Total Hip Replacement

Surgical Techniques - Total Hip Replacement

Your hip pain from arthritis has gotten so bad that you can no longer function well or tolerate the pain with even simple daily activities. The evaluation of your hip by physical exam and X-ray review; and the failure to respond to more conservative measures has left you wondering about your next step. What can be done now?

The answer may well be a total hip replacement done with the most advanced minimally invasive surgical techniques and rehabilitation program available anywhere in the world. As a recognized leader, teacher and innovator in minimally invasive surgical techniques for total hip replacement surgery, Dr. Robert Zehr of the Zehr Center for Orthopaedics has had the opportunity to refine the various aspects of the surgical experience for his patients both in the operating room and in the care postoperatively.

Hip replacement surgery is certainly not new or uncommon. In fact, last year it is estimated that some 375,000 Americans underwent this highly successful operation to relieve the pain of an arthritic or broken hip joint. Yet the question for surgeons always remains--can it be done better? The answer is unequivocally -- YES!

Mini Posterior Approach

Over the recent years many surgeons have been able to reduce the surgical incision and detachment of surrounding musculature when performing a hip replacement surgery. A typical surgical procedure performed by Dr. Zehr over the years has been through a "mini-posterior approach" with a 3" skin incision and only a fraction of the muscle detachment usually required by most surgeons. This technique results in far less post-operative pain and a much quicker rehabilitation and return to full activity.

Although the mini posterior approach for a total hip replacement is still a very good and standard approach, it is still one in which muscle is detached and must be repaired. This increases the pain felt post-operatively and healing of this repair takes several weeks. In addition, a posterior approach to the hip has some intrinsic and increased risk of dislocation that although rare is still a concern. Despite these concerns Dr. Zehr’s patients usually are able to return to normal activities such as golf, biking, swimming, doubles tennis and long distance walking in just 4-6 weeks after surgery.

Direct Anterior Approach

One of the most exciting advances in the surgical technique of implanting a hip replacement prosthesis has been achieved with the use of the "Direct Anterior Approach" to the hip joint which is Dr. Zehr’s preferred approach for this type of surgery along with that of only ~5% of hip surgeons throughout the U.S. currently.

You may be asking yourself -- "Why is this "approach" such an advancement?" Specifically, a simple change in the direction from which the surgeon enters the hip joint, the "anterior approach" to the hip (coming in straight from the front of the hip) is quickly becoming the most sought after surgical approach by discerning patients who need a hip replacement. The reasons for the tremendous interest in this surgical technique are the multiple advantages it provides to the patient.

Advantage One: Faster Recovery. Patients get up walking full weight bearing on their operative hip the same day of surgery shortly after returning from the recovery area. Many patients need only a cane to walk about in the hospital and are able to start general activities within a few weeks. While it may take patients four to six months to fully recover following conventional hip replacement surgery, the anterior approach technique enables patients often to recover and return to activities such as golf, tennis, biking and of course distance walking in as short as four weeks.

Advantage Two: Minimally Invasive. The anterior approach to hip replacement is the most minimally invasive choice for people suffering from arthritis, hip pain, stiffness and limited hip movement. A small 4" incision is created directly over the front of the hip. No muscle is cut or detached from bone in this approach. Some muscles in the front of the hip are temporarily pushed apart to allow work on the bones of the hip joint but are left uninjured and completely functional in this approach. This, of course, results is far less pain than is typical in other approaches to the hip used by most surgeons and compliments the faster recovery.

Advantage Three: Less Restrictive. After conventional hip replacement surgery, patients must limit flexing of the hip to no more than 60 to 90 degrees, which complicates normal activities like sitting in a chair, on a toilet seat, putting on shoes or getting into a car. Simply climbing stairs may also be more difficult during recovery when following the conventional replacement surgery. These restrictions, simply do not apply after hip replacement using the anterior approach technique.

Following the anterior approach surgical procedure, patients are instructed to use their hip normally without cumbersome restrictions and are sent home from the hospital often in less than three days. Patients can immediately bend their hip freely and bear full weight when comfortable, resulting in a rapid return to normal function. Patients and doctors alike are encouraging this method because it reduces pain, blood loss, scarring, muscle trauma and the risk of dislocation.

Advantage Four: More Accurate. The real time use of a specialized X-ray machine known as a fluoroscope allows the surgeon to see the placement of the component parts of the hip replacement and to make adjustments immediately to give the patient the most accurately placed hip prosthesis and to have the most equal leg lengths before leaving the operating room. A hip replacement made too long would be very rare with this technique.

Again, the "anterior approach" to hip replacement surgery allows the surgeon to reach the hip joint from the front of the hip in contrast to the lateral (side) or the posterior (back) approach which are by far the most commonly used approaches to the hip currently used in this country. This way, the hip can be replaced without detachment of muscle from the pelvis or femur during surgery as is required in traditional surgery. The surgeon can simply work through the natural interval between the muscles. The most important muscles for hip function, the gluteal muscles and external rotators of the hip that attach to the pelvis and femur, are left undisturbed and, therefore, do not require a healing process to recover from surgical trauma.

So you may be wondering, if the anterior approach to the hip is so much better, why doesn’t every surgeon use this technique? This, indeed, would be a very fair question. The answer, however, is a bit complex. In fact, the anterior approach to hip surgery has been used in Europe since the late 1940’s, but with the use of conventional operating room tables, it is a technically demanding and often a time consuming activity which did not lend itself well to acceptance by American orthopaedic surgeons. Thus, only a very few hip surgeons are currently offering this approach to their patients. In fact, it has been recently estimated that only ~5% of orthopaedic surgeons nationwide are using the anterior approach to hip surgery due to the steep learning curve of this technique.

In recent years, however, a breakthrough in design of a specialized operating table called the "hana arthroplasty table" has rekindled the interest of hip surgeons in this most minimally invasive of all surgical hip approaches. The table has unique capabilities to facilitate this smaller and less invasive approach.

A patient is positioned lying flat on their back with both legs stretched out on carbon fiber spars which support the legs and can move appropriately to manipulate the operated leg into various positions required during surgery. This positioning is the key to this anterior approach as it allows the use of live time X-ray guidance during the surgery to assess the position of the artificial hip components and allow for a more accurate measurement of leg lengths at the time of surgery. Additionally, the table has a sterile motorized robotic attachment that reaches inside the wound and lifts the femur to an accessible position which is the most difficult part of the anterior approach without this unique device.

Accordingly, implementation of this unique table and the "anterior approach" technique is Dr. Zehr’s preferred method for primary hip replacement. This is truly a revolutionary advance in the field of hip replacement surgery and the results in our patients have been nothing short of amazing.

If this breakthrough approach to hip replacement surgery interests you, please click on the following video attachments for more information!

Below are pre-op and post-op X-rays of an arthritic hip which underwent a total hip replacement and is doing very well.

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