Advantages of Anterior Hip Arthroplasty

By Farshad Adib, MD

Case
FJ is a 57-year-old male who had bilateral hip replacement and needed a right hip revision arthroplasty due to acetabular osteolysis and multiple hip dislocations. After undergoing anterior hip revision arthroplasty, he was discharged to home one day after surgery and was able to return to his job less than 10 days post-operatively. FJ used narcotic medication for less than a week following his procedure. Despite the far greater complexity of the revision hip surgery, he noted that the procedure was much easier than his previous surgeries.

Discussion
Hip osteoarthritis is a common condition that many people develop during middle age or older. The most common symptom of osteoarthritis is pain around the joint. Decreased range of motion in the hip joint may cause a limp.

Although there is no cure for osteoarthritis, there are a number of treatment options to help relieve pain and improve mobility, including lifestyle modifications, physical therapy, assistive devices, and medication. Recommendations for surgery are based on a patient’s pain and disability, not his or her age. As the technology and the implants have improved, the hip replacement’s annual failure rate has fallen to between 0.5-1.0%.

There are multiple approaches to hip joint replacement: from the posterior (mini post), lateral, antero-lateral or anterior. Each approach has risks and benefits. Anterior (or direct anterior) hip replacement has been used since 1980, but over the past decade, it has become more popularized with the advancement in instrumentation and knowledge of hip anatomy. The benefits of different surgical approaches for total hip arthroplasty continue to be debated. Up to one year post-surgery, the direct anterior group demonstrated significant improvement compared with the direct lateral group. At two years, results in both groups were the same.

Advantages of the anterior hip replacement procedure include:

1. It is performed in the supine position, while in other approaches patients may be in a lateral position, which is a non-physiologic position. This approach also may interfere with positioning of the implants.
2. In the supine position, the surgeon can use intra-operative fluoroscopy to recreate normal anatomy and recheck the implant’s positioning.
3. It is much easier to measure the length of the lower extremities and avoid limb-length discrepancy.
4. This approach uses the plane between the muscles, precluding the need to cut them. While the surgeon can repair muscles and tendons that are cut in other approaches, healing time and rehabilitation may be lengthened.
5. As the anterior approach is more muscle-preserving compared to other approaches, patients usually have less pain after the procedure and are able to engage in physical therapy sooner, possibly shortening length of stay.
6. The anterior approach is a true minimally invasive surgery that is not based on the length of incision. Instead, the approach is based on cutting less muscle and detaching fewer tendons from bone. Patients have less pain, feel better and regain function faster, compared to other approaches.
7. With less soft tissue disruption, the precautions and limitations after surgery are minimal. There is no need for an elevated toilet seat or avoiding hip flexion greater than 90 degrees, as is typical of other approaches.
8. This muscle-sparing approach could decrease the chance of dislocation.
9. As the incision is at the front of the hip joint, patients do not experience pain from sitting on the incision.
10. As the muscles are preserved during the anterior hip replacement, the need for physical therapy is typically less than in other approaches.

The anterior hip replacement surgery offers considerable advantages to patients due to faster recovery, less post-operative pain and fewer restrictions. Our practice has found that we can perform a better and more accurate replacement surgery for our patients, that also appears to be more stable. Based on our results and patient feedback, the anterior hip replacement is the preferred approach for all of our primary hip replacement cases and the majority of our hip revision surgeries.

While the anterior approach for total hip arthroplasty is a tissue-sparing alternative to the traditional hip replacement and there are some early advantages to this approach, longer-term results may be similar when the implants are placed correctly

Farshad Adib, MD, is assistant professor of Orthopaedic Surgery at the University of Maryland School of Medicine. He can be reached at fadib1@umoa.umm.edu

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