Anterior vs. posterior hip replacement (THR): How do you decide?

Posted by happybug @happybug, Apr 2, 2019

What factors come into play on a doctor’s decision to do anterior vs posterior hip replacement?

Hello @happybug. I'd like to invite some Connect members who have had each type of hip replacement. @marysapp, @mrcapri, @melar1, @lynnd1961, @scottjeffe all discussed having the anterior approach done in this conversation, https://connect.mayoclinic.org/discussion/has-anyone-had-sharp-thigh-pain-after-hip-replacement/. @khalt and @smiseel recently discussed having anterior replacement. Each member may be able to share a bit about the discussions they had with their surgeon and their experiences with the approach that was used.

@happybug, if you don't mind sharing, are you looking at having a hip replaced and has your surgeon discussed which route they would use?

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@happybug , Hi happy, I had posterior 8 months ago. What I have found is that each surgeon has a preference and usually does one or the other but not both. They'll tell you that this method or that method is better, but what they really mean is, "I'm comfortable doing this method so that's what i'm going to talk you in to." This is not necessarily a bad thing, you want your surgeon confident in their method. Anterior approach seems to have a quicker heal time, but it is a limited view surgery and therefor a bit more risky if complications arise during. These are my personal observances and opinions, I'm sure others may have differing.

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@JustinMcClanahan

Hello @happybug. I'd like to invite some Connect members who have had each type of hip replacement. @marysapp, @mrcapri, @melar1, @lynnd1961, @scottjeffe all discussed having the anterior approach done in this conversation, https://connect.mayoclinic.org/discussion/has-anyone-had-sharp-thigh-pain-after-hip-replacement/. @khalt and @smiseel recently discussed having anterior replacement. Each member may be able to share a bit about the discussions they had with their surgeon and their experiences with the approach that was used.

@happybug, if you don't mind sharing, are you looking at having a hip replaced and has your surgeon discussed which route they would use?

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I am writing for my husband. He is due to have the THR in a few days. A nurse friend just told us that she would never have the posterior surgery as the healing time is so much longer. He had one THR a few years ago – posterior. My husband called the dr’s office to see if he could request the anterior. PA called back and said he wasn’t a candidate for that but no reason was given. Will be having a pre-op dr appt in a few days.

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@khalt

@happybug , Hi happy, I had posterior 8 months ago. What I have found is that each surgeon has a preference and usually does one or the other but not both. They'll tell you that this method or that method is better, but what they really mean is, "I'm comfortable doing this method so that's what i'm going to talk you in to." This is not necessarily a bad thing, you want your surgeon confident in their method. Anterior approach seems to have a quicker heal time, but it is a limited view surgery and therefor a bit more risky if complications arise during. These are my personal observances and opinions, I'm sure others may have differing.

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Thank you. Yes, maybe it is a doctor’s preference. Another friend said that because he has about 20extra lbs it might be riskier to do the anterior.

Are you doing physical therapy. We were told that no PT is recommended last time for hip replacement.

Thanks again for your reply.

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@happybug

Thank you. Yes, maybe it is a doctor’s preference. Another friend said that because he has about 20extra lbs it might be riskier to do the anterior.

Are you doing physical therapy. We were told that no PT is recommended last time for hip replacement.

Thanks again for your reply.

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@khalt @happybug I was speaking to someone today who had just read up on this! Anterior is a newer procedure. I believe she said it can be riskier for nerves so if your doctor wants to do it you should make sure the doctor has done at least hundreds of them. Other than that it can be a superior method, speedier recovery, but if your doctor prefers posterior then you should trust him and have your THR done with method. Her husband opted for posterior.
JK

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Hi, I understand that "supposedly" most hip replacements go well and that is why those people are not on forums. However, I do wonder if those with less-than-good outcomes just suffer in silence and are not counted. So basically I am nervous about how to proceed. I have a femur head that is collapsed and has been for about 6 years. It is fusing onto the socket that it should be rotating in. The ortho doc I went to back then because I was having a problem walking took X-rays to ID the problem and told me that, since I had no pain in it, he would not replace it.

Since then, my hip continues to NOT hurt. However, because it is locked in place, my back and my knee must do the movement and pain has developed in those two parts. My glute muscles also have atrophied. I did seek other opinions – one said it was too complicated for his approach, another said he would not do it because I did not have hip pain, and another said his approach could leave me in a wheelchair. I gave up for several years but, because of pain in knee, decided to get more opinions and see if knee could be fixed.

Now I have two ortho docs who say they can replace my hip. Both say I will probably still walk with a cane, probably still need a shoe lift, but I should get back "some" ROM — I have no sideways ROM at all — and that should help. Both say the operation will take about 2x as long as typical hip replacement and the scar will be much larger. My concern is that one says, for my situation, it has to be done from the posterior. The other says anterior. I know each doc has his/her preferences, but I would like to know what is best for MY situation. Surely not every approach is good for each situation, right? I don't want to endanger my already atrophied muscles, or get an infection from an incision that is very long, etc.

Any thoughts anyone cares to share? Thanks.

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@mamie

Hi, I understand that "supposedly" most hip replacements go well and that is why those people are not on forums. However, I do wonder if those with less-than-good outcomes just suffer in silence and are not counted. So basically I am nervous about how to proceed. I have a femur head that is collapsed and has been for about 6 years. It is fusing onto the socket that it should be rotating in. The ortho doc I went to back then because I was having a problem walking took X-rays to ID the problem and told me that, since I had no pain in it, he would not replace it.

Since then, my hip continues to NOT hurt. However, because it is locked in place, my back and my knee must do the movement and pain has developed in those two parts. My glute muscles also have atrophied. I did seek other opinions – one said it was too complicated for his approach, another said he would not do it because I did not have hip pain, and another said his approach could leave me in a wheelchair. I gave up for several years but, because of pain in knee, decided to get more opinions and see if knee could be fixed.

Now I have two ortho docs who say they can replace my hip. Both say I will probably still walk with a cane, probably still need a shoe lift, but I should get back "some" ROM — I have no sideways ROM at all — and that should help. Both say the operation will take about 2x as long as typical hip replacement and the scar will be much larger. My concern is that one says, for my situation, it has to be done from the posterior. The other says anterior. I know each doc has his/her preferences, but I would like to know what is best for MY situation. Surely not every approach is good for each situation, right? I don't want to endanger my already atrophied muscles, or get an infection from an incision that is very long, etc.

Any thoughts anyone cares to share? Thanks.

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Hello @mamie, you may notice that I moved your discussion and combined it with an existing discussion titled, "Anterior vs. Posterior hip replacement: How do you decide?" I did this so the members already discussing this topic would see your message and so that you could read some of their previous posts. From some of the other members' posts, your assessment on it coming down to what the surgeon is comfortable with is typically what members have experienced. Have you discussed with each surgeon what the benefit(s) is/are to his or her approach?

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Hi, @JustinMcClanahan Thanks for moving my post to the proper category.

Basically, yes, what seems to be the situation is that ortho docs do the approach they like to use.
What I want is the approach best for me.
It would be refreshing to hear a doctor say: "You know. I think that with your situation, I would recommend you see a doctor that uses this approach."
Instead they are willing to use whatever approach they use to handle every situation. Can that possibly be correct?

The one who would use the anterior approach also does do posterior and has for about 14 years. He said that because of the fusing, he would probably have to open the incision longer than normal which could lead to it opening up, etc., later which would require a visit to the wound center. Plus I am overweight and that can cause problems with belly fat. Why even suggest that then?

The other only does posterior and has for 30 years. I worry that the posterior approach would injure my atrophied muscles — already seen as atrophied/fatty on an MRI and confirmed by other docs — but this doc says he doesn't think my muscles are as weak as others have told me. So what am I to believe?

Plus neither have mentioned — other than saying I would need a shoe lift, which I already use now — if they would have to cut off any more bone before inserting the femoral stem — making my leg even shorter. Depending on which doctors I believe (2 say no/3 say yes) I do or do not have idiopathic avascular necrosis and can mean weakened bone.

I've also read that it is important to find a doc who does a lot of hip replacements.
So the one who would do anterior hips also does shoulders — about 150 surgeries a year.
The one who does hips also does knees — about 60 hips and 140 knees a year.
Are those enough? How do I choose?

I know there are no promises in surgery but it sure would be nice if the docs themselves really looked at each case and brought up the various points instead of a patient having to try to remember what to ask — so they aren't surprised at the outcome. It all seems so much like an "assembly line."

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Can anyone tell me any advantage of a posterior approach when the patient is a good candidate for either? I had the posterior approach with all of those muscles cut, woke up with 28 staples, two drains and a lot of pain. My buddy same age as me had the anterior approach. Small incision and little pain. He was walking with a cain the next day. I spent a week with a walker.

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@edmcrae

Can anyone tell me any advantage of a posterior approach when the patient is a good candidate for either? I had the posterior approach with all of those muscles cut, woke up with 28 staples, two drains and a lot of pain. My buddy same age as me had the anterior approach. Small incision and little pain. He was walking with a cain the next day. I spent a week with a walker.

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Hi @edmcrae, welcome to Connect. I moved your message to this existing discussion so that you can connect with other members talking about anterior vs posterior approach for total hip replacement, like @happybug @khalt @mamie. Simply click VIEW & REPLY to read past posts.

Ed, were you a candidate for either approach?

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@colleenyoung

Hi @edmcrae, welcome to Connect. I moved your message to this existing discussion so that you can connect with other members talking about anterior vs posterior approach for total hip replacement, like @happybug @khalt @mamie. Simply click VIEW & REPLY to read past posts.

Ed, were you a candidate for either approach?

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This will me my second THR. I had the first one eight years ago. I have one surgeon ready to do anterior approach Feb. 12. Another surgeon ready to do posterior. Both have outstanding credential and did Ortho fellowships in nationally recognized hospitals. I'm in Atlanta so I have many good surgeons to choose from. It appears to me that it's a matter of the age of the Doctor. The older Docs were trained in posterior approach the younger ones can do both but prefer anterior unless there are complicating factors. I told my regular doctor (internal medicine) I have a choice and he said why would you want the posterior approach?

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@edmcrae

This will me my second THR. I had the first one eight years ago. I have one surgeon ready to do anterior approach Feb. 12. Another surgeon ready to do posterior. Both have outstanding credential and did Ortho fellowships in nationally recognized hospitals. I'm in Atlanta so I have many good surgeons to choose from. It appears to me that it's a matter of the age of the Doctor. The older Docs were trained in posterior approach the younger ones can do both but prefer anterior unless there are complicating factors. I told my regular doctor (internal medicine) I have a choice and he said why would you want the posterior approach?

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I have had both hips replaced in the year 2018. My doctor did the anterior approach. He said the reason he does the anterior approach is because there is a chance of cutting the tendon which can happen more often with the posterior approach. This is precisely what happened to my sister who is now having numerous problems which I feel could have been avoided had she had the anterior approach. I did much research prior and am very satisfied and happy with my decision and the doctor I used. My recovery time was far easier and faster. I wish you the best.

Liked by Scott

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I'll try to give you a long term perspective. For reasons I don't need to address, I have had 2 total hip replacements and 3 revisions, over a period of 6 years. The last was in 2012, and I am doing fine, active and the only pain is from arthritis and a little bursitis.
In 2006 I had both total hips, 3 months apart. My original doc did both anterior and posterior, but would only consider posterior because the hips appeared to be badly eroded on xray and were pretty well frozen in the joints (I was only 55 and of very average weight – he said he expected someone over 85 based on the pics)
Healing time was about 2-3 weeks longer than for my cousin who had surgery at the same time. I was walking with crutches the day of surgery, and with barely a cane after 3-4 weeks, and dancing at 6 weeks.
At 5 years both implants failed and required revision, which the second surgeon did 6 weeks apart, posterior. He would not consider anterior (which he also does) because he said my small stature left "no room for even minor inaccuracy" which according to him is the biggest down side of the anterior approach where the doctor cannot see the joint as well. Those revisions, and a subsequent one were all done within an 8 week period -don't ever do that! The recovery time from 3 major surgeries with anesthesia and blood loss in that short time took a year. A relative my age and size talked her doc into an anterior incision at that time, her initial recovery was about a month shorter than mine. However her joint never aligned right and she still walks with a cane and pain.
Fast forward to 2020 – I barely remember the recovery time, but my hips were positioned exactly right, the scars don't look any worse than my friends' and everything works.
Also, at the times of my surgeries, each doc had done well over 1500 hip replacement surgeries, so I had confidence in their skill.
Here is another strong recommendation : Ask for at least a few a physical therapy sessions, especially if you have had a frozen joint or have been limping for a long time. At a minimum you need gait training to get you walking in such a way as to minimize stress on back and knees. Some strength and flexibility work is helpful as well. And do the recommended exercises as instructed. I am sure that was partly responsible for my success.

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