Issue 9 Stories
Physicians Perspective

Less Pain, More Gain

The Benefits of the Direct Anterior Approach to Total Hip Replacement

If you ever experience pain in your hip, you might be tempted to think that kind of discomfort is just part of getting old. But don’t sell yourself short with that bit of “conventional wisdom.” If medications, therapy and other conservative modes of treatment aren’t working for you, and if debilitating pain and stiffness in your hip are limiting your daily activities and preventing you from enjoying your lifestyle, you may need a total hip replacement. 

Total hip replacement surgery has become much more commonplace since its beginnings in the 1960s. In fact, more than 270,000 people in the United States now undergo this procedure annually to relieve pain, stiffness and restricted mobility. 

Hip replacement surgery has a number of variations, all with proven track records of restoring function and alleviating pain. Recently, however, an innovative approach has emerged as a viable and extremely safe alternative to the more traditional standard approach. The direct anterior approach offers patients a faster recovery with long-term outcomes and results that are equal to or even better than those for other types of hip replacement surgery. 

Hip Replacement for Worn-Out or Damaged Joints 

Hip pain can have many causes, but the most frequent cause is some form of arthritis. It’s estimated that one in five people in the U.S. will suffer from arthritis at some time in their life. 

In a healthy joint, smooth, flexible connective tissue called cartilage provides cushioning between the ends of the bones within the joint. Over time, disease and injury can cause damage to that cartilage, causing it to wear away down to bare bone. The exposed surfaces of the bones then rub against each other, resulting in pain and loss of function. The pain can worsen progressively and eventually become disabling and crippling. 

Total hip replacement is a surgical procedure in which the worn cup-shaped hip socket of the pelvis and the bare-bone ball segment of the thigh bone are replaced with artificial metal and plastic parts called prostheses or implants. During the procedure, an incision is made to allow access to the hip joint, so that the worn surfaces of the bones can be replaced with the implants. 

Approaching the Hip from the Back or Side 

In a traditional total hip replacement surgery, the hip socket can be reached through the back of the hip, known as the posterior approach, or through the side of the hip, known as the anterolateral or lateral approach. The posterior approach is the most commonly used method. 

Both of these surgical approaches disrupt the soft tissues around the hip joint, since they require the surgeon to cut through the surrounding muscles and tendons. This kind of traumatic soft-tissue injury then requires time after surgery for the body to heal and recover. 

Approaching the Hip from the Front 

More recently, an extremely safe, nonexperimental alternative, known as the direct anterior or front approach to the hip joint has been reintroduced into the specialty of orthopedic surgery. During the direct anterior approach, a small incision is made through the front of the hip and thigh region, allowing the surgeon to reach the hip joint by separating the muscles and keeping them intact, as opposed to cutting through the muscles and tendons. 

The direct anterior approach actually was developed and submitted to clinical trials many years ago, but at that time produced inconsistent patient outcomes. However, with the introduction of new surgical instrumentation, a special high-tech operating table and the use of fluoroscopic X-ray during the surgery, the direct anterior approach now can be performed with much greater ease, resulting in consistent, excellent patient outcomes. The special table and fluoroscopic X-rays enable the surgeon to place the implants on the bone surfaces with greater accuracy, helping to ensure that the patient’s legs are of equal length following surgery. 

Benefits of Performing Hip Replacement Surgery from the Front 

The potential benefits of the direct anterior approach are numerous in comparison to those of the more traditional approach. With less damage and disruption to the surrounding muscles and soft tissues, the direct anterior approach typically results in less postoperative pain for patients, with quicker recovery and rehabilitation. 

This approach also generally results in fewer postoperative limitations and restrictions on patients as they recover. Patients typically enjoy increased mobility and better stability, and there is a decrease in the number of dislocations following this type of surgery. 

The anterior approach also can allow for smaller incisions and reduced scarring after surgery. In addition, since the incision is located on the front of the leg and thigh, patients don’t have to sit or lie on the surgical scar, as they would if the surgery had been done using a posterior or lateral approach. 

As an added advantage, patients who have anterior hip surgery often have shorter hospital stays and go home sooner than those operated on with the posterior approach. Although each of the surgical approaches offers virtually the same postoperative outcomes at six weeks after surgery, the direct anterior approach appears to offer significant benefits, particularly during the recovery period. 

Which Patients Aren’t Candidates for Anterior Hip Replacement Surgery? 

People have total hip replacement surgery because they suffer with moderate to severe arthritis of the hip, including osteoarthritis, rheumatoid arthritis, post-traumatic arthritis, avascular necrosis of the femoral head, and/or multiple other causes that interfere with and restrict a patient’s daily activities. 

However, some patients with moderate or severe arthritis are ineligible for hip replacement of any sort because they are at increased risk for postoperative complications. This includes patients with any existing infection, as well as patients with significant medical comorbidities, such as uncontrolled diabetes or significant heart disease, which cause the risks of surgery to outweigh the benefits. 

Other factors that may rule out total hip replacement surgery include excessive tobacco use, severe osteoporosis and morbid obesity. Patients who are obese are more prone to medical complications, postoperative infections and surgical wound healing issues. 

Patients who may be ineligible specifically for direct anterior approach total hip replacement include those who have had previous hip surgery with retained hardware, those with a significant bony deformity of the hip joint, and patients who have had previous spine surgery with a fusion from the lower back to the pelvis. 

Careful patient selection improves the odds of a successful surgery and lowers the risk of postsurgical problems. While many patients are good candidates for total hip replacement surgery and the direct anterior approach, the decision to proceed with surgery should be made on a case-by-case basis after a thorough discussion with the orthopedic surgeon.  

TO LEARN MORE If you are interested in this procedure and would like to learn more, please contact Sentara Orthopedic & Sports Medicine Specialists at 540-689-5500.

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