What are the different approaches to hip replacement? Which one is best?
There are a number of different approaches to total hip replacement. The most commonly used, in no particular order, are the anterior, posterior, and lateral approaches. Which is right for you? Which approach is the best? In short, each approach has its own advantages and disadvantages, and one approach might be better for a particular patient, and another might be better for another patient. I truly do not believe that hip replacement is a “cookie cutter” surgery. Each patient has unique and individual characteristics and qualities that should influence surgical approach. As a fellowship trained hip replacement surgeon, I take pride in the fact that I am comfortable with all of the different approaches to hip replacement, and will work with you to determine which one is best for YOU before scheduling surgery. Let’s go into a little more detail regarding the advantages and disadvantages of the three most commonly utilized surgical approaches to total hip replacement.
The direct anterior, or anterior approach, to total hip replacement has been around for a very long time, but has recently gained more traction and popularity in the United States. It is the only approach that utilizes a true intermuscular plane, which means that we do not have to violate or cut any muscles to perform the hip replacement surgery. In my experience, this allows patients to recover faster and with less pain compared to the other surgical approaches. The anterior approach has also been shown to be associated with a lower rate of dislocation when compared to other traditional approaches. The disadvantages of this approach are a slightly higher risk of wound healing complications, numbness of the thigh, and slightly higher risk of fracture at the time of surgery. Also, this approach might not be best for complex hip replacement and revision, or “redo” surgery, as it is not as easily extended as some of the other approaches.
The posterior approach is the most traditional and still the most commonly used approach for total hip replacement in the United States. It is safe, reproducible, and provides excellent exposure of the hip joint at the time of surgery. It is able to be used for almost any patient, without significant limitations related to body habitus or complexity of surgery. The drawbacks of the posterior approach include the fact that muscles have to be split or cut at the time of surgery to access the hip joint, and some studies have shown a slightly higher risk of hip dislocation compared to other approaches. However, when necessary, many surgeons like myself utilize a more modern version of this approach called the “mini posterior approach”, in which we minimize the amount of soft tissue dissection and muscle violation, and perform a meticulous repair of the hip capsule at the end of surgery. Recent studies have shown similar recovery and dislocation rates with the mini posterior approach compared to the other approaches.
The lateral approach to hip replacement is probably the least utilized approach for primary hip replacement in the United States. The lateral approach has been around for a long time, is safe and reproducible, and if done well can achieve good long-term outcomes. The main advantage of this approach, when compared to the posterior approach, is that the hip is entered through the anterior aspect of the joint, and has shown a slightly lower risk of dislocation when compared to the traditional posterior approach. The main drawback of this approach is that more musculature has to be violated, including the abductor muscles around the hip, which can result in a slower recovery and a persistent limp after surgery. I do not routinely use or recommend this approach for hip replacement.
In summary, I do not believe that hip replacement is a “one size fits all” type of surgery. Regardless of the approach used, if you are treated by an experienced surgeon, and the procedure is performed in a technically sound manner, you will likely have a good outcome. I would recommend seeking treatment by a fellowship trained hip replacement surgeon, like myself, who is comfortable with all approaches to hip replacement. This allows for determination, without limitation, of which approach is optimal and most safe for YOU, in order to minimize complications and achieve the best short- and long-term outcomes possible.