What’s the Best Way to Replace a Hip?

Wound Closure Surgical Video and Imaging Pain Management Orthopedics

By: Joe Paone | Senior Editor

Published: 10/3/2022

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Surgeons must decide between the anterior and posterior approaches, which are both safe and effective.


The anterior or the posterior approach — which is better for total hip replacements? The debate has raged in the orthopedic community at conferences, in journals and online as surgeons often discuss the technique that causes the least amount of postoperative pain, allows patients to mobilize soon after surgery and results in wounds healing more rapidly.

Kimberly Bartosiak, MD, and Charles Hannon, MD, MBA, two assistant professors of orthopedic surgery in the Division of Joint Preservation, Resurfacing and Replacement at Washington University Orthopedics in St. Louis, took the debate out of academia and conference halls and brought it directly to YouTube. Here, Drs. Bartosiak and Hannon compare numerous aspects of total hip replacements through the prism of each approach.

Clinical considerations

The posterior approach has long been the workhorse technique for hip surgeons, but that is changing as the direct anterior approach gains supporters (see “Direct Anterior Approach Increasing in Popularity”). However, viewing the choice between either approach as binary is reductive. Drs. Bartosiak and Hannon believe both options are safe and effective, and either could be the superior option based on the needs of individual patients.

“I don’t think there are absolute indications for an anterior approach over a posterior approach, but there are patients who I think would benefit from the former,” says Dr. Hannon, who performs both methods. “For example, patients who are at high risk of dislocation due to significant lumbar spine disease or previous lumbar fusion, or who had a hip replacement on the other side that’s well positioned, would benefit from the anterior approach because the data is clear that it is definitely more protective of dislocation postoperatively than the posterior approach.”

Dr. Bartosiak, who exclusively employs the posterior approach, says, “I occasionally come across a patient who I think would benefit from an anterior approach to minimize dislocation risk. These patients are often thin, ligamentously lax women without much arthritis who have a diagnosis of osteonecrosis.” In such cases, Dr. Bartosiak refers her patients to a surgeon who performs the anterior approach.

Dr. Hannon says patients are optimized for hip replacement surgery the same way, regardless of the approach used. “When it’s being done by the right surgeon consistently on a regular basis using modern protocols, I think the approaches are nearly equivalent,” he says.

Surgeons should focus on addressing modifiable risk factors before surgery, such as working to get patients’ BMIs below 40, getting them to quit smoking and weaning them off any narcotics they’re taking, notes Dr. Hannon. He says failure to address these risk factors could result in poor outcomes, pain, infection and even revision surgery.

The key to efficiency and success is to have consistent teams who work with the surgeon on a regular basis.
— Charles Hannon, MD, MBA

Surgeons who employ either approach are prescribing far less opioids than they had been thanks to multimodal pain management techniques. “We used to give patients 90 to 120 opioid pills after surgery,” says Dr. Hannon. “Now, we’re giving 30. As we refine multimodal strategies even further, we’re going to hopefully get to a point where we’re not giving patients any opioids and can individualize pain protocols for patients based on their demographic and medical risk factors.”

The biggest change that has been made in the care of these patients has been the use of tranexamic acid to limit surgical bleeding and decrease the need for blood transfusion, according to Dr. Bartosiak, who says, “Tranexamic acid is now standard in joint replacements.”

Both approaches take about an hour to complete on average, according to Dr. Hannon. “The key to efficiency and success is to have consistent teams who work with the surgeon on a regular basis and are comfortable with the equipment,” he says. “The value-add that provides is amazing in terms of efficiency in the OR, particularly in surgery centers.”

Proponents of the anterior approach laud its relative muscle-sparing benefit compared to the posterior approach. However, outcomes between anterior and posterior are not radically different. The anterior approach might offer a slightly quicker recovery, but it’s not that significant. “The best study I’ve seen compares a surgeon who does posterior hips to a surgeon who does anterior hips, with both doing them extremely well,” says Dr. Bartosiak. “It showed that patients came off of a cane about a week earlier with the anterior approach.”

The practical effect of this result is that the anterior approach can be an intriguing option for younger, fitter and more demanding patients who want to get back to normal activities as soon as possible. “Those six days may matter to them,” says Dr. Bartosiak.

Capital equipment needs

Dr. Hannon says the posterior approach does not require a specialized table. For the anterior approach, he says, surgeons can use a regular table or a specialized traction table with a translucent surface designed to provide single-incision access to the joint and the opportunity to take intraoperative X-rays. 

When performing an anterior hip, many surgeons use fluoroscopy or C-arm imaging, according to Dr. Bartosiak. When performing a posterior hip, she says, surgeons typically employ a single-shot X-ray. “There are some benefits to working with an intraoperative image,” says Dr. Bartosiak, noting that she typically takes one to evaluate the component position, leg length and restoration of the patient’s anatomy following the hip replacement. The X-ray allows for imperfections in those variables to be resolved intraoperatively.

Dr. Bartosiak is increasingly using an intraoperative computer navigation system that allows her to position the implant even more precisely. “Two pins are placed in the iliac crest with a camera mounted to them and a small tracker is located in the greater trochanter,” she says. “The system gives nearly all the same information as an X-ray.” Her goal is to eventually move away from intraoperative X-rays entirely in favor of using the image guidance system.

Metal-on-metal implants are still occasionally used during hip resurfacing procedures, which are uncommon but employed for some athletes engaging in high-impact activities, according to Dr. Bartosiak. But, she says, because metal-on-metal implants have led to significant post-op complications, scores of malpractice lawsuits and generated such bad press — including the recent Netflix documentary “The Bleeding Edge” — most surgeons are now using ceramic-on-plastic bearings or opting for dual mobility implants.

Direct Anterior Approach Increasing in Popularity
SURVEY RESULTS
DIFFERENCE OF OPINION Surgeons are largely split on their preferred hip replacement technique.   |  Pamela Bevelhymer

Physicians who attended the 2018 Annual Meeting of the American Association of Hip and Knee Surgeons (AAHKS) participated in an audience response poll to determine current practice patterns among members. At 47%, posterior was the most commonly used approach for routine total hip replacements, followed by direct anterior (40%) and anterolateral (12%).

At the 2020 Annual Meeting, the survey was taken again. Compared to 2018, posterior held steady at 46%, but direct anterior had nearly drawn even (45%). Meanwhile, anterolateral had further declined (9%).

To place these developments in a larger frame of evolution, AAHKS shared the results of its 2009 survey, when posterior was the preferred approach of 65% of surgeons, with direct anterior at a mere 12% and anterolateral at a higher 20%.

“Historically, posterior was the most common approach used, but just within the past year and a half, use of the anterior approach in primary hip replacement among fellowship-trained surgeons is increasing,” says Charles Hannon, MD, MBA, an assistant professor of orthopedic surgery at Washington University Orthopedics in St. Louis. “The posterior approach is becoming a little less common, but I would say it’s close to 50-50 now with the anterior approach. Lateral is the approach that has suffered the most as a result.”

The direct anterior approach continues to gain proponents, but the posterior approach remains widely used as well. More importantly, both are considered safe and effective.

— Joe Paone

A shared decision

There are certainly pros and cons to each approach, and one is not definitively better than the other, according to Dr. Hannon. “The decision by a surgeon to offer an anterior versus a posterior approach is often related to the surgeon’s training, comfort and, of course, a risk-benefit discussion with the patient,” he says. “The patient and the surgeon then should decide together the best option and how to proceed with the procedure.”

Dr. Bartosiak says some patients know about the different approaches and have opinions, but for the most part they place their trust in their surgeon to perform the best procedure possible. “My patients just want to get better and trust that surgery will get them back to what they are missing in life, no matter which route is taken to get to the hip,” she says. OSM

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