Atlantic Orthopaedic Associates, LLC
So, why the Anterior Approach? Let’s
first discuss the alternative approaches
and the downsides associates with them.
The overwhelming majority of total hip
replacements are performed through a
posterior approach (through the back of
the hip) or a direct lateral approach
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(through the side of the hip). Although these approaches are
adequate, they do have significant disadvantages.
The Posterior Approach involves splitting the gluteus
maximus muscle and then cutting a number of tendons off
the femur in order to gain access to the hip joint. These
“external rotator muscles” (labeled in fig. 6) play an
important role in hip motion (and therefore walking) and
stabilize the hip joint, preventing dislocation.
The most worrisome complication associated with a posterior
approach is a dislocation. This is a direct consequence of
cutting the muscles and tendons that would normally prevent
the ball from coming out of the socket. When a dislocation
(fig. 7) does occur, a patient must be brought to the hospital
where they are given sedation or general anesthesia so that
the hip can be “reduced” (or “popped back in”).
Another disadvantage to the posterior approach is that it
requires the surgeon to work in the vicinity of the sciatic
nerve (fig. 8). This is a very important nerve that controls
all the muscle function and sensation of the leg below the
knee. Although injury to the Sciatic nerve is rare in total hip
surgery, the risk does exist.
Direct Lateral Approach
This method involves detaching the gluteus medius muscle
and tendon off the side of the femur, sometimes with a
portion of bone. Unlike the posterior approach, this
approach does not require cutting the “external rotators”
and therefore has a lesser chance of dislocation.
The common and concerning disadvantage of the lateral
approach is a residual limp. The muscle that must be
violated in this approach, the gluteus medius (fig. 9), is
very important in hip stability and mechanics and essentially
in normal “gait” (or walking pattern).
The gait abnormality commonly seen is a lurching type
pattern (fig. 10). The patient must shift his/her upper body
to the side to compensate for the weakened gluteus medius
muscle. Such a limp can resolve, but usually with
considerable physical therapy for strengthening.