A less invasive approach to hip surgery

Marilyn Bafus had always stayed active on the wheat farm she and her husband operate near Colfax, doing “farm wife things,” maintaining a big garden and caring for the half-dozen horses she rode on trails with friends.

Until, as the hip pain that started five years ago worsened slowly but persistently, she couldn’t. At some point, she grew unable to swing a leg over a horse. Smaller gestures – using the stairs, climbing in and out of a car – grew painful, too.

“Joint diseases like that steal little bits of your life, a little bit at a time,” said Bafus, 64, who had arthritic hips and hip dysplasia. “… You end up being the person that says, ‘No, no, I’ll wait here while you guys go do something.’ And all you’re doing is looking around for the next place to sit down.”

To help her regain her mobility, Bafus’ surgeon, Dr. Jonathan Keeve, suggested a kind of hip replacement surgery that’s been attracting attention and patients in recent years, in part because many surgeons say it helps patients recover faster.

Keeve replaced Bafus’ right hip using an anterior “approach” – “in doctor talk, how you get to the hip,” he said – making an incision at the front of her leg rather than from the rear or the side, called posterior or lateral approaches. Keeve replaced Bafus’ left hip about a year later using the same technique.

The frontal approach allowed Keeve to reach Bafus’ hip joints without cutting through muscles.

“Basically, we work between the muscle planes rather than through them,” Keeve said. “It’s what we call soft-tissue sparing – it’s a little kinder and gentler to the local anatomy.”

For Bafus, the improvement was immediate.

“You have surgical pain, sure, but that awful joint pain is just gone,” she said. “The first time you stand up, you just think, ‘Oh, my gosh.’ It is kind of like magic.”

Popular operation among aging adults

About 300,000 hip replacements are performed each year in the U.S., and that number is growing as baby boomers age, as aging people want to stay more active, and as the obesity epidemic puts more stress on Americans’ joints, said Dr. William Barrett, a spokesman for the American Association of Hip and Knee Surgeons and an orthopedic surgeon on the West Side.

The anterior approach is used in about 10 percent of those surgeries, but that’s growing, too, Barrett said – even though there’s debate in medical literature about claims of less painful recoveries and other claimed advantages to the approach, often touted as “minimally invasive.”

Keeve, a surgeon at Northwest Orthopaedic Specialists’ Spokane Valley office, said he’s been taking an anterior approach to hip replacements for several years and now uses it for most of his hip replacement patients.

The anterior approach is not for everyone, Keeve said. Overweight patients or those with significantly deformed hips may be poor candidates. But he said patients who get it tend to experience less pain and faster, less-restrictive rehabilitation.

Many are back to normal within about a month, he said, compared with three or four months for patients who get posterior or lateral surgery.

But to call the surgery minimally invasive, Keeve said, “makes it sounds like you do it with mirrors.” It’s still a big operation, in which surgeons cut off the top of the femur and remove damaged bone and cartilage from the hip socket, then replace them with artificial parts.

Dr. David Scott, a hip and knee surgeon at Orthopaedic Specialty Clinic of Spokane, remains unconvinced that the anterior approach – which is not new, but newly touted as a better option for many – would improve outcomes for his patients.

That’s despite taking courses, reading the research comparing methods and attending presentations on the anterior approach, Scott said, including a couple earlier this month at a meeting of a hip and knee surgeons association.

One of the latter, he said, found patients with the anterior approach stopped using their canes about 24 days after surgery, about a week earlier than the other patients. But the other major difference, he said, was that anterior surgeries took significantly longer – about 45 to 60 minutes longer – even in the hands of expert surgeons. (Keeve said anterior surgeries take about 15 minutes longer, in his experience.)

The longer a patient spends under anesthesia with their hip open to the operating room, Scott said, the more likely they are to suffer complications such as infections and blood clots.

The anterior approach is “not bad, but it’s not necessarily better,” Scott said. “That’s the bottom line. And the only way it can even be as good as the posterior approach is if it’s done in the hands of a highly skilled surgeon,” because of a higher potential for complications, including nerve injuries.

‘How have we changed things?’

Still, for the growing number of people seeking to relieve their pain and resume their lives, the surgery’s proponents point out some appealing advantages.

Patients are able sooner to bear weight on their new hips, Keeve said. And he worries less about them dislocating their new joints, popping the ball out of the socket. Those who get conventional hip replacements are asked to avoid sitting in low chairs after surgery and to place foam wedges between their legs to keep the new joint aligned – steps anterior patients can skip.

After undergoing anterior surgery, patients “can pretty much resume all of their regular activities as soon as they can tolerate it,” Keeve said.

While the surgery can be performed on a conventional operating table, in recent years it’s been more often done on a special table, called a Hana table. The table’s availability could be a factor in the number of surgeons performing the surgery, he said. It allows a patient’s leg to be hyperextended and externally rotated, allowing surgeons easier access to the top of the femur.

Even with the table, though, the surgery is technically more difficult, Keeve said. And until five or six years ago, few medical schools taught the anterior approach.

“Conventional hip surgery is fairly intuitive – where the parts go, how things line up,” Keeve said. “This is not.”

For Scott, the extra training required of surgeons and what he sees as a higher risk of complications for patients aren’t worth an early recovery process that may be faster and easier. Within a few weeks or months after surgery, he said, patients who undergo conventional hip replacements have caught up, recovering to the same degree as those who got anterior surgery.

“These folks talk about the anterior approach at our meetings and the educational symposiums,” he said, “and it’s like, ‘Yeah, that’s exactly what we do with our posterior approach patients. They’re up the same day. They’re walking down the hall. They go home the same day. How have we changed things?’ ”

Scott said patients should choose a doctor, rather than a technique, and ask their potential surgeons about their track records, including surgical times, infection and dislocation rates and previous patients’ recovery times and satisfaction levels.

“If you take a surgeon who is really good at the posterior approach, they are basically going to have results that are every bit as good as the very best anterior hip results, but with a shorter operative time,” Scott said.

Barrett, of the American Association of Hip and Knee Surgeons, said the role of the anterior approach for patients and surgeons will continue to evolve as more studies are done and results reviewed. Results depend on a lot of factors, he said, including the surgeon’s experience and the patient’s overall health, weight and activity level.

Bafus said she read up on the surgery before getting on that operating table, seeking out reputable sources online, and asked for input from her physician daughter, who endorsed the anterior approach.

She has no regrets.

Up and walking a day after surgery, Bafus set a major goal for physical therapy – to ride her horses again – and worked daily to rebuild muscle she’d lost when hip pain limited her activity. She was back on a horse eight or nine months after her first surgery. After her left hip was replaced about 15 months after the right, she could ride again in just a few months, carefully but pain-free.

She rides around her farm and joins friends in trail-riding competitions, which involve jumping, crossing water and moving in and out of gates and completing physical challenges on horseback.

For her, the surgery was “huge,” she said. “It just kind of gave me my life back.”