Anterior Vs. Posterior Hip Replacement: Which Approach Is Best for You?
Advice to improve your movement, fitness, and overall health from the world's #1 in orthopedics.
Hip replacement is among the most common orthopedic procedures, with an estimated 544,000 such surgeries performed annually in the United States. In most cases, patients with osteoarthritis of the hip are offered two options for the operation: the front, or anterior, approach or the back, or posterior, method.
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The posterior approach to hip replacement was the original and primary approach until the late 1990s to early 2000s. In this method, surgeons make an incision on the back of the hip to gain access to the hip joint. They then remove the natural joint and the top of the femur (the major bone of the leg), clear away damaged cartilage, smooth down any abnormal bone formations in the area and install the implant. Recent modifications to this approach, called the STAR approach, preserve most of the posterior muscles as well as the piriformis tendon, allowing for a quicker recovery and no precautions after surgery.
For an anterior hip replacement, surgeons make an incision in the front of the groin to access the hip joint. As with a posterior replacement, they then remove the natural joint and the top of the femur, clear away damaged cartilage, smooth down any abnormal bone formations in the area and install the implant. This approach allows them to perform the procedure by separating the muscles surrounding the joint, preserving most of the muscle structures, which in turn can lead to less pain in the early postoperative period. A third method—the side, or lateral, approach—is performed infrequently at HSS.
The implant for all three techniques is identical. The prosthetic consists of a titanium stem that inserts into the center of the femur and a ball made of either metal or ceramic.
Recovery and Return to Activity
Patients who undergo posterior hip replacement often report feeling more stiffness and pain during the first two weeks after surgery than do those who undergo anterior replacement, but those differences quickly disappear, says Jose Rodriguez, MD, an orthopedic surgeon at HSS. Data from a large randomized controlled trial of some 400 patients show no differences in gait, return to function or complications of surgery between the two procedures, Dr. Rodriguez says.
At HSS, patients experience no difference in surgical complications—including infection of the surgical site, blood clots, and fractures—with either approach, says Jonathan Vigdorchik, MD, also an orthopedic surgeon at HSS. However, wound healing can be slightly more problematic for heavier patients, who generally undergo anterior hip replacement, because the skin on the front side of the joint tends to be somewhat less robust than it is on the back, he adds.
As with any surgery, the first several weeks are about tissue healing and recovery. “With our newer surgical approaches and variety of pain management therapies, patients experience less pain,” says Dr. Vigdorchik. For that reason, he recommends his patients use a cane or crutches for the first week or two after the procedure. “Without the pain to guide behavior, patients may do things beyond what their body can tolerate and then they cause themselves more pain,” he says.
How much activity a person can tolerate in the early weeks after hip replacement surgery depends in large part on how active they were before the procedure. “It really depends on how strong they are coming in,” Dr. Rodriguez says. After surgery, “a week on a walker just to protect yourself and a month with a cane to keep yourself from falling is wise.”
Choosing a Surgeon: The Importance of Experience
The posterior approach historically has been associated with a higher rate of dislocation than anterior surgery. On the other hand, the anterior approach was thought to carry a higher risk for infection, fracture of the bones involved in the procedure, as well as loosening of the prosthetic stem. But today, the rate of complications for either approach is about 1 per 1,000 operations, which means patients can feel secure with either route, Dr. Vigdorchik says. “It doesn’t matter what approach you get as long as it’s done well and is thoughtfully planned out and technically executed,” he adds.
Until relatively recently, surgeons have recommended the posterior approach for heavier patients and those with significant deformities of the hip, such as dysplasia. Advances in surgical techniques have all but eliminated the differences in outcomes between the two procedures, and now the choice is generally a matter of preference for the patient and their surgeon.
Dr. Rodriguez likens the decision to entering a home. “You can go in the front door or the back door. Either door will bring me home,” he says.
Training and experience are critical factors to consider. Some hip surgeons perform an average of 12 procedures per year, or one per month. Dr. Vigdorchik and other surgeons at HSS often do a dozen hip replacements each week, he says. For patients, the result of that repetition is reassurance—both in terms of expected outcomes and, for patients, the level of confidence they should have that the operation will succeed.
When looking for a surgeon, there are some key questions to ask, Dr. Vigdorchik says. “Do they use technology that can make them better? Do they have a surgical team that allows them to be excellent that day? All of those things need to be taken into consideration when you’re choosing a surgeon because it’s a really great operation when you do it well.”
Questions
Here are some questions you should ask when talking with a surgeon about hip replacement:
What is your experience with hip replacement surgeries?
Don’t be afraid to ask about the surgeon’s experience, including how many hip replacement procedures they have performed, which approach – anterior or posterior – they have done the most, and their success rates for either method.
What types of hip replacement procedures do you perform and how often?
It's important to know if the surgeon is experienced with various techniques, such as traditional hip replacement, minimally invasive procedures, or robotic-assisted surgery, and which method is most suitable for your condition.
How do you define success for this procedure and how likely am I to achieve that outcome?
Not everyone has the same goals for hip replacement. For some people, anything short of a return to the tennis court or vigorous activity is not good enough. For others, relief from pain is enough. Talk with your surgeon about your goals for surgery and be clear about what you would consider to be success. Another important consideration is the longevity of the hip replacement. Prosthetic joints can last for 20 years or more, but they eventually wear out. Your surgeon can help you determine if surgery is the best option for your hip condition.
What is the expected recovery process and timeline for this operation?
Patients should have a clear understanding of the recovery process, including how long they might need to stay in the hospital, the requirements for physical therapy, and the duration of restrictions, if any, on their daily activities. Knowing how your body is likely to feel in the near, medium, and long term will help you set realistic expectations for the weeks and months after your procedure.
What are the potential risks and complications associated with this surgery?
Every patient should understand the risks involved in any surgical procedure they are considering and how those complications might affect recovery and success. Potential risks of hip replacement include infections, blood clots, dislocation, and other complications with the implant. You also should feel comfortable asking your surgeon how they plan to mitigate these risks.
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