Hip Replacement - Total Hip Arthroplasty - History

Anterior Total Hip Arthroplasty

Some history regarding this approach and how I learned it.

The anterior approach to the hip is not a new procedure and it is not something I invented.  The procedure was first performed in France in the late 1940's for the treatment of a hip fracture.  Dr. Judet in France would perform what is referred to as the Smith-Peterson approach to replace the femoral head of patients who had femoral neck fractures (hip fracture).  He would replace the bony femoral head with an acrylic prostheses.  With the approach, the surgeon enters the hip joint thru the front aspect of it and can avoid detaching muscles because there is a true internervous plane, whereby muscles are only moved to the side.  By doing so, muscles and their nerves are actually relaxed rather than stretched. 

Because the femoral head was replaced with acrylic, eventually the hip prostheses would fail.  The orthopaedic community at that time did not adopt this approach.  However, in France, they continued to use this approach and as technology evolved, so did the implants they used.  In the early 1960's, Sir Charnley from England began implanting what he referred to as low friction arthroplasty for the treatment of hip arthritis.  This was the beginning of modern type total hip arthroplasty and his new device was a success.  When Sir Charnley performed his surgery, he would detach a very important muscle from the hip with a piece of bone (trochanteric osteotomy) through a direct lateral approach.  This would allow him to perform the surgery, then he would reattach the bone with metal wires.  Because this important muscle and bone were detached, he would restrict the patients to strict bedrest for the first several weeks, sometimes even 4 weeks.  This bedrest would allow the bone to heal back together, and then the patient would be allowed to begin walking.

Because of his success with this approach and this implant, he taught other surgeons this technique and then the approach and the technique made its way to the United States.  Here in the United States, we began to encounter some problems with the technique, including a big complication which was trochanteric escape or non-union of the greater trochanter.  When the bone that was detached did not heal, then patients would limp and they were also at a higher risk of hip dislocation.  So surgeons in the United States modified their approach and they found that they could perform the whole preocedure without detaching the trochanter bone from the femur.  This is when the posterior approach to the hip was adopted.  The posterior approach goes by many different names (modifications of): Moore (Southern Approach) and Kocher Langenbeck.