HIP APPROACHES

approaches to the hip for tha direct anterior approach anterior-lateral approach gibson approach and posterior approach southern approach

DIRECT ANTERIOR APPROACH

Muscle Sparing. The Direct Anterior (DA) approach to the hip is minimally invasive because its muscle-sparing.  When defining the term “minimally invasive” its important to recognize that skin incision size is important, but its not the whole story.  The amount of muscle stripping and reflection is probably more important to postoperative pain and speed of recovery.  The DA utilizes native inter-nervous muscle planes to approach the hip leading to less muscle injury (in contrast to both anterior-lateral and posterior-lateral, which require greater degrees of muscle reflection) [1] [2].

Early Recovery.  Multiple studies suggest that DA reduces immediate postop pain, systemic inflammation, and allows earlier functional recovery [1, 3, 4] [5] [6] [7] [8] [9].  In comparison to the posterior or antero-lateral approach, the DA shows:

Improved postop pain scores

Reduced pain medication

Improved Function

Decreased length of stay

Greater discharge home

It is unclear how many weeks postop the DA offers improved outcomes compared to other approaches.  Some studies suggest the improvements last only 2 weeks [7], while others suggest 6 weeks [5, 6] [10], or 6 months to 1 year [11]. 

Functional outcomes after 6 weeks diminish. 

Increased Stability.  Lower dislocation rates have been shown because the posterior capsule and soft tissue is preserved, protecting the hip during sitting (where it most susceptible to dislocation) [12] [13]

Learning Curve. Femoral Exposure can be a challenge in this approach and a sequential series of capsular releases are essential to obtain the necessary exposure, leading to higher complication rates in surgeons changing approaches [14] [15].

Femur Fracture. The acetabulum is very accessible during the DA, however, the femur is less accessible.  Broaching is a challenge, and the femur can be torqued or over tensioned to obtain exposure.  The combination of these challenges have lead to an increased rate of femur fracture via this approach [16] [17] [18]. 

Technique. Patient Positioning and Sequential Capsular Releases are the keys to the procedure. The patient can be placed supine on a standard radiolucent table or placed on a specialized table, such as the Hana Table. C-arm fluoroscopy is typically available in the room.  On a standard table the pubic symphysis is placed over the break in the table, and a small bump is placed under the coccyx slightly off-center (closer to the operative side).  During femoral exposure, a femoral elevator (hook that goes posterior behind the the femur) is fixed to the table and pulls the proximal femur out of the wound, while the table is “opened” – foot of table dropped to 45° and the bed is 15° of Trendelenburg.

 

POSTERIOR APPROACH

The posterior approach remains the gold standard for THA.

Extensile.  Gives excellent exposure distally to access the entire femur.  Gives excellent exposure proximally to access the posterior wall and acetabulum. When broaching the femur, the surgeon is in-line with the femoral shaft, giving excellent access and low risk for femoral cortex injury. 

Dislocation risk.  While initial studies suggested increased risk of THA dislocation with the posterior approach, a meticulous soft-tissue repair [19] and larger femoral head [20]significantly reduces dislocation risk, and rates are similar to other approaches (anterolateral and direct anterior) [21] [22]. Other studies suggest a persistent slightly higher risk for posterior [23] [24].  However, hip precautions are recommended for posterior approach regardless of the quality of soft tissue repair.  Precautions are not required for DA [25].  Because hip instability is related to both patient factors (ie compliance) and surgical factors, patients are faced with additional risk factors for dislocation with the posterior approach (as compared with DA).

REFERENCES

1.         Alecci, V., et al., Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: perioperative findings. J Orthop Traumatol, 2011. 12(3): p. 123-9.
2.         Bremer, A.K., et al., Soft-tissue changes in hip abductor muscles and tendons after total hip replacement: comparison between the direct anterior and the transgluteal approaches. J Bone Joint Surg Br, 2011. 93(7): p. 886-9.
3.         Bergin, P.F., et al., Comparison of minimally invasive direct anterior versus posterior total hip arthroplasty based on inflammation and muscle damage markers. J Bone Joint Surg Am, 2011. 93(15): p. 1392-8.
4.         Noth, U., et al., [Minimally invasive anterior approach]. Orthopade, 2012. 41(5): p. 390-8.
5.         Parvizi, J., C. Restrepo, and M.G. Maltenfort, Total Hip Arthroplasty Performed Through Direct Anterior Approach Provides Superior Early Outcome: Results of a Randomized, Prospective Study. Orthop Clin North Am, 2016. 47(3): p. 497-504.
6.         Zawadsky, M.W., et al., Early outcome comparison between the direct anterior approach and the mini-incision posterior approach for primary total hip arthroplasty: 150 consecutive cases. J Arthroplasty, 2014. 29(6): p. 1256-60.
7.         Rodriguez, J.A., et al., Does the direct anterior approach in THA offer faster rehabilitation and comparable safety to the posterior approach? Clin Orthop Relat Res, 2014. 472(2): p. 455-63.
8.         Christensen, C.P. and C.A. Jacobs, Comparison of Patient Function during the First Six Weeks after Direct Anterior or Posterior Total Hip Arthroplasty (THA): A Randomized Study. J Arthroplasty, 2015. 30(9 Suppl): p. 94-7.
9.         Goebel, S., et al., Reduced postoperative pain in total hip arthroplasty after minimal-invasive anterior approach. Int Orthop, 2012. 36(3): p. 491-8.
10.       Berend, K.R., et al., Enhanced early outcomes with the anterior supine intermuscular approach in primary total hip arthroplasty. J Bone Joint Surg Am, 2009. 91 Suppl 6: p. 107-20.
11.       Restrepo, C., et al., Prospective randomized study of two surgical approaches for total hip arthroplasty. J Arthroplasty, 2010. 25(5): p. 671-9 e1.
12.       Matta, J.M. and T.A. Ferguson, The anterior approach for hip replacement. Orthopedics, 2005. 28(9): p. 927-8.
13.       Matta, J.M., C. Shahrdar, and T. Ferguson, Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res, 2005. 441: p. 115-24.
14.       D'Arrigo, C., et al., Learning curve in tissue sparing total hip replacement: comparison between different approaches. J Orthop Traumatol, 2009. 10(1): p. 47-54.
15.       Yi, C., et al., Early complications of anterior supine intermuscular total hip arthroplasty. Orthopedics, 2013. 36(3): p. e276-81.
16.       Spaans, A.J., J.A. van den Hout, and S.B. Bolder, High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach. Acta Orthop, 2012. 83(4): p. 342-6.
17.       Berend, K.R., et al., Risk of Periprosthetic Fractures With Direct Anterior Primary Total Hip Arthroplasty. J Arthroplasty, 2016. 31(10): p. 2295-8.
18.       Barnett, S.L., et al., Is the Anterior Approach Safe? Early Complication Rate Associated with 5090 Consecutive Primary Total Hip Arthroplasty Procedures Performed Using the Anterior Approach. J Arthroplasty, 2015.
19.       Pellicci, P.M., M. Bostrom, and R. Poss, Posterior approach to total hip replacement using enhanced posterior soft tissue repair. Clin Orthop Relat Res, 1998(355): p. 224-8.
20.       Howie, D.W., et al., Large femoral heads decrease the incidence of dislocation after total hip arthroplasty: a randomized controlled trial. J Bone Joint Surg Am, 2012. 94(12): p. 1095-102.
21.       Kwon, M.S., et al., Does surgical approach affect total hip arthroplasty dislocation rates? Clin Orthop Relat Res, 2006. 447: p. 34-8.
22.       Khatod, M., et al., An analysis of the risk of hip dislocation with a contemporary total joint registry. Clin Orthop Relat Res, 2006. 447: p. 19-23.
23.       Sheth, D., et al., Anterior and Anterolateral Approaches for THA Are Associated With Lower Dislocation Risk Without Higher Revision Risk. Clin Orthop Relat Res, 2015. 473(11): p. 3401-8.
24.       Hailer, N.P., et al., Dual-mobility cups for revision due to instability are associated with a low rate of re-revisions due to dislocation: 228 patients from the Swedish Hip Arthroplasty Register. Acta Orthop, 2012. 83(6): p. 566-71.
25.       Restrepo, C., et al., Hip dislocation: are hip precautions necessary in anterior approaches? Clin Orthop Relat Res, 2011. 469(2): p. 417-22.