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

[ljpviper]

Hello Lakarune,

HSS in Palm Beach did my anterior dual mobility. Surgeon was Dr. Wang, very good bed side manor.

Good luck,

Larry

 

[LaKarune]

Hello Lakarune,

HSS in Palm Beach did my anterior dual mobility. Surgeon was Dr. Wang, very good bed side manor.

Good luck,

Larry

Thank you!!

 

[Caison113]

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

I do hit the heavy bags yes. No issues.

 

[PolarIce]

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.

Well I was super active before surgery and am super active now and got a dual mobility joint BECAUSE I am super active and very flexible.

I was a young patient when I got it in 11 months ago and would not go back to my pre-surgery conditions. I am super active(work for the police force as well), ride and train horses on my days off and never sit down. The dual mobility joint is usually targeted for people who are very active or have hyper mobility so it allows you a bigger range of motion and a smaller chance of dislocation.
I also had an anterior approach with it which had me walking without any aids in about 10 days and was given the go ahead to start riding again at 3 months post op.

Definitely do your research and get some opinions. I believe posterior approach gives you a permanent no 90 degree bending post op to(someone correct me if im wrong). I have zero restrictions with my dual mobility joint and don't even think about it anymore.

 

[Mojo333]

I believe posterior approach gives you a permanent no 90 degree bending post op to(someone correct me if im wrong).

This IS incorrect, thankfully...

 

[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.

Well I was super active before surgery and am super active now and got a dual mobility joint BECAUSE I am super active and very flexible.

I was a young patient when I got it in 11 months ago and would not go back to my pre-surgery conditions. I am super active(work for the police force as well), ride and train horses on my days off and never sit down. The dual mobility joint is usually targeted for people who are very active or have hyper mobility so it allows you a bigger range of motion and a smaller chance of dislocation.
I also had an anterior approach with it which had me walking without any aids in about 10 days and was given the go ahead to start riding again at 3 months post op.

Definitely do your research and get some opinions. I believe posterior approach gives you a permanent no 90 degree bending post op to(someone correct me if im wrong). I have zero restrictions with my dual mobility joint and don't even think about it anymore.

It is so good to hear how active you are post THR. You’re the second person on this thread who was able to get a dual mobility bearing with an Anterior approach, so clearly this is possible to do and do really well. The surgeons here in LA who use the Anterior approach really discouraged me from pursuing the dual mobility cup, which I haven’t entirely puzzled together yet.

Other than prohibiting the dual mobility bearing, part of why I was hesitant about the Anterior approach is that my basis of movement is dance, and I am not ready to give up my front splits yet. I’m learning from these surgeons that while dislocation risk is considered to be quite low for any of the approaches most commonly used these days, it’s the site of surgical entry that represents the weakest link, so to speak. So for me and my splits, an Anterior entry might represent a higher dislocation risk than it would for a skier or a horse trainer, simply because I’d be putting more pressure on the point of entry than other athletic ranges of motion do.

The surgeon I am using calls the method he uses a “mini posterior“, and the entry is on the side of the hip over the bony part (usually women know exactly what I’m talking about - the bony bit that juts out when we cock a hip to the side). It’s a muscle and soft tissue sparing approach that another surgeon has nicknamed SPAIRE - I have a couple of good articles about it but I don’t think I’m allowed to post them, so for the curious, go ahead and Google or direct message me.

I am learning that the word “posterior“ scares people off because of the old old old types of hip replacements that used to cut through the gluteus muscles, but literally no one does those anymore. The “mini posterior“ according to some comparisons I found may be the most soft tissue and nerve sparing approach being used these days, so I have high hopes. My surgeon prefers it himself to Anterior because he says it prevents permanent numbness around the surgical site. AND my surgeon uses dual mobility bearings in nearly all of his patients. Yaaayyyy. His approach is MAKO robot assisted and as minimally invasive as humanly and robot-ly possible.

With this point of entry, the dislocation risk would be a knee- to- chin cross midline bend that has some force applied to it, so I’ll have to try my hardest to remember not to try to pretzel myself. (I’m laughing as I write this because I truly truly hope that my recovery is so good that I have to remind myself not to try to make a pretzel out of my legs.)

You all have taught me well that all bodies and all recoveries are as individual as can be, so I am approaching this with cautious informed optimism and prehabbing as best I can to prevent more lean muscle loss. ::prayer-hands emoji::

 

[HollyNY]

I had anterior surgery but it used the Mako. It is guided by CT scan data so no surprises anatomically. Less time under anesthesia. Less blood loss. More accurate and repeatable than even the best surgeon's hands alone.

This is state of the art care when in the hands of a gifted surgeon.

 

[Caison113]

@LaKarune -- Following up, I had the mini-posterior (incision is about 5 inches) and honestly had no issues apart from normal recovery. I was walking without any assistance after about 8 days (albeit slow shuffling) and after three months was back in full action. No limitations on bending 90 degrees or more, kicking, lifting, hiking. All good. I know the anterior has some risk of numbness due to the pressure on the nerve during operation. I can't speak to the mobility bearing as I have a normal ceramic ball with the plastic cup, but I wasn't focused on extreme flexibility as mentioned before.

I will stress going with the best surgeon as opposed to their approach. If you are speaking with a reputable sports ortho, they will have tons of experience and track record. Sounds like you found one who fits your needs and will be in good hands! Good luck.

 

[dapplega]

@LaKarune - Chiming in here as another recipient of a dual mobility hip via mini-posterior approach. I'm going on year 6 and don't have any restrictions (although I have not returned to running or other high impact activities mainly because I'm babying the right hip which will also need to be done). My scar from the mini-posterior is only about 2.5-3 inches long. I'm in Seattle area and my surgeon only used that approach and only used dual mobility implants. Frankly, from the research I did and in my opinion, I'd be less worried about approach and make sure you are comfortable with the surgeon. After six weeks, I was cleared of restrictions (within reason of course, but didn't have to worry about 90 degrees, crossing legs, etc.). I can also relate to the struggles of accepting the need for the surgery as I went through a bit of depression afterwards. Be prepared for some blues if this is your first major surgery but know that it will pass. Best of luck to you!

 

[PolarIce]

Thank you @Mojo333 for the correction!

It sounds like you have a really great surgeon you're working with. Excited to see where your journey takes you.

 

[LaKarune]

@LaKarune - Chiming in here as another recipient of a dual mobility hip via mini-posterior approach. I'm going on year 6 and don't have any restrictions (although I have not returned to running or other high impact activities mainly because I'm babying the right hip which will also need to be done). My scar from the mini-posterior is only about 2.5-3 inches long. I'm in Seattle area and my surgeon only used that approach and only used dual mobility implants. Frankly, from the research I did and in my opinion, I'd be less worried about approach and make sure you are comfortable with the surgeon. After six weeks, I was cleared of restrictions (within reason of course, but didn't have to worry about 90 degrees, crossing legs, etc.). I can also relate to the struggles of accepting the need for the surgery as I went through a bit of depression afterwards. Be prepared for some blues if this is your first major surgery but know that it will pass. Best of luck to you!

I’ve already been dealing with such intense feelings of grief, so when you all mention this period of depression post surgery, I am seriously wondering how it gets worse than this. Is it related to the very real post surgical pain vs the anticipated pain pre surgery? Or deeper? I’m wondering how to mentally and emotionally prepare for that post surgery blues season.

 

[djklaugh]

@LaKarune I think it is a combination of the things you mentioned plus maybe fears of growing old, anticipating loss of a life long body part, and maybe other individual concerns. The night before my bilateral surgery I did a bit of meditation/internal dialogue and said good bye to my hip joints. I remembered some special times where strong hips were important. Thanked them for their service. Commiserated with their pain. And said good bye. For me that helped a lot!

Also the post op depression varies from person to person and may also be in part the side effects of both surgical anesthesia and post op pain medications. Usually these periods are very short but they can be intense.

Your particular feelings pre op are probably more anticipatory ... while reading things here can help you prepare they are only words on a screen. And no matter how much others say all will be well it is hard - especially when you are in a lot of pain - to accept that that will be the case. For now stay as busy as you can, get your home ready for you going in for surgery, and try not to worry!! Find ways to laugh 0 those endorphins really do help! And do keep posting here ... we do like to help and we do understand what you are going through.

 

[LaKarune]

@LaKarune I think it is a combination of the things you mentioned plus maybe fears of growing old, anticipating loss of a life long body part, and maybe other individual concerns. The night before my bilateral surgery I did a bit of meditation/internal dialogue and said good bye to my hip joints. I remembered some special times where strong hips were important. Thanked them for their service. Commiserated with their pain. And said good bye. For me that helped a lot!

Also the post op depression varies from person to person and may also be in part the side effects of both surgical anesthesia and post op pain medications. Usually these periods are very short but they can be intense.

Your particular feelings pre op are probably more anticipatory ... while reading things here can help you prepare they are only words on a screen. And no matter how much others say all will be well it is hard - especially when you are in a lot of pain - to accept that that will be the case. For now stay as busy as you can, get your home ready for you going in for surgery, and try not to worry!! Find ways to laugh 0 those endorphins really do help! And do keep posting here ... we do like to help and we do understand what you are going through.

I love this idea of communicating spiritually with our hip joints. I’m gonna try this.

Pain definitely makes me spiral emotionally, so that makes a lot of sense to me, especially mixed with cocktails of chemicals that definitely mess with our brains.

Wondering too if the surgical offices with their timelines create unrealistic optimism and we feel like we are failing when our experience doesn’t match the surgical packet?

My therapist told me she used to run 12 step groups for surgeons, and the orthopedic surgeons surprised her by having the biggest egos of all (I would have put money on the plastic surgery dudes but apparently they were just a close second). Could some of the post op blues be related to our bruised egos running into the brick wall of their extreme confidence?? After all, they aren’t getting these surgeries themselves so if they don’t have the empathy that comes from experiencing the flip side of the knife, their confidence may inadvertently cause us emotional pain, bc our experience is like a failure to meet their expectations in some part of our minds??

It seems like a weird balance they’d need to hit between confidence (to gain our trust and quiet our fears) and realism (which might spike our fears and diminish our trust). IDK but definitely planning to up my therapy sessions post surgery bc none of this sounds good to me. (Except the part where I might be able to be totally healed and living my best active life again.)

 

[dapplega]

@LaKarune - I think I owe you an apology. I didn't mean to raise your anxiety. As far as I can tell, for the great majority of folks post surgery depression is minimal and limited to a couple days of being frustrated about being dependent on others. My right hip surgery was my first major surgery. I had an image of myself as strong, athletic, in shape, being the cool grandparent that could beat his kids in tennis - that sort of thing . It was a real hit to my ego to have this surgery at 52 (one member here called it a "reality cookie" and that always stuck with me). I also had other things going on in my life contributing to my mental state. Since then I've had 2 more surgeries (both shoulders). I didn't suffer any depression with those, in great part I think because I was better able to accept my situation. I like to give the potential warning to others as I wasn't ready for that depression. I'd never dealt with it before and it really floored me for a good couple months. Fast forward to today and all is good. Your surgeon sounds top notch and I'm confident you will be pleased with the outcome. Wishing you peace and less anxiety .

 

[PolarIce]

Aww you poor girl. The depression is a real thing. I really didn't think about it until it happened to me to and it seems to be a very common thing. Take care of yourself and be kind to yourself. The surgery is a big one and it will al iron itself out, but remember to be kind to yourself. We are all here for you.

 

[LaKarune]

@LaKarune - I think I owe you an apology. I didn't mean to raise your anxiety. As far as I can tell, for the great majority of folks post surgery depression is minimal and limited to a couple days of being frustrated about being dependent on others. My right hip surgery was my first major surgery. I had an image of myself as strong, athletic, in shape, being the cool grandparent that could beat his kids in tennis - that sort of thing . It was a real hit to my ego to have this surgery at 52 (one member here called it a "reality cookie" and that always stuck with me). I also had other things going on in my life contributing to my mental state. Since then I've had 2 more surgeries (both shoulders). I didn't suffer any depression with those, in great part I think because I was better able to accept my situation. I like to give the potential warning to others as I wasn't ready for that depression. I'd never dealt with it before and it really floored me for a good couple months. Fast forward to today and all is good. Your surgeon sounds top notch and I'm confident you will be pleased with the outcome. Wishing you peace and less anxiety .

You truly don’t need to apologize. I’ve been waiting for the right time to ask about the post op blues. I’m big on emotional preparation and emotional resourcing (thus therapy ) and noticed BoneSmart has an article about it that they post on everyone’s recovery threads, so it’s clearly something everyone encounters in some way. This will be my first major surgery too, and it came as a shock that I even need it at all, so I’m soaking up all the wisdom you all are offering here and truly appreciate your generosity of spirit.

Now that I know you are an expert on surgical recoveries, I hope to learn more from your experiences as I shuffle towards my date and then out the other side into healing. Big heart emoji for sharing your experience with me and don’t worry about freaking me out. I am genuinely curious about the journey.

 

[LaKarune]

Aww you poor girl. The depression is a real thing. I really didn't think about it until it happened to me to and it seems to be a very common thing. Take care of yourself and be kind to yourself. The surgery is a big one and it will al iron itself out, but remember to be kind to yourself. We are all here for you.

Thank you!!! You all are so kind, very grateful to know you’re here as a resource for me through this Spiralic journey. I will absolutely be taking you up on the invitation to lean on y’all.

 

[PolarIce]

Please do it. We all went through it and the experience is different for every single person. Reaching out is the hardest thing to do, but at least here, you have a general anonymaty that i think makes it a little bit easier to share how you're feeling with people who can relate with you. Big hugs, you've got this. It does get easier and it will go away <3

 

[thepuckhead]

I’ve already been dealing with such intense feelings of grief, so when you all mention this period of depression post surgery, I am seriously wondering how it gets worse than this. Is it related to the very real post surgical pain vs the anticipated pain pre surgery? Or deeper? I’m wondering how to mentally and emotionally prepare for that post surgery blues season.

Hello -
I'm just 2 weeks post op, so I don't have a lot of experience, but your posts have been resonating with me, especially this part about grieving a body that isn't working the way it used to. I have a friend who was a ballerina and, as such, was very, very in tune with her body. She could name every single muscle and identify how to move it. I am seriously in awe at the connection dancers have with their bodies. It's very different from mine - I don't connect; I tell myself to push harder, go faster and just grit my teeth and do it. Afterwards, I love the rush and high of exertion and pushing boundaries, but it's not the same kind of deep connection at all.

In any case, when my friend suffered injuries, they really, really affected her mentally. The worst was one year when she had a "mystery" illness that nobody could figure out - her muscles would just tighten up randomly to the point where she couldn't move. Test after test after test after test....nope, nothing more than vague diagnoses. Like you, she researched like a PhD student and didn't stop until she found something that started to help (ended up being a novel and experimental therapy). It resolved, finally, but it was a brutal year. All this to say that I respect and sympathize with what a double-edged sword a deep mind-body connection can be in a time of illness or injury. And to thank you for sharing because your posts have given me a lot to think about and aspire to with my own healing.

If there's any silver lining, it's that you know the hip is the problem. A clear diagnosis is critical to a successful surgery. You know exactly what you're dealing with, which I hope gives you some confidence.

I also wanted to chime in on what @djklaugh mentioned about grief related to a fear of growing old. There is, sadly, a good amount of ignorance with regards to joint replacement surgeries. A lot of people (and I'd include myself in this) see them as a last gasp effort to get granny's pain reduced enough to let her hobble across the street to the mailbox if she's careful. But that's not the reality at all. Not anymore. The message is now that patients expect to be active and that hips in particular work very well in younger patients. What's the other alternative? To gradually stop doing what you love and keep making your life smaller? That's how you age and lose yourself, not by getting a hip replacement.

If it helps, the post-op blues I've experienced are very manageable when you know what they are and have prepared for them. I wasn't much for meditation as a healing strategy before, but boy I am now. I was stunned when I put my hand on my hip during one session and started weeping. That weepiness was coming from relief of finally listening to my body. Tears can be healing, too.

Good luck and thanks for sharing your thoughts!

 

[LaKarune]

I’ve already been dealing with such intense feelings of grief, so when you all mention this period of depression post surgery, I am seriously wondering how it gets worse than this. Is it related to the very real post surgical pain vs the anticipated pain pre surgery? Or deeper? I’m wondering how to mentally and emotionally prepare for that post surgery blues season.

Hello -
I'm just 2 weeks post op, so I don't have a lot of experience, but your posts have been resonating with me, especially this part about grieving a body that isn't working the way it used to. I have a friend who was a ballerina and, as such, was very, very in tune with her body. She could name every single muscle and identify how to move it. I am seriously in awe at the connection dancers have with their bodies. It's very different from mine - I don't connect; I tell myself to push harder, go faster and just grit my teeth and do it. Afterwards, I love the rush and high of exertion and pushing boundaries, but it's not the same kind of deep connection at all.

In any case, when my friend suffered injuries, they really, really affected her mentally. The worst was one year when she had a "mystery" illness that nobody could figure out - her muscles would just tighten up randomly to the point where she couldn't move. Test after test after test after test....nope, nothing more than vague diagnoses. Like you, she researched like a PhD student and didn't stop until she found something that started to help (ended up being a novel and experimental therapy). It resolved, finally, but it was a brutal year. All this to say that I respect and sympathize with what a double-edged sword a deep mind-body connection can be in a time of illness or injury. And to thank you for sharing because your posts have given me a lot to think about and aspire to with my own healing.

If there's any silver lining, it's that you know the hip is the problem. A clear diagnosis is critical to a successful surgery. You know exactly what you're dealing with, which I hope gives you some confidence.

I also wanted to chime in on what @djklaugh mentioned about grief related to a fear of growing old. There is, sadly, a good amount of ignorance with regards to joint replacement surgeries. A lot of people (and I'd include myself in this) see them as a last gasp effort to get granny's pain reduced enough to let her hobble across the street to the mailbox if she's careful. But that's not the reality at all. Not anymore. The message is now that patients expect to be active and that hips in particular work very well in younger patients. What's the other alternative? To gradually stop doing what you love and keep making your life smaller? That's how you age and lose yourself, not by getting a hip replacement.

If it helps, the post-op blues I've experienced are very manageable when you know what they are and have prepared for them. I wasn't much for meditation as a healing strategy before, but boy I am now. I was stunned when I put my hand on my hip during one session and started weeping. That weepiness was coming from relief of finally listening to my body. Tears can be healing, too.

Good luck and thanks for sharing your thoughts!

Thank you so much for chiming in here. I’ve been reading both your threads and have found your shares so incredibly courageous, thoughtful, and helpful (also you do know how to make yourself laugh, which is damned delightful).

I feel very seen here! “Research like a PhD” is definitely my jam. The mind/body connection is powerful and I’m grateful that modern psychology has started centering it — I have book recommendations for anyone interested (low key do not recommend “The Body Keeps the Score” bc many people w trauma find it retraumatizing - try “My Grandma’s Hands” or “What My Bones Know” if interested). Anyway yes, dancers do tend to have a high degree of mind/body awareness, so emotional work related to body injury comes with the territory.

Hips are also widely understood as the main place our bodies store Grief. I heard a podcast with former yogi and now fascia expert Jill Miller talk about her THR totally unexpectedly releasing old “forgotten” memories of trauma and grief that she didn’t anticipate. Putting together the math that way, post op blues around hip surgery in particular makes SO much sense. Add to it the weird complications or unexpected physical sensations that are so common with this surgery, and you get an equation that really invites us to be very VERY gentle with ourselves through this process.

While I *know* all this, I’m actually very much like you, in that I often just want to rush to the end of a challenge and get it done. My brain works fast and I want everything around me to keep up. Feeling trapped or stuck or held back is fruuuuuustratingggggg for me.

I’ve been working through a feeling that’s childlike but very present, that it’s completely unfair for life to force me to look at issues around aging that I didn’t expect to have to confront for another 30 years. I tell myself I will be a deeper soul and better prepared for it when it comes back around later in life, but really I just want to be baby and have fun. Permissioning myself for those feelings to both be present and true at the same time.

Repeating so much advice here like a mantra: “listen to your hip and don’t push too hard” - “your body knows how to heal” - “resting post op IS healing” - etc. Will need it when my time comes!

So yes your share around mental preparation and meditation helps IMMENSELY. Thank you thank you. <3