Ortho Dx: Anterior vs posterior approach in total hip replacement

A 67-year-old man presents with end-stage arthritis of the left hip as shown in an anteroposterior pelvis X-ray (Figure 1). He has failed conservative treatment and wishes to have a total hip replacement. He had a right hip replacement 5 years ago using the posterior approach. He recently heard about the anterior approach and asks if this is the best approach for him now.

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The anterior approach is an increasingly popular approach to total hip replacement. Recent advances in operating room tables and implant designs have made the anterior approach more surgeon friendly. The anterior approach is unique to the posterior approach in that...

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The anterior approach is an increasingly popular approach to total hip replacement. Recent advances in operating room tables and implant designs have made the anterior approach more surgeon friendly. The anterior approach is unique to the posterior approach in that the anterior approach advances through a true internervous and intermuscular plane. The posterior approach requires cutting through muscles to get to the joint capsule, which can increase postoperative pain and slow recovery time as compared with the anterior approach. Patients who undergo the anterior approach tend to have shorter hospitals stays, less postoperative narcotic use, fewer postoperative hip precautions, and a quicker return to walking independently without a walker or crutches. Several studies have shown a lower postoperative dislocation rate with the anterior approach, although other studies have refuted this data with equal rates for both anterior and posterior approaches.

One disadvantage of the anterior approach is the steep learning curve it takes for orthopedic surgeons to master the technique. This learning curve often leads to increased operating room times and operative blood loss. It generally takes 50 to 100 operative cases before orthopedic surgeons are proficient with the anterior approach. The anterior approach is often avoided in obese patients as a large pannus can fold over the anterior incision and increase infection potential.

Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).

References

1. Zawadsky MW, Paulus MC, Murray PJ, Johansen MA. Early outcome comparison between the direct anterior approach and the mini-incision posterior approach for primary total hip arthroplasty: 150 consecutive cases. J Arthroplasty. 2014;29:1256-1260.
2. Higgins BT, Barlow DR, Heagerty NE, Lin TJ. Anterior vs. posterior approach for total hip arthroplasty, a systematic review and meta-analysis. J Arthroplasty. 2015;30:419-434.