Hip replacements are procedures that are carried out when all or part of a damaged hip is replaced by an artificial joint. How does the anterior approach compare to more traditional operative procedures? Esteemed consultant trauma and orthopaedic surgeon, Mr Jose Blanco, shares his expertise in the operation. The Kettering-based surgeon also discusses what you should know pre- and post-operation, like who a good candidate is and how it is done, as well as risks to be aware of and what to expect from recovery.
Is anterior hip replacement the "best" hip replacement method?
I think this is a really controversial question. Even amongst orthopaedic surgeons, certainly, in the UK, there is a degree of controversy about it. The implants are the same, the method of implanting them is the only thing that changes. The reason I think the anterior approach to the hip is so valuable is that rather than cutting through muscles like other procedures, the muscles are just moved out of the way.
This is hugely beneficial; there is less scarring, less damage to the nerve supply to each individual muscle, and less bleeding. The muscles may be a little bit bruised afterward, but certainly nothing in comparison to the more aggressive approaches where the muscles are detached and then reattached. Therefore, the recovery is really accelerated. The majority of patients having day-case surgery are having anterior approaches to the hip. In some ways, the UK is lagging behind other countries, such as France, where about eighty per cent of hip replacements are done through the anterior approach.
Whilst we remain very traditional and although there is certainly value in being conservative and continuing to get good results with the normal hip procedure, the anterior approach may be the difference between being back to work within two weeks or being back to work within eight weeks. Whether that’s important to an individual patient or not, we should be offering patients a quick recovery.
The final outcome after about a year is identical. We're not trading long-term survivorship or long-term function for short-term gain. From my point of view, the anterior approach to the hip is an excellent technique with real benefits for the recovering and rehabilitating patient in the short term.
Who is eligible for anterior hip replacement?
Anterior hip replacement, in theory, can be performed on anyone. The benefits of causing less damage to the muscles, soft tissues, bones, tendons, and muscles can be optimally achieved in a slimmer and taller patient. The surgery becomes more challenging in the case of patients with a very short neck of their femur, which would be identified with x-rays, patients who are carrying a lot of weight around the abdomen, or patients who are quite short. There is an increased risk of bruising the soft tissue if they need to be pulled and pushed. In such instances, some of the benefits of the anterior approach to the hip are lost.
How is anterior hip replacement performed?
The anterior approach to the hip is performed in a very similar way to a traditional approach in the sense that we use a surgical table. But one of the big differences is that with traditional approaches, the patient is put on their side, whereas the anterior approach is performed with the patient lying on their back.
The incision is approximately ten to twelve centimetres in the front of the groin. The operation is performed through that approach, sometimes with a special table that allows us to pull the leg and rotate it out to the side. I often do my surgery without a special table, and it means that we can move the hip around where we want it to be, while still giving us access to the pelvis as well as to the femur itself.
Are there risks specific to anterior hip replacement?
The main risk is damage to one of the nerves right at the front of the groin that supplies the patch of skin to the outside of the leg. The risk of damage is just under four per cent generally and is not permanent, though it can be on occasions. Often, it'll cause a burning or electric shock sensation as moving and stretching the nerve causes bruising, but eventually, it settles back down.
There is a risk with certain types of implants fracturing the bone, but this is associated with all types of uncemented hip replacements. For a long time, there was a published increased risk of infection or maceration of the skin, generally, around the wound. Typically, that occurs in patients who are carrying some excess fat around the abdomen where there's more moisture and the wound can struggle to heal in that environment. Modern dressings and additional caution and care ensuring the area is cleaned and kept sterile have reduced this risk. Personally, I have only seen one infection over the last five years.
When can I return to work after anterior hip replacement?
We shouldn't underestimate that it is a big procedure, like all hip replacements. However, generally, people are walking on the hip on the same day and they are able to stand up with minimal discomfort around the groin itself within about 4 to 6 hours after the surgery. As the spinal anaesthetic wears off, the pain can become more established and it’s normal for patients to see some discomfort in the first couple of days or so. Most patients are back at work within two weeks, depending on the nature of their work. With traditional approaches, it can be about 6 to 8 weeks.
How can I speed up recovery after anterior hip replacement?
With an operation that's already so accelerated compared to traditional approaches, there's not a huge amount that you can do.
One of the most important things is to be as healthy as possible prior to the surgery. Your fitness, both in terms of the local muscles around the hip, the pelvis, and the core as well as your general fitness will benefit you. If you have a good, healthy diet that you really keep on top of, this allows the pain relief to make sure that you're never in excessive pain. After the surgery, you’ll be able to do more and function more effectively and that will help with the recovery, and also help to prevent complications.
If you are interested in hearing more about the anterior hip replacement technique or finding out about more options that are available, you can book a consultation with Mr Jose Blanco directly via his Top Doctors profile today.