Over the years a number of different surgical approaches have been used to carry out hip replacement surgery.
The basic principles of any surgical approach to a joint are to avoid as much damage as is possible to surrounding muscles, developing a path between nerves, arteries and vessels that have to be kept safe to ensure satisfactory and safe access to the joint. It has to be appreciated that in hip replacement surgery our fundamental aim is to remove the arthritic and worn part of the joint, replacing it with a mechanical bearing to improve pain and maintain mobility. It is absolutely essential that we protect the nerve supply to the muscles and the muscles themselves, as it those that will drive our mechanical bearing.
All surgical approaches have been modified over time. More recently, attention has been directed towards reduced access and minimally invasive surgery, the aim being to reduce the morbidity associated with the soft tissue components of the hip replacement, reducing any associated muscle damage and maintaining a minimal chance of any other soft tissue neurovascular concern whilst ensuring safe access to the hip.
In my opinion it is essential, regardless of the surgical approach, that the surgeon has adequate visualisation of both the acetabulum and the femur. This is to ensure that the components that are to be implanted are implanted soundly against host bone in a satisfactory orientation to optimise function and reduce the chance of risks such as dislocation.
Different surgeons practise different approaches. Much will depend on any surgeon’s training, their experience and of course their outcomes.
Over the course of my years in practice I have looked at numerous different surgical approaches to the hip and indeed have performed a number of those. Throughout my years as a consultant hip surgeon, my practice has been based around the posterior approach. I believe this is the safest, the most reliable and the most versatile approach through which we can carry out surgery.
The posterior approach has been developed over years to access the joint, as the name would suggest, from the posterior aspect of the buttock. The skin and soft tissues are divided as is the fascia beneath. Muscles are split, rather than cut, to gain access to the posterior hip. To access the hip joint itself, the posterior short external rotators are released along with the capsule of the back of the hip. This creates a flap that can be elevated posteriorly to protect the sciatic nerve. Via this approach the surgeon can achieve excellent circumferential visualisation of the acetabulum and safe mobilisation of the femur so that the hip replacement can be performed safely. This approach provides what I believe is the best view to ensure the components are satisfactorily orientated and that soft tissue balance is achieved. The posterior capsule and muscles can be brought back comfortably against the bone and secured nicely so that a sound and intact soft tissue envelope is maintained once biomechanics have been re-established. One of the most important and beneficial aspects of this approach is that the hip abductors are not significantly involved and the nerve supply to the hip abductor muscles themselves is left intact. A limp following this surgical approach is therefore unusual and the scar itself heals nicely giving a good cosmetic result.
When carrying out surgery, I am always careful to minimise any soft tissue damage, keeping my surgery as minimally invasive as is safe. By using what I would describe as a reduced ‘mini’ posterior approach, in many patients, I can achieve very satisfactory visualisation and reconstruction. On some occasions, particularly in more complex indications for hip surgery or indeed in more thick-set patients, one has to increase the length of the incision, though the approach itself is the same. The scar heals nicely and, over all the years in practice, I have not had patients who have come back to me unhappy with the length or indeed the healing of their scars in this area.
A more detailed demonstration of my technique for total hip replacement using the posterior approach can be seen elsewhere on this website.
In recent times other approaches have been put forward. While I have reviewed the approaches and indeed debated with colleagues from around the world (where some of the approaches, specifically the direct anterior approach, are performed) I still believe that the posterior approach that I use is versatile, can be extended as required and allows me to perform more straightforward, complex and indeed revision surgery consistently with the same releases. For these reasons I still base my practice on the posterior approach.
To date, the clinical evidence base has shown no direct or specific advantage of other approaches over the posterior approach. While in other parts of the world the direct anterior approach has gained support and is used more widely, the use of the direct anterior approach in the United Kingdom remains limited. At this stage, I have reviewed this further and if I were to think that the anterior approach did offer anything over and above the approach that I use, the posterior approach, then I would obviously consider a change. With my outcomes to date, using the approach with which I am familiar and that I have used over many thousands hip of replacements, I would need to be very convinced that my patients were going to do better than the excellent results that I have achieved to date.
I am very happy to discuss all the issues that surround surgical approach, exposure, size of scars and healing as well as rate of rehabilitation at any stage.