Total Hip Replacement (Direct Anterior Approach)
If you need a hip replacement, you may be worried about what lies ahead. That’s natural and understandable—but you will be pleased to learn that, in terms of outcome, a hip replacement is one of the most successful operations you can have. Though they sound dramatic and off-putting, hip replacements can be counted upon to reliably deliver pain relief and restore quality of life.
A type of hip replacement surgery called the direct anterior hip approach can make the early recovery after surgery even better. This is a minimally invasive technique. With anterior hip replacement, the surgeon makes a small incision near the front of the hip to allow for removal of damaged bone and cartilage, and implantation of an artificial hip without damaging surrounding muscle and tendons. Patients leave the hospital sooner than they would with some other approaches.
Lee Rubin, MD, an orthopedic surgeon and chief of the Yale Medicine Joint Replacement Program, is a leading expert in the direct anterior approach. He is one of the few surgeons in the U.S to have learned the approach directly from Kristaps J. Keggi, MD, a Yale Medicine orthopedic surgeon who was among the first to recognize the benefits of the direct anterior approach. Since Dr. Keggi started performing direct anterior hip surgeries in the 1970s, the technique has sparked the evolution of minimally invasive hip surgery, according to Dr. Rubin. “As a result of this innovation, hip surgery has become a positively transformative experience for my patients,” he says.
What is the direct anterior hip approach and how is it different?
A total hip replacement is exactly what it sounds like—a surgery to replace a natural hip joint that has worn out or been damaged with an artificial one. There are several surgical approaches that generally follow the same path: Your surgeon makes an incision near the hip joint, carefully extracts the diseased or damaged bone and cartilage, then inserts an artificial hip and secures it in place. (Your new hip might be made out of metal, plastic, or ceramic—or some combination of those materials.)
The direct anterior approach is a minimally invasive way to perform hip replacement surgery, and surgeons who perform it say it has advantages over traditional approaches. For example, the incision for the direct anterior approach is only three or four inches, compared to up to 12 inches with the traditional approach. Also, recovery after surgery is generally quicker. Patients typically go home sooner than with other approaches, have less pain, and can reach therapy milestones more rapidly after the procedure.
Why is this? The key difference is in how the surgery is done. The direct anterior method is considered “muscle sparing” because it does not involve cutting into (and later repairing) muscles and tendons to reach the damaged bone and tendon. Instead, the surgeon gently pushes the groups of muscle and ligaments aside, inserts the implants, and then moves them back to their proper position.
Because the anterior approach is more technically demanding, some surgeons use a minimally invasive posterior approach. This involves making an incision of about four to five inches on the back of the hip, while the patient lays on their side on the operating table. The posterior approach involves detaching some muscles and tissues to reach the hip joint. However, the surgeon avoids cutting into abductor muscles, which are the major walking muscles.
There has been much debate about which minimally invasive approach is better. While some surgeons may continue to prefer the posterior approach, the anterior approach may become more popular as more surgeons learn the technique.
What will my experience be like with direct anterior hip replacement?
You and your doctor will decide whether you should have general or regional anesthesia. An example of regional anesthesia is a spinal anesthetic, which injects anesthesia into the spinal canal to reduce pain without loss of consciousness. You can expect the surgery to take up to several hours. Your care team will monitor your heart rate and other vital signs throughout the procedure.
You should be able to start moving around within hours after your surgery. You may even be able to go home the same day.
What are the benefits of the direct anterior hip approach?
Because the surgeon does not cut through muscle and soft tissue areas, you will typically have less pain and better mobility after the surgery, go home from the hospital sooner, use less pain medicine, and be able to heal well without extensive physical therapy.
Studies have shown patients who have the anterior hip approach walk on their own as much as six days earlier than those who have traditional surgery.
What are the risks of direct anterior hip replacement?
A hip replacement is one of the safest, most effective operations you can have, but all surgical procedures carry some risks. One risk of hip surgery is hip dislocation, especially in the weeks after the operation. However, because the muscles and soft tissues are preserved and play a role in preventing hip dislocation, you are less likely to dislocate your hip after hip surgery using the anterior approach.
One risk of surgery unique to the direct anterior hip approach is a numbness of the skin in the front of your thigh. This can occur because of stretching in the skin nerves. It typically resolves after a few months.
With most hip replacements—and many surgeries—the risks have less to do with the surgical approach than with the patient’s general health. As with any surgery, it’s important to talk to both your anesthesiologist and your surgeon about your age, your weight, any medications you may be taking and your general health, and let them know if you are a smoker. All of these things can impact your risks.
Why should you go to Yale Medicine for a direct anterior hip replacement?
Yale Medicine Orthopedics & Rehabilitation is a leader in all types of total hip replacement surgeries. Our surgeons are skilled in providing minimally invasive approaches that may not be easy to find elsewhere. These are approaches that can mean smoother surgical experiences and quicker recoveries.
Yale Medicine has special expertise in anterior hip replacement surgery. In 2016, Dr. Keggi and Dr. Rubin published the first comprehensive textbook for surgeons on the direct anterior approach, summarizing more than 40 years worth of expert knowledge on the topic. In addition, Dr. Rubin continues to research, author papers, and teach on the subject, helping to advance the field into the future for surgeons across the country and around the world.
Yale Medicine surgeons also have reported dramatic improvements among geriatric hip fracture patients who are been treated through the Fragility Hip Fracture Program at Yale New Haven Hospital. This program established processes in the emergency room for prioritizing patients who have had traumatic hip fractures, providing pain control and scheduling surgery as quickly as possible.