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Approaches to Hip Replacement

Total Hip Replacement is an extremely successful surgical procedure to improve a patient’s quality of life when arthritic hip pain becomes debilitating.

Hip replacement surgery offers patients the ability to return to their daily (and some sporting) activities without pain and with improvement in hip flexibility and movement. Patients with a significant limp as a result of an arthritic hip will often walk normally again after recovering from surgery.

The timing of surgery is a quality of life decision and it is never to late to replace the hip joint provided ones general health is satisfactory.

There are various approaches that surgeons use to replace the arthritic hip with all recognised surgical approaches working well. The most important determining factor in ensuring a successful hip replacement that should last well over 20 - 25 years is for the patient to choose a surgeon who is well skilled in hip replacement surgery and be guided by his or her recommendations.

The Australian Joint Replacement Registry and many publications show clear data confirming that more experienced surgeons have better patient outcomes.

it goes without saying that every patient would like to recover as quickly as possible  and with as little pain as possible. Surgical and Anaesthetic techniques have improved significantly and these improved techniques have allowed an easier recovery.


General Information on the minimally invasive direct anterior approach

The Minimally Invasive Direct Anterior Approach (often termed DAA or AMIS) is an approach that lends itself to a quicker short-term recovery due to the fact that the surgical approach uses intermuscular planes allowing exposure of the hip joint without detaching muscle off bone. This allows a patient the ability to recover quicker and return to function quicker compared to other approaches.

There are many published articles (references at end of this article) that have confirmed that the anterior approach leads to a quicker short term recovery HOWEVER all published articles also confirm that after 12 months patients having had a successful hip replacement function equally well no matter what approach is used.

The most commonly used worldwide approach to hip surgery is the Posterior Approach (ie from the back) and published results show there is no significant difference between a well done posterior approach and well done anterior approach at 12 months after surgery. The posterior approach requires splitting the gluteus maximus (buttock) muscle and detachment of the short external rotator muscles and then reattachment of these muscles/capsule and hence the slightly slower recovery compared to the anterior approach.

There are some short-term hip movement restrictions in the posterior approach (internal rotation of the hip beyond 90 degrees of flexion) for 6-8 weeks to prevent hip dislocation whilst the capsule/muscle repair recovers. The anterior approach is inherently a very stable approach not requiring muscle repair and movement restriction. Patients usually can return to driving at an earlier stage if they have had an anterior approach.


Important Information

As an experienced hip surgeon, I am comfortable performing either the anterior or posterior approach for arthritic hip replacement surgery.

However, not all patients may be suitable for the anterior approach due to many factors. These include:

  • Obesity
  • Abnormal anatomy (such as Hip Dysplasia, Perthes, previous fractures, abnormal bone structure etc.)
  • Severe osteoporosis
  • Significant muscular build resulting in very tight and limited joint visualization)
  • Significant leg length discrepancy
  • Deficient bone requiring bone grafting or augmentation of the socket
  • Specialised hip implants needing to replace the hip joint
  • Most revision hip surgery unless a simple head/liner exchange

The Responsible Approach:

Every patient I see has an individual assessment taking into account their hip pathology, degree of arthritis, day to day function, general health and body habitus. I will then advise what I believe to be the best surgical approach to achieve the best clinical outcome with the least chance of complication.

Whilst I would prefer from a general recovery perspective to perform an anterior approach it is MORE IMPORTANT to ensure a safe recovery with appropriate attention to the underlying problems at hand. If I feel that the anterior approach is not suitable I will perform a posterior approach AND will reassure the patient that whilst they may have a slightly slower recovery compared to the anterior approach, their LONG TERM function will be identical.

The Final Word on approaches..........

The key to a successful hip replacement with the best chance of a good functional outcome and the least chance of complications is to choose an experienced skilled hip surgeon. Whilst the Anterior Approach may afford a quicker short-term recovery, not all patients are suitable for this approach, yet be reassured that at 6-12 months the posterior approach performs equally as well.

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