Study Says Anterior-Approach Hip Replacements Are Better

A new study concludes that a frontal (anterior) approach to hip replacement makes for better patient outcomes than a back (posterior) approach.

Mark Zawadsky, M.D., orthopedic surgeon at MedStar Georgetown University Hospital (MGUH), in Washington, D.C., studied 150 of his consecutive patients using both a minimally invasive posterior approach and the direct approach from the front to access and replace the bad hip. He found that patients who had the newer, anterior approach left the hospital sooner, experienced less pain and needed fewer narcotics after surgery than those whose incision was made in the back. These patients were also more likely to be discharged to their home, rather than a rehabilitation center and were far less likely to need a walker, after surgery.

Fifty year old Justin Kenney of Maryland is one such patient.

“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 had his hip replaced in April 2013. “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.”

When using the anterior approach, the surgeon makes a 10-12 centimeter incision at the front of the upper thigh and unlike the posterior approach, does not need to detach the muscle from the bone.

“This means that I don’t have to repair muscles and the patient doesn’t have to wait for a repair to heal,” said Zawadsky. “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, who is also medical director of MGUH’s bloodless medicine program, also applied bloodless medicine protocols, 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,” he said. “We use anesthesia techniques and medication during surgery to lessen blood loss.”

The Centers for Disease Control and Prevention (CDC) reports that one in four people will develop hip arthritis, also called hip osteoarthritis, sometime in their lifetime. The symptoms include pain, aching or stiffness in the thigh, buttocks or groin and the incidence is the same in men and women, blacks and whites, across education levels and regardless of body mass weight.

The CDC also reports that hip replacement surgeries in nonfederal community hospitals rose from 304,700 in 2000 to more than 453,600 in 2010. 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,” said Zawadsky. “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,” said Kenney. “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.”

“Performing the anterior approach is a technique that requires a learning curve for the surgeon,” said Zawadsky. “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. It’s a win-win situation.”