Anterior Approach to Hip Replacement

This is Weekly Dose of Wellness, brought to you by MemorialCare Health System. Here's Deborah Howell.

Deborah Howell (Host): And welcome to the show. I am Deborah Howell, and today we'll ask the question, "Just what is the anterior approach to hip replacement?" Our guest today is Dr. Abraham Kim, an orthopedic surgeon at South County Orthopedic Specialists and MemorialCare Saddleback Medical Center. Welcome, Dr. Kim.

Abraham Kim, MD: Hey, good morning, Deborah. Thanks so much for having me on the show.

Deborah Howell (Host): Excellent to have you. Let's dive right in. What is the anterior approach to hip replacement?

Abraham Kim, MD: So the anterior hip replacement is a minimally invasive muscle sparing approach to performing a hip replacement, which is a very common surgery that's been done and that continues to be done in the United States and the world.

Deborah Howell (Host): Short and sweet. Okay. How does this differ from the posterior approach?

Abraham Kim, MD: So the anterior approach is performed through the front of the hip rather than having to cut muscle and significantly destabilize the hip with the traditional posterior approach. The same hip replacement can be performed without cutting any muscles, and this will result in less trauma to the surrounding tissues and therefore a faster recovery.

Deborah Howell (Host): Well, that sounds great. And how long have surgeons been doing this new approach?

Abraham Kim, MD: So the approach itself has been around for about 40 years or so. It's been really popularized in terms of its use in hip replacement per se in the last 5 to 10 years.

Deborah Howell (Host): Okay. And what are the benefits associated with the anterior approach to hip replacement?

Abraham Kim, MD: So since no muscles are cut with the anterior approach, it allows for faster recovery and less restrictions after surgery. Moreover, because patients are positioned flat on their backs during surgery, an x-ray machine is used to ensure, number one, more accurate positioning of the hip replacement component, and number two, no change in the length of the patient's legs from surgery.

Deborah Howell (Host): Oh, that's interesting. So the other approach often results in legs of being of different length?

Abraham Kim, MD: It can more often, correct, but not always. If in the right hand, it can produce very good outcomes and results, just like the anterior approach, but there can be a little bit more variability because the way patients are positioned on their sides and again, the destabilizing effect of cutting the muscles through the back of the hip.

Deborah Howell (Host): Okay, this is good then. No muscle cutting with the interior approach and faster recovery and less pain. Am I right to say that?

Abraham Kim, MD: Yes, that's correct as well.

Deborah Howell (Host): So who's a good candidate for anterior approach to hip replacement?

Abraham Kim, MD: So for me personally, I perform all my hip replacements exclusively through the anterior approach. So in my hands, any patient who is a good candidate for hip replacement in general is going to be a candidate for the anterior approach.

Deborah Howell (Host): Give us a couple examples of patients you've seen recently that needed this hip replacement.

Abraham Kim, MD: So I think anyone who has failed to improve with non-operative treatments like medications, injections, or physical therapy, whose hip pain is getting worse and worse and they're noticing a affect a negative effect on their quality of life who is now considering a hip replacement to improve the motion of their hip and improve their pain, again, they would be a good candidate for an anterior approach hip replacement.

Deborah Howell (Host): Okay. So symptoms are pain, pain getting worse, maybe is there a change in their gait?

Abraham Kim, MD: Absolutely. So a lot of my patients with bone-on-bone hip arthritis can find themselves limping, walking hunched over, using a cane, relying upon medications to kind of get them through the day or having to limit what they would otherwise enjoy doing in terms of being out and about, being on their feet because of their hip arthritis becoming more and more symptomatic and limiting to their everyday quality of life.

Deborah Howell (Host): And do some patients think this is just attributed to old age?

Abraham Kim, MD: Absolutely. And I think in general, arthritis does tend to happen more often in patients who are older. It is a process whereby the normal cartilage or the cushioning in the hip wears out over time. Certainly, like any mechanical part, including the tires on our cars, the more miles you have, the more likely you are to have wear and tear. So certainly older patients do have a higher likelihood of having arthritis in their hips. However, nowadays, as people stay active longer, we are starting to see hip arthritis fairly earlier on, even in patients in their 50s and 60s.

Deborah Howell (Host): Due to sports and just overactivity, right?

Abraham Kim, MD: Correct. So certainly activity can contribute to hip arthritis. Genetics can predispose people to arthritis. Weight can predispose people to arthritis. So there's usually a multitude of factors, not usually one.

Deborah Howell (Host): All right, Dr. Kim, take me through it from start to beginning, from start to finish. Say my dad is 65 years old. He's still working. He has a couple more years to work. He's having pain. He's been using a cane. He wants to get back to work as soon as possible. So he comes to you one day, you make the diagnosis, you determine he's going to have surgery. How long is it going to take for the entire process to unfold where he can get back in the car, drive and go to work?

Abraham Kim, MD: Sure. So the recovery process of surgery is as follows. So some patients after the surgery can go home the same day while most stay overnight. The surgery itself is about an hour and a half. After surgery, patients will work with a physical therapist to put full weight on their legs right away after surgery. And this will usually involve using a walker for one to two weeks just to give them stability, follow back cane for one to two weeks, and thereafter patients can progress to using no assistive devices. As far as work is concerned, I generally tell people if they mostly work a desk job, they can look forward to going back as early as anywhere from two to four weeks after surgery. If someone works a more physical or just kind of a physically demanding job where they're spending more time on their feet, I would probably kind of put that at more at six to eight weeks before returning to work. But again, every patient's a little bit different, but that's about the timeline you're looking at. So I generally say the recovery period is about six to eight weeks or so.

Deborah Howell (Host): Incredible. And unless you drive a stick shift, of course, that's going to take you a little longer.

Abraham Kim, MD: Absolutely. That's a very good question. So driving-wise, I tell patients they can go back as early as they feel comfortable. So even with the stick-shift car, again, it's all about just pressing the pedals and feeling comfortable driving the car. So in general, patients aren't on any heavy medications and kind of feel like they're progressing well enough to try to drive a car. I tell them it's kind of up to them, and I've had patients go back as early as a week or two after surgery. Again, that's kind of on the earlier side, but it's really dependent on how the patient is progressing and how confident they feel.

Deborah Howell (Host): And what about a PT regimen?

Abraham Kim, MD: So, absolutely, PT is an essential part of the recovery process. Patients always will work with a therapist in the hospital to make sure that they're able to familiarize themselves with the use of the walker and the cane, and they'll demonstrate that they're able to kind of navigate around safely so that when they do go home, and the majority of patients do go home after the surgery, that they're able to basically take care of themselves. In other words, getting from the bed to the bathroom, the kitchen. Obviously, if you have someone to help you out, that's always a bonus, but by no means is it necessary. So once the patients are home, the physical therapist will come to your house and work with the patients every two, three days or so to continue to help them do the exercises. And the most important part of the recovery process is not how often you see the therapist, but how often you're able to keep up the exercises on your own. And with time, the muscles are able to recover, get stronger, and really overcome the stiffness and the weakness that a lot of patients have developed prior to undergoing the surgery because they've been dealing with hip pain and an altered gait for such a long period of time.

Deborah Howell (Host): Now, you mentioned that the physical therapists come to your house, but then do you also go to a physical therapy sports facility after?

Abraham Kim, MD: That's a great question. I appreciate you clarifying that. So, yes, they do. Most patients get therapy at home just for their convenience for anywhere from three or four weeks after surgery, up to three or four weeks after surgery. And thereafter, patients will go to a therapist that they're choosing close by and convenient to them. And they will continue the therapy with an outpatient at an outpatient center where there's a little bit more equipment. available to help them continue on in their recovery process.

Deborah Howell (Host): And how many weeks usually? I mean, if everything goes well.

Abraham Kim, MD: Sure. So it's usually about a month or so of therapy at home and then thereafter another month of therapy at an outpatient facility.

Deborah Howell (Host): Boy, it sounds like it's a great day to be a hip replacement patient because it really doesn't alter your lifestyle that much. A couple of weeks and you're back to work. Amazing.

Abraham Kim, MD: That's correct. And compared to the amount of pain and disability patients we're having before surgery, most people notice an immediate improvement in their quality of life and pain, even as they're recovering from surgery.

Deborah Howell (Host): Which brings me to my last question. Doctor, how does someone know if they should consider hip replacement?

Abraham Kim, MD: Sure, and I think that's a very important question. So any patient experiencing worsening symptoms of hip arthritis, which can include groin pain, hip pain, and stiffness in the hip, which results in difficulty putting socks and shoes on, would be a candidate for a hip replacement because these are the typical symptoms of hip arthritis. So any patient whose pain, moreover, is no longer responding to the conserved treatment, such as medication, physical therapy, and injections, can consider undergoing a hip replacement to alleviate his or her pain and improve his or her quality of life.

Deborah Howell (Host): Do you start by going with your main doctor and then he refers you to a specialist?

Abraham Kim, MD: So that's usually how it's done. I've had some people, some patients come to see me because they've been recommended by a friend whom I've had the privilege of taking care of. I've had people come to me through referral from their physical therapist. But generally, the majority of patients do come to me upon referral from their primary care doctor, but there's kind of many, many roads that patients have taken me to come see me.

Deborah Howell (Host): And all roads lead to recovery. Well, we want to thank you so much for being on the show with us today, Dr. Kim. We do appreciate your time.

Abraham Kim, MD: Thanks so much for having me.

Deborah Howell (Host): For more info or to listen to a podcast of this show, please go to memorialcare.org. That's all for this time. I'm Deborah Howell. Thanks for listening and have yourself a terrific day.