Anterior approach with large heads

[Scott]

I'm so very jealous of those with anterior surgeries because of the quick recovery, but I'm curious if this approach works or works well with the larger heads?

Totally hindsight, of course, but this is not something I really understood before my surgery, so I didn't really address it. My OS gave me some marketing material on MIS, but I'm not sure if that is just anterior or if there is a MIS posterior approach as well. Regardless, my OS chose a posterior approach with a large (very?) incision for me. I had previous damage, so that may have played a role, but I'm fascinated by the decisions by various OSes.

Just pondering on a Friday.

 

[PRGal]

Scott,

MIS and anterior are not the same, though anterior is sometimes called "minimally invasive," since it typically involves only a 4-5" incision. Most surgeons who do the anterior approach, however, prefer to call it "tissue-sparing," since muscles are spread, not cut or detached. MIS often involves special computer-guided surgical tools (& 2 smaller incisions)--kind of like laparoscopic techniques.

Of course, surgical techniques continually evolve, so who knows how they'll be doing THRs even just 10 years from now! (Have you heard about the new "natural orifice" surgeries? Like when they removed a kidney from a woman donor transvaginally? Can't imagine orthopedic surgery progressing in that direction--I mean, could they ever really give up their love of power tools :hehe: ?)

As for large metal heads, they are possible with anterior. A friend of mine (who's the one who told me about my OS) had a metal-on-metal in the largest size suitable for a female of her size. (She's battled degenerative arthritis for years & is the metal queen, with surgeries & replacement parts in her hands, hip, knee, spine & shoulder!)

As a matter of fact (and boy, do I hesitate to bring this up :hehe, my OS is one of the few in the U.S. that does anterior approach resurfacing--which, of course, involves a fairly large head. Incision is a bit longer to allow needed access--approx 6"--but basically same shortened early recovery time & lack of restrictions.

It's truly an amazing world . . .

 

[Scott]

Great stuff, PR. What you say makes since, since the literature I received didn't mention or allude to an anterior incision, only a smaller than normal one. Admittedly, I am fairly ignorant about the two options, but curious - even if it doesn't matter to me at this point :cool:

With this vast ( :hehe: ) knowledge I've gained the past few months, I wish I would've been able to have an anterior resurfacing! BUT, I won't complain. Except for being impatient to be able to work on my ROM, I'm tickled so far.

I've got to be honest, "natural orifice" scares the daylights out of me. I want no part of that. There is no orifice I want hip replacement parts going through :whis: (it is fascinating to think about the future, though)

Good stuff from you, as always!

 

[mdakota]

see yall put these ideas into my head. lol. since i started comming here especially listening to the folks with anterior i've wished i had that planned. because i was already with my os i just stayed but i've really wanted the anterior. me changing started cuz i was upset but after i calmed down all i thought is i have the chance to ask for the sun and the stars too. first os didnt have the table to do anterior. of course didnt even mention it to me dosent do mis/robotic either. but when i look at your post scott you said exactly what i'd been thinking. too late to change now. when they messed up it actually brought all the actual options into my head.
thank you

the other thing with the mis i did some research on that too. with the two mini incisions you definatley have to look at how many the surgeon has done they showed a high failure rate with first attempts in a study i read. definate correlation with practice makes perfect.

 

[PRGal]

Technically, the special table isn't absolutely necessary for anterior, though it does make things easier for the surgeon. I've watched videos of anterior surgeries done both with & without. The specialized training in the approach--& experience--are what's critical. That's how I chose my OS--never even asked if the hospital had the table!

 

[mdakota]

ok. and yeah one of my questions is definatly going to be experience with the procedure. this hospitals procedure is xrays before you leave the or. the first hospital dosent and honestly that makes me feel better.

 

[Josephine]

Anterior - or more properly, antero-lateral - has been in use far longer than the posterior approaches. Charnley always used them and like his predecessors, he had no special table either! We just used a standard flat table. However, McKee did use the (then) current standard orthopaedic table, the one that was designed for pinning fractured necks of femurs with xray control. That table was primarily needed to get the xrays machines in the proper place rather than anything to do with the surgery. Actually the same as current - the surgeons now use the table for image intensifier access rather than the surgery. However, since the majority of surgeons rely upon eyeballing the position of the prostheses, it's not necessary for them.

As for the size of the head, in hemi-arthroplasty for fractured necks of femur that are not suitable for pinning, they were done either with posterior or antero-lateral but the heads were of anatomical size being anything between 1+5/8" to 2½" in diameter! And remember, hemi-arthroplasties preceeded THR by some 20 or 30 years!

(hemi-arthroplasties mean that since the acetabulum was in good condition, no replacement cup was needed)

 

[webbie73]

Technically, the special table isn't absolutely necessary for anterior, though it does make things easier for the surgeon. I've watched videos of anterior surgeries done both with & without. The specialized training in the approach--& experience--are what's critical. That's how I chose my OS--never even asked if the hospital had the table!

I had a MIS computer navigated antero-lateral right hip replacement. As far as I know the special table was not used. LOL I do remember seeing the room as I got on the operating table and it did have that "leg holder". My scar is about 6 inches long with a slight curve. It healed beautifullyI am so pleased with the computer aspect of my surgery. Set that hip perfectly. I have not difference in my leg length. I do have to ask what brand of prothesis he use though. Just for future reference. Most of the problems I have are not related to the surgery but my prior condition and the stupid ambulance driver.

 

[PRGal]

Is there perhaps some variance in the definitions of approaches among surgeons, Jo? My OS, for example, says anterolateral is from the side, while anterior is directly from the front. Below is the illustration he uses.

Also, here's a pic of the specialized table my OS uses. (It's used for a number of lower extremity surgeries, including knees.) For a THR, patient's feet are in the boots, and all the necessary manipulations are done with controls on the table rather than manually. (It's obviously a wonderful example of medical engineering, but does rather evoke a mental of image of being stretched on a medieval rack, don't you think? :hehe

 

[Josephine]

That's pretty much a standard orthopaedic table with modified atachements, PR. And much the same as the one McKee used back in the 60s! It's also used for intramedullary nailing of femora and tibia, also with modified attachments.

As for the incisions, I doubt there are any two surgeons that make exactly the same incisions nor make exactly the same from one patient to another.

btw - as a means of expressing affection, it was not unknown for the OR staff to get a departing junior doctor strapped into one of those tables and then all go out to lunch and leave him there! (but the table we used had a post which goes between the legs at the perineum, to hold him there!)

 

[Judles]

That's wicked, Jo! LOL!!!

 

[Jamie]

Ohhhhh, Joooooo.....I'm seeing a whole 'nother side of you that you've kept hidden......you devil!!!

 

[PRGal]

:shk:

Definitely can see the motivation to stay put!

 

[mdakota]

lol. i love it. most of my scars pr are right where your pic shows they start at the top of the pelvic bone and go down to mid thigh and curve back. if they do it anterior i might not end up with scars in a new position they can just use the same site. it would be nice

 

[mdakota]

and jo i always knew you had it in you. you cant have been around as long as you have been without being a little salty. lol. i love it.

 

[Josephine]

You don't know the half of it, folks! :evil: :evil: :evil:

 

[Judles]

Jo!!!! We're looking forward to your autobiography!!!!

 

[Tommy Utah]

My incisions are exactly on the side so they are not anterior but I'd hesitate to call them posterior either???

 

[TBONE]

Folks--I had anterior approach bilateral, large ball MOM, 54mm and 56mm, respectively. PR- my incision looks a lot like the diagram, but a bit longer. My incisions are about 5 inches right and 6 inches left. I did not have MIS and I had no special table or other attachments.
I requested, or, more accurately, suggested, a desire for large diameter MOM and surgeon agreed. I subsequently learned that he did not do as many of these as plastic and/or ceramic, probably because of concerns, as yet largely unproven, of metal ions. In addition, since I am a bilat, I have 2x the metal ions, theoretically. Well just have to see how that works out.
As for anterior approach, I am belatedly very happy to have had it because I had no restrictions at all, though I understand that all approaches are pretty much the same after about 6 months. I suppose I had a preference for anterior or anterior-lateral, but I would have done whatever my OS recommended.
I'm coming up on 12 weeks now and I am pretty much back to my old self, with the exception of flexibility problems which are not from the hips themselves, but rather from having arthritis for so long. This flexibility problem is now the focus of much of my workouts and PT and will be for the next 6 months or so, and probably for life. And a wonderful life it is!

 

[mdakota]

tbone, so glad to see you. i've been waiting to see you post. i've switched to a surgeon who can do anterior. still leary of the bilat. surgeon still leary of simultaneous but gave good reason. i think you are the one person that might remember me saying that i wanted to find your surgeon to have anterior. well not yours but i found a good one. i'll have the rom problems but just the same its going to take time and work. however being almost back to normal 12 weeks from now, bonus.
thanks monique