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Dr. Swanson
Re: Anterior Approach
Mon Aug 23, 2010 11:38am

The anterior approach for total hip replacement has been around for many years, initially termed the Smith-Peterson approach or the Hueter approach. Recently, with the advent of a special orthopedic table designed and popularized by Joel Matta in California, it has received a lot of media attention. The approach utilizes natural tissue planes to approach the hip from the front rather from the side or back. The fact that the approach “cuts no muscle” has led to many (unproven) claims of quicker recoveries and improved function. Additionally, any approach that leaves the posterior hip capsule and external rotator muscles intact is likely to have a lower posterior dislocation rate than the posterior approach which requires detachment of some of the external rotators and part of the posterior capsule.

Unfortunately, as with many new techniques or technologies, they sometimes are too good to be true. Additionally, they are often hyped to market a surgeon’s practice in spite of little or no data supporting the claims. Having just completed writing a book chapter on the posterior MIS approach to the hip, I have reviewed all of the literature on all of the MIS approaches and can say that the anterior approach has no significant proven advantages over the posterior approach. A retrospective study comparing the 2 techniques suggests that patients may function at a slightly higher level at 3 weeks with the anterior approach, but the downside is that there is more blood loss, a higher risk of transfusion, and the hips can still dislocate (often anteriorly rather than posteriorly). A cadaveric comparison of muscle damage caused by each of the 2 approaches showed that the anterior approach does damage muscle around the hip in spite of utilizing natural tissue planes—just different muscles than those affected by the posterior approach. Even more interesting is that in ˝ of the anterior cases studied, the posterior capsule and external rotators had been transected, even though the hip was approached from the front!

So the jury is still out regarding any significant functional differences between the anterior and posterior approaches. The dislocation rate with a posterior approach is approaching 0 due to better implants (larger heads and high offset stems) and surgical technique (repairing the posterior capsule, such as with the Capsular Noose Technique), so there really is no advantage using the anterior approach with respect to dislocation rates any more. I have heard that at least 1 prospective randomized study is underway, and I with another surgeon who uses the anterior approach have received IRB approval to do our own prospective study comparing the 2 approaches. But for the time being, I think all that can be said is that both approaches work well and can give good results in the hands of surgeons trained and experienced in the techniques. As always, don’t believe everything you hear.

Dr. Todd Swanson

  • Anterior ApproachAnonymous, Mon Aug 23 11:02am
    I am hearing more and more about the anterior approach and I would be interested in learning more from Dr. Swanson. He has such an EXCELLENT reputation among his peer group which says so much about... more
    • Anterior approachJohn, Tue May 17 11:24am
      Dr Swanson, have not seen an updated post since 2010 on your findings on the anterior approach. Has any new documentation been posted discussing the pros and cons.
    • Re: Anterior Approach — Dr. Swanson, Mon Aug 23 11:38am
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