The Anterior Approach. 

It’s about precision, it’s about anatomy and it’s about the patient. The nuances of the anterior approach drastically changed the way hip replacement is delivered and the result.

I was at a meeting in the early 2000’s when I heard two surgeons behind me speak of a new way to perform Hip Replacement surgery. At that time, the complication rate for hip replacements was NOT low. The incision was long, frequently painful and the dissection was brutal. Component positioning was frequently inaccurate. Limb length was frequently off and worst of all, dislocation, which required the patient to endure a painful trip to the ER to put the hip back in was as high as 10%. I felt that I was well trained and that the components were durable, but I was frustrated by our inability to deliver a more consistent product. I didn’t know it at the time, but this bus ride would change everything for me.

I’d always hoped for a way to add precision both in limb length and restoration of unique anatomy. I anticipated a day when we would have “eyes” or x-ray imaging live in the surgery theatre to confirm that the hip replacement was done exactly. At that time the post op x-rays weren’t obtained until after the patient returned to clinic or at best in the recovery room. Both of which were too late to affect a change.

As soon as I got home, I booked a plane ticket to Los Angeles, CA where I met Dr. Joel Matta. I was astounded at the solutions to issues of the previous generation of hip replacements. The x-rays that we took during that case showed exact reproduction of the patient’s anatomy. There I saw for the first time what has become known as the Hana table. This table allows the surgeon to position a patient so that reproducible x-rays can be taken before the case starts. After every stage of the case, confirmation x-rays can be taken. I was introduced to a small incision that went between two muscles; notably, not on the side and not in the front, but in the middle or about a 1:30 position on a clock face. This is much less intrusive to major muscles, tendons and tissue.

Upon my return to Ogden, I immediately spoke to hospital administration and began the process of training and acquiring equipment. The training took me back to Los Angeles, Texas, and then to Las Vegas to study cadavers. There were three surgeons in Utah that were learning the technique at the same time. My colleagues in Salt Lake acquired the very expensive equipment a few months before I did, so I spent time scrubbing in with them and refining the technique. By the time I did my first case I felt I had learned the new procedure well. 

In Fall of 2007, I performed Ogden, Utah’s first Anterior Approach Hip Replacement. A nice gal with incapacitating pain agreed to be that first case. The entire staff and x-ray crew were tasked with learning new procedural steps, and it took a little longer than normal, as you can imagine, but I felt the operation went extremely well. Following surgery that day, I was giving a symposium regarding new developments in the field of hip replacement. The room was packed with folks interested in this “new thing” in joint replacement. The head nurse on the floor approached me while I was giving the talk to update me on the patient. “She’s doing amazing!” she said. She asked if I’d like her to come down. Anxiously I agreed and then with astonishment we all watched as this first Anterior Hip Replacement patient walked into the auditorium with a smile on her face. No limp, no cane, and no walker, mere hours after having a surgical hip replacement.

One of the then unknown advantages of the anterior approach is that patients just don’t hurt. This first patient asked me that afternoon if she could go home. I hadn’t thought of it since the norm of the time was days in the hospital, but very quickly agreed that she had met criteria. For me and my practice, outpatient surgery had begun.

Initially, only thin patients were thought to be treatable this way. However, within a few years every hip replacement that I did was through the anterior approach. Going from the front allowed incredible precision and exact component positioning. Errors seen in postop films became a thing of the past now that limb length could be scrutinized to the eighth of an inch while in the operating room. Over the years, I developed techniques using x-rays, patient assessment using blocks, and soft tissue tensions that ensure reproduction with appropriate, equalizing length. 

Another benefit to the advance was a significant decrease in dislocations. Prior to the anterior approach, dislocations were probably the worst thing that could happen to a patient, and the patient’s surgeon! The moment a dislocation occurs is terrifying and horribly painful. It requires an ambulance and a crew to carry the patient to the hospital for x-rays, which are frequently followed by attempts to tug on the leg to reduce the hip. If it can be reduced, the fear that it dislocates again is forever on a patient’s mind. Often, it required another operation. Frequently, the implant would need to be made longer to tighten up the tissues to stabilize the hip but resulted in incorrect length and frequently more pain. All hip replacement surgeons dread the phone call where the emergency room doctor tells the story of dislocation. It’s a terrible moment, one that all of us wish we never ever received. The reason the anterior hip replacement technique has remarkably fewer dislocations is that tendons called the external rotators as well as the posterior capsule are not violated. When patients sit down and stand up from a toilet or a couch or bend over to tie their shoes, they have the tendons and capsule intact to do so. This has been a game changer.

Former dislocation precautions or limitations of movement were arduous. Patients were tasked with trying to not bend or twist or put any stress on the joint. The use of elevated toilets seats, wedges between legs while sleeping and near immobilization for up to six weeks while soft tissues healed and stabilized the hip was the norm. Today, with the anterior approach, patients can live relatively normal lifestyles right after surgery. Patients can use normal toilets, sit on everyday chairs, and frequently return to community functions that weekend and are ready for work by Monday. 

Most surgeons who choose the anterior approach do not incorporate formal physical therapy. The basic recommendation is don’t twist or bend too much. Be gentle on the new hip. This is all that is required.

Helping to usher in this breakthrough in surgical care has been one of the most gratifying experiences in my joint replacement career.