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Anterior Approaches for Hip Replacement in Seattle, WA

Approaches to the Hip

In 1939, Dr. Marion N. Smith-Peterson originated and popularized the direct anterior approach to the hip for placing hip prostheses.1 For many years, the approach was called the Smith-Peterson approach. It was known to be an extensile, direct, muscle-sparing approach into the hip that provided good visualization of the acetabulum. Smith-Peterson used a resurfacing femoral head prosthesis that had no stem. As stem-supported femoral prostheses were developed, placing them in the femur using this approach became more challenging.

Positioning the femur to achieve direct access to the femoral shaft requires the use of curved femoral prostheses. Many of the early total hip prostheses had a curved stem, and the anterior approach was used. With the development of longer and straighter femoral stems, other approaches also became popular.

Currently, 4 approaches are used for total and partial hip replacement and hip resurfacing. The posterior approach is quite popular because of its ease and direct access to both the acetabulum and extensile access to the femur. The patient is placed in a decubitus position, and a curved incision following the direction of the gluteus maximus muscle is made. This muscle is carefully retracted, and the small external rotator muscles are detached from the greater trochanter and are preserved for later reattachment.

Postoperatively, the skin incision for a posterior approach is not very apparent, and cosmetic concerns are rarely an issue. The hip is dislocated by flexion and internal rotation, and both the femur and acetabulum come into direct view even with smaller incisions. The two anterior approaches are the anterolateral and direct anterior.

No controlled studies describe convincing proof that one approach is superior to another. However, postoperative hip instability is less of a concern with the direct anterior and anterolateral approaches compared with the posterior approach. In addition, the anterolateral and superior approaches have the lower complication rate among the 4 common approaches (i.e., direct anterior, anterolateral, posterior and superior). The superior approach is more demanding to find the correct interval but it can be executed in the side lying position.

Anterior Approaches

The direct anterior (Smith-Peterson) approach is made with the patient in the supine position. The entire hip and leg can be dropped free or the patient's feet can be placed in traction to assist in working inside the femur. The approach and positioning maneuvers are the same with or without the traction table.

The selection of the anterior approach may be preferred when there is a significant flexion contracture or if there is prior anterior scar from prior surgical procedures or femoral catheterization. Femoral artery catheterization is performed on the right side in 95% of patients.

The skin incision is made anteriorly using the anterior superior iliac crest as a landmark. The incision is extended distally, as needed. The surgical approach is between the tensor fascia lata and sartorius muscles, so the approach is muscle sparing. The dissection is carried down the joint capsule, which is opened. If the tendon of the rectus femoris is a barrier to dislocating the hip, it is released and repaired later. Anterior retractors are carefully placed.

The lateral femoral cutaneous nerve is directly in the way for the anterior approach. Identifying and retracting this nerve is important to avoid including it in the closing repair. Numbness and pain from this nerve are common with the anterior approach, but motor function is not affected. The common femoral nerve and sciatic nerve are injured with equal frequency in the anterior approach compared to the posterior approach. There is more blood loss with the anterior and anterolateral approaches compared to the posterior and superior approaches.

Intraoperative radiographs are more easily obtained with anterior and anterolateral approaches compared to posterior or superior approaches. The sciatic nerve is more accessible with the posterior approach.

Once the hip joint is entered, the hip is dislocated by adduction and external rotation. After the femoral head is dislocated, it can either be removed using a saw for total hip replacement or resurfaced. With the femoral head removed, direct access to the acetabulum is available, and the acetabular component can be placed with direct visualization and, if desired, with intraoperative radiographic imaging, as well.

The access to the femur is created by bringing the femur into external rotation, adduction, and extension. For surgeons who use a special table, achieving additional extension by dropping the patient's operative leg below the height of the table is helpful. The use of the table requires a skilled assistant to avoid injury to the patient.

Usually, use of a curved femoral stem and preparation tools to work inside the femur are still needed. Current survivorship data support the use of a curved femoral prosthesis as comparable to straight stem prostheses. Special offset broach handles are very helpful for anterior hip approaches.

Anterolateral Approach to the Hip

The anterolateral approach to the hip has been one of the most commonly used approaches for total hip replacement around the world for the last 40 years. It provides excellent and safe access to the hip, and hip dislocation following the anterolateral approach has been uncommon. No special tables or instruments are necessary for anterolateral approaches, although broach handles can facilitate the approach.

The patient is placed in a supine or, if desired, a lateral position on the operating table. A straight lateral incision is made, and dissection down to the fascia Iata follows. The interval between the vastus lateralis and abductor muscles is developed. The abductor can be released and repaired later with the closure. The hip capsule is identified and opened, and the hip is dislocated by traction and external rotation. The femoral head is then removed, allowing direct access to the acetabulum. The femur is placed into a figure-of-four position for broaching.

Virtually any type of prosthesis can be used with the anterolateral approach. Because of retraction of the abductors with this approach, some patients can have a limp lasting for 3-4 weeks and a longer period to regain abduction strength. This approach results in stable hip, superior limb-length symmetry, and is considered versatile across a wide range of implant choices.

Anterior Approach to Hip Replacement in Seattle, WA

James W. Pritchett, MD, is a board certified orthopedic surgeon who specializes in the anterior approach to total hip replacement. Dr. Pritchett provides the highest quality and advanced treatment for joint pain relief to patients in the Seattle, Washington area. To learn more about hip replacement surgery, schedule an appointment with Dr. Pritchett at his office - 901 Boren Avenue North, Suite 900.



References

  1. Smith-Peterson MN. Arthroplasty of the hip. A new method. J Bone Joint Surg Am. 1939;21:269-288.
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Last Modified: April 20, 2018