Tuesday, November 28, 2023

Total Hip Replacement Anterior Approach Protocol

What Should You Do To Prepare For Hip Replacement

“Anterior” Total Hip Replacement Precautions- BEWARE!

Once you have decided to discuss anterior approach hip replacement, call my office for a consultation date. If you have a date already, make arrangements for time off work. The duration of time will vary from person to person and specific occupation. It is also preferable if you have someone with you after surgery. This is only necessary until you are mobile enough to be independent. If you smoke, stop. Smoking significantly increases your surgical risks and complications.

Bactroban Nasal Ointment We will giving you a prescription for Bactroban ointment to apply to your nasal passages to prevent staph infections during surgery.

Directions for use: Apply generously inside each nostril with a separate Q-tip for each nostril and each application. This is done twice a day starting 5 days before your surgery, so that you finish the last application the night before surgery.

Hibiclens Body Wash

This is given to also help reduce skin bacteria at the incision site. Wash the affected body part once or twice a day for 5 days prior to surgery. You can also use the morning of your surgery.

Post operatively we recommend that you use dial antibacterial soap to gently clean your incision. You will be allowed to shower 24-48 hours after surgery and begin washing the incision. DO NOT take a tub bath or soak the incision for 2-3 weeks post operatively.

Early Mechanical Complication And Cementing Technique

Early revision due to femoral stem under-sizing and inadequate femoral stem positioning and fixation have been associated with the anterior approach, especially early on in the learning curve, possibly due to inadequate exposure and visibility.38,44,81,83,84 Ponzio et al,26 on the other hand, found a reduced rate of early revision compared to the posterior approach in a retrospective study of 4538 THA cases, interestingly including the learning curve in the anterior hip group. The Anterior Total Hip Arthroplasty Collaborative Investigators,38 in a multi-centre study of 1277 DAA THA cases, report an early revision rate of 2.7%, of which 1.3% is attributed to femoral loosening, and note that there was a significant correlation between surgeon and early revision. The adequacy of the exposure even for cementation has been demonstrated in a cadaveric study by Mayr et al,85 who found no difference in cement mantle between the lateral and the anterior approach.

As for the femoral component positioning, varus implantation has been reported in as many as 7.5% of cases82 during the learning curve, but there does not seem to be a difference in comparison to posterior or lateral approaches,35,63 and in some studies significantly better stem positioning has been achieved with the anterior approach,12 possibly due to the intraoperative use of fluoroscopy.

Why Might I Need A Total Hip Replacement With Anterior Approach

If you are having problems with your hip, your healthcare provider may first advise other treatments. These include medicine for pain or inflammation, walking aids, and physical therapy. If you keep on having pain and have a hard time getting around, hip replacement surgery may be an option.

The purpose of most hip replacements is to treat pain and damage from arthritis. In osteoarthritis, long-term wear-and-tear damages the joint. In rheumatoid arthritis, inflammation causes pain, swelling, stiffness, and tissue damage. Other reasons for getting a hip replacement include:

  • Broken or injured hip
  • Bone that has died because it didn’t get enough blood

Total hip replacement with anterior approach is not an option for everyone. You may have other surgical choices, such as standard total hip replacement. Talk with your healthcare provider to see what makes sense for you.

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Early Postoperative Pain Scores And Patient

Randomized controlled trials


Currently there are no large RCTs comparing the early and medium-term outcomes of different surgical approaches for THA. In the current literature the DAA seems to be superior to the LA and equal to or superior to the posterior approaches. To offset the small number of patients in the RCTs, meta-analyses have been conducted. Miller et al17 pooled data from 13 prospective comparative studies comparing the anterior and posterior approaches for short-term outcomes, concluding that the anterior approach was superior in terms of pain scores and hip function. Similarly, Putananon et al18 conducted a meta-analysis using data from 14 RCTs showing the superiority of the anterior approach in terms of early outcomes compared to the lateral and posterior. On the contrary, Higgins et al19 in their meta-analysis of 17 studies, including both prospective and retrospective, found no significant difference in outcomes between anterior and posterior approaches. However, they found superiority of the anterior approach in terms of reduced hospitalization and dislocation rate.

Large retrospective studies

Who Should Consider Direct Anterior Approach Total Hip Replacement

Left Total Hip Replacement via Anterior Approach

Joint replacement should be considered when:

  • Arthritis is affecting a patients quality of life
  • Arthritis is affecting a patients ability to function normally
  • Arthritis is moderate to severe on xrays
  • Patients are healthy enough to safely undergo an elective procedure
  • The benefits of the surgery outweighs the risks of the surgery
  • For most patients who have hip arthritis, pain is also a significant limitation. Pain is a fairly subjective measure however, and some patients who have a high pain tolerance may be able to live with pain for many years. For most patient, quality of life is the most important factor in making a decision towards surgery.

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    Preparing For Anterior Hip Replacement Surgery

    I found a lot of what I did before my surgery was very helpful during my recovery from anterior hip replacement, said Roger B. Probably the most important thing I did was get in shape. Ive always tried to incorporate physical activity into my daily routine, but I made it a point to visit the gym more often than I normally did in the weeks and months leading up to my surgery. I also increased the length of my walks through the neighborhood as much as I could given the pain I was in.

    I was 72 years old when I had my anterior hip replacement surgery and my kids were grown-ups. My orthopedic surgeon had advised me to arrange for someone to help me since I wouldnt be able to drive or do certain things around the house for several weeks after my procedure. So, I called one of my daughters who agreed to help me out. Knowing my daughter was going to stay with me took a lot of pressure off when it came to taking care of everything else I needed to get done to prepare for my surgery. It also helped that she arrived in town several days before my operation and was able to help with my last minute preparations.

    In addition to making arrangements for your post-operative care and getting in better shape, there are other things you can do to prepare for your anterior hip replacement surgery, including the following:

    These steps will help you prepare for your surgery:

    What Happens During A Total Hip Replacement With Anterior Approach

    Your healthcare provider can tell you what to expect. An orthopedic surgeon with special nurses will do the surgery. An anesthesiologist will make sure you don’t feel any pain during it. The surgery may take a few hours. In general:

    • You will likely get general anesthesia so that you can sleep through the surgery. If you get regional anesthesia, you may also get medicine to make you relaxed and sleepy.
    • Medical staff will closely watch your heart rate, blood pressure, and other vital signs before, during, and after the surgery.
    • You may get antibiotics to help prevent infection.
    • The skin around the surgical site will be cleaned. Any hair will be removed.
    • The surgeon makes a cut in front of your hip joint.
    • The surgeon separates your muscles to see your hip joint.
    • The surgeon removes the upper part of your femur and the damaged cartilage and bone from your pelvis.
    • The surgeon replaces your acetabulum and the head, neck, and part of the shaft of your femur with an artificial joint.
    • The surgeon may take an X-ray to make sure the joint is in the right place.
    • The surgeon or an assistant will close up the incision.

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    What To Expect After Anterior Hip Replacement

    After having an anterior total hip replacement you can expect the following:

    • Procedure and Post Procedure
    • Outpatient robotic hip surgery ranges from 60-90 minutes and once patients are stable they can go home
  • Patients will go home with a walker for balance and are up walking within a few hours of surgery
  • Patients can shower the same day as surgery
  • Physical Therapy
  • Patients often do not require formal physical therapy after an anterior hip replacement
  • Walking after your hip replacement is the best therapy for patients, which is why they begin walking within an hour of surgery
  • What Will My Experience Be Like With Direct Anterior Hip Replacement

    Hip Precautions & How To Follow Them – Total 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.

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    Anterior Hip Replacement Surgery Recovery

    As the less invasive approach to total hip replacement surgery, the anterior technique allows for a shorter recovery and rehabilitation time. This means patients can return to daily activities and even go back to work sooner. However, the recovery process still involves distinct phases to ensure the tissue is healing properly and that you will have maximum functionality.

    Although each patient is different, there are a few things you can anticipate during the recovery process after anterior hip replacement surgery. However, your progression depends totally on your unique set of circumstances. One of the greatest advantages about recovering from an anterior approach to hip replacement as opposed to the posterior is that you wont have to follow any specific anterior hip replacement precautions like not bending past 90 degrees or crossing your leg. This is because there is less risk of dislocation and less leg length discrepancy with the anterior technique.

    After undergoing an anterior hip replacement surgery, here are some of the phases of the recovery process you can expect:

    During the antererior hip replacement recovery time, your doctor and your physical therapist will work together to ensure you are on track for a successful recovery. They will be looking out to make sure you reacquire full balance, your tendons and muscles stretch properly and your muscles regain their full strength.

    Proximal And Distal Extension Of The Skin Incision

    One of the major points of criticism of DAA is the potentially limited extensibility and possible obscure intraoperative exposure. In a cadaveric study, Grob et al67 found that the distal extension between TFL and vastus lateralis endangers the transverse and descending branches of the lateral femoral circumflex artery along with their accompanying motor branches for VL and vastus intermedius , cautioning against possible denervation of these two muscles. The authors advocated using the subvastus approach to pass cerclage wires as a safer route for the neurovascular structures. Ghijselings et al68 conducted a cadaveric anatomical study and demonstrated that the position of the distal neurovascular bundles is, for the most part, stable in reference to anatomical landmarks, and predictable. They concluded that distal extension is feasible and proximal femoral cerclage wiring can be safely performed. Nogler and Thaler69 in their cadaveric study showed that by dividing the iliotibial band and utilizing the subvastus rather than the intervastus approach, a safe distal access can be easily achieved. The proximal aspect of the approach can be easily extended utilizing the originally described Smith-Petersen approach. This approach has been successfully used, especially in complex revision cases where reconstruction of anterior and medial wall defects was deemed necessary.70

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    Anterior Hip Replacement Dos And Donts

    Immediately after hip replacement surgery, a patient is given a list of precautionscertain movements and activities that should be avoided in order to protect the new hips ball and socket from injury, particularly dislocation. Unlike other types of hip replacements, anterior hip replacements require few, if any, precautions.

    See Post-Surgical Hip Replacement Precautions and Tips

    For example, people who have traditional hip replacements are told not to bend at the hip more than 90 degrees for about 6 weeks. This precaution makes it challenging to sit on low chairs, sofas, or toilets. Anterior hip replacement patients do not have to follow this precaution.

    Stories From Our Patients

    Left Total Hip Replacement via Anterior Approach

    Roger B. was a police officer for nearly thirty years before he underwent double knee replacement surgery in the late 1990s. I knew I needed to have my knees done for years before I actually had the surgery. Even though it was painful to do my normal daily activities, I had to postpone the surgery for as long as I could because my wife had suffered a series of devastating strokes and needed my help on the home front. When I realized I couldnt tend to her the way I needed to, thats when I knew I couldnt put the surgery off anymore.

    After my wife died several years ago, I resumed fishing and some of the other things I wasnt able to do during the years leading up to her death. On one fishing trip, I stumbled on the beach and ended up twisting in a way that wasnt natural. From that point on, I had never-ending pain in my right hip. I tried, in vain, to reduce the pain by changing the way I walked, taking over-the counter pain medication, getting shots in my hip joint, etc., but nothing helped. When I realized I couldnt pick up my granddaughter anymore because of the pain and I couldnt sleep for more than an hour or two at a time because of my discomfort, I knew I had to do something.

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    What Happens During An Anterior Approach Total Hip Replacement

    During a total hip replacement, the ball and socket in the hip bone are cleaned and replaced. With anterior approach total hip replacement, a surgeon starts by creating a small incision on the front of the body as opposed to the traditional posterior approach. An anterior total hip replacement allows for a faster recovery and less downtime for patients because the surgeon can spare muscle and tissue as opposed to cutting them .

    Typically, recovery and rehabilitation time can be cut by several weeks using the anterior approach total hip replacement technique.

    The surgeon uses precision instruments to remove the damaged cartilage and bone from the socket. The new hip is a durable prosthetic. The damaged part of the femur is replaced with a metal stem and a ball is placed on top of the stem to recreate the ball and socket of the hip.

    Anterior approach total hip replacement is recommended for people who have had trauma to their hip or have had damaged caused by arthritis or years of wear and tear.

    A patient may consider hip replacement if they are experiencing:

    • Persistent hip pain despite pain medication
    • Hip pain that worsens when walking
    • Hip pain that interferes with your sleep
    • Hip pain that affects your ability to walk up or down stairs
    • Hip pain that makes it difficult to rise from a seated position
    • Stiffness in the hip

    Advanced Exercises And Activities

    The pain from your hip problems before your surgery and the pain and swelling after surgery have weakened your hip muscles. In addition, the muscles around your hip prior to total hip replacement became short and tight because your hip didn’t move. A full recovery will take many months, and it will take time for your muscles to recondition and get used to your new hip that moves freely. The following exercises and activities will help your hip muscles recover fully.

    These exercises should be done in 10 repetitions, 4 times a day. Place one end of the tubing around the ankle of your operated leg and attach the opposite end of the tubing to a stationary object such as a locked door or heavy furniture. Hold on to a chair or bar for balance.

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    What Happens Without Surgery

    The natural history of denegeratie arthritis is that symptoms tend to progressively worsen over time. Arthritis may have a “waxing and waning”pattern, with good days and bad, but over the course of time, symptoms have a tendency to become persistent. Typically the progression is slow, generally over several months or years, but this is generally very difficult to predict.

    Arthritis is not a life threatening condition however. There is, generally speaking, never a “need” to have surgery for arthritis may have effects on a patients cardiovascular health, weight, etc. which are difficult to predict or quantify.

    What Is The Recovery Time

    Anterior Approach Total Hip Arthroplasty

    Hip replacement surgery is now much less invasive, with less tendon and muscle trauma, less bleeding, less pain and less life interruption. Patients recover more quickly and return to work and activities within weeks rather than months. Anterior approach hip replacement patients are up and walking immediately following surgery and regain range of motion, strength and flexibility after several weeks of physical therapy. Hospital stays have been reduced to one or two days and the vast majority of patients can go directly home without having to use a rehabilitation center. As with all surgical procedures, specific recovery time varies by patient and demand.

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