Surgical Approaches Used for Hip Replacement

Total hip replacement has become one of the most common, and most successful, orthopedic surgeries that is performed. Nearly 500,000 hip replacement surgeries are performed in the United States every year. While hip replacement surgery is largely standardized, there are variations in the surgical technique. Different surgeons prefer different techniques to perform a total hip replacement, and here we discuss some of these options and how they differ.

On a positive note, total hip replacement can be very successful no matter which of these surgical techniques is used. They can all be done as minimally invasive techniques. They all also have risks associated with each of the surgical approaches. While some surgeons may favor a particular technique in hopes that it minimizes certain risks, there may be other downsides of that surgical procedure. In addition, one surgical technique may be appropriate for one patient, but not ideal for another. For that reason, you should always ask your surgeon if you have questions about a particular surgical approach, or if you think one might be better for your situation.


Posterior Hip Replacement

photo of a man with hip pain talking with his doctor
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The posterior approach for a hip replacement surgery is by far the most common surgical technique used in the United States and throughout the world. This surgical procedure is performed with a patient lying on their side, and a surgical incision made along the outside of the hip. The reason this is called a posterior approach is that the actual hip joint is visualized from behind the thigh bone, the posterior aspect of the hip joint.

The advantage of this surgical procedure is most notably the versatility. The surgical procedure provides excellent visualization of the hip joint. In situations that are particularly challenging because of bone deformity, hardware within the hip, or other complicating factors, the approach can be easily extended to allow for more complex surgical reconstruction. Most any implant can be inserted from a posterior approach.

The primary disadvantage of a posterior approach is that there are concerns about a higher dislocation rate of a total hip replacement implant. Long-term data has yet to be gathered, but one of the hopes with other surgical approaches is that the dislocation rate will prove to be less when compared to posterior incisions. The other major disadvantage with this surgical approach, and one of the reasons that may contribute to the higher dislocation rate, is the fact that some muscles and tendons are typically cut and later reattached in order to get access to the hip joint. These tendons, called the external rotators of the hip, are separated off of the bone in order to get ​into the hip joint.


Direct Anterior Hip Replacement

The direct anterior approach to the hip is becoming much more commonly performed. This surgical procedure has been around for a long time, more than 100 years, but has gained significant interest from surgeons performing total hip replacement over the course of the past decade. The direct anterior approach is performed with a patient lying on their back, and a surgical incision coming down the front of the thigh.

There are several potential advantages of the direct anterior approach. The two specific advantages that proponents of this surgical approach will talk about are dislocation risk and early postoperative recovery. Many people feel that the risk of dislocation following anterior approach hip replacement is lower than compared to posterior approach hip replacement. While the risk with a posterior approach may only be 1 or 2%, the ability to minimize that with a surgical approach change is an appealing consideration. The second factor is that many people feel the early postoperative recovery is faster. People undergoing direct anterior surgery tend to have a faster recovery in shorter hospitalization.

The disadvantage of the anterior approach is primarily the fact that the surgical exposure can be more difficult, especially in people who are very muscular or have significant girth to the center of their body. It is clear that it takes time and practice for surgeons to become skilled in this approach, and complications in surgeons early in the use of direct anterior hip replacement are more common. In addition, not all implants can be easily utilized from an anterior approach, and addressing some deformities or performing revision hip replacement is not always as easy as with a posterior approach.

Lastly, a skin nerve called the lateral femoral cutaneous nerve can be injured at the time of surgery. While this does not alter gait or function, some people are bothered by a patch of numbness on the front of the thigh.


Lateral Surgical Approaches

A direct lateral or anterolateral approach is performed on the side of the hip joint. This surgical approach is often seen by surgeons as a balance between the anterior and posterior approaches. The dislocation rate seems to be lower than with posterior approaches, while the surgical exposure and ability to extend the incision for better visualization is better than the anterior approach. People undergoing a lateral approach are positioned on their side, and the surgical incision goes directly down the outside of the hip.

Again, the primary advantage with this surgical exposure is the balance of being a versatile incision that can be used to perform not only a typical straightforward hip replacement but also to correct deformities and insert specialized implants. Dislocation rates following surgery seem to be less than with a posterior surgical approach.

The disadvantage of the direct lateral approach is that the abductor muscles of the hip joint are cut in order to enter the hip. These muscles may heal normally, but if they do not, people can develop a limp that can be persistent. In addition, dissection through these muscles can cause a condition called heterotopic ossification. While heterotopic ossification can occur after any surgical procedure on the hip joint, it seems to be more common after the direct lateral approach is performed.


Alternative Surgical Approaches

There are also some other surgical procedures that are performed, although much less commonly than the three approaches mentioned previously.

Alternative surgical procedures include a 2-incision procedure and the direct superior approach. Both of these surgical procedures were developed in an effort to make smaller surgical incisions and limit the amount of muscle injury that occurs at the time of surgery. Both of the procedures rely heavily on indirect visualization, meaning your surgeon uses x-rays during the surgical procedure to assist with proper insertion of the implants. Both of these surgical procedures can be extended into a more typical hip replacement incision in the event that better visualization is required at the time of surgery.

There is only limited data available on the potential benefits of the surgical procedures, but certainly limiting damage to normal muscle tissue can lead to a faster recovery following any surgical procedure.

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