Mini-Posterior Approach for Hip Replacement

The mini-posterior approach to hip replacement surgery involves dividing the muscle by separating – not cutting – muscle fibers at the side or the back of the hip. This method insures that muscle function is preserved.

Advantages of the Mini-Posterior Approach for Hip Replacement

• As with the anterior approach, the mini-posterior approach is muscle splitting and not muscle cutting.
• Many believe the mini-posterior approach to be the simplest and easiest approach, thereby providing the greatest safety margin for the patient. 
• The speed of recovery is equal to the anterior approach.
• Exposure of both the hip socket and the femur is straightforward.
• Due to ease of exposure, there is minimal risk of femoral fracture or poor positioning of the implant.
• The risk of neurologic injury is less.
• Because of ease of exposure, any component system and any type of fixation can be used.
• No special surgical equipment is required.
• The majority of major teaching institutes in the United States continue to perform and teach the posterior approach as their primary approach.
• It is by far the most common approach used by surgeons throughout the world.

Disclaimers for all Hip Replacement Approaches

The incidence of dislocation after hip replacement has been dramatically diminished by improved technology and improved surgical techniques. With the advent of “large head” hip replacement systems, the risk of hip dislocation has effectively been eliminated. In the hands of an experienced surgeon, both the anterior and the mini-posterior approaches can produce excellent results, and the recovery time is the same for both approaches.

I believe it is important to stay focused on the important issues:  excellent long-term results and minimizing risk of injury or complication in the short term or long term.  Though it is important to discuss new procedures and technology with your surgeon, in the end, you need trust that the surgeon you have chosen will choose what is best for you. My advice is to pick your surgeon based on reputation, experience, and the feeling of trust and personal connection you get.

The Anterior Approach

It has been clearly shown that there is no difference in recovery time between the posterior and anterior approaches. And with the advent of “large head” hip replacement systems, the single possible advantage of alowered risk of hip dislocation has effectively been eliminated. As with many things, what is old becomes new as weconstantly strive to both reinvent and improve tried and true procedures. Sometimes this leads to better methodsof treating patients. And sometimes these “new” recycled methods work no better the second or third timearound. What is really new in our modern medical world is the hype and marketing in the lay press of all thingsnew before scientific proof of success is available.My word of advice to patients remains this: Stay focused on the important issue – the long term results.

Though itis important to discuss new procedures and technology, in the end let the surgeon in whom you place your trustpick what is best for you. All that is new is not necessarily better, and this is especially true of ideas that have thatmay have had a past history of problems or failures.

New Tools, New Anesthesia, New Therapy Means Big Changes in Hip Replacement

David Heuck’s biggest regret about his minimally invasive hip replacement was not having it done sooner. Recovery times are much shorter with this procedure.

http://stanfordhealthcare.org/medical-clinics/orthopaedic-surgery-clinic-los-gatos.html/presentation-mode/stanford-health-now/2011/heuck-hip-replacement

Why I No Longer Use the Anterior Approach for Primary Total Hip Replacement Surgery

- See more at:

http://holycrossleonecenter.com/blog/longer-use-anterior-approach-primary-total-hip-replacement-surgery/

As a surgeon with a specialty practice in hip and knee replacement surgery, patients rely on my expertise.  Recently, a patient asked me why I no longer use the anterior approach for total hip replacement.  I stopped performing this procedure because in my experience there are no advantages to the surgery, rather a number of potential disadvantages.  Simply, I couldn’t continue to use a procedure that I could not trust to deliver every time.

With the mini-posterior approach, there is significantly less bleeding which reduces post-operative anemia. In my experience, recovery is more consistent because patients feel better and stronger more quickly.  Also, the need for a blood transfusion is minimized. In fact, I find in my practice that having to transfuse someone after surgery is rare. However, there is increased blood loss associated with the anterior approach and more patients develop symptomatic anemia, increasing the likelihood of a transfusion.

Exposing the femur for reconstruction is more difficult with the anterior approach. As a result, many surgeons will use a special table to aid in this technique. Regardless, the positioning of standard-length, time-tested stems is more difficult when approaching anteriorly. Because of this, most of the major orthopedic manufacturing companies now are producing new, shorter stems which are much easier to place.  How these stems will perform over the years remains to be seen, as with all new prosthetics being devised. The surgical community has hope that this new crop of short stems will do well. Time will tell.I felt the anterior approach is limited what type of femoral stem I could use. With the mini posterior approach, I can choose the best stem for the patient, not the procedure.

As a revision surgeon, I also carefully consider every next step and “what if” as I construct an implant. No matter how carefully a surgery is performed, at some point a femur will fracture from an accident or an old replacement will wear out. If a fracture occurs during an anterior approach, it is much more difficult to fix and often requires a separate incision. I’ve also seen a number of patients who were treated with the anterior approach by other doctors and developed complications associated with a non-recognized fracture that became apparent during the post-operative course. If a fracture occurs during a mini posterior approach, I believe it is easier to assess and also relatively simple to lengthen the existing incision to fix the fracture.

The mini-posterior approach involves separating the muscle fibers of the gluteus muscle located at the side and the back of the hip. Because the muscle fibers are separated, not cut, the nerve path is not disturbed. There are a number of studies that have gauged the muscle damage resulting from both approaches by measuring the levels of specific muscle enzymes that elevate when muscle is harmed.  Many of these studies do not show a significant difference between either approaches.  The amount of muscle damage in an individual case is directly related to a surgeon’s experience, technique and how gently tissues are handled. It’s also related to the specific patient’s anatomy.

I encourage patients to be very active after surgery, and most stop using a walker or cane, can drive their cars and are exercising in the pool, just two weeks after surgery.

Patients continue to “teach” us what they can and cannot do. When components are optimally positioned, the soft tissue is reconstructed well, and the mechanics are optimized, the incidence of complications is very minimal.

Finally, I’ve spoken to a number of orthopedic surgeons who will offer the anterior approach to their patients if requested. They privately have shared with me that the decision to perform the anterior approach stemmed from patient demand and the need to remain competitive in the surgical community. While I understand, I am not willing to continue to use a procedure that I feel cannot deliverconsistently optimal results.

As with any surgery, choosing the right surgeon is as important as the procedure.  Talk candidly with your surgeon about his or her experience, success rates, incidence of short- and long-term complications and what procedure, technologies and prostheses will be right for you. Most importantly, you need to feel comfortable not only with the orthopedic surgeon but with the entire staff as well.  I use a team approach to provide state-of-the-art orthopedic care combined with a high level of personal attention to make your entire experience comfortable with the best possible outcome.

Anterior vs. Posteriorminimally Invasive Surgical Approaches
for Total Hip Replacement

	Anterior	Posterior
1. Origins of Modern Incision	Many generations old. Historically known as the “Smith-Pete” approach.	Many generations old. Historically known as the “Southern Approach”.
2. Incision Length	8 – 10 cm long depending on difficulty of case	Same
3. Blood loss – risk of transfusion	Greater	Less
4. Preservation – protection of hip muscles during surgery	The claim that the Anterior Approach is completely muscle sparing is false. Classically it exposes the joint by splitting through the interval between Tensor and Sartorius muscles. To lessen the high risk of Lateral Femoral Cutaneous nerve damage, most surgeons have moved the incision laterally and split through the middle of the fibers of the Tensor muscle. The top external rotator muscle (Piriformis) attaches at the proper insertion site for the femoral component and must be cut to properly insert and position the component. The Piriformis cannot be repaired from this approach. Net effect: equal of posterior approach at muscle preservation.	Gluteus maximus muscle is split (not cut) along their fibers thus preserving and protecting them (no repair is necessary). The top two of the 4 small external rotators (Piriformis and Superior Gemeli muscles) are divided and later repaired with no impact on overall hip strength. Net effect: equal of anterior approach at muscle preservation.
5. Risk of nerve damage	Greater. The Lateral Femoral Cutaneous nerve, supplying sensation to the thigh is at significant risk to permanent damage. The femoral nerve innervating the Quadriceps muscle is also at some risk. There is risk to a temporary Sciatic nerve injury due to vigorous operative retraction.	Rare. In experienced surgeon’s hands, risk is near zero.
6. Risk of fracture of femur	Greater. Due to difficulties of exposure, risk of femoral fracture significantly higher with the Anterior Approach due to need to lever on the bone to gain exposure. Risks higher still in patients with osteoporosis.	Minimal. Exposure of the femur is easier necessitating less vigorous retraction.
7. Risk of Improper Implant Positioning	Higher. Intraoperative x-rays required. The femur is especially difficult to expose, and the same factors that can lead to fracture can lead to improper implant positioning affecting both short and longterm functioning of the hip.	Lower.
8. Hip Dislocation Risk	Risk is very low. Dislocations, when they do occur, are anterior and very disabling since they occur when the patient externally rotates the leg while standing, walking or participating inrecreational activities.	Risk is very low. Dislocations when theydo occur are posterior and can be avoided by not sitting on low seats (thus since easily avoidable are not as disabling).
9. Hip Dislocation Risk: Impact of Modern Hip Implants	Modern “large head” hip implants very stable, making dislocations much less likely than in the past and much less of an issue in pre op decision making.	Same.
10. Need for Postop “Hip Precautions”	No specific precautions needed.	Same.
11. “Position of Risk” for dislocation	Standing with leg externally rotated.	Sitting in very low chair with hip hyper flexed and internally rotated and crossed one leg over the other.
12. Postop Weight Bearing Status	Full.	Same.
13. Time in Hospital	1 to 2 nights (3 for older patients). One night stay is possible for motivated patients with proper support at home.	Same.
14. Time on Walker – Crutches	Patient may wean off as tolerated. Younger fit motivated patients will be off walker after a few days.	Same.
15. Need for Physical Therapy	Minimal.	Same.
16. Time to Driving	In part a question of liability and in part depending on “left vs. right” hip. Usually in a few weeks, but ultimate answer is whenever a patient feels he/ she can safely handle a car.	Same.
17. Special Surgical Equipment Required	Some surgeons initially require use of an expensive special operative table to aid in femoral exposure, but with greater operative experience most have subsequently have determined this to be unnecessary.	None required.
18. Time to return to work	1 – 2 weeks to sedentary job / 1 – 3months heavy job (motivation issuesimportant)	Same.
19. Time to return to sports	3 -4 weeks light recreational (golf) / 6 – 12 weeks vigorous sports (tennis, snow skiing)	Same.