By Moby Parsons, MD

Total hip replacement is now in its 4th decade of development as a treatment for end stage hip arthritis. It is considered by patients, surgeons and healthcare economists to be one of the most successful operations in all of medicine given its ability to improve comfort and function and return patients to work, recreation and leisure time physical activities. Throughout its 40 year history, engineers and surgeons have focused on improving the material and techniques of this surgery to facilitate a fast recovery and to extend the lifespan of the prosthesis. One such recent technical advancement is the resurgence in interest in performing the operation through the anterior approach, which allows access to the hip joint through the front rather than the back.

The anterior approach was first described over a hundred years ago and was a popular technique in the early 20th century. However, the posterior approach became the workhorse method for total hip replacement in the 1980s, 90s and early 2000s based on surgeon familiarity and ease of exposure. The posterior approach, however, requires the surgeon to divide the large gluteus maximus muscle on the back of the hip and to detach several smaller muscles on the back of the hip joint in order to access the joint. While these muscles are repaired at the end of the procedure, there is some risk that their detachment may lead to increased risk of dislocation and a more prolonged recovery due to the damage and subsequent healing that comes with muscle detachment.

Recognizing these drawbacks, the anterior approach has come back into favor with the general trend in orthopedics of tissue sparing, less invasive surgery. This approach uses natural planes between muscles to access the hip and does not require any muscle detachment. As such, recovery of comfort and function is faster, and patients may be able to resume activities such as driving, return to work and return to sports earlier than when compared to the posterior approach. Furthermore, because there is no muscle detachment, the hip replacement may be more stable and less prone to dislocation.

Other advantages of the anterior approach include the use of intraoperative Xray imaging which allows the surgeon to confirm the size, position and orientation of the hip replacement components. This allows better restoration of leg lengths and proper muscle tension, improved hip stability and likely improved prosthesis durability by optimizing the mechanics of the joint. As this approach has gained increasing popularity in recent years, the majority of patients presenting with hip arthritis are suitable candidates to have a hip replacement using this technique.