Patients rave about anterior hip replacement, but it's not right for all

Ann Elias, 71, walks through her Countryside neighborhood in Clearwater recently. Elias said she put off hip replacement surgery for two years because of horror stories she heard about recovery from standard, posterior approach surgery. 
Ann Elias, 71, walks through her Countryside neighborhood in Clearwater recently. Elias said she put off hip replacement surgery for two years because of horror stories she heard about recovery from standard, posterior approach surgery. 
Published April 18, 2013


Ann Elias knew something was wrong when her much-loved tennis games produced more pain than pleasure. X-rays showed the source of her discomfort — enough damage to her hip joint to warrant hip replacement surgery. But the 71-year-old put it off for more than two years after friends shared frightening stories about the long, painful recovery from hip surgery done in the conventional way, through an incision made on the back side of the body.

"One friend who had it done the regular way took one step after surgery and screamed in pain," said Elias. "So I decided not to do it."

More than 400,000 Americans undergo the surgery each year. Usually, an incision is made just above the buttocks, cutting through layers of muscle before sawing through bones with surgical power tools. The damaged joint is removed, and new plastic, metal, or ceramic components are put in.

Back in the 1970s, some surgeons tried reaching the hip joint from the front of the body, known as the anterior approach. That way, muscles could be moved aside rather than cut, making recovery quicker and less painful. Since then, improvements in implants, surgical instruments, and techniques have made the anterior procedure easier for surgeons and more popular with patients.

But still, most surgeons are sticking with the posterior technique they learned during their training.

Orthopedic surgeon Kenneth Gustke of Florida Orthopedic Institute in Tampa has been in the business 30 years but underwent training to do the anterior approach nine years ago, in response to patient requests.

Anterior surgery "really started getting attention for total hip replacement within the last 10 years because of newer implants and instruments," he said.

Anterior "is a more difficult surgical approach," said Gustke. "It's not the one that most orthopedic surgeons were taught in their training. And there's a learning curve. It takes time to get better at it."

Some surgeons are reluctant to replace a well-tested surgery with one that is promising but hasn't been the subject of large-scale clinical trials. It's not right for all patients, especially those who are obese, or have conditions that preclude manipulating the hip without cutting muscles.

Plus, the set up of special X-ray equipment in the operating room to check placement of the implant can add time to the procedure.

Elias heard about the anterior approach from a postal worker who had the surgery and was delivering mail — on foot — in six weeks. Elias contacted the woman's doctor, Morton Plant Mease orthopedic surgeon Andrew J. Cooper, and set up an appointment. Cooper had just started offering the procedure to carefully selected patients. He was drawn to learning it because it spares muscle tissue, and he'd heard reports from other surgeons who said patients had fewer complications.

For instance, with the anterior approach there is less danger of the new ball joint popping out of its socket in the six weeks or so after surgery. "Medicare estimates that 2 to 3 percent of all (hip replacement) patients nationally have dislocation" with the standard surgery, Cooper said. "With anterior, it's 0.2 percent.''

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Elias had the procedure on a Monday in September 2011. She was released from the hospital two days later and went out to dinner with her husband that Friday. "Without a walker, no crutches, cane, without anything," she said.

A physical therapist came to her home twice a week for two or three weeks. "The doctor thought I should have it, but I really didn't need it,'' she said of the therapy. "I never took any pain meds once I left the hospital. I didn't even take a Tylenol.

"The people I talked with who had the (posterior) surgery took three months to get where I was in my recovery in three weeks," she said.

Gustke says the anterior approach will really catch on as a new generation of surgeons is trained.

"Anterior is getting more attention because surgeons are getting exposed to it, and patients are requesting it," said Gustke, who has performed the procedure on 1,400 patients in the past nine years. "At our national meetings, everyone is talking about it."

But he notes that most reports of shorter recoveries, less pain and lower complication rates are anecdotal or based on small studies at single institutions. No long term, large-scale clinical trials have been done.

"But I see it every day in my patients," said Gustke.

Not everybody can expect the kind of results that the tennis-playing Elias enjoyed. Patients who are physically fit and active before surgery tend to do very well and recover the fastest.

"I've had patients come back in three weeks and tell me they've been out playing golf. It's rare and I don't recommend that, but it happens."