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Approach can Affect Outcome in Hip Replacement Procedures

Orthopedic surgeons have been torn for years over access to defective hips, debating frequently amongst themselves whether a frontal or rear approach is best for patients.

A new study, however, might finally put the issue to rest. Research conducted by Mark Zawadsky, M.D., found that anterior (front) access is better for patients than a posterior (rear) approach, resulting in less pain and shorter hospitalizations. Patients whose hip replacement was approached from the front also needed fewer painkillers after surgery, were more likely to be discharged to their home (rather than a rehabilitation center) and less likely to need a walker during their recovery.

Zawadsky, an orthopaedic surgeon at MedStar Georgetown University Hospital (MGUH) in Washington, D.C., studied 150 of his patients using both a minimally invasive approach from the back and a direct frontal approach to replace defective hips. He presented his findings last month at the International Society for Technology in Arthroplasty Annual Congress.

Fifty-year-old Justin Kenney of Maryland was one of Zawadsky's study patients.

"I have two children, age five and seven and I noticed it was getting more painful trying to keep up with them," said Kenney, who underwent hip replacement surgery in April. "I liked the idea that because he accessed my hip from the front, Dr. Zawadsky didn't need to cut through my muscle to get to my bad hip and put in a new hip. I left the hospital the next evening able to walk with the use of a cane and manage my pain. There is no question that my hip feels better now than it did before the surgery."

Anterior approaches to hip replacement procedures call for only a 10-12 centimeter incision at the front of the upper thigh, and they eliminate the need to detach muscle from the bone as required in posterior access.

"This means I don't have to repair muscles and the patient doesn't have to wait for a repair to heal," Zawadsky said. "There are no 'hip precautions,' like restricting movement that patients usually have to follow after hip surgery. And there isn't the pain associated with cutting through muscle. The posterior procedure goes through the gluteal muscles and that usually means a pretty painful recovery."

Zawadsky, medical director of MGUH's Bloodless Medicine Program, also applied bloodless medicine protocols in his procedures, so the anterior approach reduced his blood transfusion rates for hip replacement from 30 percent to 3 percent. "We pay attention to pre-operative anemia and treat it before surgery. We use anesthesia techniques and medication during surgery to lessen blood loss," he noted.

The Centers for Disease Control and Prevention (CDC) reports that one in four people will develop hip arthritis, also called hip osteoarthritis, within their lifetime. Hip replacement surgeries in nonfederal community hospitals rose from 304,700 in 2000 to more than 453,600 in 2010, according to the agency. In national costs, that translates to a growth in healthcare dollars spent from $4.5 billion in 2000 to $7.9 billion in 2010.

"In addition to a more rapid recovery for patients this anterior or frontal approach means a cost savings for the health care system overall," Zawadsky said. "Patients need fewer hours of physical therapy and are back to walking with no aid or just a cane much more quickly, functioning in society earlier and not out of work for as long. They can drive and be independent much sooner."

"I followed 'doctor's orders' to rest and took it easy for about four weeks after my surgery," Kenney said. "I did in-home physical therapy and slowly increased my walking from the end of the driveway to around the block. Six weeks later I was back in the pool, riding my bike and driving my car."

While the anterior approach might be better for patients, it's more difficult for surgeons to learn, Zawadsky noted.

"Performing the anterior approach is a technique that requires a learning curve for the surgeon," he said. "It's a difficult procedure to perform and it takes extensive training. I attended courses, had video training and observed experienced surgeons conduct this approach. This is a procedure where experience matters. The more you do the more routine it becomes and outcomes improve."

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