Dr. Miller: Two approaches to have your hip replaced, which one's best for you? We're going to talk about that next on Scope Radio.
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Dr. Miller: I'm Dr. Tom Miller and I'm here with Jeremy Gililland. He's a professor of orthopedics here at the University of Utah in the department of orthopedics. What's the best way to have your hip replaced, from the back or from the front?
Dr. Gililand: The honest to goodness truth is you should have your hip replaced by a surgeon who knows what they're doing from what approach they're using.
Dr. Miller: That's pretty good basic advice. Know your approach and know it well.
Dr. Gililand: Exactly.
Dr. Miller: So talk to me about the differences because patients do assume that maybe one approach is better for them, maybe it's less invasive, requires less time in the O.R. I just don't know.
Dr. Gililand: Sure. So I think there are two major approaches in hip replacement today and that is either the direct anterior approach or the posterior approach. Both have been around for a long time. The anterior approach is not a new approach. It's been around since the 1950s, It's just taken a hold, I would say, in the last decade as a . . .
Dr. Miller: Mainstream procedure.
Dr. Gililand: Mainstream procedure. Exactly.
Dr. Miller: Why would one do an anterior approach or why did the posterior approach become ascendant?
Dr. Gililand: So the posterior approach has always been a very nice approach with very good visualization, good access to the pelvis and to the femur and it's quite extensile. Meaning if there's any troubles during surgery, you can get access to everything you need and fix any troubles there. However, with the posterior approach, we've had issues with dislocation and dislocation is a big problem for patients if you have a dislocation.
Dr. Miller: So once the hip's replaced then the patient post-operatively has a higher risk of dislocation than in a patient who's had an anterior approach.
Dr. Gililand: Well, we like to think that. We like to think that the anterior approach has mitigated some of the dislocation risks. So that's really where the surge and popularity of the anterior approach came in as well as it being a little bit less invasive, smaller incisions and patients like to think that's it's muscle sparing as compared to the posterior approach. So that's really what's driven a lot of the popularity of this approach.
Dr. Miller: Now, you do the anterior approach in your practice?
Dr. Gililand: Correct, I do.
Dr. Miller: Do you do primarily an anterior approach?
Dr. Gililand: I would say it's about 90 to 95% of my patients that I do hip replacement on get anterior approach and a small percentage will get posterior approach based on certain factors.
Dr. Miller: But other surgeons in your practice will utilize primarily the posterior approach.
Dr. Gililand: Absolutely.
Dr. Miller: So how does a patient choose?
Dr. Gililand: There's a lot of stuff on hype on the Internet, a lot of information that I would be careful of reading. I think that patients need to talk with their surgeon. They need to feel comfortable with their surgeon and they need to really listen to what their surgeon has to say in terms of their expertise and their feelings of the surgery.
I think for approach one versus the other, there are benefits potentially the anterior approach. Patients sometimes feel like in the first six weeks they're up on it quicker. It's a little easier and less painful for recovery. There's definitely less concerns for positions of the hip in terms of dislocation.
With the posterior approach we give you certain precautions or positions to avoid for dislocation. With the anterior approach there's less of those precautions. However nowadays with a well done posterior approach or a well done anterior approach, dislocation risk is very, very low and patients can do well with both.
Dr. Miller: So it comes back to what you were saying earlier which revolves around the surgeon's expertise in that particular approach, their ability to perform that particular procedure over and over again and do it really well. So I think for the patient who's looking to have a particular approach, they should listen to what the surgeon does mostly or what the surgeon recommends and not try to push him in a direction that the surgeon is not comfortable with or less comfortable with.
Dr. Gililand: Absolutely. One of the problems we've see with the anterior approach is that it has become a marketing tool for surgeons. So surgeons will use that to bring patients into their practice and start saying, "I do the anterior approach, please come and get your hip done with me."
The problem being is they may have a very low number of hips in their experience there. It's got a significant learning curve, probably around 100 hip replacements before you really are competent with the approach, and so patients may not know that their surgeon has had very little experience on the approach yet says that they do the approach and the surgeon may say that they prefer that. So I think it's wise for patients to always ask their surgeon what's your experience with this approach, why are you saying that I need this approach and be educated on that.
Dr. Miller: What's nice in your practice or your group practice is that you have surgeons doing both. Have you had a patient request a posterior approach that you've then referred to your colleague or vice versa?
Dr. Gililand: Absolutely. I think that . . . and I'll have patients come to me that request an anterior approach and I'll tell them I don't think they're a good candidate for it for x, y or z reasons. If they are not comfortable with it, they can find somebody else who may be comfortable to do that approach but we offer all approaches here at our practice. I think we all have very very good success with our hip patients regardless of approach. Again I think it boils down to surgeon's comfort and patient's comfort with their surgeon.
Dr. Miller: On the redo prosthetics of patients will come back and they'll need a new hip after a number of years. Either approach or one in particular?
Dr. Gililand: I think the posterior approach is generally the workhorse for us when it comes to going for revision surgery. They are certain cases when I will do revision surgery through an anterior approach but that really is somewhat select. Most of the time we're using the posterior approach, again, because of the nature of it being a more extensile approach that gives us better visualization of both the pelvis and the femur.
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