Each surgeon selects an approach which, through training and experience, provides the best results in their hands. 
The anterior approach is rapidly gaining popularity in America, with utilization increasing from 12% to 45% between 2009 and 2020 among surgeons in the American Association of Hip and Knee Surgeons. Although utilization spiked only over the past two decades, it is not a new approach. Described in a German surgical textbook in 1881 by Dr. Carl Hueter, it was first used for total hip replacement by the Judet brothers in Paris in the 1940s. After further development in Europe, it was brought to America in 1997 by Dr. Joel Matta, who further popularized it throughout the 2000s.
Studies comparing outcomes of total hip replacement tend to show improved early rehabilitation with the anterior approach. In one randomized trial, patients who had an anterior approach were able to walk further on the first two days after surgery. By week six, significantly more patients were able to walk unlimited distances and use stairs normally. Patient-reported functional outcome scores were also better among anterior hip patients at six weeks. A systematic review and meta-analysis showed anterior hip patients had lower pain severity and lower narcotic usage. However, these benefits tend to even out around three months, with posterior and anterior patients achieving similar levels of function and pain relief. There does not appear to be a long-term difference in survival of the hip replacement based on choice of approach.
One of the main benefits of anterior hip replacement may be reduced dislocation rate. Hip dislocations are a problematic complication, causing significant pain and disability for patients. They require at minimum a visit to the emergency department, and sometimes even additional surgery. Most studies show the risk of dislocation after posterior approach to be between 1% and 2%, with the risk of dislocation after anterior approach at less than 1%.
This may be because of better preservation of the soft tissue structures around the hip with the anterior approach, leading to improved stability. Many anterior surgeons do not even place restrictions on hip motion postoperatively. Conversely, most posterior surgeons recommend avoiding excessive hip flexion and internal rotation for the lifetime of the implant to avoid positions that may risk dislocation.
Another factor may be routine use of fluoroscopy during anterior hip surgery to check the position of the acetabular component (the cup) on x-ray. The cup position is an important factor in determining risk of dislocation. As a result of fluoroscopy, surgeons are more accurate and have less outliers in cup position through an anterior approach.
Still, the superiority of one approach over the other is hotly debated among orthopaedic surgeons. Data can be found to support either argument and must be interpreted carefully. Many factors impact outcomes and specific surgical techniques vary from surgeon to surgeon. High-quality studies also exist showing no difference between the two approaches for outcomes including dislocation rate. There are risks specific to the anterior approach, including increased wound complications, higher intra-operative blood loss, lateral thigh numbness and risk of femur fracture during surgery. Importantly, each approach is safe and successful when performed properly. Each surgeon selects an approach which, through training and experience, provides the best results in their hands. As always, decisions are best made through discussion and shared decision making between the surgeon and patient. FBN
By Liam Bosch, M.D.
Flagstaff Bone and Joint is delighted to announce the addition of fellowship-trained orthopaedic surgeon, Dr. Liam Bosch, to their practice. Dr. Bosch brings his expertise in hip and knee replacement for patients suffering from arthritis. Additionally, he specializes in conducting revision surgeries for knee and hip implants, addressing any complications that may arise. With a dedication to utilizing cutting-edge techniques, Dr. Bosch offers advanced procedures, such as anterior total hip arthroplasty and robotic total knee arthroplasty. His commitment to providing exceptional care and innovative treatments makes him a valuable asset to Northern and Central Arizona.
For further information, please visit: www.flagstaffboneandjoint.com.
