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Anterior Approach to Hip Replacement
Dr. Kenneth Rauschenbach discusses anterior approach to hip replacement.
Featuring:
Kenneth Rauschenbach, D.O.
Dr. Rauschenbach, DO is a board-certified Orthopedic Surgeon in New Windsor, NY. He has expertise in sports medicine, hip and knee replacement and trauma. Dr. Rauschenbach graduated from New York Medical College in 1994 and has been in practice for 25 years. He completed a residency at Peninsula Hospital Center. He currently practices at Orthopedic Associates of Dutchess County P C. and is affiliated with Montefiore St. Luke’s Cornwall. Transcription:
Melanie Cole: Welcome to Doc Talk presented by Montefiore St. Luke's Cornwall. I'm Melanie Cole and today we're discussing the anterior approach to hip replacement. Joining me is Dr. Kenneth Rauschenbach, he's Board Certified Orthopedic Surgeon at Montefiore St. Luke's Cornwall. Dr. Rauschenbach. It's a pleasure to have you on again today. Tell us first what types of conditions cause the hip joint to break down, what do you see most commonly?
Dr. Rauschenbach: The most common reason for hip destruction and breakdown is osteoarthritis of the hip. That's the most common type of arthritis. It's typically noted as the wear and tear and we all get it and it comes from a combination of factors of age, injury, how much a beating we put on our body over the years, and we all have it to a certain degree and it progresses over time.
Host: What's the first line of defense? I mean, obviously hip replacement is not the first thing we try. So what do you try first?
Dr. Rauschenbach: Certainly not hip replacement. There's always a last resort, typically activity modification, weight loss, followed by a combination of therapies, which can include anti-inflammatory medication, injections, other types of noninvasive therapy. And we take these on a stepwise approach until nothing works. And at that point then we start to consider surgical intervention.
Host: So then let's talk about the surgical intervention. Tell us the different types of hip replacement that are available and then discuss the anterior approach for us and why you would choose this approach.
Dr. Rauschenbach: There's many approaches available. The old saying there's more than one way to skin a cat. This really applies to the hip replacement. Hip replacements have been being placed for many, many years. The most traditional and typical approach is the posterior approach. It's probably done still more than 50% of the time in the United States. It's very reliable, reproducible that has some mild shortcomings, meaning that the patient would have to follow some dislocation precautions for a lifetime although rare because we disrupt the posterior soft tissues there's a potential for dislocation of the hip. There is an anterior lateral approach and honestly I could come up with about five or six more approaches, but typically the anterior lateral, the posterior approach have been the workhorses of hip replacement over the last 30 years. These newer approaches, some have come and gone due to issues with them, but this new anterior approach has been going on about 10 years and has made quite a bit of headway in the mainstream orthopedic community.
Host: Tell us why. What's different about the anterior approach?
Dr. Rauschenbach: The nice part of the anterior approach is that it's a muscle sparing approach and at no point do we have to detach any of the muscles which we do in the other approaches. By doing that, you know, we maintain the soft tissue envelope around the hip and provide extra stability. It's also nice, it's through a very limited incision and the rehab seems to be a little bit quicker than the other approaches. Again, due to that lack of need to remove that tendons attachment to the bone
Host: Are all hip replacement patients candidate for this type approach.
Dr. Rauschenbach: There are some surgeons in the United States that do this on a come all basis, in my hand and in many people's hands, this is limited to a certain body habitus because it's a very limited approach, meaning there's only a small window to get in there. Some are the heavyset people, morbid obesity, big strong men with big giant muscles are not a great candidate due to the limited access, this is not an extend style approach where we can extend the incision and make it bigger to get better view because of the limitations of the anatomy.
Host: That's so interesting. And what a great explanation. So why don't all doctors do hip replacement this way? You just mentioned that some people are not candidates, but not everybody's doing this. Is there a learning curve? Is this an experienced physician thing to do?
Dr. Rauschenbach: Actually more of the physicians that are doing it are the younger physicians who essentially trained in it on their way up as we come up with these new techniques, the older physicians are set in their ways a lot of the times. And unless there's a massive change in results, a lot of doctors are very happy to stick with what's been working with them for years. I still do approximately 60% posterior approach compared to the 40% anterior approach due to the limitations we spoke about earlier. But a lot of older doctors who are experienced in multiple approaches have, you know, adapted the anterior approach due to its benefits. There's definitely a learning curve. You know, typically when I first started doing these four or five years ago, my typical surgical time for a posterior approach would be about 45 minutes to an hour. Once I did this anterior approach again because I was learning it as I went, attended classes and went to cadaver labs, it added about 20 minutes to my procedure. It was well worth it and I've been happy with it. And then since then it has really come down to be about the same time-frame as my posterior approach.
Host: Wow. So you've told us about the benefits and about the patient selection criteria. What about post-surgery and recovery is this much quicker and how long generally, what's the difference between postsurgical recovery for the posterior approach and the anterior approach?
Dr. Rauschenbach: Well, that's really what got me interested in this. I've been, you know, really impressed with how quickly these solutions back down and for a fair amount of patients. Now this is becoming same day surgery compared to the posterior approach, which isn't longer by that much. It's usually an overnight stay to be honest with you. I just find that they bounce back a lot quicker, get to that normal gait and with less pain. We've also noticed limited opioid use with this because of the, you know, pain difference that I've noticed in my practice and there's been, you know, borne out in the literature as well. So between the quicker recovery, less pain, less use of narcotics, which as we all know is a problem in the United States this time. I think it's got excellent advantages again, if you're a good candidate for the procedure.
Host: What a great point about pain management after the procedure. That's so important. Wrap it up for us. What would you like patients that are considering hip replacement to know about the anterior approach and how you can help them at Montefiore St. Luke's Cornwall?
Dr. Rauschenbach: Well, I believe the anterior approach is just more tools in my toolbox. Not every patient is a candidate for it. I do think if you are a candidate for it, it's an excellent choice. I think it'll give you a slightly quicker recovery, a little less pain and not having the burden of those dislocation precautions going forward. I would also say that the surgeon you're seeing trust the Doctor that speaks to I wouldn't insist on any particular approach as the lay person or the patient, do your research and if it's something you're really interested in, find someone that does that approach. But by all means, don't look down on the other approaches. They've been working great for years. They gave us a really nice result and good longevity as well.
Host: And now before we wrap up, give us your best advice about keeping healthy hips. So maybe we don't need a replacement.
Dr. Rauschenbach: Well, the most important thing is one, be active. That means keep the muscles strong. It doesn't have to be high impact exercise, even light walking, low-impact biking slight jogging, stuff like that. Keep your weight down. That's super important. The more weight your body has to bear. The more the generation that these hips, knees, all of our joints take the beating and that wear and tear can lead to earlier arthritic changes. Healthy diet is super important and again, once you start experienced symptoms, don't wait so long that there's no other options besides the joint replacement. Go see your doctor, they'll evaluate you, do a good history and physical and of course treat you with the most conservative options until they no longer work and then you're a candidate for something surgical.
Host: Thank you so much Dr. Rauschenbach. It's great information and so important. Thank you very much for joining us and sharing your expertise. That concludes this episode of Doc Talk presented by Montefiore St. Luke's Cornwall. Please visit our website at montefioreslc.org for more information and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Montefiore St. Luke's Cornwall podcasts. I'm Melanie Cole.
Melanie Cole: Welcome to Doc Talk presented by Montefiore St. Luke's Cornwall. I'm Melanie Cole and today we're discussing the anterior approach to hip replacement. Joining me is Dr. Kenneth Rauschenbach, he's Board Certified Orthopedic Surgeon at Montefiore St. Luke's Cornwall. Dr. Rauschenbach. It's a pleasure to have you on again today. Tell us first what types of conditions cause the hip joint to break down, what do you see most commonly?
Dr. Rauschenbach: The most common reason for hip destruction and breakdown is osteoarthritis of the hip. That's the most common type of arthritis. It's typically noted as the wear and tear and we all get it and it comes from a combination of factors of age, injury, how much a beating we put on our body over the years, and we all have it to a certain degree and it progresses over time.
Host: What's the first line of defense? I mean, obviously hip replacement is not the first thing we try. So what do you try first?
Dr. Rauschenbach: Certainly not hip replacement. There's always a last resort, typically activity modification, weight loss, followed by a combination of therapies, which can include anti-inflammatory medication, injections, other types of noninvasive therapy. And we take these on a stepwise approach until nothing works. And at that point then we start to consider surgical intervention.
Host: So then let's talk about the surgical intervention. Tell us the different types of hip replacement that are available and then discuss the anterior approach for us and why you would choose this approach.
Dr. Rauschenbach: There's many approaches available. The old saying there's more than one way to skin a cat. This really applies to the hip replacement. Hip replacements have been being placed for many, many years. The most traditional and typical approach is the posterior approach. It's probably done still more than 50% of the time in the United States. It's very reliable, reproducible that has some mild shortcomings, meaning that the patient would have to follow some dislocation precautions for a lifetime although rare because we disrupt the posterior soft tissues there's a potential for dislocation of the hip. There is an anterior lateral approach and honestly I could come up with about five or six more approaches, but typically the anterior lateral, the posterior approach have been the workhorses of hip replacement over the last 30 years. These newer approaches, some have come and gone due to issues with them, but this new anterior approach has been going on about 10 years and has made quite a bit of headway in the mainstream orthopedic community.
Host: Tell us why. What's different about the anterior approach?
Dr. Rauschenbach: The nice part of the anterior approach is that it's a muscle sparing approach and at no point do we have to detach any of the muscles which we do in the other approaches. By doing that, you know, we maintain the soft tissue envelope around the hip and provide extra stability. It's also nice, it's through a very limited incision and the rehab seems to be a little bit quicker than the other approaches. Again, due to that lack of need to remove that tendons attachment to the bone
Host: Are all hip replacement patients candidate for this type approach.
Dr. Rauschenbach: There are some surgeons in the United States that do this on a come all basis, in my hand and in many people's hands, this is limited to a certain body habitus because it's a very limited approach, meaning there's only a small window to get in there. Some are the heavyset people, morbid obesity, big strong men with big giant muscles are not a great candidate due to the limited access, this is not an extend style approach where we can extend the incision and make it bigger to get better view because of the limitations of the anatomy.
Host: That's so interesting. And what a great explanation. So why don't all doctors do hip replacement this way? You just mentioned that some people are not candidates, but not everybody's doing this. Is there a learning curve? Is this an experienced physician thing to do?
Dr. Rauschenbach: Actually more of the physicians that are doing it are the younger physicians who essentially trained in it on their way up as we come up with these new techniques, the older physicians are set in their ways a lot of the times. And unless there's a massive change in results, a lot of doctors are very happy to stick with what's been working with them for years. I still do approximately 60% posterior approach compared to the 40% anterior approach due to the limitations we spoke about earlier. But a lot of older doctors who are experienced in multiple approaches have, you know, adapted the anterior approach due to its benefits. There's definitely a learning curve. You know, typically when I first started doing these four or five years ago, my typical surgical time for a posterior approach would be about 45 minutes to an hour. Once I did this anterior approach again because I was learning it as I went, attended classes and went to cadaver labs, it added about 20 minutes to my procedure. It was well worth it and I've been happy with it. And then since then it has really come down to be about the same time-frame as my posterior approach.
Host: Wow. So you've told us about the benefits and about the patient selection criteria. What about post-surgery and recovery is this much quicker and how long generally, what's the difference between postsurgical recovery for the posterior approach and the anterior approach?
Dr. Rauschenbach: Well, that's really what got me interested in this. I've been, you know, really impressed with how quickly these solutions back down and for a fair amount of patients. Now this is becoming same day surgery compared to the posterior approach, which isn't longer by that much. It's usually an overnight stay to be honest with you. I just find that they bounce back a lot quicker, get to that normal gait and with less pain. We've also noticed limited opioid use with this because of the, you know, pain difference that I've noticed in my practice and there's been, you know, borne out in the literature as well. So between the quicker recovery, less pain, less use of narcotics, which as we all know is a problem in the United States this time. I think it's got excellent advantages again, if you're a good candidate for the procedure.
Host: What a great point about pain management after the procedure. That's so important. Wrap it up for us. What would you like patients that are considering hip replacement to know about the anterior approach and how you can help them at Montefiore St. Luke's Cornwall?
Dr. Rauschenbach: Well, I believe the anterior approach is just more tools in my toolbox. Not every patient is a candidate for it. I do think if you are a candidate for it, it's an excellent choice. I think it'll give you a slightly quicker recovery, a little less pain and not having the burden of those dislocation precautions going forward. I would also say that the surgeon you're seeing trust the Doctor that speaks to I wouldn't insist on any particular approach as the lay person or the patient, do your research and if it's something you're really interested in, find someone that does that approach. But by all means, don't look down on the other approaches. They've been working great for years. They gave us a really nice result and good longevity as well.
Host: And now before we wrap up, give us your best advice about keeping healthy hips. So maybe we don't need a replacement.
Dr. Rauschenbach: Well, the most important thing is one, be active. That means keep the muscles strong. It doesn't have to be high impact exercise, even light walking, low-impact biking slight jogging, stuff like that. Keep your weight down. That's super important. The more weight your body has to bear. The more the generation that these hips, knees, all of our joints take the beating and that wear and tear can lead to earlier arthritic changes. Healthy diet is super important and again, once you start experienced symptoms, don't wait so long that there's no other options besides the joint replacement. Go see your doctor, they'll evaluate you, do a good history and physical and of course treat you with the most conservative options until they no longer work and then you're a candidate for something surgical.
Host: Thank you so much Dr. Rauschenbach. It's great information and so important. Thank you very much for joining us and sharing your expertise. That concludes this episode of Doc Talk presented by Montefiore St. Luke's Cornwall. Please visit our website at montefioreslc.org for more information and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Montefiore St. Luke's Cornwall podcasts. I'm Melanie Cole.