07 March 2018
Total Hip Replacement is an extremely successful surgical procedure to improve a patient’s quality of life, when arthritic hip pain becomes debilitating. Consultant Trauma and Orthopaedic Surgeon, Professor Ali Ghoz talks about the Direct Anterior approach to hip replacement surgery, that results in:
- quicker recovery
- less postoperative pain
- reduced blood loss
- reduced risk of dislocation
- a shorter stay in hospital and faster return to daily activities
- reduction of scar tissue
- immediate postoperative muscle tone preservation.
Hip replacement surgery offers patients the ability to return to their daily (and some sporting) activities with improvement in hip flexibility and movement. Patients with a significant limp as a result of an arthritic hip will often walk normally again once recovered from surgery.
The timing of surgery is a quality of life decision and there is no age limit to replacing the hip joint provided your general health is satisfactory. There are various approaches that surgeons use to replace the arthritic hip.
All recognized surgical approaches work and the most important determining factor in ensuring a successful hip replacement, that should last well over 20 - 25 years, is for the patient to choose a surgeon who is skilled in this type of surgery.
The British and Australian Joint Replacement Registries and many publications show clear data confirming that more experienced surgeons have better patient outcomes. 
All patients would like to recover as quickly as possible with as little pain as possible. Surgical and Anaesthetic techniques have improved significantly and these improved techniques have also allowed an easier recovery from this type of surgery.
General information on the Minimally Invasive Direct Anterior Approach:
The Minimally Invasive Direct Anterior Approach (often termed DAA or AMIS) is an approach that lends itself to a quicker recovery. This arises because the surgical approach uses intermuscular planes, allowing exposure of the hip joint without detaching muscle off bone. A patient can thus recover quicker and return to normal life faster compared to other approaches.
There are many published articles that have confirmed that the anterior approach in the short term, leads to a quicker recovery.
The most commonly used worldwide approach to hip surgery is the Posterior Approach (i.e. from the back) and published results show there is no significant difference between a well done posterior approach and well done anterior approach at 12 months after surgery. The posterior approach requires splitting the gluteus maximus (buttock) muscle and detachment of the short external rotator muscles and then reattachment of these muscles plus capsule. Hence the slightly slower recovery compared to the anterior approach.
There are some short-term hip movement restrictions in the posterior approach (internal rotation of the hip beyond 90 degrees of flexion) for six to eight weeks to prevent hip dislocation whilst the capsule/muscle repair recovers.
The anterior approach is inherently a very stable approach since there is no muscle repair involved and subsequent movement restriction. Patients can usually return to driving at an earlier stage if they have had an anterior approach, as against a posterior.
As an experienced hip surgeon, I am comfortable performing either the anterior or posterior approach for arthritic hip replacement surgery. Not all patients may be suitable for the anterior approach due to many factors including: obesity, abnormal anatomy, severe osteoporosis, significant leg length discrepancy, deficient bone requiring bone grafting, or augmentation of the socket.
The responsible approach
Every patient I see has an individual assessment, taking into account their hip pathology, degree of arthritis, day to day function, general health and body habitus. I will then advise what I believe to be the best surgical approach to achieve the best clinical outcome with the least chance of complication.
Whilst I would prefer, from a general recovery perspective, to perform an anterior approach it is more important to ensure a safe recovery with appropriate attention to the underlying problems at hand. If I feel that the anterior approach is not suitable I will perform a posterior approach and will reassure the patient that whilst they may have a slightly slower recovery compared to the anterior approach, their long term function will be identical.
The final word on approaches
The key to a successful hip replacement with the best chance of a good functional outcome and the least chance of complications is to choose an experienced skilled hip surgeon. Whilst the Anterior Approach may afford a quicker short term recovery, not all patients are suitable for this approach. However, they can be reassured that at 6-12 months the posterior approach performs equally as well.