- What is an anterior hip replacement?
- What are the advantages of an anterior approach?
- What are the downsides of an anterior hip replacement surgery?
- Are different implants used for anterior total hip replacement surgery?
- What does it entail to have a total hip replacement surgery?
- What are the general complications of total hip replacement surgery?
- What is my activity level when I get home?
- How Long has Dr. Boettner been doing anterior hip replacements?
- How many anterior total hip replacements is Dr. Boettner currently doing?
- Is the anterior total hip replacement the future of hip replacement?
- Differences between an anterior and posterior approach:
- Podcast on anterior vs. posterior THA:
- Why should I have my surgery at the Hospital for Special Surgery?
What is an anterior hip replacement?
An anterior hip replacement is a total hip replacement performed through a special approach that utilizes a muscle interval in the front of the hip (anterior) and allows access to the joint without violating any muscles. This approach has been known for many years, but more recently has become utilized for total hip replacement surgery.
What are the advantages of an anterior approach?
The main advantage of the anterior approach is that the early rehabilitation is faster. You can get out of bed faster and usually feel more comfortable with the hip. That does not necessarily mean that you are going to walk further than patients with a posterior approach. However, the handling of the leg is usually less inhibited. In addition, patients with an anterior approach do not need to follow standard hip precautions. That means with some minor restrictions, patients after an anterior approach can sit on regular chairs, they can drive a car once they are comfortable and they do not need to use a pillow between their legs at night when sleeping. Although recent published dislocation rates between the anterior and posterior approach do not show a difference we have clearly seen a lower dislocation rate after anterior approach total hip replacement. Since starting anterior surgery in 2012 we have not seen a dislocation that required closed reduction and we are more comfortable to let our patients engage in Yoga, ballet or activities that require more extreme motions of the hip. Since none of the main stabilizing muscles are released during the surgery these hips are more stable early on.
What are the downsides of an anterior hip replacement surgery?
The main disadvantages of an anterior approach are the following:
The lateral femoral cutaneous nerve crosses in the front of the thigh and can be injured during an anterior total hip replacement. This can result in numbness over the lateral aspect of the thigh (up to 20% of patients) and rarely nerve pain. Most of the nerve symptoms disappear over time. The anterior location of the incision can also be problematic for patients that have a large belly or a skin fold since the incision might then be localized in a moist tissue fold, which could predispose it to infection. For most of these patients Dr. Boettner will recommend a posterior approach. In general, the downside of anterior surgery is that it is not as versatile. If the surgeon encounters a situation that requires more complex reconstructions, there are limits to what can be done through an anterior approach.
Are different implants used for anterior total hip replacement surgery?
Since the access to the femur is more difficult through an anterior approach we usually use shorter and curved femoral implants. Since 2012 Dr. Boettner has gained experience with a number of different implants for the anterior approach and currently select one of four different implants based on individual size, shape and bone quality of the femur. Although many surgeons state that a cemented fixation is not possible through an anterior approach Dr. Boettner has gained experience using a cemented implant fixation for some of his older and more fragile patients.
What does it entail to have a total hip replacement surgery?
Usually after you undergo medical clearance you are admitted to the hospital the day of your surgery. You will then undergo a spinal anesthesia, a regional anesthesia that allows us to control your pain during surgery and has less risks than general anesthesia. The surgery itself takes about 45 to 60 minutes and after the surgery you initially will be transferred to a postoperative recovery room where your vital signs and the weaning of the anesthesia is monitored by an anesthesiologist. Postoperative radiographs will be taken to confirm the position of implant. You are then transferred to the floor and physical therapy will usually be started the day of surgery. Usually within 1-2 days you are able to leave the hospital. By the time you leave the hospital, you should be able to walk 100 feet with either a cane or walker and you should be able to walk a flight of stairs. Dr. Boettner recommends that you are discharged home. Inpatient rehabilitation is for most patients neither covered by insurance nor beneficial. At home he recommends to walk a little bit more every day inside the house the first week, up to 5 blocks the second week, up to 10 blocks the 3rd week and a mile the fourth week. If you have pain decrease your activities rather than take pain medication. Anterior hip replacement is “a surgery for lazy people”, it does not require exercises or physical therapy in the first 4 weeks.
Do Not massage the hip or the incision!
Do Not use weights or rubber bands to strengthen your hip
Do Not do exercises or engage in physical therapy!
What are the general complications of total hip replacement surgery?
Although we have not seen a dislocation in our patients, Dr. Boettner assumes there is a small risk of dislocation following anterior total hip replacement. Certain extreme motions are not advised after surgery. Further complications of an anterior approach can include intraoperative fracture, deep implant infection, blood loss requiring blood transfusion, leg length discrepancy, wound drainage, early femoral component loosening, implant loosening over time secondary to wear of the components or loss of fixation as well as numbness or pain from injury to the lateral femoral cutaneous nerve. Nerve injuries of larger nerves, like the femoral or sciatic nerve are possible and can result in significant pain, functional limitation (foot drop, knee weakness) and long term chronic sympathetic pain syndromes. The frequency is about 1 in 750. Medical complications like deep venous thrombosis are possible and you will be placed on a blood thinner (usually aspirin). More serious complications like a pulmonary emboli, heart attack and stroke, etc. as well as bleeding complications are relatively rare. Our preoperative clearance program reduces the risk of serious complications significantly, and almost all of our patients today will avoid major medical complications because of our thorough preoperative medical work up.
What is my activity level when I get home?
By the time you go home you should be able to move inside your house and go for short walks in the second week. We do close the incisions with resorbable/dissolvable stitches covered by surgical glue and therefore you should be able to shower right after you get home. Do NOT bath or swim. There are no exercises required for an anterior approach hip replacement. Walking is all that the hip needs to build strength and coordination. I recommend that you increase your walk distance every day and come off the cane once you are comfortable to walk without a limp. Remember even if you feel great the implant and your body need time to heal, doing exercises or hikes is not recommended! DO NOT perform straight leg raises or hip flexion exercises in the first 4 weeks since they can trigger groin pain. By one week you should be off all narcotic pain medication. You can return to work and drive when you are comfortable. Do not drive as long as you are on narcotic pain medications or have not regained full control of your right leg.
How Long has Dr. Boettner been doing anterior hip replacements?
Dr. Boettner trained on an anterolateral approach during my Residency in Germany. After his fellowship at Hospital for Special Surgery he switched to doing posterior approach pretty much exclusively until 2012. In early 2012, he attended training courses for anterior hip replacement and visited a number of surgeons to learn from their experience in anterior hip replacement surgery. Dr Boettner then performed the first anterior hip replacement surgery in the summer of 2012. Since 2014, we have been using the HANA table for anterior hip replacement surgery and since 2016 Dr. Boettner has worked as an instructor for table based anterior hip replacement surgery training surgeons all over the United States and in Europe on this technique.
How many anterior total hip replacements is Dr. Boettner currently doing?
Currently, I do about 70% of my hip replacements through an anterior approach. Every year I perform approximately 300 total hip replacements and resurfacings and since 2012 I have performed more than 1000 anterior hip replacements.
Is the anterior total hip replacement the future of hip replacement?
Total hip replacement is not a “one fits all” approach. Patients differ in their activity level, anatomy, body shape, and expectations. While some patients are better off with an anterior approach, others might be better off with a posterior approach or hip resurfacing. The goal is to maximize the individual outcome while minimizing the risk of complication. Dr. Boettner has the expertise and experience with different approaches that allows him to guide you through this decision process. As much as Dr. Boettner is excited that the anterior approach does not require postoperative hip precautions and has virtually eliminated postoperative dislocation in his practice, he does know it is not the best surgery for every patient. While he considers the anterior approach the better option for almost all women in his practice, he favors the versatility of the posterior approach for patients with severe deformities, developmental dysplasia, posttraumatic deformities or for heavy muscular male patients. Which approach to choose is an individual decision. Dr. Boettner is a specialist in minimal invasive total hip replacement and resurfacing and his experience in anterior and posterior approaches allows him to select what is right for yourather than to do a “one fits all” approach. During your preoperative appointment Michelle his Physician Assistant and he will take the time to discuss the pros and cons of each approach and will guide you to make the right decisions for your upcoming hip replacement.
Differences between an anterior and posterior approach:
Whether you are a better candidate for one or the other should be discussed based on your individual situation during an office appointment. It makes little sense to rely on your neighbor’s experience or dr. google. Deciding which approach is right foryou takes careful balancing of risk and benefits of each approach taking into consideration your level of activity, bony anatomy, body shape etc.. During your office visit we can discuss this in detail but the following table provides you with some basic differences:
- Anterior Approach
- Posterior Approach
- Functional recovery?
- No precautions, slightly faster
- 4 weeks of hip precautions
- Return to driving?
- 1-2 weeks after left and 2-4 weeks after right side
- 4 weeks after surgery
- Yoga or Ballett
- Only with restrictions
- Postoperative: Tennis, Golf, Biking, Hiking
- Working out in the Gym
- Short distance (up to 2-3 miles) light jogging
- Full contact fighting, Judo, etc.
- No (Resurfacing: Yes)
- Extreme mogul skiing or Heli-skiing
- No (Resurfacing: Yes)
- Construction work, work on roofs or unsafe environments?
- No (Resurfacing: Yes)
- Dislocation risk?
- Since 2012 we have not had a dislocation after an anterior approach
- Risk of complication during surgery?
- In heavy male patients or very osteoporotic patients there is a slightly higher risk of femoral fractures.
- Level of postoperative pain?
- No difference
- No difference
- Likelihood of major nerve injury?
- No difference, very low
- No difference, very low
- Likelihood of minor nerve injury or dysfunction?
- Higher, usually affecting the “lateral femoral cutaneous nerve” in up to 20% of patients, most of them resolve
- Very low
- Anticipated Revision Rate after 20 years:
- < 5%
- < 5%
- Suitability for all patients?
- less suitable for morbidly obese patients (skin fold in the front of the hip), very muscular male patients, patients with poor bone quality, or patients with complex bony deformities
- Suitable for all patients
- Minimally invasive?
- Difference in long-term outcome?
- Use of X-ray during surgery?
- Always used to control implant position
Podcast on anterior vs. posterior THA:
Dr. Boettner is featured in the following PodCast on Hip Replacement:
Back in the game patient’s stories:
Why should I have my surgery at the Hospital for Special Surgery?
Please find more information about the Hospital for Special Surgery here www.hss.edu/reasons-to-choose-hss.asp
Learn more about total hip replacement at hss.edu link: www.hss.edu/condition-list_hip-replacement.asp