The anterior approach procedure for total hip replacement has been gaining popularity recently due to its numerous potential benefits. Orthopedic surgeons are opting for this technique because they believe it offers patients potential advantages that may include:
- Possible accelerated recovery time because key muscles are not detached during the operation. (Some other procedures require cutting or disturbing the important muscles at the side or back of the leg). The anterior approach is known as a tissue-sparing procedure because it avoids cutting these key muscles and tissues and therefore minimizes muscle damage.
- Potential for fewer restrictions during recovery. Although each patient responds differently, this procedure seeks to help patients more freely bend their hip and bear their full weight immediately or soon after surgery.
- Possible reduced scarring because the technique allows for one relatively small incision.
- Potential for stability of the implant sooner after the surgery, resulting in part from the fact that the key muscles and tissues are not disturbed during the operation. The desired outcome is enhanced stability and less discomfort during the crucial recovery period.
We will explain the specifics of the anterior procedure in a moment, but first we need to provide context so you will understand where this technique fits in among your surgeon’s options. Your surgeon has many good techniques to choose from. They include traditional hip replacement and minimally invasive techniques.
Traditional hip replacement
The typical hip replacement procedure, called a posterior-lateral approach uses a single larger incision on the side of the hip and upper thigh.
Minimally invasive techniques
The term refers to the use of smaller incisions. There are several variations, and the distinctions between them are important. Minimally invasive hip surgery can be done with either a single incision or with two incisions.
Traditional Total Hip Replacement Incision
Single incision techniques for minimally invasive surgery include:
The anterior approach. Anterior means front. So this technique uses one small incision on the front of the upper thigh. The technique is sometimes called the “true anterior approach” to distinguish it from a different technique that accesses the hip nearer the side of the thigh, rather than the front.
Anterior Approach Incision
- The posterior lateral approach. Posterior means rear. The incision is made on the outer side of the thigh, closer to the back of the thigh (as referred to above).
Two-incision techniques use one opening nearer the front of the thigh to insert the socket part of the implant, and a separate small incision toward the back of the thigh to insert the stem of the implant.
As with any surgery, each of these techniques poses some risks. Recovery takes time and hard work. The life of a new joint depends on weight, activity level, age and other factors. Each patient responds differently. The most common adverse events following hip arthroplasty include implant loosening, deformation or wear of one or more of the components, bone loss, infection, fracture of the components or bone, change in position of the components, dislocation and tissue reaction.
A closer look at the anterior approach
With the anterior approach, the surgeon uses one small incision on the front (anterior) of your hip. This technique allows the surgeon to work between your muscles and tissues without detaching them from either the hip or thigh bones, sparing these tissues from trauma and a lengthy healing process. Keeping these muscles intact may also help prevent dislocations. Since the incision is in front, you’ll avoid the pain of sitting on the incision site.
The anterior approach is typically made possible with the use of a high-tech operating table that places the leg and pelvis in a stable position. This specially engineered table includes leg supports that allow the surgeon to adjust the operative leg during surgery with a great degree of control and precision. Surgeons who use this technique say this table is designed to help achieve excellent alignment and positioning of the implant. Rather than being positioned on their side or stomach, the patient is laid flat on his/her back, which minimizes tilting of the pelvis during the operation. The table also gives the surgeon excellent access to the femur, or thighbone, in order to position the stem of the implant effectively.
The procedure itself begins with the surgeon exposing the hip in a way that does not detach muscles or tendons from the bone – a key attribute of the anterior approach. The surgeon removes the diseased cup portion of the hip and replaces it with an implant. The surgeon then uses the specially designed table to rotate the operative leg so the foot points outward, extending toward the floor. This allows excellent access to the thigh bone, or femur, so the surgeon can replace the diseased portion of the bone with the stem implant. This is important since visibility is often limited due to smaller incisions.
Sometimes side-by-side TV screens are used to provide X-ray views of the operative hip and the patient’s opposite hip. This comparison gives the surgeon the information used to determine the best positioning for an effective, stable hip replacement implant. The combination of this X-ray imaging and the high-tech table allows the doctor to seek more precise control over the patient’s leg length as well.
The incision length, typically smaller than with standard surgery, varies according to a patient’s size, weight and other factors. The anterior approach lends itself to a relatively small incision because the hip joint is closest to the skin at the front of the hip. The muscle and fat layers are thinner than the muscle and fat tissue encountered when using other approaches on the side or rear of the thigh. While the smaller scar is a cosmetic advantage, surgeons say the actual size of the incision for each patient varies.
Another way that the anterior approach differs from some other techniques is with patient selection. Other minimally invasive techniques place more restrictions on patient selection. With other procedures, patients may need to be at their ideal bodyweight, for example. The anterior approach may make minimally invasive hip surgery possible for a wider range of patients, including larger, heavier patients. That’s because the anterior approach enters the body closer to the hip joint, with far less tissue between the skin and the bones of the hip, so more patients may be candidates.
Your doctor will tell you what restrictions you will have after surgery, and every surgeon has his or her own set of precautions for you to follow. Some surgeons who use the anterior approach place fewer restrictions in the days after surgery because the operation spares the major muscles of the thigh, allowing patients to get back to activities of daily living with fewer limitations.