Anterior hip replacement is an example of how the medical field is continually evolving and trying to improve outcomes for patients. This surgery is the subject of ongoing research and—though thousands are performed every year—it is estimated that only 15% to 20% of hip replacement surgeries in the United States currently use the anterior approach.

In the meantime, patients and doctors must use the knowledge available to make informed choices. The bullet points below summarize much of what we know about the pros and cons of anterior hip replacement surgery.

Potential Advantages of Anterior Hip Replacement

Proponents of anterior hip replacement surgery believe it offers several advantages, including:

    Less damage to major muscles. The anterior approach avoids cutting major muscles. There are fewer muscles at the front of the hip, and the surgeon works between them, rather than cutting through muscle fibers or detaching muscles from bones (and then having to make repairs at the end of the surgery).

    Less post-operative pain. Because the surgery does not require cutting major muscles, patients typically experience less pain after surgery and require less pain medication.

    Faster recovery. After surgery, a patient can bend at the hip and bear weight as soon as it is comfortable. Most anterior hip replacement patients can use crutches or a walker sooner than patients who have had a traditional surgery. Patients may also walk on their own sooner: A 2014 study of 54 patients found that anterior hip replacement patients walked unaided 6 days earlier than other hip replacement patients.3

    Decreased risk of hip dislocation. A major post-surgical worry for most hip replacement patients is that the new hip’s ball and socket will dislocate. However, anterior hip replacement surgery does not disturb the muscles and soft tissue structures that naturally prevent the hip from dislocating, therefore anterior surgical patients are less likely to suffer a hip dislocation.

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    Better range of movement. Patients may bend over or sit with their legs crossed without risking hip dislocations. Most traditional hip replacement patients are told to avoid sitting with legs crossed for at least 6 to 8 weeks following surgery, and, depending on surgeon preference, to avoid deep bending at the hip or extreme internal rotation of the hip from then on.

    Shorter hospital stay. A patient who undergoes anterior hip replacement can typically expect a shorter hospital stay than with a traditional approach, but much of this depends on the patient and the frequency of physical therapy sessions that patients are provided in the hospital.

While anterior hip replacement may offer some advantages, there are also potential limitations or disadvantages.

Potential Disadvantages of Anterior Hip Replacement

Anterior hip replacement does have a few limitations. These limitations include:

    Obese or very muscular people may not be good candidates. Depending on the surgeon's experience, this surgery may not be appropriate for obese or very muscular patients, because the additional soft tissue can make it difficult for the surgeon to access the hip joint.

    It is a technically demanding surgery. Surgeons face a steep learning curve for this procedure. The anterior incision provides a restricted view of the hip joint, making it a technically demanding procedure.

    There is potential for nerve damage. There is a potential risk of nerve injury with any type of hip replacement approach. In anterior hip replacement, the surgical area is located near the lateral cutaneous femoral nerve, which runs down the front of the pelvis and past the hip to supply sensation to the outer thigh (it does not affect muscle control). Following anterior hip replacement surgery, there is potential for numbness in the thigh, and, in rare cases, a painful irritation of the skin supplied by that nerve, known as meralgia paresthetica. This condition is rare and happens in less than 1% of patients.4

    While research is limited, many studies seem to suggest that the risk of damage to the major nerves near the hip, in particular the sciatic nerve, is lower with the anterior approach than with the traditional approaches.5,6,7 This is because the sciatic nerve runs behind the hip joint, so it is not exposed when using the anterior approach.

    There may be wound healing issues. Surgeons who routinely perform the anterior approach recognize that the surgical incisions can get irritated, especially in very large patients or patients with large amount of abdominal fat, because that area can take longer to heal.

    For example, one study identified surgical wound complications (e.g. infection where the surgical incision was made) in 1.4% of patients who had undergone anterior hip replacement and 0.2% of patients who had undergone posterior hip replacement.8 However, these wound-healing issues are usually mild and self-limiting, meaning they typically resolve over time even without medical treatment. To date, there is no evidence to suggest that either approach has a higher or lower incidence of hip joint infection, which is a much more serious issue than incision healing delay.

It is important to remember that a successful hip replacement surgery depends on many factors besides the surgical approach. For example, the knowledge and skill of the surgeon, the type of hip prosthesis used, the patient's weight and build, and the ability and willingness of the patient to participate in surgical preparation and post-surgical rehabilitation are important factors.

A patient considering anterior hip replacement surgery should speak with his or her surgeon about potential advantages and disadvantages in the context of the individual's specific circumstances, such as the patient’s hip arthritis, anatomy, overall health, and lifestyle.

References:

  1. Taunton MJ, Mason JB, Odum SM, Springer BD. Direct Anterior Total Hip Arthroplasty Yields More Rapid Voluntary Cessation of All Walking Aids: A Prospective, Randomized Clinical Trial. J Arthroplasty. 2014 May 25. pii: S0883-5403(14)00340-4. doi: 10.1016/j.arth.2014.03.051. [Epub ahead of print] PubMed PMID: 25007723.
  2. Post, ZD, Orozco F, Diaz-Ledezma C, Hozack WJ, and Ong A. Direct anterior approach for total hip arthroplasty: indications, technique, and results. Journal of the American Academy of Orthopaedic Surgeons. 2014;22:595-603.
  3. Kennon RE, Keggi JM, et al. Total hip arthroplasty through a minimally invasive anterior surgical approach. Journal of Bone and Joint Surgery. 2013;85-A:39-48.
  4. Berend KR, Lombardi, AV, et al. Enhanced early outcomes with the anterior supine intermuscular approach in primary total hip arthroplasty. Journal of Bone and Joint Surgery. 2009;91 Supple:107-20.
  5. Matta JM et al. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clinical Orthopaedics and Related Research. 2005;441:115-124.
  6. Christensen CP, Karthikeyan T, Jacobs CA. Greater Prevalence of Wound Complications Requiring Reoperation With Direct Anterior Approach Total Hip Arthroplasty. J Arthroplasty. 2014 May 2. pii: S0883-5403(14)00294-0. doi: 10.1016/j.arth.2014.04.036. [Epub ahead of print] PubMed PMID: 24890998.
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