go either in front or behind the trochanter of the femur. The two common current approaches therefore are the anterolateral or Hardinge approach, and the posterior approach.

Is there a problem with the posterior and with the anterolateral approaches?

The posterior approach is a very good approach, in that it preserves the hip abductors and does not cause as much limping as the anterolateral approach. The problem with the posterior approach is that statistics show it has a slightly higher dislocation rate.

Compared to the posterior approach, the other commonly performed hip approach, the anterolateral approach, has a statistically lower dislocation risk. Its downside is prolonged limping after surgery. Patients sometimes limp for a year, sometimes for ever, when this could have been avoided.

The anterior approach

The anterior approach implies going between (as opposed to through) the muscles and the tendons of the hip. This approach therefore has been called muscle sparing. The anterior approach presumes to avoid the limping of the anterolateral approach, at the same time keeping the dislocation rate lower than the posterior approach.

Why don't all surgeons do the anterior approach for every hip replacement?

I avoid an anterior approach to the hip in patients with inflammation in the abdominal crease, which often arises in cases of deep skin folds prone to moisture retention and inadequate aeration.

With or without the Hana table?

I use the Hana orthopedic traction table during this operation.

The patient is positioned with the legs secured in "ski boot" holders. The table allows secure manipulation and appropriate positioning of the left during the surgery.

The table allows safe manipulation of the hip joint. In addition, duing surgery patient is positioned flat on his or her back, and it is easy to get good xrays and confirm position of the prosthesis before surgery is over.

While the incision is smaller and the muscles are treated with more respect, the rest of the operation is still the same: power saws and power reamers are used inside the body to cut and shape the bones for the artificial implant: In the picture below the tool in my left hand is a sterile power saw. I was doing a right hip replacement.

Here's a picture of an arthritic eburnated femoral head that has been cut out, soon to be replaced with an artificial piece.

Again, a major advantage, at least the way I see it, is that the procedure is performed with the patient on his or her back, allowing the surgeon to use xray during surgery. This allows surgeon to notice and perform minor adjustments in real time.

Case study #1

Since the patient is supine, it is possible to perform bilateral simultaneous hip replacements. Here's the appearance of my patient who had both hips replaced:

Video at 2 weeks

This is a video of a patient 2 weeks after anterior hip replacement.