The hip joint can be approached from the front of the hip
(anterior approach), from the back (posterior approach), from
the side (trans-trochanteric approach), or from midway between
front and side (antero-lateral approach).
With the side-approach the trochanter bone is cut, and later
re-attached with steel wires. This was the standard for many
years, but is now only occasionally used for re-operations.
In ANTERIOR HIP REPLACEMENT the operation is performed through a single incision in the groin. This approach is between muscles, and not a single muscle or tendon is cut. The incision is usually about four inches long and is minimally invasive. This is the most painless approach, with the shortest time to full recovery, including driving, and including normal walking without a cane or other support. It has the lowest risk of dislocation, and there are no restrictions after the surgery as there are with the other approaches. The incision is usually about four inches long. It is a more difficult and risky approach, and the surgeon needs special training. Not every patient is a good candidate for Anterior Hip Replacement.
THE GLUTEAL SPLIT is a significant improvement of the posterior approach. The gluteus maximus muscle arises on the pelvis and attaches to a broad flat ligament, the Facia Lata, which in turn attaches to bone at the knee.
In a standard posterior approach about two and a half inches of the gluteal muscle fibers are split to the junction with the Facia Lata, which is incised for a further four inches in the same line (see illustration), for a total of six to eight inches.
It turns out that not cutting into the Fascia Lata hugely facilitates a rapid return to normal walking.
However, splitting the muscle without cutting the fascia gives a very small window through which to do the surgery. Safe surgery through this two and a half inch incision has only recently been made possible by the development of special instruments. One small tendon, the pyriformis, is cut and reattached at the end of the operation. This tendon has been routinely cut in hip surgery for over a hundred years, and cutting and reattaching it is in no way detrimental.
This Gluteal Split hugely shortens the time to normal walking. Most patients can walk with a single cane within two days of surgery and are off the cane after about a week. The key is staying out of the Fascia Lata.
THE POSTERIOR APPROACH is the one used by most surgeons.
Small, unimportant tendons (short rotators) are detached to
get to the hip joint, and re-attached later in the operation.
Normal walking returns much sooner than with the antero-lateral
approach, sometimes in less than six weeks. Ninety percent or more of all hip surgeons use this approach. Although the recovery is slower than with the Anterior Approach or the Gluteal Split, there is nothing wrong with this approach, and the end result after six months will be just as good, as long as the surgeon did a good job to begin with.
Minimally Invasive Hip Replacement (mini-incision hip replacement) is an important recent development. It is used with the Gluteal Split and the Anterior Hip Replacement approaches. In the past the incision was routinely ten or more inches long. With specially designed new instruments, the operation is now possible through an incision as small as two and a half inches in a thin patient, and in obese patients the incision is less than half what it would otherwise have been. However, it is not the length of the skin incision that is important. It is what goes on under the skin that counts.
With minimally invasive hip replacement there is less trauma to the muscles and ligaments around the hip, so, less blood loss and less pain, and a much quicker return to normal walking. Few orthopedic surgeons have mastered the posterior mini-incision (Gluteal Split) and fewer still the Anterior Hip Replacement. Very few can do a perfect hip replacement, with accurate leg-length, through such a small incision. Dr. Huddleston routinely uses the mini-incision Gluteal Split, and Anterior Hip Replacement approaches.
THE ANTERO-LATERAL APPROACH, is the second most commonly
used. The chance of hip dislocation is thought to be less with
this approach. However, there is a trade-off. About one third
of the most important hip muscle (gluteus medius) is detached
from the bone, and later re-attached. This weakens it, leaving
most patients with a limp, sometimes for up to a year.
Dr Huddleston performs conventional hip replacement through the Anterior Approach or the Gluteal Split. These are MINIMALLY INVASIVE APPROACHES. He is also an expert on Surface Replacement, which is performed through a Posterior Approach. |
