Johnston often has patients come in specifically asking for direct anterior hip replacement, a somewhat new procedure that has been heavily marketed. And he’s not surprised. “It’s one of the most talked-about things in orthopaedics,” he says.
Johnston was trained in the anterior approach during his fellowship at the Mayo Clinic as it was being developed. And now anterior hip replacement comprises about 20% of Johnston’s practice. But the newest “new” thing isn’t always best for any given patient.
Here are some questions to consider before talking to your orthopaedic surgeon.
What exactly is direct anterior hip replacement?Direct anterior hip replacement was developed in the 1970s as a less invasive method of performing the procedure. Instead of making incisions through the side of the hip (lateral), the surgeon enters through the front of the hip (anterior).
Am I a good candidate for one?The anterior approach is not for everyone — but it can be a great option for some. The primary benefit of the anterior approach is that patients do not have hip precautions post operatively, meaning they can move the hip more freely. Patients of the anterior approach tend to be slightly more confident and have slightly better early function. But whatever approach is used, patients are usually at about the same function two to three months after surgery.
Weight, bony anatomy, skin status and wound healing“The posterior approach gives fantastic results, so we have to be careful about using the anterior approach in high-risk patients who might have a complication they might be less likely to experience with another approach” says Dr. Johnston. Being overweight or being very muscular makes the anterior approach more difficult and can require a surgeon to release more tissue around the hip, including muscles, to gain access to the hip. This negates a lot of the benefits of the anterior procedure. “In addition, the area in front of the hip where the incision is made can have trouble healing, so we have to be careful in patients who might have wound problems such as smokers, people who have diabetes or vascular disease and patients taking certain medications.”
What are the benefits?“With the right patient selection, patients with anterior approach are usually walking slightly farther distances and a bit more independently than their peers with other approaches in the first month or so. In early recovery — the first six weeks — it’s a little easier to get around,” explains Johnston.
The confidence is key. Patients who are not advised to limit their hip movement tend to be more active patients, which can make recovery easier and faster.
What are the drawbacks?While the term “minimally-invasive” and the promise of a shorter, easier recovery time make the anterior approach to hip replacement sound too good to be true, there are, of course, drawbacks.
What hip replacement patients gain in terms of early recovery time, says Johnston, they are more likely to give up in terms of tendonitis and nerve pain, especially early on. But like other potential side effects of hip replacement surgery, regardless of the approach, by six weeks out, the recovery is typically the same.
Which hip replacement is right for me?That’s a question to discuss with your orthopaedic surgeon. The answer depends on so many factors, including which procedure your surgeon is most comfortable doing and balancing short-term and long-term benefits.
It is important for surgeons to listen to the patient with empathy to get an understanding of their goals and desires, and then tailor the approach for hip surgery to their needs while minimizing the chance of complications. “What we care about most as orthopaedic surgeons when we do joint replacements is ensuring long-term, dependable results for our patients that stand up to the test of time,” says Johnston. “We have traditionally measured our success in terms of years and decades, but listening to patients has taught us that they want faster recovery, so it is exciting to have the direct anterior approach, and it’s always better for patients to have more options.”