Direct Anterior Hip Replacement is a muscle-sparing alternative to traditional hip replacement surgery, which involves accessing the hip joint between two muscles at the front of the hip rather than detaching any muscle at the back or side of the hip as occurs with the other techniques traditionally used for hip replacement.

As no mucles are detached during the anterior hip replacement procedure,  the anterior approach offers the potential for quicker recovery, shorter hospital stay and less post operative pain.
Also, as the back of the hip is not opened during surgery there is no requirement for traditional post operative restrictions and lower risk of post operative dislocation.

anterior hip replacement
Anterior Hip Replacement

Anterior hip replacement surgery can be performed through either a short straight skin incision or through a short oblique skin incision hidden in the groin crease or bikini line (what some surgeons have called a bikini approach or “Bikini Hip Replacement”). Suitability for one skin incision over another will depend on patient body shape. 

The anterior approach is relatively new to Australia but is not new in Europe, where it was first developed and refined.
Mr Freedman received a prestigious research scholarship from the European Federation of Orthopaedics and Traumatology (EFORT) to travel to Paris to be trained in the Anterior Minimally Invasive (AMIS) Direct Anterior approach for total hip replacement in by Dr Frederic Laude.
Dr Laude developed the anterior approach and is regarded by many as the best hip surgeon in the world.

Mr Freedman is the only surgeon in Melbourne to have undertaken an EFORT fellowship in Anterior Hip Replacement with Dr Frederic Laude in Paris.

History of the Anterior Approach:

This anterior approach for hip replacement is not strictly a “new” surgical approach as it was actually described by an American surgeon by the name of Marius Smith-Peterson from Mass General Hospital (MGH) in Boston in the 1930’s.
However, at first this technique was technically very difficult, hard to learn, not reproducible and so was not feasible for total joint replacement surgery. It therefore did not gain wide attention or popularity.

However, more recently, Dr Frederic Laude,  a surgeon from Paris under whom Mr Freedman directly trained, devised many improvements to the technique.
This included development of new surgical instrumentation, better prostheses and an advancement new operating table and operating theatre equipment that allows the leg to be carefully positioned and held in position for the operation.
This has revolutionised the use of a direct anterior approach to the hip and has enabled this approach to be reliably applied for minimally invasive direct anterior total hip replacement surgery. Mr Freedman has trained directly with Dr Laude in Paris to learn his operating techniques and still regularly discusses cases with his former mentor.

 

Direct Anterior Total Hip Replacement Technique:
anterior hip replacement

Compared to traditional anterior hip replacement, which involves the patient in a lateral (side-lying) position and an incision on the side or back of the hip, the direct anterior total hip replacement is a front (anterior) approach with the patient supine (lying on their back).

Surgery is performed between the muscles at the front of the hip, which avoids the need to detach any muscles on the side or back of the hip.
The gluteal muscles at the side of the hip are extremely important for balance and walking. Avoiding surgery near these muscles facilitates a quicker post operative recovery.

  • Dr Laude’s innovations have included the advent of a special operating theatre table attachment that allows the leg to be carefully and safely moved and positioned in a very controlled manner to enable appropriate surgical exposure. Importantly, this is NOT a traction table as used by some surgeons. This particular table extension is simply a leg positioning device. When the leg is extended (moved backwards) all traction is completely released.

As the patient is supine (lying on their back), x-rays can be obtained during the procedure to verify correct implant placement and to check leg length. This is very helpful to the surgeon to ensure that the implant position is correct.

 

The Direct Anterior approach offers several potential advantages over other approaches:

  • Smaller incision (usually only ~ 6-8cm) compared with > 15cm typical for other approaches.
  • ​As the posterior capsule (sack) at the back of the hip is not opened during surgery,  the risk of posterior dislocation is greatly reduced (near zero).
  • The stability of the hip allows patients to be rehabilitated very quickly after surgery.
  • Mr Freedman’s patients who have surgery through this technique generally require NO post operative restrictions (e.g no crutches, able to sit in a regular height chair, allowed to cross legs and sleep on one’s side).
  • As there are no major muscle releases or incisions required surgery post operative discomfort and pain-medication requirements are often reduced.
  • Avoiding need for strong analgesia avoids side effects such as nausea and constipation.
  • Performing surgery with the patient lying on their back allows use of x-rays during the procedure to check the position of the implants and leg length to make sure that these are very accurate.

There are some potential disadvantages to this technique:

  • In particular, the view (or ‘exposure’) available to the surgeon through the small incision used is more limited compared to traditional approaches.
  • It can, therefore, be more difficult for the surgeon to access parts of the hip or to visualise whether the implants are positioned in the correct alignment. This can be a potential issue in larger patients and so in some patients this technique may not be the best option.
  • In overweight patients an incision close to the groin crease at the front of the hip may be at higher risk for an infection that a wound away from the groin as occurs with other approaches.
  • This approach can be more difficult to learn and perform than traditional surgery. It should therefore only be performed by highly trained experts.

Direct Anterior Approach requires training and experience:large_logo-ParisV_logo_home_etb

The success of technically complicated surgery depends on several elements, but one important factors is having a highly-trained and experienced surgeon.

Mr Freedman  completed a orthopaedic research fellowship at Harvard University’s Massachusetts General Hospital, where the direct anterior approach was first described, and then completed two International Hip Surgery Fellowships.
Mr Freedman trained] in the UK and then in Paris, where he worked directly with Dr Frederic Laude – a world expert in Direct Anterior hip surgery.
Dr Laude devised many of the new instruments used for anterior hip surgery and regularly travels internationally as an expert mentor to teach surgeons.

Mr Freedman has participated in multiple instructional courses in direct anterior hip replacement and has learned the technique directly from the most some of the most experienced direct anterior hip surgeons in the world.


Summary:

The Direct Anterior Approach for total hip replacement is an exciting advance in joint replacement surgery that allows for a smaller incision, less post operative pain and a quicker and easier post operative recovery.
However, the surgery can be technically challenging and so should only be performed by surgeons with extensive training.
In Mr Freedman’s experience the Direct Anterior approach can be offered to most patients requiring a hip replacement.

To discuss whether you may be a candidate for the anterior approach please contact our office to make an appointment. Tel (03) 9532 3333.

 

A selection of publications on anterior hip replacement can be read here: http://melbournehipsurgeon.com.au/anterior-hip-publications/