Anterior Surgical Approach Beneficial in Patients Often Told They are Not Candidates for Hip Replacement Due to Obesity
(Washington, D.C.) Rita Holliday of Laurel, Maryland couldn’t wait for her hip replacement.
“I had shooting pain down my legs and charley horses in my legs each day,” said Rita. “When I woke up in the morning the only way to get going was to take a warm bath and rub my legs. The pain was often disorienting.”
Rita’s doctors diagnosed her with degenerative osteoarthritis. As the pain worsened, she was less able to move around. Regular exercise became excruciating. Her Body Mass Index (BMI) rose as she gained weight.
“It was a vicious cycle. I used to power walk with my co-workers three miles at a time, but the pain meant I couldn’t move. In my younger days I was a cheerleader and enjoyed roller skating until the spring of 2013, the year the pain began to worsen.”
Rita’s BMI (Body Mass Index), an indication of obesity reached 40. She was turned down for hip replacement surgery because of the known risk for complications in people with a BMI over 30. In addition she struggled with high blood pressure, type-2 diabetes and an autoimmune disease that required taking prednisone since 2009.
The World Health Organization (WHO) defines obesity as a person with a BMI of 30 or over. People with a BMI between 25 and 30 are considered to be pre-obese.
But orthopaedic surgeon Mark Zawadsky, MD and colleagues at MedStar Georgetown University Hospital recently published data showing that patients with a high BMI can also benefit from a new frontal approach to hip replacement. “The anterior approach to hip replacement surgery is easier on patients because I don’t have to cut muscle to access the hip joint,” said Dr. Zawadsky.
Dr. Zawadsky conducted earlier published studies which found that the anterior or frontal approach to hip replacement meant patients left the hospital sooner, experienced less pain and needed fewer narcotics than those whose incision was made the traditional way, in the back. Patients who had the anterior approach to hip replacement 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.
But still the question remained. Could obese patients benefit from the same technique?
“Obese patients receiving hip replacement have a greater risk of wound complications, infections increased time in the operating room and a greater need for pain management after surgery,” said Dr. Zawadsky. “They also are in greater need of assistive devices and stay in the hospital longer after surgery than those with a normal BMI.”
To answer the question about the anterior technique and individuals with a high BMI, Dr. Zawadsky and his team looked at 210 consecutive patients who received total hip arthroplasty through the direct anterior approach. Sixty-one patients had a normal BMI, 71 were pre-obese and 79 were obese as defined by the WHO.
“While the obese group clearly had more of the expected complications than the other two groups, this study showed that they also saw the same benefits the other groups did due to the anterior approach,” said Dr. Zawadsky. “The anterior approach was no more risky for patients with a high BMI in comparison to the other surgical approaches. In fact the technique showed advantages.”
After being turned down for surgery by another orthopaedic surgeon, Rita sought a second opinion from Dr. Zawadsky. He operated on Rita in April of this year and used the anterior approach. “I feel infinitely better,” said Rita. “My family says I look so much better, just the expression on my face and the way I’m able to move around again. This procedure has changed the quality of my life for the better. It’s been unbelievable. Patients should understand that it takes hard work and you must stick to the prescribed physical therapy regimen to see continued success. I am incorporating daily exercise and a healthy diet to get the weight off that I need to.”
Dr. Zawadsky, who helped establish MedStar Georgetown’s Bloodless Medicine Program, also applies bloodless medicine protocols, so the anterior hip approach has reduced his blood transfusion rates for hip replacement 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. When you combine these protocols with the anterior approach, we’re finding that all of our patients, including those with a high BMI are tolerating hip replacement much better than patients of just three to five years ago.”
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