THR Nerve Damage with Anterior Approach

[Curious George]

I am in need of a hip replacement. I am trying to choose between the anterior approach and the posterior approach to surgery before I choose a doctor.

I have read many medical articles and have also read many comments in forums that indicate that there is frequently (if not always) numbness and or pain in the thigh after anterior approach surgery. I need to get a better sense of how serious of a problem this is and for how long it lasts. I understand that this is a nerve issue and does not impair the function of the hip but it certainly seems to be a problem that many people have trouble dealing with post operatively. In some cases there is numbness that is permanent. In some cases there is pain that is permanent.

From what I understand, the lateral femoral cutaneous nerve is in the surgical field and cannot be avoided. It is either injured by dissection, by compresseion from the retractors that are used during surgery, by stretching, or by scar tissue that forms in the wound after surgery is complete. It seems like a big deal that this nerve injury is part of the package with the anterior approach.

If you have had hip replacement via the anterior approach and experienced numbness and or pain afterwards, I would be interested in knowing how difficult it was to deal with.

 

[Pumpkin]

@Curious George
Welcome to BoneSmart, glad you joined us!

the lateral femoral cutaneous nerve is in the surgical field and cannot be avoided. It is either injured by dissection

The lateral femoral cutaneous nerve is sensory only, if it is injured or bruised you will have numbness along the outside of your hip and down the side. It usually resolves as you heal.

If the femoral nerve is injured it effects your quads and sensation on the front of the leg. It usually resolves with healing.

You may want to sign up for our yearly presentation from a panel of surgeons.
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[Jaycey]

@Curious George Welcome to BoneSmart. I would recommend you find a surgeon you can work with and let that surgeon use the approach they feel most comfortable with given your medical situation. Sometimes the decision on approach is based on the condition of your hip and the type of access the surgeon will need.

 

[Raftin21]

Hi Al, I definitely agree with Jaycey, finding the right surgeon is key and there are a lot of things the surgeons consider for what type of procedure you even qualify for. I did mine as outpatient and didn’t even know that was an option!!!

I had the anterior hip replacement with robotic assist in February. It went great and I am super happy with it. I did have thigh numbness and it lasted for about 6 weeks, it felt really strange, but kept getting less as the weeks passed and now is completely gone. I am getting my second THR in May with the anterior approach again. My surgeon is amazing and that really is the most important part.

 

[Eman85]

I've had both hips done and my OS used posterior. I didn't know or really care how he got them in there when I was searching for an OS. I wanted the guy that could handle the job and give me the end product I wanted. It was after I was scheduled that I called and asked where the incision would be.

 

[Curious George]

I would like to change the username on my account to Curious George.
Can someone please help me with this request?

 

[Pumpkin]

@Curious George
Admin has been notified and will change your username for you when they see the notification.
Thanks,
Chris

 

[Jamie]

@Curious George .... I have changed your username as requested.

 

[Schaargi]

Hi @Curious George

I had an anterior approach and experienced a worst-case scenario where I lost the use of my quad for a few months due to a rare femoral nerve damage. While the lack of response from my quad was terrifying, the numbness was not a big deal at all. It's just a bit curious to pinch your leg and not feel anything.

I'm almost a year out and my quad is working. The numbness covered the anterior part of my whole thigh at first, but it has shrunk to a few square inches on my knee. I regained functionality before the numbness went away.

At any rate, my situation was rare and if asked, I would do it again. (Actually, my other hip is failing now and I am likely going to go through it again.)

I'm glad I had the surgery and trust my surgeon to take care of me when the other hip needs replacement. If my situation leads him to believe an anterior approach is best, I'm fine with it.

Hope this helps!

 

[Curious George]

Thank

 

[Curious George]

Thanks to those who took the time to reply to my post. I greatly appreciate it.

The surgeons I have seen each specialize in a specific surgical approach. Of course, each surgeon advocates for the approach they use. The anterior doctor will tell me why that approach is better, the posterior doctor will tell me why that approach is better. Additionally, they will comment on the negative aspects of the other approach.

I have been told that I am a good candidate for either the anterior or the posterior approach. It is left up to me to decide which approach I prefer. That is my dilemma right now. Although I have met with outstanding surgeons that do either one approach or the other, I need to choose the surgical approach that I want before I choose the surgeon.

From what I read, the posterior approach seems to be the safest approach for the patient. However, it involves cutting hip rotator muscles that require surgical repair and take weeks to heal. This leads to more hip precautions, more pain from surgery, and greater recovery time. The anterior approach seems to provide for quicker recovery time and more accurate placement of the hip components, but there is a high incidence of injury to the lateral femoral cutaneous nerve that can result in numbness or pain in the thigh (sometimes permanent), as well as higher risk of fracture of the femur. I know there's a lot more to it than this simple summary, but you get the gist of what I'm saying.

I am hoping to hear from those of you who have been through the surgery and have an opinion on this.

 

[Schaargi]

Hi @Curious George

You are a brilliant summarizer! Your former teachers would be proud.

Well, then, in that case I would go with the surgeon you feel most comfortable with, the one you trust to do a good job and follow through. The one who will answer your questions thoroughly and honestly.

Each surgeon will be best at the approach he or she touts, so I would focus on the one you trust the most.

 

[DGrant]

From what I read, the posterior approach seems to be the safest approach for the patient. However, it involves cutting hip rotator muscles that require surgical repair and take weeks to heal. This leads to more hip precautions, more pain from surgery, and greater recovery time. The anterior approach seems to provide for quicker recovery time and more accurate placement of the hip components, but there is a high incidence of injury to the lateral femoral cutaneous nerve that can result in numbness or pain in the thigh (sometimes permanent), as well as higher risk of fracture of the femur. I know there's a lot more to it than this simple summary, but you get the gist of what I'm saying.

I am hoping to hear from those of you who have been through the surgery and have an opinion on this.

I'm not sure where you read the posterior post takes "weeks" to heal, or how/what it involves or what cutting needs to be done, but I had a TLHR over 5yrs ago and my surgeon used the posterior approach and I had immediate relief... no more pain other then the incision and some muscle tension, and obviously inflammation for a short time because of the manipulation... nothing ice couldn't take care of.
My recovery time with the posterior approach was astounding. I was off the walker in 5 days, off the cane totally in 10 days. I was mowing my lawn 30 days post op and enjoying every minute of it. It totally changed my life. I was riding my motorcycle exactly 60 days post op(could have done it in 30days). Point is, in my case, what you stated above didn't apply in any way at all. I can't speak for everyone, but this was my experience. I can't imagine recovery being any quicker.

If you really want to know, the healing process goes far beyond simply getting off a cane, and does last for weeks, so in that aspect you are correct... but moderate/normal activity can resume as soon as a person is capable... and it's a good thing. I was walking a mile a day also a month after. That right there is your best therapy.

I will be getting a RTHR May 5th, and the surgeon I now have (the other guy retired from surgery, but is still in practice doing treatments, consults, and referrals)... and my new surgeon is apparently going in with the anterior approach. I consulted with my first surgeon (that did my LTHR and also referred me to my current surgeon) and I totally trust my first surgeon (he actually did my daughters hips too(she's got RA, I've got OA)), he looked me in the eye and said ""just get it done, let the guy do his job and do what he knows best""..... I always liked his honesty.

I guess at this point for me, after been through it, and knowing how much of a game changer it is for the better, I'm not waiting around to try and figure out their job. I know what it's like to be free and fixed. I'm to the point I'll just walk in and say "where do I lay down".

Yeah there's a healing process, but the only way to get to the healing process is to let the guys do their job once you're comfortable with them, and therein is sometimes a bigger challenge, moreso then them doing the job is the patients being Ok with them.... If you can take the pain until you find a surgeon that's up to you, but you might be in pain for a long time, when really you might not have to be.

It's different for everyone of course. It's quite scary when we think about it, but there's a reason hip-replacement surgery is probably the most successful surgery in the country, and after you have it, you'll be much better off.. no doubt in my mind.

I just might post back to you and share what my experience is with having 2 hips done with different techniques. I think it will be interesting, and I also think it will be good. Anything is better then dragging my right leg around and wincing in pain every step.

I wish you well on your journey, and sincerely hope you find the help you need.

 

[Dmcfad2]

I’ve been through a lateral approach on my left hip and anterior on my right. Anterior has been SO much better for me in terms of recovery. I would never do it another way again.

 

[DGrant]

I’ve been through a lateral approach on my left hip and anterior on my right. Anterior has been SO much better for me in terms of recovery. I would never do it another way again.

That's good to know too. I've wondered how far technology has gone even in the last 5yrs. I've been a little reluctant with my new surgeon, just because he's younger then my first one, and I'm also taking into consideration my own hesitancy, but we have to keep in mind, there's some real talent working on these hips and they don't get there easily. One or many of them are most likely masterminds... and far beyond my comprehension. My first surgeon was/is somewhat like "old-school" private practice, my new guy is younger and most likely very well versed on modern technology and techniques.... and a member/doctor in a much larger organization... so just in that it's different for me.

There's nothing wrong with that in my mind... and it could be better then the first time. My bet is that it will be.

If my anterior approach goes anything like my posterior did (or even better) it's going to be a great summer getting back to what we love doing. I've missed some great hikes over the last several months, but hope to make it up this year.

Again, I do hope Mr. George gets the help he needs, and moreso that he's comfortable with them and the results of his surgery. Therein is a big key. Even the best surgeon in the world isn't the best unless we believe it.

 

[Celle]

From what I read, the posterior approach seems to be the safest approach for the patient. However, it involves cutting hip rotator muscles that require surgical repair and take weeks to heal. This leads to more hip precautions, more pain from surgery, and greater recovery time. The anterior approach seems to provide for quicker recovery time and more accurate placement of the hip components, but there is a high incidence of injury to the lateral femoral cutaneous nerve that can result in numbness or pain in the thigh (sometimes permanent), as well as higher risk of fracture of the femur.

Not all surgeons doing the posterior approach cut muscle.

While the anterior approach may appear to offer a faster recovery initially, the truth is that whichever approach is used, hip replacement is major surgery, from which complete recovery can take as long as a full year.

There's no way you can speed up recovery, no, matter how much you want to. You have to allow your wounded tissues the time they need to recover.

It's much more important to choose the best surgeon you can than it is to select a surgeon by the approach he/she chooses. When all's said and done, the most important factor for success is the skill of your surgeon.

 

[Going4fun]

Go with the anterior approach surgeon if you want, but I highly recommend that you do not assume that your recovery is faster than anyone else's. Happens all the time on this board, weekly at least it seems.

Someone comes here and says "I had the anterior approach. I wasn't expecting my recovery to be slow. I thought I would be up and walking immediately." The surgeon and/or the patient didn't manage expectations. Allow yourself room for a regular recovery with ups and downs and yes some frustraionts-- just like everyone else's.

All approaches have been improved over the years. Surgeons are constantly making improvements, little and big. In fact, part of the problem surrounding the hype of the anterior approach is that lay people compare their friend, John, who had surgery via the anterior approach recently with their grandmother Mary, who spent three weeks in the hospital three decades ago.

Surgeons using all of the approaches send you home (for the most part) the day after surgery. Patients of surgeons using all the approaches benefit from better pain protocols and medication cocktails than people decades ago. And patients of surgeons using all approaches recover faster and with less pain than decades ago.

 

[Eman85]

As I said I've had 2 posterior approach THR's. My OS chose the approach and I chose him on his ability. I asked him about approach after my first and he said he's used both but prefers posterior for simply put room to work. My first had pins in my femur that had to be removed so the room to work was important. My second was supposed to be routine and simple. When in there he found a bone cyst and had to clean it out and fill it. Did the room to work give him a better chance of finding and fixing this? I don't now but it surely didn't hurt. As far as recovery goes it seems it's got a lot to do with how the OS does and how the patient's body responds. Either way is pretty invasive since they're dislocating your joint, hacking off the end of you femur, driving a railroad spike in it and reaming out your pelvis. Not pretty but it's the reality. I don't think there's any way in there that allows them to do this that doesn't cause trauma.

 

[Trailgirl]

I had a Left hip anterior approach in early 2019- Overall I chose a doctor that did this approach because the post surgery movement--that is bending and movements with the posterior approach. I am very short and with my living circumstances this was best for my recovery circumstances. Also, the surgeon I chose, did a minimally invasive type incision--smaller than others I have seen with the posterior approach and was told less incidence of infection by the surgeon. That said, I did have a very odd lack of feeling in my leg almost all the way down to my knees post hip surgery. According to the surgeon, they have to move those large nerves out of the way-and it may depend upon your health status, weight, etc (I was and am around 50 LBs overweight).. so I am not sure. The PTs told me to dry brush and stimulate the area with my hands.

I recently (a few months ago) had a sacroiliac fusion plus lower lumbar fusion. After the recent surgery, this same area went numb again, but not quite as pronounced.

Taking the post LHR PT advice with stimulating the area, I am 4 months out from my most recent surgery and the numbness is gone again.

 

[Granny Di]

Hello!
I am having the anterior approach on Monday, Nov.8 and will be able to compare the two approaches as I had the posterior approach in 2015.
Hopefully all will go well and recovery will be better and faster. There are no guarantees in this business. Best of luck to all!