Anterior Approach Total Hip Replacement
The first hip replacement performed through the anterior approach was by Robert Judet in 1947 at Garches Hospital in Paris. Today Thierry Judet, the son of Robert Judet continues to use this approach for hip replacement. Prof. Thierry Judet, Chief of Orthopedics at Garches, has used this approach for over 20 years and more than 2000 cases. It has been the preferred technique for primary and revision hip replacement at Garches since 1947.
In 1981, Dr. Joel Matta traveled to Paris to study acetabular and pelvic surgery. He learned the procedure at that time, but did not pursue it further because of his interest in pelvic and acetabular fractures. In 1996, while Dr. Matta was practicing in Los Angeles, a patient who had an anterior approach hip replacement in France approached him with severe arthritis of the other hip. He reconsidered the procedure and began performing the operation. At first, he replaced 20 to 30 hips per year, but now performs over 500 cases yearly. Dr. Matta has been a pioneer for advancement of the anterior approach here in the United States. He accepts one orthopaedic surgeon per year to become his fellow. Dr. Yerasimides went to Los Angeles in 2005 for one year, mentoring under Dr. Matta and assisting on all surgeries.
The typical incision is about 4 inches long on the front of the hip varying slightly in length depending on the size of the patient. The smaller incision is more cosmetic, but adequate for implanting the artificial hip parts. The anterior approach works well because the hip joint is closer to the skin in the front and covered by a thinner layer of muscle and fat than from the back (posterior) or side (anterolateral). Almost all patients regardless of size, shape or age are candidates for this procedure.
The posterior approach to the hip is the most common approach for hip replacement, which exposes the hip joint by splitting the gluteal muscles and detaching other important muscles from the femur. The anterolateral approach, which is also commonly used, also requires detachment of important muscle groups from the femur. The anterior approach goes between muscles to expose the hip joint, leaving all muscles attachments to the femur intact.
An artificial hip depends on the muscles around the hip for stability. With the anterior approach, muscles are left intact, giving immediate stability to the hip after surgery. More traditional hip replacement techniques require periods of strict precautions after surgery to assure the artificial hip will not dislocate. These precautions commonly include limits on flexion of the hip requiring elevated toilet seats and chairs. Patients are also instructed to avoid crossing legs or tying shoelaces. Since the anterior approach preserves muscle attachments, dislocation precautions are not needed. Patients are encouraged to use and position the leg in any manner avoiding the cumbersome restrictions. This accelerates rehabilitation and decreases the hospital stay after surgery.
Along with dislocation risks, leg length inequality has long been a problem with hip replacement surgery. With the anterior approach, the patient lies on their back during the surgery. In this position, fluoroscopy is used to determine leg lengths, correct position and proper sizing of the implants. This ensures that every patient leaves the operating room with the artificial hip components most suited for their body.
With all the advantages the anterior approach provides, some patients ask why orthopaedic surgeons do not commonly use it across the country. The main reason is lack of training in this particular approach. Orthopaedic surgeons in the United States are routinely taught the posterior and anterolateral approaches for hip replacement, but very few know the anterior approach. The other two approaches have been used for many years by many surgeons and are felt to be fundamentally sound for total hip replacement. This is true and these approaches are very good, but both require cutting natural muscle attachments that can lead to increased dislocation rates and longer rehabilitation compared to the anterior approach. Another obstacle for many surgeons with the anterior approach is the orthopaedic table. A special table is used to position the femur during surgery. Without the table, the surgery can be extremely difficult to perform. Because the table allows the procedure to be performed with the patient lying supine (on back), both hips can be replaced in the same operative setting for those patients with severe bilateral hip arthritis.
Typically, patients are seen by physical therapists in the hospital for gait training and functional activities. Full weight bearing is allowed and patients can go home after achieving basic therapy goals. In general, additional physical therapy is not required as walking and general activity is adequate. If additional therapy is needed, it can be provided on an outpatient basis. Again, there are no dislocation precautions after surgery. Patients are allowed to bend, twist or cross the legs in any position that is comfortable. Patients are commonly discharged home 1-3 days after surgery.