Minimally Invasive Anterior Total Hip Replacement

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Introduction

Total Hip Arthroplasty, otherwise known as Total Hip Replacement, is a surgical procedure designed to replace the diseased hip joint with artificial components. The aim is to alleviate pain, restore function, preserve anatomy, and enhance the quality of life. Total hip replacement has completely revolutionised the way in which the arthritic hip is treated and is considered one of the most successful orthopaedic interventions of its generation.

Total Hip Replacement can be performed through various approaches; however, in our practice, we particularly prefer the anterior approach. This approach involves minimally invasive surgery, conducted through the front of the hip joint. It allows for the preservation of muscles and soft tissues around the joint and is argued to provide superior stability for the artificial joint. Patients can undergo an accelerated rehabilitation, leading to a shorter and more efficient recovery.

Other possible approaches are: The posterior, the lateral, and the anterolateral hip approach. Although all carry their own benefits, we consider the anterior approach to be superior for the vast majority of our patients.

Indications and Contraindications for Minimally Invasive Anterior Total Hip Replacement

Indications for Minimally Invasive Anterior Total Hip Replacement:

Hip Osteoarthritis: When patients suffer from hip osteoarthritis that causes pain, limited mobility, and has not responded to non-surgical treatments.
Femoral Neck Fractures: Certain femoral neck fractures may be amenable to minimally invasive anterior hip replacement.
Rheumatoid Arthritis: In cases of severe hip joint damage due to rheumatoid arthritis.
Hip Dysplasia: Severe hip dysplasia that leads to structural abnormalities in the hip joint, causing pain and instability.
Avascular Necrosis: When the blood supply to the femoral head is compromised, leading to bone death and collapse of the hip joint.
Developmental Deformities: Congenital or developmental deformities of the hip joint that result in pain and dysfunction

Contraindications for Minimally Invasive Anterior Total Hip Replacement:

The contraindications for Minimally Invasive Anterior Hip Replacement include the contraindications to Hip Replacement in general, and those specific to Anterior Hip Replacement:

Severe Obesity: Patients with a high body mass index (BMI) may not be ideal candidates due to potential technical challenges and increased surgical risks.
Prior Abdominal Surgery: Patients with a history of extensive abdominal surgery or conditions that make access to the hip joint difficult may not be suitable candidates.
Inability to Position: Patients who are unable to be positioned properly on the operating table or those with physical limitations that hinder the surgical approach may not be suitable candidates.

The decision to pursue minimally invasive anterior hip replacement should be made after a thorough evaluation by a healthcare professional, considering the patient’s specific medical history, condition, and overall health.

Benefits and Risks of Minimally Invasive Anterior Hip Replacement:

Benefits of Minimally Invasive Anterior Hip Replacement:

Smaller Incision: This approach typically involves a smaller incision, resulting in less tissue damage, reduced scarring, and potentially a more cosmetically pleasing outcome.
Faster Recovery: Patients often experience a quicker recovery and reduced hospital stay compared to traditional hip replacement approaches.
Less Muscle Trauma: The technique aims to spare important muscles and tendons, which can lead to improved post-operative strength and function.
Reduced Pain: Many patients report less post-operative pain and discomfort, potentially requiring fewer pain medications.
Improved Range of Motion: Minimally invasive anterior hip replacement can result in better post-operative hip joint mobility.

Risks of Minimally Invasive Anterior Hip Replacement:

The risks for Minimally Invasive Anterior Hip Replacement include the contraindications to Hip Replacement in general, and those specific to Anterior Hip Replacement:

Technical Complexity: This approach can be technically challenging, and it requires a high level of surgical expertise. Professor Al Muderis has an experience of thousands of surgeries performed through this approach.
Limited Visibility: The restricted surgical field and access can make it challenging to visualize and address certain issues, potentially leading to complications.
Risk of Fractures: The procedure carries a slightly higher risk of femur fractures during surgery due to the specific positioning and instruments used.
Nerve Damage: There is a risk of nerve injury, particularly to sensory nerves around the surgical site.
Pulmonary Embolism: Like other surgical procedures, there is a risk of blood clots, such as deep vein thrombosis (DVT) or pulmonary embolism.
Infection: As with any surgery, the risk of post-operative infection remains, although it’s generally low when proper aseptic techniques are followed.
Implant Positioning: The minimally invasive approach can make precise implant positioning more challenging, potentially affecting long-term implant durability.

Patients considering minimally invasive anterior hip replacement should discuss the potential benefits and risks with their healthcare provider. The decision to proceed with this approach should be based on individual medical history, condition, and the expertise of the surgical team.

Surgical Approach

The anterior approach involves accessing the hip joint from the front rather than the side or back (lateral or posterior). It avoids the need to cut or detach muscles from the pelvis or femur, making it less invasive. This warrants a quicker recovery and less Post-operative pain. Patients can resume their daily activities faster.

It’s worth noting that the suitability of this approach is determined on a case-by-case basis, taking individual patient factors into consideration.

Pre-Surgery Information

The following is what can be expected before Invasive Anterior Hip Replacement surgery:

Patient Evaluation: A thorough assessment of the patient’s overall health, medical history, and orthopaedic condition. When necessary, your health might need optimisation and we may refer you to another specialist.
Medications: Inform your healthcare provider about any medications you’re taking, as some may need to be adjusted before surgery. You should stop taking aspirin or anti-inflammatory medications 10 days prior to the surgery. Also, you should discontinue any naturopathic or herbal medications during this period.
Imaging: X-rays, CT scans, and MRIs are used to evaluate the extent of damage and plan the surgery. CT scans are especially helpful in planning the surgical steps.
Skin preparation: The night before and on the morning of the operation, you will be asked to wash the leg with a sponge provided at the pre-admission clinic. If there is any suspicion of an iodine allergy, a Betadine Skin test might be used.
Bowel Prep: Glycerin suppositories will be provided at the pre-admission clinic, and you will need to administer them the evening prior to the surgery. An instruction leaflet will be given to guide them.
Patient education: During a physiotherapy assessment, a qualified physical therapist will provide you with personalised instructions on gait training, the use of crutches, and pre- and postoperative exercises. You will be fitted with crutches to take home and practise before the surgery.

On the day of the Surgery

Surgical paperwork will be administered by the nurses, and the anaesthetist will meet with the patient to ask a few questions.
A hospital gown will be given, and the operation site will be shaved and cleaned.
Betadine skin prep will be applied to the area above the operation site and wrapped.
All x-rays are to be sent with the patient to the theatre.

Surgical Procedure

The procedure is performed under general anaesthesia or spinal anaesthesia.

Patient Positioning: The patient is typically positioned on their back on a specialised surgical table.
Incision: A smaller incision is made at the front of the hip, typically 3-4 inches in length, providing access to the joint.
Soft Tissue Preservation: The surgeon carefully works through the natural muscle planes, which minimizes muscle trauma and allows for a more tissue-sparing approach.
Joint Exposure: damaged or arthritic socket and femoral head are removed.
Implant Placement: High-quality prosthetic components, including the acetabular cup (for socket) and femoral stem with a ceramic head (for ball) are securely inserted into the prepared areas.
Closure: After ensuring the stability and proper alignment of the components, the surgeon closes the incision with sutures.

Post-surgery Information

Post-surgery care is essential to ensure a successful recovery. Here are some key aspects:

Immobilisation and Weight-Bearing: Patients may initially use crutches or a walker to avoid putting excessive weight on the operated hip. The surgeon will provide specific weight-bearing guidelines that should be closely followed to protect the joint.
Pain Management: Medications are prescribed to manage post-operative pain. Patients should adhere to the prescribed regimen and communicate any concerns about pain control with their healthcare provider.
Physical Therapy: Physical therapy is a critical component of recovery. Therapists design a customised exercise program to improve strength, flexibility, and joint mobility. Patients should diligently participate in these exercises to aid their rehabilitation.
Wound Care: Proper wound care is essential. Keep the surgical site clean, dry, and inspect for signs of infection, such as redness or swelling.
Activity Restrictions: Patients should adhere to activity restrictions and avoid high-impact activities or movements that could stress the hip joint, especially in the early post-operative period.
Follow-Up Appointments: Regular follow-up appointments with the surgeon are crucial to monitor progress and address any concerns or complications that may arise.
- 1 week postop: for wound check,
- 2 weeks postop: for sutures removal,
- 6 weeks postop: for x-ray assessment of healing progressing,
- 3 months, 6 months, 12 months and later annually for x-ray assessment of healing progress
Medication Management: Patients may need to continue medications, such as blood thinners, to prevent blood clots as advised by their healthcare provider.
Assistive Devices: In some cases, patients may need assistive devices for an extended period, such as raised toilet seats or grab bars, to enhance safety and mobility at home.
Lifestyle Adjustments: Depending on individual circumstances, patients might need to make adjustments to their living space or daily routines to facilitate a smoother recovery.

Comprehensive post-surgery care is vital to a patient’s overall well-being and the long-term success of complex primary hip replacement surgery. Effective communication with the healthcare team and strict adherence to their recommendations are crucial for a smooth recovery process.

Concerns

If patients are worried about their level of pain, experience significant bleeding, or notice fever or redness around the surgical site, they should contact the office immediately. If assistance is needed after hours, patients can contact the hospital where the surgery was performed, and they will contact Professor Al Muderis on their behalf.

Norwest Private Hospital: (02) 8882 8882

Macquarie University Hospital: (02) 9812 3000