Less-invasive approaches to hip replacement surgery gaining popularity

Robert Olseski Jr. realized last year that his right hip pain, due to osteoarthritis, was affecting the quality of his life. He found it difficult to get in and out of the car easily, an important part of his job for his family-owned food distribution business, W.E. Ryan Co.

He could no longer take walks with his wife in Valley Forge Park. Doing yard work and shoveling snow were becoming painful. He also developed a limp.

“I had my left hip done 15 years ago and they told me then that I would need to have the other hip done eventually,” recalled Olseski, 58, from Wayne. “For the last year and a half it was bothering me but with the pandemic I had to put it off until January.”

The experience was easier this time around, Olseski said. He discussed his options with Charles L. Nelson, an orthopedic surgeon at Penn Medicine, and decided to have a total hip replacement with a less-invasive technique than when he had his left-hip surgery.

Olseski spent one night in the hospital and then started physical therapy to help strengthen his new hip. He used a walker for a couple days, then a cane for a few weeks. After five weeks, he returned to work with full mobility.

“I was amazed,” he said. “My hip is great.”

Roughly a half-million people in the United States had hip replacement surgery in 2019, according to C. Lowry Barnes, president of the Association of Hip and Knee Surgeons, based in Little Rock, Ark. That’s up from about 375,000 just five years earlier. He estimates that about one million hips will be replaced annually by 2030, due in part to Americans’ increasingly active lifestyle and confidence in new medical technologies.

Significant developments have been made in surgical approaches to hip replacements, with some doctors now using robotic assistance to ensure precision.

Like Olseski, more patients who qualify for it are opting for the anterior approach, where patients are lying on their back and the surgeon comes in from the front in between muscle groups.

“It’s just like you’re parting curtains, so it gives you a window into the hip without detaching muscles,” said Nelson, chief of adult reconstruction and professor of orthopaedic surgery at Penn Medicine.

Some studies suggest that this approach may result in less damage to major muscles, less postoperative pain, a smaller scar, and a quicker recovery than more traditional approaches, in which a larger incision is made from the side or from behind.

Other studies don’t bear out that the anterior approach yields superior results, Barnes said, noting that long-term outcomes will help create a clearer picture. Barnes estimated that the anterior approach is now being used in 10% to 15% of hip replacement surgeries.

The typical hip replacement recipients are in their mid-60s and suffer from arthritis of the hip, though other reasons for replacement include fractures and loss of blood supply, Barnes said. The surgical procedure involves replacing the damaged hip joint — the ball and socket — with a prosthetic implant.

“The person commonly has groin pain that interferes with his or her activities of daily living – pain getting up from a chair, going up and down stairs, walking or sleeping,” Barnes said. Often, the pain prevents them from their favorite activity, such as golf or tennis.

The modern hip replacement was developed in the 1960s with a lateral approach, in which the doctor makes a long incision at the side of the hip, splitting the abductor muscles, allowing the hip to be dislocated and viewed by the surgeon. Most common today is the posterior approach, in which patients are lying on their side and the surgeon comes in behind the abductor muscles. But the anterior method is gaining popularity as more surgeons train to use it.

“You come into the hip from the front, in the interval between two groups of muscles,” Nelson said. “It’s a very muscle-friendly approach to get into the hip.”

Of the roughly 650 hip and knee replacements Nelson performed last year, about 300 were first-time hip replacements, 100 of which he performed with the direct anterior approach. That’s up from 60 to 75 five years ago.

Yet this less-invasive surgery isn’t appropriate for all hip-replacement patients.

“I don’t use that approach when cases are complex with prior hardware or [with] patients who are morbidly obese,” he said.

Jeremy J. Reid, attending orthopedic surgeon at Virtua Health, was trained using the anterior approach before starting his practice in 2014, and uses it in about 90% of his hip replacement surgeries.

Reid is also an advocate of robotic surgery.

The robot helps the surgeon prepare the bone for prosthetics, he said, by helping guide removal of diseased bone and cartilage. It also aids in determining the final depth and orientation of the replacement of the prosthetic component, he said. Robotics also help measure limb length and the position of the femur relative to the pelvis.

“Studies show about 97% of plans are executed within one to two millimeters of target, which is well above what can be executed with the naked eye or with instruments alone,” he said.

Along with other approaches to hip replacement, the anterior approach is covered by Medicare and most insurance plans. The use of robotics is similarly covered, Reid said.

Nelson said that he uses robots in the posterior approach, but not the anterior. In those cases, he uses fluoroscopy, which he described as real time X-ray with computer-assisted image navigation.

When considering hip replacement surgery, it is important to discuss the various approaches with your doctor.

“The data show that regardless of the type of approach used to do the hip replacement, the results are all very similar, with less than 3% having significant issues,” Barnes said. “After a while you forget you ever had a hip replacement because it’s so normal.”

Olseski is thrilled with his surgery and recovery. “I came home the next day and now I have no pain and a more positive outlook,” he said. “I feel like a new man.”