Recommended Approaches for Total Hip Replacement
The posterior approach is recommended as the primary surgical approach for total hip arthroplasty due to its superior outcomes in pain management and functional recovery, with multimodal pain management including spinal anesthesia with local anesthetic plus opioid providing optimal analgesia. 1, 2
Surgical Approaches
Posterior Approach
- Provides excellent exposure of the acetabulum and femur
- Allows preservation of the abductor mechanism
- Associated with lower risk of abductor muscle damage compared to lateral approaches
- May have higher risk of dislocation if not properly repaired
Anterolateral Approach
- Provides good exposure of the acetabulum
- Associated with higher risk of abductor muscle damage
- May lead to abductor weakness and Trendelenburg gait
- Lower risk of dislocation compared to posterior approach
Direct Anterior Approach
- Muscle-sparing approach utilizing intermuscular planes
- Potentially faster early recovery
- Lower dislocation rates
- Technical challenges include femoral exposure
- Higher risk of lateral femoral cutaneous nerve injury
Perioperative Management
Anesthesia Options
- Spinal anesthesia with local anesthetic plus opioid (morphine 0.1-0.2 mg) is recommended for superior analgesia and duration compared to either agent alone 1
- General anesthesia is an acceptable alternative when spinal anesthesia is contraindicated
- Regional nerve blocks (femoral or posterior lumbar plexus) provide excellent analgesia with fewer side effects than neuraxial techniques 1
Pain Management
- Multimodal approach is essential:
- NSAIDs/COX-2 inhibitors (unless contraindicated)
- Acetaminophen/paracetamol as baseline treatment
- Opioids for breakthrough pain only
- Regional anesthesia techniques (nerve blocks)
- Posterior lumbar plexus blocks have greater efficacy than femoral nerve blocks but carry higher risk of complications 1
Postoperative Care and Rehabilitation
Movement Precautions (Based on Approach)
- Posterior approach: Avoid hip flexion >90°, internal rotation, and adduction for 6-12 weeks
- Anterolateral approach: Avoid external rotation and adduction
- Direct anterior approach: Fewer restrictions, avoid hyperextension
Rehabilitation Protocol
- Day 1: Begin ankle pumps, gluteal exercises, assisted sitting
- Days 2-3: Standing transfers, short-distance ambulation
- Days 4-14: Progress ambulation distance, stair training
- Weeks 2-4: Progress from walker to crutches or cane
- Weeks 4-6: Progress to single cane, increase strengthening
- Weeks 6-8: Transition to walking without assistive devices
- Weeks 8-12: Functional strengthening, return to daily activities 2
Monitoring and Follow-up
Imaging
- Routine radiographs are recommended for asymptomatic patients during follow-up 1
- For symptomatic patients:
- Initial imaging should be radiography of the hip
- CT without contrast for cases with acute injury
- MRI without contrast or image-guided aspiration if infection is suspected
- MRI without contrast for patients with metal-on-metal prostheses to evaluate for adverse reactions to metal debris 1
Abductor Mechanism Evaluation
- Trochanteric pain may indicate abductor injury, particularly after anterolateral approach
- Ultrasound or MRI without contrast is recommended to evaluate abductor injuries 1
Complication Prevention
Venous Thromboembolism Prophylaxis
- Essential for all THA patients, with 93% of patients receiving prophylaxis in recent studies 1
- Continue prophylaxis for several weeks after surgery, particularly for high-risk patients
Infection Prevention
- Perioperative antibiotics
- Strict adherence to sterile technique
- Optimization of modifiable risk factors (glycemic control, smoking cessation)
Common Pitfalls to Avoid
- Inadequate pain management leading to delayed mobilization and increased complications
- Failure to recognize abductor mechanism injury, particularly after anterolateral approach
- Insufficient VTE prophylaxis duration, especially in high-risk patients
- Overlooking leg length discrepancies during surgical planning
- Inadequate patient education regarding movement precautions based on surgical approach
The choice of surgical approach should be based on surgeon experience, patient anatomy, and specific clinical considerations. While each approach has advantages and disadvantages, the posterior approach with proper soft tissue repair and a comprehensive multimodal pain management strategy offers excellent outcomes for most patients undergoing total hip arthroplasty.