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Minimally Invasive Hip Surgery With Anterior Approach
Gone are the days when the only way to replace a hip was to place the patient in a lateral position and make an incision 8-12 inches long.
Minimally invasive procedures are being developed in many areas of medicine to decrease morbidity. The anterior approach to hip replacement is definitely meeting that goal and has become a focus in the advancement of minimally invasive total joint replacement.
Excellent patient results have been consistently seen throughout the 10 years of using this approach with more than 100 patients each year.
Benefits to Patients
The patient experiences many benefits because the technique allows surgeons to preserve the primary support muscles, nerves and soft tissues surrounding the joint. A natural plane in the anterior portion of the hip easily allows spreading of the muscles and gives direct access to the hip joint. The abductor muscles and tendons remain intact. This preservation enables patients to walk the day of surgery and experience less postoperative pain.
Other benefits include:
- Faster rehabilitation. There is more stability post operatively. Therapy can be half the traditional 6-8 weeks. Patients are ambulating directly after surgery utilizing a walker and also progress to a cane sometimes within 24 hours. A quicker return to activities of daily life is often seen.
- Better recovery time. A majority of patients are discharged on post op day one. If needed they will stay in the hospital but it’s rare to have a patient stay beyond post op day two.
- Fewer complications. Early ambulation can potentially decrease the incident of DVT and embolic phenomenon long term. Venous system is much less compromised. Narcotic analgesics can be discontinued earlier.
- Little to no hip precautions. Patients can position their legs as tolerated at any time after surgery, and the chance of dislocation is significantly decreased.
- Smaller incision. At just 3 to 5 inches with this approach, patients experience less pain and faster healing.
How the Technique Is Performed
The technique is performed with the patient in a supine position. A special fracture table can be used to keep both legs free. A standard operating room table can also be used with the Omni tract retractor. The legs are draped out separately and can be moved independently.
The benefits for supine approach allow for use of fluoroscopy to determine the exact placement of the components. We typically utilize fluoroscopy to make sure that we have a level pelvis without any flexion, extension or rotation in the supine position. Fluoroscopy is utilized to ream the acetabulum and verify version. The abduction angle can be estimated by pointing the apex of the acetabular shell just inferior to the sacral iliac joint on the fluoroscopic image. In an average case, actual fluoroscopy time is less than a minute.
The prosthesis can be the same as with a conventional approach, although some companies provide a bone sparing femur that is smaller “microplasty” shorter in length. Specialized retractors provide the needed exposure. Surgeons can place full length uncemented, cemented and revision type stems through this approach. This approach has also been very successful for polyethylene liner and head exchanges.
Skin closure for an anterior hip is done differently. Muscle and tendons do not need reattached. A subcuticular stitch covered with dermabond and steri strips remains intact much better than a bulky lateral hip dressing.
These are just some of the basic benefits to patients: a smaller incision, a very minimal chance of dislocation, less pain, faster healing, smoother rehabilitation and a quicker return to daily activities. These result in higher patient satisfaction and lower overall cost for the hospital and patient.
Dr. Tim Conlan and Dr. Jeffrey Dulik are orthopaedic surgeons who practice at Aultman Hospital with Spectrum Orthopaedics. They have offices in Canton and Massillon.
MD News March/April 2011, Cleveland/Akron/Canton