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Surgical Approach

What are the disadvantages of each surgical approach? What muscles/nerves are affect and what kind of post op pain.

Dr. Mont: Postoperative pain is a very hard thing to quantify. If patients are placed on pain pumps and with blocks, they may have absolutely no pain and in some cases can be sent home right away, in some ways the pain being completely camouflaged. Most patients of resurfacings, in my opinion, have much less pain than total hip replacements. They may have pain in the first day, which usually breaks by the second day. There are a large group of patients that really have minimal pain postoperatively. It is hard to make direct statements about this because many patients go in with different levels of pain preoperatively, different sensitivities of pain, and then they get different types of analgesia, depending on the medical condition of the patient. It sometimes is very hard to specifically state what type of postoperative pain people are going to have.

Neck capsule preservation--if they don't do it, why? Thoughts on this?

Dr. Kreuzer: We do not preserve the entire hip capsule. With the posterior approach we only remove the superior posterior hip capsule as that facilitate the mobilization of the femoral head. With the anterior approach we only remove a portion of the anterior hip capsule to allow exposure. We maintain the hip capsule around the neck as that has shown to improve the chances to maintain the blood supply to the femoral neck.

Dr. Mont: I personally prefer using an anterolateral approach to preserve as much of the neck capsule as possible. The advantages there are a presumptive preservation of blood supply. There also may be something about preserving feeling or proprioceptive sense. It certainly fits into an overall philosophy of doing the least amount of dissection to get the job done when that is possible.

What is the difference in learning curve for anterior vs. posterior.

Dr. Mont: In a British study that was presented at long-term follow-up with two high volume famous surgeons that has not been published, there were no differences in the results with one surgeon performing an anterolateral approach versus a posterior approach. I think this speaks for itself that the patient should have the resurfacing done with the approach that the surgeon feels most comfortable with and that is the most important factor here.

Risks and benefits of anterior vs. posterior approach?

Dr. Kreuzer: It is important not to confuse direct anterior (DAA also know as smith peteresen) with anterior lateral (harding) approach. The benefits of the DAA is avoidance of detaching major muscle groups from bone, higher likely hood to maintain the blood supply to the remaining femoral neck, less likely to dislocate as the dynamic hip stabilizer (short external rotators) are completely unaffected (posterior approach releases all the dynamic stabilizer of the hip), and less likely to limp since the abductor are not released from the greater trochanter (as in the anterior lateral approach). The main disadvantage of the DAA is that it is more difficult for the surgeon, not all patients are candidates and we do not have long-term follow-up data. In the short term it appears that the DAA has a shorter recovery phase, a shorter hospital stay, improved component position and improved early function. I do want to emphasize that we do not have enough data to make these claims but our data appears to have a trend it this direction.

Dr. Mont: This has been debated profusely by surgeons. What is typically being proffered is that surgeons that are more comfortable with an anterolateral approach perform that approach for resurfacing and surgeons that are more comfortable with a posterior approach should use that approach. Every advantage for anterior approach has been stated as an advantage for posterior approaches and vice versa. For example, some surgeons maintain there is less muscle damage with a posterior approach and yet there are other studies that have shown just as much or more muscle damage with posterior or minimally invasive approaches. There are some studies that show that there are saving of the blood supply using an anterolateral approach versus a posterior approach, but there are other studies that show no differences. Typically, many surgeons perform an anterolateral approach because the risk of dislocation is much reduced. In this surgeon’s hands, having done over 1400 resurfacings, he has never had a dislocation. However, there are many surgeons that perform posterior approaches that never had dislocations.

How do doctors chose different surgical approaches and why?

Dr. Kreuzer: The choice of surgical approach used by the doctor is mainly based on what the doctor feels most comfortable with and what allows for a most predictable positive outcome. Doctors that use more then one approach will base their choice most commonly on patient factors such as BMI, x-ray findings, etc.

What is the newest anterior approach? Pros and cons.

Dr. Kreuzer: The benefits of the DAA is avoidance of detaching major muscle groups from bone, higher likely hood to maintain the blood supply to the remaining femoral neck, less likely to dislocate as the dynamic hip stabilizer (short external rotators) are completely unaffected (posterior approach releases all the dynamic stabilizer of the hip), and less likely to limp since the abductor are not released from the greater trochanter (as in the anterior lateral approach). The main disadvantage of the DAA is that it is more difficult for the surgeon, not all patients are candidates and we do not have long-term data available. In the short term it appears that the DAA has a shorter recovery phase, a shorter hospital stay (one day less), improved early function, and in our series improved component position for the femoral and the acetabular component. Only time will tell if these perceived advantages appear to hold true.

Does the surgery cut off blood supply to the femoral head during surgery or in the long term?

Dr. Kreuzer: One of the main benefits of the Direct anterior approach for HR is the potential of maintaining the blood supply to the femoral neck which is achieved in the majority of the cases. As of today, we do not know the clinical significance or benefit of maintaining the blood supply. We hope that it may decrease neck resorbtion and therefore lower the risk for neck fracture and loosening caused by avascular necrosis but we do not have clinical evidence to make these claims. Maintaining the blood supply may only be a theoretical advantage.

Which muscles and tendons will be cut? Will any muscles or tendons not be re-attached?

Dr. Kreuzer: With the direct anterior approach for HR most often two muscles are detached from bone. A prominent reflected head of the rectus sometimes needs to be released from its insertion on the superior aspect of the acetabulum. This can frequently be re-attached. In shorter more stocky patients, the tensor fascia lata sometimes (30%) has to be released from the anterior superior iliac spine. This can also easily be re-attached. In patients with a short neck, sometime the piriformis is released or lengthened. If it is released, it is not reattached.