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Posterior vs. Anterior Total Hip Replacement

When a patient has arthritis of the hip, the underlying bone develops spurs and irregularities which can cause pain and loss of motion. A total hip replacement has the ability to relieve pain and restore normal function in patients whose hip joint has been destroyed by trauma or disease. In this type of surgery, the damaged hip socket and ball of the femur are replaced by man made implants. This surgery has been done routinely for the past 50+ years with great success. The average hip replacement lasts 20-30 years or more.

There is renewed interest in the news and medical world lately regarding surgical approaches to hip replacement, specifically anterior (through the front of the hip) versus posterior (through the back of the hip) methods. Of all the joints currently replaced in the human body, the hip joint has had the most success, the quickest recovery, and is the most durable.

The posterior approach to total hip replacement is the most commonly used method and allows the surgeon excellent visibility of the joint, more precise placement of implants and is minimally invasive.

As the medical world constantly strives to improve medical devices and implants, shorten surgical and recovery time, and minimize pre-, intra-, and postop- complications, previous surgical techniques have gained renewed interest — namely the anterior total hip replacement. A careful comparison of the minimally invasive posterior hip replacement with the newer anterior hip replacement reveals similarities and differences, as you will see below.

A Minimally Invasive Approach to Hip Replacement

To date there is no clinical study showing the superiority of one approach over the other. As with any surgery, there are risks and benefits unique to each type of approach. The most important factors are not the type of approach used, but the experience, reputation and trust you have with your surgeon.

Dr. Kruse has been performing hip replacements for more than 10 years and is familiar with all methods of total hip replacement. He is constantly attending conferences and education seminars to stay up to date on the most current techniques.

There are a variety of approaches available to orthopedic surgeons regarding total hip replacement. No matter the approach or type of implant used, when performed by an experienced surgeon, surgical time, hospital stay, speed of recovery, and rates of complications are very low.

At the clinic visit where surgery is discussed, be prepared to ask your surgeon about his experience, complications and overall outcomes. Should you have any questions regarding total hip replacement, please feel free to make an appointment with Dr. Kruse, who would be happy to go over the options available to you.

Minimally Invasive Posterior vs. Direct Anterior Approach to Hip Replacement

  Minimally Invasive Posterior Approach Direct Anterior Approach
Position of patient On your side On your back
Location & length of incision • Just behind the hip, along the outer buttock area
• 4–6 inches.
• Larger incisions may be needed for larger patients and those with previous surgery or abnormal anatomy
• Front of upper thigh
• 4–6 inches
• Larger incisions may be needed for larger patients and those with previous surgery or abnormal anatomy
Muscle preservation • The gluteus maximus muscle is split and does not require repair as the whole tendon is not removed.
• The piriformis and superior gemeli muscles (2 of 4 external rotators of the hip) are detached and later reattached to bone and will heal over 4–6 weeks.
• Current advocates claim this approach is entirely muscle sparing, which is not exactly the case. Because of the higher risk of damage to a specific nerve in the thigh, the incision may be moved more to the side, forcing an incision through the muscle bellies of the tensor fascia latae and sartorius muscles, rather than in between.
• The piriformis muscle (1 of 4 muscles that allow for external rotation of the hip) is also cut to allow implantation of the new femoral implant. It cannot be reattached from this approach.
Risk of nerve damage • No risk of injury to lateral femoral cutaneous nerve.
• Very small risk to sciatic nerve from excessive retraction during surgery. Risk of injury is less than one percent.
• Higher risk of injury to lateral femoral cutaneous nerve which supplies sensation to the outer thigh.
• Some risk to sciatic nerve from excessive retraction during surgery.
Risk of fracture Low risk of fracture due to easier exposure. • Higher risk of femur and ankle fracture due to more difficult exposure and positioning.
• Risk increases in patients with osteoporosis.
Intraoperative visualization • Exposure technique allows direct, full visualization of hip cup and femur.
• No intraoperative xrays needed.
• Used predominantly by orthopedic surgeons as it is the simplest approach and provides the greatest patient safety.
• Technically challenging.
• Impaired visualization due to working between muscle planes.
• Special surgical table utilized for manipulation of the leg during surgery.
• Intraoperative xrays needed for implant positioning.
• Patients should find someone very experienced in this type of approach — one who does more than 1–2 per month.
Risk of dislocation & hip precautions • Low risk but may be as high as 9%.
• Dislocations are posterior and can occur when bending further than 90° at the hip/waist.
• Risk is incredibly low by 2 months after surgery.
• Low risk.
• Dislocations are usually anterior and can occur with external rotation of the leg during any activity.
• Hip precautions usually not needed.
Good candidate Majority of patients. Patients who do not have significant hip deformities, flexion contractures or are not significantly overweight.
Length of surgery 60–90 minutes 2–3 hours
Hospital stay 2–3 days Same
Postoperative complications Risk to normal structures, blood clots to legs or lungs, infection, death, anesthesia risks. Same
Use of medical equipment Walker, cane or crutch, depending on upper body strength and recovery time, weaning off as strength returns. Same
Use of physical therapy Generally not used outpatient Same
Return to sedentary work 2 weeks 1–2 weeks
Return to physical work 3 months 1–3 months
Return to sports (light/vigorous) 6 weeks/3 months 1 month/3 months