THR Approaches input: Direct Anterior vs. Direct Superior with Dual Mobility cup (aka Superpath)

[LaKarune]

Hello BoneSmart smarties,

I’m up to my eyeballs in research about different approaches and bearings for the THR I need to get. This whole situation has come as a complete shock to me, but I have a wonderful primary doc and a wonderful PT who I’m grateful to have worked with for athletic injuries for years before this hip situation started to come into focus. I’m located in Los Angeles, on the Westside, and have spoken to two well-regarded surgeons so far— Michael Gerhardt and Andrew Yun— both of whom use the Direct Anterior approach. I’m pretty athletic, and my movement basis is dance. I do yoga, Pilates, ski, run, bike, weight train, hike, and I’m dying to learn how to surf. So I researched dance and flexibility after THR, and one of the first posts that popped up recommended asking about dual-mobility cups. I had no clue what that meant, so I asked both the surgeons. I also asked them whether they thought I’d be able to do a split again after THR.

Gerhardt said he normally doesn’t use them, that the procedure needed to place them is higher risk, and that since I’m a good candidate for the Anterior approach, he wouldn’t recommend pursuing dual mobility. When I asked Yun about splits and dual mobility cups, he also said he doesn’t use them and didn't advise splits. He did give me some referrals to other surgeons, though.

So I have an appointment next month (trying to move it up but these doctors are booked OUT) with Jason Snibbe, who uses what I gather is a much newer procedure called the direct superior approach (which some call SuperPATH), and he uses dual mobility cups in his procedures. DS appears to be a less invasive form of the posterior approach that may preserve more muscle even than the Anterior approach.

I am seeking feedback from RECOVERED THR folks who were highly mobile and active pre-op, and have experience with either approach (especially interested in DS dual mobility recoveries since they are harder to find). How much of your mobility have you been able to regain since your surgery? How about your strength? How is your quality of movement feeling?

I’m not totally convinced that a dual mobility cup will be best for me, since my understanding at the moment is that more acetabular bone has to be reamed to accommodate the larger DM cup, and part of what’s lead me here is a congenital and undiagnosed displastic hip, which means my acetabular bone never fully grew in the first place. I’m concerned that if I get a larger cup and lose more bone with my first surgery, that any future revision in like 20 years will be that much more difficult. Happy to be told I'm wrong about that!

Thanks for reading and I look forward to learning from your experiences.

 

[AllieBucks]

Hello!
I'm excited to follow this post. I'm an old ballerina, just had Direct Anterior THR 4 weeks ago. My goal wasn't to do the splits again but I certainly want to be able to do more than just walk! I'm curious to know more about the SuperPath. I remember reading about it. Great luck to you with your search. You've come to a great source of info.

 

[LaKarune]

Hey Allie!! Dr. Yun's outcomes are so good that I haven’t crossed him off my list.

How are you doing in your recovery so far? Do you have a recovery thread I should follow? Curious about where you were @ physically right before your surgery vs how far you’ve come in the first four weeks, if you care to share. ☺️

 

[CricketHip]

We have a library of articles that show examples or outstanding recoveries.
I think you would be pleased to see this one here

Keep in mind, though that we all heal at a different timeline. But I think this will be heartening to you.

Welcome to BoneSmart!

 

[CricketHip]

Here's other articles of value. I hope you take the time to read them. They were so helpful for so many of us!
The amazing recoveries article at the bottom is one you'll like. Again,


HIP
If you are at the stage where you have joint pain but don't know for sure if you are ready to have surgery, these links may help:

Score Chart: How bad is my arthritic hip?​

Choosing a surgeon and a prosthesis​

BMI Calculator - What to do if your surgeon says you're too heavy for joint replacement surgery​

Longevity of implants and revisions: How long will my new joint last?​

If you are at the stage where you are planning to have surgery but are looking for information so you can be better prepared for what is to come, take a look at these links:

Recovery Aids: A comprehensive list for hospital and home​

Recliner Chairs: Things you need to know if buying one for your recovery​

Pre-Op Interviews: What's involved?​

And if you want to picture what your life might be like with a replaced hip, take a look at the posts and threads from other BoneSmarties provided in this link:

Stories of amazing hip recoveries​

 

[AllieBucks]

I haven't really done a recovery thread but maybe I should since I'm chiming in here and there. I just found this site a few days ago and started hovering. I'll work on it later today!

 

[Eman85]

This is a major operation despite how common it has become. I was first looked at for a THR in 1985 and the OS was very realistic. He said that things go wrong and once he starts there is no turning back, which meant not walking. I would appreciate an OS that is realistic over the ones that lead people into unrealistic ideas about what this operation is.
Post-op I was thrilled to come out of anesthesia and then that my leg was still there and my foot was facing the right direction.

 

[LaKarune]

@Eman85 I hear that 100%. I go through phases of sobbing / crying about the fact that they have to cut off the head of my femur. I love my bones and I would like to keep them all. That said, if they are doing such violence inside my body, I want restoration to a level of movement that will allow me to eventually feel joy inside my body again.

The HUGENESS of the surgery is another reason that doc is still on my list. His surgical outcomes are tops. I just don’t know if the Anterior approach will end up being the one that offers MY best chance of feeling that joy in my body again. I like what I’ve heard about the DS approach having virtually no dislocation risk and possibly saving more muscles than Anterior. However, I need to understand whether they’d actually be taking more bone off my acetebelum that I might need in 20 years for a revision. I don’t even think they have 20 years of data about this form of surgery so it may be a gamble no matter what.

 

[LaKarune]

We have a library of articles that show examples or outstanding recoveries.
I think you would be pleased to see this one …
Keep in mind, though that we all heal at a different timeline. But I think this will be heartening to you.

Thanks @CricketHip. Actually that recovery story was one of the first ones I saw on this forum. But I’ve also been sorting through recoveries that are really rough for people because I’m definitely not a 24 YO ballerina anymore. I’ve been searching for DS / SuperPath recovery stories but have only found a handful. If you come across any, I’d be grateful for the links. (Side note - how do I post links to threads like you did here?)

 

[Gray Horse]

Have you looked into resurfacing? Be careful what DR you go with, a number of patients have had procedures they were unhappy with, regarding a west coast DR (I can message you his name). My first resurfacing lasted 16 years, (though I would have bad spells / flare-ups for 3 days a couple of times a year), I rode horse and actually had better flexibility on that side. Then I had a failed cup revision that basically crippled me, and dislocated....headed for THR at the end of the month.

 

[LaKarune]

Have you looked into resurfacing? Be careful what DR you go with, a number of patients have had procedures they were unhappy with, regarding a west coast DR (I can message you his name). My first resurfacing lasted 16 years, (though I would have bad spells / flare-ups for 3 days a couple of times a year), I rode horse and actually had better flexibility on that side. Then I had a failed cup revision that basically crippled me, and dislocated....headed for THR at the end of the month.

I would appreciate that name!

I hadn’t looked into resurfacing and now that I have, I’m not sure it’s for me. The metal on metal friction concerns me a lot, for one. I wish there was a way they could cover the femoral head with something less reactive. Reading about it, I’m kind of understanding why they cut off the femoral head and use a ceramic ball… but I’m still gutted by that image. It seems so needlessly violent.

What a bizarre situation we find ourselves in, you know?!

 

[Caison113]

@LaKarune - you and I are the same age and I had my left hip replaced a little over a year ago, and my right one is coming up shortly. When they go they go!

Anyway, I teach boxing/muay thai/self defense, lift kettlebells, hike, play tennis etc. I still do those today. The only differences are: (1) no pain (in my new hip), (2) increased flexibility (more on that in a second), and (3) more fun! Sure, the very base line is walking again, but in today's world, no one is happy with, or expecting just that.

On to flexibility -- I was not flexible before the operation. Dysplasia and arthritis robbed me of that over the years, and while I was never super flexible, in my 20s I was doing martial arts and kicking over my head, so I felt pretty good about it, even without doing full splits. Now, my new hip side is much more flexible than it was, and once I am done with my right, I expect to be in a much better situation overall. My ortho has given me no real limitations once healed other than "extreme yoga" which isn't an issue for me! I'm still doing all my sports and activities which include kicking a heavy bag (and people on occasion!). I don't go as hard as I did in my 20s, but that would be the same if I had two healthy, original hips.

Last thing I will say is that I get your thoughts on loving your original parts. I had the same sort of weird thoughts, but once the pain went away, I quickly lost my fond feelings for my deformed hip bones. ;) Your best approach is to go with the best doctor after some due diligence (sounds like you are good there), and then then trust their skills. You can argue posterior vs. anterior vs. lateral all day, but I'd rather go with a doctor who has perfected their procedure than one who just does the one I think I want (I had a "minimally invasive posterior" for the record).

Good luck!

 

[LaKarune]

Thank you SO MUCH @Caison113 — this is helping me find some optimism about what I’m facing. The doctor who expressed such negative reactions to my desire to continue moving in ways that bring me pleasure and joy really got in my head, and I’ve been crushed by expectations of my post surgical limitations since then. That doctor does the Direct Anterior approach almost exclusively, so it has really planted doubts in me about my potential movement constraints should I choose that approach. Hearing your story is so encouraging. It comes coincidentally at a time when I happened to learn about a form of mini posterior THR surgery that doctors nicknamed SPAIRE; not sure anyone in my area has expertise with that approach but I do have one potential lead. I’d been scared off posterior approaches by stories about the older muscle-cutting forms of that surgery, but have since seen and heard testimony about newer posterior approaches that are opening my mind to it. I SO appreciate your sharing your story with me. By way of quick follow up: do you know if you have a dual mobility bearing or a standard bearing in your repaired left hip?

 

[zauberflöte]

Hi @LaKarune ! Days ago I wrote a post here and the internet ate it so now I'm back.

I was never a ballerina by any stretch of the imagination, but I had 20 years of classes, as a child/teen, and from 25-35. I am not built flexible. I had both legs front splits the year I turned 15, but it went away, never to return. For much of my adult life jogging was my daily exercise of choice (hello destroyed hips!), with some weight lifting, hiking, swimming, less biking after kids.

Fast forward through two anterior hips with what I will assume are off-the-shelf implants. Not sure dual mobility cups were a big thing then? Anyway, 18 months after the second, I decided I'd like to go back to ballet. Well! Just about everything except my eyelashes and fingernails begged to differ with that decision. I stumbled upon a form of exercise called Barre, here taught by a former ballerina with real choreography chops, and at a few weeks from 71 I am a Barre poster child. The classes give me joy in my body, even as I exhaust the poor muscles. The same things that felt awful (and/or hurt) in ballet can now be worked around. I took one Pilates class and caught covid but I think that would have been alright to continue with if it had been any fun. Yoga has never suited me. Did I say I have never been flexible? Anyway, I think you would be reasonable to expect that a great deal of what you do now, you could work up to after recovery. There's been a ski instructor on here, many yoga practitioners, equestrians, a couple of heavy duty fire fighters. We can make it work!

I was only given one "never do this" position. It is a very deep lunge, torso upright, most weight on rear leg, and then, turn the rear (op) leg IN. That is where my dislocate risk lies. Not something I ever considered doing intentionally. I also have never skied, only surfed once in my teens and no plans to go again, and water skiing seems attractive but not going to try. You are 10 years younger than I was at first THR and have all these proficiencies under your belt. I am very hopeful for your abilities post-recovery. Just, whatever approach and hardware you end up with, don't let anybody fool you that you can rush your body's plans for healing. It takes what it takes, which is about a year. That much is medical knowledge. Until then, follow your body's lead. If it hurts, stop! If it doesn't? Hurray!

 

[djklaugh]

@LaKarune It is good you found your way here to BoneSmart! I've been coming here for nearly 12 years now and have seen every surgical approach, technique, and implant available. And have seen excellent outcomes with all those .... and some not excellent outcomes with all of them. IMO the best predictors of good outcomes is the surgeon's experience and skills, the patient's general good health, and the patient's ability and willingness to HEAL FIRST before trying to rush back into strenuous job or activities.

My hip replacements (I was 64yo at the time) were done with a anterio-lateral approach (straight down the outside of each hip). Now I had both done at the same surgical session so my experience is different from someone getting just one hip done. Implants today are expected to last for 30+ years ... and some of the original ones lasted for 40+ years! So please don't worry too much about the longevity of implants. There are too many factors to be able to predict if YOU would need a revision any time after a hip replacement.

Personally I prefer a surgeon who is conservative in what they promise rather than one who promises the moon. My surgeon just promised I'd walk without pain- and he kept that promise! And when he officially discharged me from his active practice he said the only life time restriction I had was "NO bungie jumping". Any thing else I wanted to do was fine with him!

Best of everything to you! And do keep us informed of what you decide .... we do love to help!

 

[tejubeha]

@LaKarune, I will share a little bit of my experience with you. I have had both my hips replaced with the Anterior approach and achieved the same level of activity as I had before my hip issues (bi-lateral impingement over time destroyed my cartilage). Until my recent knee issues, I could be found in the woods cutting, splitting and loading trees for firewood. When not in the woods, I was on the softball field 4-5 days a week playing or coaching. My wife has also had bi-lateral hip replacement (same OS and same approach) and is in the gym routinely working out with her personal trainer, weights, cross-fit and cardio. I am in my mid-fifties and she is in her early fifties. I feel like I have the same ROM and activity level as before and my OS says I have no restrictions.

I hope this helps!

 

[HollyNY]

@LaKarune I am 53. I was never hospitalized for anything. No broken bones, accidents, etc.

It was very tough to accept that I needed a bionic hip. I also had hip dysplasia on the right side only. I felt like my own bone had failed me .

But the pain of the bone on bone hip only gets worse. Any time it was bearing weight was agonizing. I did not get good sleep for 6 months.

In 20yrs there might be more ways to prolong cartilage or inject new lubricants for the joint.

But right now we have what we have.

Get seen by the best possible surgeon. You are placing your life in his or her hands.

Your age and overall fitness will help you heal.

I had direct anterior surgery on 9/12. On 12/12 I very carefully brushed 3" of snow off of my car. That was unthinkable last winter w the arthritis.

I did not get a dual mobility implant but some here have.

For me it has been life changing already. The hip gets stronger every week.


Holly

 

[ljpviper]

Caison, do you hit heavy bags with your replaced hip? I practiced Muay Thai for 15 years, and want to get back into it.

I have an anterior approach dual mobility feels very natural.

Thank,

Larry

 

[LaKarune]

@LaKarune, I will share a little bit of my experience with you. I have had both my hips replaced with the Anterior approach and achieved the same level of activity as I had before my hip issues (bi-lateral impingement over time destroyed my cartilage). Until my recent knee issues, I could be found in the woods cutting, splitting and loading trees for firewood. When not in the woods, I was on the softball field 4-5 days a week playing or coaching. My wife has also had bi-lateral hip replacement (same OS and same approach) and is in the gym routinely working out with her personal trainer, weights, cross-fit and cardio. I am in my mid-fifties and she is in her early fifties. I feel like I have the same ROM and activity level as before and my OS says I have no restrictions.

I hope this helps!

Thank you so much for sharing yours and your wife’s experiences. It does help to hear that you’re both back to your pre-issue levels of activity. Are you experiencing any lingering side effects from the surgeries, like numbness? Also, how long has it been since your hip replacement surgeries?

I have a consult with a third Anterior method surgeon in the AM. Hoping he will be able to answer more of my questions and restore a bit of my confidence in that method, especially if it means forgoing the dual mobility cup.

 

[LaKarune]

@LaKarune I am 53. I was never hospitalized for anything. No broken bones, accidents, etc.

It was very tough to accept that I needed a bionic hip. I also had hip dysplasia on the right side only. I felt like my own bone had failed me .

But the pain of the bone on bone hip only gets worse. Any time it was bearing weight was agonizing. I did not get good sleep for 6 months.

In 20yrs there might be more ways to prolong cartilage or inject new lubricants for the joint.

But right now we have what we have.

Get seen by the best possible surgeon. You are placing your life in his or her hands.

Your age and overall fitness will help you heal.

I had direct anterior surgery on 9/12. On 12/12 I very carefully brushed 3" of snow off of my car. That was unthinkable last winter w the arthritis.

I did not get a dual mobility implant but some here have.

For me it has been life changing already. The hip gets stronger every week.


Holly

Thank you so much for sharing your journey so far. Four months out, and you’re able to move more freely?

I really relate to the shock of realizing your body wasn’t able to support the life you want. When I say shock — I had literally no idea I had a dysplastic hip until the first PA told me I’d need a hip replacement. There’s a joke in there about dating before we get married but it doesn’t feel all that funny.

Ironically, my pain was so much worse in November than it is now. I’ve been prehabbing (new word for me) with PT for about a month, made possible largely by Celebrex and a really great physical therapist, and I have so much less pain and more stability now. I’m finding myself slipping into some magical thinking, like maybe my body is figuring this whole cartilage thing out on its own.

There’s no way I could go back to ballet class or even a Pilates group class at the moment. But maybe in a couple more weeks…. Magic? I like magic much better than slicing and saws and titanium spikes.

I meet with a third Anterior approach surgeon in the AM and I’m hoping he can answer more of my questions than the other two. The first guy is super positive about my chances for recovery but is very much trying to dissuade me from dual mobility, and the second one made me so worried about the surgical approach that I felt a little frozen with fear. Hoping #3 can move the needle in a way that makes sense. How did you end up choosing your surgeon?

Thanks again for sharing your journey. I’m really grateful to all of you for taking this time.