♦  Where is the incision for an anterior hip replacement:

The incision is at the front of the thigh, usually slightly off to the side. The incision is usually short and straight, and about 6-8cm in length. There are some variations in the skin incision that are sometimes performed. For example, the skin incision may be positioned diagonally in the groin crease. This is called a “bikini incision” as the incision in placed in the bikini line.

♦  How long is the incision for an Anterior Hip Replacement:

The incision is small – about 6-8cm.

♦  Are all hip replacement patients suitable candidates for the anterior approach?

Yes – with an experienced just about all patients can be considered for anterior hip replacement but this does depend on surgeon experience.
The anterior approach is technically intricate surgery, where hip replacement is performed through a small incision between muscles at the front of the thigh. The approach is easier to perform on skinnier patients than on very large or muscly patients.  Some surgeons who don’t perform large numbers of hip replacement cases a year or don’t commonly do the anterior approach may therefore chose to only offer this approach to selected patients.
Mr Freedman has extensive experience with the anterior approach and one of Australia’s leading proponents of this surgery. Mr Freedman is able to offer the anterior approach to essentially all hip replacement patients.

♦    How is the patient positioned for Anterior Approach Hip Replacement?

The patient is positioned lying flat on their back on the operating table. This is different to the other approaches (posterior or lateral), where the patient is usually positioned lying on their side. Having the patient lying on their back is a relative advantage in that it is easier to assess the patient’s leg lengths as the legs can be placed together, and this positioning also lends itself well to use of intra-operative X-ray to check the position of the implant.

♦   Are “hip precautions” required after anterior approach hip replacement?

No. In the posterior approach, a range of post op precautions are often prescribed to protect the posterior hip structures that are cut and then repaired at the end of the surgery. The anterior approach preserves the abductor muscles and posterior muscles and posterior capsule of the hip and the joint is consequently very stable. Mr Freedman subsequently has no range of movement restrictions after anterior hip replacement and is happy for patients to lie on their side, sit on a low chair, use a normal toilet seat, kneel, travel in a low car and place their hip in any position they like immediately after anterior hip replacement surgery.
Our only caution to patients is that it does still take a few weeks for the bone to fully fuse to the prosthesis and so we advise against running or jumping in the early post op period.

♦  Is the Anterior Approach to the hip “new”?

Actually no. The anterior approach has been described and utilised for French surgeons since the1940s. However, due to limitations in instruments and implants, the anterior approach was not commonly utilised for hip replacement surgery. The big change occurred in the early 2000’s when a french surgeon by the name of Dr Frederic Laude devised a new operating table and new instruments that allowed hip replacement to be performed via the anterior approach in a safe and reproducible manner. The anterior approach then quickly became the dominant approach for hip replacement in France, where surgeons now have more than 10 years of experience with the technique. More recently, as surgeons from around the world have travelled to France to get trained in the anterior approach.

♦   Is there a greater risk of fracture with the anterior approach?

No, not for surgeons experienced with the technique.  The anterior approach is technically intricate surgery and it is recognised that it can take a surgeon a moderately large number of cases (~50) to learn this technique in the so-called “learning curve”.  In their “learning curve” surgeons new to this surgery may experience some difficulties in mastering the approach.

Reputable orthopaedic implant companies recognise this and provide advanced training programs to make sure that surgeons are well supported during the learning curve  through visitations where more experienced surgeons assist them with their early cases. Difficulties have arisen where surgeons not properly trained in the anterior approach have attempted to perform the procedure without appropriate support or training.
Patients considering anterior approach hip replacement are well advised to ask the surgeon how many anterior approach hip replacements they have performed, where they learned to do the surgery and what formal training they have undertaken.

♦   Is it possible to perform revision hip replacement via the anterior approach?

Yes, absolutely.  An anterior approach can be used for just about all hip replacement scenarios. However,  the pros and cons of each approach need to be considered in the context of the required surgery. The anterior approach provides fantastic exposure to the hip socket (acetabulum) and so lends itself well to most revision surgery of the acetabulum. The anterior approach also provides sufficient access to the femur for simple revision cases of the femur, such as cases which require replacement of a loose femoral stem. However, the standard anterior approach does not provide extensile exposure to more complex femoral surgery, such as placement of an extended length stem or tumour prosthesis. Additional exposure can obtained by way of soft tissue releases or bone cuts (osteotomy) but once these additional releases are required, many of the primary benefits of an anterior approach (i.e not needing to cut any muscle) may be diminished and the anterior approach may no longer be the best approach for the case.  Mr Freedman will therefore typically utilise the anterior approach for revision cases of the acetabulum and for simple femoral revisions, but may prefer a traditional posterior approach for more complex revision cases.

♦  How long will an Anterior Approach Hip Replacement last before it needs to be revised?

Answer: Longevity of a hip replacement prosthesis is generally not dependent on the surgical approach. Instead, the relevant factors are whether the implant is positioned and inserted correctly and the quality of the material used to manufacture the implant. So long as the implant is positioned properly and good materials are used, the implants should usually last more than 20 years. With newer materials currently being used (e.g high quality ceramics), surgeons hope that current implants will last far longer than this and that hopefully hip replacements being put in now, will not beed to be revised. Reproducible correct positioning of the implants is certainl very attainable via the anterior approach, and so anterior hip replacements done well should last a very long time.

♦  What don’t more surgeons perform the Anterior Approach?

The procedures surgeons perform are a reflection of where they did their training. Surgical training is a essentially an advanced apprenticeship – most trainee surgeons learn by working under the preceding generation of local surgeons and then go on to later teach the procedures to new trainees.  Historically, most surgeons in Australia, the UK and the USA have been trained in classic British surgical techniques. They are able to achieve good results with surgeries that they know well and which get passed from surgeon to surgeon. Surgeons understandably are hesitant to change techniques when they are able to achieve good results with techniques they’ve been well trained in.
The anterior approach is a relatively new surgical technique that was developed and refined in France and has, until recently, not been widely available outside of Europe as surgeons have not had access to local training in the technique.
Mr Freedman was fortunate to receive a scholarship from the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) to be able to undertake advanced training in Paris with the preeminent surgeon who developed the anterior approach (Dr Frederic Laude). To the best of our knowledge, Mr Freedman is the only surgeon in Melbourne to have completed an EFORT Fellowship with Dr Laude. In time, as Mr Freedman and other trained surgeons teach the technique locally it will become more available.

♦ Is the Anterior Approach better than the other approaches?

All hip replacement approaches are able to achieve excellent results for patients and the literature demonstrates that the long term results  (ie. > 6 months after surgery) are equivalent between the different approaches. However, several studies have demonstrated that early functional recovery (eg off crutches, off pain medication and back to work and activities) is quicker and easier after the anterior approach.
The anterior approach has rapidly gained in popularity as surgeons have sought to improve recovery times from hip replacement surgery.
Mr Freedman prefers the anterior approach over other approaches as he feels that it offers many advantages in terms of quicker and recovery.

  Is a special operating table required for the Anterior Approach:

Answer: No not strictly speaking, but it’s strongly recommended.  The anterior approach was first described more than 50 years ago but until recently was considered a difficult approach for hip replacement. A revolution in practice occurred when Dr Laude in Paris developed a special leg-holding attachment for the operating table which allows the patient’s leg to be extended, rotated and carefully held in appropriate position for surgery in a way which was not possible previously. This device was patented. As the anterior approach has gained popularity, other orthopaedic companies which do not have access to this patented leg holder have revisited the idea of doing the approach without the leg holder. In Mr Freedman’s opinion, this is a return to when the anterior approach was difficult to reproduce. Surgeons who don’t use a leg holding attachment typically require a second assistant to help hold the leg in the necessary position for surgery.

♦   How long will I be off work after a hip replacement?

Timing re return to work depends on your type of work. After anterior hip replacement the joint is very stable and you can expect to have very little discomfort and be able to return to sedentary jobs very quickly. We commonly have patients who are sitting up a desk in the hospital, dresses normally, seated in a normal chair and able to do office work day 1 after surgery. Therefore, for office type work the only real barrier to returning to work is the commute to work (i.e getting there and home). You should plan to not be driving for about 2 weeks after surgery. If you can make other transport arrangements it would be sensible to take a week off work (you may feel a bit tired and run down after surgery) but could return to work the very next week. You can work from work from home within days of surgery.
For light jobs that require a bit of walking around (such as job in retail where you are on your feet for hours), a two week off period would be sensible.  By that stage you should be well off crutches and able to walk safely unaided.
For more physical jobs (such as labouring), we advise 4-6 weeks off work.  The reason for this is that Mr Freedman typically uses new-generation uncemented implants, which are coated with a special surface coating which stimulates the neighbouring bone to grow onto the prosthesis. The benefit here is that once your bone has grown ono the prosthesis the prosthesis will be stable for a very long time (likely forever) and not be exposed to the risk of late loosening as can happen with cemented implants where the cement can eventually dissolve. So as to not compromise the ability of the bone to grow onto the prosthesis we prefer to jarring, vibrations and sudden heavy impact movements for 6 weeks and therefore advise patients to avoid those sort of work activities for that time period.

♦   When can I drive after a hip replacement?

driving after hip replacement

The classic advice that surgeons used to give patients after “traditional” hip replacement surgery was that they could return to driving 6 weeks after surgery. However, as surgery techniques have improved these old fashioned guidelines have been challenged.  Several recent research papers have described that “total brake response times” can recover within days of minimally invasive surgery.
One study reported Day 8 for left side surgery and Day 14 for right side surgery, and another paper claimed that brake times were already normalised by Day 2 after surgery.
Mr Freedman therefore adopts the following guidelines to patients: Before returning to driving we want you to (1) Be off crutches and able to walk comfortable unaided, (2) Be off all strong pain medication (3) Be seen by a qualified physiotherapist to have your reaction/response times assessed as safe to drive.  Many patients are able to achieve this very quickly and some patients even drive themselves to their early post op check up appointments – but it’s not a race of a competition. You should be able drive far quicker than the traditional recommendation of 6 weeks, but it is important to make sure that you are safe to do so and each patient will achieve this at slightly different times.

 

This page is continually being edited and refined.  If you have other questions regarding the Anterior Approach for hip replacement please send to us and we will endeavour to answer your questions.

 

Anterior Approach Total Hip Replacement from Ilan Freedman on Vimeo.