Cambize Shahrdar, M.D. total knee and hip replacement specialist
Knee and Hip Surgeon specialist
About Dr. Shahrdar
Hip and Knee surgeries performed
Anterior Total Hip Anthroplasty
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Hip Replacement - Total Hip Arthroplasty

Anterior Total Hip Arthroplasty

  Total hip arthroplasty, also referred to as hip replacement, is one of the most successful procedures in medicine.  It has a predictable outcome which may give long lasting pain relief.  At the same time, the complication rate from the surgery is low.

Why anterior total hip arthroplasty?

Traditional surgery, which is performed through a posterior approach, means that in order to get into the hip, muscle and tendon are detached, split, and or cut from the bone.  Also, because these muscles and ligaments are removed from the backside of the hip joint, it destabilizes the joint, meaning that there is no support on the back of the joint until the tissue heals, which may be up to 6 or 8 weeks.  With traditional surgery, after surgery, the patient must follow and adhere to specific restrictions.  We call them hip precautions.  The reason why the patient must follow these restrictions is to prevent the new hip replacement from popping out the back.  We call this dreaded event a hip dislocation.  The hip precautions include the following restrictions:
1.  Cannot sleep on your side or stomach for first 6 weeks.
2.  Cannot cross your legs over.
3.  Cannot sit in low chairs.
4.  Cannot flex your hip more than 90 degrees.
5.  You must use an elevated commode adaptor.
6.  You must use specialized equipement, which are to assist you with putting socks and shoes on since you are not allowed to reach towards your feet.
With the anterior total hip arthroplasty, the surgery is performed through the front of the hip joint where there is a natural plane where surgeons can get into the hip joint without detaching, splitting, or cutting muscle.  The incision is usually 7 to 10 centimeteres in length.  The whole surgery can be performed with one single incision and the use of a specialized operating room table called the ProFX.

After surgery, there are no restrictions or precautions to follow.  All you have to do is walk.  Most patients will be in the hospital for 3 days, but some people may be in from 2 days up to 5 days, depending on their muscle strength, level of activity, and motivational level going into the surgery.

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. 

With the posterior approach, the following muscles are split or detached from:  Iliotibial band, gluteus maximus, piriformis, superior and inferior gemellus, obturator internus, and quadratus femoris.  Sometimes the gluteus maximus tendon is also released from the femur.  Also, the posterior hip capsule, which is part of the ischiofemoral ligament, is cut out or split open.  The ischiofemoral ligament is the main ligamentous posterior restraint of the hip joint.  It affords stability to the back side (posterior) of the hip joint.

When muscles in the back of the hip are cut as well as tendons and ligaments, after surgery, the hip is weak and has less stability.  For these reasons, the patient has to to adhere to the hip precautions taught to them by the physical therapists.  Also, the recovery time is longer and the pain level is higher.  Patients are also at a higher risk of hip dislocation, meaning that the hip socket can pop out of place.

Dr. Keggi in the United States has been perfoming anterior Total Hip Arthroplasty for many years, and he has been very successful with his approach.  One of my mentors, Dr. Joel Matta, learned this technique, the anterior approach to Total Hip Arthroplasty from Dr. LeTournel and Dr. Judet in France.  He brought the procedure to Los Angeles over 8 years ago and he has performed over 800 total hips with this approach.  His complication rate is very low and there has been only 3 dislocations.  My first fellowship was with Dr. Lawrence Dorr, and with him, I learned how to perform a  Minimally Invasive total hip replacement through a posterior approach with an incision that is less than 10 centimeters in length.  However, the following year, I learned the anterior approach and I became a
convert. Deep down in my heart, I believe that this is the best procedure for patients.  All of the merits of this procedure benefit only one person most, the patient.

1.  No hip precautions to follow after surgery.
2.  Less pain after surgery.
3.  The surgery is performed with fluoroscopic image guidance, which helps to maximize component positioning, and further decrease the risk of dislocation and to maximize equality of leg lengths.
4.  Immediately after surgery, the patient can move their hip as they wish, they can flex as much as they want, they can reach towards their feet, they can sleep in any position they want, they can sit in a chair, on a regular toilet, they can put full weight on their leg.




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