Anterior hip surgery - is it time to lead from the front?

When hip replacement was introduced in the 1960’s the pioneering surgeons made their patients rest in bed for three weeks. It took months for the patients to regain independent mobility and they were discouraged from engaging in vigorous or sporting activity. In the early 2000’s, consultant orthopaedic surgeon Professor Richard Field noticed that many of the world’s top hip surgeons were adopting the direct anterior approach (DAA) for their hip replacements. Using this approach, the surgeons were able undertake their hip replacements without cutting any muscles or detaching any tendons and their patients were enjoying a faster early recovery, with less pain. Professor Field visited Innsbruck and Paris to learn DAA hip replacement and has now undertaken over 2000 DAA hip replacements. He is the UK’s most experienced surgeon in DAA hip replacement.

The benefits of an anterior approach

Professor Field generally uses what has become known as the bikini incision as the scar becomes almost invisible after a few months. The nursing and physiotherapy staff also benefit when patients have a DAA hip because the patients need less help getting in and out of bed, they can walk to the bathroom, use the shower and find stairs less challenging.

Professor Field tells us that "When the hip replacement is undertaken in the morning many of our patients choose to go home in the evening. These patients benefit from being at home with their family and being able to sleep in their own bed. When the operation is undertaken in the afternoon, we encourage them to stay overnight and have some physiotherapy before they leave the next day.

Occasionally patients take a little longer to regain their mobility and, in such cases, a longer admission is best. When early discharge is possible, it has the added advantage of minimising the risk of hospital acquired infection and the other hazards of reduced mobility."

Adopting the direct anterior approach

Although DAA hip replacement is widely practiced in the USA, Australia and across Europe, the technique is being adopted more slowly in the UK. Many patients who have previously had a hip replacement using the Posterior or Lateral approach report that they make a much faster recovery when their second hip is undertaken by Professor Field, using the DAA. They inevitably ask Professor Field why other UK surgeons don’t use the DAA. Professor Field explains that “A growing number of the younger hip surgeons are returning from their fellowships trained in DAA and my colleague Mr Emeka Oragui is using the DAA for his patients at The Lister Hospital.

Regarding his more established colleagues, Professor Field says that “while a few of my established colleagues have adopted the DAA, the majority are probably wise to continue with the technique that they learned during their training and that works well in their hands. We know all operations have a learning curve and there is a higher rate of complications and failures during the learning phase. We know that 4 to 6 weeks after a hip replacement, there is no discernible difference between patients whose operations were undertaken by the different approaches and the benefit of a faster early recovery may not be worthwhile if the price is avoidable complications.”

With all its rehabilitation and mobility benefits, Professor Field believes that DAA hip replacement will continue to gain ground in the UK. “I anticipate that DAA hip replacement will become commonplace in the UK and in ten years most hip surgeons will be able to offer this procedure to their patients. In the meantime, it is good to be able to match the best possible levels of care within HCA UK – and be as good as anywhere in the world.”