- Why should I consider doing a posterior approach total hip replacement surgery?
- What are the main downsides of a posterior approach?
- What type of implants can be used through a posterior approach?
- 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?
- What will be my activity after four weeks?
- What sport activities are possible after posterior approach total hip replacement?
- How many posterior hip replacement surgeries is Dr. Boettner doing?
- Differences between an anterior and posterior approach
- Why should I have my surgery at the Hospital for Special Surgery?
Why should I consider doing a posterior approach total hip replacement surgery?
The posterior approach is a very versatile approach. It offers easy visualization, can be extended and enables any type of reconstruction around the hip. Many patients have a normal anatomy and weight, and for most of these patients an anterior approach can be used with the same success rate as a posterior approach; however, whenever complex deformities, like developmental dysplasia, or excessive weight are encountered, the posterior approach remains the preferred treatment option.
A further advantage of the posterior approach is that both cemented as well as uncemented fixation is possible, that means the surgeon can during the procedure switch from an uncemented to a cemented fixation without changing his exposure or implant preparation.
Should in the future a further revision be needed, any of these revisions can be performed through a posterior approach, and therefore all surgeries can be performed through the same approach which decreases the risk of dislocation following revision procedures.
What are the main downsides of a posterior approach?
The main downside of the posterior approach is the need to observe hip precautions in the first 4 weeks and the risk of dislocation down the road. The absence of hip precautions after an anterior approach facilitates recovery especially for women. However, many patients, especially males, will often have a similar progress in their early rehabilitation after a posterior approach despite hip precautions. In Dr. Boettner’s experience, the first two to four weeks the rehabilitation after a posterior approach is a little bit slower. Having said this, at about four weeks, patients after a posterior approach usually reach a similar activity level as patients with an anterior approach. Patients with a posterior approach will have to observe hip precautions, that means they have to sit on a high chair, have to use a toilet seat elevation, and usually are recommended to use a pillow between the legs at night. We often also limit driving a car for some of our patients who undergo a posterior approach and will not allow them to drive within the first four weeks after surgery.
What type of implants can be used through a posterior approach?
Any type of implant can be used through a posterior approach. There is no limit in regard to type of implant or type of fixation (“press fit” uncemented or “glued” cemented) through a posterior approach.
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 the implants. 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. I recommend that you go home after surgery. Inpatient rehabilitation is for most patients neither covered by insurance nor beneficial. At home we will provide you with a physical therapist that will work with you 2 or 3 days a week to make sure you understand your exercises and progress accordingly. 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. By the time of discharge, your incision should be dry.
Do Not massage the hip or the incision!
Do Not use weights or rubber bands to strengthen your hip
What are the general complications of total hip replacement surgery?
The main complications after a posterior approach hip replacement is the risk of dislocation. In my practice, the risk of dislocation has been about less than 1%. Some years ago we evaluated 800 consecutive patients who underwent surgery with Dr. Boettner between 2011 and 2013. Of those patients, eight patients (1%) suffered a postoperative dislocation. Further complications of a posterior approach can include things like intraoperative fracture, deep implant infection, blood loss requiring blood transfusion, leg length discrepancy, wound drainage, implant loosening over time secondary to wear of the components or loss of fixation. 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 extremely 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. 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. During the day, you will be required to do a basic set of exercises. I recommend that you increase your walk distance every day and come off the cane once you are comfortable to walk without a limp. By one week you should be off all narcotic pain medication. You can return to work when you are comfortable and start driving after 4 weeks after you saw Dr. Boettner in the office for follow up.
What will be my activity after four weeks?
Four weeks after a posterior approach you will usually be able to walk without assisting devices. Your walking distance will vary between 5 and 25 blocks. You should be able to reach your shoes and socks after your four-week appointment. You also should be able to drive a car after four weeks. Most patients will return to work between two and six weeks after a posterior approach total hip replacement surgery. Please be aware that your postoperative function will often depend on your preoperative function. If you are very disabled, or only able to walk with assisting devices prior to surgery, or if your walking distance is less than one block, postoperative rehabilitation can be slower and it might take you longer to reach independence from assisting devices.
What sport activities are possible after posterior approach total hip replacement?
Our modern total hip implants show minimal wear and can withstand quite intense loads. However, traditionally low impact activities like biking, swimming, golf, hiking and elliptical exercises have been recommended. However, patients can return to tennis, skiing, boxing and other more intense activities. Especially if your BMI is below 30 short low impact jogging for 1 to 3 miles should be ok, but there are currently no long-term data. Dr. Boettner does not recommend to participate in activities that do not allow you to control the position of your legs at all time, like rock climbing, water skiing and full contact fighting or sports performed in unsafe environments like heli-skiing.
How many posterior hip replacement surgeries is Dr. Boettner doing?
Dr. Boettner started my practice at Hospital for Special Surgery after three clinical fellowships in 2006. Dr. Boettner performs approximately 600 joint replacements every year of which about 50% are total hip replacement surgeries. He has performed more than 3500 posterior approach total hip replacement surgeries and hip resurfacings. Since he started his practice he performs minimal a invasive posterior approach with incisions measuring between 3 and 4 inches.
Differences between an anterior and posterior approach:
I perform both direct anterior and posterior approach hip replacement surgeries. 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 for you 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:
Find encouragement in our back in the game stories:
Please find our back in the game stories on the HSS website. backinthegame.hss.edu/
Why should I have my surgery at the Hospital for Special Surgery?
Please find more information about the Hospital for Special Surgery here https://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