Hip arthroplasty has been a successful procedure for more than four decades. Yet, as doctors performing this surgery, we continually found ourselves repeating a list of “don’ts” to our patients as they faced the long recovery after hip replacement surgery: “Don’t get in a car,” “Don’t bend over,” “Don’t sleep on your side,” and other restrictions.
This discouraging, but important, post-operative advice was a by-product of standard arthroplasty, in which the surgeon removes the hip joint using a lateral or posterior approach, cutting muscles, ligaments and tendons along the way. Proper recovery takes several months and requires the patient to limit hip motion during that time. Those restrictions following standard arthroplasty allow tissue to heal adequately, as well as reduce the significant and ongoing risk of dislocation. As a result, patients have to be cautious when sitting down, putting on shoes, climbing stairs and doing other simple movements of daily life.
Now, for many of our hip replacement patients at Abington Memorial Hospital, we’re changing our approach—literally—by performing hip arthroplasty from an anterior (front) direction. This enables us to avoid cutting muscles, which are attached to the pelvis or femur, thus causing less trauma and preserving hip stability for post-operative activities.
Patients who receive anterior hip replacement often experience less blood loss, shorter hospital stays, less pain and faster recoveries. Unlike the dislocation risk of standard arthroplasty, there have been no dislocations in the more than 200 patients who have received new hips at Abington Memorial Hospital through the anterior approach.
This surgery is appropriate for most patients whose hip complaints arise from degenerative arthritis. We do not use it with patients who have had multiple prior surgeries or who have severe bone deformities (conventional surgery gives more access to address those problems). Both younger and older patients do well with anterior hip replacement and appreciate being able to avoid the considerable disruption to work and personal activities experienced after standard arthroplasty.
Because we haven’t cut any posterior structures in anterior hip replacement, the quality-of-life differences for patients have been dramatic. We can let them go at their own pace for healing and moving after surgery, with minimal precautions. Many are back to normal and walking without cane assistance within a few weeks.
Initially, we used anterior hip replacement with a small group of patients, most of whom were thin. Working on a traditional surgical table, it was difficult to achieve front access to the hip joints of more muscular or obese patients. Nonetheless, over a three-year period, the percentage of my hip replacement patients having anterior surgery at Abington grew from 10 percent to over 50 percent.
That number will likely climb to 80 or 90 percent shortly now that Abington recently acquired and put into service an innovative surgical table specially designed for anterior approach surgery and available in only a few hospitals nationwide. The advanced design of the hana™ Hip and Knee Arthroplasty Table, allows us to work through a smaller incision, with the patient’s leg extended downward. We can then hyperextend, adduct and rotate the hip for proper femoral positioning without disturbing or detaching tissues. Conventional operating-room tables do not allow such manipulation.
The new technology of the hana™ table also enables x-ray imaging to determine leg length with greater control and improved implant placement. At Abington, we use contemporary ceramic, metal or plastic hip replacement devices in anterior, as well as conventional arthroplasty.
Having performed joint replacement surgery now for over 20 years, it is so gratifying to have many of our anterior patients feel well enough to ask to go home within a day after their surgery. Of course, our goal at Abington is always to do things safely, so we discharge our patients as quickly as is possible clinically. Their enthusiasm is so encouraging to our entire clinical team including the nurses who care for our patients post-operatively. None of these patients has suffered a dislocation of the joint following surgery.
Best of all, we are helping patients—who were in pain and limiting movement—to enjoy physical activities and a fuller life again, more quickly.
Andrew M. Star, MD, is Chief, Orthopaedic Surgery Division and Director, Joint Replacement Surgery, at Abington Memorial Hospital (www.amh.org).