Anterior Hip Replacement Surgery Questions Answered
A new study just completed about hip replacement answers the question that many orthopaedic surgeons have been asking in recent years: Which technique is easier on the patient, surgery from the back or surgery from the front?
June 5, 2015
Mark Zawadsky, MD, Studied Standard Approach versus Anterior Total Hip Replacement for Patient Benefit and Cost
(Washington, D.C.) Patients who need a hip replacement are benefitting from research conducted at MedStar Georgetown University Hospital that sought to answer a question no center had studied before: which works better, the standard minimally invasive hip replacement with the surgical approach from the back, or anterior hip replacement where the surgeon operates through the front of the patient?
It might seem like a minor variation, but for patients, one approach versus the other can make a big difference in recovery and cost.
Mark Zawadsky, MD, orthopaedic surgeon with the MedStar Georgetown Orthopaedic Institute found that the anterior hip procedure, also called anterior total hip or direct anterior hip replacement, is easier on the patient in several ways.
Dr. Zawadsky studied 150 of his consecutive patients using both a minimally invasive approach from the back (posterior) and the direct approach from the front (anterior) to access and replace the bad hip. What he found is that patients who had the newer, frontal approach left the hospital sooner, experienced less pain and needed fewer narcotics after surgery than those whose incision was made in the back. Patients who had the anterior hip replacement were also more likely to be discharged to their home, rather than to a rehabilitation center and were far less likely to need a walker, after surgery.
Justin Kenney, 52, 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 Justin who had his hip replaced at MedStar Georgetown University Hospital 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.”
For a direct anterior hip replacement the surgeon makes a three to four inch 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 Dr. 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.”
Dr. Zawadsky, medical director of MedStar Georgetown’s Bloodless Medicine Program, also applied bloodless medicine protocols, so the anterior hip approach reduced his blood transfusion rates for hip replacement from 30% to less than 1%. “We pay attention to pre-operative anemia and treat it before surgery. 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 Dr. 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 Justin. “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 an anterior hip replacement or anterior total hip is a technique that requires a steep learning curve for the surgeon,” said Dr. 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.”
Dr. Zawadsky’s study was published by the Journal of Arthroplasty in 2014 and was presented at the October 2013 meeting of the International Society for Technology in Arthroplasty Annual Congress.
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