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Why the Anterior Approach for Total Hip Replacement?

The “anterior approach” indicates that the hip is exposed from the front of the body (“anterior”), rather than from the side (“lateral”) or back (“posterior”).  The popularity of the anterior approach for THA is rapidly growing because of its measured advantages and improved outcomes.  Rehabilitation is simplified and accelerated, dislocation risk is reduced, leg length restoration is more accurate, and the surgery is done without detaching muscles from the hip and pelvis.

The “anterior approach” indicates that the hip is exposed from the front of the body (“anterior”), rather than from the side (“lateral”) or back (“posterior”).  The popularity of the anterior approach for THA is rapidly growing because of its measured advantages and improved outcomes.  Rehabilitation is simplified and accelerated, dislocation risk is reduced, leg length restoration is more accurate, and the surgery is done without detaching muscles from the hip and pelvis.

Figure 1: The anterior approach vs the posterior approach to the hip. 

The anterior approach allows the patient exposure to the hip through the natural interval between muscles, without cutting through any muscles.

The posterior and lateral surgical exposures require dissection through muscles, which has ramifications on weakness and hip stability.

The hip socket is very stable anteriorly, and it is difficult to get the femur out of the socket to allow the surgeon access to replace the hip.  Professor Judet designed an orthopaedic table to enhance the surgeon’s ability to access the hip, without damaging muscles, through the anterior incision.  The availability of the table made this beneficial method of hip replacement the preferred option for total hip surgery at Professor Judet’s hospital in France, where it has been utilized ever since.  A similar table is now available in the United States (the HANA table, Misuzi OSI).  Dr. Ferguson has been instrumental in the evolution of the HANA table’s use for aTHA in the United States, working with the company (Misuzi OSI) and educating surgeons and OR staff on optimal use of the HANA table to maximize safety during aTHA.

The HANA® Table (Mizuho OSI)

Dr. Ferguson discusses use of the HANA® Table.

Advantages of Anterior Approach THA

  • The anterior approach allows Dr. Ferguson to replace the arthritic hip through naturally occurring intervals between the hip muscles without cutting through or detaching muscles from the hip and pelvis (as required in other surgical exposures to the hip.)
  • The replaced hip is inherently stable after the aTHA, decreasing the risk of hip dislocation after replacement.
  • After the anterior approach surgery, there are no limitations or restrictions on post-operative motion.  Thus, patients are encouraged to walk and move their hip freely, simplifying rehabilitation and accelerating recovery.
  • The aTHA preserves the muscles, minimizing problems with weakness and limping, and also limiting the pain associated with surgery.
  • The surgical technique allows the surgeon to more accurately place the prosthetic components, and the normal anatomy and leg lengths can be controlled precisely.

Muscle Preserving  Surgery

Other surgical approaches (the lateral and posterior approaches) necessitate detachment of the hip stabilizing muscles (particularly the gluteus and the posterior rotators) from the femur during surgery. In the anterior approach, by contrast, the hip is approached and replaced through a natural interval between muscles, and the muscles for hip function and stability are left intact. The accelerated rehabilitation and short hospital stays associated with the anterior approach have been attributed to the muscle sparring nature of the exposure.

NO Activity Restrictions After Surgery

Due to the inherent stability and preservation of the muscles, there are no post-surgical “precautions” or motion limitations after anterior approach THA.  After lateral or posterior approaches for arthroplasty, patients are commonly instructed to follow strict precautions that limit hip motion after surgery. These limitations complicate a patient’s simple daily activities such as sitting in a chair or on the toilet, or getting into a car.   Barring complications, Dr. Ferguson gets her patients walking immediately after surgery without any restrictions on motions.  Patients are typically able to climb stairs within HOURS of the operation, and resume limitless activities, including high competition athletics!!

This drawing depicts the anterior musculature originating from pelvis bone and covering the hip socket.

With the anterior approach, the hip is accessed by spreading the muscles with retractors, rather than cutting through or detaching them from the hip.

With the anterior approach the patient lies supine (on their back) during surgery.  This allows Dr. Ferguson to utilize a Fluoroscopically Based Component Navigation technique for precise positioning of the acetabular component.

Figure 4: Dislocation rate has been closely associated with a poorly placed acetabular (socket) component. Dr. Ferguson uses an incredibly precise navigation to ensure that the acetabular component is placed with an orientation optimizes the hip’s stability and mechanics.

This fluoroscopic navigation technique is also associated with precise restoration of a patient’s optimal hip anatomy, leg length, and pelvic mechanics.   This ”anatomical” restoration of your own body mechanical properties is essential for patients trying to get back to active lifestyles and performance athletics.

Figure 5: The hips length and femoral offset (distance from the pelvis) is different in each patient. Dr. Ferguson utilizes fluoroscopic navigation to precisely restore normal relationships and anatomy in the hip, optimizing patient functions. One of the topics Dr. Ferguson is best know for in the world of hip surgery is understanding fluoroscopy based navigation, and she teaches surgeons throughout the world how to improve their patients outcomes by utilizing these techniques.

To summarize, the anterior approach arthroplasty procedure is a long-standing approach to total hip replacement, dating back to 1947.  Dr. Ferguson has been a pioneer with the anterior approach THA and has more than a decade of experience with this surgery. Patients benefit from the low risk of hip dislocation, faster and simplified rehabilitation, muscle sparing surgery, and anatomical restoration of the hip mechanics and lengths.  Studies prove conclusively that anterior approach THA is associated with a very low complication rate, substantially decreased risk of dislocation, less opioid pain medication and faster return to functional activities than other approachs for THA.  Dr. Ferguson has used this approach exclusively for her primary hip replacements since 2004 and has used this surgery to help thousands of patients with hip problems.

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