From the front or from the back: approaches to hip replacement

Hip replacement is one of the most successful surgical procedures known to man. It alleviates pain and improves the quality of life in patients affected by bad hip arthritis. Over time, there have been improvements in hip replacement surgery. There have been improvements in the materials for a hip replacement. There have been improvements in technology. However, arguably nothing brings up more debate than the location of the incision for the surgery.

        To patients, there are two approaches to the hip: “from the front” or “from the back.” In reality, there are a few other approaches that can be used to perform hip replacements. That said, the debate about approach/incision in 2022 is mainly about the anterior (front) and posterior (back) approaches. 

        The anterior approach accesses the hip with an incision in front of the hip. The anterior approach to hip replacement is a modification of an approach first described in the late 1800s. There is a belief that tendons, ligaments, and muscles are not cut with this approach. This is not universally true. Exposure needed for the surgery can dictate releases of tendons and ligaments with this approach similar to what you would see with other approaches. Muscles can also be damaged with this approach. A potential benefit is faster recovery with this approach. This can be true for the first 6 weeks. After 6 weeks, the recovery between the anterior and posterior approaches can be similar. Another potential benefit is a decreased dislocation rate. The “overall” complication rate is the similar between the two approaches. The deep infection risk is similar. However, the risk of fractures of the thigh bone is higher with this approach. The risk of loosening of the femoral component is also higher with the anterior approach.

        The posterior approach accesses the hip with an incision on the side of the hip that curves posteriorly. It involves cutting tendons in the posterior hip though the extent can be limited. The cut structures are repaired in the modern posterior approach hip. The risk of fracture of the thigh bone is lower with this approach. The risk of loosening of the femoral component is also lower with this approach. The speed of recovery can be decreased within the first 6 weeks when compared to the anterior approach. It is generally stated that the dislocation rate is higher with the posterior approach. However, this rate is lower than historical rates with the modern posterior approach hip. 

        I perform both approaches. The decision to choose one over the other is individualized. This decision is based on body habitus, hip anatomy, presence of hip deformity or hardware. Length of stay in the hospital is similar between the approaches. The most important thing to consider when thinking about hip replacement is NOT the approach. It is choosing a surgeon experienced with whichever approach is chosen for the surgery.