Anterior vs Posterior vs Anterolateral Hip Replacement: Does the Approach Matter?

What is a surgical approach in hip replacement?

If you are considering a hip replacement, you may hear a lot about the “approach” your surgeon uses.

Some surgeons perform hip replacement through the front of the hip. Others use the side or the back. You may also hear terms such as direct anterior, posterior, anterolateral, or muscle-sparing.

During a total hip replacement, the damaged ball and socket of the hip are replaced with artificial components. To do that, the surgeon needs a pathway to reach the joint. That pathway is called the surgical approach.

The main approaches are named for the direction the surgeon comes from:

• Direct anterior: from the front of the hip
• Anterolateral: from the front and side of the hip
• Posterior: from the back of the hip

All three can be used to perform a successful hip replacement. The differences are mainly in how the surgeon reaches the joint, which tissues are moved or released, how the patient is positioned, and how the surgeon sees the hip during the operation.

What is the direct anterior approach?

The direct anterior approach reaches the hip from the front.

One reason it has become popular is that the surgeon can work between muscle groups rather than cutting directly through a large muscle belly. The posterior muscles and tendons of the hip are also left intact.

Some surgeons perform direct anterior hip replacement on a standard operating table. Others use a special traction table that helps position and move the leg during surgery.

Many surgeons also use X-ray imaging, called fluoroscopy, during direct anterior hip replacement to help evaluate implant position and leg length.

Direct anterior hip replacement can produce excellent results when performed by a surgeon who is experienced with the technique.

What is the posterior approach?

The posterior approach reaches the hip from the back.

It is one of the most widely used approaches to hip replacement and gives the surgeon excellent access to the hip joint.

To reach the joint, several of the smaller muscles and tendons at the back of the hip are typically released. These structures are usually repaired at the end of the operation.

Historically, one concern with the posterior approach has been the risk of the hip dislocating after surgery. Modern surgical techniques, careful repair of the soft tissues, improved implants, and accurate implant positioning have helped reduce that risk.

Like the anterior approach, the posterior approach can provide excellent results in experienced hands.

What is an anterolateral approach?

An anterolateral approach reaches the hip from the front and side.

There are several versions of anterolateral hip replacement, so the exact technique can vary from surgeon to surgeon.

In my practice, I use a specific version called the Mayo Modified Anterolateral Approach.

The Mayo approach preserves the tissues at the back of the hip, including structures that help provide stability. It also gives me the exposure I need to position the implants and rebuild the hip.

I perform the operation on a standard operating table. My technique does not require a specialized traction table or fluoroscopic X-ray imaging during surgery.

Another reason I value the approach is its versatility. If I need more exposure during a difficult hip replacement, the approach can be extended rather than limiting what I can do.

Is one hip replacement approach better than the others?

This is where the discussion can become misleading.

You may see advertisements suggesting that one approach is the “best,” “least invasive,” or guarantees a faster recovery. The evidence is not that simple.

Each major approach has advantages and disadvantages. Excellent hip replacements can be performed through anterior, anterolateral, and posterior approaches.

A surgeon's experience with the approach matters greatly.

What matters besides the approach?

A successful hip replacement requires much more than choosing where to make the incision.

The surgeon must determine the correct implant size and position, restore the center of the hip, balance leg length, restore the proper tension of the muscles around the hip, obtain stable fixation, and make sure the new hip is stable.

Your anatomy also matters.

Some patients have unusual bone shape, poor bone quality, previous surgery, retained hardware, spine problems, or major differences in leg length. Those factors can affect how the hip should be reconstructed.

That is why I believe the approach should serve the reconstruction — not define it.

The goal is not simply to perform the operation through a particular incision. The goal is to build the best hip replacement possible for that patient.

Does the approach affect recovery?

It can, particularly during the early part of recovery.

Different approaches affect different tissues around the hip, so patients may notice differences in soreness, weakness, or movement during the first few weeks.

But the surgical approach is only one factor.

Your recovery also depends on your health before surgery, muscle strength, severity of arthritis, complexity of the operation, pain response, and how quickly you are able to return to normal activity.

For most patients, the long-term goal is the same regardless of approach: a stable hip with less pain that allows them to return to the activities that matter to them.

What about “muscle-sparing” hip replacement?

This is another term patients commonly see online. It is useful, but it can also be misleading.

Every hip replacement requires the surgeon to move and work around muscles, tendons, the joint capsule, and bone. No approach makes a hip replacement a minor operation.

Some approaches do preserve certain muscles or tendons better than others.

For example, both direct anterior hip replacement and the Mayo Modified Anterolateral Approach preserve the posterior soft tissues.

Instead of focusing only on the phrase “muscle-sparing,” I encourage patients to ask their surgeon which tissues are affected by the approach and why the surgeon prefers that technique.

Why do I use the Mayo Modified Anterolateral Approach?

I use the Mayo Modified Anterolateral Approach because it fits the way I think about hip reconstruction.

It preserves the posterior soft tissues. It does not require me to use a specialized traction table. I can perform the operation without intraoperative fluoroscopy. And when a more complicated reconstruction requires greater exposure, the approach can be extended.

I use the same general approach for routine primary hip replacements and for selected complex revision hip procedures.

I am currently the only orthopedic surgeon in the St. Louis area performing primary hip replacement using the Mayo Modified Anterolateral Approach.

That does not mean every other approach is wrong or that the Mayo approach is right for every patient. It means this is the technique I have chosen based on my training, experience, and the way I prefer to reconstruct the hip.

What should you ask your hip replacement surgeon?

If you are meeting with a surgeon about hip replacement, you do not need to become an expert on surgical approaches.

A few simple questions can tell you much more:

1. Which approach do you use most often, and why?
2. How much experience do you have with that approach?
3. Are any muscles or tendons released during the operation?
4. Do you use a special table, X-ray imaging, navigation, or a robot during surgery?
5. Are there reasons my anatomy might make one approach more appropriate for me?

A good surgeon should be able to explain those answers in a way that makes sense to you.

The bottom line

Yes, the approach used for hip replacement matters — but it is not the only thing that matters.

Anterior, posterior, and anterolateral hip replacement can all produce excellent results.

The most important goal is a well-planned, accurately performed, stable hip replacement that restores the mechanics of your hip while treating the surrounding tissues with care.

The surgical approach is the pathway that allows your surgeon to accomplish that goal.

In my practice, that pathway is the Mayo Modified Anterolateral Approach.