Painful Joints Can be Replaced

A forward-thinking approach to hip replacement surgery brings faster healing



Illustration by Stephen Sauer

Spring is here and, our wimpy winter notwithstanding, no doubt you are looking forward to the strolling, golfing, gardening and other outdoor delights that the season offers - well, unless you're one of the millions of Americans who suffer from chronic hip pain, that is. In that case, you might be calculating how many anti-inflammatory pills you're likely to need to see you through some of those spring pleasures.

If you're considering hip replacement surgery, good news: a newly popular surgical technique, called direct anterior hip replacement, offersnotable improvements over traditional hip surgery, including a shorter hospital stay, less post-operative pain and faster healing time.

Healthy hips have a cushion of cartilage where the thigh bone meets its socket in the hip, but like tread on a tire, cartilage wears down with use, says Akhil Sastry, MD, an orthopaedic surgeon with Sports Medicine Atlantic Orthopaedics in Portsmouth and York, Maine, and Portsmouth Regional Hospital.

As the cartilage thins, pain can develop and become progressively worse, triggering a cascade of problems, from loss of motion and decreased muscle tone to a diminished capacity to walk for extended periods of time and an inability to participate in certain events, activities or work, says John T. Lynn II, MD, an orthopaedic surgeon at New Hampshire Orthopaedic Center in Nashua, Londonderry, Manchester, Amherst and Salem. After finding no real relief from less-invasive measures such as anti-inflammatory drugs, physical therapy and steroid injections in the hip, "people get to the point where they say, 'That's it. I want to get the hip replacement done,'" Lynn says.

Traditional, or posterior, hip replacement surgery begins with an incision in the patient's backside. Direct anterior hip replacement surgery takes the opposite approach. The idea of making the incision in the front of the hip is not new; it's been around for 50 years or so, Lynn says. But the development of a special operating-room table has sparked renewed interest in the technique. "With the 'hana' table, I'm able to manipulate and move the patient's leg and hip in a manner that makes it easier to access and be more predictably successful in performing the operation," Lynn says. "It's like having an extra pair or two of hands."

With posterior hip replacement, the surgeon cuts through the gluteus maximus muscle in the patient's derriere, along with smaller muscles and tendons, to reach the hip joint and perform the repair. After surgery, traditional hip replacement patients can typically expect some discomfort for a while - the surgical worksite was in their backside, after all, and most people spend a fair amount of time sitting - and for four to six weeks, they must adhere to hip precautions, including not bending their hips past a certain degree, sleeping with a wedge between their legs and using an elevated toilet seat, Sastry says. Such precautions are necessary to prevent putting stress on the area of the cut and reattached muscle, he says. (Alternatively, some surgeons make the hip replacement incision in the side of the hip, which also necessitates cutting through muscle and calls for a lengthy rehab period, Sastry says.)

In contrast, an anterior approach allows the surgeon to nudge aside muscles and tendons rather than cut them to gain access to the hip joint. Post-operative restrictions are pretty much nil. "You don't have to follow any precautions," Sastry says. "You can bend your hip as far as you'd like, but in addition to that, the recovery time seems to be faster because none of the muscles are cut - they're all left undisturbed."

In addition, with an anterior hip replacement, "rehab is much, much quicker," Lynn says. Whereas posterior hip replacement patients might have four to eight weeks of out-patient therapy after their surgery, anterior patients typically only need two or three weeks, he says. "For a posterior approach, it may be six to eight weeks before people are starting to feel like they're getting back to themselves," Lynn says. With anterior surgery, "I'm seeing, in two or three weeks, people are getting back to work, getting back into activities. It cuts it in half at least," he says.

Anterior hip replacement patients are likely to spend less time in the hospital after surgery too. "The stay tends to be a little shorter," Lynn says. "Typically it's three or four days for the posterior approach; I'm seeing two or three days for the anterior approach," he says. "So, shorter hospitalization, less rehab, quicker on your feet and the cost savings are pretty dramatic," he says.

The only apparent downside to the anterior procedure compared with traditional hip replacement surgery is that there tends to be slightly more blood loss, Lynn says. "I think partially that's related to, with a posterior approach, you're basically compressing your incision because you're sitting on it, so that helps decrease the blood loss," he says. The increased blood loss is "not dramatic," he says, just something surgeons should be aware of and strive to improve.

Limitations on what patients can typically do after they've fully recovered from anterior hip surgery "has more to do with the implant than it does the surgical approach," Sastry says, because the implants used in hip replacement surgery are the same regardless of whether the surgeon's approach is anterior or posterior or from the side. The more stress you put on an implant - by, say, running long distances or playing squash rather than swimming and hitting the elliptical machine - the higher the chance that the implant will wear out more quickly. Patients should use good judgment and weigh the risk to their hips against their enjoyment of high-impact activities, Sastry says. But in general, no matter which surgical approach is used, 95 percent of implant patients can expect their new hips to last for at least 15 to 20 years, he says.

Clearly, the benefits of anterior hip replacement over traditional hip replacement surgery come in the initial days and weeks following surgery. "At a year out, there's no difference in the results," Lynn says. And, whether hip replacement surgery begins in the front, back or side, patients still run the same risk of infection, blood clots and dislocation. "None of that changes," Lynn says. Direct anterior hip replacement surgery "is not this perfect, no-problem operation. But, in my opinion, it has so many benefits that I'm sold on it, and it's all I use."

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