Anterior Approach to Total Hip Replacement - A Muscle Preserving Philosophy

Introduction
When debilitating pain and stiffness in your hip limits your daily activities, you may need a total hip replacement. The development of total hip replacement began over 40 years ago. In 2004, more than 224,000 people in the United States underwent conventional hip replacement surgery to relieve pain and stiffness and restore mobility (Solucient, 2004). Today, there are many options in hip replacement surgery. This article focuses on the similarities and differences between conventional hip replacement and the Anterior Approach to hip replacement.

When conservative methods of treatment (medications, physical therapy, etc.) fail to provide adequate relief, total hip replacement is considered. If your X-rays show destruction of the joint, you and your surgeon will decide if the degree of pain, deterioration and loss of movement are severe enough that you should undergo the operation. Total joint replacement is a successful operation that has transformed the lives of many people by enabling them to regain activity with reduced or no pain. It allows them to return to an active, enjoyable lifestyle.

The Hip Joint
A joint is a junction where two or more bones meet. The hip joint forms where the top of the femur (thigh bone) meets the acetabulum (the socket of the pelvic bone). The top of the femur is ball-shaped and fits snugly in the socket formed by the acetabulum.
 
The bones of the hip joint are covered by a layer of smooth, shiny cartilage that cushions and protects the bones while allowing easy motion. Tough fibers, called ligaments, connect the bones of the joint to hold them in place and add strength and elasticity for movement. Muscles and tendons play an important role in keeping the joint stable.
 
Treatment Options
Your doctor carefully considers factors such as age, health status, weight, and activity levels before determining the appropriate treatment method. Non-surgical treatment options may be suggested for less severe hip pain. These treatments may include rest, drugs and analgesics. When non-surgical options fail to provide adequate pain relief, hip replacement may be suggested. If you are in pain, you should discuss treatment options with your surgeon. One such option is hip replacement using the Anterior Approach .
 
Traditional Total Hip Replacement
Total hip replacement or total hip arthroplasty is the surgical replacement of the ball and socket of the hip joint with artificial parts called prostheses. There are two main modular components used in total hip replacement. The femoral stem and ball component is made of metal and replaces the worn out top of the femur. The acetabular component, that includes a cup and liner, replaces the socket. These components may be made of metal, ceramic and polyethylene combinations.
 
In traditional hip replacement surgery, a surgeon will make an incision along the side of your leg in order to access your hip joint. The natural ball portion of the top of the femur (thigh bone) is removed during surgery. The remaining preparation of the femur (thigh bone) and acetabulum (socket) involves reshaping to allow solid, accurate insertion of the hip components. The femoral component is inserted inside the thigh bone and the acetabulum is inserted inside the socket of the pelvis.
 
The Anterior Approach - A Muscle Preserving Philosophy
The Anterior Approach is an alternative to conventional hip replacement surgery. This technique approaches the hip joint from the front as opposed to the side or back. Unlike conventional hip surgery, a surgeon can work between your muscles without detaching them from the hip or thigh-bones. These important muscles are left relatively undisturbed and are therefore spared a lengthy healing process. Keeping these muscles intact also helps prevent dislocations. Further, since the incision is on the front side of the leg, you may be spared from the pain of sitting on scar tissue.

Advanced Surgical Table & Instruments

The Anterior Approach utilizes a technologically advanced table and special instruments. This table allows your surgeon to precisely position your hip for surgery, enabling your surgeon to accurately position the replacement components for proper hip joint mechanics. Special instruments and implant components allow for less tissue disruption.
 

Advanced Surgical Table 

Your Hip Evaluation
An orthopaedic surgeon specializes in problems affecting bones and joints. The surgeon will ask you many questions about your hip symptoms, as well as your general health to determine if hip surgery is safe and appropriate for you. The evaluation will include a careful examination and review of your X-rays and other tests. This will help the surgeon understand your pain and limitations in activity and the progression of your hip problem.
 
After your history is taken, a physical exam is performed. The range of motion of your hips and knees is measured and your muscle strength is evaluated. The surgeon will observe how you walk, sit, bend and move.
 
X-rays are taken of your hip joint. Bring any previous hip X-rays with you to help your surgeon plan the surgery and evaluate the fit of your new hip prosthesis.
 
Before Surgery
You will likely be asked to see your family physician or an internal medicine doctor for a thorough medical evaluation. To prepare yourself for surgery, you may be asked to do a number of things: including weight loss and smoking cessation. If you smoke, it is important for you to stop smoking two weeks prior to surgery.
 
It is essential that you tell your surgeon about any medications or supplements you are taking. Bring a list of all medications and dosages. If you are taking aspirin or certain arthritis medications, inform your surgeon; you may need to stop taking these two weeks before surgery. If you are taking aspirin under the direction of a physician for vascular or cardiac reasons, your doctor may advise you to continue taking it as directed. You may want to ask your doctor to donate your own blood ahead of time for a possible transfusion during surgery.
 
Your Surgery
Usually patients are admitted to the hospital the morning of surgery. You cannot eat or drink anything after midnight the day of surgery.
 
The Recovery Room
You will awaken after your surgery in the Post-Anesthesia Recovery Room. You will remain there until you have recovered from the anesthesia, you are breathing well, and your blood pressure and pulse are stable. You may feel as though you only left your room for a few minutes. If you experience pain, medication will be available. Post-operative pain control is started immediately in the recovery room.
 
What To Expect After Surgery
You may move both legs as soon as you awaken. The nurse will help you find comfortable positions. The nurse will encourage you to do ankle pumping exercises every hour to help protect against blood clots.
 
An IV is seldom used for more than 24 hours. You will quickly begin regular fluid and food intake in the hospital under the direction and advice of your surgeon.
 
You may have a tube or drain coming through the surgical dressing that is attached to a drainage apparatus. This system provides gentle, continuous suction to remove any blood that may accumulate in the surgical area. The drain will probably be removed soon after surgery. Your dressing will be changed and a smaller one applied.
 
To prevent problems in your lungs, you may receive a device called an incentive spirometer after surgery to encourage you to cough and breathe deeply. This is used every hour while you are awake.
 
It is normal to feel discomfort after surgery, but severe post-op pain resolves very quickly. With modern pain management techniques, there is no reason to suffer. Inform the nurse of your pain, and medication will be ordered.
 
Improved Patient Recovery
The Anterior Approach is a tissue sparing procedure. It seeks to help patients freely bend their hip and bear full weight immediately after surgery. This may result in a better and faster recovery. Conventional hip replacement surgery, in contrast, typically requires strict precautions for several months. You need to discuss your specific situation with your surgeon.
 
Physical Therapy
Isometric exercises (tightening muscles without moving the joint) will begin while you are still in bed. You will be instructed to do these exercises a number of times per day while awake. You will be encouraged by the physical therapist to move your ankle and other joints so that you will remain strong.

You will be taught about joint replacement recovery and will rapidly start walking and doing exercises.

The physical therapist will check your progress daily and will keep your surgeon informed. Pain medication may be taken prior to your physical therapy if you request it.

Progress
The usual hospital stay for hip joint replacement is two to four days. 

The therapist will teach you how to dress and get out of bed without help. You will continue to work to strengthen yourself in preparation for your return home.

It is important for you to adhere to your doctor's directions and follow proper positioning techniques throughout your rehabilitation. By the time you leave the hospital, you will normally be progressing well in regaining mobility and stability. If your sutures or clips require removal, you will be advised about who will remove them and where this will be done. It is not uncommon to still experience some pain. Remember that full recovery may take two to three months.

Preparing To Go Home
Just prior to your discharge, you will receive instructions for your in-home recovery. Until you see the surgeon for your follow-up visit, you must take certain precautions.

Look for any changes around your incision. Contact your surgeon if you develop any of the following:

• Drainage and/or foul odor coming from the incision.
• Fever (temperature about 101 degrees F or 38 degrees C) for two days.
• Increased swelling, tenderness, redness and/or pain.

Take time to adjust to your home environment. It is okay to take it easy.
 
Returning to Regular Activities
Your recovery is based, in part, on your condition prior to surgery. Rehabilitation is hard work and recovery takes time. By sparing your major muscles from being cut during surgery, you may experience a faster recovery.
 
Many patients undergoing the Anterior Approach to hip replacement surgery are back to normal activities within a few weeks.
 
You usually may begin driving once you are able to bear full weight on your hip, usually within 5 to 7 days. Be sure you are comfortable with your strength, and practice driving in a safe area. You may resume driving when you are comfortable with your mobility.
 
Sexual intercourse may be resumed at any time as long as it is comfortable.
 
During recovery, you should continue to be active in order to control your weight and muscle tone. It is generally two to three weeks before you can resume low-impact aerobic activities such as bicycling and swimming. Jogging, high-impact aerobics and certain sports can be resumed after two to three months. Running, however, is not advised. Remember, your new hip is artificial, and although made of extremely durable materials, it is subject to wear and tear.
 
After one to two months, many patients report having little or no pain at all. In the end, it is your responsibility to discuss and follow a plan set forward with your surgeon.
 
Medication/Pain Control
It is normal for you to have some discomfort during recovery. You will probably receive a prescription for pain medication before you go home. If a refill is needed, please call your surgeon's nurse a few days before you run out of pills. Contact your surgeon if your discomfort or pain increases.
 
Special Instructions
The Anterior Approach seeks to remove serious restrictions from your recovery period.
In order to check up on your progress, you will likely be seen three to four weeks after your surgery, then again after six and twelve months. You should see your surgeon every other year after the first year.
 
Any infection must be promptly treated with proper antibiotics, because infection can spread from one area to another through the blood stream. Every effort must be made to prevent infection in your artificial joint. You should always tell your dentist or physician that you have an artificial joint before undergoing any treatment.