Anterior vs. posterior hip replacement approaches

Anterior approach to hip surgery has the advantage of a speedier recovery, according to Jeffrey D. Stimac, M.D., an orthopedic surgeon with Norton Orthopedic Institute.

Patients who need a hip replacement often ask about anterior versus posterior hip replacement approaches.

Both approaches work well over the long term, but the anterior approach has the advantage of a speedier recovery, according to Jeffrey D. Stimac, M.D., an orthopedic surgeon and reconstructive surgery specialist with Norton Orthopedic Institute.

Patients who have had a posterior approach on one hip and an anterior approach on the other almost universally say recovery was easier with the anterior approach, according to Dr. Stimac.

Evidence backs this up. These patients typically have less postoperative pain, get off walkers and canes faster, and are able reach the point where they can go up and down stairs faster with the anterior approach. They also have less of a risk of dislocation after surgery.

Studies show there is less muscle damage with the anterior approach. Making the incision in the front of the hip allows the surgeon to access the joint by navigating between muscles. With the posterior approach, the incision is in the buttock to the lateral hip, and the gluteus is split.

A posterior approach might be preferable in patients who have had post-traumatic arthritis and have screws and plates in the pelvis that need to come out during surgery, according to Dr. Stimac. A defect in the acetabulum that requires a metal augment is another. Some revision surgeries are other situations where a posterior approach is preferable.

Beyond the first two months of recovery, both approaches produce similar results.

“Choosing your physician is maybe more important than choosing your approach,” Dr. Stimac said. “I think as a patient you would be better off to get a posterior approach by a surgeon who does 300 hip replacements a year than you would be getting an anterior approach but done by a surgeon who does 25 hip replacements a year.”

Dr. Stimac spoke during a recent episode of the “MedChat” continuing medical education podcast, “A Review of Total Hip Arthroplasty.”

A surgeon’s preferred approach may be related to their training. Fellowship programs tend to favor one approach versus another, according to Dr. Stimac.

“If you’re comparing a posterior approach surgeon who’s fellowship trained to an anterior approach surgeon who’s fellowship trained, I think you’d be in good hands in both situations, but the anterior approach recovery certainly can be quicker,” Dr. Stimac said.

In the United States, the anterior approach has become more common in recent years. Approximately half of hip replacements are now done with an anterior approach.

At Norton Orthopedic Institute, 70% to 75% of hip replacement patients go home the same day, and 20% go home the next day.

Total hip arthroplasty considerations

Osteoarthritis of the hip joint is the most common indication for a total hip arthroplasty (THA). Other common indications include avascular necrosis, post-traumatic arthritis, rheumatoid arthritis and femoral neck fractures.

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Before insurance will approve a hip replacement, patients usually must undergo three months of conservative treatment, such as activity modifications and anti-inflammatory drugs.

“Most of our patients are doing much longer than that — six months, a year, several years sometimes,” Dr. Stimac said.

After failed conservative treatment, the other consideration before total hip arthroplasty is whether the patient has comorbidities. Patients with a higher body mass index (BMI) have a higher risk of wound complications and infections. For example, the data show a BMI over 40 increases the risk of these complications significantly. A1C level is another useful indicator. A1C above 7 significantly increases the risk of wound complications and infections.

Injections don’t work well for hips, according to Dr. Stimac, who does not recommend hyaluronic acid or platelet-rich plasma injections for the hip.

“Honestly, people do so well with surgery, a lot of times I’m just telling patients, ‘Move forward and get it done. You’ll be glad you did,’” Dr. Stimac said.

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